OHP Drug List (Formulary)

Transcription

OHP Drug List
(Formulary)
2016
For members of Columbia Pacific, Health Share/CareOregon and Jackson Care Connect
If you want a copy of this book, need this book in another language, large print, Braille, CD, or other format, please call the Customer Service number of your CCO listed below. TTY/TDD users can call 7‐1‐1. You can always view the most recent version of this drug list on your CCO’s website. Columbia Pacific CCO Customer Service: toll‐free, 1‐855‐722‐8206; online: www.colpachealth.org Health Share/CareOregon Customer Service: 503‐416‐4100 or toll‐free, 1‐800‐224‐4840; online: www.careoregon.org/healthshare Jackson Care Connect Customer Service: toll‐free, 1‐855‐722‐8208; online: www.jacksoncareconnect.org Si desea una copia de este documento, necesita este documento en otro idioma, letra grande, Braille, CD u otro formato, llame al número de servicio al cliente de su CCO que se encuentra más adelante. Los usuarios de TTY/TDD pueden llamar al 7‐1‐1. Puede consultar en cualquier momento la versión más reciente de esta lista de medicamentos en el sitio web de su CCO. Columbia Pacific CCO Servicio al cliente: llame gratis al 1‐855‐722‐8206; en línea: www.colpachealth.org Health Share/CareOregon Servicio al cliente: 503‐416‐4100 o llame gratis al 1‐800‐224‐4840; en línea: www.careoregon.org/healthshare Jackson Care Connect Servicio al cliente: llame gratis al 1‐855‐722‐8208; en línea: www.jacksoncareconnect.org Haddii aad doonayso nuqulka buugan, u baahan tahay buugan oo ku qoran luqad kale, far waaweyn, farta dadka indhaha aan qabin wax ku akhriyaan ee Braille, CD, ama qaab kale, fadlan wac lambarka Adeega Macmiilka ee CCO‐gaaga ee hoos ku qoran. Dadka isticmaala TTY/TDD waxay wici karaan 7‐1‐1. Waxaad markasta liiskii u dambeeyay ee daawadan ka fiirin kartaa website‐kaaga CCO. Columbia Pacific CCO Adeega Macmiilka: khadka bilaashka ah, 1‐855‐722‐8206; internet‐ka: www.colpachealth.org Health Share/CareOregon Adeega Macmiilka: 503‐416‐4100 ama khadka bilaashka ah, 1‐800‐224‐4840; internet‐ka: www.careoregon.org/healthshare Jackson Care Connect Adeega Macmiilka: khadka bilaashka ah, 1‐855‐722‐8208; internet‐ka: www.jacksoncareconnect.org Если вы желаете получить копию данного материала или вам необходимо, чтобы данный материал был переведен на другой язык, напечатан крупным шрифтом, шрифтом Брайля, записан на компакт‐диск или был доступен в каком‐либо другом формате, пожалуйста, позвоните в отдел обслуживания клиентов вашей организации координированного обслуживания (CCO) по телефону, указанному ниже. Пользователи системы телетайп (TTY/TDD) могут звонить на номер 7‐1‐1. Самую последнюю версию данного перечня лекарственных препаратов всегда можно увидеть на веб‐
сайте вашей организации COO. Отдел обслуживания клиентов организации Columbia Pacific CCO: бесплатный номер, 1‐855‐722‐8206; в Интернете: www.colpachealth.org Отдел обслуживания клиентов организации Health Share/CareOregon: 503‐416‐4100 или бесплатный номер, 1‐800‐224‐4840; в Интернете: www.careoregon.org/healthshare Отдел обслуживания клиентов организации Jackson Care Connect: бесплатный номер, 1‐855‐722‐8208; в Интернете: www.jacksoncareconnect.org 如果您想獲得一份本手冊、需要本手冊的其他語言版本、大字版、盲文版、CD 或其他格式，請致電下
列您 CCO 的客戶服務部電話號碼。聽語障專線使用者可致電 7-1-1。
您可隨時在您 CCO 的網站上檢視本藥物清單的最新版本。
Columbia Pacific CCO 客戶服務部：免費電話 1-855-722-8206；網站：www.colpachealth.org
Health Share/CareOregon 客戶服務部：503-416-4100 或免費電話 1-800-224-4840；
網站：www.careoregon.org/healthshare Jackson Care Connect 客戶服務部：免費電話 1-855-722-8208；網站：www.jacksoncareconnect.org
Nếu quý vị muốn có một bản sao của cuốn sách này, cần cuốn sách này trên ngôn ngữ khác, bản in khổ lớn, chữ nổi Braille, CD, hoặc hình thức khác, xin vui lòng gọi số điện thoại dịch vụ khách hàng của Tổ chức Săn sóc Phối hợp (Coordinated Care Organization/CCO) của quý vị được liệt kê dưới đây. Những ai sử dụng điện thoại dành cho người khiếm thính/điếc (TTY/TDD) có thể gọi số 7‐1‐1. Quý vị luôn có thể xem phiên bản mới nhất của danh mục thuốc này trên trang web của CCO của quý vị. Dịch vụ Khách hang của Columbia Pacific CCO: số miễn phí, 1‐855‐722‐8206; trực tuyến: www.colpachealth.org Dịch vụ Khách hang của Health Share/CareOregon: 503‐416‐4100 hoặc số miễn phí, 1‐800‐224‐4840; trực tuyến: www.careoregon.org/healthshare Dịch vụ Khách hàng của Jackson Care Connect: số miễn phí, 1‐855‐722‐8208; trực tuyến: www.jacksoncareconnect.org 2016 OHP Drug List (Formulary)
Administered by
INTRODUCTION
Pharmacy benefit
As a member of your CCO, you have Medicaid prescription drug coverage under the Oregon
Health Plan (OHP). This booklet is your list of the drugs that are covered. We call it a drug
“formulary.” A group of pharmacists and doctors decide which drugs should be in the
formulary. Their goal is to create a formulary with medications that are safe and effective.
This formulary is administered by CareOregon, a partner in your CCO.
This booklet was last updated on October 1, 2016. Usually, we will update this formulary every
two months. To get up-to-date information about drugs covered by us, call your CCO’s
Customer Service department. They are available Monday-Friday, from 8 a.m. to 5 p.m.
Columbia Pacific CCO Customer Service: toll free, 1-855-722-8206
Health Share/CareOregon Customer Service: 503-416-4100 or toll free, 1-800-224-4840
Jackson Care Connect Customer Service: toll free, 1-855-722-8208
Getting started
For some drugs, your provider will need to check with us before we will cover the prescription.
This will save you time, help you avoid any hassles and get you started on your medication as
soon as possible.
Important things for you to know are:
1. Before you leave your provider’s office, ask if your CCO covers the drug.
2. If we don’t cover it, ask if there is a covered drug that would work for you.
3. If your provider does not prescribe a different drug for you, ask your provider’s office
staff to mail or fax a Prior Authorization or Formulary Exception Request Form to us. A
copy of this form can be found on your CCO’s website in the “Provider Forms and
Policies” section.
Be sure to follow your provider’s and pharmacist’s directions for taking your medication(s).
i
How to fill your prescriptions
You must fill your prescriptions at a participating network pharmacy. A list of pharmacies can be
found using the online Provider Directory on your CCO’s web site.
Columbia Pacific CCO: www.colpachealth.org/providerdirectory
Health Share/CareOregon: www.careoregon.org/providerdirectory.aspx
Jackson Care Connect: www.jacksoncareconnect.org/providerdirectory
Show your CCO ID card every time you fill a prescription.
The drugs listed in the formulary do not have copays. If a pharmacy asks you to pay for a
prescription, call Customer Service before you pay.
IMPORTANT: As a member, it is your responsibility to contact Customer Service before paying
out-of-pocket for prescriptions. In situations where contacting us is not possible due to
emergency, we may pay you back on prescriptions you paid for on your own. This depends on
your benefit coverage and the limitations and exclusions of the plan.
A form with instructions for getting paid back can be found in the “Member Forms” section on
your CCO’s website.
If your PCP’s clinic is closed and you think you need a prescription filled immediately, call your
PCP’s after-hours telephone number. There will usually be someone there that can answer your
questions.
How to search the formulary
You can search for a drug in the formulary in two ways:
1. By medical condition
The drugs are organized into categories that match the type of medical conditions each drug
treats. For example, drugs to treat heart conditions are listed under the category
“Cardiovascular Agents.”
If you know what a drug is used for, start by looking for its category in the table of contents.
Then check the category for the name of your drug.
2. Alphabetically
If you’re not sure which category a drug is in, look for the drug in the index that begins on page
93. The number next to the drug shows which page has information on the drug. Turn to that
page and find the name of your drug in the first column.
Note: If the formulary includes only generic versions of a drug, this means that we do not cover
the brand-name drug.
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Non-covered drugs
To help members have the best possible health outcomes, your CCO may add or remove drugs
from the formulary or change coverage rules on drugs. If we remove a drug from the formulary
or change the rules for a drug that you take, we will tell you at least 30 days before we do it.
The following items are not covered:
• Drugs not listed in the formulary (see section titled “Drugs Not Listed in the Formulary”
for more information)
• Drugs used to treat conditions that are not covered by the Oregon Health Plan, such as
fibromyalgia, allergic rhinitis, acne and chronic back pain
• Drugs used for cosmetic purposes
• Drugs used for non-medically accepted indications
• Investigational drugs and/or drugs used in an investigational manner
Mental health drugs, such as antidepressants, anxiolytics and antipsychotics, are covered
through the state’s Medical Assistance Programs (MAP). These drugs are not listed in this
formulary. Your pharmacist sends the bill directly to MAP.
Your CCO covers some over-the-counter drugs that are listed in the formulary. These drugs are
covered if you have a prescription for the drug from your provider.
Non-formulary or restricted drugs for a chronic (constant)
medical condition
New members or members who move to a different level of care may be using a non-formulary
or restricted drug. If a provider asks for this drug to be covered, we may provide a 60-day
transition supply.
A transition supply gives you time to try a different formulary drug to see if it meets your needs.
Meanwhile, your provider may send a Prior Authorization or Formulary Exception Request Form
to us, with reasons why this drug should be covered. A copy of this form can be found on your
CCO’s website in the “Provider Forms and Policies” section.
Generic drugs
A generic drug is a copy of a brand-name drug. It has the same active ingredients as the brandname drug. Generic drugs are approved by the U.S. Food and Drug Administration after being
tested for effectiveness and safety. They usually cost less than brand-name drugs and become
available after the patent for a brand- name drug expires.
If your PCP decides that you have a medical need for a brand-name drug that does not have a
generic equivalent, they must send a Prior Authorization or Formulary Exception Request Form
to us.
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Restrictions on the formulary drugs
Some covered drugs may have special rules related to their use. These rules may include:
• Prior Authorization (PA): If providers want to prescribe a drug marked “PA” in the
formulary, they must send a Prior Authorization or Formulary Exception Request Form
to us. We cannot pay for the prescription unless we approve the request in advance.
Usually, we only approve prior authorization requests if the drug treats conditions
covered by the Oregon Health Plan. Also, the prescription must meet drug use rules set
by our Pharmacy & Therapeutics Committee.
Each Prior Authorization or Formulary Exception Request Form must have only one
medication request. All fields on the form must be complete and legible.
• Quantity Limits (QL): For drugs marked “QL,” we limit the amount of the drug we’ll pay
for. Your provider must send a Prior Authorization or Formulary Exception Request Form
to us if they want to prescribe an amount of the drug that is over our quantity limits.
Our decisions for prior authorization and formulary exception requests are based only
on appropriate care and coverage. Our staff are not rewarded for denying requests. We
do not use financial incentives to reward underutilization.
• Step Therapy (ST): Sometimes we ask you to try other drugs before we cover a drug
marked “ST.” Suppose Drug A and Drug B both treat your medical condition. We may
not cover Drug B before you try Drug A. If Drug A has harmful side effects or doesn’t
work for you, we’ll cover Drug B.
• Age Restriction (AR): For some drugs, we require you to be younger than or older than a
specific age. For example, a drug may be restricted to people under age 6 or over age
16.
• Over-the-Counter (OTC): Some over-the-counter (OTC) drugs are in the formulary. We
can cover an OTC drug if you get a prescription from your provider and give it to a
network pharmacist.
Exceptions
You may get up to a 90-day supply of the following drugs:
•
•
•
•
•
Note:
•
•
•
•
Generic oral contraceptives (birth control pills)
Pediatric multivitamins with fluoride, prenatal vitamins, folic acid, sodium fluoride
Digoxin, furosemide, hydrochlorothiazide, atenolol, metoprolol, captopril, enalapril,
lisinopril
Levothyroxine
Albuterol HFA inhalers and nebulizer solutions
Your CCO may approve an additional refill in the following situations:
Your prescription is lost, stolen, or spilled.
You need extra medication because you will be out of town.
You need extra medication because your dosage was increased.
You need a supply of a certain medication for work or school.
For more information call your CCO’s Customer Service department.
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Drugs not listed in the formulary
Drugs usually are not covered unless they are in the formulary. However, if your provider
believes a drug outside of our formulary is the best drug for you, the provider can ask us to
cover it. This is called “making a formulary exception request.” Your provider will need to
submit a Prior Authorization or Formulary Exception Request Form to us.
Usually, we’ll approve formulary exception requests only if other formulary drugs would be less
effective in treating your condition, or would cause side effects that could hurt you.
Urgent needs for non-formulary or restricted drugs
You, or your provider or a pharmacist may ask for a five-day emergency supply of a nonformulary or restricted drug. This gives you, or your provider time to send a Prior Authorization
or Formulary Exception Request Form to us. To ask for an emergency supply, call your CCO’s
Customer Service.
Formulary updates
As mentioned above, the formulary is updated about every two months. Generally, drugs on
the formulary will not change during the year unless:
• The same medication becomes available in generic form.
• The FDA deems a drug to be unsafe.
• The drug’s manufacturer removes the drug from the market.
For more information
For the most up-to-date information about medications covered by your pharmacy benefit,
visit your CCO’s website, or call the Customer Service department. Customer service hours are
8 a.m.-5 p.m., Monday through Friday.
Columbia Pacific CCO Customer Service: toll free, 1-855-722-8206
Health Share/CareOregon Customer Service: 503-416-4100 or toll free, 1-800-224-4840
Jackson Care Connect Customer Service: toll free, 1-855-722-8208
Other prescription drug resources
To keep track of your prescription history, search for network pharmacies or check on the
status of a prior authorization request, you can create an account with OptumRx. Simply go to
your CCO’s website at one of the links below and click on the big yellow button at the bottom of
the page.
Columbia Pacific CCO: www.colpachealth.org/druglist
Health Share/CareOregon: www.careoregon.org/druglist.aspx
Jackson Care Connect: www.jacksoncareconnect.org/druglist
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TABLE OF CONTENTS
ANTI-INFECTIVES .......................................................................................................... 1
PENICILLINS ........................................................................................................................................................ 1
CEPHALOSPORINS.............................................................................................................................................. 2
MACROLIDES...................................................................................................................................................... 3
TETRACYCLINES.................................................................................................................................................. 3
FLUOROQUINOLONES ....................................................................................................................................... 3
AMEBICIDES ....................................................................................................................................................... 4
AMINOGLYCOSIDES ........................................................................................................................................... 4
ANTITUBERCULOSIS AGENTS ............................................................................................................................ 4
ANTIFUNGALS .................................................................................................................................................... 4
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) ............................................................................................................ 5
ANTIVIRALS ........................................................................................................................................................ 6
HEPATITIS AGENTS............................................................................................................................................. 6
HIV ...................................................................................................................................................................... 7
INFLUENZA AGENTS........................................................................................................................................... 9
ANTIMALARIALS ................................................................................................................................................ 9
ANTHELMINTICS .............................................................................................................................................. 10
ANTI-INFECTIVE AGENTS: MISC .............................................................................................................................. 10
HEPATIC ENCEPHALOPATHY ........................................................................................................................... 11
MONOBACTAMS ............................................................................................................................................. 11
BIOLOGICALS (VACCINES) ........................................................................................... 11
VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN.................................................................... 11
ANTI-NEOPLASTICS ..................................................................................................... 12
ANTIDOTES....................................................................................................................................................... 12
ANTIMETABOLITES ..................................................................................................... 13
ANTINEOPLASTIC AGENTS ............................................................................................................................... 13
PROGESTINS..................................................................................................................................................... 17
ENDOCRINE AND METABOLIC DRUGS ......................................................................... 17
ADRENALS ........................................................................................................................................................ 17
ANDROGENS .................................................................................................................................................... 18
ESTROGENS ...................................................................................................................................................... 18
CONTRACEPTIVES ............................................................................................................................................ 19
ALPHA-GLUCOSIDASE INHIBITORS.................................................................................................................. 23
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS........................................................................................... 24
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BIGUANIDES ..................................................................................................................................................... 24
COMBO ANTI-DIABETIC ......................................................................................................................................... 24
GLUCAGON .......................................................................................................................................................... 24
INCRETIN MIMETICS ........................................................................................................................................ 24
INSULINS .......................................................................................................................................................... 24
SULFONYLUREAS ............................................................................................................................................. 25
THIAZOLIDINEDIONES ..................................................................................................................................... 26
ANTITHYROID AGENTS .................................................................................................................................... 26
THYROID AGENTS ............................................................................................................................................ 26
OXYTOCICS ....................................................................................................................................................... 28
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS .......................................................................................... 28
ESTROGEN AGONIST-ANTAGONISTS .............................................................................................................. 28
GONADOTROPINS ........................................................................................................................................... 28
OSTEOPOROSIS ................................................................................................................................................ 28
OTHER MISCELLANEOUS THERAPEUTIC AGENTS ........................................................................................... 28
PITUITARY ........................................................................................................................................................ 29
SOMATOTROPIN AGONISTS ............................................................................................................................ 29
SOMATOTROPIN ANTAGONISTS ..................................................................................................................... 30
VITAMIN D........................................................................................................................................................ 30
CARDIOVASCULAR AGENTS ........................................................................................ 31
CARDIOTONIC AGENTS .................................................................................................................................... 31
CARDIAC DRUGS, MISCELLANEOUS ................................................................................................................ 31
NITRATES AND NITRITES .................................................................................................................................. 31
BETA-ADRENERGIC BLOCKING AGENTS .......................................................................................................... 32
CALCIUM-CHANNEL BLOCKING AGENTS ........................................................................................................ 33
ANTIARRHYTHMICS................................................................................................................................................ 35
ANGIOTENSIN II RECEPTOR ANTAGONISTS .................................................................................................... 36
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ....................................................................................... 36
CENTRAL ALPHA-AGONISTS ............................................................................................................................ 37
COMBO HYPERTENSION MEDS ....................................................................................................................... 37
DIRECT VASODILATORS ................................................................................................................................... 38
CARBONIC ANHYDRASE INHIBITORS (EENT) ................................................................................................... 38
LOOP DIURETICS .............................................................................................................................................. 38
POTASSIUM-SPARING DIURETICS ................................................................................................................... 39
THIAZIDE AND THIAZIDE-LIKE DIURETICS........................................................................................................ 39
ALPHA-ADRENERGIC AGONISTS...................................................................................................................... 39
EPINEPHRINE ................................................................................................................................................... 39
ANTILIPEMIC AGENTS, MISCELLANEOUS ........................................................................................................ 40
BILE ACID SEQUESTRANTS ............................................................................................................................... 40
CHOLESTEROL ABSORPTION INHIBITORS ....................................................................................................... 40
vii
FIBRIC ACID DERIVATIVES ................................................................................................................................ 40
PCSK9 INHIBITORS ........................................................................................................................................... 40
STATINS ............................................................................................................................................................ 40
PULMONARY HYPERTENSION ......................................................................................................................... 41
RESPIRATORY AGENTS ................................................................................................ 41
ANTI-HISTAMINES............................................................................................................................................ 41
NASAL STEROIDS .............................................................................................................................................. 42
COUGH ............................................................................................................................................................. 42
CYSTIC FIBROSIS ............................................................................................................................................... 42
INHALED ANTICHOLINERGICS ......................................................................................................................... 42
INHALED BETA-AGONISTS ............................................................................................................................... 43
INHALED COMBO ANTICHOLINERGICS/BETA-AGONISTS .............................................................................. 43
INHALED COMBO BETA-AGONISTS/ANTICHOLINERGICS .............................................................................. 43
INHALED COMBO STEROID/BETA-AGONISTS ................................................................................................. 43
INHALED STEROIDS .......................................................................................................................................... 43
LEUKOTRIENE MODIFIERS ............................................................................................................................... 44
MAST-CELL STABILIZERS .................................................................................................................................. 44
OTHER ASTHMA/COPD.................................................................................................................................... 44
GASTROINTESTINAL AGENTS ...................................................................................... 45
CATHARTICS AND LAXATIVES - (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY) .................... 45
ANTACIDS AND ADSORBENTS - (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY) ................... 45
ANTIMUSCARINICS/ANTISPASMODICS .......................................................................................................... 46
HISTAMINE H2-ANTAGONISTS ........................................................................................................................ 46
PROSTAGLANDINS ........................................................................................................................................... 47
PROTECTANTS.................................................................................................................................................. 47
PROTON-PUMP INHIBITORS............................................................................................................................ 47
ANTI-NAUSEA................................................................................................................................................... 48
DIGESTANTS ..................................................................................................................................................... 49
CHOLELITHOLYTIC AGENTS ............................................................................................................................. 49
INFLAMMATORY BOWEL AGENTS .................................................................................................................. 49
PHOSPHATE-REMOVING AGENTS................................................................................................................... 50
PROKINETIC AGENTS ....................................................................................................................................... 50
GENITOURINARY PRODUCTS ...................................................................................... 50
INCONTINENCE/URINARY FREQUENCY .......................................................................................................... 50
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)...................................................................................... 51
CONTRACEPTIVES (E.G. FOAMS, DEVICES) ..................................................................................................... 51
VAGINAL ANTI-INFECTIVES .............................................................................................................................. 51
ALKALINIZING AGENTS .................................................................................................................................... 52
viii
IRRIGATING SOLUTIONS .................................................................................................................................. 52
MISCL URINARY AGENTS ................................................................................................................................. 52
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT .......................................................................................... 52
CENTRAL NERVOUS SYSTEM DRUGS ........................................................................... 52
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. .............................................................................................. 52
BENZODIAZEPINES ................................................................................................................................................. 53
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) ............................................................................................... 53
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANT AGENTS ............................... 53
AMPHETAMINES.............................................................................................................................................. 53
METHYLPHENIDATES ....................................................................................................................................... 54
RESPIRATORY AND CNS STIMULANTS ............................................................................................................. 55
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC ...................................... 55
ALCOHOL DETERRENTS ................................................................................................................................... 55
ANTIDEMENTIA AGENTS ................................................................................................................................. 55
MULTIPLE SCLEROSIS ....................................................................................................................................... 55
SMOKING DETERRENTS ................................................................................................................................... 56
ANALGESICS AND ANESTHETICS ................................................................................. 57
ANALGESICS AND ANTIPYRETICS, MISC. (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY) .... 57
SALICYLATES (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY) ................................................ 57
OPIATE PARTIAL AGONISTS ............................................................................................................................. 57
OPIATES............................................................................................................................................................ 57
ANTI-TNF INHIBITORS ...................................................................................................................................... 60
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ........................................................................................... 60
MISCL BIOLOGIC............................................................................................................................................... 60
NONSTEROIDAL ANTI-INFLAMMATORY (NSAID) (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED
ONLY) ................................................................................................................................................................. 60
MIGRAINE PRODUCTS ..................................................................................................................................... 61
TRIPTANS.......................................................................................................................................................... 61
ANTIGOUT AGENTS ......................................................................................................................................... 62
URICOSURIC AGENTS ....................................................................................................................................... 62
NEUROMUSCULAR DRUGS ......................................................................................... 64
ANTICHOLINERGIC AGENTS (CNS)................................................................................................................... 64
ANTIPARKINSON .............................................................................................................................................. 64
DOPAMINERGICS ............................................................................................................................................. 64
CENTRAL NERVOUS SYSTEM AGENTS, MISC. .................................................................................................. 65
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT .......................................................................................... 65
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS ............................................................................................ 65
ix
NUTRITIONAL PRODUCTS ........................................................................................... 65
VITAMIN B COMPLEX ....................................................................................................................................... 65
MULTIVITAMIN PREPARATIONS ..................................................................................................................... 66
FLUORIDE ............................................................................................................................................................ 74
REPLACEMENT PREPARATIONS ...................................................................................................................... 75
CALORIC AGENTS
(MOST NUTRITIONAL SUPPLEMENTS COVERED WITH PRIOR AUTHORIZATION REQUIRED; NOT ALL PRODUCTS LISTED)................ 78
HEMATOLOGICAL AGENTS .......................................................................................... 78
HEMATOPOIETIC AGENTS ............................................................................................................................... 78
IRON PREPARATIONS....................................................................................................................................... 79
ANTICOAGULANTS .......................................................................................................................................... 80
HEMOSTATICS.................................................................................................................................................. 82
HEMORRHEOLOGIC AGENTS........................................................................................................................... 82
PLATELET-ACTING AGENTS ............................................................................................................................. 82
TOPICAL PRODUCTS.................................................................................................... 82
ALPHA-ADRENERGIC AGONISTS (EENT) .......................................................................................................... 82
ANTIBACTERIALS (EENT) .................................................................................................................................. 82
ANTIVIRALS (EENT) .......................................................................................................................................... 83
BETA-ADRENERGIC BLOCKING AGENTS (EENT) .............................................................................................. 83
CORTICOSTEROIDS (EENT)............................................................................................................................... 83
EENT DRUGS, MISCELLANEOUS ...................................................................................................................... 84
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS ............................................................................................... 84
MIOTICS ........................................................................................................................................................... 84
MYDRIATICS ..................................................................................................................................................... 84
PROSTAGLANDIN ANALOGS ............................................................................................................................ 85
LOCAL ANESTHETICS (EENT) ............................................................................................................................ 85
EENT ANTI-INFECTIVES, MISCELLANEOUS ...................................................................................................... 85
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE).......................................................................................... 85
ANTIPRURITICS AND LOCAL ANESTHETICS ..................................................................................................... 85
LOCAL ANTI-INFECTIVES, MISCELLANEOUS .................................................................................................... 85
SCABICIDES AND PEDICULICIDES..................................................................................................................... 86
SKIN AND MUCOUS MEMBRANE AGENTS, MISC. .......................................................................................... 86
TOPICAL CORTICOSTEROIDS............................................................................................................................ 86
MISCELLANEOUS PRODUCTS ...................................................................................... 88
EMETICS ........................................................................................................................................................... 88
OPIATE ANTAGONISTS..................................................................................................................................... 88
ADRENOCORTICAL INSUFFICIENCY ................................................................................................................. 88
MISCL OTHER ................................................................................................................................................... 89
x
DEVICES ............................................................................................................................................................ 89
IMMUNOSUPPRESSIVE AGENTS ..................................................................................................................... 91
POTASSIUM-REMOVING AGENTS ................................................................................................................... 92
xi
Drug Name
ANTI-INFECTIVES
Dosage Form/Strength
Drug Type
TAB 250MG
TAB 500MG
TAB 875MG
CHW 200MG
CHW 400MG
SUS 200/5ML
SUS 250/5ML
SUS 400/5ML
SUS 600/5ML
TAB 875MG
CAP 250MG
CAP 500MG
CHW 250MG
SUS 125/5ML
SUS 200/5ML
SUS 250/5ML
SUS 400/5ML
TAB ER
CAP 250MG
CAP 500MG
INJ 1.5GM
INJ 1-0.5GM
INJ 1.5GM
INJ 3GM
INJ 2-1GM
INJ 10-5GM
INJ 15GM
INJ 600000
INJ 1200000
INJ 2400000
CAP 250MG
CAP 500MG
INJ 5000000
TAB 250MG
TAB 500MG
SOL 125/5ML
SOL 250/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
PENICILLINS
AMOXICILLIN/CLAVULANATE POTASSIUM
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMPICILLIN
AMPICILLIN
AMP-SULBACTA
AMP-SULBACTA
AMP-SULBACTA
AMP-SULBACTA
AMP-SULBACTA
AMP-SULBACTA
AMP-SULBACTA
BICILLIN L-A
BICILLIN L-A
BICILLIN L-A
DICLOXACILLIN SODIUM
DICLOXACILLIN SODIUM
PENICILLIN G POTASSIUM
PENICILLN VK
PENICILLN VK
PENICILLN VK
PENICILLN VK
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
1
Drug Name
Drug Type
CAP 250MG
CAP 500MG
CAP 500MG
TAB 1GM
SUS 250/5ML
SUS 500/5ML
INJ 500MG
INJ 1GM
INJ 10GM
INJ 20GM
INJ 100GM
INJ 300GM
INJ 1GM/50ML
SOL 1GM
SOL 2GM
CAP 300MG
SUS 125/5ML
SUS 250/5ML
SUS 100/5ML
SUS 200/5ML
TAB 100MG
TAB 200MG
TAB 250MG
TAB 500MG
SUS 125/5ML
SUS 250/5ML
INJ 250MG
INJ 500MG
INJ 1GM
INJ 2GM
INJ 10GM
INJ 100GM
INJ DEX 1GM
INJ DEX 2GM
TAB 250MG
TAB 500MG
CAP 250MG
CAP 500MG
SUS 125/5ML
SUS 250/5ML
SUS 500/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Requirements
CEPHALOSPORINS
CEFACLOR
CEFACLOR
CEFADROXIL
CEFADROXIL
CEFADROXIL
CEFADROXIL
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN/DEXTROSE
CEFAZOLIN/DEXTROSE
CEFDINIR
CEFDINIR
CEFDINIR
CEFIXIME
CEFIXIME
CEFPODOXIME
CEFPODOXIME
CEFPROZIL
CEFPROZIL
CEFPROZIL
CEFPROZIL
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFTRIAXONE
CEFUROXIME
CEFUROXIME
CEPHALEXIN
CEPHALEXIN
CEPHALEXIN
CEPHALEXIN
SUPRAX
2
Drug Name
Drug Type
TAB 250MG
TAB 500MG
TAB 600MG
SUS 100/5ML
SUS 200/5ML
POW 1GM PAK
TAB 250MG
TAB 500MG
SUS 125/5ML
SUS 250/5ML
TAB 500MG ER
TAB 400MG
SUS 200/5ML
SUS 200-600
SUS 200/5ML
TAB 250MG EC
TAB 333MG EC
TAB 500MG EC
TAB 400MG
TAB 250MG BS
TAB 500MG BS
TAB 500MG EC
POW 1GM PAK
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Requirements
MACROLIDES
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
E.E.S. 400
E.E.S. GRANULES
E.S.P.
ERYPED
ERY-TAB
ERY-TAB
ERY-TAB
ERYTHROM ETH
ERYTHROMYCIN
ERYTHROMYCIN
PCE
ZITHROMAX
TETRACYCLINES
DOXYCYCLINE MONOHYDRATE
CAP 50MG
Generic
DOXYCYCLINE MONOHYDRATE
CAP 100MG
Generic
MONDOXYNE NL
CAP 50MG
Generic
MONDOXYNE NL
VIBRAMYCIN
CAP 100MG
SYP 50MG/5ML
Generic
Brand
SUS 250MG/5
SUS 500MG/5
TAB 100MG
TAB 250MG
TAB 500MG
TAB 750MG
INJ 200MG
INJ 400MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 14 day supply per 60
days
days
days
days
AR PA required > 6
FLUOROQUINOLONES
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
3
Drug Name
LEVOFLOXACIN
LEVOFLOXACIN
LEVOFLOXACIN
LEVOFLOXACIN
MOXIFLOXACIN
TAB 250MG
TAB 500MG
TAB 750MG
SOL 25MG/ML
TAB 400MG
Drug Type
Generic
Generic
Generic
Generic
Generic
CAP 250MG
TAB 210MG
TAB 650MG
Generic
Brand
Brand
NEB 300/4ML
TAB 500MG
NEB 300/5ML
INJ 80MG/2ML
INJ 40MG/ML
Brand
Generic
Generic
Generic
Generic
TAB 100MG
TAB 400MG
TAB 100MG
TAB 300MG
TAB 500MG
CAP 150MG
CAP 150MG
CAP 300MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
INJ 50MG
POW
TAB 50MG
TAB 100MG
TAB 150MG
TAB 200MG
SUS 10MG/ML
SUS 40MG/ML
CAP 250MG
CAP 500MG
SUS 125/5ML
CAP 100MG
TAB 200MG
TAB 100 MG DR
SUSP 40MG/ML
TAB 500000
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Requirements
AMEBICIDES
PAROMOMYCIN
YODOXIN
YODOXIN
AMINOGLYCOSIDES
BETHKIS
NEOMYCIN
TOBRAMYCIN
TOBRAMYCIN
TOBRAMYCIN
QL 280ml per 60 days
ANTITUBERCULOSIS AGENTS
ETHAMBUTOL
ETHAMBUTOL
ISONIAZID
ISONIAZID
PYRAZINAMIDE
RIFABUTIN
RIFAMPIN
RIFAMPIN
ANTIFUNGALS
AMPHOTERICIN
BIO-STATIN
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCYTOSINE
FLUCYTOSINE
GRISEOFULVIN
ITRACONAZOLE
KETOCONAZOLE
NOXAFIL
NOXAFIL
NYSTATIN
PA
PA
PA required > 6
PA Required
PA
PA
4
Drug Name
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
NYSTATIN
SPORANOX
TERBINAFINE
VORICONAZOLE
VORICONAZOLE
VORICONAZOLE
VORICONAZOLE
POW
SUS 100000
POW 10BU
POW 50MU
POW 150MU
POW 500MU
POW 1BU
POW 2BU
POW 5BU
CRE 100000
OIN 100000
SOL 10MG/ML
TAB 250MG
TAB 50MG
TAB 200MG
SUS 40MG/ML
INJ 200MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Requirements
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
3 DAY VAGINAL
3 DAY VAGINAL
ATHLETE FOOT
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
DESENEX
JOCK ITCH
MICADERM
MICONAZOLE
MICONAZOLE
MICONAZOLE CRE 2%
MICONAZOLE POW
MICONAZOLE 3
MICONAZOLE 7
MICONAZOLE 7
MICONAZOLE 7
MICRO GUARD
NEOSPORIN AF
PODACTIN
CRE 2%
CRE 4%
CRE 1%
CRE 1%
CRE 1% VAG
CRE 2%
CRE 3 DAY
TRO 10MG
LOZ 10MG
CRE GRX 1%
CRE 1%
CRE 1%
CRE 2%
3 KIT COMBO PK
SUP 100MG
CRE 2%
POW
CRE 4%
CRE TUBE/KIT
CRE 2%
SUP 100MG
CRE 2%
CRE 2% JOCK
CRE 2%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA
5
Drug Name
RINGWORM
SM ANTIFUNGL
SOOTHE&COOL
TINEACIDE
VAGISTAT-3
CRE 1%
CRE 1%
CRE INZO 2%
CRE
KIT COMBO PK
Drug Type
Generic
Generic
Generic
Generic
Generic
Requirements
TAB 100MG
CAP 100MG
SYP 50MG/5ML
TAB 100MG
CAP 200MG
TAB 400MG
TAB 800MG
SUS 200/5ML
TAB 125MG
TAB 250MG
TAB 500MG
TAB 500MG
TAB 1GM
SOL 50MG/ML
TAB 450MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 10MG
SOL .05MG/ML
INJ 75MG/ML
Generic
Brand
Generic
DAKLINZA
TAB 30MG
Brand
DAKLINZA
ENTECAVIR
ENTECAVIR
TAB 60MG
TAB 0.5MG
TAB 1MG
Brand
Generic
Generic
EPCLUSA
TAB 400-100
Brand
PA QL 1 per day;
84 tabs per life
PA QL 1 per day;
84 tabs per life
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day; 84 tabs
per life
TAB 90-400MG
INJ 9MCG
INJ 15MCG
TAB 200MG
INJ 180MCG/M
INJ PROCLICK
INJ
KIT 120MCG
KIT 50MCG RP
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
PA QL 1 per day; 84 tabs
per life
PA
PA
PA
PA QL 4mls per 30 days
PA
PA
ANTIVIRALS
AMANTADINE
AMANTADINE
AMANTADINE
RIMANTADINE
ACYCLOVIR
ACYCLOVIR
ACYCLOVIR
ACYCLOVIR
FAMCICLOVIR
FAMCICLOVIR
FAMCICLOVIR
VALACYCLOVIR
VALACYCLOVIR
VALGANCICLOVIR
VALGANCICLOVIR
PA
PA
PA
PA required > 6
HEPATITIS AGENTS
ADEFOVIR DIPIVOXIL
BARACLUDE
CIDOFOVIR
HARVONI
INFERGEN
INFERGEN
MODERIBA
PEGASYS
PEGASYS
PEGASYS
PEG-INTRON
PEG-INTRON
PA QL 1 per day
PA QL 20 per day
6
Drug Name
PEG-INTRON
PEG-INTRON
PEG-INTRON
PEG-INTRON
PEG-INTRON
PEG-INTRON
PEG-INTRON
RIBASPHERE
RIBASPHERE
RIBAVIRIN
RIBAVIRIN
KIT 50MCG
KIT 80MCG
KIT 80MCG RP
KIT 120 RP
KIT 120MCG
KIT 150MCG
KIT 150 RP
CAP 200MG
TAB 200MG
CAP 200MG
TAB 200MG
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Requirements
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
SOVALDI
TYZEKA
TAB 400MG
TAB 600MG
Brand
Brand
PA QL 1 per day;
84 tabs per life
PA QL 1 per day
ZEPATIER
TAB 50-100MG
Brand
PA QL 1 per day;
84 tabs per life
HIV
ABACAVIR
SULFATE/LAMIVUDINE/ZIDOVUDINE
ABACAVIR
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN
CRIXIVAN
DESCOVY
DIDANOSINE
DIDANOSINE
DIDANOSINE
DIDANOSINE
EDURANT
EMTRIVA
EMTRIVA
EPIVIR HBV
EPZICOM
EVOTAZ
FUZEON
GENVOYA
INTELENCE
INTELENCE
INTELENCE
TAB 300MG-150MG300MG
TAB 300MG
CAP 250MG
SOL
TAB
TAB 200MG-25MG300MG
CAP 200MG
CAP 400MG
TAB 200/25MG
CAP 125MG
CAP 200MG
CAP 250MG
CAP 400MG
TAB 25MG
CAP 200MG
SOL 10MG/ML
SOL 5MG/ML
TAB 600-300
TAB 300-150
INJ 90MG
TAB 150-150-200-10 MG
TAB 100MG
TAB 200MG
TAB 25MG
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
QL 1 per day
QL 1 per day
QL 1 per day
7
Drug Name
INVIRASE
INVIRASE
ISENTRESS
ISENTRESS
ISENTRESS
ISENTRESS
KALETRA
KALETRA
KALETRA
LAMIVUDINE/ZIDOVUDINE
LAMIVUDINE
LAMIVUDINE
LAMIVUDINE
LAMIVUDINE
LEXIVA
LEXIVA
NEVIRAPINE
NEVIRAPINE
NEVIRAPINE
NORVIR
NORVIR
NORVIR
ODEFSY
PREZCOBIX
PREZISTA
PREZISTA
PREZISTA
PREZISTA
PREZISTA
PREZISTA
RESCRIPTOR
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
REYATAZ
REYATAZ
SELZENTRY
SELZENTRY
STAVUDINE
STAVUDINE
STAVUDINE
CAP 200MG
TAB 500MG
CHEW 100MG
CHEW 25MG
POW 100MG
TAB 400MG
TAB 100-25MG
TAB 200-50MG
SOL
TAB 150-300
TAB 150MG
TAB 300MG
SOL 10MG/ML
TAB 100MG
TAB 700MG
SUS 50MG/ML
SUS 50MG/5ML
TAB 200MG
TAB 400MG ER
CAP 100MG
TAB 100MG
SOL 80MG/ML
TAB 200-25-25MG
TAB 800-150
TAB 75MG
TAB 150MG
TAB 400MG
TAB 600MG
TAB 800MG
SUS 100MG/ML
TAB 100 MG
TAB 200MG
INJ 10MG/ML
CAP 150MG
CAP 200MG
CAP 300MG
POW 50MG
TAB 150MG
TAB 300MG
CAP 15MG
CAP 20MG
CAP 30MG
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Requirements
QL 1 per day
QL 1 per day
QL 1 per day
8
Drug Name
STAVUDINE
STAVUDINE
STRIBILD
SUSTIVA
SUSTIVA
SUSTIVA
TIVICAY
TIVICAY
TIVICAY
TRIUMEQ
TRUVADA
TRUVADA
TRUVADA
TRUVADA
TYBOST
VIDEX
VIDEX
VIRACEPT
VIRACEPT
VIRAMUNE
VIRAMUNE
VIREAD
VIREAD
VIREAD
VIREAD
VIREAD
VITEKTA
VITEKTA
ZIAGEN
ZIDOVUDINE
ZIDOVUDINE
ZIDOVUDINE
CAP 40MG
SOL 1MG/ML
TAB
CAP 200MG
CAP 50MG
TAB 600MG
TAB 10MG
TAB 25MG
TAB 50MG
TAB
TAB 100-150
TAB 133-200
TAB 167-250
TAB 200-300
TAB 150MG
SOL 2GM
SOL 4GM
TAB 250MG
TAB 625MG
SUS 50MG/5ML
XR TAB 100MG
TAB 150MG
TAB 200MG
TAB 250MG
TAB 300MG
POW 40MG/GM
TAB 150MG
TAB 85MG
SOL 20MG/ML
CAP 100MG
TAB 300MG
SYP 50MG/5ML
Drug Type
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Requirements
RELENZA
TAMIFLU
TAMIFLU
TAMIFLU
MIS DISKHALE
CAP 30MG
CAP 45MG
CAP 75MG
Brand
Brand
Brand
Brand
QL 20 per 30 days
QL 40 per 365 days
QL 20 per 365 days
QL 20 per 365 days
TAMIFLU
SUS 6MG/ML
Brand
AR PA required > 8;
QL 240mls per 365 days
TAB 62.5-25
TAB 250-100
Generic
Generic
QL 1 per day
QL 1 per day
QL 1 per day
QL 1 per day
QL 1 per day
QL 1 per day
QL 1 per day
AR PA required > 18
QL 1 per day
AR PA required > 6
QL 1 per day
QL 1 per day
INFLUENZA AGENTS
ANTIMALARIALS
ATOVAQUONE/PROGUANIL
ATOVAQUONE/PROGUANIL
9
Drug Name
CHLOROQUINE
CHLOROQUINE
COARTEM
DARAPRIM
HYDROXYCHLOR
MEFLOQUINE
TAB 250MG
TAB 500MG
TAB 20-120MG
TAB 25MG
TAB 200MG
TAB 250MG
Drug Type
Generic
Generic
Brand
Brand
Generic
Generic
Requirements
TAB 200MG
TAB 600MG
TAB 3MG
TAB MEDICINE
SUS 50MG/ML
SUS PINWORM
Brand
Brand
Generic
Generic
Generic
Generic
PA required
SUS 750/5ML
CAP 75MG
CAP 150MG
CAP 300MG
SOL 75MG/5ML
CAP 50MG
TAB 600MG
INJ 2MG/ML
CAP 375MG
TAB 250MG
TAB 500MG
INH 300MG
INJ 25MG
CAP 25MG
CAP 50MG
CAP 100MG
SUS 25MG/5ML
CAP 100MG
INJ 300MG
TAB 800-160
TAB 400-80MG
SUS 200-40/5
SUS 200-40/5
INJ 50MG
INJ 100MG/ML
TAB 100MG
CAP 125MG
CAP 250MG
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
ANTHELMINTICS
ALBENZA
BILTRICIDE
IVERMECTIN
PINWORM
PIN-X
REESES MED
ANTI-INFECTIVE AGENTS: MISC
ATOVAQUONE
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
IMPAVIDO
LINEZOLID
LINEZOLID
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
NEBUPENT
NEUTREXIN
NITROFURANTOIN MACROCRYSTALS
NITROFURANTOIN
NITROFURANTOIN
PENTAM 300
SMZ/TMP DS
SMZ-TMP
SMZ-TMP
SULFATRIM PD
SYNAGIS
SYNAGIS
TRIMETHOPRIM
VANCOMYCIN
VANCOMYCIN
AR PA required > 6
PA Required QL 3 per day
QL 14 day supply per fill
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
PA QL 5 fills per 6 months
PA QL 5 fills per 6 months
10
Drug Name
VANCOMYCIN
VANCOMYCIN
VANCOMYCIN
VANCOMYCIN
VANCOMYCIN
VANCOMYCIN
VANCOMYCIN/DEXTROSE
VANCOMYCIN/DEXTROSE
VANCOMYCIN/DEXTROSE
INJ 500MG
INJ 750MG
INJ 1 GM
INJ 1000MG
INJ 5GM
INJ 10GM
INJ 500MG/100ML
INJ 750MG/150ML
INJ 1GM/200ML
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
SOL 10GM/15
SOL 10GM/15
SOL 10GM/15
SOL 10GM/15
SOL 20GM/30
TAB 550MG
Generic
Generic
Generic
Generic
Generic
Brand
PA
INH 75MG
Brand
PA 84mls per 60 days
HEPATIC ENCEPHALOPATHY
CONSTULOSE
ENULOSE
GENERLAC
LACTULOSE
LACTULOSE
XIFAXAN
MONOBACTAMS
CAYSTON
BIOLOGICALS (VACCINES)
VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN
ADACEL
AFLURIA
AFLURIA
AFLURIA
AFLURIA
BEXSERO
BOOSTRIX
DAPTACEL
ENGERIX-B
ENGERIX-B
FLUARIX PF
FLUARIX QUAD
FLUARIX QUAD
FLUBLOK
FLUBLOK
FLUCELVAX
FLUCELVAX
FLUCELVAX
FLULAVAL
INJ
INJ 2014-15
INJ 2015-16
INJ PF 14-15
INJ PF 15-16
INJ
INJ
INJ
INJ 10/0.5ML
INJ 20MCG/ML
INJ 2014-15
INJ 2014-15
INJ 2015-16
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
AR <19 covered by VFC
AR covered for ages 19-25
SOL 2014-15
Brand
AR <19 covered by VFC;
Not covered > 49
Brand
Brand
Brand
Brand
Brand
Not covered > 49
SOL 2015-16
INJ 2014-15
INJ 2015-16
INJ 2013-14
INJ 2014-15
11
Drug Name
FLULAVAL QUAD
FLULAVAL QUAD
INJ 2014-15
INJ 2015-16
Drug Type
Brand
Brand
Requirements
FLUMIST QUAD
SUS 2014-15
Brand
Not covered > 49
FLUMIST QUAD
FLUVIRIN
FLUVIRIN
FLUVIRIN PF
FLUZONE
FLUZONE
FLUZONE HD
FLUZONE HD
FLUZONE QUAD
FLUZONE QUAD
FLUZONE SPLT
FLUZONE SPLT
GARDASIL 9
HAVRIX
HAVRIX
INFANRIX
MENACTRA
MENOMUNE
MENVEO
M-M-R II
SUS 2015-16
INJ 2014-15
INJ 2015-16
INJ 2014-15
INJ INTRADRM
INJ PF 14-15
INJ PF 14-15
INJ PF 15-16
INJ 15-16
INJ 2015-16
INJ 2014-15
INJ 2015-16
INJ
INJ 720UNIT
INJ 1440UNIT
INJ
INJ
INJ A/C/Y/W
INJ
INJ
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Not covered > 49
AR < 65 not covered
AR < 65 not covered
AR Covered for ages 19-26
AR Covered for ages 19-55
PNEUMOVAX 23
PREVNAR 13
RECOMBIVA HB
RECOMBIVA HB
RECOMBIVA HB
TRUMENBA
VAQTA
VAQTA
VARIVAX
ZOSTAVAX
INJ 25/0.5
INJ
INJ 5MCG/0.5
INJ 10MCG/ML
INJ 40MCG/ML
INJ
INJ 25/0.5ML
INJ 50UNT/ML
INJ
INJ
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
QL 0.5ml per day
AR Covered ages 19-25
AR < 60 not covered
TAB 5MG
TAB 10MG
TAB 15MG
TAB 25MG
Generic
Generic
Generic
Generic
ANTI-NEOPLASTICS
ANTIDOTES
LEUCOVOR CA
LEUCOVOR CA
LEUCOVOR CA
LEUCOVOR CA
12
Drug Name
ANTIMETABOLITES
MERCAPTOPURINE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
Drug Type
TAB 50MG
INJ 100/4ML
INJ 1GM
INJ 1GM/40ML
INJ 200/8ML
INJ 250/10ML
INJ 25MG/ML
INJ 50MG/2ML
TAB 2.5MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
INJ 2MU/0.5
TAB 10MG
TAB 2.5MG
TAB 5MG
TAB 7.5MG
TAB 2MG
TAB 2MG
TAB 3MG
TAB 5MG
CAP 150MG
INJ 5MU/ML
TAB 2MG
TAB 1MG
TAB 50MG
TAB 100MG
TAB 500MG
TAB 20MG
TAB 40MG
TAB 60MG
TAB 150MG
TAB 500MG
TAB 100MG
TAB 300MG
KIT 60MG
KIT 100MG
KIT 140MG
TAB 20MG
CAP 25MG
CAP 50MG
CAP 200MG
CAP 300MG
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Requirements
ANTINEOPLASTIC AGENTS
ACTIMMUNE
AFINITOR
AFINITOR
AFINITOR
AFINITOR
AFINITOR DIS
AFINITOR DIS
AFINITOR DIS
AFINITOR DIS
ALECENSA
ALFERON N
ALKERAN
ANASTROZOLE
BICALUTAMIDE
BOSULIF
BOSULIF
CABOMETYX
CABOMETYX
CABOMETYX
CAPECITABINE
CAPECITABINE
CAPRELSA
CAPRELSA
COMETRIQ
COMETRIQ
COMETRIQ
COTELLIC
CYCLOPHOSPH
CYCLOPHOSPH
DROXIA
DROXIA
PA
PA QL 1 per day
PA QL 1 per day
PA QL 2 per day
PA QL 1 per day
PA
PA
PA
PA
PA QL 8 per day
PA
PA
PA
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 2 per day
PA QL 1 per day
PA QL 3 per day
PA QL 2 per day
PA QL 4 per day
PA
13
Drug Name
DROXIA
ELIGARD
ELIGARD
EMCYT
ERIVEDGE
ETOPOSIDE
EXEMESTANE
FARESTON
FARYDAK
FARYDAK
FARYDAK
FLUTAMIDE
GILOTRIF
GILOTRIF
GILOTRIF
HEXALEN
HYCAMTIN
HYCAMTIN
HYDROXYUREA
IBRANCE
IBRANCE
IBRANCE
ICLUSIG
ICLUSIG
IMATINIB MESYLATE
IMATINIB MESYLATE
IMBRUVICA
INLYTA
INLYTA
INTRON A
INTRON A
INTRON A
INTRON A
IRESSA
LENVIMA
LENVIMA
LENVIMA
LENVIMA
LENVIMA
LENVIMA
LETROZOLE
LEUKERAN
CAP 400MG
INJ 22.5MG
INJ 7.5MG
CAP 140MG
TAB 150MG
CAP 50MG
TAB 25MG
TAB 60MG
CAP 10MG
CAP 15MG
CAP 20MG
CAP 125MG
TAB 20MG
TAB 30MG
TAB 40mg
CAP 50MG
CAP 0.25MG
CAP 1MG
CAP 500MG
CAP 100MG
CAP 125MG
CAP 75MG
TAB 15MG
TAB 45MG
TAB 100MG
TAB 400MG
CAP 140MG
TAB 1MG
TAB 5MG
INJ 10MU
INJ 18MU
INJ 25MU
INJ 50MU
TAB 250MG
CAP 8MG
CAP 10MG
CAP 14 MG
CAP 18MG
CAP 20 MG
CAP 24MG
TAB 2.5MG
TAB 2MG
Drug Type
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Requirements
PA
PA
PA QL 1 per day
PA
PA
PA
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 0.75/day
PA QL 0.75/day
PA QL 0.75/day
PA
PA
PA QL 1 per day
PA QL 1 per day
PA
PA QL 8 per day
PA QL 4 per day
PA
PA
PA
PA
PA QL 1 per day
PA QL 2 per day
PA QL 1 per day
PA QL 2 per day
PA QL 3 per day
PA QL 2 per day
PA QL 3 per day
14
Drug Name
LEUPROLIDE
LOMUSTINE
LOMUSTINE
LOMUSTINE
LONSURF
LONSURF
LUPANETA
LUPANETA
LUPR DEP-PED
LUPR DEP-PED
LUPR DEP-PED
LUPR DEP-PED
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LYNPARZA
LYSODREN
MATULANE
MEGESTROL AC
MEGESTROL AC
MEGESTROL AC
MEGESTROL AC
MEKINIST
MEKINIST
MYLERAN
NEXAVAR
NILANDRON
NINLARO
NINLARO
NINLARO
ODOMZO
POMALYST
POMALYST
POMALYST
POMALYST
REVLIMID
REVLIMID
REVLIMID
REVLIMID
INJ 1MG/0.2
CAP 100MG
CAP 10MG
CAP 40MG
TAB 15-6.14MG
TAB 20-8.19MG
KIT 11.25-5
KIT 3.75-5
INJ 11.25MG
INJ 15MG
INJ 30MG
INJ 7.5MG
INJ 11.25MG
INJ 22.5MG
INJ 3.75MG
INJ 30MG
INJ 45MG
INJ 7.5MG
CAP 50MG
TAB 500MG
CAP 50MG
SUS 400MG/10
SUS 40MG/ML
TAB 20MG
TAB 40MG
TAB 0.5MG
TAB 2MG
TAB 2MG
TAB 200MG
TAB 150MG
CAP 2.3MG
CAP 3MG
CAP 4MG
CAP 200MG
CAP 1MG
CAP 2MG
CAP 3MG
CAP 4MG
CAP 2.5 MG
CAP 5 MG
CAP 10 MG
CAP 20 MG
Drug Type
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
PA
PA
PA
PA
PA
PA
PA
PA QL 1 per day
PA
PA QL 1 per 90 days
PA QL 1 per 90 days
PA
PA
PA
PA
PA 8 per day
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
PA QL 3 per day
PA QL 1 per day
PA QL 4 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA
PA
PA
PA
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
15
Drug Name
REVLIMID
SPRYCEL
SPRYCEL
SPRYCEL
SPRYCEL
SPRYCEL
SPRYCEL
STIVARGA
SUTENT
SUTENT
SUTENT
SUTENT
TABLOID
TAFINLAR
TAFINLAR
TAGRISSO
TAGRISSO
TAMOXIFEN
TAMOXIFEN
TARCEVA
TARCEVA
TARCEVA
TASIGNA
TEMOZOLOMIDE
TEMOZOLOMIDE
TEMOZOLOMIDE
TEMOZOLOMIDE
TEMOZOLOMIDE
TEMOZOLOMIDE
TRETINOIN
TYKERB
VENCLEXTA
VENCLEXTA
VENCLEXTA
VENCLEXTA
VOTRIENT
XALKORI
XTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYDELIG
CAP 25 MG
TAB 100MG
TAB 140MG
TAB 20MG
TAB 50MG
TAB 70MG
TAB 80MG
TAB 40 MG
CAP 12.5MG
CAP 25MG
CAP 37.5MG
CAP 50MG
TAB 40MG
CAP 50MG
CAP 75MG
TAB 40MG
TAB 80MG
TAB 10MG
TAB 20MG
TAB 100MG
TAB 150MG
TAB 25MG
CAP 200MG
CAP 100MG
CAP 140MG
CAP 180MG
CAP 20MG
CAP 250MG
CAP 5MG
CAP 10MG
TAB 250MG
TAB 10MG
TAB 50MG
TAB 100MG
TAB STARTER PACK
TAB 200MG
CAP 200MG
TAB 40MG
TAB 240MG
CAP 100MG
TAB 100MG
TAB 150MG
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
PA QL 1 per day
PA
PA
PA
PA
PA
PA
PA QL 4 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 4 per day
PA QL 4 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA QL 1 per day
PA
PA
PA
PA
PA
PA
PA
PA QL 5 per day
PA QL 4 per day
PA QL 4 per day
PA QL 4 per day
PA QL 1 fill per 180 days
PA QL 4 per day
PA
PA
PA QL 8 per day
PA
PA QL 2 per day
PA QL 2 per day
16
Drug Name
ZYKADIA
ZYTIGA
CAP 150MG
TAB 250MG
Drug Type
Brand
Brand
INJ 400/ML
POW CAPROATE
INJ 150MG/ML
TAB 2.5MG
TAB 5MG
TAB 10MG
TAB 5MG
CAP 100MG
CAP 200MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ELX 0.5/5ML
TAB 20MG
ELX 0.5/5ML
TAB 0.5MG
TAB 0.75MG
TAB 1MG
TAB 1.5MG
TAB 2MG
TAB 4MG
TAB 6MG
ELX 0.5/5ML
CON 1MG/ML
SOL 0.5/5ML
TAB 0.1MG
TAB 10MG
TAB 5MG
TAB 20MG
TAB 4MG
TAB 8MG
TAB 16MG
TAB 32MG
PAK 4MG
SOL 5MG/5ML
SOL 5MG/5ML
SOL 15MG/5ML
SYP 15MG/5ML
TAB 1MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
PA QL 5 per day
PA QL 4 per day
PROGESTINS
DEPO-PROVERA
HYDROXYPROG
MEDROXYPR AC
MEDROXYPR AC
MEDROXYPR AC
MEDROXYPR AC
NORETHIN ACE
PROGESTERONE
PROGESTERONE
ENDOCRINE AND METABOLIC DRUGS
QL 1 injection per 90 days
ADRENALS
BAYCADRON
DELTASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
FLUDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
METHYLPREDNISOLONE
METHYLPREDNISOLONE
METHYLPREDNISOLONE
METHYLPREDNISOLONE
METHYLPREDNISOLONE
PREDNISOLONE SODIUM PHOSPHATE
PREDNISOLONE SODIUM PHOSPHATE
PREDNISOLONE
PREDNISOLONE
PREDNISONE
17
Drug Name
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
TAB 2.5MG
TAB 5MG
TAB 10MG
TAB 20MG
TAB 50MG
SOL 5MG/5ML
PAK 5MG
PAK 10MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
DIS 4MG/24HR
DIS 2MG/24HR
CAP 50MG
CAP 100MG
CAP 200MG
INJ 100MG/ML
INJ 200MG/ML
OIN 2%
TAB 10MG
TAB 2.5MG
GEL 1%(50MG)
INJ 100MG/ML
INJ 200MG/ML
INJ 200MG/ML
GEL 1%(25MG)
GEL 1%(50MG)
GEL PUMP 1%
INJ 250MG/ML
GEL 1%(50MG)
GEL PUMP 1%
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
PA
PA
DIS .05/.14
DIS .05/.25
CRE 0.1MG/GM
TAB 0.5MG
TAB 1MG
TAB 2MG
Brand
Brand
Brand
Generic
Generic
Generic
AR PA required >64
AR PA required >64
AR PA required >64
ESTRADIOL (Generic Climara)
PATCH WKLY 0.025MG
Generic
QL 4 per month AR PA
required >64
PATCH WKLY
0.0375MG
Generic
required >64
PATCH WKLY 0.05MG
Generic
required >64
ANDROGENS
ANDRODERM
ANDRODERM
DANAZOL
DANAZOL
DANAZOL
DEPO-TESTOSTERONE
DEPO-TESTOSTERONE
FIRST-TESTOSTERONE
METHITEST
OXANDROLONE
TESTIM
TESTOSTERONE CYPIONATE
TESTOSTERONE CYPIONATE
TESTOSTERONE ENATHATE
TESTOSTERONE
TESTOSTERONE
TESTOSTERONE
TESTOSTERONE
VOGELXO
VOGELXO
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ESTROGENS
COMBIPATCH
COMBIPATCH
ESTRACE VAG
ESTRADIOL
ESTRADIOL
ESTRADIOL
18
Drug Name
Drug Type
Requirements
PATCH WKLY 0.06MG
Generic
required >64
PATCH WKLY 0.075MG
Generic
required >64
PATCH WKLY 0.1MG
Generic
required >64
ESTRADIOL (Generic Vivelle Dot)
PATCH TW 0.025MG
Generic
QL 8 per month; AR PA
required >64
PATCH TW 0.0375MG
Generic
required >64
PATCH TW 0.05MG
Generic
required >64
PATCH TW 0.075MG
Generic
required >64
PATCH TW 0.1MG
Generic
required >64
ESTRADIOL VALERATE
INJ 10MG/ML
Generic
ST (patches); AR PA
required >64
ESTRADIOL VALERATE
INJ 200MG/5
Generic
ST (patches); AR PA
required >64
ESTRADIOL VALERATE
INJ 20MG/ML
Generic
ST (patches); AR PA
required >64
ST (patches); AR PA
required >64
ESTRADIOL VALERATE
INJ 40MG/ML
Generic
DEPO-ESTRADIOL
ESTRING
ESTROPIPATE
ESTROPIPATE
ESTROPIPATE
MENEST
MENEST
MENEST
MENEST
ORTHO-EST
ORTHO-EST
PREMARIN VAG
VAGIFEM
INJ 5MG/ML
MIS 2MG
TAB 0.75MG
TAB 1.5MG
TAB 3MG
TAB 0.3MG
TAB 0.625MG
TAB 1.25MG
TAB 2.5MG
TAB 0.625
TAB 1.25
CRE 0.625MG
TAB 10MCG
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
TAB 1.5MG
TAB
TAB 1/35
Generic
Generic
Generic
ST (patches); AR PA
required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
QL 1 per day
CONTRACEPTIVES
AFTERA
ALTAVERA
ALYACEN
19
Drug Name
ALYACEN
AMETHIA
AMETHIA LO
AMETHYST
APRI
ARANELLE
ASHLYNA
AUBRA
AVIANE
AZURETTE
BALZIVA
BEYAZ
BRIELLYN
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CESIA
CHATEAL
CRYSELLE-28
CYCLAFEM
CYCLAFEM
CYRED
DASETTA
DASETTA
DAYSEE
DEBLITANE
DELYLA
DESO/ETHINYL
DROSPIR/ETHI
DROSPIRENONE
ECONTRA EZ
ELINEST
ELLA
EMOQUETTE
ENPRESSE-28
ENSKYCE
ERRIN
ESTARYLLA
FALLBACK
FALMINA
GIANVI
TAB 7/7/7
TAB
TAB
TAB 90-20MCG
TAB
TAB
TAB
TAB 0.1-0.02
TAB
TAB 28 DAY
TAB
TAB
TAB
TAB 0.35MG
TAB
TAB
PAK
PAK
TAB 0.15/30
TAB 28 TABS
TAB 1/35
TAB 7/7/7
TAB
TAB 1/35
TAB 7/7/7
TAB
TAB 0.35MG
TAB 0.1-0.02
TAB ESTRADIO
TAB 3-0.03MG
TAB ETHY EST
TAB 1.5MG
TAB
TAB 30MG
TAB
TAB
TAB
TAB 0.35MG
TAB 0.25-35
TAB 1.5MG
TAB
TAB 3-0.02MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 3 tabs per 31 days
20
Drug Name
GILDAGIA
GILDESS
GILDESS
GILDESS 24
GILDESS FE
GILDESS FE
HEATHER
IMPLANON
INTROVALE
JENCYCLA
JOLESSA
JOLIVETTE
JULEBER
JUNEL 1.5/30
JUNEL 1/20
JUNEL FE
JUNEL FE
JUNEL FE 24
KARIVA
KELNOR
KIMIDESS
KURVELO
LARIN
LARIN
LARIN 24
LARIN FE
LARIN FE
LAYOLIS FE
LEENA
LESSINA
LEVO-ETH EST
LEVONEST
LEVONOR/ETHI
LEVONOR/ETHI
LEVONORGESTR
LEVONORGESTR
LEVORA-28
LO LOESTRIN
LO MINASTRIN
LOMEDIA 24
LORYNA
LOW-OGESTREL
TAB 0.4-35
TAB 1/20
TAB 1.5/30
TAB FE 1/20
TAB 1/20
TAB 1.5/30
TAB 0.35MG
IMP 68MG
TAB
TAB 0.35MG
TAB
TAB 0.35MG
TAB
TAB
TAB
TAB 1/20
TAB 1.5/30
TAB 1/20
TAB 28 DAY
TAB 1/35
TAB
TAB 0.15/30
TAB 1/20
TAB 1.5/30
TAB FE 1/20
TAB 1/20
TAB 1.5/30
CHW
TAB
TAB
TAB 90-20MCG
TAB
TAB 0.1-0.02
TAB ESTRADIO
TAB 0.75MG
TAB 1.5MG
TAB 0.15/30
TAB
PAK FE
TAB FE
TAB 3-0.02MG
TAB
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Requirements
21
Drug Name
LUTERA
LYZA
MARLISSA
MICROGESTIN
MICROGESTIN
MICROGESTIN
MICROGESTIN
MINASTRIN 24
MONO-LINYAH
MONONESSA
MY WAY
MYZILRA
NECON
NECON
NECON
NECON
NECON
NEXT CHOICE
NIKKI
NORA-BE
NORETH/ETHIN
NORETH/ETHIN
NORETH/ETHIN
NORETHINDRON
NORGEST/ETHI
NORGEST/ETHI
NORINYL
NORLYROC
NORTREL
NORTREL
NORTREL
NUVARING
OCELLA
OGESTREL
OPCICON
ORSYTHIA
ORTHO TRI-CYCLN LO
PHILITH
PIMTREA
PIRMELLA
PIRMELLA
PLAN B
TAB
TAB 0.35MG
TAB 0.15/30
TAB 1/20
TAB 1.5/30
TAB FE 1/20
TAB FE1.5/30
CHW FE
TAB 0.25-35
TAB
TAB 1.5MG
TAB
TAB 0.5/35
TAB 1/35
TAB 1/50-28
TAB 10/11-28
TAB 7/7/7
TAB 1.5MG
TAB 3-0.02MG
TAB 0.35MG
TAB 1/20
CHW FE
TAB FE 1/20
TAB 0.35MG
TAB 0.25/35
TAB ESTRADIO
TAB 1+50-28
TAB 0.35MG
TAB 0.5/35
TAB 1/35
TAB 7/7/7
MIS
TAB 3-0.03MG
TAB
TAB 1.5MG
TAB
TAB
TAB 0.4-35
TAB
TAB 1/35
TAB 7/7/7
TAB 0.75MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Requirements
22
Drug Name
PLAN B
PORTIA-28
PREVIFEM
QUARTETTE
QUASENSE
RECLIPSEN
SAFYRAL
SETLAKIN
SHAROBEL
SOLIA
SPRINTEC 28
SRONYX
SYEDA
TAKE ACTION
TARINA FE
TILIA FE
TRI-ESTARYLL
TRI-LEGEST
TRI-LINYAH
TRINESSA
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
VELIVET
VESTURA
VIORELE
VYFEMLA
WERA
WYMZYA FE
XULANE
ZARAH
ZENCHENT
ZENCHENT FE
ZOVIA
ZOVIA
TAB 1.5MG
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB 0.35MG
TAB
TAB 28 DAY
TAB
TAB 3-0.03MG
TAB 1.5MG
TAB 1/20
TAB
TAB
TAB FE
TAB
TAB
TAB
TAB
TAB
PAK
TAB 3-0.02MG
TAB
TAB 0.4-35
TAB 0.5/35
CHW 0.4MG-35
DIS 150-35
TAB 3-0.03MG
TAB
CHW 0.4MG-35
TAB 1/35E
TAB 1/50E
Drug Type
Brand
Generic
Generic
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
TAB 50MG
TAB 100MG
TAB 25MG
Generic
Generic
Generic
QL 3 per day
QL 3 per day
QL 3 per day
ALPHA-GLUCOSIDASE INHIBITORS
ACARBOSE
ACARBOSE
ACARBOSE
23
Drug Name
Drug Type
Requirements
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
DEX4
DEX4
CHW 1GM
GLUCOSE CHW QK DISLV
CHW 4GM various
flavors
CHW 1GM
GEL 40%
GEL 40%
GEL 77.4%
SUS 50MG/ML
Generic
Brand
Generic
Generic
Brand
Brand
METFORMIN
METFORMIN
METFORMIN
METFORMIN
METFORMIN
TAB 500MG
TAB 850MG
TAB 1000MG
TAB 500MG ER
TAB 750MG ER
Generic
Generic
Generic
Generic
Generic
GLIPIZIDE/METFORMIN
GLIPIZIDE/METFORMIN
GLIPIZIDE/METFORMIN
GLYBURIDE/METFORMIN
GLYBURIDE/METFORMIN
GLYBURIDE/METFORMIN
PIOGLITAZONE/METFORMIN
PIOGLITAZONE/METFORMIN
TAB 2.5-250M
TAB 2.5-500M
TAB 5-500MG
TAB 1.25-250
TAB 2.5-500
TAB 5-500MG
TAB 15-500MG
TAB 15-850MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
INJ HYPOKIT
KIT 1MG
Brand
Brand
INJ
INJ 10MCG
INJ 5MCG
INJ 30MG
INJ 50MG
INJ 18MG/3ML
Brand
Brand
Brand
Brand
Brand
Brand
INJ 100/ML
KWIK INJ 100/ML
KWIK INJ 200/ML
MIX INJ 50/50
MIX INJ 50/50KWP
Brand
Brand
Brand
Brand
Brand
GLUCOSE
GLUCOSE BITS
GLUTOSE 15
GLUTOSE 45
INSTA-GLUCOS
PROGLYCEM
Brand
Brand
BIGUANIDES
COMBO ANTI-DIABETIC
AR PA required > 64
AR PA required > 64
AR PA required > 64
QL 3 per day
QL 3 per day
GLUCAGON
GLUCAGEN
GLUCAGON
INCRETIN MIMETICS
BYDUREON
BYETTA
BYETTA
TANZEUM
TANZEUM
VICTOZA
PA QL 0.143 per day
PA QL 2.4 per month
PA QL 1.2 per month
PA QL 0.143 per day
PA QL 0.143 per day
PA QL 0.3 per day
INSULINS
HUMALOG
HUMALOG
HUMALOG
HUMALOG
HUMALOG
PA
PA
PA
24
Drug Name
HUMALOG
HUMALOG
HUMULIN
HUMULIN
HUMULIN
HUMULIN
HUMULIN
HUMULIN
HUMULIN
LANTUS
LANTUS
LEVEMIR
LEVEMIR
LEVEMIR
NOVOLIN
NOVOLIN
NOVOLIN
NOVOLIN
NOVOLIN
NOVOLIN
NOVOLOG
NOVOLOG
NOVOLOG
NOVOLOG
NOVOLOG
RELION
TOUJEO
MIX INJ 75/25KWP
MIX SUS 75/25
INJ 70/30
INJ 70/30KWP
N INJ U-100
N INJ U-100KWP
N PN INJ U-100
PEN INJ 70/30
R INJ U-100
INJ 100/ML
INJ SOLOSTAR
INJ
INJ FLEXPEN
INJ FLEXTOUC
INJ 70/30
N INJ RELION
N INJ U-100
R INJ RELION
R INJ U-100
70/30 INJ RELION
INJ 100/ML
INJ FLEXPEN
INJ PENFILL
MIX INJ 70/30
MIX INJ FLEXPEN
R INJ 100/ML
SOLO INJ 300IU/ML
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
PA
TAB 1MG
TAB 2MG
TAB 4MG
TAB 5MG
TAB 10MG
TAB 2.5MG
TAB 5MG
TAB 10MG
TAB 2.5MG
TAB 5MG
TAB 10MG
TAB 1.5MG
TAB 3MG
TAB 6MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 2 per day
QL 2 per day
QL 2 per day
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
SULFONYLUREAS
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE ER
GLIPIZIDE ER
GLIPIZIDE XL
GLIPIZIDE XL
GLIPIZIDE XL
GLYBURID MCR
GLYBURID MCR
GLYBURID MCR
AR PA required > 64
AR PA required > 64
AR PA required > 64
25
Drug Name
GLYBURIDE
GLYBURIDE
GLYBURIDE
TOLAZAMIDE
TAB 1.25MG
TAB 2.5MG
TAB 5MG
TAB 250MG
Drug Type
Generic
Generic
Generic
Generic
Requirements
AR PA required > 64
AR PA required > 64
AR PA required > 64
TAB 15MG
TAB 30MG
TAB 45MG
Generic
Generic
Generic
QL 1 per day
QL 1 per day
QL 1 per day
TAB 5MG
TAB 10MG
TAB 50MG
SOL 1GM/ML
Generic
Generic
Generic
Brand
TAB 15MG
TAB 30MG
TAB 60MG
TAB 90MG
TAB 120MG
TAB 180MG
TAB 240MG
TAB 300MG
TAB 25MCG
TAB 50MCG
TAB 75MCG
TAB 88MCG
TAB 100MCG
TAB 112MCG
TAB 125MCG
TAB 137MCG
TAB 150MCG
TAB 175MCG
TAB 200MCG
TAB 300MCG
INJ 100MCG
INJ 200MCG
INJ 500MCG
TAB 25MCG
TAB 50MCG
TAB 75MCG
TAB 88MCG
TAB 100MCG
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
THIAZOLIDINEDIONES
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
ANTITHYROID AGENTS
METHIMAZOLE
METHIMAZOLE
PROPYLTHIOUR
SSKI
THYROID AGENTS
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOTHYROXINE
LEVOXYL
LEVOXYL
LEVOXYL
LEVOXYL
LEVOXYL
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
QL 90 day fill available
26
Drug Name
LEVOXYL
LEVOXYL
LEVOXYL
LEVOXYL
LEVOXYL
LEVOXYL
LIOTHYRONINE
LIOTHYRONINE
LIOTHYRONINE
NP THYROID
NP THYROID
NP THYROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID DIRECT
UNITHROID
UNITHROID
TAB 112MCG
TAB 125MCG
TAB 137MCG
TAB 150MCG
TAB 175MCG
TAB 200MCG
TAB 5MCG
TAB 25MCG
TAB 50MCG
TAB 30MG
TAB 60MG
TAB 90MG
TAB 25MCG
TAB 50MCG
TAB 75MCG
TAB 88MCG
TAB 100MCG
TAB 112MCG
TAB 125MCG
TAB 137MCG
TAB 150MCG
TAB 175MCG
TAB 200MCG
TAB 300MCG
TAB 60MG
TAB 30MG
TAB 15MG
TAB 120MG
TAB 180MG
TAB 25MCG
TAB 50MCG
TAB 75MCG
TAB 88MCG
TAB 100MCG
TAB 112MCG
TAB 125MCG
TAB 150MCG
TAB 175MCG
TAB 200MCG
TAB 300MCG
TAB 25MCG
TAB 50MCG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
AR PA required > 64
AR PA required > 64
AR PA required > 64
27
Drug Name
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
TAB 75MCG
TAB 88MCG
TAB 100MCG
TAB 112MCG
TAB 125MCG
TAB 137MCG
TAB 150MCG
TAB 175MCG
TAB 200MCG
TAB 300MCG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 0.2MG
Generic
Requirements
OXYTOCICS
METHYLERGON
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
CABERGOLINE
TAB 0.5MG
Generic
QL 20 per month
TAB 60MG
Generic
INJ 10000UNT
INJ 10000UNT
INJ 10000UNT
Generic
Generic
Generic
PA
PA
PA
TAB 5MG
TAB 10MG
TAB 35MG
TAB 40MG
TAB 70MG
SPR 200/ACT
TAB 200MG
TAB 400MG
TAB 150MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 1 per day
QL 1 per day
QL 4 per 30 days
QL 1 per day
QL 4 per 30 days
QL 3.7mls per 30 days
RISEDRONATE
TAB 5MG
Generic
RISEDRONATE
TAB 30MG
Generic
RISEDRONATE
TAB 35MG
Generic
RISEDRONATE
TAB 150MG
Generic
ESTROGEN AGONIST-ANTAGONISTS
RALOXIFENE
GONADOTROPINS
CHORIONIC GONADOTROPIN
NOVAREL
PREGNYL
OSTEOPOROSIS
ALENDRONATE
ALENDRONATE
ALENDRONATE
ALENDRONATE
ALENDRONATE
CALCITONIN
ETIDRONATE DISODIUM
ETIDRONATE DISODIUM
IBANDRONATE
QL 1 per 30 day
ST (Alendronate)
QL 1 per day
ST (Alendronate)
QL 1 per day
ST (Alendronate)
QL 4 per 30 days
ST (Alendronate)
QL 4 per 30 days
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
FISH OIL
FISH OIL
FISH OIL
CAP 1000MG
CAP 1200MG
CAP 500MG
Generic
Generic
Generic
28
Drug Name
FISH OIL
FISH OIL
FISH OIL
KUVAN
KUVAN
KUVAN
LEVOCARNITINE
LEVOCARNITINE
OMEGA III
SAM-E.P.A.
SENSIPAR
SENSIPAR
SENSIPAR
SUPER DHA
SUPER OMEGA
SUPER OMEGA
SUPER OMEGA
CAP 300MG
CAP 435MG
CAP 900MG
POW 100MG
POW 500MG
TAB 100MG
TAB 330MG
SOL 1GM/10ML
CAP EPA+DHA
CAP 500MG
TAB 30MG
TAB 60MG
TAB 90MG
CAP GEMS
CAP 500MG
CAP -3
CAP-EPA
Drug Type
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Requirements
TAB 0.1MG
TAB 0.2MG
INJ 4MCG/ML
SOL 0.01%
SPR 0.01%
Generic
Generic
Generic
Generic
Generic
PA
PA
PA
PA
PA
INJ 5MG
INJ 12MG
INJ 0.2MG
INJ 0.4MG
INJ 0.6MG
INJ 0.8MG
INJ 1MG
INJ 1.2MG
INJ 1.4MG
INJ 1.6MG
INJ 1.8MG
INJ 2MG
INJ 5MG
INJ 6MG
INJ 12MG
INJ 24MG
INJ 40MG/4ML
INJ 5/1.5ML
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PITUITARY
DESMOPRESSIN
DESMOPRESSIN
DESMOPRESSIN
DESMOPRESSIN
DESMOPRESSIN
SOMATOTROPIN AGONISTS
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
GENOTROPIN
HUMATROPE
HUMATROPE
HUMATROPE
HUMATROPE
INCRELEX
NORDITROPIN
29
Drug Name
NORDITROPIN
NORDITROPIN
NORDITROPIN
NUTROPIN
NUTROPIN AQ
NUTROPIN AQ
OCTREOTIDE
OCTREOTIDE
OMNITROPE
OMNITROPE
OMNITROPE
SIGNIFOR
SIGNIFOR
SIGNIFOR
TEV-TROPIN
ZOMACTON
ZOMACTON
INJ 10/1.5ML
INJ 15/1.5ML
INJ 30/3ML
INJ 10MG
INJ NUSPIN 5
INJ 10MG/2ML
INJ 100MCG
INJ 1000MCG
INJ 5/1.5ML
INJ 10/1.5ML
INJ 5.8MG
INJ 0.3MG/ML
INJ 0.6MG/ML
INJ 0.9MG/ML
INJ 5MG
INJ 5MG
INJ 10MG
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
INJ 10MG
INJ 15MG
INJ 20MG
INJ 25MG
INJ 30MG
Brand
Brand
Brand
Brand
Brand
PA
PA
PA
PA
PA
CAP 0.25MCG
CAP 0.5MCG
SOL 1MCG/ML
CHW 400UNIT
CHW 400UNIT
CHW 400UNIT
CHW 400UNIT
LIQ 400UNIT
LIQ 400UNIT
DRO 8000/ML
SOL 8000/ML
LIQ 400UNIT
TAB 5MG
CAP 1 MCG
CAP 2 MCG
CAP 4 MCG
TAB 4000UNIT
CHW D 1000IU
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Brand
Generic
SOMATOTROPIN ANTAGONISTS
SOMAVERT
SOMAVERT
SOMAVERT
SOMAVERT
SOMAVERT
VITAMIN D
CALCITRIOL
CALCITRIOL
CALCITRIOL
CHILD VIT D
D 400
D-3 GUMMY
D3 KIDS
D-VI-SOL
D-VITA
ERGOCALCIFER
ERGOCALCIFER
JUST D
MEPHYTON
PARICALCITOL
PARICALCITOL
PARICALCITOL
THERA-D
VITAJOY DALY
PA QL 15 per 31 days
30
Drug Name
VITAMIN D
VITAMIN D
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VITAMIN D3
VIT D GUMMIE
CHW 400UNIT
TAB 5000IU
TAB 1000UNIT
TAB 2000UNIT
TAB 3000UNIT
TAB 400UNIT
TAB 5000UNIT
TAB 50000UNIT
CAP 400UNIT
CAP 5000UNIT
CAP 10000UNT
CAP 2000UNIT
CHW 1000UNIT
CHW 400UNIT
DRO 400UNIT
CHW 400UNIT
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
DIGITEK
TAB 0.125MG
Generic
DIGITEK
DIGOX
TAB 0.25MG
TAB 0.125MG
Generic
Generic
QL 90 day fill available; PA
required > 64
CARDIOVASCULAR AGENTS
CARDIOTONIC AGENTS
DIGOX
DIGOXIN
TAB 0.25MG
TAB 0.125MG
Generic
Generic
required > 64
DIGOXIN
DIGOXIN
TAB 0.25MG
SOL 50MCG/ML
Generic
Generic
required > 64
TAB 5MG
TAB 7.5MG
TAB 24-26MG
TAB 49-51MG
TAB 97-103MG
TAB 500MG
TAB 1000MG
Brand
Brand
Brand
Brand
Brand
Brand
Brand
CAP 40MG
TAB 40MG
TAB 5MG
TAB 10MG
Brand
Brand
Generic
Generic
CARDIAC DRUGS, MISCELLANEOUS
CORLANOR
CORLANOR
ENTRESTO
ENTRESTO
ENTRESTO
RANEXA
RANEXA
QL 2 per day
QL 2 per day
PA QL 2 per day
PA QL 2 per day
PA QL 2 per day
NITRATES AND NITRITES
DILATRATE SR
ISORDIL
ISOSORBIDE DINITRATE
31
Drug Name
ISOSORBIDE MONONITRATE
MINITRAN
MINITRAN
MINITRAN
MINITRAN
NITRO-BID
NITRO-DUR
NITRO-DUR
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
TAB 20MG
TAB 30MG
TAB 40MG ER
TAB 10MG
TAB 20MG
TAB 30MG ER
TAB 60MG ER
TAB 120MG ER
DIS 0.1MG/HR
DIS 0.2MG/HR
DIS 0.4MG/HR
DIS 0.6MG/HR
OIN 2%
DIS 0.3MG/HR
DIS 0.8MG/HR
INJ 5MG/ML
DIS 0.1MG/HR
DIS 0.2MG/HR
DIS 0.4MG/HR
DIS 0.6MG/HR
SPR 0.4MG
SPR LINGUAL
SUB 0.3MG
SUB 0.4MG
SUB 0.6MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
BETA-ADRENERGIC BLOCKING AGENTS
ACEBUTOLOL
ACEBUTOLOL
ATENOLOL
ATENOLOL
ATENOLOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
LABETALOL
LABETALOL
LABETALOL
METOPROLOL TARTRATE
METOPROLOL TARTRATE
METOPROLOL TARTRATE
METOPROLOL
CAP 200MG
CAP 400MG
TAB 25MG
TAB 50MG
TAB 100MG
TAB 3.125MG
TAB 6.25MG
TAB 12.5MG
TAB 25MG
TAB 100MG
TAB 200MG
TAB 300MG
TAB 25MG
TAB 50MG
TAB 100MG
TAB 25MG ER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 90 day supply available
32
Drug Name
METOPROLOL
METOPROLOL
METOPROLOL
NADOLOL
NADOLOL
NADOLOL
PINDOLOL
PINDOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
PROPRANOLOL
SORINE
SORINE
SORINE
SORINE
SOTALOL AF
SOTALOL AF
SOTALOL AF
SOTALOL HCL
SOTALOL HCL
SOTALOL HCL
SOTALOL HCL
TAB 50MG ER
TAB 100MG ER
TAB 200MG ER
TAB 20MG
TAB 40MG
TAB 80MG
TAB 10MG
TAB 5MG
CAP 60MG ER
CAP 80MG ER
CAP 120MG ER
CAP 160MG ER
TAB 10MG
TAB 20MG
TAB 40MG
TAB 60MG
TAB 80MG
SOL 20MG/5ML
SOL 40MG/5ML
TAB 80MG
TAB 120MG
TAB 160MG
TAB 240MG
TAB 80MG
TAB 120MG
TAB 160MG
TAB 80MG
TAB 120MG
TAB 160MG
TAB 240MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
AR PA required >6
AR PA required >6
CALCIUM-CHANNEL BLOCKING AGENTS
AFEDITAB
AFEDITAB
AMLODIPINE
AMLODIPINE
AMLODIPINE
CARTIA XT
CARTIA XT
CARTIA XT
CARTIA XT
DILT-CD
DILT-CD
TAB 30MG CR
TAB 60MG CR
TAB 2.5MG
TAB 5MG
TAB 10MG
CAP 120/24HR
CAP 180/24HR
CAP 240/24HR
CAP 300/24HR
CAP 120MG
CAP 180MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
33
Drug Name
DILT-CD
DILT-CD
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILTIAZEM
DILT-XR
DILT-XR
DILT-XR
DILTZAC
DILTZAC
DILTZAC
DILTZAC
DILTZAC
NIFEDIAC CC
NIFEDIAC CC
NIFEDICAL XL
NIFEDICAL XL
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
TAZTIA XT
CAP 240MG
CAP 300MG
TAB 30MG
TAB 60MG
TAB 90MG
TAB 120MG
CAP 60MG ER
CAP 90MG ER
CAP 120MG ER
CAP 180MG ER
CAP 240MG ER
CAP 120MG/24
CAP 180MG/24
CAP 240MG/24
CAP 300MG/24
CAP 360MG/24
CAP 360MG ER
CAP 420MG/24
CAP 120MG CD
CAP 180MG CD
CAP 240MG CD
CAP 300MG ER
CAP 300MG CD
CAP 360MG CD
CAP 120MG
CAP 180MG
CAP 240MG
CAP 120MG/24
CAP 180MG/24
CAP 240MG/24
CAP 300MG/24
CAP 360MG/24
TAB 30MG ER
TAB 60MG ER
TAB 30MG
TAB 60MG
CAP 10MG
CAP 20MG
TAB 30MG ER
TAB 60MG ER
TAB 90MG ER
CAP 120MG/24
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
AR PA required > 64
AR PA required > 64
34
Drug Name
TAZTIA XT
TAZTIA XT
TAZTIA XT
TAZTIA XT
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
VERAPAMIL
CAP 180MG/24
CAP 240MG/24
CAP 300MG/24
CAP 360MG/24
TAB 40MG
TAB 80MG
TAB 120MG
TAB 120MG ER
TAB 180MG ER
TAB 240MG ER
INJ 2.5MG/ML
CAP 100MG ER
CAP 120MG ER
CAP 120MG SR
CAP 180MG ER
CAP 180MG SR
CAP 200MG ER
CAP 240MG ER
CAP 240MG SR
CAP 300MG ER
CAP 360MG SR
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
INJ 6MG/2ML
INJ 12MG/4ML
TAB 200MG
INJ 50MG/ML
INJ 150MG/3M
CAP 100MG
CAP 150MG
CAP 125MCG
CAP 250MCG
CAP 500MCG
TAB 50MG
TAB 100MG
TAB 150MG
INJ 20MG/ML
CAP 150MG
CAP 200MG
CAP 250MG
TAB 400MG
CAP 100MG CR
CAP 150MG CR
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Requirements
ANTIARRHYTHMICS
ADENOSINE
ADENOSINE
AMIODARONE
AMIODARONE
AMIODARONE
DISOPYRAMIDE
DISOPYRAMIDE
DOFETILIDE
DOFETILIDE
DOFETILIDE
FLECAINIDE
FLECAINIDE
FLECAINIDE
LIDOCAINE
MEXILETINE
MEXILETINE
MEXILETINE
MULTAQ
NORPACE
NORPACE
AR PA required > 64
AR PA required > 64
PA QL 2 per day
35
Drug Name
PACERONE
PROCAINAMIDE
PROCAINAMIDE
PROPAFENONE
PROPAFENONE
PROPAFENONE
QUINIDINE GLUCONATE
QUINIDINE GLUCONATE
QUINIDINE SULFATE
QUINIDINE SULFATE
TAB 200MG
INJ 100MG/ML
INJ 500MG/ML
TAB 150MG
TAB 225MG
TAB 300MG
TAB 324MG CR
TAB 324MG ER
TAB 200MG
TAB 300MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA
PA
PA
PA
PA
PA
PA
ANGIOTENSIN II RECEPTOR ANTAGONISTS
CANDESARTAN
CANDESARTAN
CANDESARTAN
CANDESARTAN
CANDESARTAN/HCTZ
CANDESARTAN/HCTZ
CANDESARTAN/HCTZ
IRBESARTAN
IRBESARTAN
IRBESARTAN
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN/HCTZ
VALSARTAN/HCTZ
VALSARTAN/HCTZ
VALSARTAN/HCTZ
VALSARTAN/HCTZ
TAB 4MG
TAB 8MG
TAB 16MG
TAB 32MG
TAB 16-12.5MG
TAB 32-12.5MG
TAB 32-25MG
TAB 75MG
TAB 150MG
TAB 300MG
TAB 25MG
TAB 100MG
TAB 40MG
TAB 80MG
TAB 160MG
TAB 320MG
TAB 80-12.5MG
TAB 160-12.5MG
TAB 160-25MG
TAB 320-12.5MG
TAB 320-25MG
PA
PA
PA
PA
PA
PA
PA
PA
PA
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
BENAZEPRIL
BENAZEPRIL
BENAZEPRIL
BENAZEPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
ENALAPRIL
TAB 5MG
TAB 10MG
TAB 20MG
TAB 40MG
TAB 12.5MG
TAB 25MG
TAB 50MG
TAB 100MG
TAB 2.5MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
36
Drug Name
ENALAPRIL
ENALAPRIL
ENALAPRIL
FOSINOPRIL
FOSINOPRIL
FOSINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
QUINAPRIL
QUINAPRIL
QUINAPRIL
QUINAPRIL
QUINAPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
TAB 5MG
TAB 10MG
TAB 20MG
TAB 10MG
TAB 20MG
TAB 40MG
TAB 2.5MG
TAB 5MG
TAB 10MG
TAB 20MG
TAB 30MG
TAB 40MG
TAB 5MG
TAB 5MG
TAB 10MG
TAB 20MG
TAB 40MG
CAP 10MG
CAP 1.25MG
CAP 2.5MG
CAP 5MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 0.1MG
TAB 0.2MG
TAB 0.3MG
TAB 1MG
TAB 2MG
TAB 250MG
TAB 500MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 50-25MG
TAB 100-25MG
TAB 5-6.25
TAB 10-12.5
TAB 20-12.5
TAB 20-25MG
Generic
Generic
Generic
Generic
Generic
Generic
TAB 2.5/6.25
Generic
TAB 5-6.25MG
Generic
TAB 10/6.25
Generic
Requirements
CENTRAL ALPHA-AGONISTS
CLONIDINE
CLONIDINE
CLONIDINE
GUANFACINE
GUANFACINE
METHYLDOPA
METHYLDOPA
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
COMBO HYPERTENSION MEDS
ATENOLOL/CHLORTHALIDONE
ATENOLOL/CHLORTHALIDONE
BENAZEPRIL/HYDROCHLOROTHIAZIDE
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE
BISOPROLOL
BISOPROLOL
37
Drug Name
CAPTOPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE
IRBESARTAN/HYDROCHLOROTHIAZIDE
IRBESARTAN/HYDROCHLOROTHIAZIDE
LISINOPRIL/HYDROCHLOROTHIAZIDE
LOSARTAN/HYDROCHLOROTHIAZIDE
METOPROLOL/HYDROCHLOROTHIAZIDE
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE
TRIAMTERENE/HYDROCHLOROTHIAZIDE
TAB 25-15MG
TAB 50-15MG
TAB 50-25MG
TAB 5-12.5MG
TAB 10-25MG
TAB 300-12.5
TAB 150-12.5
TAB 10-12.5
TAB 20-12.5
TAB 20-25MG
TAB 50-12.5
TAB 100-12.5
TAB 100-25
TAB 50-25MG
TAB 100-25MG
TAB 100-50MG
TAB 25/25
CAP 37.5-25
TAB 37.5-25
TAB 75-50MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 10MG
TAB 25MG
TAB 50MG
TAB 100MG
TAB 2.5MG
TAB 10MG
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
DIRECT VASODILATORS
HYDRALAZINE
HYDRALAZINE
HYDRALAZINE
HYDRALAZINE
MINOXIDIL
MINOXIDIL
CARBONIC ANHYDRASE INHIBITORS (EENT)
ACETAZOLAMIDE
ACETAZOLAMIDE
ACETAZOLAMIDE
AZOPT
DORZOLAMIDE/TIMOLOL MALEATE
DORZOLAMIDE
METHAZOLAMIDE
METHAZOLAMIDE
TAB 125MG
TAB 250MG
CAP 500MG ER
SUS 1% OP
SOL 22.3-6.8
SOL 2% OP
TAB 25MG
TAB 50MG
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
TAB 0.5MG
TAB 1MG
TAB 2MG
INJ 0.25/ML
TAB 20MG
Generic
Generic
Generic
Generic
Generic
LOOP DIURETICS
BUMETANIDE
BUMETANIDE
BUMETANIDE
BUMETANIDE
FUROSEMIDE
38
Drug Name
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
TORSEMIDE
TORSEMIDE
TORSEMIDE
TORSEMIDE
TAB 40MG
TAB 80MG
INJ 10MG/ML
INJ 20MG/2ML
INJ 40MG/4ML
INJ 100/10ML
SOL 8MG/ML
SOL 10MG/ML
TAB 5MG
TAB 10MG
TAB 20MG
TAB 100MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 5-50
TAB 5MG
CAP 50MG
CAP 100MG
TAB 25MG
TAB 50MG
TAB 100MG
Generic
Generic
Brand
Brand
Generic
Generic
Generic
TAB 25MG
TAB 50MG
TAB 100MG
CAP 12.5MG
TAB 25MG
TAB 50MG
TAB 1.25MG
TAB 2.5MG
TAB 2.5MG
TAB 5MG
TAB 10MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 2.5MG
TAB 5MG
TAB 10MG
Generic
Generic
Generic
INJ 0.15MG
INJ 0.3MG
INJ 0.15MG
INJ 0.3MG
Brand
Brand
Brand
Brand
Requirements
POTASSIUM-SPARING DIURETICS
AMILORIDE/HYDROCHLOROTHIAZIDE
AMILORIDE
DYRENIUM
DYRENIUM
SPIRONOLACTONE
SPIRONOLACTONE
SPIRONOLACTONE
THIAZIDE AND THIAZIDE-LIKE DIURETICS
CHLORTHALIDONE
CHLORTHALIDONE
CHLORTHALIDONE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
INDAPAMIDE
INDAPAMIDE
METOLAZONE
METOLAZONE
METOLAZONE
ALPHA-ADRENERGIC AGONISTS
MIDODRINE
MIDODRINE
MIDODRINE
EPINEPHRINE
ADRENACLICK
ADRENACLICK
AUVI-Q
AUVI-Q
39
Drug Name
EPINEPHRINE
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN-JR
INJ 0.15MG
INJ 0.3MG
INJ 0.3MG
INJ 2-PAK
Drug Type
Generic
Generic
Brand
Brand
Requirements
ANTILIPEMIC AGENTS, MISCELLANEOUS
NIACIN
NIACIN ER
NIACIN ER
NIACIN ER
TAB 500MG ER
TAB 500MG
TAB 1000MG
TAB 750MG
Generic
Generic
Generic
Generic
POW 4GM
POW 4GM LITE
TAB 1GM
GRA 5GM
POW 4GM
POW 4GM PK
Generic
Generic
Generic
Generic
Generic
Generic
BILE ACID SEQUESTRANTS
CHOLESTYRAM
CHOLESTYRAM
COLESTIPOL
COLESTIPOL
PREVALITE
PREVALITE
CHOLESTEROL ABSORPTION INHIBITORS
ZETIA
TAB 10MG
Brand
TAB 48MG
TAB 54MG
TAB 160MG
CAP 43MG
CAP 67MG
CAP 134MG
CAP 45MG DR
TAB 600MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SYRINGE 150MG/ML
PEN 150MG/ML
SYRINGE 75MG/ML
PEN 75MG/ML
Brand
Brand
Brand
Brand
TAB 10MG
TAB 20MG
TAB 40MG
TAB 80MG
TAB 10MG
TAB 20MG
TAB 40MG
TAB 10MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA
FIBRIC ACID DERIVATIVES
FENOFIBRATE
FENOFIBRATE
FENOFIBRATE
FENOFIBRATE
FENOFIBRATE
FENOFIBRATE
FENOFIBRIC
GEMFIBROZIL
PCSK9 INHIBITORS
PRALUENT
PRALUENT
PRALUENT
PRALUENT
PA QL .072 per day
PA QL .072 per day
PA QL .072 per day
PA QL .072 per day
STATINS
ATORVASTATIN
ATORVASTATIN
ATORVASTATIN
ATORVASTATIN
LOVASTATIN
LOVASTATIN
LOVASTATIN
PRAVASTATIN
40
Drug Name
PRAVASTATIN
PRAVASTATIN
PRAVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
TAB 20MG
TAB 40MG
TAB 80MG
TAB 5MG
TAB 10MG
TAB 20MG
TAB 40MG
TAB 80MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
TAB 20MG
TAB 0.5MG
TAB 1MG
TAB 1.5MG
TAB 2MG
TAB 2.5MG
INJ 0.5MG
INJ 1.5MG
TAB 5MG
TAB 10MG
INJ 1MG/ML
INJ 2.5MG/ML
INJ 5MG/ML
INJ 10MG/ML
TAB 20MG
TAB 62.5MG
TAB 125MG
INJ 0.5MG
INJ 1.5MG
SOL 10MCG/ML
SOL 20MCG/ML
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Generic
Brand
Brand
PA QL 2 per day
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA QL 3 per day
PA
PA
PA
PA
PA
PA
TAB 2MG
TAB 10MG
TAB 50MG
TAB 4MG
CAP 25MG
TAB 25MG
LIQ 12.5/5ML
TAB 12MG CR
TAB DYE-FREE
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 1 per day
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
PULMONARY HYPERTENSION
ADCIRCA
ADEMPAS
ADEMPAS
ADEMPAS
ADEMPAS
ADEMPAS
EPOPROSTENOL
EPOPROSTENOL
LETAIRIS
LETAIRIS
REMODULIN
REMODULIN
REMODULIN
REMODULIN
SILDENAFIL
TRACLEER
TRACLEER
VELETRI
VELETRI
VENTAVIS
VENTAVIS
RESPIRATORY AGENTS
ANTI-HISTAMINES
ALA-HIST IR
ALAVERT
ALER-DRYL
CHLORPHENIRAMINE MALEATE
DIPHENHYDRAMINE
DIPHENHYDRAMINE
DIPHENHYDRAMINE
CHLORPHENIRAMINE MALEATE
DIPHENHYDRAMINE
41
Drug Name
DIPHENHYDRAMINE
DIPHENHYDRAMINE
DIPHENHYDRAMINE
DIPHENHYDRAMINE
CETIRIZINE
CETIRIZINE
CETIRIZINE
CETIRIZINE
CETIRIZINE
CETIRIZINE
CYPROHEPTADINE
CYPROHEPTADINE
DIABET TUSS
DIPHENHYDRAMINE
LORATADINE
LORATADINE
LORATADINE
LIQ 12.5/5ML
CHW 12.5MG
ELX 12.5/5ML
LIQ 50/20ML
TAB 5MG
TAB 10MG
SYP 5MG/5ML
SYP 1MG/ML
SOL 1MG/ML
SOL 5MG/5ML
TAB 4MG
SYP 2MG/5ML
SYP ALLERGY
INJ 50MG/ML
TAB 10MG
SOL 5MG/5ML
SYP 5MG/5ML
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
QL 1 per day
QL 1 per day
SPR 0.025%
SPR 50MCG
SPR 55MCG/AC
Generic
Generic
Brand
ST
CAP 100MG
CAP 200MG
Generic
Generic
TAB 150MG
PAK 50MG
PAK 75MG
NEB 3%
TAB 200-125
NEB 7%
SOL 1MG/ML
NEB 0.9%
NEB 3%
NEB 7%
Brand
Brand
Brand
Generic
Brand
Generic
Brand
Generic
Generic
Generic
HFA AER 17MCG
CAP HANDIHLR
SPR RESPIMAT
Brand
Brand
Brand
AR PA required > 64
AR PA required > 64
QL 1 per day
NASAL STEROIDS
FLUNISOLIDE
FLUTICASONE
NASACORT ALR
COUGH
BENZONATATE
BENZONATATE
CYSTIC FIBROSIS
KALYDECO
KALYDECO
KALYDECO
NEBUSAL
ORKAMBI
PULMOSAL
PULMOZYME
SODIUM CHLORIDE
SODIUM CHLORIDE
SODIUM CHLORIDE
PA QL 2 per day
PA QL 2 per day
PA QL 2 per day
PA QL 4 tabs per day
QL 150 per 31 days
INHALED ANTICHOLINERGICS
ATROVENT
SPIRIVA
SPIRIVA
QL 1 per day
QL 2 puffs per day
42
Drug Name
Drug Type
Requirements
NEB 0.083%
NEB 0.5%
NEB 0.63MG/3
NEB 1.25MG/3
AER
AER HFA
AER 50MCG
AER
AER
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
ST
Brand
Brand
PA QL 2 per day
PA QL 0.134 per day
INHALED BETA-AGONISTS
ALBUTEROL
ALBUTEROL
ALBUTEROL
ALBUTEROL
PROAIR HFA
PROVENTIL
SEREVENT DISKUS
VENTOLIN HFA
XOPENEX HFA
INHALED COMBO ANTICHOLINERGICS/BETA-AGONISTS
ANORO ELLIPTA
STIOLTO
AER 62.5-25
AER RESPIMAT
INHALED COMBO BETA-AGONISTS/ANTICHOLINERGICS
COMBIVENT
COMBIVENT
IPRATROPIUM/
IPRATROPIUM/
AER
AER RESPIMAT
SOL ALBUTER
SOL SULFATE
Brand
Brand
Generic
Generic
INHALED COMBO STEROID/BETA-AGONISTS
ADVAIR DISKUS
ADVAIR DISKUS
ADVAIR DISKUS
ADVAIR HFA
ADVAIR HFA
ADVAIR HFA
SYMBICORT
SYMBICORT
AER 100/50
AER 250/50
AER 500/50
AER 45/21
AER 115/21
AER 230/21
AER 80-4.5
AER 160-4.5
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
QL 2 per day
QL 2 per day
QL 2 per day
SUS 0.25MG/2
SUS 0.5MG/2
SUS 1MG/2ML
HFA AER 110MCG
HFA AER 220MCG
HFA AER 44MCG
AER 100MCG
AER 50MCG
AER 250MCG
AER 40MCG
AER 80MCG
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
AR PA > 6 years of age
QL 60 days per fill
QL 60 days per fill
QL 60 days per fill
QL 60 days per fill
INHALED STEROIDS
BUDESONIDE
BUDESONIDE
BUDESONIDE
FLOVENT
FLOVENT
FLOVENT
FLOVENT DISK
FLOVENT DISK
FLOVENT DISK
QVAR
QVAR
QL 60 days per fill
QL 50 days per fill
QL 50 days per fill
43
Drug Name
Drug Type
Requirements
TAB 10MG
CHW 4MG
CHW 5MG
GRA 4MG
TAB 10MG
TAB 20MG
Generic
Generic
Generic
Generic
Generic
Generic
PA
PA
PA
PA
SOD NEB 20MG/2ML
Generic
TAB 4MG ER
TAB 2MG
TAB 4MG
SYP 2MG/5ML
INJ 400MG
INJ 500MG
INJ 800MG
INJ 1000MG
ELX 80/15ML
SYP 10MG/5ML
INJ 1000MG
TAB 2.5MG
TAB 5MG
CAP 200MG CR
TAB 100MG CR
TAB 200MG CR
TAB 300MG CR
TAB 100MG ER
TAB 100MG CR
TAB 200MG ER
TAB 200MG CR
TAB 300MG ER
TAB 450MG ER
TAB 400MG ER
TAB 600MG ER
SOL 150MG
INJ 1000MG
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
LEUKOTRIENE MODIFIERS
MONTELUKAST
MONTELUKAST
MONTELUKAST
MONTELUKAST
ZAFIRLUKAST
ZAFIRLUKAST
MAST-CELL STABILIZERS
CROMOLYN
OTHER ASTHMA/COPD
ALBUTEROL
ALBUTEROL
ALBUTEROL
ALBUTEROL
ARALAST NP
ARALAST NP
ARALAST NP
ARALAST NP
ELIXOPHYLLIN
METAPROTEREN
PROLASTIN-C
TERBUTALINE
TERBUTALINE
THEO-24
THEOCHRON
THEOCHRON
THEOCHRON
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
XOLAIR
ZEMAIRA
PA
PA
PA
PA
PA
PA
PA
44
Drug Name
GASTROINTESTINAL AGENTS
Drug Type
Requirements
CATHARTICS AND LAXATIVES - (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE
PRODUCTS LISTED ONLY)
BISACODYL
CASCARA SAGRADA
DOCUSATE SODIUM
ENEMA
GLYCERIN
KONSYL
MAGNESIUM CITRATE
METAMUCIL
MILK OF MAGNESIUM
MINERAL OIL
SALINE
POLYETHYLENE GLYCOL
PSYLLIUM FIBER
SENNA
SENNA-DOCUSATE SODIUM
GAVILYTE-C
GAVILYTE-G
GAVILYTE-N
PEDIA-LAX
TRILYTE
SUPP, TAB, TAB EC,
CAP 450MG
CAP, SOFTGEL, SOL,
SYRUP, TAB
Generic
Generic
SUPP
CAP
SOLN
PACKET, WAFER
SUSP
ENEMA, LAXATIVE
LAXATIVE
POWDER, PACKET
TAB, POWDER
TAB, LAXATIVE
TAB
SOLN
SOLN
SOLN
LIQ 50MG
SOL
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
CHW 420MG
CHW 1000MG
Generic
Generic
TAB, GELCAP, CHEW
TAB, SUSP
CHW 1000MG
CHW 500MG
CHW 750MG
CHW 500MG
TAB 648MG
CHW 400MG
CHW PEPTO
SUS
LIQ, CHEW
TAB 400MG
TAB 10GR
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ANTACIDS AND ADSORBENTS - (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE
PRODUCTS LISTED ONLY)
ALCALAK
ALMACONE
SUS
ANTACID
CALC ANTACID
CALC ANTACID
CALC ANTACID
CALCIUM CARB
CALCIUM CARB
CHILD SOOTHE
CHILDRENS
COMFORT GEL
MAALOX
MAG OXIDE
SODIUM BICAR
45
Drug Name
SODIUM BICAR
STOMACH RLF
TAB 650MG
CHW 400MG
Drug Type
Generic
Generic
Requirements
SUP 16.2-30
SUP 16.2-60
TAB 100MG
TAB 25MG
CAP 10MG
SOL 10MG/5ML
TAB 20MG
TAB 0.125MG
SUB 0.125MG
DRO 0.125/ML
ELX 0.125/5
SUB 0.125MG
TAB 0.375 ER
TAB 0.375 SR
DRO 0.125/ML
ELX 0.125/5
SOL 0.02%INH
TAB 0.125MG
TAB 0.125MG
SUB 0.125MG
TAB 0.375MG
TAB 15MG
TAB 0.125MG
SUB 0.125MG
TAB 0.375MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 1 per 180 days
QL 1 per 180 days
TAB 10MG
TAB 150MG
TAB 20MG
TAB 75MG
TAB 10MG
TAB 150MG
TAB 200MG
TAB 20MG
TAB 75MG
TAB 200MG
SOL 300/5ML
TAB 200MG
TAB 300MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ANTIMUSCARINICS/ANTISPASMODICS
BELLA/OPIUM
BELLA/OPIUM
DAPSONE
DAPSONE
DICYCLOMINE
DICYCLOMINE
DICYCLOMINE
ED-SPAZ
HYOMAX-SL
HYOSCYAMINE
HYOSCYAMINE
HYOSCYAMINE
HYOSCYAMINE
HYOSCYAMINE
HYOSYNE
HYOSYNE
IPRATROPIUM
NULEV
OSCIMIN
OSCIMIN
OSCIMIN SR
PROPANTHELIN
SYMAX FASTAB
SYMAX-SL
SYMAX-SR
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
HISTAMINE H2-ANTAGONISTS
ACID CONTROL
ACID CONTROL
ACID CONTROL
ACID CONTROL
ACID REDUCER
ACID REDUCER
ACID REDUCER
ACID REDUCER
ACID REDUCER
ACID RELIEF
CIMETIDINE
CIMETIDINE
CIMETIDINE
46
Drug Name
CIMETIDINE
CIMETIDINE
EQL HEARTBRN
FAMOTIDINE
FAMOTIDINE
FAMOTIDINE
HEARTBRN REL
HEARTBRN REL
HEARTBURN
HEARTBURN
NIZATIDINE
PEPCID AC
RANITIDINE
RANITIDINE
RANITIDINE
RANITIDINE
RANITIDINE
RANITIDINE
RANITIDINE
RANITIDINE
SM ACID REDU
WAL-ZAN
WAL-ZAN
WAL-ZAN 75
TAB 400MG
TAB 800MG
TAB 10MG
TAB 10MG
TAB 20MG
TAB 40MG
TAB 200MG
TAB 75MG
TAB 150MG
TAB 20MG
SOL 15MG/ML
TAB 20MG
CAP 150MG
CAP 300MG
SYP 150/10ML
SYP 15MG/ML
SYP 75MG/5ML
TAB 150MG
TAB 300MG
TAB 75MG
TAB 200MG
TAB 150MG
TAB 75MG
TAB
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 100MCG
TAB 200MCG
Generic
Generic
SUS 1GM/10ML
TAB 1GM
Brand
Generic
SUS 2MG/ML
SUS 3MG/ML
CAP 15MG DR
CAP 30MG DR
CAP 10MG
CAP 20MG
CAP 40MG
SUS SYRSPEND
TAB 20MG
TAB 40MG
TAB 20MG
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Requirements
AR PA required > 6
PROSTAGLANDINS
MISOPROSTOL
MISOPROSTOL
PROTECTANTS
CARAFATE
SUCRALFATE
PROTON-PUMP INHIBITORS
FIRST-OMEPRA
LANSOPRAZOLE
LANSOPRAZOLE
LANSOPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
OMEPRAZOLE +
PANTOPRAZOLE
PANTOPRAZOLE
RABEPRAZOLE
AR PA > 6
PA
PA QL 1 per day
PA QL 1 per day
AR PA Required > 6
QL 1 per day
PA
47
Drug Name
Drug Type
TAB 25MG
SUP 25MG
SUP 25MG
TAB 50MG
TAB 25MG
TAB 50MG
CAP 2.5MG
CAP 5MG
CAP 10MG
CAP 40MG
CAP 80MG
CAP 125MG
PAK 80 & 125
INJ 0.1MG/ML
INJ 4MG/4ML
INJ 1MG/ML
SOL 2MG/10ML
CHW 25MG
TAB 12.5MG
TAB 25MG
TAB 25MG
CHW 25MG
TAB 50MG
CHW 25MG
SOL 4MG/5ML
TAB 4MG ODT
TAB 8MG ODT
TAB 4MG
TAB 8MG
TAB 24MG
SUP 12.5MG
SUP 25MG
SUP 12.5MG
SUP 25MG
SUP 50MG
SUP 25MG
TAB 5MG
TAB 10MG
TAB 12.5MG
TAB 25MG
TAB 50MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
ANTI-NAUSEA
AMBIZINE
COMPAZINE
COMPRO
DIMENHYDRIN
DRAMAMINE
DRIMINATE
DRONABINOL
DRONABINOL
DRONABINOL
EMEND
EMEND
EMEND
EMEND
GRANISETRON
GRANISETRON
GRANISETRON
GRANISOL
MECLIZINE
MECLIZINE
MECLIZINE
MEDI-MECLIZI
MOTION RELF
MOTION SICK
MOTION-TIME
ONDANSETRON
ONDANSETRON
ONDANSETRON
ONDANSETRON
ONDANSETRON
ONDANSETRON
PHENADOZ
PHENADOZ
PHENERGAN
PHENERGAN
PHENERGAN
PROCHLORPER
PROCHLORPER
PROCHLORPER
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PA QL 2 per day
PA
PA QL 2 per day
PA
PA
PA
PA
PA
PA
PA
PA
QL 6 per day
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
QL 1 per day
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2 or > 64
48
Drug Name
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PROMETHAZINE
PROMETHEGAN
PROMETHEGAN
PROMETHEGAN
TRAVEL SICK
TRAVEL SICK
TRAV-TABS
TRIPTONE
WAL-DRAM
WAL-DRAM II
SYP 6.25/5ML
SOL 6.25/5ML
INJ 25MG/ML
INJ 50MG/ML
SUP 12.5MG
SUP 25MG
SUP 50MG
SUP 12.5MG
SUP 25MG
SUP 50MG
CHW 25MG
TAB 50MG
TAB 50MG
TAB 50MG
TAB 50MG
TAB 25MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CAP 3000UNIT
CAP 6000UNIT
CAP 12000UNT
CAP 24000UNT
CAP 36000UNT
CAP 4200UNIT
CAP 10500UNT
CAP 16800UNT
CAP 21000UNT
CAP 5000UNIT
CAP 3000UNIT
CAP 5000UNIT
CAP 10000UNT
CAP 15000UNT
CAP 20000UNT
CAP 25000UNT
CAP 40000UNT
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
CAP 300MG
TAB 250MG
TAB 500MG
Generic
Generic
Generic
CAP 0.375GM
TAB 800MG
CAP 750MG
Brand
Brand
Generic
Requirements
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
AR PA required < 2
DIGESTANTS
CREON
CREON
CREON
CREON
CREON
PANCREAZE
PANCREAZE
PANCREAZE
PANCREAZE
PANCRELIPASE
ZENPEP
ZENPEP
ZENPEP
ZENPEP
ZENPEP
ZENPEP
ZENPEP
CHOLELITHOLYTIC AGENTS
URSODIOL
URSODIOL
URSODIOL
INFLAMMATORY BOWEL AGENTS
APRISO
ASACOL HD
BALSALAZIDE
QL 6 per day
49
Drug Name
CANASA
DELZICOL
DIPENTUM
MESALAMINE
MESALAMINE
PENTASA
PENTASA
SFROWASA
SULFADIAZINE
SULFASALAZIN
SULFASALAZIN
SULFAZINE
SULFAZINE EC
SUP 1000MG
CAP 400MG
CAP 250MG
ENE 4GM
TAB 800MG DR
CAP 250MG CR
CAP 500MG CR
ENE 4GM
TAB 500MG
TAB 500MG
TAB 500MG DR
TAB 500MG
TAB 500MG
Drug Type
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
CAP 667MG
TAB 667MG
CHW 500MG
CHW 750MG
CHW 1000MG
POW 750MG
POW 1000MG
TAB 400MG
TAB 800MG
TAB 800MG
PAK 0.8GM
PAK 2.4GM
TAB 800MG
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
TAB 5MG
TAB 10MG
INJ 5MG/ML
INJ 10MG/2ML
SOL 5MG/5ML
SOL 10/10ML
Generic
Generic
Generic
Generic
Generic
Generic
TAB 5MG
SYP 5MG/5ML
TAB 5MG ER
TAB 10MG ER
TAB 15MG ER
Generic
Generic
Generic
Generic
Generic
Requirements
QL 42 per fill
QL 6 per day
PHOSPHATE-REMOVING AGENTS
CALCIUM ACETATE
CALCIUM ACETATE
FOSRENOL
FOSRENOL
FOSRENOL
FOSRENOL
FOSRENOL
RENAGEL
RENAGEL
RENVELA
RENVELA
RENVELA
SEVELAMER
PROKINETIC AGENTS
METOCLOPRAMIDE
METOCLOPRAMIDE
METOCLOPRAMIDE
METOCLOPRAMIDE
METOCLOPRAMIDE
METOCLOPRAMIDE
GENITOURINARY PRODUCTS
INCONTINENCE/URINARY FREQUENCY
OXYBUTYNIN
OXYBUTYNIN
OXYBUTYNIN
OXYBUTYNIN
OXYBUTYNIN
50
Drug Name
OXYTROL/WOMN
TOLTERODINE
TOLTERODINE
DIS 3.9MG/24
TAB 1MG
TAB 2MG
Drug Type
Brand
Generic
Generic
Requirements
ST
PA
PA
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
BETHANECHOL
BETHANECHOL
BETHANECHOL
BETHANECHOL
PILOCARPINE
PYRIDOSTIGMINE BROMIDE
PYRIDOSTIGMINE BROMIDE
REGONOL
TAB 5MG
TAB 10MG
TAB 25MG
TAB 50MG
TAB 5MG
TAB 60MG
TAB 180MG
INJ 5MG/ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONDOMS
ORTHO COIL
ORTHO COIL
ORTHO COIL
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
VCF VAGINAL
WIDE-SEAL
WIDE-SEAL
WIDE-SEAL
WIDE-SEAL
WIDE-SEAL
WIDE-SEAL
Various
DPR KIT 50
DPR KIT 100
DPR KIT 105
DPR KIT 55
DPR KIT 60
DPR KIT 65
DPR KIT 70
DPR KIT 75
DPR KIT 80
DPR KIT 85
DPR KIT 90
DPR KIT 95
DPR 65MM
DPR 70MM
DPR 75MM
DPR 80MM
AER CONTRACP
DPR KIT 60
DPR KIT 65
DPR KIT 70
DPR KIT 75
DPR KIT 80
DPR KIT 85
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
SUP 100MG
CRE 2% VAG
GEL 0.75%VAG
GEL 0.75%
Generic
Generic
Generic
Generic
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
QL 1 per 365 days
VAGINAL ANTI-INFECTIVES
CLEOCIN
CLINDAMYCIN
METRONIDAZOLE
VANDAZOLE
51
Drug Name
Drug Type
SOL
PACK
SOL
SYP
SOL
SOL
INJ 4%
TAB 540MG ER
TAB 1080MG
TAB 1620MG
PACK
INJ 8.4%
INJ 4.2%
INJ 7.5%
SOL 500-334
SOL
SOL 1100-334
SOL
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SOL 0.9%
SOL 100ML
SOL 0.9% IRR
SOL 0.9% IRR
SOL IRRIG
Generic
Generic
Generic
Generic
Generic
CAP 100MG
TAB 200MG
TAB 100MG
TAB 200MG
Brand
Generic
Generic
Generic
Requirements
ALKALINIZING AGENTS
CITRIC ACID/SODIUM CITRATE
CYTRA K CRYSTALS
CYTRA-2
CYTRA-3
CYTRA-K
POTASSIUM CITRATE/CITRIC ACID
NEUT
POTASSIUM CITRATE
POTASSIUM CITRATE
POTASSIUM CITRATE
POTASSIUM CITRATE/CITRIC ACID
SOD BICARB
SOD BICARB
SOD BICARB
VIRTRATE-2
VIRTRATE-2
VIRTRATE-K
VIRTRATE-K
IRRIGATING SOLUTIONS
ARGYL SALINE
ARGYL SALINE
CURITY SALIN
SODIUM CHLOR
STERIL WATER
MISCL URINARY AGENTS
ELMIRON
PHENAZO
PHENAZOPYRID
PHENAZOPYRID
PA
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
TAMSULOSIN
CAP 0.4MG
CENTRAL NERVOUS SYSTEM DRUGS
Generic
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
COMPOZ
DIPHENHYDRAM
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
TAB 50MG
TAB 50MG
TAB 10MG
TAB 25MG
TAB 50MG
SYP 10MG/5ML
SOL 10MG/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
52
Drug Name
HYDROXYZINE PAMOATE
HYDROXYZINE PAMOATE
HYDROXYZINE PAMOATE
IBUPROFEN PM
MOTRIN PM
SLEEP AID
SLEEP AID
ZOLPIDEM
ZOLPIDEM
CAP 25MG
CAP 50MG
CAP 100MG
TAB 200-38MG
TAB 200-38MG
CAP 50MG
TAB 25MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
TAB 5MG
Generic
PA required > 64 QL 15
per 30 days
TAB 10MG
Generic
PA required > 64 QL 15
per 30 days
TAB 0.5MG
TAB 1MG
TAB 2MG
GEL 5-10MG
GEL 12.5-20
GEL 2.5M GEL
GEL 2.5MG
GEL 10MG
GEL 20MG
INJ 2MG/ML
INJ 4MG/ML
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
PA required
PA required
PA required
TAB 15MG
TAB 16.2MG
TAB 30MG
TAB 32.4MG
TAB 60MG
TAB 64.8MG
TAB 97.2MG
TAB 100MG
ELX 20MG/5ML
SOL 20MG/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
AR PA required > 64
TAB 30MG
Generic
QL 3 per day
BENZODIAZEPINES
CLONAZEPAM
CLONAZEPAM
CLONAZEPAM
DIASTAT ACDL
DIASTAT ACDL
DIASTAT PED
DIAZEPAM
DIAZEPAM
DIAZEPAM
LORAZEPAM
LORAZEPAM
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANT AGENTS
AMPHETAMINES
AMPHETAMINE (Generic Adderall IR)
AMPHETAMINE (Generic Adderall XR)
CAP 15MG ER
Generic
Age > 18 not covered QL
1 per day
CAP 20MG ER
Generic
1 per day
53
Drug Name
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
(Generic Adderall IR)
TAB 5MG
TAB 7.5MG
TAB 10MG
TAB 12.5MG
TAB 15MG
TAB 20MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
CAP 5MG ER
Generic
1 per day
CAP 10MG ER
Generic
1 per day
CAP 20MG ER
Generic
1 per day
CAP 25MG ER
Generic
1 per day
DEXEDRINE
DEXEDRINE
DEXTROAMPHETAMINE (Dexedrine IR)
CAP 30MG ER
TAB 5MG
TAB 10MG
TAB 5MG
TAB 10MG
TAB 10MG
Generic
Generic
Generic
Generic
Generic
Generic
TAB 2.5MG
TAB 5MG
TAB 10MG
CAP 10MG
CAP 20MG
CAP 30MG
CAP 40MG
CAP 50MG
CAP 60MG
TAB 5MG
TAB 10MG
TAB 20MG
TAB 18MG ER
TAB 27MG ER
TAB 36MG ER
TAB 54MG ER
SOL 5MG/5ML
SOL 10MG/5ML
CAP 20MG ER
CAP 30MG ER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
1 per day
METHYLPHENIDATES
DEXMETHYLPHENIDATE
DEXMETHYLPHENIDATE
DEXMETHYLPHENIDATE
METHYLPHENIDATE (generic Metadate CD)
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE (generic Concerta)
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE (generic Ritalin LA)
AR PA >18
AR PA >18
AR PA >18
AR PA >18
AR PA >18
AR PA >18
AR PA>64
AR PA>64
AR PA>64
AR PA >18; QL 1 per day
AR PA>6
AR PA>6
AR PA > 18; QL 1 per day
54
Drug Name
RITALIN LA
CAP 40MG ER
CAP 10MG
Drug Type
Generic
Brand
Requirements
INJ 60MG/3ML
SOL 20MG/ML
SOL 60MG/3ML
Generic
Generic
Generic
AR PA >1
AR PA >1
AR PA >1
TAB 333MG
TAB 250MG
TAB 500MG
Generic
Generic
Generic
PA QL 6 per day
TAB 5MG
TAB 10MG
TAB 5MG ODT
TAB 10MG ODT
TAB 4MG
TAB 8MG
TAB 12MG
CAP 8MG ER
CAP 16MG ER
CAP 24MG ER
TAB HCL 5MG
TAB HCL 10MG
SOL 2MG/ML
CAP 7MG
CAP 14MG
CAP 21MG
CAP 28MG
CAP TITRATIO
CAP 1.5MG
CAP 3MG
CAP 4.5MG
CAP 6MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
QL 1 per day
QL 1 per day
QL 1 per day
QL 1 per day
TAB 7MG
TAB 14MG
KIT 30MCG
KIT 30MCG
KIT 30MCG
INJ 0.3MG
Brand
Brand
Brand
Brand
Brand
Brand
PA
PA
QL 4 per month
QL 1 per 30 days
QL 1 per 30 days
QL 14 per month
RESPIRATORY AND CNS STIMULANTS
CAFFEINE CIT
CAFFEINE CIT
CAFFEINE CIT
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC
ALCOHOL DETERRENTS
ACAMPRO CAL
DISULFIRAM
DISULFIRAM
ANTIDEMENTIA AGENTS
DONEPEZIL
DONEPEZIL
DONEPEZIL
DONEPEZIL
GALANTAMINE
GALANTAMINE
GALANTAMINE
GALANTAMINE
GALANTAMINE
GALANTAMINE
MEMANTINE
MEMANTINE
MEMANTINE HC
NAMENDA XR
NAMENDA XR
NAMENDA XR
NAMENDA XR
NAMENDA XR
RIVASTIGMINE
RIVASTIGMINE
RIVASTIGMINE
RIVASTIGMINE
PA
PA
PA
PA
PA
PA
PA
PA
MULTIPLE SCLEROSIS
AUBAGIO
AUBAGIO
AVONEX
AVONEX PEN
AVONEX PREFL
EXTAVIA
55
Drug Name
GLATOPA (Generic Copaxone 20 mg)
PLEGRIDY
PLEGRIDY
PLEGRIDY
PLEGRIDY PEN
REBIF
REBIF
REBIF REBIDO
REBIF REBIDO
REBIF REBIDO
REBIF TITRTN
TECFIDERA
TECFIDERA
TECFIDERA
INJ 20MG/ML
INJ PEN
INJ
INJ STARTER
INJ STARTER
INJ 22/0.5
INJ 44/0.5
INJ 22/0.5
INJ 44/0.5
INJ TITRATN
INJ PACK
MIS STARTER
CAP 120MG
CAP 240MG
Drug Type
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
TAB 150MG
Generic
QL 2 per day;180 days per
365 days
SMOKING DETERRENTS
BUPROBAN
Requirements
QL 0.036 per day
QL 0.036 per day
QL 1 per 180 days
QL 1 per 180 days
QL 6ml per 30 days
QL 6ml per 30 days
QL 6ml per 30 days
QL 6ml per 30 days
PA
PA
PA
CHANTIX
PAK 1MG
Brand
QL 2 per day; max benefit
90 days per 365 days
CHANTIX
PAK 0.5& 1MG
Brand
CHANTIX
TAB 0.5MG
Brand
CHANTIX
TAB 1MG
Brand
NICOTINE
GUM 2MG
Generic
NICOTINE
GUM 4MG
Generic
NICOTINE
PATCH 7MG/24HR
Generic
NICOTINE
LOZENGE 2MG
Generic
NICOTINE
LOZENGE 4MG
Generic
NICOTINE
PATCH 21MG/24H
Generic
NICOTINE
PATCH 14MG/24H
Generic
NICOTINE SYS
KIT TRANSDER
Generic
NICOTROL
NASAL SPRAY
10MG/ML
Brand
QL 24 pieces per day max
QL 24 pieces per day; 180
days per 365 days
QL 1 patch per day; 180
days per 365 days
QL 20 lozenges per day;
QL 20 lozenges per day;
QL 1 patch per day;
QL 1 patch per day;
QL 1 patch per day;
180 days per 365 days; 56
day supply per fill
PA QL 4mls per day (80
sprays) 180 day supply per
365 days
56
Drug Name
Drug Type
NICOTROL
INHALER 10MG
Brand
ANALGESICS AND ANESTHETICS
Requirements
PA QL
16 cartridges per day
ANALGESICS AND ANTIPYRETICS, MISC. (LIST NOT ALL ENCOMPASSING.
REPRESENTATIVE PRODUCTS LISTED ONLY)
ACETAMINOPHEN
ACETAMINOPHEN/CAFF/PYRILAMINE
CAP, CHEW, DROPS,
ELIX, GELCAP, SOLN,
SUPP,SUSP, TAB
TAB
Generic
Generic
SALICYLATES (LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY)
ASPIRIN
CHILD ASPIRIN
CHOLINE MAG TRISALICYLATE
SALSALATE
SALSALATE
TAB, CHEW, TAB EC,
SUP
CHW 81MG
TAB, LIQ
TAB 500MG
TAB 750MG
Generic
Generic
Generic
Generic
Generic
SUB 2-0.5MG
SUB 8-2MG
SUB 2MG
SUB 8MG
Generic
Generic
Generic
Generic
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
TAB 300-15MG
TAB 300-30MG
TAB 300-60MG
SOL 120-12/5
TAB 30MG
TAB 60MG
INJ 250MG
TAB 5-325MG
TAB 7.5-325
TAB 7.5-500M
TAB 10-325MG
TAB 10-650MG
TAB
DIS 12MCG/HR
DIS 25MCG/HR
DIS 37.5MCG
DIS 50MCG/HR
DIS 62.5MCG
DIS 75MCG/HR
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 13 per day
QL 13 per day
QL 13 per day
OPIATE PARTIAL AGONISTS
BUPRENORPHINE/NALOXONE
BUPRENORPHINE/NALOXONE
BUPRENORPHINE
BUPRENORPHINE
OPIATES
APAP/CODEINE
APAP/CODEINE
APAP/CODEINE
APAP/CODEINE
CODEINE SULF
CODEINE SULF
DILAUDID-HP
ENDOCET
ENDOCET
ENDOCET
ENDOCET
ENDOCET
ENDODAN
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
QL 12 per day
QL 12 per day
QL 8 per day
QL 12 per day
QL 6 per day
PA QL 11 per month
PA QL 11 per month
PA QL 11 per month
PA QL 11 per month
PA QL 11 per month
PA QL 11 per month
57
Drug Name
FENTANYL
FENTANYL
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/APAP
HYDROCODONE/IBUPROFEN
HYDROGESIC
HYDROMORPHONE
HYDROMORPHONE
HYDROMORPHONE
HYDROMORPHONE
HYDROMORPHONE
HYDROMORPHONE
LORCET
LORCET HD
LORCET PLUS
LORTAB
LORTAB
LORTAB
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
DIS 87.5MCG
DIS 100MCG/H
TAB 10-325MG
TAB 2.5-500
TAB 5-500MG
TAB 7.5-500
TAB 10-500MG
TAB 7.5-650
TAB 10-650MG
TAB 10-660MG
TAB 7.5-750
TAB 5-325MG
TAB 7.5-325
SOL 7.5-325
SOL 5-217/10
SOL 7.5-500
TAB 7.5-200
CAP 5-500MG
INJ 1MG/ML
INJ 2MG/ML
INJ 4MG/ML
INJ 10MG/ML
INJ 50MG/5ML
INJ 500/50ML
TAB 5-325MG
TAB 10-325MG
TAB 7.5-325
TAB 10-325MG
TAB 5-325MG
TAB 7.5-325
TAB 15MG
TAB 30MG
TAB 15MG ER
TAB 30MG ER
TAB 60MG ER
TAB 100MG ER
TAB 200MG ER
INJ 1MG/ML
INJ 2MG/ML
INJ 4MG/ML
INJ 5MG/ML
INJ 150/30ML
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
PA QL 11 per month
PA QL 11 per month
QL 12 per day
QL 8 per day
QL 8 per day
QL 8 per day
QL 6 per day
QL 6 per day
QL 6 per day
QL 5 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 12 per day
QL 3 per day
QL 3 per day
QL 3 per day
PA QL 3 per day
PA QL 3 per day
58
Drug Name
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/APAP
OXYCODONE/ASA
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCODONE
OXYCONTIN
OXYCONTIN
OXYCONTIN
OXYCONTIN
OXYCONTIN
OXYCONTIN
OXYCONTIN
ROXICET
STAGESIC
TRAMADL/APAP
TRAMADOL HCL
INJ 25MG/ML
INJ 50MG/ML
SOL 10MG/5ML
SOL 20MG/5ML
SOL 100/5ML
SUP 5MG
SUP 10MG
SUP 20MG
SUP 30MG
CAP 5-500MG
TAB 5-325MG
SOLN 5-325MG/5ML
TAB 7.5-325
TAB 7.5-500
TAB 10-325MG
TAB 10-650MG
TAB
TAB 5MG
TAB 10MG
TAB 15MG
TAB 20MG
TAB 30MG
CON 100/5ML
CON 20MG/ML
SOL 5MG/5ML
TAB 10MG ER
TAB 20MG ER
TAB 40MG ER
TAB 80MG ER
TAB 10MG CR
TAB 15MG CR
TAB 20MG CR
TAB 30MG CR
TAB 40MG CR
TAB 60MG CR
TAB 80MG CR
TAB 5-325MG
CAP 5-500MG
TAB 37.5-325
TAB 50MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Requirements
QL 8 per day
QL 12 per day
QL 12 per day
QL 8 per day
QL 12 per day
QL 6 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
QL 12 per day
QL 10 per day
QL 8 per day
59
Drug Name
Drug Type
Requirements
INJ 25MG
INJ 25/0.5ML
INJ 50MG/ML
INJ 50MG/ML
INJ 10MG/0.2
KIT 20MG/0.4
KIT 40MG/0.8
INJ CROHNS STARTER
PACK
Brand
Brand
Brand
Brand
Brand
Brand
Brand
PA QL 8mls per month
PA QL 2 per 31 days
PA QL 4 per 31 days
PA QL 4 per 31 days
PA QL 2 per 31 days
PA QL 2.4 per 31 days
PA QL 2 per 31 days
Brand
HUMIRA PEN
INJ 40MG/0.8
Brand
PA QL 2 syringes per
month
HUMIRA PEN
INJ CROHNS
Brand
PA QL 6 syringes per 180
days
HUMIRA PEN
INJ PSORIASI
Brand
PA QL 4 syringes per 180
days
TAB 10MG
TAB 20MG
TAB 30MG
TAB 10/20/30
Generic
Generic
Brand
Brand
PA QL 2 tabs per day
ACTEMRA
COSENTYX
COSENTYX PEN
TALTZ
INJ 162/0.9
INJ 150MG/ML
INJ 150MG/ML
INJ 80MG/ML
Brand
Brand
Brand
Brand
PA QL 3.6 per 31 days
PA QL 0.072 per day
PA QL 0.072 per day
PA QL 0.036 per day
CELECOXIB
CELECOXIB
DICLOFEN POTASSIUM
DICLOFENAC
DICLOFENAC
DICLOFENAC
DICLOFENAC
FLURBIPROFEN
ETODOLAC
ETODOLAC
ETODOLAC
ETODOLAC
FLURBIPROFEN
GENPRIL
CAP 100MG
CAP 200MG
TAB 50MG
TAB 25MG DR
TAB 50MG DR
TAB 75MG DR
TAB 100MG ER
TAB 50MG
CAP 200MG
CAP 300MG
TAB 400MG
TAB 500MG
TAB 100MG
TAB 200MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA QL 1 per day
PA QL 2 per day
ANTI-TNF INHIBITORS
ENBREL
ENBREL
ENBREL
ENBREL SRCLK
HUMIRA
HUMIRA
HUMIRA
HUMIRA PEDIA
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
LEFLUNOMIDE
LEFLUNOMIDE
OTEZLA
OTEZLA
MISCL BIOLOGIC
NONSTEROIDAL ANTI-INFLAMMATORY (NSAID)
(LIST NOT ALL ENCOMPASSING. REPRESENTATIVE PRODUCTS LISTED ONLY)
ST (meloxicam)
ST (meloxicam)
ST (meloxicam)
ST (meloxicam)
60
Drug Name
IBU-DROPS
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN IB
IBUPROFEN JR
INDOCIN
INDOMETHACIN
INDOMETHACIN
INDOMETHACIN
KETOPROFEN
KETOPROFEN
MEDI-PROFEN
MEDI-PROFEN
MEDI-PROFEN
MEDI-PROFEN
MELOXICAM
MELOXICAM
MIDOL
NABUMETONE
NABUMETONE
NAPROXEN
NAPROXEN
NAPROXEN
NAPROXEN
PROVIL
SULINDAC
SULINDAC
DRO 40MG/ML
CAP 200MG
TAB 200MG
TAB 400MG
TAB 600MG
TAB 800MG
DRO 50/1.25
SUS 100/5ML
TAB 200MG
CHW 100MG
SUS 25MG/5ML
CAP 25MG
CAP 50MG
CAP 75MG ER
CAP 50MG
CAP 75MG
CAP 200MG
TAB 200MG
SUS 40MG/ML
SUS 100/5ML
TAB 7.5MG
TAB 15MG
CAP 200MG
TAB 500MG
TAB 750MG
TAB 250MG
TAB 375MG
TAB 500MG
SUS 125/5ML
TAB 200MG
TAB 150MG
TAB 200MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
INJ 1MG/ML
SPR 4MG/ML
SUB 2MG
Generic
Generic
Brand
TAB 1MG
TAB 2.5MG
TAB 5MG
TAB 10MG
SPR 5MG/ACT
Generic
Generic
Generic
Generic
Generic
QL 9 per 30 days
QL 9 per 30 days
QL 12 per 30 days
QL 12 per 30 days
QL 6 per 30 days
AR PA required > 64
AR PA required > 64
AR PA required > 64
QL 2 per day
MIGRAINE PRODUCTS
DIHYDROERGOT
DIHYDROERGOT
ERGOMAR
TRIPTANS
NARATRIPTAN
NARATRIPTAN
RIZATRIPTAN
RIZATRIPTAN
SUMATRIPTAN
61
Drug Name
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
ZOLMITRIPTAN
ZOLMITRIPTAN
SPR 20MG/ACT
TAB 25MG
TAB 50MG
TAB 100MG
INJ 4MG/0.5
INJ 6MG/0.5
TAB 2.5MG
TAB 5MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 100MG
TAB 300MG
TAB 0.6MG
TAB 0.6MG
Generic
Generic
Generic
Brand
TAB 500-0.5
TAB 500MG
TAB 200MG
CHW 100MG
SUS 100/5ML
CAP 100MG ER
CAP 200MG ER
CAP 300MG ER
TAB 100MG ER
TAB 200MG ER
TAB 400MG ER
CAP 300MG
CHW 50MG
CAP 30MG
CAP 100MG
SUS 125/5ML
TAB 200MG
CAP 250MG
SOL 250/5ML
TAB 400MG
TAB 600MG
SUS 600/5ML
INJ 100/2ML
INJ 500/10ML
CAP 100MG
CAP 300MG
CAP 400MG
TAB 600MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 6 per 30 days
QL 9 per 30 days
QL 9 per 30 days
QL 9 per 30 days
QL 3mls per 30 days
QL 12 per 30 days
QL 12 per 30 days
ANTIGOUT AGENTS
ALLOPURINOL
ALLOPURINOL
COLCHICINE
COLCRYS
URICOSURIC AGENTS
PROBEN/COLCH
PROBENECID
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CELONTIN
DILANTIN
DILANTIN
DILANTIN
DILANTIN-125
EPITOL
ETHOSUXIMIDE
ETHOSUXIMIDE
FELBAMATE
FELBAMATE
FELBAMATE
FOSPHENYTOIN
FOSPHENYTOIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
62
Drug Name
GABAPENTIN
GABAPENTIN
GABITRIL
GABITRIL
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LEVETIRACETA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
OXCARBAZEPIN
OXCARBAZEPIN
OXCARBAZEPIN
OXCARBAZEPIN
OXCARBAZEPIN
PEGANONE
PHENYTOIN
PHENYTOIN
PHENYTOIN
PHENYTOIN EX
PHENYTOIN EX
PHENYTOIN EX
PRIMIDONE
PRIMIDONE
SABRIL
SABRIL
TIAGABINE
TIAGABINE
TOPIRAGEN
TOPIRAGEN
TOPIRAGEN
TAB 800MG
SOL 250/5ML
TAB 12MG
TAB 16MG
SOL 100MG/ML
TAB 500MG
TAB 750MG
TAB 1000MG
SOL 100MG/ML
SOL 500/5ML
TAB 500MG ER
TAB 750MG ER
CAP 150MG
CAP 25MG
CAP 50MG
CAP 75MG
CAP 100MG
CAP 200MG
CAP 225MG
CAP 300MG
SOL 20MG/ML
TAB 150MG
TAB 300MG
TAB 600MG
SUS 300MG/5M
SUS 300MG/5M
TAB 250MG
CHW 50MG
SUS 125/5ML
INJ 50MG/ML
CAP 100MG
CAP 200MG
CAP 300MG
TAB 50MG
TAB 250MG
TAB 500MG
POW 500MG
TAB 2MG
TAB 4MG
TAB 25MG
TAB 50MG
TAB 100MG
Drug Type
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Requirements
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 3 per day
PA QL 2 per day
PA QL 2 per day
PA
PA
PA
63
Drug Name
TOPIRAGEN
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TRILEPTAL
VIMPAT
VIMPAT
VIMPAT
VIMPAT
VIMPAT
VIMPAT
ZONISAMIDE
ZONISAMIDE
ZONISAMIDE
NEUROMUSCULAR DRUGS
TAB 200MG
TAB 25MG
TAB 50MG
TAB 100MG
TAB 200MG
CAP 15MG
CAP 25MG
SUS 300MG/5M
TAB 100MG
TAB 150MG
TAB 50MG
TAB 200MG
INJ 200MG/20
SOL 10MG/ML
CAP 25MG
CAP 50MG
CAP 100MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
TAB 0.5MG
TAB 1MG
TAB 2MG
INJ 1MG/ML
TAB 2MG
TAB 5MG
ELX 0.4MG/ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
TAB 200MG
CAP 5MG
TAB 5MG
TAB 100MG
Generic
Generic
Generic
Generic
CAP 5MG
TAB 2.5MG
TAB 10-100MG
TAB 25-100MG
TAB 25-250MG
ER TAB 25-100MG
ER TAB 50-200MG
TAB 0.125MG
TAB 0.25MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
PA
PA
PA
PA
PA
ANTICHOLINERGIC AGENTS (CNS)
BENZTROPINE
BENZTROPINE
BENZTROPINE
BENZTROPINE
TRIHEXYPHEN
TRIHEXYPHEN
TRIHEXYPHEN
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
ANTIPARKINSON
ENTACAPONE
SELEGILINE
SELEGILINE
TOLCAPONE
DOPAMINERGICS
BROMOCRIPTIN
BROMOCRIPTIN
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
PRAMIPEXOLE
PRAMIPEXOLE
QL 3 per day
QL 3 per day
64
Drug Name
PRAMIPEXOLE
PRAMIPEXOLE
PRAMIPEXOLE
PRAMIPEXOLE
ROPINIROLE
ROPINIROLE
ROPINIROLE
ROPINIROLE
ROPINIROLE
ROPINIROLE
ROPINIROLE
TAB 0.5MG
TAB 0.75MG
TAB 1MG
TAB 1.5MG
TAB 0.25MG
TAB 0.5MG
TAB 1MG
TAB 2MG
TAB 3MG
TAB 4MG
TAB 5MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 3 per day
QL 3 per day
QL 3 per day
QL 3 per day
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
RILUZOLE
TAB 50MG
Generic
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
BACLOFEN
BACLOFEN
CHLORZOXAZONE
CYCLOBENZAPRINE
CYCLOBENZAPRINE
METHOCARBAMOL
METHOCARBAMOL
TIZANIDINE
TIZANIDINE
TAB 10MG
TAB 20MG
TAB 500MG
TAB 5MG
TAB 10MG
TAB 500MG
TAB 750MG
TAB 2MG
TAB 4MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
AR PA required >64
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
DANTROLENE
DANTROLENE
DANTROLENE
NUTRITIONAL PRODUCTS
CAP 25MG
CAP 50MG
CAP 100MG
Generic
Generic
Generic
TAB 250MG
INJ 1000MCG
TAB 250MG SR
TAB 500MG SR
TAB 1000MCG
TAB 400MCG
TAB 800MCG
TAB 1MG
TAB 1000MCG
INJ 5MG/ML
TAB XTRA
CAP 250MG TR
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
VITAMIN B COMPLEX
B1 NATURAL
CYANOCOBALAM
ENDUR-ACIN
ENDUR-ACIN
EQL B-12
FOLIC ACID
FOLIC ACID
FOLIC ACID
FOLIC ACID
FOLIC ACID
FOLIC ACID
NIACIN
90 day supply available
65
Drug Name
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN ER
NIACIN ER
NIACIN TR
NIACINAMIDE
NIACINAMIDE
SLO-NIACIN
THIAMINE HCL
VITAMIN B-1
VITAMIN B-1
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
VITAMIN B-12
CAP 250MG TD
CAP 250MG ER
CAP 250MG SR
CAP 500MG TR
CAP 500MG SR
TAB 50MG
TAB 100MG
TAB 250MG
TAB 500MG
TAB 250MG SR
TAB 500MG CR
TAB 500MG ER
TAB 500MG PR
TAB 750MG TR
CAP 250MG
CAP 500MG
TAB 1000MG
TAB 100MG
TAB 500MG
TAB 250MG CR
TAB 100MG
TAB 50MG
TAB 100MG
TAB 50MCG
TAB 100MCG
TAB 250MCG
TAB 500MCG
TAB 1000MCG
TAB 2000MCG
TAB 1000 CR
TAB 1000 TR
SUB 500MCG
SUB 1000MCG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
DRO 0.25MG
TAB
TAB
TAB
SOL TRI-VITE
SOFT CHEW
Generic
Generic
Generic
Brand
Generic
Generic
AR PA required > 2
MULTIVITAMIN PREPARATIONS
ACD/FLUORIDE
B COMPLEX WITH VITAMIN C
B COMPLEX W/C & FOLIC ACID
BIOTIN FORTE
BPROTECTED
CALCIUM
CALNA
TAB
Brand
AR PA required > 2
AR PA required >50;
covered for females only
66
Drug Name
Drug Type
Requirements
AR PA required >50;
CAVAN-EC SOD
MIS DHA
Generic
CENTRUM SPEC
CHEW CALCIUM
PAK PRENATAL
CHW
Brand
Generic
PAK DHA
Brand
AR PA required >50;
CITRANATAL
AR PA required >50;
CITRANATAL
PAK ASSURE
Brand
AR PA required >50;
CL PRENATAL
TAB 28-0.8MG
Generic
AR PA required >50;
COMP PRNATAL
MIS DHA
Generic
AR PA required >50;
COMPL PRENAT
MIS +DHA
Brand
AR PA required >50;
COMPLETENATE
CHW
Generic
AR PA required >50;
CO-NATAL FA
TAB 29-1MG
Generic
AR PA required >50;
CONCEPT OB
CAP
Brand
AR PA required >50;
TAB 28-0.8MG
Brand
AR PA required >50;
CVS PRENATAL
CVS PRENATAL
CVS STRESS
CVS SUPER B
DIALYVITE
DIALYVITE
DIALYVITE/
TAB
TAB FORMULA
TAB COMPLX/C
TAB 800
TAB
TAB ZINC
Generic
Generic
Generic
Generic
Generic
Brand
AR PA required >50;
ELITE-OB
TAB
Generic
AR PA required >50;
ENFAMIL
MIS EXPECTA
Brand
AR PA required >50;
EQL PRENATAL
TAB FORMULA
Generic
AR PA required >50;
FOCALGIN CA
MIS
Brand
AR PA required >50;
CAP OMEGA 3
Brand
AR PA required >50;
Brand
AR PA required >50;
FOLCAPS
FOLIVANE-OB
CAP
67
Drug Name
FOLIVANE-PRX
FULL SPECT
GESTICARE
GNP PRENATAL
Drug Type
Requirements
AR PA required >50;
CAP DHA NF
TAB B/ VIT C
Brand
Generic
PAK DHA
Brand
AR PA required >50;
TAB 28-0.8MG
Generic
AR PA required >50;
AR PA required >50;
GOODSENSE
HM B COMPLEX
TAB 28-0.8MG
TAB WITH C
Brand
Generic
HM PRENATAL
TAB
Brand
AR PA required >50;
INATAL ADV
TAB
Generic
AR PA required >50;
INATAL GT
TAB
Generic
AR PA required >50;
INATAL ULTRA
KP B COMPLEX
TAB
TAB /C
Generic
Generic
KP PRENATAL
TAB MULTIVIT
Brand
AR PA required >50;
TAB
Brand
AR PA required >50;
KPN PRENATAL
AR PA required >50;
MISSION PREN
TAB
Brand
AR PA required >50;
MISSION PREN
TAB HP
Generic
AR PA required >50;
MULTI PRENAT
MULTI-VIT/FE
MULTI-VIT/FL
MULTI-VIT/FL
MULTI-VIT/FL
TAB
DRO /FL 0.25
DRO 0.25MG
DRO 0.5MG/ML
DRO /FE 0.25
Generic
Generic
Generic
Generic
Generic
AR PA required >50;
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
TAB 27-1MG
Generic
AR PA required >50;
M-VIT
MYNATAL
CAP
Brand
AR PA required >50;
MYNATAL
TAB
Generic
AR PA required >50;
MYNATAL
TAB ADVANCE
Generic
AR PA required >50;
Generic
AR PA required >50;
MYNATAL PLUS
TAB
68
Drug Name
MYNATAL-Z
MYNEPHROCAPS
NATAL-V RX
NATALVIRT CA
Drug Type
Requirements
AR PA required >50;
TAB
CAP
Generic
Generic
TAB 29-1MG
Brand
AR PA required >50;
PAK
Brand
AR PA required >50;
AR PA required >50;
NATALVIT
NEPHPLEX RX
NEPHRONEX
NEPHRO-VITE
TAB 75-1MG
TAB
TAB 1MG
TAB
Brand
Brand
Generic
Brand
NIVA-PLUS
NOVAFERRUM
TAB
DRO 10MG/ML
Brand
Generic
AR PA required >50;
AR PA required > 2
OB COMPLETE
TAB
Brand
AR PA required >50;
OB-NATAL ONE
CAP 27-1MG
Generic
AR PA required >50;
TAB PRENATAL
Brand
AR PA required >50;
TAB
Brand
AR PA required >50;
PNV FE FUM
TAB DOC/FA
Brand
AR PA required >50;
PNV FOLIC AC
TAB + IRON
Brand
AR PA required >50;
PNV OB+DHA
PAK
Brand
AR PA required >50;
TAB PLUS
Brand
AR PA required >50;
PNV TABS
TAB 29-1MG
Brand
AR PA required >50;
PNV-DHA
CAP
Generic
AR PA required >50;
O-CAL
O-CAL FA
PNV PRENATAL
PNV-SELECT
TAB
Brand
AR PA required >50;
PNV-VP-U
POLY-VI-SOL
POLY-VI-SOL
POLY-VITA
POLY-VITA
CAP 106.5-1
DRO
DRO/IRON
DRO
DRO/IRON
Brand
Brand
Brand
Generic
Generic
AR PA required >50;
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
69
Drug Name
POLYVITAMIN
POLYVITAMIN
POLY-VITE
POLY-VITE
DRO
DRO/IRON
DRO
SOL/IRON
Drug Type
Generic
Generic
Generic
Generic
Requirements
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
PRENAISSANCE
PAK DHA
Brand
AR PA required >50;
PRENAISSANCE
PAK PROMISE
Brand
AR PA required >50;
TAB
Generic
AR PA required >50;
PRENAT PLUS
TAB 27-1MG
Brand
AR PA required >50;
PRENATABS FA
TAB
Generic
AR PA required >50;
PRENATABS RX
TAB
Generic
AR PA required >50;
PRENATAL
TAB
Generic
AR PA required >50;
PRENAPLUS
PRENATAL
TAB FORTE
Generic
AR PA required >50;
PRENATAL
TAB VITAMINS
Generic
AR PA required >50;
PRENATAL
TAB PLUS FE
Brand
AR PA required >50;
PRENATAL
TAB COMPLETE
Brand
AR PA required >50;
PRENATAL
TAB 27-0.8MG
Generic
AR PA required >50;
PRENATAL
TAB LOW IRON
Generic
AR PA required >50;
PRENATAL
TAB 27-1MG
Brand
AR PA required >50;
PRENATAL
TAB PLUS
Brand
AR PA required >50;
PRENATAL
TAB 28-0.8MG
Generic
AR PA required >50;
PRENATAL
TAB FORMULA
Generic
AR PA required >50;
PRENATAL
TAB PLUS DHA
Brand
AR PA required >50;
Brand
AR PA required >50;
PRENATAL 1
CAP
70
Drug Name
Drug Type
Requirements
PRENATAL 19
CHW 29-1MG
Brand
AR PA required >50;
PRENATAL 19
CHW TAB
Generic
AR PA required >50;
PRENATAL 19
TAB 29-1MG
Brand
AR PA required >50;
TAB
Generic
AR PA required >50;
PRENATAL FRM
TAB A-FREE
Brand
AR PA required >50;
PRENATAL MV
MIS + DHA
Brand
AR PA required >50;
PRENATAL AD
PRENATAL VIT
TAB 28-0.8MG
Generic
AR PA required >50;
PRENATAL/FE
TAB
Generic
AR PA required >50;
PRENATAL+DHA
MIS
Brand
AR PA required >50;
PRENATAL+DHA
MIS WOMENS
Brand
AR PA required >50;
TAB 29-1MG
Brand
AR PA required >50;
PRENATAL+FE
PRENATAL-U
CAP 106.5-1
Generic
AR PA required >50;
PRENATL MULT
CAP + DHA
Brand
AR PA required >50;
TAB 27-1MG
Brand
AR PA required >50;
TAB 29-1MG
Brand
AR PA required >50;
TAB MULTIVIT
Generic
AR PA required >50;
PREPLUS
PRETAB
PX PRENATAL
QC PRENATAL
QUFLORA PED
QUFLORA PED
RA CALCIUM
RA CALCIUM
TAB 28-0.8MG
DRO 0.25MG
DRO 0.5MG/ML
CHW CARAMEL
CHW MLK CHOC
Brand
Generic
Generic
Generic
Generic
RA PRENATAL
TAB FORMULA
Brand
RA PRENATAL
RENAL
TAB 28-0.8MG
CAP SOFTGEL
Generic
Generic
AR PA required >50;
AR PA required > 2
AR PA required > 2
AR PA required >50;
AR PA required >50;
71
Drug Name
RENAL
RENALPREN
RENA-VITE
RENA-VITE RX
RENO
TAB MULTIVIT
CAP
TAB
TAB
CAP
Drug Type
Generic
Generic
Generic
Generic
Generic
Requirements
RULAVITE DHA
CAP
Brand
AR PA required >50;
SE-NATAL 19
CHW
Generic
AR PA required >50;
SE-TAN DHA
CAP
Generic
AR PA required >50;
PAK EARLY SH
CHW
Brand
Generic
SIMILAC PREN
SM CALCIUM
AR PA required >50;
AR PA required >50;
SM PRENATAL
STRESS 500
STRESS FORM
TAB VITAMINS
TAB B-COMPLE
TAB
Generic
Generic
Generic
STUART PREN
SUPER B-COMP
SUPER B-COMP
SUPERPLEX-T
TAB
TAB VIT C/FA
TAB /VIT C
TAB
Brand
Generic
Generic
Generic
TAB VITAMINS
Brand
AR PA required >50;
TH PRENATAL
AR PA required >50;
THERANATAL
MIS COMPLETE
Brand
AR PA required >50;
THERANATAL
MIS PLUS
Brand
AR PA required >50;
THRIVITE 19
TAB
Brand
AR PA required >50;
AR PA required >50;
THRIVITE RX
TOTAL B/C
TAB 29-1MG
TAB
Brand
Generic
TRIADVANCE
TAB
Generic
AR PA required >50;
TRICARE
TAB PRENATAL
Generic
AR PA required >50;
TRINATAL
TAB ULTRA
Brand
AR PA required >50;
TAB
Brand
AR PA required >50;
TRINATAL GT
72
Drug Name
Drug Type
Requirements
AR PA required >50;
TRINATAL RX
TAB 1
Generic
TRINATE
TRIPHROCAPS
TRI-VI-SOL
TRI-VIT/FL
TRI-VIT/FL
TRI-VIT/FLUO
TRI-VIT/FLUO
TRI-VITA
TRI-VITA/FL
TRI-VITAMIN
TAB
CAP
SOL
DRO 0.25MG
DRO 0.5MG
DRO 0.25MG
DRO 0.5MG
SOL
DRO 0.25MG
DRO
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CAP ONE
Generic
AR PA required >50;
ULTIMATECARE
AR PA required >50;
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
AR PA required > 2
ULTRA TABS
TAB
Generic
AR PA required >50;
VENATAL-FA
TAB
Brand
AR PA required >50;
VINATE AZ EX
TAB
Brand
AR PA required >50;
VINATE CAL
TAB
Brand
AR PA required >50;
VINATE GT
TAB
Generic
AR PA required >50;
VINATE IC
CAP
Generic
AR PA required >50;
VINATE II
TAB
Generic
AR PA required >50;
VINATE ONE
TAB
Generic
AR PA required >50;
VINATE ULTRA
TAB
Generic
AR PA required >50;
VIRT NATE
TAB
Brand
AR PA required >50;
AR PA required >50;
VIRT NATE
TAB 28-1MG
Brand
VIRT-ADVANCE
VIRT-CAPS
TAB 90-1MG
CAP
Brand
Generic
CAP ONE
Brand
VIRT-CARE
AR PA required >50;
AR PA required >50;
73
Drug Name
Drug Type
Requirements
VIRT-PN
TAB
Brand
AR PA required >50;
VIRT-PN DHA
CAP
Brand
AR PA required >50;
VIRT-VITE GT
VITA-BEE/C
TAB 90-1MG
TAB
Brand
Generic
VITAFOL-OB
TAB 65-1MG
Generic
VITAFOL-PN
VOL-CARE RX
TAB
TAB
Brand
Generic
AR PA required >50;
AR PA required >50;
AR PA required >50;
VOL-NATE
TAB
Brand
AR PA required >50;
VOL-PLUS
TAB
Brand
AR PA required >50;
VOL-TAB RX
TAB
Brand
AR PA required >50;
AR PA required >50;
VP-ERA OB
VP-VITE RX
PAK PLUS
TAB
Brand
Generic
ZATEAN-PN
TAB
Brand
AR PA required >50;
CAP DHA
Brand
AR PA required >50;
GEL 1.1%
CRE 1.1%
CRE PLUS
CRE PLUS 2PK
GEL 1.1%
DRO
DRO 0.125MG
CHW 0.25MG F
CHW 0.5MG F
CHW 1MG F
CHW 0.25MG F
CHW 0.5MG F
CHW 1MG F
GEL 1.1%
GEL WHITENIN
CHW 0.25MG F
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
ZATEAN-PN
FLUORIDE
CAVAREST
CONTROLRX
DENTA 5000
DENTA 5000
DENTAGEL
FLUORABON
FLUOR-A-DAY
FLUOR-A-DAY
FLUOR-A-DAY
FLUOR-A-DAY
FLUORIDE
FLUORIDE
FLUORIDE
FLUORIDEX
FLUORIDEX
FLUORITAB
74
Drug Name
FLUORITAB
FLUORITAB
FLUORITAB
FLUORITAB
FLURA-DROPS
FLURA-DROPS
KARIDIUM
KARIGEL
KARIGEL-N
LUDENT
LUDENT
LUDENT
NAFRINSE
NAFRINSE
NEUTRAGARD
PHOS-FLUR
SF
SF 5000 PLUS
SOD FLUORIDE
SOD FLUORIDE
SOD FLUORIDE
SOD FLUORIDE
SOD FLUORIDE
SOD FLUORIDE
CHW 0.5MG F
CHW 1MG F
CHW 2.2MG
DRO 0.125MG
DRO 0.125MG
DRO 0.25MG F
DRO 0.125MG
GEL 0.5%
GEL 1.1%
CHW 0.25MG F
CHW 0.5MG F
CHW 1MG F
CHW 1MG F
DRO 0.125MG
GEL 1.1%
GEL 1.1%
GEL 1.1%
CRE 1.1%
CHW 0.25MG F
CHW 0.5MG F
CHW 1.1MG
CHW 1MG F
CHW 2.2MG
DRO 0.5MG/ML
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CHW 500MG
CHW 600-400
CHEW TAB 500MG-100
TAB
TAB
TAB 600MG-200
TAB
TAB
TAB
CHEW TAB
1250/5ML SUSP
TAB
TAB
TAB
TAB
LIQ
SOL
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Requirements
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
AR > 18 not covered
REPLACEMENT PREPARATIONS
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM W/VIT D & POTASSIUM
CALCIUM/PLUS D
CALCIUM CITRATE
CALCIUM W/VIT D
CALCIUM CITRATE PLUS VIT D
CALCIUM PLUS D/ MINERALS
CALCIUM PLUS D3
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM CITRATE PLUS VITAMIN D
CALCIUM GLUCONATE
CALCIUM LACTATE
CERALYTE 70
CERASPORT
75
Drug Name
CERASPORT
CIT CALC/D
CIT CALC/D
D5W/NACL
D5W/NACL
EFFER-K
ENFALYTE
ENFAMIL
FLUSH SYRING
GERBER
GNP CALCIUM
K-EFFERVESCE
KLOR-CON
KLOR-CON 10
KLOR-CON 8
KLOR-CON M10
KLOR-CON M20
KLOR-CON SPR
KLOR-CON SPR
KLOR-CON/EF
KLOR-CON/EF
KP CALCIUM
K-PHOS
K-PRIME
K-SOL
K-SOL
K-VESCENT
K-VESCENT
LIQ CA/VIT D
MAG OXIDE
NATURALYTE
NORML SALINE
ORAL ELECTRO
ORALYTE
OS-CAL
OS-CAL
OSCAL
OYS SHELL CA
OYS SHELL+D
OYS SHELL+D
OYSCO
OYST CAL/D
SOL EX1
TAB 200-250
TAB 315-250
INJ 0.45%
INJ 0.9%
TAB 25MEQ EF
SOL
SOL ENFALYTE
INJ 0.9%
SOL REPLENSH
TAB 500/D
TAB 25MEQ EF
POW 20MEQ
TAB 10MEQ ER
TAB 8MEQ ER
TAB 10MEQ ER
TAB 20MEQ ER
CAP 8MEQ
CAP 10MEQ
TAB 25MEQ EF
TAB 25MEQ FR
TAB 600+D
TAB
TAB 25MEQ EF
SOL 10%
SOL 20%
TAB 25MEQ EF
POW 20MEQ
CAP 600MG
TAB 400MG
SOL
INJ IV FLUSH
SOL H-E-B
SOL
CHW 500-600
500 CHW
TAB 500/200 D-3
TAB 500MG
TAB 250-125
CHW 500-400
500 + D CHW
TAB 250MG
Drug Type
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
76
Drug Name
OYST CAL/D
OYST SHELL/D
OYST SHELL/D
OYST SHELL/D
OYST SHELL/D
OYST SHELL/D
OYST SHELL/D
PEDIALYTE
PHOSPHA 250
POT ACETATE
POT ACETATE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CHLORIDE
POT CL MICRO
POT CL MICRO
POT CL MICRO
POT GLUCONAT
POT GLUCONAT
POT GLUCONAT
POT GLUCONAT
POT GLUCONAT
POTASSIUM
SALINE FLUSH
SALINE FLUSH
SOD CHLORIDE
SOD CHLORIDE
SOD CHLORIDE
TAB 500MG
TAB 250MG
TAB 500MG
TAB 500-200
TAB 600MG
TAB 500-125
TAB 500-400
SOL
TAB NEUTRAL
INJ 2MEQ/ML
INJ 4MEQ/ML
CAP 8MEQ ER
CAP 10MEQ ER
TAB 8MEQ ER
TAB 8MEQ SR
TAB 10MEQ ER
TAB 10MEQ CR
TAB 20MEQ ER
INJ 2MEQ/ML
INJ 10MEQ
INJ 20MEQ
INJ 40MEQ
SOL 10% SF
SOL 10%
SOL 20% SF
SOL 20%
POW 20MEQ
TAB 25MEQ EF
TAB 10MEQ ER
TAB 10MEQ CR
TAB 20MEQ ER
TAB 2MEQ
TAB 550MG
TAB 2.5MEQ
TAB 99MG
TAB 595MG
TAB 99MG
INJ 0.9%
INJ ZR 0.9%
INJ 0.45%
INJ 0.9%
INJ 3%
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
77
Drug Name
SOD CHLORIDE
SOD CHLORIDE
SOD CHLORIDE
SOD CHLORIDE
TH CALCIUM/D
VIRT-PHOS
INJ 5%
INJ 23.4%
INJ 4MEQ/ML
INJ 2.5/ML
TAB 600-400
TAB 250 NEUT
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
CALORIC AGENTS (MOST NUTRITIONAL SUPPLEMENTS COVERED WITH PRIOR
AUTHORIZATION REQUIRED; NOT ALL PRODUCTS LISTED)
BOOST
PA
ENSURE
PA
GLUCERNA
PA
PEDIASURE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
DEXTROSE
PA
HEMATOLOGICAL AGENTS
INJ 5%
INJ 5% PGBK
INJ 10%
INJ 20%
INJ 25%
INJ 30%
INJ 40%
INJ 50%
INJ 70%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
INJ 25MCG
INJ 40MCG
INJ 60MCG
INJ 100MCG
INJ 150MCG
INJ 200MCG
INJ 300MCG
INJ 10MCG
INJ 500MCG
INJ 2000/ML
INJ 3000/ML
INJ 4000/ML
INJ 10000/ML
INJ 20000/ML
INJ 300/0.5
INJ 480/0.8
INJ 6MG/0.6M
KIT 6MG/0.6M
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
HEMATOPOIETIC AGENTS
ARANESP
ARANESP
ARANESP
ARANESP
ARANESP
ARANESP
ARANESP
ARANESP
ARANESP
EPOGEN
EPOGEN
EPOGEN
EPOGEN
EPOGEN
GRANIX
GRANIX
NEULASTA
NEULASTA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA QL 0.6mls per 31 days
PA QL 0.6mls per 31 days
78
Drug Name
NEUPOGEN
NEUPOGEN
NEUPOGEN
NEUPOGEN
PROCRIT
PROCRIT
PROCRIT
PROCRIT
PROCRIT
PROCRIT
PROMACTA
PROMACTA
PROMACTA
PROMACTA
ZARXIO
ZARXIO
INJ 300MCG
INJ 480MCG
INJ 300/0.5
INJ 480/0.8
INJ 2000/ML
INJ 3000/ML
INJ 4000/ML
INJ 10000/ML
INJ 20000/ML
INJ 40000/ML
TAB 12.5MG
TAB 25MG
TAB 50MG
TAB 75MG
INJ 300 MCG/0.5ML
INJ 480 MCG/0.8ML
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
TAB 325MG
TAB 325MG EC
TAB 65MG
TAB 27MG
TAB 28MG
TAB 27MG
DRO 15MG/ML
ELX 220/5ML
CAP 150MG
CAP 150MG
TAB 325MG
TAB
DRO 15MG/ML
TAB 240MG
TAB 324MG
TAB 325MG
TAB 225MG
LIQ 220/5ML
TAB 325MG
TAB 325MG FC
TAB 5GR
TAB 324MG EC
TAB 325MG EC
ELX 220/5ML
SYP 300/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
IRON PREPARATIONS
FE GLUCONATE
FE TABS
FEOSOL
FERATE
FERATE
FERGON
FER-IRON
FEROSUL
FERREX 150
FERRIC X-150
FERRO-BOB
FERROTABS
FERROUS
FERROUS GLUCONATE
FERROUS GLUCONATE
FERROUS GLUCONATE
FERROUS GLUCONATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
79
Drug Name
FERROUS SULFATE
FERUS
IFEREX 150
IRON
IRON
IRON
IRON
IRON SUPPLEM
IRON SUPPLMT
IRON THERAPY
MYFERON 150
NEPHRON FA
NU-IRON 150
PEDIA IRON
POLY-IRON
SLOW IRON
SLOW REL FE
SLOW REL FE
SLOW RELEASE
SLOW RELEASE
SM IRON
SM IRON SLOW
TH IRON
DRO 15MG/ML
CAP 150MG
CAP
TAB 65MG
TAB 325MG
TAB 27MG
TAB 28MG
TAB THERAPY
DRO 15MG/ML
TAB 200MG
CAP 150MG
TAB
CAP 150MG
DRO 15MG/ML
CAP 150MG
TAB 160MG CR
TAB 143MG CR
TAB 160MG CR
TAB 143MG
TAB 47.5MG
TAB 325MG
TAB 160MG CR
TAB 65MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
TAB 1MG
TAB 2MG
TAB 2.5MG
TAB 3MG
TAB 4MG
TAB 5MG
TAB 6MG
TAB 7.5MG
TAB 10MG
INJ 5 MG
TAB 2.5MG
TAB 5MG
INJ 30/0.3ML
INJ 40/0.4ML
INJ 60/0.6ML
INJ 80/0.8ML
INJ 100MG/ML
INJ 120/0.8
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
ANTICOAGULANTS
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
ELIQUIS
ELIQUIS
ENOXAPARIN
ENOXAPARIN
ENOXAPARIN
ENOXAPARIN
ENOXAPARIN
ENOXAPARIN
QL 2 per day
QL 2 per day
QL 0.6mls per day
QL 0.8mls per day
QL 1.2mls per day
QL 1.6mls per day
QL 2mls per day
QL 1.6mls per day
80
Drug Name
ENOXAPARIN
ENOXAPARIN
FONDAPARINUX
FONDAPARINUX
FONDAPARINUX
FONDAPARINUX
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
HEPARIN SOD
HEPARIN SOD
HEPARIN SOD
HEPARIN SOD
HEPARIN SOD
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
JANTOVEN
PRADAXA
PRADAXA
PRADAXA
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
WARFARIN
INJ 150MG/ML
INJ 300/3ML
INJ 2.5/0.5
INJ 5/0.4ML
INJ 7.5/0.6
INJ 10/0.8ML
INJ 10000/ML
INJ 2500/0.2
INJ 5000/0.2
INJ 7500/0.3
INJ 12500UNT
INJ 15000UNT
INJ 18000UNT
INJ 25000/ML
INJ 95000UNT
INJ 1000/ML
INJ 5000/ML
INJ 5000/0.5
INJ 10000/ML
INJ 20000/ML
TAB 1MG
TAB 2MG
TAB 2.5MG
TAB 3MG
TAB 4MG
TAB 5MG
TAB 6MG
TAB 7.5MG
TAB 10MG
CAP 75MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
CAP 110MG
CAP 150MG
TAB 1MG
TAB 2MG
TAB 2.5MG
TAB 3MG
TAB 4MG
TAB 5MG
TAB 6MG
TAB 7.5MG
SOD TAB 10MG
TAB 10MG
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 2mls per day
14 day supply per fill
QL 0.5 per day
QL 0.4 per day
QL 0.6 per day
QL 0.8 per day
QL 2mls per 30 days
QL 2mls per 30 days
QL 3mls per 30 days
QL 5mls per 30 days
QL 6mls per 30 days
QL 7.2mls per 30 days
QL 2 per day
QL 2 per day;
#70 per 180 days
QL 2 per day
81
Drug Name
XARELTO
XARELTO
XARELTO
XARELTO STAR
TAB 10MG
TAB 20MG
TAB 15MG
TAB 15/20MG
Drug Type
Brand
Brand
Brand
Brand
SYRUP 25%
Generic
TAB 400MG ER
Generic
CAP 25-200MG
CAP 0.5MG
CAP 1MG
CAP 25-200MG
TAB 50MG
TAB 100MG
TAB 75MG
TAB 250MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SOL 0.2% OP
SOL 0.15%
TAB 8MG
TAB 1MG
TAB 2MG
TAB 4MG
HCL CAP 1MG
HCL CAP 2MG
HCL CAP 5MG
CAP 10MG
CAP 1MG
CAP 2MG
CAP 5MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OIN OP
OIN OP
OIN OP
OIN 0.3% OP
SOL 0.3% OP
OIN 5MG/GM
OIN OP
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Requirements
QL 35 days per 180 days
QL 1 per 365 days
HEMOSTATICS
AMINOCAPROIC ACID
HEMORRHEOLOGIC AGENTS
PENTOXIFYLLI
PLATELET-ACTING AGENTS
AGGRENOX
ANAGRELIDE
ANAGRELIDE
ASA/DIPYRIDA
CILOSTAZOL
CILOSTAZOL
CLOPIDOGREL
TICLOPIDINE
TOPICAL PRODUCTS
AR PA required >64
ALPHA-ADRENERGIC AGONISTS (EENT)
BRIMONIDINE
BRIMONIDINE
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
PRAZOSIN
PRAZOSIN
PRAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
ANTIBACTERIALS (EENT)
AK-POLY-BAC
BACIT/POLYMY
BACITRACIN
CILOXAN
CIPROFLOXACIN
ERYTHROMYCIN
ERYTHROMYCIN
82
Drug Name
GARAMYCIN
GATIFLOXACIN
GENTAK
GENTAMICIN
GENTAMICIN
ILOTYCIN
ILOTYCIN
NEO/BAC/POLY
NEO/POLY/GRA
NEO-POLYCIN
OFLOXACIN
OFLOXACIN
POLYCIN
POLYCIN
POLYCIN B
POLYMYXIN B/SOL TRIMETHOPRIM SULFATE
ROMYCIN
SULFACET SOD
TOBRAMYCIN
TRIMETHOPRIM SOL POLYMYXN
OIN 0.3% OP
SOL 0.5%
OIN 0.3% OP
SOL 0.3% OP
OIN 0.3% OP
OIN OP
OIN OP
OIN OP
SOL OP
OIN OP
DRO 0.3% OP
DRO 0.3%OTIC
OIN OP
OIN OP
OIN OP
SOL
SOL 10% OP
SOL 0.3% OP
SOL
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SOL 1% OP
GEL 0.15%
Generic
Brand
Requirements
ANTIVIRALS (EENT)
TRIFLURIDINE
ZIRGAN
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
BETOPTIC-S
LEVOBUNOLOL
LEVOBUNOLOL
METIPRANOLOL
TIMOLOL GEL
TIMOLOL GEL
TIMOLOL MAL
TIMOLOL MAL
SUS 0.25% OP
SOL 0.25% OP
SOL 0.5% OP
SOL 0.3% OPH
SOL 0.25% OP
SOL 0.5% OP
SOL 0.25% OP
SOL 0.5% OP
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SOL OTIC
SUS OP
OIN S.O.P.
SUS 0.3-0.1%
SOL 0.1% OP
SUS 0.1% OP
OIN 0.1% OP
SUS 0.25% OP
SOL OTIC
Generic
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Generic
CORTICOSTEROIDS (EENT)
ACETASOL HC
BLEPHAMIDE
BLEPHAMIDE
CIPRODEX
DEXAMETH PHO
FLUOROMETHOL
FML
FML FORTE
HC/ACET ACID
PA
83
Drug Name
NEO/POLY/BAC
NEO/POLY/DEX
NEO/POLY/DEX
NEO/POLY/HC
NEO/POLY/HC
NEO/POLY/HC
NEO-POLYCIN
POLY-DEX
PRED MILD
PRED SOD PHO
PREDNISOLONE
SULF/PRED NA
TOBRA/DEXAME
TOBRADEX
OIN /HC 1%OP
SUS 0.1% OP
OIN 0.1% OP
SUS OP
SUS 1% OTIC
SOL 1% OTIC
OIN HC 1%OP
OIN 0.1% OP
SUS 0.12% OP
SOL 1% OP
SUS 1% OP
SOL OP
SUS 0.3-0.1%
OIN 0.3-0.1%
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
SOL 2% OTIC
SOL 0.5% OP
Generic
Generic
Requirements
EENT DRUGS, MISCELLANEOUS
ACETIC ACID
APRACLONIDIN
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
DICLOFENAC
FLURBIPROFEN
KETOROLAC
KETOROLAC
SOL 0.1% OP
SOL 0.03% OP
SOL 0.4%
SOL 0.5%
Generic
Generic
Generic
Generic
SOL 0.125%OP
SOL 1% OP
SOL 2% OP
SOL 4% OP
Brand
Generic
Generic
Generic
SOL 1% OP
SOL 1% OP
SOL OP
SOL 1% OP
SOL 2% OP
SOL 0.5% OP
SOL 5% OP
SOL 5% OP
SOL 0.5% OP
SOL 1% OP
SOL 0.5% OP
SOL 1% OP
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MIOTICS
PHOSPHOLINE
PILOCARPINE
PILOCARPINE
PILOCARPINE
MYDRIATICS
ATROPIN-CARE
ATROPINE SUL
CYCLOMYDRIL
CYCLOPENTOL
CYCLOPENTOL
CYCLOPENTOLATE
HOMATROPAIRE
HOMATROPINE
MYDRAL
MYDRAL
TROPICAMIDE
TROPICAMIDE
84
Drug Name
Drug Type
SOL 0.005%
DRO 0.004%
Generic
Generic
SOL OTIC
SOL OTIC
SOL 2% VISC
Generic
Generic
Generic
SOL 0.12%
SOL 0.12%
SOL 0.12%
Generic
Generic
Generic
Requirements
PROSTAGLANDIN ANALOGS
LATANOPROST
TRAVOPROST
LOCAL ANESTHETICS (EENT)
ANTIPY/BENZO
AURODEX
LIDOCAINE
EENT ANTI-INFECTIVES, MISCELLANEOUS
CHLORHEX GLU
PAROEX
PERIOGARD
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
ANTIBIOTIC
ANTIBIOTIC
BAC/NEO/POLY
BACITR ZINC
GENTAMICIN
GENTAMICIN
LANABIOTIC
MUPIROCIN
NEOPORACIN
NEOSPORIN+PN
SM FIRST AID
OIN
OIN PAIN RLF
OIN
OIN 500/GM
CRE 0.1%
OIN 0.1%
OIN
OIN 2%
OIN
OIN RELF MAX
OIN 500/GM
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ANTIPRURITICS AND LOCAL ANESTHETICS
GLYDO
LIDO/PRILOCN
LIDO/PRILOCN
LIDOCAINE
LIDOCAINE
LIVIXIL PAK
LP LITE PAK
RELADOR PAK
RELADOR PAK
GEL 2%
CRE 2.5-2.5%
KIT 2.5-2.5%
GEL 2% JELLY
SOL 4%
KIT 2.5-2.5%
KIT 2.5-2.5%
KIT 2.5-2.5%
KIT PLUS
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL 2 grams per day
QL 2 grams per day
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
ALCOHOL
ALCOHOL WIPE
AVC
RA ALCOHOL
SILVER SULFA
SSD
THERMAZENE
MIS WIPES
MIS 70%
CRE 15%
MIS WIPES
CRE 1%
CRE 1%
CRE 1%
Generic
Generic
Brand
Brand
Generic
Generic
Generic
85
Drug Name
Drug Type
CRE 5%
CRE 10%
LOT 10%
SHA 0.33-4%
LOT 1%
LIQ 1%
LIQ CRM RNSE
LIQ MAX ST
SHA 0.33-4%
LOT 1%
SHA 1%
CRE 5%
LOT 1%
LIQ MOUSSE
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
SCABICIDES AND PEDICULICIDES
ACTICIN
EURAX
EURAX
LICE KILLING
LICE TREATMENT
LICE TRTMNT
LICE TRTMNT
LICIDE
LICIDE
LINDANE
LINDANE
PERMETHRIN
PERMETHRIN
PRONTO PLUS
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
CALCIPOTRIEN
CALCIPOTRIEN
CAPREX +
CAPSAICIN
CAPSAICIN
CAPZASIN-P
CONDYLOX
FLUOROURACIL
FLUOROURACIL
FLUOROURACIL
IMIQUIMOD
PODOFILOX
PSORIASIN
RA ARTH PAIN
REGRANEX
SCALPICIN
STELARA
STELARA
THERAGEN HP
TRIXAICIN HP
VEREGEN
SOL 0.005%
CRE 0.005%
CRE 0.075%
CRE 0.025%
CRE 0.1%
CRE 0.035%
GEL 0.5%
DRO 5%
SOL 5%
CRE 5%
CRE 5%
SOL 0.5%
LIQ 3%
CRE 0.075%
GEL 0.01%
LIQ 3%
INJ 45MG/0.5
INJ 90MG/ML
CRE 0.075%
CRE 0.075%
OIN 15%
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Brand
Brand
Generic
Generic
Brand
LOT 1%
CRE 1%
CRE 0.05%
LOT 0.05%
Generic
Generic
Generic
Generic
PA
PA
PA
PA
PA
PA
PA QL 2
PA 0.018 per day
PA 0.036 per day
TOPICAL CORTICOSTEROIDS
ANTI-ITCH
ANTI-ITCH
AUGMENTED BETAMETHASONE
BETAMETH DIP
86
Drug Name
BETAMETHASONE
COLOCORT
CORT INTENSE
CORTAID
CORTAID
CORTAID ADV
CORTIFOAM
CORTISONE
CORTISONE
CORTISONE
CORTIZONE-10
CORTIZONE-10
CORTIZONE-10
CORTIZONE-10
CORTIZONE-10
CORTIZONE-10
DESOXIMETAS
FLUTICASONE
FLUTICASONE
GYNECORT 10
HYDROSKIN
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORT AC
HYDROCORT/AB
HYDROCREAM
HYDRO-LOTION
HYDROSKIN
INSTACORT 5
KERICORT 10
K HYDROCORTISON
LANACORT 10
MED-DERM HC
MED-DERM HC
MEDI-CORT
CRE 0.1%
ENE 100MG
CRE 1%
CRE 1%
SPR 1%
CRE 1% 12 HR
AER 90MG
CRE 1%
LOT 1%
OIN 1%MAX ST
OIN 1%
CRE /ALOE 1%
CRE HEALING
CRE PLUS
LOT ECZEMA
LOT HYDRATEN
CRE 0.25%
CRE 0.05%
OIN 0.005%
CRE 1%
LOT 1%
OIN 0.5%
CRE 0.5%
CRE 1%
CRE 2.5%
ENE 100MG
LOT 1%
LOT 2.5%
OIN 1%
OIN 2.5%
CRE 1%
OIN 1%
CRE 1%
LOT 1%
CRE 1%
CRE 0.5%
CRE 1%
CRE PLS 1%
CRE 1%
CRE 1%
CRE 0.5%
CRE 1%
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 60mls per day
QL 60mls per day
87
Drug Name
MOMETASONE
MOMETASONE
MOMETASONE
NEOSPORIN
NOBLE FORMUL
NOBLE FORMUL
NYSTAT/TRIAM
NYSTAT/TRIAM
PREP H HC
PROCTO-PAK
PROCTOSOL HC
PROCTOZONE
QC HYDROCORT
RECORT PLUS
REDERM
SARNOL-HC
SB HYDROCORT
SCALP RELIEF
SCALPICIN
TRIAMCINOLON
TRIAMCINOLON
TRIAMCINOLON
TRIAMCINOLON
TRIAMCINOLON
TRIDERM
MISCELLANEOUS PRODUCTS
CRE 1%
OIN 0.1%
SOL 0.1%
CRE ECZEMA
CRE HC 1%
SPR 1%
CRE
OIN
CRE 1%
CRE 1%
CRE 2.5%
CRE -HC 2.5%
CRE 1%
CRE 1%
LOT 1%
LOT 1%
CRE 1%
SOL 1%
SOL 1%
OIN 0.1%
CRE 0.025%
CRE 0.1%
CRE 0.5%
LOT 0.025%
CRE 0.1%
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SYP
SYP
Generic
Generic
Requirements
PA
PA
EMETICS
IPECAC
SM IPECAC
OPIATE ANTAGONISTS
NALOXONE
NALOXONE
NALTREXONE
NARCAN
INJ 0.4MG/ML
Generic
INJ 1MG/ML
TAB 50MG
Generic
Generic
SPRAY 4MG/0.1ML
Brand
INJ 0.25MG
Generic
QL 2 per fill; max
1 fill per 180 days
QL 4 MLs per fill;
max 1 fill per 180 days
QL 2 per fill;
max 1 fill per 180 days
ADRENOCORTICAL INSUFFICIENCY
COSYNTROPIN
88
Drug Name
Drug Type
SYP
SYP
SYP CONCENTR
OIL
SUS
LIQ
SYP
LIQ S/F
SYP
SUS
SUS
LIQ SUSPENDI
LIQ
LIQ
LIQ FLAVORED
LIQ SF
LIQ
SYP
SYP
SYP -SF
SYP VEHICLE
SUS
SYP
INJ
SUS VEHICLE
SYP
LIQ
SYP VEHICLE
SYP VEHICLE
SYP
SYP
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Brand
Brand
MIS SM MASK
MIS FLOW-VU
MIS LRG MASK
MIS STAT PLS
MIS PLUS
MIS FLOSIGNA
MIS PLUS
MIS MV
MIS CHAMBER
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
MISCL OTHER
BUBBLE GUM
CHERRY
CHERRY
COTTONSEED
FLAVOR BLEND
FLAVOR PLUS
FLAVOR SWEET
FLAVOR SWEET
GRAPE
ORA-BLEND
ORA-BLEND SF
ORAL MIX
ORAL MIX SF
ORAL SUSPEND
ORAL SYRUP
ORAL SYRUP
ORA-PLUS
ORA-SWEET
ORA-SWEET SF
PCCA SWEET
PCCA SYRUP
PCCA-PLUS
SIMPLE
STERIL WATER
SUSPENSION
SYRPALTA
SYRSPEND SF
SYRUP
SYRUP SF
VERSAFREE
VERSAPLUS
DEVICES
AERCHMBR PLS
AERCHMBR PLS
AERCHMBR PLS
AERCHMBR ZAEROCHAMBER
AEROCHAMBER
AEROCHAMBER
AEROCHAMBER
AEROCHAMBER
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
89
Drug Name
AEROCHAMBER
AIRZONE PEAK
ALCOHOL PREP
ALCOHOL PREP SWAB
ALCOHOL SWAB
ALCOHOL WIPE
ARIAL
ASSESS METER
ASSESS METER
ASSESS METER
ASSESS METER
ASTHMA CHECK
ASTHMAMENTOR
BAND-AID
BD SWAB BFLY
BD SWAB REG
BREATHERITE
BREATHERITE
BREATHERITE
BREATHERITE
BREATHERITE
BREATHERITE
DERMACEA
EASIVENT
EASIVENT
EASIVENT
EASIVENT
EQL GAUZE
E-Z SPACER
E-Z SPACER
INSPIREASE
LITEAIRE
MASK VORTEX/
MASK VORTEX/
MASK VORTEX/
MASK VORTEX/
MICROCHAMBER
MICROLIFE
MICROSPACER
MINI WRIGHT
MINI WRIGHT
MIRASORB
KIT ACTION
MIS FLOW MTR
PAD
PAD
PAD
PAD
MIS CHAMBER
MIS FULL RNG
MIS LOW RANG
MIS FULL
MIS LOW
MIS SYSTEM
MIS
PAD 2"X2"
PAD SNGL USE
PAD SNGL USE
MIS
MIS W/MASK
MIS LG MASK
MIS MED MASK
MIS SM MASK
MIS SPACER
PAD 2"X2"
MIS
MIS MASK SM
MIS MASK MED
MIS MASK LG
PAD 2"X2"
MIS
MIS BODY GRD
MIS DD SYST
MIS
MIS BABY DUC
MIS DUCK
MIS LADY BUG
MIS FROG
MIS
MIS PEAK FLO
MIS
MIS PFM
MIS PFM LOW
MIS 2" X 2"
Drug Type
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Requirements
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
90
Drug Name
NESSI SPACER
NESSI SPACER
NESSI SPACER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
OPTICHAMBER
PANDA MASK
PANDA MASK
PANDA MASK
PANDA MASK
PEAK AIR FLO
PEAK FLOW
PEAK FLW MTR
PERSONAL BES
PERSONAL BES
PIKO 1
POCKET PEAK
POCKETPEAK
POCKETPEAK
PRIMEAIRE
TABLET
RITEFLO
TRUZONE PEAK
VALVD HOLDNG
VORTEX VALVE
VORTEX/MASK
VORTEX/MASK
WATCHHALER
MIS MOUTHPC
MIS SM/MED
MIS LARGE
MIS ADVANTAG
MIS ADV SM
MIS ADV MED
MIS ADV LRG
MIS FACE MAS
MIS DIAMOND
MIS DIA SM
MIS DIA MD
MIS DIA LG
MIS PEDIATRI
MIS SMALL
MIS MEDIUM
MIS LARGE
MIS ADLT/PED
MIS METER
MIS UNIVERSL
MIS FULL RNG
MIS LOW RANG
MIS ELECTRON
MIS METER
MIS UNIVERSA
MIS MTR LOW
MIS CHAMBER
CUTTER
MIS
MIS FLOW MTR
MIS CHAMBER
MIS CHAMBER
MIS TODDLER
MIS CHILDS
MIS
Drug Type
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
TAB 50MG
CAP 25MG
CAP 100MG
CAP 25MG MOD
CAP 50MG MOD
CAP 100MG MD
SOL MODIFIED
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 1 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
QL 2 per 365 days
IMMUNOSUPPRESSIVE AGENTS
AZATHIOPRINE
CYCLOSPORINE
CYCLOSPORINE
CYCLOSPORINE
CYCLOSPORINE
CYCLOSPORINE
CYCLOSPORINE
91
Drug Name
GENGRAF
GENGRAF
GENGRAF
HECORIA
HECORIA
HECORIA
MYCOPHENOLAT
MYCOPHENOLAT
MYCOPHENOLAT
RAPAMUNE
SIROLIMUS
SIROLIMUS
SIROLIMUS
TACROLIMUS
TACROLIMUS
TACROLIMUS
ZORTRESS
ZORTRESS
ZORTRESS
CAP 25MG
CAP 100MG
SOL 100MG/ML
CAP 0.5MG
CAP 1MG
CAP 5MG
CAP 250MG
TAB 500MG
SUS 200MG/ML
SOL 1MG/ML
TAB 0.5MG
TAB 1MG
TAB 2MG
CAP 0.5MG
CAP 1MG
CAP 5MG
TAB 0.25MG
TAB 0.5MG
TAB 0.75MG
Drug Type
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
SUS 15GM/60
POW
SUL SUS 15GM/60
SUL SUS 30/120ML
SUL SUS 50/200ML
SUL POW
SUS 15GM/60
POW 8.4GM
POW 16.8GM
POW 25.2GM
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Requirements
QL 2 per day
QL 2 per day
QL 2 per day
QL 2 per day
POTASSIUM-REMOVING AGENTS
KIONEX
KIONEX
SOD POLY
SOD POLY
SOD POLY
SOD POLY
SPS
VELTASSA
VELTASSA
VELTASSA
PA QL 1 packet per day
92
INDEX OF DRUGS
ALA-HIST IR ................................................................... 41
ALAVERT........................................................................ 41
ALBENZA ....................................................................... 10
ALBUTEROL ............................................................. 43, 44
ALCALAK ........................................................................ 45
ALCOHOL....................................................................... 85
ALCOHOL PREP ............................................................. 90
ALCOHOL PREP SWAB ................................................... 90
ALCOHOL SWAB ............................................................ 90
ALCOHOL WIPE ....................................................... 85, 90
ALECENSA ..................................................................... 13
ALENDRONATE.............................................................. 28
ALER-DRYL..................................................................... 41
ALFERON N.................................................................... 13
ALKERAN ....................................................................... 13
ALLOPURINOL ............................................................... 62
ALMACONE SUS ........................................................ 45
ALTAVERA ..................................................................... 19
ALYACEN ................................................................. 19, 20
AMANTADINE ................................................................. 6
AMBIZINE ...................................................................... 48
AMETHIA ....................................................................... 20
AMETHIA LO.................................................................. 20
AMETHYST .................................................................... 20
AMILORIDE.................................................................... 39
AMILORIDE/HYDROCHLOROTHIAZIDE.......................... 39
AMINOCAPROIC ACID ................................................... 82
AMIODARONE ............................................................... 35
AMLODIPINE ................................................................. 33
AMOXICILLIN ................................................................... 1
AMOXICILLIN/CLAVULANATE POTASSIUM ..................... 1
AMPHETAMINE (Generic Adderall IR) ................... 53, 54
AMPHETAMINE (Generic Adderall XR) .................. 53, 54
AMPHOTERICIN .............................................................. 4
AMPICILLIN ..................................................................... 1
AMP-SULBACTA .............................................................. 1
ANAGRELIDE ................................................................. 82
ANASTROZOLE .............................................................. 13
ANDRODERM ................................................................ 18
ANORO ELLIPTA ............................................................ 43
ANTACID ....................................................................... 45
ANTIBIOTIC ................................................................... 85
3
3 DAY VAGINAL ............................................................... 5
A
ABACAVIR ........................................................................ 7
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ............ 7
ACAMPRO CAL .............................................................. 55
ACARBOSE ..................................................................... 23
ACD/FLUORIDE .............................................................. 66
ACEBUTOLOL ................................................................. 32
ACETAMINOPHEN ......................................................... 57
ACETAMINOPHEN/CAFF/PYRILAMINE .......................... 57
ACETASOL HC ................................................................ 83
ACETAZOLAMIDE........................................................... 38
ACETIC ACID .................................................................. 84
ACID CONTROL .............................................................. 46
ACID REDUCER .............................................................. 46
ACID RELIEF ................................................................... 46
ACTEMRA ...................................................................... 60
ACTICIN ......................................................................... 86
ACTIMMUNE ................................................................. 13
ACYCLOVIR ...................................................................... 6
ADACEL .......................................................................... 11
ADCIRCA ........................................................................ 41
ADEFOVIR DIPIVOXIL ....................................................... 6
ADEMPAS ...................................................................... 41
ADENOSINE ................................................................... 35
ADRENACLICK ................................................................ 39
ADVAIR DISKUS ............................................................. 43
ADVAIR HFA .................................................................. 43
AERCHMBR PLS ............................................................. 89
AERCHMBR Z- ................................................................ 89
AEROCHAMBER ....................................................... 89, 90
AFEDITAB....................................................................... 33
AFINITOR ....................................................................... 13
AFINITOR DIS ................................................................. 13
AFLURIA ......................................................................... 11
AFTERA .......................................................................... 19
AGGRENOX .................................................................... 82
AIRZONE PEAK ............................................................... 90
AK-POLY-BAC ................................................................. 82
93
B
ANTI-ITCH ...................................................................... 86
ANTIPY/BENZO .............................................................. 85
APAP/CODEINE.............................................................. 57
APRACLONIDIN.............................................................. 84
APRI ............................................................................... 20
APRISO .......................................................................... 49
APTIVUS........................................................................... 7
ARALAST NP .................................................................. 44
ARANELLE ...................................................................... 20
ARANESP ....................................................................... 78
ARGYL SALINE ................................................................ 52
ARIAL ............................................................................. 90
ARMOUR THYROID ........................................................ 26
ASA/DIPYRIDA ............................................................... 82
ASACOL HD .................................................................... 49
ASHLYNA ....................................................................... 20
ASPIRIN.......................................................................... 57
ASSESS METER............................................................... 90
ASTHMA CHECK............................................................. 90
ASTHMAMENTOR.......................................................... 90
ATENOLOL ..................................................................... 32
ATENOLOL/CHLORTHALIDONE ..................................... 37
ATHLETE FOOT ................................................................ 5
ATORVASTATIN ............................................................. 40
ATOVAQUONE............................................................... 10
ATOVAQUONE/PROGUANIL............................................ 9
ATRIPLA ........................................................................... 7
ATROPIN-CARE .............................................................. 84
ATROPINE SUL ............................................................... 84
ATROVENT ..................................................................... 42
AUBAGIO ....................................................................... 55
AUBRA ........................................................................... 20
AUGMENTED BETAMETHASONE .................................. 86
AURODEX ...................................................................... 85
AUVI-Q .......................................................................... 39
AVC ................................................................................ 85
AVIANE .......................................................................... 20
AVONEX ......................................................................... 55
AVONEX PEN ................................................................. 55
AVONEX PREFL .............................................................. 55
AZATHIOPRINE .............................................................. 91
AZITHROMYCIN ............................................................... 3
AZOPT ............................................................................ 38
AZURETTE ...................................................................... 20
B COMPLEX W/C & FOLIC ACID .................................... 66
B COMPLEX WITH VITAMIN C ....................................... 66
B1 NATURAL.................................................................. 65
BAC/NEO/POLY ............................................................. 85
BACIT/POLYMY ............................................................. 82
BACITR ZINC .................................................................. 85
BACITRACIN .................................................................. 82
BACLOFEN ..................................................................... 65
BALSALAZIDE................................................................. 49
BALZIVA......................................................................... 20
BAND-AID ...................................................................... 90
BARACLUDE .................................................................... 6
BAYCADRON ................................................................. 17
BD SWAB BFLY .............................................................. 90
BD SWAB REG ............................................................... 90
BELLA/OPIUM ............................................................... 46
BENAZEPRIL .................................................................. 36
BENAZEPRIL/HYDROCHLOROTHIAZIDE ........................ 37
BENZONATATE .............................................................. 42
BENZTROPINE ............................................................... 64
BETAMETH DIP.............................................................. 86
BETAMETHASONE ......................................................... 87
BETHANECHOL .............................................................. 51
BETHKIS ........................................................................... 4
BETOPTIC-S ................................................................... 83
BEXSERO ....................................................................... 11
BEYAZ ............................................................................ 20
BICALUTAMIDE ............................................................. 13
BICILLIN L-A ..................................................................... 1
BILTRICIDE ..................................................................... 10
BIO-STATIN ..................................................................... 4
BIOTIN FORTE ............................................................... 66
BISACODYL .................................................................... 45
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE .... 37
BLEPHAMIDE ................................................................. 83
BOOST ........................................................................... 78
BOOSTRIX ...................................................................... 11
BOSULIF ........................................................................ 13
BPROTECTED ................................................................. 66
BREATHERITE ................................................................ 90
BRIELLYN ....................................................................... 20
BRIMONIDINE ............................................................... 82
BROMOCRIPTIN ............................................................ 64
94
BUBBLE GUM ................................................................ 89
BUDESONIDE ................................................................. 43
BUMETANIDE ................................................................ 38
BUPRENORPHINE .......................................................... 57
BUPRENORPHINE/NALOXONE ...................................... 57
BUPROBAN .................................................................... 56
BYDUREON .................................................................... 24
BYETTA .......................................................................... 24
CAPTOPRIL/HYDROCHLOROTHIAZIDE .......................... 38
CAPZASIN-P ................................................................... 86
CARAFATE ..................................................................... 47
CARBAMAZEPINE .......................................................... 62
CARBIDOPA/LEVODOPA ............................................... 64
CARTIA XT ..................................................................... 33
CARVEDILOL .................................................................. 32
CASCARA SAGRADA ...................................................... 45
CAVAN-EC SOD ............................................................. 67
CAVAREST ..................................................................... 74
CAYSTON ....................................................................... 11
CAZIANT ........................................................................ 20
CEFACLOR ....................................................................... 2
CEFADROXIL .................................................................... 2
CEFAZOLIN ...................................................................... 2
CEFAZOLIN/DEXTROSE .................................................... 2
CEFDINIR ......................................................................... 2
CEFIXIME ......................................................................... 2
CEFPODOXIME ................................................................ 2
CEFPROZIL ....................................................................... 2
CEFTRIAXONE.................................................................. 2
CEFUROXIME .................................................................. 2
CELECOXIB .................................................................... 60
CELONTIN ...................................................................... 62
CENTRUM SPEC............................................................. 67
CEPHALEXIN .................................................................... 2
CERALYTE 70 ................................................................. 75
CERASPORT ............................................................. 75, 76
CESIA ............................................................................. 20
CETIRIZINE..................................................................... 42
CHANTIX ........................................................................ 56
CHATEAL ....................................................................... 20
CHERRY ......................................................................... 89
CHEW CALCIUM ............................................................ 67
CHILD ASPIRIN............................................................... 57
CHILD SOOTHE .............................................................. 45
CHILD VIT D ................................................................... 30
CHILDRENS .................................................................... 45
CHLORHEX GLU ............................................................. 85
CHLOROQUINE .............................................................. 10
CHLORPHENIRAMINE MALEATE ................................... 41
CHLORTHALIDONE ........................................................ 39
CHLORZOXAZONE ......................................................... 65
CHOLESTYRAM .............................................................. 40
C
CABERGOLINE ............................................................... 28
CABOMETYX .................................................................. 13
CAFFEINE CIT ................................................................. 55
CALC ANTACID............................................................... 45
CALCIPOTRIEN ............................................................... 86
CALCITONIN................................................................... 28
CALCITRIOL .................................................................... 30
CALCIUM ....................................................................... 66
CALCIUM ACETATE ........................................................ 50
CALCIUM CARB .............................................................. 45
CALCIUM CARBONATE .................................................. 75
CALCIUM CITRATE ......................................................... 75
CALCIUM CITRATE PLUS VIT D ...................................... 75
CALCIUM CITRATE PLUS VITAMIN D ............................. 75
CALCIUM GLUCONATE .................................................. 75
CALCIUM LACTATE ........................................................ 75
CALCIUM PLUS D/ MINERALS........................................ 75
CALCIUM PLUS D3 ......................................................... 75
CALCIUM W/VIT D ......................................................... 75
CALCIUM W/VIT D & POTASSIUM ................................. 75
CALCIUM/D ................................................................... 78
CALCIUM/PLUS D .......................................................... 75
CALNA ........................................................................... 66
CAMILA .......................................................................... 20
CAMRESE ....................................................................... 20
CAMRESE LO.................................................................. 20
CANASA ......................................................................... 50
CANDESARTAN .............................................................. 36
CANDESARTAN/HCTZ .................................................... 36
CAPECITABINE ............................................................... 13
CAPRELSA ...................................................................... 13
CAPREX + ....................................................................... 86
CAPSAICIN ..................................................................... 86
CAPTOPRIL .................................................................... 36
95
CHOLINE MAG TRISALICYLATE ...................................... 57
CHORIONIC GONADOTROPIN ....................................... 28
CIDOFOVIR ...................................................................... 6
CILOSTAZOL ................................................................... 82
CILOXAN ........................................................................ 82
CIMETIDINE ............................................................. 46, 47
CIPRODEX ...................................................................... 83
CIPROFLOXACIN ........................................................ 3, 82
CIT CALC/D .................................................................... 76
CITRANATAL .................................................................. 67
CITRIC ACID/SODIUM CITRATE...................................... 52
CL PRENATAL ................................................................. 67
CLARITHROMYCIN ........................................................... 3
CLEOCIN ........................................................................ 51
CLINDAMYCIN ......................................................... 10, 51
CLONAZEPAM................................................................ 53
CLONIDINE .................................................................... 37
CLOPIDOGREL................................................................ 82
CLOTRIMAZOLE ............................................................... 5
COARTEM ...................................................................... 10
CODEINE SULF ............................................................... 57
COLCHICINE ................................................................... 62
COLCRYS ........................................................................ 62
COLESTIPOL ................................................................... 40
COLOCORT..................................................................... 87
COMBIPATCH ................................................................ 18
COMBIVENT .................................................................. 43
COMETRIQ..................................................................... 13
COMFORT GEL ............................................................... 45
COMP PRNATAL ............................................................ 67
COMPAZINE................................................................... 48
COMPL PRENAT ............................................................. 67
COMPLERA ...................................................................... 7
COMPLETENATE ............................................................ 67
COMPOZ ........................................................................ 52
COMPRO ....................................................................... 48
CO-NATAL FA ................................................................. 67
CONCEPT OB ................................................................. 67
CONDOMS ..................................................................... 51
CONDYLOX .................................................................... 86
CONSTULOSE ................................................................. 11
CONTROLRX .................................................................. 74
CORLANOR .................................................................... 31
CORT INTENSE ............................................................... 87
CORTAID ....................................................................... 87
CORTAID ADV................................................................ 87
CORTIFOAM .................................................................. 87
CORTISONE ................................................................... 87
CORTIZONE-10 .............................................................. 87
COSENTYX ..................................................................... 60
COSENTYX PEN.............................................................. 60
COSYNTROPIN ............................................................... 88
COTELLIC ....................................................................... 13
COTTONSEED ................................................................ 89
COUMADIN ................................................................... 80
CREON ........................................................................... 49
CRIXIVAN ......................................................................... 7
CROMOLYN ................................................................... 44
CRYSELLE-28.................................................................. 20
CURITY SALIN ................................................................ 52
CVS PRENATAL .............................................................. 67
CVS STRESS ................................................................... 67
CVS SUPER B ................................................................. 67
CYANOCOBALAM .......................................................... 65
CYCLAFEM ..................................................................... 20
CYCLOBENZAPRINE ....................................................... 65
CYCLOMYDRIL ............................................................... 84
CYCLOPENTOL ............................................................... 84
CYCLOPENTOLATE......................................................... 84
CYCLOPHOSPH .............................................................. 13
CYCLOSPORINE ............................................................. 91
CYPROHEPTADINE ........................................................ 42
CYRED ........................................................................... 20
CYTRA K CRYSTALS ........................................................ 52
CYTRA-2 ........................................................................ 52
CYTRA-3 ........................................................................ 52
CYTRA-K ........................................................................ 52
D
D 400 ............................................................................. 30
D-3 GUMMY .................................................................. 30
D3 KIDS ......................................................................... 30
D5W/NACL .................................................................... 76
DAKLINZA ........................................................................ 6
DANAZOL ...................................................................... 18
DANTROLENE ................................................................ 65
DAPSONE ...................................................................... 46
DAPTACEL ..................................................................... 11
96
DARAPRIM..................................................................... 10
DASETTA ........................................................................ 20
DAYSEE .......................................................................... 20
DEBLITANE .................................................................... 20
DELTASONE ................................................................... 17
DELYLA .......................................................................... 20
DELZICOL ....................................................................... 50
DENTA 5000 .................................................................. 74
DENTAGEL ..................................................................... 74
DEPO-ESTRADIOL .......................................................... 19
DEPO-PROVERA............................................................. 17
DEPO-TESTOSTERONE ................................................... 18
DERMACEA .................................................................... 90
DESCOVY ......................................................................... 7
DESENEX .......................................................................... 5
DESMOPRESSIN ............................................................. 29
DESO/ETHINYL............................................................... 20
DESOXIMETAS ............................................................... 87
DEX4 .............................................................................. 24
DEXAMETH PHO ............................................................ 83
DEXAMETHASONE ......................................................... 17
DEXEDRINE .................................................................... 54
DEXMETHYLPHENIDATE ................................................ 54
DEXTROAMPHETAMINE ................................................ 54
DEXTROSE ..................................................................... 78
DIABET TUSS.................................................................. 42
DIALYVITE ...................................................................... 67
DIALYVITE/ .................................................................... 67
DIASTAT ACDL ............................................................... 53
DIASTAT PED ................................................................. 53
DIAZEPAM ..................................................................... 53
DICLOFEN POTASSIUM .................................................. 60
DICLOFENAC ............................................................ 60, 84
DICLOXACILLIN SODIUM ................................................. 1
DICYCLOMINE................................................................ 46
DIDANOSINE .................................................................... 7
DIGITEK.......................................................................... 31
DIGOX ............................................................................ 31
DIGOXIN ........................................................................ 31
DIHYDROERGOT ............................................................ 61
DILANTIN ....................................................................... 62
DILANTIN-125 ................................................................ 62
DILATRATE SR ................................................................ 31
DILAUDID-HP ................................................................. 57
DILT-CD ................................................................... 33, 34
DILTIAZEM..................................................................... 34
DILT-XR.......................................................................... 34
DILTZAC ......................................................................... 34
DIMENHYDRIN .............................................................. 48
DIPENTUM .................................................................... 50
DIPHENHYDRAM ........................................................... 52
DIPHENHYDRAMINE ............................................... 41, 42
DISOPYRAMIDE ............................................................. 35
DISULFIRAM .................................................................. 55
DOCUSATE SODIUM...................................................... 45
DOFETILIDE ................................................................... 35
DONEPEZIL .................................................................... 55
DORZOLAMIDE.............................................................. 38
DORZOLAMIDE/TIMOLOL MALEATE ............................. 38
DOXAZOSIN ................................................................... 82
DOXYCYCLINE MONOHYDRATE ...................................... 3
DRAMAMINE................................................................. 48
DRIMINATE ................................................................... 48
DRONABINOL ................................................................ 48
DROSPIR/ETHI ............................................................... 20
DROSPIRENONE ............................................................ 20
DROXIA ................................................................... 13, 14
D-VI-SOL ........................................................................ 30
D-VITA ........................................................................... 30
DYRENIUM .................................................................... 39
E
E.E.S. 400 ........................................................................ 3
E.E.S. GRANULES ............................................................. 3
E.S.P. ............................................................................... 3
EASIVENT ...................................................................... 90
ECONTRA EZ .................................................................. 20
ED-SPAZ ........................................................................ 46
EDURANT ........................................................................ 7
EFFER-K ......................................................................... 76
ELIGARD ........................................................................ 14
ELINEST ......................................................................... 20
ELIQUIS ......................................................................... 80
ELITE-OB........................................................................ 67
ELIXOPHYLLIN ............................................................... 44
ELLA............................................................................... 20
ELMIRON ....................................................................... 52
EMCYT ........................................................................... 14
97
ESTRACE VAG ................................................................ 18
ESTRADIOL .................................................................... 18
ESTRADIOL (Generic Climara) ................................. 18, 19
ESTRADIOL (Generic Vivelle Dot) .................................. 19
ESTRADIOL VALERATE ................................................... 19
ESTRING ........................................................................ 19
ESTROPIPATE ................................................................ 19
ETHAMBUTOL ................................................................. 4
ETHOSUXIMIDE ............................................................. 62
ETIDRONATE DISODIUM ............................................... 28
ETODOLAC .................................................................... 60
ETOPOSIDE .................................................................... 14
EURAX ........................................................................... 86
EVOTAZ ........................................................................... 7
EXEMESTANE ................................................................ 14
EXTAVIA ........................................................................ 55
E-Z SPACER .................................................................... 90
EMEND .......................................................................... 48
EMOQUETTE ................................................................. 20
EMTRIVA ......................................................................... 7
ENALAPRIL ............................................................... 36, 37
ENALAPRIL/HYDROCHLOROTHIAZIDE ........................... 38
ENBREL .......................................................................... 60
ENBREL SRCLK ............................................................... 60
ENDOCET ....................................................................... 57
ENDODAN...................................................................... 57
ENDUR-ACIN.................................................................. 65
ENEMA .......................................................................... 45
ENFALYTE ...................................................................... 76
ENFAMIL .................................................................. 67, 76
ENGERIX-B ..................................................................... 11
ENOXAPARIN ........................................................... 80, 81
ENPRESSE-28 ................................................................. 20
ENSKYCE ........................................................................ 20
ENSURE ......................................................................... 78
ENTACAPONE ................................................................ 64
ENTECAVIR ...................................................................... 6
ENTRESTO ..................................................................... 31
ENULOSE ....................................................................... 11
EPCLUSA .......................................................................... 6
EPINEPHRINE ................................................................. 40
EPIPEN 2-PAK ................................................................ 40
EPIPEN-JR ...................................................................... 40
EPITOL ........................................................................... 62
EPIVIR HBV ...................................................................... 7
EPOGEN ......................................................................... 78
EPOPROSTENOL ............................................................ 41
EPZICOM ......................................................................... 7
EQL B-12 ........................................................................ 65
EQL GAUZE .................................................................... 90
EQL HEARTBRN.............................................................. 47
EQL PRENATAL .............................................................. 67
ERGOCALCIFER .............................................................. 30
ERGOMAR ..................................................................... 61
ERIVEDGE ...................................................................... 14
ERRIN ............................................................................. 20
ERYPED ............................................................................ 3
ERY-TAB ........................................................................... 3
ERYTHROM ETH .............................................................. 3
ERYTHROMYCIN ........................................................ 3, 82
ESTARYLLA ..................................................................... 20
F
FALLBACK ...................................................................... 20
FALMINA ....................................................................... 20
FAMCICLOVIR.................................................................. 6
FAMOTIDINE ................................................................. 47
FARESTON ..................................................................... 14
FARYDAK ....................................................................... 14
FE GLUCONATE ............................................................. 79
FE TABS ......................................................................... 79
FELBAMATE................................................................... 62
FENOFIBRATE ................................................................ 40
FENOFIBRIC ................................................................... 40
FENTANYL ............................................................... 57, 58
FEOSOL.......................................................................... 79
FERATE .......................................................................... 79
FERGON ........................................................................ 79
FER-IRON....................................................................... 79
FEROSUL ....................................................................... 79
FERREX 150 ................................................................... 79
FERRIC X-150 ................................................................. 79
FERRO-BOB ................................................................... 79
FERROTABS ................................................................... 79
FERROUS ....................................................................... 79
FERROUS GLUCONATE .................................................. 79
FERROUS SULFATE .................................................. 79, 80
FERUS ............................................................................ 80
98
FIRST-OMEPRA .............................................................. 47
FIRST-TESTOSTERONE ................................................... 18
FISH OIL ................................................................... 28, 29
FLAVOR BLEND .............................................................. 89
FLAVOR PLUS................................................................. 89
FLAVOR SWEET ............................................................. 89
FLECAINIDE.................................................................... 35
FLOVENT........................................................................ 43
FLOVENT DISK ............................................................... 43
FLUARIX PF .................................................................... 11
FLUARIX QUAD .............................................................. 11
FLUBLOK ........................................................................ 11
FLUCELVAX .................................................................... 11
FLUCONAZOLE ................................................................. 4
FLUCYTOSINE .................................................................. 4
FLUDROCORTISONE ...................................................... 17
FLULAVAL ...................................................................... 11
FLULAVAL QUAD ........................................................... 12
FLUMIST QUAD ............................................................. 12
FLUNISOLIDE ................................................................. 42
FLUORABON .................................................................. 74
FLUOR-A-DAY ................................................................ 74
FLUORIDE ...................................................................... 74
FLUORIDEX .................................................................... 74
FLUORITAB .............................................................. 74, 75
FLUOROMETHOL ........................................................... 83
FLUOROURACIL ............................................................. 86
FLURA-DROPS................................................................ 75
FLURBIPROFEN ........................................................ 60, 84
FLUSH SYRING ............................................................... 76
FLUTAMIDE ................................................................... 14
FLUTICASONE .......................................................... 42, 87
FLUVIRIN ....................................................................... 12
FLUVIRIN PF................................................................... 12
FLUZONE ....................................................................... 12
FLUZONE HD.................................................................. 12
FLUZONE QUAD ............................................................ 12
FLUZONE SPLT ............................................................... 12
FML................................................................................ 83
FML FORTE .................................................................... 83
FOCALGIN CA ................................................................ 67
FOLCAPS ........................................................................ 67
FOLIC ACID .................................................................... 65
FOLIVANE-OB ................................................................ 67
FOLIVANE-PRX .............................................................. 68
FONDAPARINUX............................................................ 81
FOSINOPRIL ................................................................... 37
FOSPHENYTOIN ............................................................. 62
FOSRENOL ..................................................................... 50
FRAGMIN ...................................................................... 81
FULL SPECT.................................................................... 68
FUROSEMIDE .......................................................... 38, 39
FUZEON ........................................................................... 7
G
GABAPENTIN ........................................................... 62, 63
GABITRIL ....................................................................... 63
GALANTAMINE.............................................................. 55
GARAMYCIN .................................................................. 83
GARDASIL 9 ................................................................... 12
GATIFLOXACIN .............................................................. 83
GAVILYTE-C ................................................................... 45
GAVILYTE-G ................................................................... 45
GAVILYTE-N ................................................................... 45
GEMFIBROZIL ................................................................ 40
GENERLAC ..................................................................... 11
GENGRAF ...................................................................... 92
GENOTROPIN ................................................................ 29
GENPRIL ........................................................................ 60
GENTAK ......................................................................... 83
GENTAMICIN ........................................................... 83, 85
GENVOYA ........................................................................ 7
GERBER ......................................................................... 76
GESTICARE .................................................................... 68
GIANVI .......................................................................... 20
GILDAGIA ...................................................................... 21
GILDESS ......................................................................... 21
GILDESS 24 .................................................................... 21
GILDESS FE .................................................................... 21
GILOTRIF ....................................................................... 14
GLATOPA (Generic Copaxone 20 mg) ........................... 56
GLIMEPIRIDE ................................................................. 25
GLIPIZIDE....................................................................... 25
GLIPIZIDE ER.................................................................. 25
GLIPIZIDE XL .................................................................. 25
GLIPIZIDE/METFORMIN ................................................ 24
GLUCAGEN .................................................................... 24
GLUCAGON ................................................................... 24
99
HYDROCODONE/APAP .................................................. 58
HYDROCODONE/IBUPROFEN........................................ 58
HYDROCORT.................................................................. 88
HYDROCORT AC ............................................................ 87
HYDROCORT/AB............................................................ 87
HYDROCORTISONE.................................................. 17, 87
HYDROCREAM .............................................................. 87
HYDROGESIC ................................................................. 58
HYDRO-LOTION ............................................................. 87
HYDROMORPHONE....................................................... 58
HYDROSKIN ................................................................... 87
HYDROXYCHLOR ........................................................... 10
HYDROXYPROG ............................................................. 17
HYDROXYUREA ............................................................. 14
HYDROXYZINE HCL ........................................................ 52
HYDROXYZINE PAMOATE.............................................. 53
HYOMAX-SL................................................................... 46
HYOSCYAMINE .............................................................. 46
HYOSYNE ....................................................................... 46
GLUCERNA..................................................................... 78
GLUCOSE ....................................................................... 24
GLUCOSE BITS ............................................................... 24
GLUTOSE 15 .................................................................. 24
GLUTOSE 45 .................................................................. 24
GLYBURID MCR ............................................................. 25
GLYBURIDE .............................................................. 24, 26
GLYBURIDE/METFORMIN.............................................. 24
GLYCERIN....................................................................... 45
GLYDO ........................................................................... 85
GNP CALCIUM ............................................................... 76
GNP PRENATAL ............................................................. 68
GOODSENSE .................................................................. 68
GRANISETRON ............................................................... 48
GRANISOL ...................................................................... 48
GRANIX .......................................................................... 78
GRAPE ........................................................................... 89
GRISEOFULVIN ................................................................ 4
GUANFACINE ................................................................. 37
GYNECORT 10 ................................................................ 87
I
H
IBANDRONATE .............................................................. 28
IBRANCE ........................................................................ 14
IBU-DROPS .................................................................... 61
IBUPROFEN ............................................................. 53, 61
IBUPROFEN IB ............................................................... 61
IBUPROFEN JR ............................................................... 61
IBUPROFEN PM ............................................................. 53
ICLUSIG ......................................................................... 14
IFEREX 150 .................................................................... 80
ILOTYCIN ....................................................................... 83
IMATINIB MESYLATE ..................................................... 14
IMBRUVICA ................................................................... 14
IMIQUIMOD .................................................................. 86
IMPAVIDO ..................................................................... 10
IMPLANON .................................................................... 21
INATAL ADV .................................................................. 68
INATAL GT ..................................................................... 68
INATAL ULTRA ............................................................... 68
INCRELEX ....................................................................... 29
INDAPAMIDE ................................................................. 39
INDOCIN ........................................................................ 61
INDOMETHACIN ............................................................ 61
INFANRIX....................................................................... 12
HARVONI ......................................................................... 6
HAVRIX .......................................................................... 12
HC/ACET ACID ............................................................... 83
HEARTBRN REL .............................................................. 47
HEARTBURN .................................................................. 47
HEATHER ....................................................................... 21
HECORIA ........................................................................ 92
HEPARIN SOD ................................................................ 81
HEXALEN ....................................................................... 14
HM B COMPLEX ............................................................. 68
HM PRENATAL ............................................................... 68
HOMATROPAIRE ........................................................... 84
HOMATROPINE ............................................................. 84
HUMALOG ............................................................... 24, 25
HUMATROPE ................................................................. 29
HUMIRA......................................................................... 60
HUMIRA PEDIA .............................................................. 60
HUMIRA PEN ................................................................. 60
HUMULIN ...................................................................... 25
HYCAMTIN ..................................................................... 14
HYDRALAZINE ................................................................ 38
HYDROCHLOROTHIAZIDE .............................................. 39
100
INFERGEN ........................................................................ 6
INLYTA ........................................................................... 14
INSPIREASE .................................................................... 90
INSTACORT 5 ................................................................. 87
INSTA-GLUCOS .............................................................. 24
INTELENCE ....................................................................... 7
INTRON A ...................................................................... 14
INTROVALE .................................................................... 21
INVIRASE ......................................................................... 8
IPECAC ........................................................................... 88
IPRATROPIUM ............................................................... 46
IPRATROPIUM/ .............................................................. 43
IRBESARTAN .................................................................. 36
IRBESARTAN/HYDROCHLOROTHIAZIDE ........................ 38
IRESSA ........................................................................... 14
IRON .............................................................................. 80
IRON SUPPLEM .............................................................. 80
IRON SUPPLMT .............................................................. 80
IRON THERAPY .............................................................. 80
ISENTRESS ....................................................................... 8
ISONIAZID ........................................................................ 4
ISORDIL .......................................................................... 31
ISOSORBIDE DINITRATE........................................... 31, 32
ISOSORBIDE MONONITRATE ......................................... 32
ITRACONAZOLE ............................................................... 4
IVERMECTIN .................................................................. 10
KARIDIUM ..................................................................... 75
KARIGEL ........................................................................ 75
KARIGEL-N ..................................................................... 75
KARIVA .......................................................................... 21
K-EFFERVESCE ............................................................... 76
KELNOR ......................................................................... 21
KERICORT 10 ................................................................. 87
KETOCONAZOLE .............................................................. 4
KETOPROFEN ................................................................ 61
KETOROLAC ................................................................... 84
KIMIDESS....................................................................... 21
KIONEX .......................................................................... 92
KLOR-CON ..................................................................... 76
KLOR-CON 10 ................................................................ 76
KLOR-CON 8 .................................................................. 76
KLOR-CON M10 ............................................................. 76
KLOR-CON M20 ............................................................. 76
KLOR-CON SPR .............................................................. 76
KLOR-CON/EF ................................................................ 76
KONSYL ......................................................................... 45
KP B COMPLEX .............................................................. 68
KP CALCIUM .................................................................. 76
KP PRENATAL ................................................................ 68
K-PHOS .......................................................................... 76
KPN PRENATAL.............................................................. 68
K-PRIME ........................................................................ 76
K-SOL ............................................................................. 76
KURVELO ....................................................................... 21
KUVAN .......................................................................... 29
K-VESCENT .................................................................... 76
J
JANTOVEN ..................................................................... 81
JENCYCLA....................................................................... 21
JOCK ITCH ........................................................................ 5
JOLESSA ......................................................................... 21
JOLIVETTE ...................................................................... 21
JULEBER ......................................................................... 21
JUNEL 1.5/30 ................................................................. 21
JUNEL 1/20 .................................................................... 21
JUNEL FE ........................................................................ 21
JUNEL FE 24 ................................................................... 21
JUST D............................................................................ 30
L
LABETALOL .................................................................... 32
LACTULOSE ................................................................... 11
LAMIVUDINE ................................................................... 8
LAMIVUDINE/ZIDOVUDINE ............................................. 8
LANABIOTIC .................................................................. 85
LANACORT 10 ............................................................... 87
LANSOPRAZOLE ............................................................ 47
LANTUS ......................................................................... 25
LARIN ............................................................................ 21
LARIN 24 ....................................................................... 21
LARIN FE ........................................................................ 21
LATANOPROST .............................................................. 85
K
K HYDROCORTISON ....................................................... 87
KALETRA .......................................................................... 8
KALYDECO ..................................................................... 42
101
LAYOLIS FE ..................................................................... 21
LEENA ............................................................................ 21
LEFLUNOMIDE ............................................................... 60
LENVIMA ....................................................................... 14
LESSINA ......................................................................... 21
LETAIRIS......................................................................... 41
LETROZOLE .................................................................... 14
LEUCOVOR CA ............................................................... 12
LEUKERAN ..................................................................... 14
LEUPROLIDE .................................................................. 15
LEVEMIR ........................................................................ 25
LEVETIRACETA ............................................................... 63
LEVOBUNOLOL .............................................................. 83
LEVOCARNITINE ............................................................ 29
LEVO-ETH EST ................................................................ 21
LEVOFLOXACIN ................................................................ 4
LEVONEST ...................................................................... 21
LEVONOR/ETHI .............................................................. 21
LEVONORGESTR ............................................................ 21
LEVORA-28 .................................................................... 21
LEVOTHYROXINE ........................................................... 26
LEVOXYL .................................................................. 26, 27
LEXIVA ............................................................................. 8
LICE KILLING .................................................................. 86
LICE TREATMENT ........................................................... 86
LICE TRTMNT ................................................................. 86
LICIDE ............................................................................ 86
LIDO/PRILOCN ............................................................... 85
LIDOCAINE ............................................................... 35, 85
LINDANE ........................................................................ 86
LINEZOLID ...................................................................... 10
LIOTHYRONINE .............................................................. 27
LIQ CA/VIT D .................................................................. 76
LISINOPRIL ..................................................................... 37
LISINOPRIL/HYDROCHLOROTHIAZIDE ........................... 38
LITEAIRE ........................................................................ 90
LIVIXIL PAK .................................................................... 85
LO LOESTRIN ................................................................. 21
LO MINASTRIN .............................................................. 21
LOMEDIA 24 .................................................................. 21
LOMUSTINE ................................................................... 15
LONSURF ....................................................................... 15
LORATADINE ................................................................. 42
LORAZEPAM .................................................................. 53
LORCET .......................................................................... 58
LORCET HD .................................................................... 58
LORCET PLUS................................................................. 58
LORTAB ......................................................................... 58
LORYNA ......................................................................... 21
LOSARTAN POTASSIUM ................................................ 36
LOSARTAN/HYDROCHLOROTHIAZIDE ........................... 38
LOVASTATIN .................................................................. 40
LOW-OGESTREL ............................................................ 21
LP LITE PAK.................................................................... 85
LUDENT ......................................................................... 75
LUPANETA ..................................................................... 15
LUPR DEP-PED............................................................... 15
LUPRON DEPOT............................................................. 15
LUTERA.......................................................................... 22
LYNPARZA ..................................................................... 15
LYRICA ........................................................................... 63
LYSODREN ..................................................................... 15
LYZA .............................................................................. 22
M
MAALOX ........................................................................ 45
MAG OXIDE ............................................................. 45, 76
MAGNESIUM CITRATE .................................................. 45
MARLISSA...................................................................... 22
MASK VORTEX/ ............................................................. 90
MATULANE ................................................................... 15
MECLIZINE..................................................................... 48
MED-DERM HC.............................................................. 87
MEDI-CORT ................................................................... 87
MEDI-MECLIZI ............................................................... 48
MEDI-PROFEN ............................................................... 61
MEDROXYPR AC ............................................................ 17
MEFLOQUINE ................................................................ 10
MEGESTROL AC ............................................................. 15
MEKINIST ...................................................................... 15
MELOXICAM.................................................................. 61
MEMANTINE ................................................................. 55
MEMANTINE HC............................................................ 55
MENACTRA ................................................................... 12
MENEST ........................................................................ 19
MENOMUNE ................................................................. 12
MENVEO ....................................................................... 12
MEPHYTON ................................................................... 30
102
MERCAPTOPURINE........................................................ 13
MESALAMINE ................................................................ 50
METAMUCIL .................................................................. 45
METAPROTEREN ........................................................... 44
METFORMIN.................................................................. 24
METHAZOLAMIDE ......................................................... 38
METHIMAZOLE .............................................................. 26
METHITEST .................................................................... 18
METHOCARBAMOL ....................................................... 65
METHOTREXATE ............................................................ 13
METHYLDOPA................................................................ 37
METHYLERGON ............................................................. 28
METHYLPHENIDATE ...................................................... 54
METHYLPHENIDATE (generic Concerta)........................ 54
METHYLPHENIDATE (generic Metadate CD) ................. 54
METHYLPHENIDATE (generic Ritalin LA) ................. 54, 55
METHYLPREDNISOLONE................................................ 17
METIPRANOLOL ............................................................ 83
METOCLOPRAMIDE ....................................................... 50
METOLAZONE................................................................ 39
METOPROLOL .......................................................... 32, 33
METOPROLOL TARTRATE .............................................. 32
METOPROLOL/HYDROCHLOROTHIAZIDE ...................... 38
METRONIDAZOLE .................................................... 10, 51
MEXILETINE ................................................................... 35
MICADERM ...................................................................... 5
MICONAZOLE .................................................................. 5
MICONAZOLE CRE 2%.................................................... 5
MICONAZOLE POW ........................................................ 5
MICONAZOLE 3 ............................................................... 5
MICONAZOLE 7 ............................................................... 5
MICRO GUARD ................................................................ 5
MICROCHAMBER........................................................... 90
MICROGESTIN ............................................................... 22
MICROLIFE ..................................................................... 90
MICROSPACER ............................................................... 90
MIDODRINE ................................................................... 39
MIDOL ........................................................................... 61
MILK OF MAGNESIUM .................................................. 45
MINASTRIN 24 ............................................................... 22
MINERAL OIL ................................................................. 45
MINI WRIGHT ................................................................ 90
MINITRAN ..................................................................... 32
MINOXIDIL ..................................................................... 38
MIRASORB .................................................................... 90
MISOPROSTOL .............................................................. 47
MISSION PREN .............................................................. 68
M-M-R II ........................................................................ 12
MODERIBA ...................................................................... 6
MOMETASONE ............................................................. 88
MONDOXYNE NL ............................................................. 3
MONO-LINYAH .............................................................. 22
MONONESSA ................................................................ 22
MONTELUKAST ............................................................. 44
MORPHINE SULFATE ............................................... 58, 59
MOTION RELF ............................................................... 48
MOTION SICK ................................................................ 48
MOTION-TIME .............................................................. 48
MOTRIN PM .................................................................. 53
MOXIFLOXACIN ............................................................... 4
MULTAQ........................................................................ 35
MULTI PRENAT .............................................................. 68
MULTI-VIT/FE ................................................................ 68
MULTI-VIT/FL ................................................................ 68
MUPIROCIN................................................................... 85
M-VIT ............................................................................ 68
MY WAY ........................................................................ 22
MYCOPHENOLAT .......................................................... 92
MYDRAL ........................................................................ 84
MYFERON 150 ............................................................... 80
MYLERAN ...................................................................... 15
MYNATAL ...................................................................... 68
MYNATAL PLUS ............................................................. 68
MYNATAL-Z ................................................................... 69
MYNEPHROCAPS........................................................... 69
MYZILRA ........................................................................ 22
N
NABUMETONE .............................................................. 61
NADOLOL ...................................................................... 33
NAFRINSE ...................................................................... 75
NALOXONE .................................................................... 88
NALTREXONE ................................................................ 88
NAMENDA XR ............................................................... 55
NAPROXEN .................................................................... 61
NARATRIPTAN ............................................................... 61
NARCAN ........................................................................ 88
NASACORT ALR ............................................................. 42
103
NATAL-V RX ................................................................... 69
NATALVIRT CA ............................................................... 69
NATALVIT ...................................................................... 69
NATURALYTE ................................................................. 76
NEBUPENT ..................................................................... 10
NEBUSAL ....................................................................... 42
NECON ........................................................................... 22
NEO/BAC/POLY ............................................................. 83
NEO/POLY/BAC ............................................................. 84
NEO/POLY/DEX ............................................................. 84
NEO/POLY/GRA ............................................................. 83
NEO/POLY/HC ............................................................... 84
NEOMYCIN ...................................................................... 4
NEO-POLYCIN .......................................................... 83, 84
NEOPORACIN ................................................................ 85
NEOSPORIN ................................................................... 88
NEOSPORIN AF ................................................................ 5
NEOSPORIN+PN ............................................................ 85
NEPHPLEX RX................................................................. 69
NEPHRON FA ................................................................. 80
NEPHRONEX .................................................................. 69
NEPHRO-VITE ................................................................ 69
NESSI SPACER ................................................................ 91
NEULASTA ..................................................................... 78
NEUPOGEN .................................................................... 79
NEUT ............................................................................. 52
NEUTRAGARD................................................................ 75
NEUTREXIN .................................................................... 10
NEVIRAPINE ..................................................................... 8
NEXAVAR ....................................................................... 15
NEXT CHOICE ................................................................. 22
NIACIN ............................................................... 40, 65, 66
NIACIN ER ................................................................ 40, 66
NIACIN TR ...................................................................... 66
NIACINAMIDE ................................................................ 66
NICOTINE ....................................................................... 56
NICOTINE SYS ................................................................ 56
NICOTROL ................................................................ 56, 57
NIFEDIAC CC .................................................................. 34
NIFEDICAL XL ................................................................. 34
NIFEDIPINE .................................................................... 34
NIKKI .............................................................................. 22
NILANDRON................................................................... 15
NINLARO........................................................................ 15
NITRO-BID ..................................................................... 32
NITRO-DUR ................................................................... 32
NITROFURANTOIN ........................................................ 10
NITROFURANTOIN MACROCRYSTALS ........................... 10
NITROGLYCERIN ............................................................ 32
NIVA-PLUS ..................................................................... 69
NIZATIDINE ................................................................... 47
NOBLE FORMUL ............................................................ 88
NORA-BE ....................................................................... 22
NORDITROPIN ......................................................... 29, 30
NORETH/ETHIN ............................................................. 22
NORETHIN ACE.............................................................. 17
NORETHINDRON ........................................................... 22
NORGEST/ETHI.............................................................. 22
NORINYL........................................................................ 22
NORLYROC .................................................................... 22
NORPACE ...................................................................... 35
NORTREL ....................................................................... 22
NORVIR ........................................................................... 8
NOVAFERRUM .............................................................. 69
NOVAREL....................................................................... 28
NOVOLIN ....................................................................... 25
NOVOLOG ..................................................................... 25
NOXAFIL .......................................................................... 4
NP THYROID .................................................................. 27
NU-IRON 150 ................................................................ 80
NULEV ........................................................................... 46
NUTROPIN ..................................................................... 30
NUTROPIN AQ ............................................................... 30
NUVARING .................................................................... 22
NYSTAT/TRIAM ............................................................. 88
NYSTATIN .................................................................... 4, 5
O
OB COMPLETE ............................................................... 69
OB-NATAL ONE ............................................................. 69
O-CAL ............................................................................ 69
O-CAL FA ....................................................................... 69
OCELLA .......................................................................... 22
OCTREOTIDE ................................................................. 30
ODEFSY ........................................................................... 8
ODOMZO ...................................................................... 15
OFLOXACIN ................................................................... 83
OGESTREL ..................................................................... 22
104
P
OMEGA III ...................................................................... 29
OMEPRAZOLE ................................................................ 47
OMEPRAZOLE + ............................................................. 47
OMNITROPE .................................................................. 30
ONDANSETRON ............................................................. 48
OPCICON ....................................................................... 22
OPTICHAMBER .............................................................. 91
ORA-BLEND ................................................................... 89
ORA-BLEND SF ............................................................... 89
ORAL ELECTRO .............................................................. 76
ORAL MIX ...................................................................... 89
ORAL MIX SF .................................................................. 89
ORAL SUSPEND.............................................................. 89
ORAL SYRUP .................................................................. 89
ORALYTE ........................................................................ 76
ORA-PLUS ...................................................................... 89
ORA-SWEET ................................................................... 89
ORA-SWEET SF .............................................................. 89
ORKAMBI ....................................................................... 42
ORSYTHIA ...................................................................... 22
ORTHO COIL .................................................................. 51
ORTHO FLAT .................................................................. 51
ORTHO FLEX .................................................................. 51
ORTHO TRI-CYCLN LO .................................................... 22
ORTHO-EST .................................................................... 19
OSCAL ............................................................................ 76
OS-CAL ........................................................................... 76
OSCIMIN ........................................................................ 46
OSCIMIN SR ................................................................... 46
OTEZLA .......................................................................... 60
OXANDROLONE ............................................................. 18
OXCARBAZEPIN ............................................................. 63
OXYBUTYNIN ................................................................. 50
OXYCODONE ................................................................. 59
OXYCODONE/APAP ....................................................... 59
OXYCODONE/ASA ......................................................... 59
OXYCONTIN ................................................................... 59
OXYTROL/WOMN .......................................................... 51
OYS SHELL CA ................................................................ 76
OYS SHELL+D ................................................................. 76
OYSCO 500+D ................................................................ 76
OYST CAL/D ............................................................. 76, 77
OYST SHELL/D................................................................ 77
PACERONE .................................................................... 36
PANCREAZE ................................................................... 49
PANCRELIPASE .............................................................. 49
PANDA MASK ................................................................ 91
PANTOPRAZOLE ............................................................ 47
PARICALCITOL ............................................................... 30
PAROEX ......................................................................... 85
PAROMOMYCIN .............................................................. 4
PCCA SWEET ................................................................. 89
PCCA SYRUP .................................................................. 89
PCCA-PLUS .................................................................... 89
PCE .................................................................................. 3
PEAK AIR FLO ................................................................ 91
PEAK FLOW ................................................................... 91
PEAK FLW MTR ............................................................. 91
PEDIA IRON ................................................................... 80
PEDIA-LAX ..................................................................... 45
PEDIALYTE ..................................................................... 77
PEDIASURE .................................................................... 78
PEGANONE.................................................................... 63
PEGASYS .......................................................................... 6
PEG-INTRON ............................................................... 6, 7
PENICILLIN G POTASSIUM............................................... 1
PENTAM 300 ................................................................. 10
PENTASA ....................................................................... 50
PENTOXIFYLLI ................................................................ 82
PEPCID AC ..................................................................... 47
PERIOGARD ................................................................... 85
PERMETHRIN ................................................................ 86
PERSONAL BES .............................................................. 91
PHENADOZ .................................................................... 48
PHENAZO ...................................................................... 52
PHENAZOPYRID............................................................. 52
PHENERGAN.................................................................. 48
PHENOBARB .................................................................. 53
PHENYTOIN ................................................................... 63
PHENYTOIN EX .............................................................. 63
PHILITH ......................................................................... 22
PHOS-FLUR .................................................................... 75
PHOSPHA 250 ............................................................... 77
PHOSPHOLINE ............................................................... 84
PIKO 1 ........................................................................... 91
PILOCARPINE........................................................... 51, 84
105
PRAMIPEXOLE ......................................................... 64, 65
PRAVASTATIN ......................................................... 40, 41
PRAZOSIN ...................................................................... 82
PRED MILD .................................................................... 84
PRED SOD PHO.............................................................. 84
PREDNISOLONE ....................................................... 17, 84
PREDNISOLONE SODIUM PHOSPHATE ......................... 17
PREDNISONE ........................................................... 17, 18
PREGNYL ....................................................................... 28
PREMARIN VAG............................................................. 19
PRENAISSANCE ............................................................. 70
PRENAPLUS ................................................................... 70
PRENAT PLUS ................................................................ 70
PRENATABS FA .............................................................. 70
PRENATABS RX .............................................................. 70
PRENATAL ......................................................... 69, 70, 72
PRENATAL 1 .................................................................. 70
PRENATAL 19 ................................................................ 71
PRENATAL AD ............................................................... 71
PRENATAL FRM ............................................................. 71
PRENATAL MV............................................................... 71
PRENATAL VIT ............................................................... 71
PRENATAL/FE ................................................................ 71
PRENATAL+DHA ............................................................ 71
PRENATAL+FE ............................................................... 71
PRENATAL-U ................................................................. 71
PRENATL MULT ............................................................. 71
PREP H HC ..................................................................... 88
PREPLUS ........................................................................ 71
PRETAB.......................................................................... 71
PREVALITE ..................................................................... 40
PREVIFEM...................................................................... 23
PREVNAR 13 .................................................................. 12
PREZCOBIX ...................................................................... 8
PREZISTA ......................................................................... 8
PRIMEAIRE .................................................................... 91
PRIMIDONE ................................................................... 63
PROAIR HFA .................................................................. 43
PROBEN/COLCH ............................................................ 62
PROBENECID ................................................................. 62
PROCAINAMIDE ............................................................ 36
PROCHLORPER .............................................................. 48
PROCRIT ........................................................................ 79
PROCTO-PAK ................................................................. 88
PIMTREA ........................................................................ 22
PINDOLOL ...................................................................... 33
PINWORM ..................................................................... 10
PIN-X.............................................................................. 10
PIOGLITAZONE ........................................................ 24, 26
PIOGLITAZONE/METFORMIN ........................................ 24
PIRMELLA ...................................................................... 22
PLAN B ..................................................................... 22, 23
PLEGRIDY ....................................................................... 56
PLEGRIDY PEN ............................................................... 56
PNEUMOVAX 23 ............................................................ 12
PNV FE FUM .................................................................. 69
PNV FOLIC AC ................................................................ 69
PNV OB+DHA ................................................................. 69
PNV PRENATAL .............................................................. 69
PNV TABS ...................................................................... 69
PNV-DHA ....................................................................... 69
PNV-SELECT ................................................................... 69
PNV-VP-U ...................................................................... 69
POCKET PEAK ................................................................ 91
POCKETPEAK ................................................................. 91
PODACTIN ....................................................................... 5
PODOFILOX ................................................................... 86
POLYCIN ........................................................................ 83
POLYCIN B ..................................................................... 83
POLY-DEX ...................................................................... 84
POLYETHYLENE GLYCOL ................................................ 45
POLY-IRON..................................................................... 80
POLYMYXIN B/SOL TRIMETHOPRIM SULFATE .............. 83
POLY-VI-SOL .................................................................. 69
POLY-VITA ..................................................................... 69
POLYVITAMIN ................................................................ 70
POLY-VITE ...................................................................... 70
POMALYST ..................................................................... 15
PORTIA-28 ..................................................................... 23
POT ACETATE ................................................................ 77
POT CHLORIDE .............................................................. 77
POT CL MICRO ............................................................... 77
POT GLUCONAT............................................................. 77
POTASSIUM ................................................................... 77
POTASSIUM CITRATE..................................................... 52
POTASSIUM CITRATE/CITRIC ACID ................................ 52
PRADAXA ....................................................................... 81
PRALUENT ..................................................................... 40
106
REBIF ............................................................................. 56
REBIF REBIDO ................................................................ 56
REBIF TITRTN................................................................. 56
RECLIPSEN ..................................................................... 23
RECOMBIVA HB............................................................. 12
RECORT PLUS ................................................................ 88
REDERM ........................................................................ 88
REESES MED .................................................................. 10
REGONOL ...................................................................... 51
REGRANEX .................................................................... 86
RELADOR PAK ............................................................... 85
RELENZA .......................................................................... 9
RELION .......................................................................... 25
REMODULIN .................................................................. 41
RENAGEL ....................................................................... 50
RENAL ..................................................................... 71, 72
RENALPREN ................................................................... 72
RENA-VITE ..................................................................... 72
RENA-VITE RX................................................................ 72
RENO ............................................................................. 72
RENVELA ....................................................................... 50
RESCRIPTOR .................................................................... 8
RETROVIR ........................................................................ 8
REVLIMID ................................................................ 15, 16
REYATAZ .......................................................................... 8
RIBASPHERE .................................................................... 7
RIBAVIRIN ....................................................................... 7
RIFABUTIN....................................................................... 4
RIFAMPIN ........................................................................ 4
RILUZOLE....................................................................... 65
RIMANTADINE ................................................................ 6
RINGWORM .................................................................... 6
RISEDRONATE ............................................................... 28
RITALIN LA..................................................................... 55
RITEFLO ......................................................................... 91
RIVASTIGMINE .............................................................. 55
RIZATRIPTAN ................................................................. 61
ROMYCIN ...................................................................... 83
ROPINIROLE .................................................................. 65
ROXICET ........................................................................ 59
RULAVITE DHA .............................................................. 72
PROCTOSOL HC ............................................................. 88
PROCTOZONE ................................................................ 88
PROGESTERONE ............................................................ 17
PROGLYCEM .................................................................. 24
PROLASTIN-C ................................................................. 44
PROMACTA.................................................................... 79
PROMETHAZINE ...................................................... 48, 49
PROMETHEGAN ............................................................ 49
PRONTO PLUS ............................................................... 86
PROPAFENONE .............................................................. 36
PROPANTHELIN ............................................................. 46
PROPRANOLOL .............................................................. 33
PROPYLTHIOUR ............................................................. 26
PROVENTIL .................................................................... 43
PROVIL ........................................................................... 61
PSORIASIN ..................................................................... 86
PSYLLIUM FIBER ............................................................ 45
PULMOSAL .................................................................... 42
PULMOZYME ................................................................. 42
PX PRENATAL ................................................................ 71
PYRAZINAMIDE ............................................................... 4
PYRIDOSTIGMINE BROMIDE ......................................... 51
Q
QC PRENATAL ................................................................ 71
QUARTETTE ................................................................... 23
QUASENSE ..................................................................... 23
QUFLORA PED ............................................................... 71
QUINAPRIL .................................................................... 37
QUINIDINE GLUCONATE ............................................... 36
QUINIDINE SULFATE ...................................................... 36
QVAR ............................................................................. 43
R
RA ALCOHOL.................................................................. 85
RA ARTH PAIN ............................................................... 86
RA CALCIUM .................................................................. 71
RA PRENATAL ................................................................ 71
RABEPRAZOLE ............................................................... 47
RALOXIFENE .................................................................. 28
RAMIPRIL ....................................................................... 37
RANEXA ......................................................................... 31
RANITIDINE ................................................................... 47
RAPAMUNE ................................................................... 92
S
SABRIL ........................................................................... 63
107
SOD BICARB .................................................................. 52
SOD CHLORIDE ........................................................ 77, 78
SOD FLUORIDE .............................................................. 75
SOD POLY ...................................................................... 92
SODIUM BICAR........................................................ 45, 46
SODIUM CHLOR ............................................................ 52
SODIUM CHLORIDE ....................................................... 42
SOLIA ............................................................................. 23
SOMAVERT .................................................................... 30
SOOTHE&COOL ............................................................... 6
SORINE .......................................................................... 33
SOTALOL AF .................................................................. 33
SOTALOL HCL ................................................................ 33
SOVALDI .......................................................................... 7
SPIRIVA ......................................................................... 42
SPIRONOLACTONE .................................................. 38, 39
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE .............. 38
SPORANOX ...................................................................... 5
SPRINTEC 28.................................................................. 23
SPRYCEL ........................................................................ 16
SPS ................................................................................ 92
SRONYX ......................................................................... 23
SSD ................................................................................ 85
SSKI ............................................................................... 26
STAGESIC ....................................................................... 59
STAVUDINE ................................................................. 8, 9
STELARA ........................................................................ 86
STERIL WATER ......................................................... 52, 89
STIOLTO ........................................................................ 43
STIVARGA ...................................................................... 16
STOMACH RLF ............................................................... 46
STRESS 500.................................................................... 72
STRESS FORM ................................................................ 72
STRIBILD .......................................................................... 9
STUART PREN ................................................................ 72
SUCRALFATE ................................................................. 47
SULF/PRED NA .............................................................. 84
SULFACET SOD .............................................................. 83
SULFADIAZINE ............................................................... 50
SULFASALAZIN .............................................................. 50
SULFATRIM PD .............................................................. 10
SULFAZINE..................................................................... 50
SULFAZINE EC................................................................ 50
SULINDAC...................................................................... 61
SAFYRAL ........................................................................ 23
SALINE ........................................................................... 45
SALINE FLUSH ................................................................ 77
SALSALATE ..................................................................... 57
SAM-E.P.A. .................................................................... 29
SARNOL-HC ................................................................... 88
SB HYDROCORT ............................................................. 88
SCALP RELIEF ................................................................. 88
SCALPICIN ................................................................ 86, 88
SELEGILINE .................................................................... 64
SELZENTRY....................................................................... 8
SE-NATAL 19 .................................................................. 72
SENNA ........................................................................... 45
SENNA-DOCUSATE SODIUM ......................................... 45
SENSIPAR ....................................................................... 29
SEREVENT DISKUS ......................................................... 43
SE-TAN DHA................................................................... 72
SETLAKIN ....................................................................... 23
SEVELAMER ................................................................... 50
SF 75
SF 5000 PLUS ................................................................. 75
SFROWASA .................................................................... 50
SHAROBEL ..................................................................... 23
SIGNIFOR ....................................................................... 30
SILDENAFIL .................................................................... 41
SILVER SULFA ................................................................ 85
SIMILAC PREN ............................................................... 72
SIMPLE........................................................................... 89
SIMVASTATIN ................................................................ 41
SIROLIMUS .................................................................... 92
SLEEP AID ...................................................................... 53
SLO-NIACIN.................................................................... 66
SLOW IRON ................................................................... 80
SLOW REL FE ................................................................. 80
SLOW RELEASE .............................................................. 80
SM ACID REDU .............................................................. 47
SM ANTIFUNGL ............................................................... 6
SM CALCIUM ................................................................. 72
SM FIRST AID ................................................................. 85
SM IPECAC ..................................................................... 88
SM IRON ........................................................................ 80
SM IRON SLOW ............................................................. 80
SMZ/TMP DS ................................................................. 10
SMZ-TMP ....................................................................... 10
108
TESTOSTERONE CYPIONATE ......................................... 18
TESTOSTERONE ENATHATE .......................................... 18
TEV-TROPIN .................................................................. 30
TH IRON ........................................................................ 80
TH PRENATAL ................................................................ 72
THEO-24 ........................................................................ 44
THEOCHRON ................................................................. 44
THEOPHYLLINE .............................................................. 44
THERA-D........................................................................ 30
THERAGEN HP ............................................................... 86
THERANATAL ................................................................ 72
THERMAZENE................................................................ 85
THIAMINE HCL .............................................................. 66
THRIVITE 19 .................................................................. 72
THRIVITE RX .................................................................. 72
THYROLAR-1.................................................................. 27
THYROLAR-1/2 .............................................................. 27
THYROLAR-1/4 .............................................................. 27
THYROLAR-2.................................................................. 27
THYROLAR-3.................................................................. 27
TIAGABINE .................................................................... 63
TICLOPIDINE .................................................................. 82
TILIA FE.......................................................................... 23
TIMOLOL GEL ................................................................ 83
TIMOLOL MAL ............................................................... 83
TINEACIDE ....................................................................... 6
TIVICAY............................................................................ 9
TIZANIDINE ................................................................... 65
TOBRA/DEXAME ........................................................... 84
TOBRADEX .................................................................... 84
TOBRAMYCIN ............................................................ 4, 83
TOLAZAMIDE................................................................. 26
TOLCAPONE .................................................................. 64
TOLTERODINE ............................................................... 51
TOPIRAGEN ............................................................. 63, 64
TOPIRAMATE ................................................................ 64
TORSEMIDE ................................................................... 39
TOTAL B/C ..................................................................... 72
TOUJEO ......................................................................... 25
TRACLEER ...................................................................... 41
TRAMADL/APAP............................................................ 59
TRAMADOL HCL ............................................................ 59
TRAVEL SICK .................................................................. 49
TRAVOPROST ................................................................ 85
SUMATRIPTAN ........................................................ 61, 62
SUPER B-COMP ............................................................. 72
SUPER DHA .................................................................... 29
SUPER OMEGA .............................................................. 29
SUPERPLEX-T ................................................................. 72
SUPRAX ........................................................................... 2
SUSPENSION .................................................................. 89
SUSTIVA ........................................................................... 9
SUTENT .......................................................................... 16
SYEDA ............................................................................ 23
SYMAX FASTAB.............................................................. 46
SYMAX-SL ...................................................................... 46
SYMAX-SR ...................................................................... 46
SYMBICORT ................................................................... 43
SYNAGIS ........................................................................ 10
SYNTHROID ................................................................... 27
SYRPALTA ...................................................................... 89
SYRSPEND SF ................................................................. 89
SYRUP ............................................................................ 89
SYRUP SF ....................................................................... 89
T
TABLET .......................................................................... 91
TABLOID ........................................................................ 16
TACROLIMUS ................................................................. 92
TAFINLAR ....................................................................... 16
TAGRISSO ...................................................................... 16
TAKE ACTION ................................................................. 23
TALTZ ............................................................................. 60
TAMIFLU .......................................................................... 9
TAMOXIFEN ................................................................... 16
TAMSULOSIN ................................................................. 52
TANZEUM ...................................................................... 24
TARCEVA ....................................................................... 16
TARINA FE ..................................................................... 23
TASIGNA ........................................................................ 16
TAZTIA XT ................................................................ 34, 35
TECFIDERA ..................................................................... 56
TEMOZOLOMIDE ........................................................... 16
TERAZOSIN .................................................................... 82
TERBINAFINE ................................................................... 5
TERBUTALINE ................................................................ 44
TESTIM .......................................................................... 18
TESTOSTERONE ............................................................. 18
109
ULTRA TABS .................................................................. 73
UNITHROID ............................................................. 27, 28
UNITHROID DIRECT ....................................................... 27
URSODIOL ..................................................................... 49
TRAV-TABS .................................................................... 49
TRETINOIN ..................................................................... 16
TRIADVANCE ................................................................. 72
TRIAMCINOLON ............................................................ 88
TRIAMTERENE/HYDROCHLOROTHIAZIDE ..................... 38
TRICARE ......................................................................... 72
TRIDERM ....................................................................... 88
TRI-ESTARYLL ................................................................. 23
TRIFLURIDINE ................................................................ 83
TRIHEXYPHEN ................................................................ 64
TRI-LEGEST .................................................................... 23
TRILEPTAL ...................................................................... 64
TRI-LINYAH .................................................................... 23
TRILYTE .......................................................................... 45
TRIMETHOPRIM ............................................................ 10
TRIMETHOPRIM SOL POLYMYXN .................................. 83
TRINATAL....................................................................... 72
TRINATAL GT ................................................................. 72
TRINATAL RX ................................................................. 73
TRINATE......................................................................... 73
TRINESSA ....................................................................... 23
TRIPHROCAPS ................................................................ 73
TRI-PREVIFEM................................................................ 23
TRIPTONE ...................................................................... 49
TRI-SPRINTEC ................................................................ 23
TRIUMEQ ......................................................................... 9
TRI-VI-SOL...................................................................... 73
TRI-VIT/FL ...................................................................... 73
TRI-VIT/FLUO ................................................................. 73
TRI-VITA ......................................................................... 73
TRI-VITA/FL.................................................................... 73
TRI-VITAMIN .................................................................. 73
TRIVORA-28 ................................................................... 23
TRIXAICIN HP ................................................................. 86
TROPICAMIDE ............................................................... 84
TRUMENBA ................................................................... 12
TRUVADA ........................................................................ 9
TRUZONE PEAK.............................................................. 91
TYBOST ............................................................................ 9
TYKERB .......................................................................... 16
TYZEKA ............................................................................ 7
V
VAGIFEM ....................................................................... 19
VAGISTAT-3 ..................................................................... 6
VALACYCLOVIR ................................................................ 6
VALGANCICLOVIR ........................................................... 6
VALSARTAN ................................................................... 36
VALSARTAN/HCTZ ......................................................... 36
VALVD HOLDNG ............................................................ 91
VANCOMYCIN ......................................................... 10, 11
VANCOMYCIN/DEXTROSE ............................................. 11
VANDAZOLE .................................................................. 51
VAQTA ........................................................................... 12
VARIVAX ........................................................................ 12
VCF VAGINAL ................................................................ 51
VELETRI ......................................................................... 41
VELIVET ......................................................................... 23
VELTASSA ...................................................................... 92
VENATAL-FA .................................................................. 73
VENCLEXTA ................................................................... 16
VENTAVIS ...................................................................... 41
VENTOLIN HFA .............................................................. 43
VERAPAMIL ................................................................... 35
VEREGEN ....................................................................... 86
VERSAFREE .................................................................... 89
VERSAPLUS ................................................................... 89
VESTURA ....................................................................... 23
VIBRAMYCIN ................................................................... 3
VICTOZA ........................................................................ 24
VIDEX .............................................................................. 9
VIMPAT ......................................................................... 64
VINATE AZ EX ................................................................ 73
VINATE CAL ................................................................... 73
VINATE GT ..................................................................... 73
VINATE IC ...................................................................... 73
VINATE II ....................................................................... 73
VINATE ONE .................................................................. 73
VINATE ULTRA............................................................... 73
VIORELE ........................................................................ 23
VIRACEPT ........................................................................ 9
U
ULTIMATECARE ............................................................. 73
110
WYMZYA FE .................................................................. 23
VIRAMUNE ...................................................................... 9
VIREAD ............................................................................ 9
VIRT NATE ..................................................................... 73
VIRT-ADVANCE .............................................................. 73
VIRT-CAPS...................................................................... 73
VIRT-CARE ..................................................................... 73
VIRT-PHOS ..................................................................... 78
VIRT-PN ......................................................................... 74
VIRT-PN DHA ................................................................. 74
VIRTRATE-2 ................................................................... 52
VIRTRATE-K ................................................................... 52
VIRT-VITE GT ................................................................. 74
VIT D GUMMIE .............................................................. 31
VITA-BEE/C .................................................................... 74
VITAFOL-OB ................................................................... 74
VITAFOL-PN ................................................................... 74
VITAJOY DALY ................................................................ 30
VITAMIN B-1 .................................................................. 66
VITAMIN B-12 ................................................................ 66
VITAMIN D ..................................................................... 31
VITAMIN D3 ................................................................... 31
VITEKTA ........................................................................... 9
VOGELXO ....................................................................... 18
VOL-CARE RX ................................................................. 74
VOL-NATE ...................................................................... 74
VOL-PLUS....................................................................... 74
VOL-TAB RX ................................................................... 74
VORICONAZOLE ............................................................... 5
VORTEX VALVE .............................................................. 91
VORTEX/MASK .............................................................. 91
VOTRIENT ...................................................................... 16
VP-ERA OB ..................................................................... 74
VP-VITE RX ..................................................................... 74
VYFEMLA ....................................................................... 23
X
XALKORI ........................................................................ 16
XARELTO ....................................................................... 82
XARELTO STAR .............................................................. 82
XIFAXAN ........................................................................ 11
XOLAIR .......................................................................... 44
XOPENEX HFA ............................................................... 43
XTANDI .......................................................................... 16
XULANE ......................................................................... 23
Y
YODOXIN ......................................................................... 4
Z
ZAFIRLUKAST................................................................. 44
ZARAH ........................................................................... 23
ZARXIO .......................................................................... 79
ZATEAN-PN ................................................................... 74
ZELBORAF...................................................................... 16
ZEMAIRA ....................................................................... 44
ZENCHENT ..................................................................... 23
ZENCHENT FE ................................................................ 23
ZENPEP .......................................................................... 49
ZEPATIER ......................................................................... 7
ZETIA ............................................................................. 40
ZIAGEN ............................................................................ 9
ZIDOVUDINE ................................................................... 9
ZIRGAN .......................................................................... 83
ZITHROMAX .................................................................... 3
ZOLINZA ........................................................................ 16
ZOLMITRIPTAN.............................................................. 62
ZOLPIDEM ..................................................................... 53
ZOMACTON ................................................................... 30
ZONISAMIDE ................................................................. 64
ZORTRESS ...................................................................... 92
ZOSTAVAX ..................................................................... 12
ZOVIA ............................................................................ 23
ZYDELIG ......................................................................... 16
ZYKADIA ........................................................................ 17
ZYTIGA........................................................................... 17
W
WAL-DRAM ................................................................... 49
WAL-DRAM II ................................................................ 49
WAL-ZAN ....................................................................... 47
WAL-ZAN 75 .................................................................. 47
WARFARIN..................................................................... 81
WATCHHALER ............................................................... 91
WERA............................................................................. 23
WIDE-SEAL..................................................................... 51
111
112

OHP Drug List (Formulary)

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