Two-Tier Prescription Member Guide 2016

Transcription

Two-Tier Prescription Member Guide
PLEASE BRING THIS GUIDE WITH YOU TO YOUR NEXT DOCTOR’S VISIT
04HR1217 R09/16
20
16
REVISED: SEPTEMBER 2016
Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana.
Both companies are independent licensees of the Blue Cross and Blue Shield Association.
Notice of Language Options
04BA0365 04/15 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc.
are subsidiaries of Blue Cross and Blue Shield of Louisiana. All three companies are independent licensees of the Blue Cross and Blue Shield Association.
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 network pharmacies dispense on an outpatient basis. See your member contract or certificate for pharmacy coverage for any exclusions and limitations that apply to you. How are prescription drugs classified? Your plan offers a 2‐tier structure for drugs that are covered: 2
Tier 1 2 Description of prescription drugs Generic drugs This tier includes generic drugs. Brand drugs This tier includes brand‐name drugs. Generally, you will pay the least out of pocket when you buy generic drugs  or drugs that are in Tier 1. You will pay the most out of pocket for brand drugs  those in Tier 2. What does it mean when the Tier section shows $0 or $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 or 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 may apply, including age, gender or frequency. Broad categories of drugs that may be eligible for this coverage include: $0: Selected contraceptives for women $0: 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. $0*: Selected additional generic preventive drugs included in the following classes: Coronary heart disease Heart failure Osteoporosis 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. 3
Tier 1 2 Drug Requirements/Limits generic [QPD] BRAND [PA] [ST] BRAND NAME drugs are in ALL CAPS. generic drugs are in lower case italics. [PA] = Prior authorization [QPD] = Quantity per dispensing limits [ST] = Step therapy restrictions [SP] = Specialty pharmacy program restrictions What do the abbreviations in the Requirements/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 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 drug. If you need a prior authorization, have your doctor contact Express Scripts: Call: 1‐800‐842‐2015 For the physician fax form, go to: http://www.bcbsla.com/Providers/PharmacyManagement Fax: 1‐877‐837‐5922 Fax: 1‐877‐837‐5922 [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. 4
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 Blue Cross. 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. [SP] Specialty Pharmacy Program restrictions Certain drugs are commonly called specialty drugs. 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 network 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: 1‐866‐781‐7533. If your doctor prescribes a drug that is not in this Guide, or if you have any questions, call Express Scripts at 1‐866‐781‐7533. 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.
5
Drug Name
Drug Tier
Requirements / Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ANCOBON
2
clotrimazole
1
CRESEMBA
2
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION
2
DIFLUCAN ORAL TABLET 100 MG, 200 MG,
50 MG
2
DIFLUCAN ORAL TABLET 150 MG
2
fluconazole oral suspension for reconstitution
1
fluconazole oral tablet 100 mg, 200 mg, 50 mg
1
fluconazole oral tablet 150 mg
1
flucytosine
1
griseofulvin microsize
1
griseofulvin ultramicrosize
1
GRIS-PEG (ULTRAMICROSIZE)
2
itraconazole
1
ketoconazole
1
LAMISIL
2
NOXAFIL
2
nystatin
1
ONMEL
2
ORAVIG
2
SPORANOX
2
SPORANOX PULSEPAK
2
QPD
terbinafine hcl
1
QPD
VFEND ORAL SUSPENSION FOR
RECONSTITUTION
2
VFEND ORAL TABLET
2
voriconazole oral suspension for reconstitution
1
voriconazole oral tablet
1
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 table.
6
Drug Name
Drug Tier
ANTIVIRALS
abacavir
1
abacavir-lamivudine-zidovudine
1
acyclovir
1
adefovir
1
amantadine hcl
1
APTIVUS
2
SP
ATRIPLA
2
SP
BARACLUDE
2
SP
COMBIVIR
2
SP
COMPLERA
2
SP
CRIXIVAN
2
SP
DAKLINZA
2
PA; SP; QPD
DESCOVY
2
SP
didanosine
1
EDURANT
2
SP
EMTRIVA
2
SP
entecavir
1
SP
EPCLUSA
2
PA; SP; QPD
EPIVIR
2
SP
EPIVIR HBV
2
SP
EPZICOM
2
SP
EVOTAZ
2
SP; QPD
famciclovir
1
QPD
FAMVIR
2
QPD
FLUMADINE
2
FUZEON
2
SP
GENVOYA
2
SP
HARVONI
2
PA; SP; QPD
HEPSERA
2
SP
INTELENCE
2
SP
SP
SP
of this table.
7
Drug Name
Drug Tier
INVIRASE
2
SP
ISENTRESS
2
SP
KALETRA
2
SP
lamivudine
1
lamivudine-zidovudine
1
LEXIVA
2
nevirapine
1
NORVIR
2
ODEFSEY
2
OLYSIO
2
PA; SP
PREZCOBIX
2
SP; QPD
PREZISTA
2
SP
RELENZA DISKHALER
2
QPD
RESCRIPTOR
2
SP
RETROVIR
2
SP
REYATAZ
2
SP
rimantadine
1
SELZENTRY
2
SITAVIG
2
SOVALDI
2
stavudine
1
STRIBILD
2
SP
SUSTIVA
2
SP
TAMIFLU
2
QPD
TECHNIVIE
2
PA; SP; QPD
TIVICAY
2
SP
TRIUMEQ
2
SP
TRIZIVIR
2
SP
TRUVADA
2
SP
TYBOST
2
SP
TYZEKA
2
SP; QPD
SP
SP
SP
PA; SP
of this table.
8
Drug Name
Drug Tier
valacyclovir
1
VALCYTE
2
valganciclovir
1
VALTREX
2
QPD
VIDEX 2 GRAM PEDIATRIC
2
SP
VIDEX EC
2
SP
VIEKIRA PAK
2
PA; SP
VIRACEPT
2
SP
VIRAMUNE
2
SP
VIRAMUNE XR
2
SP
VIREAD
2
SP
VITEKTA
2
SP; QPD
ZEPATIER
2
PA; SP; QPD
ZERIT
2
SP
ZIAGEN
2
SP
zidovudine
1
ZOVIRAX
2
QPD
CEPHALOSPORINS
CEDAX
2
cefaclor
1
cefadroxil
1
cefdinir
1
cefditoren pivoxil
1
cefixime
1
cefpodoxime
1
cefprozil
1
ceftibuten
1
CEFTIN
2
cefuroxime axetil
1
cephalexin
1
KEFLEX
2
of this table.
9
Drug Name
SUPRAX
Drug Tier
2
ERYTHROMYCINS & OTHER MACROLIDES
azithromycin
1
BIAXIN
2
clarithromycin
1
DIFICID
2
e.e.s. 400
1
E.E.S. GRANULES
2
ERYPED
2
ery-tab oral tablet,delayed release (dr/ec) 250 mg,
333 mg
1
ERY-TAB ORAL TABLET,DELAYED
RELEASE (DR/EC) 500 MG
2
erythrocin (as stearate)
1
erythromycin
1
erythromycin ethylsuccinate
1
PCE
2
ZITHROMAX
2
ZMAX
2
QPD
MISCELLANEOUS ANTIINFECTIVES
ALBENZA
2
ALINIA
2
atovaquone
1
atovaquone-proguanil
1
BETHKIS
2
BILTRICIDE
2
CAYSTON
2
chloroquine phosphate
1
CLEOCIN
2
clindamycin hcl
1
clindamycin palmitate hcl
1
clindamycin pediatric
1
SP
SP
of this table.
10
Drug Name
Drug Tier
COARTEM
2
CYCLOSERINE
2
dapsone
1
DARAPRIM
2
EMVERM
2
ethambutol
1
FLAGYL
2
FLAGYL ER
2
hydroxychloroquine
1
IMPAVIDO
2
isoniazid
1
ivermectin
1
KETEK
2
linezolid
1
MALARONE
2
MALARONE PEDIATRIC
2
mefloquine
1
MEPRON
2
metronidazole
1
MYAMBUTOL
2
MYCOBUTIN
2
NEBUPENT
2
neomycin
1
paromomycin
1
PASER
2
PLAQUENIL
2
PRIFTIN
2
PRIMAQUINE
2
pyrazinamide
1
QUALAQUIN
2
quinine sulfate
1
QPD
PA; QPD
QPD
of this table.
11
Drug Name
Drug Tier
rifabutin
1
RIFADIN
2
RIFAMATE
2
rifampin
1
RIFATER
2
SIRTURO
2
SIVEXTRO
2
STROMECTOL
2
TINDAMAX
2
tinidazole
1
TOBI
2
SP; QPD
TOBI PODHALER
2
SP; QPD
tobramycin in 0.225 % nacl
1
SP; QPD
TRECATOR
2
XIFAXAN
2
ZYVOX
2
SP
QPD
PENICILLINS
amoxicillin oral capsule
1
amoxicillin oral suspension for reconstitution
1
amoxicillin oral tablet
1
AMOXICILLIN ORAL TABLET, ER
MULTIPHASE 24 HR
2
amoxicillin oral tablet,chewable
1
amoxicillin-pot clavulanate
1
ampicillin
1
AUGMENTIN
2
AUGMENTIN ES-600
2
AUGMENTIN XR
2
dicloxacillin
1
MOXATAG
2
penicillin v potassium
1
of this table.
12 Drug Name
Drug Tier
QUINOLONES
AVELOX
2
AVELOX ABC PACK
2
CIPRO
2
CIPRO XR
2
ciprofloxacin
1
ciprofloxacin (mixture)
1
ciprofloxacin hcl
1
FACTIVE
2
LEVAQUIN
2
levofloxacin
1
moxifloxacin
1
ofloxacin
1
SULFA'S & RELATED AGENTS
BACTRIM
2
BACTRIM DS
2
sulfadiazine
1
sulfamethoxazole-trimethoprim
1
sulfatrim
1
TETRACYCLINES
ACTICLATE
2
ST
avidoxy
1
AVIDOXY DK
2
demeclocycline
1
DORYX
2
ST
DORYX MPC
2
ST
doxycycline hyclate
1
doxycycline monohydrate oral capsule
1
DOXYCYCLINE MONOHYDRATE ORAL
CAPSULE,IR - DELAY REL,BIPHASE
2
doxycycline monohydrate oral suspension for
reconstitution
1
ST
ST
of this table.
13 Drug Name
Drug Tier
doxycycline monohydrate oral tablet
1
MINOCIN
2
minocycline
1
mondoxyne nl
1
MONODOX
2
morgidox
1
MORGIDOX
2
ST
ORACEA
2
ST
SOLODYN
2
ST
tetracycline
1
VIBRAMYCIN
2
ST
ST
ST
URINARY TRACT AGENTS
FURADANTIN
2
HIPREX
2
MACROBID
2
MACRODANTIN
2
methenamine hippurate
1
methenamine mandelate
1
MONUROL
2
nitrofurantoin
1
nitrofurantoin macrocrystal
1
nitrofurantoin monohyd/m-cryst
1
PRIMSOL
2
trimethoprim
1
VANCOMYCIN
VANCOCIN
2
vancomycin
1
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
1
MESNEX
2
SP
of this table.
14
Drug Name
VISTOGARD
Drug Tier
2
SP; QPD
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
AFINITOR
2
SP; QPD
AFINITOR DISPERZ
2
SP; QPD
ALECENSA
2
SP; QPD
ALKERAN
2
SP
anastrozole
1
ARIMIDEX
2
AROMASIN
2
ASTAGRAF XL
2
AZASAN
2
azathioprine
1
bexarotene
1
bicalutamide
1
BOSULIF
2
SP; QPD
CABOMETYX
2
SP; QPD
capecitabine
1
SP
CAPRELSA
2
SP; QPD
CASODEX
2
CELLCEPT
2
COMETRIQ
2
SP; QPD
COTELLIC
2
SP
cyclosporine
1
cyclosporine modified
1
DROXIA
2
EMCYT
2
ENVARSUS XR
2
ERIVEDGE
2
SP; QPD
etoposide
1
SP
exemestane
1
FARESTON
2
SP
of this table.
15
Drug Name
Drug Tier
FARYDAK
2
FEMARA
2
flutamide
1
gengraf
1
GILOTRIF
2
SP
GLEEVEC
2
SP
GLEOSTINE
2
SP
HEXALEN
2
SP
HYCAMTIN
2
SP
HYDREA
2
hydroxyurea
1
IBRANCE
2
SP
ICLUSIG
2
SP; QPD
imatinib
1
SP
IMBRUVICA
2
SP
IMURAN
2
INLYTA
2
SP; QPD
IRESSA
2
SP
JAKAFI
2
SP; QPD
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X
1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10
MG X 2-4 MG X 1)
2
SP
LENVIMA ORAL CAPSULE 18 MG/DAY (10
MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2)
2
SP; QPD
letrozole
1
LEUKERAN
2
LONSURF
2
SP
LYNPARZA
2
SP
LYSODREN
2
SP
MATULANE
2
SP
MEGACE
2
SP
MEGACE ES
2
of this table.
16
Drug Name
Drug Tier
megestrol
1
MEKINIST
2
mercaptopurine
1
methotrexate sodium
1
mycophenolate mofetil
1
mycophenolate sodium
1
MYFORTIC
2
MYLERAN
2
NEORAL
2
NEXAVAR
2
SP
NILANDRON
2
SP
NINLARO
2
SP; QPD
octreotide acetate
1
SP
ODOMZO
2
SP
PROGRAF
2
PURIXAN
2
RAPAMUNE
2
RHEUMATREX
2
SANDIMMUNE
2
SANDOSTATIN
2
SP
SIGNIFOR
2
PA; SP; QPD
sirolimus
1
SOLTAMOX
2
SPRYCEL
2
SP; QPD
STIVARGA
2
SP; QPD
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50
MG
2
SP; QPD
SUTENT ORAL CAPSULE 37.5 MG
2
SP
SYNRIBO
2
SP
TABLOID
2
tacrolimus
1
TAFINLAR
2
SP; QPD
SP
SP; QPD
of this table.
17
Drug Name
Drug Tier
TAGRISSO
2
tamoxifen
$0
TARCEVA
2
SP
TARGRETIN
2
SP
TASIGNA
2
SP; QPD
TEMODAR
2
SP
temozolomide
1
SP
THALOMID
2
SP
tretinoin (chemotherapy)
1
TREXALL
2
TYKERB
2
SP; QPD
VENCLEXTA
2
SP; QPD
VENCLEXTA STARTING PACK
2
SP; QPD
VOTRIENT
2
SP
XALKORI
2
SP; QPD
XELODA
2
SP
XTANDI
2
SP; QPD
ZELBORAF
2
SP; QPD
ZOLINZA
2
SP; QPD
ZORTRESS
2
SP
ZYDELIG
2
SP
ZYKADIA
2
SP
ZYTIGA
2
SP; QPD
SP; QPD
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM
2
BANZEL
2
BRIVIACT
2
carbamazepine
1
CARBATROL
2
CELONTIN
2
QPD
PA; QPD
of this table.
18 Drug Name
Drug Tier
clonazepam
1
DEPAKENE
2
DEPAKOTE
2
DEPAKOTE ER
2
DEPAKOTE SPRINKLES
2
DIASTAT
2
DIASTAT ACUDIAL
2
diazepam
1
DILANTIN
2
DILANTIN EXTENDED
2
DILANTIN INFATABS
2
DILANTIN-125
2
divalproex
1
epitol
1
EQUETRO
2
ethosuximide
1
felbamate
1
FELBATOL
2
FYCOMPA
2
gabapentin
1
GABITRIL
2
GRALISE
2
QPD
GRALISE 30-DAY STARTER PACK
2
QPD
KEPPRA
2
KEPPRA XR
2
KLONOPIN
2
LAMICTAL
2
LAMICTAL ODT
2
LAMICTAL ODT STARTER
2
LAMICTAL STARTER KIT
2
LAMICTAL XR
2
of this table.
19
Drug Name
Drug Tier
LAMICTAL XR STARTER
2
lamotrigine
1
levetiracetam
1
LYRICA
2
MYSOLINE
2
NEURONTIN
2
ONFI
2
oxcarbazepine
1
OXTELLAR XR
2
PEGANONE
2
phenobarbital
1
PHENYTEK
2
phenytoin
1
phenytoin sodium extended
1
POTIGA
2
primidone
1
QUDEXY XR
2
roweepra
1
SABRIL
2
PA; SP; QPD
SPRITAM
2
PA
TEGRETOL
2
TEGRETOL XR
2
tiagabine
1
TOPAMAX
2
topiramate oral capsule, sprinkle
1
TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER 24HR
2
topiramate oral tablet
1
TRILEPTAL
2
TROKENDI XR
2
valproic acid
1
valproic acid (as sodium salt)
1
QPD
of this table.
20
Drug Name
Drug Tier
VIMPAT
2
ZARONTIN
2
ZONEGRAN
2
zonisamide
1
ANTIPARKINSONISM AGENTS
APOKYN
2
AZILECT
2
benztropine
1
bromocriptine
1
carbidopa
1
carbidopa-levodopa
1
carbidopa-levodopa-entacapone
1
COMTAN
2
ELDEPRYL
2
entacapone
1
LODOSYN
2
MIRAPEX
2
MIRAPEX ER
2
NEUPRO
2
PARLODEL
2
pramipexole
1
REQUIP
2
REQUIP XL
2
ropinirole oral tablet
1
ropinirole oral tablet extended release 24 hr
1
RYTARY
2
selegiline hcl
1
SINEMET
2
SINEMET CR
2
STALEVO
2
TASMAR
2
SP
QPD
QPD
QPD
of this table.
21
Drug Name
Drug Tier
tolcapone
1
trihexyphenidyl
1
ZELAPAR
2
MIGRAINE & CLUSTER HEADACHE THERAPY
almotriptan malate
1
QPD
ALSUMA
2
ST; QPD
AMERGE
2
ST; QPD
AXERT
2
ST; QPD
CAFERGOT
2
dihydroergotamine
1
ERGOMAR
2
FROVA
2
ST; QPD
frovatriptan
1
QPD
IMITREX
2
ST; QPD
IMITREX STATDOSE KIT REFILL
2
ST; QPD
IMITREX STATDOSE PEN
2
ST; QPD
isometh-dichloral-acetaminophn
1
isomethepten-caf-acetaminophen
1
MAXALT
2
ST; QPD
MAXALT-MLT
2
ST; QPD
migergot
1
MIGRANAL
2
QPD
naratriptan
1
QPD
nodolor
1
ONZETRA XSAIL
2
PRODRIN
2
RELPAX
2
ST; QPD
rizatriptan
1
QPD
sumatriptan
1
QPD
sumatriptan succinate oral
1
QPD
sumatriptan succinate subcutaneous cartridge
1
QPD
QPD
ST; QPD
of this table.
22 Drug Name
Drug Tier
sumatriptan succinate subcutaneous pen injector
1
QPD
sumatriptan succinate subcutaneous solution
1
QPD
sumatriptan succinate subcutaneous syringe
1
SUMAVEL DOSEPRO SUBCUTANEOUS
NEEDLE-FREE INJECTOR 4 MG/0.5 ML
2
ST
SUMAVEL DOSEPRO SUBCUTANEOUS
NEEDLE-FREE INJECTOR 6 MG/0.5 ML
2
ST; QPD
ZEMBRACE SYMTOUCH
2
ST; QPD
zolmitriptan
1
QPD
ZOMIG NASAL SPRAY,NON-AEROSOL 2.5
MG
2
ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG
2
ST; QPD
ZOMIG ZMT
2
ST; QPD
AMPYRA
2
PA; SP; QPD
ARICEPT
2
QPD
donepezil
1
QPD
EXELON
2
QPD
galantamine oral capsule,ext rel. pellets 24 hr
1
QPD
galantamine oral solution
1
galantamine oral tablet
1
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG
2
HORIZANT ORAL TABLET EXTENDED
RELEASE 600 MG
2
QPD
KEVEYIS
2
PA; SP; QPD
memantine oral solution
1
memantine oral tablet
1
MEMANTINE ORAL TABLETS,DOSE PACK
2
NAMENDA
2
NAMENDA TITRATION PAK
2
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK
2
MISCELLANEOUS NEUROLOGICAL THERAPY
QPD
QPD
of this table.
23
Drug Name
Drug Tier
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
2
NAMZARIC
2
NUEDEXTA
2
QPD
RAZADYNE
2
QPD
RAZADYNE ER
2
QPD
rivastigmine
1
QPD
rivastigmine tartrate
1
QPD
tetrabenazine
1
PA; SP
XENAZINE
2
PA; SP
MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
AMRIX
2
baclofen
1
carisoprodol
1
carisoprodol-asa-codeine
1
carisoprodol-aspirin
1
chlorzoxazone
1
cyclobenzaprine
1
DANTRIUM
2
dantrolene
1
FEXMID
2
LORZONE
2
meprobamate
1
MESTINON
2
MESTINON TIMESPAN
2
metaxall
1
metaxalone
1
methocarbamol
1
orphenadrine citrate
1
PARAFON FORTE DSC
2
pyridostigmine bromide
1
QPD
QPD
QPD
of this table.
24 Drug Name
Drug Tier
ROBAXIN
2
ROBAXIN-750
2
SKELAXIN
2
SOMA
2
tizanidine
1
ZANAFLEX
2
QPD
NARCOTIC ANALGESICS
ABSTRAL
2
acetaminophen-codeine
1
ACTIQ
2
ascomp with codeine
1
aspirin-caffeine-dihydrocodein
1
BELBUCA
2
buprenorphine hcl
1
butalbital compound w/codeine
1
butalbital-acetaminop-caf-cod
1
butalbital-acetaminophen
1
butalbital-acetaminophen-caff
1
butalbital-aspirin-caffeine
1
BUTRANS
2
capacet
1
codeine sulfate
1
codeine-butalbital-asa-caff
1
DEMEROL
2
DILAUDID
2
diskets
1
DOLOPHINE
2
DURAGESIC
2
EMBEDA
2
endocet
1
ESGIC
2
PA; QPD
PA; QPD
QPD
QPD
ST
of this table.
25
Drug Name
Drug Tier
EXALGO ER
2
ST
fentanyl citrate
1
PA; QPD
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1
FENTANYL TRANSDERMAL PATCH 72
HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR,
87.5 MCG/HOUR
2
FENTORA
2
FIORICET
2
FIORICET WITH CODEINE
2
FIORINAL
2
FIORINAL-CODEINE #3
2
HYCET
2
hydrocodone-acetaminophen
1
hydrocodone-ibuprofen
1
hydromorphone
1
HYSINGLA ER
2
IBUDONE
2
ibuprofen-oxycodone
1
KADIAN
2
ST
LAZANDA
2
PA; QPD
levorphanol tartrate
1
lorcet (hydrocodone)
1
lorcet hd
1
lorcet plus
1
lortab
1
LORTAB ELIXIR
2
margesic
1
marten-tab
1
meperidine
1
methadone
1
methadose
1
PA; QPD
ST; QPD
of this table.
26
Drug Name
Drug Tier
morphine
1
morphine concentrate
1
MS CONTIN
2
NORCO
2
OPANA
2
OPANA ER
2
OXAYDO
2
oxycodone oral capsule
1
oxycodone oral concentrate
1
oxycodone oral solution
1
oxycodone oral tablet
1
OXYCODONE ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR
2
oxycodone-acetaminophen
1
oxycodone-aspirin
1
OXYCONTIN
2
oxymorphone oral tablet
1
oxymorphone oral tablet extended release 12 hr
1
PERCOCET
2
reprexain
1
ROXICODONE
2
SUBSYS
2
SYNALGOS-DC
2
tencon
1
TYLENOL-CODEINE #3
2
TYLENOL-CODEINE #4
2
verdrocet
1
vicodin
1
vicodin es
1
vicodin hp
1
XARTEMIS XR
2
XODOL
2
ST
ST; QPD
ST; QPD
PA; ST; QPD
QPD
PA; QPD
of this table.
27
Drug Name
Drug Tier
XTAMPZA ER
2
ST; QPD
xylon 10
1
zamicet
1
zebutal
1
ZOHYDRO ER
2
ST; QPD
ANAPROX DS
2
ST
ARTHROTEC
2
ST
BUNAVAIL
2
PA
buprenorphine-naloxone
1
PA
butorphanol tartrate
1
QPD
CAMBIA
2
ST; QPD
CELEBREX
2
ST; QPD
celecoxib
1
QPD
CONZIP
2
DAYPRO
2
diclofenac potassium
1
diclofenac sodium oral
1
diclofenac sodium topical drops
1
diclofenac sodium topical gel
1
diclofenac-misoprostol
1
diflunisal
1
DISALCID
2
EC-NAPROSYN
2
etodolac
1
EVZIO
2
QPD
FELDENE
2
ST
FENOPROFEN ORAL CAPSULE
2
ST
fenoprofen oral tablet
1
FLECTOR
2
flurbiprofen
1
NON-NARCOTIC ANALGESICS
ST
QPD
ST
ST; QPD
of this table.
28 Drug Name
Drug Tier
ibuprofen
1
INDOCIN
2
indomethacin
1
ketoprofen
1
ketorolac
1
QPD
klofensaid ii
1
QPD
meclofenamate
1
mefenamic acid
1
meloxicam
1
QPD
MOBIC
2
ST; QPD
nabumetone
1
NALFON
2
ST
naloxone
1
QPD
naltrexone
1
NAPRELAN CR
2
ST
NAPROSYN
2
ST
naproxen
1
naproxen sodium
1
NARCAN
2
NUCYNTA
2
NUCYNTA ER
2
oxaprozin
1
PENNSAID
2
pentazocine-naloxone
1
piroxicam
1
PONSTEL
2
REVIA
2
salsalate
1
SPRIX
2
ST; QPD
SUBOXONE
2
PA
sulindac
1
ST
QPD
ST; QPD
ST
ST
of this table.
29 Drug Name
Drug Tier
TIVORBEX
2
tolmetin
1
TRAMADOL ORAL CAPSULE,ER BIPHASE
24 HR
2
tramadol oral tablet
1
tramadol oral tablet extended release 24 hr
1
tramadol oral tablet, er multiphase 24 hr
1
tramadol-acetaminophen
1
ULTRACET
2
ULTRAM
2
ULTRAM ER
2
VIVLODEX
2
VOLTAREN
2
VOLTAREN-XR
2
ST
ZIPSOR
2
ST
ZORVOLEX
2
ST; QPD
ZUBSOLV
2
PA
ABILIFY
2
QPD
ADASUVE
2
ADDERALL
2
ADDERALL XR
2
ADZENYS XR-ODT
2
alprazolam
1
alprazolam intensol
1
AMBIEN
2
ST; QPD
AMBIEN CR
2
ST; QPD
amitriptyline
1
amitriptyline-chlordiazepoxide
1
amoxapine
1
ANAFRANIL
2
ST; QPD
ST; QPD
PSYCHOTHERAPEUTIC DRUGS
QPD
of this table.
30 Drug Name
Drug Tier
APLENZIN
2
QPD
APTENSIO XR
2
QPD
aripiprazole oral solution
1
aripiprazole oral tablet
1
QPD
aripiprazole oral tablet,disintegrating
1
QPD
armodafinil
1
PA; QPD
ATIVAN
2
BELSOMRA
2
ST; QPD
BRISDELLE
2
QPD
bupropion hcl oral tablet
1
bupropion hcl oral tablet extended release
1
QPD
bupropion hcl oral tablet extended release 24 hr
1
QPD
buspirone
1
BUTISOL
2
QPD
CELEXA
2
ST; QPD
chlordiazepoxide hcl
1
chlorpromazine
1
citalopram oral solution
1
citalopram oral tablet
1
clomipramine
1
clonidine hcl
1
clorazepate dipotassium
1
clozapine oral tablet
1
clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 25 mg
1
CLOZAPINE ORAL
TABLET,DISINTEGRATING 150 MG, 200 MG
2
CLOZARIL
2
CONCERTA
2
CYMBALTA
2
QPD
DAYTRANA
2
QPD
desipramine
1
QPD
of this table.
31
Drug Name
Drug Tier
DESOXYN
2
DESVENLAFAXINE
2
ST; QPD
DESVENLAFAXINE FUMARATE
2
ST; QPD
dexedrine
1
DEXEDRINE SPANSULE
2
dexmethylphenidate
1
dextroamphetamine
1
dextroamphetamine-amphetamine
1
diazepam
1
diazepam intensol
1
DORAL
2
doxepin
1
duloxetine
1
QPD
DYANAVEL XR
2
QPD
EDLUAR
2
ST; QPD
EFFEXOR XR
2
ST; QPD
EMSAM
2
QPD
ergoloid
1
escitalopram oxalate oral solution
1
escitalopram oxalate oral tablet
1
QPD
estazolam
1
QPD
eszopiclone
1
QPD
EVEKEO
2
FANAPT
2
FAZACLO
2
FETZIMA
2
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
QPD
of this table.
32
Drug Name
Drug Tier
fluphenazine hcl
1
flurazepam
1
QPD
fluvoxamine
1
QPD
FOCALIN
2
FOCALIN XR
2
FORFIVO XL
2
GEODON
2
QPD
guanfacine
1
QPD
guanidine
1
HALCION
2
haloperidol
1
haloperidol lactate
1
HETLIOZ
2
imipramine hcl
1
imipramine pamoate
1
INTERMEZZO
2
ST; QPD
INTUNIV ER
2
QPD
INVEGA
2
QPD
IRENKA
2
QPD
KAPVAY
2
KHEDEZLA
2
ST; QPD
LATUDA
2
QPD
LEXAPRO ORAL SOLUTION
2
ST
LEXAPRO ORAL TABLET
2
ST; QPD
lithium carbonate
1
lithium citrate
1
LITHOBID
2
lorazepam
1
lorazepam intensol
1
loxapine succinate
1
LUNESTA
2
QPD
PA; SP; QPD
ST; QPD
of this table.
33
Drug Name
Drug Tier
maprotiline
1
MARPLAN
2
METADATE CD
2
metadate er
1
methamphetamine
1
METHYLIN
2
methylphenidate
1
mirtazapine oral tablet 15 mg, 30 mg, 45 mg
1
mirtazapine oral tablet 7.5 mg
1
mirtazapine oral tablet,disintegrating
1
QPD
modafinil
1
PA
molindone
1
NARDIL
2
nefazodone
1
NORPRAMIN
2
nortriptyline
1
NUPLAZID
2
SP; QPD
NUVIGIL
2
PA; QPD
olanzapine
1
QPD
olanzapine-fluoxetine
1
OLEPTRO ER
2
ORAP
2
oxazepam
1
paliperidone
1
PAMELOR
2
PARNATE
2
paroxetine hcl
1
QPD
PAXIL CR
2
ST; QPD
PAXIL ORAL SUSPENSION
2
ST
PAXIL ORAL TABLET
2
ST; QPD
perphenazine
1
QPD
QPD
QPD
of this table.
34
Drug Name
Drug Tier
perphenazine-amitriptyline
1
PEXEVA
2
phenelzine
1
pimozide
1
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG, 50 MG
2
ST; QPD
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR 25 MG
2
ST
procentra
1
protriptyline
1
PROVIGIL
2
PA
PROZAC
2
ST; QPD
PROZAC WEEKLY
2
ST; QPD
quazepam
1
QPD
quetiapine
1
QPD
QUILLICHEW ER
2
QPD
QUILLIVANT XR
2
QPD
REMERON
2
QPD
REMERON SOLTAB
2
QPD
RESTORIL
2
QPD
REXULTI
2
QPD
RISPERDAL
2
RISPERDAL M-TAB
2
risperidone
1
RITALIN
2
RITALIN LA
2
ROZEREM
2
ST; QPD
SAPHRIS
2
QPD
SARAFEM
2
ST; QPD
seconal sodium
1
SEROQUEL
2
QPD
SEROQUEL XR
2
QPD
ST; QPD
of this table.
35
Drug Name
Drug Tier
sertraline oral concentrate
1
sertraline oral tablet
1
QPD
SILENOR
2
ST; QPD
SONATA
2
ST; QPD
STRATTERA
2
SURMONTIL
2
SYMBYAX
2
temazepam
1
thioridazine
1
thiothixene
1
TOFRANIL
2
TRANXENE T-TAB
2
tranylcypromine
1
trazodone
1
triazolam
1
trifluoperazine
1
trimipramine
1
TRINTELLIX
2
VALIUM
2
venlafaxine
1
QPD
VERSACLOZ
2
SP
VIIBRYD
2
ST; QPD
VRAYLAR
2
QPD
VYVANSE
2
QPD
WELLBUTRIN SR
2
QPD
WELLBUTRIN XL
2
QPD
XANAX
2
XANAX XR
2
XYREM
2
SP
zaleplon
1
QPD
zenzedi oral tablet 10 mg, 5 mg
1
QPD
QPD
QPD
of this table.
36
Drug Name
Drug Tier
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20
MG, 30 MG, 7.5 MG
2
QPD
ziprasidone hcl
1
QPD
ZOLOFT ORAL CONCENTRATE
2
ST
ZOLOFT ORAL TABLET
2
ST; QPD
zolpidem
1
QPD
ZOLPIMIST
2
ST; QPD
ZYPREXA
2
QPD
ZYPREXA ZYDIS
2
QPD
CARDIOVASCULAR, HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone
1
BETAPACE
2
BETAPACE AF
2
disopyramide phosphate
1
flecainide
1
mexiletine
1
MULTAQ
2
NORPACE
2
NORPACE CR
2
pacerone
1
propafenone
1
quinidine gluconate
1
quinidine sulfate
1
RYTHMOL
2
RYTHMOL SR
2
sotalol
1
sotalol af
1
SOTYLIZE
2
TIKOSYN
2
ANTIHYPERTENSIVE THERAPY
of this table.
37 Drug Name
Drug Tier
ACCUPRIL
2
ST; QPD
ACCURETIC
2
ST
acebutolol
2
ADALAT CC
2
ST; QPD
$0*
ALDACTAZIDE
2
ALDACTONE
2
ALTACE
2
amiloride
1
amiloride-hydrochlorothiazide
1
ST; QPD
amlodipine
$0*
amlodipine-benazepril
$0*
amlodipine-valsartan
$0*
QPD
amlodipine-valsartan-hcthiazid
$0*
QPD
ATACAND
2
ST; QPD
ATACAND HCT
2
ST
atenolol
$0*
atenolol-chlorthalidone
$0*
QPD
AVALIDE
2
ST
AVAPRO
2
ST; QPD
AZOR
2
ST
benazepril
$0*
benazepril-hydrochlorothiazide
$0*
QPD
BENICAR
2
ST; QPD
BENICAR HCT
2
ST; QPD
betaxolol
BIDIL
$0*
2
bisoprolol fumarate
$0*
bisoprolol-hydrochlorothiazide
$0*
bumetanide
$0*
ACEON
afeditab cr
1
of this table.
38
Drug Name
Drug Tier
BYSTOLIC
2
CALAN
2
CALAN SR
2
candesartan
$0*
candesartan-hydrochlorothiazid
$0*
captopril
$0*
captopril-hydrochlorothiazide
$0*
ST
QPD
QPD
CARDIZEM
2
CARDIZEM CD
2
CARDIZEM LA
2
CARDURA
2
QPD
CARDURA XL
2
QPD
carvedilol
1
CATAPRES
2
CATAPRES-TTS
2
chlorothiazide
$0*
chlorthalidone
$0*
QPD
clonidine
1
clonidine hcl
1
clorpres oral tablet 0.1-15 mg, 0.2-15 mg
1
CLORPRES ORAL TABLET 0.3-15 MG
2
COREG
2
ST
COREG CR
2
ST
CORGARD
2
ST
CORZIDE
2
ST
COZAAR
2
ST; QPD
DEMADEX
2
DEMSER
2
DIBENZYLINE
2
diltiazem
$0*
DIOVAN
2
QPD
SP
ST; QPD
of this table.
39
Drug Name
Drug Tier
DIOVAN HCT
2
DIURIL
2
doxazosin
1
QPD
DUTOPROL
2
ST; QPD
DYAZIDE
2
DYRENIUM
2
EDARBI
2
PA; ST; QPD
EDARBYCLOR
2
PA; ST; QPD
EDECRIN
2
enalapril maleate
$0*
enalapril-hydrochlorothiazide
$0*
ST
QPD
EPANED
2
eplerenone
1
eprosartan
$0*
EXFORGE
2
ST; QPD
EXFORGE HCT
2
ST; QPD
felodipine
$0*
fosinopril
$0*
fosinopril-hydrochlorothiazide
$0*
furosemide oral solution
1
furosemide oral tablet
1
guanfacine
1
HEMANGEOL
2
hydralazine
1
hydrochlorothiazide oral capsule
$0*
hydrochlorothiazide oral tablet 12.5 mg
$0*
hydrochlorothiazide oral tablet 25 mg, 50 mg
$0*
HYZAAR
2
indapamide
$0*
ST
QPD
QPD
QPD
QPD
QPD
ST
INDERAL LA
2
ST
INDERAL XL
2
ST
of this table.
40 Drug Name
Drug Tier
INNOPRAN XL
2
INSPRA
2
irbesartan
$0*
irbesartan-hydrochlorothiazide
$0*
isradipine
$0*
labetalol
1
LASIX
2
LEVATOL
2
ST
QPD
ST
lisinopril
$0*
QPD
lisinopril-hydrochlorothiazide
$0*
QPD
LOPRESSOR
2
ST
LOPRESSOR HCT
2
ST
losartan
$0*
losartan-hydrochlorothiazide
$0*
QPD
LOTENSIN
2
ST; QPD
LOTENSIN HCT
2
ST
LOTREL
2
ST
MAVIK
2
ST; QPD
MAXZIDE
2
MAXZIDE-25MG
2
methyclothiazide
$0*
methyldopa
1
methyldopa-hydrochlorothiazide
1
metolazone
$0*
metoprolol succinate
$0*
metoprolol ta-hydrochlorothiaz
$0*
metoprolol tartrate
$0*
QPD
MICARDIS
2
ST; QPD
MICARDIS HCT
2
ST
MICROZIDE
2
MINIPRESS
2
QPD
of this table.
41
Drug Name
Drug Tier
minoxidil
1
moexipril
$0*
moexipril-hydrochlorothiazide
$0*
nadolol
$0*
nadolol-bendroflumethiazide
$0*
nicardipine
$0*
nifedical xl
$0*
nifedipine
$0*
nimodipine
1
nisoldipine
$0*
NORVASC
2
NYMALIZE
2
ORENITRAM
2
perindopril erbumine
phenoxybenzamine
$0*
QPD
PA; SP
QPD
1
pindolol
$0*
prazosin
1
QPD
PRESTALIA
2
ST
PRINIVIL
2
ST; QPD
PROCARDIA
2
PROCARDIA XL
2
propranolol
$0*
propranolol-hydrochlorothiazid
$0*
quinapril
$0*
quinapril-hydrochlorothiazide
$0*
ramipril
$0*
reserpine
1
SECTRAL
2
spironolactone
1
spironolacton-hydrochlorothiaz
1
SULAR
2
QPD
QPD
ST
of this table.
42
Drug Name
Drug Tier
TARKA
2
ST
TEKTURNA
2
ST; QPD
TEKTURNA HCT
2
ST
telmisartan
$0*
QPD
telmisartan-amlodipine
$0*
QPD
telmisartan-hydrochlorothiazid
$0*
TENEX
2
TENORETIC
2
ST
TENORMIN
2
ST
terazosin
1
QPD
TIAZAC
2
timolol maleate
$0*
TOPROL XL
2
torsemide
1
trandolapril
$0*
trandolapril-verapamil
$0*
ST
QPD
triamterene-hydrochlorothiazid oral capsule 37.525 mg
1
QPD
triamterene-hydrochlorothiazid oral capsule 50-25
mg
1
triamterene-hydrochlorothiazid oral tablet
1
QPD
TRIBENZOR
2
ST; QPD
TWYNSTA
2
ST; QPD
UPTRAVI
2
PA; SP; QPD
valsartan
$0*
valsartan-hydrochlorothiazide
$0*
QPD
VASERETIC
2
ST
VASOTEC
2
ST; QPD
verapamil
$0*
VERELAN
2
VERELAN PM
2
ZEBETA
2
ST
of this table.
43 Drug Name
Drug Tier
ZESTORETIC
2
ST
ZESTRIL
2
ST; QPD
ZIAC
2
ST
CARDIAC GLYCOSIDES
digitek
1
digox
1
digoxin
1
LANOXIN
2
COAGULATION THERAPY
AGGRENOX
2
AMICAR
2
ARIXTRA
2
QPD
$0*
QPD
BRILINTA
2
QPD
cilostazol
1
QPD
$0*
QPD
aspirin-dipyridamole
clopidogrel
COUMADIN
2
dipyridamole
$0*
DURLAZA
2
PA; QPD
EFFIENT
2
QPD
ELIQUIS
2
QPD
enoxaparin
1
fondaparinux
1
FRAGMIN
2
heparin (porcine)
1
heparin, porcine (pf)
1
jantoven
$0*
LOVENOX
2
MEPHYTON
2
pentoxifylline
1
PHYTONADIONE (VITAMIN K1)
2
of this table.
44
Drug Name
Drug Tier
PLAVIX
2
QPD
PRADAXA
2
QPD
PROMACTA
2
SP
SAVAYSA
2
ticlopidine
$0*
vitamin k
1
warfarin
$0*
XARELTO
2
ZONTIVITY
2
QPD
QPD
LIPID/CHOLESTEROL LOWERING AGENTS
ALTOPREV
amlodipine-atorvastatin
ANTARA
atorvastatin
CADUET
2
$0*
$0*
2
$0*
cholestyramine light
$0*
COLESTID
2
COLESTID FLAVORED
2
CRESTOR
QPD
ST; QPD
$0*
2
fenofibrate micronized
$0*
fenofibrate nanocrystallized
$0*
FENOFIBRATE ORAL CAPSULE
QPD
2
cholestyramine (with sugar)
colestipol
ST; QPD
QPD
2
fenofibrate oral tablet
$0*
fenofibric acid
$0*
fenofibric acid (choline)
$0*
FENOGLIDE
2
FIBRICOR
2
fluvastatin
$0*
gemfibrozil
$0*
QPD
of this table.
45
Drug Name
Drug Tier
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5
MG
2
PA; SP; QPD
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60
MG
2
PA; SP
KYNAMRO
2
PA; SP; QPD
LESCOL
2
ST; QPD
LESCOL XL
2
ST; QPD
LIPITOR
2
ST; QPD
LIPOFEN
2
LIVALO
2
LOFIBRA
2
LOPID
2
lovastatin
$0*
niacin
$0*
ST; QPD
QPD
NIACOR
2
NIASPAN EXTENDED-RELEASE
2
omega-3 acid ethyl esters
1
PA
PRALUENT
2
PA; SP; QPD
PRAVACHOL
2
ST; QPD
pravastatin
$0*
prevalite
$0*
QPD
QUESTRAN
2
QUESTRAN LIGHT
2
REPATHA
2
rosuvastatin
$0*
QPD
simvastatin
$0*
QPD
PA; SP; QPD
TRICOR
2
TRIGLIDE
2
TRILIPIX
2
VASCEPA
2
PA; QPD
VYTORIN
2
ST; QPD
WELCHOL
2
of this table.
46 Drug Name
Drug Tier
ZETIA
2
QPD
ZOCOR
2
ST; QPD
CORLANOR
2
QPD
ENTRESTO
2
QPD
RANEXA
2
VECAMYL
2
MISCELLANEOUS CARDIOVASCULAR AGENTS
SP
NITRATES
DILATRATE-SR
2
ISOCHRON
2
ISORDIL
2
ISORDIL TITRADOSE
2
isosorbide dinitrate
1
isosorbide mononitrate
1
MINITRAN
2
nitro-bid
1
NITRO-DUR
2
nitroglycerin
1
NITROLINGUAL
2
NITROMIST
2
NITROSTAT
2
nitro-time
1
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin
1
calcipotriene
1
calcipotriene-betamethasone
1
calcitrene
1
calcitriol
1
COAL TAR
2
COSENTYX
2
PA; SP; QPD
of this table.
47
Drug Name
Drug Tier
DOVONEX
2
drithocreme hp
1
EPIFOAM
2
hydrocortisone-pramoxine
1
OVACE
2
OVACE PLUS
2
OVACE PLUS SHAMPOO
2
OVACE PLUS WASH
2
PRAMOSONE
2
ST; QPD
PRAMOSONE E
2
ST
seb-prev
1
selenium sulfide
1
SELRX
2
SORIATANE
2
SORILUX
2
STELARA
2
sulfacetamide sodium
1
TACLONEX
2
TALTZ
2
TERSI FOAM
2
VECTICAL
2
ZITHRANOL
2
ZITHRANOL-RR
2
ST
PA; SP; QPD
PA; SP; QPD
BURN THERAPY
SILVADENE
2
silver sulfadiazine
1
ssd
1
thermazene
1
KERATOLYTICS
BENSAL HP
2
INOVA 4-1
2
ST
of this table.
48
Drug Name
Drug Tier
INOVA 8-2
2
KERALYT RX
2
KERALYT SCALP COMPLETE
2
PODOCON
2
POTASSIUM HYDROXIDE
2
salacyn
1
SALEX
2
salicylic acid
1
SALKERA
2
salvax
1
SALVAX DUO PLUS
2
VIRASAL
2
ST
MISCELLANEOUS DERMATOLOGICALS
8-MOP
2
ALUVEA
2
bp-50% urea
1
CARAC
2
cem-urea
1
CONDYLOX
2
CORTANE-B
2
DERMASORB XM COMPLETE KIT
2
diclofenac sodium
1
doxepin
1
EFUDEX
2
ELIDEL
2
FLUOROPLEX
2
FLUOROURACIL TOPICAL CREAM 0.5 %
2
fluorouracil topical cream 5 %
1
fluorouracil topical solution
1
GORDONS UREA
2
HYDRO 35
2
SP
of this table.
49
Drug Name
Drug Tier
HYDRO 40
2
KERAFOAM
2
KERALAC
2
latrix
1
LEVULAN
2
LOUTREX
2
methoxsalen rapid
1
SP
OXSORALEN
2
SP
OXSORALEN ULTRA
2
SP
PANRETIN
2
SP
PICATO
2
podofilox
1
PROTOPIC
2
prudoxin
1
rea lo 39
1
rea lo 40
1
REGRANEX
2
remeven
1
silver nitrate
1
silver nitrate applicators
1
SOLARAZE
2
tacrolimus
1
TOLAK
2
umecta
1
UMECTA PD
2
URAMAXIN
2
URAMAXIN GT
2
urea
1
urea nail stick
1
urea-hyaluronate sodium
1
ure-k
1
QPD
of this table.
50
Drug Name
Drug Tier
UTOPIC
2
VALCHLOR
2
SP
VEREGEN
2
QPD
ZONALON
2
THERAPY FOR ACNE
ABSORICA
2
ST
ACANYA
2
ST
ACZONE
2
ST
adapalene
1
ATRALIN
2
PA
AVAR LS
2
ST
avar topical cleanser
1
AVAR TOPICAL FOAM
2
ST
AVAR TOPICAL PADS, MEDICATED
2
ST
AVAR-E GREEN
2
ST
AVAR-E LS
2
ST
avita
1
PA
AZELEX
2
ST
BENZACLIN
2
ST
BENZACLIN PUMP
2
ST
BENZAMYCIN
2
ST
BENZAMYCINPAK
2
ST
BENZEFOAM
2
ST
BENZEFOAM ULTRA
2
ST
benzepro
1
BENZEPRO (MICROSPHERES)
2
benzoyl peroxide
1
bp 10-1
1
bpo
1
claravis
1
cleansing wash
1
of this table.
51
Drug Name
Drug Tier
CLEOCIN T
2
ST
CLINDACIN ETZ
2
ST
clindacin p
1
CLINDACIN PAC
2
ST
CLINDAGEL
2
ST
clindamycin phosphate
1
clindamycin-benzoyl peroxide
1
DIFFERIN
2
DUAC
2
ST
EPIDUO
2
ST
EPIDUO FORTE
2
ST
ery pads
1
erygel
1
erythromycin with ethanol
1
erythromycin-benzoyl peroxide
1
EVOCLIN
2
FABIOR
2
FINACEA
2
INOVA
2
METROCREAM
2
METROGEL
2
METROLOTION
2
metronidazole
1
MIRVASO
2
myorisan
1
neuac
1
NORITATE
2
NUOX
2
ST
ONEXTON
2
ST
PACNEX
2
ST
PLEXION
2
ST
ST
ST
of this table.
52
Drug Name
Drug Tier
PLEXION CLEANSING CLOTHS
2
ST
PR BENZOYL PEROXIDE
2
RETIN-A
2
PA
RETIN-A MICRO
2
PA
RETIN-A MICRO PUMP
2
PA
rosadan
1
ROSANIL
2
ST
ROSULA
2
ST
rosula cleansing cloths
1
SOOLANTRA
2
ss 10-2
1
sss 10-5
1
sulfacetamide sodium-sulfur
1
sulfacetamide sod-sulfur-urea
1
sulfacetamide-sulfur-cleansr23
1
sulfacleanse 8-4
1
sulfact na-sul-avobnz-otn-ocsa
1
SUMAXIN CP
2
ST
SUMAXIN TOPICAL CLEANSER
2
ST; QPD
SUMAXIN TOPICAL PADS, MEDICATED
2
ST
SUMAXIN TS
2
ST
TAZORAC
2
tretinoin
1
PA
tretinoin microspheres
1
PA
TRETIN-X
2
PA
TRETIN-X CREAM KIT
2
PA
VANOXIDE-HC
2
VELTIN
2
zenatane
1
zencia
1
ZIANA
2
PA; ST
PA; ST
of this table.
53
Drug Name
Drug Tier
TOPICAL ANESTHETICS
ethyl chloride
1
glydo
1
lidocaine hcl
1
lidocaine hcl-hydrocortison ac
1
lidocaine topical adhesive patch,medicated
1
lidocaine topical ointment
1
lidocaine viscous
1
lidocaine-prilocaine
1
LIDODERM
2
PA
SYNERA
2
QPD
PA
TOPICAL ANTIBACTERIALS
ALTABAX
2
CENTANY
2
CENTANY AT
2
CORTISPORIN
2
gentamicin
1
KLARON
2
mupirocin
1
mupirocin calcium
1
NEO-SYNALAR
2
NEO-SYNALAR KIT
2
sulfacetamide sodium (acne)
1
SULFAMYLON
2
ST; QPD
TOPICAL ANTIFUNGALS
ciclodan
1
ciclopirox
1
ciclopirox-ure-camph-menth-euc
1
clotrimazole
1
clotrimazole-betamethasone
1
CNL 8 NAIL
2
of this table.
54
Drug Name
Drug Tier
econazole
1
ECOZA
2
ERTACZO
2
EXELDERM
2
EXODERM
2
EXTINA
2
JUBLIA
2
QPD
KERYDIN
2
QPD
ketoconazole
1
LOPROX
2
LOTRISONE
2
LUZU
2
MENTAX
2
NAFTIFINE TOPICAL CREAM 1 %
2
naftifine topical cream 2 %
1
NAFTIN
2
NIZORAL
2
nyamyc
1
nystatin
1
nystatin-triamcinolone
1
nystop
1
oxiconazole
1
OXISTAT
2
PENLAC
2
TRIACETIN
2
TRIPLE DYE
2
XOLEGEL
2
TOPICAL ANTIVIRALS
acyclovir
1
DENAVIR
2
ZOVIRAX
2
of this table.
55
Drug Name
Drug Tier
TOPICAL CORTICOSTEROIDS
ala-cort
1
ALA-SCALP
2
alclometasone
1
amcinonide
1
apexicon e
1
betamethasone dipropionate
1
betamethasone valerate
1
betamethasone, augmented
1
CAPEX
2
clobetasol
1
clobetasol-emollient
1
CLOBEX
2
ST
CLOCORTOLONE PIVALATE
2
ST
clodan
1
CLODERM
2
ST
CORDRAN
2
ST
CORDRAN TAPE SMALL ROLL
2
ST
cormax
1
CUTIVATE TOPICAL CREAM
2
ST
CUTIVATE TOPICAL LOTION
2
ST; QPD
DERMA-SMOOTHE/FS BODY OIL
2
ST
DERMA-SMOOTHE/FS SCALP OIL
2
ST
DERMASORB HC COMPLETE KIT
2
ST
DERMASORB TA COMPLETE KIT
2
ST
DERMATOP
2
ST
DESONATE
2
ST; QPD
desonide
1
DESOWEN
2
desoximetasone
1
diflorasone
1
ST
ST
ST; QPD
of this table.
56
Drug Name
Drug Tier
DIPROLENE
2
ST
DIPROLENE AF
2
ST
ELOCON
2
ST
fluocinolone
1
fluocinolone and shower cap
1
fluocinonide
1
fluocinonide-e
1
flurandrenolide
1
fluticasone
1
halobetasol propionate
1
HALOG
2
hydrocortisone
1
hydrocortisone butyrate
1
hydrocortisone butyr-emollient
1
hydrocortisone valerate
1
hydrocortisone-min oil-wht pet
1
KENALOG
2
ST
LOCOID
2
ST
LOCOID LIPOCREAM
2
ST
LUXIQ
2
ST
mometasone
1
OLUX
2
ST
OLUX-E
2
ST
PANDEL
2
ST
prednicarbate
1
PSORCON
2
scalacort
1
SCALACORT DK
2
SERNIVO
2
ST; QPD
SYNALAR
2
ST
SYNALAR CREAM KIT
2
ST
ST; QPD
ST
of this table.
57
Drug Name
Drug Tier
SYNALAR OINTMENT KIT
2
ST
SYNALAR TS
2
ST
TEMOVATE
2
ST
TEXACORT
2
ST
TOPICORT
2
ST
triamcinolone acetonide
1
trianex
1
triderm
1
ULTRAVATE
2
ST
ULTRAVATE X
2
ST
VANOS
2
ST
VERDESO
2
ST; QPD
TOPICAL ENZYMES
SANTYL
2
TOPICAL SCABICIDES / PEDICULICIDES
ELIMITE
2
EURAX
2
lindane
1
malathion
1
NATROBA
2
OVIDE
2
permethrin
1
SKLICE
2
spinosad
1
ULESFIA
2
QPD
QPD
DIAGNOSTICS & MISCELLANEOUS AGENTS
ANTIDOTES
ATROPEN
2
IRRIGATING SOLUTIONS
lactated ringers
1
neomycin-polymyxin b gu
1
of this table.
58
Drug Name
Drug Tier
NEOSPORIN GU IRRIGANT
2
PHYSIOLYTE
2
PHYSIOSOL IRRIGATION
2
ringers
1
SORBITOL
2
SORBITOL-MANNITOL
2
tis-u-sol pentalyte
1
MISCELLANEOUS AGENTS
acamprosate
1
acetic acid
1
ACTONEL
2
AGRYLIN
2
alendronate
$0*
anagrelide
1
ANTABUSE
2
BUPHENYL
2
caffeine citrated
1
CARNITOR
2
CARNITOR (SUGAR-FREE)
2
cevimeline
1
CHEMET
2
disulfiram
1
etidronate disodium
1
EVOXAC
2
EXJADE
2
SP
FERRIPROX
2
SP
INCRELEX
2
PA; SP
JADENU
2
SP
levocarnitine
1
levocarnitine (with sugar)
1
LIPOCHOL PLUS
2
ST; QPD
QPD
SP
of this table.
59
Drug Name
Drug Tier
LITHOSTAT
2
METOPIRONE
2
midodrine
1
NORTHERA
2
PA; SP
ORFADIN
2
SP
pilocarpine hcl
1
RADIOGARDASE
2
RAVICTI
2
SP
RILUTEK
2
SP
riluzole
1
SP
risedronate
$0*
SALAGEN
2
sodium chloride
1
sodium phenylbutyrate
1
SYPRINE
2
THIOLA
2
water for irrigation, sterile
1
XURIDEN
2
QPD
PA; SP; QPD
SMOKING DETERRENTS
CHANTIX
$0
NICODERM CQ
$0
NICORETTE
$0
nicotine
$0
NICOTINE (POLACRILEX)
$0
NICOTROL
$0
NICOTROL NS
$0
QUIT 2
$0
QUIT 4
$0
EAR, NOSE & THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ASTEPRO
2
ST; QPD
of this table.
60 Drug Name
Drug Tier
azelastine
1
BACTROBAN NASAL
2
chlorhexidine gluconate
1
CLINPRO 5000
2
denta 5000 plus
1
dentagel
1
fluoridex daily defense
1
FLUORIDEX SENSITIVITY RELIEF
2
ipratropium bromide
1
olopatadine
1
oralone
1
PATANASE
2
PERIDEX
2
periogard
1
pilocarpine hcl
1
PREVIDENT
2
PREVIDENT 5000 BOOSTER PLUS
2
PREVIDENT 5000 DRY MOUTH
2
PREVIDENT 5000 ENAMEL PROTECT
2
PREVIDENT 5000 SENSITIVE
2
SALAGEN
2
sf
1
sf 5000 plus
1
sodium fluoride
1
triamcinolone acetonide
1
TYZINE
2
QPD
QPD
ST; QPD
MISCELLANEOUS OTIC PREPARATIONS
acetasol hc
1
acetic acid
1
acetic acid-aluminum acetate
1
CETRAXAL
2
of this table.
61
Drug Name
Drug Tier
ciprofloxacin hcl
1
DERMOTIC OIL
2
fluocinolone acetonide oil
1
hydrocortisone-acetic acid
1
ofloxacin
1
OTIC STEROID / ANTIBIOTIC
CIPRO HC
2
CIPRODEX
2
COLY-MYCIN S
2
neomycin-polymyxin-hc
1
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P.
2
CORTEF
2
cortisone
1
deltasone
1
dexamethasone
1
dexamethasone intensol
1
DEXPAK
2
fludrocortisone
1
hydrocortisone
1
MEDROL
2
MEDROL (PAK)
2
methylprednisolone
1
millipred dp
1
MILLIPRED ORAL SOLUTION
2
millipred oral tablet
1
ORAPRED ODT
2
PEDIAPRED
2
prednisolone
1
prednisolone sodium phosphate
1
PA; SP; QPD
of this table.
62
Drug Name
Drug Tier
prednisone
1
prednisone intensol
1
RAYOS
2
veripred 20
1
ANTITHYROID AGENTS
methimazole
1
propylthiouracil
1
SSKI
2
TAPAZOLE
2
BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES
ACCU-CHEK AVIVA PLUS TEST STRP
2
PA
ACCU-CHEK COMPACT TEST
2
PA
ACCU-CHEK SMARTVIEW TEST STRIP
2
PA
ACCUTREND GLUCOSE
2
PA
ADVANCED GLUC METER TEST STRIP
2
PA
ADVOCATE REDI-CODE
2
PA
ADVOCATE TEST STRIPS
2
PA
AGAMATRIX AMP TEST STRIPS
2
PA
ASSURE 4 STRIPS
2
PA
ASSURE PLATINUM
2
PA
ASSURE PRISM MULTI STRIP
2
PA
BG-STAR
2
PA
BIONIME RIGHTEST TEST STRIPS
2
PA
BLOOD GLUCOSE TEST
2
PA
BREEZE 2 TEST STRIPS
2
CARESENS N TEST STRIPS
2
PA
CLEVER CHOICE MICRO TEST STRIP
2
PA
CLEVER CHOICE PRO
2
PA
CLEVER CHOICE TEST STRIPS
2
PA
CLEVER CHOICE VOICE+ TEST
2
PA
CONTOUR NEXT STRIPS
2
of this table.
63
Drug Name
Drug Tier
CONTOUR TEST STRIPS
2
CONTROL G3
2
PA
COOL GLUCOSE TEST STRIP
2
PA
DIATRUE PLUS TEST STRIP
2
PA
EASY PLUS II TEST
2
PA
EASY STEP
2
PA
EASY TALK GLUCOSE TEST
2
PA
EASY TOUCH TEST STRIP
2
PA
EASY TRAK GLUCOSE TEST
2
PA
EASYGLUCO PLUS
2
PA
EASYGLUCO TEST
2
PA
EASYMAX
2
PA
ELEMENT COMPACT TEST STRIPS
2
PA
ELEMENT TEST STRIPS
2
PA
EMBRACE BLOOD GLUCOSE SYSTEM
2
PA
EMBRACE EVO TEST STRIPS
2
PA
EMBRACE PRO TEST STRIPS
2
PA
EVENCARE G2
2
PA
EVENCARE G3 TEST
2
PA
EVENCARE MINI GLUCOSE TEST STR
2
PA
EVOLUTION TEST STRIPS
2
PA
EZ SMART PLUS TEST
2
PA
EZ SMART TEST
2
PA
FIFTY50 TEST STRIP
2
PA
FORA D10
2
PA
FORA D15G
2
PA
FORA D20
2
PA
FORA D40-G31 TEST STRIPS
2
PA
FORA G20
2
PA
FORA G30A
2
PA
FORA GD50 TEST STRIPS
2
PA
of this table.
64 Drug Name
Drug Tier
FORA TEST STRIP
2
PA
FORA TN'G VOICE TEST STRIPS
2
PA
FORA V10
2
PA
FORA V12 GLUCOSE
2
PA
FORA V20
2
PA
FORACARE GD20
2
PA
FORACARE GD40
2
PA
FORTISCARE GLUCOSE TEST STRIPS
2
PA
FREESTYLE INSULINX
2
PA
FREESTYLE INSULINX TEST STRIPS
2
PA
FREESTYLE LITE STRIPS
2
PA
FREESTYLE PRECISION NEO STRIPS
2
PA
FREESTYLE TEST
2
PA
GE100 BLOOD GLUCOSE TEST STRIP
2
PA
GENSTRIP TEST STRIP
2
PA
GLUCO NAVII TEST STRIP
2
PA
GLUCOCARD 01 SENSOR PLUS
2
PA
GLUCOCARD EXPRESSION
2
PA
GLUCOCARD SHINE TEST STRIPS
2
PA
GLUCOCARD VITAL SENSOR
2
PA
GLUCOCARD VITAL TEST STRIPS
2
PA
GLUCOCOM GLUCOSE
2
PA
GM100
2
PA
GMATE TEST STRIPS
2
PA
HEALTHPRO TEST STRIPS
2
PA
INFINITY TEST STRIPS
2
PA
LIBERTY TEST
2
PA
MICRO BLOOD GLUCOSE
2
PA
MICRODOT BLOOD GLUCOSE SYSTEM
2
PA
MYGLUCOHEALTH
2
PA
NEUTEK 2TEK TEST STRIPS
2
PA
of this table.
65
Drug Name
Drug Tier
NOVA MAX GLUCOSE TEST
2
PA
ON CALL EXPRESS TEST STRIP
2
PA
ON CALL PLUS TEST STRIP
2
PA
ON CALL VIVID TEST STRIP
2
PA
ONETOUCH ULTRA TEST
2
PA
ONETOUCH VERIO
2
PA
OPTIUM EZ
2
PA
OPTIUM TEST
2
PA
OPTUMRX
2
PA
PHARMACIST CHOICE
2
PA
PRECISION PCX PLUS TEST
2
PA
PRECISION PCX TEST
2
PA
PRECISION POINT OF CARE TEST
2
PA
PRECISION Q-I-D TEST
2
PA
PRECISION XTRA TEST
2
PA
PREMIUM V10
2
PA
PRODIGY NO CODING
2
PA
QUINTET AC
2
PA
REFUAH PLUS
2
PA
RELION CONFIRM-MICRO
2
PA
RELION PRIME TEST STRIPS
2
PA
REVEAL TEST STRIP
2
PA
RIGHTEST GS550 TEST STRIPS
2
PA
SMART SENSE TEST STRIPS
2
PA
SMARTEST TEST
2
PA
SOLUS V2 TEST STRIPS
2
PA
SURE-TEST EASYPLUS MINI
2
PA
TELCARE TEST STRIPS
2
PA
TEST N'GO TEST
2
PA
TRUE METRIX GLUCOSE TEST STRIP
2
TRUETEST TEST STRIPS
2
of this table.
66
Drug Name
Drug Tier
TRUETRACK TEST
2
ULTIMA TEST STRIPS
2
PA
ULTRATRAK
2
PA
ULTRATRAK ULTIMATE
2
PA
UNISTRIP1 TEST STRIP
2
PA
WAVESENSE JAZZ
2
PA
WAVESENSE PRESTO
2
PA
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
2
GLUCAGON EMERGENCY KIT (HUMAN)
2
PROGLYCEM
2
INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU
LANCETS
2
INSULIN THERAPY
AFREZZA
2
PA
APIDRA
2
PA
APIDRA SOLOSTAR
2
PA
HUMALOG
2
PA
HUMALOG KWIKPEN
2
PA
HUMALOG MIX 50-50
2
PA
HUMALOG MIX 50-50 KWIKPEN
2
PA
HUMALOG MIX 75-25
2
PA
HUMALOG MIX 75-25 KWIKPEN
2
PA
HUMULIN 70/30
2
PA
HUMULIN 70/30 KWIKPEN
2
PA
HUMULIN N
2
PA
HUMULIN N KWIKPEN
2
PA
HUMULIN R
2
PA
HUMULIN R U-500 (CONC) KWIKPEN
2
HUMULIN R U-500 (CONCENTRATED)
2
LANTUS
2
of this table.
67
Drug Name
Drug Tier
LANTUS SOLOSTAR
2
LEVEMIR
2
LEVEMIR FLEXTOUCH
2
NOVOLIN 70/30
2
NOVOLIN N
2
NOVOLIN R
2
NOVOLOG
2
NOVOLOG FLEXPEN
2
NOVOLOG MIX 70-30
2
NOVOLOG MIX 70-30 FLEXPEN
2
NOVOLOG PENFILL
2
TOUJEO SOLOSTAR
2
TRESIBA FLEXTOUCH U-100
2
PA
TRESIBA FLEXTOUCH U-200
2
PA
MISCELLANEOUS HORMONES
ANADROL-50
2
ANDRODERM
2
PA; QPD
ANDROGEL
2
PA; QPD
ANDROID
2
androxy
1
AXIRON
2
cabergoline
1
calcitonin (salmon)
1
calcitriol
1
CERDELGA
2
danazol
1
DDAVP NASAL
2
DDAVP ORAL
2
DEPO-TESTOSTERONE
2
desmopressin
1
doxercalciferol
1
PA; QPD
QPD
SP
SP
of this table.
68
Drug Name
Drug Tier
FORTESTA
2
PA; QPD
fortical
1
QPD
HECTOROL
2
KORLYM
2
PA; SP; QPD
KUVAN
2
PA; SP
METHITEST
2
methyltestosterone
1
MIACALCIN INJECTION
2
MIACALCIN NASAL
2
QPD
MYALEPT
2
PA; SP; QPD
NATESTO
2
PA; QPD
NATPARA
2
SP; QPD
OXANDRIN
2
oxandrolone
1
paricalcitol
1
ROCALTROL
2
SAMSCA
2
SENSIPAR
2
SOMAVERT SUBCUTANEOUS RECON SOLN
10 MG, 15 MG, 20 MG
2
SP; QPD
SOMAVERT SUBCUTANEOUS RECON SOLN
25 MG, 30 MG
2
SP
STIMATE
2
SP
STRENSIQ
2
PA; SP
STRIANT
2
PA; QPD
SYNAREL
2
TESTIM
2
testosterone cypionate
1
testosterone enanthate
1
testosterone transdermal gel in metered-dose
pump 1.25 gram/ actuation (1 %)
1
SP
PA; QPD
PA; QPD
of this table.
69 Drug Name
Drug Tier
TESTOSTERONE TRANSDERMAL GEL IN
METERED-DOSE PUMP 10 MG/0.5 GRAM
/ACTUATION
2
PA; QPD
testosterone transdermal gel in packet
1
PA; QPD
TESTRED
2
VOGELXO
2
PA; QPD
ZAVESCA
2
SP
ZEMPLAR
2
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose
1
ACTOPLUS MET
2
ST; QPD
ACTOPLUS MET XR
2
ST; QPD
ACTOS
2
ST; QPD
ALOGLIPTIN
2
PA; QPD
ALOGLIPTIN-METFORMIN
2
PA; QPD
ALOGLIPTIN-PIOGLITAZONE
2
ST; QPD
AMARYL
2
AVANDIA
2
ST; QPD
BYDUREON
2
PA; QPD
BYETTA
2
PA; QPD
chlorpropamide
1
CYCLOSET
2
ST
DUETACT
2
ST; QPD
FARXIGA
2
ST; QPD
FORTAMET
2
ST
glimepiride
1
glipizide
1
QPD
glipizide-metformin
1
QPD
GLUCOPHAGE
2
ST
GLUCOPHAGE XR
2
ST
GLUCOTROL
2
GLUCOTROL XL
2
of this table.
70
Drug Name
Drug Tier
GLUCOVANCE
2
QPD
GLUMETZA
2
ST
glyburide
1
glyburide micronized
1
glyburide-metformin
1
GLYNASE
2
GLYSET
2
GLYXAMBI
2
ST; QPD
INVOKAMET
2
ST; QPD
INVOKANA
2
ST; QPD
JANUMET
2
ST; QPD
JANUMET XR
2
ST; QPD
JANUVIA
2
ST; QPD
JARDIANCE
2
ST; QPD
JENTADUETO
2
PA; ST; QPD
JENTADUETO XR
2
PA; ST; QPD
KAZANO
2
PA; ST; QPD
KOMBIGLYZE XR
2
ST; QPD
metformin oral tablet
1
QPD
metformin oral tablet extended release 24 hr
1
QPD
metformin oral tablet extended release 24hr
1
metformin oral tablet,er gast.retention 24 hr
1
miglitol
1
nateglinide
1
NESINA
2
PA; ST; QPD
ONGLYZA
2
ST; QPD
OSENI
2
ST; QPD
pioglitazone
1
QPD
pioglitazone-glimepiride
1
QPD
pioglitazone-metformin
1
QPD
PRANDIN
2
QPD
of this table.
71
Drug Name
Drug Tier
PRECOSE
2
repaglinide
1
repaglinide-metformin
1
RIOMET
2
STARLIX
2
SYMLINPEN
2
PA; QPD
SYNJARDY
2
ST; QPD
TANZEUM
2
PA; QPD
tolazamide
1
tolbutamide
1
TRADJENTA
2
PA; ST; QPD
TRULICITY
2
PA; QPD
VICTOZA
2
PA; QPD
XIGDUO XR
2
ST; QPD
ST
THYROID HORMONES
ARMOUR THYROID
2
CYTOMEL
2
levothyroxine
1
levoxyl
1
liothyronine
1
nature-throid
1
np thyroid
1
SYNTHROID
2
THYROLAR
2
TIROSINT
2
unithroid
1
westhroid
1
WP THYROID
2
GASTROENTEROLOGY
ANTIDIARRHEALS & ANTISPASMODICS
anaspaz
1
of this table.
72 Drug Name
Drug Tier
belladonna alkaloids-opium
1
belladonna-opium
1
BENTYL
2
chlordiazepoxide-clidinium
1
CUVPOSA
2
dicyclomine
1
diphenoxylate-atropine
1
DONNATAL
2
ed-spaz
1
FULYZAQ
2
glycopyrrolate
1
hyoscyamine sulfate
1
hyosyne
1
LEVBID
2
LEVSIN
2
LEVSIN/SL
2
LIBRAX (WITH CLIDINIUM)
2
LOMOTIL
2
loperamide
1
methscopolamine
1
NULEV
2
opium tincture
1
oscimin
1
oscimin sl
1
oscimin sr
1
paregoric
1
phenohytro
1
propantheline
1
ROBINUL
2
ROBINUL FORTE
2
SYMAX DUOTAB
2
SP; QPD
of this table.
73
Drug Name
Drug Tier
symax fastabs
1
symax-sl
1
symax-sr
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
ACTIGALL
2
AKYNZEO
2
QPD
alosetron
1
QPD
AMITIZA
2
QPD
ANA-LEX KIT
2
ANALPRAM E
2
ANALPRAM-HC
2
ANALPRAM-HC SINGLES
2
ANTIVERT
2
anucort-hc
1
ANUSOL-HC
2
ANZEMET
2
APRISO
2
ASACOL HD
2
AURYXIA
2
AZULFIDINE
2
AZULFIDINE EN-TABS
2
balsalazide
1
bisacodyl
$0
budesonide
1
calcium acetate
1
CANASA
2
CESAMET
2
QPD
CHENODAL
2
SP
CHOLBAM
2
PA; SP
CIMZIA
2
PA; SP; QPD
citrate of magnesia
$0
QPD
PA
of this table.
74
Drug Name
Drug Tier
COLAZAL
2
colocort
1
COLYTE WITH FLAVOR PACKS
2
COMPAZINE
2
compro
1
constulose
1
CORTENEMA
2
CORTIFOAM
2
CREON
2
cromolyn
1
CYSTADANE
2
DICLEGIS
2
DIPENTUM
2
dronabinol
1
eliphos
1
EMEND
2
ENTOCORT EC
2
enulose
1
FOSRENOL
2
GASTROCROM
2
GATTEX 30-VIAL
2
gavilyte-c
$0
gavilyte-g
$0
gavilyte-h and bisacodyl
$0
gavilyte-n
$0
generlac
1
GIAZO
2
GOLYTELY
2
granisetron hcl
1
hydrocortisone
1
hydrocortisone acetate
1
SP; QPD
QPD
PA
PA; SP
QPD
of this table.
75
Drug Name
Drug Tier
hydrocortisone-pramoxine
1
KAYEXALATE
2
kionex
1
KRISTALOSE
2
lactulose
1
laxative peg 3350
$0
LIALDA
2
lidocaine hcl-hydrocortison ac rectal cream
1
LIDOCAINE HCL-HYDROCORTISON AC
RECTAL GEL
2
lidocaine hcl-hydrocortison ac rectal kit
1
lidocaine-hydrocortisone-aloe
1
LINZESS
2
QPD
LOTRONEX
2
QPD
MAGNEBIND 400
2
MARINOL
2
meclizine
1
mesalamine
1
mesalamine with cleansing wipe
1
metoclopramide hcl
1
METOZOLV ODT
2
milk of magnesia concentrated
$0
MOVANTIK
2
MOVIPREP
2
NULYTELY WITH FLAVOR PACKS
2
OCALIVA
2
PA; SP; QPD
ondansetron
1
QPD
ondansetron hcl
1
QPD
OSMOPREP
2
PANCREAZE
2
peg 3350-electrolytes
$0
peg-3350 with flavor packs
$0
QPD
of this table.
76
Drug Name
Drug Tier
peg-electrolyte soln
$0
peg-prep
$0
PENTASA
2
PERTZYE
2
PHOSLO
2
PA
PHOSLYRA
2
PA
phosphate laxative
$0
polyethylene glycol 3350
$0
pramcort
1
PREPOPIK
2
prochlorperazine
1
prochlorperazine maleate
1
PROCORT
2
PROCTOCORT
2
PROCTOFOAM HC
2
procto-med hc
1
procto-pak
1
proctosol hc
1
proctozone-hc
1
RECTIV
2
REGLAN
2
RELISTOR
2
SP; QPD
RENAGEL
2
PA
RENVELA
2
PA
ROWASA
2
SANCUSO
2
sodium polystyrene sulfonate oral
1
sodium polystyrene sulfonate rectal enema 30
gram/120 ml
1
SODIUM POLYSTYRENE SULFONATE
RECTAL ENEMA 50 GRAM/200 ML
2
sps
1
QPD
of this table.
77
Drug Name
Drug Tier
SUCRAID
2
sulfasalazine
1
SUPREP BOWEL PREP KIT
2
TIGAN
2
TRANSDERM-SCOP
2
trilyte with flavor packets
$0
trimethobenzamide
1
UCERIS
2
URSO 250
2
URSO FORTE
2
ursodiol
1
VARUBI
2
QPD
VELPHORO
2
PA
VELTASSA
2
SP; QPD
VIBERZI
2
QPD
VIOKACE
2
ZENPEP
2
ZOFRAN (AS HYDROCHLORIDE)
2
QPD
ZOFRAN ODT
2
QPD
ZUPLENZ
2
QPD
ACIPHEX
2
ST; QPD
ACIPHEX SPRINKLE
2
ST
amoxicil-clarithromy-lansopraz
1
carafate oral suspension
1
CARAFATE ORAL TABLET
2
cimetidine
1
cimetidine hcl
1
CYTOTEC
2
DEXILANT
2
ST; QPD
esomeprazole magnesium
1
QPD
SP
ULCER THERAPY
of this table.
78
Drug Name
Drug Tier
famotidine
1
lansoprazole
1
misoprostol
1
NEXIUM PACKET
2
nizatidine
1
OMECLAMOX-PAK
2
omeprazole
1
QPD
pantoprazole
1
QPD
PEPCID
2
PREVACID SOLUTAB
2
PREVPAC
2
PRILOSEC
2
ST; QPD
PROTONIX
2
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
2
QPD
QPD
ST; QPD
QPD
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
MOZOBIL
2
SP
EGRIFTA
2
PA; SP
GENOTROPIN
2
PA; SP
GENOTROPIN MINIQUICK
2
PA; SP
HUMATROPE
2
PA; SP
NORDITROPIN FLEXPRO
2
PA; SP
NUTROPIN AQ
2
PA; SP
NUTROPIN AQ NUSPIN
2
PA; SP
GROWTH HORMONES
of this table.
79 Drug Name
Drug Tier
OMNITROPE
2
PA; SP
SAIZEN
2
PA; SP
SAIZEN CLICK.EASY
2
PA; SP
SEROSTIM
2
PA; SP
ZOMACTON
2
PA; SP
ZORBTIVE
2
PA; SP
AUBAGIO
2
SP; QPD
AVONEX
2
SP; QPD
BETASERON
2
PA; SP; QPD
COPAXONE
2
SP; QPD
COPEGUS
2
SP; QPD
EXTAVIA
2
SP; QPD
GILENYA
2
SP; QPD
glatopa
1
SP; QPD
moderiba
1
QPD
moderiba dose pack
1
QPD
PEGASYS
2
PA; SP; QPD
PEGASYS PROCLICK
2
PA; SP; QPD
PEGINTRON
2
PA; SP; QPD
PEGINTRON REDIPEN
2
PA; SP; QPD
PLEGRIDY
2
SP; QPD
POMALYST
2
SP; QPD
REBETOL
2
SP
REBIF
2
SP; QPD
REVLIMID
2
SP; QPD
ribasphere
1
QPD
ribasphere ribapak
1
QPD
ribavirin
1
QPD
SYLATRON
2
SP; QPD
TECFIDERA
2
SP; QPD
INTERFERONS
of this table.
80
Drug Name
Drug Tier
ZINBRYTA
2
PA; SP; QPD ACTIMMUNE
2
PA; SP
ALDARA
2
ARCALYST
2
imiquimod
1
KINERET
2
ZYCLARA TOPICAL CREAM IN METEREDDOSE PUMP
2
ZYCLARA TOPICAL CREAM IN PACKET
2
INTERLEUKINS
SP; QPD
SP; QPD
QPD
VACCINES & MISCELLANEOUS IMMUNOLOGICALS
ADACEL(TDAP ADOLESN/ADULT)(PF)
$0
BOOSTRIX TDAP
$0
CERVARIX VACCINE (PF)
$0
DAPTACEL (DTAP PEDIATRIC) (PF)
$0
ENGERIX-B (PF)
$0
ENGERIX-B PEDIATRIC (PF)
$0
FLUARIX QUAD 2016-2017 (PF)
$0
FLULAVAL QUAD 2016-2017
$0
FLUZONE HIGH-DOSE 2016-17 (PF)
$0
FLUZONE INTRADERM QUAD 2016-17
$0
FLUZONE QUAD 2016-2017
$0
FLUZONE QUAD 2016-2017 (PF)
$0
FLUZONE QUAD PEDI 2016-17 (PF)
$0
GARDASIL (PF)
$0
GARDASIL 9 (PF)
$0
GRASTEK
2
HAVRIX (PF)
$0
INFANRIX (DTAP) (PF)
$0
IPOL
$0
KINRIX (PF)
$0
PA
of this table.
81
Drug Name
Drug Tier
MENACTRA (PF) $0
MENOMUNE - A/C/Y/W-135
$0
MENOMUNE - A/C/Y/W-135 (PF)
$0
MENVEO A-C-Y-W-135-DIP (PF) $0
M-M-R II (PF) $0
ORALAIR
2
PEDIARIX (PF) $0
PEDVAX HIB (PF) $0
PENTACEL (PF) $0
PNEUMOVAX 23
$0
PREVNAR 13 (PF) $0
PROQUAD (PF) $0
QUADRACEL (PF) $0
RAGWITEK
2
RECOMBIVAX HB (PF) $0
ROTARIX $0
ROTATEQ VACCINE $0
TENIVAC (PF) $0
TETANUS,DIPHTHERIA TOX PED(PF) $0
TETANUS-DIPHTHERIA TOXOIDS-TD $0
TWINRIX (PF) $0
VAQTA (PF) $0
VARIVAX (PF) $0
VARIZIG $0
ZOSTAVAX (PF) $0
PA
PA
MUSCULOSKELETAL & RHEUMATOLOGY
GOUT THERAPY
allopurinol
1
COLCHICINE
2
colchicine-probenecid
1
COLCRYS
2
of this table.
82
Drug Name
Drug Tier
MITIGARE
2
probenecid
1
ULORIC
2
ZYLOPRIM
2
QPD
OSTEOPOROSIS THERAPY
ACTONEL
2
alendronate oral solution
$0*
alendronate oral tablet
$0*
ST; QPD
QPD
ATELVIA
2
ST; QPD
BINOSTO
2
ST; QPD
BONIVA
2
ST; QPD
EVISTA
2
QPD
FORTEO
2
PA; SP; QPD
FOSAMAX
2
ST; QPD
FOSAMAX PLUS D
2
ST; QPD
ibandronate
$0*
QPD
raloxifene
$0
QPD
risedronate
$0*
QPD
OTHER RHEUMATOLOGICALS
ACTEMRA
2
PA; SP
ARAVA
2
QPD
CUPRIMINE
2
DEPEN TITRATABS
2
ENBREL
2
PA; SP; QPD
HUMIRA
2
PA; SP; QPD
leflunomide
1
QPD
ORENCIA
2
PA; SP; QPD
OTEZLA
2
PA; SP; QPD
OTREXUP (PF)
2
RASUVO (PF)
2
RIDAURA
2
of this table.
83
Drug Name
Drug Tier
SAVELLA
2
QPD
SIMPONI
2
PA; SP; QPD
XELJANZ
2
PA; SP; QPD
XELJANZ XR
2
PA; SP; QPD
OBSTETRICS & GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
CAYA CONTOURED
$0
FC2 FEMALE CONDOM
$0
FEMCAP
$0
WIDE-SEAL DIAPHRAGM
$0
ESTROGENS & PROGESTINS
ACTIVELLA
2
ALORA
2
ANGELIQ
2
AYGESTIN
2
camila
$0
CLIMARA
2
QPD
CLIMARA PRO
2
QPD
COMBIPATCH
2
QPD
covaryx
1
covaryx h.s.
1
CRINONE
2
deblitane
$0
DELESTROGEN
2
DEPO-ESTRADIOL
2
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
2
SUSPENSION
2
QPD
SYRINGE
2
QPD
DEPO-SUBQ PROVERA 104
$0
QPD
QPD
of this table.
84
Drug Name
Drug Tier
DIVIGEL
2
QPD
DUAVEE
2
eemt
1
eemt hs
1
ELESTRIN
2
errin
$0
ESTRACE
2
estradiol oral
1
estradiol transdermal
1
estradiol valerate
1
estradiol-norethindrone acet
1
ESTRING
2
QPD
ESTROGEL
2
QPD
estrogens-methyltestosterone
1
estropipate
1
EVAMIST
2
FEMHRT LOW DOSE
2
FEMRING
2
fyavolv
1
heather
$0
QPD
jencycla
$0
QPD
jevantique lo
1
jinteli
1
jolivette
$0
lopreeza
1
lyza
$0
MAKENA
2
PA; SP; QPD
medroxyprogesterone intramuscular suspension
$0
QPD
medroxyprogesterone intramuscular syringe
$0
medroxyprogesterone oral
1
MENEST
2
QPD
QPD
QPD
QPD
of this table.
85
Drug Name
Drug Tier
MENOSTAR
2
mimvey
1
mimvey lo
1
MINIVELLE
2
nora-be
$0
norethindrone (contraceptive)
$0
norethindrone acetate
1
norethindrone ac-eth estradiol
1
norlyroc
$0
NOR-QD
2
ORTHO MICRONOR
2
PREFEST
2
PREMARIN ORAL TABLET 0.3 MG, 0.625 MG,
0.9 MG, 1.25 MG
2
PREMARIN ORAL TABLET 0.45 MG
2
PREMARIN VAGINAL
2
PREMPHASE
2
QPD
PREMPRO
2
QPD
progesterone micronized
1
PROMETRIUM
2
PROVERA
2
sharobel
$0
VAGIFEM
2
VIVELLE-DOT
2
QPD
QPD
QPD
QPD
MISCELLANEOUS OB/GYN
AVC VAGINAL
2
CERVIDIL
2
CLEOCIN
2
clindamycin phosphate
1
CLINDESSE
2
CONCEPTROL
$0
of this table.
86 Drug Name
Drug Tier
fem ph
1
GYNAZOLE-1
2
isoxsuprine
1
LYSTEDA
2
METROGEL VAGINAL
2
metronidazole
1
miconazole-3
1
NUVARING
$0
NUVESSA
2
RELAGARD
2
TERAZOL
2
terconazole
1
TODAY CONTRACEPTIVE SPONGE
$0
tranexamic acid
1
vaginal contraceptive foam
$0
vandazole
1
VCF CONTRACEPTIVE FILM
$0
VCF CONTRACEPTIVE GEL
$0
xulane
$0
QPD
ORAL CONTRACEPTIVES & RELATED AGENTS
AFTERA
2
QPD
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
ashlyna
$0
aubra
$0
QPD
of this table.
87
Drug Name
Drug Tier
aviane
$0
azurette (28)
$0
balziva (28)
$0
bekyree (28)
$0
BEYAZ
$0
blisovi 24 fe
$0
blisovi fe 1.5/30 (28)
$0
blisovi fe 1/20 (28)
$0
BREVICON (28)
2
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)
2
cyred
$0
dasetta 1/35 (28)
$0
dasetta 7/7/7 (28)
$0
daysee
$0
delyla (28)
$0
desog-e.estradiol/e.estradiol
$0
DESOGEN
2
desogestrel-ethinyl estradiol
$0
drospirenone-ethinyl estradiol oral tablet 3-0.02
mg
$0
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
$0
econtra ez
$0
elinest
$0
QPD
QPD
QPD
of this table.
88
Drug Name
Drug Tier
ELLA
$0
QPD
emoquette
$0
enpresse
$0
enskyce
$0
estarylla
$0
ESTROSTEP FE-28
2
fallback solo
$0
falmina (28)
$0
FEMCON FE
2
GENERESS FE
2
gianvi (28)
$0
gildagia
$0
gildess 1.5/30 (21)
$0
gildess 1/20 (21)
$0
gildess 24 fe
$0
gildess fe 1.5/30 (28)
$0
gildess fe 1/20 (28)
$0
introvale
$0
QPD
jolessa
$0
QPD
juleber
$0
junel 1.5/30 (21)
$0
junel 1/20 (21)
$0
junel fe 1.5/30 (28)
$0
junel fe 1/20 (28)
$0
junel fe 24
$0
kaitlib fe
$0
kariva (28)
$0
kelnor 1/35 (28)
$0
kimidess (28)
$0
kurvelo
$0
l norgest/e.estradiol-e.estrad
$0
QPD
QPD
of this table.
89
Drug Name
Drug Tier
larin 1.5/30 (21)
$0
larin 1/20 (21)
$0
larin 24 fe
$0
larin fe 1.5/30 (28)
$0
larin fe 1/20 (28)
$0
layolis fe
$0
leena 28
$0
lessina
$0
levonest (28)
$0
levonorgestrel-ethinyl estrad oral tablet
$0
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month
$0
levonorg-eth estrad triphasic
$0
levora-28
$0
LO LOESTRIN FE $0
LOESTRIN 1.5/30 (21) $0
LOESTRIN 1/20 (21) $0
LOESTRIN FE 1.5/30 (28-DAY) $0
LOESTRIN FE 1/20 (28-DAY)
$0
lomedia 24 fe
$0
loryna (28)
$0
LOSEASONIQUE
2
low-ogestrel (28) $0
lutera (28) $0
marlissa
$0
microgestin 1.5/30 (21) $0
microgestin 1/20 (21) $0
MICROGESTIN 24 FE
$0
microgestin fe 1.5/30 (28)
$0
microgestin fe 1/20 (28)
$0
MINASTRIN 24 FE
$0
MIRCETTE (28)
2
QPD
QPD
of this table.
90
Drug Name
Drug Tier
MODICON (28)
2
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 one dose $0
nikki (28) $0
noreth-ethinyl estradiol-iron $0
norethindrone ac-eth estradiol $0
norethindrone-e.estradiol-iron $0
norgestimate-ethinyl estradiol $0
NORINYL 1+35 (28)
2
nortrel 0.5/35 (28) $0
nortrel 1/35 (21) $0
nortrel 7/7/7 (28) $0
ocella
$0
ogestrel (28) $0
opcicon one-step $0
orsythia
$0
ORTHO TRI-CYCLEN (28)
2
ORTHO TRI-CYCLEN LO (28)
$0
ORTHO-CYCLEN (28)
2
ORTHO-NOVUM 1/35 (28)
2
ORTHO-NOVUM 7/7/7 (28)
2
OVCON-35 (28)
2
QPD
QPD
QPD
of this table.
91
Drug Name
Drug Tier
philith
$0
pimtrea (28)
$0
pirmella
$0
PLAN B ONE-STEP
2
portia
$0
previfem
$0
QUARTETTE
$0
QPD
quasense
$0
QPD
react
$0
QPD
reclipsen (28)
$0
SAFYRAL
$0
SEASONIQUE
2
QPD
setlakin
$0
QPD
sprintec (28)
$0
sronyx
$0
syeda
$0
TAKE ACTION
2
tarina fe 1/20 (28)
$0
tilia fe
$0
tri-estarylla
$0
tri-legest fe
$0
tri-linyah
$0
tri-lo-estarylla
$0
tri-lo-marzia
$0
tri-lo-sprintec
$0
trinessa (28)
$0
trinessa lo
$0
TRI-NORINYL (28)
2
tri-previfem (28)
$0
tri-sprintec (28)
$0
trivora (28)
$0
QPD
QPD
of this table.
92
Drug Name
Drug Tier
velivet triphasic regimen (28)
$0
vestura (28)
$0
vienva
$0
viorele (28)
$0
vyfemla (28)
$0
wera (28)
$0
wymzya fe
$0
YASMIN (28)
2
YAZ (28)
2
zarah
$0
zenchent (28)
$0
zenchent fe
$0
zovia 1/35e (28)
$0
zovia 1/50e (28)
$0
OXYTOCICS
methergine
1
methylergonovine
1
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE
2
bacitracin
1
bacitracin-polymyxin b
1
BESIVANCE
2
BETADINE OPHTHALMIC PREP
2
CILOXAN
2
ciprofloxacin hcl
1
erythromycin
1
gatifloxacin
1
gentak
1
gentamicin
1
ILOTYCIN
2
of this table.
93
Drug Name
Drug Tier
levofloxacin
1
MOXEZA
2
NATACYN
2
neomycin-bacitracin-polymyxin
1
neomycin-polymyxin-gramicidin
1
neo-polycin
1
NEOSPORIN (NEO-POLYM-GRAMICID)
2
OCUFLOX
2
ofloxacin
1
polycin
1
polymyxin b sulf-trimethoprim
1
POLYTRIM
2
tobramycin
1
TOBREX
2
VIGAMOX
2
ZYMAXID
2
ANTIVIRALS
trifluridine
1
VIROPTIC
2
ZIRGAN
2
BETA-BLOCKERS
BETAGAN
2
betaxolol
1
BETIMOL
2
BETOPTIC S
2
carteolol
1
ISTALOL
2
levobunolol
1
metipranolol
1
timolol maleate
1
TIMOPTIC
2
of this table.
94
Drug Name
Drug Tier
TIMOPTIC OCUDOSE (PF)
2
TIMOPTIC-XE
2
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE
2
CYCLOPLEGIC MYDRIATICS
atropine
1
CYCLOGYL
2
cyclopentolate
1
homatropaire
1
homatropine hbr
1
ISOPTO ATROPINE
2
MYDRIACYL
2
tropicamide
1
DIRECT ACTING MIOTICS
ISOPTO CARPINE
2
pilocarpine hcl
1
MISCELLANEOUS OPHTHALMOLOGICS
ALCAINE
2
ALOCRIL
2
ALOMIDE
2
altafluor
1
azelastine
1
BEPREVE
2
cromolyn
1
CYSTARAN
2
ELESTAT
2
EMADINE
2
epinastine
1
fluorescein-benoxinate
1
flurox
1
LACRISERT
2
SP
of this table.
95
Drug Name
Drug Tier
LASTACAFT
2
olopatadine
1
PATADAY
2
PATANOL
2
PAZEO
2
RESTASIS
2
QPD
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACULAR
2
ACULAR LS
2
ACUVAIL (PF)
2
bromfenac
1
diclofenac sodium
1
flurbiprofen sodium
1
ILEVRO
2
ketorolac
1
NEVANAC
2
OCUFEN
2
PROLENSA
2
ORAL DRUGS FOR GLAUCOMA
acetazolamide
1
DIAMOX SEQUELS
2
methazolamide
1
NEPTAZANE
2
OTHER GLAUCOMA DRUGS
AZOPT
2
bimatoprost
1
COMBIGAN
2
COSOPT
2
COSOPT (PF)
2
dorzolamide
1
dorzolamide-timolol
1
PA
of this table.
96
Drug Name
Drug Tier
latanoprost
1
PA
LUMIGAN
2
PA
MITOSOL
2
SIMBRINZA
2
TRAVATAN Z
2
PA
travoprost (benzalkonium)
1
PA
TRUSOPT
2
XALATAN
2
PA
ZIOPTAN (PF)
2
PA
STEROID-ANTIBIOTIC COMBINATIONS
MAXITROL
2
neomycin-bacitracin-poly-hc
1
neomycin-polymyxin b-dexameth
1
neomycin-polymyxin-hc
1
neo-polycin hc
1
PRED-G
2
PRED-G S.O.P.
2
TOBRADEX
2
TOBRADEX ST
2
tobramycin-dexamethasone
1
ZYLET
2
STEROIDS
ALREX
2
dexamethasone sodium phosphate
1
DUREZOL
2
FLAREX
2
fluorometholone
1
FML FORTE
2
FML LIQUIFILM
2
FML S.O.P.
2
LOTEMAX
2
of this table.
97
Drug Name
Drug Tier
MAXIDEX
2
OMNIPRED
2
PRED FORTE
2
PRED MILD
2
prednisolone acetate
1
prednisolone sodium phosphate
1
VEXOL
2
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE
2
BLEPHAMIDE S.O.P.
2
sulfacetamide-prednisolone
1
SULFONAMIDES
BLEPH-10
2
sulfacetamide sodium
1
SYMPATHOMIMETICS
ALPHAGAN P
2
apraclonidine
1
brimonidine
1
IOPIDINE
2
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl
1
RESPIRATORY, ALLERGY, COUGH & COLD
ANTIHISTAMINE & ANTIALLERGENIC AGENTS
ADRENACLICK
2
arbinoxa
1
carbinoxamine maleate
1
CLARINEX ORAL SYRUP
2
ST
CLARINEX ORAL TABLET
2
ST; QPD
clemastine
1
cyproheptadine
1
desloratadine
1
QPD
of this table.
98
Drug Name
Drug Tier
diphenhydramine hcl
1
epinephrine
1
EPIPEN 2-PAK
2
EPIPEN JR 2-PAK
2
hydroxyzine hcl
1
hydroxyzine pamoate
1
KARBINAL ER
2
levocetirizine
1
phenadoz
1
phenergan
1
promethazine
1
promethegan
1
VISTARIL
2
XYZAL
2
QPD
ST; QPD
COUGH & COLD THERAPY
benzonatate
1
BROMFED DM
2
brompheniramine-pseudoeph-dm
1
CAPCOF
2
centergy
1
cheratussin ac
1
cheratussin dac
1
CLARINEX-D 12 HOUR
2
codeine-guaifenesin
1
guaifenesin ac
1
guaifenesin dac
1
hydrocodone-chlorpheniramine
1
hydrocodone-cpm-pseudoephed
1
hydrocodone-homatropine
1
hydromet
1
iophen c-nr
1
ST; QPD
of this table.
99
Drug Name
Drug Tier
lortuss ex
1
MAR-COF BP
2
MAR-COF CG
2
m-clear wc
1
M-END MAX D
2
M-END PE
2
phenylhistine dh
1
POLY-TUSSIN AC
2
promethazine vc
1
promethazine vc-codeine
1
promethazine-codeine
1
promethazine-dm
1
promethazine-phenyleph-codeine
1
PRO-RED AC (W/ DEXCHLORPHENIR)
2
relcof c
1
RESPA-AR
2
rydex
1
TESSALON PERLES
2
tusnel c
1
TUSNEL PEDIATRIC
2
tussigon
1
TUSSIONEX PENNKINETIC ER
2
virtussin ac
1
virtussin dac
1
ZODRYL AC
2
ZODRYL DAC
2
ZODRYL DEC
2
ZONATUSS
2
Z-TUSS AC
2
ZUTRIPRO
2
PULMONARY AGENTS
of this table.
100
Drug Name
Drug Tier
ACCOLATE
2
acetylcysteine
1
ADCIRCA
2
PA; SP; QPD
ADEMPAS
2
PA; SP; QPD
ADVAIR DISKUS
2
QPD
ADVAIR HFA
2
QPD
AEROSPAN
2
albuterol sulfate
1
ALVESCO
2
QPD
ANORO ELLIPTA
2
QPD
ARCAPTA NEOHALER
2
QPD
ARNUITY ELLIPTA
2
QPD
ASMANEX HFA
2
ASMANEX TWISTHALER
2
QPD
ATROVENT HFA
2
QPD
BECONASE AQ
2
ST; QPD
BEVESPI AEROSPHERE
2
QPD
BREO ELLIPTA
2
QPD
BROVANA
2
QPD
budesonide
1
QPD
CINRYZE
2
PA; SP; QPD
COMBIVENT RESPIMAT
2
QPD
cromolyn
1
DALIRESP
2
DULERA
2
QPD
DYMISTA
2
ST; QPD
ELIXOPHYLLIN
2
ESBRIET
2
PA; SP
FIRAZYR
2
PA; SP; QPD
FLOVENT DISKUS
2
QPD
FLOVENT HFA
2
QPD
of this table.
101 Drug Name
Drug Tier
flunisolide
1
QPD
fluticasone
1
QPD
FORADIL AEROLIZER
2
QPD
HYPER-SAL
2
INCRUSE ELLIPTA
2
ipratropium bromide
1
ipratropium-albuterol
1
QPD
KALYDECO
2
PA; SP; QPD
LETAIRIS
2
PA; SP; QPD
levalbuterol hcl
1
metaproterenol
1
mometasone
1
QPD
montelukast
1
QPD
NASONEX
2
ST; QPD
NEBUSAL
2
OFEV
2
PA; SP
OMNARIS
2
ST; QPD
OPSUMIT
2
PA; SP
ORKAMBI
2
PA; SP; QPD
PERFOROMIST
2
QPD
PROAIR HFA
2
QPD
PROAIR RESPICLICK
2
QPD
PROVENTIL HFA
2
QPD
PULMICORT
2
QPD
PULMICORT FLEXHALER
2
QPD
pulmosal
1
PULMOZYME
2
SP
QNASL NASAL HFA AEROSOL INHALER 40
MCG/ACTUATION
2
ST
QNASL NASAL HFA AEROSOL INHALER 80
MCG/ACTUATION
2
ST; QPD
QVAR
2
QPD
of this table.
102 Drug Name
Drug Tier
REVATIO
2
PA; SP; QPD RUCONEST
2
PA; SP
SEEBRI NEOHALER
2
QPD
SEREVENT DISKUS
2
QPD
sildenafil
1
PA; QPD
SINGULAIR
2
ST; QPD
sodium chloride
1
SPIRIVA RESPIMAT
2
QPD
SPIRIVA WITH HANDIHALER
2
QPD
STIOLTO RESPIMAT
2
QPD
STRIVERDI RESPIMAT
2
SYMBICORT
2
terbutaline
1
THEO-24
2
theochron
1
theophylline
1
TRACLEER
2
PA; SP
TUDORZA PRESSAIR
2
QPD
TYVASO
2
PA; SP
UTIBRON NEOHALER
2
QPD
VENTAVIS
2
PA; SP
VENTOLIN HFA
2
QPD
VERAMYST
2
ST; QPD
VOSPIRE ER
2
XOPENEX
2
XOPENEX CONCENTRATE
2
XOPENEX HFA
2
zafirlukast
1
ZETONNA
2
ST; QPD
ZYFLO
2
QPD
ZYFLO CR
2
QPD
QPD
QPD
of this table.
103
Drug Name
Drug Tier
UROLOGICALS
ANTICHOLINERGICS & ANTISPASMODICS
darifenacin
1
QPD
DETROL
2
ST; QPD
DETROL LA
2
ST; QPD
DITROPAN XL
2
ST; QPD
ENABLEX
2
ST; QPD
flavoxate
1
GELNIQUE
2
ST; QPD
MYRBETRIQ
2
ST; QPD
oxybutynin chloride oral syrup
1
oxybutynin chloride oral tablet
1
oxybutynin chloride oral tablet extended release
24hr
1
QPD
OXYTROL
2
ST; QPD
tolterodine
1
QPD
TOVIAZ
2
ST; QPD
trospium
1
QPD
VESICARE
2
ST; QPD
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin
1
AVODART
2
QPD
CIALIS
2
PA; QPD
dutasteride
1
QPD
dutasteride-tamsulosin
1
QPD
finasteride
1
QPD
FLOMAX
2
QPD
JALYN
2
QPD
PROSCAR
2
QPD
RAPAFLO
2
QPD
tamsulosin
1
QPD
of this table.
104
Drug Name
UROXATRAL
Drug Tier
2
CHOLINERGIC STIMULANTS
bethanechol chloride
1
URECHOLINE
2
MISCELLANEOUS UROLOGICALS
CYSTAGON
2
cytra k crystals
1
cytra-2
1
cytra-3
1
cytra-k
1
ELMIRON
2
hyolev mb
1
K-PHOS NO 2
2
K-PHOS ORIGINAL
2
methen-sod phos-meth blue-hyos
1
ORACIT
2
phosphasal
1
pot,sodium citrate-citric acid
1
potassium citrate
1
potassium citrate-citric acid
1
PROCYSBI
2
SHOHL'S MODIFIED
2
sodium citrate-citric acid
1
tricitrates
1
ur n-c
1
uramit mb
1
URELLE
2
uretron d-s
1
URIBEL
2
urimar-t
1
urin ds
1
PA; SP
of this table.
105
Drug Name
Drug Tier
UROCIT-K
2
urogesic-blue
1
uro-l
1
urolet mb
1
uro-mp
1
UROQID-ACID NO.2
2
uryl
1
utira-c
1
virtrate-2
1
virtrate-3
1
virtrate-k
1
URINARY ANESTHETICS
phenazopyridine
1
PYRIDIUM
2
VITAMINS, HEMATINICS & ELECTROLYTES
ELECTROLYTES
calcium 500 with d
$0
calcium carb and citrate-vitd3
$0
calcium citrate + d
$0
calcium citrate-vitamin d2
$0
EFFER-K ORAL TABLET, EFFERVESCENT 10
MEQ, 20 MEQ
2
effer-k oral tablet, effervescent 25 meq
1
GALZIN
2
k-effervescent
1
klor-con
1
klor-con 10
1
klor-con 8
1
klor-con m10
1
klor-con m15
1
klor-con m20
1
of this table.
106
Drug Name
Drug Tier
klor-con sprinkle
1
KLOR-CON/25
2
klor-con/ef
1
k-sol
1
K-TAB ORAL TABLET EXTENDED RELEASE
10 MEQ, 20 MEQ
2
k-tab oral tablet extended release 8 meq
1
lugols
1
POTABA
2
potassium bicarb and chloride
1
potassium bicarb-citric acid
1
potassium chloride
1
strong iodine
1
MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES
FORTAVIT
2
VITAMINS & HEMATINICS
b complex 100
1
b complex-vitamin b12
$0
b complex-vitamin c-folic acid
$0
balanced b-100 complex
1
b-complex with vitamin c
$0
classic prenatal
$0
cyanocobalamin (vitamin b-12)
1
dialyvite 800
$0
fluor-a-day (with xylitol)
$0
fluoritab
$0
folic acid
$0
full spectrum b-vitamin c
$0
hydroxocobalamin
1
ludent fluoride
$0
multi-vit with fluoride-iron
$0
of this table.
107
Drug Name
Drug Tier
multi-vitamin with fluoride oral drops
$0
multi-vitamin with fluoride oral tablet,chewable
0.25 mg, 0.5 mg
$0
multi-vitamin with fluoride oral tablet,chewable 1
mg
1
multivitamins with fluoride
$0
mvc-fluoride
$0
natural b-100 complex
$0
one daily prenatal
$0
perry prenatal
$0
poly-vitamin with iron
$0
PREFERA-OB
2
prena1 true
$0*
prenatal
$0
prenatal complete
$0
prenatal one daily
$0
prenatal vit#96-ferrous fum-fa
$0
prenatal vitamin
$0
prenatal vitamin plus low iron
$0*
rena-vite
$0
risacal-d
$0
sodium fluoride
$0
stress formula
$0
tri-vit with fluoride and iron
$0
tri-vitamin with fluoride
$0
virt-nate dha
$0*
vit b complex-folic acid
$0
VITAFOL ULTRA
2
vitamin d3
$0
vitamins a,c,d and fluoride
$0
of this table.
108 Index
8
8-MOP..................................49 A
abacavir .................................. 7 abacavir-lamivudinezidovudine .......................... 7 ABILIFY .............................. 30 ABSORICA..........................51
ABSTRAL............................25
acamprosate .......................... 59 ACANYA.............................51 acarbose................................70 ACCOLATE....................... 101 ACCU-CHEK AVIVA PLUS TEST STRP......................63 ACCU-CHEK COMPACT TEST ................................ 63 ACCU-CHEK SMARTVIEW
TEST STRIP ....................63 ACCUPRIL .......................... 38 ACCURETIC ....................... 38 ACCUTREND GLUCOSE ..63 acebutolol ............................. 38 ACEON ................................ 38 acetaminophen-codeine ........ 25 acetasol hc ............................61 acetazolamide ....................... 96 acetic acid....................... 59, 61
acetic acid-aluminum acetate61 acetylcysteine ..................... 101 ACIPHEX ............................ 78 ACIPHEX SPRINKLE ........78 acitretin.................................47 ACTEMRA .......................... 83 ACTHAR H.P. .....................62 ACTICLATE........................13
ACTIGALL..........................74 ACTIMMUNE ..................... 81 ACTIQ..................................25
ACTIVELLA ....................... 84 ACTONEL ..................... 59, 83
ACTOPLUS MET................70 ACTOPLUS MET XR .........70 ACTOS.................................70 ACULAR ............................. 96 ACULAR LS........................96 ACUVAIL (PF)....................96 acyclovir ........................... 7, 55 ACZONE..............................51 ADACEL(TDAP ADOLESN/ADULT)(PF) 81 ADALAT CC .......................38 adapalene ..............................51 ADASUVE...........................30 ADCIRCA ..........................101 ADDERALL ........................ 30 ADDERALL XR ..................30 adefovir...................................7
ADEMPAS.........................101 ADRENACLICK ................. 98 ADVAIR DISKUS .............101 ADVAIR HFA ...................101 ADVANCED GLUC METER TEST STRIP..................... 63 ADVOCATE REDI-CODE . 63 ADVOCATE TEST STRIPS63 ADZENYS XR-ODT ...........30 AEROSPAN.......................101 afeditab cr .............................38 AFINITOR ........................... 15 AFINITOR DISPERZ ..........15 AFREZZA ............................67 AFTERA .............................. 87 AGAMATRIX AMP TEST STRIPS.............................63 AGGRENOX........................ 44 AGRYLIN ............................59 AKYNZEO...........................74
ala-cort..................................56 ALA-SCALP ........................56 ALBENZA ........................... 10 albuterol sulfate ..................101 ALCAINE ............................ 95 alclometasone ....................... 56 ALDACTAZIDE..................38 ALDACTONE...................... 38 ALDARA ............................. 81 ALECENSA ......................... 15 alendronate ..................... 59, 83
alfuzosin ............................. 104 ALINIA ................................ 10 ALKERAN ...........................15 allopurinol.............................82
almotriptan malate ................22 ALOCRIL.............................95 ALOGLIPTIN ...................... 70 ALOGLIPTIN-METFORMIN
..........................................70 ALOGLIPTINPIOGLITAZONE .............70 ALOMIDE............................95 ALORA ................................84 alosetron ............................... 74 ALPHAGAN P.....................98 alprazolam ............................30 alprazolam intensol ...............30 ALREX.................................97 ALSUMA .............................22 ALTABAX ........................... 54 ALTACE .............................. 38 altafluor.................................95
altavera (28)..........................87 ALTOPREV .........................45 ALUVEA..............................49 ALVESCO..........................101 alyacen 1/35 (28) ..................87 alyacen 7/7/7 (28) .................87 amantadine hcl ........................7 AMARYL.............................70 AMBIEN .............................. 30 AMBIEN CR ........................30 amcinonide ...........................56 AMERGE .............................22 amethia ................................. 87 amethia lo .............................87 amethyst ................................ 87 AMICAR .............................. 44 amiloride ............................... 38 amiloride-hydrochlorothiazide
..........................................38 amiodarone ...........................37 AMITIZA .............................74 amitriptyline ......................... 30 amitriptyline-chlordiazepoxide
..........................................30 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
109 APTIVUS ............................... 7 AUGMENTIN XR ...............12 amlodipine ............................ 38 aranelle (28)..........................87 AURYXIA............................74 amlodipine-atorvastatin ........ 45 ARAVA................................83 AVALIDE ............................38 amlodipine-benazepril .......... 38 AVANDIA ...........................70 amlodipine-valsartan ............ 38 arbinoxa ................................98 AVAPRO..............................38 amlodipine-valsartan-hcthiazid
ARCALYST.........................81 avar ....................................... 51 ..........................................38 ARCAPTA NEOHALER...101 AVAR...................................51 amoxapine ............................ 30 ARICEPT ............................. 23 amoxicil-clarithromy-lansopraz
ARIMIDEX ..........................15 AVAR LS .............................51 ..........................................78 aripiprazole...........................31 AVAR-E GREEN.................51 amoxicillin............................12
ARIXTRA ............................ 44 AVAR-E LS .........................51 AMOXICILLIN ................... 12 armodafinil ........................... 31 AVC VAGINAL ..................86 amoxicillin-pot clavulanate ..12 ARMOUR THYROID .........72 AVELOX..............................13 ampicillin..............................12
ARNUITY ELLIPTA.........101 AVELOX ABC PACK.........13 AMPYRA.............................23 AROMASIN......................... 15
aviane....................................88 AMRIX ................................ 24 ARTHROTEC ......................28 avidoxy .................................13 ANADROL-50 .....................68 ASACOL HD .......................74 AVIDOXY DK.....................13 ANAFRANIL.......................30 ascomp with codeine ............25 avita ...................................... 51 anagrelide ............................. 59 ashlyna..................................87 AVODART.........................104
ANA-LEX KIT ....................74 ASMANEX HFA ...............101 AVONEX ............................. 80 ANALPRAM E ....................74 ASMANEX TWISTHALER
AXERT.................................22 ANALPRAM-HC................. 74 ........................................101 AXIRON...............................68
ANALPRAM-HC SINGLES74 aspirin-caffeine-dihydrocodein
AYGESTIN ..........................84 ANAPROX DS ....................28 ..........................................25 AZASAN..............................15 anaspaz ................................. 72 aspirin-dipyridamole ............ 44 AZASITE ............................. 93 anastrozole............................15
ASSURE 4 STRIPS ............. 63 azathioprine .......................... 15 ANCOBON ............................ 6 ASSURE PLATINUM .........63 azelastine ........................ 61, 95
ANDRODERM .................... 68 ASSURE PRISM MULTI AZELEX...............................51
ANDROGEL........................68 STRIP ............................... 63 AZILECT ............................. 21 ANDROID ........................... 68 ASTAGRAF XL................... 15 azithromycin .........................10 androxy.................................68 ASTEPRO ............................ 60 AZOPT ................................. 96 ANGELIQ ............................ 84 ATACAND .......................... 38 AZOR ...................................38 ANORO ELLIPTA ............101 ATACAND HCT .................38 AZULFIDINE ......................74 ANTABUSE......................... 59 ATELVIA.............................83
AZULFIDINE EN-TABS ....74 ANTARA ............................. 45 atenolol ................................. 38 azurette (28)..........................88 ANTIVERT..........................74 atenolol-chlorthalidone.........38 B
anucort-hc.............................74 ATIVAN...............................31
b complex 100 ....................107 ANUSOL-HC.......................74 atorvastatin ........................... 45 b complex-vitamin b12 .......107 ANZEMET...........................74 atovaquone............................ 10 b complex-vitamin c-folic acid
apexicon e.............................56 atovaquone-proguanil...........10 ........................................107 APIDRA ...............................67 ATRALIN ............................ 51 bacitracin .............................. 93 APIDRA SOLOSTAR .........67 ATRIPLA ............................... 7 bacitracin-polymyxin b .........93 APLENZIN .......................... 31 ATROPEN............................ 58 baclofen ................................ 24 APOKYN ............................. 21 atropine.................................95 BACTRIM............................13 apraclonidine ........................ 98 ATROVENT HFA .............101 BACTRIM DS......................13 apri........................................87
AUBAGIO............................ 80 BACTROBAN NASAL .......61 APRISO................................74
aubra ..................................... 87 balanced b-100 complex .....107 APTENSIO XR ....................31 AUGMENTIN ...................... 12 balsalazide ............................74 APTIOM ..............................18 AUGMENTIN ES-600 .........12 balziva (28)...........................88 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
110 BIAXIN ................................10 butalbital compound w/codeine
BANZEL .............................. 18 bicalutamide ......................... 15 ..........................................25 BARACLUDE ....................... 7 BIDIL ................................... 38 butalbital-acetaminop-caf-cod
b-complex with vitamin c...107 BILTRICIDE........................10 ..........................................25 BECONASE AQ ................101 bimatoprost ........................... 96 butalbital-acetaminophen .....25 bekyree (28).......................... 88 BINOSTO.............................83
butalbital-acetaminophen-caff
BELBUCA ........................... 25 BIONIME RIGHTEST TEST ..........................................25 belladonna alkaloids-opium . 73 STRIPS.............................63 butalbital-aspirin-caffeine.....25
belladonna-opium.................73 BUTISOL .............................31 BELSOMRA ........................ 31 bisacodyl...............................74
butorphanol tartrate ..............28 benazepril ............................. 38 bisoprolol fumarate............... 38 BUTRANS ...........................25 benazepril-hydrochlorothiazide
bisoprolol-hydrochlorothiazide
BYDUREON........................70 ..........................................38 ..........................................38 BENICAR ............................ 38 BYETTA .............................. 70 BLEPH-10 ............................98 BENICAR HCT ...................38 BYSTOLIC...........................39
BLEPHAMIDE .................... 98 BENSAL HP ........................48 BLEPHAMIDE S.O.P..........98 C
BENTYL .............................. 73 cabergoline ...........................68 blisovi 24 fe ..........................88 BENZACLIN ....................... 51 blisovi fe 1.5/30 (28) ............88 CABOMETYX.....................15 BENZACLIN PUMP ...........51 CADUET..............................45 blisovi fe 1/20 (28) ...............88 BENZAMYCIN ................... 51 BLOOD GLUCOSE TEST ..63 CAFERGOT .........................22 BENZAMYCINPAK ........... 51 caffeine citrated ....................59 BONIVA .............................. 83 BENZEFOAM ..................... 51 CALAN ................................39 BOOSTRIX TDAP............... 81 BENZEFOAM ULTRA .......51 CALAN SR ..........................39 BOSULIF ............................. 15 benzepro ............................... 51 calcipotriene ......................... 47 bp 10-1..................................51 BENZEPRO bp-50% urea .........................49 calcipotriene-betamethasone 47 (MICROSPHERES) .........51 bpo ........................................51 calcitonin (salmon) ...............68 benzonatate...........................99 BREEZE 2 TEST STRIPS ...63 calcitrene...............................47
benzoyl peroxide ..................51 BREO ELLIPTA ................101 calcitriol .......................... 47, 68
benztropine ...........................21 BREVICON (28)..................88 calcium 500 with d .............106 BEPREVE ............................ 95 briellyn.................................. 88 calcium acetate .....................74 BESIVANCE ....................... 93 BRILINTA ........................... 44 calcium carb and citrate-vitd3
BETADINE OPHTHALMIC brimonidine .......................... 98 ........................................106 PREP ................................ 93 BRISDELLE ........................ 31 calcium citrate + d ..............106 BETAGAN...........................94 BRIVIACT ........................... 18 calcium citrate-vitamin d2 ..106 betamethasone dipropionate . 56 BROMFED DM ...................99 CAMBIA .............................. 28 betamethasone valerate ........56 bromfenac.............................96 camila ...................................84 betamethasone, augmented... 56 bromocriptine ....................... 21 camrese .................................88 BETAPACE ......................... 37 brompheniramine-pseudoephcamrese lo .............................88 BETAPACE AF ...................37 dm.....................................99 CANASA..............................74 BETASERON ...................... 80 BROVANA ........................ 101 candesartan ........................... 39 betaxolol ......................... 38, 94
budesonide .................... 74, 101
candesartan-hydrochlorothiazid
bethanechol chloride ..........105 bumetanide ........................... 38 ..........................................39 BETHKIS .............................10 BUNAVAIL ......................... 28 capacet .................................. 25 BETIMOL ............................ 94 BUPHENYL.........................59
CAPCOF...............................99
BETOPTIC S .......................94 buprenorphine hcl.................25 capecitabine .......................... 15 BEVESPI AEROSPHERE . 101 buprenorphine-naloxone.......28
CAPEX .................................56 bexarotene ............................ 15 bupropion hcl........................31 CAPRELSA..........................15 BEYAZ ................................ 88 buspirone .............................. 31 captopril................................39 BG-STAR.............................63 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
111 CELONTIN ..........................18 ciprofloxacin hcl.......13, 62, 93 captopril-hydrochlorothiazide
cem-urea ............................... 49 citalopram .............................31 ..........................................39 CENTANY...........................54 citrate of magnesia ................74 CARAC ................................ 49 CENTANY AT.....................54 claravis..................................51 carafate ................................. 78 CLARINEX..........................98 CARAFATE.........................78 centergy ................................ 99 carbamazepine ...................... 18 cephalexin...............................9
CLARINEX-D 12 HOUR ....99 CARBATROL......................18
CERDELGA.........................68
clarithromycin.......................10
carbidopa .............................. 21 CERVARIX VACCINE (PF)
classic prenatal....................107 carbidopa-levodopa .............. 21 ..........................................81 cleansing wash......................51 carbidopa-levodopaCERVIDIL ........................... 86 clemastine .............................98 entacapone........................21 CESAMET ........................... 74 CLEOCIN .......................10, 86
carbinoxamine maleate.........98 CETRAXAL.........................61
CLEOCIN T .........................52 CARDIZEM .........................39 cevimeline ............................ 59 CLEVER CHOICE MICRO CARDIZEM CD ..................39 CHANTIX ............................60 TEST STRIP .....................63 CARDIZEM LA...................39 chateal...................................88
CLEVER CHOICE PRO......63 CARDURA .......................... 39 CHEMET.............................. 59 CLEVER CHOICE TEST CARDURA XL ....................39 CHENODAL ........................74 STRIPS ............................. 63 CARESENS N TEST STRIPS
cheratussin ac .......................99 CLEVER CHOICE VOICE+ ..........................................63 cheratussin dac .....................99 TEST.................................63
carisoprodol..........................24 chlordiazepoxide hcl............. 31 CLIMARA............................84 carisoprodol-asa-codeine......24
chlordiazepoxide-clidinium .. 73 CLIMARA PRO...................84 carisoprodol-aspirin..............24
chlorhexidine gluconate .......61 CLINDACIN ETZ................52 CARNITOR ......................... 59 chloroquine phosphate..........10 clindacin p ............................52 CARNITOR (SUGAR-FREE)
chlorothiazide ....................... 39 CLINDACIN PAC ...............52 ..........................................59 chlorpromazine ..................... 31 CLINDAGEL ....................... 52 carteolol................................94 chlorpropamide.....................70 clindamycin hcl ....................10 carvedilol..............................39 chlorthalidone.......................39 clindamycin palmitate hcl.....10 CASODEX ...........................15 chlorzoxazone.......................24 clindamycin pediatric ...........10 CATAPRES ......................... 39 CHOLBAM ..........................74 clindamycin phosphate ... 52, 86 CATAPRES-TTS .................39 cholestyramine (with sugar) . 45 clindamycin-benzoyl peroxide
CAYA CONTOURED.........84 cholestyramine light .............45 ..........................................52 CAYSTON ...........................10 CIALIS ............................... 104 CLINDESSE.........................86
caziant (28)...........................88 ciclodan ................................ 54 CLINPRO 5000 ....................61 CEDAX .................................. 9 ciclopirox..............................54 clobetasol..............................56 cefaclor ...................................9 ciclopirox-ure-camph-menthclobetasol-emollient ............. 56 cefadroxil................................9
euc .................................... 54 CLOBEX .............................. 56 cefdinir ................................... 9 cilostazol...............................44
CLOCORTOLONE cefditoren pivoxil ...................9 CILOXAN ............................93 PIVALATE.......................56
cefixime ..................................9 cimetidine ............................. 78 clodan ................................... 56 cefpodoxime ...........................9 cimetidine hcl .......................78 CLODERM...........................56
cefprozil..................................9
CIMZIA................................74 clomipramine ........................ 31 ceftibuten................................9 CINRYZE...........................101
clonazepam ...........................19 CEFTIN..................................9 CIPRO .................................. 13 clonidine ...............................39 cefuroxime axetil ....................9 CIPRO HC............................62 clonidine hcl ................... 31, 39
CELEBREX ......................... 28 CIPRO XR............................13 clopidogrel............................44 celecoxib............................... 28 CIPRODEX ..........................62 clorazepate dipotassium........31 CELEXA .............................. 31 ciprofloxacin.........................13 clorpres ................................. 39 CELLCEPT .......................... 15 ciprofloxacin (mixture).........13 CLORPRES..........................39 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
112 CORGARD ..........................39 cytra k crystals....................105 clotrimazole ...................... 6, 54
CORLANOR ........................47 cytra-2.................................105 clotrimazole-betamethasone . 54 cormax .................................. 56 cytra-3.................................105 clozapine............................... 31 CORTANE-B .......................49 cytra-k.................................105 CLOZAPINE........................31
CORTEF...............................62
CLOZARIL .......................... 31 D
CORTENEMA ..................... 75 DAKLINZA ...........................7 CNL 8 NAIL ........................54 CORTIFOAM ...................... 75 DALIRESP ......................... 101 COAL TAR ..........................47 danazol..................................68 COARTEM ..........................11 cortisone ............................... 62 DANTRIUM.........................24
codeine sulfate......................25 CORTISPORIN....................54 codeine-butalbital-asa-caff ...25 dantrolene ............................. 24 CORZIDE.............................39
dapsone .................................11 codeine-guaifenesin..............99 COSENTYX.........................47
DAPTACEL (DTAP COLAZAL ........................... 75 COSOPT...............................96
COLCHICINE......................82
PEDIATRIC) (PF) ............81 COSOPT (PF) ...................... 96 colchicine-probenecid .......... 82 COTELLIC...........................15 DARAPRIM .........................11 COLCRYS ........................... 82 COUMADIN ........................ 44 darifenacin ..........................104 COLESTID .......................... 45 covaryx ................................. 84 dasetta 1/35 (28) ...................88 COLESTID FLAVORED ....45 dasetta 7/7/7 (28) ..................88 covaryx h.s............................ 84 colestipol .............................. 45 COZAAR.............................. 39 DAYPRO..............................28 colocort.................................75 CREON ................................ 75 daysee ...................................88 COLY-MYCIN S .................62 CRESEMBA .......................... 6 DAYTRANA ........................ 31 COLYTE WITH FLAVOR DDAVP ................................ 68 CRESTOR ............................45 PACKS .............................75 CRINONE ............................ 84 deblitane ............................... 84 COMBIGAN ........................ 96 CRIXIVAN ............................ 7 DELESTROGEN .................84 COMBIPATCH....................84
cromolyn................. 75, 95, 101 deltasone ............................... 62 COMBIVENT RESPIMAT101 cryselle (28)..........................88 delyla (28).............................88 COMBIVIR............................7 CUPRIMINE ........................83 DEMADEX .......................... 39 COMETRIQ .........................15 CUTIVATE ..........................56 demeclocycline ..................... 13 COMPAZINE ...................... 75 CUVPOSA ........................... 73 DEMEROL...........................25 COMPLERA .......................... 7 cyanocobalamin (vitamin b-12)
DEMSER..............................39 compro.................................. 75
........................................107 DENAVIR ............................ 55 COMTAN ............................ 21 cyclafem 1/35 (28)................88 denta 5000 plus.....................61 CONCEPTROL....................86
cyclafem 7/7/7 (28) ..............88 dentagel.................................61
CONCERTA ........................ 31 CYCLESSA (28)..................88 DEPAKENE .........................19 CONDYLOX ....................... 49 cyclobenzaprine....................24 DEPAKOTE .........................19 constulose .............................75 CYCLOGYL ........................ 95 DEPAKOTE ER...................19 CONTOUR NEXT STRIPS . 63 cyclopentolate.......................95
DEPAKOTE SPRINKLES...19 CONTOUR TEST STRIPS ..64 CYCLOSERINE .................. 11 DEPEN TITRATABS ..........83 CONTROL G3 .....................64 CYCLOSET ......................... 70 DEPO-ESTRADIOL ............ 84 CONZIP ............................... 28 cyclosporine.......................... 15 DEPO-PROVERA................84 COOL GLUCOSE TEST cyclosporine modified ..........15 DEPO-SUBQ PROVERA 104
STRIP ...............................64 CYMBALTA........................ 31 ..........................................84 COPAXONE ........................ 80 cyproheptadine ..................... 98 DEPO-TESTOSTERONE....68 COPEGUS............................80
cyred ..................................... 88 DERMA-SMOOTHE/FS CORDRAN .......................... 56 CYSTADANE......................75 BODY OIL .......................56 CORDRAN TAPE SMALL CYSTAGON ...................... 105 DERMA-SMOOTHE/FS ROLL ............................... 56 CYSTARAN ........................ 95 SCALP OIL ......................56 COREG ................................ 39 CYTOMEL...........................72
DERMASORB HC COREG CR ..........................39 CYTOTEC............................ 78 COMPLETE KIT .............56 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
113 dicloxacillin ..........................12 doxycycline monohydrate ...13, DERMASORB TA
dicyclomine .......................... 73 14 COMPLETE KIT .............56 didanosine...............................7
DOXYCYCLINE DERMASORB XM DIFFERIN ............................52 MONOHYDRATE...........13 COMPLETE KIT .............49 DIFICID ............................... 10 drithocreme hp ......................48 DERMATOP........................56 dronabinol.............................75 DERMOTIC OIL .................62 diflorasone ............................56 DESCOVY .............................7 drospirenone-ethinyl estradiol
DIFLUCAN............................6 desipramine .......................... 31 diflunisal...............................28 ..........................................88 desloratadine......................... 98 DROXIA...............................15
digitek...................................44 desmopressin ........................ 68 digox.....................................44 DUAC...................................52 desog-e.estradiol/e.estradiol .88
DUAVEE..............................85 digoxin..................................44 DESOGEN ........................... 88 dihydroergotamine................ 22 DUETACT ........................... 70 desogestrel-ethinyl estradiol. 88 DILANTIN...........................19 DULERA............................101 DESONATE.........................56 duloxetine ............................. 32 DILANTIN EXTENDED.....19 desonide................................56
DILANTIN INFATABS ......19 DURAGESIC .......................25 DESOWEN .......................... 56 DUREZOL ........................... 97 DILANTIN-125....................19 desoximetasone .................... 56 DURLAZA ...........................44 DILATRATE-SR ................. 47 DESOXYN...........................32 dutasteride...........................104
DILAUDID .......................... 25 DESVENLAFAXINE .......... 32 dutasteride-tamsulosin ........ 104 diltiazem ...............................39 DESVENLAFAXINE DIOVAN .............................. 39 DUTOPROL.........................40 FUMARATE....................32 DIOVAN HCT .....................40 DYANAVEL XR .................32 DETROL ............................ 104 DYAZIDE ............................40 DIPENTUM ......................... 75 DETROL LA......................104 DYMISTA..........................101 diphenhydramine hcl ............99 dexamethasone ..................... 62 diphenoxylate-atropine.........73 DYRENIUM.........................40
dexamethasone intensol........ 62 DIPROLENE........................57 E
dexamethasone sodium
DIPROLENE AF..................57 e.e.s. 400 ...............................10 phosphate..........................97
dipyridamole......................... 44
E.E.S. GRANULES..............10 dexedrine .............................. 32 DISALCID ........................... 28 EASY PLUS II TEST...........64 DEXEDRINE SPANSULE ..32 diskets...................................25 EASY STEP .........................64 DEXILANT..........................78
disopyramide phosphate .......37 EASY TALK GLUCOSE dexmethylphenidate ............. 32 disulfiram.............................. 59 TEST.................................64
DEXPAK..............................62
DITROPAN XL .................104 EASY TOUCH TEST STRIP
dextroamphetamine .............. 32 DIURIL ................................ 40 ..........................................64 dextroamphetaminedivalproex.............................19 EASY TRAK GLUCOSE amphetamine .................... 32 TEST.................................64
DIVIGEL..............................85 dialyvite 800.......................107 DOLOPHINE ....................... 25 EASYGLUCO PLUS ...........64 DIAMOX SEQUELS...........96 donepezil .............................. 23 EASYGLUCO TEST ...........64 DIASTAT.............................19 EASYMAX .......................... 64 DONNATAL........................73 DIASTAT ACUDIAL..........19 DORAL ................................ 32 EC-NAPROSYN ..................28 DIATRUE PLUS TEST STRIP
DORYX................................13 econazole .............................. 55 ..........................................64 DORYX MPC ......................13 econtra ez..............................88 diazepam......................... 19, 32 dorzolamide .......................... 96 ECOZA.................................55 diazepam intensol .................32 EDARBI ............................... 40 dorzolamide-timolol ............. 96 DIBENZYLINE ................... 39 DOVONEX .......................... 48 EDARBYCLOR ................... 40 DICLEGIS............................75
doxazosin..............................40 EDECRIN.............................40 diclofenac potassium ............28 doxepin ........................... 32, 49 EDLUAR..............................32 diclofenac sodium .... 28, 49, 96
ed-spaz..................................73 doxercalciferol......................68 diclofenac-misoprostol ......... 28 doxycycline hyclate..............13 EDURANT .............................7 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
114 enskyce ................................. 89 estradiol-norethindrone acet . 85 eemt ......................................85 entacapone ............................21 ESTRING ............................. 85 eemt hs.................................. 85 entecavir .................................7 ESTROGEL..........................85 effer-k .................................106 ENTOCORT EC................... 75 estrogens-methyltestosterone85
EFFER-K............................106
ENTRESTO.......................... 47 estropipate.............................85
EFFEXOR XR .....................32 enulose..................................75 ESTROSTEP FE-28 .............89 EFFIENT..............................44 ENVARSUS XR ..................15 eszopiclone ........................... 32 EFUDEX .............................. 49 ethambutol ............................ 11 EGRIFTA .............................79 EPANED .............................. 40 ethosuximide......................... 19
ELDEPRYL ......................... 21 EPCLUSA .............................. 7 ELEMENT COMPACT TEST ethyl chloride ........................54 EPIDUO ............................... 52 etidronate disodium ..............59 STRIPS.............................64 EPIDUO FORTE..................52 etodolac.................................28
ELEMENT TEST STRIPS... 64 EPIFOAM ............................48 ELESTAT............................. 95 etoposide...............................15 epinastine..............................95 ELESTRIN ...........................85 epinephrine ........................... 99 EURAX ................................58 ELIDEL................................49 EPIPEN 2-PAK ....................99 EVAMIST ............................ 85 ELIMITE..............................58 EPIPEN JR 2-PAK...............99 EVEKEO .............................. 32 elinest ................................... 88 EVENCARE G2...................64 epitol.....................................19 eliphos .................................. 75 EPIVIR ................................... 7 EVENCARE G3 TEST ........64 ELIQUIS .............................. 44 EPIVIR HBV..........................7 EVENCARE MINI ELIXOPHYLLIN...............101 eplerenone ............................ 40 GLUCOSE TEST STR.....64 ELLA....................................89
EVISTA................................83 eprosartan ............................. 40 ELMIRON..........................105
EPZICOM ..............................7 EVOCLIN.............................52
ELOCON..............................57
EQUETRO ........................... 19 EVOLUTION TEST STRIPS
EMADINE ........................... 95 ergoloid.................................32
..........................................64 EMBEDA .............................25 ERGOMAR .......................... 22 EVOTAZ ................................ 7 EMBRACE BLOOD ERIVEDGE ..........................15 EVOXAC ............................. 59 GLUCOSE SYSTEM.......64 errin ...................................... 85 EVZIO ..................................28 EMBRACE EVO TEST ERTACZO............................ 55 EXALGO ER........................26 STRIPS.............................64 ery pads................................. 52 EXELDERM ........................55 EMBRACE PRO TEST erygel ....................................52 EXELON .............................. 23 STRIPS.............................64 ERYPED .............................. 10 exemestane ...........................15 EMCYT................................15 ery-tab...................................10
EXFORGE............................40 EMEND................................75
ERY-TAB.............................10
EXFORGE HCT...................40 emoquette ............................. 89 erythrocin (as stearate) .........10 EXJADE ............................... 59 EMSAM ............................... 32 erythromycin .................. 10, 93 EXODERM ..........................55 EMTRIVA..............................7
erythromycin ethylsuccinate. 10 EXTAVIA ............................ 80 EMVERM ............................11 erythromycin with ethanol.... 52 EXTINA ............................... 55 ENABLEX ......................... 104 erythromycin-benzoyl peroxide
EZ SMART PLUS TEST .....64 enalapril maleate ..................40 ..........................................52 EZ SMART TEST................64 enalapril-hydrochlorothiazide
ESBRIET............................101 F
..........................................40 escitalopram oxalate .............32 FABIOR ............................... 52 ENBREL .............................. 83 ESGIC .................................. 25 FACTIVE ............................. 13 endocet ................................. 25 esomeprazole magnesium..... 78 fallback solo..........................89 ENGERIX-B (PF) ................81 estarylla ................................ 89 falmina (28) ..........................89 ENGERIX-B PEDIATRIC estazolam ..............................32 famciclovir .............................. 7 (PF)...................................81 ESTRACE ............................ 85 famotidine .............................79 enoxaparin ............................ 44 estradiol ................................ 85 FAMVIR.................................7
enpresse ................................ 89 estradiol valerate...................85 FANAPT...............................32
of this table.
115 FLOVENT DISKUS ..........101 FML FORTE ........................97 FARESTON ......................... 15 FLOVENT HFA.................101 FML LIQUIFILM ................97 FARXIGA ............................ 70 FLUARIX QUAD 2016-2017 FML S.O.P............................97 FARYDAK .......................... 16 (PF)...................................81 FOCALIN.............................33 FAZACLO ........................... 32 FOCALIN XR ......................33 FC2 FEMALE CONDOM ...84 fluconazole ............................. 6 folic acid .............................107 felbamate .............................. 19 flucytosine .............................. 6 fondaparinux.........................44 FELBATOL ......................... 19 fludrocortisone...................... 62 FORA D10............................64 FELDENE ............................ 28 FLULAVAL QUAD 2016FORA D15G.........................64 felodipine..............................40
2017 ..................................81 FORA D20............................64 fem ph...................................87 FLUMADINE ........................ 7 FORA D40-G31 TEST FEMARA ............................. 16 flunisolide...........................102 STRIPS ............................. 64 FEMCAP..............................84 fluocinolone..........................57 FEMCON FE .......................89 fluocinolone acetonide oil ....62 FORA G20............................64 FEMHRT LOW DOSE ........85 FORA G30A.........................64 fluocinolone and shower cap 57 FEMRING............................85 fluocinonide..........................57 FORA GD50 TEST STRIPS 64 fenofibrate ............................ 45 FORA TEST STRIP .............65 fluocinonide-e.......................57 FENOFIBRATE...................45 FORA TN'G VOICE TEST fluor-a-day (with xylitol)....107 fenofibrate micronized .........45 STRIPS .............................65 fluorescein-benoxinate ......... 95 fenofibrate nanocrystallized . 45 FORA V10............................65 fluoridex daily defense .........61 fenofibric acid ......................45 FLUORIDEX SENSITIVITY FORA V12 GLUCOSE ........65 fenofibric acid (choline) .......45 RELIEF ............................ 61 FORA V20............................65 FENOGLIDE ....................... 45 fluoritab .............................. 107 FORACARE GD20 ..............65 fenoprofen ............................ 28 fluorometholone ................... 97 FORACARE GD40 ..............65 FENOPROFEN .................... 28 FLUOROPLEX ....................49 FORADIL AEROLIZER....102 fentanyl.................................26 fluorouracil ........................... 49 FORFIVO XL ....................... 33
FENTANYL.........................26 FLUOROURACIL ............... 49 FORTAMET.........................70
fentanyl citrate......................26 fluoxetine..............................32 FORTAVIT ........................107 FENTORA ........................... 26 FLUOXETINE ..................... 32 FORTEO...............................83
FERRIPROX........................59 fluphenazine hcl ...................33 FORTESTA..........................69 FETZIMA ............................ 32 flurandrenolide ..................... 57 fortical...................................69
FEXMID .............................. 24 flurazepam ............................33 FORTISCARE GLUCOSE FIBRICOR ........................... 45 flurbiprofen...........................28 TEST STRIPS ..................65 FIFTY50 TEST STRIP ........64 flurbiprofen sodium..............96 FOSAMAX...........................83
FINACEA ............................ 52 flurox .................................... 95 FOSAMAX PLUS D ............83 finasteride ...........................104 flutamide ............................... 16 fosinopril...............................40
FIORICET............................26 fluticasone .................... 57, 102
fosinopril-hydrochlorothiazide
FIORICET WITH CODEINE
fluvastatin ............................. 45 ..........................................40 ..........................................26 fluvoxamine ..........................33 FOSRENOL .........................75 FIORINAL ........................... 26 FLUZONE HIGH-DOSE FRAGMIN............................44 FIORINAL-CODEINE #3 ...26 2016-17 (PF) .................... 81 FREESTYLE INSULINX ....65 FIRAZYR...........................101 FLUZONE INTRADERM FREESTYLE INSULINX FLAGYL .............................. 11 QUAD 2016-17 ................81 TEST STRIPS ..................65 FLAGYL ER ........................11 FLUZONE QUAD 2016-2017
FREESTYLE LITE STRIPS 65 FLAREX .............................. 97 ..........................................81 FREESTYLE PRECISION flavoxate .............................104 FLUZONE QUAD 2016-2017 NEO STRIPS....................65 flecainide ..............................37 (PF)...................................81 FREESTYLE TEST .............65 FLECTOR ............................ 28 FLUZONE QUAD PEDI FROVA.................................22
FLOMAX ...........................104 2016-17 (PF) .................... 81 frovatriptan ...........................22 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
116 GLEOSTINE ........................16 guaifenesin dac .....................99 full spectrum b-vitamin c ...107 glimepiride............................ 70 guanfacine....................... 33, 40
FULYZAQ ........................... 73 glipizide ................................70 guanidine .............................. 33 FURADANTIN....................14 GYNAZOLE-1 ..................... 87 furosemide ............................40 glipizide-metformin .............. 70 FUZEON ................................ 7 GLUCAGEN HYPOKIT .....67 H
HALCION ............................33 fyavolv..................................85
GLUCAGON EMERGENCY halobetasol propionate..........57 FYCOMPA .......................... 19 KIT (HUMAN).................67 HALOG ................................57 GLUCO NAVII TEST STRIP
G
haloperidol............................33 gabapentin ............................ 19 ..........................................65 haloperidol lactate ................33 GABITRIL ........................... 19 GLUCOCARD 01 SENSOR HARVONI..............................7 galantamine .......................... 23 PLUS ................................ 65 HAVRIX (PF) ......................81 GALZIN .............................106 GLUCOCARD EXPRESSION
GARDASIL (PF) ................. 81 ..........................................65 HEALTHPRO TEST STRIPS
GARDASIL 9 (PF) .............. 81 GLUCOCARD SHINE TEST ..........................................65 GASTROCROM ..................75 STRIPS.............................65 heather .................................. 85 gatifloxacin...........................93 GLUCOCARD VITAL HECTOROL.........................69 GATTEX 30-VIAL ..............75 SENSOR...........................65
HEMANGEOL.....................40 gavilyte-c..............................75 GLUCOCARD VITAL TEST heparin (porcine) ..................44 gavilyte-g..............................75
STRIPS.............................65 heparin, porcine (pf) .............44 gavilyte-h and bisacodyl....... 75 GLUCOCOM GLUCOSE....65 HEPSERA .............................. 7 gavilyte-n..............................75
GLUCOPHAGE...................70 HETLIOZ .............................33 GE100 BLOOD GLUCOSE GLUCOPHAGE XR ............70 HEXALEN ...........................16 TEST STRIP ....................65 GLUCOTROL......................70 HIPREX................................14 GELNIQUE........................104
GLUCOTROL XL ...............70 homatropaire .........................95 gemfibrozil ........................... 45 GLUCOVANCE .................. 71 homatropine hbr....................95 GENERESS FE ....................89 GLUMETZA ........................71 HORIZANT..........................23 generlac ................................ 75 glyburide...............................71
HUMALOG..........................67 gengraf..................................16
glyburide micronized............71 HUMALOG KWIKPEN ......67 GENOTROPIN .................... 79 glyburide-metformin ............ 71 HUMALOG MIX 50-50.......67 GENOTROPIN MINIQUICK
glycopyrrolate.......................73 HUMALOG MIX 50-50 ..........................................79 glydo.....................................54 KWIKPEN ........................ 67 GENSTRIP TEST STRIP ....65 GLYNASE ........................... 71 HUMALOG MIX 75-25.......67 gentak ................................... 93 GLYSET...............................71
HUMALOG MIX 75-25 gentamicin ...................... 54, 93 GLYXAMBI ........................ 71 KWIKPEN ........................ 67 GENVOYA ............................ 7 GM100.................................. 65 HUMATROPE ..................... 79 GEODON .............................33 GMATE TEST STRIPS .......65 HUMIRA..............................83 gianvi (28) ............................89 GOLYTELY.........................75
HUMULIN 70/30 .................67 GIAZO ................................. 75 GORDONS UREA...............49 HUMULIN 70/30 KWIKPEN
gildagia .................................89 GRALISE ............................. 19 ..........................................67 gildess 1.5/30 (21) ................89 GRALISE 30-DAY STARTER HUMULIN N .......................67 gildess 1/20 (21) ...................89 PACK ............................... 19 HUMULIN N KWIKPEN ....67 gildess 24 fe..........................89 granisetron hcl ......................75 HUMULIN R........................67 gildess fe 1.5/30 (28)............89 GRASTEK............................ 81 HUMULIN R U-500 (CONC) gildess fe 1/20 (28)...............89 griseofulvin microsize ............6 KWIKPEN ........................ 67 GILENYA ............................ 80 griseofulvin ultramicrosize .....6 HUMULIN R U-500 GILOTRIF............................16
GRIS-PEG (CONCENTRATED) ....... 67 glatopa .................................. 80 (ULTRAMICROSIZE) ......6 HYCAMTIN.........................16
GLEEVEC............................16
guaifenesin ac .......................99 HYCET.................................26 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
117 imipramine pamoate ............. 33 ISOPTO ATROPINE ........... 95 hydralazine ........................... 40 imiquimod ............................ 81 ISOPTO CARPINE ..............95 HYDREA ............................. 16 IMITREX ............................. 22 ISORDIL .............................. 47 HYDRO 35........................... 49 IMITREX STATDOSE KIT ISORDIL TITRADOSE .......47 HYDRO 40........................... 50 REFILL ............................ 22 isosorbide dinitrate ...............47 hydrochlorothiazide.............. 40
IMITREX STATDOSE PEN22 isosorbide mononitrate .........47 hydrocodone-acetaminophen 26 IMPAVIDO .......................... 11 hydrocodone-chlorpheniramine
isoxsuprine ............................ 87 IMURAN .............................. 16 isradipine ..............................41 .......................................... 99 INCRELEX .......................... 59 hydrocodone-cpmISTALOL ............................. 94 INCRUSE ELLIPTA.......... 102 pseudoephed ..................... 99 itraconazole.............................6
indapamide ........................... 40 ivermectin ............................. 11 hydrocodone-homatropine ... 99 hydrocodone-ibuprofen ........ 26 INDERAL LA ...................... 40 J
hydrocortisone .......... 57, 62, 75 JADENU...............................59
INDERAL XL ...................... 40 hydrocortisone acetate .......... 75 JAKAFI ................................ 16 INDOCIN ............................. 29 hydrocortisone butyrate ........ 57 JALYN ...............................104 indomethacin ........................ 29 hydrocortisone butyr-emollient
jantoven ................................ 44 INFANRIX (DTAP) (PF)..... 81 .......................................... 57 JANUMET ........................... 71 INFINITY TEST STRIPS .... 65 hydrocortisone valerate ........ 57 JANUMET XR .....................71 INLYTA ............................... 16 hydrocortisone-acetic acid.... 62 INNOPRAN XL ................... 41 JANUVIA ............................. 71 hydrocortisone-min oil-wht pet
JARDIANCE ........................ 71 INOVA ................................. 52 .......................................... 57 INOVA 4-1........................... 48 jencycla ................................. 85 hydrocortisone-pramoxine .. 48, JENTADUETO ....................71 INOVA 8-2........................... 49 76 JENTADUETO XR .............. 71 INSPRA ................................ 41 hydromet............................... 99 jevantique lo ......................... 85 INTELENCE .......................... 7 hydromorphone .................... 26 jinteli ..................................... 85 INTERMEZZO .................... 33 hydroxocobalamin .............. 107 jolessa ...................................89 introvale ................................ 89 hydroxychloroquine ............. 11 INTUNIV ER ....................... 33 jolivette ................................. 85 hydroxyurea.......................... 16
INVEGA............................... 33
JUBLIA ................................ 55 hydroxyzine hcl .................... 99 INVIRASE ............................. 8 juleber ................................... 89 hydroxyzine pamoate ........... 99 INVOKAMET ...................... 71 junel 1.5/30 (21) ................... 89 hyolev mb........................... 105 INVOKANA ........................ 71 junel 1/20 (21) ......................89 hyoscyamine sulfate ............. 73 iophen c-nr ............................ 99 junel fe 1.5/30 (28) ............... 89 hyosyne ................................ 73 IOPIDINE............................. 98
junel fe 1/20 (28) .................. 89 HYPER-SAL ...................... 102 IPOL ..................................... 81 junel fe 24 ............................. 89 HYSINGLA ER ................... 26 ipratropium bromide ..... 61, 102 JUXTAPID ........................... 46 HYZAAR ............................. 40 ipratropium-albuterol.......... 102 K
irbesartan .............................. 41 KADIAN .............................. 26 I
ibandronate ........................... 83 irbesartan-hydrochlorothiazide
kaitlib fe ................................ 89 IBRANCE ............................ 16 .......................................... 41 KALETRA .............................8 IBUDONE ............................ 26 IRENKA ............................... 33 KALYDECO ...................... 102 ibuprofen .............................. 29 IRESSA ................................ 16 KAPVAY .............................33 ibuprofen-oxycodone ........... 26 ISENTRESS ........................... 8 KARBINAL ER ................... 99 ICLUSIG .............................. 16 ISOCHRON.......................... 47 kariva (28) ............................ 89 ILEVRO ............................... 96 isometh-dichloralKAYEXALATE ...................76 ILOTYCIN ........................... 93 acetaminophn.................... 22 KAZANO .............................71 imatinib ................................ 16 isomethepten-cafk-effervescent .....................106 IMBRUVICA ....................... 16 acetaminophen .................. 22 KEFLEX ................................. 9 imipramine hcl...................... 33 isoniazid................................ 11 kelnor 1/35 (28) .................... 89 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
118 LAMICTAL ......................... 19 levocarnitine .........................59 KENALOG........................... 57 LAMICTAL ODT ................ 19 levocarnitine (with sugar) ..... 59 KEPPRA .............................. 19 LAMICTAL ODT STARTER
levocetirizine ........................ 99 KEPPRA XR ........................ 19 .......................................... 19 levofloxacin ....................13, 94 KERAFOAM ....................... 50 LAMICTAL STARTER KIT
levonest (28) ......................... 90 KERALAC ........................... 50 .......................................... 19 levonorgestrel-ethinyl estrad 90 KERALYT RX..................... 49 LAMICTAL XR ................... 19 levonorg-eth estrad triphasic 90 KERALYT SCALP LAMICTAL XR STARTER 20 levora-28 ............................... 90 COMPLETE ..................... 49 LAMISIL ................................ 6 levorphanol tartrate ............... 26 KERYDIN ............................ 55 levothyroxine ........................ 72 KETEK ................................. 11 lamivudine .............................. 8 levoxyl .................................. 72 ketoconazole ..................... 6, 55 lamivudine-zidovudine ........... 8 LEVSIN ................................73 ketoprofen............................. 29 lamotrigine............................ 20 ketorolac ......................... 29, 96 LEVSIN/SL .......................... 73 LANCETS ............................ 67 KEVEYIS ............................. 23 LEVULAN ...........................50 LANOXIN ............................ 44 KHEDEZLA......................... 33 LEXAPRO ............................ 33 lansoprazole .......................... 79 kimidess (28) ........................ 89 LEXIVA .................................8 LANTUS .............................. 67 KINERET ............................. 81 LIALDA ...............................76 LANTUS SOLOSTAR......... 68 KINRIX (PF) ........................ 81 LIBERTY TEST ...................65 larin 1.5/30 (21) .................... 90 kionex ................................... 76 larin 1/20 (21) ....................... 90 LIBRAX (WITH KLARON ............................. 54 larin 24 fe.............................. 90 CLIDINIUM) ................... 73 klofensaid ii .......................... 29 larin fe 1.5/30 (28) ................ 90 lidocaine ............................... 54 KLONOPIN ......................... 19 lidocaine hcl.......................... 54 larin fe 1/20 (28) ................... 90 klor-con .............................. 106 lidocaine hcl-hydrocortison ac
LASIX .................................. 41 klor-con 10 ......................... 106 LASTACAFT ....................... 96 .................................... 54, 76 klor-con 8 ........................... 106 latanoprost ............................ 97 LIDOCAINE HCLklor-con m10 ...................... 106 latrix...................................... 50 HYDROCORTISON AC .76 klor-con m15 ...................... 106 LATUDA.............................. 33 lidocaine viscous .................. 54 klor-con m20 ...................... 106 laxative peg 3350.................. 76 lidocaine-hydrocortisone-aloe
klor-con sprinkle ................ 107 layolis fe ............................... 90 .......................................... 76 KLOR-CON/25 .................. 107 LAZANDA........................... 26
lidocaine-prilocaine ..............54 klor-con/ef .......................... 107 leena 28................................. 90 LIDODERM .........................54 KOMBIGLYZE XR ............. 71 leflunomide ........................... 83 lindane .................................. 58 KORLYM ............................ 69 LENVIMA............................ 16 linezolid ................................ 11 K-PHOS NO 2.................... 105 LESCOL ............................... 46 LINZESS .............................. 76 K-PHOS ORIGINAL ......... 105 LESCOL XL......................... 46 liothyronine........................... 72
KRISTALOSE ..................... 76 lessina ................................... 90 LIPITOR ...............................46 k-sol .................................... 107 LETAIRIS .......................... 102 LIPOCHOL PLUS................59 k-tab.................................... 107
letrozole ................................ 16 LIPOFEN .............................. 46 K-TAB................................ 107
leucovorin calcium ............... 14 lisinopril ................................ 41 kurvelo.................................. 89
LEUKERAN ........................ 16 lisinopril-hydrochlorothiazide
KUVAN ............................... 69 levalbuterol hcl ................... 102 .......................................... 41 KYNAMRO ......................... 46 LEVAQUIN ......................... 13 lithium carbonate .................. 33 LEVATOL............................ 41 lithium citrate........................ 33 L
l norgest/e.estradiol-e.estrad. 89 LEVBID ............................... 73 LITHOBID ........................... 33 labetalol ................................ 41 LEVEMIR ............................ 68 LITHOSTAT ........................60 LACRISERT ........................ 95 LEVEMIR FLEXTOUCH ... 68 LIVALO ............................... 46 lactated ringers ..................... 58 levetiracetam ........................ 20 LO LOESTRIN FE ............... 90 lactulose................................ 76
levobunolol ........................... 94 LOCOID ............................... 57 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
119 LUZU ................................... 55 MENEST .............................. 85
LOCOID LIPOCREAM....... 57 LYNPARZA......................... 16
MENOMUNE - A/C/Y/W-135
LODOSYN ........................... 21 LYRICA ............................... 20 .......................................... 82 LOESTRIN 1.5/30 (21) ........ 90 LYSODREN......................... 16
MENOMUNE - A/C/Y/W-135 LOESTRIN 1/20 (21) ........... 90 LYSTEDA ............................ 87 (PF) ................................... 82 LOESTRIN FE 1.5/30 (28lyza ....................................... 85 MENOSTAR ........................ 86 DAY) ................................ 90 LOESTRIN FE 1/20 (28-DAY)
MENTAX .............................55 M
MACROBID ........................ 14 MENVEO A-C-Y-W-135-DIP .......................................... 90 MACRODANTIN ................ 14 LOFIBRA ............................. 46 (PF) ................................... 82 MAGNEBIND 400............... 76 lomedia 24 fe ........................ 90 meperidine ............................26 LOMOTIL ............................ 73 MEPHYTON ........................ 44 MAKENA ............................ 85 LONSURF............................ 16
meprobamate ........................ 24 MALARONE ....................... 11 loperamide ............................ 73 MEPRON .............................11 MALARONE PEDIATRIC . 11 LOPID .................................. 46 mercaptopurine ..................... 17 malathion .............................. 58 lopreeza ................................ 85 mesalamine ........................... 76 maprotiline............................ 34 LOPRESSOR ....................... 41 mesalamine with cleansing MAR-COF BP .................... 100 LOPRESSOR HCT .............. 41 wipe .................................. 76 MAR-COF CG ................... 100 LOPROX .............................. 55 MESNEX .............................. 14 margesic................................ 26 lorazepam ............................. 33 MESTINON ......................... 24 MARINOL ........................... 76 lorazepam intensol................ 33 MESTINON TIMESPAN ....24 marlissa ................................. 90 lorcet (hydrocodone) ............ 26 METADATE CD.................. 34 MARPLAN .......................... 34 lorcet hd ................................ 26 metadate er............................ 34 marten-tab ............................. 26 lorcet plus ............................. 26 metaproterenol .................... 102 MATULANE........................ 16 lortab..................................... 26 metaxall ................................ 24 MAVIK ................................ 41 LORTAB ELIXIR ................ 26 metaxalone ............................ 24 MAXALT ............................. 22 lortuss ex ............................ 100 metformin ............................. 71 MAXALT-MLT ................... 22 loryna (28) ............................ 90 MAXIDEX ........................... 98 methadone............................. 26
LORZONE ........................... 24 MAXITROL ......................... 97 methadose ............................. 26 losartan ................................. 41 MAXZIDE............................ 41 methamphetamine................. 34
losartan-hydrochlorothiazide 41 MAXZIDE-25MG ................ 41 methazolamide ...................... 96 LOSEASONIQUE ............... 90 m-clear wc .......................... 100 methenamine hippurate ........14 LOTEMAX .......................... 97 meclizine .............................. 76 methenamine mandelate ....... 14 LOTENSIN .......................... 41 meclofenamate...................... 29
methen-sod phos-meth blueLOTENSIN HCT ................. 41 MEDROL ............................. 62 hyos................................. 105
LOTREL............................... 41 MEDROL (PAK) ................. 62 methergine ............................93 LOTRISONE........................ 55
medroxyprogesterone ........... 85 methimazole ......................... 63 LOTRONEX ........................ 76 mefenamic acid..................... 29 METHITEST ........................ 69 LOUTREX ........................... 50 mefloquine ............................ 11 methocarbamol ..................... 24 lovastatin .............................. 46 MEGACE ............................. 16 methotrexate sodium ............17 LOVENOX........................... 44 methoxsalen rapid ................. 50 MEGACE ES ....................... 16 low-ogestrel (28) .................. 90 methscopolamine .................. 73 megestrol .............................. 17 loxapine succinate ................ 33 MEKINIST ........................... 17 methyclothiazide................... 41
ludent fluoride .................... 107 meloxicam ............................ 29 methyldopa ........................... 41 lugols .................................. 107 memantine ............................ 23 methyldopaLUMIGAN ........................... 97 MEMANTINE...................... 23 hydrochlorothiazide .......... 41 LUNESTA............................ 33
MENACTRA (PF) ............... 82 methylergonovine .................93 lutera (28) ............................. 90 M-END MAX D................. 100 METHYLIN .........................34 LUXIQ ................................. 57 M-END PE ......................... 100 methylphenidate ...................34 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
120 mycophenolate mofetil .........17 methylprednisolone .............. 62 minoxidil ..............................42 mycophenolate sodium.........17 methyltestosterone................ 69
MIRAPEX ............................21 MYDRIACYL......................95 metipranolol ......................... 94 MIRAPEX ER......................21 metoclopramide hcl ..............76 MIRCETTE (28) ..................90 MYFORTIC .........................17 metolazone ........................... 41 mirtazapine ........................... 34 MYGLUCOHEALTH..........65 METOPIRONE .................... 60 MIRVASO............................ 52 MYLERAN .......................... 17 metoprolol succinate ............41 misoprostol ........................... 79 myorisan ...............................52 metoprolol ta-hydrochlorothiaz
MITIGARE .......................... 83 MYRBETRIQ.....................104
..........................................41 MITOSOL ............................ 97 MYSOLINE ......................... 20 metoprolol tartrate ................41 M-M-R II (PF)......................82 myzilra..................................91 METOZOLV ODT...............76 MOBIC.................................29 N
METROCREAM..................52
modafinil .............................. 34 nabumetone...........................29
METROGEL ........................ 52 moderiba...............................80 nadolol .................................. 42 METROGEL VAGINAL .....87 moderiba dose pack ..............80 nadolol-bendroflumethiazide 42 METROLOTION .................52 MODICON (28) ...................91 naftifine.................................55
metronidazole ........... 11, 52, 87
moexipril .............................. 42 NAFTIFINE ......................... 55 mexiletine ............................. 37 moexipril-hydrochlorothiazide
NAFTIN ............................... 55 MIACALCIN ....................... 69 ..........................................42 NALFON..............................29 MICARDIS .......................... 41 molindone.............................34 naloxone ............................... 29 MICARDIS HCT .................41 mometasone .................. 57, 102
naltrexone .............................29 miconazole-3 ........................ 87 mondoxyne nl .......................14 NAMENDA..........................23 MICRO BLOOD GLUCOSE
MONODOX ......................... 14 NAMENDA TITRATION ..........................................65 mono-linyah.......................... 91 PAK .................................. 23 MICRODOT BLOOD mononessa (28)..................... 91 NAMENDA XR ............. 23, 24
GLUCOSE SYSTEM.......65 montelukast ........................ 102 NAMZARIC.........................24 microgestin 1.5/30 (21) ........90 MONUROL..........................14 NAPRELAN CR ..................29 microgestin 1/20 (21) ...........90 morgidox .............................. 14 NAPROSYN.........................29
MICROGESTIN 24 FE........90 MORGIDOX ........................14 naproxen ............................... 29 microgestin fe 1.5/30 (28) ....90 morphine...............................27
naproxen sodium ..................29 microgestin fe 1/20 (28) .......90 morphine concentrate ...........27 naratriptan.............................22 MICROZIDE........................41
MOVANTIK ........................ 76 NARCAN ............................. 29 midodrine ............................. 60 MOVIPREP..........................76 NARDIL ............................... 34 migergot ............................... 22 MOXATAG.......................... 12 NASONEX .........................102 miglitol ................................. 71 MOXEZA.............................94 NATACYN...........................94
MIGRANAL ........................ 22 moxifloxacin.........................13 NATAZIA ............................ 91 milk of magnesia concentrated
MOZOBIL............................79 nateglinide ............................ 71 ..........................................76 MS CONTIN ........................27 NATESTO............................69 millipred ...............................62 MULTAQ.............................37 NATPARA ...........................69 MILLIPRED......................... 62 multi-vit with fluoride-iron 107 NATROBA...........................58 millipred dp ..........................62 multi-vitamin with fluoride 108 natural b-100 complex ........108 mimvey ................................. 86 multivitamins with fluoride 108 nature-throid ......................... 72 mimvey lo.............................86 mupirocin.............................. 54 NEBUPENT .........................11 MINASTRIN 24 FE .............90 mupirocin calcium................54 NEBUSAL..........................102 MINIPRESS .........................41 mvc-fluoride ....................... 108 necon 0.5/35 (28)..................91 MINITRAN..........................47 my way .................................91 necon 1/35 (28).....................91 MINIVELLE ........................ 86 MYALEPT ........................... 69 necon 1/50 (28).....................91 MINOCIN ............................ 14 MYAMBUTOL....................11 necon 10/11 (28)...................91 MYCOBUTIN......................11 necon 7/7/7 (28)....................91 minocycline .......................... 14 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
121 nimodipine ............................ 42 NOVOLIN R ........................68 nefazodone ........................... 34 NINLARO ............................ 17 NOVOLOG .......................... 68 neomycin .............................. 11 nisoldipine ............................ 42 NOVOLOG FLEXPEN ........68 neomycin-bacitracin-poly-hc 97 nitro-bid ................................ 47 NOVOLOG MIX 70-30 ....... 68 neomycin-bacitracinNITRO-DUR ........................ 47 NOVOLOG MIX 70-30 polymyxin ........................ 94 nitrofurantoin ........................ 14 neomycin-polymyxin b gu ... 58 FLEXPEN.........................68
nitrofurantoin macrocrystal .. 14 neomycin-polymyxin bNOVOLOG PENFILL ......... 68 nitrofurantoin monohyd/mdexameth .......................... 97 NOXAFIL............................... 6
cryst .................................. 14 neomycin-polymyxinnp thyroid..............................72 nitroglycerin ......................... 47 gramicidin......................... 94 NUCYNTA........................... 29
NITROLINGUAL ................ 47 neomycin-polymyxin-hc 62, 97 NUCYNTA ER .................... 29 NITROMIST ........................ 47 neo-polycin ........................... 94 NUEDEXTA ........................ 24 NITROSTAT ........................ 47 neo-polycin hc ...................... 97 NULEV................................. 73
nitro-time .............................. 47 NEORAL.............................. 17
NULYTELY WITH FLAVOR nizatidine .............................. 79 NEOSPORIN (NEO-POLYMPACKS ............................. 76 GRAMICID) .................... 94 NUOX................................... 52
NIZORAL ............................ 55 NEOSPORIN GU IRRIGANT
NUPLAZID .......................... 34 nodolor.................................. 22 .......................................... 59 NUTROPIN AQ ................... 79 nora-be .................................. 86 NEO-SYNALAR ................. 54 NUTROPIN AQ NUSPIN ....79 NORCO ................................ 27 NEO-SYNALAR KIT .......... 54 NUVARING .........................87 NORDITROPIN FLEXPRO 79 NEPTAZANE ...................... 96 NUVESSA ............................ 87 noreth-ethinyl estradiol-iron . 91 NESINA ............................... 71 NUVIGIL .............................34 norethindrone (contraceptive)
neuac..................................... 52 nyamyc .................................55 .......................................... 86 NEUPRO .............................. 21 NYMALIZE .........................42 norethindrone acetate ........... 86 NEURONTIN....................... 20 nystatin .............................6, 55 norethindrone ac-eth estradiol
NEUTEK 2TEK TEST nystatin-triamcinolone .......... 55 .................................... 86, 91 STRIPS ............................. 65 nystop ...................................55 norethindrone-e.estradiol-iron
NEVANAC .......................... 96 .......................................... 91 O
nevirapine ............................... 8 OCALIVA ............................ 76 norgestimate-ethinyl estradiol
NEXAVAR .......................... 17 ocella..................................... 91
.......................................... 91 NEXIUM PACKET ............. 79 octreotide acetate .................. 17 NORINYL 1+35 (28) ........... 91 next choice one dose ............ 91 NORITATE .......................... 52 OCUFEN .............................. 96 niacin .................................... 46 norlyroc ................................ 86 OCUFLOX ........................... 94 NIACOR .............................. 46 NORPACE ........................... 37 ODEFSEY .............................. 8 NIASPAN EXTENDEDNORPACE CR ..................... 37 ODOMZO.............................17
RELEASE ........................ 46 NORPRAMIN ...................... 34 OFEV .................................. 102 nicardipine ............................ 42 NOR-QD .............................. 86 ofloxacin ...................13, 62, 94 NICODERM CQ .................. 60 NORTHERA ........................ 60 ogestrel (28) .......................... 91 NICORETTE........................ 60
nortrel 0.5/35 (28)................. 91 olanzapine ............................. 34 nicotine ................................. 60 nortrel 1/35 (21).................... 91 olanzapine-fluoxetine ........... 34 NICOTINE (POLACRILEX)
nortrel 7/7/7 (28) .................. 91 OLEPTRO ER ...................... 34 .......................................... 60 nortriptyline .......................... 34 olopatadine ..................... 61, 96 NICOTROL.......................... 60
NORVASC ........................... 42 OLUX ...................................57 NICOTROL NS ................... 60 NORVIR................................. 8
OLUX-E ...............................57 nifedical xl ............................ 42 NOVA MAX GLUCOSE OLYSIO ................................. 8 nifedipine.............................. 42
TEST ................................ 66 OMECLAMOX-PAK........... 79
nikki (28) .............................. 91 NOVOLIN 70/30.................. 68 omega-3 acid ethyl esters ..... 46 NILANDRON ...................... 17 NOVOLIN N ........................ 68 omeprazole ........................... 79 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
122 ORTHO-NOVUM 7/7/7 (28)
paromomycin ........................ 11 .......................................... 91 paroxetine hcl ....................... 34 oscimin ................................. 73 PASER .................................. 11 oscimin sl.............................. 73 PATADAY ........................... 96 oscimin sr ............................. 73 PATANASE .........................61 OSENI .................................. 71 PATANOL ........................... 96 OSMOPREP ......................... 76 PAXIL ..................................34 OTEZLA .............................. 83 PAXIL CR ............................ 34 OTREXUP (PF) ................... 83 PAZEO ................................. 96 OVACE ................................ 48 PCE ....................................... 10 OVACE PLUS ..................... 48 PEDIAPRED ........................62 PEDIARIX (PF) ...................82 OVACE PLUS SHAMPOO . 48 PEDVAX HIB (PF) ..............82 OVACE PLUS WASH......... 48 peg 3350-electrolytes............ 76 OVCON-35 (28) ................... 91 peg-3350 with flavor packs .. 76 OVIDE.................................. 58 PEGANONE......................... 20
OXANDRIN......................... 69
PEGASYS ............................ 80 oxandrolone .......................... 69 PEGASYS PROCLICK........80 oxaprozin .............................. 29 peg-electrolyte soln .............. 77 OXAYDO............................. 27
PEGINTRON ....................... 80 oxazepam .............................. 34 oxcarbazepine ....................... 20 PEGINTRON REDIPEN......80 oxiconazole ........................... 55 peg-prep ................................ 77 OXISTAT ............................. 55 penicillin v potassium........... 12 PENLAC............................... 55
OXSORALEN ...................... 50 PENNSAID .......................... 29 OXSORALEN ULTRA ....... 50 OXTELLAR XR .................. 20 PENTACEL (PF).................. 82 oxybutynin chloride ............ 104 PENTASA ............................ 77 oxycodone ............................ 27 pentazocine-naloxone ...........29 OXYCODONE..................... 27
pentoxifylline ........................ 44 oxycodone-acetaminophen ... 27 PEPCID ................................79 oxycodone-aspirin ................ 27 PERCOCET .......................... 27 OXYCONTIN ...................... 27 PERFOROMIST................. 102
oxymorphone ........................ 27 PERIDEX ............................. 61 OXYTROL ......................... 104 perindopril erbumine ............ 42 periogard ............................... 61 P
pacerone................................ 37 permethrin............................. 58
PACNEX .............................. 52 perphenazine ......................... 34 paliperidone .......................... 34 perphenazine-amitriptyline ... 35 PAMELOR ........................... 34 perry prenatal ...................... 108 PANCREAZE ...................... 76 PERTZYE............................. 77
PANDEL .............................. 57 PEXEVA .............................. 35 PANRETIN .......................... 50 PHARMACIST CHOICE ....66 pantoprazole ......................... 79 phenadoz ............................... 99 PARAFON FORTE DSC ..... 24 phenazopyridine ................. 106 paregoric ............................... 73 phenelzine .............................35 paricalcitol ............................ 69 phenergan .............................99 PARLODEL ......................... 21 phenobarbital ........................20 PARNATE............................ 34 phenohytro ............................73 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
123 OMNARIS ......................... 102 OMNIPRED ......................... 98 OMNITROPE....................... 80 ON CALL EXPRESS TEST STRIP ............................... 66 ON CALL PLUS TEST STRIP
.......................................... 66 ON CALL VIVID TEST STRIP ............................... 66 ondansetron .......................... 76 ondansetron hcl .................... 76 one daily prenatal ............... 108 ONETOUCH ULTRA TEST
.......................................... 66 ONETOUCH VERIO ........... 66 ONEXTON........................... 52 ONFI .................................... 20 ONGLYZA........................... 71 ONMEL.................................. 6
ONZETRA XSAIL .............. 22 OPANA ................................ 27 OPANA ER .......................... 27 opcicon one-step................... 91 opium tincture ...................... 73 OPSUMIT .......................... 102 OPTIUM EZ......................... 66 OPTIUM TEST .................... 66 OPTUMRX .......................... 66 ORACEA ............................. 14 ORACIT ............................. 105 ORALAIR ............................ 82 oralone .................................. 61 ORAP ................................... 34 ORAPRED ODT .................. 62 ORAVIG ................................ 6 ORENCIA ............................ 83 ORENITRAM ...................... 42 ORFADIN ............................ 60 ORKAMBI ......................... 102 orphenadrine citrate .............. 24 orsythia ................................. 91 ORTHO MICRONOR.......... 86 ORTHO TRI-CYCLEN (28) 91 ORTHO TRI-CYCLEN LO (28) ................................... 91 ORTHO-CYCLEN (28) ....... 91 ORTHO-NOVUM 1/35 (28) 91 POTABA ............................107 prenatal complete................108 phenoxybenzamine ............... 42 potassium bicarb and chloride
prenatal one daily ...............108 phenylephrine hcl .................98 ........................................107 prenatal vit#96-ferrous fum-fa
phenylhistine dh .................100 potassium bicarb-citric acid 107 ........................................108 PHENYTEK.........................20 potassium chloride..............107 prenatal vitamin ..................108 phenytoin..............................20 potassium citrate .................105 prenatal vitamin plus low iron
phenytoin sodium extended..20 potassium citrate-citric acid 105 ........................................108 philith ................................... 92 PREPOPIK ...........................77 PHOSLO .............................. 77 POTASSIUM HYDROXIDE
PRESTALIA.........................42
PHOSLYRA.........................77 ..........................................49 phosphasal .......................... 105 PREVACID SOLUTAB.......79 POTIGA ............................... 20 prevalite ................................ 46 phosphate laxative ................77 PR BENZOYL PEROXIDE . 53 PREVIDENT........................61 PHOSPHOLINE IODIDE....95 PRADAXA...........................45
PHYSIOLYTE ..................... 59 PREVIDENT 5000 BOOSTER PRALUENT ......................... 46 PHYSIOSOL IRRIGATION 59 PLUS ................................ 61 pramcort................................ 77 PHYTONADIONE PREVIDENT 5000 DRY pramipexole .......................... 21 (VITAMIN K1) ................44 MOUTH ...........................61 PRAMOSONE ..................... 48 PICATO ............................... 50 PREVIDENT 5000 ENAMEL PRAMOSONE E..................48 pilocarpine hcl .......... 60, 61, 95 PROTECT ........................61 PRANDIN ............................ 71 pimozide ............................... 35 PREVIDENT 5000 PRAVACHOL ..................... 46 pimtrea (28) ..........................92 SENSITIVE......................61 pravastatin ............................ 46 pindolol ................................ 42 previfem................................92 prazosin ................................ 42 pioglitazone .......................... 71 PREVNAR 13 (PF) ..............82 PRECISION PCX PLUS TEST
pioglitazone-glimepiride ...... 71 PREVPAC ............................ 79 ..........................................66 pioglitazone-metformin ........ 71 PRECISION PCX TEST ......66 PREZCOBIX ..........................8 pirmella................................. 92 PREZISTA ............................. 8 PRECISION POINT OF piroxicam..............................29
PRIFTIN ...............................11 CARE TEST.....................66 PLAN B ONE-STEP............92 PRECISION Q-I-D TEST ....66 PRILOSEC ...........................79 PLAQUENIL ....................... 11 PRECISION XTRA TEST...66 PRIMAQUINE .....................11 PLAVIX ............................... 45 PRECOSE ............................ 72 primidone .............................. 20 PLEGRIDY .......................... 80 PRED FORTE ......................98 PRIMSOL.............................14 PLEXION.............................52 PRED MILD......................... 98 PRINIVIL .............................42 PLEXION CLEANSING PRED-G................................ 97 PRISTIQ ...............................35 CLOTHS .......................... 53 PRED-G S.O.P. ....................97 PROAIR HFA ....................102 PNEUMOVAX 23 ...............82 prednicarbate ........................ 57 PROAIR RESPICLICK......102 PODOCON .......................... 49 prednisolone ......................... 62 probenecid ............................83 podofilox .............................. 50 prednisolone acetate .............98 PROCARDIA ....................... 42 polycin..................................94 prednisolone sodium phosphate
PROCARDIA XL.................42 polyethylene glycol 3350 .....77 .................................... 62, 98 procentra ............................... 35 polymyxin b sulf-trimethoprim
prednisone ............................ 63 prochlorperazine ...................77 ..........................................94 prednisone intensol...............63 prochlorperazine maleate......77 POLYTRIM ......................... 94 PREFERA-OB ................... 108 PROCORT............................77 POLY-TUSSIN AC ........... 100 PREFEST ............................. 86 PROCTOCORT....................77 poly-vitamin with iron........108 PREMARIN .........................86 PROCTOFOAM HC ............77 POMALYST ........................ 80 PREMIUM V10 ...................66 procto-med hc .......................77 PONSTEL ............................ 29 PREMPHASE ...................... 86 procto-pak.............................77 portia..................................... 92 PREMPRO ........................... 86 proctosol hc ..........................77 pot,sodium citrate-citric acid
prena1 true..........................108 proctozone-hc ....................... 77 ........................................105 prenatal ............................... 108 PROCYSBI.........................105
of this table.
124 QUADRACEL (PF) ............. 82 relcof c ................................ 100 PRODIGY NO CODING ..... 66 QUALAQUIN ...................... 11 RELENZA DISKHALER ......8 PRODRIN ............................ 22 QUARTETTE ...................... 92 RELION CONFIRM-MICRO
progesterone micronized ...... 86 quasense................................ 92 .......................................... 66 PROGLYCEM ..................... 67 quazepam .............................. 35 RELION PRIME TEST PROGRAF ........................... 17 QUDEXY XR....................... 20 STRIPS .............................66 PROLENSA ......................... 96 QUESTRAN......................... 46
RELISTOR ........................... 77 PROMACTA........................ 45
QUESTRAN LIGHT............ 46 RELPAX...............................22
promethazine ........................ 99 REMERON........................... 35
promethazine vc ................. 100 quetiapine ............................. 35 REMERON SOLTAB .......... 35 promethazine vc-codeine.... 100 QUILLICHEW ER ............... 35 remeven ................................ 50 promethazine-codeine ........ 100 QUILLIVANT XR ............... 35 RENAGEL ........................... 77 promethazine-dm................ 100
quinapril................................ 42 promethazine-phenylephrena-vite ..............................108 quinapril-hydrochlorothiazide
codeine ........................... 100 RENVELA ........................... 77 .......................................... 42 promethegan ......................... 99 repaglinide ............................72 quinidine gluconate .............. 37 PROMETRIUM ................... 86 quinidine sulfate ................... 37 repaglinide-metformin .......... 72 propafenone .......................... 37 quinine sulfate ...................... 11 REPATHA ............................ 46 propantheline ........................ 73 QUINTET AC ...................... 66 reprexain ............................... 27 propranolol ........................... 42 QUIT 2 ................................. 60 REQUIP ................................ 21 propranolol-hydrochlorothiazid
QUIT 4 ................................. 60 REQUIP XL .........................21 .......................................... 42 QVAR................................. 102
RESCRIPTOR ........................ 8 propylthiouracil .................... 63 reserpine ............................... 42 R
PROQUAD (PF) .................. 82 rabeprazole ........................... 79 RESPA-AR ......................... 100 PRO-RED AC (W/ RADIOGARDASE .............. 60 RESTASIS ............................ 96 DEXCHLORPHENIR) .. 100 RAGWITEK......................... 82
RESTORIL ........................... 35 PROSCAR.......................... 104
raloxifene .............................. 83 RETIN-A .............................. 53 PROTONIX.......................... 79
ramipril ................................. 42 RETIN-A MICRO ................53 PROTOPIC .......................... 50 RANEXA ............................. 47 RETIN-A MICRO PUMP ....53 protriptyline .......................... 35 ranitidine hcl ......................... 79 RETROVIR ............................ 8 PROVENTIL HFA............. 102 RAPAFLO .......................... 104 REVATIO........................... 103
PROVERA ........................... 86 RAPAMUNE........................ 17 REVEAL TEST STRIP ........ 66 PROVIGIL ........................... 35 RASUVO (PF) ..................... 83 REVIA ..................................29 PROZAC .............................. 35 RAVICTI .............................. 60 REVLIMID........................... 80
PROZAC WEEKLY ............ 35 RAYOS ................................ 63 REXULTI ............................. 35 prudoxin ............................... 50 RAZADYNE ........................ 24 REYATAZ ............................. 8 PSORCON ........................... 57 RAZADYNE ER .................. 24 RHEUMATREX ..................17 PULMICORT ..................... 102 rea lo 39 ................................ 50 ribasphere ............................. 80 PULMICORT FLEXHALER
rea lo 40 ................................ 50 ribasphere ribapak ................ 80 ........................................ 102 react ...................................... 92 ribavirin ................................ 80 pulmosal ............................. 102 REBETOL ............................ 80 RIDAURA ............................83 PULMOZYME .................. 102 REBIF................................... 80
rifabutin ................................ 12 PURIXAN ............................ 17 reclipsen (28) ........................ 92 RIFADIN .............................. 12 PYLERA .............................. 79 RECOMBIVAX HB (PF) .... 82 RIFAMATE .......................... 12 pyrazinamide ........................ 11 RECTIV................................ 77 rifampin ................................12 PYRIDIUM ........................ 106 REFUAH PLUS ................... 66 RIFATER .............................12 pyridostigmine bromide ....... 24 REGLAN .............................. 77 RIGHTEST GS550 TEST REGRANEX ........................ 50 STRIPS .............................66 Q
QNASL .............................. 102 RELAGARD ........................ 87 RILUTEK ............................. 60 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
125 SALVAX DUO PLUS ......... 49 SITAVIG ................................8 riluzole.................................. 60
SAMSCA ............................. 69 SIVEXTRO .......................... 12 rimantadine ............................. 8 SANCUSO ........................... 77 SKELAXIN .......................... 25 ringers ................................... 59 SANDIMMUNE .................. 17 SKLICE ................................ 58 RIOMET .............................. 72 SANDOSTATIN .................. 17 SMART SENSE TEST risacal-d .............................. 108 SANTYL .............................. 58 STRIPS ............................. 66 risedronate ...................... 60, 83 SAPHRIS ............................. 35 RISPERDAL ........................ 35 SMARTEST TEST ...............66 SARAFEM ........................... 35 sodium chloride ............60, 103 RISPERDAL M-TAB .......... 35 SAVAYSA ........................... 45 risperidone ............................ 35 sodium citrate-citric acid .... 105 SAVELLA ............................ 84 RITALIN .............................. 35 sodium fluoride .............61, 108 scalacort ................................ 57 sodium phenylbutyrate ......... 60 RITALIN LA........................ 35 rivastigmine .......................... 24 sodium polystyrene sulfonate
SCALACORT DK ............... 57 rivastigmine tartrate.............. 24 .......................................... 77 SEASONIQUE ..................... 92 rizatriptan ............................. 22 SODIUM POLYSTYRENE seb-prev ................................ 48 ROBAXIN............................ 25
SULFONATE ...................77 seconal sodium ..................... 35 ROBAXIN-750 .................... 25 SECTRAL ............................ 42 SOLARAZE .........................50 ROBINUL ............................ 73 SEEBRI NEOHALER........ 103 SOLODYN ........................... 14 ROBINUL FORTE .............. 73 selegiline hcl ......................... 21 SOLTAMOX ........................17 ROCALTROL ...................... 69 selenium sulfide.................... 48 SOLUS V2 TEST STRIPS ...66 ropinirole .............................. 21 SOMA...................................25
SELRX ................................. 48 rosadan ................................. 53 SELZENTRY ......................... 8 SOMAVERT ........................ 69 ROSANIL ............................ 53 SENSIPAR ........................... 69 SONATA .............................. 36 ROSULA .............................. 53 SEREVENT DISKUS ........ 103 SOOLANTRA ...................... 53 rosula cleansing cloths ......... 53 SORBITOL........................... 59
SERNIVO............................. 57
rosuvastatin........................... 46 SEROQUEL ......................... 35 SORBITOL-MANNITOL ....59 ROTARIX ............................ 82 SEROQUEL XR................... 35 SORIATANE ....................... 48 ROTATEQ VACCINE ........ 82 SEROSTIM .......................... 80 SORILUX ............................. 48 ROWASA ............................ 77 sertraline ............................... 36 sotalol ................................... 37 roweepra ............................... 20 setlakin.................................. 92 sotalol af ............................... 37 ROXICODONE ................... 27 sf 61 SOTYLIZE ...........................37 ROZEREM ........................... 35 sf 5000 plus .......................... 61 SOVALDI............................... 8
RUCONEST ....................... 103 sharobel ................................ 86 spinosad ................................ 58 rydex ................................... 100 SHOHL'S MODIFIED ....... 105 SPIRIVA RESPIMAT ........103 RYTARY ............................. 21 SIGNIFOR............................ 17 SPIRIVA WITH RYTHMOL .......................... 37 sildenafil ............................. 103 HANDIHALER .............. 103 RYTHMOL SR .................... 37 SILENOR ............................. 36 spironolactone.......................42
SILVADENE........................ 48 spironolacton-hydrochlorothiaz
S
SABRIL................................ 20
silver nitrate .......................... 50 .......................................... 42 SAFYRAL............................ 92
silver nitrate applicators ....... 50 SPORANOX...........................6
SAIZEN................................ 80
silver sulfadiazine ................. 48 SPORANOX PULSEPAK ..... 6 SAIZEN CLICK.EASY ....... 80 SIMBRINZA ........................ 97 sprintec (28) .......................... 92 salacyn .................................. 49 SIMPONI.............................. 84 SPRITAM .............................20 SALAGEN ..................... 60, 61 simvastatin ............................ 46 SPRIX ................................... 29 SALEX ................................. 49 SINEMET............................. 21
SPRYCEL............................. 17
salicylic acid ......................... 49 SINEMET CR ...................... 21 sps .........................................77 SALKERA ........................... 49 SINGULAIR ...................... 103 sronyx ...................................92 salsalate ................................ 29 sirolimus ............................... 17 ss 10-2 ...................................53 salvax.................................... 49
SIRTURO ............................. 12 ssd ......................................... 48 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
126 SUPREP BOWEL PREP KIT
TECFIDERA ........................80 .......................................... 78 TECHNIVIE ...........................8 SURE-TEST EASYPLUS TEGRETOL .........................20 MINI ................................. 66 TEGRETOL XR ................... 20 SURMONTIL....................... 36
TEKTURNA.........................43
SUSTIVA ............................... 8 TEKTURNA HCT................ 43 SUTENT............................... 17
TELCARE TEST STRIPS ...66 syeda ..................................... 92 telmisartan ............................ 43 SYLATRON......................... 80
telmisartan-amlodipine ......... 43 SYMAX DUOTAB .............. 73 telmisartan-hydrochlorothiazid
symax fastabs ....................... 74 .......................................... 43 symax-sl................................ 74 temazepam ............................ 36 TEMODAR .......................... 18 symax-sr ............................... 74 TEMOVATE ........................58 SYMBICORT..................... 103
temozolomide ....................... 18 SYMBYAX .......................... 36 tencon ................................... 27 SYMLINPEN ....................... 72 TENEX .................................43 SYNALAR ........................... 57 TENIVAC (PF) .................... 82 SYNALAR CREAM KIT .... 57 TENORETIC ........................43 SYNALAR OINTMENT KIT
TENORMIN .........................43 .......................................... 58 TERAZOL ............................ 87 SYNALAR TS ..................... 58 terazosin ................................ 43 SYNALGOS-DC .................. 27 terbinafine hcl .........................6 SYNAREL............................ 69 terbutaline ...........................103 SYNERA .............................. 54 terconazole ............................ 87 SYNJARDY ......................... 72 TERSI FOAM ......................48 SYNRIBO ............................ 17 TESSALON PERLES ........100 SYNTHROID ....................... 72 TEST N'GO TEST................ 66 SYPRINE ............................. 60 TESTIM ................................ 69 T
testosterone ..................... 69, 70 TABLOID ............................ 17 TESTOSTERONE ................ 70 TACLONEX ........................ 48 tacrolimus ....................... 17, 50 testosterone cypionate ..........69 testosterone enanthate ...........69 TAFINLAR .......................... 17 TAGRISSO .......................... 18 TESTRED............................. 70
TAKE ACTION ................... 92 TETANUS,DIPHTHERIA TALTZ ................................. 48 TOX PED(PF) .................. 82 TAMIFLU .............................. 8 TETANUS-DIPHTHERIA tamoxifen .............................. 18 TOXOIDS-TD .................. 82 tamsulosin........................... 104
tetrabenazine ......................... 24 TANZEUM .......................... 72 tetracycline ........................... 14 TAPAZOLE ......................... 63 TEXACORT .........................58 TARCEVA ........................... 18 THALOMID .........................18 TARGRETIN ....................... 18 THEO-24 ............................ 103 tarina fe 1/20 (28) ................. 92 theochron ............................103 TARKA ................................ 43 theophylline ........................103 TASIGNA ............................ 18 thermazene ............................ 48 TASMAR ............................. 21 THIOLA ...............................60 TAZORAC ........................... 53 thioridazine ...........................36 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
127 SSKI ..................................... 63 sss 10-5................................. 53 STALEVO............................ 21
STARLIX ............................. 72 stavudine................................. 8 STELARA ............................ 48 STIMATE ............................ 69 STIOLTO RESPIMAT ...... 103 STIVARGA.......................... 17
STRATTERA ....................... 36 STRENSIQ ........................... 69 stress formula ..................... 108 STRIANT ............................. 69 STRIBILD .............................. 8 STRIVERDI RESPIMAT .. 103 STROMECTOL ................... 12 strong iodine ....................... 107 SUBOXONE ........................ 29 SUBSYS ............................... 27 SUCRAID ............................ 78 sucralfate .............................. 79 SULAR ................................. 42 sulfacetamide sodium ..... 48, 98 sulfacetamide sodium (acne) 54 sulfacetamide sodium-sulfur 53 sulfacetamide sod-sulfur-urea
.......................................... 53 sulfacetamide-prednisolone.. 98
sulfacetamide-sulfur-cleansr23
.......................................... 53 sulfacleanse 8-4 .................... 53 sulfact na-sul-avobnz-otn-ocsa
.......................................... 53 sulfadiazine........................... 13 sulfamethoxazole-trimethoprim
.......................................... 13 SULFAMYLON .................. 54 sulfasalazine ......................... 78 sulfatrim ............................... 13 sulindac................................. 29 sumatriptan ........................... 22 sumatriptan succinate ..... 22, 23 SUMAVEL DOSEPRO ....... 23 SUMAXIN ........................... 53 SUMAXIN CP ..................... 53 SUMAXIN TS...................... 53 SUPRAX .............................. 10 TRAMADOL ....................... 30 trinessa (28) .......................... 92 thiothixene ............................ 36 tramadol-acetaminophen ...... 30 trinessa lo ..............................92 THYROLAR ........................ 72 trandolapril ........................... 43 TRI-NORINYL (28) ............. 92 tiagabine ............................... 20 trandolapril-verapamil .......... 43 TRINTELLIX .......................36 TIAZAC ............................... 43 tranexamic acid..................... 87 TRIPLE DYE ....................... 55 ticlopidine ............................. 45 TRANSDERM-SCOP .......... 78 tri-previfem (28) ................... 92 TIGAN ................................. 78 TRANXENE T-TAB ............ 36 tri-sprintec (28) ..................... 92 TIKOSYN ............................ 37 tranylcypromine.................... 36 TRIUMEQ .............................. 8 tilia fe.................................... 92 tri-vit with fluoride and iron
timolol maleate ............... 43, 94 TRAVATAN Z..................... 97 TIMOPTIC ........................... 94 ........................................ 108 travoprost (benzalkonium) ... 97 tri-vitamin with fluoride ..... 108 TIMOPTIC OCUDOSE (PF)
trazodone .............................. 36 trivora (28) ............................ 92 .......................................... 95 TRECATOR ......................... 12 TIMOPTIC-XE .................... 95 TRIZIVIR ............................... 8 TRESIBA FLEXTOUCH UTINDAMAX ........................ 12 TROKENDI XR ...................20 100 .................................... 68 tinidazole .............................. 12 tropicamide ...........................95 TRESIBA FLEXTOUCH UTIROSINT............................ 72
200 .................................... 68 trospium .............................. 104 tis-u-sol pentalyte ................. 59 TRUE METRIX GLUCOSE tretinoin ................................ 53 TIVICAY ............................... 8 TEST STRIP ..................... 66 tretinoin (chemotherapy) ...... 18 TIVORBEX.......................... 30
TRUETEST TEST STRIPS .66 tretinoin microspheres .......... 53 tizanidine .............................. 25 TRUETRACK TEST............67 TRETIN-X............................ 53 TOBI .................................... 12 TRULICITY .........................72 TRETIN-X CREAM KIT..... 53 TOBI PODHALER .............. 12 TRUSOPT ............................ 97 TREXALL ............................ 18 TOBRADEX ........................ 97 TRIACETIN ......................... 55 TRUVADA............................. 8
TOBRADEX ST .................. 97 triamcinolone acetonide . 58, 61 TUDORZA PRESSAIR .....103 tobramycin............................ 94
triamterene-hydrochlorothiazid
tusnel c ................................ 100 tobramycin in 0.225 % nacl.. 12 .......................................... 43 TUSNEL PEDIATRIC ....... 100 tobramycin-dexamethasone .. 97 trianex ................................... 58 tussigon ...............................100 TOBREX .............................. 94 triazolam ............................... 36 TUSSIONEX PENNKINETIC TODAY CONTRACEPTIVE TRIBENZOR........................ 43 ER ................................... 100 SPONGE .......................... 87 tricitrates ............................. 105 TWINRIX (PF) .....................82 TOFRANIL .......................... 36 TRICOR ............................... 46 TWYNSTA........................... 43
TOLAK ................................ 50 triderm .................................. 58 TYBOST................................. 8
tolazamide ............................ 72 tri-estarylla............................ 92 TYKERB .............................. 18 tolbutamide ........................... 72 trifluoperazine ...................... 36 TYLENOL-CODEINE #3 ....27 tolcapone .............................. 22 trifluridine............................. 94 TYLENOL-CODEINE #4 ....27 tolmetin ................................ 30 TRIGLIDE............................ 46 TYVASO ............................103 tolterodine........................... 104 trihexyphenidyl..................... 22
TYZEKA ................................8 TOPAMAX .......................... 20 tri-legest fe ............................ 92 TYZINE ................................ 61 TOPICORT .......................... 58 TRILEPTAL......................... 20
U
topiramate ............................. 20 tri-linyah ............................... 92 UCERIS ................................ 78 TOPIRAMATE .................... 20 TRILIPIX ............................. 46 ULESFIA .............................. 58 TOPROL XL ........................ 43 tri-lo-estarylla ....................... 92 ULORIC ............................... 83 torsemide .............................. 43 tri-lo-marzia .......................... 92 ULTIMA TEST STRIPS ......67 TOUJEO SOLOSTAR ......... 68 tri-lo-sprintec ........................ 92 ULTRACET ......................... 30 TOVIAZ ............................. 104 trilyte with flavor packets ..... 78 ULTRAM .............................30 TRACLEER ....................... 103 trimethobenzamide ............... 78 ULTRAM ER ....................... 30 TRADJENTA ....................... 72 trimethoprim ......................... 14 ULTRATRAK ......................67 tramadol................................ 30
trimipramine ......................... 36 ULTRATRAK ULTIMATE 67 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
128 valsartan-hydrochlorothiazide
vicodin es ..............................27 .......................................... 43 vicodin hp ............................. 27 VALTREX ............................. 9 VICTOZA............................. 72
VANCOCIN ......................... 14 VIDEX 2 GRAM PEDIATRIC
vancomycin .......................... 14 ............................................ 9 vandazole .............................. 87 VIDEX EC.............................. 9 VIEKIRA PAK ....................... 9 VANOS ................................ 58 vienva ................................... 93 VANOXIDE-HC .................. 53 VIGAMOX ........................... 94 VAQTA (PF) ........................ 82 VIIBRYD ............................. 36 VARIVAX (PF) ................... 82 VIMPAT ............................... 21 VARIZIG.............................. 82 VIOKACE ............................ 78 VARUBI ............................... 78
viorele (28) ........................... 93 VASCEPA ............................ 46 VIRACEPT............................. 9
VASERETIC ........................ 43 VIRAMUNE........................... 9
VASOTEC............................ 43 VIRAMUNE XR .................... 9 VCF CONTRACEPTIVE FILM ................................ 87 VIRASAL ............................. 49 VCF CONTRACEPTIVE GEL
VIREAD ................................. 9 VIROPTIC ............................ 94 .......................................... 87 virt-nate dha ........................ 108 VECAMYL .......................... 47 VECTICAL .......................... 48 virtrate-2 .............................106 velivet triphasic regimen (28)
virtrate-3 .............................106 .......................................... 93 virtrate-k .............................106 VELPHORO......................... 78
virtussin ac ..........................100 VELTASSA.......................... 78 virtussin dac ........................100 VELTIN................................ 53 VISTARIL ............................ 99 VENCLEXTA ...................... 18 VISTOGARD ....................... 15 VENCLEXTA STARTING vit b complex-folic acid ...... 108 PACK ............................... 18 VITAFOL ULTRA ............. 108 venlafaxine ........................... 36 vitamin d3 ........................... 108 VENTAVIS ........................ 103 vitamin k ...............................45 VENTOLIN HFA ............... 103 vitamins a,c,d and fluoride . 108 VERAMYST ...................... 103 VITEKTA ............................... 9 verapamil .............................. 43 VIVELLE-DOT .................... 86 VERDESO............................ 58 VIVLODEX ......................... 30 verdrocet ............................... 27 VOGELXO ........................... 70 VEREGEN ........................... 51 VOLTAREN.........................30
VERELAN ........................... 43 VOLTAREN-XR .................. 30 VERELAN PM..................... 43 voriconazole ........................... 6 veripred 20 ............................ 63 VOSPIRE ER .....................103 VERSACLOZ ...................... 36 VOTRIENT .......................... 18 VESICARE ........................ 104 VRAYLAR ........................... 36 vestura (28) ........................... 93 vyfemla (28) ......................... 93 VEXOL ................................ 98 VYTORIN ............................ 46 VFEND................................... 6
VYVANSE ........................... 36 VIBERZI .............................. 78 W
VIBRAMYCIN .................... 14 warfarin................................. 45
vicodin .................................. 27 water for irrigation, sterile .... 60 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
129 ULTRAVATE ...................... 58 ULTRAVATE X .................. 58 umecta .................................. 50 UMECTA PD ....................... 50 UNISTRIP1 TEST STRIP ... 67 unithroid ............................... 72 UPTRAVI ............................ 43 ur n-c .................................. 105 URAMAXIN ........................ 50 URAMAXIN GT ................. 50 uramit mb ........................... 105 urea ....................................... 50 urea nail stick ....................... 50 urea-hyaluronate sodium ...... 50 URECHOLINE .................. 105 ure-k ..................................... 50 URELLE............................. 105 uretron d-s .......................... 105 URIBEL ............................. 105 urimar-t ............................... 105 urin ds ................................. 105 UROCIT-K ......................... 106 urogesic-blue ...................... 106 uro-l .................................... 106 urolet mb ............................ 106 uro-mp ................................ 106 UROQID-ACID NO.2 ....... 106 UROXATRAL ................... 105 URSO 250 ............................ 78 URSO FORTE ..................... 78 ursodiol ................................. 78 uryl ..................................... 106 UTIBRON NEOHALER.... 103 utira-c ................................. 106 UTOPIC ............................... 51 V
VAGIFEM ............................ 86
vaginal contraceptive foam .. 87 valacyclovir ............................ 9 VALCHLOR ........................ 51 VALCYTE ............................. 9 valganciclovir ......................... 9 VALIUM .............................. 36 valproic acid ......................... 20 valproic acid (as sodium salt)
.......................................... 20 valsartan ............................... 43 WAVESENSE JAZZ ........... 67 WAVESENSE PRESTO ...... 67 WELCHOL .......................... 46 WELLBUTRIN SR .............. 36 WELLBUTRIN XL.............. 36 wera (28) .............................. 93 westhroid .............................. 72 WIDE-SEAL DIAPHRAGM
.......................................... 84 WP THYROID ..................... 72 wymzya fe ............................ 93 X
XALATAN........................... 97 XALKORI ............................ 18 XANAX ............................... 36 XANAX XR ......................... 36 XARELTO ........................... 45 XARTEMIS XR ................... 27 XELJANZ ............................ 84 XELJANZ XR ...................... 84 XELODA ............................. 18 XENAZINE.......................... 24
XIFAXAN ............................ 12 XIGDUO XR........................ 72 XODOL ................................ 27 XOLEGEL ........................... 55 XOPENEX ......................... 103 XOPENEX CONCENTRATE
........................................ 103 XOPENEX HFA ................ 103 XTAMPZA ER .................... 28 XTANDI............................... 18 xulane ................................... 87 XURIDEN ............................ 60 xylon 10 ................................ 28 XYREM ............................... 36 XYZAL ................................ 99 Y
YASMIN (28) ...................... 93 YAZ (28) .............................. 93 Z
zafirlukast ........................... 103 zaleplon ................................ 36 zamicet.................................. 28 ZANAFLEX ......................... 25 ZANTAC .............................. 79 zarah ..................................... 93 ZARONTIN.......................... 21 ZAVESCA............................ 70 ZEBETA............................... 43
zebutal .................................. 28 ZELAPAR ............................ 22 ZELBORAF ......................... 18 ZEMBRACE SYMTOUCH . 23 ZEMPLAR ........................... 70 zenatane ................................ 53 zenchent (28) ........................ 93 zenchent fe ............................ 93 zencia .................................... 53 ZENPEP ............................... 78 zenzedi .................................. 36 ZENZEDI ............................. 37 ZEPATIER ............................. 9 ZERIT..................................... 9
ZESTORETIC ...................... 44 ZESTRIL .............................. 44 ZETIA .................................. 47 ZETONNA ......................... 103 ZIAC..................................... 44
ZIAGEN ................................. 9 ZIANA.................................. 53 zidovudine .............................. 9 ZINBRYTA .......................... 81 ZIOPTAN (PF) ..................... 97 ziprasidone hcl...................... 37 ZIPSOR ................................ 30 ZIRGAN ............................... 94 ZITHRANOL ....................... 48 ZITHRANOL-RR ................ 48 ZITHROMAX ...................... 10 ZMAX .................................. 10 ZOCOR ................................ 47 ZODRYL AC ..................... 100 ZODRYL DAC .................. 100 ZODRYL DEC ................... 100
ZOFRAN (AS
HYDROCHLORIDE) ......78 ZOFRAN ODT ..................... 78 ZOHYDRO ER .................... 28 ZOLINZA .............................18 zolmitriptan...........................23
ZOLOFT ...............................37 zolpidem ............................... 37 ZOLPIMIST .........................37 ZOMACTON ....................... 80 ZOMIG ................................. 23 ZOMIG ZMT........................23 ZONALON ........................... 51 ZONATUSS ....................... 100 ZONEGRAN ........................ 21 zonisamide ............................ 21 ZONTIVITY.........................45
ZORBTIVE .......................... 80 ZORTRESS .......................... 18 ZORVOLEX.........................30
ZOSTAVAX (PF) ................82 zovia 1/35e (28) .................... 93 zovia 1/50e (28) .................... 93 ZOVIRAX ........................9, 55 Z-TUSS AC ........................ 100 ZUBSOLV ............................ 30 ZUPLENZ ............................ 78 ZUTRIPRO......................... 100
ZYCLARA ...........................81 ZYDELIG .............................18 ZYFLO ...............................103 ZYFLO CR .........................103 ZYKADIA ............................ 18 ZYLET ................................. 97 ZYLOPRIM .......................... 83 ZYMAXID ........................... 94 ZYPREXA ............................ 37 ZYPREXA ZYDIS ...............37 ZYTIGA ............................... 18 ZYVOX ................................12 You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
130

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