Four-Tier Prescription Member Guide

Four-Tier Prescription Member Guide
20
15
PLEASE BRING THIS GUIDE WITH YOU TO YOUR NEXT DOCTOR’S VISIT
04HQ1216 R10/14 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
October 2014
Your Guide to Your Prescription Drug Program
Because drug benefits can be complex, understanding your benefits is key to getting the most from your health plan. That’s
why Blue Cross and Blue Shield of Louisiana and our subsidiary, HMO Louisiana, Inc., along with Express Scripts,* an
independent company that serves as our pharmacy benefit manager, created this Prescription Member Guide.
Throughout the year, our Blue Cross Pharmacy and Therapeutics Committee  a group of Louisiana doctors and
pharmacists  reviews literature about the safety, efficacy, and cost of prescription medicines.
You and your doctor always make the final decision for your healthcare needs. To help you both make informed decisions,
you should share this Guide with your doctor at your next visit or before you fill your next prescription. That way, together
you may choose the best drug for you while keeping your costs down.
Please talk to your doctor or pharmacist about any questions or concerns you may have about your drug therapy.
Please Note: Inclusion of a drug in a drug formulary does not guarantee that a member's physician or other authorized
prescriber will prescribe the drug for a particular medical condition or mental illness.
What do you need to know about the drugs you take?
Before you fill a prescription for any drug, you should ask these important questions:
Must you first try a generic before your plan will cover a brand-name drug for your condition?
Must your doctor get a prior authorization before your plan will pay for your drug?
Are there limits to the quantity of medication that will be covered each time you fill a prescription?
Must you buy the drug from a specialty pharmacy?
In this Guide, we answer these key questions and list the drugs in a table so that you can easily look up the ones you may
have to take.
Note:
This Guide is intended to include all drugs that your plan covers, as of the time the document was created. But the list may change as
changes occur in the marketplace.
This Guide may not apply to all benefit plans. Some benefit plans may have different coverage for specific drugs.
The Guide applies only to prescription drugs that participating pharmacies dispense on an outpatient basis.
See your member contract or certificate for pharmacy coverage for any exclusions and limitations that apply to you.
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
2
How are prescription drugs classified?
Your plan offers a 4-tier structure for drugs that are covered:
Tier
Description of prescription drugs
1
2
3
Value drugs
Primarily generic drugs, although some brand-name drugs may fall into this category
Preferred brand drugs
Brand-name drugs
Non-preferred brand
or generic drugs
Primarily brand-name drugs that may have a therapeutic alternative that is in Tier 1 or
Tier 2, although some generic drugs may fall into this category
Covered compounded drugs are included in this tier.
4
Specialty drugs
High-cost brand-name or generic drugs that are identified as specialty drugs
Generally, you will pay the least out of pocket when you buy value drugs  or drugs that are in Tier 1. You will pay the
most out of pocket for non-preferred brand or generic drugs  those in Tier 3  and specialty drugs those in Tier 4.
Note that if any preferred brand drug loses patent protection after the printing of this publication and it becomes available
as a generic equivalent, you must pay the Tier 3 copayment if it is not a specialty drug.
What does it mean when the Tier section shows $0?
Certain drugs may be eligible for first-dollar coverage. That means you do not pay out of pocket for them and you do not
pay a deductible. Drugs in these programs are marked with a $0 under the tier column. Since some benefit plans do not
have this type of coverage, you should see your plan materials to find out if you have it. Note that restrictions or limitations
apply, including age, gender, or frequency.
Broad categories of drugs that may be eligible for this coverage include:
Selected contraceptives for women
Selected preventive drugs as recommended by the U.S. Preventive Services Task Force (USPSTF): For example, selected
bowel prep products when used with a wellness screening colonoscopy and selected vitamin D products, for people
identified as having an increased risk for falls may be covered.
How can you find information about your drugs?
In the index, we list drugs alphabetically along with a page reference in which the drug appears. Simply look for the drug
you take and quickly learn several important things:
If you must first try a generic before your plan will cover a brand-name drug for your condition,
If your doctor must get prior authorization before your plan will pay for the drug,
If your plan limits the quantity that will be covered each time you fill a prescription, or
If you must go to a specialty pharmacy.
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
3
Tier
1
3
Drug
Generic
Requirements/Limits
[QPD, 30]
generic
BRAND
generic
[PA] [ST]
BRAND NAME drugs are in ALL CAPS.
generic drugs are in lower case
italics.
Shows you if a lower
cost medication is
available in another
tier.
[PA] = Prior authorization
[QPD] = Quantity per dispensing limits
[ST] = Step therapy restrictions
What Requirements apply to my plan? What do the abbreviations in the Requirements or Limits column
mean?
[PA]: Medications requiring prior authorization
We must authorize certain drugs before your plan will pay for them. After considering current medical literature, the
Pharmacy and Therapeutics Committee sets up the criteria needed for the drugs to be authorized. Then, Express
Scripts processes the prior authorization requests.
If you need prior authorization, have your doctor contact Express Scripts:
Call: 1-800-842-2015
Fax: 1-877-837-5922
For the physician fax form, go to: http://www.bcbsla.com/Providers/PharmacyManagement
[ST]: Medications requiring participation in the Lead with Generics Step Therapy Program
In certain drug classes, you must first try a generic before your plan will cover a brand-name drug for your condition.
For example, if Drug A (a generic) and Drug B (a brand-name) both treat your medical condition, we may require that
your doctor prescribe Drug A first. Then if Drug A does not work for you, we will cover a prescription for Drug B.
Based on your history, if you cannot tolerate Drug A or if your doctor requests that you try Drug B first, your doctor
must first have authorization before your plan will pay for the medication. If you need a prior authorization, have
your doctor contact Express Scripts:
Call: 1-800-842-2015
Fax: 1-877-837-5922
For the physician fax form, go to: http://www.bcbsla.com/Providers/PharmacyManagement
[QPD]: Medications that have Quantity Per Dispensing limitations
Covered prescriptions have a day-supply limitation (typically up to a 30-day supply at a retail pharmacy and up to a
90-day supply for mail-order). Your plan also limits the amount of certain drugs that can be dispensed at one time.
We call those restrictions Quantity Per Dispensing (QPD) limitations.
QPD limits are additional to the day-supply limitation and are based on the manufacturer’s recommended dosage
and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations or
clinical studies, and as determined by BCBSLA. QPD limits or allowances are subject to quantity limits per day supply,
per dispensing event, or any combination of the two. See your member contract or certificate for the limits for your
plan.
For a complete list of drugs and their QPD limitations, go to: www.bcbsla.com/pharmacy.
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
4
Specialty Pharmacy Program restrictions on Tier 4 Drugs
Certain drugs are commonly called specialty drugs. Covered specialty drugs are in Tier 4 on this plan. Specialty drugs
include biotechnology drugs or other drug products that may require special ordering, handling, or customer service.
To receive in-network benefits, your policy may require you to buy these drugs at a network specialty pharmacy. Your
policy may also limit specialty drugs to the retail day supply listed in your plan (typically a 30-day supply).
See your Schedule of Benefits for any restrictions that apply to you.
For a complete list of drugs included in the Specialty Pharmacy Program, go to: www.bcbsla.com/pharmacy.
For information about our contracted specialty pharmacies, call the Customer Service number on your member ID
card.
For a copy of this guide, go to: www.bcbsla.com/pharmacy or call Express Scripts Customer Service toll-free at: 1-866-7817533
If your doctor prescribes a drug that is not in this Guide, or if you have any questions, call Express Scripts at 1-866-7817533.
For more information and updates, go to: www.bcbsla.com/pharmacy or www.express-scripts.com.
* Express Scripts is an independent company that serves as the pharmacy benefit manager for Blue Cross and Blue Shield of
Louisiana and HMO Louisiana, Inc.
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
5
Drug Name
Drug Tier
Requirements / Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ANCOBON
3
clotrimazole
1
DIFLUCAN ORAL SUSPENSION
3
DIFLUCAN ORAL TABLET 100 MG, 200 MG,
50 MG
3
DIFLUCAN ORAL TABLET 150 MG
3
fluconazole oral suspension
1
fluconazole oral tablet 100 mg, 200 mg, 50 mg
1
fluconazole oral tablet 150 mg
1
flucytosine
1
GRIFULVIN V
3
GRIS-PEG (ULTRAMICROSIZE)
3
griseofulvin
1
itraconazole
1
ketoconazole
1
LAMISIL
3
NOXAFIL
3
nystatin
1
NYSTATIN
3
ONMEL
2
ORAVIG
3
SPORANOX ORAL CAPSULE/PULSEPAK
3
SPORANOX ORAL SOLUTION
3
terbinafine hcl
1
VFEND ORAL SUSPENSION
2
VFEND ORAL TABLET
3
voriconazole oral suspension
1
voriconazole oral tablet
1
QPD
QPD
QPD
QPD
PA; QPD
QPD
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
6
Drug Name
Drug Tier
Requirements / Limits
ANTIVIRALS
abacavir
4
abacavir-lamivudine-zidovudine
4
acyclovir
1
adefovir
4
amantadine hcl
1
APTIVUS
4
ATRIPLA
4
BARACLUDE
4
COMBIVIR
4
COMPLERA
4
COPEGUS
4
CRIXIVAN
4
didanosine
4
EDURANT
4
EMTRIVA
4
entecavir
4
EPIVIR
4
EPIVIR HBV
4
EPZICOM
4
famciclovir
1
QPD
FAMVIR
3
QPD
FLUMADINE
3
FUZEON
4
HARVONI
4
HEPSERA
4
INCIVEK
4
INTELENCE
4
INVIRASE
4
ISENTRESS
4
KALETRA
4
lamivudine
4
QPD
QPD
PA; QPD
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
7
Drug Name
Drug Tier
Requirements / Limits
lamivudine-zidovudine
4
LEXIVA
4
moderiba
4
QPD
moderiba dose pack oral tablets, dose pack
4
QPD
nevirapine
4
NORVIR
4
OLYSIO
4
PREZISTA
4
REBETOL ORAL CAPSULE
4
REBETOL ORAL SOLUTION
4
RELENZA DISKHALER
3
RESCRIPTOR
4
RETROVIR
4
REYATAZ
4
ribapak dose pack oral tablets, dose pack
4
QPD
ribasphere
4
QPD
RIBATAB DOSE PACK
4
QPD
ribavirin
4
QPD
rimantadine
1
SELZENTRY
4
SITAVIG
3
SOVALDI
4
stavudine
4
STRIBILD
4
SUSTIVA
4
TAMIFLU
3
TIVICAY
4
TRIUMEQ
4
TRIZIVIR
4
TRUVADA
4
TYZEKA
4
QPD
valacyclovir
1
QPD
PA
QPD
QPD
PA
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
8
Drug Name
Drug Tier
Requirements / Limits
VALCYTE
2
VALTREX
3
QPD
VICTRELIS
4
PA; QPD
VIDEX
4
VIDEX EC
4
VIRACEPT
4
VIRAMUNE/XR
4
VIREAD
4
ZERIT
4
ZIAGEN
4
zidovudine
4
ZOVIRAX
3
CEPHALOSPORINS
CEDAX
3
cefaclor
1
cefadroxil
1
cefdinir
1
cefditoren pivoxil
1
cefpodoxime
1
cefprozil
1
ceftibuten
1
CEFTIN
3
cefuroxime axetil
1
cephalexin
1
KEFLEX
3
SPECTRACEF
3
SUPRAX
3
ERYTHROMYCINS & OTHER MACROLIDES
azithromycin
1
BIAXIN/XL/PAK
3
clarithromycin
1
DIFICID
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
9
Drug Name
Drug Tier
e.e.s. 400
1
E.E.S. GRANULES
3
ery-tab oral tablet,delayed release (dr/ec) 250 mg,
333 mg
1
ERY-TAB ORAL TABLET,DELAYED
RELEASE (DR/EC) 500 MG
3
ERYPED
3
erythromycin
1
erythromycin-sulfisoxazole
1
PCE
3
ZITHROMAX/TRI-PAK/Z-PAK
3
ZMAX
3
Requirements / Limits
MISCELLANEOUS ANTIINFECTIVES
ALBENZA
2
ALINIA
2
atovaquone
1
atovaquone-proguanil
1
BETHKIS
4
BILTRICIDE
2
CAYSTON
4
chloroquine phosphate
1
CLEOCIN
3
clindamycin hcl
1
clindamycin palmitate hcl
1
COARTEM
3
CYCLOSERINE
3
DAPSONE
2
DARAPRIM
2
ethambutol
1
FLAGYL/ER
3
hydroxychloroquine
1
isonarif
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
10
Drug Name
Drug Tier
Requirements / Limits
isoniazid
1
KETEK
3
MALARONE
3
mebendazole
1
mefloquine
1
MEPRON
2
metronidazole
1
MYAMBUTOL
3
MYCOBUTIN
2
NEBUPENT
2
neomycin
1
paromomycin
1
PASER
3
PLAQUENIL
3
PRIFTIN
3
PRIMAQUINE
2
pyrazinamide
1
QUALAQUIN
3
quinine sulfate
1
rifabutin
1
RIFADIN
3
RIFAMATE
3
rifampin
1
RIFATER
3
SEROMYCIN
2
SIRTURO
4
STROMECTOL
2
TINDAMAX
3
tinidazole
1
TOBI
4
QPD
TOBI PODHALER
4
QPD
tobramycin in 0.225 % nacl
4
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
11
Drug Name
Drug Tier
TRECATOR
3
XIFAXAN
3
YODOXIN
2
ZYVOX
3
Requirements / Limits
QPD
PENICILLINS
amoxicillin oral capsule, suspension, tablet
1
AMOXICILLIN ORAL TABLET, ER
MULTIPHASE 24 HR
3
amoxicillin oral tablet, chewable
1
amoxicillin-pot clavulanate
1
ampicillin
1
AUGMENTIN/XR
3
AUGMENTIN ES-600
3
dicloxacillin
1
MOXATAG
3
penicillin v potassium
1
QUINOLONES
AVELOX
3
CIPRO/XR
3
ciprofloxacin
1
FACTIVE
3
LEVAQUIN
3
levofloxacin
1
moxifloxacin
1
NOROXIN
3
ofloxacin
1
SULFA'S & RELATED AGENTS
BACTRIM/DS
3
SEPTRA DS
3
sulfadiazine
1
sulfamethoxazole-trimethoprim
1
SULFATRIM
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
12
Drug Name
Drug Tier
Requirements / Limits
TETRACYCLINES
ADOXA
3
ST
avidoxy
1
AVIDOXY DK
3
demeclocycline
1
DORYX ORAL TABLET,DELAYED RELEASE
3
doxycycline
1
DYNACIN
3
ST
MINOCIN ORAL CAPSULE
3
ST
minocycline
1
MONODOX
3
morgidox
1
MORGIDOX
3
ocudox
1
ORACEA
3
PERIOSTAT
3
SOLODYN
3
tetracycline
1
VIBRAMYCIN
3
ST
ST
ST
ST
ST
ST
ST
URINARY TRACT AGENTS
FURADANTIN
3
HIPREX
3
MACROBID
3
MACRODANTIN
3
methenamine
1
MONUROL
3
nitrofurantoin
1
nitrofurantoin macrocrystal
1
nitrofurantoin monohyd/m-cryst
1
PRIMSOL
3
trimethoprim
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
13
Drug Name
Drug Tier
Requirements / Limits
VANCOMYCIN
VANCOCIN
3
vancomycin
1
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
4
MESNEX
4
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
AFINITOR
4
QPD
AFINITOR DISPERZ
4
QPD
ALKERAN
4
anastrozole
1
ARIMIDEX
3
AROMASIN
3
ASTAGRAF XL
3
AZASAN
3
azathioprine
1
bicalutamide
1
BOSULIF
4
QPD
CAPRELSA
4
QPD
CASODEX
3
CEENU
2
CELLCEPT ORAL CAPSULE, TABLET
3
CELLCEPT ORAL SUSPENSION
2
COMETRIQ
4
CYCLOPHOSPHAMIDE ORAL CAPSULE
3
cyclophosphamide oral tablet
1
cyclosporine
1
DROXIA
3
EMCYT
2
ERIVEDGE
4
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
14
Drug Name
Drug Tier
Requirements / Limits
exemestane
1
FARESTON
2
FEMARA
3
FIRMAGON
4
flutamide
1
gengraf
1
GILOTRIF
4
GLEEVEC
4
hecoria
1
HEXALEN
4
HYCAMTIN
4
HYDREA
3
hydroxyurea
1
ICLUSIG
4
IMBRUVICA
4
IMURAN
3
INLYTA
4
QPD
IRESSA
4
QPD
JAKAFI
4
QPD
letrozole
1
LEUKERAN
2
LOMUSTINE
4
LYSODREN
4
MATULANE
4
MEGACE
3
MEGACE ES
3
megestrol
1
MEKINIST
4
mercaptopurine
1
methotrexate sodium
4
mycophenolate mofetil
1
mycophenolate sodium
1
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
15
Drug Name
Drug Tier
Requirements / Limits
MYFORTIC
3
MYLERAN
2
NEORAL
2
NEXAVAR
4
NILANDRON
2
POMALYST
4
PROGRAF ORAL CAPSULE
3
PURINETHOL
3
RAPAMUNE
3
REVLIMID
4
RHEUMATREX
3
SANDIMMUNE ORAL CAPSULE
2
SIGNIFOR
4
sirolimus
1
SOLTAMOX
3
SPRYCEL
4
QPD
STIVARGA
4
QPD
SUTENT ORAL CAPSULE
4
QPD
SYNRIBO
4
TABLOID
2
tacrolimus
1
TAFINLAR
4
tamoxifen
$0
TARCEVA
4
TARGRETIN
4
TASIGNA
4
TEMODAR
4
temozolomide
4
THALOMID
4
tretinoin
4
TREXALL
3
TYKERB
4
QPD
QPD
PA; QPD
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
16
Drug Name
Drug Tier
Requirements / Limits
VANDETANIB
4
QPD
VOTRIENT
4
XALKORI
4
XELODA
4
XTANDI
4
QPD
ZELBORAF
4
QPD
ZOLINZA
4
QPD
ZORTRESS
3
QPD
ZYDELIG
4
ZYKADIA
4
ZYTIGA
4
QPD
QPD
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM
3
BANZEL
2
carbamazepine
1
CARBATROL
3
CELONTIN
3
clonazepam
1
DEPAKENE
3
DEPAKOTE/ER/SPRINKLES
3
DIASTAT
3
diazepam
1
DILANTIN
2
divalproex
1
epitol
1
EQUETRO
3
ethosuximide
1
felbamate
1
FELBATOL ORAL SUSPENSION
2
FELBATOL ORAL TABLET
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
17
Drug Name
Drug Tier
Requirements / Limits
FYCOMPA
3
gabapentin
1
GABITRIL
2
GRALISE
3
QPD
GRALISE 30-DAY STARTER PACK
3
QPD
KEPPRA/XR
3
KLONOPIN
3
LAMICTAL
3
LAMICTAL ODT
3
LAMICTAL STARTER
3
LAMICTAL XR
3
lamotrigine
1
levetiracetam
1
LYRICA
3
MYSOLINE
3
NEURONTIN
3
ONFI
2
oxcarbazepine
1
OXTELLAR XR
3
PEGANONE
3
phenobarbital
1
PHENYTEK
3
phenytoin
1
POTIGA
3
primidone
1
QUDEXY XR
3
SABRIL
4
STAVZOR
3
TEGRETOL/XR
2
tiagabine
1
TOPAMAX
3
topiragen
1
QPD
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
18
Drug Name
Drug Tier
topiramate oral capsule, sprinkle
1
TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER 24HR
3
topiramate oral tablet
1
TRILEPTAL
3
TROKENDI XR
3
valproic acid
1
valproic acid (as sodium salt)
1
VIMPAT
3
ZARONTIN
3
ZONEGRAN
3
zonisamide
1
Requirements / Limits
ANTIPARKINSONISM AGENTS
APOKYN
4
AZILECT
2
benztropine
1
bromocriptine
1
carbidopa
1
carbidopa-levodopa
1
carbidopa-levodopa-entacapone
1
COMTAN
3
ELDEPRYL
3
entacapone
1
LODOSYN
3
MIRAPEX
3
MIRAPEX ER
3
NEUPRO
3
PARCOPA
3
PARLODEL
3
pramipexole
1
REQUIP
3
REQUIP XL
3
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
19
Drug Name
Drug Tier
ropinirole oral tablet
1
ropinirole oral tablet extended release 24 hr
1
selegiline hcl
1
SINEMET/CR
3
STALEVO
3
TASMAR
3
trihexyphenidyl
1
ZELAPAR
3
Requirements / Limits
QPD
MIGRAINE & CLUSTER HEADACHE THERAPY
ALSUMA
3
ST; QPD
AMERGE
3
ST; QPD
AXERT
3
ST; QPD
CAFERGOT
3
dihydroergotamine
1
ERGOMAR
2
ergotamine-caffeine
1
FROVA
3
ST; QPD
IMITREX
3
ST; QPD
isomethepten-caf-acetaminophen
1
MAXALT/MLT
3
migergot
1
migragesic ida
1
MIGRALAM
3
MIGRANAL
3
QPD
naratriptan
1
QPD
nodolor
1
PRODRIN
3
RELPAX
3
ST; QPD
rizatriptan
1
QPD
sumatriptan
1
QPD
SUMAVEL DOSEPRO
3
ST; QPD
TREXIMET
3
ST; QPD
QPD
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
20
Drug Name
Drug Tier
Requirements / Limits
zolmitriptan
1
QPD
ZOMIG NASAL SPRAY,NON-AEROSOL 2.5
MG
3
ST
ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG
2
ST; QPD
ZOMIG ORAL/ZMT
3
ST; QPD
AMPYRA
4
PA; QPD
ARICEPT ORAL TABLET 10 MG, 5 MG
3
QPD
ARICEPT ORAL TABLET 23 MG
2
QPD
ARICEPT ODT
3
QPD
AUBAGIO
4
QPD
COPAXONE SUBCUTANEOUS SYRINGE
4
QPD
donepezil
1
QPD
EXELON ORAL CAPSULE
3
QPD
EXELON ORAL SOLUTION
2
EXELON TRANSDERMAL
2
QPD
galantamine oral capsule,ext rel. pellets 24 hr
1
QPD
galantamine oral solution
1
galantamine oral tablet
1
QPD
GILENYA
4
QPD
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG
3
HORIZANT ORAL TABLET EXTENDED
RELEASE 600 MG
3
MYTELASE
3
NAMENDA ORAL SOLUTION
3
NAMENDA ORAL TABLET
2
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK
2
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
2
NUEDEXTA
2
RAZADYNE ORAL SOLUTION
3
MISCELLANEOUS NEUROLOGICAL THERAPY
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
21
Drug Name
Drug Tier
Requirements / Limits
RAZADYNE ORAL TABLET
3
QPD
RAZADYNE ER
3
QPD
rivastigmine tartrate
1
QPD
TECFIDERA
4
QPD
XENAZINE
4
PA
MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
AMRIX
3
baclofen
1
carisoprodol
1
carisoprodol-asa-codeine
1
carisoprodol-aspirin
1
chlorzoxazone
1
cyclobenzaprine
1
DANTRIUM
2
dantrolene
1
FEXMID
3
FLEXERIL
3
LORZONE
3
meprobamate
1
MESTINON ORAL SYRUP
2
MESTINON ORAL TABLET
3
MESTINON TIMESPAN
2
metaxalone
1
methocarbamol
1
orphenadrine citrate
1
orphenadrine compound
1
orphenadrine compound-ds
1
PARAFON FORTE DSC
3
PROSTIGMIN
2
pyridostigmine bromide
1
ROBAXIN
3
SKELAXIN
3
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
22
Drug Name
Drug Tier
SOMA
3
tizanidine
1
ZANAFLEX
3
Requirements / Limits
QPD
NARCOTIC ANALGESICS
ABSTRAL
3
acetaminophen-codeine
1
ACTIQ
3
alagesic lq
1
ascomp with codeine
1
AVINZA
3
BUPAP ORAL TABLET 50-300 MG
3
bupap oral tablet 50-650 mg
1
buprenorphine hcl
1
butalbital compound
1
butalbital compound w/codeine
1
butalbital-acetaminop-caf-cod
1
butalbital-acetaminophen
1
butalbital-acetaminophen-caff
1
butalbital-aspirin-caffeine
1
BUTRANS TRANSDERMAL PATCH WEEKLY
3
capacet
1
CAPITAL WITH CODEINE
3
cephadyn
1
co-gesic
1
cocet
1
COCET PLUS
3
CODEINE SULFATE ORAL SOLUTION
3
codeine sulfate oral tablet
1
DEMEROL
3
dihydrocode-acetaminophen-caff
1
dihydrocodeine-aspirin-caff
1
DILAUDID
3
PA; QPD
PA; QPD
ST; QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
23
Drug Name
Drug Tier
Requirements / Limits
diskets
1
DOLGIC PLUS
3
DOLOPHINE ORAL TABLET 10 MG
3
DOLOPHINE ORAL TABLET 5 MG
2
DURAGESIC
3
endocet
1
endodan
1
ESGIC
3
ESGIC-PLUS
3
EXALGO ER
3
ST; QPD
fentanyl citrate
1
PA; QPD
fentanyl patches
1
FENTORA
3
FIORICET
3
FIORICET WITH CODEINE
3
FIORINAL
3
FIORINAL-CODEINE #3
3
HYCET
3
hydrocodone-acetaminophen oral capsule
1
hydrocodone-acetaminophen oral solution 5-163
mg/7.5ml(7.5ml), 7.5-500 mg/15 ml
1
HYDROCODONE-ACETAMINOPHEN ORAL
SOLUTION 7.5-325 MG/15 ML
3
hydrocodone-acetaminophen oral tablet
1
hydrocodone-ibuprofen
1
hydromorphone oral liquid, tablet
1
hydromorphone oral tablet extended release 24 hr
1
IBUDONE
3
ibuprofen-oxycodone
1
KADIAN
3
ST; QPD
LAZANDA
3
PA; QPD
levorphanol tartrate
1
PA; QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
24
Drug Name
Drug Tier
Requirements / Limits
lorcet (hydrocodone)
1
LORCET 10/650
3
lorcet hd
1
lorcet plus oral tablet 7.5-325 mg
1
LORCET PLUS ORAL TABLET 7.5-650 MG
3
LORTAB
3
lortab 10-325
1
LORTAB ELIXIR
3
MAGNACET
3
margesic
1
marten-tab
1
MAXIDONE
3
meperidine
1
meperitab
1
methadone
1
methadone intensol
1
methadose
1
morphine oral capsule, er multiphase 24 hr
1
morphine oral capsule, solution, tablet, extended
relsease
1
MS CONTIN
3
NORCO
3
NUCYNTA
3
ST
NUCYNTA ER
3
ST; QPD
ONSOLIS
3
PA; QPD
OPANA
3
OPANA ER
3
ST; QPD
ORAMORPH SR
3
ST; QPD
ORBIVAN
3
OXECTA
3
oxycodone
1
oxycodone hcl-oxycodone-asa
1
QPD
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
25
Drug Name
Drug Tier
oxycodone-acetaminophen
1
oxycodone-aspirin
1
OXYCONTIN
3
oxymorphone oral tablet
1
oxymorphone oral tablet extended release 12 hr
1
PERCOCET
3
PERCODAN
3
PHRENILIN FORTE
3
PRIMLEV
3
promacet
1
repan
1
reprexain
1
ROXICET ORAL SOLUTION
3
roxicet oral tablet
1
ROXICODONE ORAL TABLET 15 MG, 30 MG
3
ROXICODONE ORAL TABLET 5 MG
2
stagesic
1
SUBSYS
3
SUBUTEX
3
SYNALGOS-DC
3
tencon
1
trezix
1
TYLENOL-CODEINE #3
3
TYLENOL-CODEINE #4
3
TYLOX
3
vicodin oral tablet 5-300 mg
1
VICODIN ORAL TABLET 5-500 MG
3
vicodin es oral tablet 7.5-300 mg
1
VICODIN ES ORAL TABLET 7.5-750 MG
3
vicodin hp oral tablet 10-300 mg
1
VICODIN HP ORAL TABLET 10-660 MG
3
VICOPROFEN
3
Requirements / Limits
ST; QPD
QPD
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
26
Drug Name
Drug Tier
XARTEMIS XR
3
XODOL
3
xolox
1
zamicet
1
zebutal
1
ZOHYDRO ER
3
ZOLVIT
3
ZYDONE
3
Requirements / Limits
ST
NON-NARCOTIC ANALGESICS
anabar
1
ANAPROX/DS
3
ST
ANSAID
3
ST
ARTHROTEC
3
ST
aspirin oral buffered, chewable, low dose
$0
BUNAVAIL
3
PA; QPD
buprenorphine-naloxone
1
PA
butorphanol tartrate
1
QPD
CAMBIA
3
ST; QPD
CATAFLAM
3
ST
CELEBREX
3
ST; QPD
children's aspirin
$0
choline,magnesium salicylate
1
choline-mag trisalicylate
1
CLINORIL
3
CONZIP
3
DAYPRO
3
depade
1
diclofenac potassium
1
diclofenac sodium
1
diclofenac-misoprostol
1
diflunisal
1
DOLOGESIC
3
ST
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
27
Drug Name
Drug Tier
Requirements / Limits
DUEXIS
3
ST; QPD
duraxin
1
e.c. prin
$0
EC-NAPROSYN
3
ecotrin
$0
ecotrin low strength
$0
ENOVARX-IBUPROFEN
3
enteric coated aspirin
$0
etodolac
1
FELDENE
3
ST
FENOPROFEN ORAL CAPSULE
3
ST
fenoprofen oral tablet
1
FLECTOR
3
flurbiprofen
1
FRENADOL
3
halfprin
$0
ibuprofen
1
INDOCIN
3
indomethacin
1
ketoprofen
1
ketorolac
1
levacet
1
meclofenamate
1
mefenamic acid
1
meloxicam
1
miniprin
$0
MOBIC
3
mst 600
1
nabumetone
1
NALFON
3
naltrexone
1
NAPRELAN CR
3
ST
ST; QPD
ST
QPD
QPD
ST; QPD
ST
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
28
Drug Name
Drug Tier
Requirements / Limits
NAPROSYN
3
naproxen
1
novagesic
1
oxaprozin
1
PENNSAID
3
pentazocine-acetaminophen
1
pentazocine-naloxone
1
piroxicam
1
PONSTEL
3
RELAGESIC
3
REVIA
3
rhinoflex-650
1
RYBIX ODT
3
RYZOLT
3
salsalate
1
SPRIX
3
ST; QPD
SUBOXONE SUBLINGUAL FILM
2
PA
SUBOXONE SUBLINGUAL TABLET
3
PA
sulindac
1
tolmetin
1
TRAMADOL ORAL CAPSULE,ER BIPHASE
24 HR 25-75
3
tramadol oral tablet
1
tramadol-acetaminophen
1
tri-buffered aspirin
$0
ULTRACET
3
ULTRAM/ER
3
VIMOVO
3
ST; QPD
VOLTAREN GEL TOPICAL GEL 1 %
3
ST
VOLTAREN-XR
3
ST
zflex
1
zgesic
1
ST
ST; QPD
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
29
Drug Name
Drug Tier
Requirements / Limits
ZIPSOR
3
ST
ZORVOLEX
3
ST
ZUBSOLV
3
PA
PSYCHOTHERAPEUTIC DRUGS
ABILIFY ORAL SOLUTION
2
ABILIFY ORAL TABLET
2
QPD
ABILIFY DISCMELT
2
QPD
ADASUVE
3
ADDERALL/XR
3
alprazolam
1
alprazolam intensol
1
AMBIEN/CR
3
amitriptyline
1
amitriptyline-chlordiazepoxide
1
amoxapine
1
amphetamine salt combo
1
ANAFRANIL
3
APLENZIN
3
ATIVAN
3
BRINTELLIX
3
ST
BRISDELLE
3
QPD
budeprion sr
1
QPD
budeprion xl
1
QPD
bupropion hcl oral tablet
1
bupropion hcl oral tablet extended release
1
buspirone
1
BUTISOL ORAL ELIXIR
3
BUTISOL ORAL TABLET
3
QPD
CELEXA
3
ST; QPD
chloral hydrate
1
chlordiazepoxide hcl
1
chlorpromazine
1
ST; QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
30
Drug Name
Drug Tier
Requirements / Limits
citalopram oral solution
1
citalopram oral tablet
1
clomipramine
1
clonidine hcl
1
clorazepate dipotassium
1
clozapine
1
CLOZARIL
3
CONCERTA
3
CYMBALTA
3
QPD
DAYTRANA
3
QPD
desipramine
1
DESOXYN
3
DESVENLAFAXINE
3
ST
DESVENLAFAXINE FUMARATE
3
ST; QPD
dexedrine
1
DEXEDRINE SPANSULE
3
dexmethylphenidate
1
dextroamphetamine
1
dextroamphetamine-amphetamine
1
diazepam
1
diazepam intensol
1
DORAL
3
doxepin
1
duloxetine
1
QPD
EDLUAR
3
ST; QPD
EFFEXOR XR
3
ST; QPD
EMSAM
3
QPD
ergoloid
1
escitalopram oxalate oral solution
1
escitalopram oxalate oral tablet
1
QPD
estazolam
1
QPD
eszopiclone
1
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
31
Drug Name
Drug Tier
Requirements / Limits
FANAPT
3
FAZACLO
3
FETZIMA
3
ST
fluoxetine oral capsule
1
QPD
fluoxetine oral capsule,delayed release(dr/ec)
1
QPD
fluoxetine oral solution
1
fluoxetine oral tablet 10 mg, 20 mg
1
QPD
FLUOXETINE ORAL TABLET 60 MG
2
ST; QPD
fluphenazine hcl
1
flurazepam
1
QPD
fluvoxamine
1
QPD
FOCALIN
3
FOCALIN XR
2
FORFIVO XL
3
GEODON
3
guanidine
1
HALCION
3
haloperidol
1
haloperidol decanoate
1
haloperidol lactate
1
HETLIOZ
4
imipramine hcl
1
imipramine pamoate
1
INTERMEZZO
3
ST; QPD
INTUNIV ER
3
QPD
INVEGA ORAL TABLET
3
QPD
KAPVAY
3
KHEDEZLA
3
ST
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 80 MG
2
QPD
LATUDA ORAL TABLET 60 MG
2
LEXAPRO
3
QPD
QPD
PA; QPD
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
32
Drug Name
Drug Tier
Requirements / Limits
lithium
1
LITHOBID
3
lorazepam
1
lorazepam intensol
1
loxapine succinate
1
LOXITANE
3
LUNESTA
3
ST; QPD
LUVOX CR
3
ST; QPD
maprotiline
1
MARPLAN
3
METADATE CD
3
metadate er
1
methamphetamine
1
METHYLIN
3
methylphenidate
1
mirtazapine oral tablet, disintegrating
1
MOBAN
3
modafinil
1
NARDIL
3
nefazodone
1
NIRAVAM
3
NORPRAMIN
3
nortriptyline
1
NUVIGIL ORAL TABLET
3
PA; QPD
olanzapine
1
QPD
olanzapine-fluoxetine
1
OLEPTRO ER
3
ORAP
2
oxazepam
1
PAMELOR
3
PARNATE
3
paroxetine/cr
1
QPD
PA
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
33
Drug Name
Drug Tier
Requirements / Limits
PAXIL ORAL SUSPENSION
2
ST; QPD
PAXIL ORAL TABLET
3
ST; QPD
PAXIL CR
3
ST; QPD
perphenazine
1
perphenazine-amitriptyline
1
PEXEVA
3
phenelzine
1
PRISTIQ
3
procentra
1
protriptyline
1
PROVIGIL
3
PA
PROZAC
3
ST; QPD
PROZAC WEEKLY
3
ST; QPD
quazepam
1
QPD
quetiapine oral tablet 100 mg, 50 mg
1
PA; QPD
quetiapine oral tablet 200 mg, 25 mg, 300 mg, 400
mg
1
QPD
QUILLIVANT XR
3
QPD
REMERON
3
QPD
RESTORIL
3
QPD
RISPERDAL
3
risperidone
1
RITALIN/LA/SR
3
ROZEREM
3
ST; QPD
SAPHRIS
3
QPD
SARAFEM
3
ST; QPD
seconal sodium
1
SEROQUEL ORAL TABLET 25 MG, 100 MG,
50 MG
3
PA; QPD
SEROQUEL ORAL TABLET 200 MG, 300 MG,
400 MG
3
QPD
SEROQUEL XR
2
QPD
sertraline oral concentrate
1
ST; QPD
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
34
Drug Name
Drug Tier
Requirements / Limits
sertraline oral tablet
1
QPD
SILENOR
3
ST; QPD
SOMNOTE
3
QPD
SONATA
3
ST; QPD
STRATTERA
3
SURMONTIL
3
SYMBYAX
3
temazepam
1
thioridazine
1
thiothixene
1
TOFRANIL
3
TRANXENE T-TAB
3
tranylcypromine
1
trazodone
1
triazolam
1
trifluoperazine
1
trimipramine
1
VALIUM
3
venlafaxine oral capsule,extended release 24hr
1
QPD
venlafaxine oral tablet
1
QPD
VENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24HR
3
ST; QPD
VERSACLOZ
4
VIIBRYD
3
VIVACTIL
3
VYVANSE
2
WELLBUTRIN
3
WELLBUTRIN SR/XL
3
XANAX/XR
3
XYREM
4
zaleplon
1
zenzedi oral tablet 10 mg, 5 mg
1
QPD
QPD
ST; QPD
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
35
Drug Name
Drug Tier
Requirements / Limits
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 7.5
MG
3
ziprasidone hcl
1
QPD
ZOLOFT
3
ST; QPD
zolpidem/er
1
QPD
ZOLPIMIST
3
ST; QPD
ZYPREXA ORAL TABLET
3
QPD
ZYPREXA ZYDIS
3
QPD
ZYPREXA RELPREVV
4
QPD
CARDIOVASCULAR, HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone
1
BETAPACE
3
CORDARONE
3
disopyramide phosphate
1
flecainide
1
mexiletine
1
MULTAQ
3
NORPACE/CR
3
pacerone
1
propafenone
1
quinidine gluconate
1
quinidine sulfate
1
RYTHMOL/SR
3
sotalol
1
TAMBOCOR
3
TIKOSYN
3
ANTIHYPERTENSIVE THERAPY
ACCUPRIL
3
ST; QPD
ACCURETIC
3
ST
acebutolol
1
ACEON
3
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
36
Drug Name
Drug Tier
Requirements / Limits
ADALAT CC
3
afeditab cr
1
ALDACTAZIDE
3
ALDACTONE
3
ALTACE
3
amiloride
1
amiloride-hydrochlorothiazide
1
amlodipine
1
amlodipine-benazepril
1
AMTURNIDE
3
ST; QPD
ATACAND
3
ST; QPD
ATACAND HCT
3
ST
atenolol
1
QPD
atenolol-chlorthalidone
1
AVALIDE
3
ST
AVAPRO
3
ST; QPD
AZOR
2
ST; QPD
benazepril
1
QPD
benazepril-hydrochlorothiazide
1
BENICAR
2
ST; QPD
BENICAR HCT
2
ST
betaxolol
1
BIDIL
3
bisoprolol fumarate
1
bisoprolol-hydrochlorothiazide
1
bumetanide
1
BYSTOLIC
3
CALAN
3
CALAN SR
3
candesartan
1
candesartan-hydrochlorothiazid
1
captopril
1
ST; QPD
ST
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
37
Drug Name
Drug Tier
Requirements / Limits
captopril-hydrochlorothiazide
1
CARDENE SR
3
CARDIZEM
3
CARDIZEM CD
3
CARDIZEM LA
3
CARDURA
3
QPD
CARDURA XL
3
QPD
cartia xt
1
carvedilol
1
CATAPRES
3
CATAPRES-TTS
3
chlorothiazide
1
chlorthalidone
1
clonidine
1
clonidine hcl
1
clorpres oral tablet 0.1-15 mg, 0.2-15 mg
1
CLORPRES ORAL TABLET 0.3-15 MG
3
COREG
3
ST; QPD
COREG CR
3
ST; QPD
CORGARD
3
ST; QPD
CORZIDE
3
ST; QPD
COVERA-HS
3
COZAAR
3
DEMADEX
3
DEMSER
2
DIBENZYLINE
2
DILACOR XR
3
dilt-cd
1
dilt-xr
1
diltia xt
1
diltiazem hcl
1
diltzac er
1
QPD
QPD
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
38
Drug Name
Drug Tier
Requirements / Limits
DIOVAN
3
ST; QPD
DIOVAN HCT
3
ST
DIURIL
3
doxazosin
1
QPD
DUTOPROL
3
ST; QPD
DYAZIDE
3
DYNACIRC CR
3
DYRENIUM
3
EDARBI
3
PA; QPD
EDARBYCLOR
3
PA; QPD
EDECRIN
2
enalapril maleate
1
enalapril-hydrochlorothiazide
1
EPANED
3
eplerenone
1
eprosartan
1
QPD
EXFORGE
3
ST; QPD
EXFORGE HCT
2
ST; QPD
felodipine
1
fosinopril
1
fosinopril-hydrochlorothiazide
1
furosemide oral solution
1
furosemide oral tablet
1
guanfacine
1
hydralazine
1
hydrochlorothiazide oral capsule
1
hydrochlorothiazide oral tablet 12.5 mg
1
hydrochlorothiazide oral tablet 25 mg, 50 mg
1
QPD
HYZAAR
3
ST
indapamide
1
INDERAL LA/XL
3
ST
INNOPRAN XL
3
ST
QPD
ST
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
39
Drug Name
Drug Tier
Requirements / Limits
INSPRA
3
irbesartan
1
irbesartan-hydrochlorothiazide
1
isradipine
1
KERLONE
3
labetalol
1
LASIX
3
LEVATOL
3
ST
lisinopril
1
QPD
lisinopril-hydrochlorothiazide
1
QPD
LOPRESSOR
3
ST; QPD
LOPRESSOR-HCT
3
ST
losartan
1
QPD
losartan-hydrochlorothiazide
1
LOTENSIN
3
ST; QPD
LOTENSIN-HCT
3
ST
LOTREL
3
ST
matzim la
1
MAVIK
3
MAXZIDE
3
MAXZIDE-25MG
3
methyclothiazide
1
methyldopa
1
methyldopa-hydrochlorothiazide
1
metolazone
1
metoprolol succinate
1
metoprolol ta-hydrochlorothiaz
1
metoprolol tartrate
1
QPD
MICARDIS
3
ST; QPD
MICARDIS HCT
3
ST
MICROZIDE
2
MIDAMOR
3
QPD
ST
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
40
Drug Name
Drug Tier
Requirements / Limits
MINIPRESS
3
minoxidil
1
moexipril
1
moexipril-hydrochlorothiazide
1
nadolol
1
nadolol-bendroflumethiazide
1
NEXICLON XR
3
nicardipine
1
nifediac cc
1
nifedical xl
1
nifedipine
1
nimodipine
1
nisoldipine
1
NORVASC
3
NYMALIZE
3
ORENITRAM
4
papaverine
1
perindopril erbumine
1
pindolol
1
prazosin
1
QPD
PRINIVIL
3
ST; QPD
PRINZIDE
3
ST
PROCARDIA
3
PROCARDIA XL
3
propranolol
1
propranolol-hydrochlorothiazid
1
quinapril
1
quinapril-hydrochlorothiazide
1
ramipril
1
reserpine
1
SECTRAL
3
spironolacton-hydrochlorothiaz
1
QPD
PA
QPD
QPD
QPD
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
41
Drug Name
Drug Tier
Requirements / Limits
spironolactone
1
SULAR
3
TARKA
3
taztia xt
1
TEKAMLO
3
ST; QPD
TEKTURNA
3
ST; QPD
TEKTURNA HCT
3
ST
telmisartan
1
QPD
telmisartan-amlodipine
1
QPD
telmisartan-hydrochlorothiazide
1
TENEX
3
TENORETIC
3
ST
TENORMIN
3
ST
terazosin
1
QPD
TEVETEN
3
ST; QPD
TEVETEN HCT
3
ST
THALITONE
3
TIAZAC
3
timolol maleate
1
TOPROL XL
3
torsemide
1
TRANDATE
3
ST
trandolapril
1
QPD
trandolapril-verapamil
1
triamterene-hydrochlorothiazide
1
QPD
TRIBENZOR
2
ST; QPD
TWYNSTA
3
ST; QPD
UNIRETIC
3
ST
UNIVASC
3
ST; QPD
valsartan
1
QPD
valsartan-hydrochlorothiazide
1
VALTURNA
3
ST
ST
ST; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
42
Drug Name
Drug Tier
Requirements / Limits
VASERETIC
3
ST
VASOTEC
3
ST; QPD
verapamil
1
VERELAN
3
VERELAN PM
3
ZAROXOLYN
3
ZEBETA
3
ST
ZESTORETIC
3
ST
ZESTRIL
3
ST; QPD
ZIAC
3
ST
CARDIAC GLYCOSIDES
digox
1
digoxin
1
LANOXIN ORAL TABLET 125 MCG, 250 MCG
2
LANOXIN ORAL TABLET 187.5 MCG, 62.5
MCG
3
COAGULATION THERAPY
AGGRENOX
2
QPD
AMICAR
3
aminocaproic acid oral solution
1
AMINOCAPROIC ACID ORAL TABLET 1,000
MG
3
aminocaproic acid oral tablet 500 mg
1
ARIXTRA
2
BRILINTA
2
QPD
cilostazol
1
QPD
clopidogrel
1
QPD
COUMADIN
2
dipyridamole
1
EFFIENT
2
QPD
ELIQUIS
2
QPD
enoxaparin
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
43
Drug Name
Drug Tier
Requirements / Limits
fondaparinux
1
FRAGMIN
3
IPRIVASK
3
jantoven
1
LOVENOX
3
MEPHYTON
3
pentoxifylline
1
PERSANTINE
3
PLAVIX
3
QPD
PLETAL
3
QPD
PRADAXA
2
QPD
PROMACTA
4
RECOTHROM
3
TACHOSIL
3
THROMBIN-JMI
3
ticlopidine
1
TISSEEL VHSD
3
TRENTAL
3
warfarin
1
XARELTO
2
ZONTIVITY
3
QPD
QPD
LIPID/CHOLESTEROL LOWERING AGENTS
ADVICOR
3
ST; QPD
ALTOPREV
3
ST; QPD
amlodipine-atorvastatin
1
QPD
ANTARA
3
atorvastatin
1
QPD
CADUET
3
ST; QPD
cholestyramine (with sugar)
1
cholestyramine light
1
COLESTID ORAL GRANULES/PACKET
2
COLESTID ORAL TABLET
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
44
Drug Name
Drug Tier
Requirements / Limits
colestipol
1
CRESTOR
2
FENOFIBRATE ORAL CAPSULE
3
fenofibrate
1
fenofibric acid
1
fenofibric acid (choline)
1
FENOGLIDE
3
FIBRICOR
3
fluvastatin
1
gemfibrozil
1
JUXTAPID
4
PA; QPD
KYNAMRO
4
PA; QPD
LESCOL
3
ST; QPD
LESCOL XL
3
ST; QPD
LIPITOR
3
ST; QPD
LIPOFEN
3
LIPTRUZET
3
ST; QPD
LIVALO
3
ST; QPD
LOFIBRA
3
LOPID
3
lovastatin
1
QPD
LOVAZA
3
PA
MEVACOR
3
ST; QPD
niacin
1
NIACOR
3
NIASPAN EXTENDED-RELEASE
2
PRAVACHOL
3
ST; QPD
pravastatin
1
QPD
prevalite
1
QUESTRAN/LIGHT
3
SIMCOR
3
ST; QPD
simvastatin
1
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
45
Drug Name
Drug Tier
Requirements / Limits
TRICOR
3
TRIGLIDE
3
TRILIPIX
2
VASCEPA
3
PA; QPD
VYTORIN
3
ST; QPD
WELCHOL
2
ZETIA
2
QPD
ZOCOR
3
ST; QPD
MISCELLANEOUS CARDIOVASCULAR AGENTS
RANEXA
3
NITRATES
DILATRATE-SR
3
IMDUR
3
ISOCHRON
3
ISORDIL
3
isosorbide dinitrate
1
isosorbide mononitrate
1
MINITRAN
3
MONOKET
3
nitro-bid
1
NITRO-DUR
2
nitroglycerin
1
NITROLINGUAL
3
NITROMIST
3
NITROSTAT
3
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin
1
calcipotriene
1
calcitrene
1
calcitriol
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
46
Drug Name
Drug Tier
CLOBETASOL-COAL TAR
3
COAL TAR
3
DOVONEX TOPICAL CREAM
2
DOVONEX TOPICAL SOLUTION
3
DRITHO-SCALP
2
drithocreme hp
1
EPIFOAM
3
hydrocortisone-pramoxine
1
OVACE
3
OVACE PLUS/SHAMPOO/WASH
3
PRAMOSONE/E
3
seb-prev
1
selenium sulfide
1
SELRX
3
SORIATANE
3
SORILUX
3
STELARA
4
sulfacetamide sodium
1
sulfacetamide sodium-urea
1
TACLONEX
3
TERSI FOAM
3
VECTICAL
3
ZITHRANOL
3
ZITHRANOL-RR
3
Requirements / Limits
ST
ST
PA; QPD
BURN THERAPY
SILVADENE
3
silver sulfadiazine
1
ssd
1
thermazene
1
KERATOLYTICS
aliclen
1
BENSAL HP
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
47
Drug Name
Drug Tier
Requirements / Limits
DURASAL
3
INOVA 4-1
3
ST
INOVA 8-2
3
ST
KERALYT RX
3
KERALYT SCALP COMPLETE
3
PODOCON
3
POTASSIUM HYDROXIDE
3
salacyn
1
SALEX
3
salicylic acid
1
salicylic acid sr-ceramides
1
SALKERA
3
salvax
1
SALVAX DUO PLUS
3
VIRASAL
3
MISCELLANEOUS DERMATOLOGICALS
8-MOP
4
ALDARA
3
ALUVEA
3
ARTISS
3
ASTRINGYN
3
benzoin (bulk)
1
CARAC
2
CARMOL HC
3
cem-urea
1
CONDYLOX TOPICAL GEL
2
CONDYLOX TOPICAL SOLUTION
3
CORTANE-B
3
DERMASORB XM COMPLETE KIT
3
diclofenac sodium
1
DRYSOL DAB-O-MATIC
3
EFUDEX
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
48
Drug Name
Drug Tier
ELIDEL
3
ENOVARX-AMITRIPTYLINE
3
ENOVARX-CYCLOBENZAPRINE
3
FLUOROPLEX
3
fluorouracil
1
GORDONS UREA
3
HYDRO
3
hypercare
1
imiquimod
1
IODOFLEX
3
IODOSORB
3
KERAFOAM
3
KEROL
3
LEVULAN
3
METVIXIA
3
MONSEL'S
3
OXSORALEN
4
OXSORALEN ULTRA
4
PANRETIN
4
PICATO
3
podofilox
1
PROTOPIC
3
prudoxin
1
PYROGALLIC ACID
3
REGRANEX
3
remeven
1
silver nitrate
1
SOLARAZE
2
tl 45% urea
1
tri-chlor
1
U-CORT
3
UMECTA TOPICAL EMULSION
3
Requirements / Limits
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
49
Drug Name
Drug Tier
Requirements / Limits
umecta topical foam
1
UMECTA PD
3
URAMAXIN
3
URAMAXIN GT
3
urea
1
UTOPIC
3
VALCHLOR
4
VENELEX
3
VEREGEN
3
XERAC AC
3
ZONALON
3
ZYCLARA TOPICAL CREAM
3
QPD
ABSORICA ORAL CAPSULE
3
ST
ACANYA
2
ST
ACZONE
3
ST
adapalene
1
AKNE-MYCIN
3
amnesteem
1
ATRALIN
3
avar topical cleanser
1
AVAR
3
ST
AVAR LS TOPICAL CLEANSER
3
ST
AVAR LS TOPICAL PADS, MEDICATED
3
ST
avita topical cream
1
PA
AVITA TOPICAL GEL
3
PA
AZELEX
2
ST
BENZAC AC
3
ST
BENZAC WASH
3
ST
BENZACLIN/PUMP
3
ST
BENZAMYCIN
3
ST
BENZAMYCINPAK
3
ST
QPD
THERAPY FOR ACNE
ST
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
50
Drug Name
Drug Tier
Requirements / Limits
BENZEFOAM/ULTRA
3
ST
benzepro
1
BENZIQ/LS
3
benzoyl peroxide
1
bp foam, wash
1
BP WASH TOPICAL CLEANSER 2.5 %, 7 %
3
bp wash acne treatment
1
bpo
1
cerisa
1
claravis
1
CLARIFOAM EF
3
claris clarifying wash
1
CLENIA EMOLLIENT
3
clenia foaming wash
1
CLEOCIN T
3
clinda-derm
1
CLINDACIN ETZ
3
clindacin p
3
CLINDACIN PAC
3
ST
CLINDAGEL
3
ST
clindamycin phosphate
1
clindamycin-benzoyl peroxide
1
CLINDAREACH
3
desquam-x
1
DIFFERIN
3
DUAC
3
emgel
1
EPIDUO
3
ery pads
1
erygel
1
erythromycin with ethanol
1
erythromycin-benzoyl peroxide
1
ST
ST
ST
ST
ST
ST
ST
ST
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
51
Drug Name
Drug Tier
Requirements / Limits
EVOCLIN
3
FABIOR
3
FINACEA
2
FINACEA PLUS
3
INOVA
3
lavoclen-4
1
METROCREAM
3
METROGEL
2
METROGEL KIT
2
METROLOTION
3
metronidazole
1
MIRVASO
3
myorisan
1
NEOBENZ MICRO CREAM PLUS PACK
3
NEUAC KIT
3
NORITATE
3
NUOX
3
ST
PACNEX
3
ST
PLEXION
3
ST
prascion
1
RETIN-A
3
PA
RETIN-A MICRO
3
PA
RIAX
3
ST
rosadan topical cream
3
rosadan topical gel
3
ROSADAN TOPICAL KIT
3
ST
ROSANIL
3
ST
se 10-5 ss
1
se bpo topical kit, cleanser and cream
1
sss 10-5
1
sulfacetamide sod-sulfur-urea topical cleanser
1
ST
ST
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
52
Drug Name
Drug Tier
Requirements / Limits
SULFACETAMIDE SOD-SULFUR-UREA
TOPICAL GEL
3
ST
sulfacetamide sodium-sulfur topical cleanser 10-2
%
1
QPD
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w), 9-4 %, 9-4.5 %
1
sulfacetamide sodium-sulfur topical cream, pads,
suspension
1
SUMADAN
3
ST
SUMAXIN
3
ST
TAZORAC
3
TRETIN-X
3
PA
tretinoin capsule
4
PA
TRIAZ CLEANSER
3
ST
VANOXIDE-HC
3
VELTIN
3
vitazol
1
zenatane
1
zencia
1
ZIANA
2
PA; ST
PA; ST
TOPICAL ANESTHETICS
AMERICAINE ANESTHETIC
3
ANACAINE
3
CETACAINE
3
cocaine
1
EMLA
3
exactacain
1
LETS KIT
3
lidocaine topical adhesive patch, medicated
1
lidocaine topical ointment
1
lidocaine hcl
1
lidocaine viscous
1
lidocaine-prilocaine
1
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
53
Drug Name
Drug Tier
LIDODERM
3
LIDORX
3
NOVACORT
3
PONTOCAINE
3
SYNERA
3
XYLOCAINE
3
XYLOCAINE JELLY
3
Requirements / Limits
PA
QPD
TOPICAL ANTIBACTERIALS
ALCORTIN A
3
ALOQUIN
3
ALTABAX
3
BACTROBAN
3
CENTANY
3
CORTISPORIN
3
DERMASORB AF COMPLETE KIT
3
dermazene
1
gentamicin
1
hydro-iodoquinol 2-1
1
iodoquinol-hc
1
KLARON
3
lugols
1
mafenide acetate
1
mupirocin
1
PHISOHEX
3
sulfacetamide sodium (acne)
1
SULFAMYLON
3
VYTONE
3
ST
TOPICAL ANTIFUNGALS
ALA-QUIN
3
ciclodan
3
CICLODAN KIT
3
ciclopirox
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
54
Drug Name
Drug Tier
ciclopirox-vite-nail lacq remo
1
clotrimazole
1
clotrimazole-betamethasone
1
CNL 8 NAIL
3
econazole
1
ECOZA
3
ERTACZO
3
EXELDERM
3
EXODERM
3
EXTINA
3
JUBLIA
3
ketoconazole
1
ketodan
1
LAMISIL
3
LOPROX
3
LOTRISONE
3
LUZU
3
MENTAX
3
NAFTIN
3
NIZORAL
3
nuzole
1
nyamyc
1
nystatin
1
nystatin-triamcinolone
1
nystop
1
OXISTAT
3
pedi-dri
1
PEDIADERM AF
3
PEDIPIROX-4
3
PENLAC
3
TRIACETIN
3
VERSICLEAR
3
Requirements / Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
55
Drug Name
Drug Tier
VUSION
3
XOLEGEL
3
Requirements / Limits
TOPICAL ANTIVIRALS
acyclovir
1
DENAVIR
2
LIDOVIR
3
XERESE
2
ZOVIRAX
3
TOPICAL CORTICOSTEROIDS
ACLOVATE
3
ST
ala-cort
1
ALA-SCALP
3
alclometasone
1
amcinonide
1
APEXICON
3
apexicon e
1
AQUA GLYCOLIC HC
3
betamethasone
1
CAPEX
2
clobetasol
1
CLOBEX TOPICAL
3
ST
CLOCORTOLONE PIVALATE
3
ST
CLODAN KIT
3
ST
CLODERM
3
ST
CORDRAN TOPICAL CREAM
3
ST
CORDRAN TOPICAL LOTION
2
ST
CORDRAN TOPICAL OINTMENT
3
ST
CORDRAN TAPE SMALL ROLL
2
ST
cormax
1
CUTIVATE
3
ST
DERMA-SMOOTHE/FS SCALP OIL
3
ST
DERMASORB COMPLETE KIT
3
ST
ST
ST
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
56
Drug Name
Drug Tier
Requirements / Limits
DERMATOP
3
ST
DESONATE
3
ST
desonide
1
DESONIL
3
ST
DESOWEN
3
ST
desoximetasone
1
diflorasone
1
DIPROLENE TOPICAL
3
ST
DIPROLENE AF
3
ST
ELOCON
3
ST
FIRST-HYDROCORTISONE
3
ST
fluocinolone
1
fluocinonide topical
1
fluocinonide-e
1
fluticasone
1
halac
1
halobetasol propionate
1
HALOG
3
halonate
1
halonate pac
1
hydrocortisone
1
hydrocortisone acet-aloe vera
1
hydrocortisone butyr-emollient
1
hydrocortisone butyrate
1
hydrocortisone valerate
1
hydrocortisone-min oil-wht pet
1
KENALOG
3
ST
LOCOID
3
ST
LUXIQ
3
ST
mometasone
1
MOMEXIN
3
ST
NUCORT
3
ST
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
57
Drug Name
Drug Tier
Requirements / Limits
OLUX
3
ST
PANDEL
2
ST
PEDIADERM
3
ST
prednicarbate
1
scalacort
1
SCALACORT DK
3
SYNALAR
3
ST
TEMOVATE
3
ST
TEMOVATE E
3
ST
TEXACORT
3
ST
TOPICORT
3
ST
triamcinolone acetonide
1
trianex
1
triderm
1
ULTRAVATE/PAC
3
ST
ULTRAVATE X
3
ST
VANOS
3
ST
VERDESO
3
ST
WESTCORT
3
ST
TOPICAL ENZYMES
GRANULEX
2
OPTASE
3
SANTYL
3
vasolex
1
XENADERM
3
TOPICAL SCABICIDES / PEDICULICIDES
ELIMITE
3
EURAX
2
lindane
1
LYCELLE
3
malathion
1
NATROBA
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
58
Drug Name
Drug Tier
OVIDE
3
permethrin
1
SKLICE
3
spinosad
1
ULESFIA
3
Requirements / Limits
QPD
DIAGNOSTICS & MISCELLANEOUS AGENTS
ANTIDOTES
ATROPEN
3
MISCELLANEOUS AGENTS
acamprosate
1
AGRYLIN
3
alendronate
1
anagrelide
1
ANTABUSE
3
BUPHENYL
4
CAFCIT
3
caffeine citrated
1
CAMPRAL
2
CARBAGLU
4
CARNITOR
3
cevimeline
1
CHEMET
4
DIDRONEL
2
disulfiram
1
ethrane
1
etidronate disodium
1
EVOXAC
3
EXJADE
4
FERRIC CITRATE
3
FERRIPROX
4
FOSRENOL
3
QPD
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
59
Drug Name
Drug Tier
Requirements / Limits
INCRELEX
4
INFASURF
3
isoflurane
1
KAYEXALATE
3
kionex
1
LAZERFORMALYDE
3
levocarnitine
1
levocarnitine (with sugar)
1
LITHOSTAT
3
LYMPHAZURIN
3
METOPIRONE
3
midodrine
1
NUTRESTORE
3
ORFADIN
4
PEG 3350-GRX
3
pilocarpine hcl
1
RAVICTI
4
RENAGEL
3
PA
RENVELA
3
PA
RILUTEK
4
riluzole
4
SALAGEN
3
sevoflurane
1
SKELID
3
sodium phenylbutyrate
1
SODIUM POLYSTYRENE SULFONATE
3
sojourn
1
SUPRANE
3
SURVANTA
3
SYPRINE
3
terrell
1
THIOLA
3
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
60
Drug Name
Drug Tier
Requirements / Limits
ULTANE
3
VELPHORO
3
PA
buproban
$0
QPD
CHANTIX
$0
COMMIT
$0
nicorelief
$0
NICORETTE
$0
nicotine
$0
nicotine (polacrilex)
$0
NICOTROL
$0
NICOTROL NS
$0
nts step 1
$0
quit 2
$0
quit 4
$0
stop smoking aid
$0
thrive nicotine
$0
SMOKING DETERRENTS
EAR, NOSE & THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ASTELIN
3
ST; QPD
ASTEPRO
2
ST; QPD
ATROVENT
3
azelastine
1
BACTROBAN NASAL
2
chlorhexidine gluconate
1
denta 5000 plus
1
dentagel
1
fluoridex daily defense
1
ipratropium bromide
1
nafrinse
1
oralone
1
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
61
Drug Name
Drug Tier
paroex oral rinse
1
PATANASE
3
PERIDEX
3
perio med
1
periogard
1
PHOS-FLUR
3
PREVIDENT
3
PREVIDENT 5000 DRY MOUTH
3
PREVIDENT 5000 ENAMEL PROTECT
3
sf 5000 plus
1
sodium fluoride dental rinse
1
stannous fluoride
1
triamcinolone acetonide
1
TYZINE
3
Requirements / Limits
ST; QPD
MISCELLANEOUS OTIC PREPARATIONS
acetasol hc
1
acetic acid
1
acetic acid-aluminum acetate
1
aero otic hc
1
antipyrine-benzocaine otic drops
1
AURAX
3
aurodex
1
CETRAXAL
3
ciprofloxacin
1
cortane-b
1
CRESYLATE
3
DERMOTIC OIL
3
exotic-hc
1
fluocinolone acetonide oil
1
hydrocortisone-acetic acid
1
myoxin
1
NEOTIC (WITH GLYCERIN)
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
62
Drug Name
Drug Tier
ofloxacin
1
OTIC CARE (ANTIPYRINE)
3
oticin/hc
1
otomax-hc
1
otozin
1
PINNACAINE
3
pramoxine-hc
1
treagan otic
1
TRIOXIN
3
VOSOL-HC
3
ZINOTIC/ES (WITH GLYCERIN)
3
Requirements / Limits
OTIC STEROID / ANTIBIOTIC
CIPRO HC
3
CIPRODEX
2
COLY-MYCIN S
3
CORTISPORIN
3
CORTISPORIN-TC
3
neomycin-polymyxin-hc
1
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P.
4
CELESTONE
3
CORTEF
3
cortisone
1
dexamethasone
1
dexamethasone intensol
1
DEXPAK 10 DAY
3
DEXPAK 13 DAY
3
DEXPAK 6 DAY
3
FLO-PRED
3
fludrocortisone
1
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
63
Drug Name
Drug Tier
hydrocortisone
1
MEDROL
3
methylprednisolone
1
MILLIPRED ORAL SOLUTION
3
millipred oral tablet
1
millipred dp
1
ORAPRED
3
ORAPRED ODT
3
PEDIAPRED
3
prednisolone
1
prednisone
1
PRELONE
3
RAYOS
3
veripred 20
1
Requirements / Limits
ANTITHYROID AGENTS
methimazole
1
propylthiouracil
1
TAPAZOLE
3
DIABETES THERAPY
acarbose
1
ACCU-CHEK ACTIVE TEST STRIPS
3
PA
ACCU-CHEK AVIVA TEST STRIPS
3
PA
ACCU-CHEK COMFORT CURVE TEST
STRIPS
3
PA
ACCU-CHEK COMPACT TEST STRIPS
3
PA
ACCU-CHEK SMARTVIEW TEST STRIPS
3
PA
ACCUTREND GLUCOSE TEST STRIPS
3
PA
ACTOPLUS MET
3
ST; QPD
ACTOPLUS MET XR
2
ST; QPD
ACTOS
3
ST; QPD
ACURA TEST STRIPS
3
PA
ADVANCED GLUC METER TEST STRIPS
3
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
64
Drug Name
Drug Tier
Requirements / Limits
ADVOCATE TEST STRIPS
3
PA
AMARYL
3
APIDRA
3
PA
APIDRA SOLOSTAR
3
PA
AVANDAMET
3
ST; QPD
AVANDARYL
3
ST; QPD
AVANDIA
3
ST; QPD
BG-STAR
3
PA
BIONIME RIGHTEST TEST STRIPS
3
PA
BLOOD GLUCOSE TEST STRIPS
3
PA
BREEZE 2 TEST STRIPS
2
BYDUREON
2
PA; QPD
BYETTA
2
PA; QPD
chlorpropamide
1
CONTOUR TEST STRIPS
2
CYCLOSET
3
DIABETA
3
DUETACT
3
ST; QPD
FARXIGA
3
ST; QPD
FORTAMET
3
ST
FREESTYLE INSULINX TEST STRIPS
3
PA
FREESTYLE LITE STRIPS
3
PA
FREESTYLE TEST STRIP
3
PA
G-4 TEST STRIPS
3
PA
GE100 BLOOD GLUCOSE TEST STRIPS
3
PA
glimepiride
1
glipizide
1
QPD
glipizide-metformin
1
QPD
GLUCOCOM GLUCOSE TEST STRIPS
3
PA
GLUCOPHAGE/XR
3
ST
GLUCOTROL
3
GLUCOTROL XL
3
ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
65
Drug Name
Drug Tier
Requirements / Limits
GLUCOVANCE
3
QPD
GLUMETZA
3
ST
glyburide
1
glyburide micronized
1
glyburide-metformin
1
GLYNASE
3
GLYSET
3
GMATE TEST STRIPS
3
PA
HUMALOG/KWIKPEN
3
PA
HUMALOG MIX 50-50/KWIKPEN
3
PA
HUMALOG MIX 75-25/KWIKPEN
3
PA
HUMULIN 70/30/KWIKPEN/PEN
3
PA
HUMULIN N/KWIKPEN/PEN
3
PA
HUMULIN R
3
PA
HUMULIN R U-500 "CONCENTRATED"
3
INFINITY TEST STRIPS
3
PA
INVOKAMET
3
ST;QPD
INVOKANA
2
ST; QPD
JANUMET
2
ST; QPD
JANUMET XR
2
ST; QPD
JANUVIA
2
ST; QPD
JARDIANCE
3
ST; QPD
JENTADUETO
3
PA; ST; QPD
JUVISYNC
2
ST; QPD
KAZANO
3
PA; ST; QPD
KOMBIGLYZE XR
2
ST; QPD
LANTUS/SOLOSTAR
2
LEVEMIR/FLEXPEN/FLEXTOUCH
2
LIBERTY TEST STRIPS
3
PA
metformin oral tablet
1
QPD
metformin oral tablet extended release 24 hr
1
QPD
nateglinide
1
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
66
Drug Name
Drug Tier
Requirements / Limits
NESINA
3
PA; ST; QPD
NEUTEK 2TEK TEST STRIPS
3
PA
NOVA MAX GLUCOSE TEST STRIPS
3
PA
NOVOLIN 70/30
2
NOVOLIN N/R
2
NOVOLOG/FLEXPEN/MIX 70-30
2
NOVOLOG PENFILL
2
ONE TOUCH ULTRA TEST STRIPS
3
PA
ONGLYZA
2
ST; QPD
OPTIUM EZ TEST STRIPS
3
PA
OPTIUM TEST STRIPS
3
PA
OSENI
3
ST; QPD
pioglitazone
1
QPD
pioglitazone-glimepiride
1
QPD
pioglitazone-metformin
1
QPD
PRANDIMET
3
PRANDIN
3
PRECISION PCX PLUS TEST STRIPS
3
PA
PRECISION PCX TEST STRIPS
3
PA
PRECISION POINT OF CARE TEST STRIPS
3
PA
PRECISION Q-I-D TEST STRIPS
3
PA
PRECOSE
3
PRODIGY NO CODING TEST STRIPS
3
PROGLYCEM
3
repaglinide
1
RIGHTEST GS550 TEST STRIPS
3
PA
RIOMET
3
ST
SMART SENSE TEST STRIPS
3
PA
SMARTEST TEST STRIPS
3
PA
SOLUS V2 TEST STRIPS
3
PA
STARLIX
3
SYMLINPEN 120
3
PA
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
67
Drug Name
Drug Tier
Requirements / Limits
SYMLINPEN 60
3
PA; QPD
TANZEUM
3
PA;QPD
tolazamide
1
tolbutamide
1
TRADJENTA
3
TRUE METRIX GLUCOSE TEST STRIPS
2
TRUETEST TEST STRIPS
2
TRUETRACK TEST STRIPS
2
UNISTRIP1 TEST STRIPS
3
PA
VICTOZA 2-PAK
2
PA; QPD
VOCAL POINT TEST STRIPS
3
PA
PA; ST; QPD
MISCELLANEOUS HORMONES
ANADROL-50
3
ANDRODERM TRANSDERMAL PATCH
3
PA; QPD
ANDROGEL TRANSDERMAL GEL
2
PA; QPD
ANDROID
3
androxy
1
AXIRON
2
cabergoline
1
calcitonin (salmon)
1
calcitriol
1
danazol
1
DDAVP NASAL
4
DDAVP ORAL
3
DELATESTRYL
3
DEPO-TESTOSTERONE
3
desmopressin nasal
4
desmopressin oral
1
doxercalciferol
1
FORTESTA
3
PA; QPD
fortical
1
QPD
HECTOROL
3
PA; QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
68
Drug Name
Drug Tier
Requirements / Limits
KORLYM
4
PA; QPD
KUVAN
4
PA
METHITEST
3
MIACALCIN NASAL
3
QPD
MYALEPT
4
PA
OXANDRIN
3
oxandrolone
1
paricalcitol
1
ROCALTROL
3
SAMSCA
4
SENSIPAR
3
SOMAVERT
4
STIMATE
4
STRIANT
3
SYNAREL
2
TESTIM
3
PA; QPD
TESTOSTERONE
3
PA; QPD
testosterone
1
TESTRED
3
VOGELXO
3
ZAVESCA
4
ZEMPLAR
3
QPD
PA; QPD
PA
THYROID HORMONES
ARMOUR THYROID
3
CYTOMEL
3
levothroid
1
levothyroxine
1
levoxyl
1
liothyronine
1
nature-throid
1
np thyroid
1
SYNTHROID
2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
69
Drug Name
Drug Tier
THYROLAR-1
3
THYROLAR-1/2
3
THYROLAR-1/4
3
THYROLAR-2
3
THYROLAR-3
3
TIROSINT
3
unithroid
1
westhroid oral tablet
1
WESTHROID-P
3
WP THYROID
3
Requirements / Limits
GASTROENTEROLOGY
ANTIDIARRHEALS & ANTISPASMODICS
anaspaz
1
belladonna
1
BENTYL
3
CANTIL
3
chlordiazepoxide-clidinium
1
CUVPOSA
3
dicyclomine
1
diphenoxylate-atropine
1
DONNATAL/EXTENTABS
3
ed-spaz
1
FULYZAQ
4
GLYCATE
3
glycopyrrolate
1
hyomax-sl
1
hyoscyamine sulfate
1
LEVBID
3
LEVSIN/SL
3
LIBRAX (WITH CLIDINIUM)
3
LOMOTIL
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
70
Drug Name
Drug Tier
loperamide
1
methscopolamine
1
MOTOFEN
3
NULEV
3
oscimin
1
oscimin sl
1
oscimin sr
1
PAMINE
3
PAMINE FORTE
3
paregoric
1
phenobarb-hyoscy-atropine-scop
1
propantheline
1
ROBINUL
3
ROBINUL FORTE
3
SAL-TROPINE
3
se-donna pb hyos
1
SYMAX DUOTAB
3
symax fastabs
1
symax-sl
1
symax-sr
3
Requirements / Limits
MISCELLANEOUS GASTROINTESTINAL AGENTS
ACTIGALL
3
alophen
$0
AMITIZA
2
ANALPRAM E
3
ANALPRAM-HC
3
ANTIVERT
3
anucort-hc
1
ANUSOL-HC
3
ANZEMET
3
APRISO
3
ASACOL/HD
2
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
71
Drug Name
Drug Tier
AZULFIDINE
3
AZULFIDINE EN-TABS
3
balsalazide
1
bisa-lax
$0
bisacodyl
$0
budesonide
1
CANASA
2
CESAMET
3
CHENODAL
4
CIMZIA
4
citrate of magnesia
$0
citroma
$0
clearlax
$0
COLAZAL
3
colocort
1
COLYTE WITH FLAVOR PACKS
3
COMPAZINE
3
compro
1
constulose
1
corrective laxative
$0
CORTENEMA
3
CORTIFOAM
2
CREON
2
cromolyn
1
CYSTADANE
4
DELZICOL
2
DICLEGIS
3
DIGEX NF
3
DIPENTUM
3
dronabinol
1
ducodyl
$0
dulcolax balance
$0
Requirements / Limits
QPD
PA; QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
72
Drug Name
Drug Tier
Requirements / Limits
EMEND
2
QPD
ENTOCORT EC
3
enulose
1
ex-lax ultra
$0
gastrinex nf
1
GASTROCROM
3
GASTROMARK
3
GATTEX 30-VIAL
4
gavilax
$0
gavilyte-c
$0
gavilyte-g
$0
gavilyte-n
$0
generlac
1
gentle laxative
$0
gentlelax
$0
GIAZO
3
glycolax
$0
GOLYTELY
3
granisetron
1
QPD
granisol
1
QPD
HALFLYTELY-BISACODYL W-FLAV PK
3
healthylax
$0
hemril-30
1
hydrocortisone
1
hydrocortisone acetate
1
hydrocortisone-pramox-e-pram#1 rectal kit, cream
and towelette
1
hydrocortisone-pramoxine
1
ipecac
1
KRISTALOSE
3
lactulose
1
laxa clear
$0
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
73
Drug Name
Drug Tier
Requirements / Limits
laxative
$0
laxative feminine
$0
laxative peg 3350
$0
LIALDA
2
LIDOCAINE HCL-HYDROCORTISON AC
RECTAL CREAM 3 %-1 % (7 GRAM)
2
lidocaine hcl-hydrocortison ac rectal cream 3-0.5
%
1
LIDOCAINE HCL-HYDROCORTISON AC
RECTAL GEL
2
lidocaine hcl-hydrocortison ac rectal kit
2
lidocaine-hydrocortisone-aloe rectal gel
1
lidocaine-hydrocortisone-aloe rectal kit
1
LINZESS
2
QPD
LOTRONEX
3
QPD
MAGNEBIND 400
3
magnesium citrate
$0
MARINOL
3
meclizine
1
mesalamine
1
metoclopramide hcl
1
METOZOLV ODT
3
milk of magnesia
$0
miralax
$0
MOVIPREP
3
NULYTELY WITH FLAVOR PACKS
3
ondansetron
1
oral saline laxative
$0
OSMOPREP
3
PANCREAZE
3
pancrelipase 5000
1
peg 3350-electrolytes
$0
peg-3350 with flavor packs
$0
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
74
Drug Name
Drug Tier
peg-electrolyte soln
$0
PENTASA
2
PERTZYE
3
phosphate laxative
$0
polyethylene glycol 3350
$0
powderlax
$0
PRAM-HCA
3
pramcort
1
preparation cleansing
$0
PREPOPIK
3
prochlorperazine
1
PROCORT
3
procto-pak
1
PROCTOCORT
3
PROCTOCREAM-HC
3
PROCTOFOAM HC
2
proctosol hc
1
proctozone-hc
1
purelax
$0
rectacort-hc
1
RECTIV
3
REGLAN
3
RELISTOR
4
ROWASA
3
SANCUSO
3
smoothlax
$0
SUCLEAR
3
SUCRAID
4
sulfasalazine
1
sulfazine/ec
1
SUPREP
2
TIGAN
3
Requirements / Limits
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
75
Drug Name
Drug Tier
Requirements / Limits
TRANSDERM-SCOP
2
trilyte with flavor packets
$0
trimethobenzamide
1
UCERIS
3
ULTRESA
3
URSO 250
3
URSO FORTE
3
ursodiol
1
VIOKACE
3
VIOKASE
3
woman's laxative
$0
women's gentle laxative(bisac)
$0
z-pram
1
ZENPEP
2
ZOFRAN/ODT
3
QPD
ZUPLENZ
3
QPD
ZYPRAM
3
ULCER THERAPY
ACIPHEX/SPRINKLE
3
ST; QPD
amoxicil-clarithromy-lansopraz
1
AXID
3
carafate oral suspension
1
CARAFATE ORAL TABLET
3
cimetidine
1
CYTOTEC
3
DEXILANT
3
ST; QPD
ESOMEPRAZOLE STRONTIUM
3
ST; QPD
famotidine
1
FIRST-LANSOPRAZOLE
3
ST; QPD
FIRST-OMEPRAZOLE
3
ST; QPD
HELIDAC
3
lansoprazole
1
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
76
Drug Name
Drug Tier
Requirements / Limits
misoprostol
1
NEXIUM ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 40 MG
3
QPD
NEXIUM PACKET ORAL GRANULES DR
FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG,
5 MG
2
QPD
NEXIUM PACKET ORAL GRANULES DR
FOR SUSP IN PACKET 40 MG
3
QPD
nizatidine
1
OMECLAMOX-PAK
3
omeprazole
1
QPD
OMEPRAZOLE+SYRSPEND SF ALKA
3
ST; QPD
omeprazole-sodium bicarbonate
1
QPD
pantoprazole
1
QPD
PEPCID
3
PREVACID
3
ST; QPD
PREVACID SOLUTAB
3
ST; QPD
PREVPAC
2
PRILOSEC
3
ST; QPD
PROTONIX
3
ST; QPD
PYLERA
2
rabeprazole
1
QPD
ranitidine hcl oral capsule
1
QPD
ranitidine hcl oral syrup
1
ranitidine hcl oral tablet
1
sucralfate
1
ZANTAC
3
ZEGERID
3
QPD
ST; QPD
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE
4
PA
ARCALYST
4
QPD
AVONEX
4
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
77
Drug Name
Drug Tier
Requirements / Limits
BETASERON
4
PA; QPD
EXTAVIA
4
QPD
GENOTROPIN
4
PA
HUMATROPE
4
PA
INFERGEN
4
QPD
MOZOBIL
4
NORDITROPIN
4
PA
NUTROPIN/AQ
4
PA
OMNITROPE
4
PA
PEGASYS
4
PA; QPD
PEGINTRON
4
PA; QPD
REBIF
4
QPD
SAIZEN
4
PA
SEROSTIM
4
PA
SYLATRON
4
QPD
TEV-TROPIN
4
PA
ZORBTIVE
4
PA
VACCINES & MISCELLANEOUS IMMUNOLOGICALS
ADACEL
$0
AFLURIA
$0
BOOSTRIX TDAP
$0
CERVARIX VACCINE
$0
COMVAX
$0
DAPTACEL
$0
DECAVAC
$0
ENGERIX-B
$0
FLUARIX
$0
FLUBLOK
$0
FLUCELVAX
$0
FLULAVAL
$0
FLUMIST
$0
FLUVIRIN
$0
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
78
Drug Name
Drug Tier
FLUZONE
$0
GARDASIL
$0
GRASTEK
3
HAVRIX
$0
HIBERIX
$0
INFANRIX (DTAP)
$0
IPOL
$0
KINRIX
$0
M-M-R II
$0
MENACTRA
$0
MENOMUNE - A/C/Y/W-135
$0
MENVEO A-C-Y-W-135-DIP
$0
ORALAIR
3
PEDIARIX
$0
PEDVAX HIB
$0
PENTACEL
$0
PNEUMOVAX 23
$0
PREVNAR 13
$0
PROQUAD
$0
RAGWITEK
3
RECOMBIVAX HB
$0
ROTARIX
$0
ROTATEQ VACCINE
$0
SINGLE USE EZ FLU 2014-15
$0
TENIVAC
$0
tetanus toxoid,adsorbed
$0
TETANUS,DIPHTHERIA TOX PED
$0
TETANUS-DIPHTHERIA TOXOIDS-TD
$0
TRIHIBIT
$0
TRIPEDIA
$0
TWINRIX
$0
VAQTA
$0
Requirements / Limits
PA; QPD
PA; QPD
PA; QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
79
Drug Name
Drug Tier
VARIVAX
$0
ZOSTAVAX
$0
Requirements / Limits
MUSCULOSKELETAL & RHEUMATOLOGY
GOUT THERAPY
allopurinol
1
colchicine-probenecid
1
COLCRYS
2
probenecid
1
ULORIC
2
ZYLOPRIM
3
QPD
OSTEOPOROSIS THERAPY
ACTONEL
3
ST; QPD
alendronate oral solution
1
alendronate oral tablet
1
QPD
ATELVIA
3
ST; QPD
BINOSTO
3
ST; QPD
BONIVA ORAL TABLET
3
ST; QPD
EVISTA
3
QPD
FORTEO
4
PA; QPD
FOSAMAX
3
ST; QPD
FOSAMAX PLUS D
2
ST; QPD
ibandronate
1
QPD
raloxifene
$0
QPD
risedronate
1
QPD
ACTEMRA SUBCUTANEOUS
4
PA
ARAVA
3
QPD
CUPRIMINE
2
DEPEN TITRATABS
3
ENBREL/SURECLICK
4
PA; QPD
HUMIRA/PEN/STARTER PCKs
4
PA; QPD
OTHER RHEUMATOLOGICALS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
80
Drug Name
Drug Tier
Requirements / Limits
KINERET
4
QPD
leflunomide
1
QPD
ORENCIA SUBCUTANEOUS SYRINGE
4
PA; QPD
OTEZLA
4
PA; QPD
OTREXUP
4
RASUVO
3
RIDAURA
2
SAVELLA
3
QPD
SIMPONI SUBCUTANEOUS SYRINGE
4
PA; QPD
XELJANZ
4
PA; QPD
OBSTETRICS & GYNECOLOGY
ESTROGENS & PROGESTINS
ACTIVELLA
3
ALORA
3
ANGELIQ
3
AYGESTIN
3
camila
$0
CENESTIN
3
CLIMARA
3
QPD
CLIMARA PRO
2
QPD
COMBIPATCH
3
QPD
covaryx
1
covaryx h.s.
1
CRINONE
2
deblitane
$0
DELESTROGEN
3
DIVIGEL
2
DUAVEE
3
eemt/hs
1
ELESTRIN
2
ENJUVIA
3
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
81
Drug Name
Drug Tier
Requirements / Limits
errin
$0
ESTRACE ORAL
3
ESTRACE VAGINAL
2
ESTRADERM
3
estradiol oral
1
estradiol transdermal
1
estradiol-norethindrone acet
1
ESTRASORB
3
QPD
ESTRING
2
QPD
ESTROGEL
2
QPD
estrogens-methyltestosterone
1
estropipate
1
EVAMIST
2
FEMHRT 1/5
3
FEMHRT LOW DOSE
3
FEMRING
3
FEMTRACE
3
heather
$0
jencycla
$0
jevantique
1
jinteli
1
jolivette
$0
lyza
$0
MAKENA
4
medroxyprogesterone oral
1
MENEST
3
MENOSTAR
3
mimvey
1
mimvey lo
1
MINIVELLE
3
NOR-QD
3
nora-be
$0
QPD
QPD
QPD
QPD
PA; QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
82
Drug Name
Drug Tier
Requirements / Limits
norethindrone (contraceptive)
$0
norethindrone acetate
1
norlyroc
1
OGEN 2.5
3
ORTHO MICRONOR
3
PREFEST
2
PREMARIN ORAL TABLET
2
PREMARIN VAGINAL
3
PREMPHASE
2
QPD
PREMPRO
2
QPD
progesterone micronized
1
PROMETRIUM
3
PROVERA
3
sharobel
1
VAGIFEM
2
VIVELLE-DOT
3
QPD
QPD
MISCELLANEOUS OB/GYN
AVC VAGINAL
2
CERVIDIL
3
CLEOCIN
3
clindamycin phosphate
1
CLINDESSE
3
CONCEPTROL
$0
FC FEMALE CONDOM
$0
FEMCAP
$0
GYNAZOLE-1
3
gynol ii
$0
LYSTEDA
3
METROGEL VAGINAL
3
metronidazole
1
miconazole-3
1
MIFEPREX
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
83
Drug Name
Drug Tier
NUVARING
$0
nystatin
1
ORTHO ALL-FLEX FITTING SET
$0
ORTHO DIAPHRAGM ALL-FLEX
$0
ORTHO EVRA
3
PREPIDIL
3
PROSTIN E2
3
RELAGARD
3
TERAZOL 3 VAGINAL CREAM
3
TERAZOL 3 VAGINAL SUPPOSITORY
2
TERAZOL 7
3
terconazole
1
TODAY CONTRACEPTIVE SPONGE
$0
VAGINAL CONTRACEPTIVE FILM
$0
vaginal contraceptive foam
$0
vandazole
1
VCF CONTRACEPTIVE FILM
$0
WIDE-SEAL DIAPHRAGM
$0
xulane
$0
Requirements / Limits
ORAL CONTRACEPTIVES & RELATED AGENTS
altavera (28)
$0
alyacen 1/35 (28)
$0
alyacen 7/7/7 (28)
$0
amethia
$0
QPD
amethia lo
$0
QPD
amethyst
$0
apri
$0
aranelle (28)
$0
aubra
$0
aviane
$0
azurette (28)
$0
balziva (28)
$0
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
84
Drug Name
Drug Tier
Requirements / Limits
BEYAZ
$0
BREVICON (28)
3
briellyn
$0
camrese
$0
QPD
camrese lo
$0
QPD
caziant (28)
$0
chateal
$0
cryselle (28)
$0
cyclafem 1/35 (28)
$0
cyclafem 7/7/7 (28)
$0
CYCLESSA (28)
3
dasetta 1/35 (28)
$0
dasetta 7/7/7 (28)
$0
daysee
$0
delyla (28)
$0
DEMULEN 1/50 (28)
3
desog-e.estradiol/e.estradiol
$0
DESOGEN
3
desogestrel-ethinyl estradiol
$0
drospirenone-ethinyl estradiol
$0
elinest
$0
ELLA
$0
emoquette
$0
enpresse
$0
enskyce
$0
estarylla
$0
ESTROSTEP FE-28
3
fallback solo
$0
falmina (28)
$0
FEMCON FE
3
GENERESS FE
$0
gianvi (28)
$0
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
85
Drug Name
Drug Tier
Requirements / Limits
gildagia
$0
gildess
$0
gildess fe
$0
introvale
$0
QPD
jolessa
$0
QPD
junel 1.5/30 (21)
$0
junel 1/20 (21)
$0
junel fe 1.5/30 (28)
$0
junel fe 1/20 (28)
$0
kariva (28)
$0
kelnor 1/35 (28)
$0
kurvelo
$0
l norgest&e estradiol-e estrad
$0
larin 1.5/30 (21)
$0
larin 1/20 (21)
$0
larin fe
$0
leena 28
$0
lessina
$0
levonest (28)
$0
levonorgestrel
$0
levonorgestrel-ethinyl estrad
$0
levora 0.15/30 (28)
$0
levora-28
$0
LO LOESTRIN FE
$0
LO MINASTRIN FE
$0
LO-OVRAL (28)
3
LO-OVRAL (8)
3
LOESTRIN 1.5/30 (21)
3
LOESTRIN 1/20 (21)
3
LOESTRIN 24 FE
$0
LOESTRIN FE 1.5/30 (28)
3
LOESTRIN FE 1/20 (28)
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
86
Drug Name
Drug Tier
Requirements / Limits
lomedia 24 fe
$0
loryna (28)
$0
LOSEASONIQUE
3
low-ogestrel (28)
$0
lutera (28)
$0
marlissa
$0
microgestin 1.5/30 (21)
$0
microgestin 1/20 (21)
$0
microgestin fe 1.5/30 (28)
$0
microgestin fe 1/20 (28)
$0
MINASTRIN 24 FE
$0
MIRCETTE (28)
3
MODICON (28)
3
mono-linyah
$0
mononessa (28)
$0
my way
$0
myzilra
$0
NATAZIA
$0
necon 0.5/35 (28)
$0
necon 1/35 (28)
$0
necon 1/50 (28)
$0
necon 10/11 (28)
$0
necon 7/7/7 (28)
$0
next choice
$0
QPD
next choice one dose
$0
QPD
nikki (28)
$0
NORDETTE (28)
3
noreth-ethinyl estradiol-iron
$0
norethindrone ac-eth estradiol
$0
norethindrone-e.estradiol-iron
$0
norgestimate-ethinyl estradiol
$0
norgestrel-ethinyl estradiol
$0
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
87
Drug Name
Drug Tier
Requirements / Limits
NORINYL 1+35 (28)
3
NORINYL 1+50 (28)
3
nortrel 0.5/35 (28)
$0
nortrel 1/35 (21)
$0
nortrel 1/35 (28)
$0
nortrel 7/7/7 (28)
$0
ocella
$0
ogestrel (28)
$0
orsythia
$0
ORTHO TRI-CYCLEN (28)
3
ORTHO TRI-CYCLEN LO (28)
$0
ORTHO-CEPT (28)
3
ORTHO-CYCLEN (28)
3
ORTHO-NOVUM 1/35 (28)
3
ORTHO-NOVUM 7/7/7 (21)
3
ORTHO-NOVUM 7/7/7 (28)
3
OVCON-35 (28)
3
OVCON-50 (28)
$0
philith
$0
pimtrea (28)
$0
pirmella
$0
PLAN B ONE-STEP
3
portia
$0
previfem
$0
QUARTETTE
$0
QPD
quasense
$0
QPD
reclipsen (28)
$0
SAFYRAL
$0
SEASONALE CONTRACEPTIVE
3
QPD
SEASONIQUE
3
QPD
sprintec (28)
$0
sronyx
$0
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
88
Drug Name
Drug Tier
syeda
$0
TAKE ACTION
3
tarina fe
$0
tilia fe
$0
tri-estarylla
$0
tri-legest fe
$0
tri-linyah
$0
TRI-NORINYL (28)
3
tri-previfem (28)
$0
tri-sprintec (28)
$0
trinessa (28)
$0
trivora (28)
$0
velivet triphasic regimen (28)
$0
vestura (28)
$0
viorele (28)
$0
vyfemla (28)
$0
wera (28)
$0
wymzya fe
$0
YASMIN (28)
3
YAZ (28)
3
zarah
$0
zenchent (28)
$0
zenchent fe
$0
zeosa
$0
zovia 1/35e (28)
$0
zovia 1/50e (28)
$0
Requirements / Limits
OXYTOCICS
METHERGINE
2
methylergonovine
1
OPHTHALMOLOGY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
89
Drug Name
Drug Tier
Requirements / Limits
ANTIBIOTICS
ak-poly-bac
1
AZASITE
3
bacitracin
1
BESIVANCE
3
BETADINE OPHTHALMIC PREP
3
CILOXAN OPHTHALMIC DROPS
3
CILOXAN OPHTHALMIC OINTMENT
2
ciprofloxacin
1
erythromycin
1
garamycin ophthalmic drops
1
GARAMYCIN OPHTHALMIC OINTMENT
3
gatifloxacin
1
gentak
1
gentamicin
1
gentasol
1
ILOTYCIN
3
IQUIX
3
levofloxacin
1
MOXEZA
2
NATACYN
3
neo-polycin
1
neomycin-bacitracin-polymyxin
1
neomycin-polymyxin-gramicidin
1
NEOSPORIN (NEO-POLYM-GRAMICID)
3
OCUFLOX
3
ofloxacin
1
polycin
1
polycin b
1
polymyxin b sulf-trimethoprim
1
POLYTRIM
3
QUIXIN
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
90
Drug Name
Drug Tier
romycin
1
tobramycin
1
tobrasol
1
TOBREX
3
VIGAMOX
2
ZYMAXID
3
Requirements / Limits
ANTIVIRALS
trifluridine
1
VIROPTIC
3
ZIRGAN
2
BETA-BLOCKERS
BETAGAN
3
betaxolol
1
BETIMOL
3
BETOPTIC S
3
carteolol
1
ISTALOL
3
levobunolol
1
metipranolol
1
OPTIPRANOLOL
3
timolol maleate
1
TIMOPTIC
3
TIMOPTIC OCUDOSE
3
TIMOPTIC-XE
3
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE
2
CYCLOPLEGIC MYDRIATICS
atropine
1
atropine sulfate
1
atropine-care
1
CYCLOGYL
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
91
Drug Name
Drug Tier
cyclopentolate
1
cylate
1
homatropaire
1
homatropine hbr
1
ISOPTO ATROPINE
3
ISOPTO HOMATROPINE
3
ISOPTO HYOSCINE
3
mydral
1
MYDRIACYL
3
PAREMYD
3
tropicamide
1
Requirements / Limits
DIRECT ACTING MIOTICS
ISOPTO CARPINE
3
pilocarpine hcl
1
PILOPINE HS
2
MISCELLANEOUS OPHTHALMOLOGICS
ALAMAST
3
ALCAINE
3
ALOCRIL
3
ALOMIDE
2
altafluor
1
azelastine
1
BEPREVE
3
cromolyn
1
CYSTARAN
4
ELESTAT
3
EMADINE
3
epinastine
1
FLURESS
3
flurox
1
goniovisc
1
LACRISERT
2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
92
Drug Name
Drug Tier
LASTACAFT
3
OPTIVAR
3
PATADAY
3
PATANOL
2
RESTASIS
3
Requirements / Limits
QPD
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACULAR
3
ACULAR LS
3
ACUVAIL
3
BROMDAY
2
bromfenac
1
diclofenac sodium
1
flurbiprofen sodium
1
ILEVRO
3
ketorolac
1
NEVANAC
3
OCUFEN
3
PROLENSA
2
VOLTAREN GEL OPHTHALMIC DROPS 0.1 %
3
ST
ORAL DRUGS FOR GLAUCOMA
acetazolamide
1
DIAMOX SEQUELS
3
methazolamide
1
NEPTAZANE
3
OTHER GLAUCOMA DRUGS
AZOPT
3
COMBIGAN
3
COSOPT
3
COSOPT
3
dorzolamide
1
dorzolamide-timolol
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
93
Drug Name
Drug Tier
Requirements / Limits
ISOPTO CARBACHOL
2
latanoprost
1
PA
LUMIGAN
2
PA
RESCULA
3
PA
SIMBRINZA
3
TRAVATAN Z
2
PA
travoprost (benzalkonium)
1
PA
TRUSOPT
3
XALATAN
3
PA
ZIOPTAN
3
PA
STEROID-ANTIBIOTIC COMBINATIONS
MAXITROL
3
neo-polycin hc
1
neomycin-bacitracin-poly-hc
1
neomycin-polymyxin-dexameth
1
neomycin-polymyxin-hc
1
poly-dex
1
PRED-G
3
PRED-G S.O.P.
3
TOBRADEX OPHTHALMIC
DROPS,SUSPENSION
3
TOBRADEX OPHTHALMIC OINTMENT
2
TOBRADEX ST
3
tobramycin-dexamethasone
1
ZYLET
3
STEROIDS
ALREX
2
dexamethasone sodium phosphate
1
DUREZOL
3
FLAREX
3
fluorometholone
1
FML FORTE
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
94
Drug Name
Drug Tier
FML LIQUIFILM
3
FML S.O.P.
3
LOTEMAX OPHTHALMIC DROPS,GEL
3
LOTEMAX OPHTHALMIC
DROPS,SUSPENSION
2
LOTEMAX OPHTHALMIC OINTMENT
3
MAXIDEX
3
OMNIPRED
3
PRED FORTE
3
PRED MILD
2
prednisol
1
prednisolone acetate
1
prednisolone sodium phosphate
1
VEXOL
3
Requirements / Limits
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE
3
BLEPHAMIDE S.O.P.
3
sulfacetamide-prednisolone
1
SULFONAMIDES
BLEPH-10
3
sulfacetamide sodium
1
sulfamide
1
SYMPATHOMIMETICS
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
2
ALPHAGAN P OPHTHALMIC DROPS 0.15 %
3
apraclonidine
1
brimonidine
1
IOPIDINE
3
VASOCONSTRICTOR DECONGESTANTS
altafrin
1
CYCLOMYDRIL
3
MYDFRIN
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
95
Drug Name
Drug Tier
naphazoline
1
phenylephrine hcl
1
Requirements / Limits
RESPIRATORY, ALLERGY, COUGH & COLD
ANTIHISTAMINE & ANTIALLERGENIC AGENTS
ADRENACLICK
3
ALLEGRA ODT
3
arbinoxa
1
AUVI-Q
2
carbinoxamine maleate
1
CLARINEX
3
clemastine
1
cyproheptadine
1
desloratadine
1
dexchlorpheniramine maleate
1
diphenhydramine hcl
1
doxytex
1
dytuss
1
ed-chlor-tan
1
epinephrine
1
EPIPEN
2
EPIPEN JR
2
hydroxyzine hcl
1
hydroxyzine pamoate
1
levocetirizine
1
palgic
1
phenadoz
1
phenergan
1
promethazine
1
promethegan
1
TWINJECT AUTOINJECTOR
2
VISTARIL
3
ST; QPD
ST; QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
96
Drug Name
XYZAL
Drug Tier
3
Requirements / Limits
ST; QPD
COUGH & COLD THERAPY
ALA-HIST AC
3
ALA-HIST DHC
3
ALLEGRA-D 12 HOUR
3
ST; QPD
ALLEGRA-D 24 HOUR
3
ST; QPD
ALLFEN CD
3
ALLFEN CDX
3
ambi 10peh-400gfn-20dm
1
AMBIFED
3
AMBIFED DM
3
benzonatate
1
BROMFED DM
3
brompheniramin-phenylephrin-dm
1
CAPCOF
3
centergy
1
centergy dm
1
cheratussin ac
1
cheratussin dac
1
chlorpheniramine-hydrocodone
1
CLARINEX-D 12 HOUR
3
ST; QPD
CLARINEX-D 24 HOUR
3
ST; QPD
CODAR AR
3
CODAR D
3
CODAR GF
3
codeine-guaifenesin
1
COTAB A
3
COTAB AX
3
COTABFLU
3
cpm-pseudoephed-hydrocodone
1
DONATUSS DC
3
endacof-dc
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
97
Drug Name
Drug Tier
ENDAL CD
3
guaiatussin ac
1
guaifenesin
1
guaifenesin ac
1
guaifenesin dac
1
hydrocodone-homatropine
1
hydromet
1
J-COF DHC
3
J-MAX DHC
3
lexuss 210
1
LORTUSS EX
3
lusair
1
m-clear
1
m-clear wc
1
M-END MAX D
3
M-END PE
3
m-end wc
1
MAR-COF BP
3
MAR-COF CG
3
MAXIFED
3
mesehist wc
1
mytussin dac
1
NASOTUSS
3
NEO AC
3
NEOTUSS-D (CHLORPHENIRAMINE)
3
pcm la
1
pe-hist dm
1
PHENFLU
3
phenylhistine dh
1
POLY HIST
3
poly-tussin
1
POLY-TUSSIN
3
Requirements / Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
98
Drug Name
Drug Tier
poly-tussin d
1
PRO-CLEAR
3
PRO-RED
3
promethazine vc
1
promethazine-codeine
1
promethazine-dm
1
promethazine-phenyleph-codeine
1
PYRIL D
3
r-tanna
1
relcof c
1
RESCON
3
RESPA-AR
3
REZIRA
3
robafen ac
1
ru-hist forte
1
SEMPREX-D
3
STATUSS GREEN (CODEINE)
3
sudatex-dm
1
TEKRAL
3
TESSALON
3
TESSALON PERLES
3
tl-hist cd
1
trexbrom
1
TRICODE AR
3
TRICODE GF
3
trymine cg
1
tusnel c
1
tusnel diabetic
1
TUSNEL PEDIATRIC
3
TUSSICAPS
3
tussigon
1
TUSSIONEX PENNKINETIC ER
3
Requirements / Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
99
Drug Name
Drug Tier
V-HIST
3
VANACOF CD
3
VITUZ
3
Z-TUSS AC
3
Z-TUSS E
3
ZODRYL
3
ZODRYL DAC
3
ZODRYL DEC
3
ZONATUSS
3
ZUTRIPRO
3
Requirements / Limits
PULMONARY AGENTS
ACCOLATE
3
ACCUNEB
3
ADCIRCA
4
PA; QPD
ADEMPAS
4
PA; QPD
ADRENALIN
3
ADVAIR DISKUS/HFA
2
AEROSPAN
3
albuterol sulfate
1
ALVESCO
3
aminophylline
1
ANORO ELLIPTA
2
QPD
ARCAPTA NEOHALER
3
QPD
ASMANEX TWISTHALER
3
QPD
ATROVENT HFA
2
QPD
BECONASE AQ
3
ST; QPD
BREO ELLIPTA
2
BRONCOMAR-1
3
BROVANA
3
QPD
budesonide
1
QPD
CINRYZE
4
PA; QPD
COMBIVENT
2
QPD
QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
100
Drug Name
Drug Tier
Requirements / Limits
COMBIVENT RESPIMAT
3
QPD
cromolyn
1
CUROSURF
3
DALIRESP
3
difil-g 400
1
DULERA
3
DUONEB
3
dylix
1
DYMISTA
3
ELIXOPHYLLIN
3
ESBRIET
4
PA; QPD
FIRAZYR
4
PA; QPD
FLONASE
3
ST; QPD
FLOVENT DISKUS
2
QPD
FLOVENT HFA
2
QPD
flunisolide
1
QPD
fluticasone
1
QPD
FORADIL AEROLIZER
2
QPD
HYPER-SAL
3
ipratropium bromide
1
ipratropium-albuterol
1
KALYDECO
4
PA; QPD
LETAIRIS
4
PA; QPD
levalbuterol hcl
1
LUFYLLIN
3
MAXAIR AUTOHALER
3
metaproterenol
1
montelukast
1
QPD
NASONEX
3
ST; QPD
NEBUSAL
3
OFEV
4
PA; QPD
OMNARIS
3
ST; QPD
QPD
ST; QPD
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
101
Drug Name
Drug Tier
Requirements / Limits
OPSUMIT
4
PA
PERFOROMIST
3
QPD
PROAIR HFA
2
QPD
PROVENTIL HFA
3
QPD
PULMICORT/FLEXHALER
2
QPD
PULMOZYME
4
QNASL
3
ST; QPD
QVAR
2
QPD
REVATIO ORAL SUSPENSION
4
PA; QPD
REVATIO ORAL TABLET
4
PA; QPD
RHINOCORT AQUA
3
ST; QPD
RUCONEST
4
PA; QPD
SEREVENT DISKUS
3
QPD
sildenafil
4
PA; QPD
SINGULAIR
3
ST; QPD
sodium chloride
1
SPIRIVA WITH HANDIHALER
2
QPD
SYMBICORT
2
QPD
terbutaline
1
THEO-24
3
theochron
1
theophylline
1
TRACLEER
4
PA
triamcinolone acetonide
1
QPD
TUDORZA PRESSAIR
3
QPD
TYVASO STARTER KIT
4
PA
VENTAVIS
4
PA
VENTOLIN HFA
2
QPD
VERAMYST
3
ST; QPD
VOSPIRE ER
3
XOPENEX
3
XOPENEX HFA
3
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
102
Drug Name
Drug Tier
Requirements / Limits
zafirlukast
1
ZETONNA
3
ZYFLO
3
ZYFLO CR
3
QPD
DETROL
3
ST; QPD
DETROL LA
3
ST; QPD
DITROPAN XL
3
ST; QPD
ENABLEX
2
ST; QPD
flavoxate
1
GELNIQUE
2
ST; QPD
MYRBETRIQ
2
ST; QPD
oxybutynin chloride oral syrup, tablet
1
oxybutynin chloride oral tablet extended release
24hr
1
QPD
OXYTROL
3
ST; QPD
SANCTURA
3
ST; QPD
SANCTURA XR
3
ST; QPD
tolterodine
1
QPD
TOVIAZ
3
ST; QPD
trospium
1
QPD
VESICARE
2
ST; QPD
ST; QPD
UROLOGICALS
ANTICHOLINERGICS & ANTISPASMODICS
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin
1
AVODART
3
QPD
finasteride
1
QPD
FLOMAX
3
QPD
JALYN
3
QPD
PROSCAR
3
QPD
RAPAFLO
3
QPD
tamsulosin
1
QPD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
103
Drug Name
UROXATRAL
Drug Tier
Requirements / Limits
3
CHOLINERGIC STIMULANTS
bethanechol chloride
1
URECHOLINE
3
MISCELLANEOUS UROLOGICALS
CIALIS 5 MG
3
CYSTAGON
3
cytra-2
1
cytra-3
1
cytra-k
1
ELMIRON
2
hyophen
1
K-PHOS
3
ORACIT
3
phosphasal
1
potassium citrate
1
potassium citrate-citric acid
1
PROCYSBI
4
PROSED/DS (ATROPINE FREE)
2
SHOHL'S MODIFIED
3
sodium citrate-citric acid
1
tricitrates
1
ur n-c
1
URELLE
3
uretron d-s
1
URIBEL
3
urimar-t
1
urin ds
1
UROCIT-K
3
urogesic-blue
1
UROQID-ACID NO.2
3
uryl
1
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
104
Drug Name
Drug Tier
ustell
1
UTA (WITH PHENYL SALICYLATE)
3
utira-c
1
Requirements / Limits
URINARY ANESTHETICS
phenazopyridine
1
phenazopyridine plus
1
PYRIDIUM
3
VITAMINS, HEMATINICS & ELECTROLYTES
ELECTROLYTES
calcarb 600 with vitamin d
$0
calcium
$0
calcium + vitamin d
$0
EFFER-K ORAL TABLET, EFFERVESCENT 10
MEQ, 20 MEQ
3
effer-k oral tablet, effervescent 25 meq
1
eliphos
1
GALZIN
3
hi-cal plus vit d
$0
k-effervescent
1
k-phos-neutral
1
K-TAB
3
klor-con
1
KLOR-CON/25
3
klor-con/ef
1
MICRO-K
3
oyster shell calcium
$0
oyster shell + vitamin d
$0
PHOSLO
3
PA
PHOSLYRA
3
PA
phospha 250 neutral
1
POTABA
3
potassium bicarb & chloride
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
105
Drug Name
Drug Tier
potassium bicarb-citric acid
1
potassium chloride
1
strong iodine
1
zinc sulfate
1
Requirements / Limits
MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES
NICAZEL
3
tri-zel
1
vp-zel
1
VITAMINS & HEMATINICS
b complete, b complex, b complex + vit b12
$0
calcium carbonate-vitamin d2
$0
calcium 600 with vitamin d3
$0
calcium carbonate-vitamin d2
$0
calvite p&d
$0
children's iron
$0
children's vitamin d
$0
cholecalciferol (vitamin d3)
$0
classic prenatal
$0
complex b-100
$0
d-vi-sol
$0
d-vita
$0
daily prenatal
$0
delta d3
$0
dialyvite 800
$0
elite-ob
$0
epiflur
$0
ergocalciferol (vitamin d2)
$0
farbee with c
$0
feosol, fer-iron, ferosul, ferro-time, ferrous sulfate
$0
ferrousul
$0
fluoritab
$0
folic acid
$0
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
106
Drug Name
Drug Tier
full spectrum b-vitamin c
$0
high potency iron
$0
iron (ferrous sulfate), chews, drops, liquid
$0
ludent fluoride
$0
MARNATAL-F
3
multi-vit with fluoride/fluroide & iron
$0
mvc-fluoride
$0
one daily prenatal
$0
oyster shell calcium with d
$0
p d natal vitamins-folic acid
$0
pediatric multivitamin-fl
$0
perry prenatal
$0
pnv cmb#95-ferrous fumarate-fa
$0
pnv vitamins
$0
poly-vita (iron)
$0
poly-vitamin with fluoride or iron
$0
poten b-150 cr
$0
PREFERA-OB ONE
3
prenatal/complete/formula/with minerals
$0
PRENATE DHA (FERR ASP GLYCIN)
3
PRENATE ENHANCE
3
PRENATE ESSENTIAL
3
PRENATE MINI
3
PRENATE RESTORE
3
PRENEXA
3
rena-vite
$0
risacal-d
$0
slow release iron
$0
sodium fluoride
$0
stress 500
$0
stress formula
$0
stress formula 600 c
$0
Requirements / Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
107
Drug Name
Drug Tier
stress/biotin
$0
strovite
$0
super b complex-vitamin c
$0
super b-50 complex plus
$0
total b/c
$0
tri-vit with fluoride & iron
$0
triveen-ten
$0
ultra b-100 complex
$0
vi-stress
$0
vit b complex-folic acid
$0
vitabee/c
$0
VITAFOL ULTRA
3
VITAFOL-PLUS
3
vitamin b complex
$0
vitamin b-100 complex
$0
vitamin d3
$0
vitamins a,c,d & fluoride
$0
vitamins b complex
$0
wee care
$0
Requirements / Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
108
Index
8
8-MOP .................................. 48
A
abacavir .................................. 7
abacavir-lamivudinezidovudine .......................... 7
ABILIFY .............................. 30
ABILIFY DISCMELT ......... 30
ABSORICA .......................... 50
ABSTRAL............................ 23
acamprosate .......................... 59
ACANYA ............................. 50
acarbose ................................ 64
ACCOLATE....................... 100
ACCU-CHEK ACTIVE TEST
.......................................... 64
ACCU-CHEK AVIVA ......... 64
ACCU-CHEK COMFORT
CURVE TEST .................. 64
ACCU-CHEK COMPACT
TEST ................................ 64
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 64
ACCUNEB ......................... 100
ACCUPRIL .......................... 36
ACCURETIC ....................... 36
ACCUTREND GLUCOSE .. 64
acebutolol ............................. 36
ACEON ................................ 36
acetaminophen-codeine ........ 23
acetasol hc ............................ 62
acetazolamide ....................... 93
acetic acid ............................. 62
acetic acid-aluminum acetate62
ACIPHEX............................. 76
acitretin ................................. 46
ACLOVATE ........................ 56
ACTEMRA .......................... 80
ACTHAR H.P. ..................... 63
ACTIGALL .......................... 71
ACTIMMUNE ..................... 77
ACTIQ .................................. 23
ACTIVELLA ....................... 81
ACTONEL ........................... 80
ACTOPLUS MET ................ 64
ACTOPLUS MET XR ......... 64
ACTOS ................................. 64
ACULAR.............................. 93
ACULAR LS ........................ 93
ACURA TEST STRIPS ....... 64
ACUVAIL ............................ 93
acyclovir ........................... 7, 56
ACZONE .............................. 50
ADACEL(TDAP
ADOLESN/ADULT) ....... 78
ADALAT CC ....................... 37
adapalene .............................. 50
ADASUVE ........................... 30
ADCIRCA .......................... 100
ADDERALL ........................ 30
adefovir ................................... 7
ADEMPAS ......................... 100
ADOXA................................ 13
ADRENACLICK ................. 96
ADRENALIN ..................... 100
ADVAIR DISKUS ............. 100
ADVANCED GLUC METER
TEST STRIP..................... 64
ADVICOR ............................ 44
ADVOCATE TEST STRIPS65
aero otic hc ........................... 62
AEROSPAN ....................... 100
afeditab cr ............................. 37
AFINITOR ........................... 14
AFINITOR DISPERZ .......... 14
AFLURIA 2014-2015 .......... 78
AGGRENOX........................ 43
AGRYLIN ............................ 59
AKNE-MYCIN .................... 50
ak-poly-bac ........................... 90
ala-cort .................................. 56
alagesic lq ............................. 23
ALA-HIST AC ..................... 97
ALA-HIST DHC .................. 97
ALAMAST ........................... 92
ALA-QUIN .......................... 54
ALA-SCALP ........................ 56
ALBENZA ........................... 10
albuterol sulfate .................. 100
ALCAINE ............................ 92
alclometasone ....................... 56
ALCORTIN A ...................... 54
ALDACTAZIDE ..................37
ALDACTONE ......................37
ALDARA ............................. 48
alendronate ..................... 59, 80
alfuzosin ............................. 103
aliclen ...................................47
ALINIA ................................ 10
ALKERAN ........................... 14
ALLEGRA ODT ..................96
ALLEGRA-D 12 HOUR ......97
ALLEGRA-D 24 HOUR ......97
ALLFEN CD ........................97
ALLFEN CDX .....................97
allopurinol............................. 80
ALOCRIL ............................. 92
ALOMIDE ............................ 92
alophen .................................71
ALOQUIN ............................ 54
ALORA ................................ 81
ALPHAGAN P .....................95
alprazolam ............................ 30
alprazolam intensol ...............30
ALREX .................................94
ALSUMA ............................. 20
ALTABAX ........................... 54
ALTACE .............................. 37
altafluor.................................92
altafrin...................................95
altavera (28) .......................... 84
ALTOPREV .........................44
ALUVEA .............................. 48
ALVESCO .......................... 100
alyacen 1/35 (28) ..................84
alyacen 7/7/7 (28) .................84
amantadine hcl ........................7
AMARYL ............................. 65
ambi 10peh-400gfn-20dm ....97
AMBIEN .............................. 30
AMBIFED ............................ 97
AMBIFED DM .....................97
amcinonide ........................... 56
AMERGE ............................. 20
AMERICAINE ANESTHETIC
..........................................53
amethia .................................84
amethia lo ............................. 84
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
109
amethyst ............................... 84
AMICAR .............................. 43
amiloride............................... 37
amiloride-hydrochlorothiazide
.......................................... 37
aminocaproic acid ................ 43
AMINOCAPROIC ACID .... 43
aminophylline ..................... 100
amiodarone ........................... 36
AMITIZA ............................. 71
amitriptyline ......................... 30
amitriptyline-chlordiazepoxide
.......................................... 30
amlodipine ............................ 37
amlodipine-atorvastatin ........ 44
amlodipine-benazepril .......... 37
amnesteem ............................ 50
amoxapine ............................ 30
amoxicil-clarithromy-lansopraz
.......................................... 76
amoxicillin............................ 12
AMOXICILLIN ................... 12
amoxicillin-pot clavulanate .. 12
amphetamine salt combo ...... 30
ampicillin.............................. 12
AMPYRA ............................. 21
AMRIX................................. 22
AMTURNIDE ...................... 37
anabar ................................... 27
ANACAINE ......................... 53
ANADROL-50 ..................... 68
ANAFRANIL ....................... 30
anagrelide ............................. 59
ANALPRAM E .................... 71
ANALPRAM-HC................. 71
ANAPROX........................... 27
anaspaz ................................. 70
anastrozole ............................ 14
ANCOBON ............................ 6
ANDRODERM .................... 68
ANDROGEL ........................ 68
ANDROID ........................... 68
androxy ................................. 68
ANGELIQ ............................ 81
ANORO ELLIPTA ............ 100
ANSAID ............................... 27
ANTABUSE......................... 59
ANTARA ............................. 44
antipyrine-benzocaine .......... 62
ANTIVERT .......................... 71
anucort-hc ............................. 71
ANUSOL-HC ....................... 71
ANZEMET ........................... 71
APEXICON .......................... 56
apexicon e ............................. 56
APIDRA ............................... 65
APIDRA SOLOSTAR ......... 65
APLENZIN .......................... 30
APOKYN ............................. 19
apraclonidine ........................ 95
apri ........................................ 84
APRISO ................................ 71
APTIOM ............................... 17
APTIVUS ............................... 7
AQUA GLYCOLIC HC ....... 56
aranelle (28) .......................... 84
ARAVA ................................ 80
arbinoxa ................................ 96
ARCALYST ......................... 77
ARCAPTA NEOHALER ... 100
ARICEPT ............................. 21
ARICEPT ODT .................... 21
ARIMIDEX .......................... 14
ARIXTRA ............................ 43
ARMOUR THYROID ......... 69
AROMASIN ......................... 14
ARTHROTEC 50 ................. 27
ARTISS ................................ 48
ASACOL .............................. 71
ascomp with codeine ............ 23
ASMANEX TWISTHALER
........................................ 100
aspir-81 ................................. 27
ASTAGRAF XL................... 14
ASTELIN ............................. 61
ASTEPRO ............................ 61
ASTRINGYN ....................... 48
ATACAND .......................... 37
ATACAND HCT ................. 37
ATELVIA ............................. 80
atenolol ................................. 37
atenolol-chlorthalidone ......... 37
ATIVAN ............................... 30
atorvastatin ........................... 44
atovaquone............................ 10
atovaquone-proguanil ........... 10
ATRALIN............................. 50
ATRIPLA ............................... 7
ATROPEN ............................ 59
atropine .................................91
atropine sulfate .....................91
atropine-care .........................91
ATROVENT.........................61
ATROVENT HFA..............100
AUBAGIO ............................ 21
aubra .....................................84
AUGMENTIN ......................12
AUGMENTIN ES-600 .........12
AURAX ................................ 62
aurodex .................................62
AUVI-Q ................................ 96
AVALIDE ............................ 37
AVANDAMET ....................65
AVANDARYL .....................65
AVANDIA ........................... 65
AVAPRO .............................. 37
avar .......................................50
AVAR ...................................50
AVAR LS ............................. 50
AVC VAGINAL ..................83
AVELOX .............................. 12
aviane ....................................84
avidoxy .................................13
AVIDOXY DK .....................13
AVINZA ............................... 23
avita ......................................50
AVITA ..................................50
AVODART......................... 103
AVONEX ............................. 77
AXERT .................................20
AXID ....................................76
AXIRON............................... 68
AYGESTIN .......................... 81
AZASAN .............................. 14
AZASITE ............................. 90
azathioprine .......................... 14
azelastine ........................ 61, 92
AZELEX............................... 50
AZILECT ............................. 19
azithromycin ...........................9
AZOPT .................................93
AZOR ...................................37
AZULFIDINE ......................72
AZULFIDINE EN-TABS ....72
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
110
azurette (28).......................... 84
B
b complete .......................... 106
bacitracin .............................. 90
baclofen ................................ 22
BACTRIM DS...................... 12
BACTROBAN ..................... 54
BACTROBAN NASAL ....... 61
balsalazide ............................ 72
balziva (28)........................... 84
BANZEL .............................. 17
BARACLUDE ....................... 7
BECONASE AQ ................ 100
belladonna alkaloids-opium . 70
benazepril ............................. 37
benazepril-hydrochlorothiazide
.......................................... 37
BENICAR ............................ 37
BENICAR HCT ................... 37
BENSAL HP ........................ 47
BENTYL .............................. 70
BENZAC AC ....................... 50
BENZAC AC WASH........... 50
BENZACLIN ....................... 50
BENZAMYCIN ................... 50
BENZAMYCINPAK ........... 50
BENZEFOAM ..................... 51
benzepro ............................... 51
BENZIQ ............................... 51
benzoin (bulk) ...................... 48
benzonatate ........................... 97
benzoyl peroxide .................. 51
benztropine ........................... 19
BEPREVE ............................ 92
BESIVANCE ....................... 90
BETADINE OPHTHALMIC
PREP ................................ 90
BETAGAN ........................... 91
betamethasone dipropionate . 56
BETAPACE ......................... 36
BETASERON ...................... 78
betaxolol ......................... 37, 91
bethanechol chloride .......... 104
BETHKIS ............................. 10
BETIMOL ............................ 91
BETOPTIC S........................ 91
BEYAZ................................. 85
BG-STAR ............................. 65
BIAXIN .................................. 9
bicalutamide ......................... 14
BIDIL ................................... 37
BILTRICIDE ........................ 10
BINOSTO ............................. 80
BIONIME RIGHTEST TEST
STRIPS ............................. 65
bisacodyl ............................... 72
bisa-lax ................................. 72
bisoprolol fumarate............... 37
bisoprolol-hydrochlorothiazide
.......................................... 37
BLEPH-10 ............................ 95
BLEPHAMIDE .................... 95
BLEPHAMIDE S.O.P. ......... 95
BLOOD GLUCOSE TEST .. 65
BONIVA .............................. 80
BOOSTRIX TDAP............... 78
BOSULIF ............................. 14
bp 10-1 .................................. 51
BP WASH ............................ 51
bp wash acne treatment ........ 51
bpo ........................................ 51
BREEZE ............................... 65
BREO ELLIPTA ................ 100
BREVICON (28) .................. 85
briellyn.................................. 85
BRILINTA ........................... 43
brimonidine .......................... 95
BRINTELLIX ...................... 30
BRISDELLE ........................ 30
BROMDAY.......................... 93
BROMFED DM ................... 97
bromfenac ............................. 93
bromocriptine ....................... 19
brompheniramin-phenylephrindm ..................................... 97
BRONCOMAR-1 ............... 100
BROVANA ........................ 100
budeprion sr .......................... 30
budeprion xl.......................... 30
budesonide .................... 72, 100
bumetanide ........................... 37
BUNAVAIL ......................... 27
bupap .................................... 23
BUPAP ................................. 23
BUPHENYL ......................... 59
buprenorphine hcl ................. 23
buprenorphine-naloxone .......27
buproban ............................... 61
bupropion hcl ........................30
buspirone .............................. 30
butalbital compound .............23
butalbital compound w/codeine
..........................................23
butalbital-acetaminop-caf-cod
..........................................23
butalbital-acetaminophen .....23
butalbital-acetaminophen-caff
..........................................23
butalbital-aspirin-caffeine.....23
BUTISOL ............................. 30
butorphanol tartrate ..............27
BUTRANS ........................... 23
BYDUREON ........................65
BYETTA .............................. 65
BYSTOLIC........................... 37
C
cabergoline ........................... 68
CADUET .............................. 44
CAFCIT ................................ 59
CAFERGOT .........................20
caffeine citrated ....................59
CALAN ................................ 37
CALAN SR .......................... 37
calcarb 600 with vitamin d .105
calcipotriene .........................46
calcitonin (salmon) ...............68
calcitrene............................... 46
calcitriol .......................... 46, 68
calcium 500 + d ..................105
calcium 500 + d (d3)...........105
calcium 600 with vitamin d3
........................................106
calcium carbonate-vitamin d2
........................................106
calvite p&d ......................... 106
CAMBIA .............................. 27
camila ...................................81
CAMPRAL ........................... 59
camrese .................................85
camrese lo ............................. 85
CANASA .............................. 72
candesartan ........................... 37
candesartan-hydrochlorothiazid
..........................................37
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
111
CANTIL ............................... 70
capacet .................................. 23
CAPCOF .............................. 97
CAPEX ................................. 56
CAPITAL WITH CODEINE
.......................................... 23
CAPRELSA ......................... 14
captopril ................................ 37
captopril-hydrochlorothiazide
.......................................... 38
CARAC ................................ 48
carafate ................................. 76
CARAFATE ......................... 76
CARBAGLU ........................ 59
carbamazepine ...................... 17
CARBATROL...................... 17
carbidopa .............................. 19
carbidopa-levodopa .............. 19
carbidopa-levodopaentacapone ........................ 19
carbinoxamine maleate ......... 96
CARDENE SR ..................... 38
CARDIZEM ......................... 38
CARDIZEM CD .................. 38
CARDIZEM LA ................... 38
CARDURA .......................... 38
CARDURA XL .................... 38
carisoprodol .......................... 22
carisoprodol-asa-codeine ...... 22
carisoprodol-aspirin .............. 22
CARMOL HC ...................... 48
CARNITOR ......................... 59
carteolol ................................ 91
cartia xt ................................. 38
carvedilol .............................. 38
CASODEX ........................... 14
CATAFLAM ........................ 27
CATAPRES ......................... 38
CATAPRES-TTS-1.............. 38
CAYSTON ........................... 10
caziant (28) ........................... 85
CEDAX .................................. 9
CEENU................................. 14
cefaclor ................................... 9
cefadroxil................................ 9
cefdinir ................................... 9
cefditoren pivoxil ................... 9
cefpodoxime ........................... 9
cefprozil .................................. 9
ceftibuten ................................ 9
CEFTIN .................................. 9
cefuroxime axetil .................... 9
CELEBREX ......................... 27
CELESTONE ....................... 63
CELEXA .............................. 30
CELLCEPT .......................... 14
CELONTIN .......................... 17
cem-urea ............................... 48
CENESTIN ........................... 81
CENTANY ........................... 54
centergy ................................ 97
centergy dm .......................... 97
cephadyn ............................... 23
cephalexin ............................... 9
cerisa ..................................... 51
CERVARIX VACCINE ....... 78
CERVIDIL ........................... 83
CESAMET ........................... 72
CETACAINE ....................... 53
CETRAXAL......................... 62
cevimeline ............................ 59
CHANTIX ............................ 61
chateal ................................... 85
CHEMET.............................. 59
CHENODAL ........................ 72
cheratussin ac ....................... 97
cheratussin dac ..................... 97
children's aspirin ................... 27
children's iron ..................... 106
children's vitamin d ............ 106
chloral hydrate ...................... 30
chlordiazepoxide hcl............. 30
chlordiazepoxide-clidinium .. 70
chlorhexidine gluconate ....... 61
chloroquine phosphate .......... 10
chlorothiazide ....................... 38
chlorpheniramine-hydrocodone
.......................................... 97
chlorpromazine ..................... 30
chlorpropamide ..................... 65
chlorthalidone ....................... 38
chlorzoxazone....................... 22
cholecalciferol (vitamin d3)106
cholestyramine (with sugar) . 44
cholestyramine light ............. 44
choline,magnesium salicylate
..........................................27
choline-mag trisalicylate ......27
CIALIS ............................... 104
ciclodan.................................54
CICLODAN KIT ..................54
ciclopirox .............................. 54
ciclopirox-vite-nail lacq remo
..........................................55
cilostazol ............................... 43
CILOXAN ............................ 90
cimetidine ............................. 76
CIMZIA ................................ 72
CINRYZE ........................... 100
CIPRO HC ............................ 63
CIPRO XR ............................ 12
CIPRODEX .......................... 63
ciprofloxacin .............12, 62, 90
citalopram ............................. 31
citrate of magnesia ................72
citroma ..................................72
claravis ..................................51
CLARIFOAM EF .................51
CLARINEX .......................... 96
CLARINEX-D 12 HOUR ....97
CLARINEX-D 24 HOUR ....97
claris clarifying wash ............51
clarithromycin.........................9
classic prenatal....................106
clearlax .................................72
clemastine ............................. 96
CLENIA EMOLLIENT........51
clenia foaming wash .............51
CLEOCIN ....................... 10, 83
CLEOCIN T .........................51
CLIMARA ............................ 81
CLIMARA PRO ...................81
CLINDACIN ETZ ................51
clindacin p ............................ 51
CLINDACIN PAC ...............51
clinda-derm ........................... 51
CLINDAGEL .......................51
clindamycin hcl ....................10
clindamycin palmitate hcl.....10
clindamycin phosphate ...51, 83
clindamycin-benzoyl peroxide
..........................................51
CLINDAREACH .................51
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
112
CLINDESSE ........................ 83
CLINORIL ........................... 27
clobetasol .............................. 56
CLOBETASOL-COAL TAR
.......................................... 47
CLOBEX .............................. 56
CLOCORTOLONE
PIVALATE ...................... 56
CLODAN KIT...................... 56
CLODERM .......................... 56
clomipramine........................ 31
clonazepam ........................... 17
clonidine ............................... 38
clonidine hcl ................... 31, 38
clopidogrel ............................ 43
clorazepate dipotassium ....... 31
clorpres ................................. 38
CLORPRES.......................... 38
clotrimazole ...................... 6, 55
clotrimazole-betamethasone . 55
clozapine............................... 31
CLOZARIL .......................... 31
CNL 8 NAIL ........................ 55
COAL TAR .......................... 47
COARTEM .......................... 10
cocaine .................................. 53
cocet ..................................... 23
COCET PLUS ...................... 23
CODAR AR ......................... 97
CODAR D ............................ 97
CODAR GF .......................... 97
codeine sulfate ...................... 23
CODEINE SULFATE .......... 23
codeine-guaifenesin .............. 97
co-gesic................................. 23
COLAZAL ........................... 72
colchicine-probenecid .......... 80
COLCRYS ........................... 80
COLESTID........................... 44
colestipol .............................. 45
colocort ................................. 72
COLY-MYCIN S ................. 63
COLYTE WITH FLAVOR
PACKS ............................. 72
COMBIGAN ........................ 93
COMBIPATCH .................... 81
COMBIVENT .................... 100
COMBIVENT RESPIMAT 101
COMBIVIR ............................ 7
COMETRIQ ......................... 14
COMMIT.............................. 61
COMPAZINE ....................... 72
COMPLERA .......................... 7
complex b-100 .................... 106
compro .................................. 72
COMTAN............................. 19
COMVAX ............................ 78
CONCEPTROL .................... 83
CONCERTA ........................ 31
CONDYLOX........................ 48
constulose ............................. 72
CONTOUR ........................... 65
CONZIP................................ 27
COPAXONE ........................ 21
COPEGUS .............................. 7
CORDARONE ..................... 36
CORDRAN .......................... 56
CORDRAN TAPE SMALL
ROLL................................ 56
COREG ................................ 38
COREG CR .......................... 38
CORGARD .......................... 38
cormax .................................. 56
corrective laxative ................ 72
cortane-b ............................... 62
CORTANE-B ....................... 48
CORTEF............................... 63
CORTENEMA ..................... 72
CORTIFOAM ...................... 72
cortisone ............................... 63
CORTISPORIN .............. 54, 63
CORTISPORIN-TC ............. 63
CORZIDE ............................. 38
COSOPT............................... 93
COSOPT............................... 93
COTAB A............................. 97
COTAB AX .......................... 97
COTABFLU ......................... 97
COUMADIN ........................ 43
covaryx ................................. 81
covaryx h.s............................ 81
COVERA-HS ....................... 38
COZAAR.............................. 38
cpm-pseudoephedhydrocodone ..................... 97
CREON ................................ 72
CRESTOR ............................ 45
CRESYLATE .......................62
CRINONE ............................ 81
CRIXIVAN............................. 7
cromolyn ................. 72, 92, 101
cryselle (28) .......................... 85
CUPRIMINE ........................80
CUROSURF .......................101
CUTIVATE .......................... 56
CUVPOSA ........................... 70
cyclafem 1/35 (28) ................85
cyclafem 7/7/7 (28)...............85
CYCLESSA (28) ..................85
cyclobenzaprine ....................22
CYCLOGYL ........................91
CYCLOMYDRIL .................95
cyclopentolate .......................92
cyclophosphamide ................14
CYCLOPHOSPHAMIDE ....14
CYCLOSERINE...................10
CYCLOSET .........................65
cyclosporine .......................... 14
cylate.....................................92
CYMBALTA ........................31
cyproheptadine .....................96
CYSTADANE ......................72
CYSTAGON ......................104
CYSTARAN.........................92
CYTOMEL ........................... 69
CYTOTEC ............................ 76
cytra-2 .................................104
cytra-3 .................................104
cytra-k .................................104
D
daily prenatal ......................106
DALIRESP ......................... 101
danazol ..................................68
DANTRIUM.........................22
dantrolene ............................. 22
DAPSONE ............................ 10
DAPTACEL (DTAP
PEDIATRIC) ....................78
DARAPRIM .........................10
dasetta 1/35 (28) ...................85
dasetta 7/7/7 (28) ..................85
DAYPRO .............................. 27
daysee ...................................85
DAYTRANA ........................31
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
113
DDAVP ................................ 68
deblitane ............................... 81
DECAVAC........................... 78
DELATESTRYL.................. 68
DELESTROGEN ................. 81
delta d3 ............................... 106
delyla (28) ............................ 85
DELZICOL .......................... 72
DEMADEX .......................... 38
demeclocycline ..................... 13
DEMEROL........................... 23
DEMSER.............................. 38
DEMULEN 1/50 (28)........... 85
DENAVIR ............................ 56
denta 5000 plus..................... 61
dentagel ................................ 61
depade................................... 27
DEPAKENE ......................... 17
DEPAKOTE ......................... 17
DEPEN TITRATABS .......... 80
DEPO-TESTOSTERONE.... 68
DERMA-SMOOTHE/FS
SCALP OIL ...................... 56
DERMASORB AF
COMPLETE KIT ............. 54
DERMASORB HC
COMPLETE KIT ............. 56
DERMASORB XM
COMPLETE KIT ............. 48
DERMATOP ........................ 57
dermazene............................. 54
DERMOTIC OIL ................. 62
desipramine .......................... 31
desloratadine......................... 96
desmopressin ........................ 68
desog-e.estradiol/e.estradiol . 85
DESOGEN ........................... 85
desogestrel-ethinyl estradiol. 85
DESONATE ......................... 57
desonide................................ 57
DESONIL ............................. 57
DESOWEN .......................... 57
desoximetasone .................... 57
DESOXYN ........................... 31
desquam-x ............................ 51
DESVENLAFAXINE .......... 31
DESVENLAFAXINE
FUMARATE .................... 31
DETROL ............................ 103
DETROL LA ...................... 103
dexamethasone ..................... 63
dexamethasone intensol ........ 63
dexamethasone sodium
phosphate .......................... 94
dexchlorpheniramine maleate
.......................................... 96
dexedrine .............................. 31
DEXEDRINE SPANSULE .. 31
DEXILANT .......................... 76
dexmethylphenidate.............. 31
DEXPAK 10 DAY ............... 63
DEXPAK 13 DAY ............... 63
DEXPAK 6 DAY ................. 63
dextroamphetamine .............. 31
dextroamphetamineamphetamine .................... 31
DIABETA ............................ 65
dialyvite 800 ....................... 106
DIAMOX SEQUELS ........... 93
DIASTAT ............................. 17
diazepam ......................... 17, 31
diazepam intensol ................. 31
DIBENZYLINE ................... 38
DICLEGIS ............................ 72
diclofenac potassium ............ 27
diclofenac sodium..... 27, 48, 93
diclofenac-misoprostol ......... 27
dicloxacillin .......................... 12
dicyclomine .......................... 70
didanosine............................... 7
DIDRONEL.......................... 59
DIFFERIN ............................ 51
DIFICID ................................. 9
difil-g 400 ........................... 101
diflorasone ............................ 57
DIFLUCAN ............................ 6
diflunisal ............................... 27
DIGEX NF ........................... 72
digox ..................................... 43
digoxin .................................. 43
dihydrocode-acetaminophencaff .................................... 23
dihydrocodeine-aspirin-caff . 23
dihydroergotamine................ 20
DILACOR XR ...................... 38
DILANTIN ........................... 17
DILATRATE-SR .................46
DILAUDID........................... 23
dilt-cd ....................................38
diltia xt ..................................38
diltiazem hcl .........................38
dilt-xr ....................................38
diltzac er ............................... 38
DIOVAN .............................. 39
DIOVAN HCT .....................39
DIPENTUM .........................72
diphenhydramine hcl ............96
diphenoxylate-atropine .........70
DIPROLENE ........................57
DIPROLENE AF ..................57
dipyridamole .........................43
diskets ...................................24
disopyramide phosphate .......36
disulfiram .............................. 59
DITROPAN XL..................103
DIURIL.................................39
divalproex ............................. 17
DIVIGEL .............................. 81
DOLGIC PLUS ....................24
DOLOGESIC .......................27
DOLOPHINE .......................24
DONATUSS DC ..................97
donepezil............................... 21
DONNATAL ........................70
DORAL ................................ 31
DORYX ................................ 13
dorzolamide .......................... 93
dorzolamide-timolol .............93
DOVONEX .......................... 47
doxazosin .............................. 39
doxepin .................................31
doxercalciferol ......................68
doxycycline hyclate ..............13
doxytex .................................96
drithocreme hp ......................47
DRITHO-SCALP .................47
dronabinol ............................. 72
drospirenone-ethinyl estradiol
..........................................85
DROXIA............................... 14
DRYSOL DAB-O-MATIC ..48
DUAC ...................................51
DUAVEE .............................. 81
ducodyl .................................72
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
114
DUETACT ........................... 65
DUEXIS ............................... 28
dulcolax balance ................... 72
DULERA ............................ 101
duloxetine ............................. 31
DUONEB ........................... 101
DURAGESIC ....................... 24
DURASAL ........................... 48
duraxin.................................. 28
DUREZOL ........................... 94
DUTOPROL......................... 39
d-vi-sol ............................... 106
d-vita................................... 106
DYAZIDE ............................ 39
dylix .................................... 101
DYMISTA .......................... 101
DYNACIN ........................... 13
DYNACIRC CR................... 39
DYRENIUM ........................ 39
dytuss .................................... 96
E
e.c. prin ................................. 28
e.e.s. 400 ............................... 10
E.E.S. GRANULES ............. 10
EC-NAPROSYN .................. 28
econazole .............................. 55
ecotrin ................................... 28
ecotrin low strength .............. 28
ECOZA................................. 55
EDARBI ............................... 39
EDARBYCLOR ................... 39
ed-chlor-tan .......................... 96
EDECRIN............................. 39
EDLUAR .............................. 31
ed-spaz .................................. 70
EDURANT ............................. 7
eemt hs.................................. 81
effer-k ................................. 105
EFFER-K............................ 105
EFFEXOR XR...................... 31
EFFIENT .............................. 43
EFUDEX .............................. 48
ELDEPRYL ......................... 19
ELESTAT............................. 92
ELESTRIN ........................... 81
ELIDEL ................................ 49
ELIMITE .............................. 58
elinest ................................... 85
eliphos ................................ 105
ELIQUIS .............................. 43
elite-ob ................................ 106
ELIXOPHYLLIN ............... 101
ELLA .................................... 85
ELMIRON .......................... 104
ELOCON .............................. 57
EMADINE............................ 92
EMCYT ................................ 14
EMEND ................................ 73
emgel .................................... 51
EMLA ................................... 53
emoquette ............................. 85
EMSAM ............................... 31
EMTRIVA .............................. 7
ENABLEX ......................... 103
enalapril maleate................... 39
enalapril-hydrochlorothiazide
.......................................... 39
ENBREL .............................. 80
endacof-dc ............................ 97
ENDAL CD .......................... 98
endocet.................................. 24
endodan ................................ 24
ENGERIX-B ........................ 78
ENJUVIA ............................. 81
ENOVARXAMITRIPTYLINE ........... 49
ENOVARXCYCLOBENZAPRINE.... 49
ENOVARX-IBUPROFEN ... 28
enoxaparin ............................ 43
enpresse ................................ 85
enskyce ................................. 85
entacapone ............................ 19
entecavir ................................. 7
enteric coated aspirin ............ 28
ENTOCORT EC................... 73
enulose .................................. 73
EPANED .............................. 39
EPIDUO ............................... 51
epiflur ................................. 106
EPIFOAM ............................ 47
epinastine .............................. 92
epinephrine ........................... 96
EPIPEN ................................ 96
EPIPEN JR ........................... 96
epitol ..................................... 17
EPIVIR ...................................7
EPIVIR HBV ..........................7
eplerenone............................. 39
eprosartan ............................. 39
EPZICOM............................... 7
EQUETRO ........................... 17
ergocalciferol (vitamin d2) .106
ergoloid .................................31
ERGOMAR .......................... 20
ergotamine-caffeine ..............20
ERIVEDGE .......................... 14
errin.......................................82
ERTACZO ............................ 55
ery pads .................................51
erygel ....................................51
ERYPED 200........................10
ery-tab ...................................10
ERY-TAB ............................. 10
erythromycin...................10, 90
erythromycin with ethanol ....51
erythromycin-benzoyl peroxide
..........................................51
erythromycin-sulfisoxazole ..10
ESBRIET ............................ 101
escitalopram oxalate .............31
ESGIC...................................24
ESGIC-PLUS .......................24
ESOMEPRAZOLE
STRONTIUM ...................76
estarylla.................................85
estazolam .............................. 31
ESTRACE ............................ 82
ESTRADERM ......................82
estradiol ................................ 82
estradiol-norethindrone acet .82
ESTRASORB .......................82
ESTRING ............................. 82
ESTROGEL .......................... 82
estrogens-methyltestosterone82
estropipate............................. 82
ESTROSTEP FE-28 .............85
ethambutol ............................ 10
ethosuximide.........................17
ethrane ..................................59
etidronate disodium ..............59
etodolac.................................28
EURAX ................................ 58
EVAMIST ............................ 82
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
115
EVISTA ................................ 80
EVOCLIN ............................ 52
EVOXAC ............................. 59
exactacain ............................. 53
EXALGO ER ....................... 24
EXELDERM ........................ 55
EXELON .............................. 21
exemestane ........................... 15
EXFORGE ........................... 39
EXFORGE HCT .................. 39
EXJADE ............................... 59
ex-lax ultra............................ 73
EXODERM .......................... 55
exotic-hc ............................... 62
EXTAVIA ............................ 78
EXTINA ............................... 55
F
FABIOR ............................... 52
FACTIVE ............................. 12
fallback solo ......................... 85
falmina (28) .......................... 85
famciclovir ............................. 7
famotidine............................. 76
FAMVIR ................................ 7
FANAPT .............................. 32
farbee with c ....................... 106
FARESTON ......................... 15
FARXIGA ............................ 65
FAZACLO ........................... 32
FC FEMALE CONDOM ..... 83
felbamate .............................. 17
FELBATOL ......................... 17
FELDENE ............................ 28
felodipine .............................. 39
FEMARA ............................. 15
FEMCAP .............................. 83
FEMCON FE........................ 85
FEMHRT 1/5........................ 82
FEMHRT LOW DOSE ........ 82
FEMRING ............................ 82
FEMTRACE......................... 82
fenofibrate ............................ 45
FENOFIBRATE ................... 45
fenofibric acid ...................... 45
fenofibric acid (choline) ....... 45
FENOGLIDE ....................... 45
fenoprofen ............................ 28
FENOPROFEN .................... 28
fentanyl citrate ...................... 24
fentanyl patches .................... 24
FENTORA............................ 24
feosol .................................. 106
FERRIPROX ........................ 59
ferrousul.............................. 106
FETZIMA ............................. 32
FEXMID ............................... 22
FIBRICOR............................ 45
FINACEA ............................. 52
FINACEA PLUS .................. 52
finasteride ........................... 103
FIORICET ............................ 24
FIORICET WITH CODEINE
.......................................... 24
FIORINAL ........................... 24
FIORINAL-CODEINE #3 ... 24
FIRAZYR ........................... 101
FIRMAGON ......................... 15
FIRST-HYDROCORTISONE
.......................................... 57
FIRST-LANSOPRAZOLE .. 76
FIRST-OMEPRAZOLE ....... 76
FLAGYL .............................. 10
FLAREX .............................. 94
flavoxate ............................. 103
flecainide .............................. 36
FLECTOR ............................ 28
FLEXERIL ........................... 22
FLOMAX ........................... 103
FLONASE .......................... 101
FLO-PRED ........................... 63
FLOVENT DISKUS .......... 101
FLOVENT HFA ................. 101
FLUARIX 2014-2015 .......... 78
FLUBLOK 2014-2015 ......... 78
FLUCELVAX 2014-2015 .... 78
fluconazole ............................. 6
flucytosine .............................. 6
fludrocortisone...................... 63
FLULAVAL 2014-2015....... 78
FLUMADINE ........................ 7
FLUMIST QUAD 2014-2015
.......................................... 78
flunisolide ........................... 101
fluocinolone .......................... 57
fluocinolone acetonide oil .... 62
fluocinonide .......................... 57
fluocinonide-e .......................57
fluoridex daily defense .........61
fluoritab .............................. 106
fluorometholone ...................94
FLUOROPLEX ....................49
fluorouracil ........................... 49
fluoxetine .............................. 32
FLUOXETINE .....................32
fluphenazine hcl....................32
flurazepam ............................ 32
flurbiprofen ........................... 28
flurbiprofen sodium ..............93
FLURESS ............................. 92
flurox ....................................92
flutamide ............................... 15
fluticasone..................... 57, 101
fluvastatin ............................. 45
FLUVIRIN 2014-2015 .........78
fluvoxamine .......................... 32
FLUZONE 2014-2015..........79
FML FORTE ........................94
FML LIQUIFILM ................95
FML S.O.P............................ 95
FOCALIN ............................. 32
FOCALIN XR ......................32
folic acid ............................. 106
fondaparinux .........................44
FORADIL AEROLIZER....101
FORFIVO XL .......................32
FORTAMET.........................65
FORTEO............................... 80
FORTESTA .......................... 68
fortical...................................68
FOSAMAX........................... 80
FOSAMAX PLUS D ............80
fosinopril............................... 39
fosinopril-hydrochlorothiazide
..........................................39
FOSRENOL .........................59
FRAGMIN ............................ 44
FREESTYLE INSULINX
TEST STRIPS ..................65
FREESTYLE LITE STRIPS 65
FREESTYLE TEST .............65
FRENADOL .........................28
FROVA.................................20
full spectrum b-vitamin c....107
FULYZAQ ........................... 70
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
116
FURADANTIN .................... 13
furosemide ............................ 39
FUZEON ................................ 7
FYCOMPA .......................... 18
G
G-4 TEST ............................. 65
gabapentin ............................ 18
GABITRIL ........................... 18
galantamine .......................... 21
GALZIN ............................. 105
garamycin ............................. 90
GARAMYCIN ..................... 90
GARDASIL.......................... 79
gastrinex nf ........................... 73
GASTROCROM .................. 73
GASTROMARK .................. 73
gatifloxacin ........................... 90
GATTEX 30-VIAL .............. 73
gavilax .................................. 73
gavilyte-c .............................. 73
gavilyte-g.............................. 73
gavilyte-n .............................. 73
GE100 BLOOD GLUCOSE
TEST STRIP .................... 65
GELNIQUE ........................ 103
gemfibrozil ........................... 45
GENERESS FE .................... 85
generlac ................................ 73
gengraf .................................. 15
GENOTROPIN .................... 78
gentak ................................... 90
gentamicin ...................... 54, 90
gentasol................................. 90
gentle laxative ...................... 73
gentlelax ............................... 73
GEODON ............................. 32
gianvi (28) ............................ 85
GIAZO ................................. 73
gildagia ................................. 86
gildess ................................... 86
gildess fe ............................... 86
GILENYA ............................ 21
GILOTRIF ............................ 15
GLEEVEC ............................ 15
glimepiride ........................... 65
glipizide ................................ 65
glipizide-metformin .............. 65
GLUCOCOM GLUCOSE.... 65
GLUCOPHAGE XR ............ 65
GLUCOTROL ...................... 65
GLUCOTROL XL ............... 65
GLUCOVANCE .................. 66
GLUMETZA ........................ 66
glyburide ............................... 66
glyburide micronized ............ 66
glyburide-metformin ............ 66
GLYCATE ........................... 70
glycolax ................................ 73
glycopyrrolate ....................... 70
GLYNASE ........................... 66
GLYSET ............................... 66
GMATE TEST STRIPS ....... 66
GOLYTELY ......................... 73
goniovisc .............................. 92
GORDONS UREA ............... 49
GRALISE ............................. 18
GRALISE 30-DAY STARTER
PACK ............................... 18
granisetron ............................ 73
granisol ................................. 73
GRANULEX ........................ 58
GRASTEK............................ 79
GRIFULVIN V....................... 6
griseofulvin microsize ............ 6
GRIS-PEG
(ULTRAMICROSIZE) ...... 6
guaiatussin ac ....................... 98
guaifenesin............................ 98
guaifenesin ac ....................... 98
guaifenesin dac ..................... 98
guanfacine ............................ 39
guanidine .............................. 32
GYNAZOLE-1 ..................... 83
gynol ii .................................. 83
H
halac...................................... 57
HALCION ............................ 32
HALFLYTELY-BISACODYL
W-FLAV PK .................... 73
halfprin ................................. 28
halobetasol propionate .......... 57
HALOG ................................ 57
halonate ................................ 57
halonate pac .......................... 57
haloperidol ............................ 32
haloperidol decanoate ........... 32
haloperidol lactate ................32
HARVONI .............................. 7
HAVRIX............................... 79
healthylax ............................. 73
heather ..................................82
hecoria ..................................15
HECTOROL .........................68
HELIDAC............................. 76
hemril-30 .............................. 73
HEPSERA .............................. 7
HETLIOZ ............................. 32
HEXALEN ........................... 15
HIBERIX .............................. 79
hi-cal plus vit d ...................105
high potency iron ................107
HIPREX ................................ 13
homatropaire .........................92
homatropine hbr....................92
HORIZANT .......................... 21
HUMALOG .......................... 66
HUMALOG MIX 50-50.......66
HUMALOG MIX 75-25.......66
HUMATROPE .....................78
HUMIRA .............................. 80
HUMULIN 70/30 .................66
HUMULIN N .......................66
HUMULIN R........................66
HUMULIN R U-500 ............66
HYCAMTIN.........................15
HYCET .................................24
hydralazine ........................... 39
HYDREA ............................. 15
HYDRO 35 ........................... 49
hydrochlorothiazide ..............39
hydrocodone-acetaminophen 24
HYDROCODONEACETAMINOPHEN ........24
hydrocodone-homatropine ....98
hydrocodone-ibuprofen ........24
hydrocortisone ..........57, 64, 73
hydrocortisone acet-aloe vera
..........................................57
hydrocortisone acetate ..........73
hydrocortisone butyrate ........57
hydrocortisone butyr-emollient
..........................................57
hydrocortisone valerate ........57
hydrocortisone-acetic acid ....62
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
117
hydrocortisone-min oil-wht pet
.......................................... 57
hydrocortisone-pramox-epram#1 .............................. 73
hydrocortisone-pramoxine .. 47,
73
hydro-iodoquinol 2-1............ 54
hydromet............................... 98
hydromorphone .................... 24
hydroxychloroquine ............. 10
hydroxyurea .......................... 15
hydroxyzine hcl .................... 96
hydroxyzine pamoate ........... 96
hyomax-sl ............................. 70
hyophen .............................. 104
hyoscyamine sulfate ............. 70
hypercare .............................. 49
HYPER-SAL ...................... 101
HYZAAR ............................. 39
I
ibandronate ........................... 80
IBUDONE ............................ 24
ibuprofen .............................. 28
ibuprofen-oxycodone ........... 24
ICLUSIG .............................. 15
ILEVRO ............................... 93
ILOTYCIN ........................... 90
IMBRUVICA ....................... 15
IMDUR................................. 46
imipramine hcl...................... 32
imipramine pamoate ............. 32
imiquimod ............................ 49
IMITREX ............................. 20
IMURAN .............................. 15
INCIVEK ............................... 7
INCRELEX .......................... 60
indapamide ........................... 39
INDERAL LA ...................... 39
INDOCIN ............................. 28
indomethacin ........................ 28
INFANRIX (DTAP) ............. 79
INFASURF .......................... 60
INFERGEN .......................... 78
INFINITY TEST STRIPS .... 66
INLYTA ............................... 15
INNOPRAN XL ................... 39
INOVA ................................. 52
INOVA 4-1........................... 48
INSPRA ................................ 40
INTELENCE .......................... 7
INTERMEZZO .................... 32
introvale ................................ 86
INTUNIV ER ....................... 32
INVEGA ............................... 32
INVIRASE ............................. 7
INVOKAMET ...................... 66
INVOKANA ........................ 66
IODOFLEX .......................... 49
iodoquinol-hc........................ 54
IODOSORB.......................... 49
IOPIDINE ............................. 95
ipecac .................................... 73
IPOL ..................................... 79
ipratropium bromide ..... 61, 101
ipratropium-albuterol.......... 101
IPRIVASK............................ 44
IQUIX ................................... 90
irbesartan .............................. 40
irbesartan-hydrochlorothiazide
.......................................... 40
IRESSA ................................ 15
iron...................................... 107
ISENTRESS ........................... 7
ISOCHRON.......................... 46
isoflurane .............................. 60
isomethepten-cafacetaminophen .................. 20
isonarif .................................. 10
isoniazid................................ 11
ISOPTO ATROPINE ........... 92
ISOPTO CARBACHOL ...... 94
ISOPTO CARPINE .............. 92
ISOPTO HOMATROPINE .. 92
ISOPTO HYOSCINE ........... 92
ISORDIL .............................. 46
isosorbide dinitrate ............... 46
isosorbide mononitrate ......... 46
isradipine .............................. 40
ISTALOL ............................. 91
itraconazole ............................ 6
J
JAKAFI ................................ 15
JALYN ............................... 103
jantoven ................................ 44
JANUMET ........................... 66
JANUMET XR ..................... 66
JANUVIA ............................. 66
JARDIANCE ........................66
J-COF DHC .......................... 98
jencycla .................................82
JENTADUETO ....................66
jevantique ............................. 82
jinteli .....................................82
J-MAX DHC ........................98
jolessa ...................................86
jolivette .................................82
JUBLIA ................................ 55
junel 1.5/30 (21) ...................86
junel 1/20 (21) ......................86
junel fe 1.5/30 (28) ...............86
junel fe 1/20 (28) ..................86
JUVISYNC ........................... 66
JUXTAPID ........................... 45
K
KADIAN .............................. 24
KALETRA ............................. 7
KALYDECO ......................101
KAPVAY ............................. 32
kariva (28) ............................ 86
KAYEXALATE ...................60
KAZANO ............................. 66
k-effervescent .....................105
KEFLEX .................................9
kelnor 1/35 (28) ....................86
KENALOG ........................... 57
KEPPRA ............................... 18
KERAFOAM ........................49
KERALYT RX .....................48
KERALYT SCALP
COMPLETE .....................48
KERLONE ........................... 40
KEROL .................................49
KETEK .................................11
ketoconazole .....................6, 55
ketodan .................................55
ketoprofen ............................. 28
ketorolac ......................... 28, 93
KHEDEZLA .........................32
KINERET ............................. 81
KINRIX ................................ 79
kionex ...................................60
KLARON ............................. 54
KLONOPIN .......................... 18
klor-con 10.......................... 105
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
118
KLOR-CON/25 .................. 105
klor-con/ef .......................... 105
KOMBIGLYZE XR ............. 66
KORLYM............................. 69
K-PHOS MF....................... 104
k-phos-neutral..................... 105
KRISTALOSE ..................... 73
K-TAB................................ 105
kurvelo .................................. 86
KUVAN ............................... 69
KYNAMRO ......................... 45
L
l norgest&e estradiol-e estrad
.......................................... 86
labetalol ................................ 40
LACRISERT ........................ 92
lactulose................................ 73
LAMICTAL ......................... 18
LAMICTAL ODT ................ 18
LAMICTAL STARTER
(BLUE) KIT ..................... 18
LAMICTAL XR ................... 18
LAMISIL .......................... 6, 55
lamivudine .............................. 7
lamivudine-zidovudine ........... 8
lamotrigine ........................... 18
LANOXIN ............................ 43
lansoprazole .......................... 76
LANTUS .............................. 66
larin 1.5/30 (21) .................... 86
larin 1/20 (21) ....................... 86
larin fe .................................. 86
LASIX .................................. 40
LASTACAFT ....................... 93
latanoprost ............................ 94
LATUDA ............................. 32
lavoclen-4 ............................. 52
laxa clear .............................. 73
laxative ................................. 74
laxative feminine .................. 74
laxative peg 3350 ................. 74
LAZANDA........................... 24
LAZERFORMALYDE ........ 60
leena 28 ................................ 86
leflunomide........................... 81
LESCOL ............................... 45
LESCOL XL ........................ 45
lessina ................................... 86
LETAIRIS .......................... 101
letrozole ................................ 15
LETS KIT ............................. 53
leucovorin calcium ............... 14
LEUKERAN ........................ 15
levacet ................................... 28
levalbuterol hcl ................... 101
LEVAQUIN ......................... 12
LEVATOL............................ 40
LEVBID ............................... 70
LEVEMIR ............................ 66
levetiracetam ........................ 18
levobunolol ........................... 91
levocarnitine ......................... 60
levocarnitine (with sugar) ..... 60
levocetirizine ........................ 96
levofloxacin .................... 12, 90
levonest (28) ......................... 86
levonorgestrel ....................... 86
levonorgestrel-ethinyl estrad 86
levora 0.15/30 (28) ............... 86
levora-28 ............................... 86
levorphanol tartrate............... 24
levothroid.............................. 69
levothyroxine ........................ 69
levoxyl .................................. 69
LEVSIN/SL .......................... 70
LEVULAN ........................... 49
LEXAPRO............................ 32
LEXIVA ................................. 8
lexuss 210 ............................. 98
LIALDA ............................... 74
LIBERTY TEST................... 66
LIBRAX (WITH
CLIDINIUM) ................... 70
lidocaine ............................... 53
lidocaine hcl ......................... 53
lidocaine hcl-hydrocortison ac
.......................................... 74
LIDOCAINE HCLHYDROCORTISON AC . 74
lidocaine viscous .................. 53
lidocaine-hydrocortisone-aloe
.......................................... 74
lidocaine-prilocaine .............. 53
LIDODERM ......................... 54
LIDORX ............................... 54
LIDOVIR.............................. 56
lindane ..................................58
LINZESS .............................. 74
liothyronine........................... 69
LIPITOR ............................... 45
LIPOFEN .............................. 45
LIPTRUZET .........................45
lisinopril ................................ 40
lisinopril-hydrochlorothiazide
..........................................40
lithium carbonate ..................33
LITHOBID ........................... 33
LITHOSTAT ........................60
LIVALO ............................... 45
LO LOESTRIN FE ...............86
LO MINASTRIN FE ............86
LOCOID ............................... 57
LODOSYN ........................... 19
LOESTRIN 1.5/30 (21) ........86
LOESTRIN 1/20 (21) ...........86
LOESTRIN 24 FE ................86
LOESTRIN FE 1.5/30 (28) ..86
LOESTRIN FE 1/20 (28) .....86
LOFIBRA ............................. 45
lomedia 24 fe ........................87
LOMOTIL ............................ 70
LOMUSTINE .......................15
LO-OVRAL (28) ..................86
LO-OVRAL (8) ....................86
loperamide ............................ 71
LOPID ..................................45
LOPRESSOR HCT ..............40
LOPROX .............................. 55
lorazepam ............................. 33
lorazepam intensol ................33
lorcet (hydrocodone) ............25
LORCET 10/650 ..................25
lorcet hd ................................ 25
lorcet plus ............................. 25
LORCET PLUS ....................25
LORTAB .............................. 25
lortab 10-325 ........................25
LORTAB ELIXIR ................25
LORTUSS EX ......................98
loryna (28) ............................ 87
LORZONE ........................... 22
losartan .................................40
losartan-hydrochlorothiazide 40
LOSEASONIQUE ................87
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
119
LOTEMAX .......................... 95
LOTENSIN HCT ................. 40
LOTREL............................... 40
LOTRISONE ........................ 55
LOTRONEX ........................ 74
lovastatin .............................. 45
LOVAZA ............................. 45
LOVENOX........................... 44
low-ogestrel (28) .................. 87
loxapine succinate ................ 33
LOXITANE .......................... 33
ludent fluoride .................... 107
LUFYLLIN ........................ 101
lugols .................................... 54
LUMIGAN ........................... 94
LUNESTA ............................ 33
lusair ..................................... 98
lutera (28) ............................. 87
LUVOX CR.......................... 33
LUXIQ ................................. 57
LUZU ................................... 55
LYCELLE ............................ 58
LYMPHAZURIN ................. 60
LYRICA ............................... 18
LYSODREN......................... 15
LYSTEDA ............................ 83
lyza ....................................... 82
M
MACROBID ........................ 13
MACRODANTIN ................ 13
mafenide acetate ................... 54
MAGNACET ....................... 25
MAGNEBIND 400 .............. 74
magnesium citrate ................ 74
MAKENA ............................ 82
MALARONE ....................... 11
malathion .............................. 58
maprotiline ........................... 33
MAR-COF BP ...................... 98
MAR-COF CG ..................... 98
margesic ............................... 25
MARINOL ........................... 74
marlissa................................. 87
MARNATAL-F.................. 107
MARPLAN .......................... 33
marten-tab............................. 25
MATULANE ....................... 15
matzim la .............................. 40
MAVIK ................................ 40
MAXAIR AUTOHALER .. 101
MAXALT ............................. 20
MAXIDEX ........................... 95
MAXIDONE ........................ 25
MAXIFED (IR) .................... 98
MAXITROL ......................... 94
MAXZIDE............................ 40
MAXZIDE-25MG ................ 40
m-clear .................................. 98
m-clear wc ............................ 98
mebendazole ......................... 11
meclizine .............................. 74
meclofenamate...................... 28
MEDROL ............................. 64
medroxyprogesterone ........... 82
mefenamic acid..................... 28
mefloquine ............................ 11
MEGACE ............................. 15
MEGACE ES ....................... 15
megestrol .............................. 15
MEKINIST ........................... 15
meloxicam ............................ 28
MENACTRA........................ 79
M-END MAX D ................... 98
M-END PE ........................... 98
m-end wc .............................. 98
MENEST .............................. 82
MENOMUNE - A/C/Y/W-135
.......................................... 79
MENOSTAR ........................ 82
MENTAX ............................. 55
MENVEO A-C-Y-W-135-DIP
.......................................... 79
meperidine ............................ 25
meperitab .............................. 25
MEPHYTON ........................ 44
meprobamate ........................ 22
MEPRON ............................. 11
mercaptopurine ..................... 15
mesalamine ........................... 74
mesehist wc .......................... 98
MESNEX.............................. 14
MESTINON ......................... 22
MESTINON TIMESPAN .... 22
METADATE CD ................. 33
metadate er ........................... 33
metaproterenol .................... 101
metaxalone ............................ 22
metformin ............................. 66
methadone............................. 25
methadone intensol ...............25
methadose ............................. 25
methamphetamine.................33
methazolamide ......................93
methenamine hippurate ........13
METHERGINE ....................89
methimazole .........................64
METHITEST ........................69
methocarbamol .....................22
methotrexate sodium ............15
methscopolamine ..................71
methyclothiazide...................40
methyldopa ........................... 40
methyldopahydrochlorothiazide ..........40
methylergonovine .................89
METHYLIN .........................33
methylphenidate ...................33
methylprednisolone ..............64
metipranolol .......................... 91
metoclopramide hcl ..............74
metolazone ............................ 40
METOPIRONE ....................60
metoprolol succinate .............40
metoprolol ta-hydrochlorothiaz
..........................................40
metoprolol tartrate ................40
METOZOLV ODT ...............74
METROCREAM ..................52
METROGEL ........................52
METROGEL KIT .................52
METROGEL VAGINAL .....83
METROLOTION .................52
metronidazole ...........11, 52, 83
METVIXIA .......................... 49
MEVACOR .......................... 45
mexiletine ............................. 36
MIACALCIN .......................69
MICARDIS........................... 40
MICARDIS HCT..................40
miconazole-3 ........................83
microgestin 1.5/30 (21) ........87
microgestin 1/20 (21) ...........87
microgestin fe 1.5/30 (28) ....87
microgestin fe 1/20 (28) .......87
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
120
MICRO-K........................... 105
MICROZIDE ........................ 40
MIDAMOR .......................... 40
midodrine ............................. 60
MIFEPREX .......................... 83
migergot ............................... 20
migragesic ida ...................... 20
MIGRALAM ........................ 20
MIGRANAL ........................ 20
milk of magnesia .................. 74
millipred ............................... 64
MILLIPRED......................... 64
millipred dp .......................... 64
mimvey ................................. 82
mimvey lo ............................. 82
MINASTRIN 24 FE ............. 87
MINIPRESS ......................... 41
miniprin ................................ 28
MINITRAN .......................... 46
MINIVELLE ........................ 82
MINOCIN ............................ 13
minocycline .......................... 13
minoxidil .............................. 41
miralax .................................. 74
MIRAPEX ............................ 19
MIRAPEX ER ...................... 19
MIRCETTE (28) .................. 87
mirtazapine ........................... 33
MIRVASO ........................... 52
misoprostol ........................... 77
M-M-R II .............................. 79
MOBAN ............................... 33
MOBIC ................................. 28
modafinil .............................. 33
moderiba ................................. 8
moderiba dose pack ................ 8
MODICON (28) ................... 87
moexipril .............................. 41
moexipril-hydrochlorothiazide
.......................................... 41
mometasone.......................... 57
MOMEXIN .......................... 57
MONODOX ......................... 13
MONOKET .......................... 46
mono-linyah ......................... 87
mononessa (28) .................... 87
MONSEL'S .......................... 49
montelukast ........................ 101
MONUROL .......................... 13
morgidox .............................. 13
MORGIDOX 1X100 ............ 13
morphine............................... 25
MOTOFEN ........................... 71
MOVIPREP .......................... 74
MOXATAG.......................... 12
MOXEZA ............................. 90
moxifloxacin......................... 12
MOZOBIL ............................ 78
MS CONTIN ........................ 25
mst 600 ................................. 28
MULTAQ ............................. 36
multi-vit with fluoride & iron
........................................ 107
mupirocin.............................. 54
mvc-fluoride ....................... 107
my way ................................. 87
MYALEPT ........................... 69
MYAMBUTOL .................... 11
MYCOBUTIN ...................... 11
mycophenolate mofetil ......... 15
mycophenolate sodium ......... 15
MYDFRIN............................ 95
mydral ................................... 92
MYDRIACYL ...................... 92
MYFORTIC ......................... 16
MYLERAN .......................... 16
myorisan ............................... 52
myoxin .................................. 62
MYRBETRIQ .................... 103
MYSOLINE ......................... 18
MYTELASE ......................... 21
mytussin dac ......................... 98
myzilra .................................. 87
N
nabumetone .......................... 28
nadolol .................................. 41
nadolol-bendroflumethiazide 41
nafrinse ................................. 61
NAFTIN ............................... 55
NALFON .............................. 28
naltrexone ............................. 28
NAMENDA.......................... 21
NAMENDA XR ................... 21
naphazoline........................... 96
NAPRELAN CR .................. 28
NAPROSYN ........................ 29
naproxen ............................... 29
naratriptan ............................. 20
NARDIL ............................... 33
NASONEX ......................... 101
NASOTUSS .........................98
NATACYN........................... 90
NATAZIA ............................ 87
nateglinide ............................ 66
NATROBA ........................... 58
nature-throid .........................69
NEBUPENT .........................11
NEBUSAL .......................... 101
necon 0.5/35 (28) ..................87
necon 1/35 (28) .....................87
necon 1/50 (28) .....................87
necon 10/11 (28) ...................87
necon 7/7/7 (28) ....................87
nefazodone ............................ 33
NEO AC ............................... 98
NEOBENZ MICRO CREAM
PLUS PACK .....................52
neomycin .............................. 11
neomycin-bacitracin-poly-hc 94
neomycin-bacitracinpolymyxin .........................90
neomycin-polymyxindexameth........................... 94
neomycin-polymyxingramicidin .........................90
neomycin-polymyxin-hc.63, 94
neo-polycin ........................... 90
neo-polycin hc ......................94
NEORAL .............................. 16
NEOSPORIN (NEO-POLYMGRAMICID).....................90
NEOTIC (WITH GLYCERIN)
..........................................62
NEOTUSS-D
(CHLORPHENIRAMINE)
..........................................98
NEPTAZANE.......................93
NESINA ............................... 67
NEUAC KIT .........................52
NEUPRO .............................. 19
NEURONTIN .......................18
NEUTEK 2TEK TEST
STRIPS ............................. 67
NEVANAC........................... 93
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
121
nevirapine ............................... 8
NEXAVAR .......................... 16
NEXICLON XR ................... 41
NEXIUM .............................. 77
NEXIUM PACKET ............. 77
next choice............................ 87
next choice one dose ............ 87
niacin .................................... 45
NIACOR............................... 45
NIASPAN EXTENDEDRELEASE ........................ 45
nicardipine ............................ 41
NICAZEL ........................... 106
nicorelief............................... 61
NICORETTE ........................ 61
nicotine ................................. 61
nicotine (polacrilex) ............. 61
NICOTROL.......................... 61
NICOTROL NS.................... 61
nifediac cc ............................ 41
nifedical xl ............................ 41
nifedipine.............................. 41
nikki (28) .............................. 87
NILANDRON ...................... 16
nimodipine............................ 41
NIRAVAM ........................... 33
nisoldipine ............................ 41
nitro-bid ................................ 46
NITRO-DUR ........................ 46
nitrofurantoin ........................ 13
nitrofurantoin macrocrystal .. 13
nitrofurantoin monohyd/mcryst .................................. 13
nitroglycerin ......................... 46
NITROLINGUAL ................ 46
NITROMIST ........................ 46
NITROSTAT........................ 46
nizatidine .............................. 77
NIZORAL ............................ 55
nodolor ................................. 20
nora-be .................................. 82
NORCO ................................ 25
NORDETTE (28) ................. 87
NORDITROPIN FLEXPRO 78
noreth-ethinyl estradiol-iron. 87
norethindrone (contraceptive)
.......................................... 83
norethindrone acetate ........... 83
norethindrone ac-eth estradiol
.......................................... 87
norethindrone-e.estradiol-iron
.......................................... 87
norgestimate-ethinyl estradiol
.......................................... 87
norgestrel-ethinyl estradiol ... 87
NORINYL 1+35 (28) ........... 88
NORINYL 1+50 (28) ........... 88
NORITATE .......................... 52
norlyroc ................................ 83
NOROXIN............................ 12
NORPACE ........................... 36
NORPRAMIN ...................... 33
NOR-QD .............................. 82
nortrel 0.5/35 (28)................. 88
nortrel 1/35 (21).................... 88
nortrel 1/35 (28).................... 88
nortrel 7/7/7 (28) .................. 88
nortriptyline .......................... 33
NORVASC ........................... 41
NORVIR ................................. 8
NOVA MAX GLUCOSE
TEST ................................ 67
NOVACORT ........................ 54
novagesic .............................. 29
NOVOLIN 70/30 .................. 67
NOVOLIN N ........................ 67
NOVOLOG .......................... 67
NOVOLOG PENFILL ......... 67
NOXAFIL .............................. 6
np thyroid ............................. 69
nts step 1 ............................... 61
NUCORT.............................. 57
NUCYNTA .......................... 25
NUCYNTA ER .................... 25
NUEDEXTA ........................ 21
NULEV ................................ 71
NULYTELY WITH FLAVOR
PACKS ............................. 74
NUOX .................................. 52
NUTRESTORE .................... 60
NUTROPIN AQ ................... 78
NUVARING ......................... 84
NUVIGIL ............................. 33
nuzole ................................... 55
nyamyc ................................. 55
NYMALIZE ......................... 41
nystatin ....................... 6, 55, 84
NYSTATIN (BULK)..............6
nystatin-triamcinolone ..........55
nystop ...................................55
O
ocella.....................................88
ocudox ..................................13
OCUFEN .............................. 93
OCUFLOX ........................... 90
OFEV ..................................101
ofloxacin ................... 12, 63, 90
OGEN 2.5 ............................. 83
ogestrel (28) .......................... 88
olanzapine ............................. 33
olanzapine-fluoxetine ...........33
OLEPTRO ER ......................33
OLUX ...................................58
OLYSIO .................................8
OMECLAMOX-PAK...........77
omeprazole ........................... 77
OMEPRAZOLE+SYRSPEND
SF ALKA.......................... 77
omeprazole-sodium
bicarbonate .......................77
OMNARIS .......................... 101
OMNIPRED .........................95
OMNITROPE .......................78
ondansetron........................... 74
one daily prenatal ...............107
ONE TOUCH ULTRA TEST
..........................................67
ONFI .....................................18
ONGLYZA ........................... 67
ONMEL ..................................6
ONSOLIS ............................. 25
OPANA ................................ 25
OPANA ER .......................... 25
OPSUMIT........................... 102
OPTASE ............................... 58
OPTIPRANOLOL ................91
OPTIUM EZ .........................67
OPTIUM TEST ....................67
OPTIVAR ............................. 93
ORACEA .............................. 13
ORACIT ............................. 104
oral saline laxative ................74
ORALAIR ............................ 79
oralone ..................................61
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
122
ORAMORPH SR ................. 25
ORAP ................................... 33
ORAPRED ........................... 64
ORAPRED ODT .................. 64
ORAVIG ................................ 6
ORBIVAN............................ 25
ORENCIA ............................ 81
ORENITRAM ...................... 41
ORFADIN ............................ 60
orphenadrine citrate .............. 22
orphenadrine compound ....... 22
orphenadrine compound-ds .. 22
orsythia ................................. 88
ORTHO ALL-FLEX FITTING
SET ................................... 84
ORTHO DIAPHRAGM ALLFLEX 65 ........................... 84
ORTHO EVRA .................... 84
ORTHO MICRONOR.......... 83
ORTHO TRI-CYCLEN (28) 88
ORTHO TRI-CYCLEN LO
(28) ................................... 88
ORTHO-CEPT (28) ............. 88
ORTHO-CYCLEN (28) ....... 88
ORTHO-NOVUM 1/35 (28) 88
ORTHO-NOVUM 7/7/7 (21)
.......................................... 88
ORTHO-NOVUM 7/7/7 (28)
.......................................... 88
oscimin ................................. 71
oscimin sl.............................. 71
oscimin sr ............................. 71
OSENI .................................. 67
OSMOPREP ......................... 74
OTEZLA .............................. 81
OTIC CARE (ANTIPYRINE)
.......................................... 63
oticin hc (bak free) ............... 63
otomax-hc ............................. 63
otozin .................................... 63
OTREXUP ........................... 81
OVACE ................................ 47
OVACE PLUS ..................... 47
OVCON-35 (28)................... 88
OVCON-50 (28)................... 88
OVIDE ................................. 59
OXANDRIN......................... 69
oxandrolone .......................... 69
oxaprozin .............................. 29
oxazepam .............................. 33
oxcarbazepine ....................... 18
OXECTA .............................. 25
OXISTAT ............................. 55
OXSORALEN ...................... 49
OXSORALEN ULTRA ....... 49
OXTELLAR XR .................. 18
oxybutynin chloride ............ 103
oxycodone ............................ 25
oxycodone hcl-oxycodone-asa
.......................................... 25
oxycodone-acetaminophen ... 26
oxycodone-aspirin ................ 26
OXYCONTIN ...................... 26
oxymorphone ........................ 26
OXYTROL ......................... 103
oysco 500/d......................... 105
oysco d ................................ 105
oyster shell calcium with d . 107
P
p d natal vitamins-folic acid
........................................ 107
pacerone................................ 36
PACNEX .............................. 52
palgic .................................... 96
PAMELOR ........................... 33
PAMINE ............................... 71
PAMINE FORTE ................. 71
PANCREAZE ...................... 74
pancrelipase 5000 ................. 74
PANDEL .............................. 58
PANRETIN .......................... 49
pantoprazole ......................... 77
papaverine ............................ 41
PARAFON FORTE DSC ..... 22
PARCOPA............................ 19
paregoric ............................... 71
PAREMYD .......................... 92
paricalcitol ............................ 69
PARLODEL ......................... 19
PARNATE............................ 33
paroex oral rinse ................... 62
paromomycin ........................ 11
paroxetine hcl ....................... 33
PASER.................................. 11
PATADAY ........................... 93
PATANASE ......................... 62
PATANOL ........................... 93
PAXIL ..................................34
PAXIL CR ............................ 34
PCE .......................................10
pcm la ...................................98
PEDIADERM AF .................55
PEDIADERM HC ................58
PEDIAPRED ........................64
PEDIARIX ........................... 79
pediatric multivitamin-fl .....107
pedi-dri .................................55
PEDIPIROX-4 ......................55
PEDVAX HIB ......................79
peg 3350-electrolytes............74
PEG 3350-GRX ....................60
peg-3350 with flavor packs ..74
PEGANONE.........................18
PEGASYS ............................ 78
peg-electrolyte soln ..............75
PEGINTRON .......................78
pe-hist dm ............................. 98
penicillin v potassium ...........12
PENLAC............................... 55
PENNSAID .......................... 29
PENTACEL .......................... 79
PENTASA ............................ 75
pentazocine-acetaminophen .29
pentazocine-naloxone ...........29
pentoxifylline ........................44
PEPCID ................................ 77
PERCOCET .......................... 26
PERCODAN.........................26
PERFOROMIST.................102
PERIDEX ............................. 62
perindopril erbumine ............41
perio med .............................. 62
periogard ............................... 62
PERIOSTAT.........................13
permethrin............................. 59
perphenazine .........................34
perphenazine-amitriptyline ...34
perry prenatal ......................107
PERSANTINE ......................44
PERTZYE............................. 75
PEXEVA .............................. 34
phenadoz ............................... 96
phenazopyridine .................105
phenazopyridine plus ..........105
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
123
phenelzine............................. 34
phenergan ............................. 96
PHENFLU CD ..................... 98
phenobarb-hyoscy-atropinescop................................... 71
phenobarbital ........................ 18
phenylephrine hcl ................. 96
phenylhistine dh ................... 98
PHENYTEK ......................... 18
phenytoin .............................. 18
philith ................................... 88
PHISOHEX .......................... 54
PHOS-FLUR ........................ 62
PHOSLO ............................ 105
PHOSLYRA ....................... 105
phospha 250 neutral ........... 105
phosphasal .......................... 104
phosphate laxative ................ 75
PHOSPHOLINE IODIDE .... 91
PHRENILIN FORTE ........... 26
PICATO ............................... 49
pilocarpine hcl ................ 60, 92
PILOPINE HS ...................... 92
pimtrea (28) .......................... 88
pindolol................................. 41
PINNACAINE ..................... 63
pioglitazone .......................... 67
pioglitazone-glimepiride ...... 67
pioglitazone-metformin ........ 67
pirmella................................. 88
piroxicam.............................. 29
PLAN B ONE-STEP ............ 88
PLAQUENIL ....................... 11
PLAVIX ............................... 44
PLETAL ............................... 44
PLEXION ............................. 52
PNEUMOVAX 23 ............... 79
pnv cmb#95-ferrous fumaratefa ..................................... 107
pnv-dha ............................... 107
PODOCON........................... 48
podofilox .............................. 49
POLY HIST DHC ................ 98
polycin .................................. 90
polycin b ............................... 90
poly-dex ................................ 94
polyethylene glycol 3350 ..... 75
polymyxin b sulf-trimethoprim
.......................................... 90
POLYTRIM.......................... 90
poly-tussin ............................ 98
POLY-TUSSIN AC .............. 98
poly-tussin d ......................... 99
poly-vita (iron) ................... 107
poly-vitamin with fluoride.. 107
POMALYST ........................ 16
PONSTEL ............................ 29
PONTOCAINE .................... 54
portia..................................... 88
POTABA ............................ 105
potassium bicarb & chloride
........................................ 105
potassium bicarb-citric acid 106
potassium chloride.............. 106
potassium citrate ................. 104
potassium citrate-citric acid 104
POTASSIUM HYDROXIDE
.......................................... 48
poten b-150 cr ..................... 107
POTIGA ............................... 18
powderlax ............................. 75
PRADAXA ........................... 44
pramcort................................ 75
PRAM-HCA ......................... 75
pramipexole .......................... 19
PRAMOSONE E .................. 47
pramoxine-hc ........................ 63
PRANDIMET ....................... 67
PRANDIN ............................ 67
prascion ................................ 52
PRAVACHOL...................... 45
pravastatin ............................ 45
prazosin ................................ 41
PRECISION PCX PLUS TEST
.......................................... 67
PRECISION PCX TEST ...... 67
PRECISION POINT OF
CARE TEST ..................... 67
PRECISION Q-I-D TEST .... 67
PRECOSE ............................ 67
PRED FORTE ...................... 95
PRED MILD......................... 95
PRED-G................................ 94
PRED-G S.O.P. .................... 94
prednicarbate ........................ 58
prednisol ............................... 95
prednisolone .........................64
prednisolone acetate .............95
prednisolone sodium phosphate
..........................................95
prednisone............................. 64
PREFERA-OB ONE ..........107
PREFEST ............................. 83
PRELONE ............................ 64
PREMARIN .........................83
PREMPHASE.......................83
PREMPRO ........................... 83
prenatal ............................... 107
PRENATE DHA (FERR ASP
GLYCIN) ........................ 107
PRENATE ENHANCE ......107
PRENATE ESSENTIAL ....107
PRENATE MINI ................107
PRENATE RESTORE .......107
PRENEXA .......................... 107
preparation cleansing ............75
PREPIDIL............................. 84
PREPOPIK ........................... 75
PREVACID .......................... 77
PREVACID SOLUTAB .......77
prevalite ................................ 45
PREVIDENT ........................62
PREVIDENT 5000 DRY
MOUTH ........................... 62
PREVIDENT 5000 ENAMEL
PROTECT ........................62
previfem ................................ 88
PREVNAR 13 ......................79
PREVPAC ............................ 77
PREZISTA ............................. 8
PRIFTIN ............................... 11
PRILOSEC ........................... 77
PRIMAQUINE .....................11
primidone .............................. 18
PRIMLEV............................. 26
PRIMSOL ............................. 13
PRINIVIL ............................. 41
PRINZIDE ............................ 41
PRISTIQ ............................... 34
PROAIR HFA ....................102
probenecid ............................ 80
PROCARDIA .......................41
PROCARDIA XL .................41
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
124
procentra ............................... 34
prochlorperazine ................... 75
PRO-CLEAR AC ................. 99
PROCORT ........................... 75
PROCTOCORT ................... 75
PROCTOCREAM-HC ......... 75
PROCTOFOAM HC ............ 75
procto-pak............................. 75
proctosol hc .......................... 75
proctozone-hc ....................... 75
PROCYSBI ........................ 104
PRODIGY NO CODING ..... 67
PRODRIN ............................ 20
progesterone micronized ...... 83
PROGLYCEM ..................... 67
PROGRAF ........................... 16
PROLENSA ......................... 93
promacet ............................... 26
PROMACTA........................ 44
promethazine ........................ 96
promethazine vc ................... 99
promethazine-codeine .......... 99
promethazine-dm .................. 99
promethazine-phenylephcodeine ............................. 99
promethegan ......................... 96
PROMETRIUM ................... 83
propafenone .......................... 36
propantheline ........................ 71
propranolol ........................... 41
propranolol-hydrochlorothiazid
.......................................... 41
propylthiouracil .................... 64
PROQUAD........................... 79
PRO-RED AC (W/
DEXCHLORPHENIR) .... 99
PROSCAR.......................... 103
PROSED/DS (ATROPINE
FREE) ............................. 104
PROSTIGMIN ..................... 22
PROSTIN E2 ........................ 84
PROTONIX .......................... 77
PROTOPIC........................... 49
protriptyline .......................... 34
PROVENTIL HFA ............. 102
PROVERA ........................... 83
PROVIGIL ........................... 34
PROZAC .............................. 34
PROZAC WEEKLY ............ 34
prudoxin................................ 49
PULMICORT ..................... 102
PULMOZYME ................... 102
purelax .................................. 75
PURINETHOL ..................... 16
PYLERA .............................. 77
pyrazinamide ........................ 11
PYRIDIUM ........................ 105
pyridostigmine bromide ....... 22
PYRIL D............................... 99
PYROGALLIC ACID .......... 49
Q
QNASL............................... 102
QUALAQUIN ...................... 11
QUARTETTE ...................... 88
quasense................................ 88
quazepam .............................. 34
QUDEXY XR....................... 18
QUESTRAN......................... 45
quetiapine ............................. 34
QUILLIVANT XR ............... 34
quinapril................................ 41
quinapril-hydrochlorothiazide
.......................................... 41
quinidine gluconate .............. 36
quinidine sulfate ................... 36
quinine sulfate ...................... 11
quit 2 ..................................... 61
quit 4 ..................................... 61
QUIXIN ................................ 90
QVAR ................................. 102
R
rabeprazole ........................... 77
RAGWITEK ......................... 79
raloxifene .............................. 80
ramipril ................................. 41
RANEXA ............................. 46
ranitidine hcl ......................... 77
RAPAFLO .......................... 103
RAPAMUNE........................ 16
RASUVO.............................. 81
RAVICTI .............................. 60
RAYOS ................................ 64
RAZADYNE .................. 21, 22
RAZADYNE ER .................. 22
REBETOL .............................. 8
REBIF (WITH ALBUMIN) . 78
reclipsen (28) ........................88
RECOMBIVAX HB .............79
RECOTHROM .....................44
rectacort-hc ........................... 75
RECTIV ................................ 75
REGLAN .............................. 75
REGRANEX ........................49
RELAGARD ........................84
RELAGESIC ........................29
relcof c ..................................99
RELENZA DISKHALER ......8
RELISTOR ........................... 75
RELPAX............................... 20
REMERON........................... 34
remeven ................................ 49
RENAGEL ........................... 60
rena-vite .............................. 107
RENVELA ........................... 60
repaglinide ............................ 67
repan .....................................26
reprexain ............................... 26
REQUIP ................................ 19
REQUIP XL .........................19
RESCON .............................. 99
RESCRIPTOR ........................8
RESCULA ............................ 94
reserpine ............................... 41
RESPA-AR ........................... 99
RESTASIS ............................ 93
RESTORIL ........................... 34
RETIN-A .............................. 52
RETIN-A MICRO ................52
RETROVIR ............................ 8
REVATIO........................... 102
REVIA ..................................29
REVLIMID........................... 16
REYATAZ ............................. 8
REZIRA ................................ 99
RHEUMATREX ..................16
RHINOCORT AQUA ........102
rhinoflex-650 ........................29
RIAX ....................................52
ribapak dose pack ...................8
ribasphere ............................... 8
RIBATAB DOSE PACK .......8
ribavirin ..................................8
RIDAURA ............................ 81
rifabutin ................................ 11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
125
RIFADIN .............................. 11
RIFAMATE ......................... 11
rifampin ................................ 11
RIFATER ............................. 11
RIGHTEST GS550 TEST
STRIPS ............................. 67
RILUTEK ............................. 60
riluzole.................................. 60
rimantadine ............................. 8
RIOMET............................... 67
risacal-d .............................. 107
risedronate ............................ 80
RISPERDAL ........................ 34
risperidone ............................ 34
RITALIN .............................. 34
rivastigmine tartrate.............. 22
rizatriptan ............................. 20
robafen ac ............................. 99
ROBAXIN ............................ 22
ROBINUL ............................ 71
ROBINUL FORTE .............. 71
ROCALTROL ...................... 69
romycin................................. 91
ropinirole .............................. 20
rosadan ................................. 52
ROSADAN........................... 52
ROSANIL............................. 52
ROTARIX ............................ 79
ROTATEQ VACCINE ........ 79
ROWASA............................. 75
roxicet ................................... 26
ROXICET............................. 26
ROXICODONE ................... 26
ROZEREM ........................... 34
r-tanna................................... 99
RUCONEST ....................... 102
ru-hist forte ........................... 99
RYBIX ODT ........................ 29
RYTHMOL .......................... 36
RYZOLT .............................. 29
S
SABRIL................................ 18
SAFYRAL............................ 88
SAIZEN ................................ 78
salacyn .................................. 48
SALAGEN ........................... 60
SALEX ................................. 48
salicylic acid ......................... 48
salicylic acid sr-ceramides.... 48
SALKERA............................ 48
salsalate ................................ 29
SAL-TROPINE .................... 71
salvax .................................... 48
SALVAX DUO PLUS ......... 48
SAMSCA.............................. 69
SANCTURA ...................... 103
SANCTURA XR ................ 103
SANCUSO ........................... 75
SANDIMMUNE .................. 16
SANTYL .............................. 58
SAPHRIS.............................. 34
SARAFEM ........................... 34
SAVELLA ............................ 81
scalacort ................................ 58
SCALACORT DK ............... 58
se 10-5 ss .............................. 52
se bpo .................................... 52
SEASONALE
CONTRACEPTIVE ......... 88
SEASONIQUE ..................... 88
seb-prev ................................ 47
seconal sodium ..................... 34
SECTRAL ............................ 41
se-donna pb hyos .................. 71
selegiline hcl ......................... 20
selenium sulfide.................... 47
SELRX ................................. 47
SELZENTRY ......................... 8
SEMPREX-D ....................... 99
SENSIPAR ........................... 69
SEPTRA DS ......................... 12
SEREVENT DISKUS ........ 102
SEROMYCIN ...................... 11
SEROQUEL ......................... 34
SEROQUEL XR................... 34
SEROSTIM .......................... 78
sertraline ......................... 34, 35
sevoflurane ........................... 60
sf 5000 plus .......................... 62
sharobel ................................ 83
SHOHL'S MODIFIED ....... 104
SIGNIFOR............................ 16
sildenafil ............................. 102
SILENOR ............................. 35
SILVADENE........................ 47
silver nitrate .......................... 49
silver sulfadiazine .................47
SIMBRINZA ........................94
SIMCOR ............................... 45
SIMPONI .............................. 81
simvastatin ............................ 45
SINEMET ............................. 20
SINGLE USE EZ FLU 201415 ......................................79
SINGULAIR.......................102
sirolimus ............................... 16
SIRTURO ............................. 11
SITAVIG ................................ 8
SKELAXIN .......................... 22
SKELID ................................ 60
SKLICE ................................ 59
slow release iron .................107
SMART SENSE TEST
STRIPS ............................. 67
SMARTEST TEST ...............67
smoothlax ............................. 75
sodium chloride ..................102
sodium citrate-citric acid ....104
sodium fluoride .............62, 107
sodium phenylbutyrate .........60
SODIUM POLYSTYRENE
SULFONATE ...................60
sojourn ..................................60
SOLARAZE .........................49
SOLODYN ........................... 13
SOLTAMOX ........................16
SOLUS V2 TEST STRIPS ...67
SOMA...................................23
SOMAVERT ........................69
SOMNOTE ........................... 35
SONATA .............................. 35
SORIATANE .......................47
SORILUX ............................. 47
sotalol ...................................36
SOVALDI............................... 8
SPECTRACEF .......................9
spinosad ................................ 59
SPIRIVA WITH
HANDIHALER ..............102
spironolactone.......................42
spironolacton-hydrochlorothiaz
..........................................41
SPORANOX...........................6
sprintec (28) .......................... 88
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
126
SPRIX................................... 29
SPRYCEL ............................ 16
sronyx ................................... 88
ssd ......................................... 47
sss 10-5 ................................. 52
stagesic ................................. 26
STALEVO 100 ..................... 20
stannous fluoride .................. 62
STARLIX ............................. 67
STATUSS GREEN
(CODEINE) ...................... 99
stavudine................................. 8
STAVZOR ........................... 18
STELARA ............................ 47
STIMATE............................. 69
STIVARGA .......................... 16
stop smoking aid................... 61
STRATTERA ....................... 35
stress 500 ............................ 107
stress formula ..................... 107
stress formula 600 c............ 107
stress/biotin......................... 108
STRIANT ............................. 69
STRIBILD .............................. 8
STROMECTOL ................... 11
strong iodine ....................... 106
strovite ................................ 108
SUBOXONE ........................ 29
SUBSYS ............................... 26
SUBUTEX ........................... 26
SUCLEAR ............................ 75
SUCRAID ............................ 75
sucralfate .............................. 77
sudatex-dm ........................... 99
SULAR ................................. 42
sulfacetamide sodium ..... 47, 95
sulfacetamide sodium (acne) 54
sulfacetamide sodium-sulfur 53
sulfacetamide sodium-urea ... 47
sulfacetamide sod-sulfur-urea
.......................................... 52
SULFACETAMIDE SODSULFUR-UREA .............. 53
sulfacetamide-prednisolone.. 95
sulfadiazine........................... 12
sulfamethoxazole-trimethoprim
.......................................... 12
sulfamide .............................. 95
SULFAMYLON ................... 54
sulfasalazine ......................... 75
SULFATRIM ....................... 12
sulfazine ec ........................... 75
sulindac................................. 29
SUMADAN .......................... 53
sumatriptan ........................... 20
SUMAVEL DOSEPRO ....... 20
SUMAXIN ........................... 53
super b complex-vitamin c . 108
super b-50 complex plus..... 108
SUPRANE ............................ 60
SUPRAX ................................ 9
SUPREP ............................... 75
SURMONTIL ....................... 35
SURVANTA ........................ 60
SUSTIVA ............................... 8
SUTENT............................... 16
syeda ..................................... 89
SYLATRON ......................... 78
SYMAX DUOTAB .............. 71
symax fastabs ....................... 71
symax-sl................................ 71
symax-sr ............................... 71
SYMBICORT ..................... 102
SYMBYAX .......................... 35
SYMLINPEN 120 ................ 67
SYMLINPEN 60 .................. 68
SYNALAR CREAM KIT .... 58
SYNALGOS-DC .................. 26
SYNAREL............................ 69
SYNERA .............................. 54
SYNRIBO ............................ 16
SYNTHROID ....................... 69
SYPRINE ............................. 60
T
TABLOID ............................ 16
TACHOSIL .......................... 44
TACLONEX ........................ 47
tacrolimus ............................. 16
TAFINLAR .......................... 16
TAKE ACTION ................... 89
TAMBOCOR ....................... 36
TAMIFLU .............................. 8
tamoxifen .............................. 16
tamsulosin........................... 103
TANZEUM .......................... 68
TAPAZOLE ......................... 64
TARCEVA ........................... 16
TARGRETIN .......................16
tarina fe .................................89
TARKA ................................ 42
TASIGNA............................. 16
TASMAR ............................. 20
TAZORAC ........................... 53
taztia xt .................................42
TECFIDERA ........................22
TEGRETOL .........................18
TEKAMLO........................... 42
TEKRAL .............................. 99
TEKTURNA.........................42
TEKTURNA HCT................42
telmisartan ............................ 42
telmisartan-amlodipine .........42
telmisartan-hydrochlorothiazid
..........................................42
temazepam ............................ 35
TEMODAR .......................... 16
TEMOVATE ........................58
TEMOVATE E .....................58
temozolomide .......................16
tencon ...................................26
TENEX .................................42
TENIVAC............................. 79
TENORETIC 100 .................42
TENORMIN .........................42
TERAZOL 3 .........................84
TERAZOL 7 .........................84
terazosin ................................ 42
terbinafine hcl .........................6
terbutaline ........................... 102
terconazole ............................ 84
terrell.....................................60
TERSI FOAM ......................47
TESSALON .......................... 99
TESSALON PERLES ..........99
TESTIM ................................ 69
TESTOSTERONE ................69
testosterone cypionate ..........69
TESTRED............................. 69
tetanus toxoid,adsorbed ........79
TETANUS,DIPHTHERIA
TOX PED .........................79
TETANUS-DIPHTHERIA
TOXOIDS-TD ..................79
tetracycline ........................... 13
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
127
TEVETEN ............................ 42
TEVETEN HCT ................... 42
TEV-TROPIN ...................... 78
TEXACORT......................... 58
THALITONE ....................... 42
THALOMID......................... 16
THEO-24 ............................ 102
theochron ............................ 102
theophylline ........................ 102
thermazene ........................... 47
THIOLA ............................... 60
thioridazine ........................... 35
thiothixene ............................ 35
thrive nicotine....................... 61
THROMBIN-JMI ................. 44
THYROLAR-1 ..................... 70
THYROLAR-1/2 .................. 70
THYROLAR-1/4 .................. 70
THYROLAR-2 ..................... 70
THYROLAR-3 ..................... 70
tiagabine ............................... 18
TIAZAC ............................... 42
ticlopidine ............................. 44
TIGAN ................................. 75
TIKOSYN ............................ 36
tilia fe.................................... 89
timolol maleate ............... 42, 91
TIMOPTIC ........................... 91
TIMOPTIC OCUDOSE ....... 91
TIMOPTIC-XE .................... 91
TINDAMAX ........................ 11
tinidazole .............................. 11
TIROSINT ............................ 70
TISSEEL VHSD .................. 44
TIVICAY ............................... 8
tizanidine .............................. 23
tl 45% urea ........................... 49
tl-hist cd ................................ 99
TOBI..................................... 11
TOBI PODHALER .............. 11
TOBRADEX ........................ 94
TOBRADEX ST .................. 94
tobramycin ............................ 91
tobramycin in 0.225 % nacl . 11
tobramycin-dexamethasone.. 94
tobrasol ................................. 91
TOBREX .............................. 91
TODAY CONTRACEPTIVE
SPONGE .......................... 84
TOFRANIL .......................... 35
tolazamide ............................ 68
tolbutamide ........................... 68
tolmetin................................. 29
tolterodine........................... 103
TOPAMAX .......................... 18
TOPICORT .......................... 58
topiragen ............................... 18
topiramate ............................. 19
TOPIRAMATE .................... 19
TOPROL XL ........................ 42
torsemide .............................. 42
total b/c ............................... 108
TOVIAZ ............................. 103
TRACLEER ....................... 102
TRADJENTA ....................... 68
tramadol ................................ 29
TRAMADOL ....................... 29
tramadol-acetaminophen ...... 29
TRANDATE ........................ 42
trandolapril ........................... 42
trandolapril-verapamil .......... 42
TRANSDERM-SCOP .......... 76
TRANXENE T-TAB ............ 35
tranylcypromine.................... 35
TRAVATAN Z..................... 94
travoprost (benzalkonium) ... 94
trazodone .............................. 35
treagan otic ........................... 63
TRECATOR ......................... 12
TRENTAL ............................ 44
tretinoin ................................ 53
tretinoin (chemotherapy) ...... 16
TRETIN-X............................ 53
TREXALL ............................ 16
trexbrom ............................... 99
TREXIMET .......................... 20
trezix ..................................... 26
TRIACETIN ......................... 55
triamcinolone acetonide 58, 62,
102
triamterene-hydrochlorothiazid
.......................................... 42
trianex ................................... 58
TRIAZ CLEANSER............. 53
triazolam ............................... 35
TRIBENZOR ........................42
tri-buffered aspirin ................29
tri-chlor .................................49
tricitrates ............................. 104
TRICODE AR ......................99
TRICODE GF .......................99
TRICOR ............................... 46
triderm ..................................58
tri-estarylla ............................ 89
trifluoperazine.......................35
trifluridine ............................. 91
TRIGLIDE ............................ 46
trihexyphenidyl .....................20
TRIHIBIT ............................. 79
tri-legest fe ............................ 89
TRILEPTAL .........................19
tri-linyah ............................... 89
TRILIPIX ............................. 46
trilyte with flavor packets .....76
trimethobenzamide ...............76
trimethoprim .........................13
trimipramine .........................35
trinessa (28) .......................... 89
TRI-NORINYL (28) .............89
TRIOXIN .............................. 63
TRIPEDIA ............................ 79
tri-previfem (28) ...................89
tri-sprintec (28) .....................89
TRIUMEQ .............................. 8
triveen-ten ........................... 108
tri-vit with fluoride & iron ..108
trivora (28) ............................ 89
tri-zel...................................106
TRIZIVIR ............................... 8
TROKENDI XR ...................19
tropicamide ........................... 92
trospium .............................. 103
TRUE METRIX GLUCOSE
TEST STRIP .....................68
TRUETEST TEST STRIPS .68
TRUETRACK TEST............68
TRUSOPT ............................ 94
TRUVADA............................. 8
trymine cg ............................. 99
TUDORZA PRESSAIR .....102
tusnel c ..................................99
tusnel diabetic .......................99
TUSNEL PEDIATRIC .........99
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
128
TUSSICAPS ......................... 99
tussigon................................. 99
TUSSIONEX PENNKINETIC
ER ..................................... 99
TWINJECT AUTOINJECTOR
.......................................... 96
TWINRIX............................. 79
TWYNSTA .......................... 42
TYKERB .............................. 16
TYLENOL-CODEINE #3.... 26
TYLENOL-CODEINE #4.... 26
TYLOX ................................ 26
TYVASO STARTER KIT . 102
TYZEKA ................................ 8
TYZINE ............................... 62
U
UCERIS ................................ 76
U-CORT ............................... 49
ULESFIA ............................. 59
ULORIC ............................... 80
ULTANE .............................. 61
ultra b-100 complex ........... 108
ULTRACET ......................... 29
ULTRAM ............................. 29
ULTRAVATE ...................... 58
ULTRAVATE X .................. 58
ULTRESA ............................ 76
umecta .................................. 50
UMECTA ............................. 49
UMECTA PD ....................... 50
UNIRETIC ........................... 42
UNISTRIP1 TEST STRIP ... 68
unithroid ............................... 70
UNIVASC ............................ 42
ur n-c .................................. 104
URAMAXIN ........................ 50
URAMAXIN GT.................. 50
urea ....................................... 50
URECHOLINE .................. 104
URELLE............................. 104
uretron d-s .......................... 104
URIBEL ............................. 104
urimar-t ............................... 104
urin ds ................................. 104
UROCIT-K 10 .................... 104
urogesic-blue ...................... 104
UROQID-ACID NO.2 ....... 104
UROXATRAL ................... 104
URSO 250 ............................ 76
URSO FORTE ...................... 76
ursodiol ................................. 76
uryl...................................... 104
ustell ................................... 105
UTA (WITH PHENYL
SALICYLATE) .............. 105
utira-c.................................. 105
UTOPIC................................ 50
V
VAGIFEM ............................ 83
VAGINAL
CONTRACEPTIVE FILM
.......................................... 84
vaginal contraceptive foam .. 84
valacyclovir ............................ 8
VALCHLOR ........................ 50
VALCYTE ............................. 9
VALIUM .............................. 35
valproic acid ......................... 19
valproic acid (as sodium salt)
.......................................... 19
valsartan................................ 42
valsartan-hydrochlorothiazide
.......................................... 42
VALTREX ............................. 9
VALTURNA ........................ 42
VANACOF CD .................. 100
VANCOCIN ......................... 14
vancomycin .......................... 14
vandazole .............................. 84
VANDETANIB .................... 17
VANOS ................................ 58
VANOXIDE-HC .................. 53
VAQTA ................................ 79
VARIVAX............................ 80
VASCEPA ............................ 46
VASERETIC ........................ 43
vasolex .................................. 58
VASOTEC............................ 43
VCF CONTRACEPTIVE
FILM ................................ 84
VECTICAL .......................... 47
velivet triphasic regimen (28)
.......................................... 89
VELPHORO ......................... 61
VELTIN................................ 53
VENELEX............................ 50
venlafaxine ........................... 35
VENLAFAXINE ..................35
VENTAVIS ........................ 102
VENTOLIN HFA ...............102
VERAMYST ......................102
verapamil .............................. 43
VERDESO ............................ 58
VEREGEN ........................... 50
VERELAN ........................... 43
VERELAN PM .....................43
veripred 20 ............................ 64
VERSACLOZ.......................35
VERSICLEAR .....................55
VESICARE......................... 103
vestura (28) ........................... 89
VEXOL.................................95
VFEND ...................................6
V-HIST ............................... 100
VIBRAMYCIN ....................13
vicodin ..................................26
VICODIN ............................. 26
vicodin es .............................. 26
VICODIN ES........................26
vicodin hp ............................. 26
VICODIN HP .......................26
VICOPROFEN .....................26
VICTOZA 2-PAK ................68
VICTRELIS ............................ 9
VIDEX 2 GRAM PEDIATRIC
............................................9
VIDEX EC.............................. 9
VIGAMOX ........................... 91
VIIBRYD ............................. 35
VIMOVO .............................. 29
VIMPAT ............................... 19
VIOKACE ............................ 76
VIOKASE 16........................76
viorele (28) ........................... 89
VIRACEPT............................. 9
VIRAMUNE...........................9
VIRASAL ............................. 48
VIREAD .................................9
VIROPTIC ............................ 91
VISTARIL ............................ 96
vi-stress ............................... 108
vit b complex-folic acid ......108
vitabee/c .............................. 108
VITAFOL ULTRA .............108
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
129
VITAFOL-PLUS ................ 108
vitamin b complex .............. 108
vitamin b-100 complex....... 108
vitamin d3........................... 108
vitamins a,c,d & fluoride .... 108
vitamins b complex ............ 108
vitazol ................................... 53
VITUZ ................................ 100
VIVACTIL ........................... 35
VIVELLE-DOT ................... 83
VOCAL POINT ................... 68
VOGELXO........................... 69
VOLTAREN GEL.......... 29, 93
VOLTAREN-XR ................. 29
voriconazole ........................... 6
VOSOL-HC .......................... 63
VOSPIRE ER ..................... 102
VOTRIENT .......................... 17
vp-zel .................................. 106
VUSION ............................... 56
vyfemla (28) ......................... 89
VYTONE ............................. 54
VYTORIN 10-10.................. 46
VYVANSE ........................... 35
W
warfarin ................................ 44
wee care .............................. 108
WELCHOL .......................... 46
WELLBUTRIN .................... 35
WELLBUTRIN SR .............. 35
wera (28) .............................. 89
WESTCORT ........................ 58
westhroid .............................. 70
WESTHROID-P ................... 70
WIDE-SEAL DIAPHRAGM
60 ...................................... 84
woman's laxative .................. 76
women's gentle laxative(bisac)
.......................................... 76
WP THYROID ..................... 70
wymzya fe ............................ 89
X
XALATAN........................... 94
XALKORI ............................ 17
XANAX ............................... 35
XARELTO ........................... 44
XARTEMIS XR ................... 27
XELJANZ ............................ 81
XELODA.............................. 17
XENADERM ....................... 58
XENAZINE .......................... 22
XERAC AC .......................... 50
XERESE ............................... 56
XIFAXAN ............................ 12
XODOL 10/300 .................... 27
XOLEGEL............................ 56
xolox ..................................... 27
XOPENEX ......................... 102
XOPENEX HFA ................ 102
XTANDI............................... 17
xulane ................................... 84
XYLOCAINE ....................... 54
XYLOCAINE JELLY .......... 54
XYREM................................ 35
XYZAL ................................ 97
Y
YASMIN (28)....................... 89
YAZ (28) .............................. 89
YODOXIN ........................... 12
Z
zafirlukast ........................... 103
zaleplon ................................ 35
zamicet.................................. 27
ZANAFLEX ......................... 23
ZANTAC .............................. 77
zarah ..................................... 89
ZARONTIN.......................... 19
ZAROXOLYN ..................... 43
ZAVESCA............................ 69
ZEBETA ............................... 43
zebutal .................................. 27
ZEGERID ............................. 77
ZELAPAR ............................ 20
ZELBORAF ......................... 17
ZEMPLAR ........................... 69
zenatane ................................ 53
zenchent (28) ........................ 89
zenchent fe ............................ 89
zencia .................................... 53
ZENPEP ............................... 76
zenzedi .................................. 35
ZENZEDI ............................. 36
zeosa ..................................... 89
ZERIT ..................................... 9
ZESTORETIC ...................... 43
ZESTRIL .............................. 43
ZETIA...................................46
ZETONNA ......................... 103
zflex ......................................29
zgesic ....................................29
ZIAC .....................................43
ZIAGEN .................................9
ZIANA ..................................53
zidovudine .............................. 9
zinc sulfate .......................... 106
ZINOTIC ES (WITH
GLYCERIN).....................63
ZIOPTAN ............................. 94
ziprasidone hcl ......................36
ZIPSOR ................................ 30
ZIRGAN ............................... 91
ZITHRANOL .......................47
ZITHRANOL-RR.................47
ZITHROMAX ......................10
ZMAX ..................................10
ZOCOR.................................46
ZODRYL AC 25 ................100
ZODRYL DAC 25 .............100
ZODRYL DEC 25 ..............100
ZOFRAN ODT .....................76
ZOHYDRO ER ....................27
ZOLINZA ............................. 17
zolmitriptan........................... 21
ZOLOFT ............................... 36
zolpidem ............................... 36
ZOLPIMIST .........................36
ZOLVIT ................................ 27
ZOMIG .................................21
ZONALON ........................... 50
ZONATUSS .......................100
ZONEGRAN ........................19
zonisamide ............................ 19
ZONTIVITY.........................44
ZORBTIVE .......................... 78
ZORTRESS .......................... 17
ZORVOLEX.........................30
ZOSTAVAX.........................80
zovia 1/35e (28) ....................89
zovia 1/50e (28) ....................89
ZOVIRAX ........................ 9, 56
z-pram ...................................76
Z-TUSS AC ........................ 100
Z-TUSS E ........................... 100
ZUBSOLV ............................ 30
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
130
ZUPLENZ ............................ 76
ZUTRIPRO ........................ 100
ZYCLARA ........................... 50
ZYDELIG............................. 17
ZYDONE ............................. 27
ZYFLO ............................... 103
ZYFLO CR ......................... 103
ZYKADIA ............................ 17
ZYLET ................................. 94
ZYLOPRIM.......................... 80
ZYMAXID ........................... 91
ZYPRAM ............................. 76
ZYPREXA ............................ 36
ZYPREXA RELPREVV ......36
ZYTIGA ............................... 17
ZYVOX ................................ 12
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this document.
131