Printable Drug Formulary - Medicaid

Transcription

Drug Formulary
7/14/15
lowercase italics= Generic drugs
UPPERCASE BOLD= Brand
name drugs
Drug
Tier
Notes
Antihistamine Drugs
Ethanolamine Derivatives
BANOPHEN ORAL LIQUID
Preferred
clemastine oral tablet
Preferred
DIPHENHIST ORAL TABLET 50 MG
Preferred
diphenhydramine hcl injection solution 50 mg/ml
Preferred
diphenhydramine hcl injection syringe
Preferred
diphenhydramine hcl oral capsule
Preferred
diphenhydramine hcl oral tablet 25 mg
Preferred
SLEEP AID (DOXYLAMINE)
Preferred
First Gen. Antihist. Derivatives, Misc.
cyproheptadine
Preferred
First Generation Antihistamines
ALLER-CHLOR ORAL SYRUP
Preferred
Preferred
Preferred
cyproheptadine
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following: PA= Prior Authorization Required, ST =Step Therapy, Required QL= Quantity
Limit, F= for females, M= for males, FL= fill, DY= day, QY=quantity, DS=days’ supply. If you have any
questions, please call Pharmacy Member Services (1-888-452-3647), Pharmacy Provider Services (1-888602-3741) or visit www.amerihealthcaritasdc.com
1
Drug
Tier
Notes
Preferred
Phenothiazine Derivatives
promethazine injection
Preferred
promethazine oral
Preferred
promethazine rectal suppository 12.5 mg, 25 mg
Preferred
PROMETHAZINE VC
Preferred
PROMETHAZINE VC-CODEINE
Preferred
Piperazine Derivatives
hydroxyzine hcl oral solution 10 mg/5 ml
Preferred
hydroxyzine hcl oral tablet
Preferred
hydroxyzine pamoate
Preferred
meclizine oral tablet 12.5 mg, 25 mg
Preferred
meclizine oral tablet, chewable
Preferred
Propylamine Derivatives
Preferred
M-END DMX
Preferred
Second Generation Antihistamines
ALAVERT D-12 ALLERGY-SINUS
Preferred
ALAVERT ORAL
TABLET,DISINTEGRATING
Preferred
ALLEGRA ALLERGY
Preferred
ALLERGY RELIEF & NASAL DECONGE
Preferred
ALLERGY RELIEF (LORATADINE) ORAL
Preferred
cetirizine oral solution 1 mg/ml
Preferred
cetirizine oral tablet
Preferred
cetirizine-pseudoephedrine
Preferred
CHILDREN'S ALLEGRA ALLERGY ORAL
TABLET
Preferred
ST
Non-preferred
PA
CLARINEX
ST
list to represent the following: PA= Prior Authorization Required, ST =Step Therapy Required, QL= Quantity
2
Drug
CLARINEX-D 12 HOUR
Tier
Non-preferred
CLARITIN REDITABS ORAL
TABLET,DISINTEGRATING 5 MG
Preferred
fexofenadine oral tablet 180 mg, 60 mg
Preferred
loratadine oral solution
Preferred
loratadine oral tablet
Preferred
LORATADINE-D ORAL TABLET
EXTENDED RELEASE 24 HR
Preferred
XYZAL
Non-preferred
Notes
PA
ST
PA
Anti-Infective Agents
Adamantanes
amantadine hcl oral capsule
Preferred
amantadine hcl oral solution
Preferred
Allylamines
terbinafine hcl oral
Preferred
QL (90 DS per 365 DYs)
Amebicides
metronidazole oral tablet
Preferred
paromomycin
Preferred
YODOXIN
Preferred
PA; QL (10 DS per 30 DYs)
Aminoglycosides
paromomycin
Preferred
PA; QL (10 DS per 30 DYs)
Aminopenicillins
amoxicillin oral capsule
Preferred
amoxicillin oral suspension for reconstitution
Preferred
amoxicillin oral tablet
Preferred
amoxicillin oral tablet, chewable 125 mg, 250 mg
Preferred
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,
600-42.9 mg/5 ml
Preferred
amoxicillin-pot clavulanate oral tablet
Preferred
3
Drug
Tier
amoxicillin-pot clavulanate oral tablet, chewable
Preferred
ampicillin
Preferred
Notes
Anthelmintics
BILTRICIDE
Preferred
Antifungals, Miscellaneous
GRIFULVIN V ORAL TABLET
Preferred
griseofulvin microsize oral suspension
Preferred
griseofulvin ultramicrosize oral tablet 250 mg
Preferred
GRIS-PEG (ULTRAMICROSIZE) ORAL
TABLET 125 MG
Preferred
SSKI
Preferred
Antimalarials
chloroquine phosphate oral
Preferred
DARAPRIM
Preferred
hydroxychloroquine oral
Preferred
mefloquine
Preferred
primaquine
Preferred
quinidine sulfate
Preferred
Antimycobacterials, Miscellaneous
dapsone
Preferred
Antiprotozoals, Miscellaneous
dapsone
Preferred
MEPRON
Preferred
metronidazole oral tablet
Preferred
PA
Antituberculosis Agents
CIPRO ORAL
SUSPENSION,MICROCAPSULE RECON
Preferred
ciprofloxacin (mixture)
Preferred
ciprofloxacin hcl oral tablet 250 mg, 500 mg
Preferred
QL (68 QY per 34 DYs)
4
Drug
Tier
Notes
ciprofloxacin hcl oral tablet 750 mg
Preferred
clarithromycin
Preferred
QL (1 FL per 30 DYs)
ethambutol
Preferred
isoniazid oral
Preferred
levofloxacin oral solution
Preferred
levofloxacin oral tablet
Preferred
moxifloxacin
Preferred
MYCOBUTIN
Preferred
pyrazinamide
Preferred
rifampin oral
Preferred
Azoles
fluconazole oral suspension for reconstitution
Preferred
fluconazole oral tablet 100 mg, 200 mg, 50 mg
Preferred
fluconazole oral tablet 150 mg
Preferred
ketoconazole oral
Preferred
VFEND
Non-preferred
PA
Chloramphenicol
chloramphenicol sod succinate
Preferred
Erythromycins
erythromycin-sulfisoxazole
Preferred
First Generation Cephalosporins
cefadroxil oral capsule
Preferred
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
Preferred
cefadroxil oral tablet
Preferred
cephalexin oral capsule 250 mg, 500 mg
Preferred
cephalexin oral suspension for reconstitution
Preferred
Glycopeptides
vancomycin oral capsule
Preferred
ST
5
Drug
Tier
Notes
Lincomycins
clindamycin hcl oral capsule 150 mg, 300 mg
Preferred
clindamycin palmitate hcl
Preferred
Macrolides
ERY-TAB
Preferred
ERYTHROCIN (AS STEARATE) ORAL
TABLET 250 MG
Preferred
erythromycin ethylsuccinate oral tablet
Preferred
erythromycin oral capsule,delayed release(dr/ec)
Preferred
Natural Penicillins
penicillin v potassium
Preferred
Neuraminidase Inhibitors
RELENZA DISKHALER
Preferred
TAMIFLU
Preferred
Nucleosides And Nucleotides
acyclovir oral capsule
Preferred
acyclovir oral suspension 200 mg/5 ml
Preferred
acyclovir oral tablet
Preferred
entecavir
Preferred
HEPSERA
Non-preferred
valacyclovir
Preferred
PA
Other Macrolides
azithromycin oral packet
Preferred
azithromycin oral suspension for reconstitution
Preferred
azithromycin oral tablet 250 mg, 600 mg
Preferred
azithromycin oral tablet 500 mg
Preferred
clarithromycin
Preferred
ZMAX
Preferred
Oxazolidinones
6
Drug
ZYVOX ORAL
Tier
Non-preferred
Notes
PA
Penicillinase-Resistant Penicillins
dicloxacillin
Preferred
Polyenes
nystatin oral
Preferred
Quinolones
CIPRO ORAL
SUSPENSION,MICROCAPSULE RECON
Preferred
ciprofloxacin hcl oral tablet 250 mg, 500 mg
Preferred
ciprofloxacin hcl oral tablet 750 mg
Preferred
levofloxacin oral solution
Preferred
levofloxacin oral tablet
Preferred
moxifloxacin
Preferred
Rifamycins
MYCOBUTIN
Preferred
rifampin oral
Preferred
Second Generation Cephalosporins
cefaclor oral capsule
Preferred
cefprozil oral suspension for reconstitution
Preferred
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION 250 MG/5 ML
Preferred
cefuroxime axetil oral suspension for
reconstitution 125 mg/5 ml
Preferred
cefuroxime axetil oral tablet
Preferred
Sulfonamides (Systemic)
sulfadiazine oral
Preferred
sulfamethoxazole-trimethoprim oral
Preferred
sulfasalazine
Preferred
Tetracyclines
7
Drug
Tier
doxycycline monohydrate oral capsule 100 mg, 50
mg
Preferred
doxycycline monohydrate oral tablet 100 mg, 50
mg
Preferred
minocycline oral capsule 100 mg, 50 mg
Preferred
tetracycline
Preferred
Notes
Third Generation Cephalosporins
cefdinir oral suspension for reconstitution
Preferred
cefpodoxime oral suspension for reconstitution
Preferred
SUPRAX ORAL TABLET
Preferred
Urinary Anti-Infectives
MACRODANTIN ORAL CAPSULE 25 MG
Preferred
nitrofurantoin macrocrystal oral capsule 100 mg,
50 mg
Preferred
nitrofurantoin monohyd/m-cryst
Preferred
nitrofurantoin oral
Preferred
trimethoprim
Preferred
Antineoplastic Agents
Antineoplastic Agents
ALKERAN ORAL
Preferred
bicalutamide
Preferred
CEENU ORAL CAPSULE 10 MG, 100 MG, 40
MG
Preferred
cyclophosphamide oral tablet
Preferred
DROXIA
Preferred
EMCYT
Preferred
FARESTON
Preferred
PA
flutamide
Preferred
M
HEXALEN
Preferred
hydroxyurea
Preferred
8
Drug
Tier
letrozole
Preferred
LEUKERAN
Preferred
LYSODREN
Preferred
MATULANE
Preferred
MEGACE ES
Preferred
megestrol oral suspension 400 mg/10 ml (40
mg/ml)
Preferred
megestrol oral tablet
Preferred
mercaptopurine
Preferred
methotrexate sodium
Preferred
methotrexate sodium (pf) injection solution
Preferred
MYLERAN
Preferred
RHEUMATREX
Preferred
TABLOID
Preferred
tamoxifen
Preferred
TREXALL ORAL TABLET 7.5 MG
Preferred
Notes
QL (1 QY per 1 DY)
F
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
Preferred
Preferred
BROMFED DM
Preferred
Preferred
CHERATUSSIN DAC
Preferred
CLARINEX-D 12 HOUR
Non-preferred
PA
epinephrine injection solution
Preferred
epinephrine injection syringe 0.1 mg/ml (1:10,000)
Preferred
EPIPEN 2-PAK
Preferred
EPIPEN JR 2-PAK
Preferred
Preferred
9
Drug
Tier
M-END DMX
Preferred
MUCINEX D
Preferred
pseudoephedrine hcl oral tablet 60 mg
Preferred
Notes
Alpha-Adrenergic Agonists
DESPEC
Preferred
methyldopa
Preferred
methyldopa-hydrochlorothiazide
Preferred
PROMETHAZINE VC
Preferred
Preferred
ROBAFEN CF ORAL LIQUID
Preferred
Antimuscarinics/Antispasmodics
ATROVENT HFA
Preferred
COMBIVENT
Preferred
COMBIVENT RESPIMAT
Preferred
dicyclomine oral capsule
Preferred
dicyclomine oral solution
Preferred
dicyclomine oral tablet
Preferred
diphenoxylate-atropine
Preferred
glycopyrrolate oral
Preferred
hydrocodone-homatropine oral syrup 5-1.5 mg/5
ml
Preferred
hydrocodone-homatropine oral tablet
Preferred
hyoscyamine sulfate oral
Preferred
ipratropium bromide inhalation
Preferred
ipratropium-albuterol
Preferred
propantheline
Preferred
SPIRIVA RESPIMAT
Preferred
SPIRIVA WITH HANDIHALER
Preferred
TUDORZA PRESSAIR
Preferred
10
Drug
Tier
Notes
Antiparkinsonian Agents
benztropine oral
Preferred
trihexyphenidyl
Preferred
Autonomic Drugs, Miscellaneous
CHANTIX
Preferred
CHANTIX STARTING MONTH BOX
Preferred
nicotine (polacrilex)
Preferred
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr
Preferred
NICOTROL
Preferred
NICOTROL NS
Preferred
Centrally Acting Skeletal Muscle Relaxnt
carisoprodol oral tablet 350 mg
Preferred
chlorzoxazone
Preferred
cyclobenzaprine oral tablet 10 mg, 5 mg
Preferred
methocarbamol oral
Preferred
tizanidine oral tablet
Preferred
Gaba-Derivative Skeletal Muscle Relaxant
baclofen
Preferred
Non-Sel. Beta-Adrenergic Blocking Agents
carvedilol
Preferred
labetalol oral
Preferred
nadolol
Preferred
nadolol-bendroflumethiazide
Preferred
pindolol
Preferred
propranolol oral
Preferred
propranolol-hydrochlorothiazid
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
11
Drug
timolol maleate oral
Tier
Notes
Preferred
Non-Sel.Alpha-1-Adrenergic Blocking Agts
doxazosin
Preferred
prazosin oral
Preferred
terazosin
Preferred
Non-Sel.Alpha-Adrenergic Blocking Agents
DIBENZYLINE
Preferred
dihydroergotamine injection
Preferred
dihydroergotamine nasal
Preferred
ERGOMAR
Preferred
Parasympathomimetic (Cholinergic Agents)
bethanechol chloride
Preferred
donepezil oral tablet 10 mg, 5 mg
Preferred
donepezil oral tablet,disintegrating
Preferred
EXELON TRANSDERMAL PATCH 24
HOUR 4.6 MG/24 HR, 9.5 MG/24 HR
Preferred
MESTINON ORAL SYRUP
Preferred
MESTINON TIMESPAN
Preferred
PROSTIGMIN
Preferred
pyridostigmine bromide oral tablet
Preferred
rivastigmine tartrate
Preferred
Selective Alpha-1-Adrenergic Block.Agent
carvedilol
Preferred
labetalol oral
Preferred
tamsulosin
Preferred
M
Selective Beta-2-Adrenergic Agonists
albuterol sulfate inhalation solution for
nebulization 2.5 mg /3 ml (0.083 %), 5 mg/ml
Preferred
albuterol sulfate oral syrup
Preferred
12
Drug
Tier
albuterol sulfate oral tablet
Preferred
COMBIVENT
Preferred
COMBIVENT RESPIMAT
Preferred
DULERA
Preferred
Preferred
SEREVENT DISKUS
Preferred
SYMBICORT
Preferred
terbutaline oral
Preferred
VENTOLIN HFA
Preferred
Notes
QL (10.2 QY per 30 DYs)
Selective Beta-Adrenergic Blocking Agent
atenolol
Preferred
bisoprolol fumarate
Preferred
bisoprolol-hydrochlorothiazide
Preferred
metoprolol succinate
Preferred
metoprolol ta-hydrochlorothiaz oral tablet 100-25
mg, 50-25 mg
Preferred
metoprolol tartrate oral
Preferred
Blood Formation,Coagulation & Thrombosis
Coumarin Derivatives
warfarin
Preferred
Direct Factor Xa Inhibitors
ELIQUIS
Preferred
XARELTO
Preferred
Direct Thrombin Inhibitors
PRADAXA
Preferred
Hemorrheologic Agents
pentoxifylline
Preferred
Hemostatics
aminocaproic acid oral
Preferred
13
Drug
Tier
Notes
desmopressin nasal solution
Preferred
PA
desmopressin nasal spray,non-aerosol
Preferred
PA
desmopressin oral
Preferred
PA
Heparins
enoxaparin subcutaneous solution
Preferred
enoxaparin subcutaneous syringe
Non-preferred
heparin (porcine) injection solution 10,000
unit/ml, 5,000 unit/ml
PA
Preferred
Iron Preparations
CERTAVITE-ANTIOXID (IRON GLUC)
ORAL LIQUID 9 MG IRON/15 ML
Preferred
DAILY VITES/IRON
Preferred
FE C PLUS
Preferred
FERRETTS
Preferred
ferrous gluconate oral tablet 324 mg (37.5 mg
iron), 324 mg (38 mg iron), 325 mg (36 mg iron)
Preferred
ferrous sulfate oral drops
Preferred
ferrous sulfate oral liquid
Preferred
ferrous sulfate oral solution
Preferred
ferrous sulfate oral tablet 325 mg (65 mg iron)
Preferred
ferrous sulfate oral tablet,delayed release (dr/ec)
325 mg (65 mg iron)
Preferred
MULTIGEN
Preferred
MULTIGEN FOLIC
Preferred
MULTIGEN PLUS
Preferred
MULTI-VIT WITH FLUORIDE & IRON
Preferred
MYNATAL PLUS
Preferred
MYNATAL-Z
Preferred
ONE-A-DAY WOMENS FORMULA ORAL
TABLET 18 MG IRON-400 MCG-500 MG CA
Preferred
14
Drug
Tier
Notes
POLY-VITAMIN WITH IRON ORAL DROPS
1,500 UNIT-400 UNIT-10 MG/ML
Preferred
PR NATAL 400
Preferred
F
PR NATAL 400 EC
Preferred
F
PR NATAL 430
Preferred
F
PRENAPLUS
Preferred
PRENATAL 19 (WITH DOCUSATE)
Preferred
PRENATAL AD
Preferred
PRENATAL LOW IRON
Preferred
PRENATAL PLUS WITH IRON (CA)
Preferred
PRENATAL VITAMIN ORAL TABLET 270.8 MG
Preferred
PRENATAL VITAMINS LOW IRON
Preferred
PRORENAL QD
Preferred
SE-NATAL 19
Preferred
SE-NATAL 19 (WITH DOCUSATE)
Preferred
TRICARE
Preferred
TRIVEEN-DUO DHA
Preferred
TRI-VIT WITH FLUORIDE & IRON
Preferred
VENATAL-FA
Preferred
VINATE GT
Preferred
VINATE II
Preferred
VINATE ONE
Preferred
VINATE ULTRA
Preferred
VITATRUM ORAL TABLET,CHEWABLE
Preferred
VOL-NATE
Preferred
VOL-PLUS
Preferred
VOL-TAB RX
Preferred
F
F
Platelet-Aggregation Inhibitors
AGGRENOX
Preferred
15
Drug
Tier
aspirin oral tablet 325 mg
Preferred
aspirin oral tablet,delayed release (dr/ec) 325 mg,
81 mg
Preferred
butalbital-aspirin-caffeine oral tablet
Preferred
cilostazol
Preferred
clopidogrel
Preferred
dipyridamole oral
Preferred
EFFIENT
Preferred
ticlopidine
Preferred
Notes
Thrombolytic Agents
Preferred
81 mg
Preferred
Preferred
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
carvedilol
Preferred
doxazosin
Preferred
labetalol oral
Preferred
prazosin oral
Preferred
terazosin
Preferred
Alpha-Adrenergic Blocking Agents (Hypotensives)
doxazosin
Preferred
labetalol oral
Preferred
prazosin oral
Preferred
terazosin
Preferred
Angiotensin Ii Receptor Antagonists (Hypotensives)
amlodipine-valsartan
Preferred
ST
candesartan
Preferred
ST
16
Drug
Tier
Notes
candesartan-hydrochlorothiazide
Preferred
ST
EXFORGE HCT ORAL TABLET 10-160-12.5
MG
Preferred
ST
EXFORGE ORAL TABLET 5-160 MG
Preferred
ST
irbesartan
Preferred
ST
irbesartan-hydrochlorothiazide
Preferred
ST
losartan
Preferred
losartan-hydrochlorothiazide
Preferred
valsartan
Preferred
valsartan-hydrochlorothiazide
Preferred
ST
Angiotensin II Receptor Antagonists
Preferred
ST
candesartan
Preferred
ST
Preferred
ST
MG
Preferred
ST
Preferred
ST
irbesartan
Preferred
ST
Preferred
ST
losartan
Preferred
Preferred
valsartan
Preferred
Preferred
ST
Angiotensin-Converting Enzyme Inhibitors(Hypotensives)
benazepril
Preferred
benazepril-hydrochlorothiazide
Preferred
captopril
Preferred
captopril-hydrochlorothiazide
Preferred
enalapril maleate
Preferred
enalapril-hydrochlorothiazide
Preferred
17
Drug
Tier
fosinopril
Preferred
fosinopril-hydrochlorothiazide
Preferred
lisinopril
Preferred
lisinopril-hydrochlorothiazide
Preferred
moexipril
Preferred
moexipril-hydrochlorothiazide
Preferred
perindopril erbumine oral tablet 4 mg, 8 mg
Preferred
quinapril-hydrochlorothiazide
Preferred
trandolapril
Preferred
Notes
Angiotensin-Converting Enzyme Inhibitors
benazepril
Preferred
Preferred
captopril
Preferred
Preferred
enalapril maleate
Preferred
Preferred
fosinopril
Preferred
Preferred
lisinopril
Preferred
Preferred
moexipril
Preferred
Preferred
perindopril erbumine oral tablet 4 mg, 8 mg
Preferred
Preferred
trandolapril
Preferred
Antiarrhythmics, Miscellaneous
DIGOX
Preferred
Antilipemic Agents, Miscellaneous
18
Drug
Tier
niacin oral capsule, extended release 250 mg, 500
mg
Preferred
NIACOR
Preferred
Notes
Beta-Adrenergic Blocking Agents
atenolol
Preferred
bisoprolol fumarate
Preferred
Preferred
carvedilol
Preferred
labetalol oral
Preferred
Preferred
metoprolol tartrate-hydrochlorothiazide oral
tablet 100-25 mg, 50-25 mg
Preferred
Preferred
nadolol
Preferred
Preferred
pindolol
Preferred
propranolol oral
Preferred
propranolol-hydrochlorothiazide
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
Preferred
Beta-Adrenergic Blocking Agents (Hypotensives)
atenolol
Preferred
bisoprolol fumarate
Preferred
Preferred
labetalol oral
Preferred
Preferred
metoprolol tartrate-hydrochlorothiazide oral
tablet 100-25 mg, 50-25 mg
Preferred
Preferred
19
Drug
Tier
nadolol
Preferred
Preferred
pindolol
Preferred
propranolol oral
Preferred
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
Preferred
Notes
Bile Acid Sequestrants
cholestyramine (with sugar)
Preferred
CHOLESTYRAMINE LIGHT ORAL
POWDER IN PACKET
Preferred
colestipol oral tablet
Preferred
PREVALITE
Preferred
Calcium-Channel Blocking Agents, Misc. (Hypotensives)
diltiazem hcl oral capsule, extended release
Preferred
diltiazem hcl oral capsule,ext release degradable
Preferred
diltiazem hcl oral capsule,extended release 12 hr
120 mg, 60 mg
Preferred
diltiazem hcl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
Preferred
diltiazem hcl oral tablet
Preferred
DILT-XR
Preferred
TAZTIA XT
Preferred
verapamil oral capsule,ext rel. pellets 24 hr 360
mg
Preferred
verapamil oral tablet
Preferred
verapamil oral tablet extended release
Preferred
Calcium-Channel Blocking Agents, Misc.
Preferred
20
Drug
Tier
Preferred
120 mg, 60 mg
Preferred
120 mg, 180 mg, 240 mg, 300 mg
Preferred
Preferred
DILT-XR
Preferred
TAZTIA XT
Preferred
mg
Preferred
Preferred
Preferred
Notes
Carbonic Anhydrase Inhibitors (Hypotensives)
acetazolamide oral capsule, extended release
Preferred
acetazolamide oral tablet
Preferred
PA
Cardiotonic Agents
DIGOX
Preferred
Central Alpha-Agonists
clonidine
Preferred
clonidine hcl oral tablet
Preferred
CLORPRES
Preferred
guanfacine oral tablet
Preferred
methyldopa
Preferred
Preferred
Cholesterol Absorption Inhibitors
ZETIA
Preferred
Class IA Antiarrhythmics
disopyramide phosphate oral capsule
Preferred
NORPACE CR
Preferred
quinidine gluconate oral
Preferred
21
Drug
quinidine sulfate
Tier
Notes
Preferred
Class IB Antiarrhythmics
DILANTIN
Preferred
DILANTIN INFATABS
Preferred
mexiletine
Preferred
phenytoin oral suspension
Preferred
phenytoin sodium extended oral capsule 100 mg
Preferred
Class IC Antiarrhythmics
flecainide
Preferred
propafenone oral tablet
Preferred
Class II Antiarrhythmics
atenolol
Preferred
bisoprolol fumarate
Preferred
Preferred
carvedilol
Preferred
labetalol oral
Preferred
Preferred
metoprolol ta-hydrochlorothiazide oral tablet 10025 mg, 50-25 mg
Preferred
Preferred
nadolol
Preferred
Preferred
pindolol
Preferred
propranolol oral
Preferred
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
Preferred
Class III Antiarrhythmics
22
Drug
Tier
amiodarone oral tablet 200 mg
Preferred
PACERONE ORAL TABLET 100 MG
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
Notes
Class IV Antiarrhythmics
Preferred
Preferred
120 mg, 60 mg
Preferred
120 mg, 180 mg, 240 mg, 300 mg
Preferred
Preferred
DILT-XR
Preferred
TAZTIA XT
Preferred
mg
Preferred
Preferred
Preferred
Dihydropyridines
amlodipine
Preferred
Preferred
ST
MG
Preferred
ST
Preferred
ST
NIFEDIAC CC
Preferred
NIFEDICAL XL
Preferred
nifedipine oral capsule
Preferred
nifedipine oral tablet extended release 24hr
Preferred
nisoldipine oral tablet extended release 24 hr 17
mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
Preferred
23
Drug
Tier
Notes
Dihydropyridines (Hypotensive Agents)
amlodipine
Preferred
Preferred
ST
MG
Preferred
ST
Preferred
ST
NIFEDIAC CC
Preferred
NIFEDICAL XL
Preferred
Preferred
Preferred
nisoldipine oral tablet extended release 24 hr 17
mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
Preferred
Direct Vasodilators
hydralazine oral
Preferred
minoxidil oral
Preferred
Diuretics, Miscellaneous (Hypotensive)
THEO-24
Preferred
theophylline oral tablet extended release
Preferred
theophylline oral tablet extended release 12 hr 200
mg, 300 mg
Preferred
Fibric Acid Derivatives
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg
Preferred
fenofibrate oral tablet 160 mg, 54 mg
Preferred
gemfibrozil oral
Preferred
HMG-CoA Reductase Inhibitors
atorvastatin oral tablet 10 mg, 20 mg, 80 mg
Preferred
fluvastatin
Preferred
ST
LESCOL XL
Preferred
ST
LIPITOR ORAL TABLET 40 MG
Preferred
24
Drug
Tier
lovastatin
Preferred
pravastatin
Preferred
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Preferred
Notes
ST
Hypotensive Agents, Miscellaneous
carvedilol
Preferred
DIBENZYLINE
Preferred
doxazosin
Preferred
pindolol
Preferred
propranolol oral
Preferred
SOTALOL AF
Preferred
sotalol oral
Preferred
terazosin
Preferred
Preferred
Loop Diuretics (Hypotensive Agents)
bumetanide oral
Preferred
furosemide oral solution 10 mg/ml, 40 mg/5 ml
Preferred
furosemide oral tablet
Preferred
torsemide oral
Preferred
Mineralocorticoid (Aldosterone) Antagonists
ALDACTAZIDE ORAL TABLET 50-50 MG
Preferred
spironolactone
Preferred
spironolacton-hydrochlorothiaz
Preferred
Mineralocorticoid(Aldosterone)Antagonists (Hypotensives)
Preferred
spironolactone
Preferred
spironolactone-hydrochlorothiazide
Preferred
Nitrates And Nitrites
ISORDIL
Preferred
isosorbide dinitrate oral
Preferred
25
Drug
Tier
isosorbide dinitrate sublingual tablet 2.5 mg
Preferred
isosorbide mononitrate
Preferred
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
Preferred
nitroglycerin oral capsule, extended release 2.5
mg, 6.5 mg
Preferred
nitroglycerin transdermal patch 24 hour
Preferred
NITROSTAT
Preferred
NITRO-TIME ORAL CAPSULE, EXTENDED
RELEASE 9 MG
Preferred
Notes
Peripheral Adrenergic Inhibitors
reserpine
Preferred
Phosphodiesterase Type 5 Inhibitors
cilostazol
Preferred
sildenafil oral
Preferred
PA
Potassium-Sparing Diuretics (Hypotensives)
Preferred
amiloride oral
Preferred
amiloride-hydrochlorothiazide
Preferred
DYRENIUM
Preferred
spironolactone
Preferred
spironolacton-hydrochlorothiazide
Preferred
triamterene-hydrochlorothiazide oral tablet
Preferred
Thiazide Diuretics(Hypotensive Agents)
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
ST
26
Drug
Tier
chlorothiazide
Preferred
DIURIL
Preferred
Preferred
Preferred
hydrochlorothiazide
Preferred
Preferred
Preferred
Preferred
methyclothiazide
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
triamterene-hydrochlorothiazid oral tablet
Preferred
Preferred
Notes
ST
Thiazide-Like Diuretics(Hypotensive Agents)
chlorthalidone oral tablet 25 mg, 50 mg
Preferred
CLORPRES
Preferred
indapamide
Preferred
metolazone
Preferred
Vasodilating Agents, Miscellaneous
AGGRENOX
Preferred
amlodipine
Preferred
Preferred
Preferred
ST
27
Drug
Tier
Notes
Preferred
120 mg, 60 mg
Preferred
120 mg, 180 mg, 240 mg, 300 mg
Preferred
Preferred
DILT-XR
Preferred
dipyridamole oral
Preferred
Preferred
ST
LETAIRIS
Preferred
PA
NIFEDIAC CC
Preferred
NIFEDICAL XL
Preferred
Preferred
Preferred
TAZTIA XT
Preferred
mg
Preferred
Preferred
Preferred
Central Nervous System Agents
Adamantanes (CNS)
amantadine hcl oral capsule
Preferred
amantadine hcl oral solution
Preferred
Amphetamines
ADDERALL XR
Preferred
AMPHETAMINE SALT COMBO
Preferred
dextroamphetamine oral capsule, extended release
Preferred
dextroamphetamine oral tablet
Preferred
VYVANSE
Preferred
Analgesics And Antipyretics, Misc.
28
Drug
Tier
acetaminophen oral elixir
Preferred
acetaminophen-codeine oral solution 120-12 mg/5
ml
Preferred
acetaminophen-codeine oral tablet
Preferred
ARTHRITIS PAIN RELIEVER
Preferred
butalbital-acetaminophen-caffeine-cod oral
capsule 50-325-40-30 mg
Preferred
butalbital-acetaminophen
Preferred
butalbital-acetaminophen-caffeine oral tablet 50325-40 mg
Preferred
CHILDREN'S PAIN RELIEF ORAL
SUSPENSION
Preferred
ENDOCET ORAL TABLET 5-325 MG
Preferred
gabapentin oral capsule
Preferred
gabapentin oral solution 250 mg/5 ml
Preferred
gabapentin oral tablet 600 mg, 800 mg
Preferred
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml, 7.5-500 mg/15 ml
Preferred
hydrocodone-acetaminophen oral tablet 10-325
mg, 10-650 mg, 5-325 mg, 5-500 mg, 7.5-325 mg,
7.5-500 mg, 7.5-750 mg
Preferred
INFANT'S PAIN RELIEF ORAL
DROPS,SUSPENSION 80 MG/0.8 ML
Preferred
oxycodone-acetaminophen oral capsule
Preferred
oxycodone-acetaminophen oral tablet 5-325 mg
Preferred
Q-PAP ORAL DROPS
Preferred
Q-PAP ORAL LIQUID
Preferred
ROXICET ORAL TABLET
Preferred
Notes
Anticholinergic Agents (CNS)
benztropine oral
Preferred
trihexyphenidyl
Preferred
Anticonvulsants, Miscellaneous
29
Drug
BANZEL ORAL TABLET
Tier
Non-preferred
carbamazepine oral suspension 100 mg/5 ml
Preferred
carbamazepine oral tablet
Preferred
carbamazepine oral tablet extended release 12 hr
Preferred
carbamazepine oral tablet,chewable
Preferred
divalproex
Preferred
gabapentin oral capsule
Preferred
gabapentin oral solution 250 mg/5 ml
Preferred
gabapentin oral tablet 600 mg, 800 mg
Preferred
LAMICTAL STARTER (BLUE) KIT
Preferred
LAMICTAL STARTER (GREEN) KIT
Preferred
LAMICTAL STARTER (ORANGE) KIT
Preferred
lamotrigine oral tablet
Preferred
lamotrigine oral tablet, chewable dispersible
Preferred
levetiracetam oral solution 100 mg/ml
Preferred
levetiracetam oral tablet
Preferred
oxcarbazepine
Preferred
TEGRETOL XR ORAL TABLET
EXTENDED RELEASE 12 HR 100 MG
Preferred
topiramate oral capsule, sprinkle
Preferred
topiramate oral tablet
Preferred
valproic acid
Preferred
valproic acid (as sodium salt) oral solution 250
mg/5 ml
Preferred
Notes
PA
Antidepressants, Miscellaneous
BUDEPRION SR ORAL TABLET
EXTENDED RELEASE 150 MG
Preferred
BUPROBAN
Preferred
bupropion hcl
Preferred
mirtazapine
Preferred
30
Drug
Tier
Notes
Antimanic Agents
divalproex
Preferred
lithium carbonate
Preferred
lithium citrate oral solution 8 meq/5 ml
Preferred
valproic acid
Preferred
mg/5 ml
Preferred
Antimigraine Agents, Miscellaneous
Preferred
81 mg
Preferred
BUTALBITAL COMPOUND W/CODEINE
Preferred
capsule 50-325-40-30 mg
Preferred
butalbital-acetaminophen-caffeine oral tablet 50325-40 mg
Preferred
Preferred
dihydroergotamine injection
Preferred
dihydroergotamine nasal
Preferred
divalproex
Preferred
ERGOMAR
Preferred
propranolol oral
Preferred
Preferred
valproic acid
Preferred
mg/5 ml
Preferred
Antipsychotics, Miscellaneous
loxapine succinate
Preferred
ORAP
Preferred
Anxiolytics, Sedatives & Hypnotics,Misc.
31
Drug
AMBIEN CR
Tier
Non-preferred
buspirone oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg
Preferred
droperidol injection solution
Preferred
EDLUAR
Non-preferred
hydroxyzine hcl oral solution 10 mg/5 ml
Preferred
hydroxyzine hcl oral tablet
Preferred
hydroxyzine pamoate
Preferred
LUNESTA
Non-preferred
meprobamate
Preferred
Preferred
promethazine oral
Preferred
promethazine rectal suppository 12.5 mg, 25 mg
Preferred
ROZEREM
Preferred
Preferred
zaleplon
Preferred
zolpidem oral tablet
Preferred
Notes
PA
PA
PA
ST
Atypical Antipsychotics
ABILIFY DISCMELT
Preferred
ABILIFY ORAL SOLUTION
Preferred
aripiprazole
Preferred
clozapine oral tablet
Preferred
FANAPT
Preferred
LATUDA
Preferred
olanzapine oral tablet
Preferred
quetiapine
Preferred
risperidone oral solution
Preferred
risperidone oral tablet
Preferred
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 5 MG
Preferred
32
Drug
Tier
SAPHRIS SUBLINGUAL TABLET 10 MG
Preferred
ziprasidone hcl
Preferred
Notes
Barbiturates (Anticonvulsants)
phenobarbital
Preferred
primidone
Preferred
Barbiturates (Anxiolytic, Sedative/Hyp)
Preferred
butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg
Preferred
butalbital-acetaminophen
Preferred
butalbital-acetaminophen-caff oral tablet 50-32540 mg
Preferred
Preferred
phenobarbital
Preferred
Benzodiazepines (Anticonvulsants)
clonazepam oral tablet
Preferred
clorazepate dipotassium
Preferred
diazepam oral tablet
Preferred
diazepam rectal
Preferred
Benzodiazepines (Anxiolytics, Sedative/Hypnotics)
alprazolam oral tablet
Preferred
amitriptyline-chlordiazepoxide
Preferred
chlordiazepoxide hcl
Preferred
clonazepam oral tablet
Preferred
clorazepate dipotassium
Preferred
diazepam oral tablet
Preferred
diazepam rectal
Preferred
estazolam
Preferred
lorazepam oral tablet
Preferred
33
Drug
Tier
oxazepam
Preferred
temazepam oral capsule 15 mg, 30 mg
Preferred
triazolam
Preferred
Notes
Butyrophenones
haloperidol decanoate
Preferred
haloperidol lactate
Preferred
haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 20 mg,
5 mg
Preferred
haloperidol oral tablet 10 mg
Non-preferred
Central Nervous System Agents, Misc.
guanfacine oral tablet
Preferred
NAMENDA ORAL TABLET
Preferred
NAMENDA TITRATION PAK
Preferred
NAMENDA XR
Preferred
STRATTERA
Preferred
Cyclooxygenase-2 (COX-2) Inhibitors
CELEBREX
Preferred
ST
Dopamine Precursors
carbidopa-levodopa oral tablet
Preferred
carbidopa-levodopa oral tablet extended release
Preferred
Ergot-Deriv. Dopamine Receptor Agonists
bromocriptine
Preferred
cabergoline
Preferred
PA
Fibromyalgia Agents
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 30 mg, 60 mg
Preferred
SAVELLA
Preferred
Hydantoins
DILANTIN
Preferred
34
Drug
Tier
DILANTIN INFATABS
Preferred
phenytoin oral suspension
Preferred
phenytoin sodium extended oral capsule 100 mg
Preferred
Notes
Monoamine Oxidase B Inhibitors
selegiline hcl
Preferred
Monoamine Oxidase Inhibitors
phenelzine
Preferred
selegiline hcl
Preferred
tranylcypromine
Preferred
Nonergot-Deriv.Dopamine Receptor Agonists
pramipexole oral tablet
Preferred
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg
Preferred
Opiate Agonists
acetaminophen-codeine oral solution 120-12 mg/5
ml
Preferred
acetaminophen-codeine oral tablet
Preferred
AVINZA
Non-preferred
Preferred
capsule 50-325-40-30 mg
Preferred
ENDOCET ORAL TABLET 5-325 MG
Preferred
ENDODAN
Preferred
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Preferred
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml, 7.5-500 mg/15 ml
Preferred
hydrocodone-acetaminophen oral tablet 10-325
mg, 10-650 mg, 5-325 mg, 5-500 mg, 7.5-325 mg,
7.5-500 mg, 7.5-750 mg
Preferred
hydromorphone oral liquid
Preferred
PA
35
Drug
Tier
hydromorphone oral tablet
Preferred
hydromorphone rectal
Preferred
KADIAN ORAL
CAPSULE,EXTEND.RELEASE PELLETS 10
MG, 200 MG
Preferred
meperidine oral
Preferred
methadone oral concentrate
Preferred
methadone oral solution
Preferred
methadone oral tablet
Preferred
methadone oral tablet, soluble
Preferred
morphine concentrate oral solution
Preferred
morphine oral capsule, extend.release pellets 100
mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
Preferred
morphine oral solution
Preferred
morphine oral tablet
Preferred
morphine oral tablet extended release
Preferred
morphine rectal
Preferred
oxycodone oral capsule
Preferred
oxycodone oral concentrate
Preferred
oxycodone oral tablet
Preferred
oxycodone-acetaminophen oral capsule
Preferred
oxycodone-acetaminophen oral tablet 5-325 mg
Preferred
Preferred
ROXICET ORAL TABLET
Preferred
tramadol oral tablet
Preferred
VICOPROFEN
Non-preferred
Notes
PA
Opiate Antagonists
naltrexone oral
Preferred
Opiate Partial Agonists
buprenorphine hcl sublingual
Non-preferred
PA
36
Drug
Tier
Notes
buprenorphine-naloxone
Preferred
PA
butorphanol tartrate nasal
Preferred
PA
nalbuphine injection
Preferred
SUBOXONE SUBLINGUAL FILM
Preferred
PA
ZUBSOLV SUBLINGUAL TABLET 1.4-0.36
MG, 5.7-1.4 MG
Preferred
PA
Other Nonsteroidal Anti-Inflammatory Agents
CHILDREN'S IBUPROFEN
Preferred
diclofenac potassium
Preferred
diclofenac sodium oral tablet, delayed release
(dr/ec)
Preferred
fenoprofen oral tablet
Preferred
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Preferred
INDOCIN ORAL
Preferred
indomethacin oral capsule
Preferred
INFANT'S IBUPROFEN
Preferred
ketoprofen oral capsule
Preferred
meclofenamate oral
Preferred
meloxicam oral tablet
Preferred
naproxen
Preferred
naproxen sodium oral tablet 275 mg, 550 mg
Preferred
oxaprozin
Preferred
piroxicam
Preferred
VICOPROFEN
Non-preferred
PA
Phenothiazines
chlorpromazine oral
Preferred
fluphenazine decanoate
Preferred
fluphenazine hcl injection
Preferred
fluphenazine hcl oral tablet
Preferred
perphenazine
Preferred
37
Drug
Tier
perphenazine-amitriptyline
Preferred
prochlorperazine
Preferred
prochlorperazine edisylate injection solution 10
mg/2 ml (5 mg/ml)
Preferred
prochlorperazine maleate oral
Preferred
thioridazine
Preferred
trifluoperazine
Preferred
Notes
PA
Respiratory And CNS Stimulants
Preferred
butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg
Preferred
butalbital-acetaminophen-caff oral tablet 50-32540 mg
Preferred
Preferred
caffeine citrated oral
Preferred
dexmethylphenidate oral capsule,er biphasic 5050 10 mg, 15 mg, 30 mg
Preferred
dexmethylphenidate oral tablet 10 mg, 5 mg
Preferred
FOCALIN XR ORAL CAPSULE,ER
BIPHASIC 50-50 20 MG, 25 MG, 35 MG
Preferred
methylphenidate oral tablet
Preferred
methylphenidate oral tablet extended release 20
mg
Preferred
methylphenidate oral tablet extended release 24hr
Preferred
Salicylates
AGGRENOX
Preferred
Preferred
81 mg
Preferred
Preferred
Preferred
38
Drug
Tier
choline,magnesium salicylate
Preferred
ENDODAN
Preferred
salsalate
Preferred
Notes
Sel. Serotonin & Norepinephrine Reuptake Inhibitors
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 30 mg, 60 mg
Preferred
SAVELLA
Preferred
venlafaxine
Preferred
Selective Serotonin Agonists
AMERGE
Non-preferred
PA; QL (12 QY per 30 DYs)
AXERT
Non-preferred
FROVA
Non-preferred
RELPAX
Non-preferred
rizatriptan
Preferred
sumatriptan
Preferred
sumatriptan succinate oral
Preferred
sumatriptan succinate subcutaneous cartridge
Preferred
sumatriptan succinate subcutaneous pen injector
Preferred
sumatriptan succinate subcutaneous solution
Preferred
ZOMIG NASAL SPRAY,NON-AEROSOL 5
MG
Non-preferred
ZOMIG ORAL
Non-preferred
ZOMIG ZMT
Non-preferred
Selective-Serotonin Reuptake Inhibitors
citalopram
Preferred
escitalopram oxalate
Preferred
fluoxetine oral capsule 10 mg, 20 mg
Preferred
fluoxetine oral capsule 40 mg
Preferred
fluoxetine oral solution
Preferred
PA
39
Drug
Tier
fluvoxamine oral tablet
Preferred
paroxetine hcl oral tablet
Preferred
paroxetine hcl oral tablet extended release 24 hr
Preferred
PAXIL ORAL SUSPENSION
Preferred
sertraline
Preferred
Notes
Serotonin Modulators
nefazodone
Preferred
trazodone
Preferred
Succinimides
ethosuximide
Preferred
Thioxanthenes
thiothixene
Preferred
Tricyclics & Other Norepinephrine-Reuptake Inhibitors
amitriptyline
Preferred
Preferred
amoxapine
Preferred
clomipramine
Preferred
desipramine oral tablet 10 mg, 150 mg, 25 mg, 50
mg
Preferred
doxepin oral capsule 10 mg, 100 mg, 25 mg, 50
mg, 75 mg
Preferred
doxepin oral concentrate
Preferred
imipramine hcl
Preferred
maprotiline
Preferred
nortriptyline oral capsule
Preferred
perphenazine-amitriptyline
Preferred
Devices
Devices
ACCU-CHEK AVIVA CONTROL SOLN
Preferred
40
Drug
Tier
ACCU-CHEK AVIVA PLUS METER
Preferred
ACCU-CHEK FASTCLIX
Preferred
ACCU-CHEK MULTICLIX LANCET
Preferred
ACCU-CHEK NANO
Preferred
ACCU-CHEK SMARTVIEW CONTRL SOL
Preferred
ACCU-CHEK SOFT DEV LANCETS
Preferred
ACCU-CHEK SOFTCLIX LANCET DEV
Preferred
ACCU-CHEK SOFTCLIX LANCETS
Preferred
SOFT TOUCH LANCETS
Preferred
Notes
Diagnostic Agents
Diabetes Mellitus
ACCU-CHEK AVIVA PLUS TEST STRP
Preferred
ACCU-CHEK SMARTVIEW TEST STRIP
Preferred
Roentgenography
MAGNEVIST INTRAVENOUS SOLUTION
10 MMOL/20 ML (469.01 MG/ML)
Preferred
Electrolytic, Caloric, And Water Balance
Alkalinizing Agents
potassium citrate oral tablet extended release 10
meq (1,080 mg), 5 meq (540 mg)
Preferred
Ammonia Detoxicants
lactulose oral solution 10 gram/15 ml
Preferred
Caloric Agents
glucose oral tablet,chewable 4 gram
Preferred
Carbonic Anhydrase Inhibitors
Preferred
Preferred
PA
Diuretics, Miscellaneous
THEO-24
Preferred
41
Drug
Tier
Preferred
mg, 300 mg
Preferred
Notes
Loop Diuretics
bumetanide oral
Preferred
furosemide oral solution 10 mg/ml, 40 mg/5 ml
Preferred
furosemide oral tablet
Preferred
torsemide oral
Preferred
Phosphate-Removing Agents
calcium acetate oral capsule
Preferred
FOSRENOL ORAL TABLET,CHEWABLE
Preferred
RENAGEL
Preferred
RENVELA ORAL TABLET
Preferred
Potassium-Removing Agents
SODIUM POLYSTYRENE (SORB FREE)
Preferred
SPS RECTAL
Preferred
Potassium-Sparing Diuretics
Preferred
amiloride oral
Preferred
Preferred
DYRENIUM
Preferred
spironolactone
Preferred
Preferred
Preferred
Replacement Preparations
ANTACID EXTRA-STRENGTH ORAL
TABLET,CHEWABLE 300 MG (750 MG)
Preferred
CALCIUM 500 WITH D
Preferred
CALCIUM 600 + D(3) ORAL TABLET 600
MG(1,500MG) -200 UNIT
Preferred
42
Drug
Tier
CALCIUM ANTACID ORAL
TABLET,CHEWABLE 400 MG (1,000 MG)
Preferred
calcium carbonate oral tablet 500 mg calcium
(1,250 mg)
Preferred
calcium carbonate oral tablet,chewable 200 mg
calcium (500 mg)
Preferred
calcium carbonate-mag oxide-zinc
Preferred
calcium carbonate-vitamin d2
Preferred
calcium carbonate-vitamin d3 oral tablet 500
mg(1,250mg) -200 unit
Preferred
calcium citrate oral tablet 250 mg calcium
Preferred
calcium citrate-vitamin d3 oral tablet 200-125 mgunit
Preferred
CITRACAL + D3 (CALCIUM PHOS) ORAL
TABLET,CHEWABLE 250 MG CALCIUM250 UNIT
Preferred
CITRUS CALCIUM ORAL TABLET 200 MG
CALCIUM -250 UNIT
Preferred
KLOR-CON
Preferred
KLOR-CON M10
Preferred
KLOR-CON M20
Preferred
LIQUID CALCIUM WITH VITAMIN D
Preferred
MAG-DELAY
Preferred
MYNATAL PLUS
Preferred
MYNATAL-Z
Preferred
Preferred
OYSCO D
Preferred
OYSTER SHELL CALCIUM 500
Preferred
OYSTER SHELL CALCIUM WITH D
Preferred
PEDIATRIC ELECTROLYTE ORAL
SOLUTION
Preferred
Notes
43
Drug
Tier
Notes
potassium chloride oral capsule, extended release
10 meq
Preferred
potassium chloride oral liquid
Preferred
potassium chloride oral tablet extended release 10
meq, 8 meq
Preferred
potassium chloride oral tablet,er particles/crystals
Preferred
PR NATAL 400
Preferred
F
PR NATAL 400 EC
Preferred
F
PR NATAL 430
Preferred
F
PRENAPLUS
Preferred
PRENATAL AD
Preferred
PRENATAL LOW IRON
Preferred
Preferred
Preferred
Preferred
F
TRIVEEN-DUO DHA
Preferred
F
VENATAL-FA
Preferred
VINATE II
Preferred
VINATE ONE
Preferred
VINATE ULTRA
Preferred
VOL-NATE
Preferred
VOL-PLUS
Preferred
VOL-TAB RX
Preferred
Thiazide Diuretics
Preferred
Preferred
Preferred
Preferred
Preferred
ST
44
Drug
Tier
Preferred
chlorothiazide
Preferred
DIURIL
Preferred
Preferred
MG
Preferred
Preferred
hydrochlorothiazide
Preferred
Preferred
Preferred
Preferred
methyclothiazide
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
Notes
ST
ST
Thiazide-Like Diuretics
chlorthalidone oral tablet 25 mg, 50 mg
Preferred
CLORPRES
Preferred
indapamide
Preferred
metolazone
Preferred
Uricosuric Agents
colchicine-probenecid
Preferred
probenecid
Preferred
45
Drug
Tier
Notes
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
brimonidine
Preferred
Antiallergic Agents
ALAWAY
Preferred
ASTEPRO NASAL SPRAY,NON-AEROSOL
Preferred
azelastine nasal aerosol,spray
Preferred
cromolyn nasal
Preferred
cromolyn ophthalmic
Preferred
ketotifen fumarate
Preferred
PATADAY
Preferred
ST; QL (1 QY per 30 DYs)
ZADITOR
Preferred
Antibacterials (Eent)
bacitracin-polymyxin b ophthalmic
CIPRODEX
Preferred
Non-preferred
ciprofloxacin hcl ophthalmic
Preferred
erythromycin ophthalmic
Preferred
GENTAK OPHTHALMIC OINTMENT
Preferred
MOXEZA
Preferred
neomycin-bacitracin-poly-hydrocortisone
Preferred
neomycin-bacitracin-polymyxin
Preferred
neomycin-polymyxin b-dexamethasone
Preferred
neomycin-polymyxin-gramicidin
Preferred
neomycin-polymyxin-hydrocortisone
Preferred
ofloxacin ophthalmic
Preferred
ofloxacin otic
Preferred
polymyxin b sulf-trimethoprim
Preferred
sulfacetamide sodium ophthalmic drops
Preferred
sulfacetamide-prednisolone
Preferred
PA; ST
46
Drug
Tier
tobramycin
Preferred
tobramycin-dexamethasone
Preferred
TOBREX OPHTHALMIC OINTMENT
Preferred
VIGAMOX
Preferred
Notes
PA
Antivirals (EENT)
trifluridine
Preferred
Beta-Adrenergic Blocking Agents (EENT)
carteolol
Preferred
dorzolamide-timolol
Preferred
levobunolol
Preferred
timolol maleate ophthalmic
Preferred
TIMOPTIC OCUDOSE (PF)
Preferred
Carbonic Anhydrase Inhibitors (EENT)
Preferred
Preferred
dorzolamide
Preferred
dorzolamide-timolol
Preferred
PA
Corticosteroids (EENT)
BECONASE AQ
Non-preferred
PA
CIPRODEX
Non-preferred
PA; ST
dexamethasone sodium phosphate ophthalmic
Preferred
FLAREX
Preferred
fluorometholone
Preferred
fluticasone nasal
Preferred
FML FORTE
Preferred
FML S.O.P.
Preferred
MAXIDEX
Preferred
NASACORT
Preferred
NASACORT AQ
Non-preferred
PA
47
Drug
Tier
neomycin-bacitracin-poly-hc
Preferred
neomycin-polymyxin b-dexamethasone
Preferred
neomycin-polymyxin-hc ophthalmic
Preferred
OMNARIS
Non-preferred
PRED MILD
Preferred
prednisolone acetate
Preferred
prednisolone sodium phosphate ophthalmic
Preferred
RHINOCORT AQUA
tobramycin-dexamethasone
Non-preferred
Notes
PA
PA
Preferred
triamcinolone acetonide nasal
Non-preferred
PA
VERAMYST
Non-preferred
PA
EENT Anti-Infectives, Miscellaneous
ACETASOL HC
Preferred
acetic acid otic
Preferred
acetic acid-aluminum acetate
Preferred
chlorhexidine gluconate mucous membrane
Preferred
EENT Drugs, Miscellaneous
apraclonidine
Preferred
ARTIFICIAL TEARS (POLYVIN ALC)
Preferred
IOPIDINE OPHTHALMIC DROPPERETTE
Preferred
ipratropium bromide nasal
Preferred
TEARS NATURALE FREE (PF)
Preferred
TEARS NATURALE II
Preferred
EENT Nonsteroidal Anti-Inflammatory Agents
flurbiprofen sodium
Preferred
ketorolac ophthalmic
Preferred
Local Anesthetics (EENT)
antipyrine-benzocaine otic drops 5.4-1.4 %
Preferred
lidocaine hcl mucous membrane jelly in applicator
Preferred
48
Drug
Tier
lidocaine hcl mucous membrane solution 4 % (40
mg/ml)
Preferred
LIDOCAINE VISCOUS
Preferred
Notes
Miotics
ISOPTO CARBACHOL
Preferred
PHOSPHOLINE IODIDE
Preferred
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %
Preferred
PILOPINE HS
Preferred
Mydriatics
cyclopentolate ophthalmic drops 2 %
Preferred
Prostaglandin Analogs
latanoprost
Preferred
TRAVATAN Z
Preferred
travoprost (benzalkonium)
Preferred
ST
Vasoconstrictors
ADRENALIN NASAL
Preferred
naphazoline
Preferred
phenylephrine hcl ophthalmic
Preferred
Gastrointestinal Drugs
5-HT3 Receptor Antagonists
ANZEMET ORAL
Preferred
granisetron hcl oral
Non-preferred
ondansetron hcl oral solution
Preferred
ondansetron hcl oral tablet 4 mg
Preferred
ondansetron hcl oral tablet 8 mg
Preferred
ondansetron oral tablet,disintegrating 4 mg
Preferred
ondansetron oral tablet,disintegrating 8 mg
Preferred
PA
Antacids And Adsorbents
49
Drug
Tier
aluminum hydroxide gel oral suspension 320 mg/5
ml
Preferred
ANTACID EXTRA-STRENGTH ORAL
TABLET,CHEWABLE 300 MG (750 MG)
Preferred
ANTACID-SIMETHICONE
Preferred
CALCIUM ANTACID ORAL
TABLET,CHEWABLE 400 MG (1,000 MG)
Preferred
calcium carbonate oral tablet,chewable 200 mg
calcium (500 mg)
Preferred
magnesium oxide oral tablet
Preferred
PINK BISMUTH ORAL
TABLET,CHEWABLE
Preferred
sodium bicarbonate oral tablet 650 mg
Preferred
Notes
Antidiarrheal Agents
Preferred
loperamide oral capsule
Preferred
PINK BISMUTH ORAL
TABLET,CHEWABLE
Preferred
Antiemetics, Miscellaneous
EMEND ORAL CAPSULE 125 MG, 80 MG
Preferred
EMEND ORAL CAPSULE 40 MG
Preferred
EMEND ORAL CAPSULE,DOSE PACK
Preferred
TRANSDERM-SCOP
Non-preferred
PA
Antiflatulents
ANTACID-SIMETHICONE
Preferred
Antihistamines (GI Drugs)
meclizine oral tablet 12.5 mg, 25 mg
Preferred
meclizine oral tablet,chewable
Preferred
prochlorperazine
Preferred
prochlorperazine edisylate injection solution 10
mg/2 ml (5 mg/ml)
Preferred
50
Drug
Tier
prochlorperazine maleate oral
Preferred
trimethobenzamide intramuscular solution
Preferred
Notes
Anti-Inflammatory Agents (GI Drugs)
balsalazide
Preferred
CANASA
Preferred
DELZICOL
Preferred
LIALDA
Preferred
mesalamine rectal
Preferred
PENTASA
Preferred
sulfasalazine
Preferred
Cathartics And Laxatives
AMITIZA
Preferred
docusate calcium
Preferred
GENTLE LAXATIVE ORAL
Preferred
MILK OF MAGNESIA
Preferred
MINERAL OIL HEAVY ORAL
Preferred
NATURAL FIBER LAXATIVE ORAL
POWDER 3.4 GRAM/7 GRAM
Preferred
NATURAL FIBER LAXATIVE THERAPY
Preferred
peg 3350-electrolytes oral recon soln 240-22.726.72 -5.84 gram
Preferred
polyethylene glycol 3350 oral powder
Preferred
Preferred
SENNA LAXATIVE ORAL TABLET 8.6 MG
Preferred
SENNA-S
Preferred
SILACE ORAL SYRUP
Preferred
SOF-LAX
Preferred
VINATE ULTRA
Preferred
Cholelitholytic Agents
51
Drug
ursodiol
Tier
Notes
Preferred
Digestants
CREON
Preferred
PANCRELIPASE 5000
Preferred
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 -55,000
UNIT, 15,000-51,000 -82,000 UNIT, 20,00068,000 -109,000 UNIT
Preferred
GI Drugs, Miscellaneous
LINZESS
Preferred
Histamine H2-Antagonists
cimetidine
Preferred
cimetidine hcl oral
Preferred
famotidine oral tablet
Preferred
nizatidine oral capsule
Preferred
ranitidine hcl oral syrup
Preferred
ranitidine hcl oral tablet
Preferred
Prokinetic Agents
metoclopramide hcl oral solution
Preferred
metoclopramide hcl oral tablet
Preferred
Prostaglandins
misoprostol
Preferred
Protectants
CARAFATE ORAL SUSPENSION
Preferred
sucralfate oral tablet
Preferred
Proton-Pump Inhibitors
ACIPHEX
Non-preferred
PA
lansoprazole oral capsule,delayed release(dr/ec)
Non-preferred
PA
NEXIUM
Non-preferred
PA
52
Drug
NEXIUM 24HR
NEXIUM PACKET ORAL GRANULES DR
FOR SUSP IN PACKET 10 MG, 20 MG, 40
MG
Tier
Notes
Preferred
ST
Non-preferred
PA
omeprazole magnesium
Preferred
omeprazole oral capsule,delayed release(dr/ec)
Preferred
omeprazole-sodium bicarbonate oral capsule 201.1 mg-gram
Preferred
pantoprazole oral
Preferred
ST
Non-preferred
PA
PREVACID 24HR
Preferred
ST
PREVACID SOLUTAB
Preferred
PREVACID
PRILOSEC ORAL SUSP,DELAYED
RELEASE FOR RECON
Non-preferred
PA
PRILOSEC OTC
Non-preferred
PA
PROTONIX ORAL GRANULES DR FOR
SUSP IN PACKET
Non-preferred
PA
rabeprazole
Non-preferred
PA
ZEGERID
Non-preferred
PA
Gold Compounds
Gold Compounds
RIDAURA
Preferred
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET
Preferred
EXJADE
Non-preferred
PA
Hormones And Synthetic Substitutes
Adrenals
53
Drug
Tier
Notes
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES), 220 MCG (120
DOSES), 220 MCG (14 DOSES), 220 MCG (30
DOSES), 220 MCG (60 DOSES)
Preferred
110 MCG (7 DOSES)
Preferred
QL (1 QY per 7 DYs)
budesonide inhalation suspension for nebulization
0.25 mg/2 ml
Preferred
0.5 mg/2 ml
Preferred
cortisone
Preferred
dexamethasone
Preferred
DEXAMETHASONE INTENSOL
Preferred
dexamethasone sodium phos (pf)
Preferred
DULERA
Preferred
ENTOCORT EC
Non-preferred
PA
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
Preferred
Preferred
Preferred
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
Preferred
AEROSOL INHALER 220
MCG/ACTUATION
Preferred
AEROSOL INHALER 44 MCG/ACTUATION
Preferred
fludrocortisone
Preferred
hydrocortisone oral
Preferred
54
Drug
Tier
Notes
MEDROL ORAL TABLET 2 MG
Preferred
methylprednisolone
Preferred
prednisolone oral solution 15 mg/5 ml
Preferred
prednisolone sodium phosphate oral solution 15
mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml)
Preferred
PREDNISONE INTENSOL
Preferred
prednisone oral
Preferred
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 1 MG/2 ML
Preferred
QVAR INHALATION AEROSOL 40
MCG/ACTUATION
Preferred
MCG/ACTUATION
Preferred
SYMBICORT
Preferred
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
Preferred
M
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62
% (40.5 MG/2.5 GRAM)
Preferred
M
ANDROXY
Preferred
danazol oral
Preferred
METHITEST
Preferred
Androgens
TESTIM
Non-preferred
testosterone enanthate
Preferred
TESTRED
Preferred
PA
PA
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg
Preferred
propylthiouracil
Preferred
SSKI
Preferred
55
Drug
Tier
Notes
Biguanides
glipizide-metformin
Preferred
glyburide-metformin
Preferred
JANUMET
Preferred
ST
JANUMET XR
Preferred
ST
JENTADUETO
Preferred
ST
KOMBIGLYZE XR
Preferred
ST
metformin oral tablet
Preferred
metformin oral tablet extended release 24 hr
Preferred
Contraceptives
APRI
Preferred
ARANELLE (28)
Preferred
AVIANE
Preferred
BALZIVA (28)
Preferred
CAMILA
Preferred
CAMRESE
Preferred
CESIA (28)
Preferred
CRYSELLE (28)
Preferred
ENPRESSE
Preferred
ERRIN
Preferred
JOLESSA
Preferred
JOLIVETTE
Preferred
JUNEL 1.5/30 (21)
Preferred
JUNEL 1/20 (21)
Preferred
JUNEL FE 1.5/30 (28)
Preferred
JUNEL FE 1/20 (28)
Preferred
KARIVA (28)
Preferred
KELNOR 1/35 (28)
Preferred
LEENA 28
Preferred
56
Drug
Tier
LESSINA
Preferred
levonorgestrel oral tablet 0.75 mg
Preferred
LEVORA-28
Preferred
LOESTRIN 24 FE
Preferred
LOW-OGESTREL (28)
Preferred
LUTERA (28)
Preferred
MICROGESTIN 1.5/30 (21)
Preferred
MICROGESTIN 1/20 (21)
Preferred
MICROGESTIN FE 1.5/30 (28)
Preferred
MICROGESTIN FE 1/20 (28)
Preferred
MONONESSA (28)
Preferred
NECON 1/35 (28)
Preferred
NECON 1/50 (28)
Preferred
NECON 10/11 (28)
Preferred
NECON 7/7/7 (28)
Preferred
NEXT CHOICE ONE DOSE
Preferred
NORA-BE
Preferred
NORTREL 0.5/35 (28)
Preferred
NORTREL 1/35 (21)
Preferred
NORTREL 1/35 (28)
Preferred
NORTREL 7/7/7 (28)
Preferred
NUVARING
Preferred
OCELLA
Preferred
OGESTREL (28)
Preferred
ORTHO TRI-CYCLEN LO (28)
Preferred
PORTIA
Preferred
QUASENSE
Preferred
RECLIPSEN (28)
Preferred
SPRINTEC (28)
Preferred
Notes
57
Drug
Tier
SRONYX
Preferred
TILIA FE
Preferred
TRINESSA (28)
Preferred
TRI-SPRINTEC (28)
Preferred
TRIVORA (28)
Preferred
VELIVET TRIPHASIC REGIMEN (28)
Preferred
XULANE
Preferred
ZENCHENT FE
Preferred
ZOVIA 1/35E (28)
Preferred
ZOVIA 1/50E (28)
Preferred
Notes
Dipeptidyl Peptidase-4(DPP-4) Inhibitors
JANUMET
Preferred
ST
JANUMET XR
Preferred
ST
JANUVIA
Preferred
ST
JENTADUETO
Preferred
ST
KOMBIGLYZE XR
Preferred
ST
ONGLYZA
Preferred
ST
TRADJENTA
Preferred
ST
Preferred
F
Estrogen Agonist-Antagonists
EVISTA
Estrogens
estradiol
Preferred
estropipate
Preferred
FEMHRT LOW DOSE
Preferred
JINTELI
Preferred
MENEST
Preferred
PREMARIN ORAL
Preferred
F
PREMARIN VAGINAL
Preferred
F
PREMPHASE
Preferred
F
F
58
Drug
Tier
Notes
Preferred
F
GLUCAGEN HYPOKIT
Preferred
GLUCAGON EMERGENCY KIT (HUMAN)
Preferred
BYETTA
Preferred
PA; ST
VICTOZA 2-PAK
Preferred
ST
VICTOZA 3-PAK
Preferred
ST
APIDRA
Preferred
APIDRA SOLOSTAR
Preferred
HUMALOG
Preferred
HUMALOG KWIKPEN SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML
Preferred
HUMALOG MIX 50-50
Preferred
HUMALOG MIX 50-50 KWIKPEN
Preferred
HUMALOG MIX 75-25
Preferred
HUMALOG MIX 75-25 KWIKPEN
Preferred
HUMULIN 70/30
Preferred
HUMULIN N
Preferred
HUMULIN R
Preferred
HUMULIN R U-500 "CONCENTRATED"
Preferred
LANTUS
Preferred
LANTUS SOLOSTAR
Preferred
Preferred
ST
PREMPRO
Glycogenolytic Agents
Incretin Mimetics
Insulins
Meglitinides
nateglinide
Parathyroid
calcitonin (salmon)
Preferred
Pituitary
59
Drug
Tier
Notes
desmopressin nasal solution
Preferred
PA
desmopressin nasal spray,non-aerosol
Preferred
PA
desmopressin oral
Preferred
PA
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
Preferred
F
FEMHRT LOW DOSE
Preferred
F
JINTELI
Preferred
medroxyprogesterone
Preferred
F
norethindrone acetate
Preferred
F
Progestins
Sulfonylureas
glimepiride
Preferred
glipizide
Preferred
glipizide-metformin
Preferred
glyburide
Preferred
glyburide micronized
Preferred
glyburide-metformin
Preferred
Thyroid Agents
ARMOUR THYROID
Preferred
levothyroxine oral
Preferred
liothyronine oral
Preferred
NATURE-THROID ORAL TABLET 130 MG,
195 MG, 32.5 MG, 65 MG
Preferred
THYROLAR-1
Preferred
THYROLAR-1/2
Preferred
THYROLAR-1/4
Preferred
THYROLAR-2
Preferred
THYROLAR-3
Preferred
Miscellaneous Therapeutic Agents
60
Drug
Tier
Notes
5-Alpha-Reductase Inhibitors
finasteride oral tablet 5 mg
Preferred
Alcohol Deterrents
disulfiram
Preferred
naltrexone oral
Preferred
Antidotes
CHEMET
Preferred
FOSRENOL ORAL TABLET,CHEWABLE
Preferred
GLUCAGEN HYPOKIT
Preferred
GLUCAGON EMERGENCY KIT (HUMAN)
Preferred
leucovorin calcium oral
Preferred
MEPHYTON
Preferred
RENAGEL
Preferred
RENVELA ORAL TABLET
Preferred
SODIUM POLYSTYRENE (SORB FREE)
Preferred
SPS RECTAL
Preferred
SSKI
Preferred
Antigout Agents
allopurinol
Preferred
colchicine-probenecid
Preferred
INDOCIN ORAL
Preferred
indomethacin oral capsule
Preferred
naproxen
Preferred
naproxen sodium oral tablet 275 mg, 550 mg
Preferred
probenecid
Preferred
Bone Resorption Inhibitors
alendronate oral tablet
Preferred
calcitonin (salmon)
Preferred
etidronate disodium
Preferred
61
Drug
EVISTA
Tier
Preferred
Notes
F
Cariostatic Agents
CLINPRO 5000
Preferred
FLUORITAB ORAL DROPS
Preferred
Preferred
MULTI-VITAMIN WITH FLUORIDE ORAL
DROPS
Preferred
MVC-FLUORIDE ORAL
TABLET,CHEWABLE 0.5 MG, 1 MG
Preferred
PHOS-FLUR DENTAL SOLUTION
Preferred
PREVIDENT 5000 BOOSTER
Preferred
SF
Preferred
SF 5000 PLUS
Preferred
sodium fluoride dental solution
Preferred
sodium fluoride oral drops
Preferred
sodium fluoride oral tablet,chewable
Preferred
Preferred
TRI-VITAMIN WITH FLUORIDE
Preferred
Disease-Modifying Antirheumatic Agents
azathioprine
Preferred
cyclosporine modified oral capsule 100 mg, 25 mg
Preferred
cyclosporine oral capsule
Preferred
GENGRAF ORAL CAPSULE
Preferred
Preferred
leflunomide
Preferred
methotrexate sodium
Preferred
Preferred
RHEUMATREX
Preferred
RIDAURA
Preferred
SANDIMMUNE ORAL SOLUTION
Preferred
62
Drug
Tier
sulfasalazine
Preferred
Preferred
Notes
Immunomodulatory Agents
azathioprine
Preferred
Preferred
Preferred
Preferred
Preferred
leflunomide
Preferred
methotrexate sodium
Preferred
Preferred
RHEUMATREX
Preferred
RIDAURA
Preferred
Preferred
sulfasalazine
Preferred
Preferred
Immunosuppressive Agents
azathioprine
Preferred
CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION
Preferred
cyclophosphamide oral tablet
Preferred
Preferred
Preferred
ELIDEL
Preferred
Preferred
mercaptopurine
Preferred
methotrexate sodium
Preferred
Preferred
mycophenolate mofetil oral capsule
Preferred
PA
63
Drug
Tier
mycophenolate mofetil oral tablet
Preferred
RHEUMATREX
Preferred
Preferred
tacrolimus oral
Preferred
Preferred
Notes
Other Miscellaneous Therapeutic Agents
acetylcysteine solution
Preferred
DEMSER
Preferred
ELMIRON
levocarnitine oral tablet
Non-preferred
PA
Preferred
Oxytocics
Oxytocics
methylergonovine oral
Preferred
Respiratory Tract Agents
Alpha And Beta Adrenergic Agonist(Respr)
Preferred
Preferred
BROMFED DM
Preferred
Preferred
CHERATUSSIN DAC
Preferred
CLARINEX-D 12 HOUR
Non-preferred
PA
epinephrine injection solution
Preferred
epinephrine injection syringe 0.1 mg/ml (1:10,000)
Preferred
EPIPEN 2-PAK
Preferred
EPIPEN JR 2-PAK
Preferred
Preferred
M-END DMX
Preferred
MUCINEX D
Preferred
64
Drug
pseudoephedrine hcl oral tablet 60 mg
Tier
Notes
Preferred
Anticholinergic Agents (Respir.Tract)
ATROVENT HFA
Preferred
COMBIVENT
Preferred
COMBIVENT RESPIMAT
Preferred
Preferred
ipratropium bromide inhalation
Preferred
Preferred
SPIRIVA WITH HANDIHALER
Preferred
TUDORZA PRESSAIR
Preferred
Antitussives
benzonatate oral capsule 100 mg, 200 mg
Preferred
BROMFED DM
Preferred
CHERATUSSIN AC
Preferred
CHERATUSSIN DAC
Preferred
hydrocodone-homatropine oral syrup 5-1.5 mg/5
ml
Preferred
hydrocodone-homatropine oral tablet
Preferred
M-END DMX
Preferred
Preferred
promethazine-codeine
Preferred
promethazine-dm
Preferred
Preferred
ROBAFEN DM
Preferred
Expectorants
CHERATUSSIN AC
Preferred
CHERATUSSIN DAC
Preferred
DESPEC
Preferred
guaifenesin oral liquid
Preferred
65
Drug
Tier
MUCINEX D
Preferred
Preferred
ROBAFEN DM
Preferred
SSKI
Preferred
Notes
First Generation Antihist.(Respir Tract)
Preferred
Preferred
BROMFED DM
Preferred
Preferred
cyproheptadine
Preferred
Preferred
Preferred
Preferred
Preferred
Preferred
M-END DMX
Preferred
Preferred
promethazine oral
Preferred
PROMETHAZINE VC
Preferred
Preferred
promethazine-codeine
Preferred
promethazine-dm
Preferred
Preferred
Leukotriene Modifiers
montelukast
Preferred
Mast-Cell Stabilizers
cromolyn inhalation
Preferred
cromolyn nasal
Preferred
cromolyn ophthalmic
Preferred
66
Drug
Tier
Notes
Mucolytic Agents
acetylcysteine solution
Preferred
Nasal Preparations (Steroids)
BECONASE AQ
Non-preferred
fluticasone nasal
Preferred
NASACORT
Preferred
PA
NASACORT AQ
Non-preferred
PA
OMNARIS
Non-preferred
PA
RHINOCORT AQUA
Non-preferred
PA
triamcinolone acetonide nasal
Non-preferred
PA
VERAMYST
Non-preferred
PA
Orally Inhaled Preparations (Steroids)
110 MCG (30 DOSES), 220 MCG (120
DOSES), 220 MCG (14 DOSES), 220 MCG (30
DOSES), 220 MCG (60 DOSES)
Preferred
110 MCG (7 DOSES)
Preferred
QL (1 QY per 7 DYs)
0.25 mg/2 ml
Preferred
0.5 mg/2 ml
Preferred
DULERA
Preferred
Preferred
Preferred
Preferred
67
Drug
Tier
Notes
AEROSOL INHALER 110
MCG/ACTUATION
Preferred
AEROSOL INHALER 220
MCG/ACTUATION
Preferred
AEROSOL INHALER 44 MCG/ACTUATION
Preferred
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 1 MG/2 ML
Preferred
MCG/ACTUATION
Preferred
MCG/ACTUATION
Preferred
SYMBICORT
Preferred
Preferred
ST
Phosphodiesterase Type 4 Inhibitors
DALIRESP
Second Generation Antihist(Respir Tract)
Preferred
ALAVERT ORAL
Preferred
ALLEGRA ALLERGY
Preferred
Preferred
ALLERGY RELIEF (LORATADINE) ORAL
Preferred
cetirizine oral solution 1 mg/ml
Preferred
cetirizine oral tablet
Preferred
Preferred
CHILDREN'S ALLEGRA ALLERGY ORAL
TABLET
Preferred
ST
CLARINEX
Non-preferred
PA
CLARINEX-D 12 HOUR
Non-preferred
PA
ST
68
Drug
Tier
CLARITIN REDITABS ORAL
TABLET,DISINTEGRATING 5 MG
Preferred
fexofenadine oral tablet 180 mg, 60 mg
Preferred
loratadine oral solution
Preferred
loratadine oral tablet
Preferred
Preferred
XYZAL
Non-preferred
Notes
ST
PA
Select.Beta-2-Adrenergic Agonist(Respir)
albuterol sulfate inhalation solution for
nebulization 2.5 mg /3 ml (0.083 %), 5 mg/ml
Preferred
albuterol sulfate oral syrup
Preferred
albuterol sulfate oral tablet
Preferred
COMBIVENT
Preferred
COMBIVENT RESPIMAT
Preferred
DULERA
Preferred
Preferred
SEREVENT DISKUS
Preferred
SYMBICORT
Preferred
terbutaline oral
Preferred
VENTOLIN HFA
Preferred
LETAIRIS
Preferred
PA
REVATIO ORAL TABLET
Preferred
PA
Vasodilating Agents (Respiratory Tract)
Xanthine Derivatives
THEO-24
Preferred
Preferred
mg, 300 mg
Preferred
Serums, Toxoids, And Vaccines
69
Drug
Tier
Notes
Toxoids
ADACEL(TDAP ADOLESN/ADULT)(PF)
Preferred
BOOSTRIX TDAP
Preferred
Vaccines
AFLURIA 2014-2015
Preferred
QL (1 EA per 180 days)
AFLURIA 2014-2015 (PF)
Preferred
FLUARIX 2014-2015 (PF)
Preferred
FLUARIX QUAD 2014-2015 (PF)
Preferred
FLUCELVAX 2014-2015 (PF)
Preferred
FLULAVAL 2014-2015
Preferred
FLUMIST QUAD 2014-2015
Preferred
FLUVIRIN 2014-2015
Preferred
FLUVIRIN 2014-2015 (PF)
Preferred
FLUZONE 2014-2015
Preferred
FLUZONE HIGH-DOSE 2014-15 (PF)
Preferred
FLUZONE INTRADERM 2014-15 (PF)
Preferred
FLUZONE QUAD 2014-2015 (PF)
Preferred
FLUZONE QUAD PEDI 2014-15 (PF)
Preferred
PNEUMOVAX 23 INJECTION SOLUTION
Preferred
ZOSTAVAX (PF)
Preferred
Skin And Mucous Membrane Agents
Antibacterials (Skin & Mucous Membrane)
bacitracin-polymyxin b topical ointment
Preferred
clindamycin phosphate topical gel
Preferred
clindamycin phosphate topical lotion
Preferred
clindamycin phosphate topical solution
Preferred
clindamycin phosphate topical swab
Preferred
ERY PADS
Preferred
erythromycin with ethanol topical gel
Preferred
70
Drug
Tier
erythromycin with ethanol topical solution
Preferred
erythromycin-benzoyl peroxide
Preferred
gentamicin topical
Preferred
METROGEL TOPICAL GEL 1 %
Preferred
metronidazole topical gel 0.75 %
Preferred
metronidazole vaginal
Preferred
mupirocin
Preferred
Notes
Anti-Inflammatory Agents (Skin & Mucous)
amcinonide topical cream
Preferred
betamethasone dipropionate
Preferred
betamethasone valerate topical cream
Preferred
betamethasone valerate topical lotion
Preferred
betamethasone valerate topical ointment
Preferred
betamethasone, augmented topical cream
Preferred
betamethasone, augmented topical lotion
Preferred
betamethasone, augmented topical ointment
Preferred
clobetasol topical cream
Preferred
clobetasol topical gel
Preferred
clobetasol topical ointment
Preferred
clobetasol topical solution
Preferred
clobetasol-emollient topical cream
Preferred
clotrimazole-betamethasone topical cream
Preferred
desonide topical ointment
Preferred
desoximetasone topical cream
Preferred
desoximetasone topical gel
Preferred
desoximetasone topical ointment 0.25 %
Preferred
diflorasone
Preferred
fluocinolone topical cream
Preferred
fluocinolone topical ointment
Preferred
71
Drug
Tier
Notes
fluocinolone topical solution
Preferred
fluocinonide topical cream 0.05 %
Preferred
fluocinonide topical gel
Preferred
fluocinonide topical ointment
Preferred
fluocinonide topical solution
Preferred
FLUOCINONIDE-E
Preferred
hydrocortisone rectal enema
Preferred
hydrocortisone topical cream 1 %, 2.5 %
Preferred
hydrocortisone topical lotion
Preferred
hydrocortisone topical ointment 1 %, 2.5 %
Preferred
hydrocortisone valerate
Preferred
hydrocortisone-min oil-wht pet
Preferred
mometasone topical cream
Preferred
mometasone topical ointment
Preferred
mometasone topical solution
Preferred
PROCTOFOAM HC
Preferred
triamcinolone acetonide topical cream
Preferred
triamcinolone acetonide topical lotion
Preferred
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
Preferred
Antipruritics And Local Anesthetics
dibucaine
Preferred
lidocaine topical ointment
Preferred
lidocaine-prilocaine topical cream
Preferred
LIDODERM
Non-preferred
phenazopyridine oral tablet 100 mg, 200 mg
Preferred
PROCTOFOAM HC
Preferred
PA
Antivirals (Skin & Mucous Membrane)
DENAVIR
Preferred
72
Drug
ZOVIRAX TOPICAL
Tier
Non-preferred
Notes
PA
Astringents
HYPERCARE
Preferred
Azoles (Skin & Mucous Membrane)
clotrimazole mucous membrane
Preferred
clotrimazole topical
Preferred
clotrimazole vaginal cream
Preferred
clotrimazole-betamethasone topical cream
Preferred
ketoconazole topical cream
Preferred
ketoconazole topical shampoo
Preferred
miconazole nitrate topical cream
Preferred
MICONAZOLE-3 VAGINAL SUPPOSITORY
Preferred
NIZORAL A-D
Preferred
ST
Basic Lotions And Liniments
ammonium lactate topical lotion
Preferred
LACLOTION
Preferred
Basic Ointments And Protectants
ammonium lactate topical cream
Preferred
Cell Stimulants And Proliferants
RETIN-A MICRO TOPICAL GEL 0.04 %
tretinoin topical
Non-preferred
PA
Preferred
PA
Keratolytic Agents
benzoyl peroxide topical gel 10 %
Preferred
clindamycin-benzoyl peroxide topical gel 1-5 %
Preferred
P & S (SALICYLIC ACID)
Preferred
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
Preferred
urea topical cream 40 %
Preferred
Keratoplastic Agents
73
Drug
DRITHOCREME HP
Tier
Notes
Preferred
Local Anti-Infectives, Miscellaneous
ALCOHOL PADS
Preferred
selenium sulfide topical suspension
Preferred
silver sulfadiazine
Preferred
sulfacetamide sodium (acne)
Preferred
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
Preferred
Polyenes (Skin & Mucous Membrane)
nystatin topical cream
Preferred
nystatin topical ointment
Preferred
nystatin-triamcinolone
Preferred
Scabicides And Pediculicides
EURAX TOPICAL LOTION
Preferred
NATROBA
Preferred
ST
permethrin topical cream
Preferred
QL (60 QY per 1 PD)
permethrin topical liquid
Preferred
AMNESTEEM
Preferred
PA
capsaicin topical cream 0.025 %
Preferred
CLARAVIS
Preferred
CONDYLOX TOPICAL GEL
Preferred
ELIDEL
Preferred
PA
imiquimod
Preferred
podofilox
Preferred
PROTOPIC TOPICAL OINTMENT 0.1 %
Preferred
RECTIV
Preferred
SANTYL
Preferred
tacrolimus topical ointment 0.03 %
Preferred
Skin And Mucous Membrane Agents, Misc.
PA
PA
PA
74
Drug
TRIXAICIN HP
Tier
Notes
Preferred
Thiocarbamates (Skin & Mucous Membrane)
tolnaftate topical cream
Preferred
Smooth Muscle Relaxants
Antimuscarinics
flavoxate
Preferred
oxybutynin chloride oral
Preferred
tolterodine
Preferred
TOVIAZ
Preferred
trospium oral tablet
Preferred
ST
Respiratory Smooth Muscle Relaxants
THEO-24
Preferred
Preferred
mg, 300 mg
Preferred
Vitamins
Multivitamin Preparations
CERTAVITE-ANTIOXID (IRON GLUC)
ORAL LIQUID 9 MG IRON/15 ML
Preferred
CHEWABLE-VITE WITH IRON
Preferred
CHILDREN'S CHEWABLE VITAMIN
Preferred
COMPLETENATE
Preferred
DAILY VITES/IRON
Preferred
GERAVIM
Preferred
Preferred
MULTI-VITAMIN WITH FLUORIDE ORAL
DROPS
Preferred
MVC-FLUORIDE ORAL
TABLET,CHEWABLE 0.5 MG, 1 MG
Preferred
MYNATAL ORAL TABLET
Preferred
F
75
Drug
Tier
Notes
MYNATAL PLUS
Preferred
MYNATAL-Z
Preferred
MYNATE 90 PLUS
Preferred
MY-VITALIFE
Preferred
ONE DAILY MULTIVITAMIN ORAL
TABLET
Preferred
ONE DAILY PLUS MINERALS
Preferred
Preferred
PEDIAVIT
Preferred
POLY-VITAMIN
Preferred
POLY-VITAMIN WITH IRON ORAL DROPS
1,500 UNIT-400 UNIT-10 MG/ML
Preferred
POLYVITAMIN/IRON
Preferred
PR NATAL 400
Preferred
F
PR NATAL 400 EC
Preferred
F
PR NATAL 430
Preferred
F
PRENAPLUS
Preferred
Preferred
PRENATAL AD
Preferred
PRENATAL LOW IRON
Preferred
Preferred
Preferred
Preferred
PRORENAL QD
Preferred
SE-NATAL 19
Preferred
Preferred
TAB-A-VITE-MINERALS
Preferred
THERATRUM COMPLETE 50 PLUS
Preferred
F
76
Drug
Tier
TRICARE
Preferred
TRIVEEN-DUO DHA
Preferred
TRIVEEN-U
Preferred
Preferred
TRI-VITAMIN
Preferred
Preferred
VENATAL-FA
Preferred
VINATE GT
Preferred
VINATE II
Preferred
VINATE M
Preferred
VINATE ONE
Preferred
VINATE ULTRA
Preferred
Preferred
VITRUM SENIOR ORAL TABLET
Preferred
VOL-NATE
Preferred
VOL-PLUS
Preferred
VOL-TAB RX
Preferred
Notes
F
Vitamin A
beta carotene oral capsule 25,000 unit
Preferred
TRI-VITAMIN
Preferred
Preferred
vitamin a oral capsule 10,000 unit
Preferred
Vitamin B Complex
B COMPLEX-VITAMIN B12
Preferred
b complex-vitamin c-folic acid
Preferred
B-COMPLEX WITH VITAMIN C ORAL
TABLET EXTENDED RELEASE 400 MCG
Preferred
biotin oral capsule 5 mg
Preferred
biotin oral tablet 1 mg, 300 mcg, 800 mcg
Preferred
77
Drug
Tier
Notes
FE C PLUS
Preferred
folic acid oral tablet
Preferred
MULTIGEN FOLIC
Preferred
MULTIGEN PLUS
Preferred
MYNATAL PLUS
Preferred
MYNATAL-Z
Preferred
niacinamide oral tablet 500 mg
Preferred
NICOMIDE
Preferred
Preferred
pantothenic acid
Preferred
PR NATAL 400
Preferred
F
PR NATAL 400 EC
Preferred
F
PR NATAL 430
Preferred
F
PRENAPLUS
Preferred
Preferred
PRENATAL AD
Preferred
PRENATAL LOW IRON
Preferred
Preferred
Preferred
Preferred
PRORENAL QD
Preferred
SE-NATAL 19
Preferred
Preferred
STRESS B-COMPLEX
Preferred
TRICARE
Preferred
TRIVEEN-DUO DHA
Preferred
VENATAL-FA
Preferred
VINATE GT
Preferred
F
F
78
Drug
Tier
VINATE II
Preferred
VINATE ONE
Preferred
VINATE ULTRA
Preferred
vit b complex-folic acid oral tablet
Preferred
VITAMIN B-1 ORAL TABLET 250 MG
Preferred
VITAMIN B-12 ORAL TABLET EXTENDED
RELEASE 1,000 MCG
Preferred
VITAMIN B-2 ORAL TABLET 100 MG
Preferred
VITAMIN B-6 ORAL TABLET 25 MG, 50 MG
Preferred
VITAMINS B COMPLEX ORAL CAPSULE
Preferred
Preferred
VOL-NATE
Preferred
VOL-PLUS
Preferred
VOL-TAB RX
Preferred
Notes
Vitamin C
FE C PLUS
Preferred
MULTIGEN FOLIC
Preferred
MULTIGEN PLUS
Preferred
STRESS B-COMPLEX
Preferred
TRI-VITAMIN
Preferred
Preferred
VITAMIN C ORAL TABLET,CHEWABLE
500 MG
Preferred
Vitamin D
calcitriol oral capsule
Preferred
CALCIUM 500 WITH D
Preferred
CALCIUM 600 + D(3) ORAL TABLET 600
MG(1,500MG) -200 UNIT
Preferred
Preferred
79
Drug
Tier
calcium carbonate-vitamin d3 oral tablet 500
mg(1,250mg) -200 unit
Preferred
calcium citrate-vitamin d3 oral tablet 200-125 mgunit
Preferred
cholecalciferol (vitamin d3) oral drops 400 unit/ml
Preferred
CITRACAL + D3 (CALCIUM PHOS) ORAL
TABLET,CHEWABLE 250 MG CALCIUM250 UNIT
Preferred
CITRUS CALCIUM ORAL TABLET 200 MG
CALCIUM -250 UNIT
Preferred
ergocalciferol (vitamin d2) oral capsule
Preferred
LIQUID CALCIUM WITH VITAMIN D
Preferred
OYSCO D
Preferred
OYSTER SHELL CALCIUM WITH D
Preferred
PRORENAL QD
Preferred
TRI-VITAMIN
Preferred
Preferred
Notes
Vitamin E
vitamin e oral capsule 400 unit
Preferred
vitamin e oral drops 100 unit/0.25 ml
Preferred
Vitamin K Activity
MEPHYTON
Preferred
80
Index
A
ABILIFY .............................. 31
ABILIFY DISCMELT ......... 31
ACCU-CHEK AVIVA
CONTROL SOLN............ 39
ACCU-CHEK AVIVA PLUS
METER ............................ 39
ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 39
ACCU-CHEK FASTCLIX .. 39
ACCU-CHEK MULTICLIX
LANCET .......................... 39
ACCU-CHEK NANO .......... 39
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 39
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 40
ACCU-CHEK SOFT DEV
LANCETS ........................ 39
ACCU-CHEK SOFTCLIX
LANCET DEV ................. 39
ACCU-CHEK SOFTCLIX
LANCETS ........................ 39
acetaminophen ...................... 28
acetaminophen-codeine .. 28, 34
ACETASOL HC .................. 46
acetazolamide ........... 20, 40, 45
acetic acid ............................. 46
acetic acid-aluminum acetate46
acetylcysteine ................. 61, 64
ACIPHEX............................. 51
acyclovir ................................. 6
ADACEL(TDAP
ADOLESN/ADULT)(PF) 67
ADDERALL XR .................. 27
ADRENALIN....................... 47
AFLURIA 2014-2015 .......... 67
AFLURIA 2014-2015 (PF) .. 67
AGGRENOX ........... 15, 26, 37
ALAVERT ....................... 2, 66
ALAVERT D-12 ALLERGYSINUS ................ 2, 9, 62, 66
ALAWAY ............................ 44
albuterol sulfate .............. 12, 66
ALCOHOL PADS................ 71
ALDACTAZIDE 24, 25, 41, 43
alendronate ........................... 59
ALKERAN ............................. 8
ALLEGRA ALLERGY .... 2, 66
ALLER-CHLOR .......... 1, 2, 63
ALLERGY RELIEF &
NASAL DECONGE 2, 9, 62,
66
ALLERGY RELIEF
(LORATADINE).......... 2, 66
allopurinol ............................ 59
alprazolam ............................ 32
aluminum hydroxide gel ....... 48
amantadine hcl .................. 3, 27
AMBIEN CR ........................ 30
amcinonide ........................... 68
AMERGE ............................. 37
amiloride......................... 25, 41
.............................. 25, 41, 43
aminocaproic acid................. 13
amiodarone ........................... 22
AMITIZA ............................. 49
amitriptyline ......................... 39
.................................... 32, 39
amlodipine ................ 22, 23, 26
amlodipine-valsartan16, 22, 23,
26
ammonium lactate ................ 70
AMNESTEEM ..................... 71
amoxapine ............................ 39
amoxicillin .............................. 3
amoxicillin-pot clavulanate .... 3
AMPHETAMINE SALT
COMBO ........................... 27
ampicillin ................................ 3
ANDROGEL ........................ 53
ANDROXY .......................... 53
ANTACID EXTRASTRENGTH ............... 41, 48
ANTACID-SIMETHICONE
.................................... 48, 49
antipyrine-benzocaine .......... 47
ANZEMET ........................... 48
APIDRA ............................... 57
APIDRA SOLOSTAR ......... 57
apraclonidine ........................ 46
APRI ..................................... 54
ARANELLE (28) ................. 54
aripiprazole ........................... 31
ARMOUR THYROID.......... 58
ARTHRITIS PAIN
RELIEVER ....................... 28
ARTIFICIAL TEARS
(POLYVIN ALC) ............. 46
ASMANEX TWISTHALER
.................................... 52, 65
aspirin ....................... 15, 30, 37
ASTEPRO ............................ 44
atenolol ............... 12, 18, 19, 21
atorvastatin ........................... 24
ATROVENT HFA.......... 10, 62
AVIANE ............................... 54
AVINZA ............................... 34
AXERT ................................. 38
azathioprine .................... 60, 61
azelastine .............................. 44
azithromycin ........................... 6
B
B COMPLEX-VITAMIN B12
.......................................... 74
b complex-vitamin c-folic acid
.......................................... 74
bacitracin-polymyxin b ... 44, 68
baclofen ................................ 11
balsalazide ............................ 49
BALZIVA (28) ..................... 54
BANOPHEN .................... 1, 63
BANZEL .............................. 28
B-COMPLEX WITH
VITAMIN C ..................... 75
BECONASE AQ ............ 46, 64
benazepril ............................. 17
.............................. 17, 25, 43
benzonatate ........................... 63
benzoyl peroxide .................. 71
benztropine ..................... 10, 28
beta carotene ......................... 74
betamethasone dipropionate . 68
betamethasone valerate ......... 68
betamethasone, augmented ... 68
bethanechol chloride ............. 12
bicalutamide ........................... 8
BILTRICIDE .......................... 4
81
biotin..................................... 75
bisoprolol fumarate . 12, 18, 19,
21
............ 12, 18, 19, 21, 25, 43
BOOSTRIX TDAP .............. 67
brimonidine .......................... 44
BROMFED DM ......... 9, 62, 63
bromocriptine ....................... 33
BUDEPRION SR ................. 29
budesonide...................... 52, 65
bumetanide ..................... 24, 40
buprenorphine hcl ................. 35
buprenorphine-naloxone....... 35
BUPROBAN ........................ 29
bupropion hcl........................ 29
buspirone .............................. 30
BUTALBITAL COMPOUND
W/CODEINE 30, 32, 34, 36,
37
butalbital-acetaminop-caf-cod
.................. 28, 30, 32, 34, 37
butalbital-acetaminophen28, 32
butalbital-acetaminophen-caff
........................ 28, 30, 32, 37
butalbital-aspirin-caffeine ... 15,
30, 32, 37
butorphanol tartrate .............. 35
BYETTA .............................. 57
C
cabergoline ........................... 33
caffeine citrated .................... 37
calcitonin (salmon) ......... 57, 59
calcitriol ................................ 76
CALCIUM 500 WITH D41, 76
CALCIUM 600 + D(3) ... 41, 76
calcium acetate ..................... 40
CALCIUM ANTACID .. 41, 48
calcium carbonate ........... 41, 48
calcium carbonate-mag oxidezn ...................................... 41
.................................... 41, 77
.................................... 41, 77
calcium citrate ...................... 41
calcium citrate-vitamin d3 ... 41,
77
CAMILA .............................. 54
CAMRESE ........................... 54
82
CANASA.............................. 49
candesartan ........................... 16
candesartan-hydrochlorothiazid
.............................. 16, 26, 43
capsaicin ............................... 71
captopril ................................ 17
.............................. 17, 26, 43
CARAFATE ......................... 50
carbamazepine ...................... 29
carbidopa-levodopa .............. 33
carisoprodol .......................... 11
carteolol ................................ 45
carvedilol 11, 12, 16, 18, 21, 24
CEENU................................... 8
cefaclor ................................... 7
cefadroxil ................................ 5
cefdinir.................................... 8
cefpodoxime ........................... 8
cefprozil .................................. 7
CEFTIN .................................. 7
cefuroxime axetil .................... 7
CELEBREX ......................... 33
CELLCEPT .......................... 61
cephalexin ............................... 5
CERTAVITE-ANTIOXID
(IRON GLUC) ............ 13, 72
CESIA (28) ........................... 54
cetirizine ........................... 2, 66
cetirizine-pseudoephedrine 2, 9,
62, 66
CHANTIX ............................ 10
CHANTIX STARTING
MONTH BOX .................. 10
CHEMET........................ 51, 58
CHERATUSSIN AC ............ 63
CHERATUSSIN DAC .... 9, 62,
63
CHEWABLE-VITE WITH
IRON ................................ 72
CHILDREN'S ALLEGRA
ALLERGY ................... 2, 66
CHILDREN'S CHEWABLE
VITAMIN ......................... 72
CHILDREN'S IBUPROFEN 35
CHILDREN'S PAIN RELIEF
.......................................... 28
chloramphenicol sod succinate
............................................ 5
chlordiazepoxide hcl............. 32
chlorhexidine gluconate........ 46
chloroquine phosphate ............ 4
chlorothiazide ................. 26, 43
chlorpromazine ..................... 36
chlorthalidone ................. 26, 44
chlorzoxazone .......................11
cholecalciferol (vitamin d3) . 77
cholestyramine (with sugar) . 19
CHOLESTYRAMINE LIGHT
.......................................... 19
choline,magnesium salicylate
.......................................... 37
cilostazol ......................... 15, 25
cimetidine ............................. 50
cimetidine hcl ....................... 50
CIPRO ................................4, 7
CIPRODEX .................... 44, 46
ciprofloxacin (mixture) ........... 4
ciprofloxacin hcl ........... 4, 7, 44
citalopram ............................. 38
CITRACAL + D3 (CALCIUM
PHOS)......................... 41, 77
CITRUS CALCIUM ...... 42, 77
CLARAVIS .......................... 71
CLARINEX ...................... 2, 66
CLARINEX-D 12 HOUR . 2, 9,
62, 66
clarithromycin..................... 4, 6
CLARITIN REDITABS ... 3, 66
clemastine ......................... 1, 63
clindamycin hcl ...................... 5
clindamycin palmitate hcl....... 5
clindamycin phosphate ......... 68
clindamycin-benzoyl peroxide
.......................................... 71
CLINPRO 5000 .................... 59
clobetasol ........................ 68, 69
clobetasol-emollient ............. 69
clomipramine ........................ 39
clonazepam ........................... 32
clonidine ............................... 20
clonidine hcl ......................... 20
clopidogrel ............................ 15
clorazepate dipotassium........ 32
CLORPRES .............. 20, 26, 44
clotrimazole .......................... 70
clotrimazole-betamethasone 69,
70
clozapine ............................... 31
colchicine-probenecid..... 44, 59
colestipol .............................. 19
COMBIVENT .... 10, 12, 62, 66
COMBIVENT RESPIMAT 10,
12, 62, 66
COMPLETENATE .............. 72
CONDYLOX ....................... 71
cortisone ............................... 52
CREON ................................ 50
cromolyn......................... 44, 64
CRYSELLE (28) .................. 54
cyclobenzaprine .................... 11
cyclopentolate....................... 47
cyclophosphamide ............ 8, 61
cyclosporine ................... 60, 61
cyclosporine modified .... 60, 61
cyproheptadine ................. 1, 63
D
DAILY VITES/IRON .... 13, 72
DALIRESP ........................... 65
danazol ................................. 53
dapsone ................................... 4
DARAPRIM ........................... 4
DELZICOL .......................... 49
DEMSER.............................. 61
DENAVIR ............................ 70
DEPO-PROVERA ............... 57
desipramine .......................... 39
desmopressin .................. 13, 57
desonide................................ 69
desoximetasone .................... 69
DESPEC ........................... 9, 63
dexamethasone ..................... 52
DEXAMETHASONE
INTENSOL ...................... 52
dexamethasone sodium phos
(pf) .................................... 52
dexamethasone sodium
phosphate.......................... 46
dexmethylphenidate ............. 37
dextroamphetamine .............. 27
diazepam............................... 32
DIBENZYLINE ............. 11, 24
dibucaine .............................. 70
diclofenac potassium ............ 35
diclofenac sodium ................ 36
dicloxacillin ............................ 6
dicyclomine .......................... 10
diflorasone ............................ 69
DIGOX ........................... 18, 20
dihydroergotamine ......... 11, 30
DILANTIN ..................... 21, 33
DILANTIN INFATABS 21, 33
diltiazem hcl ....... 19, 20, 22, 27
DILT-XR .................. 20, 22, 27
DIPHENHIST .................. 1, 63
diphenhydramine hcl .. 1, 63, 64
diphenoxylate-atropine .. 10, 48,
62
dipyridamole ................... 15, 27
disopyramide phosphate ....... 21
disulfiram.............................. 58
DIURIL .......................... 26, 43
divalproex ....................... 29, 30
docusate calcium .................. 49
donepezil .............................. 12
dorzolamide .......................... 45
dorzolamide-timolol ............. 45
doxazosin .................. 11, 16, 24
doxepin ................................. 39
doxycycline monohydrate ...... 7
DRITHOCREME HP ........... 71
droperidol ............................. 30
DROXIA ................................ 8
DULERA ............ 12, 52, 65, 66
duloxetine ....................... 33, 37
DYRENIUM .................. 25, 41
E
EDLUAR .............................. 30
EFFIENT .............................. 15
ELIDEL .......................... 61, 72
ELIQUIS .............................. 13
ELMIRON ............................ 61
EMCYT .................................. 8
EMEND ................................ 48
enalapril maleate................... 17
.............................. 17, 26, 43
ENDOCET ..................... 28, 34
ENDODAN .................... 34, 37
enoxaparin ............................ 13
ENPRESSE .......................... 54
entecavir ................................. 6
ENTOCORT EC................... 52
epinephrine ....................... 9, 62
EPIPEN 2-PAK ................ 9, 62
EPIPEN JR 2-PAK ........... 9, 62
ergocalciferol (vitamin d2) ... 77
ERGOMAR .................... 11, 30
ERRIN .................................. 54
ERY PADS ........................... 68
ERY-TAB ............................... 6
ERYTHROCIN (AS
STEARATE) ...................... 6
erythromycin..................... 6, 44
erythromycin ethylsuccinate ... 6
erythromycin with ethanol .... 68
erythromycin-benzoyl peroxide
.......................................... 68
erythromycin-sulfisoxazole .... 5
escitalopram oxalate ............. 38
estazolam .............................. 32
estradiol ................................ 56
estropipate............................. 56
ethambutol .............................. 4
ethosuximide......................... 38
etidronate disodium .............. 59
EURAX ................................71
EVISTA .......................... 56, 59
EXELON .............................. 12
EXFORGE .......... 16, 22, 23, 27
EXFORGE HCT . 16, 22, 23, 43
EXJADE ............................... 51
F
famotidine ............................. 50
FANAPT............................... 31
FARESTON ........................... 8
FE C PLUS ............... 13, 75, 76
FEMHRT LOW DOSE .. 56, 58
fenofibrate............................. 23
fenofibrate micronized.......... 23
fenoprofen............................. 36
fentanyl ................................. 34
FERRETTS........................... 13
ferrous gluconate .................. 14
ferrous sulfate ....................... 14
fexofenadine ..................... 3, 66
finasteride ............................. 58
FLAREX............................... 46
flavoxate ............................... 72
flecainide .............................. 21
FLOVENT DISKUS ...... 52, 65
FLOVENT HFA ............. 52, 65
FLUARIX 2014-2015 (PF) .. 67
FLUARIX QUAD 2014-2015
(PF) ................................... 67
FLUCELVAX 2014-2015 (PF)
.......................................... 67
fluconazole ............................. 5
fludrocortisone ...................... 52
FLULAVAL 2014-2015 ....... 67
83
FLUMIST QUAD 2014-2015
.......................................... 67
fluocinolone.......................... 69
fluocinonide.......................... 69
FLUOCINONIDE-E ............ 69
FLUORITAB ....................... 59
fluorometholone ................... 46
fluoxetine.............................. 38
fluphenazine decanoate ........ 36
fluphenazine hcl ................... 36
flurbiprofen sodium .............. 47
flutamide................................. 8
fluticasone ...................... 46, 64
fluvastatin ............................. 24
FLUVIRIN 2014-2015 ......... 67
FLUVIRIN 2014-2015 (PF) . 67
fluvoxamine.......................... 38
FLUZONE 2014-2015 ......... 67
FLUZONE HIGH-DOSE
2014-15 (PF) .................... 67
FLUZONE INTRADERM
2014-15 (PF) .................... 67
FLUZONE QUAD 2014-2015
(PF) ................................... 67
FLUZONE QUAD PEDI
2014-15 (PF) .................... 68
FML FORTE ........................ 46
FML S.O.P. .......................... 46
FOCALIN XR ...................... 37
folic acid ............................... 75
fosinopril .............................. 17
.............................. 17, 26, 43
FOSRENOL ................... 40, 59
FROVA ................................ 38
furosemide ...................... 24, 40
G
gabapentin ...................... 28, 29
gemfibrozil ........................... 23
GENGRAF ..................... 60, 61
GENTAK ............................. 45
gentamicin ............................ 68
GENTLE LAXATIVE ......... 49
GERAVIM ........................... 73
glimepiride ........................... 58
glipizide ................................ 58
glipizide-metformin ........ 53, 58
GLUCAGEN HYPOKIT 56, 59
GLUCAGON EMERGENCY
KIT (HUMAN) .......... 56, 59
84
glucose .................................. 40
glyburide ............................... 58
glyburide micronized ............ 58
glyburide-metformin ...... 54, 58
glycopyrrolate ....................... 10
granisetron hcl ...................... 48
GRIFULVIN V....................... 4
griseofulvin microsize ............ 4
griseofulvin ultramicrosize ..... 4
GRIS-PEG
(ULTRAMICROSIZE) ...... 4
guaifenesin............................ 63
guanfacine ...................... 20, 33
H
haloperidol ............................ 33
haloperidol decanoate ........... 32
haloperidol lactate ................ 32
heparin (porcine) .................. 13
HEPSERA .............................. 6
HEXALEN ............................. 8
HUMALOG.......................... 57
HUMALOG KWIKPEN ...... 57
HUMALOG MIX 50-50 ...... 57
HUMALOG MIX 50-50
KWIKPEN........................ 57
HUMALOG MIX 75-25 ...... 57
HUMALOG MIX 75-25
KWIKPEN........................ 57
HUMULIN 70/30 ................. 57
HUMULIN N ....................... 57
HUMULIN R ....................... 57
HUMULIN R U-500 ............ 57
hydralazine ........................... 23
hydrochlorothiazide ........ 26, 43
hydrocodone-acetaminophen
.................................... 28, 34
hydrocodone-homatropine... 10,
63
hydrocortisone ................ 52, 69
hydrocortisone valerate ........ 69
hydrocortisone-min oil-wht pet
.......................................... 69
hydromorphone .................... 34
hydroxychloroquine.......... 4, 60
hydroxyurea ............................ 8
hydroxyzine hcl ................ 2, 31
hydroxyzine pamoate ....... 2, 31
hyoscyamine sulfate ............. 10
HYPERCARE ...................... 70
I
ibuprofen............................... 36
imipramine hcl ...................... 39
imiquimod............................. 72
indapamide ..................... 26, 44
INDOCIN ....................... 36, 59
indomethacin .................. 36, 59
INFANT'S IBUPROFEN ..... 36
INFANT'S PAIN RELIEF .... 28
IOPIDINE ............................. 47
ipratropium bromide . 10, 47, 62
ipratropium-albuterol ..... 10, 12,
62, 66
irbesartan .............................. 16
........................ 16, 17, 26, 43
isoniazid .................................. 5
ISOPTO CARBACHOL ...... 47
ISORDIL .............................. 25
isosorbide dinitrate ............... 25
isosorbide mononitrate ......... 25
J
JANUMET ..................... 54, 56
JANUMET XR ............... 54, 56
JANUVIA ............................. 56
JENTADUETO .............. 54, 56
JINTELI .......................... 56, 58
JOLESSA ............................. 54
JOLIVETTE ......................... 54
JUNEL 1.5/30 (21) ............... 54
JUNEL 1/20 (21) .................. 54
JUNEL FE 1.5/30 (28) ......... 54
JUNEL FE 1/20 (28) ............ 54
K
KADIAN .............................. 34
KARIVA (28) ....................... 54
KELNOR 1/35 (28) .............. 54
ketoconazole ..................... 5, 70
ketoprofen ............................. 36
ketorolac ............................... 47
ketotifen fumarate ................. 44
KLOR-CON ......................... 42
KLOR-CON M10 ................. 42
KLOR-CON M20 ................. 42
KOMBIGLYZE XR ....... 54, 56
L
labetalol .. 11, 12, 16, 18, 19, 21
LACLOTION ....................... 70
lactulose ................................ 40
LAMICTAL STARTER
(BLUE) KIT ..................... 29
LAMICTAL STARTER
(GREEN) KIT .................. 29
LAMICTAL STARTER
(ORANGE) KIT ............... 29
lamotrigine ........................... 29
lansoprazole .......................... 51
LANTUS .............................. 57
LANTUS SOLOSTAR ........ 57
latanoprost ............................ 47
LATUDA ............................. 31
LEENA 28 ............................ 54
leflunomide........................... 60
LESCOL XL ........................ 24
LESSINA ............................. 54
LETAIRIS ...................... 27, 67
letrozole .................................. 8
leucovorin calcium ............... 59
LEUKERAN .......................... 8
levetiracetam ........................ 29
levobunolol ........................... 45
levocarnitine ......................... 61
levofloxacin ........................ 5, 7
levonorgestrel ....................... 54
LEVORA-28 ........................ 54
levothyroxine ........................ 58
LIALDA ............................... 49
lidocaine ............................... 70
lidocaine hcl ......................... 47
LIDOCAINE VISCOUS ...... 47
lidocaine-prilocaine .............. 70
LIDODERM ......................... 70
LINZESS .............................. 50
liothyronine .......................... 58
LIPITOR............................... 24
LIQUID CALCIUM WITH
VITAMIN D ............... 42, 77
lisinopril ......................... 17, 18
........................ 17, 18, 26, 43
lithium carbonate .................. 30
lithium citrate ....................... 30
LOESTRIN 24 FE ................ 55
loperamide ............................ 48
loratadine .......................... 3, 66
LORATADINE-D .. 3, 9, 62, 66
lorazepam ............................. 32
losartan ........................... 16, 17
........................ 16, 17, 26, 43
lovastatin .............................. 24
LOW-OGESTREL (28) ....... 55
loxapine succinate ................ 30
LUNESTA ............................ 31
LUTERA (28)....................... 55
LYSODREN ........................... 8
M
MACRODANTIN .................. 8
MAG-DELAY ...................... 42
magnesium oxide.................. 48
MAGNEVIST ...................... 40
maprotiline............................ 39
MATULANE.......................... 8
MAXIDEX ........................... 46
meclizine .......................... 2, 49
meclofenamate...................... 36
MEDROL ............................. 53
medroxyprogesterone ........... 58
mefloquine .............................. 4
MEGACE ES ......................... 8
megestrol ................................ 8
meloxicam ............................ 36
M-END DMX... 2, 9, 62, 63, 64
MENEST .............................. 56
meperidine ............................ 34
MEPHYTON .................. 59, 77
meprobamate ........................ 31
MEPRON ............................... 4
mercaptopurine ................. 9, 61
mesalamine ........................... 49
MESTINON ......................... 12
MESTINON TIMESPAN .... 12
metformin ............................. 54
methadone ...................... 34, 35
methimazole ......................... 53
METHITEST ........................ 53
methocarbamol ..................... 11
methotrexate sodium .. 9, 60, 61
methotrexate sodium (pf) 9, 60,
61
methyclothiazide ............ 26, 43
methyldopa ....................... 9, 20
methyldopahydrochlorothiazide ..... 9, 21,
26, 43
methylergonovine ................. 62
methylphenidate ................... 37
methylprednisolone .............. 53
metoclopramide hcl .............. 50
metolazone ...................... 26, 44
metoprolol succinate 13, 18, 19,
21
metoprolol ta-hydrochlorothiaz
............ 13, 18, 19, 21, 26, 43
metoprolol tartrate ... 13, 18, 19,
21
METROGEL ........................ 68
metronidazole ............... 3, 4, 68
mexiletine .............................21
miconazole nitrate ................ 70
MICONAZOLE-3 ................ 70
MICROGESTIN 1.5/30 (21) 55
MICROGESTIN 1/20 (21) ... 55
MICROGESTIN FE 1.5/30
(28) ................................... 55
MICROGESTIN FE 1/20 (28)
.......................................... 55
MILK OF MAGNESIA ........ 49
MINERAL OIL HEAVY ..... 49
minocycline ............................ 7
minoxidil............................... 23
mirtazapine ........................... 29
misoprostol ........................... 50
moexipril......................... 17, 18
........................ 17, 18, 26, 43
mometasone ..........................69
MONONESSA (28).............. 55
montelukast........................... 64
morphine ............................... 35
morphine concentrate ........... 35
MOXEZA ............................. 45
moxifloxacin ....................... 5, 7
MUCINEX D.............. 9, 62, 63
MULTIGEN ......................... 14
MULTIGEN FOLIC . 14, 75, 76
MULTIGEN PLUS .. 14, 75, 76
MULTI-VIT WITH
FLUORIDE & IRON 14, 59,
73
MULTI-VITAMIN WITH
FLUORIDE ................ 59, 73
mupirocin .............................. 68
MVC-FLUORIDE .......... 59, 73
MYCOBUTIN .................... 5, 7
mycophenolate mofetil ......... 61
MYLERAN ............................ 9
MYNATAL .......................... 73
85
MYNATAL PLUS .. 14, 42, 73,
75
MYNATAL-Z .... 14, 42, 73, 75
MYNATE 90 PLUS ............. 73
MY-VITALIFE .................... 73
N
nadolol ................ 11, 18, 19, 21
............ 11, 18, 19, 21, 26, 43
nalbuphine ............................ 35
naltrexone ....................... 35, 58
NAMENDA ......................... 33
NAMENDA TITRATION
PAK .................................. 33
NAMENDA XR ................... 33
naphazoline........................... 47
naproxen ......................... 36, 59
naproxen sodium ............ 36, 59
NASACORT .................. 46, 64
NASACORT AQ............ 46, 64
nateglinide ............................ 57
NATROBA........................... 71
NATURAL FIBER
LAXATIVE ...................... 49
NATURAL FIBER
LAXATIVE THERAPY .. 49
NATURE-THROID ............. 58
NECON 1/35 (28) ................ 55
NECON 1/50 (28) ................ 55
NECON 10/11 (28) .............. 55
NECON 7/7/7 (28) ............... 55
nefazodone ........................... 38
neomycin-bacitracin-poly-hc
.................................... 45, 46
neomycin-bacitracinpolymyxin......................... 45
neomycin-polymyxin bdexameth .................... 45, 46
neomycin-polymyxingramicidin......................... 45
neomycin-polymyxin-hc 45, 46
NEXIUM .............................. 51
NEXIUM 24HR ................... 51
NEXIUM PACKET ............. 51
NEXT CHOICE ONE DOSE
.......................................... 55
niacin .................................... 18
niacinamide .......................... 75
NIACOR............................... 18
NICOMIDE .......................... 75
86
nicotine ................................. 10
nicotine (polacrilex) ............. 10
NICOTROL .......................... 10
NICOTROL NS .................... 11
NIFEDIAC CC ......... 22, 23, 27
NIFEDICAL XL............. 23, 27
nifedipine ........................ 23, 27
nisoldipine ............................ 23
NITRO-DUR ........................ 25
nitrofurantoin .......................... 8
nitrofurantoin macrocrystal .... 8
nitrofurantoin monohyd/mcryst .................................... 8
nitroglycerin ......................... 25
NITROSTAT ........................ 25
NITRO-TIME ....................... 25
nizatidine .............................. 50
NIZORAL A-D .................... 70
NORA-BE ............................ 55
norethindrone acetate ........... 58
NORPACE CR ..................... 21
NORTREL 0.5/35 (28) ......... 55
NORTREL 1/35 (21) ............ 55
NORTREL 1/35 (28) ............ 55
NORTREL 7/7/7 (28) ........... 55
nortriptyline .......................... 39
NUVARING ......................... 55
nystatin ............................. 6, 71
nystatin-triamcinolone .......... 71
O
OCELLA .............................. 55
ofloxacin ............................... 45
OGESTREL (28) .................. 55
olanzapine............................. 31
omeprazole ........................... 51
omeprazole magnesium ........ 51
omeprazole-sodium
bicarbonate ....................... 51
OMNARIS...................... 46, 64
ondansetron .......................... 48
ondansetron hcl..................... 48
ONE DAILY
MULTIVITAMIN ............ 73
ONE DAILY PLUS
MINERALS...................... 73
ONE-A-DAY WOMENS
FORMULA .... 14, 42, 73, 75
ONGLYZA ........................... 56
ORAP ................................... 30
ORTHO TRI-CYCLEN LO
(28) ................................... 55
oxaprozin .............................. 36
oxazepam .............................. 32
oxcarbazepine ....................... 29
oxybutynin chloride .............. 72
oxycodone............................. 35
oxycodone-acetaminophen .. 28,
35
OYSCO D ....................... 42, 77
OYSTER SHELL CALCIUM
500 .................................... 42
OYSTER SHELL CALCIUM
WITH D ...................... 42, 77
P
P & S (SALICYLIC ACID) . 71
PACERONE ......................... 22
PANCRELIPASE 5000 ........ 50
pantoprazole ......................... 51
pantothenic acid .................... 75
paromomycin .......................... 3
paroxetine hcl ....................... 38
PATADAY ........................... 44
PAXIL .................................. 38
PEDIATRIC ELECTROLYTE
.......................................... 42
PEDIAVIT ............................ 73
peg 3350-electrolytes............ 49
penicillin v potassium ............. 6
PENTASA ............................ 49
pentoxifylline ........................ 13
perindopril erbumine ...... 17, 18
permethrin............................. 71
perphenazine ......................... 36
perphenazine-amitriptyline .. 36,
39
phenazopyridine ................... 70
phenelzine ............................. 33
phenobarbital .................. 31, 32
phenylephrine hcl ................. 47
phenytoin ........................ 21, 33
phenytoin sodium extended . 21,
33
PHOS-FLUR ........................ 60
PHOSPHOLINE IODIDE .... 47
pilocarpine hcl ...................... 47
PILOPINE HS ...................... 47
pindolol ......... 11, 18, 19, 21, 24
PINK BISMUTH .................. 48
piroxicam .............................. 36
PNEUMOVAX 23 ............... 68
podofilox .............................. 72
polyethylene glycol 3350 ..... 49
polymyxin b sulf-trimethoprim
.......................................... 45
POLY-VITAMIN ................. 73
POLY-VITAMIN WITH
IRON .......................... 14, 73
POLYVITAMIN/IRON ....... 73
PORTIA ............................... 55
potassium chloride................ 42
potassium citrate ................... 40
PR NATAL 400 . 14, 42, 73, 75
PR NATAL 400 EC 14, 42, 73,
75
PR NATAL 430 . 14, 42, 73, 75
PRADAXA........................... 13
pramipexole .......................... 34
pravastatin ............................ 24
prazosin .......................... 11, 16
PRED MILD ........................ 46
prednisolone ......................... 53
prednisolone acetate ............. 46
prednisolone sodium phosphate
.................................... 46, 53
prednisone ............................ 53
PREDNISONE INTENSOL 53
PREMARIN ......................... 56
PREMPHASE ...................... 56
PREMPRO ........................... 56
PRENAPLUS ..... 14, 42, 73, 75
PRENATAL 19 (WITH
DOCUSATE) ....... 14, 73, 75
PRENATAL AD 14, 42, 73, 75
PRENATAL LOW IRON ... 14,
42, 73, 75
PRENATAL PLUS WITH
IRON (CA) ..... 14, 42, 73, 75
PRENATAL VITAMIN 14, 42,
73, 75
PRENATAL VITAMINS
LOW IRON .... 14, 42, 73, 75
PREVACID .......................... 51
PREVACID 24HR ............... 51
PREVACID SOLUTAB ...... 51
PREVALITE ........................ 19
PREVIDENT 5000 BOOSTER
.......................................... 60
PRILOSEC ........................... 51
PRILOSEC OTC .................. 51
primaquine .............................. 4
primidone.............................. 31
probenecid ...................... 44, 59
prochlorperazine ............. 36, 49
prochlorperazine edisylate ... 36,
49
prochlorperazine maleate 36, 49
PROCTOFOAM HC ...... 69, 70
promethazine .............. 2, 31, 64
PROMETHAZINE VC 2, 9, 64
PROMETHAZINE VCCODEINE .. 2, 10, 35, 63, 64
promethazine-codeine .... 63, 64
promethazine-dm ............ 63, 64
propafenone .......................... 21
propantheline ........................ 10
propranolol .. 11, 18, 19, 22, 24,
30
............ 11, 18, 19, 22, 26, 44
propylthiouracil .................... 53
PRORENAL QD 14, 74, 75, 77
PROSTIGMIN...................... 12
PROTONIX .......................... 51
PROTOPIC ........................... 72
pseudoephedrine hcl ......... 9, 62
PULMICORT ................. 53, 65
pyrazinamide .......................... 5
pyridostigmine bromide ....... 12
Q
Q-PAP .................................. 28
QUASENSE ......................... 55
quetiapine ............................. 31
........................ 17, 18, 26, 44
quinidine gluconate .............. 21
quinidine sulfate ............... 4, 21
QVAR ............................. 53, 65
R
rabeprazole ........................... 51
ranitidine hcl ......................... 50
RECLIPSEN (28) ................. 55
RECTIV................................ 72
RELENZA DISKHALER ...... 6
RELPAX .............................. 38
RENAGEL ..................... 40, 59
RENVELA ..................... 40, 59
reserpine ............................... 25
RETIN-A MICRO ................ 70
REVATIO ............................ 67
RHEUMATREX ........ 9, 60, 61
RHINOCORT AQUA .... 46, 64
RIDAURA ................ 51, 60, 61
rifampin .............................. 5, 7
risperidone ............................ 31
rivastigmine tartrate .............. 12
rizatriptan .............................. 38
ROBAFEN CF................ 10, 63
ROBAFEN DM .................... 63
ropinirole ..............................34
ROXICET ....................... 28, 35
ROZEREM ........................... 31
S
salsalate................................. 37
SANDIMMUNE............. 60, 61
SANTYL .............................. 72
SAPHRIS .............................. 31
SAPHRIS (BLACK
CHERRY)......................... 31
SAVELLA ...................... 33, 37
selegiline hcl ................... 33, 34
selenium sulfide .................... 71
SE-NATAL 19.......... 14, 74, 75
SE-NATAL 19 (WITH
DOCUSATE) . 14, 49, 74, 75
SENNA LAXATIVE............ 49
SENNA-S ............................. 50
SEREVENT DISKUS .... 12, 67
sertraline ............................... 38
SF .......................................... 60
SF 5000 PLUS ...................... 60
SILACE ................................ 50
sildenafil ............................... 25
silver sulfadiazine ................. 71
simvastatin ............................ 24
................................ 1, 31, 64
sodium bicarbonate ............... 48
sodium fluoride ..................... 60
SODIUM POLYSTYRENE
(SORB FREE) ............ 41, 59
SOF-LAX ............................. 50
SOFT TOUCH LANCETS... 39
sotalol ........... 11, 18, 19, 22, 24
SOTALOL AF ... 11, 18, 19, 22,
24
SPIRIVA RESPIMAT .......... 10
SPIRIVA WITH
HANDIHALER .......... 10, 62
spironolactone........... 24, 25, 41
87
.................. 24, 25, 26, 41, 44
SPRINTEC (28) ................... 55
SPS ................................. 41, 59
SRONYX ............................. 55
SSKI ..................... 4, 53, 59, 63
STRATTERA ....................... 33
STRESS B-COMPLEX . 75, 76
SUBOXONE ........................ 35
sucralfate .............................. 50
sulfacetamide sodium ........... 45
sulfacetamide sodium (acne) 71
sulfacetamide sodium-sulfur 71
sulfacetamide-prednisolone.. 45
sulfadiazine............................. 7
sulfamethoxazole-trimethoprim
............................................ 7
sulfasalazine ......... 7, 49, 60, 61
sumatriptan ........................... 38
sumatriptan succinate ........... 38
SUPRAX ................................ 8
SYMBICORT..... 12, 53, 65, 67
T
TAB-A-VITE-MINERALS . 74
TABLOID .............................. 9
tacrolimus ....................... 61, 72
TAMIFLU .............................. 6
tamoxifen................................ 9
tamsulosin............................. 12
TAZTIA XT ............. 20, 22, 27
TEARS NATURALE FREE
(PF) ................................... 47
TEARS NATURALE II ....... 47
TEGRETOL XR ................... 29
temazepam ............................ 32
terazosin ................... 11, 16, 24
terbinafine hcl ......................... 3
terbutaline ....................... 12, 67
TESTIM ............................... 53
testosterone enanthate .......... 53
TESTRED ............................ 53
tetracycline ............................. 7
THEO-24 ............ 23, 40, 67, 72
theophylline ........ 23, 40, 67, 72
THERATRUM COMPLETE
50 PLUS ........................... 74
thioridazine ........................... 36
thiothixene ............................ 39
THYROLAR-1 ..................... 58
THYROLAR-1/2 .................. 58
88
THYROLAR-1/4 .................. 58
THYROLAR-2 ..................... 58
THYROLAR-3 ..................... 58
ticlopidine ............................. 15
TILIA FE .............................. 55
timolol maleate .. 11, 18, 19, 22,
24, 30, 45
TIMOPTIC OCUDOSE (PF)
.......................................... 45
tizanidine .............................. 11
tobramycin ............................ 45
tobramycin-dexamethasone . 45,
46
TOBREX .............................. 45
tolnaftate ............................... 72
tolterodine............................. 72
topiramate ............................. 29
torsemide ........................ 24, 40
TOVIAZ ............................... 72
TRADJENTA ....................... 56
tramadol ................................ 35
trandolapril ..................... 17, 18
TRANSDERM-SCOP .......... 48
tranylcypromine.................... 34
TRAVATAN Z..................... 47
travoprost (benzalkonium) ... 47
trazodone .............................. 38
tretinoin ................................ 70
TREXALL .................. 9, 60, 61
triamcinolone acetonide 46, 64,
69
triamterene-hydrochlorothiazid
........................ 25, 26, 41, 44
triazolam ............................... 32
TRICARE ................. 15, 74, 75
trifluoperazine ...................... 36
trifluridine............................. 45
trihexyphenidyl ............... 10, 28
trimethobenzamide ............... 49
trimethoprim ........................... 8
TRINESSA (28) ................... 55
TRI-SPRINTEC (28) ............ 55
TRIVEEN-DUO DHA .. 15, 43,
74, 76
TRIVEEN-U ......................... 74
TRI-VIT WITH FLUORIDE &
IRON .................... 15, 60, 74
TRI-VITAMIN ......... 74, 76, 77
TRI-VITAMIN WITH
FLUORIDE .... 60, 74, 76, 77
TRIVORA (28) ..................... 56
TRIXAICIN HP .................... 72
trospium ................................ 72
TUDORZA PRESSAIR . 10, 62
U
urea ....................................... 71
ursodiol ................................. 50
V
valacyclovir ............................ 6
valproic acid ................... 29, 30
valproic acid (as sodium salt)
.................................... 29, 30
valsartan .......................... 16, 17
........................ 16, 17, 26, 44
vancomycin............................. 5
VELIVET TRIPHASIC
REGIMEN (28) ................ 56
VENATAL-FA ... 15, 43, 74, 76
venlafaxine ........................... 37
VENTOLIN HFA ........... 12, 67
VERAMYST .................. 46, 64
verapamil .................. 20, 22, 27
VFEND ................................... 5
VICOPROFEN ............... 35, 36
VICTOZA 2-PAK ................ 57
VICTOZA 3-PAK ................ 57
VIGAMOX ........................... 45
VINATE GT ............. 15, 74, 76
VINATE II.......... 15, 43, 74, 76
VINATE M ........................... 74
VINATE ONE .... 15, 43, 74, 76
VINATE ULTRA .... 15, 43, 50,
74, 76
vit b complex-folic acid ........ 76
vitamin a ............................... 74
VITAMIN B-1 ......................76
VITAMIN B-12 ....................76
VITAMIN B-2 ......................76
VITAMIN B-6 ......................76
VITAMIN C ......................... 76
vitamin e ............................... 77
VITAMINS B COMPLEX ... 76
VITATRUM ............. 15, 74, 76
VITRUM SENIOR ............... 74
VOL-NATE ........ 15, 43, 74, 76
VOL-PLUS ......... 15, 43, 74, 76
VOL-TAB RX .... 15, 43, 74, 76
VYVANSE ........................... 27
W
warfarin ................................ 13
X
XARELTO ........................... 13
XULANE ............................. 56
XYZAL ............................ 3, 66
Y
YODOXIN ............................. 3
Z
ZADITOR ............................ 44
zaleplon ................................ 31
ZEGERID ............................. 51
ZENCHENT FE ................... 56
ZENPEP ............................... 50
ZETIA .................................. 21
ziprasidone hcl ...................... 31
ZMAX .................................... 6
zolpidem ............................... 31
ZOMIG ................................. 38
ZOMIG ZMT........................ 38
ZOSTAVAX (PF) ................ 68
ZOVIA 1/35E (28) ............... 56
ZOVIA 1/50E (28) ............... 56
ZOVIRAX ............................ 70
ZUBSOLV ............................ 35
ZYVOX .................................. 6
89
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Printable Drug Formulary - Medicaid

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