Drug Formulary

Transcription

Drug Formulary

2016 FORMULARY
(Commercial)
EFFECTIVE 01/01/16
Introduction
This formulary is a list of generic and brand medications covered by your prescription drug benefit. It is
designed to offer you and your doctor cost-effective choices for safe and clinically effective prescription
drugs.
Coverage for the drugs included on the 2016 PreferredOne Formulary is determined by your
benefit plan design. It is important to note that this formulary is not a complete list of
medications and not all listed drugs may be covered by your plan. Please refer to the benefit
documents provided by your employer or health plan for information on your specific benefit
coverage. You may also contact the PreferredOne Customer Service Department at 1-800997-1750 or visit PreferredOne.com for more information.
How is the formulary developed?
This formulary was developed based on the recommendations of an independent Pharmacy and
Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several
times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing
review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to
determine whether a drug should be included in the formulary.
Does the formulary change throughout the year?
The 2016 PreferredOne Formulary may change throughout the year as new drugs or clinical
information becomes available. Drugs may be added as they are introduced to the marketplace and
other drugs may change tier status as generics become available.
Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or
visit PreferredOne.com for the most current formulary information.
What are formulary tiers?
This formulary is made up of different cost levels or tiers. Your health plan or employer determines your
out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit
structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative
lower tier options with your doctor to help save money on your out of pocket costs.
Are generic drugs different than brand drugs?
Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and
effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost
significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if
a generic medication is right for you.
How do I fill my specialty medication?
Specialty medications are typically used to treat rare or chronic conditions and often require special
handling.
To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications,
your plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty
pharmacies provide personalized care and offer convenient delivery to your home or other approved
location.
Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit
PreferredOne.com for the most current formulary information.
Are there any restrictions on my coverage?
Some medications on the formulary may have additional requirements or limits on coverage. These
requirements or limits may include:
Prior Authorization — Your benefit plan may require that the medication you have been prescribed
receive prior authorization. This means that you will need to get approval from your plan before you fill
your prescription. If you don’t get approval, the medication may not be covered by your drug benefit.
Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your
benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by
your plan before coverage will apply.
Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your
medical condition before another drug for that condition will be covered. For example, if two drugs are
used to treat the same medical condition, you may be required to first try one drug before the second
drug is covered.
Your doctor can request a prior authorization, a quantity limit override, or a step therapy override
approval by submitting the appropriate request form to PreferredOne on your behalf. PreferredOne will
review the request and make a determination of coverage for the drug.
For more information about the 2016 PreferredOne Formulary:
Call the PreferredOne Customer Service Department at 1-800-997-1750
Or, visit PreferredOne.com
LEGEND
TIER
DESCRIPTION
1
Generics
2
Preferred Brands
3
Non-Preferred Brands
4
Specialty Generics
5
Specialty Preferred Brands
6
Specialty Non-Preferred
Brands
7
Non-Specialty Injectable
Generics
8
Non-Specialty Injectable
Preferred Brands
9
Non-Specialty Injectable Non
Preferred Brands
TYPE
QL
PA
ST
PAGE 4
DESCRIPTION
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
Prior Authorization
You (or your physician) are required to get prior authorization before
you fill your prescription for this drug. Without prior approval, we may
not cover this drug.
Step Therapy
In some cases, you may be required to first try certain drugs to treat
your medical condition before we will cover another drug for that
condition.
LAST UPDATED 10/2015
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
Analgesics
Nonsteroidal Anti-inflammatory Drugs
ANAPROX
3
ANAPROX DS
3
ANSAID
3
ARTHROTEC 50
3
ARTHROTEC 75
3
aspirin
1
CALDOLOR (400 MG/4 ML VIAL, 800 MG/8 ML VIAL)
9
QL
960 / 30 days
CAMBIA
3
QL
27 / 90 days
CATAFLAM
3
QL
CELEBREX 100 MG CAPSULE
90 / 30 days
2
ST
QL
120 / 30 days
2
ST
QL
60 / 30 days
2
ST
QL
150 / 30 days
2
ST
QL
celecoxib 100 mg capsule
90 / 30 days
1
ST
QL
120 / 30 days
1
ST
QL
60 / 30 days
1
ST
QL
150 / 30 days
1
ST
choline salicylate/magnesium salicylate
PAGE 5
1
PRODUCT DESCRIPTION
TIER
COMFORT PAC-MELOXICAM
3
COMFORT PAC-NAPROXEN
3
DAYPRO
3
DERMACINRX LEXITRAL
3
DERMASILKRX DICLOPAK
3
diclofenac potassium
1
diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg
tablet dr, 100 mg tab er 24h)
1
diclofenac sodium/misoprostol (50 tab ir dr, 75 tab ir dr)
1
diflunisal
1
DUEXIS
3
DURLAZA
3
DYLOJECT
9
EC-NAPROSYN (EC-NAPROSYN EC 375 MG TABLET,
NAPROSYN EC 500 MG TABLET)
3
etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h,
400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er
24h)
1
FELDENE (10 MG CAPSULE, 20 MG CAPSULE)
3
fenoprofen calcium (400 mg capsule, 600 mg tablet)
1
FLECTOR
3
flurbiprofen (50 mg tablet, 100 mg tablet)
1
hydrochlorothiazide 25 mg tablet
1
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet,
800 mg tablet)
1
ibuprofen/oxycodone hcl
1
INDOCIN (25 MG/5 ML SUSPENSION, 50 MG
SUPPOSITORY)
3
indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule
er)
1
indomethacin sodium
7
ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel)
1
PAGE 6
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
ketorolac tromethamine (15 mg/ml vial, 15 mg/ml cartridge,
30mg/ml(1) vial, 30 mg/ml syringe, 30 mg/ml cartridge, 30
mg/ml vial, 60 mg/2 ml vial)
7
ketorolac tromethamine 10 mg tablet
1
LEVACET
3
meclofenamate sodium (50 mg capsule, 100 mg capsule)
1
mefenamic acid
1
meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet)
1
MOBIC (7.5 MG TABLET, 7.5 MG/5 ML SUSPENSION, 15 MG
TABLET)
3
nabumetone (500 mg tablet, 750 mg tablet)
1
NALFON
3
NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET, CR
750 MG TABLET)
3
NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375
MG TABLET, 500 MG TABLET)
3
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet,
375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)
1
naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg
tbmp 24hr, 550 mg tablet)
1
oxaprozin
1
piroxicam (10 mg capsule, 20 mg capsule)
1
PONSTEL
3
salsalate (500 mg tablet, 750 mg tablet)
1
sulindac (150 mg tablet, 200 mg tablet)
1
TIVORBEX (20 MG CAPSULE, 40 MG CAPSULE)
3
tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mg tablet)
1
VIMOVO (DR 375-20 MG TABLET, DR 500-20 MG TABLET)
3
VOLTAREN-XR
3
ZIPSOR
3
ZORVOLEX (18 MG CAPSULE, 35 MG CAPSULE)
3
QL
20 / 30 days
QL
60 / 30 days
QL
120 / 30 days
QL
90 / 30 days
ST
PAGE 7
PRODUCT DESCRIPTION
TIER
Opioid Analgesics, Long-acting
ACTIQ (200 MCG LOZENGE, 400 MCG LOZENGE, 600 MCG
LOZENGE, 800 MCG LOZENGE, 1,200 MCG LOZENGE,
1,600 MCG LOZENGE)
3
QL
120 / 30 days
AVINZA (30 MG CAPSULE, 45 MG CAPSULE, 60 MG
CAPSULE, 75 MG CAPSULE, 90 MG CAPSULE, 120 MG
CAPSULE)
3
QL
30 / 30 days
BUTRANS (5 PATCH, 7.5 PATCH, 10 PATCH, 15 PATCH, 20
PATCH)
3
QL
4 / 28 days
CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG
CAPSULE)
3
DISKETS
1
DOLOPHINE HCL (5 MG TABLET, 10 MG TABLET)
3
DURAGESIC (12 PATCH, 25 PATCH, 50 PATCH, 75 PATCH,
100 PATCH)
3
QL
10 / 30 days
EMBEDA (ER 20-0.8 MG CAPSULE, ER 30-1.2 MG
CAPSULE, ER 50-2 MG CAPSULE, ER 60-2.4 MG CAPSULE,
ER 80-3.2 MG CAPSULE, ER 100-4 MG CAPSULE)
3
QL
60 / 30 days
EXALGO (ER 12 MG TABLET, ER 16 MG TABLET, ER 32 MG
TABLET)
3
QL
60 / 30 days
EXALGO ER 8 MG TABLET
3
QL
180 / 30 days
fentanyl (12 mcg/hr patch td72, 25mcg/hr patch td72,
37.5mcg/hr patch td72, 50mcg/hr patch td72, 62.5mcg/hr patch
td72, 75mcg/hr patch td72, 87.5mcg/hr patch td72, 100 mcg/hr
patch td72)
1
QL
10 / 30 days
fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600
mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd,
1600 mcg lozenge hd)
1
QL
120 / 30 days
fentanyl citrate/pf (50 mcg/ml ampul, 50 mcg/ml vial,
100mcg/2ml syringe)
7
FENTORA (100 MCG TABLET, 200 MCG TABLET, 400 MCG
TABLET, 600 MCG TABLET, 800 MCG TABLET)
3
QL
120 / 30 days
hydromorphone hcl (12 mg tab er 24h, 16 mg tab er 24h, 32 mg
tab er 24h)
1
QL
60 / 30 days
hydromorphone hcl 8 mg tab er 24h
1
QL
180 / 30 days
HYSINGLA ER (ER 20 MG TABLET, ER 30 MG TABLET, ER
40 MG TABLET, ER 60 MG TABLET, ER 80 MG TABLET, ER
100 MG TABLET, ER 120 MG TABLET)
3
PAGE 8
PRODUCT DESCRIPTION
TIER
KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30
MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE,
ER 60 MG CAPSULE, ER 70 MG CAPSULE, ER 80 MG
CAPSULE, ER 100 MG CAPSULE, ER 130 MG CAPSULE, ER
150 MG CAPSULE, ER 200 MG CAPSULE)
3
LAZANDA (100 MCG SPRAY, 400 MCG SPRAY)
3
levorphanol tartrate
1
methadone hcl (5 mg/5 ml solution, 5 mg tablet, 10 mg/5 ml
solution, 10 mg/ml oral conc, 10 mg tablet, 40 mg tablet sol)
1
methadone hcl 10 mg/ml vial
9
METHADOSE
3
morphine sulfate (10 mg cap er pel, 20 mg cap er pel, 50 mg
cap er pel, 80 mg cap er pel, 100 mg cap er pel)
1
morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet
er, 100 mg tablet er, 200 mg tablet er)
1
morphine sulfate (30 mg cpmp 24hr, 30 mg cap er pel, 45 mg
cpmp 24hr, 60 mg cpmp 24hr, 60 mg cap er pel, 75 mg cpmp
24hr, 90 mg cpmp 24hr, 120 mg cpmp 24hr)
1
MS CONTIN (15 MG TABLET, CR 30 MG TABLET, 60 MG
TABLET, 100 MG TABLET, 200 MG TABLET)
3
NUCYNTA ER (ER 50 MG TABLET, ER 100 MG TABLET, ER
150 MG TABLET, ER 200 MG TABLET, ER 250 MG TABLET)
QL
60 / 30 days
QL
60 / 30 days
QL
30 / 30 days
3
QL
60 / 30 days
ONSOLIS (200 MCG FILM, 400 MCG FILM, 600 MCG FILM,
800 MCG FILM, 1,200 MCG FILM)
6
PA
OPANA ER (ER 5 MG TABLET, ER 7.5 MG TABLET, ER 10
MG TABLET, ER 15 MG TABLET, ER 20 MG TABLET, ER 30
MG TABLET, ER 40 MG TABLET)
3
oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h, 40 mg tab
er 12h, 80 mg tab er 12h)
1
QL
120 / 30 days
OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG
TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80
MG TABLET)
2
QL
120 / 30 days
oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg
tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er
12h, 40 mg tab er 12h)
1
SUBLIMAZE
9
SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG
SPRAY, 600 MCG SPRAY, 800 MCG SPRAY, 1,200 MCG
SPRAY, 1,600 MCG SPRAY)
3
PAGE 9
PRODUCT DESCRIPTION
TIER
tramadol hcl (100 mg cpbp 25-75, 100 mg tab er 24h, 150 mg
cpbp 25-75, 200 mg tab er 24h, 200 mg cpbp 25-75, 300 mg
tab er 24h, 300 mg cpbp 17-83)
1
tramadol hcl (100 mg tbmp 24hr, 200 mg tbmp 24hr, 300 mg
tbmp 24hr)
1
ULTRAM ER (ER 100 MG TABLET, ER 200 MG TABLET, ER
300 MG TABLET)
3
XARTEMIS XR
3
ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE,
CAPSULE, ER 50 MG CAPSULE)
3
QL
30 / 30 days
QL
15 / 90 days
QL
120 / 30 days
Opioid Analgesics, Short-acting
ABSTRAL (100 MCG TAB, 200 MCG TAB, 300 MCG TAB, 400
MCG TAB, 600 MCG TAB, 800 MCG TAB)
3
acetaminophen with codeine phosphate (120-12mg/5 solution,
300mg/12.5 solution, 300mg-30mg tablet, 300mg-60mg tablet,
300mg-15mg tablet)
1
ALFENTA
9
alfentanil hcl
7
ASTRAMORPH-PF (5 ML VIAL, 10 ML VIAL)
7
BUPRENEX
9
buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe)
7
butalbit/acetamin/caff/codeine 50-300-30 capsule
1
butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial)
7
butorphanol tartrate 10 mg/ml spray
1
CAPITAL W-CODEINE
3
codeine phosphate/carisoprodol/aspirin
1
codeine sulfate (15 mg tablet, 30 mg tablet, 30 mg/5 ml
solution, 60 mg tablet)
1
DEMEROL (25 MG/ML SYRINGE, 50 MG/ML AMPUL, 50
MG/ML VIAL, 50 MG/ML SYRINGE, 75 MG/1.5 ML AMPUL, 75
MG/ML SYRINGE, 100 MG/ML SYRINGE, 100 MG/ML
AMPUL, 100 MG/ML VIAL)
9
DEMEROL (50 MG TABLET, 100 MG TABLET)
3
DEPODUR (10 MG/ML VIAL, 15 MG/1.5 ML VIAL)
9
dhcodeine bt/acetaminophn/caff 16-356-30 capsule
2
PAGE 10
PRODUCT DESCRIPTION
TIER
dihydrocodeine bitartrate/acetaminophen/caffeine (16-320.5mg
capsule, 32-713-60 tablet)
1
dihydrocodeine bitartrate/aspirin/caffeine
3
DILAUDID (1 MG/ML AMPUL, 2 MG/ML AMPUL, 4 MG/ML
AMPUL)
9
DILAUDID (1 MG/ML LIQUID, 2 MG TABLET, 4 MG TABLET, 8
MG TABLET)
3
DILAUDID-HP (10 MG/ML AMPUL, 10 MG/ML VIAL, 250 MG
VIAL)
9
DURAMORPH (5 ML AMPUL, 10 ML AMPUL)
7
fentanyl citrate in 0.9 % sodium chloride/pf
7
FIORICET-COD 50-300-40-30 CAP
3
HYCET
3
hydrocodone bitartrate/acetaminophen (2.5-325mg tablet, 2.5167/5 solution, 2.5-108/5 solution, 2.5-500 mg tablet, 5mg300mg tablet, 5 mg-500mg capsule, 5-217mg/10 solution, 5
mg-325mg tablet, 5-163/7.5 solution, 5 mg-500mg tablet, 5334mg/10 solution, 7.5-750mg tablet, 7.5-325mg tablet, 7.5300mg tablet, 7.5-500mg tablet, 7.5-500/15 solution, 7.5-325/15
solution, 7.5-650 mg tablet, 10-660mg tablet, 10-325/15
solution, 10mg-650mg tablet, 10mg-325mg tablet, 10mg-300mg
tablet, 10-300/15 solution, 10-750mg tablet, 10mg-500mg
tablet)
1
hydrocodone/ibuprofen (2.5-200mg tablet, 5mg-200mg tablet,
7.5-200 mg tablet, 10mg-200mg tablet)
1
hydromorphone hcl (0.5mg/.5ml syringe, 1 mg/ml syringe, 2
mg/ml syringe, 2 mg/ml vial, 4 mg/ml syringe)
7
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect,
4 mg tablet, 8 mg tablet)
1
hydromorphone hcl/pf (1 mg/ml ampul, 2 mg/ml ampul, 4 mg/ml
ampul, 10 mg/ml ampul, 10 mg/ml vial)
7
IBUDONE
3
INFUMORPH (200 ML AMPUL, 500 ML AMPUL)
7
J-MAX DHC
3
LORCET 10-650
3
LORCET PLUS
3
LORTAB (7.5-500 MG/15 ML ELIXIR, 7.5-500 TABLET, 10-500
TABLET)
3
MAGNACET (5 MG TABLET, 7.5 MG TABLET, 10 MG
TABLET)
3
PAGE 11
PRODUCT DESCRIPTION
TIER
MAXIDONE
3
meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg
tablet)
1
meperidine hcl 10 mg/ml cartridge
7
meperidine hcl/pf (25 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial)
7
morphine sulfate (10 mg/5 ml solution, 15 mg tablet, 20 mg/5 ml
solution, 30 mg tablet, 100 mg/5ml solution)
1
morphine sulfate (2 mg/ml cartridge, 2 mg/ml syringe, 4 mg/ml
vial, 4 mg/ml syringe, 4 mg/ml cartridge, 5 mg/ml vial, 5 mg/ml
syringe, 8 mg/ml vial, 8 mg/ml cartridge, 8 mg/ml syringe, 10
mg/ml vial, 10 mg/ml syringe, 10mg/0.7ml pen injctr, 10 mg/ml
cartridge, 15 mg/ml cartridge, 15 mg/ml vial, 25 mg/ml vial, 30
mg/30ml pca syring, 50 mg/ml vial, 100 mg/4ml vial port,
250mg/10ml vial port)
7
morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 20 mg
supp.rect, 30 mg supp.rect)
2
morphine sulfate/pf (0.5 mg/ml vial, 0.5 mg/ml ampul, 1 mg/ml
ampul, 1 mg/ml vial, 30 mg/30ml pca vial, 150mg/30ml pca vial)
7
nalbuphine hcl (10 mg/ml vial, 10 mg/ml ampul, 20 mg/ml vial,
20 mg/ml ampul)
7
NORCO (5-325 TABLET, 7.5-325 TABLET, 10-325 TABLET)
3
NUCYNTA (50 MG TABLET, 75 MG TABLET, 100 MG
TABLET)
3
OPANA (5 MG TABLET, 10 MG TABLET)
3
OPANA 1 MG/ML INJ AMPULE
9
OXAYDO (5 MG TABLET, 7.5 MG TABLET)
3
OXECTA (5 MG TABLET, 7.5 MG TABLET)
3
oxycodone hcl (5 mg capsule, 5 mg/5 ml solution, 5 mg tablet,
10 mg tablet, 15 mg tablet, 20 mg/ml oral conc, 20 mg tablet, 30
mg tablet)
1
oxycodone hcl/acetaminophen (2.5-325mg tablet, 5mg-300mg
tablet, 5 mg-325mg tablet, 5 mg-500mg capsule, 7.5-300mg
tablet, 7.5-325mg tablet, 7.5-500mg tablet, 10mg-650mg tablet,
10mg-325mg tablet, 10mg-500mg tablet, 10mg-300mg tablet)
1
oxycodone hcl/aspirin
1
oxymorphone hcl (5 mg tablet, 10 mg tablet)
1
pentazocine hcl/acetaminophen
1
pentazocine hcl/naloxone hcl
1
PAGE 12
QL
180 / 30 days
PRODUCT DESCRIPTION
TIER
PERCOCET (2.5-325 MG TABLET, 5-325 MG TABLET, 7.5500 MG TABLET, 7.5-325 MG TABLET, 10-650 MG TABLET,
10-325 MG TABLET)
3
PERCODAN
3
REPREXAIN (2.5-200 MG TABLET, 5-200 MG TABLET)
3
ROXICET
3
ROXICODONE (5 MG TABLET, 15 MG TABLET, 30 MG
TABLET)
3
SUFENTA (50 MCG/ML AMPUL, 100 MCG/2 ML AMPUL, 250
MCG/5 ML AMPULE)
9
sufentanil citrate (50 mcg/ml vial, 50 mcg/ml ampul)
7
SYNALGOS-DC
3
TALWIN (30 MG/ML VIAL, 30 MG/ML AMPUL)
9
tramadol hcl 50 mg tablet
1
QL
240 / 30 days
tramadol hcl/acetaminophen
1
QL
240 / 30 days
TREZIX
3
TYLENOL-CODEINE NO.3
3
3
ULTIVA (1 MG VIAL, 2 MG VIAL, 5 MG VIAL)
9
ULTRACET
3
QL
240 / 30 days
ULTRAM
3
QL
240 / 30 days
VICOPROFEN
3
VITUZ
3
XODOL 10-300
3
XODOL 5-300
3
XODOL 7.5-300
3
ZAMICET
3
ZOLVIT
3
ZYDONE (5-400 MG TABLET, 7.5-400 MG TABLET, 10-400
MG TABLET)
3
PAGE 13
PRODUCT DESCRIPTION
TIER
Anesthetics
Local Anesthetics
ADAZIN
3
ADVANCED DNA MEDICATED COLLECT (CLLCT KT III,
COLLCT KT II, COLLECT KIT)
3
ALCAINE
3
AMIDATE (2 MG/ML ABBOJECT, 2 MG/ML AMPUL, 20 MG/10
ML VIAL, 40 MG/20 ML VIAL)
9
ANACAINE
3
ARTICADENT DENTAL (4%-1:200,000, 4%-1:100,000)
9
BREVITAL SODIUM (2.5 GM VIAL, 200 MG VIAL, 500 MG
VIAL)
9
BUCALSEP (SOLUTION, SPRAY)
3
bupivacaine hcl (2.5 mg/ml vial, 5 mg/ml vial)
7
bupivacaine hcl/dextrose-water/pf
7
bupivacaine hcl/epinephrine (0.25-.0005 vial, 0.5-1:200k vial)
7
bupivacaine hcl/epinephrine bitartrate
7
bupivacaine hcl/epinephrine/pf (0.25-.0005 vial, 0.5-1:200k vial,
0.75-.0005 vial)
7
bupivacaine hcl/pf (2.5 mg/ml vial, 2.5 mg/ml ampul, 5 mg/ml
vial, 5 mg/ml ampul, 7.5 mg/ml vial, 7.5 mg/ml ampul)
7
CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL)
9
CETACAINE
3
CETACAINE ANESTHETIC
3
chloroprocaine hcl/pf (20 mg/ml vial, 30 mg/ml vial)
7
CITANEST FORTE DENTAL
9
CITANEST PLAIN DENTAL
9
cocaine hcl
1
DIPRIVAN (100 MG/10 ML VIAL, 200 MG/20 ML VIAL, 500
MG/50 ML VIAL, 1,000 MG/100 ML VIAL)
9
EMLA
3
enflurane
1
ethyl chloride
3
etomidate
7
PAGE 14
PRODUCT DESCRIPTION
TIER
EXPAREL
9
FORANE
3
isoflurane
1
KETALAR (200 MG/20 ML VIAL, 500 MG/5 ML VIAL, 500
MG/10 ML VIAL)
9
ketamine hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial)
7
lidocaine (5%(700mg) adh. patch, 5 % oint. (g))
1
lidocaine hcl (2 % jel/pf app, 2 % solution, 2 % jel (ml), 3 %
cream (g), 3 % lotion, 4 % solution, 40 mg/ml solution)
1
lidocaine hcl (5 mg/ml vial, 10 mg/ml vial, 20 mg/ml vial)
7
lidocaine hcl/dextrose 5%-water/pf (4 mg/ml iv soln, 8 mg/ml iv
soln)
7
lidocaine hcl/dextrose 7.5%-water/pf
1
lidocaine hcl/epinephrine (0.5-1:200k vial, 1%-1:100k vial, 2 %1:100k vial)
7
lidocaine hcl/epinephrine bitartrate (2%-1:50000 cartridge, 2 %1:100k cartridge)
7
lidocaine hcl/epinephrine/pf (1.5-1:200k vial, 1.5-1:200k ampul,
2%-1:200k vial)
7
lidocaine hcl/glycerin
1
lidocaine hcl/pf (5 mg/ml vial, 10 mg/ml vial, 10 mg/ml ampul,
15 mg/ml ampul, 20 mg/ml ampul luer, 20 mg/ml ampul, 20
mg/ml vial, 40 mg/ml ampul)
7
lidocaine/menthol
1
lidocaine/prilocaine
1
lidocaine/tetracaine
1
LIDODERM
3
LIDOPIN
3
LIDORX
3
LIDOVEX
3
LIVIXIL PAK
3
LP LITE PAK
3
MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL)
9
MARCAINE SPINAL
9
MARCAINE WITH EPINEPHRINE
9
PAGE 15
PRODUCT DESCRIPTION
TIER
MARCAINE-EPINEPHRINE (0.25%-EPI 0.0005 VIAL, 0.5%EPI 0.0005 VIAL)
9
mepivacaine hcl (10 mg/ml vial, 20 mg/ml vial)
7
mepivacaine hcl/pf (10 mg/ml vial, 15 mg/ml vial, 20 mg/ml vial)
7
NAROPIN (0.2% 20 MG/10 ML VIAL, 0.2% 400 MG/200 ML
BAG, 0.2% 40 MG/20 ML VIAL, 0.2% 200 MG/100 ML BAG,
0.2% 20 MG/10 ML AMP, 0.2% 40 MG/20 ML AMP, 0.2% 400
MG/200 ML BTL, 0.5% 150 MG/30 ML VIAL, 0.5% 100 MG/20
ML AMP, 0.5% 100 MG/20 ML VIAL, 0.75% 150 MG/20 ML
AMP, 0.75% 150 MG/20 ML VL, 1% 200 MG/20 ML AMPULE,
1% 200 MG/20 ML VIAL, 1% 100 MG/10 ML VIAL, 1% 100
MG/10 ML AMPULE, 2 MG/ML INFUSION BTL, 5 MG/ML
INFUSION BTL, 200 MG/100 ML INF BTL)
9
NESACAINE (1% VIAL, 2% VIAL)
9
NESACAINE-MPF (2% VIAL, 3% VIAL)
9
PAIN EASE
3
PAIN RELIEF
3
PLIAGLIS
3
PONTOCAINE (1% AMPUL, 20 MG AMPUL)
9
PONTOCAINE 2% SOLUTION
3
PRE-ATTACHED LTA KIT
3
proparacaine hcl
1
propofol
7
PROPOVEN (200 MG/20 ML AMPUL, 500 MG/50 ML VIAL,
1,000 MG/100 ML VIAL)
7
REGENECARE
3
ropivacaine hcl/pf (2 mg/ml vial, 5 mg/ml vial, 7.5 mg/ml vial, 10
mg/ml vial)
7
SCAR
3
SENSORCAINE-MPF
7
sevoflurane
1
SILVERA
3
SPRAY AND STRETCH
3
SUPRANE
3
SYNERA
3
SYNVEXIA TC
3
PAGE 16
PRODUCT DESCRIPTION
TIER
tetracaine hcl/pf 10 mg/ml ampul
7
ULTANE
3
VELMA
3
VEXA
3
XYLOCAINE (0.5% VIAL, 1% VIAL, 2% VIAL)
9
XYLOCAINE 2%-EPI 1:50,000
7
XYLOCAINE 4% SOLUTION
3
XYLOCAINE IV
9
XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 1%EPI 1:100,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000)
9
XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1% VIAL, 1.5%
AMPUL, 2% VIAL, 2% AMPUL, 4% AMPUL)
9
XYLOCAINE-MPF WITH EPINEPHRINE (XYLOCAIN 1.5-EPI
1:200,000-MPF, XYLOCAINE-MPF 1%-EPI 1:200,000)
9
ZINGO
9
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium
1
ANTABUSE (250 MG TABLET, 500 MG TABLET)
3
CAMPRAL
3
disulfiram (250 mg tablet, 500 mg tablet)
1
EVZIO
8
naltrexone hcl
1
VIVITROL
9
Opioid Antagonists
BUNAVAIL (2.1-0.3 MG FILM, 4.2-0.7 MG FILM, 6.3-1 MG
FILM)
3
buprenorphine hcl (2 mg tab subl, 8 mg tab subl)
1
buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab
subl, /naloxone 8 mg-2 mg tab subl)
1
naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml syringe, 1 mg/ml
syringe)
7
SUBOXONE (2 MG-0.5 MG FILM, 4 MG-1 MG FILM)
2
PAGE 17
QL
60 / 30 days
QL
90 / 30 days
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
SUBOXONE (8 MG-2 MG FILM, 12 MG-3 MG FILM)
2
QL
60 / 30 days
ZUBSOLV (1.4-0.36 MG TABLET, 8.6-2.1 MG TABLET)
3
QL
60 / 30 days
ZUBSOLV (2.9-0.71 MG TABLET, 5.7-1.4 MG TABLET, 11.42.9 MG TABLET)
3
QL
90 / 30 days
Smoking Cessation Agents
bupropion hcl 150 mg tablet er
1
CHANTIX (1 MG CONT MONTH BOX, 1 MG TABLET)
3
QL
90 / 30 days
CHANTIX 0.5 MG TABLET
3
QL
60 / 30 days
CHANTIX STARTING MONTH BOX
3
QL
120 / 30 days
NICOTROL
3
NICOTROL NS
3
ZYBAN
3
ST
Anti-inflammatory Agents
Glucocorticoids
ALA-CORT
3
ALA-SCALP
3
alclometasone dipropionate (0.05 % oint. (g), 0.05 % cream (g))
1
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))
1
ANUSOL-HC
3
betamethasone dipropionate (0.05 % lotion, 0.05 % gel (gram),
0.05 % cream (g), 0.05 % oint. (g))
1
betamethasone dipropionate/propylene glycol (0.05 % cream
(g), 0.05 % oint. (g), 0.05 % lotion)
1
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 %
oint. (g), 0.12 % foam)
1
CAPEX SHAMPOO
2
CARMOL HC
3
clobetasol propionate (0.05 % solution, 0.05 % lotion, 0.05 %
shampoo, 0.05 % spray, 0.05 % cream (g), 0.05 % foam, 0.05
% oint. (g), 0.05 % gel (gram))
1
clobetasol propionate/emollient base (0.05 % foam, 0.05 %
cream (g))
1
CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION)
3
PAGE 18
PRODUCT DESCRIPTION
TIER
clocortolone pivalate
1
CLODERM (CREAM, CREAM PUMP)
3
CORDRAN (4 CM TAPE LARGE, 4 CM TAPE SMALL)
3
CORDRAN (CREAM, LOTION)
3
cortisone acetate
1
CORTISPORIN CREAM
2
CORTISPORIN EAR SOLUTION
3
CUTIVATE (CREAM, LOTION)
3
DELTASONE
3
DEPO-MEDROL (20 MG/ML VIAL, 40 MG/ML VIAL, 80 MG/ML
VIAL)
9
DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL)
3
DESONATE
3
desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g))
1
DESOWEN (CREAM, LOTION)
3
desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 %
oint. (g), 0.25 % oint. (g), 0.25 % cream (g))
1
dexamethasone sod phosphate (4 mg/ml vial, 10 mg/ml vial)
7
dexamethasone sodium phosphate/pf
7
diflorasone diacetate (0.05 % oint. (g), 0.05 % cream (g))
1
DIPROLENE (LOTION, OINTMENT)
3
DIPROLENE AF
3
FLO-PRED
3
fludrocortisone acetate
1
fluocinolone acetonide (0.01 % oil, 0.01 % solution, 0.025 %
oint. (g), 0.025 % cream (g))
1
fluocinolone acetonide/shower cap
1
fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream
(g), 0.05 % oint. (g), 0.1 % cream (g))
1
fluocinonide/emollient base
1
fluticasone propionate (0.005 % oint. (g), 0.05 % lotion, 0.05 %
cream (g))
1
halobetasol propionate (0.05 % oint. (g), 0.05 % cream (g))
1
PAGE 19
QL
6 / 90 days
PRODUCT DESCRIPTION
TIER
HALOG (CREAM, OINTMENT)
3
hydrocortisone (1 % cream (g), 2 % lotion, 2.5 % lotion, 2.5 %
cream (g), 2.5 % oint. (g), 2.5 % cream/appl)
1
hydrocortisone butyrate 0.1 % cream (g)
1
hydrocortisone butyrate/emollient base
1
KENALOG
2
LOCOID LIPOCREAM
3
LUXIQ
3
MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16
3
methylprednisolone (4 mg tab ds pk, 8 mg tablet, 16 mg tablet,
32 mg tablet)
1
methylprednisolone sodium succinate (40 mg vial, 40 mg/ml
vial, 125 mg/2ml vial, 125 mg vial, 1000 mg vial)
7
MILLIPRED
3
neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops
susp, solution)
1
nystatin/triamcinolone acetonide (cream (g), oint. (g))
1
OLUX
3
OLUX-E
3
ORAPRED
3
ORAPRED ODT (ODT 10 MG TABLET, ODT 15 MG TABLET,
ODT 30 MG TABLET)
3
PEDIADERM HC
3
PEDIAPRED
3
prednisolone (5 mg (48) tab ds pk, 5 mg (21) tab ds pk, 15 mg/5
ml solution)
1
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab
rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 25 mg/5 ml
solution, 30 mg tab rapdis)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg/5 ml solution, 5
mg/ml oral conc, 10 mg tab ds pk, 20 mg tablet, 50 mg tablet)
1
PRELONE
3
PROCTOCORT 1% CREAM
3
RAYOS (DR 1 MG TABLET, DR 2 MG TABLET, DR 5 MG
TABLET)
3
PAGE 20
PRODUCT DESCRIPTION
TIER
SOLU-MEDROL (1 GM VIAL, 40 MG VIAL, 125 MG VIAL, 500
MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL)
9
SYNALAR (0.01% SOLUTION, 0.025% CREAM KIT, 0.025%
OINTMENT KIT)
3
SYNALAR (CREAM, OINTMENT)
1
SYNALAR TS
3
TEMOVATE (CREAM, OINTMENT)
3
TEMOVATE EMOLLIENT
3
TEXACORT
3
TOPICORT (0.05% GEL, 0.05% OINTMENT, 0.05% CREAM,
0.25% CREAM, 0.25% OINTMENT)
3
triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g),
0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g),
0.1 % paste (g), 0.147mg/g aerosol, 0.5 % oint. (g), 0.5 %
cream (g))
1
ULTRAVATE (CREAM, OINTMENT)
3
VANOS
3
VERDESO
3
VERIPRED 20
3
Nonsteroidal Anti-inflammatory Drugs
SPRIX
3
QL
15 / 90 days
Antibacterials
Aminoglycosides
amikacin sulfate (500 mg/2ml vial, 1000mg/4ml vial)
7
BETHKIS
3
GARAMYCIN 3 MG/GM EYE OINTMENT
1
GARAMYCIN 3 MG/ML EYE DROPS
3
gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint.
(g), 0.3 % drops)
1
gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial)
7
gentamicin sulfate in sodium chloride, iso-osmotic (gentamic60
mg/50ml piggyback, gentamic80 mg/50ml piggyback,
gentamic80mg/100ml piggyback, gentamic100mg/0.1l
piggyback, gentamic120mg/0.1l piggyback)
7
PAGE 21
PRODUCT DESCRIPTION
TIER
gentamicin sulfate in sodium chloride, iso-osmotic (gentamic70
mg/50ml piggyback, gentamic90mg/100ml piggyback,
gentamic100mg/50ml piggyback)
1
gentamicin sulfate/pf (20 mg/2 ml vial, 60 mg/6 ml vial port, 80
mg/8 ml vial port, 100mg/10ml vial port)
7
KITABIS PAK
6
QL
300 / 30 days
PA
neomycin sulfate
1
paromomycin sulfate
1
streptomycin sulfate
1
TOBI
3
QL
300 / 30 days
PA
TOBI PODHALER
6
TOBRADEX EYE OINTMENT
2
tobramycin
1
tobramycin in 0.225 % sodium chloride
1
PA
QL
300 / 30 days
PA
tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial)
7
tobramycin sulfate/sodium chloride (60 mg/50ml piggyback,
80mg/100ml piggyback)
1
TOBREX 0.3% EYE DROPS
3
TOBREX 0.3% EYE OINTMENT
2
Antibacterials, Other
acetic acid 2 % solution
1
acetic acid/aluminum acetate
1
acetic acid/hydrocortisone
1
acetic acid/oxyquinoline sulfate
3
ALTABAX
3
AMINOACETIC ACID
7
AVYCAZ
6
bacitracin 500 unit/g oint. (g)
1
bacitracin 50000 unit vial
7
PAGE 22
PA
PRODUCT DESCRIPTION
TIER
BACTROBAN (CREAM, OINTMENT)
3
BACTROBAN NASAL
2
CENTANY
3
CENTANY AT
3
chloramphenicol sod succ
1
chlorhexidine gluconate
1
CLEOCIN 100 MG VAGINAL OVULE
2
CLEOCIN 2% VAGINAL CREAM
3
CLEOCIN HCL (75 MG CAPSULE, 150 MG CAPSULE, 300
MG CAPSULE)
3
CLEOCIN PALMITATE
3
CLEOCIN PHOSPHATE (150 MG/ML ADDVN VIAL, PHOS 150
MG/ML VIAL, PHOS 300 MG/2 ML VIAL, PHOS 600 MG/4 ML
VIAL, PHOS 900 MG/6 ML VIAL)
9
CLEOCIN PHOSPHATE IN D5W (300, 600, 900)
9
CLEOCIN T (GEL, LOION, PLEDGES, SOLUION)
3
CLIN SINGLE USE
9
CLINDACIN ETZ
3
CLINDACIN PAC
3
clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg
capsule)
1
clindamycin palmitate hcl
1
clindamycin phosphate (1 % foam, 1 % lotion, 1 % med. swab,
1 % gel (gram), 1 % solution, 2 % cream/appl)
1
clindamycin phosphate (150 mg/ml vial, 300 mg/2ml vial port,
600 mg/4ml vial port, 900mg/6ml vial port)
7
clindamycin phosphate/dextrose 5 % in water (300mg/50ml
piggyback, 600mg/50ml piggyback, 900mg/50ml piggyback)
7
CLINDESSE
3
colistin (as colistimethate sodium)
7
COLY-MYCIN M PARENTERAL
9
CUBICIN
9
cycloserine
1
DALVANCE
9
PAGE 23
PRODUCT DESCRIPTION
TIER
erythromycin ethylsuccinate/sulfisoxazole acetyl
1
EVOCLIN
3
FEM PH
3
FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET)
3
FLAGYL ER
3
FURADANTIN
3
glutaraldehyde
3
glycine urologic solution
7
HIPREX
3
LINCOCIN
9
linezolid 600 mg tablet
1
linezolid 600mg/300 iv soln
7
linezolid in 0.9 % sodium chloride
7
MACROBID
3
MACRODANTIN (25 MG CAPSULE, 50 MG CAPSULE, 100
MG CAPSULE)
3
mafenide acetate
1
methenamine hippurate
1
methenamine mandelate 1 g tablet
1
methenamine mandelate 500 mg tablet
3
methenamine/methylene blue/benzoic acid/salicylate/hyoscy
1
methenamine/methylene blue/salicylate/sodium phos/hyoscy
(capsule, tablet)
1
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
(81-0.12mg tablet, 81.6-10.8 tablet, 118-10-36 capsule)
1
methenamine/sodium phosphate,monobasic/meth blue/hyosc
sul (81.6-.12mg tablet, 120-40.8mg capsule)
1
METRO IV
9
METROCREAM
3
METROGEL (GEL, PUMP)
2
METROGEL-VAGINAL
3
METROLOTION
3
PAGE 24
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 %
gel w/appl, 0.75 % lotion, 1 % gel w/pump, 1 % gel (gram), 250
mg tablet, 375 mg capsule, 500 mg tablet)
1
metronidazole in sodium chloride
7
MONUROL
3
mupirocin
1
mupirocin calcium
1
neomycin sulfate/polymyxin b sulfate (ampul, vial)
7
NEOSPORIN G.U. IRRIGANT (40 MG/ML VIAL, 40 MG/ML
AMP)
9
nitrofurantoin
1
nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule, 100
mg capsule)
1
nitrofurantoin monohydrate/macrocrystals
1
NORITATE
3
NUVESSA
3
ORBACTIV
9
PERIDEX
3
polymyxin b sulfate
7
PRIMSOL
3
PROSED-DS
3
ROSADAN (CREAM KIT, GEL KIT)
3
SEROMYCIN
3
SIVEXTRO 200 MG TABLET
3
SIVEXTRO 200 MG VIAL
9
SULFAMYLON (8.5% CREAM, POWDER PACKET)
3
SYNERCID
9
TINDAMAX (250 MG TABLET, 500 MG TABLET)
3
tinidazole (250 mg tablet, 500 mg tablet)
1
trimethoprim
1
TYGACIL
9
URELLE
3
URETRON D-S
3
PAGE 25
PRODUCT DESCRIPTION
TIER
URIBEL
3
UROGESIC-BLUE
3
UROQID-ACID NO.2
3
UTA
3
VANCOCIN HCL (125 MG CAPSULE, 250 MG CAPSULE)
3
vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 500 mg
vial, 500 mg vial port, 750 mg vial port, 750 mg vial)
7
vancomycin hcl (125 mg capsule, 250 mg capsule)
1
vancomycin hcl/dextrose 5 % in water (1g/200ml froz.piggy,
500mg/0.1l froz.piggy)
7
vancomycin in dextrose, iso-osmotic
7
VANDAZOLE
1
VIBATIV (250 MG VIAL, 750 MG VIAL)
9
VOSOL HC
3
XIFAXAN (200 MG TABLET, 550 MG TABLET)
3
ZYVOX (200 MG/100 ML IV SOLN, 600 MG/300 ML IV SOLN)
9
ZYVOX 100 MG/5 ML SUSPENSION
3
ZYVOX 600 MG TABLET
3
QL
60 / 30 days
Beta-lactam, Cephalosporins
CEDAX (90 MG/5 ML SUSPENSION, 180 MG/5 ML
SUSPENSION, 400 MG CAPSULE)
3
cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250
mg capsule, 375 mg/5ml susp recon, 500 mg tab er 12h, 500
mg capsule)
1
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule,
500 mg/5ml susp recon)
1
cefazolin sodium (1 g vial, 10 g vial, 20 g vial, 100 g bulkbaginj,
300g bulkbaginj, 500 mg vial)
7
cefazolin sodium 1 g vial port
1
cefazolin sodium in 0.9 % sodium chloride
7
cefazolin sodium/dextrose, iso-osmotic (1 ml froz.piggy, 1 ml
piggyback, 2 ml piggyback)
7
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300
mg capsule)
1
cefditoren pivoxil (200 mg tablet, 400 mg tablet)
1
PAGE 26
PRODUCT DESCRIPTION
TIER
cefepime hcl (1 g vial, 2 g vial)
7
cefepime hcl/dextrose 5 % in water (1 ml piggyback, 2 ml
piggyback)
7
cefepime hcl/dextrose, iso-osmotic (1 g/50 ml froz.piggy, 2
g/100 ml froz.piggy)
7
cefixime (100 susp recon, 200 susp recon)
1
cefotaxime sodium (1 g vial, 2 g vial, 10 g vial, 500 mg vial)
7
cefotetan disodium (1 g vial, 2 g vial, 10 g vial)
1
cefotetan disodium/dextrose, iso-osmotic (1 ml piggyback, 2 ml
piggyback)
1
cefoxitin sodium (1 g vial, 2 g vial, 10 g vial)
7
cefoxitin sodium/dextrose, iso-osmotic (1 ml piggyback, 2 ml
piggyback)
1
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet,
100 mg/5ml susp recon, 200 mg tablet)
1
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml
susp recon, 500 mg tablet)
1
ceftazidime (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 6 g vial)
7
ceftazidime in dextrose 5% and water (1 ml piggyback, 2 ml
piggyback)
7
ceftibuten (180 mg/5ml susp recon, 400 mg capsule)
1
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL
SUSP, 250 MG TABLET, 500 MG TABLET)
3
ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial,
10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial)
7
ceftriaxone sodium/dextrose, iso-osmotic (1 ml piggyback, 1 ml
froz.piggy, 2 ml froz.piggy, 2 ml piggyback)
7
cefuroxime axetil (250 mg tablet, 500 mg tablet)
1
cefuroxime sodium (1.5 g vial, 7.5g vial, 7.5 g vial, 75 g
bulkbaginj, 750 mg vial)
7
cefuroxime sodium/dextrose, iso-osmotic (1.5g/50ml piggyback,
7
cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg
capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg
capsule, 750 mg capsule)
1
CLAFORAN (1 GM VIAL, 2 GM VIAL, 10 GM VIAL, 500 MG
VIAL)
9
PAGE 27
PRODUCT DESCRIPTION
TIER
CLAFORAN (1 GM VL, 2 GM VL)
3
FORTAZ (1 GM ADD-VANTAGE VIAL, 1 GM VIAL, 1 GM
TWISTVIAL, 2 GM VIAL, 2 GM TWISTVIAL, 2 GM ADDVANTAGE VIAL, 6 GM VIAL, 500 MG VIAL)
9
FORTAZ IN ISO-OSMOTIC DEXTROSE (FORTAZ-ISOOSMOT 2 ML, FORTAZ-ISO-OSMOTIC 1 ML)
9
KEFLEX (250 MG CAPSULE, 500 MG CAPSULE, 750 MG
CAPSULE)
3
MAXIPIME (1 GRAM VIAL, 1 GM ADD-VANTAGE VL, 2 GRAM
VIAL, 2 GM ADD-VANTAGE VL)
3
MEFOXIN (1 ML PIGGYBACK, 2 ML PIGGYBACK)
3
ROCEPHIN (1 GM VIAL, 500 MG VIAL)
9
SPECTRACEF (200 MG PACK TB, 400 MG PACK TB)
3
SUPRAX (100 MG/5 ML SUSPENSION, 100 MG TABLET
CHEWABLE, 200 MG/5 ML SUSPENSION, 200 MG TABLET
CHEWABLE, 400 MG TABLET, 400 MG CAPSULE, 500 MG/5
ML SUSPENSION)
3
TEFLARO (400 MG VIAL, 600 MG VIAL)
9
ZINACEF (1.5 GM TWISTVIAL, 1.5 GRAM/50 ML, 1.5 GM
VIAL, 1.5 GM ADD-VANT VIAL, 7.5 GM VIAL, 750 MG VIAL,
750 MG ADD-VANT VIAL, 750 MG TWISTVIAL)
9
ZINACEF ISO-OSMOTIC DEXTROSE
9
QL
30 / 30 days
QL
84 / 56 days
Beta-lactam, Other
AZACTAM (1 GM VIAL, 2 GM VIAL)
9
AZACTAM-ISO-OSMOTIC DEXTROSE (1 ML, 2 ML)
9
aztreonam (1 g vial, 2 g vial)
7
CAYSTON
6
DORIBAX (250 MG VIAL, 500 MG VIAL)
9
imipenem/cilastatin sodium (250 mg vial, 500 mg vial)
7
INVANZ (1 GM VIAL, 1 GM ADD-VANTAGE VIAL)
9
meropenem (1 g vial, 500 mg vial)
7
meropenem in 0.9 % sodium chloride (1 g/50 ml piggyback,
7
MERREM (IV 1 GM VIAL, IV 500 MG VIAL)
9
PRIMAXIN (250 MG VIAL, 500 MG VIAL)
9
PAGE 28
PRODUCT DESCRIPTION
TIER
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200
mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250
mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500
mg capsule, 775 mg tbmp 24hr, 875 mg tablet)
1
amoxicillin/potassium clavulanate (200-28.5mg tab chew, 20028.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon,
400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg
tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab
er 12h)
1
ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial port, 10
g vial, 125 mg vial, 250 mg vial, 500 mg vial)
7
ampicillin sodium/sulbactam sodium (1.5 g vial port, 1.5 g vial, 3
g vial, 3 g vial port, 15 g vial)
7
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule,
250 mg/5ml susp recon, 500 mg capsule)
1
AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, 500125 TABLET, 875-125 TABLET)
3
AUGMENTIN ES-600
3
AUGMENTIN XR
3
BICILLIN C-R (1.2 MILLION UNIT, 900-300 SYRINGE)
9
BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS, 2,400,000
UNITS)
9
dicloxacillin sodium (250 mg capsule, 500 mg capsule)
1
MOXATAG
3
nafcillin in dextrose, iso-osmotic (1 g/50 ml froz.piggy, 2 g/100
ml froz.piggy)
8
nafcillin sodium (1 g vial port, 2 g vial port)
1
nafcillin sodium (1 g vial, 2 g vial, 10 g vial)
7
oxacillin sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 10
g vial)
7
oxacillin sodium/dextrose, iso-osmotic (1 ml froz.piggy, 2 ml
froz.piggy)
7
penicillin g potassium (g 5mm unit vial, g 20mm unit vial)
7
penicillin g potassium/dextrose-water (pen g 1mm/50ml
froz.piggy, pen g 2mm/50ml froz.piggy, pen g 3mm/50ml
froz.piggy)
7
penicillin g procaine (g 1.2mm/2 ml syringe, g 600000/ml
syringe)
1
PAGE 29
PRODUCT DESCRIPTION
TIER
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet,
250 mg/5ml soln recon, 500 mg tablet)
1
piperacillin sodium/tazobactam sodium (2.25 g vial port, 2.25 g
vial, 3.375 g vial, 3.375 g vial port, 4.5 g vial, 4.5 g vial port,
40.5 g vial)
7
TIMENTIN (3.1 GM/100 ML ISO, 3.1 GM VIAL, 31 GM BULK
VIAL)
9
UNASYN (1.5 GM PIGGYBACK BOTTLE, 1.5 GM VIAL, 3 GM
VIAL, 15 GM VIAL)
9
ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL,
3.375 GRAM VIAL, 3.375 GM/50 ML GALAXY, 4.5 GRAM
VIAL, 4.5 GM/100 ML GALAXY BAG, 40.5 GRAM BULK VIAL)
9
Macrolides
AKNE-MYCIN
2
AZASITE
3
azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml
susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet)
1
azithromycin (500 mg vial port, 500 mg vial)
7
BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500
MG TABLET)
3
BIAXIN XL
3
clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp
recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)
1
DIFICID
6
E.E.S. 200
3
E.E.S. 400
1
ERY-TAB (EC 250 MG TABLET, EC 333 MG TABLET, EC 500
MG TABLET)
3
ERYPED 200
3
ERYPED 400
3
ERYTHROCIN LACTOBIONATE (1 GM ADDVANT VIAL, 500
MG VIAL, 500 MG ADDVNT VL)
9
ERYTHROCIN STEARATE
3
erythromycin base (5 mg/g oint. (g), 250 mg tablet, 250 mg
capsule dr, 500 mg tablet)
1
erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution,
2 % gel (gram))
1
PAGE 30
PA
PRODUCT DESCRIPTION
TIER
erythromycin ethylsuccinate
1
ILOTYCIN
3
KETEK (300 MG TABLET, 400 MG TABLET)
2
PCE (333 MG TABLET, 500 MG TABLET)
3
ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP,
200 MG/5 ML SUSP, 250 MG Z-PAK TABLET, 250 MG
3
ZITHROMAX I.V. 500 MG VIAL
9
ZITHROMAX TRI-PAK
3
ZMAX
2
Quinolones
AVELOX
3
AVELOX ABC PACK
3
AVELOX IV
9
BESIVANCE
3
CILOXAN (EYE DROPS, OINTMENT)
3
CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG
TABLET, 500 MG TABLET)
3
CIPRO I.V. (200 MG/100 ML, 400 MG/200 ML)
9
CIPRO XR (500 MG TABLET, 1,000 MG TABLET)
3
ciprofloxacin (250 sus mc rec, 500 sus mc rec)
1
ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet,
1
ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial)
7
ciprofloxacin lactate/dextrose 5 % in water (200mg/0.1l
piggyback, 400mg/0.2l piggyback)
7
ciprofloxacin/ciprofloxacin hcl (500 mg tbmp 24hr, 1000 mg
tbmp 24hr)
1
FACTIVE
3
QL
7 / 30 days
gatifloxacin
1
QL
2 / 30 days
LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET, 500 MG
3
LEVAQUIN (250 MG/50 ML BAG, 500 MG/100 ML BAG, 750
MG/150 ML BAG)
9
PAGE 31
PRODUCT DESCRIPTION
TIER
levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet,
500 mg tablet, 500mg/20ml solution, 750 mg tablet)
1
levofloxacin 25 mg/ml vial
7
levofloxacin/dextrose 5 % in water (250mg/50ml piggyback,
500mg/0.1l piggyback, 750mg/.15l piggyback)
7
MOXEZA
3
moxifloxacin hcl
1
moxifloxacin hcl in sodium acetate and sulfate,water,iso-osm
7
NOROXIN
3
OCUFLOX
3
ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg
tablet)
1
VIGAMOX
3
ZYMAXID
3
QL
9 / 90 days
QL
2 / 30 days
Sulfonamides
AVC
3
BACTRIM
3
BACTRIM DS
3
BLEPH-10
3
KLARON
3
OVACE PLUS (FOAM, LOTION)
3
SILVADENE
3
silver sulfadiazine
1
SSD
1
sulfacetamide sodium (10 % drops, 10 % suspension)
1
sulfadiazine
1
sulfamethoxazole/trimethoprim (80-16mg/ml vial, 200-40mg/5
oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160
mg tablet)
1
SULFATRIM
1
THERMAZENE
1
PAGE 32
PRODUCT DESCRIPTION
TIER
Tetracyclines
ACTICLATE (75 MG TABLET, 150 MG TABLET)
3
ADOXA
3
ALODOX
3
AVIDOXY DK
3
BENOXYLDOXY 30
3
BENOXYLDOXY 60
3
demeclocycline hcl (150 mg tablet, 300 mg tablet)
1
DORYX (DR 50 MG TABLET, DR 150 MG TABLET, DR 200
MG TABLET)
3
doxycycline hyclate (20 mg tablet, 50 mg capsule, 75 mg tablet
dr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg
tablet dr)
1
doxycycline hyclate 100 mg vial
7
doxycycline monohydrate (25 mg/5 ml susp recon, 40 mg cap ir
dr, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet,
100 mg tablet, 100 mg capsule, 150 mg tablet, 150 mg capsule)
1
DYNACIN
3
MINOCIN (50 MG PELLETIZED CAP, KIT 50 MG COMBO, 75
MG PELLETIZED CAP, 100 MG PELLETIZED CAP, KIT 100
MG COMBO)
3
MINOCIN 100 MG VIAL
9
minocycline hcl (45 mg tab er 24h, 50 mg tablet, 50 mg
capsule, 75 mg capsule, 75 mg tablet, 90 mg tab er 24h, 100
mg capsule, 100 mg tablet, 135 mg tab er 24h)
1
MONODOX (50 MG CAPSULE, 75 MG CAPSULE, 100 MG
CAPSULE)
3
MORGIDOX (1X100 MG KIT, 2X100 MG KIT)
3
OCUDOX
3
ORACEA
3
SOLODYN (ER 45 MG TABLET, ER 55 MG TABLET, ER 65
MG TABLET, ER 80 MG TABLET, ER 90 MG TABLET, ER 105
MG TABLET, ER 115 MG TABLET, ER 135 MG TABLET)
3
tetracycline hcl (250 mg capsule, 500 mg capsule)
1
VIBRAMYCIN (50 MG/5 ML SYRUP, 100 MG CAPSULE)
3
VIBRAMYCIN 25 MG/5 ML SUSP
2
PAGE 33
PRODUCT DESCRIPTION
TIER
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg tablet, 250 mg tablet)
1
acetazolamide sodium
7
FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8
MG TABLET, 10 MG TABLET, 12 MG TABLET)
3
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG
TABLET, 750 MG TABLET, 1,000 MG TABLET)
3
KEPPRA 500 MG/5 ML VIAL
9
KEPPRA XR (500 MG TABLET, 750 MG TABLET)
3
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg/5ml
solution, 500 mg tablet, 750 mg tablet, 1000 mg tablet)
1
levetiracetam (500 mg tab er 24h, 750 mg tab er 24h)
1
levetiracetam 500 mg/5ml vial
7
levetiracetam in sodium chloride, iso-osmotic (500mg/0.1l
piggyback, 1000mg/100 piggyback, 1500mg/100 piggyback)
9
MYSOLINE (50 MG TABLET, 250 MG TABLET)
3
POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG TABLET,
400 MG TABLET)
3
primidone (50 mg tablet, 250 mg tablet)
1
QL
30 / 30 days
QL
30 / 30 days
QL
30 / 30 days
QL
120 / 30 days
Calcium Channel Modifying Agents
CELONTIN
2
ethosuximide (250 mg/5ml solution, 250 mg capsule)
1
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)
2
LYRICA 20 MG/ML ORAL SOLUTION
2
ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION)
3
ZONEGRAN (25 MG CAPSULE, 100 MG CAPSULE)
3
zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule)
1
Gamma-aminobutyric Acid (GABA) Augmenting Agents
DEPACON
9
DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION)
3
PAGE 34
PRODUCT DESCRIPTION
TIER
DEPAKOTE (DR 125 MG TABLET, DR 250 MG TABLET, DR
500 MG TABLET)
3
DEPAKOTE ER (ER 250 MG TABLET, ER 500 MG TABLET)
3
DEPAKOTE SPRINKLE
3
DIASTAT
3
DIASTAT ACUDIAL (5-7.5-10 MG KT, 12.5-15-20 MG)
3
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit)
1
divalproex sodium (125 mg tablet dr, 125 mg cap sprink, 250
mg tab er 24h, 250 mg tablet dr, 500 mg tablet dr, 500 mg tab
er 24h)
1
FANATREX
3
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg/6ml
solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800
mg tablet)
1
GABITRIL (12 MG TABLET, 16 MG TABLET)
2
GABITRIL (2 MG TABLET, 4 MG TABLET)
3
GRALISE (30-DAY STARTER PACK, ER 300 MG TABLET, ER
600 MG TABLET)
3
ST
HORIZANT ER 600 MG TABLET
3
ST
NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300
MG CAPSULE, 400 MG CAPSULE, 600 MG TABLET, 800 MG
TABLET)
3
ST
ONFI (2.5 MG/ML SUSPENSION, 5 MG TABLET, 10 MG
3
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir,
30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet,
97.2mg tablet, 100 mg tablet)
1
phenobarbital sodium (65 mg/ml vial, 130mg/ml vial)
7
PA
phenobarbital sodium 130mg/ml syringe
7
PA
SABRIL (500 MG TABLET, 500 MG POWDER PACKET)
9
QL
180 / 30 days
PA
STAVZOR (DR 125 MG CAPSULE, DR 250 MG CAPSULE,
DR 500 MG CAPSULE)
3
tiagabine hcl (2 mg tablet, 4 mg tablet)
1
TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG
CAPSULE)
3
PAGE 35
PRODUCT DESCRIPTION
TIER
TROKENDI XR 200 MG CAPSULE
3
valproic acid
1
valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml
solution, 500mg/10ml solution)
1
valproic acid (as sodium salt) 500 mg/5ml vial
7
PA
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)
1
FELBATOL (400 MG TABLET, 600 MG TABLET)
3
FELBATOL 600 MG/5 ML SUSP
2
LAMICTAL (2 MG DISPER TABLET, 5 MG DISPER TABLET,
25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET,
150 MG TABLET, 200 MG TABLET)
3
LAMICTAL (BLUE)
3
LAMICTAL (GREEN)
3
LAMICTAL (ORANGE)
3
LAMICTAL ODT (BLUE)
3
LAMICTAL ODT (GREEN)
3
LAMICTAL ODT (ODT 25 MG TABLET, ODT 50 MG TABLET,
ODT 100 MG TABLET, ODT 200 MG TABLET)
3
LAMICTAL ODT (ORANGE)
3
LAMICTAL XR (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG
TABLET)
3
LAMICTAL XR (BLUE)
3
LAMICTAL XR (GREEN)
3
LAMICTAL XR (ORANGE)
3
lamotrigine (5 mg tb chw dsp, 25mg (35) tab ds pk, 25 mg
tablet, 25 mg tab er 24, 25 mg tab rapdis, 25 mg tb chw dsp, 50
mg tab rapdis, 50 mg tab er 24, 100 mg tab er 24, 100 mg tab
rapdis, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab
er 24, 200 mg tab rapdis, 250 mg tab er 24, 300 mg tab er 24)
1
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG
3
TOPAMAX (15 MG SPRINKLE CAP, 25 MG TABLET, 25 MG
SPRINKLE CAP, 50 MG TABLET, 100 MG TABLET, 200 MG
TABLET)
3
PAGE 36
PRODUCT DESCRIPTION
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet,
25 mg cap spr 24, 50 mg cap spr 24, 50 mg tablet, 100 mg cap
spr 24, 100 mg tablet, 150 mg cap spr 24, 200 mg tablet, 200
mg cap spr 24)
TIER
1
Sodium Channel Agents
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG
3
BANZEL (200 MG TABLET, 400 MG TABLET)
3
BANZEL 40 MG/ML SUSPENSION
3
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100
mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg
cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)
1
CARBATROL (ER 100 MG CAPSULE, ER 200 MG CAPSULE,
ER 300 MG CAPSULE)
3
CEREBYX (100 MG PE/2 ML VIAL, 500 MG PE/10 ML VIAL)
9
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG
CAPSULE)
2
DILANTIN-125
2
EQUETRO (100 MG CAPSULE, 200 MG CAPSULE, 300 MG
CAPSULE)
3
fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial)
7
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral
susp, 600 mg tablet)
1
OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG
TABLET)
3
PEGANONE
3
PHENYTEK 200 MG CAPSULE
1
PHENYTEK 300 MG CAPSULE
3
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml
oral susp)
1
phenytoin sodium (50 mg/ml syringe, 50 mg/ml vial, 50 mg/ml
ampul)
7
phenytoin sodium extended (100 mg capsule, 200 mg capsule,
300 mg capsule)
1
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET)
2
TEGRETOL XR (100 MG TABLET, 200 MG TABLET, 400 MG
TABLET)
2
PAGE 37
QL
240 / 30 days
QL
120 / 30 days
PRODUCT DESCRIPTION
TIER
TRILEPTAL (150 MG TABLET, 300 MG TABLET, 600 MG
TABLET)
2
TRILEPTAL 300 MG/5 ML SUSP
3
VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MG TABLET,
200 MG TABLET)
3
VIMPAT 10 MG/ML SOLUTION
3
VIMPAT 200 MG/20 ML VIAL
9
VIMPAT STARTER KIT
ziprasidone hcl 20 mg capsule
QL
60 / 30 days
3
QL
28 / 180 days
1
QL
60 / 30 days
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates
1
Cholinesterase Inhibitors
ARICEPT (5 MG TABLET, 10 MG TABLET, 23 MG TABLET)
3
QL
30 / 30 days
ARICEPT ODT (ODT 5 MG TABLET, ODT 10 MG TABLET)
3
QL
30 / 30 days
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg
tab rapdis, 23 mg tablet)
1
QL
30 / 30 days
EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG
CAPSULE, 6 MG CAPSULE)
3
QL
60 / 30 days
EXELON (4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH, 13.3
MG/24HR PATCH)
2
QL
30 / 30 days
EXELON 2 MG/ML ORAL SOLUTION
2
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12
mg tablet)
1
galantamine hbr (8 mg cap24h pel, 16 mg cap24h pel, 24 mg
cap24h pel)
1
QL
30 / 30 days
RAZADYNE (4 MG/ML ORAL SOLUTION, 4 MG TABLET, 8
3
RAZADYNE ER (ER 8 MG CAPSULE, ER 16 MG CAPSULE,
ER 24 MG CAPSULE)
3
QL
30 / 30 days
rivastigmine (4.6mg/24hr patch td24, 9.5mg/24hr patch td24,
13.3mg/24h patch td24)
1
QL
30 / 30 days
rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg
1
QL
60 / 30 days
PAGE 38
PRODUCT DESCRIPTION
TIER
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl (5 mg-10 mg tab ds pk, 5 mg tablet, 10 mg
tablet, 10 mg/5 ml solution)
1
NAMENDA (5-10 MG TITRATION PK, 5 MG TABLET, 10 MG
TABLET, 10 MG/5 ML SOLUTION)
2
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG
CAPSULE, 28 MG CAPSULE, TITRATION PACK)
3
QL
30 / 30 days
ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15
MG TABLET, 20 MG TABLET, 30 MG TABLET)
3
QL
30 / 30 days
ABILIFY 1 MG/ML SOLUTION
3
ABILIFY 9.7 MG/1.3 ML VIAL
9
ABILIFY DISCMELT (10 MG TABLET, 15 MG TABLET)
3
QL
30 / 30 days
ABILIFY MAINTENA (ER 300 MG SYR, ER 400 MG SYR)
9
ABILIFY MAINTENA (ER 300 MG VL, ER 400 MG VL)
3
APLENZIN (ER 174 MG TABLET, ER 348 MG TABLET, ER
522 MG TABLET)
QL
30 / 30 days
3
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 10 mg tab
rapdis, 15 mg tablet, 15 mg tab rapdis, 20 mg tablet, 30 mg
tablet)
1
aripiprazole 1 mg/ml solution
1
ARISTADA (ER 441 MG/1.6 ML SYRN, ER 662 MG/2.4 ML
SYRN, ER 882 MG/3.2 ML SYRN)
9
bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet,
200 mg tablet er)
1
bupropion hcl 150 mg tab er 24h
Antidepressants
Antidepressants, Other
ST
QL
30 / 30 days
1
QL
90 / 30 days
bupropion hcl 300 mg tab er 24h
1
QL
30 / 30 days
FORFIVO XL
3
ST
maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet)
1
mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab rapdis, 30
mg tablet, 30 mg tab rapdis, 45 mg tablet, 45 mg tab rapdis)
1
nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet,
1
PAGE 39
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
olanzapine/fluoxetine hcl (3 mg-25 mg capsule, 6mg-50mg
capsule, 6mg-25mg capsule, 12mg-25mg capsule, 12mg-50mg
capsule)
1
OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET)
3
QL
30 / 30 days
QL
30 / 30 days
ST
perphenazine/amitriptyline hcl (2 mg-10 mg tablet, 2 mg-25 mg
tablet, 4 mg-25 mg tablet, 4mg-50mg tablet, 4mg-10mg tablet)
1
REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG
TABLET, 30 MG SOLTAB, 45 MG TABLET, 45 MG SOLTAB)
3
SEROQUEL XR (300 MG TABLET, 400 MG TABLET)
2
QL
60 / 30 days
SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG
TABLET)
2
QL
30 / 30 days
SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE, 6-50 MG
CAPSULE, 12-25 MG CAPSULE, 12-50 MG CAPSULE)
3
QL
30 / 30 days
trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300
mg tablet)
1
QL
VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET)
30 / 30 days
3
QL
30 / 30 days
ST
ST
VIIBRYD 10-20-40 MG STARTER PK
3
QL
WELLBUTRIN (75 MG TABLET, 100 MG TABLET)
3
ST
WELLBUTRIN SR (100 MG TABLET, 150 MG TABLET, 200
MG TABLET)
3
ST
WELLBUTRIN XL 150 MG TABLET
3
QL
30 / 30 days
90 / 30 days
ST
QL
WELLBUTRIN XL 300 MG TABLET
30 / 30 days
3
ST
Monoamine Oxidase Inhibitors
EMSAM (6 PATCH, 9 PATCH, 12 PATCH)
3
MARPLAN
3
NARDIL
3
PARNATE
3
phenelzine sulfate
1
tranylcypromine sulfate
1
PAGE 40
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
Serotonin/Norepinephrine Reuptake Inhibitors
QL
BRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG
TABLET)
3
BRISDELLE
3
30 / 30 days
ST
QL
30 / 30 days
ST
CELEXA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET)
3
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20
mg tablet, 40 mg tablet)
1
CYMBALTA (30 MG CAPSULE, 60 MG CAPSULE)
3
ST
QL
30 / 30 days
ST
QL
CYMBALTA 20 MG CAPSULE
90 / 30 days
3
ST
desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 100 mg tab
er 24h, 100 mg tab er 24)
1
desvenlafaxine fumarate (50 mg tab er 24, 100 mg tab er 24)
1
duloxetine hcl (30 mg capsule dr, 40 mg capsule dr, 60 mg
capsule dr)
1
QL
30 / 30 days
duloxetine hcl 20 mg capsule dr
1
QL
90 / 30 days
QL
EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE)
60 / 30 days
3
ST
QL
EFFEXOR XR 75 MG CAPSULE
90 / 30 days
3
ST
escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mg tablet)
1
QL
30 / 30 days
escitalopram oxalate 5 mg/5 ml solution
1
QL
620 / 30 days
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE,
CAPSULE)
QL
30 / 30 days
3
fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20
mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet,
90 mg capsule dr)
1
fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h)
1
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
PAGE 41
ST
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
QL
IRENKA
30 / 30 days
3
ST
KHEDEZLA (ER 50 MG TABLET, ER 100 MG TABLET)
3
LEXAPRO (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)
3
ST
QL
30 / 30 days
ST
QL
LEXAPRO 5 MG/5 ML SOLUTION
620 / 30 days
3
ST
QL
LUVOX CR (CR 100 MG CAPSULE, CR 150 MG CAPSULE)
30 / 30 days
3
ST
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg
tablet)
1
paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg
tab er 24h)
1
QL
PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG
3
ST
PAXIL CR (CR 12.5 MG TABLET, CR 25 MG TABLET, CR
37.5 MG TABLET)
3
PEXEVA (10 MG TABLET, 20 MG TABLET, 30 MG TABLET,
40 MG TABLET)
3
PRISTIQ ER (ER 25 MG TABLET, ER 50 MG TABLET, ER 100
MG TABLET)
3
PROZAC (10 MG, 20 MG, 40 MG)
3
ST
PROZAC WEEKLY
3
ST
SARAFEM (10 MG TABLET, 20 MG TABLET)
3
ST
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet,
100 mg tablet)
1
venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75
mg tablet, 100 mg tablet)
1
venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tab er 24, 150 mg
cap er 24h, 150 mg tab er 24)
1
QL
60 / 30 days
venlafaxine hcl (75 mg cap er 24h, 75 mg tab er 24)
1
QL
90 / 30 days
VENLAFAXINE HCL ER (ER 37.5 MG TAB, ER 150 MG TAB)
1
QL
60 / 30 days
PAGE 42
QL
60 / 30 days
60 / 30 days
ST
QL
30 / 30 days
ST
QL
30 / 30 days
ST
PRODUCT DESCRIPTION
TIER
VENLAFAXINE HCL ER 225 MG TAB
2
ST
VENLAFAXINE HCL ER 75 MG TAB
1
QL
ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG
3
ST
90 / 30 days
Tricyclics
amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75
mg tablet, 100 mg tablet, 150 mg tablet)
1
amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 150 mg
tablet)
1
ANAFRANIL (25 MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE)
3
clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg
capsule)
1
desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75
mg tablet, 100 mg tablet, 150 mg tablet)
1
doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150
mg capsule)
1
imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet)
1
imipramine pamoate (75 mg capsule, 100 mg capsule, 125 mg
1
NORPRAMIN (10 MG TABLET, 25 MG TABLET, 50 MG
TABLET, 75 MG TABLET, 100 MG TABLET, 150 MG TABLET)
3
nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule)
1
PAMELOR (10 MG CAPSULE, 25 MG CAPSULE, 50 MG
3
protriptyline hcl (5 mg tablet, 10 mg tablet)
1
SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE, 100 MG
CAPSULE)
3
TOFRANIL (10 MG TABLET, 25 MG TABLET, 50 MG TABLET)
3
TOFRANIL-PM (75 MG CAPSULE, 100 MG CAPSULE, 125
MG CAPSULE, 150 MG CAPSULE)
3
trimipramine maleate (25 mg capsule, 50 mg capsule, 100 mg
capsule)
1
VIVACTIL (5 MG TABLET, 10 MG TABLET)
3
PAGE 43
PRODUCT DESCRIPTION
TIER
Antiemetics
Antiemetics, Other
ALOXI
9
ANTIVERT (12.5 MG TABLET, 25 MG TABLET, 50 MG
TABLET)
3
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25 mg/ml
ampul, 50 mg tablet, 100 mg tablet, 200 mg tablet)
1
COMPAZINE (5 MG TABLET, 10 MG TABLET)
3
COMPAZINE 25 MG SUPPOSITORY
1
DICLEGIS
3
diphenhydramine hcl (50 mg/ml vial, 50 mg/ml syringe)
7
droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial)
7
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg
tablet, 50 mg/25ml solution, 50 mg tablet)
1
hydroxyzine hcl 25 mg/ml vial
1
PA
hydroxyzine hcl 50 mg/ml vial
7
PA
hydroxyzine pamoate (25 mg capsule, 50 mg capsule, 100 mg
capsule)
1
meclizine hcl (12.5 mg tablet, 25 mg tablet)
1
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg
tablet, 10 mg/10ml solution)
1
metoclopramide hcl (5 mg/ml vial, 10 mg/2 ml syringe)
7
metoclopramide hcl 5 mg tab rapdis
1
QL
120 / 30 days
METOZOLV ODT (ODT 5 MG TABLET, ODT 10 MG TABLET)
3
QL
120 / 30 days
perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg
tablet)
1
PHENERGAN (12.5 MG, 25 MG, 50 MG)
1
PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML
VIAL, 50 MG/ML AMPUL)
9
prochlorperazine
1
prochlorperazine maleate (5 mg tablet, 10 mg tablet)
1
promethazine hcl (25 mg/ml vial, 25 mg/ml ampul, 25 mg/ml
syringe, 50 mg/ml ampul, 50 mg/ml vial)
7
PAGE 44
PA
PRODUCT DESCRIPTION
TIER
promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5
mg tablet, 25 mg supp.rect, 50 mg supp.rect, 50 mg tablet)
1
REGLAN (5 MG TABLET, 10 MG TABLET)
3
TIGAN 100 MG/ML VIAL
9
TIGAN 300 MG CAPSULE
3
TRANSDERM-SCOP
3
trimethobenzamide hcl 100 mg/ml vial
7
trimethobenzamide hcl 300 mg capsule
1
VISTARIL (25 MG CAPSULE, 50 MG CAPSULE)
3
QL
10 / 30 days
QL
4 / 30 days
Emetogenic Therapy Adjuncts
AKYNZEO
3
ANZEMET (50 MG TABLET, 100 MG TABLET)
3
ANZEMET 20 MG/ML VIAL
9
CESAMET
3
dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg capsule)
1
EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG
CAPSULE, TRIFOLD PACK)
3
EMEND 150 MG VIAL
9
granisetron hcl (1 mg/ml(1) vial, 1 mg/ml vial)
7
granisetron hcl 1 mg tablet
1
granisetron hcl/pf (1 mg/ml(1) vial, 100 mcg/ml vial)
7
MARINOL (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MG
CAPSULE)
3
ondansetron (4 mg tab rapdis, 8 mg tab rapdis)
1
ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet,
24 mg tablet)
1
ondansetron hcl 2 mg/ml vial
7
ondansetron hcl/pf (4 ml ampul, 4 ml vial, 4 ml syringe)
7
SANCUSO
3
VARUBI
3
ZOFRAN (4 MG/5 ML ORAL SOLN, 4 MG TABLET, 8 MG
TABLET)
3
ZOFRAN 2 MG/ML VIAL
9
PAGE 45
PRODUCT DESCRIPTION
TIER
ZOFRAN ODT (ODT 4 MG TABLET, ODT 8 MG TABLET)
3
ZUPLENZ (4 MG FILM, 8 MG FILM)
3
Antifungals
ABELCET
9
AMBISOME
9
ANCOBON (250 MG CAPSULE, 500 MG CAPSULE)
3
CANCIDAS (IV 50 MG VIAL, IV 70 MG VIAL)
9
CICLODAN (0.77% CREAM KIT, 8% KIT)
3
ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution)
1
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)
1
ciclopirox/urea/camphor/menthol/eucalyptol
1
ciclopirox/vitamin e mixed/nail lacquer remover, non-acet
1
clotrimazole (1 % cream (g), 1 % solution, 10 mg troche)
1
CNL 8
3
CRESEMBA (186 MG CAPSULE, 372 MG VIAL)
6
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML
SUSPENSION, 50 MG TABLET, 100 MG TABLET, 150 MG
3
econazole nitrate
1
ECOZA
3
ERAXIS (WATER DILUENT) (50 MG VIAL, 100 MG VIAL)
9
ERTACZO
3
EXELDERM (CREAM, SOLUTION)
3
EXTINA
3
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg
tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)
1
fluconazole in dextrose, iso-osmotic (200mg/0.1l piggyback,
400mg/0.2l piggyback)
7
fluconazole in sodium chloride, iso-osmotic (100mg/50ml
pggybk btl, 200mg/0.1l pggybk btl, 200mg/0.1l piggyback,
400mg/0.2l pggybk btl, 400mg/0.2l piggyback)
7
flucytosine (250 mg capsule, 500 mg capsule)
1
GRIFULVIN V
3
PAGE 46
PA
PRODUCT DESCRIPTION
TIER
GRIS-PEG (125 MG TABLET, 250 MG TABLET)
3
griseofulvin ultramicrosize (125 mg tablet, 250 mg tablet)
1
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet)
1
itraconazole
1
JUBLIA
3
KERYDIN
3
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg
tablet)
1
KETODAN
3
LAMISIL (125 MG GRANULES PACKET, 187.5 MG
GRANULES PACK)
3
LAMISIL 250 MG TABLET
3
LOPROX (0.77% GEL, 1% SHAMPOO)
3
LUZU
3
MENTAX
3
miconazole nitrate
1
MYCAMINE (50 MG VIAL, 100 MG VIAL)
9
naftifine hcl
1
NAFTIN (1% GEL, 1% CREAM, 2% CREAM, 2% GEL)
3
NATACYN
3
NIZORAL
3
NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET)
3
NOXAFIL 300 MG/16.7 ML VIAL
9
nystatin (50mm unit powder(ea), 150mm unit powder(ea),
500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp,
100000/g powder, 100000/g cream (g), 100000/g oint. (g))
1
ONMEL
3
ORAVIG
3
OXISTAT (CREAM, LOTION)
3
PEDIADERM AF
3
PEDIPIROX-4
3
PENLAC
3
PAGE 47
QL
90 / 365 days
QL
90 / 365 days
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
TIER
SPORANOX 10 MG/ML SOLUTION
3
SPORANOX 100 MG CAPSULE
3
TERAZOL 3 80 MG SUPPOSITORY
3
TERAZOL 3 CREAM
QL
90 / 365 days
3
QL
45 / 30 days
TERAZOL 7
3
QL
45 / 30 days
terbinafine hcl
1
QL
90 / 365 days
TERBINEX
3
terconazole (0.4 % cream/appl, 0.8 % cream/appl)
1
QL
45 / 30 days
terconazole 80 mg supp.vag
1
triacetin
1
VFEND (40 MG/ML SUSPENSION, 50 MG TABLET, 200 MG
TABLET)
3
VFEND IV
9
voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml susp
recon)
1
voriconazole 200 mg vial
7
XOLEGEL
3
QL
30 / 30 days
Antigout Agents
allopurinol (100 mg tablet, 300 mg tablet)
1
allopurinol sodium
7
ALOPRIM
9
colchicine (0.6 mg capsule, 0.6 mg tablet)
1
colchicine/probenecid
1
COLCRYS
3
KRYSTEXXA
6
MITIGARE
3
probenecid
1
ULORIC (40 MG TABLET, 80 MG TABLET)
3
ZYLOPRIM (100 MG TABLET, 300 MG TABLET)
3
PAGE 48
PRODUCT DESCRIPTION
TIER
Antimigraine Agents
Ergot Alkaloids
CAFERGOT
3
D.H.E.45
9
dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial)
7
dihydroergotamine mesylate 0.5mg/spry spray/pump
3
ERGOMAR
3
ergotamine tartrate/caffeine 1 mg-100mg tablet
1
MIGRANAL
3
QL
48 / 90 days
QL
48 / 90 days
Prophylactic
BOTOX (100 VIAL, 200 VIAL)
9
BOTOX COSMETIC (50 VIAL, 100 VIAL)
9
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)
1
Serotonin (5-HT) 1b/1d Receptor Agonists
almotriptan malate 12.5 mg tablet
1
QL
36 / 90 days
almotriptan malate 6.25 mg tablet
1
QL
54 / 90 days
ALSUMA
3
QL
9 / 90 days
AMERGE 1 MG TABLET
3
QL
54 / 90 days
AMERGE 2.5 MG TABLET
3
QL
27 / 90 days
AXERT 12.5 MG TABLET
3
QL
36 / 90 days
AXERT 6.25 MG TABLET
3
QL
54 / 90 days
FROVA
3
QL
54 / 90 days
IMITREX (25 MG TABLET, 50 MG TABLET)
3
QL
54 / 90 days
IMITREX (4 ML PEN INJECT, 4 ML CARTRIDGES, 6 ML PEN
INJECT, 6 ML VIAL, 6 ML CARTRIDGES)
9
QL
9 / 90 days
IMITREX (5 MG SPRAY, 20 MG SPRAY)
3
QL
36 / 90 days
IMITREX 100 MG TABLET
3
QL
27 / 90 days
MAXALT 10 MG TABLET
3
QL
36 / 90 days
MAXALT 5 MG TABLET
3
QL
72 / 90 days
PAGE 49
PRODUCT DESCRIPTION
TIER
MAXALT MLT 10 MG TABLET
3
QL
36 / 90 days
MAXALT MLT 5 MG TABLET
3
QL
72 / 90 days
naratriptan hcl 1 mg tablet
1
QL
54 / 90 days
naratriptan hcl 2.5 mg tablet
1
QL
27 / 90 days
RELPAX 20 MG TABLET
2
QL
36 / 90 days
RELPAX 40 MG TABLET
2
QL
18 / 90 days
rizatriptan benzoate (10 mg tablet, 10 mg tab rapdis)
1
QL
36 / 90 days
rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis)
1
QL
72 / 90 days
sumatriptan (5 mg spray, 20 mg spray)
1
QL
36 / 90 days
sumatriptan succinate (25 mg tablet, 50 mg tablet)
1
QL
54 / 90 days
sumatriptan succinate (4 pen injctr, 4 cartridge, 6 pen injctr, 6
syringe, 6 cartridge, 6 vial)
7
QL
9 / 90 days
sumatriptan succinate 100 mg tablet
1
QL
27 / 90 days
SUMAVEL DOSEPRO (4 ML, 6 ML)
9
TREXIMET
3
ZECUITY
3
zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet)
1
QL
36 / 90 days
zolmitriptan (5 mg tab rapdis, 5 mg tablet)
1
QL
18 / 90 days
ZOMIG (2.5 MG NASAL SPRAY, 2.5 MG TABLET, 5 MG
NASAL SPRAY)
3
QL
36 / 90 days
ZOMIG 5 MG TABLET
3
QL
18 / 90 days
ZOMIG ZMT 2.5 MG TABLET
3
QL
36 / 90 days
ZOMIG ZMT 5 MG TABLET
3
QL
18 / 90 days
Antimyasthenic Agents
Parasympathomimetics
BLOXIVERZ (5 ML VIAL, 10 ML VIAL)
9
ENLON-PLUS
9
guanidine hcl
2
MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG
TIMESPAN)
2
PAGE 50
PRODUCT DESCRIPTION
TIER
neostigmine methylsulfate (0.5 mg/ml vial, 1 mg/ml vial, 1:2000
vial, 1:1000 vial)
7
physostigmine salicylate
8
PROSTIGMIN
2
pyridostigmine bromide (60 mg tablet, 180 mg tablet er)
1
REGONOL
8
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg tablet, 100 mg tablet)
1
MYCOBUTIN
3
rifabutin
1
Antituberculars
CAPASTAT SULFATE
9
ethambutol hcl (100 mg tablet, 400 mg tablet)
1
isoniazid (50 mg/5 ml solution, 100 mg/ml vial, 100 mg tablet,
300 mg tablet)
1
MYAMBUTOL
3
PASER
3
PRIFTIN
3
pyrazinamide
1
RIFADIN (150 MG CAPSULE, 300 MG CAPSULE)
3
RIFADIN IV 600 MG VIAL
9
RIFAMATE
3
rifampin (150 mg capsule, 300 mg capsule)
1
rifampin 600 mg vial
7
RIFATER
3
SIRTURO
6
TRECATOR
3
PA
Antineoplastics
Alkylating Agents
ALKERAN 2 MG TABLET
PAGE 51
2
PRODUCT DESCRIPTION
TIER
ALKERAN 50 MG VIAL
9
BICNU
9
BUSULFEX
9
carboplatin (10 mg/ml vial, 150 mg vial)
7
CEENU (10 MG CAPSULE, 40 MG CAPSULE)
6
cisplatin
7
cyclophosphamide (1 g vial, 2 g vial, 500 mg vial)
7
cyclophosphamide (25 mg tablet, 25 mg capsule, 50 mg tablet,
50 mg capsule)
1
dacarbazine 100 mg vial
1
dacarbazine 200 mg vial
7
ELOXATIN (50 MG/10 ML VIAL, 100 MG/20 ML VIAL, 200
MG/40 ML VIAL)
9
PA
GLEOSTINE (10 MG CAPSULE, 40 MG CAPSULE, 100 MG
CAPSULE)
6
PA
GLIADEL
3
IFEX (1 GM VIAL, 3 GM VIAL)
9
ifosfamide (1 g/20 ml vial, 1 g vial, 3g/60ml vial, 3 g vial)
7
ifosfamide/mesna
1
LEUKERAN
2
LOMUSTINE (10 MG CAPSULE, 40 MG CAPSULE, 100 MG
CAPSULE)
6
PA
LONSURF (15 MG-6.14 MG TABLET, 20 MG-8.19 MG
TABLET)
6
PA
MATULANE
6
PA
melphalan hcl
7
MUSTARGEN
9
MYLERAN
2
oxaliplatin (50 mg vial, 100 mg vial)
7
PA
oxaliplatin (50 mg/10ml vial, 100mg/20ml vial)
7
PA
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG
CAPSULE)
6
PA
PAGE 52
PA
PRODUCT DESCRIPTION
TIER
TEMODAR 100 MG VIAL
6
PA
temozolomide (5 mg capsule, 20 mg capsule, 100 mg capsule,
140 mg capsule, 180 mg capsule, 250 mg capsule)
4
PA
TREANDA (25 MG VIAL, 45 MG/0.5 ML VIAL, 100 MG VIAL,
180 MG/2 ML VIAL)
9
VALCHLOR
6
ZANOSAR
9
QL
60 / 30 days
QL
22 / 30 days
Antiangiogenic Agents
POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG
6
REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MG
CAPSULE)
6
PA
THALOMID (50 MG CAPSULE, 100 MG CAPSULE, 150 MG
6
PA
PA
Antiestrogens/Modifiers
EMCYT
2
FARESTON
2
FASLODEX
6
SOLTAMOX
3
tamoxifen citrate (10 mg tablet, 20 mg tablet)
1
PA
Antimetabolites
ALIMTA (100 MG VIAL, 500 MG VIAL)
9
ARRANON
9
azacitidine
7
capecitabine (150 mg tablet, 500 mg tablet)
4
cladribine
7
CLOLAR
9
cytarabine
7
cytarabine/pf (1 g vial, 2 g/20 ml vial, 20 mg/ml vial, 100 mg
vial, 100 mg/5ml vial, 500 mg vial)
7
DACOGEN
9
decitabine
7
PAGE 53
PA
PRODUCT DESCRIPTION
TIER
DEPOCYT
9
DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400 MG
CAPSULE)
3
floxuridine
7
FLUDARA
9
fludarabine phosphate (50 mg vial, 50 mg/2 ml vial)
7
fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial,
500mg/10ml vial)
7
FOLOTYN (20 MG/ML VIAL, 40 MG/2 ML VIAL)
9
gemcitabine hcl (1 g vial, 1 g/26.3ml vial, 2 g/52.6ml vial, 200
mg vial, 200mg/5.26 vial)
7
PA
gemcitabine hcl 2 g vial
7
PA
GEMZAR (1 GRAM VIAL, 200 MG VIAL)
9
PA
HYDREA
3
hydroxyurea
1
mercaptopurine
1
methotrexate sodium 2.5 mg tablet
1
methotrexate sodium 25 mg/ml vial
7
methotrexate sodium/pf 1 g vial
7
NIPENT
9
pentostatin
7
PURINETHOL
3
PURIXAN
3
TABLOID
2
TREXALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,
15 MG TABLET)
3
VIDAZA
9
XELODA (150 MG TABLET, 500 MG TABLET)
6
PA
Antineoplastics, Other
ABRAXANE
9
ADRIAMYCIN
7
ALDARA
3
PAGE 54
PRODUCT DESCRIPTION
TIER
ALFERON N
6
amifostine crystalline
7
BCG (TICE STRAIN)
9
BELEODAQ
6
bleomycin sulfate (15 unit vial, 30 unit vial)
7
CERUBIDINE
9
COSMEGEN
9
dactinomycin
7
daunorubicin hcl (5 mg/ml vial, 20 mg vial)
7
DAUNOXOME
9
dexrazoxane hcl (250 mg vial, 500 mg vial)
7
DOCEFREZ (20 MG VIAL, 80 MG VIAL)
9
docetaxel (20 mg/2 ml vial, fnl 20mg/2 vial, 20mg/ml(1) vial, 80
mg/4 ml vial, 80 mg/8 ml vial, fnl 80mg/8 vial, 140 mg/7ml vial,
160 mg/8ml vial, 160mg/16ml vial, 200mg/20ml vial)
7
DOXIL
9
doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml vial, 20
mg/10ml vial, 20 mg vial, 50 mg vial, 50 mg/25ml vial)
7
doxorubicin hcl pegylated liposomal
7
ELLENCE
9
ELSPAR
9
epirubicin hcl (50 mg vial, 50 mg/25ml vial, 200mg/0.1l vial)
7
epirubicin hcl 200 mg vial
1
ERWINAZE
3
FARYDAK (10 MG CAPSULE, 15 MG CAPSULE, 20 MG
CAPSULE)
6
flutamide
1
FUSILEV
9
HALAVEN
3
HEXALEN
2
IDAMYCIN PFS
9
idarubicin hcl
7
imiquimod
1
PAGE 55
PA
PRODUCT DESCRIPTION
TIER
INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10
MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION
UNITS VIL)
6
IXEMPRA (15 MG KIT, 45 MG KIT)
9
JEVTANA
6
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25
mg tablet)
1
leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350
mg vial, 500mg/50ml vial, 500 mg vial)
7
leucovorin calcium 10 mg/ml vial
9
levoleucovorin calcium
7
MARQIBO
9
mesna
7
MESNEX 1 GRAM/10 ML VIAL
9
MESNEX 400 MG TABLET
3
mitomycin (5 mg vial, 20 mg vial, 40 mg vial)
7
mitoxantrone hcl
1
NAVELBINE (10 MG/ML VIAL, 50 MG/5 ML VIAL)
9
ONCASPAR
9
ONTAK
9
paclitaxel
7
PHOTOFRIN
7
PROLEUKIN
9
PROVENGE
6
SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT)
6
PA
PA
PA
PA
QL
1 / 28 days
PA
QL
SYLATRON 4-PACK (200 MCG, 300 MCG, 888 MCG)
4 / 28 days
6
PA
SYNRIBO
6
TAXOTERE (20 MG/ML VIAL, 80 MG/2 ML VIAL, 80 MG/4 ML
VIAL)
9
teniposide
9
THERACYS
9
PAGE 56
PRODUCT DESCRIPTION
TIER
TOTECT
9
TRELSTAR (3.75 MG SYRINGE, 11.25 MG SYRINGE, 22.5
MG VIAL, 22.5 MG SYRINGE)
3
TRELSTAR DEPOT
3
TRELSTAR LA
3
TRISENOX
9
VALSTAR
8
vinblastine sulfate (1 mg/ml vial, 10 mg vial)
1
vincristine sulfate (1 mg/ml vial, 2 mg/2 ml vial)
7
vinorelbine tartrate (10 mg/ml vial, 50 mg/5 ml vial)
7
VORAXAZE
3
XOFIGO
3
ZINECARD (250 MG VIAL, 500 MG VIAL)
9
ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM PUMP,
3.75% CREAM)
3
Aromatase Inhibitors, 3rd Generation
anastrozole
1
QL
30 / 30 days
ARIMIDEX
3
QL
30 / 30 days
AROMASIN
3
exemestane
1
FEMARA
3
PA
letrozole
1
PA
Enzyme Inhibitors
QL
BOSULIF 100 MG TABLET
60 / 30 days
6
PA
QL
BOSULIF 500 MG TABLET
30 / 30 days
6
PA
CAMPTOSAR (40 MG/2 ML VIAL, 100 MG/5 ML VIAL, 300
MG/15 ML VIAL)
9
ETOPOPHOS
9
etoposide 20 mg/ml vial
7
PAGE 57
PRODUCT DESCRIPTION
TIER
etoposide 50 mg capsule
1
GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET)
6
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE)
6
HYCAMTIN 4 MG VIAL
9
IMBRUVICA
6
PA
PA
QL
120 / 30 days
PA
QL
INLYTA (1 MG TABLET, 5 MG TABLET)
120 / 30 days
6
PA
irinotecan hcl (40 mg/2 ml vial, 100 mg/5ml vial, 500mg/25ml
vial)
7
JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20
6
QL
LYNPARZA
6
PA
MEKINIST (0.5 MG TABLET, 2 MG TABLET)
3
QL
60 / 30 days
30 / 30 days
PA
QL
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE)
120 / 30 days
3
PA
topotecan hcl (4 mg/4 ml vial, 4 mg vial)
7
VOTRIENT
6
ZELBORAF
6
PA
QL
240 / 30 days
PA
QL
ZYTIGA
120 / 30 days
6
PA
Molecular Target Inhibitors
QL
30 / 30 days
AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,
10 MG TABLET)
6
AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG
TABLET)
6
CAPRELSA 100 MG TABLET
6
QL
60 / 30 days
CAPRELSA 300 MG TABLET
6
QL
30 / 30 days
PAGE 58
PA
QL
30 / 30 days
PA
PRODUCT DESCRIPTION
TIER
QL
COMETRIQ 100 MG DAILY-DOSE PK
60 / 30 days
6
PA
QL
COMETRIQ 140 MG DAILY-DOSE PK
120 / 30 days
6
PA
QL
COMETRIQ 60 MG DAILY-DOSE PACK
90 / 30 days
6
PA
QL
ERIVEDGE
30 / 30 days
6
PA
GLEEVEC (100 MG TABLET, 400 MG TABLET)
5
PA
HERCEPTIN
9
PA
IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MG
CAPSULE)
6
ICLUSIG (15 MG TABLET, 45 MG TABLET)
6
ISTODAX
9
KADCYLA (100 MG VIAL, 160 MG VIAL)
3
KYPROLIS
3
LENVIMA (14 MG DAILY, 20 MG DAILY)
6
QL
21 / 28 days
PA
QL
30 / 30 days
QL
60 / 30 days
PA
QL
LENVIMA 10 MG DAILY DOSE
30 / 30 days
6
PA
QL
LENVIMA 24 MG DAILY DOSE
90 / 30 days
6
PA
NEXAVAR
6
PA
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET,
80 MG TABLET, 100 MG TABLET, 140 MG TABLET)
6
PA
STIVARGA
6
QL
252 / 84 days
PA
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG
6
PA
TARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG
TABLET)
6
PA
PAGE 59
PRODUCT DESCRIPTION
TIER
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE)
5
TORISEL
3
TYKERB
6
VECTIBIX (100 MG/5 ML VIAL, 400 MG/20 ML VIAL)
9
VELCADE
8
XALKORI (200 MG CAPSULE, 250 MG CAPSULE)
6
ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL)
3
ZOLINZA
6
ZYDELIG (100 MG TABLET, 150 MG TABLET)
3
ZYKADIA
6
PA
PA
PA
PA
Monoclonal Antibodies
ADCETRIS
3
ARZERRA (100 MG/5 ML VIAL, 1,000 MG/50 ML VIAL)
3
AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL)
9
BEXXAR (14 MG/ML DOSIMETRIC, 14 MG/ML
THERAPEUTIC, 131 IODINE THERAPEUTIC, 131 IODINE
DOSIMETRIC)
9
BLINCYTO
6
CYRAMZA (100 MG/10 ML VIAL, 500 MG/50 ML VIAL)
9
ERBITUX (100 MG/50 ML VIAL, 200 MG/100 ML VIAL)
9
GAZYVA
9
KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)
6
ODOMZO
6
PERJETA
3
PROLIA
6
PA
RITUXAN
9
PA
UNITUXIN
9
XGEVA
9
YERVOY (50 MG/10 ML VIAL, 200 MG/40 ML VIAL)
3
ZEVALIN
3
PAGE 60
PA
PA
PA
PRODUCT DESCRIPTION
TIER
Retinoids
bexarotene
4
PANRETIN
2
TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG CAPSULE)
6
PA
TRETIN-X 0.075% CREAM
3
ST
tretinoin 10 mg capsule
4
PA
PA
Antiparasitics
Anthelmintics
ALBENZA
3
BILTRICIDE
3
ivermectin
1
SOOLANTRA
3
spinosad
1
STROMECTOL
3
ULESFIA
2
QL
1362 / 30 days
QL
72 / 90 days
QL
1 / 30 days
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET)
3
atovaquone
1
atovaquone/proguanil hcl (62.5-25 mg tablet, 250-100 mg
tablet)
1
chloroquine phosphate (250 mg tablet, 500 mg tablet)
1
COARTEM
3
DARAPRIM
3
hydroxychloroquine sulfate
1
MALARONE (62.5-25 MG PED TAB, 250-100 MG TABLET)
3
mefloquine hcl
1
MEPRON
3
NEBUPENT
3
PENTAM 300
9
PLAQUENIL
3
PAGE 61
PRODUCT DESCRIPTION
TIER
primaquine phosphate
1
QUALAQUIN
3
quinine sulfate
1
YODOXIN (210 MG TABLET, 650 MG TABLET)
3
Pediculicides/Scabicides
EURAX (CREAM, LOTION)
3
lindane (1 % lotion, 1 % shampoo)
1
malathion
1
OVIDE
3
permethrin
1
SKLICE
3
QL
120 / 7 days
QL
90 / 30 days
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
benztropine mesylate (2 ml vial, 2 ml ampul)
7
COGENTIN
9
trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)
1
Antiparkinson Agents, Other
amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg
capsule)
1
carbidopa/levodopa/entacapone (12.5-50 mg tablet, 18.7575mg tablet, 25-100-200 tablet, 31.25-125 tablet, 37.5-150mg
tablet, 50-200-200 tablet)
1
COMTAN
3
entacapone
1
STALEVO 100
2
STALEVO 125
2
STALEVO 150
2
STALEVO 200
2
STALEVO 50
2
STALEVO 75
2
TASMAR
2
PAGE 62
PRODUCT DESCRIPTION
tolcapone
TIER
1
QL
90 / 30 days
Dopamine Agonists
APOKYN
6
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)
1
MIRAPEX (0.125 MG TABLET, 0.25 MG TABLET, 0.5 MG
TABLET, 0.75 MG TABLET, 1 MG TABLET, 1.5 MG TABLET)
3
QL
90 / 30 days
MIRAPEX ER (ER 0.375 MG TABLET, ER 0.75 MG TABLET,
ER 1.5 MG TABLET, ER 2.25 MG TABLET, ER 3 MG TABLET,
ER 3.75 MG TABLET, ER 4.5 MG TABLET)
3
QL
30 / 30 days
NEUPRO (1 HR PATCH, 2 HR PATCH, 3 HR PATCH, 4 HR
PATCH, 6 HR PATCH, 8 HR PATCH)
3
QL
30 / 30 days
PARLODEL (2.5 MG TABLET, 5 MG CAPSULE)
3
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg
tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)
1
QL
90 / 30 days
pramipexole di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h,
1.5 mg tab er 24h, 3 mg tab er 24h, 4.5 mg tab er 24h)
1
QL
30 / 30 days
REQUIP (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET,
2 MG TABLET, 3 MG TABLET, 4 MG TABLET, 5 MG TABLET)
3
REQUIP XL (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8
3
QL
30 / 30 days
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg
1
ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er
24h, 8 mg tab er 24h, 12 mg tab er 24h)
1
QL
30 / 30 days
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa
1
carbidopa/levodopa (10mg-100mg tab rapdis, 10mg-100mg
tablet, 25mg-250mg tab rapdis, 25mg-250mg tablet, 25mg100mg tab rapdis, 25mg-100mg tablet er, 25mg-100mg tablet,
50mg-200mg tablet er)
1
DUOPA
6
LODOSYN
3
PARCOPA (10 MG-100 MG ODT, 25 MG-100 MG ODT, 25
MG-250 MG ODT)
3
RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG
CAP, ER 48.75 MG-195 MG CAP, ER 61.25 MG-245 MG CAP)
3
SINEMET 10-100
3
PAGE 63
PRODUCT DESCRIPTION
TIER
SINEMET 25-100
3
SINEMET 25-250
3
SINEMET CR (CR 25-100 TABLET, CR 50-200 TABLET)
3
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT (0.5 MG TABLET, 1 MG TABLET)
3
ELDEPRYL
3
selegiline hcl (5 mg tablet, 5 mg capsule)
1
ZELAPAR
3
Antipsychotics
1st Generation/Typical
QL
ADASUVE
30 / 30 days
6
PA
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet,
2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)
1
HALDOL
9
HALDOL DECANOATE 100
9
HALDOL DECANOATE 50
9
haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet,
1
haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul, 100
mg/ml ampul, 100 mg/ml vial)
7
haloperidol lactate (5 mg/ml vial, 5 mg/ml ampul)
7
haloperidol lactate 2 mg/ml oral conc
1
loxapine succinate (5 mg capsule, 10 mg capsule, 25 mg
1
LOXITANE (5 MG CAPSULE, 10 MG CAPSULE, 25 MG
CAPSULE)
3
ORAP (1 MG TABLET, 2 MG TABLET)
2
pimozide (1 mg tablet, 2 mg tablet)
1
thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100
mg tablet)
1
thiothixene (1 mg capsule, 2 mg capsule, 5 mg capsule, 10 mg
capsule)
1
trifluoperazine hcl (1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg
tablet)
1
PAGE 64
PRODUCT DESCRIPTION
TIER
2nd Generation/Atypical
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG
TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET,
TITRATION PACK)
3
QL
60 / 30 days
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG
3
QL
60 / 30 days
GEODON 20 MG/ML VIAL
8
INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 9 MG
TABLET)
3
QL
30 / 30 days
INVEGA ER 6 MG TABLET
3
QL
60 / 30 days
INVEGA SUSTENNA (39 MG SYR, 78 MG SYR, 117 MG SY,
156 MG SY, 234 MG SY)
9
INVEGA TRINZA (273 MG/0.875 ML, 410 MG/1.315 ML, 546
MG/1.75 ML, 819 MG/2.625 ML)
9
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET,
3
QL
30 / 30 days
olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg
tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg
tablet, 20 mg tablet, 20 mg tab rapdis)
1
QL
30 / 30 days
olanzapine 10 mg vial
7
paliperidone (1.5 mg tab er 24, 3 mg tab er 24, 9 mg tab er 24)
1
QL
30 / 30 days
paliperidone 6 mg tab er 24
1
QL
60 / 30 days
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet,
200 mg tablet, 300 mg tablet, 400 mg tablet)
1
QL
60 / 30 days
REXULTI (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET,
3
QL
30 / 30 days
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG
3
QL
60 / 30 days
RISPERDAL 1 MG/ML SOLUTION
3
RISPERDAL 4 MG TABLET
3
QL
120 / 30 days
RISPERDAL CONSTA (12.5 MG SYR, 25 MG SYR, 37.5 MG
SYR, 50 MG SYR)
9
RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG ODT, 3
MG ODT)
3
QL
60 / 30 days
RISPERDAL M-TAB 4 MG ODT
3
QL
120 / 30 days
risperidone (0.25 mg tab rapdis, 1 mg/ml solution)
1
PAGE 65
PRODUCT DESCRIPTION
TIER
risperidone (0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mg tablet, 1
mg tab rapdis, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg
tab rapdis, 3 mg tablet)
1
QL
60 / 30 days
risperidone (4 mg tab rapdis, 4 mg tablet)
1
QL
120 / 30 days
SAPHRIS (5 MG TAB SL BLK CHERRY, 5 MG TABLET
SUBLINGUAL, 10 MG TAB SUBLINGUAL, 10 MG TAB SL BLK
CHERY)
3
QL
60 / 30 days
SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
3
QL
60 / 30 days
ziprasidone hcl (40 mg capsule, 60 mg capsule, 80 mg capsule)
1
QL
60 / 30 days
ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,
2
QL
30 / 30 days
ZYPREXA 10 MG VIAL
9
QL
ZYPREXA RELPREVV (210 MG VL KIT, 300 MG VL KIT)
2 / 30 days
9
PA
QL
ZYPREXA RELPREVV 405 MG VL KIT
1 / 30 days
9
PA
ZYPREXA ZYDIS (5 MG TABLET, 10 MG TABLET, 15 MG
2
QL
30 / 30 days
clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 100 mg tab
rapdis)
3
QL
120 / 30 days
clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 150 mg
tab rapdis, 200 mg tablet, 200 mg tab rapdis)
1
QL
120 / 30 days
CLOZARIL (25 MG TABLET, 100 MG TABLET)
3
QL
120 / 30 days
FAZACLO (12.5 MG ODT, 25 MG ODT, 100 MG ODT, 150 MG
ODT, 200 MG ODT)
3
QL
120 / 30 days
VERSACLOZ
3
Treatment-Resistant
Antispasticity Agents
baclofen (10 mg tablet, 20 mg tablet)
1
COMFORT PAC-TIZANIDINE
3
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE, 100 MG
CAPSULE)
3
DANTRIUM 20 MG VIAL
9
PAGE 66
PRODUCT DESCRIPTION
TIER
dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg
capsule)
1
dantrolene sodium 20 mg vial
7
GABLOFEN (50 MCG/ML SYRINGE, 10,000 MCG/20 ML VIAL,
10,000 MCG/20 ML SYRG, 40,000 MCG/20 ML VIAL, 40,000
MCG/20 ML SYRG)
6
PA
GABLOFEN (ML SYRG, ML VIAL)
9
PA
LIORESAL INTRATHECAL (0.05 MG/1 ML AMP, 10 MG/5 ML
K, 10 MG/20 ML K, 40 MG/20 ML K)
9
MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET)
3
QL
30 / 30 days
ST
tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg tablet, 4 mg
1
XEOMIN (50 VIAL, 100 VIAL)
6
ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG
TABLET, 6 MG CAPSULE)
3
PA
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT
2
QL
30 / 30 days
INTELENCE (25 MG TABLET, 100 MG TABLET)
2
QL
120 / 30 days
INTELENCE 200 MG TABLET
2
QL
60 / 30 days
nevirapine (50 mg/5 ml oral susp, 200 mg tablet, 400 mg tab er
24h)
1
RESCRIPTOR (100 MG TABLET, 200 MG TABLET)
2
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG
TABLET)
2
VIRAMUNE 200 MG TABLET
3
VIRAMUNE 50 MG/5 ML SUSP
2
VIRAMUNE XR (100 MG TABLET, 400 MG TABLET)
3
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir sulfate
1
abacavir sulfate/lamivudine/zidovudine
1
COMBIVIR
3
PAGE 67
PRODUCT DESCRIPTION
TIER
COMPLERA
2
didanosine (125 mg capsule dr, 200 mg capsule dr, 250 mg
capsule dr, 400 mg capsule dr)
1
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
2
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG
TABLET)
2
EPZICOM
2
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet)
1
lamivudine/zidovudine
1
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE)
3
RETROVIR 200 MG/20 ML VIAL
6
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule,
30 mg capsule, 40 mg capsule)
1
TRIZIVIR
2
TRUVADA
2
VIDEX (2 GM SOLN, 4 GM SOLN)
2
VIDEX EC (EC 125 MG CAPSULE, EC 200 MG CAPSULE, EC
250 MG CAPSULE, EC 400 MG CAPSULE)
3
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG
2
VIREAD POWDER
3
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG
3
ZIAGEN 20 MG/ML SOLUTION
2
ZIAGEN 300 MG TABLET
3
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)
1
PA
Anti-HIV Agents, Other
ATRIPLA
2
FUZEON (90 MG VIAL, CONVENIENCE KIT)
6
ISENTRESS 100 MG POWDER PACKET
3
QL
60 / 30 days
ISENTRESS 100 MG TABLET CHEW
2
QL
180 / 30 days
ISENTRESS 25 MG TABLET CHEW
2
QL
120 / 30 days
ISENTRESS 400 MG TABLET
2
PAGE 68
PRODUCT DESCRIPTION
TIER
SELZENTRY (150 MG TABLET, 300 MG TABLET)
2
STRIBILD
2
TIVICAY
6
TRIUMEQ
3
TYBOST
3
VITEKTA (85 MG TABLET, 150 MG TABLET)
3
QL
30 / 30 days
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)
2
CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE)
2
EVOTAZ
3
INVIRASE (200 MG CAPSULE, 500 MG TABLET)
2
KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400100/5 ML ORAL SOLU)
2
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
2
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG
SOFTGEL CAP)
2
PREZCOBIX
3
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150
MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG
TABLET)
2
REYATAZ (100 MG CAPSULE, 150 MG CAPSULE, 200 MG
2
REYATAZ 50 MG POWDER PACKET
3
VIRACEPT (250 MG TABLET, 625 MG TABLET)
2
Anti-cytomegalovirus (CMV) Agents
cidofovir
7
CYTOVENE
9
foscarnet sodium
7
FOSCAVIR
9
ganciclovir sodium
7
VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET)
6
PA
valganciclovir hcl
4
PA
VISTIDE
9
PAGE 69
PRODUCT DESCRIPTION
ZIRGAN
TIER
3
Anti-influenza Agents
FLUMADINE
3
RELENZA
3
rimantadine hcl
1
TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE)
QL
20 / 180 days
2
QL
10 / 180 days
TAMIFLU 30 MG CAPSULE
2
QL
20 / 180 days
TAMIFLU 6 MG/ML SUSPENSION
2
QL
30 / 30 days
Antihepatitis Agents
adefovir dipivoxil
4
PA
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1
MG TABLET)
6
PA
COPEGUS
6
PA
DAKLINZA (30 MG TABLET, 60 MG TABLET)
6
PA
entecavir (0.5 mg tablet, 1 mg tablet)
4
PA
EPIVIR HBV 100 MG TABLET
6
QL
30 / 30 days
PA
EPIVIR HBV 25 MG/5 ML SOLN
6
PA
HARVONI
5
PA
HEPSERA
6
QL
30 / 30 days
PA
INCIVEK
6
PA
INFERGEN 15 MCG/0.5 ML VIAL
6
QL
6 / 30 days
INFERGEN 9 MCG/0.3 ML VIAL
6
QL
4 / 30 days
QL
lamivudine 100 mg tablet
30 / 30 days
4
PA
OLYSIO
6
QL
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)
5
PA
PAGE 70
30 / 30 days
PRODUCT DESCRIPTION
TIER
PEGASYS PROCLICK (135, 180)
5
PEGINTRON (50 MCG KIT, 80 MCG KIT, 120 MCG KIT, 150
MCG KIT)
6
PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80 MCG, 80
MCG 4PK, 120 MCG 4PK, 120 MCG, 150 MCG, 150 MCG
4PK)
6
REBETOL 200 MG CAPSULE
6
PA
REBETOL 40 MG/ML SOLUTION
6
PA
RIBASPHERE RIBAPAK (200-400 MG, 600-600 MG, 600-400
MG)
6
PA
RIBASPHERE RIBAPAK 400-400 MG
6
PA
RIBATAB (400-600 MG, 600-600 MG)
6
PA
RIBATAB 400-400 MG DOSEPACK
6
PA
ribavirin (200-400(7) tab ds pk, 200 mg tablet, 400-400(7) tab
ds pk, 400 mg tablet, 600-600(7) tab ds pk, 600-400(7) tab ds
pk, 600 mg tablet)
4
PA
ribavirin 200 mg capsule
4
PA
SOVALDI
5
QL
TECHNIVIE
6
PA
TYZEKA
6
PA
VICTRELIS
6
PA
VIEKIRA PAK
6
PA
VIRAZOLE
3
PA
PA
QL
4 / 28 days
PA
QL
4 / 28 days
PA
30 / 30 days
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg
tablet, 800 mg tablet)
1
acyclovir 5 % oint. (g)
1
acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg vial)
7
DENAVIR
3
famciclovir (125 mg tablet, 250 mg tablet, 500 mg tablet)
1
FAMVIR (125 MG TABLET, 250 MG TABLET, 500 MG
TABLET)
3
PAGE 71
QL
30 / 30 days
QL
15 / 90 days
PRODUCT DESCRIPTION
TIER
SITAVIG
3
trifluridine
1
valacyclovir hcl (500 mg tablet, 1000 mg tablet)
1
VALTREX (1 GM, 500 MG)
3
VIROPTIC
3
XERESE
3
ZOVIRAX (200 MG/5 ML SUSP, 200 MG CAPSULE, 400 MG
3
ZOVIRAX 5% CREAM
2
ZOVIRAX 5% OINTMENT
3
QL
5 / 30 days
QL
30 / 30 days
Anxiolytics
Anxiolytics, Other
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er
24h, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg/ml oral conc, 1 mg
tablet, 1 mg tab rapdis, 1 mg tab er 24h, 2 mg tab rapdis, 2 mg
tablet, 2 mg tab er 24h, 3 mg tab er 24h)
1
amitriptyline hcl/chlordiazepoxide (12.5mg-5mg tablet, 25 mg10mg tablet)
1
ATIVAN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET)
3
ATIVAN (2 MG/ML VIAL, 20 MG/10 ML VIAL)
9
PA
ATIVAN (4 MG/ML VIAL, 40 MG/10 ML VIAL)
9
PA
buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg
1
BUTISOL SODIUM (30 MG TABLET, 30 MG/5 ML ELX, 50 MG
TABLET)
3
chlordiazepoxide hcl (5 mg capsule, 10 mg capsule, 25 mg
capsule)
1
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg
tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet, 2 mg tab
rapdis, 2 mg tablet)
1
clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet, 15 mg
tablet)
1
diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml
oral conc, 10 mg tablet)
1
diazepam 5 mg/ml syringe
9
PAGE 72
PA
PRODUCT DESCRIPTION
TIER
diazepam 5 mg/ml vial
1
KLONOPIN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET)
3
lisinopril (5 mg tablet, 10 mg tablet)
1
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg/ml oral conc, 2 mg
tablet)
1
lorazepam (2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml syringe)
7
PA
lorazepam 4 mg/ml vial
7
PA
meprobamate (200 mg tablet, 400 mg tablet)
1
midazolam hcl (2 mg/2 ml vial, 5 mg/ml(1) vial, 5 mg/ml vial, 5
mg/5 ml vial, 10 mg/10ml vial, 10 mg/2 ml vial)
7
midazolam hcl 2 mg/ml syrup
1
midazolam hcl/pf (2 mg/2 ml cartridge, 2 mg/2 ml vial, 2 mg/2
ml syringe, 5 mg/ml cartridge, 5 mg/ml syringe, 5 mg/5 ml vial, 5
mg/ml(1) vial, 10 mg/2 ml vial, 10 mg/2 ml syringe)
7
NIRAVAM (0.25 MG ODT, 0.5 MG ODT, 1 MG ODT, 2 MG
ODT)
3
oxazepam (10 mg capsule, 15 mg capsule, 30 mg capsule)
1
TRANXENE T-TAB (3.75 MG, 7.5 MG, 15 MG)
3
VALIUM (2 MG TABLET, 5 MG TABLET, 10 MG TABLET)
3
XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2
MG TABLET)
3
XANAX XR (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3
MG TABLET)
3
PA
Bipolar Agents
Bipolar Agents, Other
SAPHRIS 2.5 MG TAB SL BLK CHRY
3
QL
60 / 30 days
Mood Stabilizers
lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg
tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule)
1
lithium citrate
2
LITHOBID
3
PAGE 73
PRODUCT DESCRIPTION
TIER
Blood Glucose Regulators
Antidiabetic Agents
acarbose (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
ACTOPLUS MET (15 MG-500 MG TAB, 15 MG-850 MG TAB)
3
QL
60 / 30 days
ST
ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB)
2
ACTOS (15 MG TABLET, 30 MG TABLET, 45 MG TABLET)
3
ST
QL
30 / 30 days
ST
AMARYL (1 MG TABLET, 2 MG TABLET, 4 MG TABLET)
3
AVANDAMET (2 MG-500 MG TABLET, 2 MG-1,000 MG TAB, 4
MG-500 MG TABLET, 4 MG-1,000 MG TABLET)
2
AVANDARYL (4 MG-2 MG TABLET, 4 MG-1 MG TABLET, 4
MG-4 MG TABLET, 8 MG-4 MG TABLET, 8 MG-2 MG
TABLET)
2
AVANDIA (2 MG TABLET, 4 MG TABLET, 8 MG TABLET)
2
ST
BYDUREON
8
QL
4 / 30 days
BYDUREON PEN
8
QL
4 / 28 days
BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ)
8
QL
2 / 30 days
chlorpropamide (100 mg tablet, 250 mg tablet)
1
CYCLOSET
3
DIABETA (1.25 MG TABLET, 2.5 MG TABLET, 5 MG TABLET)
3
DUETACT (30-4 MG TABLET, 30-2 MG TABLET)
3
FARXIGA (5 MG TABLET, 10 MG TABLET)
3
FORTAMET (ER 500 MG TABLET, ER 1,000 MG TABLET)
3
glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet)
1
glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg
tab er 24, 10 mg tablet)
1
glipizide/metformin hcl (2.5-250 mg tablet, 2.5-500 mg tablet, 5
mg-500mg tablet)
1
GLUCOPHAGE (500 MG TABLET, 850 MG TABLET, 1,000
MG TABLET)
3
PAGE 74
QL
60 / 30 days
ST
QL
60 / 30 days
ST
ST
ST
ST
PRODUCT DESCRIPTION
TIER
GLUCOPHAGE XR (500 MG TAB, 750 MG TAB)
3
GLUCOTROL (5 MG TABLET, 10 MG TABLET)
3
GLUCOTROL XL (2.5 MG TABLET, 5 MG TABLET, 10 MG
TABLET)
3
GLUCOVANCE (2.5-500 MG TABLET, 5-500 MG TABLET)
3
ST
GLUMETZA (ER 500 MG TABLET, ER 1,000 MG TABLET)
3
ST
glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet)
1
glyburide,micronized (1.5 mg tablet, 3 mg tablet, 6 mg tablet)
1
glyburide/metformin hcl (1.25-250mg tablet, 2.5-500 mg tablet,
5 mg-500mg tablet)
1
GLYNASE (1.5 MG, 3 MG, 6 MG)
3
GLYSET (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
2
GLYXAMBI (10 MG TABLET, 25 MG TABLET)
3
QL
INVOKAMET (50-1,000 MG TABLET, 50-500 MG TABLET,
150-1,000 MG TABLET, 150-500 MG TABLET)
2
ST
INVOKANA 100 MG TABLET
2
QL
60 / 30 days
INVOKANA 300 MG TABLET
2
QL
30 / 30 days
JANUMET (50-1,000 MG TABLET, 50-500 MG TABLET)
2
ST
JANUMET XR (50-500 MG TABLET, 50-1,000 MG TABLET,
100-1,000 MG TABLET)
2
JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
2
ST
QL
30 / 30 days
30 / 30 days
ST
QL
30 / 30 days
ST
JARDIANCE (10 MG TABLET, 25 MG TABLET)
2
JENTADUETO (2.5 MG-850 MG TAB, 2.5 MG-1000 MG TAB,
2.5 MG-500 MG TAB)
2
JUVISYNC (50-10 MG TABLET, 50-20 MG TABLET, 50-40 MG
TABLET, 100-20 MG TABLET, 100-40 MG TABLET, 100-10
MG TABLET)
3
KAZANO (12.5-500 MG TABLET, 12.5-1,000 MG TABLET)
3
QL
60 / 30 days
ST
QL
60 / 30 days
ST
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500
MG TABLET)
PAGE 75
QL
60 / 30 days
2
ST
PRODUCT DESCRIPTION
TIER
metformin hcl (500 mg tab er 24, 500 mg tab er 24h, 500 mg
tablet, 750 mg tab er 24h, 850 mg tablet, 1000 mg tab er 24,
1000 mg tablet)
1
nateglinide (60 mg tablet, 120 mg tablet)
1
NESINA (6.25 MG TABLET, 12.5 MG TABLET, 25 MG
TABLET)
3
ONGLYZA (2.5 MG TABLET, 5 MG TABLET)
2
QL
90 / 30 days
QL
30 / 30 days
ST
QL
30 / 30 days
ST
OSENI (12.5-15 MG TABLET, 12.5-30 MG TABLET, 12.5-45
MG TABLET, 25-30 MG TABLET, 25-15 MG TABLET, 25-45
MG TABLET)
3
ST
pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg tablet)
1
QL
30 / 30 days
pioglitazone hcl/glimepiride (30 mg-4 mg tablet, 30 mg-2 mg
tablet)
1
pioglitazone hcl/metformin hcl (15mg-500mg tablet, 15mg850mg tablet)
1
QL
60 / 30 days
QL
PRANDIMET (1 MG TABLET, 2 MG TABLET)
60 / 30 days
3
ST
PRANDIN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET)
3
QL
240 / 30 days
PRECOSE (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
3
repaglinide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
QL
240 / 30 days
RIOMET
3
ST
STARLIX (60 MG TABLET, 120 MG TABLET)
3
QL
90 / 30 days
SYMLINPEN 120
3
SYMLINPEN 60
3
SYNJARDY (5-1,000 MG TABLET, 5-500 MG TABLET, 12.5500 MG TABLET, 12.5-1,000 MG TABLET)
3
TANZEUM (30 MG PEN, 50 MG PEN)
9
QL
4 / 28 days
tolazamide (250 mg tablet, 500 mg tablet)
1
tolbutamide
1
QL
TRADJENTA
30 / 30 days
2
ST
PAGE 76
PRODUCT DESCRIPTION
TIER
TRULICITY (0.75 ML PEN, 1.5 ML PEN)
9
QL
2 / 28 days
VICTOZA 2-PAK
8
QL
10 / 30 days
VICTOZA 3-PAK
8
QL
10 / 30 days
WELCHOL (3.75G PACKET, 625 MG TABLET)
3
XIGDUO XR (5 MG-1,000 MG TABLET, 5 MG-500 MG
TABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)
3
ST
Glycemic Agents
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL, 1 MG
HYPOKIT 2-PACK)
8
GLUCAGON EMERGENCY KIT
8
glucagon hcl
7
PROGLYCEM
3
Insulins
AFREZZA (4 UNITS CARTRIDGE INH, 30-4 UNIT + 60-8
UNIT, 60-4 UNIT + 30-8 UNIT, 60-8 UNIT + 30-12 UNIT)
3
APIDRA
2
APIDRA SOLOSTAR
2
HUMALOG (100 CARTRIDGE, 100 VIAL)
2
HUMALOG KWIKPEN U-100
2
2
HUMALOG MIX 50-50
2
HUMALOG MIX 50-50 KWIKPEN
2
HUMALOG MIX 75-25
2
2
HUMULIN R U-500
2
LANTUS
2
LANTUS SOLOSTAR
2
LEVEMIR
2
LEVEMIR FLEXPEN
2
LEVEMIR FLEXTOUCH
2
NOVOLOG (100 CARTRIDGE, 100 VIAL)
2
NOVOLOG FLEXPEN
2
PAGE 77
PRODUCT DESCRIPTION
TIER
NOVOLOG MIX 70-30
2
NOVOLOG MIX 70-30 FLEXPEN
2
TOUJEO SOLOSTAR
3
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
ACD-A
3
ACTIVASE (50 MG VIAL, 100 MG VIAL)
9
ANGIOMAX
9
argatroban
1
argatroban in 0.9 % sodium chloride (0.9 % 125 mg/125 vial,
0.9 % 250mg/250 iv soln)
7
argatroban in sodium chloride, iso-osmotic
7
ARIXTRA (2.5 MG SYRINGE, 2.5 MG/0.5 ML SYRINGE, 5
MG/0.4 ML SYRINGE, 7.5 MG/0.6 ML SYRINGE, 10 MG/0.8
ML SYRINGE)
6
bivalirudin 250 mg vial
7
CATHFLO ACTIVASE
9
CEPROTIN (400-600 VIAL, 800-1,200 VIAL)
6
citrate phosphate dextros soln
3
COUMADIN (1 MG TABLET, 2 MG TABLET, 2.5 MG TABLET,
3 MG TABLET, 4 MG TABLET, 5 MG TABLET, 6 MG TABLET,
7.5 MG TABLET, 10 MG TABLET)
2
COUMADIN 5 MG VIAL
9
ELIQUIS (2.5 MG TABLET, 5 MG TABLET)
3
QL
30 / 30 days
enoxaparin sodium (100 mg/ml syringe, 150 mg/ml syringe)
4
QL
60 / 30 days
enoxaparin sodium (80mg/0.8ml syringe, 120mg/.8ml syringe)
4
QL
48 / 30 days
enoxaparin sodium 300mg/3ml vial
4
QL
180 / 30 days
enoxaparin sodium 30mg/0.3ml syringe
4
QL
18 / 30 days
4
QL
24 / 30 days
4
QL
36 / 30 days
fondaparinux sodium (2.5 mg/0.5 syringe, 5mg/0.4ml syringe,
7.5mg/0.6 syringe, 10mg/0.8ml syringe)
4
PAGE 78
PA
PRODUCT DESCRIPTION
TIER
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML
SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING,
12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000
UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML
VL)
6
heparin sodium,porcine (10 unit/ml vial, 10 unit/ml syringe,
100/ml (1) syringe, 100/ml vial, 200/2 ml syringe, 300/3 ml
syringe, 500/5 ml syringe, 1000/ml vial, 5000/ml vial, 5000/ml(1)
cartridge, 10000/ml vial, 20000/ml vial)
7
heparin sodium,porcine in 0.45 % sodium chloride
(hepar12500/250 iv soln, hepar25000/500 iv soln,
hepar25000/250 iv soln)
7
heparin sodium,porcine in 0.9 % sodium chloride (% 10 unit/ml
kit, % 30 unit/3 syringe, % 100/ml kit)
7
heparin sodium,porcine in 0.9 % sodium chloride/pf (2k/1000ml
iv soln, 1000/500ml iv soln)
7
heparin sodium,porcine/dextrose 5 % in water (20k/500ml iv
soln, 12500/250 iv soln, 25000/250 iv soln, 25000/500 iv soln)
7
heparin sodium,porcine/pf (1 unit/ml syringe, 10 unit/ml syringe,
10 unit/ml vial, 100/ml (1) vial, 100/ml (1) syringe, 200/2 ml
syringe, 300/3 ml syringe, 500/5 ml syringe, 1000/10 ml syringe,
1000/ml vial, 5000/0.5ml syringe, 5000/0.5ml vial)
7
IPRIVASK
9
LOVENOX (100 MG/ML SYRINGE, 150 MG/ML SYRINGE)
6
QL
60 / 30 days
LOVENOX (80 ML SYRINGE, 120 ML SYRINGE)
6
QL
48 / 30 days
LOVENOX 30 MG/0.3 ML SYRINGE
6
QL
18 / 30 days
LOVENOX 300 MG/3 ML VIAL
6
QL
180 / 30 days
6
QL
24 / 30 days
6
QL
36 / 30 days
PRADAXA (75 MG CAPSULE, 150 MG CAPSULE)
2
QL
60 / 30 days
REFLUDAN
3
RETAVASE (VIAL HALF-KIT, VIAL KIT)
9
SAVAYSA (15 MG TABLET, 30 MG TABLET, 60 MG TABLET)
3
TNKASE
9
TRICITRASOL
3
PAGE 79
PRODUCT DESCRIPTION
TIER
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg
tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10
mg tablet)
1
XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET)
2
QL
30 / 30 days
XARELTO STARTER PACK
2
QL
51 / 365 days
Blood Formation Modifiers
AGRYLIN
3
ALBUKED-25
6
PA
ALBUKED-5
6
PA
albumin human (5 % iv soln, 25 % iv soln, 25 % vial)
4
PA
ALBUMINAR-25
6
PA
ALBUMINAR-5
6
PA
ALBURX (5% VIAL, 25% VIAL)
6
PA
ALBUTEIN (5% VIAL, 25% VIAL)
6
PA
anagrelide hcl (0.5 mg capsule, 1 mg capsule)
1
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML VIAL, 25
MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40 MCG/0.4 ML
SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100
MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 150 MCG/0.3 ML
SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML
SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE,
300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)
5
ATRYN 1,750 UNIT VIAL
6
BERINERT
6
PA
BUMINATE (5% IV SOLUTION, 25% IV SOLUTION)
6
PA
CINRYZE
6
EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000
UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML
VIAL, 20,000 UNITS/ML VIAL)
6
QL
FLEXBUMIN (5% IV SOLUTION, 25% IV SOLUTION)
6
PA
GRANIX (300 MCG/0.5 ML SYRINGE, 300 MCG/0.5 ML SAFE
SYR, 480 MCG/0.8 ML SYRINGE, 480 MCG/0.8 ML SAFE
SYR)
6
PA
HESPAN
9
PAGE 80
13 / 30 days
PRODUCT DESCRIPTION
TIER
hetastarch in 0.9 % sodium chloride
7
HEXTEND LACTATED ELECTROLYTE
3
KEDBUMIN
6
LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL)
9
MIRCERA (50 ML SYRINGE, 75 ML SYRINGE, 100 ML
SYRINGE, 200 ML SYRINGE)
6
MOZOBIL (20 MG/ML VIAL, 24 MG/1.2 ML VIAL)
9
NEULASTA 6 MG/0.6 ML DLVRY KIT
6
NEULASTA 6 MG/0.6 ML SYRINGE
6
NEUMEGA
6
PA
PA
QL
1 / 30 days
QL
21 / 30 days
PA
NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480
MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)
6
NPLATE (250 MCG VIAL, 500 MCG VIAL)
9
OCTAPLAS (BLOOD A IV BAG, BLOOD AB IV BAG, BLOOD B
IV BAG, BLOOD O IV BAG)
6
PA
PLASBUMIN-25
6
PA
PLASBUMIN-5
6
PA
PLASMANATE
6
PA
PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 VIAL, 10,000 VIAL,
20,000 VIAL, 40,000 VIAL)
5
QL
13 / 30 days
PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MG
3
QL
90 / 30 days
SOLIRIS
9
THROMBATE III
6
VOLUVEN
9
ZARXIO (300 MCG/0.5 ML SYRINGE, 480 MCG/0.8 ML
SYRINGE)
6
PA
Coagulants
ADVATE (200-400 VIAL, 401-800 VIAL, 801-1,200 VIAL, 1,2011,800 VIAL, 1,801-2,400 VIAL, 2,401-3,600 VIAL, 3,601-4,800
VIAL)
6
PA
ADVATE H
6
PA
PAGE 81
PRODUCT DESCRIPTION
TIER
ADVATE L
6
PA
ADVATE M
6
PA
ADVATE SH
6
PA
ADVATE UH
6
PA
ALPHANATE (250-100 UNIT VIAL, 500-200 UNIT VIAL, 1,000400 UNIT VIAL, 1,500-600 UNIT VIAL)
6
PA
ALPHANINE SD (500 VIAL, 1,000 VIAL, 1,500 VIAL)
6
PA
ALPROLIX (500 UNIT, 1,000 UNIT, 2,000 UNIT, 3,000 UNIT)
3
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET,
1,000 MG TABLET)
6
PA
aminocaproic acid (250 mg/ml vial, 250 mg/ml solution, 500 mg
4
PA
BEBULIN
6
PA
BENEFIX (250 UNIT KIT, 500 UNIT KIT, 1,000 UNIT KIT, 2,000
UNIT KIT, 3,000 UNIT KIT)
6
PA
CORIFACT
6
PA
CYKLOKAPRON 1,000 MG/10 ML VL
9
PA
CYKLOKAPRON 100 MG/ML AMPUL
9
PA
FEIBA NF (400-650 UNIT VIAL, 500 UNIT (NOMINAL), 6511,200 UNIT VIAL, 1,000 UNIT (NOMINAL), 1,750-3,250 UNIT
VIAL, 2,500 UNIT (NOMINAL))
6
PA
HELIXATE FS (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT
VIAL, 2,000 UNIT VIAL, 3,000 UNITS VIAL)
6
PA
HEMOFIL M (HEOFIL 250 UNIT NOINAL, HEOFIL 500 UNIT
NOINAL, HEOFIL 1,000 UNIT NOINAL, HEOFIL 1,700 UNIT
NOINAL)
6
PA
HUMATE-P (600 UNIT, 1,200 UNIT, 2,400 UNIT)
6
PA
KCENTRA (500 UNIT KIT, 1,000 UNIT KIT)
3
KOATE-DVI (250 VIAL, 500 VIAL, 500 KIT, 1,000 VIAL)
6
PAGE 82
PA
PRODUCT DESCRIPTION
TIER
KOGENATE FS (250 UNIT VIAL, 250 UNIT VL-BIOSET, 250
UNIT VL-ADAPTR, 500 UNIT VIAL, 500 UNIT VL-ADAPTR,
500 UNIT VL-BIOSET, 1,000 UNIT-ADAPTER, 1,000 UNITBIOSET, 1,000 UNITS VIAL, 2,000 UNIT VIAL, 2,000 UNITADAPTER, 2,000 UNIT-BIOSET, 3,000 UNIT-ADAPTER, 3,000
UNIT-BIOSET, 3,000 UNITS VIAL)
6
PA
LYSTEDA
3
QL
MONOCLATE-P (1,000 KIT, 1,500 KIT)
6
PA
MONONINE
6
PA
NOVOSEVEN RT (1 MG VIAL, 2 MG VIAL, 5 MG VIAL, 8 MG
VIAL)
6
PA
PROFILNINE (500 VIAL, 1,000 VIAL, 1,500 VIAL)
6
PA
protamine sulfate
1
RECOMBINATE (220-400 UNIT VIAL, 401-800 UNIT VIAL,
801-1,240 UNIT VL, 1,241-1,800 UNIT V, 1,801-2,400 UNIT V)
6
PA
RIASTAP
6
PA
RIXUBIS (250 UNIT, 500 UNIT, 1,000 UNIT, 2,000 UNIT, 3,000
UNIT)
6
PA
tranexamic acid 1000 mg/10 ampul
7
PA
tranexamic acid 1000 mg/10 vial
7
PA
tranexamic acid 650 mg tablet
1
QL
TRETTEN
9
PA
WILATE (450-450 UNIT KIT, 500-500 UNIT KIT, 900-900 UNIT
KIT, 1,000-1,000 UNIT KIT)
6
PA
XYNTHA (250 UNIT KIT, 500 UNIT KIT, 1,000 UNIT KIT, 2,000
UNIT KIT, 3,000 UNIT SYRINGE KIT)
6
PA
XYNTHA SOLOFUSE (250 UNIT KIT, 500 UNIT KIT, 1,000
UNIT KIT, 2,000 UNIT KIT)
6
PA
30 / 30 days
30 / 30 days
Platelet Modifying Agents
AGGRASTAT (5 MG/100 ML IV SOLN, 12.5 MG/250 ML)
9
AGGRENOX
2
aspirin/dipyridamole
1
BRILINTA (60 MG TABLET, 90 MG TABLET)
3
cilostazol (50 mg tablet, 100 mg tablet)
1
PAGE 83
PRODUCT DESCRIPTION
TIER
clopidogrel bisulfate (75 mg tablet, 300 mg tablet)
1
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet)
1
dipyridamole 5 mg/ml vial
7
EFFIENT (5 MG TABLET, 10 MG TABLET)
2
INTEGRILIN (20 MG/10 ML VIAL, 75 MG/100 ML VIAL, 200
MG/100 ML VIAL)
9
KENGREAL
9
PERSANTINE (25 MG TABLET, 50 MG TABLET, 75 MG
TABLET)
3
PLAVIX (75 MG TABLET, 300 MG TABLET)
3
PLETAL (50 MG TABLET, 100 MG TABLET)
3
REOPRO
9
ticlopidine hcl
1
ZONTIVITY
3
QL
30 / 30 days
QL
30 / 30 days
QL
30 / 30 days
Cardiovascular Agents
Alpha-adrenergic Agonists
CATAPRES (0.1 MG TABLET, 0.2 MG TABLET, 0.3 MG
TABLET)
3
CATAPRES-TTS 1
3
CATAPRES-TTS 2
3
CATAPRES-TTS 3
3
clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk,
0.3mg/24hr patch tdwk)
1
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)
1
clonidine hcl/pf (1000mcg/10 vial, 5000mcg/10 vial)
7
DURACLON (100 MCG/ML VIAL, 500 MCG/ML VIAL)
9
guanfacine hcl (1 mg tablet, 2 mg tablet)
1
methyldopa (250 mg tablet, 500 mg tablet)
1
methyldopate hcl
1
midodrine hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
1
TENEX (1 MG TABLET, 2 MG TABLET)
3
PAGE 84
PRODUCT DESCRIPTION
TIER
Alpha-adrenergic Blocking Agents
CARDURA (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 8
MG TABLET)
3
ST
CARDURA XL (4 MG TABLET, 8 MG TABLET)
3
ST
DIBENZYLINE
3
doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg
tablet)
1
MINIPRESS (1 MG CAPSULE, 2 MG CAPSULE, 5 MG
CAPSULE)
3
phenoxybenzamine hcl
1
phentolamine mesylate 5 mg/ml(1) vial
9
prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule)
1
reserpine (0.1 mg tablet, 0.25 mg tablet)
2
terazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule, 10
mg capsule)
1
Angiotensin II Receptor Antagonists
QL
ATACAND (4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32
MG TABLET)
3
AVAPRO (75 MG TABLET, 150 MG TABLET, 300 MG
TABLET)
3
BENICAR (5 MG TABLET, 20 MG TABLET, 40 MG TABLET)
3
30 / 30 days
ST
QL
30 / 30 days
ST
QL
30 / 30 days
ST
candesartan cilexetil (4 mg tablet, 8 mg tablet, 16 mg tablet, 32
mg tablet)
1
COZAAR (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
3
QL
30 / 30 days
QL
30 / 30 days
ST
QL
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET,
320 MG TABLET)
3
EDARBI (40 MG TABLET, 80 MG TABLET)
3
30 / 30 days
ST
QL
30 / 30 days
ST
eprosartan mesylate
1
irbesartan (75 mg tablet, 150 mg tablet, 300 mg tablet)
1
PAGE 85
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
losartan potassium (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
MICARDIS (20 MG TABLET, 40 MG TABLET, 80 MG TABLET)
3
QL
30 / 30 days
QL
30 / 30 days
ST
telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet)
1
QL
TEVETEN (400 MG TABLET, 600 MG TABLET)
3
ST
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet, 320 mg
tablet)
1
QL
30 / 30 days
30 / 30 days
Angiotensin-converting Enzyme (ACE) Inhibitors
ACCUPRIL (5 MG TABLET, 10 MG TABLET, 20 MG TABLET,
40 MG TABLET)
3
ACEON (4 MG TABLET, 8 MG TABLET)
3
ALTACE (1.25 MG CAPSULE, 2.5 MG CAPSULE, 5 MG
3
benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg
tablet)
1
captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg
tablet)
1
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20
mg tablet)
1
enalaprilat dihydrate
7
EPANED
3
fosinopril sodium (10 mg tablet, 20 mg tablet, 40 mg tablet)
1
lisinopril (2.5 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg
tablet)
1
LOTENSIN (10 MG TABLET, 20 MG TABLET, 40 MG TABLET)
3
MAVIK (1 MG TABLET, 2 MG TABLET, 4 MG TABLET)
3
moexipril hcl (7.5 mg tablet, 15 mg tablet)
1
perindopril erbumine (2 mg tablet, 4 mg tablet, 8 mg tablet)
1
PRINIVIL (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)
3
quinapril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg
tablet)
1
ramipril (1.25 mg capsule, 2.5 mg capsule, 5 mg capsule, 10
mg capsule)
1
trandolapril (1 mg tablet, 2 mg tablet, 4 mg tablet)
1
PAGE 86
PRODUCT DESCRIPTION
TIER
UNIVASC (7.5 MG TABLET, 15 MG TABLET)
3
VASOTEC (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET,
20 MG TABLET)
3
ZESTRIL (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET,
3
Antiarrhythmics
ADENOCARD (6 MG/2 ML SYRINGE, 12 MG/4 ML SYRINGE)
9
adenosine (3 mg/ml syringe, 3 mg/ml vial)
7
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet)
1
amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 150 mg/3ml
syringe)
7
ATROPEN (0.5 ML SYRINGE, 1 ML SYRINGE, 2 ML
SYRINGE)
9
atropine sulfate (0.05mg/ml syringe, 0.1 mg/ml disp syrin, 0.1
mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial)
7
BETAPACE (80 MG TABLET, 120 MG TABLET, 160 MG
3
ST
BETAPACE AF (80 MG TABLET, 120 MG TABLET, 160 MG
TABLET)
3
ST
CALAN (80 MG TABLET, 120 MG TABLET)
3
ST
CORDARONE
3
CORVERT
9
diltiazem hcl 100 mg vial port
1
diltiazem hcl 5 mg/ml vial
7
disopyramide phosphate (100 mg capsule, 150 mg capsule)
1
flecainide acetate (50 mg tablet, 100 mg tablet, 150 mg tablet)
1
glycopyrrolate 0.2 mg/ml vial
7
ibutilide fumarate
7
lidocaine hcl/pf (50 mg/5 ml syringe, 100 mg/5ml syringe)
7
mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg
capsule)
1
MULTAQ
3
NEXTERONE (150 MG/100 ML BAG, 360 MG/200 ML BAG)
9
NORPACE (100 MG CAPSULE, 150 MG CAPSULE)
3
PAGE 87
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
NORPACE CR (CR 100 MG CAPSULE, CR 150 MG
CAPSULE)
3
PACERONE (100 MG TABLET, 400 MG TABLET)
1
procainamide hcl (100 mg/ml vial, 500 mg/ml vial)
7
propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg
tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg cap er 12h)
1
quinidine gluconate 324 mg tablet er
1
quinidine gluconate 80 mg/ml vial
9
quinidine sulfate (200 mg tablet, 300 mg tablet er, 300 mg
tablet)
1
ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG/5 ML
VIAL, 4 MG/20 ML VIAL)
9
RYTHMOL (150 MG TABLET, 225 MG TABLET)
3
RYTHMOL SR (225 MG CAPSULE, 325 MG CAPSULE, 425
MG CAPSULE)
3
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg
tablet)
1
sotalol hcl 150mg/10ml vial
9
SOTYLIZE
3
TAMBOCOR (50 MG TABLET, 100 MG TABLET, 150 MG
TABLET)
3
TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE, 500
MCG CAPSULE)
6
verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet)
1
ST
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg capsule, 400 mg capsule)
1
atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
betaxolol hcl (10 mg tablet, 20 mg tablet)
1
bisoprolol fumarate (5 mg tablet, 10 mg tablet)
1
BREVIBLOC (10 MG/ML VIAL, 10 MG/ML IV BAG, 20 MG/ML
IV BAG)
9
BYSTOLIC (2.5 MG TABLET, 5 MG TABLET, 20 MG TABLET)
3
QL
60 / 30 days
ST
QL
BYSTOLIC 10 MG TABLET
120 / 30 days
3
ST
PAGE 88
PRODUCT DESCRIPTION
TIER
carvedilol (3.125 mg tablet, 6.25 mg tablet, 12.5 mg tablet, 25
mg tablet)
1
COREG (3.125 MG TABLET, 6.25 MG TABLET, 12.5 MG
3
COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR
40 MG CAPSULE, CR 80 MG CAPSULE)
2
CORGARD (20 MG TABLET, 40 MG TABLET, 80 MG
TABLET)
3
esmolol hcl
7
HEMANGEOL
3
ST
INDERAL LA (60 MG CAPSULE, 80 MG CAPSULE, 120 MG
3
ST
INDERAL XL (80 MG CAPSULE, 120 MG CAPSULE)
3
ST
INNOPRAN XL (80 MG CAPSULE, 120 MG CAPSULE)
3
ST
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet)
1
labetalol hcl (5 mg/ml vial, 20 mg/4 ml syringe)
7
LEVATOL
3
ST
LOPRESSOR (50 MG TABLET, 100 MG TABLET)
3
ST
LOPRESSOR 5 MG/5 ML AMPUL
9
metoprolol succinate (25 mg tab er 24h, 50 mg tab er 24h, 100
mg tab er 24h, 200 mg tab er 24h)
1
metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
metoprolol tartrate (5 ml ampul, 5 ml syringe, 5 ml vial)
7
nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet)
1
pindolol (5 mg tablet, 10 mg tablet)
1
propranolol hcl (10 mg tablet, 20 mg/5 ml solution, 20 mg tablet,
40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg
tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160
mg cap sa 24h)
1
propranolol hcl 1 mg/ml vial
7
SECTRAL (200 MG CAPSULE, 400 MG CAPSULE)
3
ST
TENORMIN (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
3
ST
TOPROL XL (25 MG TABLET, 50 MG TABLET, 100 MG
3
ST
PAGE 89
ST
QL
30 / 30 days
ST
ST
PRODUCT DESCRIPTION
TIER
TRANDATE (100 MG TABLET, 200 MG TABLET, 300 MG
TABLET)
3
ST
ZEBETA (5 MG TABLET, 10 MG TABLET)
3
ST
ADALAT CC (30 MG TABLET, 60 MG TABLET, 90 MG
TABLET)
3
ST
amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
1
QL
CALAN SR (120 MG, 180 MG, 240 MG)
3
ST
CARDENE I.V. (CARDENE I.V. 25 MG/10 ML AMPUL,
CARDENE-DEX 20 MG/200 ML SOLN, CARDENE-DEX 40
MG/200 ML IV, CARDENE-NACL 20 MG/200 ML SOLN,
CARDENE-NACL 40 MG/200 ML IV)
9
ST
CARDENE SR (30 MG CAPSULE, 45 MG CAPSULE, 60 MG
CAPSULE)
3
ST
CARDIZEM (30 MG TABLET, 60 MG TABLET, 90 MG
3
ST
CARDIZEM CD (120 MG CAPSULE, 180 MG CAPSULE, 240
MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE)
3
ST
CARDIZEM LA (120 MG TABLET, 180 MG TABLET, 240 MG
TABLET)
3
ST
CLEVIPREX (25 MG/50 ML VIAL, 50 MG/100 ML VIAL)
9
ST
DILACOR XR
3
ST
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90
mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er
24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180
mg cap er 24h, 180 mg capsule er, 180 mg tab er 24h, 180 mg
cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap
er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg tab er
24h, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule
er, 360 mg tab er 24h, 420mg tab er 24h, 420mg capsule er)
1
felodipine (2.5 mg tab er 24h, 5 mg tab er 24h, 10 mg tab er
24h)
1
isradipine (2.5 mg capsule, 5 mg capsule)
1
nicardipine hcl (20 mg capsule, 30 mg capsule)
1
nicardipine hcl (25 vial, 25 ampul)
7
Calcium Channel Blocking Agents
PAGE 90
30 / 30 days
PRODUCT DESCRIPTION
TIER
nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30
mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24,
90 mg tablet er)
1
nimodipine
1
nisoldipine (8.5mg tab er 24h, 17 mg tab er 24h, 20 mg tab er
24h, 25.5 mg tab er 24h, 30 mg tab er 24h, 40 mg tab er 24h)
1
nisoldipine 34 mg tab er 24h
2
NORVASC (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET)
3
QL
30 / 30 days
ST
QL
NYMALIZE
2520 / 21 days
3
PA
PROCARDIA
3
ST
PROCARDIA XL (30 MG TABLET, 60 MG TABLET, 90 MG
TABLET)
3
ST
SULAR (ER 8.5 MG TABLET, ER 17 MG TABLET, ER 34 MG
TABLET)
3
ST
TIAZAC (ER 120 MG CAPSULE, ER 180 MG CAPSULE, ER
240 MG CAPSULE, ER 300 MG CAPSULE, ER 360 MG
CAPSULE, ER 420 MG CAPSULE)
3
ST
verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg
cap24h pel, 180 mg cap24h pel, 180 mg tablet er, 200 mg
cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg
cap24h pct, 360 mg cap24h pel)
1
verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 2.5 mg/ml
syringe)
7
VERELAN (120 MG CAP PELLET, 180 MG CAP PELLET, 240
MG CAP PELLET, 360 MG CAP PELLET)
3
ST
VERELAN PM (100 MG CAP PELLET, 200 MG CAP PELLET,
300 MG CAP PELLET)
3
ST
Cardiovascular Agents, Other
ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET, 2025 MG TABLET)
3
ALDACTAZIDE (25-25 TABLET, 50-50 TABLET)
3
alprostadil
7
amiloride hcl/hydrochlorothiazide
1
PAGE 91
PRODUCT DESCRIPTION
TIER
amlodipine besylate/atorvastatin calcium (2.5mg-20mg tablet,
2.5mg-40mg tablet, 2.5mg-10mg tablet, 5 mg-20 mg tablet, 5
mg-80 mg tablet, 5 mg-40 mg tablet, 5 mg-10 mg tablet, 10 mg80mg tablet, 10 mg-20mg tablet, 10 mg-40mg tablet, 10 mg10mg tablet)
1
amlodipine besylate/benazepril hcl (2.5mg-10mg capsule, 5
mg-40 mg capsule, 5 mg-10 mg capsule, 5 mg-20 mg capsule,
10 mg-40mg capsule, 10 mg-20mg capsule)
1
QL
30 / 30 days
amlodipine besylate/valsartan (5mg-160mg tablet, 5mg-320mg
tablet, 10mg-160mg tablet, 10mg-320mg tablet)
1
QL
30 / 30 days
amlodipine besylate/valsartan/hydrochlorothiazide (5-160-25mg
tablet, 5-160-12.5 tablet, 10mg-160mg tablet, 10-320-25 tablet,
10-160-25 tablet)
1
QL
30 / 30 days
AMTURNIDE (150-5-12.5 MG TAB, 300-5-25 MG TAB, 300-1012.5 MG TAB, 300-10-25 MG TAB, 300-5-12.5 MG TAB)
3
QL
30 / 30 days
ATACAND HCT (16-12.5 MG TAB, 32-12.5 MG TAB, 32-25 MG
TABLET)
QL
30 / 30 days
3
atenolol/chlorthalidone (50 mg-25mg tablet, 100mg-25mg
tablet)
1
AVALIDE (150-12.5 MG TABLET, 300-12.5 MG TABLET)
3
QL
30 / 30 days
ST
ST
QL
30 / 30 days
ST
AZOR (5-20 MG TABLET, 5-40 MG TABLET, 10-20 MG
TABLET, 10-40 MG TABLET)
3
benazepril hcl/hydrochlorothiazide (5-6.25mg tablet, 10-12.5mg
tablet, 20-12.5 mg tablet, 20-25mg tablet)
1
BENICAR HCT (20-12.5 MG TABLET, 40-25 MG TABLET, 4012.5 MG TABLET)
3
BIDIL
3
bisoprolol fumarate/hydrochlorothiazide (2.5-6.25mg tablet, 56.25mg tablet, 10-6.25mg tablet)
1
CADUET (2.5 MG-40 MG TABLET, 2.5 MG-20 MG TABLET,
2.5 MG-10 MG TABLET, 5 MG-80 MG TABLET, 5 MG-10 MG
TABLET, 5 MG-40 MG TABLET, 5 MG-20 MG TABLET, 10
MG-10 MG TABLET, 10 MG-20 MG TABLET, 10 MG-80 MG
TABLET, 10 MG-40 MG TABLET)
3
candesartan cilexetil/hydrochlorothiazide (16-12.5mg tablet, 3212.5mg tablet, 32mg-25mg tablet)
1
captopril/hydrochlorothiazide (25 mg-25mg tablet, 25 mg-15mg
tablet, 50 mg-15mg tablet, 50 mg-25mg tablet)
1
PAGE 92
QL
30 / 30 days
ST
QL
30 / 30 days
ST
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
cardioplegic solution no.1
7
CORLANOR (5 MG TABLET, 7.5 MG TABLET)
3
CORZIDE (40-5 TABLET, 80-5 TABLET)
3
CYANOKIT
9
DEMSER
2
DIGIFAB
9
digoxin (250 mcg/ml ampul, 250 mcg/ml syringe)
7
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet)
1
DIOVAN HCT (80-12.5 MG TABLET, 160-25 MG TABLET, 16012.5 MG TAB, 320-12.5 MG TAB, 320-25 MG TABLET)
3
dobutamine hcl
7
dobutamine hcl/dextrose 5 % in water (250mg/250 iv soln,
500mg/250 iv soln, 500 mg/500 iv soln, 1000mg/250 iv soln)
7
dopamine hcl (200 mg/5ml vial, 400 mg/5ml vial, 400mg/10ml
vial, 800mg/10ml vial)
7
dopamine hcl 800mg/5ml vial
1
dopamine hcl/dextrose 5 % in water (200mg/.25l plast. bag,
400mg/0.5l plast. bag, 400mg/.25l plast. bag, 800mg/0.5l plast.
bag, 800mg/.25l plast. bag)
7
DUTOPROL (25-12.5 MG TABLET, 50-12.5 MG TABLET, 10012.5 MG TABLET)
3
DYAZIDE
3
EDARBYCLOR (40-12.5 MG TABLET, 40-25 MG TABLET)
3
ST
QL
30 / 30 days
ST
QL
120 / 30 days
ST
QL
30 / 30 days
ST
enalapril maleate/hydrochlorothiazide (5mg-12.5mg tablet, 10
mg-25mg tablet)
1
ENTRESTO (24 MG-26 MG TABLET, 49 MG-51 MG TABLET,
97 MG-103 MG TABLET)
3
QL
60 / 30 days
EXFORGE (5-320 MG TABLET, 5-160 MG TABLET, 10-320
MG TABLET, 10-160 MG TABLET)
3
QL
30 / 30 days
EXFORGE HCT (5-160-25 MG TAB, 5-160-12.5 MG TAB, 10320-25 MG TAB, 10-160-12.5 MG TAB, 10-160-25 MG TAB)
3
QL
30 / 30 days
fomepizole
7
fosinopril sodium/hydrochlorothiazide (10-12.5mg tablet, 2012.5 mg tablet)
1
PAGE 93
PRODUCT DESCRIPTION
TIER
QL
30 / 30 days
HYZAAR (50-12.5 TABLET, 100-12.5 TABLET, 100-25
TABLET)
3
irbesartan/hydrochlorothiazide (150-12.5mg tablet, 300-12.5mg
tablet)
1
isoxsuprine hcl (10 mg tablet, 20 mg tablet)
1
ISUPREL (0.2 MG/ML AMPUL, 1 MG/5 ML AMPUL)
9
LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG
TABLET, 250 MCG TABLET)
2
LANOXIN 500 MCG/2 ML AMPULE
9
LANOXIN PEDIATRIC (0.1 MG/ML AMPUL, 100 MCG/ML
AMPUL)
9
LEVOPHED BITARTRATE (1 MG/ML VIAL, 1 MG/ML AMPUL,
4 MG/4 ML VIAL, 4 MG/4 ML AMPUL)
9
lisinopril/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg
tablet, 20-25mg tablet)
1
LOPRESSOR HCT (50-25 TABLET, 100-25 TABLET)
3
ST
losartan potassium/hydrochlorothiazide (50-12.5 mg tablet, 10012.5mg tablet, 100mg-25mg tablet)
1
QL
30 / 30 days
LOTENSIN HCT (10-12.5 MG TABLET, 10-12.5 TABLET, 2025 TABLET, 20-12.5 TABLET, 20-25 MG TABLET, 20-12.5 MG
TABLET)
3
LOTREL (2.5-10 MG CAPSULE, 5-40 MG CAPSULE, 5-20 MG
CAPSULE, 5-10 MG CAPSULE, 10-40 MG CAPSULE, 10-20
MG CAPSULE)
QL
30 / 30 days
3
mannitol (5 % iv soln, 10 % iv soln, 20 % iv soln, 25 % vial)
7
MAXZIDE
3
MAXZIDE-25 MG
3
methyldopa/hydrochlorothiazide (250mg-25mg tablet, 250mg15mg tablet)
1
metoprolol tartrate/hydrochlorothiazide (50 mg-25mg tablet,
100mg-50mg tablet, 100mg-25mg tablet)
1
MICARDIS HCT (40-12.5 MG TABLET, 80-12.5 MG TABLET,
80-25 MG TABLET)
3
milrinone lactate
7
milrinone lactate/dextrose 5 % in water (20mg/100ml
piggyback, 40mg/200ml piggyback)
7
PAGE 94
ST
QL
30 / 30 days
ST
QL
30 / 30 days
ST
PRODUCT DESCRIPTION
TIER
moexipril hcl/hydrochlorothiazide (7.5-12.5mg tablet, 15-25mg
tablet, 15-12.5mg tablet)
1
nadolol/bendroflumethiazide (40 mg tablet, 80 mg tablet)
1
NATRECOR
9
NEO-SYNEPHRINE
9
NEOPROFEN
9
norepinephrine bitartrate (1 mg/ml ampul, 1 mg/ml vial)
7
NORTHERA (100 MG CAPSULE, 200 MG CAPSULE, 300 MG
CAPSULE)
6
OSMITROL (5% IV SOLUTION, 10% IV SOLUTION, 15% IV
SOLUTION, 20% IV SOLUTION)
7
papaverine hcl 150 mg capsule er
1
papaverine hcl 30 mg/ml vial
7
pentoxifylline
1
phenylephrine hcl 10 mg/ml vial
7
PLEGISOL
9
PRESTALIA (3.5 MG-2.5 MG TABLET, 7 MG-5 MG TABLET,
14 MG-10 MG TABLET)
3
propranolol hcl/hydrochlorothiazide (40 tablet, 80 tablet)
1
PROSTIN VR PEDIATRIC
9
quinapril hcl/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg
tablet, 20-25mg tablet)
1
RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET)
2
sodium nitrite
9
spironolactone/hydrochlorothiazide
1
TARKA (ER 1-240 MG TABLET, ER 2-180 MG TABLET, ER 2240 MG TABLET, ER 4-240 MG TABLET)
QL
120 / 30 days
2
QL
30 / 30 days
TEKAMLO (150 MG-10 MG TABLET, 150 MG-5 MG TABLET,
300 MG-10 MG TABLET, 300 MG-5 MG TABLET)
2
QL
30 / 30 days
TEKTURNA (150 MG TABLET, 300 MG TABLET)
2
QL
30 / 30 days
TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG TABLET,
300-12.5 MG TAB, 300-25 MG TABLET)
2
QL
30 / 30 days
telmisartan/amlodipine besylate (40 mg-10mg tablet, 40 mg-5
mg tablet, 80 mg-10mg tablet, 80 mg-5 mg tablet)
1
QL
30 / 30 days
PAGE 95
PRODUCT DESCRIPTION
TIER
TENORETIC 100
3
ST
TENORETIC 50
3
ST
TEVETEN HCT (600-12.5 MG TAB, 600-25 MG TAB)
3
ST
trandolapril/verapamil hcl (1-240mg tab bp 24h, 2-240mg tab bp
24h, 2 mg-180mg tab bp 24h, 4-240mg tab bp 24h)
1
QL
30 / 30 days
TRENTAL
3
triamterene/hydrochlorothiazide (37.5-25 mg capsule, 37.5-25
mg tablet, 75 mg-50mg tablet)
1
TRIBENZOR (20-5-12.5 MG TABLET, 40-5-25 MG TABLET,
40-5-12.5 MG TABLET, 40-10-12.5 MG TABLET, 40-10-25 MG
TABLET)
3
QL
30 / 30 days
TWYNSTA (40-10 MG TABLET, 40-5 MG TABLET, 80-10 MG
3
QL
30 / 30 days
UNIRETIC (7.5-12.5 MG TABLET, 15-12.5 TABLET, 15-25 MG
TABLET)
3
valsartan/hydrochlorothiazide (80-12.5mg tablet, 160-12.5mg
tablet, 160-25mg tablet, 320mg-25mg tablet, 320-12.5mg
tablet)
1
QL
30 / 30 days
VASERETIC
3
VAZCULEP (10 MG/ML VIAL, 50 MG/5 ML VIAL, 100 MG/10
ML VIAL)
9
ZESTORETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET, 2025 MG TABLET)
3
ZIAC (2.5-6.25 MG TABLET, 5-6.25 MG TABLET, 10-6.25 MG
TABLET)
3
ST
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 500 mg capsule er
1
DIAMOX SEQUELS
3
KEVEYIS
6
methazolamide (25 mg tablet, 50 mg tablet)
1
NEPTAZANE (25 MG TABLET, 50 MG TABLET)
3
PA
Diuretics, Loop
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
bumetanide 0.25 mg/ml vial
7
DEMADEX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET,
100 MG TABLET)
3
PAGE 96
PRODUCT DESCRIPTION
TIER
EDECRIN
3
ethacrynate sodium
7
furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet,
40mg/5ml solution, 80 mg tablet)
1
furosemide (10 mg/ml syringe, 10 mg/ml vial)
7
LASIX (20 MG TABLET, 40 MG TABLET, 80 MG TABLET)
3
SODIUM EDECRIN
9
torsemide (5 mg tablet, 10 mg tablet, 20 mg/2 ml vial, 20 mg
tablet, 50 mg/5 ml vial, 100 mg tablet)
1
Diuretics, Potassium-sparing
ALDACTONE (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
3
amiloride hcl
1
DYRENIUM (50 MG CAPSULE, 100 MG CAPSULE)
3
eplerenone (25 mg tablet, 50 mg tablet)
1
QL
60 / 30 days
INSPRA (25 MG TABLET, 50 MG TABLET)
3
QL
60 / 30 days
spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
QL
60 / 30 days
Diuretics, Thiazide
chlorothiazide (250 mg tablet, 500 mg tablet)
1
chlorothiazide sodium
7
chlorthalidone (25 mg tablet, 50 mg tablet)
1
DIURIL
3
hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 50 mg
tablet)
1
indapamide (1.25 mg tablet, 2.5 mg tablet)
1
methyclothiazide
1
metolazone (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
1
MICROZIDE
3
SODIUM DIURIL
9
ZAROXOLYN (2.5 MG TABLET, 5 MG TABLET)
3
Dyslipidemics, Fibric Acid Derivatives
ANTARA (30 MG CAPSULE, 43 MG CAPSULE, 90 MG
CAPSULE)
PAGE 97
3
PRODUCT DESCRIPTION
TIER
ANTARA 130 MG CAPSULE
3
fenofibrate (40 mg tablet, 50 mg capsule, 120 mg tablet, 150
mg capsule)
1
fenofibrate (54 mg tablet, 160 mg tablet)
QL
30 / 30 days
1
QL
30 / 30 days
fenofibrate nanocrystallized (48 mg tablet, 145mg tablet)
1
QL
30 / 30 days
fenofibrate,micronized (67 mg capsule, 130 mg capsule, 134mg
1
QL
30 / 30 days
fenofibrate,micronized 43 mg capsule
1
QL
60 / 30 days
QL
fenofibric acid (35 mg tablet, 105 mg tablet)
30 / 30 days
1
ST
fenofibric acid (choline) (45 mg capsule dr, 135 mg capsule dr)
1
QL
FENOGLIDE (40 MG TABLET, 120 MG TABLET)
3
ST
FIBRICOR (35 MG TABLET, 105 MG TABLET)
3
QL
30 / 30 days
30 / 30 days
ST
gemfibrozil
1
LIPOFEN (50 MG CAPSULE, 150 MG CAPSULE)
3
LOPID
3
TRICOR (48 MG TABLET, 145 MG TABLET)
3
TRIGLIDE
2
TRILIPIX (DR 45 MG CAPSULE, DR 135 MG CAPSULE)
2
QL
30 / 30 days
QL
30 / 30 days
ST
Dyslipidemics, HMG CoA Reductase Inhibitors
QL
ALTOPREV (20 MG TABLET, 40 MG TABLET, 60 MG
TABLET)
3
atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg tablet,
80 mg tablet)
1
CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET,
40 MG TABLET)
2
fluvastatin sodium (20 mg capsule, 40 mg capsule)
1
fluvastatin sodium 80 mg tab er 24h
1
PAGE 98
30 / 30 days
ST
QL
30 / 30 days
QL
30 / 30 days
ST
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
QL
LESCOL (20 MG CAPSULE, 40 MG CAPSULE)
60 / 30 days
3
ST
LESCOL XL
3
LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET,
80 MG TABLET)
3
LIVALO (1 MG TABLET, 2 MG TABLET, 4 MG TABLET)
3
lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet)
1
MEVACOR (20 MG TABLET, 40 MG TABLET)
3
PRAVACHOL (20 MG TABLET, 40 MG TABLET, 80 MG
TABLET)
3
pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80
mg tablet)
1
QL
30 / 30 days
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg
1
QL
30 / 30 days
ZOCOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40
QL
30 / 30 days
3
ST
QL
30 / 30 days
ST
ST
ST
QL
30 / 30 days
ST
ST
Dyslipidemics, Other
ADVICOR (500 MG-20 MG TABLET, 750 MG-20 MG TABLET,
1,000 MG-40 MG TABLET, 1,000 MG-20 MG TABLET)
3
cholestyramine (with sugar) (4 g powder, 4 g powd pack)
1
cholestyramine/aspartame (4 g powd pack, 4 g powder)
1
COLESTID (1 GM TABLET, FLAVORED GRANULES,
GRANULES, GRANULES PACKET)
3
colestipol hcl (1 g tablet, 5 g packet, 5 g granules)
1
JUXTAPID (40 MG CAPSULE, 60 MG CAPSULE)
6
QL
30 / 30 days
PA
QL
JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG
CAPSULE)
6
JUXTAPID 30 MG CAPSULE
6
90 / 30 days
PA
QL
60 / 30 days
PA
QL
KYNAMRO
4 / 30 days
6
PA
PAGE 99
PRODUCT DESCRIPTION
TIER
LIPOCHOL PLUS
3
LIPTRUZET (10-40 MG TABLET, 10-80 MG TABLET, 10-20
MG TABLET, 10-10 MG TABLET)
3
LOVAZA
3
niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er
24h)
1
QL
60 / 30 days
NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET, ER
1,000 MG TABLET)
3
QL
60 / 30 days
omega-3 acid ethyl esters
1
PRALUENT PEN (75 MG/ML PEN, 150 MG/ML PEN)
6
PA
PRALUENT SYRINGE (75 MG/ML SYRINGE, 150 MG/ML
SYRINGE)
6
PA
QUESTRAN LIGHT (PACKET, POWDER)
3
SIMCOR (500-20 MG TABLET, 500-40 MG TABLET, 750-20
MG TABLET, 1,000-20 MG TABLET, 1,000-40 MG TABLET)
3
VASCEPA
3
VAYAROL
3
VYTORIN (10-80 MG TABLET, 10-10 MG TABLET, 10-40 MG
3
ZETIA
3
QL
120 / 30 days
QL
30 / 30 days
ST
QL
30 / 30 days
Vasodilators, Direct-acting Arterial
CORLOPAM (10 MG/ML AMPUL, 10 MG/ML VIAL)
9
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100
mg tablet)
1
hydralazine hcl 20 mg/ml vial
7
minoxidil (2.5 mg tablet, 10 mg tablet)
1
NITROPRESS
3
RECTIV
3
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR
3
IMDUR ER 120 MG TABLET
3
ISORDIL
3
ISORDIL TITRADOSE
3
PAGE 100
PRODUCT DESCRIPTION
TIER
isosorbide dinitrate (2.5 mg tab subl, 5 mg tablet, 5 mg tab subl,
10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er)
1
isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab
er 24h, 60 mg tab er 24h, 120 mg tab er 24h)
1
NITRO-BID
3
NITRO-DUR (0.1 PATCH, 0.2 PATCH, 0.3 PATCH, 0.4
PATCH, 0.6 PATCH, 0.8 PATCH)
3
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,
0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er,
6.5 mg capsule er, 9 mg capsule er, 50 mg/10ml vial)
1
nitroglycerin 400mcg/spr spray
3
nitroglycerin/dextrose 5 % in water (25mg/250ml infus. btl,
50mg/500ml infus. btl, 50mg/250ml infus. btl, 100mg/250 infus.
btl, 200mg/500 infus. btl)
7
NITROLINGUAL
3
NITROMIST
3
NITRONAL (25 MG/25 ML AMPULE, 50 MG/50 ML VIAL)
3
NITROSTAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6 MG
TABLET)
2
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,
12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG
TABLET)
3
ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG
CAPSULE)
3
DESOXYN
3
DEXEDRINE (SPANSULE 5 MG, 5 MG TABLET, 10 MG
TABLET, SPANSULE 10 MG, SPANSULE 15 MG)
3
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate (5 mg cap er 24h, 5 mg tablet, 7.5 mg tablet, 10 mg
tablet, 10 mg cap er 24h, 12.5 mg tablet, 15 mg tablet, 15 mg
cap er 24h, 20 mg tablet, 20 mg cap er 24h, 25 mg cap er 24h,
30 mg tablet, 30 mg cap er 24h)
1
dextroamphetamine sulfate (5 mg/5 ml solution, 5 mg tablet, 5
mg capsule er, 10 mg capsule er, 10 mg tablet, 15 mg capsule
er)
1
EVEKEO (5 MG TABLET, 10 MG TABLET)
3
PAGE 101
PA
PRODUCT DESCRIPTION
TIER
methamphetamine hcl
1
VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG
3
ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET,
3
PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG
3
clonidine hcl 0.1 mg tab er 12h
1
QL
60 / 30 days
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 54
MG TABLET)
3
QL
30 / 30 days
CONCERTA ER 36 MG TABLET
3
QL
60 / 30 days
DAYTRANA (10 HR PATCH, 15 HR PATCH, 20 HOUR
PATCH, 30 HOUR PATCH)
3
QL
30 / 30 days
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 5 mg cpbp
50-50, 10 mg cpbp 50-50, 10 mg tablet, 15 mg cpbp 50-50, 20
mg cpbp 50-50, 30 mg cpbp 50-50, 40 mg cpbp 50-50)
1
FOCALIN (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET)
3
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG
3
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er
24h, 4 mg tab er 24h)
1
QL
30 / 30 days
INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3 MG
TABLET, ER 4 MG TABLET)
3
QL
30 / 30 days
KAPVAY (ER 0.1 MG TABLET, 0.1-0.2 MG DOSEPACK)
3
QL
60 / 30 days
METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG
3
QL
60 / 30 days
METADATE CD (50 MG CAPSULE, 60 MG CAPSULE)
3
QL
30 / 30 days
METHYLIN (2.5 MG CHEWABLE TAB, 5 MG/5 ML SOLUTION,
5 MG CHEWABLE TABLET, 10 MG/5 ML SOLUTION, 10 MG
CHEWABLE TABLET)
3
methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 30
mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 30-70)
1
QL
60 / 30 days
PAGE 102
PRODUCT DESCRIPTION
TIER
methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 50 mg
cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70)
1
methylphenidate hcl (2.5 mg tab chew, 5 mg tablet, 5 mg/5 ml
solution, 5 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5
ml solution, 10 mg tab chew, 20 mg tablet er, 20 mg tablet, 20
mg cpbp 50-50, 30 mg cpbp 50-50, 40 mg cpbp 50-50)
1
QUILLIVANT XR
3
RITALIN (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)
3
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG
3
RITALIN-SR
3
STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG
2
QL
30 / 30 days
QL
360 / 30 days
QL
60 / 30 days
Central Nervous System Agents, Other
ADIPEX-P
3
ANECTINE
7
atracurium besylate
7
BELVIQ
3
benzphetamine hcl
1
BONTRIL PDM
3
butalbit/acetamin/caff/codeine 50-325-30 capsule
1
butalbital/acetaminophen (50mg-300mg tablet, 50mg-325mg
tablet, 50mg-650mg tablet)
1
butalbital/acetaminophen/caffeine (50-500-40 capsule, 50-30040 capsule, 50-325-40 tablet, 50-500-40 tablet, 50-325/15
solution, 50-325-40 capsule)
1
butalbital/aspirin/caffeine (capsule, tablet)
1
CAFCIT 20 MG/ML ORAL SOLN
3
CAFCIT 60 MG/3 ML VIAL
9
caffeine citrated 60 mg/3 ml solution
1
caffeine citrated 60 mg/3 ml vial
7
caffeine/sodium benzoate
8
cevimeline hcl
1
cisatracurium besylate (2 mg/ml vial, 10 mg/ml vial)
7
PAGE 103
PRODUCT DESCRIPTION
TIER
codeine phosphate/butalbital/aspirin/caffeine
1
DIDREX
3
diethylpropion hcl (25 mg tablet, 75 mg tablet er)
1
DOLGIC PLUS
3
DYSPORT (300 UNIT VIAL, 500 UNITS VIAL)
9
ESGIC (50-325-40 MG TABLET, CAPSULE)
3
ESGIC-PLUS (ESGIC PLUS CAPSULE, ESGIC-PLUS 50-50040 MG TABLET)
3
EVOXAC
3
FIORICET-COD 30-50-325-40 CAP
3
FIORINAL
3
FIORINAL WITH CODEINE #3
QL
180 / 30 days
3
QL
180 / 30 days
HORIZANT ER 300 MG TABLET
3
ST
isometheptene mucate/caffeine/acetaminophen (65-20-325
tablet, 130-20-500 tablet)
1
isometheptene mucate/dichloralphenazone/acetaminophen
1
MARGESIC
1
MARTEN-TAB
1
MYOBLOC (2,500 UNIT/0.5 ML VIAL, 5,000 UNITS/1 ML VIAL,
10,000 UNITS/2 ML VIAL)
9
NAMZARIC (14 MG CAPSULE, 28 MG CAPSULE)
3
NIMBEX (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 200 MG/20
ML VIAL)
9
NUEDEXTA
3
ORBIVAN
3
ORBIVAN CF
3
pancuronium bromide
7
phendimetrazine tartrate (35 mg tablet, 105 mg capsule er)
1
phentermine hcl (15 mg capsule, 30 mg capsule, 37.5 mg
capsule, 37.5 mg tablet)
1
PHRENILIN FORTE
3
PRIALT (25 MCG/ML VIAL, 100 MCG/ML VIAL)
9
PRODRIN
3
PAGE 104
PRODUCT DESCRIPTION
TIER
QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG
CAPSULE, 11.25 MG-69 MG CAPSULE, 15 MG-92 MG
CAPSULE)
3
QUELICIN (100 MG/ML VIAL, 200 MG/10 ML VIAL)
7
REGIMEX
3
RILUTEK
3
riluzole
1
rocuronium bromide
7
SUPRENZA ODT (ODT 15 MG TABLET, ODT 30 MG TABLET,
ODT 37.5 MG TABLET)
3
tetrabenazine (12.5 mg tablet, 25 mg tablet)
4
vecuronium bromide (10 mg vial, 20 mg vial)
7
XENAZINE (12.5 MG TABLET, 25 MG TABLET)
6
ZEBUTAL
1
ZEMURON
9
PA
Fibromyalgia Agents
QL
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG
3
SAVELLA TITRATION PACK
3
60 / 30 days
ST
QL
55 / 365 days
ST
Multiple Sclerosis Agents
AMPYRA
6
AUBAGIO (7 MG TABLET, 14 MG TABLET)
6
QL
30 / 30 days
QL
30 / 30 days
PA
QL
AVONEX
1 / 30 days
5
PA
QL
AVONEX ADMINISTRATION PACK
4 / 30 days
5
PA
QL
AVONEX PEN
1 / 30 days
5
PA
QL
BETASERON
15 / 30 days
5
PA
PAGE 105
PRODUCT DESCRIPTION
TIER
QL
COPAXONE 20 MG/ML SYRINGE
30 / 30 days
5
PA
QL
COPAXONE 40 MG/ML SYRINGE
12 / 28 days
5
PA
QL
EXTAVIA 0.3 MG KIT
15 / 30 days
6
PA
QL
EXTAVIA 0.3 MG VIAL
45 / 30 days
6
PA
QL
GILENYA
30 / 30 days
6
PA
QL
glatiramer acetate
30 / 30 days
4
PA
PA
LEMTRADA
6
ST
QL
PLEGRIDY (125 MCG/0.5 ML SYRING, SYRINGE STARTER
PACK)
6
PLEGRIDY PEN (125 MCG/0.5 ML PEN, PEN INJ STARTER
PACK)
6
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE,
TITRATION PACK)
6
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML,
TITRATION PACK)
6
TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE,
STARTER PACK)
5
TYSABRI
6
1 / 28 days
PA
QL
1 / 28 days
PA
QL
13 / 30 days
PA
QL
13 / 30 days
PA
QL
60 / 30 days
PA
PA
Dental and Oral Agents
AQUORAL
2
ARESTIN
3
CAPHOSOL
2
CLINPRO 5000
1
PAGE 106
PRODUCT DESCRIPTION
TIER
DEBACTEROL (SOLUTION, SWABSTICK)
3
EPISIL
3
FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1
MG TABLET CHEW)
2
FLUORIDEX SENSITIVITY RELIEF
3
GELCLAIR
3
GELX
3
KEPIVANCE
9
MUCOTROL
3
MUGARD
3
NAFRINSE DAILY-NEUTRAL
3
NEUTRASAL 538 MG POWDER PACKET
3
NUMOISYN LIQUID
2
NUMOISYN LOZENGE
3
ORAMAGICRX
3
pilocarpine hcl (5 mg tablet, 7.5 mg tablet)
1
PREVIDENT (5000 BOOSTER PLUS, DENTAL RINSE)
3
PREVIDENT 5000
3
PREVIDENT 5000 ENAMEL PROTECT
3
PREVIDENT 5000 PLUS
3
PREVIDENT 5000 SENSITIVE
3
SALAGEN (5 MG TABLET, 7.5 MG TABLET)
3
sodium fluoride (0.2 % solution, 1.1 % cream (g), 1.1 % gel
(gram))
1
stannous fluoride
1
Dermatological Agents
ALEVICYN ANTIPRURITIC SG
3
APOP
3
ARIDA
3
AVAR 9.5%-5% FOAM
3
AVAR LS 10%-2% FOAM
3
COSENTYX (2 SYRINGES)
6
PAGE 107
PA
PRODUCT DESCRIPTION
TIER
COSENTYX PEN
6
PA
COSENTYX PEN (2 PENS)
6
PA
COSENTYX SYRINGE
6
PA
DERMACINRX SILAZONE
3
DERMACINRX SURGICAL PHARMAPAK
3
DERMAPAK PLUS
3
EPIDUO FORTE
3
FINACEA 15% FOAM
3
ONEXTON (1.2%-3.75% GEL, GEL PUMP)
3
ROSULA
3
UREVAZ
3
WHYTEDERM TDPAK
3
8-MOP
2
ABSORICA (10 MG CAPSULE, 20 MG CAPSULE, 25 MG
CAPSULE)
2
ACANYA
3
acitretin (10 mg capsule, 17.5 mg capsule, 25 mg capsule)
1
ACLARO
3
ACLARO PD
3
ACZONE
3
adapalene (0.1 % gel (gram), 0.1 % lotion, 0.1 % cream (g), 0.3
% gel (gram), 0.3 % gel w/pump)
1
ALA-QUIN
2
ALCORTIN A
3
ALOQUIN
3
ALPHAQUIN HP
1
aluminum acetate
1
aluminum chloride
1
ALUVEA
3
ammonium lactate (12 % lotion, 12 % cream (g))
1
ATOPICLAIR
3
PAGE 108
QL
150 / 365 days
PRODUCT DESCRIPTION
TIER
PA
ATRALIN
3
ST
ATRAPRO CP
3
ATRAPRO DERMAL SPRAY
3
ATRAPRO HYDROGEL
2
AURSTAT (ANTI-ITCH HYDROGEL KIT, KIT)
3
AURSTAT ANTI-ITCH HYDROGEL
3
AVAGE
3
AVAR 9.5-5% CLEANSING PADS
3
AVAR LS (10-2% CLEANSING PADS, CLEANSER)
3
AVAR-E LS
3
AVITA (CREAM, GEL)
3
AZELEX
3
BENZAC AC
3
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP)
3
BENZAMYCIN
3
BENZAMYCINPAK
2
BENZEFOAM
3
BENZEFOAM ULTRA
3
benzoic acid/salicylic acid
3
benzoyl peroxide (3 % towelette, 5.3% foam, 6 % towelette, 7
% cleanser, 9% towelette, 9.8 % foam)
1
benzoyl peroxide (4 % gel (gram), 8 % gel (gram), 10 %
cleanser)
3
benzoyl peroxide microspheres
1
BIAFINE
1
BIONECT (CREAM, GEL, SPRAY)
3
C-CLARIFYING SERUM
3
C-THERAPY NIGHT CREAM
3
calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 %
solution)
1
calcipotriene/betamethasone dipropionate
1
PAGE 109
PA
ST
PRODUCT DESCRIPTION
TIER
calcitriol 3 mcg/g oint. (g)
3
CARAC (0.5% CREAM, CREAM)
2
CARB-O-PHILIC
3
CELACYN
1
CLARIFOAM EF
3
CLINDAGEL
3
clindamycin phosphate/benzoyl peroxide (1 %-5 % gel (gram),
1.2(1)%-5% gel (gram))
1
clotrimazole/betamethasone dipropionate (1 % lotion, 1 %
cream (g))
1
CONDYLOX (GEL, TOPICAL SOLN)
3
CORTISPORIN OINTMENT
2
cyclosporine, modified (25 mg capsule, 50 mg capsule, 100
mg/ml solution, 100 mg capsule)
1
DERMASORB AF
3
DERMASORB XM
3
DERMATOP (CREAM, EMOLLIENT CREAM, OINTMENT)
3
diclofenac sodium 1.5 % drops
1
diclofenac sodium 3 % gel (gram)
1
DIFFERIN (0.1% LOTION, 0.1% GEL, 0.1% CREAM, 0.3%
GEL, 0.3% GEL PUMP)
3
dioxybenzone/padimate o/hydroquinone (cream (g), gel (gram))
1
DOVONEX
3
DRITHOCREME HP
3
DRYSOL (DAB-O-MATIC SOLUTION, SOLUTION)
3
DUAC
3
EFUDEX
3
ELDOPAQUE FORTE
3
ELETONE (CREAM, CREAM TWIN PACK)
3
ELIDEL
3
ELOCON (CREAM, LOTION)
3
emol#53/na mg fluorosilicate/cyclometh/phosph ac/nahco3/nacl
1
PA
emol53/e.water/namgfs/naphos/nacl/hypochlorous
acid/nahypocl (96.53 kt crm gel, 96.53 cmb gel fm)
3
PA
PAGE 110
QL
150 / 30 days
ST
PRODUCT DESCRIPTION
TIER
emollient combination no.10
1
3
3
1
emollient combination no.53 cream (g)
3
emollient combination no.53 foam
1
EPICERAM (EMULSION TWIN PACK, SKIN BARRIER
EMULSION)
3
EPIDUO (GEL, GEL PUMP)
3
erythromycin base/benzoyl peroxide
1
FABIOR
3
FINACEA 15% GEL
3
FLUOROPLEX
2
fluorouracil (0.5 % cream (g), 2 % solution, 5 % solution, 5 %
cream (g))
1
FORMA-RAY
3
FORMADON
1
formaldehyde
1
GENADUR (KIT, NAIL LACQUER)
3
GORDO-UREA (22%, 40%)
3
GRANULEX
3
HYDRO 35
3
HYDRO 40
3
hydrocortisone acetate/iodoquinol/aloe vera
1
hydrocortisone/iodoquinol
1
hydroquinone 30 mg/ml solution
2
hydroquinone 4 % cream (g)
1
hydroquinone microspheres
1
hydroquinone/ferric oxide
1
HYLATOPIC
3
HYLATOPIC PLUS (CREAM, EMOLLIENT FOAM)
3
INOVA (4% PAD, 8% PAD)
3
PAGE 111
QL
270 / 90 days
PA
PRODUCT DESCRIPTION
TIER
INOVA 4-1
3
INOVA 8-2
3
iodine/potassium iodide
3
IODOFLEX
3
IODOSORB
3
isotretinoin (10 mg capsule, 20 mg capsule, 30 mg capsule, 40
mg capsule)
1
KERAFOAM (30% FOAM, 42% FOAM)
3
KERALAC
3
KERALYT
3
KERALYT SCALP
3
KEROL
3
LAC-HYDRIN (CREAM, LOTION)
3
lactic acid (10 % cream (g), 10 % lotion)
1
LATISSE
3
LEVULAN
3
LOTRISONE
3
LOUTREX
3
LUSTRA-AF
3
LUSTRA-ULTRA
3
LYCELLE
3
methoxsalen, rapid
1
METVIXIA
3
MIRVASO
3
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g))
1
NATROBA
3
NEO-SYNALAR (0.5%-0.025% CREAM, 0.5-0.025% CRM KIT)
3
NEORAL (25 MG GELATIN CAPSULE, 100 MG/ML
SOLUTION, 100 MG GELATIN CAPSULE)
2
NEOSALUS (CREAM, FOAM)
3
NEOSALUS CP
3
NEOSALUS LOTION
1
PAGE 112
QL
150 / 365 days
QL
9 / 90 days
PRODUCT DESCRIPTION
TIER
NEUAC
3
NU-DERM SUNFADER
3
NUOX
3
NUVAIL
3
OVACE
3
OVACE PLUS (SHAMPOO, WASH)
3
OVACE PLUS 10% CREAM
2
OVACE PLUS WASH
3
OXALIS
3
OXSORALEN
3
OXSORALEN-ULTRA
2
PACNEX
1
PACNEX HP
3
PACNEX LP
3
PACNEX MX
3
PEDIADERM TA
3
PENNSAID 1.5% SOLUTION
3
PENNSAID 2% PUMP
3
PHISOHEX
3
PICATO 0.015% GEL
QL
150 / 30 days
3
QL
9 / 30 days
PICATO 0.05% GEL
3
QL
4 / 30 days
PLEXION (CLEANSER, CREAM, LOTION)
3
PA
PLEXION 9.8-4.8% CLNSING CLOTH
3
podofilox
1
podophyllum resin
2
potassium hydroxide
3
prednicarbate (0.1 % cream (g), 0.1 % oint. (g))
1
PRESERA
3
PROMISEB
3
PROMISEB COMPLETE
3
protectives combination no.2/ceramides 1,3,6-11
1
PAGE 113
PRODUCT DESCRIPTION
TIER
PROTOPIC (0.03%, 0.1%)
2
PRUDOXIN
3
PYROGALLIC ACID
3
QUTENZA
6
QL
4 / 84 days
PA
RADIAPLEXRX
2
RADIGEL
3
REGRANEX
3
RENOVA
3
RENOVA PUMP
3
RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%
CREAM, 0.1% CREAM)
3
ST
RETIN-A MICRO (0.04% GEL, 0.1% GEL)
3
ST
RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.08%
GEL, PUMP 0.1% GEL)
3
ST
SALEX (CREAM KIT, LOTION KIT, SHAMPOO)
3
salicylic acid (6 % cream (g), 6 % gel (gram), 6 % foam, 6 %
shampoo, 6 % crm er (g), 6 % lotion er, 6 % lotion, 26 % liquid,
27.5 % liq-film, 28.5 % liq-film)
1
salicylic acid 3 % oint. (g)
3
salicylic acid/ammonium lactate/aloe vera
3
salicylic acid/ceramides 1,3,6-11 (cmb 6 % kit clcmer, cmb 6 %
combo. pkg)
1
SALKERA
3
SALVAX
3
SALVAX DUO PLUS
3
SANTYL
3
selenium sulfide (2.25 % shampoo, 2.5 % suspension)
1
SELRX
3
silver nitrate (0.5 % solution, 10 % oint. (g), 10 % solution, 25 %
solution, 50 % solution)
3
silver nitrate/potassium nitrate
1
SILVRSTAT
2
PAGE 114
PRODUCT DESCRIPTION
TIER
sodium thiosulfate/salicylic acid
1
SOLARAZE
3
SORIATANE (10 MG CAPSULE, 17.5 MG CAPSULE, 25 MG
CAPSULE)
2
SORILUX
3
STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE)
5
sulfacetamide sodium (10 % clnsr gel, 10 % clnsgel er, 10 %
cleanser, 10 % shampoo)
1
sulfacetamide sodium/sulfur (8 %-4 % suspension, 9 %-4.5 %
cleanser, 9 %-4 % cleanser, 10 %-4 % med. pad, 10 %-5 %
med. pad, 10-5%(w/w) lotion, 10-5%(w/v) lotion, 10-5%(w/w)
cream (g), 10-5%(w/w) cleanser, 10-5%(w/w) suspension, 10
%-1 % cleanser, 10 %-2 % cream (g), 10 %-2 % cleanser, 10
%-5 % foam)
1
sulfacetamide sodium/sulfur (cleanser, cream (g), lotion)
1
sulfacetamide sodium/sulfur/avobenzone/octinoxate/octyl sal
1
sulfacetamide sodium/sulfur/skin cleanser comb no.23
1
sulfacetamide sodium/sulfur/urea (10%-5%-10% gel (gram),
10%-4%-10% cleanser, 10%-5%-10% cleanser)
1
sulfacetamide sodium/sulfur/witch hazel
1
SUMADAN (9%-4.5% WASH, KIT)
3
SUMADAN XLT
3
SUMAXIN (CLEANSING PADS, WASH)
3
SUMAXIN CP
3
SUMAXIN TS
3
TACLONEX (0.005%-0.064% SUSPENS, OINTMENT)
3
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g))
1
TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL, 0.1%
CREAM)
3
TERSI FOAM
3
TETRIX
3
TOPICORT 0.25% SPRAY
3
TRETIN-X (0.025% CREAM COMB PCK, 0.0375% CREAM,
0.05% COMBO PACK, 0.1% COMBO PACK)
3
tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 %
cream (g), 0.05 % cream (g), 0.1 % cream (g))
1
PAGE 115
PA
PA
ST
PRODUCT DESCRIPTION
TIER
tretinoin 0.05 % gel (gram)
1
tretinoin microspheres (0.04 % gel w/pump, 0.04 % gel (gram),
0.1 % gel (gram), 0.1 % gel w/pump)
1
tretinoin/emollient base
1
TRI-CHLOR
3
TRI-LUMA
3
triamcinolone acetonide 0.05 % oint. (g)
1
TRIPLE DYE
2
TROPAZONE (CREAM, LOTION)
1
trypsin/balsam peru/castor oil
1
ULTRASAL-ER
3
UMECTA (EMULSION, NAIL FILM PEN, NAIL FILM SUSP,
SUSPENSION)
3
UMECTA PD (EMULSION, SUSPENSION)
3
URAMAXIN (20% FOAM, 45% UREA CREAM, 45% NAIL GEL,
45% LOTION)
3
URAMAXIN GT (KIT, PRE-FILLED APP)
3
urea (35 % foam, 39 % cream (g), 40 % lotion, 40 % gel (ml),
40 % cream (g), 40 % nl fm susp, 40 % foam, 45 % lotion, 45 %
cream (g), 45 % gel (ml), 45 % gel/pf app, 47 % cream (g), 50
% sol/pf app, 50 % cream (g))
1
urea/hyaluronate sodium
1
urea/lactic ac/zn undecylenate 45 % eml md pmp
3
urea/lactic ac/zn undecylenate 50 % emulsn(g)
1
urea/lactic acid/salicylic acid
1
UTOPIC
3
UVADEX
9
VANIQA
3
VANOXIDE-HC
3
VECTICAL
3
VELTIN
3
VENELEX
3
VEREGEN
3
PAGE 116
PA
QL
90 / 90 days
PRODUCT DESCRIPTION
TIER
VIRASAL
3
vitamin e acet (dl,tocopheryl)/grape/hyaluronic acid
3
VOLTAREN
3
VUSION
3
VYTONE
3
XCLAIR
3
XENADERM
3
ZIANA
3
ZITHRANOL
3
ZITHRANOL-RR
3
ZONALON
3
Enzyme Replacement/ Modifiers
ADAGEN
9
ALDURAZYME
9
AMMONUL
9
BUPHENYL 500 MG TABLET
2
BUPHENYL POWDER
3
CARBAGLU
6
CERDELGA
6
CEREZYME 400 UNITS VIAL
9
CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE, DR
12,000 CAPSULE, DR 24,000 CAPSULE, DR 36,000
CAPSULE)
2
CYSTADANE
3
ELAPRASE
9
ELELYSO
3
ELITEK (1.5 MG VIAL, 7.5 MG VIAL)
9
FABRAZYME (5 MG VIAL, 35 MG VIAL)
6
PA
KUVAN (100 MG POWDER PACKET, 500 MG POWDER
PACKET)
6
PA
KUVAN 100 MG TABLET
6
PA
lipase/protease/amylase
1
PAGE 117
PA
PRODUCT DESCRIPTION
TIER
LUMIZYME
9
PA
MYOZYME
9
PA
NAGLAZYME
6
PA
ORFADIN (2 MG CAPSULE, 5 MG CAPSULE, 10 MG
CAPSULE)
6
PANCREAZE (DR 4,200 UNIT CAP, DR 10,500 UNIT CAP, DR
16,800 UNIT CAP, DR 21,000 UNIT CAP)
3
PERTZYE (DR 8,000 CAPSULE, DR 16,000 CAPS)
2
RAVICTI
3
QL
525 / 30 days
PA
sodium phenylbutyrate
1
SUCRAID
6
ULTRESA (DR 13,800 UNIT CAPSULE, DR 20,700 UNIT
CAPSULE, DR 23,000 UNIT CAPSULE)
3
VIMIZIM
9
VIOKACE (10,440-39,150 TB, 20,880-78,300 TB)
3
VPRIV
9
ZAVESCA
6
ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE, DR
10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000
CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE)
3
PA
PA
PA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ANASPAZ
3
BENTYL (10 MG CAPSULE, 20 MG TABLET)
3
BENTYL 10 MG/ML AMPUL
9
CANTIL
3
chlordiazepoxide/clidinium bromide
1
CUVPOSA
3
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg
tablet)
1
DIGEX NF
3
PAGE 118
QL
1419 / 30 days
PRODUCT DESCRIPTION
TIER
GLYCATE
3
glycopyrrolate (1 mg tablet, 2 mg tablet)
1
hyoscyamine sulfate (0.125mg/ml drops, 0.125 mg tablet, 0.125
mg tab rapdis, 0.125 mg tab subl, 0.375 mg tab er 12h,
125mcg/5ml elixir)
1
LEVBID
3
LEVSIN 0.125 MG TABLET
3
LEVSIN 0.5 MG/ML AMPUL
9
LEVSIN-SL
3
LIBRAX
3
methscopolamine bromide (2.5 mg tablet, 5 mg tablet)
1
PAMINE
3
PAMINE FORTE
3
PAMINE FQ
3
ROBINUL 1 MG TABLET
3
ROBINUL FORTE
3
scopolamine hydrobromide
9
SYMAX DUOTAB
3
Gastrointestinal Agents, Other
ACTIGALL
3
ANALPRAM ADVANCED (1 OZ KIT, 30 X 4G KIT)
3
ANALPRAM E
3
ANALPRAM HC (1% CREAM, 1% CREAM SINGLES, 2.5%-1%
CRM SINGLE, 2.5% CRM SINGLES, 2.5% CREAM, 2.5%-1%
LOTION, 2.5% LOTION, 2.5%-1% CREAM)
3
APRISO
3
ASACOL
2
ASACOL HD
2
AZULFIDINE (500 MG TABLET, ENTAB 500 MG)
3
CANASA
2
CESINEX
3
CHENODAL
3
PAGE 119
QL
120 / 30 days
PA
PRODUCT DESCRIPTION
TIER
CHOLBAM (50 MG CAPSULE, 250 MG CAPSULE)
6
CORTIFOAM
3
DELZICOL
3
dexpanthenol
8
diphenoxylate hcl/atropine sulfate (2.5-.025mg tablet, 2.5-.025/5
liquid)
1
DONNATAL (ELIXIR, TABLET)
3
ENTEREG
3
FULYZAQ
3
PA
QL
180 / 30 days
QL
60 / 30 days
PA
GATTEX (5 MG ONE-VIAL KIT, 5 MG 30-VIAL KIT)
6
HELIDAC
3
hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect)
1
hydrocortisone acetate/lidocaine hcl/aloe vera (0.55%-2.8% gel
w/appl, 2.5-3%(7g) kit)
1
hydrocortisone acetate/pramoxine hcl (1 %-1 % cream/appl, 2.5
%-1 % cream/appl, 2.5-1%(4g) cream/appl)
1
hydrocortisone acetate/pramoxine/emollient/pramoxine comb#1
1
hydrocortisone/lidocaine/aloe 2 %-2 % kit
3
ipecac
1
KINEVAC
9
lansoprazole/amoxicillin trihydrate/clarithromycin
1
LIALDA
3
lidocaine hcl/hydrocortisone acetate (3 %-0.5 % kit, 3%-1%(7 g)
kit, 3 %-0.5 % cream (g), 3 %-0.5 % cream/appl)
1
LOMOTIL
3
loperamide hcl
1
mesalamine
1
mesalamine with cleansing wipes
1
methyltetrahydrofolate glucosamine
1
MOTOFEN
3
MOVANTIK (12.5 MG TABLET, 25 MG TABLET)
3
PAGE 120
PA
PRODUCT DESCRIPTION
TIER
OMECLAMOX-PAK
3
opium tincture
1
opium/belladonna alkaloids (30-16.2mg supp.rect, 60-16.2mg
supp.rect)
2
paregoric
1
PENTASA (250 MG CAPSULE, 500 MG CAPSULE)
3
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
(16.2mg/5ml elixir, 16.2 mg tablet)
1
PREVPAC
3
PROCORT
3
PROCTOCORT 30 MG SUPPOSITORY
3
PROCTOFOAM-HC (1%-1% FOAM, FOAM)
3
propantheline bromide
1
PYLERA
2
RELISTOR (12 ML SYRINGE, 12 ML VIAL)
6
QL
80 / 365 days
ST
QL
9 / 30 days
PA
QL
RELISTOR 12 MG/0.6 ML KIT
14 / 30 days
6
PA
QL
RELISTOR 8 MG/0.4 ML SYRINGE
6 / 30 days
6
PA
REZYST
3
REZYST IM
3
ROWASA
3
SFROWASA
3
sulfasalazine (500 mg tablet, 500 mg tablet dr)
1
URSO
3
URSO FORTE
3
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)
1
VSL#3 DS
3
XENICAL
3
ZYPRAM
3
PAGE 121
PRODUCT DESCRIPTION
TIER
Histamine2 (H2) Receptor Antagonists
AXID
3
cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet, 800 mg
tablet)
1
cimetidine hcl 300 mg/5ml solution
1
DEPRIZINE
3
famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg tablet)
1
famotidine 10 mg/ml vial
7
famotidine in sodium chloride, iso-osmotic/pf
7
famotidine/pf
7
nizatidine (150mg/10ml solution, 150 mg capsule, 300 mg
capsule)
1
PEPCID (20 MG TABLET, 40 MG/5 ML ORAL SUSP, 40 MG
TABLET)
3
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet,
300 mg tablet, 300 mg capsule)
1
ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial)
7
ZANTAC (15 MG/ML SYRUP, 150 MG TABLET, 300 MG
TABLET)
3
ZANTAC (25 MG/ML VIAL, 50 MG/2 ML VIAL, 50 MG/50 ML
PLAST-BAG, 150 MG/6 ML VIAL, 1,000 MG/40 ML VIAL)
9
Irritable Bowel Syndrome Agents
alosetron hcl (0.5 mg tablet, 1 mg tablet)
1
QL
60 / 30 days
AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES)
3
QL
60 / 30 days
LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE)
3
QL
30 / 30 days
LOTRONEX (0.5 MG TABLET, 1 MG TABLET)
3
QL
60 / 30 days
Laxatives
bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350
1
COLYTE WITH FLAVOR PACKETS
3
COLYTE WITH FLAVOR PACKS
3
GOLYTELY (PACKET, SOLUTION)
3
HALFLYTELY-BISACODYL
3
KRISTALOSE (10 GM PACKET, 20 GM PACKET)
3
PAGE 122
PRODUCT DESCRIPTION
TIER
lactulose (10 g/15 ml solution, 20 g/30 ml solution)
1
MOVIPREP
3
NULYTELY WITH FLAVOR PACKS
3
peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl
(236-22.74g soln recon, 240-22.72g soln recon)
1
polyethylene glycol 3350
1
PREPOPIK
3
sodium chloride/sodium bicarbonate/potassium chloride/peg
1
SUCLEAR
3
SUPREP
3
Protectants
CARAFATE (1 GM/10 ML SUSP, 1 GM TABLET)
3
CYTOTEC (100 MCG TABLET, 200 MCG TABLET)
3
misoprostol (100 mcg tablet, 200 mcg tablet)
1
sucralfate
1
Proton Pump Inhibitors
QL
ACIPHEX
30 / 30 days
3
ST
ACIPHEX SPRINKLE (DR 5 MG CAP, DR 10 MG CAP)
3
DEXILANT (DR 30 MG CAPSULE, DR 60 MG CAPSULE)
3
QL
30 / 30 days
ST
QL
esomeprazole magnesium (20 mg capsule dr, 40 mg capsule
dr)
1
esomeprazole sodium (20 mg vial, 40 mg vial)
7
ESOMEPRAZOLE STRONTIUM (DR 24.65 MG CAP, DR 49.3
MG CAP)
1
lansoprazole (15 mg capsule dr, 30 mg capsule dr)
1
NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG
PACKET, DR 20 MG PACKET, DR 40 MG PACKET)
3
NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE)
2
30 / 30 days
ST
QL
30 / 30 days
QL
30 / 30 days
ST
QL
30 / 30 days
ST
PAGE 123
PRODUCT DESCRIPTION
TIER
NEXIUM I.V. (20 MG VIAL, 40 MG VIAL)
9
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg
capsule dr)
1
QL
60 / 30 days
omeprazole/sodium bicarbonate (20mg-1.1g capsule, 40mg1.1g capsule)
1
QL
30 / 30 days
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)
1
QL
30 / 30 days
pantoprazole sodium 40 mg vial
7
PREVACID (DR 15 MG CAPSULE, 15 MG SOLUTAB, 30 MG
SOLUTAB, DR 30 MG CAPSULE)
QL
30 / 30 days
3
PRILOSEC (DR 10 MG CAPSULE, DR 20 MG CAPSULE, DR
40 MG CAPSULE)
3
PRILOSEC (DR 2.5 MG SUSPENSION, DR 10 MG
SUSPENSION)
3
PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET)
3
ST
QL
60 / 30 days
ST
QL
30 / 30 days
ST
PROTONIX 40 MG SUSPENSION
2
PROTONIX IV
9
rabeprazole sodium
1
QL
30 / 30 days
ZEGERID (20 MG PACKET, 20 MG CAPSULE, 40 MG
PACKET, 40 MG CAPSULE)
3
QL
30 / 30 days
QL
60 / 30 days
Genitourinary Agents
Antispasmodics, Urinary
DETROL (1 MG TABLET, 2 MG TABLET)
3
ST
QL
DETROL LA (2 MG CAPSULE, 4 MG CAPSULE)
30 / 30 days
3
ST
DITROPAN XL (5 MG TABLET, 10 MG TABLET, 15 MG
TABLET)
3
ENABLEX (7.5 MG TABLET, 15 MG TABLET)
2
ST
QL
30 / 30 days
ST
flavoxate hcl
1
GELNIQUE (3% GEL, 10% GEL SACHETS)
3
QL
30 / 30 days
ST
PAGE 124
PRODUCT DESCRIPTION
TIER
oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg tab er
24, 10 mg tab er 24, 15 mg tab er 24)
1
OXYTROL
3
QL
9 / 30 days
ST
QL
SANCTURA
60 / 30 days
3
ST
QL
SANCTURA XR
30 / 30 days
3
ST
tolterodine tartrate (1 mg tablet, 2 mg tablet)
1
QL
60 / 30 days
tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 24h)
1
QL
30 / 30 days
QL
TOVIAZ (ER 4 MG TABLET, ER 8 MG TABLET)
30 / 30 days
2
ST
trospium chloride 20 mg tablet
1
QL
60 / 30 days
trospium chloride 60 mg cap er 24h
1
QL
30 / 30 days
QL
VESICARE (5 MG TABLET, 10 MG TABLET)
30 / 30 days
2
ST
Benign Prostatic Hypertrophy Agents
alfuzosin hcl
1
AVODART
2
QL
30 / 30 days
QL
30 / 30 days
ST
QL
CIALIS (2.5 MG TABLET, 5 MG TABLET)
18 / 90 days
2
ST
dutasteride
1
finasteride 1 mg tablet
1
finasteride 5 mg tablet
1
FLOMAX
3
QL
30 / 30 days
QL
30 / 30 days
QL
60 / 30 days
ST
JALYN
3
PROPECIA
3
PAGE 125
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
QL
PROSCAR
30 / 30 days
3
ST
QL
RAPAFLO (4 MG CAPSULE, 8 MG CAPSULE)
30 / 30 days
3
ST
tamsulosin hcl
1
UROXATRAL
3
QL
60 / 30 days
QL
30 / 30 days
ST
Genitourinary Agents, Other
acetic acid 0.25 % irrig soln
7
bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet,
50 mg tablet)
1
CAVERJECT (IMPULSE 10 MCG KIT, IMPULSE 20 MCG KIT,
20 MCG VIAL, 40 MCG VIAL)
9
CERVIDIL
3
CIALIS (10 MG TABLET, 20 MG TABLET)
2
citric acid/sodium citrate (300-500 mg solution, 334-500mg
solution)
1
CUPRIMINE
3
CYSTAGON (50 MG CAPSULE, 150 MG CAPSULE)
6
DEPEN
3
EDEX (10 MCG CARTRIDGE 2-PK KIT, 10 MCG CARTRIDGE
6-PK KIT, 20 MCG CARTRIDGE 2-PK KIT, 20 MCG
CARTRIDGE 6-PK KIT, 40 MCG CARTRIDGE 6-PK KIT, 40
MCG CARTRIDGE 2-PK KIT)
9
ELMIRON
2
K-PHOS NEUTRAL
3
K-PHOS NO.2
2
K-PHOS ORIGINAL
3
LEVITRA (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET,
20 MG TABLET)
3
LITHOSTAT
2
mannitol/sorbitol solution
9
methylergonovine maleate (ampul, vial)
7
PAGE 126
QL
18 / 90 days
QL
18 / 90 days
PA
QL
18 / 90 days
QL
18 / 90 days
PRODUCT DESCRIPTION
TIER
methylergonovine maleate 0.2 mg tablet
1
MUSE (125 MCG SUPPOS, 250 MCG SUPPOS, 500 MCG
SUPPOS, 1,000 MCG SUPP)
3
ORACIT
2
oxytocin
7
phenazopyridine hcl (100 mg tablet, 200 mg tablet)
1
phenazopyridine hcl/hyoscyamine/butabarbital
1
phosphorus #1
1
PITOCIN
9
potassium citrate/citric acid (1100-334/5 solution, 3300-1002
packet)
1
PREPIDIL
3
PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE)
6
PROSTIN E2 VAGINAL SUPPOSITORY
3
PYRIDIUM (100 MG TABLET, 200 MG TABLET)
3
RENACIDIN
8
RESECTISOL
9
RIMSO-50
3
sodium/potassium/potassium citrate/sodium citrate/cit ac
1
sorbitol solution 3 % irrig soln
1
sorbitol solution 3.3% irrig soln
9
STAXYN
3
STENDRA (50 MG TABLET, 100 MG TABLET, 200 MG
TABLET)
3
THIOLA
2
URECHOLINE (5 MG TABLET, 10 MG TABLET, 25 MG
3
VIAGRA (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
2
QL
18 / 90 days
QL
6 / 30 days
QL
18 / 90 days
Phosphate Binders
AURYXIA
3
calcium acetate (667 mg capsule, 667 mg tablet)
1
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET
CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER
PACK, 1,000 MG TABLET CHEW)
3
PAGE 127
PRODUCT DESCRIPTION
TIER
PHOSLO
3
PHOSLYRA
3
RENAGEL (400 MG TABLET, 800 MG TABLET)
3
RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER
PACKET, 800 MG TABLET)
3
sevelamer carbonate
1
VELPHORO
3
QL
180 / 30 days
QL
10 / 30 days
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
ADV ALLERGY COLLECTION KIT
3
AQUA GLYCOLIC HC
3
ARISTOSPAN (5 MG/ML VIAL, 20 MG/ML VIAL)
9
BETA 1
9
betamethasone acetate/betamethasone sodium phosphate
7
budesonide 3 mg capdr - er
1
CELESTONE 0.6 MG/5 ML SOLUTION
2
CELESTONE SOLUSPAN 6 MG/ML
9
CLODAN
3
CORDRAN 0.05% OINTMENT
3
CORTANE-B LOTION
2
CORTEF (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)
3
DERMASORB HC
3
DERMASORB TA
3
DERMOTIC
3
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml
solution, 0.75 mg tablet, 1 mg/ml drops, 1 mg tablet, 1.5 mg
1
dexamethasone sod phosphate 0.1 % drops
1
DEXPAK (6 1.5 MG TABLET, 10 1.5 MG TABLET, 13 1.5 MG
TABLET)
3
diclofenac sodium 0.1 % drops
1
DUREZOL
3
PAGE 128
PRODUCT DESCRIPTION
TIER
ELOCON 0.1% OINTMENT
3
ENTOCORT EC
3
EPIFOAM
3
EZ USE JOINT-TUNNEL-TRIGGER
9
FLAREX
2
FLONASE
3
FLOVENT DISKUS (50 MCG, 100 MCG, 250 MCG)
2
FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG
INHALER, HFA 220 MCG INHALER)
2
fluocinolone acetonide 0.01 % cream (g)
1
fluocinolone acetonide oil
1
fluorometholone
1
fluticasone propionate 50 mcg spray susp
1
FML
3
FML FORTE
2
FML S.O.P.
2
halobetasol propionate/ammonium lactate (cmb ont fm, cmb ont
lt)
1
hydrocortisone (1 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mg
tablet)
1
hydrocortisone acetate/aloe vera
1
hydrocortisone acetate/urea
1
hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)
1
hydrocortisone sod succinate
7
hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g))
1
hydrocortisone/mineral oil/petrolatum,white
1
hydrocortisone/pramoxine 2.5 %-1 % cream (g)
1
KENALOG-10
9
KENALOG-40
9
LOCOID (CREAM, LOTION, OINTMENT, SOLUTION)
3
MAXIDEX
3
MEDROL 2 MG TABLET
3
PAGE 129
ST
PRODUCT DESCRIPTION
TIER
methylprednisolone 4 mg tablet
1
methylprednisolone acetate (40 mg/ml vial, 80 mg/ml vial)
7
mometasone furoate 0.1 % solution
1
MOMEXIN
3
NASACORT AQ
3
NOVACORT
3
NUCORT
3
PANDEL
3
PHYSICIANS EZ USE M-PRED
9
PRAMOSONE (1%-1% CREAM, 1% OINTMENT, 1% CREAM,
1%-1% OINTMENT, 1% LOTION, 2.5%-1% OINTMENT, 2.5%1% CREAM, 2.5%-1% LOTION, 2.5% LOTION, 2.5%
OINTMENT)
3
PRAMOSONE E
3
prednisone (5 mg tablet, 5 mg tab ds pk, 10 mg tablet)
1
PRO-C-DURE 5
9
PRO-C-DURE 6
9
SCALACORT DK
3
SOLU-CORTEF (100 MG VIAL, 250 MG VIAL, 500 MG VIAL,
1,000 MG VIAL)
9
triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial)
7
triamcinolone acetonide 55 mcg spray
1
ULTRAVATE PAC
3
ULTRAVATE X (CREAM PACK, OINTMENT PAC)
3
VERAMYST
2
WESTCORT
3
ST
ST
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin, human
7
DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 MG
TABLET, 10 MCG/0.1 ML SOLUTION)
3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL)
9
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2
mg tablet, 10/spray spray/pump)
1
PAGE 130
QL
3 / 30 days
PRODUCT DESCRIPTION
TIER
desmopressin acetate (ampul, vial)
7
desmopressin acetate (non-refrigerated)
1
EGRIFTA 1 MG VIAL
6
PA
EGRIFTA 2 MG VIAL
6
PA
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG,
MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG,
MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG,
MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12
MG CARTRIDGE)
6
PA
H.P. ACTHAR
9
PA
HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG
CARTRIDGE, 24 MG CARTRIDGE)
6
PA
INCRELEX
6
PA
NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5,
30 MG/3 ML)
6
PA
NORDITROPIN NORDIFLEX
6
PA
NOVAREL
7
QL
NUTROPIN
5
PA
NUTROPIN AQ (5 MG/ML VIAL, 20 MG/2ML PEN CART, PEN
CARTRIDGE)
5
PA
NUTROPIN AQ NUSPIN (5, 10, 20)
5
PA
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5
ML CRTG)
6
PA
PITRESSIN
9
PREGNYL
7
QL
SAIZEN (5 MG VIAL, 8.8 MG VIAL, 8.8 MG CLICK.EASY
CARTG)
5
PA
SEROSTIM (4 MG VIAL, 6 MG VIAL)
6
PA
SEROSTIM 5 MG VIAL
6
PA
SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT, 40 MG
VIAL, 60 MG VIAL, 60 MG KIT)
6
PA
STIMATE
6
TEV-TROPIN
5
PAGE 131
3 / 30 days
3 / 30 days
PA
PRODUCT DESCRIPTION
TIER
vasopressin
9
VASOSTRICT
3
ZOMACTON (5 MG VIAL, 10 MG VIAL)
6
PA
ZORBTIVE
6
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
HEMABATE
9
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
3
OXANDRIN (2.5 MG TABLET, 10 MG TABLET)
3
oxandrolone (2.5 mg tablet, 10 mg tablet)
1
Androgens
ANDRODERM (2 MG/24HR PATCH, 4 MG/24HR PATCH)
3
ANDROGEL (1%(5G) GEL PACKET, 1%(2.5G) GEL PACKET,
1% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62% GEL PUMP,
1.62%(2.5G) GEL PCKT)
2
ANDROID
3
AVEED
9
AXIRON
2
danazol (50 mg capsule, 100 mg capsule, 200 mg capsule)
1
DELATESTRYL
9
DEPO-TESTOSTERONE (100 MG/ML VL, 200 MG/ML VL, 200
MG/ML)
9
fluoxymesterone
2
FORTESTA
3
METHITEST
3
methyltestosterone
1
NATESTO
3
STRIANT
3
TESTIM
2
TESTONE CIK
9
PAGE 132
QL
180 / 30 days
QL
120 / 30 days
PRODUCT DESCRIPTION
TIER
TESTOPEL
3
testosterone (1.25g (1%) gel md pmp, 25mg(1%) gel packet, 50
mg (1%) gel (gram), 50 mg (1%) gel packet)
1
testosterone 10 mg (2%) gel md pmp
1
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial)
7
testosterone enanthate
7
TESTRED
3
VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5 GEL
PACKT)
3
QL
120 / 30 days
QL
8 / 28 days
QL
30 / 30 days
Estrogens
ACTIVELLA (0.5-0.1 MG TABLET, 1 MG-0.5 MG TABLET)
3
ALORA (0.025 MG PATCH, 0.05 MG PATCH, 0.075 MG
PATCH, 0.1 MG PATCH)
2
ANGELIQ (0.25 MG-0.5 MG TABLET, 0.5 MG-1 MG TABLET)
3
BEYAZ
3
BREVICON
3
CENESTIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG
TABLET, 0.9 MG TABLET, 1.25 MG TABLET)
2
CLIMARA (0.025 MG/DAY PATCH, 0.0375 MG/DAY PATCH,
0.05 MG/DAY PATCH, 0.06/MG DAY PATCH, 0.075 MG/DAY
PATCH, 0.1 MG/DAY PATCH)
3
QL
4 / 28 days
CLIMARA PRO
3
QL
4 / 28 days
COMBIPATCH (0.05-0.14 MG, 0.05-0.25 MG)
2
CYCLESSA
1
DELESTROGEN (10 MG/ML VIAL, 20 MG/ML VIAL, 40 MG/ML
VIAL)
9
DEPO-ESTRADIOL
3
DESOGEN
3
desogestrel-ethinyl estradiol (0.15-0.03 tablet, 7 days x 3 tablet)
1
desogestrel-ethinyl estradiol/ethinyl estradiol
1
DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1
MG GEL PACKET)
3
DUAVEE
3
ELESTRIN
3
PAGE 133
PRODUCT DESCRIPTION
TIER
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG
TABLET, 0.9 MG TABLET, 1.25 MG TABLET)
3
ESTRACE (0.01% CREAM, 0.5 MG TABLET, 1 MG TABLET, 2
MG TABLET)
3
estradiol (.025mg/24h patch tdsw, .0375mg/24 patch tdsw,
0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hr
patch tdsw)
1
QL
8 / 28 days
estradiol (.025mg/24h patch tdwk, .0375mg/24 patch tdwk,
0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk, .075mg/24h
patch tdwk, 0.1mg/24hr patch tdwk)
1
QL
4 / 28 days
estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
estradiol valerate (10 mg/ml vial, 20 mg/ml vial, 40 mg/ml vial)
7
estradiol/norethindrone acetate (0.5-0.1mg tablet, 1 mg-0.5mg
tablet)
1
ESTRASORB
3
ESTRING
2
QL
1 / 90 days
ESTROGEL
3
estrogens,esterified/methyltestosterone (0.625-1.25 tablet,
1.25-2.5mg tablet)
1
estropipate (0.75 mg tablet, 1.5 mg tablet, 3 mg tablet)
1
ESTROSTEP FE
3
ethinyl estradiol/drospirenone (0.02-3(24) tablet, 0.03mg-3mg
tablet)
1
ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet
1
EVAMIST
3
QL
16 / 30 days
FEMCON FE (MCON CHEWABLE TABLET, MCON TABLET)
3
FEMHRT
2
FEMRING (0.05 MG RING, 0.10 MG RING)
3
GENERESS FE
3
LAYOLIS FE
3
levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 0.15-0.03
tbdspk 3mo, 0.15-0.03 tablet, 6-5-10 tablet, 90-20mcg tablet)
1
levonorgestrel/ethinyl estradiol and ethinyl estradiol (100-20(84)
tbdspk 3mo, 150-30(84) tbdspk 3mo)
1
LO LOESTRIN FE
3
PAGE 134
PRODUCT DESCRIPTION
TIER
LO MINASTRIN FE
3
LOESTRIN (21 1-20 TABLET, 21 1.5-30 TABLET)
3
LOESTRIN 24 FE
3
LOESTRIN FE (1-20 TABLET, 1.5-30 TABLET)
3
LOSEASONIQUE
3
MAKENA
3
MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MG
TABLET, 2.5 MG TABLET)
3
MENOSTAR
3
MINASTRIN 24 FE
2
MINIVELLE (0.025 MG PATCH, 0.0375 MG PATCH, 0.05 MG
PATCH, 0.075 MG PATCH, 0.1 MG PATCH)
2
MIRCETTE
3
MODICON
3
NATAZIA
3
NORDETTE-28
3
norelgestromin/ethinyl estradiol
1
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg20mcg tablet, 1mg-5mcg tablet, 1.5-0.03mg tablet)
1
norethindrone acetate-ethinyl estradiol/ferrous fumarate (1mg20(24) tablet, 1mg-20(21) tablet, 1.5-30(21) tablet, 5-7-9-7
tablet)
1
norethindrone-ethinyl estradiol (0.4-0.035 tablet, 0.5-0.035
tablet, 1 mg-35mcg tablet, 7-9-5 tablet, 7 days x 3 tablet, 10-11
tablet)
1
norethindrone-ethinyl estradiol/ferrous fumarate (0.4-35(21) tab
chew, 0.8-25(24) tab chew)
1
norethindrone-mestranol
1
norgestimate-ethinyl estradiol (0.25-0.035 tablet, 7daysx3 28
tablet)
1
norgestrel-ethinyl estradiol 0.3-0.03mg tablet
1
NORINYL 1+35
3
NORINYL 1+50
3
NUVARING
3
PAGE 135
QL
8 / 28 days
QL
30 / 30 days
QL
9 / 84 days
QL
1 / 30 days
PRODUCT DESCRIPTION
TIER
OGEN
3
ORTHO EVRA
3
ORTHO TRI-CYCLEN
3
ORTHO TRI-CYCLEN LO
2
ORTHO-CEPT
3
ORTHO-CYCLEN
1
ORTHO-NOVUM (1-35-28 TABLET, 7-7-7-28 TABLET)
3
OVCON-35
3
PREFEST
2
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG
TABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINAL
CREAM-APPL)
2
PREMARIN 25 MG VIAL
9
PREMPHASE
2
PREMPRO (0.3 MG-1.5 MG TABLET, 0.45-1.5 MG TABLET,
0.625-5 MG TABLET, 0.625-2.5 MG TABLET)
2
QUARTETTE
3
SAFYRAL
3
SEASONIQUE
3
TRI-NORINYL
3
VAGIFEM
3
VIVELLE-DOT (0.025 MG PATCH, 0.0375 MG PATCH, 0.05
MG PATCH, 0.075 MG PATCH, 0.1 MG PATCH)
2
YASMIN 28
3
YAZ
3
QL
9 / 84 days
QL
8 / 28 days
QL
1 / 90 days
Progestins
AYGESTIN
3
CRINONE (4% GEL, 8% GEL)
2
DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL,
400 MG/ML VIAL)
9
DEPO-SUBQ PROVERA 104
9
ELLA
3
ENDOMETRIN
3
PAGE 136
PRODUCT DESCRIPTION
TIER
IMPLANON
9
levonorgestrel 0.75 mg tablet
1
QL
2 / 365 days
levonorgestrel 1.5 mg tablet
1
QL
1 / 365 days
LILETTA
3
medroxyprogesterone acetate (150 mg/ml vial, 150 mg/ml
syringe)
7
QL
1 / 90 days
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10
mg tablet)
1
MEGACE
3
MEGACE ES
3
megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral
susp, 625mg/5ml oral susp)
1
MIRENA
3
NEXPLANON
9
NOR-Q-D
3
norethindrone
1
norethindrone acetate
1
ORTHO MICRONOR
3
PLAN B ONE-STEP
3
QL
1 / 365 days
progesterone
7
progesterone,micronized (100 mg capsule, 200 mg capsule)
1
PROMETRIUM (100 MG CAPSULE, 200 MG CAPSULE)
3
PROVERA (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET)
3
SKYLA
3
QL
30 / 30 days
Selective Estrogen Receptor Modifying Agents
EVISTA
2
ST
OSPHENA
3
QL
30 / 30 days
raloxifene hcl
1
QL
30 / 30 days
PAGE 137
PRODUCT DESCRIPTION
TIER
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
ARMOUR THYROID (15 MG TABLET, 30 MG TABLET, 60 MG
TABLET, 90 MG TABLET, 120 MG TABLET, 180 MG TABLET,
3
CYTOMEL (5 MCG TABLET, 25 MCG TABLET, 50 MCG
TABLET)
3
LEVOTHROID (25 MCG TABLET, 50 MCG TABLET, 75 MCG
TABLET, 88 MCG TABLET, 100 MCG TABLET, 112 MCG
TABLET)
1
levothyroxine sodium (100 mcg vial, 200 mcg vial, 500 mcg vial)
7
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg
tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg
tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg
tablet, 300 mcg tablet)
1
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 75 MCG
TABLET, 175 MCG TABLET, 200 MCG TABLET)
1
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet)
1
liothyronine sodium 10 mcg/ml vial
7
NATURE-THROID (16.25 MG TABLET, 32.5 MG TABLET, 65
MG TABLET, 81.25 MG TABLET, 113.75 MG TABLET, 130
MG TABLET)
2
NATURE-THROID (48.75 MG TABLET, 97.5 MG TABLET, 260
3
SYNTHROID (25 MCG TABLET, 50 MCG TABLET, 75 MCG
TABLET)
2
thyroid,pork (30 mg tablet, 60 mg tablet, 90 mg tablet)
1
THYROLAR-1
3
THYROLAR-1/2
3
THYROLAR-1/4
3
THYROLAR-2
3
THYROLAR-3
3
PAGE 138
PRODUCT DESCRIPTION
TIER
TIROSINT (13 MCG CAPSULE, 25 MCG CAPSULE, 50 MCG
CAPSULE, 75 MCG CAPSULE, 88 MCG CAPSULE, 100 MCG
CAPSULE, 112 MCG CAPSULE, 125 MCG CAPSULE, 137
MCG CAPSULE, 150 MCG CAPSULE)
3
TRIOSTAT
9
UNITHROID (25 MCG TABLET, 50 MCG TABLET, 75 MCG
TABLET)
1
WESTHROID (16.25 MG TABLET, 32.5 MG TABLET, 65 MG
2
WESTHROID (48.75 MG TABLET, 81.25 MG TABLET, 97.5
3
WESTHROID-P (48.75 MG TABLET, 97.5 MG TABLET)
3
WP THYROID (16.25 MG TABLET, 32.5 MG TABLET, 65 MG
2
WP THYROID (48.75 MG TABLET, 81.25 MG TABLET, 97.5
MG TABLET, 113.75 MG TABLET)
3
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
2
SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML)
6
PA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml
solution)
1
calcitriol 1 mcg/ml ampul
7
paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule)
1
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1
MCG/ML ORAL SOLN)
3
SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG TABLET)
6
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE, 4 MCG
CAPSULE)
3
ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML
VIAL)
9
PA
Hormonal Agents, Suppressant (Pituitary)
cabergoline
PAGE 139
1
PRODUCT DESCRIPTION
TIER
CETROTIDE (0.25 MG KIT, 3 MG KIT)
9
ELIGARD (7.5 MG SYRINGE KIT, 22.5 MG SYRINGE KIT, 30
MG SYRINGE KIT, 45 MG SYRINGE KIT)
6
FIRMAGON (2 120 MG VIALS, 2 120 MG KIT)
9
QL
2 / 30 days
FIRMAGON (80 MG KIT, 80 MG VIAL)
9
QL
1 / 30 days
GANIRELIX ACETATE
9
leuprolide acetate
4
LUPANETA PACK (PK 3.75-5 MG 1MO KIT, PK 11.25-5 MG
3MO KIT)
3
LUPRON DEPOT (DEPOT 3.75 MG KIT, DEPOT-4 MONTH
KIT, DEPOT 7.5 MG KIT, DEPOT 11.25 MG 3MO KIT, DEPOT
22.5 MG 3MO KIT, DEPOT 45 MG 6MO KIT)
5
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25
MG KIT, 15 MG KIT, 30 MG 3MO KIT)
5
octreotide acetate (50 mcg/ml ampul, 100 mcg/ml ampul, 200
mcg/ml vial, 500 mcg/ml ampul, 1000mcg/ml vial)
4
PA
octreotide acetate (50 mcg/ml vial, 50 mcg/ml syringe, 100
mcg/ml vial, 100 mcg/ml syringe, 500 mcg/ml syringe, 500
mcg/ml vial)
4
PA
SANDOSTATIN (0.05 MG/ML AMPUL, 0.1 MG/ML AMPUL, 0.2
MG/ML VIAL, 0.5 MG/ML AMPUL, 1 MG/ML VIAL)
6
PA
SANDOSTATIN LAR (10 MG KIT, 20 MG KIT, 30 MG KIT)
6
PA
SANDOSTATIN LAR DEPOT (10 MG KT, 20 MG KT, 30 MG
KT)
6
PA
SOMATULINE DEPOT (60 MG/0.2 ML, 90 MG/0.3 ML, 120
MG/0.5 ML)
9
SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL, 25 MG
VIAL, 30 MG VIAL)
6
SUPPRELIN LA
3
SYNAREL
6
VANTAS
9
ZOLADEX (3.6 MG IMPLANT SYRN, 10.8 MG IMPLANT
SYRN)
3
PAGE 140
PA
PA
PRODUCT DESCRIPTION
TIER
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide
1
QL
30 / 30 days
CASODEX
3
QL
30 / 30 days
NILANDRON
2
QL
XTANDI
120 / 30 days
9
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg tablet, 10 mg tablet)
1
propylthiouracil
1
TAPAZOLE (5 MG TABLET, 10 MG TABLET)
3
Immunological Agents
Immune Suppressants
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG
CAPSULE)
3
ATGAM
9
AZASAN (75 MG TABLET, 100 MG TABLET)
3
azathioprine
1
BENLYSTA (120 MG VIAL, 400 MG VIAL)
6
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500
MG TABLET)
2
CELLCEPT 500 MG VIAL
3
CIMZIA (200 MG VIAL KIT, 200 MG/ML STARTER KIT, 200
MG/ML SYRINGE KIT)
5
cyclosporine (25 mg capsule, 100 mg capsule)
1
cyclosporine (250 vial, 250 ampul)
7
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML
SYRINGE, 50 MG/ML SURECLICK SYR)
6
ENTYVIO
6
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG
TABLET)
3
PAGE 141
PA
PA
QL
4 / 30 days
PA
PRODUCT DESCRIPTION
TIER
QL
HUMIRA (10 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE,
40 MG/0.8 ML SYRINGE)
5
HUMIRA PEDIATRIC CROHN'S
5
2 / 28 days
PA
QL
6 / 28 days
PA
QL
HUMIRA PEN
2 / 28 days
5
PA
QL
HUMIRA PEN CROHN'S-UC-HS
6 / 28 days
5
PA
QL
HUMIRA PEN PSORIASIS
4 / 28 days
5
PA
IMURAN
3
KINERET
6
QL
30 / 30 days
PA
methotrexate sodium/pf 25 mg/ml vial
7
mycophenolate mofetil (200 mg/ml susp recon, 250 mg
capsule, 500 mg tablet)
1
mycophenolate sodium (180 mg tablet dr, 360 mg tablet dr)
1
MYFORTIC (180 MG TABLET, 360 MG TABLET)
3
NULOJIX
6
PA
ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL)
6
PA
OTREXUP (7.5 ML, 10 ML, 15 ML, 20 ML, 25 ML)
3
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG/ML
AMPULE, 5 MG CAPSULE)
3
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML
ORAL SOLN, 2 MG TABLET)
3
RASUVO (7.5 MG/0.15 ML, 10 MG/0.2 ML, 12.5 MG/0.25 ML,
15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45
ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML)
9
REMICADE
6
RESTASIS
3
RHEUMATREX
3
SANDIMMUNE (25 MG CAPSULE, 100 MG/ML SOLN, 100 MG
CAPSULE)
2
PAGE 142
PA
PRODUCT DESCRIPTION
TIER
SANDIMMUNE 50 MG/ML AMPUL
8
SIMPONI (50 MG/0.5 ML SYRINGE, 50 MG/0.5 ML PEN
INJEC, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE)
5
PA
SIMPONI ARIA
5
PA
SIMULECT (10 MG VIAL, 20 MG VIAL)
3
sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
SYLVANT (100 MG VIAL, 400 MG VIAL)
3
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)
1
ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG
TABLET)
6
QL
60 / 30 days
PA
Immunizing Agents, Passive
BIVIGAM
9
FLEBOGAMMA DIF
9
GAMASTAN S-D
8
GAMMAGARD LIQUID
3
GAMMAGARD S-D (2.5 GM VL W/ST, 5 G (IGA<1) SOLN, 5
GM VL W/SET, 10 G (IGA<1) SOL, 10 GM VL W/ST)
3
GAMMAKED (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML VIAL, 5
GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML
VIAL)
9
GAMMAPLEX
8
GAMUNEX
9
GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML VIAL, 5
GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML
VIAL, 40 GRAM/400 ML VIAL)
9
HIZENTRA (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4
GRAM/20 ML VIAL, 10 GRAM/ 50 ML VIAL)
9
HYPERRAB S-D
8
HYPERRHO S-D (250 SYRINGE, 1500 SYR)
9
HYPERTET S-D
9
HYQVIA (2.5 GM/200 UNIT VIAL, 5 GM/400 UNIT VIAL, 10
GM/800 UNIT VIAL, 20 GM/1,600 UNIT VIAL, 30 GM/2,400
UNIT VIAL)
9
immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml
7
immune globulin,gamm(igg)/sucrose/iga greater than 50 mcg/ml
(3 g vial, 6 g vial, 12 g vial)
8
PAGE 143
PRODUCT DESCRIPTION
TIER
immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
9
immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml
8
IMOGAM RABIES-HT
8
MICRHOGAM ULTRA-FILTERED PLUS
8
OCTAGAM (5% VIAL, 10% VIAL)
8
rho(d) immune globulin
7
RHOGAM ULTRA-FILTERED PLUS
9
RHOPHYLAC
9
THYMOGLOBULIN
3
VARIZIG 125 UNIT VIAL
3
VARIZIG 125 UNIT/1.2 ML VIAL
9
WINRHO SDF (1,500 VIAL, 2,500 VIAL, 5,000 VIAL, 15,000
VIAL)
9
Immunomodulators
ACTEMRA (80 MG/4 ML VIAL, 162 MG/0.9 ML SYRINGE, 200
MG/10 ML VIAL, 400 MG/20 ML VIAL)
6
PA
ACTIMMUNE
6
PA
ARAVA (10 MG TABLET, 20 MG TABLET)
3
ARCALYST
9
QL
4 / 28 days
FIRAZYR
6
QL
3 / 30 days
QL
ILARIS
1 / 56 days
6
PA
leflunomide (10 mg tablet, 20 mg tablet)
1
OTEZLA (28 DAY STARTER PACK, 30 MG TABLET,
STARTER PACK)
6
RIDAURA
3
SYNAGIS (50 MG/0.5 ML VIAL, 100 MG/1 ML VIAL)
6
XELJANZ
6
QL
60 / 30 days
PA
Vaccines
ACTHIB (VIAL, WITH DILUENT)
9
ADACEL TDAP (SYRINGE, VIAL)
9
PAGE 144
PRODUCT DESCRIPTION
TIER
BCG VACCINE (TICE STRAIN)
9
BEXSERO
9
BIOTHRAX
9
BOOSTRIX TDAP (SYRINGE, VIAL)
9
botulism antitoxin heptavalent a,b,c,d,e,f,g(equine)/maltose
1
CERVARIX
9
COMVAX
9
CYTOGAM
9
DAPTACEL DTAP
9
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL)
9
ENGERIX-B PEDIATRIC-ADOLESCENT (10 ML PED VL,
PEDI 10 SYRN)
9
GARDASIL (SYRINGE, VIAL)
9
GARDASIL 9 (9 VIAL, 9 SYRINGE)
9
HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML SYRINGE,
1,440 UNITS/ML VIAL, 1,440 UNITS/ML SYRINGE)
9
HEPAGAM B
8
HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL)
8
IMOVAX RABIES VACCINE
9
INFANRIX DTAP (SYRINGE, VIAL)
9
IPOL (SINGLE DOSE SYRINGE, VIAL)
9
IXIARO
9
KINRIX (TIP-LOK SYRINGE, VIAL)
3
M-M-R II VACCINE
3
MENACTRA
9
MENHIBRIX
9
MENOMUNE-A-C-Y-W-135
9
MENVEO A-C-Y-W-135-DIP
6
NABI-HB
8
PEDIARIX
3
PEDVAXHIB
8
PENTACEL
3
PAGE 145
PA
PRODUCT DESCRIPTION
TIER
PENTACEL ACTHIB COMPONENT
9
PENTACEL DTAP-IPV COMPONENT
9
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL)
8
QL
0.5 / 365 days
PREVNAR 13
9
QL
0.5 / 365 days
PROQUAD
9
QUADRACEL DTAP-IPV
9
RABAVERT
9
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10
MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL)
9
ROTARIX
3
ROTATEQ
3
TENIVAC (SYRINGE, VIAL)
8
tetanus and diphtheria toxoids, adult
9
tetanus toxoid, adsorbed/pf
9
tetanus,diphtheria toxoid ped/pf
9
TWINRIX (SYRINGE, VIAL)
9
TYPHIM VI (25 ML SYRNG, 25 ML AL)
9
VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL,
50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)
9
VARIVAX VACCINE
9
VIVOTIF BERNA
3
YF-VAX (1 VIAL, 5 VIAL)
9
ZOSTAVAX
9
QL
180 / 30 days
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
1
COLAZAL
3
DIPENTUM
3
GIAZO
3
Glucocorticoids
CORTENEMA (100 MG/60 ML ENEMA, 100 MG ENEMA)
PAGE 146
3
PRODUCT DESCRIPTION
TIER
hydrocortisone 100mg/60ml enema
1
UCERIS 2 MG RECTAL FOAM
3
UCERIS 9 MG ER TABLET
3
QL
30 / 30 days
MISCELLANEOUS THERAPEUTIC AGENTS
ABLAVAR (2.5 MMOL/10 ML VIAL, 3.75 MMOL/15 ML VIAL)
9
ACETADOTE
9
acetaminophen/phenyltoloxamine citrate (500-55mg tablet, 60066mg tablet er)
1
acetaminophen/phenyltolx 650mg-50mg tablet
3
acetylcysteine 200 mg/ml vial
7
ACTHREL
9
ADDYI
3
ADENOSCAN
9
ADREVIEW
9
AK-FLUOR 10% VIAL
7
AK-FLUOR 25% VIAL
9
ALPHANATE 2,000-800 UNIT VIAL
6
AMERICAN COCKROACH EXTRACT
9
AMERICAN ELM
9
AMERICAN SYCAMORE
9
aminohippurate sodium
9
AMYVID
9
ANASCORP
9
antivenin,latrodectus mactans
7
antivenin,micrurus fulvius
9
APLISOL
9
APPTRIM
3
APPTRIM-D
3
ARIDOL
3
ARTISS (2 ML SYRINGE, 4 ML SYRINGE, 10 ML SYRINGE)
3
ASCLERA (10 ML (0.5%) AMP, 20 ML (1%) AMPULE)
9
PAGE 147
PA
PRODUCT DESCRIPTION
TIER
ASPERGILLUS FUMIGATUS
9
ASTRINGYN
3
ATRYN 525 UNIT VIAL
6
AVENOVA
3
AVITENE (FLOUR, SHEET 35MMX35MM, SHEET
70MMX35MM, SHEET 70MMX70MM)
3
BAHIA
9
BAL IN OIL
9
balsam peru/castor oil
1
barium sulfate (60%(w/v) oral susp, 210 % oral susp)
3
BAYBERRY
9
BEAU RX
3
BIONECT 0.2% FOAM
3
bivalirudin 250 mg vial port
7
BLACK WALNUT POLLEN
9
BOX ELDER
9
BRAVELLE
9
CA-DTPA
3
CANDIDA ALBICANS
9
CANDIN
9
CARDIOLITE
3
CARTICEL
9
CERENX
3
CERETEC
9
CHIRHOSTIM
9
CHOLOGRAFIN MEGLUMINE
9
clomiphene citrate
1
CO-VERATROL
3
COMPLETE FORMULATION D3000
1
COMPLETE FORMULATION PEDIATRIC
3
CONRAY
9
CONRAY-30
9
PAGE 148
PRODUCT DESCRIPTION
TIER
CONRAY-43
9
CONTRAVE
3
CORTROSYN
9
cosyntropin (0.25 mg vial, 0.25 mg/ml vial)
7
CROFAB
9
cyanocobalamin/levomefolate calcium/pyridoxine hcl
1
CYSTO-CONRAY II
9
CYSTOGRAFIN
9
CYSTOGRAFIN-DILUTE
9
D.FARINAE MITE EXTRACT
9
D.PTERONYSSINUS MITE EXTRACT
9
DATSCAN
9
deferoxamine mesylate (2 g vial, 500 mg vial)
7
DEFINITY
9
DERMASILKRX LIDORXKIT
3
DESFERAL
9
DESFERAL MESYLATE
9
diatrizoate meglumine/diatrizoate sodium
1
DIGIBAR
3
DILUENT
9
DMSA
9
DOG EPITHELIUM EXTRACT
9
DOTAREM (5 MMOL/10 ML SYRINGE, 5 MMOL/10 ML VIAL,
7.5 MMOL/15 ML VIAL, 7.5 MMOL/15 ML SYRINGE, 10
MMOL/20 ML SYRINGE, 10 MMOL/20 ML VIAL, 50 MMOL/100
ML VIAL)
3
DRAXIMAGE DTPA
9
DRAXIMAGE MAA
3
DRAXIMAGE MDP-25
3
DUODOTE
9
E-Z DISK
3
E-Z-CAT (CONCENTRATE SUSP, DRY SUSPENSION)
3
E-Z-DOSE-LIQ POLIBAR PLUS
3
PAGE 149
PRODUCT DESCRIPTION
TIER
E-Z-HD
3
E-Z-PAQUE
3
E-Z-PASTE
3
EASTERN COTTONWOOD
9
ELLIOTTS B
9
ELOCTATE (250 UNIT, 500 UNIT, 750 UNIT, 1,000 UNIT,
1,500 UNIT, 2,000 UNIT, 3,000 UNIT)
9
ENDO-AVITENE (5MM SHEET, 10MM SHEET)
3
ENGLISH PLANTAIN
9
ENTERO VU (13% LIQUID, 13% PACKET, 24% LIQUID)
3
EOVIST (2.5 MMOL/10 ML VIAL, 3.75 MMOL/15 ML VIAL)
9
ESCAVITE D
3
ESOPHO-CAT
3
ETHAMOLIN
9
ethyl alcohol (98 % vial, 98 % ampul)
7
FERIDEX I.V.
3
FERIVA 21-7
3
FERIVA FA
3
FERRLECIT
9
FLOWTUSS
3
fludeoxyglucose f-18
1
flumazenil
7
FLUOR-I-STRIP AT
1
fluorescein sodium
1
FLUORESCITE
9
FOLLISTIM AQ (75 UNIT VIAL, 150 UNIT VIAL, 300 UNIT
CARTRIDG, 600 UNIT CARTRIDG, 900 UNIT CARTRIDG)
9
FUL-GLO
3
GADAVIST (1 MMOL/ML BULK VIAL, 2 MMOL/2 ML VIAL, 7.5
MMOL/7.5 ML VIAL, 7.5 MMOL/7.5 ML SYR, 10 MMOL/10 ML
SYRINGE, 10 MMOL/10 ML VIAL, 15 MMOL/15 ML VIAL, 15
MMOL/15 ML SYRINGE)
9
GASTROGRAFIN
3
PAGE 150
PRODUCT DESCRIPTION
TIER
GASTROMARK
3
GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE,
POWDER, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200
SPONGE)
3
GELFOAM COMPRESSED
3
glycine/sodium/water for injection,sterile/sodium hydroxide
1
GONAL-F (450 VIAL, 1,050 VIAL)
9
GONAL-F RFF (75 VIAL, 300 PEN, 450 PEN, 900 PEN)
9
GONAL-F RFF REDI-JECT (300 UNIT, 450 UNIT, 900 UNIT)
3
GRAFIX CORE (1.5CM 2CM, 3CM 4CM)
3
GRAFIX PRIME (1.5CM 2CM MATR, 3CM 4CM MATRI)
3
HORSE EPITHELIUM
9
HYALGAN (20 ML SYRINGE, 20 ML VIAL)
3
hyaluronate sodium
1
hyaluronate sodium/hydroxyethylcellulose/polyethylene glycol
1
HYCOFENIX
3
HYLENEX
9
hypochlorous acid/sodium chloride
1
IC GREEN
9
INDICLOR
9
INDIGO CARMINE
7
INDIUM IN-111 DTPA
9
indium in-111 oxyquinoline
9
indocyanine green
7
insulin admin. supplies
2
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach
1
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
isosulfan blue
7
ISOVUE-200 (INFUS BOTTLE, VIAL)
9
ISOVUE-250 (BULK, INFUS BOTTLE, VIAL)
9
9
9
PAGE 151
PRODUCT DESCRIPTION
TIER
ISOVUE-M 200
9
ISOVUE-M 300
9
IXINITY (500 UNIT VIAL, 1,000 UNIT VIAL, 1,000 UNIT VIAL -2
VLS, 1,500 UNIT VIAL, 1,500 UNIT VIAL -2 VLS)
6
JOHNSON GRASS
9
KALBITOR
6
kit for prep tc 99m/sestamibi combination no.1
1
kit for prep tc 99m/sodium thiosulfate
1
kit for prep tc-99m/mebrofenin
1
kit for prep tc-99m/medronate sodium
1
kit for prep tc-99m/sodium pyrophosphate
1
KORLYM
6
LAMB'S QUARTERS
9
LDO PLUS
3
levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil
1
levomefolate calcium/schizochytrium algal oil (oil 7.5-90.314
capsule, oil 15-90.314 capsule)
1
LEXISCAN
9
LIQUID POLIBAR
3
LIQUID POLIBAR PLUS
3
LUMASON
9
LYMPHAZURIN
9
MACUVEX
3
MACUZIN
3
MAGNEVIST (BULK VIAL, SYRINGE, VIAL)
9
MATRISTEM (3CM 7CM WND SHEET, 3CM 3.5CM WD
SHEET, 7CM 10CM WND SHEET, 10CM 15CM WD SHEET)
3
MATRISTEM MICROMATRIX (MICROMATRIC 30 MG,
MICROMATRIX 20 MG, MICROMATRIX 60 MG, MICROMTRX
100 MG, MICROMTRX 200 MG)
3
MD-76 R (R INFUSION BOTTLE, R VIAL)
9
MEDI-10
3
MENOPUR
9
PAGE 152
PA
PRODUCT DESCRIPTION
TIER
MESQUITE
9
METASTRON
9
methylene blue (1 % vial, 1 % ampul)
7
METOPIRONE
3
MIFEPREX
3
MIXED RAGWEED EXTRACT
9
MONOVISC
9
MONSEL'S
3
MOUNTAIN CEDAR
9
MUGWORT
9
MULTIHANCE
9
MULTIHANCE MULTIPACK
9
MYALEPT
6
MYOVIEW
9
NASCOBAL
3
NEUTRASAL POWDER PACKET
3
NEXAVIR
9
niacinamide/azelaic ac/quercet/turmer/fa/b6/zinc ox/copper
1
NICOMIDE
3
NITHIODOTE
9
NOVOEIGHT (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT
VIAL, 1,500 UNIT VIAL, 2,000 UNIT VIAL, 3,000 UNIT VIAL)
6
PA
OBIZUR (500 UNIT VIAL, 500 UNIT VIAL -10 VIALS, 500 UNIT
VIAL - 5 VIALS)
6
PA
OBREDON
3
OCTREOSCAN
9
OCUVEL
3
OFIRMEV
9
OMNIPAQUE (140 MG/ML BOTTLE, 180 MG/ML VIAL, 240
MG/ML VIAL, 240 MG/ML INFU BTL, 240 MG/ML BOTTLE,
300 MG/ML PLUSPAK BT, 300 MG/ML BOTTLE, 300 MG/ML
INFU BTL, 300 MG/ML VIAL, 350 MG/ML INFU BTL)
9
OMNISCAN (287 MG/ML SYRINGE, 287 MG/ML VIAL)
9
PAGE 153
PA
PRODUCT DESCRIPTION
TIER
OMNISCAN PREFILL PLUS
3
OPTIMARK (5 MMOL/10 ML SYRINGE, 7.5 MMOL/15 ML
SYRING, 10 MMOL/20 ML SYRINGE, 15 MMOL/30 ML
SYRINGE, 330.9 MG/ML VIAL)
9
OPTIRAY 300 (300 VIAL, 300 SYRN)
9
OPTIRAY 320 (320 SYRN, 320 VIAL)
9
OPTIRAY 350 (350 VIAL, 350 SYRN)
9
OPTISON
9
ORTHOVISC
3
OVIDREL
6
OXILAN-350
9
OXYCEL
3
PANHEMATIN
6
PARAGARD T 380-A
3
PECAN POLLEN
9
ped mv a,c,d3 #21 w-fluoride 0.25 mg/ml drops
1
pediatric multivitamin combination no.2/sodium fluoride (0.25
mg/ml drops, 0.5 mg/ml drops)
1
pediatric multivitamin combo no.45/fluoride/ferrous sulfate
1
pen needle, diabetic (pen 30gx 5/16" dis needle, pen 31
gx3/16" dis needle, pen 31 gx5/16" dis needle)
2
petrolatum,white
3
POLIBAR ACB
3
POLY-VI-FLOR FS (0.25 MG FILM, 0.5 MG FILM, 1 MG FILM
STRP)
3
polydimethylsiloxanes/silicon dioxide
1
pralidoxime chloride
9
PRE-PEN
9
PRECEDEX 80 MCG/20 ML INJECT
9
PROHANCE (279.3 MG/ML SYRINGE, 279.3 MG/ML VIAL)
9
PROHANCE MULTIPACK
9
PROSTASCINT
9
PROTOPAM CHLORIDE
9
PAGE 154
PA
PRODUCT DESCRIPTION
TIER
PROVOCHOLINE
3
PURALOR CI
3
QUADRAMET
7
QUFLORA (0.25 MG/ML DROP, 0.5 MG/ML DROP)
3
R-GENE 10
9
RADIOGARDASE
3
READI-CAT
3
READI-CAT 2
3
RECOTHROM (5,000 UNITS VIAL, 20,000 UNITS VIAL,
20,000 UNIT SPRAY KT, 20,000 UNITS KIT)
3
RED BIRCH
9
RED CEDAR
9
RELAGESIC
3
RELAMINE
3
RELYYKS
3
RELYYT
3
REMESENSE
3
REPATHA SURECLICK
6
PA
REPATHA SYRINGE
6
PA
REPRONEX
9
RESTORA RX
3
ROUGH PIGWEED
9
RUCONEST
6
RUSSIAN THISTLE
9
SAGEBRUSH
9
saliva collection device/ibuprofen
1
SAXENDA
9
SCLEROSOL
3
SCULPTRA (AESTHETIC VIAL, VIAL)
9
SEROPHENE
3
SHAGBARK HICKORY
9
PAGE 155
QL
6 / 30 days
PRODUCT DESCRIPTION
TIER
SHEEP SORREL-YELLOW DOCK
9
SINOGRAFIN
9
SITZMARKS
3
sodium morrhuate
7
sodium nitrite/sodium thiosulfate/amyl nitrite
3
sodium thiosulfate 1 g/10 ml vial
8
sodium thiosulfate 12.5g/50ml vial
7
SOLESTA
3
SOTRADECOL (1% VIAL, 3% VIAL)
9
SPHERUSOL
9
STANDARD BERMUDA GRASS POLLEN
9
STANDARDIZED CAT HAIR
9
STANDARDIZED TIMOTHY GRASS
9
SULFZIX
3
SYNVISC
3
SYNVISC-ONE
3
SYRINGE AVITENE
3
syringe with needle, insulin, safety, 0.5 ml (29 g x1/2" disp syrin,
30gx 5/16" disp syrin)
2
syringe with needle, insulin, safety, 1 ml
2
syringe with needle,disposable,insulin 1 ml (syringe & ml disp
syrin, syringe & ml 28gx1/2" disp syrin, syringe & ml 29 g x1/2"
disp syrin, syringe & ml 30gx 5/16" disp syrin)
2
syringe with needle,insulin disposable,0.3 ml
2
syringe with needle,insulin disposable,0.5 ml (syring ml 28
gauge disp syrin, syring ml 29 g x1/2" disp syrin, syring ml 30gx
5/16" disp syrin)
2
syringe,needle,insuln,sf,0.3ml 29 g x1/2" disp syrin
3
syringe,needle,insuln,sf,0.3ml 30gx 5/16" disp syrin
2
TACHOSIL (4.8 CM 4.8 CM PATCH, 9.5 CM 4.8 CM PATCH)
3
TAGITOL
3
talc
3
thallous chloride tl-201
9
PAGE 156
PRODUCT DESCRIPTION
TIER
THERAMINE PLUS
3
THROMBI-GEL (10, 40, 100)
3
THROMBI-PAD
3
THROMBIN-JMI (5,000 VIAL, 5,000 EPIST, 5,000 SYR, 20,000
VIAL, 20,000 PUMP, 20,000 SYR)
3
THYROGEN
9
TISSEEL VHSD (FROZEN 2 ML SYR, 2 ML KIT, FROZEN 4
ML SYR, 4 ML KIT, FROZEN 10 ML SYR, 10 ML KIT)
3
TREPADONE
3
TRIFERIC
9
TUBERSOL
9
TUZISTRA XR
3
ULTRAFOAM (2X6.25X7CM SPONGE, 8X6.25X1CM
SPONGE, 8X12.5X3CM SPONGE, 8X12.5X1CM SPONGE)
3
ULTRAVIST (150 MG/ML VIAL, 240 MG/ML VIAL, 300 MG/ML
VIAL, 370 MG/ML VIAL)
9
VARIBAR HONEY
3
VARIBAR NECTAR
3
VARIBAR PUDDING
3
VARIBAR THIN HONEY
3
VARIBAR THIN LIQUID
3
VARITHENA
9
VEHICLE-N
3
VEHICLE-N MILD
3
VIRGINIA LIVE OAK
9
VISIPAQUE (270 MG/ML VIAL, 270 MG/ML INFU BTL, 270
MG/ML BOTTLE, 320 MG/ML INFU BTL, 320 MG/ML VIAL,
320 MG/ML INFUS BTL, 320 MG/ML BOTTLE)
9
VITRASE
9
VOLUMEN
3
water for inj.,bacteriostatic
7
water for inj.,bacteriostatic/methylparaben/propylparaben
9
water for injection,sterile (ampul, iv soln, vial)
7
water for irrigation,sterile
7
PAGE 157
PRODUCT DESCRIPTION
TIER
WHITE ASH
9
WHITE OAK EXTRACT
9
XIAFLEX
9
XIZFLUS
3
ZN-DTPA
3
Metabolic Bone Disease Agents
ACTONEL (5 MG TABLET, 30 MG TABLET, 35 MG TABLET,
150 MG TABLET)
2
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40
mg tablet, 70 mg/75ml solution, 70 mg tablet)
1
ATELVIA
3
BINOSTO
3
BONIVA 150 MG TABLET
3
BONIVA 3 MG/3 ML SYRINGE
8
ST
QL
4 / 28 days
ST
PA
ST
calcitonin,salmon,synthetic
1
DIDRONEL
3
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg
capsule)
1
doxercalciferol (ampul, vial)
7
etidronate disodium (200 mg tablet, 400 mg tablet)
1
FORTEO
5
PA
ST
FORTICAL
3
FOSAMAX
3
FOSAMAX PLUS D (70 MG-5,600, 70 MG-2,800)
3
HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5
MCG CAPSULE)
3
HECTOROL (2 MCG/ML VIAL, 4 MCG/2 ML VIAL)
9
ibandronate sodium 150 mg tablet
1
ibandronate sodium 3 mg/3 ml syringe
7
ST
PA
ST
PAGE 158
PRODUCT DESCRIPTION
TIER
ibandronate sodium 3 mg/3 ml vial
4
MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL)
9
MIACALCIN 200 UNIT NASAL SPRAY
3
NATPARA (25 MCG CARTRIDGE, 50 MCG CARTRIDGE, 75
MCG CARTRIDGE, 100 MCG CARTRIDGE)
6
pamidronate disodium (30 mg vial, 30mg/10ml vial, 60 mg/10ml
vial, 90 mg vial, 90 mg/10ml vial)
1
paricalcitol (2 mcg/ml vial, 5 mcg/ml vial)
7
RECLAST
6
PA
PA
PA
ST
risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet,
150 mg tablet)
1
ST
risedronate sodium 35 mg tablet dr
1
QL
4 / 28 days
SKELID
3
QL
60 / 30 days
zoledronic acid 4 mg vial
4
zoledronic acid 4 mg/5 ml vial
4
zoledronic acid/mannitol&water 4 mg/100ml piggyback
4
zoledronic acid/mannitol&water 5 mg/100ml infus. btl
4
PA
PA
ST
zoledronic acid/mannitol&water 5 mg/100ml piggyback
4
ST
ZOMETA 4 MG/100 ML INJECTION
3
PA
ZOMETA 4 MG/5 ML VIAL
6
PA
Miscellaneous Therapeutic Agents
ACCU-CHECK TEST STRIPS
2
ACCUTREND TEST STRIPS
2
BREEZE2 TEST STRIPS
3
CONTOUR TEST STRIPS
3
DIASTIX TEST STRIPS
3
FREESTYLE TEST STRIPS
3
KETO-DIASTIX TEST STRIPS
3
KETOSTIX TEST STRIPS
3
PAGE 159
PRODUCT DESCRIPTION
TIER
ONETOUCH TEST STRIPS
2
OPTIUM TEST STRIPS
3
PRECISION TEST STRIPS
3
SURESTEP TEST STRIPS
2
ULTIMA TEST STRIPS
3
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost
1
QL
5 / 30 days
latanoprost
1
QL
15 / 90 days
LUMIGAN
3
QL
15 / 90 days
TRAVATAN Z
3
QL
15 / 90 days
travoprost (benzalkonium)
1
XALATAN
3
QL
15 / 90 days
Ophthalmic Agents, Other
AKTEN
3
AMVISC
9
AMVISC PLUS
9
atropine sulfate (1 % drops, 1 % oint. (g))
1
bacitracin/polymyxin b sulfate
1
balanced salt irrig soln no.2
7
benoxinate hcl/fluorescein sodium
1
BETADINE
3
BLEPHAMIDE
3
BLEPHAMIDE S.O.P.
3
BSS
9
BSS PLUS
9
CELLUGEL
3
CYCLOGYL (0.5% DROPS, 1% DROPS, 2% DROPS)
3
CYCLOMYDRIL
3
cyclopentolate hcl (1 % drops, 2 % drops)
1
PAGE 160
PRODUCT DESCRIPTION
TIER
CYSTARAN
6
DISCOVISC
3
DUOVISC
3
EYLEA
3
FLUCAINE
1
FLURESS
3
GELFILM
3
homatropine hbr
1
hypromellose
1
ISOPTO ATROPINE
3
ISOPTO HOMATROPINE
3
ISOPTO HYOSCINE
2
JETREA
6
LACRISERT
2
LUCENTIS (0.3 MG VIAL, 0.5 MG VIAL)
3
MACUGEN
9
MAXITROL (DROPS, OINTMENT)
3
MEMBRANEBLUE
3
MIOCHOL-E
9
MITOSOL
3
MYDRIACYL
3
naphazoline hcl
1
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone
1
neomycin sulfate/bacitracin/polymyxin b
1
neomycin sulfate/polymyxin b sulfate/gramicidin d
1
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
1
neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops
susp, 3.5-10k-.1 oint. (g))
1
OMIDRIA
3
PAREMYD
3
phenylephrine hcl (2.5 % drops, 10 % drops)
1
polymyxin b sulfate/trimethoprim
1
PAGE 161
PA
PRODUCT DESCRIPTION
TIER
POLYTRIM
3
PRED-G (1% DROPS, S.O.P. OINTMENT)
3
proparacaine hcl/fluorescein sodium
1
sulfacetamide sodium 10 % oint. (g)
1
sulfacetamide sodium/prednisolone sodium phosphate
1
tetracaine hcl
1
tetracaine hcl/pf 0.5 % drops
1
TETRAVISC
1
TETRAVISC FORTE
1
TOBRADEX EYE DROPS
3
TOBRADEX ST
3
tobramycin/dexamethasone
1
tropicamide (0.5 % drops, 1 % drops)
1
VISCOAT
3
VISIONBLUE
3
VISUDYNE
9
ZYLET
3
QL
5 / 30 days
QL
10 / 30 days
Ophthalmic Anti-allergy Agents
ALOCRIL
2
ALOMIDE
2
azelastine hcl 0.05 % drops
1
BEPREVE
3
cromolyn sodium 4 % drops
1
ELESTAT
3
EMADINE
3
epinastine hcl
1
LASTACAFT
3
OPTIVAR
3
PATADAY
3
PATANOL
3
PAZEO
3
PAGE 162
PRODUCT DESCRIPTION
TIER
Ophthalmic Anti-inflammatories
ACULAR
3
ACULAR LS
3
ACUVAIL
3
ALREX
2
BROMDAY (DROP TWINPAK, DROPS)
3
bromfenac sodium
1
flurbiprofen sodium
1
ILEVRO
3
ILUVIEN
6
ketorolac tromethamine (0.4 % drops, 0.5 % drops)
1
LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC
GEL)
2
NEVANAC
3
OCUFEN
3
OMNIPRED
3
OZURDEX
9
PRED FORTE
3
PRED MILD
3
prednisolone acetate
1
prednisolone sod phosphate 1 % drops
1
PROLENSA
3
RETISERT
9
TRIESENCE
9
VEXOL
3
QL
30 / 60 days
PA
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
2
ALPHAGAN P 0.15% EYE DROPS
3
apraclonidine hcl
1
AZOPT
2
BETAGAN
3
PAGE 163
PRODUCT DESCRIPTION
TIER
betaxolol hcl 0.5 % drops
1
BETIMOL (0.25% DROPS, 0.5% DROPS)
3
BETOPTIC S
2
brimonidine tartrate (0.15 % drops, 0.2 % drops)
1
carteolol hcl
1
COMBIGAN
3
COSOPT
3
COSOPT PF
3
dorzolamide hcl
1
dorzolamide hcl/timolol maleate
1
IOPIDINE (0.5% DROPS, 1% DROPS)
3
ISOPTO CARBACHOL
3
ISOPTO CARPINE (1% DROPS, 2% DROPS, 4% DROPS)
3
ISTALOL
3
levobunolol hcl (0.25 % drops, 0.5 % drops)
1
metipranolol
1
MIOSTAT
9
PHOSPHOLINE IODIDE
3
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)
1
PILOPINE HS
3
RESCULA
2
SIMBRINZA
3
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel,
0.5 % drops)
1
TIMOPTIC (0.25% DROPS, 0.5% DROPS)
3
TIMOPTIC OCUDOSE (0.25% DROP, 0.5% DROP)
3
TIMOPTIC-XE (0.25% SOLN, 0.5% SOLN)
3
TRUSOPT
3
ZIOPTAN
3
Otic Agents
antipyrine/benzocaine (5.4 drops, 5.5 drops)
1
antipyrine/benzocaine/glycerin/zinc acetate
1
PAGE 164
PRODUCT DESCRIPTION
TIER
benzocaine
2
CETRAXAL
3
chloroxylenol/benzocaine/hydrocortisone acetate
1
chloroxylenol/pramoxine hcl
1
CIPRO HC
2
CIPRODEX
2
ciprofloxacin hcl 0.2 % droperette
1
COLY-MYCIN S
2
CORTANE-B OTIC DROPS
3
CORTISPORIN-TC
2
CRESYLATE
2
hydrocortisone/pramoxine hcl/chloroxylenol
1
TRIOXIN
3
QL
14 / 7 days
QL
14 / 7 days
QL
12 / 30 days
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
AEROSPAN
3
ALVESCO (80 MCG INHALER, 160 MCG INHALER)
3
ARNUITY ELLIPTA (100 MCG, 200 MCG)
3
ASMANEX (110 MCG #7, 220 MCG #14)
3
ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220
MCG #60, TWISTHALER 220 MCG #30, TWISTHALR 220
MCG #120)
3
QL
3 / 90 days
ASMANEX HFA (HFA 100 MCG INHALER, HFA 200 MCG
INHALER)
3
QL
13 / 30 days
BECONASE AQ
3
ST
BREO ELLIPTA 100-25 MCG INH
2
QL
60 / 30 days
ST
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1
mg/2 ml ampul-neb)
1
budesonide 32mcg spray/pump
1
flunisolide (25 mcg spray, 29mcg spray)
1
NASONEX
3
PAGE 165
QL
140 / 30 days
ST
PRODUCT DESCRIPTION
TIER
QL
OMNARIS
12 / 30 days
3
ST
PULMICORT (0.25 ML RESPUL, 0.5 ML RESPULE, 1 ML
RESPULE)
3
PULMICORT FLEXHALER (90 MCG, 180 MCG)
2
QNASL
3
QL
140 / 30 days
QL
9 / 30 days
ST
QL
QNASL CHILDREN
4.9 / 30 days
3
ST
QVAR (40 MCG ORAL INHALER, 80 MCG ORAL INHALER)
2
RHINOCORT AQUA
2
ZETONNA
3
ST
QL
6 / 30 days
ST
Antihistamines
ALLEGRA ODT
3
ASTELIN
3
ASTEPRO
3
azelastine hcl 137 mcg spray/pump
1
azelastine hcl 205.5mcg spray/pump
1
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid)
1
cetirizine hcl
1
CLARINEX 0.5 MG/ML (2.5 MG/5)
3
CLARINEX 2.5 MG REDITABS
QL
30 / 30 days
QL
30 / 30 days
3
QL
90 / 30 days
CLARINEX 5 MG REDITABS
3
QL
60 / 30 days
CLARINEX 5 MG TABLET
3
QL
30 / 30 days
clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet)
1
cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup, 4 mg
tablet)
1
desloratadine 2.5 mg tab rapdis
1
QL
90 / 30 days
desloratadine 5 mg tab rapdis
1
QL
60 / 30 days
PAGE 166
PRODUCT DESCRIPTION
TIER
desloratadine 5 mg tablet
1
DICOPANOL
3
diphenhydramine hcl (12.5mg/5ml elixir, 50 mg capsule)
1
doxylamine succinate
3
fexofenadine hcl (30 mg tablet, 60 mg tablet)
QL
30 / 30 days
1
QL
60 / 30 days
fexofenadine hcl 180 mg tablet
1
QL
30 / 30 days
KARBINAL ER
3
levocetirizine dihydrochloride 2.5 mg/5ml solution
1
levocetirizine dihydrochloride 5 mg tablet
1
QL
30 / 30 days
olopatadine hcl
1
PATANASE
3
promethazine hcl 25 mg tablet
1
XYZAL 2.5 MG/5 ML SOLUTION
3
XYZAL 5 MG TABLET
3
QL
30 / 30 days
ACCOLATE (10 MG TABLET, 20 MG TABLET)
3
QL
60 / 30 days
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab
chew, 10 mg tablet)
1
QL
30 / 30 days
SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG
TABLET CHEW, 10 MG TABLET)
3
QL
30 / 30 days
zafirlukast (10 mg tablet, 20 mg tablet)
1
QL
60 / 30 days
ZYFLO
3
ZYFLO CR
3
QL
120 / 30 days
Antileukotrienes
Bronchodilators, Anticholinergic
ATROVENT (0.03% SPRAY, 0.06% SPRAY)
3
ATROVENT HFA
2
INCRUSE ELLIPTA
3
ipratropium bromide (0.2 mg/ml solution, 21 mcg spray, 42mcg
spray)
1
SPIRIVA
2
QL
90 / 90 days
SPIRIVA RESPIMAT (1.25 MCG INH, INHAL SPRAY)
2
QL
4 / 30 days
PAGE 167
PRODUCT DESCRIPTION
TUDORZA PRESSAIR
TIER
3
QL
1 / 30 days
QL
360 / 30 days
QL
6 / 90 days
QL
60 / 30 days
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophylline (250mg/10ml vial, 250mg/10ml ampul,
500mg/20ml vial, 500mg/20ml ampul)
7
ELIXOPHYLLIN
3
LUFYLLIN (LUFYLLIN 200 MG TABLET, LUFYLLIN-400
TABLET)
3
THEO-24 (ER 100 MG CAPSULE, ER 200 MG CAPSULE, ER
300 MG CAPSULE, ER 400 MG CAPSULE)
3
theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution,
100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400
mg tablet er, 450 mg tab er 12h, 600 mg tablet er)
1
theophylline/dextrose 5 % in water (200mg/0.1l iv soln,
200mg/50ml iv soln, 800mg/.25l iv soln)
1
theophylline/dextrose 5 % in water (400mg/0.5l iv soln,
400mg/.25l iv soln, 800mg/0.5l iv soln)
7
Bronchodilators, Sympathomimetic
ACCUNEB 0.63 MG/3 ML INH SOLN
3
ACCUNEB 1.25 MG/3 ML INH SOLN
3
ADRENACLICK 0.15 MG AUTO-INJCT
9
ADRENACLICK 0.3 MG AUTO-INJECT
9
ADRENALIN
9
ADRENALIN 1:1,000 NASAL SOLN
3
ADRENALIN CL 1 MG/ML VIAL
9
ADVAIR DISKUS (100-50, 250-50, 500-50)
2
ST
QL
ADVAIR HFA (HFA 45-21 MCG INHALER, HFA 115-21 MCG
INHALER, HFA 230-21 MCG INHALER)
2
albuterol sulfate (1.25mg/3ml vial-neb, 2 mg/5 ml syrup, 2 mg
tablet, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 4 mg tab er
12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h)
1
albuterol sulfate 0.63mg/3ml vial-neb
1
ANORO ELLIPTA
3
12 / 30 days
ST
QL
360 / 30 days
QL
60 / 30 days
ST
PAGE 168
PRODUCT DESCRIPTION
TIER
ARCAPTA NEOHALER
3
AUVI-Q 0.15 MG AUTO-INJECTOR
9
AUVI-Q 0.3 MG AUTO-INJECTOR
9
BREO ELLIPTA 200-25 MCG INH
2
QL
6 / 90 days
QL
60 / 30 days
ST
BROVANA
3
COMBIVENT
2
COMBIVENT RESPIMAT
3
DULERA (100 MCG INHALER, 200 MCG INHALER)
3
QL
6 / 30 days
QL
13 / 30 days
ST
DUONEB
3
epinephrine (0.1 mg/ml syringe, 0.15/0.15 auto injct, 1 mg/ml
vial, 1 mg/ml(1) ampul)
7
epinephrine 0.3mg/0.3 auto injct
7
epinephrine hcl/pf
7
epinephrine/pf
7
EPIPEN 2-PAK
QL
6 / 90 days
8
QL
6 / 90 days
EPIPEN JR 2-PAK
8
QL
6 / 90 days
EPISNAP
9
FORADIL
3
QL
60 / 30 days
ipratropium bromide/albuterol sulfate
1
levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb,
1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)
1
MAXAIR AUTOHALER
3
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg
tablet)
1
PERFOROMIST
3
PROAIR HFA
2
QL
51 / 90 days
PROAIR RESPICLICK
3
QL
6 / 90 days
PROVENTIL HFA
3
QL
40 / 90 days
SEREVENT DISKUS
2
QL
60 / 30 days
PAGE 169
PRODUCT DESCRIPTION
TIER
QL
STIOLTO RESPIMAT
4 / 30 days
3
ST
STRIVERDI RESPIMAT
3
SYMBICORT (80-4.5 MCG INHALER, 160-4.5 MCG INHALER)
2
ST
QL
10 / 30 days
ST
terbutaline sulfate (2.5 mg tablet, 5 mg tablet)
1
terbutaline sulfate 1 mg/ml vial
7
VENTOLIN HFA
2
VOSPIRE ER (ER 4 MG TABLET, ER 8 MG TABLET)
3
XOPENEX (0.31 ML SOLUTION, 0.63 ML SOLUTION, 1.25 ML
SOLUTION)
3
XOPENEX CONCENTRATE
3
XOPENEX HFA
3
QL
108 / 90 days
QL
60 / 30 days
Mast Cell Stabilizers
cromolyn sodium (20 mg/ml oral conc, 20 mg/2 ml ampul-neb)
1
GASTROCROM
3
Pulmonary Antihypertensives
ADCIRCA
6
PA
ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET,
2 MG TABLET, 2.5 MG TABLET)
6
epoprostenol sodium (glycine) (0.5 mg vial, 1.5 mg vial)
7
FLOLAN (0.5 MG VIAL, 1.5 MG VIAL)
9
LETAIRIS (5 MG TABLET, 10 MG TABLET)
5
OPSUMIT
5
PA
QL
30 / 30 days
PA
QL
ORENITRAM ER (ER 0.125 MG TABLET, ER 0.25 MG
TABLET, ER 1 MG TABLET, ER 2.5 MG TABLET)
6
REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5 MG/ML
VIAL, 10 MG/ML VIAL)
6
REVATIO (10 MG/12.5 ML VIAL, 10 MG/ML ORAL SUSP)
6
PAGE 170
90 / 30 days
PA
PA
PRODUCT DESCRIPTION
TIER
QL
REVATIO 20 MG TABLET
90 / 30 days
6
PA
sildenafil citrate 10 mg/12.5 vial
4
sildenafil citrate 20 mg tablet
1
PA
QL
90 / 30 days
PA
TRACLEER (62.5 MG TABLET, 125 MG TABLET)
5
TYVASO (1.74 MG/2.9 ML SOLUTION, INHALATION REFILL
KIT, INHALATION STARTER KIT, INSTITUTIONAL START
KIT)
6
VELETRI (0.5 MG VIAL, 1.5 MG VIAL)
8
VENTAVIS (10 ML SOLUTION, 20 ML SOLUTION)
9
Respiratory Tract Agents, Other
acetylcysteine 100 mg/ml vial
1
ALAHIST DHC
3
ALLEGRA-D 24 HOUR
3
ALLFEN CDX (LIQUID, TABLET)
3
ARALAST NP (500 MG VIAL, 1,000 MG VIAL)
9
benzonatate (100 mg capsule, 150 mg capsule, 200 mg
capsule)
1
chlorpheniramine maleate/codeine phosphate
1
CLARINEX-D 12 HOUR
3
QL
120 / 30 days
CLARINEX-D 24 HOUR
3
QL
150 / 30 days
COTABFLU
3
CUROSURF (120 MG/1.5 ML VIAL, 240 MG/3 ML VIAL)
3
DALIRESP
3
QL
30 / 30 days
dextromethorphan hbr/phenylephrine hcl/chlorpheniramine
1
dextromethorphan hbr/pseudoephedrine hcl/brompheniramine
1
DONATUSS DC
3
DOPRAM
9
doxapram hcl
7
DYMISTA
3
PAGE 171
PRODUCT DESCRIPTION
TIER
ephedrine sulfate (50 mg/ml vial, 50 mg/ml ampul)
7
ESBRIET
6
GLASSIA
9
GRASTEK
3
guaifenesin/codeine phosphate
1
hydrocodone bitartrate/homatropine methylbromide (5 mg1.5mg tablet, 5-1.5 mg/5 syrup)
1
hydrocodone polistirex/chlorpheniramine polistirex
1
HYPER-SAL (3.5% VIAL, 7% VIAL)
3
INFASURF
3
J-COF DHC
3
KALYDECO (50 MG GRANULES PACKET, 75 MG
GRANULES PACKET, 150 MG TABLET)
6
MAXIFED CDX
3
MAXIFLU CD
3
MAXIFLU CDX
3
MAXIPHEN CD
3
MAXIPHEN CDX
3
NEBUSAL
3
OFEV (100 MG CAPSULE, 150 MG CAPSULE)
6
ORALAIR (100 IR STARTER PACK, 300 IR STARTER PACK,
300 IR SUBLINGUAL TAB)
3
ORKAMBI
6
PHENFLU CD
3
PHENFLU CDX
3
phenylephrine hcl/chlorpheniramine maleate
1
phenylephrine hcl/promethazine hcl
1
POLY-TUSSIN DHC
3
PROLASTIN C
9
promethazine hcl/codeine
1
promethazine hcl/dextromethorphan hbr
1
PAGE 172
PA
QL
60 / 30 days
PA
PA
PA
PRODUCT DESCRIPTION
TIER
promethazine/phenylephrine hcl/codeine
1
pseudoephedrine hcl/hydrocodone bitartrate/chlorpheniramine
1
PULMOZYME
6
QL
75 / 30 days
PA
RAGWITEK
3
RESPA A.R.
3
REZIRA
2
SEMPREX-D
3
sodium chloride for inhalation (0.9 % vial-neb, 3 % vial-neb, 10
% vial-neb)
1
sodium chloride for inhalation 7 % vial-neb
3
SURFAXIN
3
SURVANTA
3
TESSALON PERLE
3
TUSNEL PEDIATRIC
3
TUSSICAPS (5 MG-4 MG CAPSULE, 10 MG-8 MG CAPSULE)
3
TUSSIONEX
3
TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE SPRAY, 0.1%
NOSE DROPS)
3
VANACOF CD
3
XOLAIR
6
ZEMAIRA
9
ZONATUSS
3
ZOTEX-C
3
ZUTRIPRO
3
Skeletal Muscle Relaxants
AMRIX (ER 15 MG CAPSULE, ER 30 MG CAPSULE)
3
QL
30 / 30 days
carisoprodol 250 mg tablet
1
carisoprodol 350 mg tablet
1
QL
120 / 30 days
carisoprodol/aspirin
1
QL
150 / 30 days
chlorzoxazone
1
PAGE 173
PRODUCT DESCRIPTION
TIER
COMFORT PAC-CYCLOBENZAPRINE
3
cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet)
1
FEXMID
3
FLEXERIL (5 MG TABLET, 10 MG TABLET)
3
LORZONE (375 MG TABLET, 750 MG TABLET)
3
metaxalone (400 mg tablet, 800 mg tablet)
1
methocarbamol (500 mg tablet, 750 mg tablet)
1
methocarbamol 100 mg/ml vial
7
orphenadrine citrate (30 mg/ml ampul, 30 mg/ml vial)
7
orphenadrine citrate 100 mg tablet er
1
orphenadrine citrate/aspirin/caffeine (25-385-30 tablet, 50-77060 tablet)
1
PARAFON FORTE DSC
3
ROBAXIN 1,000 MG/10 ML VIAL
9
ROBAXIN 500 MG TABLET
3
ROBAXIN-750
3
RYANODEX
9
SKELAXIN
3
SOMA 250 MG TABLET
3
SOMA 350 MG TABLET
3
QL
120 / 30 days
AMBIEN (5 MG TABLET, 10 MG TABLET)
3
QL
30 / 30 days
AMBIEN CR (CR 6.25 MG TABLET, CR 12.5 MG TABLET)
3
QL
30 / 30 days
AMYTAL SODIUM
9
PA
DORAL
3
EDLUAR (5 MG TABLET, 10 MG TABLET)
3
estazolam (1 mg tablet, 2 mg tablet)
1
eszopiclone (1 mg tablet, 2 mg tablet, 3 mg tablet)
1
flurazepam hcl (15 mg capsule, 30 mg capsule)
1
HALCION
3
Sleep Disorder Agents
GABA Receptor Modulators
PAGE 174
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
INTERMEZZO (1.75 MG TAB, 3.5 MG TAB)
3
LUNESTA (1 MG TABLET, 2 MG TABLET, 3 MG TABLET)
3
NEMBUTAL SODIUM
9
quazepam
3
RESTORIL (7.5 MG CAPSULE, 15 MG CAPSULE, 22.5 MG
3
SECONAL SODIUM
3
SONATA (5 MG CAPSULE, 10 MG CAPSULE)
3
temazepam (7.5 mg capsule, 15 mg capsule, 22.5 mg capsule,
30 mg capsule)
1
triazolam (0.125 mg tablet, 0.25 mg tablet)
1
zaleplon (5 mg capsule, 10 mg capsule)
QL
30 / 30 days
QL
30 / 30 days
1
QL
30 / 30 days
zolpidem tartrate (5 mg tablet, 6.25 mg tab mphase, 10 mg
tablet, 12.5 mg tab mphase)
1
QL
30 / 30 days
ZOLPIMIST
3
QL
30 / 30 days
QL
30 / 30 days
Sleep Disorders, Other
BELSOMRA (5 MG TABLET, 10 MG TABLET, 15 MG TABLET,
20 MG TABLET)
3
dexmedetomidine hcl
7
HETLIOZ
3
PA
modafinil 100 mg tablet
1
QL
120 / 30 days
modafinil 200 mg tablet
1
QL
60 / 30 days
NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG TABLET,
250 MG TABLET)
3
QL
30 / 30 days
PRECEDEX (200 MCG/2 ML VIAL, 200 MCG/50 ML INJECT,
400 MCG/100 ML INJECT)
9
PROVIGIL 100 MG TABLET
3
QL
120 / 30 days
PROVIGIL 200 MG TABLET
3
QL
60 / 30 days
ROZEREM
3
QL
30 / 30 days
SILENOR (3 MG TABLET, 6 MG TABLET)
3
QL
30 / 30 days
QL
XYREM
540 / 30 days
9
PA
PAGE 175
PRODUCT DESCRIPTION
TIER
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET)
3
CARNITOR 1 GM/5 ML VIAL
9
CARNITOR SF
3
CHEMET
3
EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG
TABLET)
6
FERRIPROX
6
PA
JADENU (90 MG TABLET, 180 MG TABLET, 360 MG
TABLET)
6
PA
KAYEXALATE
3
levocarnitine (with sugar)
1
levocarnitine 200 mg/ml vial
7
levocarnitine 330 mg tablet
1
SAMSCA (15 MG TABLET, 30 MG TABLET)
6
QL
60 / 30 days
PA
sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml
enema, 50g/200ml enema, powder)
1
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA)
3
SYPRINE
3
VAPRISOL-5% DEXTROSE
9
Electrolyte/Mineral Replacement
0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9 %
syringe cp, 0.9 % 0.9 % syringe, 0.9 % pggybk prt, 0.9 % 0.9 %
vial, 0.9 % pgy vl prt)
7
acetylcysteine/mecobalamin/levomefolate calcium
1
ACTIVE FE
3
ACTIVE OB
3
ADDAMEL N
3
AMINOSYN (7% IV SOLUTION, 10% IV SOLUTION)
9
AMINOSYN 3.5% IV SOLUTION
6
AMINOSYN 7%-ELECTROLYTE SOL
9
PAGE 176
PRODUCT DESCRIPTION
TIER
AMINOSYN 8.5% IV SOLUTION
7
AMINOSYN 8.5%-ELECTROLYTES SOL
7
AMINOSYN II (7% IV SOLUTION, 10% IV SOLUTION, 15% IV
SOLUTION)
9
AMINOSYN II 8.5% IV SOLUTION
7
AMINOSYN II WITH ELECTROLYTES
7
AMINOSYN M
6
AMINOSYN-HBC
9
AMINOSYN-PF (7% IV SOLUTION, 10% IV SOLUTION)
9
AMINOSYN-RF
3
ammonium chloride
1
ANIMI-3
3
AQUASOL A
9
ascorbic acid
7
ATABEX EC
3
AVAILNEX
3
AXONA
3
B-NEXA
3
BACMIN
1
BAL-CARE DHA ESSENTIAL
3
BIFERA RX
3
ca carbonate/mag oxide/vitamin d3/vit b12/fa/vit b6/boron (5001.1mg tablet, 500-300-1 wafer)
3
CADEAU DHA
3
calcium chloride (100 mg/ml vial, 100 mg/ml syringe)
7
calcium gluconate
7
CARDIOTEK-RX
3
CARDIOVID PLUS
3
CEREFOLIN
3
CEREFOLIN NAC
3
chromic chloride
7
CITRANATAL 90 DHA (90 PACK, 90 COMBO PACK)
2
PAGE 177
PRODUCT DESCRIPTION
TIER
CITRANATAL ASSURE
2
CITRANATAL B-CALM
3
CITRANATAL DHA
2
CITRANATAL HARMONY
1
CITRANATAL RX
2
CLINIMIX (2.75%-5% SOLUTION, 4.25%-5% SOLUTION, 5%20% SOLUTION, 5%-25% SOLUTION, 5%-15% SOLUTION)
9
CLINIMIX (4.25%-25% SOLUTION, 4.25%-20% SOLUTION,
4.25%-10% SOLUTION)
8
CLINIMIX E (2.75%-5% SOLUTION, 2.75%-10% SOLUTION,
4.25%-10% SOLUTION, 4.25%-5% SOLUTION, 5%-15%
SOLUTION, 5%-25% SOLUTION, 5%-20% SOLUTION)
9
CLINIMIX E 4.25%-25% SOLUTION
8
CONCEPT DHA
3
CONCEPT OB
3
CORVITE
3
CORVITE 150
3
CORVITE FE
3
CORVITE FREE
1
cupric chloride
9
cupric sulfate
9
cyanocobalamin (vitamin b-12)
7
cyanocobalamin-salcaprozate sodium
1
cyanocobalamin/folic acid/pyridoxine (0.5-2.2-25 tablet, 1-2.225mg tablet, 1-2.5-25mg tablet, 2-2.5-25mg tablet)
1
cyanocobalamin/levomefolate calcium/pyridoxine/riboflavin
1
cysteine hcl
7
DELFLEX WITH 1.5% DEXTROSE
9
6
7
DEPLIN
3
DEPLIN-ALGAL OIL (OIL 7.5 MG CAP, OIL 15 MG CAPSULE)
3
DERMANIC
3
PAGE 178
PRODUCT DESCRIPTION
TIER
DEXFERRUM (50 MG/ML VIAL, 100 MG/2 ML VIAL)
7
dextrose 10 % and 0.2 % nacl 10 %-0.2 % dehp fr bg
7
dextrose 10 % and 0.2 % nacl 10 %-0.2 % iv soln
8
dextrose 10 % and 0.45 % sodium chloride
9
1
dextrose 10 % in water
7
dextrose 2.5 % and 0.45 % sodium chloride
7
dextrose 2.5 % in water
7
7
7
7
7
7
8
7
7
dextrose 5 % in lactated ringers
7
dextrose 5 % in water (5 % 5 % iv soln, 5 % pgy vl prt, 5 %
pggybk prt, 5 % 5 % vial)
7
dextrose 5% in ringers
7
dextrose 50 % in water (50 % 50 % iv soln, 50 % 50 % vial, 50
% 50 % syrge)
7
7
DIALYVITE
1
DIALYVITE 3000
3
DIALYVITE 5000
3
DIALYVITE 800 WITH IRON
3
DIALYVITE SUPREME D
3
DIALYVITE ZINC
2
DIANEAL PD-2 W-1.5% DEXTROSE
8
8
8
PAGE 179
PRODUCT DESCRIPTION
TIER
DIANEAL WITH 1.5% DEXTROSE
7
9
6
DRISDOL
3
DUET DHA (400 MG PACK, 430 MG PACK)
3
DUET DHA 400
3
DUET DHA BALANCED ((24 MG IRON), (25 MG IRON), (26
MG IRON), COMBO PACK)
3
DUET DHA EC (400 EC PACK, EC 400 MG PACK, EC 430 MG
PACK, 430 EC PACK)
3
EFFER-K (10 TABLET EFF, 20 TABLET EFF)
3
ELDERCAPS
3
electrolyte-48 solution/dextrose 5 % in water
8
ENBRACE HR
3
ENLYTE
3
ENTERAGAM
3
ergocalciferol (vitamin d2)
1
ESCAVITE
3
ESCAVITE LQ
1
EXTRANEAL ICODEXTRIN DIALYSIS
6
FERAHEME
9
FERIVA
3
FEROTRINSIC
1
FERRALET 90
3
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
ferrous fumarate/folic acid
1
ferrous fumarate/folic acid/multivitamins with min no. 15
2
ferrous sulfate/ascorbic acid/folic acid
1
FLORIVA (0.25 MG CHEW TABLET, 0.25 MG/ML DROPS, 0.5
MG CHEWABLE TABLET, 1 MG CHEWABLE TABLET)
3
FLUOR-A-DAY 2.5 MG/ML DROPS
1
FLUORABON
3
fluoride/iron/vitamins a,c,and d
1
PAGE 180
PRODUCT DESCRIPTION
TIER
FLUORITAB
1
FLURA-DROPS
2
FOLET DHA
3
FOLET ONE
3
FOLGARD OS
3
FOLGARD RX
3
folic acid (1 mg tablet, 5 mg/ml vial)
1
folic acid/multivitamins,ther w-minerals/lycopene/lutein
1
folic acid/vitamin b comp w-c 0.5 mg tablet
1
folic acid/vitamin b comp w-c 5 mg tablet
2
folic acid/vitamin b comp w-c/copper/zinc oxide
1
FOLTRATE
3
FOLTX
3
FORTAVIT
3
FOSTEUM
3
FOSTEUM PLUS
3
FOVEX
3
FREAMINE HBC
9
FREAMINE III (8.5% IV, 10% IV)
9
FUSION PLUS
3
GABADONE
3
GALZIN (25 MG CAPSULE, 50 MG CAPSULE)
3
genistein/citrated zinc bisglycinate/vitamin d3
3
GESTICARE DHA
3
GLYCOPHOS
3
HEMATOGEN
1
HEMATRON
3
HEMATRON-AF
3
HEMOCYTE PLUS
2
HEMOCYTE-F
1
HEPATAMINE
7
PAGE 181
PRODUCT DESCRIPTION
TIER
HEPATASOL
7
hydroxocobalamin
1
HYPERLYTE CR
7
HYPERTENSA
3
ICAR-C PLUS
3
INFANATE BALANCE
3
INFED
7
INFUVITE
7
INFUVITE ADULT (BULK VIAL, VIAL)
7
INJECTAFER
6
INTEGRA F
3
INTEGRA PLUS
3
INTRALIPID (20% IV EMUL, 30% IV EMUL)
9
IODOPEN
9
IONOSOL B WITH DEXTROSE 5%
9
IONOSOL MB-DEXTROSE 5%
9
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
2
iron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
1
iron fumarate & polysac comp/folic acid/vit b comp & c no.9
3
iron fumarate & polysac comp/folic acid/vitamin c/niacin
1
iron fumarate-iron polysacchar/folic acid/mv comb18
1
iron fumarate/vit c/vit b12/fa 200-250mg capsule
2
iron fumarate/vit c/vit b12/fa 460-60mg capsule
1
iron polysacchar complx/iron heme polypeptide/folic acid/b12
1
iron polysaccharide complex/cyanocobalamin/folic acid
1
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
1
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
1
iron,carbonyl/folic acid/multivitamin w-minerals
2
iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc
1
PAGE 182
PA
PRODUCT DESCRIPTION
TIER
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
3
iron/folic acid/vitamin b comp w-c/minerals
1
IROSPAN
3
ISOLYTE M WITH DEXTROSE
7
ISOLYTE P WITH DEXTROSE
9
ISOLYTE S (IV OLN PH7.4, IV OLUTION-EXCEL)
9
K-TAB ER (ER 8 TABLET, ER 10 TABLET, ER 20 TABLET)
3
KABIVEN
9
KAOCHLOR-EFF
3
KLOR-CON
3
KLOR-CON 10
1
KLOR-CON 8
1
KLOR-CON M15
1
L-METHYLFOLATE FORMULA (7.5 MG, 15 MG)
3
L-METHYLFOLATE FORTE (7.5 MG CP, 15 MG CAP)
3
levomefolate ca/acetylcysteine/mecobalamin/schiz. algal oil
1
levomefolate calcium (7.5 mg tablet, 15 mg tablet)
1
LIMBREL (250 MG CAPSULE, 500 MG CAPSULE)
3
LIMBREL250
3
LIMBREL500
3
LIPOSYN II
9
LIPOSYN III (10% IV, 20% IV, 30% IV)
9
LUNGLAID
3
LYSIPLEX PLUS
1
M-VIT
2
M.V.I. ADULT
8
M.V.I. PEDIATRIC
8
M.V.I.-12
8
MACUTEK
3
MAGNEBIND 400 RX
3
magnesium chloride
7
PAGE 183
PRODUCT DESCRIPTION
TIER
magnesium sulfate (4 syringe, 4 vial)
7
magnesium sulfate in sterile water (2 g/50 ml piggyback, 4 g/50
ml piggyback, 4 g/100 ml piggyback, 20 g/500ml iv soln,
40g/1000ml iv soln)
7
magnesium sulfate/dextrose 5 % in water
7
manganese chloride
9
manganese sulfate
8
MARNATAL-F
3
MAXARON FORTE
3
MAXFE
3
MAXINATE
3
mecobalamin/levomefolate calcium/pyridoxal phosphate
1
MEPHYTON
3
METANX
3
molybdenum (ammonium molybdate)
8
MULTICHEW
3
MULTITRACE-4
9
multivit with min#10/folic acid//vit d3/a lipoic acid/lutein
1
multivitamins with min no.44/cholecalciferol (vit d3)/vit k
3
multivitamins with min no.7/folic acid
1
MULTIVITAMINS-A,B,D,E,K,ZN
3
multivits,therap w-fe,hematin (27mg-0.8mg tablet, tablet)
1
MVC-FLUORIDE (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1
MG TAB CHEW)
1
MYKIDZ IRON FL
3
MYNATAL
2
NATA KOMPLETE
3
NATACHEW
3
NATAFORT
3
NATALVIT
3
NATELLE ONE
3
NEEVO DHA
3
NEEVODHA
3
PAGE 184
PRODUCT DESCRIPTION
TIER
NEPHPLEX RX
2
NEPHRAMINE
9
NEPHRO-VITE RX
3
NEPHROCAPS
3
NEPHROCAPS QT
3
NEPHRON FA
2
NESTABS
3
NESTABS ABC
3
NESTABS DHA
3
NEURIN-SL
3
NEUT
9
NEXA PLUS
3
NEXA SELECT
3
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
NICADAN
3
NICAZEL
1
NICAZEL FORTE
1
NIRON KOMPLETE
3
NORMOSOL-M AND DEXTROSE
7
NORMOSOL-R
9
NORMOSOL-R AND DEXTROSE
9
NORMOSOL-R PH 7.4
9
NOVAFERRUM
3
NUTRESTORE
3
NUTRICAP
1
NUTRILIPID
9
NUTRILYTE
7
O-CAL FA
2
O-CAL PRENATAL
3
OB COMPLETE 400
3
OB COMPLETE CAPLET
2
PAGE 185
PRODUCT DESCRIPTION
TIER
OB COMPLETE CHEWABLE TABLET
3
OB COMPLETE ONE
3
OB COMPLETE PETITE
3
OB COMPLETE PREMIER
3
OB COMPLETE WITH DHA
3
OBSTETRIX EC
2
OBTREX
2
OBTREX DHA
3
omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13
3
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
omega-3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol
1
OSMOPREP
3
parenteral amino acid 15% combination no.1
7
ped mv a,c,d3 #21 w-fluoride 0.5 mg/ml drops
1
pediatric multivitamin combo no.75/fluoride/ferrous sulfate
1
pediatric multivitamin no.47 with iron & sodium fluoride
3
pediatric multivitamins a,c,& d3 no.38 with sodium fluoride (0.25
mg/ml drps sp bp, 0.5 mg/ml drps sp bp)
1
pediatric multivitamins no.16 with sodium fluoride (0.25 mg tab
chew, 0.5 mg tab chew, 1 mg tab chew)
1
pediatric multivitamins no.17 with sodium fluoride (0.25 mg tab
chew, 0.5 mg tab chew, 1 mg tab chew)
1
pediatric multivitamins no.82 with sodium fluoride (0.25 mg/ml
drops, 0.5 mg/ml drops)
1
PEDITRACE
3
PERCURA
3
PERIKABIVEN
9
PHYSICIANS EZ USE B-12
9
PHYSIOLYTE
3
PHYSIOSOL
7
phytonadione (1mg/0.5ml syringe, 1mg/0.5ml ampul, 10 mg/ml
ampul)
7
PLASMA-LYTE 148
8
PAGE 186
PRODUCT DESCRIPTION
TIER
PLASMA-LYTE 56 IN DEXTROSE
8
PLASMA-LYTE A PH 7.4
9
pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa
3
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
3
pnv with ca no.37/iron carb & asp gly/fa/omega-3 fatty acids
1
pnv,ca,no.35/iron,carbonyl & asp gly/fa/dss/omega-3
2
PNV-DHA PLUS
3
PNV-IRON
3
pnv39/iron fumarate/fa/dss/dha 30-1.2-55 capsule
2
3
1
3
pnv69/iron,carbonyl/fa/dss/dha 27-1-50 mg capsule
3
pnv69/iron,carbonyl/fa/dss/dha 28-1-50 mg capsule
1
PODIAPN
3
POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5
MG TAB CHEW, 1 MG TAB CHEW)
3
POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG)
3
POTABA
3
potassium acetate (2 vial, 4 vial)
7
potassium bicarbonate/citric acid
1
potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 10meq/0.1l
piggyback, 10meq/50ml piggyback, 20meq/50ml piggyback,
20meq/0.1l piggyback, 30meq/0.1l piggyback, 40meq/0.1l
piggyback)
7
potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq
tab er prt, 10 meq tablet er, 10 meq capsule er, 15 meq tab er
prt, 20meq/15ml liquid, 20 meq packet, 20 meq tablet er, 20
meq tab er prt, 40meq/15ml liquid)
1
potassium chloride in 0.45 % sodium chloride
7
potassium chloride in 0.9 % sodium chloride (20 iv soln, 40 iv
soln)
7
potassium chloride in 5 % dextrose in water (20 iv soln, 40 iv
soln)
7
potassium chloride in d5w 30 meq/l iv soln
1
PAGE 187
PRODUCT DESCRIPTION
TIER
potassium chloride in dextrose 5 %-0.2 % sodium chloride (10
iv soln, 30 iv soln, 40 iv soln)
1
potassium chloride in dextrose 5 %-0.45 % sodium chloride (10
iv soln, 20 iv soln, 30 iv soln, 40 iv soln)
7
potassium chloride in dextrose 5% and 0.3 % sodium chloride
7
potassium chloride in lactated ringers and 5 % dextrose (20 iv
soln, 40 iv soln)
1
potassium chloride/d5-0.2%nacl 20 meq/l iv soln
7
7
1
potassium chloride/potassium bicarbonate/citric acid
1
potassium citrate (5 tablet er, 10 tablet er, 15 tablet er)
1
potassium iodide
3
potassium iodide/iodine
3
potassium phos,m-basic-d-basic
7
PREFERA OB
3
PREFERA-OB ONE
3
PREFERA-OB PLUS DHA
3
PREMASOL (6% IV SOLUTION, 10% IV SOLUTION)
9
PRENA1 CHEW
3
PRENAISSANCE NEXT-B
3
PRENATA
3
PRENATABS FA
2
PRENATABS RX
1
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
prenatal vit comb no.4/iron carbonyl-iron gluconate/fa/doss
2
prenatal vit w/o calc no.10/iron fum&polysac comp/fa/omega-3
2
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
2
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
3
prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6
3
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
3
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
3
prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger (1.240-100 tablet, 1.2-42 mg tablet)
1
PAGE 188
PRODUCT DESCRIPTION
TIER
prenatal vit/iron bisglycin/fa 27 mg-1 mg tablet
3
prenatal vit/iron bisglycin/fa 29 mg-1 mg tablet
2
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
2
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha
3
prenatal vitamin combo no.22/iron/folic acid/omega-3/dha
3
prenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
3
prenatal vitamin no.105/iron edta &polysaccha/fa/om3/dha/epa
3
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
1
2
prenatal vitamin no.19/iron polysacc & iron hem/folic ac/dha
1
prenatal vitamin no.21/iron polysaccharid & heme polypep/fa
1
prenatal vitamin no.57/iron fum/folic acid/dss/dha
1
prenatal vitamin no.67/sodium feredetate-iron poly/fa/omega3
3
3
prenatal vitamin no.8/iron polysacchar & heme polypeptide/fa
3
1
prenatal vitamin no.86/iron bis-glycinate/folic acid
1
3
prenatal vitamins #39/iron amino acid chelate/fa combo#6/dha
1
prenatal vitamins comb 10/ferrous fumarate/folic acid/dha
3
prenatal vitamins comb no.115/iron fumarate/folic acid
2
prenatal vitamins comb no.115/iron fumarate/folic acid/dss
1
prenatal vitamins comb no.119/iron fumarate/folic acid/dss
1
prenatal vitamins comb no.19/iron bg hcl&suc-prot/fa/omega-3
2
prenatal vitamins comb no.42/folic acid comb no.6
1
prenatal vitamins comb no.48/iron na feredetate/fa/omega-3
2
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
2
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
2
prenatal vitamins comb no.55/iron bg hcl&suc-prot/fa/omega-3
2
prenatal vitamins comb no.87/iron bisgly/folic acid/dha
1
PAGE 189
PRODUCT DESCRIPTION
TIER
prenatal vitamins combo no.14/ferrous fumarate/folic acid
2
prenatal vitamins combo no.25/iron fumarate/fa combo#6/dha
1
prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha
3
prenatal vitamins combo no.60/ferrous fumarate/folic acid
2
prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha
1
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
3
prenatal vitamins no.12/iron,carbonyl/fa/docusate na/omega-3
3
prenatal vitamins no.15/iron fumarate & polysac comp/fa
3
prenatal vitamins no.18/iron,carbonyl/fa/ubidecarenone/dha
3
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
2
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
2
prenatal vitamins no.26/iron polysaccharides/fa/dha
3
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
2
prenatal vitamins no.59/iron carbonyl & fumarate/fa/dss/dha
1
prenatal vitamins no.72/iron carbonyl & gluconate/fa/dss/dha
1
prenatal vitamins no.73/iron carbonyl & gluconate/fa/dss/dha
1
prenatal vitamins with calcium/ferrous fumarate/docusate/fa
2
prenatal vitamins with calcium/ferrous fumarate/fa/selenium
1
prenatal vitamins with calcium/ferrous fumarate/folic acid
2
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
2
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
3
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
2
prenatal vits with calcium #44/iron,carbonyl/folic acid
2
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
prenatal vits with calcium #62/ferrous fumarate/fa/dha
3
prenatal vits with calcium #7/fe asp gly/docusate/folic acid
2
prenatal vits with calcium #70/ferrous fumarate/fa/dha
1
prenatal vits with calcium #71/ferrous fumarate/folic acid
2
2
1
1
PAGE 190
PRODUCT DESCRIPTION
TIER
1
1
1
prenatal vits with calcium#118/ferrous fumarate/folic acid
2
prenatal vits without calc no5/ferrous fumarate/folic acid
1
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
2
PRENATE AM
3
PRENATE CHEWABLE
3
PRENATE DHA
3
PRENATE ELITE
3
PRENATE ENHANCE
3
PRENATE ESSENTIAL
3
PRENATE MINI
3
PRENATE PIXIE
3
PRENATE RESTORE
3
PRENATE STAR
3
PRENEXA
3
PREQUE 10
3
PRISMASOL (B22GK 4/0, B22GK 2/0, BGK 0/2.5, BGK 2/0,
BGK 2/3.5, BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2)
9
PROBARIMIN QT
3
PROCALAMINE
3
PROFERRIN-FORTE
3
PROSOL
3
PROTECT BONE
3
PROTECT IRON
3
PROTECT NATAL
3
PROTECT PLUS
3
PROVIDA DHA
3
PROVIDA OB
3
PUREFE OB PLUS
2
PUREFE PLUS
2
PAGE 191
PRODUCT DESCRIPTION
TIER
pyridoxine hcl
7
Q-TABS
3
QUFLORA (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 1 MG
CHEW TAB)
3
REQ49+
1
RHEUMATE
3
ringers solution (solution irrig soln, solution iv soln)
7
ringers solution,lactated (irrig soln, iv soln)
7
SELECT-OB
2
SELECT-OB + DHA
3
selenium
9
SENTRA AM
3
SENTRA PM
3
SETONET-EC
2
SIDEROL
1
sodium acetate (2 vial, 4 vial)
7
sodium bicarbonate (0.5meq/ml syringe, 0.5meq/ml vial,
0.9meq/ml syringe, 1 meq/ml syringe, 1 meq/ml vial,
10meq/10ml syringe)
7
sodium chloride (2.5 vial, 4 vial)
7
sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 % 0.45 % iv
soln)
7
sodium chloride 3 %
7
sodium chloride 5 %
7
sodium chloride irrigating solution
7
sodium ferric gluconate complex in sucrose
7
sodium fluoride (0.125/drop drops, 0.25(0.55) tab chew,
0.25mg/drp drops, 0.5(1.1)mg tab chew, 0.5 mg/ml drops,
1mg(2.2mg) tab chew)
1
sodium lactate 167meq/l iv soln
8
sodium lactate 5 meq/ml vial
7
sodium phos,m-basic-d-basic
7
sodium/potassium/magnesium/calcium/chloride/acetate
7
STROVITE
3
PAGE 192
PRODUCT DESCRIPTION
TIER
STROVITE FORTE
3
STROVITE ONE
1
STROVITE PLUS
1
SUPERVITE
3
SUPERVITE EC
3
SWABFLUSH
7
SYNAGEX
3
TANDEM PLUS
3
TARON-DUO EC
2
TEXAVITE LQ
3
THAM
9
THERAMINE
3
thiamine hcl
7
thiamine hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine
7
THRIVITE RX
3
TL FOLATE
3
TL-ICARE
3
TL-SELECT DHA
3
TOZAL
3
TPN ELECTROLYTES
7
TPN ELECTROLYTES II
7
TRACE ELEMENTS-4
9
TRAVASOL
9
TRI-VI-FLOR (0.25 MG DROPS, 0.5 MG DROPS)
3
TRICARE
2
TRICARE PRENATAL COMPLEAT
3
TRICARE PRENATAL DHA ONE
3
TRINATE
2
TRISTART DHA
3
TROPHAMINE (6% IV SOLUTION, 10% IV SOLUTION)
9
UDAMIN
3
PAGE 193
PRODUCT DESCRIPTION
TIER
UDAMIN SP
3
UROCIT-K (ER 15 TABLET, SR 5 TABLET, SR 10 TABLET)
3
VASCAZEN
3
VASCULERA
3
VAYACOG
3
VAYARIN
3
VENOFER (50 MG/2.5 ML VIAL, 100 MG/5 ML VIAL, 200
MG/10 ML VIAL)
9
VINATE CARE
2
VINATE DHA RF
3
VIRT-BAL DHA
3
VIRT-BAL DHA PLUS
3
VIRT-VITE PLUS
2
VITA-RESPA
3
VITAFOL
3
VITAFOL NANO
3
VITAFOL ULTRA
3
VITAFOL-OB
2
VITAFOL-OB+DHA
3
VITAFOL-ONE
3
VITAFOL-PN
2
VITAL-D RX
3
VITAMEDMD ONE RX
3
VITAMEDMD PLUS RX
3
VITAMEDMD REDICHEW RX
3
vitamin b complex & vitamin c no.20/folic acid
1
vitamin b complx no.3/folic acid/ascorbic acid/biotin
1
VITAPEARL
3
VIVA CT
3
VIVA DHA
3
VP CH ULTRA
3
VP-PNV-DHA (CAPSULE, SOFTGEL)
3
PAGE 194
PRODUCT DESCRIPTION
TIER
zinc chloride
8
zinc sulf/cuso4 p-hyd/mn/cr/se 20-1000 vial
8
zinc sulf/cuso4 p-hyd/mn/cr/se 60-5000 vial
7
zinc sulfate (1 mg/ml vial, 5 mg/ml vial)
9
zinc sulfate 220(50)mg capsule
1
zinc sulfate/cupric sulfate/manganese sulf/chromic chloride (10.4-0.1 vial, 1.5-0.1-25 vial)
8
znso4/cuso4/mang su/chromic cl 5-1-0.5-10 vial
7
ZYTAZE
3
Uncategorized
Unclassified
amyl nitrite
1
FUSION SPRINKLES
3
IRESSA
6
LISTER-V
3
METHAZEL
3
phenylephrine hcl in 0.9 % sodium chloride/pf
7
PRAXBIND
3
RESTORA SPRINKLES
3
sodium citrate
1
TOLAK
3
PAGE 195
QL
30 / 30 days
Index of covered drugs
0
0.9 % sodium chloride
176
8
8-MOP
108
A
ACIPHEX
123
ACIPHEX SPRINKLE
123
acitretin
108
ACLARO
108
ACLARO PD
108
ACTEMRA
144
ACTHIB
144
ACTHREL
147
abacavir sulfate
67
ACTICLATE
abacavir sulfate/lamivudine/zidovudine
67
ACTIGALL
119
ABELCET
46
ACTIMMUNE
144
ABILIFY
39
ACTIQ
ABILIFY DISCMELT
39
ACTIVASE
78
ABILIFY MAINTENA
39
ACTIVE FE
176
147
ACTIVE OB
176
ABRAXANE
54
ACTIVELLA
133
ABSORICA
108
ACTONEL
158
ABLAVAR
33
8
ABSTRAL
10
ACTOPLUS MET
74
acamprosate calcium
17
ACTOPLUS MET XR
74
ACTOS
74
ACANYA
108
acarbose
74
ACULAR
163
ACCOLATE
167
ACULAR LS
163
ACCU-CHECK
159
ACUVAIL
163
ACCUNEB
168
acyclovir
71
ACCUPRIL
86
acyclovir sodium
71
ACCURETIC
91
ACZONE
108
ACCUTREND
159
ADACEL TDAP
144
117
ACD-A
78
ADAGEN
acebutolol hcl
88
ADALAT CC
ACEON
86
adapalene
108
147
ADASUVE
64
ADAZIN
14
ADCETRIS
60
ADCIRCA
170
ADDAMEL N
176
ADDERALL
101
ACETADOTE
acetaminophen with codeine phosphate
10
acetaminophen/phenyltoloxamine citrate
147
acetazolamide
acetazolamide sodium
acetic acid
34,96
34
22,126
90
acetic acid/aluminum acetate
22
ADDERALL XR
101
acetic acid/hydrocortisone
22
ADDYI
147
acetic acid/oxyquinoline sulfate
22
adefovir dipivoxil
acetylcysteine
147,171
acetylcysteine/mecobalamin/levomefolate calcium 176
PAGE 196
ADEMPAS
ADENOCARD
70
170
87
ADENOSCAN
147
adenosine
87
ADIPEX-P
103
ADOXA
33
ALBURX
80
ALBUTEIN
80
albuterol sulfate
168
ALCAINE
14
18
ADRENACLICK
168
alclometasone dipropionate
ADRENALIN
168
ALCORTIN A
ADRENALIN CHLORIDE
168
ALDACTAZIDE
91
ADREVIEW
147
ALDACTONE
97
ALDARA
54
ADRIAMYCIN
54
108
ADV ALLERGY COLLECTION KIT
128
ALDURAZYME
117
ADVAIR DISKUS
168
alendronate sodium
158
ADVAIR HFA
168
ALEVICYN ANTIPRURITIC SG
107
ADVANCED DNA MEDICATED COLLECT
14
ALFENTA
10
ADVATE
81
alfentanil hcl
10
ADVATE H
81
ALFERON N
55
ADVATE L
82
alfuzosin hcl
125
ADVATE M
82
ALIMTA
53
ADVATE SH
82
ALINIA
61
ADVATE UH
82
ALKERAN
ADVICOR
99
ALLEGRA ODT
166
ALLEGRA-D 24 HOUR
171
171
AEROSPAN
165
51,52
AFINITOR
58
ALLFEN CDX
AFINITOR DISPERZ
58
allopurinol
48
AFREZZA
77
allopurinol sodium
48
AGGRASTAT
83
almotriptan malate
49
AGGRENOX
83
ALOCRIL
162
AGRYLIN
80
ALODOX
33
147
ALOMIDE
162
30
ALOPRIM
48
160
ALOQUIN
108
AK-FLUOR
AKNE-MYCIN
AKTEN
AKYNZEO
45
ALORA
133
ALA-CORT
18
alosetron hcl
122
ALA-QUIN
108
ALA-SCALP
ALAHIST DHC
ALOXI
18
ALPHAGAN P
171
ALPHANATE
44
163
82,147
ALBENZA
61
ALPHANINE SD
82
ALBUKED-25
80
ALPHAQUIN HP
108
ALBUKED-5
80
alprazolam
72
albumin human
80
ALPROLIX
82
ALBUMINAR-25
80
alprostadil
91
ALBUMINAR-5
80
ALREX
PAGE 197
163
ALSUMA
49
amlodipine besylate/atorvastatin calcium
92
ALTABAX
22
amlodipine besylate/benazepril hcl
92
ALTACE
86
amlodipine besylate/valsartan
92
ALTOPREV
98
amlodipine besylate/valsartan/hydrochlorothiazide
92
aluminum acetate
108
ammonium chloride
177
aluminum chloride
108
ammonium lactate
108
ALUVEA
108
AMMONUL
117
ALVESCO
165
amoxapine
43
amantadine hcl
62
amoxicillin
29
AMARYL
74
amoxicillin/potassium clavulanate
29
AMBIEN
174
ampicillin sodium
29
AMBIEN CR
174
ampicillin sodium/sulbactam sodium
29
AMBISOME
46
ampicillin trihydrate
29
amcinonide
18
AMPYRA
105
AMERGE
49
AMRIX
173
AMERICAN COCKROACH EXTRACT
147
AMTURNIDE
92
AMERICAN ELM
147
AMVISC
160
AMERICAN SYCAMORE
147
AMVISC PLUS
160
AMICAR
82
amyl nitrite
195
AMIDATE
14
AMYTAL SODIUM
174
amifostine crystalline
55
AMYVID
147
amikacin sulfate
21
ANACAINE
amiloride hcl
97
ANADROL-50
amiloride hcl/hydrochlorothiazide
91
ANAFRANIL
43
AMINOACETIC ACID
22
anagrelide hcl
80
aminocaproic acid
82
ANALPRAM ADVANCED
119
14
132
aminohippurate sodium
147
ANALPRAM E
119
aminophylline
168
ANALPRAM HC
119
AMINOSYN
176,177
ANAPROX
5
5
AMINOSYN II
177
ANAPROX DS
AMINOSYN II WITH ELECTROLYTES
177
ANASCORP
147
AMINOSYN M
177
ANASPAZ
118
176,177
anastrozole
57
AMINOSYN-HBC
177
ANCOBON
46
AMINOSYN-PF
177
ANDRODERM
132
AMINOSYN-RF
177
ANDROGEL
132
amiodarone hcl
87
ANDROID
132
122
ANECTINE
103
133
AMINOSYN WITH ELECTROLYTES
AMITIZA
amitriptyline hcl
43
ANGELIQ
amitriptyline hcl/chlordiazepoxide
72
ANGIOMAX
amlodipine besylate
90
ANIMI-3
PAGE 198
78
177
ANORO ELLIPTA
ANSAID
ANTABUSE
ANTARA
168
aripiprazole
39
5
ARISTADA
39
17
97,98
ARISTOSPAN
128
ARIXTRA
78
antipyrine/benzocaine
164
ARMOUR THYROID
138
antipyrine/benzocaine/glycerin/zinc acetate
164
ARNUITY ELLIPTA
165
antivenin,latrodectus mactans
147
AROMASIN
57
antivenin,micrurus fulvius
147
ARRANON
53
ANTIVERT
44
ARTHROTEC 50
5
ANUSOL-HC
18
ARTHROTEC 75
5
ANZEMET
45
ARTICADENT DENTAL
APIDRA
77
ARTISS
APIDRA SOLOSTAR
77
ARZERRA
APLENZIN
39
ASACOL
119
ASACOL HD
119
ASCLERA
147
APLISOL
147
APOKYN
63
14
147
60
APOP
107
ascorbic acid
177
APPTRIM
147
ASMANEX
165
APPTRIM-D
147
ASMANEX HFA
165
apraclonidine hcl
163
ASPERGILLUS FUMIGATUS
148
APRISO
119
aspirin
APTENSIO XR
102
aspirin/dipyridamole
5
83
APTIOM
37
ASTAGRAF XL
141
APTIVUS
69
ASTELIN
166
166
AQUA GLYCOLIC HC
128
ASTEPRO
AQUASOL A
177
ASTRAMORPH-PF
AQUORAL
106
ASTRINGYN
148
ARALAST NP
171
ATABEX EC
177
ARANESP
80
10
ATACAND
85
92
ARAVA
144
ATACAND HCT
ARCALYST
144
ATELVIA
ARCAPTA NEOHALER
169
atenolol
88
ARESTIN
106
atenolol/chlorthalidone
92
argatroban
78
ATGAM
141
argatroban in 0.9 % sodium chloride
78
ATIVAN
72
argatroban in sodium chloride, iso-osmotic
78
ATOPICLAIR
ARICEPT
38
atorvastatin calcium
98
ARICEPT ODT
38
atovaquone
61
61
158
108
ARIDA
107
atovaquone/proguanil hcl
ARIDOL
147
atracurium besylate
103
ATRALIN
109
ARIMIDEX
PAGE 199
57
ATRAPRO CP
109
AVYCAZ
22
ATRAPRO DERMAL SPRAY
109
AXERT
49
ATRAPRO HYDROGEL
109
AXID
122
ATRIPLA
68
AXIRON
132
ATROPEN
87
AXONA
177
AYGESTIN
136
atropine sulfate
87,160
ATROVENT
167
azacitidine
53
ATROVENT HFA
167
AZACTAM
28
AZACTAM-ISO-OSMOTIC DEXTROSE
28
ATRYN
AUBAGIO
80,148
105
AZASAN
141
AUGMENTIN
29
AZASITE
30
AUGMENTIN ES-600
29
azathioprine
AUGMENTIN XR
29
azelastine hcl
141
162,166
AURSTAT
109
AZELEX
109
AURYXIA
127
AZILECT
64
AUVI-Q
169
azithromycin
30
AVAGE
109
AZOPT
163
AVAILNEX
177
AZOR
92
28
AVALIDE
92
aztreonam
AVANDAMET
74
AZULFIDINE
AVANDARYL
74
AVANDIA
74
B
AVAPRO
85
B-NEXA
177
22
119
AVAR
107,109
bacitracin
AVAR LS
107,109
bacitracin/polymyxin b sulfate
AVAR-E LS
160
109
baclofen
66
AVASTIN
60
BACMIN
177
AVC
32
BACTRIM
32
132
BACTRIM DS
32
AVELOX
31
BACTROBAN
23
AVELOX ABC PACK
31
BACTROBAN NASAL
23
AVELOX IV
31
BAHIA
148
AVENOVA
148
BAL IN OIL
148
BAL-CARE DHA ESSENTIAL
177
balanced salt irrig soln no.2
160
AVEED
AVIDOXY DK
AVINZA
33
8
AVITA
109
balsalazide disodium
146
AVITENE
148
balsam peru/castor oil
148
AVODART
125
BANZEL
37
AVONEX
105
BARACLUDE
70
AVONEX ADMINISTRATION PACK
105
barium sulfate
148
AVONEX PEN
105
BAYBERRY
148
PAGE 200
BCG (TICE STRAIN)
55
betamethasone valerate
18
BCG VACCINE (TICE STRAIN)
145
BETAPACE
87
BEAU RX
148
BETAPACE AF
87
BEBULIN
82
BECONASE AQ
165
BETASERON
105
betaxolol hcl
88,164
BELEODAQ
55
bethanechol chloride
126
BELSOMRA
175
BETHKIS
21
BELVIQ
103
BETIMOL
164
164
benazepril hcl
86
BETOPTIC S
benazepril hcl/hydrochlorothiazide
92
bexarotene
61
BENEFIX
82
BEXSERO
145
BENICAR
85
BEXXAR
BENICAR HCT
92
BEYAZ
133
109
60
BENLYSTA
141
BIAFINE
benoxinate hcl/fluorescein sodium
160
BIAXIN
30
30
BENOXYLDOXY 30
33
BIAXIN XL
BENOXYLDOXY 60
33
bicalutamide
141
BENTYL
118
BICILLIN C-R
29
BENZAC AC
109
BICILLIN L-A
29
BENZACLIN
109
BICNU
52
BENZAMYCIN
109
BIDIL
92
BENZAMYCINPAK
109
BIFERA RX
177
BENZEFOAM
109
BILTRICIDE
61
BENZEFOAM ULTRA
109
bimatoprost
160
benzocaine
165
BINOSTO
158
benzoic acid/salicylic acid
109
BIONECT
109,148
benzonatate
171
BIOTHRAX
benzoyl peroxide
109
bisacodyl/sodium chlor/sodium bicarb/potassium
benzoyl peroxide microspheres
109
chl/peg 3350
benzphetamine hcl
103
bisoprolol fumarate
88
bisoprolol fumarate/hydrochlorothiazide
92
benztropine mesylate
62
145
122
BEPREVE
162
bivalirudin
78,148
BERINERT
80
BIVIGAM
143
BESIVANCE
31
BLACK WALNUT POLLEN
148
BETA 1
128
bleomycin sulfate
55
BETADINE
160
BLEPH-10
32
BETAGAN
163
BLEPHAMIDE
160
BLEPHAMIDE S.O.P.
160
betamethasone acetate/betamethasone sodium
phosphate
128
BLINCYTO
60
50
betamethasone dipropionate
18
BLOXIVERZ
betamethasone dipropionate/propylene glycol
18
BONIVA
PAGE 201
158
BONTRIL PDM
103
BUSULFEX
52
BOOSTRIX TDAP
145
butalbital/acetaminophen
103
103
BOSULIF
57
butalbital/acetaminophen/caffeine
BOTOX
49
butalbital/acetaminophen/caffeine/codeine
BOTOX COSMETIC
49
phosphate
botulism antitoxin heptavalent
10,103
butalbital/aspirin/caffeine
103
a,b,c,d,e,f,g(equine)/maltose
145
BUTISOL SODIUM
72
BOX ELDER
148
butorphanol tartrate
10
BRAVELLE
148
BUTRANS
BREEZE2
159
BYDUREON
74
BYDUREON PEN
74
BYETTA
74
BYSTOLIC
88
BREO ELLIPTA
165,169
BREVIBLOC
88
BREVICON
133
BREVITAL SODIUM
14
BRILINTA
83
brimonidine tartrate
164
8
C
C-CLARIFYING SERUM
109
109
BRINTELLIX
41
C-THERAPY NIGHT CREAM
BRISDELLE
41
ca carbonate/mag oxide/vitamin d3/vit b12/fa/vit
BROMDAY
163
b6/boron
177
bromfenac sodium
163
CA-DTPA
148
cabergoline
139
177
bromocriptine mesylate
63
BROVANA
169
CADEAU DHA
BSS
160
CADUET
92
BSS PLUS
160
CAFCIT
103
BUCALSEP
14
budesonide
128,165
bumetanide
CAFERGOT
49
caffeine citrated
103
96
caffeine/sodium benzoate
103
BUMINATE
80
CALAN
87
BUNAVAIL
17
CALAN SR
90
BUPHENYL
117
calcipotriene
109
bupivacaine hcl
14
calcipotriene/betamethasone dipropionate
109
bupivacaine hcl/dextrose-water/pf
14
calcitonin,salmon,synthetic
158
bupivacaine hcl/epinephrine
14
calcitriol
bupivacaine hcl/epinephrine bitartrate
14
calcium acetate
127
bupivacaine hcl/epinephrine/pf
14
calcium chloride
177
bupivacaine hcl/pf
14
calcium gluconate
177
BUPRENEX
10
CALDOLOR
5
CAMBIA
5
buprenorphine hcl
buprenorphine hcl/naloxone hcl
10,17
17
bupropion hcl
18,39
buspirone hcl
72
PAGE 202
110,139
CAMPRAL
17
CAMPTOSAR
57
CANASA
119
CANCIDAS
46
CARNITOR SF
176
candesartan cilexetil
85
carteolol hcl
164
candesartan cilexetil/hydrochlorothiazide
92
CARTICEL
148
CANDIDA ALBICANS
148
carvedilol
CANDIN
148
CASODEX
CANTIL
118
CATAFLAM
5
CAPASTAT SULFATE
51
CATAPRES
84
capecitabine
53
CATAPRES-TTS 1
84
CAPEX SHAMPOO
18
CATAPRES-TTS 2
84
106
CATAPRES-TTS 3
84
78
CAPHOSOL
89
141
CAPITAL W-CODEINE
10
CATHFLO ACTIVASE
CAPRELSA
58
CAVERJECT
captopril
86
CAYSTON
28
captopril/hydrochlorothiazide
92
CEDAX
26
CARAC
110
CEENU
52
CARAFATE
123
cefaclor
26
CARB-O-PHILIC
110
cefadroxil
26
CARBAGLU
117
cefazolin sodium
26
126
carbamazepine
37
cefazolin sodium in 0.9 % sodium chloride
26
CARBATROL
37
cefazolin sodium/dextrose, iso-osmotic
26
carbidopa
63
cefdinir
26
carbidopa/levodopa
63
cefditoren pivoxil
26
carbidopa/levodopa/entacapone
62
cefepime hcl
27
166
cefepime hcl/dextrose 5 % in water
27
CARBOCAINE
14
cefepime hcl/dextrose, iso-osmotic
27
carboplatin
52
cefixime
27
CARDENE I.V.
90
cefotaxime sodium
27
CARDENE SR
90
cefotetan disodium
27
CARDIOLITE
148
cefotetan disodium/dextrose, iso-osmotic
27
cefoxitin sodium
27
carbinoxamine maleate
cardioplegic solution no.1
93
CARDIOTEK-RX
177
cefoxitin sodium/dextrose, iso-osmotic
27
CARDIOVID PLUS
177
cefpodoxime proxetil
27
CARDIZEM
90
cefprozil
27
CARDIZEM CD
90
ceftazidime
27
CARDIZEM LA
90
ceftazidime in dextrose 5% and water
27
CARDURA
85
ceftibuten
27
CARDURA XL
85
CEFTIN
27
carisoprodol
173
ceftriaxone sodium
27
carisoprodol/aspirin
173
ceftriaxone sodium/dextrose, iso-osmotic
27
cefuroxime axetil
27
cefuroxime sodium
27
CARMOL HC
CARNITOR
PAGE 203
18
176
cefuroxime sodium/dextrose, iso-osmotic
CELACYN
27
110
chloroquine phosphate
61
chlorothiazide
97
97
CELEBREX
5
chlorothiazide sodium
celecoxib
5
chloroxylenol/benzocaine/hydrocortisone acetate
165
chloroxylenol/pramoxine hcl
165
chlorpheniramine maleate/codeine phosphate
171
CELESTONE
CELEXA
128
41
CELLCEPT
141
chlorpromazine hcl
44
CELLUGEL
160
chlorpropamide
74
CELONTIN
34
chlorthalidone
97
CENESTIN
133
chlorzoxazone
173
CENTANY
23
CHOLBAM
120
CENTANY AT
23
cholestyramine (with sugar)
99
cephalexin
27
cholestyramine/aspartame
99
CEPROTIN
78
choline salicylate/magnesium salicylate
CERDELGA
117
CHOLOGRAFIN MEGLUMINE
148
37
chorionic gonadotropin, human
130
177
CEREBYX
5
CEREFOLIN
177
chromic chloride
CEREFOLIN NAC
177
CIALIS
CERENX
148
CICLODAN
46
CERETEC
148
ciclopirox
46
CEREZYME
117
ciclopirox olamine
46
ciclopirox/urea/camphor/menthol/eucalyptol
46
CERUBIDINE
55
125,126
CERVARIX
145
ciclopirox/vitamin e mixed/nail lacquer remover, non-
CERVIDIL
126
acet
46
CESAMET
45
cidofovir
69
CESINEX
119
cilostazol
83
CETACAINE
14
CILOXAN
31
CETACAINE ANESTHETIC
14
cimetidine
122
cetirizine hcl
166
cimetidine hcl
122
CETRAXAL
165
CIMZIA
141
CETROTIDE
140
CINRYZE
80
cevimeline hcl
103
CIPRO
31
CHANTIX
18
CIPRO HC
165
CHEMET
176
CIPRO I.V.
31
CHENODAL
119
CIPRO XR
31
CHIRHOSTIM
148
CIPRODEX
165
chloramphenicol sod succ
23
ciprofloxacin
31
chlordiazepoxide hcl
72
ciprofloxacin hcl
chlordiazepoxide/clidinium bromide
118
31,165
ciprofloxacin lactate
31
chlorhexidine gluconate
23
ciprofloxacin lactate/dextrose 5 % in water
31
chloroprocaine hcl/pf
14
ciprofloxacin/ciprofloxacin hcl
31
PAGE 204
cisatracurium besylate
103
CLINIMIX E
178
106
cisplatin
52
CLINPRO 5000
citalopram hydrobromide
41
clobetasol propionate
18
CITANEST FORTE DENTAL
14
clobetasol propionate/emollient base
18
CITANEST PLAIN DENTAL
14
CLOBEX
18
19
CITRANATAL 90 DHA
177
clocortolone pivalate
CITRANATAL ASSURE
178
CLODAN
CITRANATAL B-CALM
178
CLODERM
19
CITRANATAL DHA
178
CLOLAR
53
CITRANATAL HARMONY
178
clomiphene citrate
CITRANATAL RX
178
clomipramine hcl
43
clonazepam
72
clonidine
84
citrate phosphate dextros soln
citric acid/sodium citrate
cladribine
CLAFORAN
78
126
53
27,28
128
148
clonidine hcl
84,102
clonidine hcl/pf
84
CLARIFOAM EF
110
clopidogrel bisulfate
84
CLARINEX
166
clorazepate dipotassium
72
CLARINEX-D 12 HOUR
171
clotrimazole
46
CLARINEX-D 24 HOUR
171
clotrimazole/betamethasone dipropionate
clarithromycin
clemastine fumarate
30
166
110
clozapine
66
CLOZARIL
66
46
CLEOCIN
23
CNL 8
CLEOCIN HCL
23
CO-VERATROL
CLEOCIN PALMITATE
23
COARTEM
61
CLEOCIN PHOSPHATE
23
cocaine hcl
14
CLEOCIN PHOSPHATE IN D5W
23
codeine phosphate/butalbital/aspirin/caffeine
CLEOCIN T
23
codeine phosphate/carisoprodol/aspirin
10
CLEVIPREX
90
codeine sulfate
10
62
148
104
CLIMARA
133
COGENTIN
CLIMARA PRO
133
COLAZAL
146
CLIN SINGLE USE
23
colchicine
48
CLINDACIN ETZ
23
colchicine/probenecid
48
CLINDACIN PAC
23
COLCRYS
48
110
COLESTID
99
CLINDAGEL
clindamycin hcl
23
colestipol hcl
99
clindamycin palmitate hcl
23
colistin (as colistimethate sodium)
23
clindamycin phosphate
23
COLY-MYCIN M PARENTERAL
23
clindamycin phosphate/benzoyl peroxide
110
COLY-MYCIN S
165
clindamycin phosphate/dextrose 5 % in water
23
COLYTE WITH FLAVOR PACKETS
122
CLINDESSE
23
COLYTE WITH FLAVOR PACKS
122
COMBIGAN
164
CLINIMIX
PAGE 205
178
COMBIPATCH
133
CORTISPORIN-TC
165
COMBIVENT
169
CORTROSYN
149
COMBIVENT RESPIMAT
169
CORVERT
87
COMBIVIR
67
CORVITE
178
COMETRIQ
59
CORVITE 150
178
174
CORVITE FE
178
178
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-MELOXICAM
6
CORVITE FREE
COMFORT PAC-NAPROXEN
6
CORZIDE
COMFORT PAC-TIZANIDINE
66
COSENTYX (2 SYRINGES)
107
COMPAZINE
44
COSENTYX PEN
108
COMPLERA
68
COSENTYX PEN (2 PENS)
108
108
COMPLETE FORMULATION D3000
148
COSENTYX SYRINGE
COMPLETE FORMULATION PEDIATRIC
148
COSMEGEN
COMTAN
62
COMVAX
93
55
COSOPT
164
145
COSOPT PF
164
CONCEPT DHA
178
cosyntropin
149
CONCEPT OB
178
COTABFLU
171
CONCERTA
102
COUMADIN
78
CONDYLOX
110
COZAAR
85
CONRAY
148
CREON
117
CONRAY-30
148
CRESEMBA
46
CONRAY-43
149
CRESTOR
98
CONTOUR
159
CRESYLATE
165
CONTRAVE
149
CRINONE
136
8
CRIXIVAN
69
CROFAB
149
CONZIP
COPAXONE
106
COPEGUS
70
cromolyn sodium
CORDARONE
87
CUBICIN
CORDRAN
19,128
162,170
23
cupric chloride
178
COREG
89
cupric sulfate
178
COREG CR
89
CUPRIMINE
126
CORGARD
89
CUROSURF
171
CORIFACT
82
CUTIVATE
19
CORLANOR
93
CUVPOSA
118
CORLOPAM
100
cyanocobalamin (vitamin b-12)
178
CORTANE-B
128,165
cyanocobalamin-salcaprozate sodium
178
178
CORTEF
128
cyanocobalamin/folic acid/pyridoxine
CORTENEMA
146
cyanocobalamin/levomefolate calcium/pyridoxine
CORTIFOAM
120
hcl
cortisone acetate
CORTISPORIN
PAGE 206
19
19,110
149
cyanocobalamin/levomefolate
calcium/pyridoxine/riboflavin
178
CYANOKIT
93
dantrolene sodium
67
CYCLESSA
133
dapsone
51
cyclobenzaprine hcl
174
DAPTACEL DTAP
CYCLOGYL
160
DARAPRIM
61
CYCLOMYDRIL
160
DATSCAN
149
cyclopentolate hcl
160
daunorubicin hcl
55
cyclophosphamide
52
DAUNOXOME
55
cycloserine
23
DAYPRO
CYCLOSET
74
DAYTRANA
102
cyclosporine
141
DDAVP
130
cyclosporine, modified
110
DEBACTEROL
107
145
6
CYKLOKAPRON
82
decitabine
CYMBALTA
41
deferoxamine mesylate
149
DEFINITY
149
60
DELATESTRYL
132
CYSTADANE
117
DELESTROGEN
133
CYSTAGON
126
178
CYSTARAN
161
178
cysteine hcl
178
178
CYSTO-CONRAY II
149
DELTASONE
CYSTOGRAFIN
149
DELZICOL
120
CYSTOGRAFIN-DILUTE
149
DEMADEX
96
cyproheptadine hcl
CYRAMZA
166
53
19
cytarabine
53
demeclocycline hcl
33
cytarabine/pf
53
DEMEROL
10
CYTOGAM
145
DEMSER
93
CYTOMEL
138
DENAVIR
71
CYTOTEC
123
DEPACON
34
69
DEPAKENE
34
DEPAKOTE
35
DEPAKOTE ER
35
DEPAKOTE SPRINKLE
35
CYTOVENE
D
D.FARINAE MITE EXTRACT
D.H.E.45
D.PTERONYSSINUS MITE EXTRACT
149
49
DEPEN
126
149
DEPLIN
178
dacarbazine
52
DEPLIN-ALGAL OIL
178
DACOGEN
53
DEPO-ESTRADIOL
133
dactinomycin
55
DEPO-MEDROL
DAKLINZA
70
DEPO-PROVERA
136
DALIRESP
171
DEPO-SUBQ PROVERA 104
136
DALVANCE
23
DEPO-TESTOSTERONE
132
danazol
DANTRIUM
PAGE 207
19
132
DEPOCYT
54
66
DEPODUR
10
DEPRIZINE
DERMA-SMOOTHE-FS
122
19
DEXPAK
128
dexpanthenol
120
DERMACINRX LEXITRAL
6
dexrazoxane hcl
55
DERMACINRX SILAZONE
108
dextroamphetamine sulf-saccharate/amphetamine sulf-
DERMACINRX SURGICAL PHARMAPAK
108
aspartate
101
DERMANIC
178
dextroamphetamine sulfate
101
DERMAPAK PLUS
108
dextromethorphan hbr/phenylephrine
DERMASILKRX DICLOPAK
6
DERMASILKRX LIDORXKIT
149
dextromethorphan hbr/pseudoephedrine
DERMASORB AF
110
hcl/brompheniramine
171
DERMASORB HC
128
179
DERMASORB TA
128
179
DERMASORB XM
110
179
DERMATOP
110
179
DERMOTIC
128
dextrose 2.5 % and 0.45 % sodium chloride
179
DESFERAL
149
dextrose 2.5 % in water
179
DESFERAL MESYLATE
149
179
43
179
desloratadine
166,167
179
desmopressin acetate
130,131
179
desipramine hcl
hcl/chlorpheniramine
171
desmopressin acetate (non-refrigerated)
131
179
DESOGEN
133
179
desogestrel-ethinyl estradiol
133
179
desogestrel-ethinyl estradiol/ethinyl estradiol
133
179
DESONATE
19
dextrose 5 % in lactated ringers
179
desonide
19
179
DESOWEN
19
dextrose 5% in ringers
179
desoximetasone
19
179
101
179
DESOXYN
desvenlafaxine
41
DIABETA
74
desvenlafaxine fumarate
41
DIALYVITE
179
DETROL
124
DIALYVITE 3000
179
DETROL LA
124
DIALYVITE 5000
179
dexamethasone
128
DIALYVITE 800 WITH IRON
179
DIALYVITE SUPREME D
179
DIALYVITE ZINC
179
dexamethasone sod phosphate
dexamethasone sodium phosphate/pf
19,128
19
DEXEDRINE
101
DIAMOX SEQUELS
DEXFERRUM
179
179
DEXILANT
123
179
dexmedetomidine hcl
175
179
dexmethylphenidate hcl
102
180
PAGE 208
96
180
dioxybenzone/padimate o/hydroquinone
110
180
DIPENTUM
146
DIASTAT
35
diphenhydramine hcl
44,167
DIASTAT ACUDIAL
35
diphenoxylate hcl/atropine sulfate
120
DIASTIX
159
DIPRIVAN
14
diatrizoate meglumine/diatrizoate sodium
149
DIPROLENE
19
DIPROLENE AF
19
diazepam
35,72,73
DIBENZYLINE
85
dipyridamole
84
DICLEGIS
44
DISCOVISC
161
diclofenac potassium
diclofenac sodium
diclofenac sodium/misoprostol
dicloxacillin sodium
6
6,110,128
6
29
DISKETS
8
disopyramide phosphate
87
disulfiram
17
DITROPAN XL
124
DICOPANOL
167
DIURIL
97
dicyclomine hcl
118
divalproex sodium
35
didanosine
68
DIVIGEL
133
149
DIDREX
104
DMSA
DIDRONEL
158
dobutamine hcl
93
diethylpropion hcl
104
dobutamine hcl/dextrose 5 % in water
93
DIFFERIN
110
DOCEFREZ
55
55
DIFICID
30
docetaxel
diflorasone diacetate
19
DOG EPITHELIUM EXTRACT
149
DIFLUCAN
46
DOLGIC PLUS
104
diflunisal
6
DOLOPHINE HCL
8
DIGEX NF
118
DONATUSS DC
DIGIBAR
149
donepezil hcl
38
DIGIFAB
93
DONNATAL
120
digoxin
93
dopamine hcl
93
dihydrocodeine bitartrate/acetaminophen/caffeine10,11
dopamine hcl/dextrose 5 % in water
93
dihydrocodeine bitartrate/aspirin/caffeine
11
DOPRAM
171
dihydroergotamine mesylate
49
DORAL
174
DILACOR XR
90
DORIBAX
28
DILANTIN
37
DORYX
33
DILANTIN-125
37
dorzolamide hcl
164
dorzolamide hcl/timolol maleate
164
DILATRATE-SR
100
171
DILAUDID
11
DOTAREM
149
DILAUDID-HP
11
DOVONEX
110
doxapram hcl
171
diltiazem hcl
87,90
DILUENT
149
DIOVAN
DIOVAN HCT
PAGE 209
doxazosin mesylate
85
85
doxepin hcl
43
93
doxercalciferol
158
DOXIL
55
DYSPORT
104
doxorubicin hcl
55
doxorubicin hcl pegylated liposomal
55
E
doxycycline hyclate
33
E-Z DISK
149
doxycycline monohydrate
33
E-Z-CAT
149
doxylamine succinate
167
E-Z-DOSE-LIQ POLIBAR PLUS
149
DRAXIMAGE DTPA
149
E-Z-HD
150
DRAXIMAGE MAA
149
E-Z-PAQUE
150
DRAXIMAGE MDP-25
149
E-Z-PASTE
150
DRISDOL
180
E.E.S. 200
30
DRITHOCREME HP
110
E.E.S. 400
30
dronabinol
45
EASTERN COTTONWOOD
droperidol
44
EC-NAPROSYN
6
DROXIA
54
econazole nitrate
46
DRYSOL
110
ECOZA
46
DUAC
110
EDARBI
85
DUAVEE
133
EDARBYCLOR
93
DUET DHA
180
EDECRIN
97
DUET DHA 400
180
EDEX
126
DUET DHA BALANCED
180
EDLUAR
174
DUET DHA EC
180
EDURANT
67
74
EFFER-K
180
DUETACT
DUEXIS
EFFEXOR XR
41
169
EFFIENT
84
41
EFUDEX
110
DUODOTE
149
EGRIFTA
131
DUONEB
169
ELAPRASE
117
63
ELDEPRYL
64
DULERA
duloxetine hcl
DUOPA
DUOVISC
6
150
161
ELDERCAPS
180
ELDOPAQUE FORTE
110
electrolyte-48 solution/dextrose 5 % in water
180
11
ELELYSO
117
DUREZOL
128
ELESTAT
162
DURLAZA
6
ELESTRIN
133
dutasteride
125
ELETONE
110
DURACLON
84
DURAGESIC
8
DURAMORPH
DUTOPROL
93
ELIDEL
110
DYAZIDE
93
ELIGARD
140
6
ELIQUIS
78
ELITEK
117
DYLOJECT
DYMISTA
171
DYNACIN
33
ELIXOPHYLLIN
168
DYRENIUM
97
ELLA
136
PAGE 210
ELLENCE
55
ENTERAGAM
180
ELLIOTTS B
150
ENTEREG
120
ELMIRON
126
ENTERO VU
150
ENTOCORT EC
129
ELOCON
110,129
ELOCTATE
150
ELOXATIN
52
ENTYVIO
141
ELSPAR
55
ENVARSUS XR
141
EOVIST
150
EPANED
86
EMADINE
EMBEDA
162
8
ENTRESTO
93
EMCYT
53
ephedrine sulfate
172
EMEND
45
EPICERAM
111
EMLA
14
EPIDUO
111
EPIDUO FORTE
108
EPIFOAM
129
epinastine hcl
162
emol#53/na mg fluorosilicate/cyclometh/phosph
ac/nahco3/nacl
110
emol53/e.water/namgfs/naphos/nacl/hypochlorous
acid/nahypocl
110
epinephrine
169
111
epinephrine hcl/pf
169
111
epinephrine/pf
169
111
EPIPEN 2-PAK
169
111
EPIPEN JR 2-PAK
169
111
epirubicin hcl
55
EMSAM
40
EPISIL
107
EMTRIVA
68
EPISNAP
169
ENABLEX
124
EPIVIR
68
enalapril maleate
86
EPIVIR HBV
70
enalapril maleate/hydrochlorothiazide
93
eplerenone
97
enalaprilat dihydrate
86
EPOGEN
80
ENBRACE HR
180
epoprostenol sodium (glycine)
ENBREL
141
eprosartan mesylate
85
ENDO-AVITENE
150
EPZICOM
68
ENDOMETRIN
136
EQUETRO
37
ERAXIS (WATER DILUENT)
46
60
enflurane
14
170
ENGERIX-B ADULT
145
ERBITUX
ENGERIX-B PEDIATRIC-ADOLESCENT
145
ergocalciferol (vitamin d2)
ENGLISH PLANTAIN
150
ergoloid mesylates
38
ENJUVIA
134
ERGOMAR
49
ergotamine tartrate/caffeine
49
180
ERIVEDGE
59
enoxaparin sodium
78
ERTACZO
46
entacapone
62
ERWINAZE
55
entecavir
70
ERY-TAB
30
ENLON-PLUS
ENLYTE
PAGE 211
50
180
ERYPED 200
30
etidronate disodium
ERYPED 400
30
etodolac
ERYTHROCIN LACTOBIONATE
30
etomidate
14
ERYTHROCIN STEARATE
30
ETOPOPHOS
57
erythromycin base
30
etoposide
erythromycin base/benzoyl peroxide
111
158
6
57,58
EURAX
62
erythromycin base/ethyl alcohol
30
EVAMIST
134
erythromycin ethylsuccinate
31
EVEKEO
101
erythromycin ethylsuccinate/sulfisoxazole acetyl
24
EVISTA
137
ESBRIET
172
EVOCLIN
24
ESCAVITE
180
EVOTAZ
69
ESCAVITE D
150
EVOXAC
104
ESCAVITE LQ
180
EVZIO
escitalopram oxalate
41
17
EXALGO
8
ESGIC
104
EXELDERM
46
ESGIC-PLUS
104
EXELON
38
89
exemestane
57
esomeprazole magnesium
123
EXFORGE
93
esomeprazole sodium
123
EXFORGE HCT
93
ESOMEPRAZOLE STRONTIUM
123
EXJADE
ESOPHO-CAT
150
EXPAREL
15
estazolam
174
EXTAVIA
106
ESTRACE
134
EXTINA
estradiol
134
EXTRANEAL ICODEXTRIN DIALYSIS
180
estradiol valerate
134
EYLEA
161
estradiol/norethindrone acetate
134
EZ USE JOINT-TUNNEL-TRIGGER
129
ESTRASORB
134
ESTRING
134
F
ESTROGEL
134
FABIOR
111
estrogens,esterified/methyltestosterone
134
FABRAZYME
117
estropipate
134
FACTIVE
31
ESTROSTEP FE
134
famciclovir
71
eszopiclone
174
famotidine
122
esmolol hcl
176
46
ethacrynate sodium
97
famotidine in sodium chloride, iso-osmotic/pf
122
ethambutol hcl
51
famotidine/pf
122
ETHAMOLIN
150
FAMVIR
71
ethinyl estradiol/drospirenone
134
FANAPT
65
ethosuximide
34
FANATREX
35
ethyl alcohol
150
FARESTON
53
ethyl chloride
14
FARXIGA
74
134
FARYDAK
55
ethynodiol diacetate-ethinyl estradiol
PAGE 212
FASLODEX
53
FEXMID
174
FAZACLO
66
fexofenadine hcl
167
FEIBA NF
82
FIBRICOR
felbamate
36
FINACEA
108,111
FELBATOL
36
finasteride
125
FELDENE
6
felodipine
90
FIORINAL
104
FEM PH
24
FIORINAL WITH CODEINE #3
104
FEMARA
57
FIRAZYR
144
140
98
FIORICET WITH CODEINE
11,104
FEMCON FE
134
FIRMAGON
FEMHRT
134
FLAGYL
24
FEMRING
134
FLAGYL ER
24
fenofibrate
98
FLAREX
129
fenofibrate nanocrystallized
98
flavoxate hcl
124
fenofibrate,micronized
98
FLEBOGAMMA DIF
143
fenofibric acid
98
flecainide acetate
fenofibric acid (choline)
98
FLECTOR
FENOGLIDE
98
FLEXBUMIN
87
6
80
fenoprofen calcium
6
FLEXERIL
174
fentanyl
8
FLO-PRED
19
fentanyl citrate
8
FLOLAN
170
11
FLOMAX
125
fentanyl citrate/pf
8
FLONASE
129
FENTORA
8
FLORIVA
180
fentanyl citrate in 0.9 % sodium chloride/pf
FERAHEME
180
FLOVENT DISKUS
129
FERIDEX I.V.
150
FLOVENT HFA
129
FERIVA
180
FLOWTUSS
150
FERIVA 21-7
150
floxuridine
54
FERIVA FA
150
FLUCAINE
161
FEROTRINSIC
180
fluconazole
46
FERRALET 90
180
fluconazole in dextrose, iso-osmotic
46
FERRIPROX
176
fluconazole in sodium chloride, iso-osmotic
46
FERRLECIT
150
flucytosine
46
ferrous fumarate/ascorbic acid/b12-if/folic acid
180
FLUDARA
54
ferrous fumarate/ascorbic acid/cyanocobalamin/folic
fludarabine phosphate
54
acid
182
fludeoxyglucose f-18
ferrous fumarate/folic acid
180
fludrocortisone acetate
19
ferrous fumarate/folic acid/multivitamins with min no.
FLUMADINE
70
15
180
flumazenil
150
ferrous sulfate/ascorbic acid/folic acid
180
flunisolide
165
FETZIMA
PAGE 213
41
fluocinolone acetonide
150
19,129
fluocinolone acetonide oil
129
FOLLISTIM AQ
150
fluocinolone acetonide/shower cap
19
FOLOTYN
54
fluocinonide
19
FOLTRATE
181
fluocinonide/emollient base
19
FOLTX
181
FLUOR-A-DAY
107,180
fomepizole
93
78
FLUOR-I-STRIP AT
150
fondaparinux sodium
FLUORABON
180
FORADIL
169
fluorescein sodium
150
FORANE
15
FLUORESCITE
150
FORFIVO XL
39
fluoride/iron/vitamins a,c,and d
180
FORMA-RAY
111
FLUORIDEX SENSITIVITY RELIEF
107
FORMADON
111
FLUORITAB
181
formaldehyde
111
fluorometholone
129
FORTAMET
74
FLUOROPLEX
111
FORTAVIT
181
fluorouracil
fluoxetine hcl
54,111
41
fluoxymesterone
132
fluphenazine hcl
FORTAZ
28
FORTAZ IN ISO-OSMOTIC DEXTROSE
28
FORTEO
158
64
FORTESTA
132
FLURA-DROPS
181
FORTICAL
158
flurazepam hcl
174
FOSAMAX
158
FOSAMAX PLUS D
158
flurbiprofen
6
flurbiprofen sodium
163
foscarnet sodium
69
FLURESS
161
FOSCAVIR
69
flutamide
55
fosinopril sodium
86
fosinopril sodium/hydrochlorothiazide
93
37
fluticasone propionate
19,129
fluvastatin sodium
98
fosphenytoin sodium
fluvoxamine maleate
41
FOSRENOL
127
FML
129
FOSTEUM
181
FML FORTE
129
FOSTEUM PLUS
181
FML S.O.P.
129
FOVEX
181
FOCALIN
102
FRAGMIN
FOCALIN XR
102
FREAMINE HBC
181
FOLET DHA
181
FREAMINE III
181
FOLET ONE
181
FREESTYLE
159
FOLGARD OS
181
FROVA
FOLGARD RX
181
FUL-GLO
150
folic acid
181
FULYZAQ
120
folic acid/multivitamins,ther w-
79
49
FURADANTIN
24
minerals/lycopene/lutein
181
furosemide
97
folic acid/vitamin b comp w-c
181
FUSILEV
55
folic acid/vitamin b comp w-c/copper/zinc oxide
181
FUSION PLUS
PAGE 214
181
FUSION SPRINKLES
195
genistein/citrated zinc bisglycinate/vitamin d3
181
131
FUZEON
68
GENOTROPIN
FYCOMPA
34
gentamicin sulfate
gentamicin sulfate in sodium chloride, iso-
G
GABADONE
21
osmotic
181
21,22
gentamicin sulfate/pf
22
65
gabapentin
35
GEODON
GABITRIL
35
GESTICARE DHA
181
GABLOFEN
67
GIAZO
146
GADAVIST
150
GILENYA
106
38
GILOTRIF
58
GALZIN
181
GLASSIA
172
GAMASTAN S-D
143
glatiramer acetate
106
GAMMAGARD LIQUID
143
GLEEVEC
59
GAMMAGARD S-D
143
GLEOSTINE
52
GAMMAKED
143
GLIADEL
52
GAMMAPLEX
143
glimepiride
74
GAMUNEX
143
glipizide
74
GAMUNEX-C
143
glipizide/metformin hcl
74
GLUCAGEN
77
GLUCAGON EMERGENCY KIT
77
glucagon hcl
77
galantamine hbr
ganciclovir sodium
GANIRELIX ACETATE
GARAMYCIN
69
140
21
GARDASIL
145
GLUCOPHAGE
74
GARDASIL 9
145
GLUCOPHAGE XR
75
GASTROCROM
170
GLUCOTROL
75
GASTROGRAFIN
150
GLUCOTROL XL
75
GASTROMARK
151
GLUCOVANCE
75
GLUMETZA
75
glutaraldehyde
24
glyburide
75
gatifloxacin
31
GATTEX
120
GAZYVA
60
GELCLAIR
107
glyburide,micronized
75
GELFILM
161
glyburide/metformin hcl
75
GELFOAM
151
GLYCATE
GELFOAM COMPRESSED
151
glycine urologic solution
GELNIQUE
124
glycine/sodium/water for injection,sterile/sodium
GELX
107
hydroxide
151
119
24
gemcitabine hcl
54
GLYCOPHOS
181
gemfibrozil
98
glycopyrrolate
87,119
GEMZAR
54
GLYNASE
75
GENADUR
111
GLYSET
75
GENERESS FE
134
GLYXAMBI
75
PAGE 215
GOLYTELY
122
HEMANGEOL
89
GONAL-F
151
HEMATOGEN
181
GONAL-F RFF
151
HEMATRON
181
GONAL-F RFF REDI-JECT
151
HEMATRON-AF
181
GORDO-UREA
111
HEMOCYTE PLUS
181
GRAFIX CORE
151
HEMOCYTE-F
181
GRAFIX PRIME
151
HEMOFIL M
82
GRALISE
35
HEPAGAM B
145
granisetron hcl
45
heparin sodium,porcine
79
granisetron hcl/pf
45
79
GRANIX
80
79
GRANULEX
111
heparin sodium,porcine in 0.9 % sodium chloride/pf 79
GRASTEK
172
heparin sodium,porcine/dextrose 5 % in water
79
79
GRIFULVIN V
46
heparin sodium,porcine/pf
GRIS-PEG
47
HEPATAMINE
181
griseofulvin ultramicrosize
47
HEPATASOL
182
griseofulvin, microsize
47
HEPSERA
70
HERCEPTIN
59
HESPAN
80
hetastarch in 0.9 % sodium chloride
81
guaifenesin/codeine phosphate
guanfacine hcl
guanidine hcl
172
84,102
50
H
H.P. ACTHAR
131
HALAVEN
55
HALCION
174
HALDOL
HETLIOZ
175
HEXALEN
55
HEXTEND LACTATED ELECTROLYTE
81
HIPREX
24
HIZENTRA
143
64
homatropine hbr
161
HALDOL DECANOATE 100
64
HORIZANT
HALDOL DECANOATE 50
64
HORSE EPITHELIUM
HALFLYTELY-BISACODYL
122
halobetasol propionate
halobetasol propionate/ammonium lactate
35,104
151
HUMALOG
77
19
77
129
77
HALOG
20
HUMALOG MIX 50-50
77
haloperidol
64
77
haloperidol decanoate
64
HUMALOG MIX 75-25
77
haloperidol lactate
64
77
HARVONI
70
HUMATE-P
82
HAVRIX
145
HUMATROPE
131
HECTOROL
158
HUMIRA
142
HELIDAC
120
HUMIRA PEDIATRIC CROHN'S
142
HUMIRA PEN
142
HUMIRA PEN CROHN'S-UC-HS
142
HELIXATE FS
HEMABATE
PAGE 216
82
132
HUMIRA PEN PSORIASIS
142
HUMULIN R U-500
77
hydroxyurea
54
hydroxyzine hcl
44
44
HYALGAN
151
hydroxyzine pamoate
hyaluronate sodium
151
HYLATOPIC
111
hyaluronate sodium/hydroxyethylcellulose/polyethylene
HYLATOPIC PLUS
111
glycol
HYLENEX
151
151
HYCAMTIN
58
hyoscyamine sulfate
119
HYCET
11
HYPER-SAL
172
HYCOFENIX
151
HYPERHEP B S-D
145
hydralazine hcl
100
HYPERLYTE CR
182
54
HYPERRAB S-D
143
HYDRO 35
111
HYPERRHO S-D
143
HYDRO 40
111
HYPERTENSA
182
hydrochlorothiazide
6,97
HYPERTET S-D
143
hypochlorous acid/sodium chloride
151
hydrocodone bitartrate/homatropine methylbromide 172
hypromellose
161
hydrocodone polistirex/chlorpheniramine polistirex 172
HYQVIA
143
hydrocodone/ibuprofen
HYSINGLA ER
HYDREA
hydrocodone bitartrate/acetaminophen
hydrocortisone
11
11
20,129,147
8
HYZAAR
94
hydrocortisone acetate
120
hydrocortisone acetate/aloe vera
129
I
hydrocortisone acetate/iodoquinol/aloe vera
111
ibandronate sodium
hydrocortisone acetate/lidocaine hcl/aloe vera
120
IBRANCE
59
120,129
IBUDONE
11
hydrocortisone acetate/pramoxine/emollient/pramoxine
ibuprofen
6
comb#1
120
ibuprofen/oxycodone hcl
6
hydrocortisone acetate/urea
129
ibutilide fumarate
hydrocortisone acetate/pramoxine hcl
hydrocortisone butyrate
hydrocortisone butyrate/emollient base
20,129
20
158,159
87
IC GREEN
151
ICAR-C PLUS
182
hydrocortisone sod succinate
129
ICLUSIG
59
hydrocortisone valerate
129
IDAMYCIN PFS
55
hydrocortisone/iodoquinol
111
idarubicin hcl
55
hydrocortisone/mineral oil/petrolatum,white
129
IFEX
52
hydrocortisone/pramoxine hcl/chloroxylenol
165
ifosfamide
52
hydromorphone hcl
8,11
ifosfamide/mesna
52
hydromorphone hcl/pf
11
ILARIS
144
hydroquinone
111
ILEVRO
163
hydroquinone microspheres
111
ILOTYCIN
hydroquinone/ferric oxide
111
ILUVIEN
hydroxocobalamin
182
IMBRUVICA
hydroxychloroquine sulfate
PAGE 217
61
IMDUR
31
163
58
100
imipenem/cilastatin sodium
28
INNOPRAN XL
89
imipramine hcl
43
INOVA
111
imipramine pamoate
43
INOVA 4-1
112
imiquimod
55
INOVA 8-2
112
IMITREX
49
INSPRA
97
immune globulin,gamm(igg)/glycine/iga greater than 50
insulin admin. supplies
151
mcg/ml
INTEGRA F
182
immune globulin,gamm(igg)/sucrose/iga greater than
INTEGRA PLUS
182
50 mcg/ml
INTEGRILIN
84
INTELENCE
67
143
143
immune globulin,gamma (igg)/proline/iga 0 to 50
mcg/ml
144
immune globulin,gamma (igg)/sorbitol/iga 0 to 50
INTERMEZZO
175
INTRALIPID
182
mcg/ml
144
INTRON A
56
IMOGAM RABIES-HT
144
INTUNIV
102
IMOVAX RABIES VACCINE
145
INVANZ
28
IMPLANON
137
INVEGA
65
IMURAN
142
INVEGA SUSTENNA
65
INCIVEK
70
INVEGA TRINZA
65
INCRELEX
131
INVIRASE
69
INCRUSE ELLIPTA
167
INVOKAMET
75
75
indapamide
97
INVOKANA
INDERAL LA
89
iodine/potassium iodide
112
INDERAL XL
89
IODOFLEX
112
INDICLOR
151
IODOPEN
182
INDIGO CARMINE
151
IODOSORB
112
INDIUM IN-111 DTPA
151
IONOSOL B WITH DEXTROSE 5%
182
indium in-111 oxyquinoline
151
IONOSOL MB-DEXTROSE 5%
182
IOPIDINE
164
ipecac
120
INDOCIN
indocyanine green
6
151
indomethacin
6
IPOL
145
indomethacin sodium
6
ipratropium bromide
167
169
INFANATE BALANCE
182
ipratropium bromide/albuterol sulfate
INFANRIX DTAP
145
IPRIVASK
79
INFASURF
172
irbesartan
85
INFED
182
irbesartan/hydrochlorothiazide
94
INFERGEN
70
IRENKA
42
INFUMORPH
11
IRESSA
195
INFUVITE
182
irinotecan hcl
INFUVITE ADULT
182
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-
INJECTAFER
182
thr/succ.acid
INLYTA
PAGE 218
58
182
58
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic
ISOPTO CARBACHOL
164
acid
ISOPTO CARPINE
164
ISOPTO HOMATROPINE
161
ISOPTO HYOSCINE
161
ISORDIL
100
ISORDIL TITRADOSE
100
iron fumarate & polysac comp/folic acid/vit b comp & c
isosorbide dinitrate
101
no.9
isosorbide mononitrate
101
isosulfan blue
151
isotretinoin
112
ISOVUE-200
151
ISOVUE-250
151
ISOVUE-300
151
ISOVUE-370
151
iron polysacchar complx/iron heme polypeptide/folic
ISOVUE-M 200
152
acid/b12
ISOVUE-M 300
152
isoxsuprine hcl
94
isradipine
90
ISTALOL
164
ISTODAX
59
ISUPREL
94
itraconazole
47
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-
ivermectin
61
min
182
IXEMPRA
56
iron,carbonyl/folic acid/multivitamin w-minerals
182
IXIARO
145
IXINITY
152
182
iron asp.glycin & fumarate /vit c/fa/mv comb 11/cathreonate
182
iron aspgly/ascorb.cal/vit b12/calcium
thr/succ.acid/stomach
151
182
iron fumarate & polysac comp/folic acid/vitamin
c/niacin
182
iron fumarate-iron polysacchar/folic acid/mv
comb18
182
iron fumarte &asp gly/ascorb.cal/vit b12/fa/cathr/succ.acid
151
182
iron polysaccharide complex/cyanocobalamin/folic
acid
182
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate
sodium
182
iron,carbonyl/ascorbic acid/cyanocobalamin/folic
acid
182
iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit
b12/zinc
182
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate
J
na
183
J-COF DHC
172
iron/folic acid/vitamin b comp w-c/minerals
183
J-MAX DHC
11
IROSPAN
183
JADENU
176
ISENTRESS
68
JAKAFI
58
isoflurane
15
JALYN
125
ISOLYTE M WITH DEXTROSE
183
JANUMET
75
ISOLYTE P WITH DEXTROSE
183
JANUMET XR
75
ISOLYTE S
183
JANUVIA
75
isometheptene mucate/caffeine/acetaminophen
104
JARDIANCE
75
JENTADUETO
75
isometheptene
mucate/dichloralphenazone/acetaminophen
isoniazid
ISOPTO ATROPINE
PAGE 219
104
51
161
JETREA
JEVTANA
JOHNSON GRASS
161
56
152
JUBLIA
47
KETODAN
47
JUVISYNC
75
ketoprofen
6
JUXTAPID
99
ketorolac tromethamine
7,163
KETOSTIX
K
159
KEVEYIS
96
K-PHOS NEUTRAL
126
KEYTRUDA
60
K-PHOS NO.2
126
KHEDEZLA
42
K-PHOS ORIGINAL
126
KINERET
142
K-TAB ER
183
KINEVAC
120
KABIVEN
183
KINRIX
145
KADCYLA
59
kit for prep tc 99m/sestamibi combination no.1
152
kit for prep tc 99m/sodium thiosulfate
152
kit for prep tc-99m/mebrofenin
152
kit for prep tc-99m/medronate sodium
152
152
KADIAN
9
KALBITOR
152
KALETRA
69
KALYDECO
172
kit for prep tc-99m/sodium pyrophosphate
KAOCHLOR-EFF
183
KITABIS PAK
22
KAPVAY
102
KLARON
32
KARBINAL ER
167
KLONOPIN
73
KAYEXALATE
176
KLOR-CON
183
KAZANO
75
KLOR-CON 10
183
KCENTRA
82
KLOR-CON 8
183
KEDBUMIN
81
KLOR-CON M15
183
KEFLEX
28
KOATE-DVI
82
KENALOG
20
KOGENATE FS
83
75
KENALOG-10
129
KOMBIGLYZE XR
KENALOG-40
129
KORLYM
152
KENGREAL
84
KRISTALOSE
122
KEPIVANCE
107
KRYSTEXXA
48
KEPPRA
34
KUVAN
117
KEPPRA XR
34
KYNAMRO
99
KERAFOAM
112
KYPROLIS
59
KERALAC
112
KERALYT
112
L
KERALYT SCALP
112
L-METHYLFOLATE FORMULA
183
KEROL
112
L-METHYLFOLATE FORTE
183
KERYDIN
47
labetalol hcl
KETALAR
15
LAC-HYDRIN
112
ketamine hcl
15
LACRISERT
161
KETEK
31
lactic acid
112
159
lactulose
123
LAMB'S QUARTERS
152
KETO-DIASTIX
ketoconazole
PAGE 220
47
89
LAMICTAL
36
LEVACET
LAMICTAL (BLUE)
36
levalbuterol hcl
LAMICTAL (GREEN)
36
LEVAQUIN
31
LAMICTAL (ORANGE)
36
LEVATOL
89
LAMICTAL ODT
36
LEVBID
LAMICTAL ODT (BLUE)
36
LEVEMIR
77
LAMICTAL ODT (GREEN)
36
LEVEMIR FLEXPEN
77
LAMICTAL ODT (ORANGE)
36
LEVEMIR FLEXTOUCH
77
LAMICTAL XR
36
levetiracetam
34
LAMICTAL XR (BLUE)
36
levetiracetam in sodium chloride, iso-osmotic
34
LAMICTAL XR (GREEN)
36
LEVITRA
126
LAMICTAL XR (ORANGE)
36
levobunolol hcl
164
LAMISIL
47
levocarnitine
176
levocarnitine (with sugar)
176
167
lamivudine
68,70
7
169
119
lamivudine/zidovudine
68
levocetirizine dihydrochloride
lamotrigine
36
levofloxacin
32
LANOXIN
94
levofloxacin/dextrose 5 % in water
32
LANOXIN PEDIATRIC
94
levoleucovorin calcium
56
lansoprazole
123
levomefolate ca/acetylcysteine/mecobalamin/schiz.
lansoprazole/amoxicillin trihydrate/clarithromycin
120
algal oil
183
LANTUS
77
levomefolate ca/pyridoxal phos/mecobalamin/schiz.
LANTUS SOLOSTAR
77
algal oil
152
LASIX
97
levomefolate calcium
183
LASTACAFT
162
levomefolate calcium/schizochytrium algal oil
152
latanoprost
160
levonorgestrel
137
LATISSE
112
levonorgestrel-ethinyl estradiol
134
LATUDA
65
LAYOLIS FE
LAZANDA
134
9
levonorgestrel/ethinyl estradiol and ethinyl estradiol 134
LEVOPHED BITARTRATE
levorphanol tartrate
94
9
LDO PLUS
152
LEVOTHROID
138
leflunomide
144
levothyroxine sodium
138
LEMTRADA
106
LEVOXYL
138
LENVIMA
59
LEVSIN
119
LESCOL
99
LEVSIN-SL
119
LESCOL XL
99
LEVULAN
112
170
LEXAPRO
42
letrozole
57
LEXISCAN
152
leucovorin calcium
56
LEXIVA
69
LEUKERAN
52
LIALDA
120
LEUKINE
81
LIBRAX
119
140
lidocaine
15
LETAIRIS
leuprolide acetate
PAGE 221
lidocaine hcl
15
LITHOBID
lidocaine hcl/dextrose 5%-water/pf
15
LITHOSTAT
lidocaine hcl/dextrose 7.5%-water/pf
15
LIVALO
99
lidocaine hcl/epinephrine
15
LIVIXIL PAK
15
lidocaine hcl/epinephrine bitartrate
15
LO LOESTRIN FE
134
lidocaine hcl/epinephrine/pf
15
LO MINASTRIN FE
135
lidocaine hcl/glycerin
15
LOCOID
129
lidocaine hcl/hydrocortisone acetate
126
LOCOID LIPOCREAM
20
15,87
LODOSYN
63
lidocaine/menthol
15
LOESTRIN
135
lidocaine/prilocaine
15
LOESTRIN 24 FE
135
lidocaine/tetracaine
15
LOESTRIN FE
135
LIDODERM
15
LOMOTIL
120
LIDOPIN
15
LOMUSTINE
52
LIDORX
15
LONSURF
52
LIDOVEX
15
loperamide hcl
LILETTA
137
LOPID
98
LIMBREL
183
LOPRESSOR
89
LIMBREL250
183
LOPRESSOR HCT
94
LIMBREL500
183
LOPROX
47
LINCOCIN
24
lorazepam
73
lindane
62
LORCET 10-650
11
linezolid
24
LORCET PLUS
11
linezolid in 0.9 % sodium chloride
24
LORTAB
11
lidocaine hcl/pf
LINZESS
LIORESAL INTRATHECAL
120
73
122
67
120
LORZONE
174
losartan potassium
86
94
liothyronine sodium
138
losartan potassium/hydrochlorothiazide
lipase/protease/amylase
117
LOSEASONIQUE
135
99
LOTEMAX
163
100
LOTENSIN
86
LOTENSIN HCT
94
94
LIPITOR
LIPOCHOL PLUS
LIPOFEN
98
LIPOSYN II
183
LOTREL
LIPOSYN III
183
LOTRISONE
112
LIPTRUZET
100
LOTRONEX
122
LIQUID POLIBAR
152
LOUTREX
112
LIQUID POLIBAR PLUS
152
lovastatin
99
73,86
LOVAZA
100
lisinopril
lisinopril/hydrochlorothiazide
LISTER-V
94
195
LOVENOX
79
loxapine succinate
64
lithium carbonate
73
LOXITANE
64
lithium citrate
73
LP LITE PAK
15
PAGE 222
LUCENTIS
161
magnesium sulfate/dextrose 5 % in water
184
LUFYLLIN
168
MAGNEVIST
152
LUMASON
152
MAKENA
135
LUMIGAN
160
MALARONE
61
LUMIZYME
118
malathion
62
LUNESTA
175
manganese chloride
184
LUNGLAID
183
manganese sulfate
184
LUPANETA PACK
140
mannitol
LUPRON DEPOT
140
mannitol/sorbitol solution
LUPRON DEPOT-PED
140
maprotiline hcl
39
LUSTRA-AF
112
MARCAINE
15
LUSTRA-ULTRA
112
MARCAINE SPINAL
15
94
126
LUVOX CR
42
MARCAINE WITH EPINEPHRINE
15
LUXIQ
20
MARCAINE-EPINEPHRINE
16
LUZU
47
MARGESIC
LYCELLE
112
MARINOL
LYMPHAZURIN
152
MARNATAL-F
104
45
184
LYNPARZA
58
MARPLAN
40
LYRICA
34
MARQIBO
56
LYSIPLEX PLUS
183
MARTEN-TAB
104
LYSODREN
139
MATRISTEM
152
MATRISTEM MICROMATRIX
152
LYSTEDA
83
M
MATULANE
52
MAVIK
86
M-M-R II VACCINE
145
MAXAIR AUTOHALER
M-VIT
183
MAXALT
49
M.V.I. ADULT
183
MAXALT MLT
50
M.V.I. PEDIATRIC
183
MAXARON FORTE
184
M.V.I.-12
183
MAXFE
184
129
MACROBID
24
MAXIDEX
MACRODANTIN
24
MAXIDONE
169
12
MACUGEN
161
MAXIFED CDX
172
MACUTEK
183
MAXIFLU CD
172
MACUVEX
152
MAXIFLU CDX
172
MACUZIN
152
MAXINATE
184
mafenide acetate
24
MAXIPHEN CD
172
MAGNACET
11
MAXIPHEN CDX
172
MAGNEBIND 400 RX
183
MAXIPIME
28
magnesium chloride
183
MAXITROL
161
magnesium sulfate
184
MAXZIDE
94
magnesium sulfate in sterile water
184
MAXZIDE-25 MG
94
PAGE 223
MD-76 R
meclizine hcl
meclofenamate sodium
152
MESNEX
56
44
MESQUITE
153
7
MESTINON
50
mecobalamin/levomefolate calcium/pyridoxal
METADATE CD
102
phosphate
184
METANX
184
MEDI-10
152
metaproterenol sulfate
169
METASTRON
153
metaxalone
174
MEDROL
medroxyprogesterone acetate
20,129
137
mefenamic acid
7
metformin hcl
76
mefloquine hcl
61
methadone hcl
9
MEFOXIN
28
METHADOSE
9
MEGACE
137
methamphetamine hcl
102
MEGACE ES
137
METHAZEL
195
megestrol acetate
137
methazolamide
96
MEKINIST
58
methenamine hippurate
24
meloxicam
7
methenamine mandelate
24
melphalan hcl
52
methenamine/methylene blue/benzoic
memantine hcl
39
acid/salicylate/hyoscy
24
MEMBRANEBLUE
161
methenamine/methylene blue/salicylate/sodium
MENACTRA
145
phos/hyoscy
MENEST
135
methenamine/methylene blue/sodium phos/pnyl
MENHIBRIX
145
sal/hyosc sul
MENOMUNE-A-C-Y-W-135
145
methenamine/sodium phosphate,monobasic/meth
MENOPUR
152
blue/hyosc sul
MENOSTAR
135
methimazole
141
47
METHITEST
132
methocarbamol
174
MENTAX
MENVEO A-C-Y-W-135-DIP
145
meperidine hcl
12
methotrexate sodium
meperidine hcl/pf
12
methotrexate sodium/pf
MEPHYTON
184
24
24
24
54
54,142
methoxsalen, rapid
112
119
mepivacaine hcl
16
methscopolamine bromide
mepivacaine hcl/pf
16
methyclothiazide
97
meprobamate
73
methyldopa
84
MEPRON
61
methyldopa/hydrochlorothiazide
94
mercaptopurine
54
methyldopate hcl
84
meropenem
28
methylene blue
meropenem in 0.9 % sodium chloride
28
methylergonovine maleate
MERREM
28
METHYLIN
153
126,127
102
mesalamine
120
methylphenidate hcl
102,103
mesalamine with cleansing wipes
120
methylprednisolone
20,130
mesna
PAGE 224
56
methylprednisolone acetate
130
methylprednisolone sodium succinate
20
MIOCHOL-E
161
methyltestosterone
132
MIOSTAT
164
methyltetrahydrofolate glucosamine
120
MIRAPEX
63
metipranolol
164
MIRAPEX ER
63
metoclopramide hcl
44
MIRCERA
81
metolazone
97
MIRCETTE
135
MIRENA
137
METOPIRONE
153
metoprolol succinate
89
mirtazapine
39
metoprolol tartrate
89
MIRVASO
112
metoprolol tartrate/hydrochlorothiazide
94
misoprostol
123
METOZOLV ODT
44
MITIGARE
48
METRO IV
24
mitomycin
56
METROCREAM
24
MITOSOL
161
METROGEL
24
mitoxantrone hcl
METROGEL-VAGINAL
24
MIXED RAGWEED EXTRACT
METROLOTION
24
MOBIC
metronidazole
25
modafinil
175
metronidazole in sodium chloride
25
MODICON
135
METVIXIA
112
MEVACOR
mexiletine hcl
56
153
7
moexipril hcl
86
99
moexipril hcl/hydrochlorothiazide
95
87
molybdenum (ammonium molybdate)
MIACALCIN
159
MICARDIS
86
MOMEXIN
MICARDIS HCT
94
MONOCLATE-P
83
miconazole nitrate
47
MONODOX
33
144
MONONINE
83
MICROZIDE
97
MONOVISC
153
midazolam hcl
73
MONSEL'S
153
midazolam hcl/pf
73
montelukast sodium
167
midodrine hcl
84
MONUROL
25
MIFEPREX
153
MORGIDOX
33
MIGRANAL
49
morphine sulfate
MILLIPRED
20
morphine sulfate/pf
milrinone lactate
94
MOTOFEN
120
milrinone lactate/dextrose 5 % in water
94
MOUNTAIN CEDAR
153
135
MOVANTIK
120
MINIPRESS
85
MOVIPREP
123
MINIVELLE
135
MOXATAG
29
MICRHOGAM ULTRA-FILTERED PLUS
MINASTRIN 24 FE
mometasone furoate
184
112,130
130
9,12
12
MINOCIN
33
MOXEZA
32
minocycline hcl
33
moxifloxacin hcl
32
minoxidil
PAGE 225
100
moxifloxacin hcl in sodium acetate and
sulfate,water,iso-osm
32
N
MOZOBIL
81
NABI-HB
145
MS CONTIN
9
MUCOTROL
107
nadolol
89
MUGARD
107
nadolol/bendroflumethiazide
95
MUGWORT
153
nafcillin in dextrose, iso-osmotic
29
nafcillin sodium
29
MULTAQ
87
nabumetone
7
MULTICHEW
184
NAFRINSE DAILY-NEUTRAL
MULTIHANCE
153
naftifine hcl
47
MULTIHANCE MULTIPACK
153
NAFTIN
47
MULTITRACE-4
184
NAGLAZYME
118
nalbuphine hcl
12
multivit with min#10/folic acid//vit d3/a lipoic
acid/lutein
184
NALFON
107
7
multivitamins with min no.44/cholecalciferol (vit d3)/vit
naloxone hcl
17
k
184
naltrexone hcl
17
multivitamins with min no.7/folic acid
184
NAMENDA
39
MULTIVITAMINS-A,B,D,E,K,ZN
184
NAMENDA XR
39
multivits,therap w-fe,hematin
184
NAMZARIC
104
161
mupirocin
25
naphazoline hcl
mupirocin calcium
25
NAPRELAN
7
127
NAPROSYN
7
naproxen
7
7
MUSE
MUSTARGEN
52
MVC-FLUORIDE
184
naproxen sodium
MYALEPT
153
naratriptan hcl
50
MYAMBUTOL
51
NARDIL
40
MYCAMINE
47
NAROPIN
16
MYCOBUTIN
51
NASACORT AQ
130
mycophenolate mofetil
142
NASCOBAL
153
mycophenolate sodium
142
NASONEX
165
MYDRIACYL
161
NATA KOMPLETE
184
MYFORTIC
142
NATACHEW
184
MYKIDZ IRON FL
184
NATACYN
MYLERAN
52
MYNATAL
47
NATAFORT
184
184
NATALVIT
184
MYOBLOC
104
NATAZIA
135
MYOVIEW
153
nateglinide
MYOZYME
118
NATELLE ONE
184
76
MYRBETRIQ
67
NATESTO
132
MYSOLINE
34
NATPARA
159
NATRECOR
PAGE 226
95
NATROBA
112
NEUMEGA
81
NATURE-THROID
138
NEUPOGEN
81
63
NAVELBINE
56
NEUPRO
NEBUPENT
61
NEURIN-SL
185
NEBUSAL
172
NEURONTIN
35
NEEVO DHA
184
NEUT
NEEVODHA
184
NEUTRASAL
nefazodone hcl
185
107,153
39
NEVANAC
163
NEMBUTAL SODIUM
175
nevirapine
67
NEO-SYNALAR
112
NEXA PLUS
185
185
NEO-SYNEPHRINE
95
NEXA SELECT
neomycin sulfate
22
NEXAVAR
59
NEXAVIR
153
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
161
NEXIUM
123
neomycin sulfate/bacitracin/polymyxin b
161
NEXIUM I.V.
124
25
NEXPLANON
137
neomycin sulfate/polymyxin b sulfate/gramicidin d 161
NEXTERONE
87
neomycin sulfate/polymyxin b
niacin
neomycin sulfate/polymyxin b sulfate
sulfate/hydrocortisone
neomycin/polymyxin b sulfate/dexamethasone
NEOPROFEN
20,161
161
95
100
niacinamide/azelaic ac/quercet/turmer/fa/b6/zinc
ox/copper
153
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa 185
NEORAL
112
NIASPAN
100
NEOSALUS
112
NICADAN
185
NEOSALUS CP
112
nicardipine hcl
90
NEOSPORIN G.U. IRRIGANT
25
NICAZEL
185
neostigmine methylsulfate
51
NICAZEL FORTE
185
NEPHPLEX RX
185
NICOMIDE
153
NEPHRAMINE
185
NICOTROL
18
NEPHRO-VITE RX
185
NICOTROL NS
18
NEPHROCAPS
185
nifedipine
91
NEPHROCAPS QT
185
NILANDRON
141
NEPHRON FA
185
NIMBEX
104
NEPTAZANE
96
nimodipine
91
NESACAINE
16
NIPENT
54
NESACAINE-MPF
16
NIRAVAM
73
NESINA
76
NIRON KOMPLETE
185
NESTABS
185
nisoldipine
NESTABS ABC
185
NITHIODOTE
153
NESTABS DHA
185
NITRO-BID
101
NEUAC
113
NITRO-DUR
101
81
nitrofurantoin
25
NEULASTA
PAGE 227
91
nitrofurantoin macrocrystal
25
NORVASC
91
nitrofurantoin monohydrate/macrocrystals
25
NORVIR
69
nitroglycerin
101
NOVACORT
130
nitroglycerin/dextrose 5 % in water
101
NOVAFERRUM
185
NITROLINGUAL
101
NOVAREL
131
NITROMIST
101
NOVOEIGHT
153
NITRONAL
101
NOVOLOG
77
NITROPRESS
100
NOVOLOG FLEXPEN
77
NITROSTAT
101
NOVOLOG MIX 70-30
78
nizatidine
122
NOVOLOG MIX 70-30 FLEXPEN
78
NIZORAL
47
NOVOSEVEN RT
83
NOR-Q-D
137
NOXAFIL
47
12
NPLATE
81
NORCO
NORDETTE-28
135
NU-DERM SUNFADER
113
NORDITROPIN FLEXPRO
131
NUCORT
130
NORDITROPIN NORDIFLEX
131
NUCYNTA
12
norelgestromin/ethinyl estradiol
135
NUCYNTA ER
norepinephrine bitartrate
95
9
NUEDEXTA
104
norethindrone
137
NULOJIX
142
norethindrone acetate
137
NULYTELY WITH FLAVOR PACKS
123
norethindrone acetate-ethinyl estradiol
135
NUMOISYN
107
NUOX
113
norethindrone acetate-ethinyl estradiol/ferrous
fumarate
135
NUTRESTORE
185
norethindrone-ethinyl estradiol
135
NUTRICAP
185
norethindrone-ethinyl estradiol/ferrous fumarate
135
NUTRILIPID
185
norethindrone-mestranol
135
NUTRILYTE
185
norgestimate-ethinyl estradiol
135
NUTROPIN
131
norgestrel-ethinyl estradiol
135
NUTROPIN AQ
131
NORINYL 1+35
135
NUTROPIN AQ NUSPIN
131
NORINYL 1+50
135
NUVAIL
113
25
NUVARING
135
NORMOSOL-M AND DEXTROSE
185
NUVESSA
25
NORMOSOL-R
185
NUVIGIL
NORMOSOL-R AND DEXTROSE
185
NYMALIZE
91
NORMOSOL-R PH 7.4
185
nystatin
47
nystatin/triamcinolone acetonide
20
NORITATE
175
NOROXIN
32
NORPACE
87
NORPACE CR
88
O
NORPRAMIN
43
O-CAL FA
185
NORTHERA
95
O-CAL PRENATAL
185
nortriptyline hcl
43
OB COMPLETE
PAGE 228
185,186
OB COMPLETE 400
185
OMNARIS
166
OB COMPLETE ONE
186
OMNIPAQUE
153
OB COMPLETE PETITE
186
OMNIPRED
163
OB COMPLETE PREMIER
186
OMNISCAN
153
OB COMPLETE WITH DHA
186
OMNISCAN PREFILL PLUS
154
OBIZUR
153
OMNITROPE
131
OBREDON
153
ONCASPAR
56
OBSTETRIX EC
186
ondansetron
45
OBTREX
186
ondansetron hcl
45
OBTREX DHA
186
ondansetron hcl/pf
45
OCTAGAM
144
ONETOUCH
160
OCTAPLAS
81
ONEXTON
108
OCTREOSCAN
153
ONFI
35
octreotide acetate
140
ONGLYZA
76
ONMEL
47
OCUDOX
33
OCUFEN
163
OCUFLOX
ONSOLIS
9
32
ONTAK
56
OCUVEL
153
OPANA
12
ODOMZO
60
OPANA ER
9
OFEV
172
opium tincture
121
OFIRMEV
153
opium/belladonna alkaloids
121
OPSUMIT
170
OPTIMARK
154
ofloxacin
OGEN
32
136
olanzapine
65
OPTIRAY 300
154
olanzapine/fluoxetine hcl
40
OPTIRAY 320
154
OLEPTRO ER
40
OPTIRAY 350
154
olopatadine hcl
167
OPTISON
154
OLUX
20
OPTIUM
160
OLUX-E
20
OPTIVAR
162
OLYSIO
70
ORACEA
33
OMECLAMOX-PAK
121
ORACIT
127
omega-3 acid ethyl esters
100
ORALAIR
172
ORAMAGICRX
107
omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv
cmb 13
186
omega-3/dha/epa/b12/folic acid/pyridoxine
hcl/phytosterols
186
omega-3/dha/epa/d3/b12/folic acid/pyridox
ORAP
64
ORAPRED
20
ORAPRED ODT
20
ORAVIG
47
25
hcl/phytosterol
186
ORBACTIV
omeprazole
124
ORBIVAN
104
omeprazole/sodium bicarbonate
124
ORBIVAN CF
104
OMIDRIA
161
ORENCIA
142
PAGE 229
ORENITRAM ER
170
oxybutynin chloride
125
ORFADIN
118
OXYCEL
154
ORKAMBI
172
oxycodone hcl
9,12
orphenadrine citrate
174
oxycodone hcl/acetaminophen
12
orphenadrine citrate/aspirin/caffeine
174
oxycodone hcl/aspirin
12
ORTHO EVRA
136
OXYCONTIN
ORTHO MICRONOR
137
oxymorphone hcl
9,12
ORTHO TRI-CYCLEN
136
oxytocin
127
ORTHO TRI-CYCLEN LO
136
OXYTROL
125
ORTHO-CEPT
136
OZURDEX
163
ORTHO-CYCLEN
136
ORTHO-NOVUM
136
P
ORTHOVISC
154
PACERONE
88
9
OSENI
76
paclitaxel
56
OSMITROL
95
PACNEX
113
OSMOPREP
186
PACNEX HP
113
OSPHENA
137
PACNEX LP
113
OTEZLA
144
PACNEX MX
113
OTREXUP
142
PAIN EASE
16
OVACE
113
PAIN RELIEF
16
paliperidone
65
43
OVACE PLUS
32,113
OVACE PLUS WASH
113
PAMELOR
OVCON-35
136
pamidronate disodium
159
PAMINE
119
PAMINE FORTE
119
OVIDE
OVIDREL
62
154
oxacillin sodium
29
PAMINE FQ
119
oxacillin sodium/dextrose, iso-osmotic
29
PANCREAZE
118
oxaliplatin
52
pancuronium bromide
104
OXALIS
113
PANDEL
130
OXANDRIN
132
PANHEMATIN
154
oxandrolone
132
PANRETIN
61
oxaprozin
7
OXAYDO
12
papaverine hcl
oxazepam
73
PARAFON FORTE DSC
174
oxcarbazepine
37
PARAGARD T 380-A
154
OXECTA
12
PARCOPA
OXILAN-350
OXISTAT
154
47
pantoprazole sodium
124
95
63
paregoric
121
PAREMYD
161
186
OXSORALEN
113
parenteral amino acid 15% combination no.1
OXSORALEN-ULTRA
113
paricalcitol
OXTELLAR XR
PAGE 230
37
PARLODEL
139,159
63
PARNATE
40
PEGINTRON REDIPEN
71
paromomycin sulfate
22
pen needle, diabetic
154
paroxetine hcl
42
penicillin g potassium
29
PASER
51
penicillin g potassium/dextrose-water
29
PATADAY
162
penicillin g procaine
29
PATANASE
167
penicillin v potassium
30
PATANOL
162
PENLAC
47
PAXIL
42
PENNSAID
113
PAXIL CR
42
PENTACEL
145
PENTACEL ACTHIB COMPONENT
146
PENTACEL DTAP-IPV COMPONENT
146
PAZEO
162
PCE
31
PECAN POLLEN
154
PEDIADERM AF
47
PENTASA
PEDIADERM HC
20
pentazocine hcl/acetaminophen
12
PEDIADERM TA
113
pentazocine hcl/naloxone hcl
12
pentostatin
54
pentoxifylline
95
PEDIAPRED
20
PEDIARIX
145
pediatric multivitamin combination no.2/sodium
PENTAM 300
61
121
PEPCID
fluoride
154
pediatric multivitamin combo no.45/fluoride/ferrous
sulfate
154
pediatric multivitamin combo no.75/fluoride/ferrous
sulfate
186
pediatric multivitamin no.47 with iron & sodium
122
PERCOCET
13
PERCODAN
13
PERCURA
186
PERFOROMIST
169
PERIDEX
25
PERIKABIVEN
fluoride
186
186
perindopril erbumine
86
pediatric multivitamins a,c,& d3 no.21 with sodium
PERJETA
60
fluoride
permethrin
62
perphenazine
44
154,186
pediatric multivitamins a,c,& d3 no.38 with sodium
fluoride
186
perphenazine/amitriptyline hcl
40
pediatric multivitamins no.16 with sodium fluoride
186
PERSANTINE
84
186
PERTZYE
118
186
petrolatum,white
154
PEDIPIROX-4
47
PEXEVA
42
PEDITRACE
186
phenazopyridine hcl
127
PEDVAXHIB
145
phenazopyridine hcl/hyoscyamine/butabarbital
127
phendimetrazine tartrate
104
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
123
phenelzine sulfate
40
PEGANONE
37
PHENERGAN
44
PEGASYS
70
PHENFLU CD
172
PEGASYS PROCLICK
71
PHENFLU CDX
172
PEGINTRON
71
phenobarbital
PAGE 231
35
phenobarbital sodium
35
phenobarbital/hyoscyamine sulf/atropine
sulf/scopolamine hb
phenoxybenzamine hcl
phentermine hcl
phentolamine mesylate
phenylephrine hcl
121
85
104
85
95,161
PLASBUMIN-25
81
PLASBUMIN-5
81
PLASMA-LYTE 148
186
PLASMA-LYTE 56 IN DEXTROSE
187
PLASMA-LYTE A PH 7.4
187
PLASMANATE
81
PLAVIX
84
phenylephrine hcl in 0.9 % sodium chloride/pf
195
PLEGISOL
95
phenylephrine hcl/chlorpheniramine maleate
172
PLEGRIDY
106
phenylephrine hcl/promethazine hcl
172
PLEGRIDY PEN
106
PHENYTEK
37
PLETAL
84
phenytoin
37
PLEXION
113
phenytoin sodium
37
PLIAGLIS
16
phenytoin sodium extended
37
PNEUMOVAX 23
146
PHISOHEX
113
pnv no.20/iron fumarate/fa/docusate na/fish oil
PHOSLO
128
conc/dha/epa
PHOSLYRA
128
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6
PHOSPHOLINE IODIDE
164
#1
phosphorus #1
127
pnv with ca no.37/iron carb & asp gly/fa/omega-3 fatty
PHOTOFRIN
56
187
187
acids
187
PHRENILIN FORTE
104
pnv,ca,no.35/iron,carbonyl & asp gly/fa/dss/omega-
PHYSICIANS EZ USE B-12
186
3
187
PHYSICIANS EZ USE M-PRED
130
PNV-DHA PLUS
187
PHYSIOLYTE
186
PNV-IRON
187
PHYSIOSOL
186
PODIAPN
187
51
podofilox
113
physostigmine salicylate
phytonadione
186
podophyllum resin
113
PICATO
113
POLIBAR ACB
154
POLY-TUSSIN DHC
172
POLY-VI-FLOR
187
pilocarpine hcl
107,164
PILOPINE HS
164
pimozide
64
POLY-VI-FLOR FS
154
pindolol
89
POLY-VI-FLOR WITH IRON
187
pioglitazone hcl
76
polydimethylsiloxanes/silicon dioxide
154
pioglitazone hcl/glimepiride
76
polyethylene glycol 3350
123
pioglitazone hcl/metformin hcl
76
polymyxin b sulfate
piperacillin sodium/tazobactam sodium
30
polymyxin b sulfate/trimethoprim
161
POLYTRIM
162
53
piroxicam
7
PITOCIN
127
POMALYST
PITRESSIN
131
PONSTEL
PLAN B ONE-STEP
137
PONTOCAINE
PLAQUENIL
PAGE 232
61
POTABA
25
7
16
187
potassium acetate
187
PRECISION
potassium bicarbonate/citric acid
187
PRECOSE
potassium chloride
187
PRED FORTE
163
187
PRED MILD
163
187
PRED-G
162
potassium chloride in 5 % dextrose in water
187
prednicarbate
113
potassium chloride in dextrose 5 % and 0.9 % sodium
prednisolone
20
chloride
prednisolone acetate
188
potassium chloride in dextrose 5 %-0.2 % sodium
chloride
188
potassium chloride in dextrose 5 %-0.45 % sodium
160
76
163
prednisolone sod phosphate
20,163
prednisone
20,130
PREFERA OB
188
PREFERA-OB ONE
188
potassium chloride in dextrose 5% and 0.3 % sodium
PREFERA-OB PLUS DHA
188
chloride
PREFEST
136
PREGNYL
131
PRELONE
20
PREMARIN
136
chloride
188
188
potassium chloride in lactated ringers and 5 %
dextrose
188
potassium chloride/potassium bicarbonate/citric
acid
188
PREMASOL
188
potassium citrate
188
PREMPHASE
136
potassium citrate/citric acid
127
PREMPRO
136
potassium hydroxide
113
PRENA1 CHEW
188
potassium iodide
188
PRENAISSANCE NEXT-B
188
potassium iodide/iodine
188
PRENATA
188
potassium phos,m-basic-d-basic
188
PRENATABS FA
188
POTIGA
34
PRENATABS RX
188
PRADAXA
79
prenatal vit #16/iron fum & ps complex/folic
pralidoxime chloride
154
acid/omega-3
PRALUENT PEN
100
prenatal vit comb no.4/iron carbonyl-iron
PRALUENT SYRINGE
100
gluconate/fa/doss
pramipexole di-hcl
63
188
188
prenatal vit w/o calc no.10/iron fum&polysac
PRAMOSONE
130
comp/fa/omega-3
188
PRAMOSONE E
130
prenatal vit with ca no.64/iron carb&gluc/folic
PRANDIMET
76
acid/dss/dha
188
PRANDIN
76
prenatal vit with ca no.68/iron fumarate/folic acid
PRAVACHOL
99
#1/dha
pravastatin sodium
99
prenatal vit with calcium #69/iron,carbon/folic
188
PRAXBIND
195
prazosin hcl
85
prenatal vit with calcium comb
PRE-ATTACHED LTA KIT
16
no.63/iron,carbonyl/fa/b6
PRE-PEN
PRECEDEX
PAGE 233
154
154,175
acid/dss/dha
187
188
prenatal vit with calcium no. 40/iron fumarate/fa cmb
no.1
188
prenatal vit with calcium no.39/iron fum/folic
acid/dss/dha
prenatal vitamins #39/iron amino acid chelate/fa
187
acid/dss/dha
187
acid/dha
189
prenatal vitamins comb no.115/iron fumarate/folic
188
prenatal vit/folic acid/b6/calcium phos di &
tribasic/ginger
189
prenatal vitamins comb 10/ferrous fumarate/folic
acid/dss/dha
combo#6/dha
acid
189
188
acid/dss
189
prenatal vitamin 27 with calcium/ferrous fumarate/folic
acid
acid/dss
189
189
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate
prenatal vitamins comb no.19/iron bg hcl&suc-
ca/dha
prot/fa/omega-3
189
189
prenatal vitamin combo no.22/iron/folic acid/omega-
prenatal vitamins comb no.42/folic acid comb no.6 189
3/dha
prenatal vitamins comb no.48/iron na
189
prenatal vitamin combo no.8/iron ps cmplx &
aspgl/fa/dha
feredetate/fa/omega-3
189
prenatal vitamin no.105/iron edta
&polysaccha/fa/om3/dha/epa
189
prenatal vitamins comb no.53/iron b-g hcl sucp/fa/omega-3
189
189
prenatal vitamins comb no.54/iron b-g hcl suc-
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate
p/fa/omega-3
sod
prenatal vitamins comb no.55/iron bg hcl&suc-
189
189
prot/fa/omega-3
sod
prenatal vitamins comb no.87/iron bisgly/folic
189
189
acid/dha
sod
prenatal vitamins combo no.14/ferrous fumarate/folic
189
189
prenatal vitamin no.19/iron polysacc & iron hem/folic
acid
ac/dha
prenatal vitamins combo no.25/iron fumarate/fa
189
prenatal vitamin no.21/iron polysaccharid & heme
190
combo#6/dha
190
polypep/fa
189
prenatal vitamins combo no.33/iron ps cmplx/folic
prenatal vitamin no.57/iron fum/folic acid/dss/dha
189
acid/dha
prenatal vitamin no.67/sodium feredetate-iron
poly/fa/omega3
prenatal vitamins combo no.60/ferrous fumarate/folic
189
poly/fa/omega3
acid
190
prenatal vitamins combo no.66/iron,carbonyl/folic
189
prenatal vitamin no.8/iron polysacchar & heme
polypeptide/fa
190
acid/dha
190
prenatal vitamins no.11/ferrous fumarate/folic
189
acid/omega-3
190
prenatal vitamins no.12/iron,carbonyl/fa/docusate
poly/fa/omega3
189
na/omega-3
prenatal vitamin no.86/iron bis-glycinate/folic acid
189
prenatal vitamins no.15/iron fumarate & polysac
poly/fa/omega3
190
comp/fa
189
190
prenatal vitamins
no.18/iron,carbonyl/fa/ubidecarenone/dha
PAGE 234
190
prenatal vitamins no.22/iron cbn & gluc/folic
acid/dss
prenatal vits with calcium #72/iron,carbonyl/folic
190
prenatal vitamins no.22/iron cbn&glucon/folic
acid/dss/dha
acid
190
prenatal vits with calcium #73/ferrous fumarate/folic
190
acid
190
prenatal vitamins no.26/iron polysaccharides/fa/dha190
prenatal vitamins no.38/iron cbn&glucon/folic
acid
acid/dss/dha
190
prenatal vitamins no.59/iron carbonyl &
fumarate/fa/dss/dha
acid
190
gluconate/fa/dss/dha
191
191
acid
190
191
prenatal vits with calcium#118/ferrous fumarate/folic
acid
191
gluconate/fa/dss/dha
190
prenatal vits without calc no5/ferrous fumarate/folic
prenatal vitamins with calcium/fe bisgly/folic acid
189
acid
prenatal vitamins with calcium/ferrous
fumarate/docusate/fa
191
prenatal without iron/folic acid/calcium
190
carb/pyridoxine/b12
191
PRENATE AM
191
PRENATE CHEWABLE
191
prenatal vitamins with calcium/ferrous fumarate/folic
PRENATE DHA
191
acid
PRENATE ELITE
191
PRENATE ENHANCE
191
PRENATE ESSENTIAL
191
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid &
PRENATE MINI
191
dha
PRENATE PIXIE
191
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-
PRENATE RESTORE
191
3
PRENATE STAR
191
PRENEXA
191
PREPIDIL
127
PREPOPIK
123
PREQUE 10
191
PRESERA
113
prenatal vitamins with calcium/ferrous
fumarate/fa/selenium
190
190
prenatal vitamins with
calcium/iron,carbonyl/docusate/fa
190
190
190
acid
190
prenatal vits with calcium #47/fe fumarate/fa cmb
#1/dha
190
prenatal vits with calcium #62/ferrous
fumarate/fa/dha
190
PRESTALIA
95
prenatal vits with calcium #7/fe asp gly/docusate/folic
PREVACID
124
acid
PREVIDENT
107
PREVIDENT 5000
107
PREVIDENT 5000 ENAMEL PROTECT
107
PREVIDENT 5000 PLUS
107
PREVIDENT 5000 SENSITIVE
107
PREVNAR 13
146
PREVPAC
121
190
prenatal vits with calcium #70/ferrous
fumarate/fa/dha
190
acid
190
acid
190
PREZCOBIX
PAGE 235
69
PREZISTA
69
PRIALT
104
PRIFTIN
51
PROMACTA
81
promethazine hcl
44,45,167
promethazine hcl/codeine
172
124
promethazine hcl/dextromethorphan hbr
172
primaquine phosphate
62
promethazine/phenylephrine hcl/codeine
173
PRIMAXIN
28
PROMETRIUM
137
primidone
34
PROMISEB
113
PRIMSOL
25
PROMISEB COMPLETE
113
PRINIVIL
86
propafenone hcl
PRILOSEC
PRISMASOL
191
PRISTIQ ER
42
88
propantheline bromide
121
proparacaine hcl
16
PRO-C-DURE 5
130
proparacaine hcl/fluorescein sodium
162
PRO-C-DURE 6
130
PROPECIA
125
PROAIR HFA
169
propofol
16
PROAIR RESPICLICK
169
PROPOVEN
16
PROBARIMIN QT
191
propranolol hcl
89
95
probenecid
48
propranolol hcl/hydrochlorothiazide
procainamide hcl
88
propylthiouracil
141
PROCALAMINE
191
PROQUAD
146
PROCARDIA
91
PROSCAR
126
PROCARDIA XL
91
PROSED-DS
prochlorperazine
44
PROSOL
191
prochlorperazine maleate
44
PROSTASCINT
154
PROCORT
121
PROCRIT
81
PROCTOCORT
20,121
25
PROSTIGMIN
51
PROSTIN E2 VAGINAL SUPPOSITORY
127
PROSTIN VR PEDIATRIC
95
PROCTOFOAM-HC
121
protamine sulfate
83
PROCYSBI
127
PROTECT BONE
191
PRODRIN
104
PROTECT IRON
191
PROFERRIN-FORTE
191
PROTECT NATAL
191
PROTECT PLUS
191
PROFILNINE
83
progesterone
137
protectives combination no.2/ceramides 1,3,6-11
113
progesterone,micronized
137
PROTONIX
124
PROTONIX IV
124
PROGLYCEM
77
PROGRAF
142
PROTOPAM CHLORIDE
154
PROHANCE
154
PROTOPIC
114
PROHANCE MULTIPACK
154
protriptyline hcl
43
PROLASTIN C
172
PROVENGE
56
PROLENSA
163
PROVENTIL HFA
169
PROLEUKIN
56
PROVERA
137
PROLIA
60
PROVIDA DHA
191
PAGE 236
PROVIDA OB
191
quinidine gluconate
88
PROVIGIL
175
quinidine sulfate
88
PROVOCHOLINE
155
quinine sulfate
62
PROZAC
42
QUTENZA
114
PROZAC WEEKLY
42
QVAR
166
PRUDOXIN
114
pseudoephedrine hcl/hydrocodone
R
bitartrate/chlorpheniramine
173
R-GENE 10
155
PULMICORT
166
RABAVERT
146
PULMICORT FLEXHALER
166
rabeprazole sodium
124
PULMOZYME
173
RADIAPLEXRX
114
PURALOR CI
155
RADIGEL
114
PUREFE OB PLUS
191
RADIOGARDASE
155
PUREFE PLUS
191
RAGWITEK
173
PURINETHOL
54
raloxifene hcl
137
PURIXAN
54
ramipril
86
PYLERA
121
RANEXA
95
pyrazinamide
PYRIDIUM
pyridostigmine bromide
51
127
51
ranitidine hcl
122
RAPAFLO
126
RAPAMUNE
142
pyridoxine hcl
192
RASUVO
142
PYROGALLIC ACID
114
RAVICTI
118
RAYOS
20
RAZADYNE
38
38
Q
Q-TABS
192
RAZADYNE ER
QNASL
166
READI-CAT
155
QNASL CHILDREN
166
READI-CAT 2
155
QSYMIA
105
REBETOL
QUADRACEL DTAP-IPV
146
REBIF
106
QUADRAMET
155
REBIF REBIDOSE
106
QUALAQUIN
62
RECLAST
159
QUARTETTE
136
RECOMBINATE
quazepam
175
RECOMBIVAX HB
146
RECOTHROM
155
QUDEXY XR
36
71
83
QUELICIN
105
RECTIV
100
QUESTRAN LIGHT
100
RED BIRCH
155
quetiapine fumarate
65
RED CEDAR
155
REFLUDAN
79
REGENECARE
16
QUFLORA
QUILLIVANT XR
155,192
103
quinapril hcl
86
REGIMEX
105
quinapril hcl/hydrochlorothiazide
95
REGLAN
45
PAGE 237
REGONOL
51
RETROVIR
68
REGRANEX
114
REVATIO
RELAGESIC
155
REVLIMID
53
RELAMINE
155
REXULTI
65
RELENZA
70
REYATAZ
69
RELISTOR
121
REZIRA
173
50
REZYST
121
RELPAX
170,171
RELYYKS
155
REZYST IM
121
RELYYT
155
RHEUMATE
192
RHEUMATREX
142
REMERON
40
REMESENSE
155
RHINOCORT AQUA
166
REMICADE
142
rho(d) immune globulin
144
REMODULIN
170
RHOGAM ULTRA-FILTERED PLUS
144
RENACIDIN
127
RHOPHYLAC
144
RENAGEL
128
RIASTAP
83
RENOVA
114
RIBASPHERE RIBAPAK
71
RENOVA PUMP
114
RIBATAB
71
RENVELA
128
ribavirin
71
REOPRO
84
RIDAURA
repaglinide
76
rifabutin
51
REPATHA SURECLICK
155
RIFADIN
51
REPATHA SYRINGE
155
RIFAMATE
51
rifampin
51
144
REPREXAIN
13
REPRONEX
155
RIFATER
51
REQ49+
192
RILUTEK
105
REQUIP
63
riluzole
105
REQUIP XL
63
rimantadine hcl
RESCRIPTOR
67
RIMSO-50
127
70
RESCULA
164
ringers solution
192
RESECTISOL
127
ringers solution,lactated
192
reserpine
85
RIOMET
76
RESPA A.R.
173
risedronate sodium
159
RESTASIS
142
RISPERDAL
65
RESTORA RX
155
RISPERDAL CONSTA
65
RESTORA SPRINKLES
195
RISPERDAL M-TAB
65
RESTORIL
175
risperidone
RETAVASE
79
65,66
RITALIN
103
RETIN-A
114
RITALIN LA
103
RETIN-A MICRO
114
RITALIN-SR
103
RETIN-A MICRO PUMP
114
RITUXAN
60
RETISERT
163
rivastigmine
38
PAGE 238
rivastigmine tartrate
38
SALVAX
114
RIXUBIS
83
SALVAX DUO PLUS
114
rizatriptan benzoate
50
SAMSCA
176
ROBAXIN
174
SANCTURA
125
ROBAXIN-750
174
SANCTURA XR
125
ROBINUL
88,119
SANCUSO
45
ROBINUL FORTE
119
SANDIMMUNE
142,143
ROCALTROL
139
SANDOSTATIN
140
SANDOSTATIN LAR
140
SANDOSTATIN LAR DEPOT
140
114
ROCEPHIN
rocuronium bromide
28
105
ropinirole hcl
63
SANTYL
ropivacaine hcl/pf
16
SAPHRIS
ROSADAN
25
SARAFEM
42
ROSULA
108
SAVAYSA
79
ROTARIX
146
SAVELLA
105
ROTATEQ
146
SAXENDA
155
ROUGH PIGWEED
155
SCALACORT DK
130
ROWASA
121
SCAR
ROXICET
13
SCLEROSOL
155
ROXICODONE
13
scopolamine hydrobromide
119
66,73
16
ROZEREM
175
SCULPTRA
155
RUCONEST
155
SEASONIQUE
136
RUSSIAN THISTLE
155
SECONAL SODIUM
175
RYANODEX
174
SECTRAL
89
RYTARY
63
SELECT-OB
192
RYTHMOL
88
SELECT-OB + DHA
192
RYTHMOL SR
88
selegiline hcl
S
SABRIL
35
64
selenium
192
selenium sulfide
114
SELRX
114
SAFYRAL
136
SELZENTRY
69
SAGEBRUSH
155
SEMPREX-D
173
SAIZEN
131
SENSIPAR
139
SALAGEN
107
SENSORCAINE-MPF
SALEX
114
SENTRA AM
192
salicylic acid
114
SENTRA PM
192
salicylic acid/ammonium lactate/aloe vera
114
SEREVENT DISKUS
169
salicylic acid/ceramides 1,3,6-11
114
SEROMYCIN
25
saliva collection device/ibuprofen
155
SEROPHENE
155
SALKERA
114
SEROQUEL
66
SEROQUEL XR
40
salsalate
PAGE 239
7
16
SEROSTIM
131
sertraline hcl
42
sodium bicarbonate
192
sodium chloride
192
SETONET-EC
192
sodium chloride 0.45 %
192
sevelamer carbonate
128
sodium chloride 3 %
192
sevoflurane
16
sodium chloride 5 %
192
SFROWASA
121
sodium chloride for inhalation
173
SHAGBARK HICKORY
155
sodium chloride irrigating solution
192
SHEEP SORREL-YELLOW DOCK
156
sodium chloride/sodium bicarbonate/potassium
SIDEROL
192
chloride/peg
123
SIGNIFOR
139
sodium citrate
195
SIGNIFOR LAR
131
SODIUM DIURIL
97
sildenafil citrate
171
SODIUM EDECRIN
97
SILENOR
175
sodium ferric gluconate complex in sucrose
192
SILVADENE
32
sodium fluoride
107,192
silver nitrate
114
sodium lactate
192
silver nitrate/potassium nitrate
114
sodium morrhuate
156
silver sulfadiazine
32
sodium nitrite
95
SILVERA
16
sodium nitrite/sodium thiosulfate/amyl nitrite
156
SILVRSTAT
114
sodium phenylbutyrate
118
SIMBRINZA
164
sodium phos,m-basic-d-basic
192
SIMCOR
100
sodium polystyrene sulfonate
176
SIMPONI
143
sodium thiosulfate
156
SIMPONI ARIA
143
sodium thiosulfate/salicylic acid
115
SIMULECT
143
sodium/potassium/magnesium/calcium/chloride/acetat
simvastatin
99
e
SINEMET 10-100
63
sodium/potassium/potassium citrate/sodium citrate/cit
SINEMET 25-100
64
ac
127
SINEMET 25-250
64
SOLARAZE
115
SINEMET CR
64
SOLESTA
156
192
SINGULAIR
167
SOLIRIS
81
SINOGRAFIN
156
SOLODYN
33
sirolimus
143
SOLTAMOX
53
SIRTURO
51
SOLU-CORTEF
130
SITAVIG
72
SOLU-MEDROL
21
SITZMARKS
156
SOMA
174
SOMATULINE DEPOT
140
SIVEXTRO
25
SKELAXIN
174
SOMAVERT
140
SKELID
159
SONATA
175
SKLICE
62
SKYLA
137
sorbitol solution
127
sodium acetate
192
SORIATANE
115
PAGE 240
SOOLANTRA
61
SORILUX
115
sotalol hcl
88
SOTRADECOL
156
STRIVERDI RESPIMAT
170
STROMECTOL
61
STROVITE
192
SOTYLIZE
88
STROVITE FORTE
193
SOVALDI
71
STROVITE ONE
193
SPECTRACEF
28
STROVITE PLUS
193
SPHERUSOL
156
SUBLIMAZE
9
spinosad
61
SUBOXONE
17,18
SPIRIVA
167
SUBSYS
SPIRIVA RESPIMAT
167
SUCLEAR
123
spironolactone
97
SUCRAID
118
spironolactone/hydrochlorothiazide
95
sucralfate
123
SPORANOX
48
SUFENTA
13
SPRAY AND STRETCH
16
sufentanil citrate
13
SPRIX
21
SULAR
91
SPRYCEL
59
sulfacetamide sodium
9
32,115,162
SPS
176
sulfacetamide sodium/prednisolone sodium
SSD
32
phosphate
162
STALEVO 100
62
sulfacetamide sodium/sulfur
115
STALEVO 125
62
sulfacetamide
STALEVO 150
62
sodium/sulfur/avobenzone/octinoxate/octyl sal
STALEVO 200
62
sulfacetamide sodium/sulfur/skin cleanser comb
STALEVO 50
62
no.23
115
STALEVO 75
62
sulfacetamide sodium/sulfur/urea
115
115
115
STANDARD BERMUDA GRASS POLLEN
156
sulfacetamide sodium/sulfur/witch hazel
STANDARDIZED CAT HAIR
156
sulfadiazine
32
STANDARDIZED TIMOTHY GRASS
156
sulfamethoxazole/trimethoprim
32
stannous fluoride
107
SULFAMYLON
25
STARLIX
76
sulfasalazine
121
stavudine
68
SULFATRIM
32
STAVZOR
35
SULFZIX
STAXYN
127
sulindac
STELARA
115
SUMADAN
115
STENDRA
127
SUMADAN XLT
115
STIMATE
131
sumatriptan
50
STIOLTO RESPIMAT
170
sumatriptan succinate
50
59
SUMAVEL DOSEPRO
50
STIVARGA
STRATTERA
7
SUMAXIN
115
22
SUMAXIN CP
115
STRIANT
132
SUMAXIN TS
115
STRIBILD
69
SUPERVITE
193
streptomycin sulfate
PAGE 241
103
156
SUPERVITE EC
193
156
SUPPRELIN LA
140
156
SUPRANE
16
SUPRAX
28
T
SUPRENZA ODT
105
TABLOID
54
SUPREP
123
TACHOSIL
156
SURESTEP
160
TACLONEX
115
SURFAXIN
173
tacrolimus
115,143
SURMONTIL
43
TAFINLAR
58
SURVANTA
173
TAGITOL
156
156
SUSTIVA
67
talc
SUTENT
59
TALWIN
13
TAMBOCOR
88
SWABFLUSH
193
SYLATRON
56
TAMIFLU
70
SYLATRON 4-PACK
56
tamoxifen citrate
53
SYLVANT
143
tamsulosin hcl
126
SYMAX DUOTAB
119
TANDEM PLUS
193
SYMBICORT
170
TANZEUM
76
SYMBYAX
40
TAPAZOLE
141
SYMLINPEN 120
76
TARCEVA
59
SYMLINPEN 60
76
TARGRETIN
61
95
SYNAGEX
193
TARKA
SYNAGIS
144
TARON-DUO EC
SYNALAR
21
TASIGNA
60
SYNALAR TS
21
TASMAR
62
SYNALGOS-DC
13
TAXOTERE
56
SYNAREL
140
SYNERA
193
TAZORAC
115
16
TECFIDERA
106
SYNERCID
25
TECHNIVIE
71
SYNJARDY
76
TEFLARO
28
SYNRIBO
56
TEGRETOL
37
TEGRETOL XR
37
TEKAMLO
95
SYNTHROID
SYNVEXIA TC
138
16
SYNVISC
156
TEKTURNA
95
SYNVISC-ONE
156
TEKTURNA HCT
95
SYPRINE
176
telmisartan
86
SYRINGE AVITENE
156
telmisartan/amlodipine besylate
95
syringe with needle, insulin, safety, 0.3 ml
156
telmisartan/hydrochlorothiazide
96
syringe with needle, insulin, safety, 0.5 ml
156
temazepam
175
syringe with needle, insulin, safety, 1 ml
156
TEMODAR
52,53
syringe with needle,disposable,insulin 1 ml
156
TEMOVATE
PAGE 242
21
TEMOVATE EMOLLIENT
21
THAM
193
temozolomide
53
THEO-24
168
TENEX
84
theophylline anhydrous
168
teniposide
56
theophylline/dextrose 5 % in water
168
TENIVAC
146
THERACYS
56
TENORETIC 100
96
THERAMINE
193
TENORETIC 50
96
THERAMINE PLUS
157
TENORMIN
89
THERMAZENE
TERAZOL 3
48
thiamine hcl
TERAZOL 7
48
thiamine
terazosin hcl
85
hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 193
terbinafine hcl
48
THIOLA
TERBINEX
48
thioridazine hcl
64
thiothixene
64
terbutaline sulfate
terconazole
170
48
THRIVITE RX
32
193
127
193
TERSI FOAM
115
THROMBATE III
81
TESSALON PERLE
173
THROMBI-GEL
157
TESTIM
132
THROMBI-PAD
157
TESTONE CIK
132
THROMBIN-JMI
157
TESTOPEL
133
THYMOGLOBULIN
144
testosterone
133
THYROGEN
157
testosterone cypionate
133
thyroid,pork
138
testosterone enanthate
133
THYROLAR-1
138
TESTRED
133
THYROLAR-1/2
138
tetanus and diphtheria toxoids, adult
146
THYROLAR-1/4
138
tetanus toxoid, adsorbed/pf
146
THYROLAR-2
138
tetanus,diphtheria toxoid ped/pf
146
THYROLAR-3
138
tetrabenazine
105
tiagabine hcl
35
tetracaine hcl
162
TIAZAC
91
ticlopidine hcl
84
TIGAN
45
tetracaine hcl/pf
tetracycline hcl
17,162
33
TETRAVISC
162
TIKOSYN
88
TETRAVISC FORTE
162
TIMENTIN
30
TETRIX
115
timolol maleate
TEV-TROPIN
131
TIMOPTIC
164
49,164
TEVETEN
86
TIMOPTIC OCUDOSE
164
TEVETEN HCT
96
TIMOPTIC-XE
164
TEXACORT
21
TINDAMAX
25
TEXAVITE LQ
193
tinidazole
25
thallous chloride tl-201
156
TIROSINT
139
TISSEEL VHSD
157
THALOMID
PAGE 243
53
TIVICAY
TIVORBEX
69
7
tramadol hcl
10,13
tramadol hcl/acetaminophen
13
tizanidine hcl
67
TRANDATE
90
TL FOLATE
193
trandolapril
86
TL-ICARE
193
trandolapril/verapamil hcl
96
TL-SELECT DHA
193
tranexamic acid
83
TNKASE
79
TRANSDERM-SCOP
45
TOBI
22
TRANXENE T-TAB
73
TOBI PODHALER
22
tranylcypromine sulfate
40
TOBRADEX
TOBRADEX ST
22,162
162
TRAVASOL
193
TRAVATAN Z
160
160
tobramycin
22
travoprost (benzalkonium)
tobramycin in 0.225 % sodium chloride
22
trazodone hcl
40
tobramycin sulfate
22
TREANDA
53
tobramycin sulfate/sodium chloride
22
TRECATOR
51
162
TRELSTAR
57
tobramycin/dexamethasone
TOBREX
22
TRELSTAR DEPOT
57
TOFRANIL
43
TRELSTAR LA
57
TOFRANIL-PM
43
TRENTAL
96
TOLAK
195
TREPADONE
157
tolazamide
76
TRETIN-X
tolbutamide
76
tretinoin
tolcapone
63
tretinoin microspheres
116
7
tretinoin/emollient base
116
tolmetin sodium
tolterodine tartrate
61,115
61,115,116
125
TRETTEN
83
TOPAMAX
36
TREXALL
54
TOPICORT
21,115
TREXIMET
50
13
topiramate
37
TREZIX
topotecan hcl
58
TRI-CHLOR
116
TOPROL XL
89
TRI-LUMA
116
TORISEL
60
TRI-NORINYL
136
torsemide
97
TRI-VI-FLOR
193
TOTECT
57
triacetin
TOUJEO SOLOSTAR
78
triamcinolone acetonide
48
21,116,130
TOVIAZ
125
triamterene/hydrochlorothiazide
TOZAL
193
triazolam
TPN ELECTROLYTES
193
TRIBENZOR
TPN ELECTROLYTES II
193
TRICARE
193
TRACE ELEMENTS-4
193
TRICARE PRENATAL COMPLEAT
193
TRACLEER
171
TRICARE PRENATAL DHA ONE
193
TRADJENTA
76
PAGE 244
TRICITRASOL
96
175
96
79
TRICOR
98
13
TRIESENCE
163
TYPHIM VI
146
TRIFERIC
157
TYSABRI
106
trifluoperazine hcl
64
TYVASO
171
trifluridine
72
TYZEKA
71
TRIGLIDE
98
TYZINE
173
trihexyphenidyl hcl
62
TRILEPTAL
38
U
TRILIPIX
98
UCERIS
147
trimethobenzamide hcl
45
UDAMIN
193
trimethoprim
25
UDAMIN SP
194
trimipramine maleate
43
ULESFIA
61
TRINATE
193
ULORIC
48
TRIOSTAT
139
ULTANE
17
TRIOXIN
165
ULTIMA
160
TRIPLE DYE
116
ULTIVA
13
ULTRACET
13
TRISENOX
TRISTART DHA
57
193
ULTRAFOAM
157
TRIUMEQ
69
ULTRAM
13
TRIZIVIR
68
ULTRAM ER
10
TROKENDI XR
35,36
ULTRASAL-ER
116
TROPAZONE
116
ULTRAVATE
21
TROPHAMINE
193
ULTRAVATE PAC
130
tropicamide
162
ULTRAVATE X
130
trospium chloride
125
ULTRAVIST
157
TRULICITY
77
ULTRESA
118
TRUSOPT
164
UMECTA
116
TRUVADA
68
UMECTA PD
116
trypsin/balsam peru/castor oil
116
UNASYN
30
TUBERSOL
157
UNIRETIC
96
TUDORZA PRESSAIR
168
UNITHROID
TUSNEL PEDIATRIC
173
UNITUXIN
60
TUSSICAPS
173
UNIVASC
87
TUSSIONEX
173
URAMAXIN
116
TUZISTRA XR
157
URAMAXIN GT
116
TWINRIX
146
urea
116
139
TWYNSTA
96
urea/hyaluronate sodium
116
TYBOST
69
urea/lactic acid/salicylic acid
116
TYGACIL
25
urea/lactic acid/zinc undecylenate
116
TYKERB
60
URECHOLINE
127
13
URELLE
PAGE 245
25
URETRON D-S
25
VARIBAR PUDDING
157
UREVAZ
108
VARIBAR THIN HONEY
157
URIBEL
26
VARIBAR THIN LIQUID
157
VARITHENA
157
UROCIT-K
194
UROGESIC-BLUE
26
VARIVAX VACCINE
146
UROQID-ACID NO.2
26
VARIZIG
144
UROXATRAL
126
VARUBI
45
URSO
121
VASCAZEN
194
URSO FORTE
121
VASCEPA
100
ursodiol
121
VASCULERA
194
26
VASERETIC
96
UTOPIC
116
vasopressin
132
UVADEX
116
VASOSTRICT
132
UTA
VASOTEC
87
VAYACOG
194
136
VAYARIN
194
valacyclovir hcl
72
VAYAROL
100
VALCHLOR
53
VAZCULEP
96
VALCYTE
69
VECTIBIX
60
valganciclovir hcl
69
VECTICAL
116
VALIUM
73
vecuronium bromide
105
valproic acid
36
VEHICLE-N
157
valproic acid (as sodium salt) (valproate sodium)
36
VEHICLE-N MILD
157
valsartan
86
VELCADE
60
valsartan/hydrochlorothiazide
96
VELETRI
171
VALSTAR
57
VELMA
VALTREX
72
VELPHORO
128
VELTIN
116
116
V
VAGIFEM
VANACOF CD
173
17
VANCOCIN HCL
26
VENELEX
vancomycin hcl
26
venlafaxine hcl
vancomycin hcl/dextrose 5 % in water
26
VENLAFAXINE HCL ER
vancomycin in dextrose, iso-osmotic
26
VENOFER
194
VANDAZOLE
26
VENTAVIS
171
VENTOLIN HFA
170
130
42
42,43
VANIQA
116
VANOS
21
VERAMYST
VANOXIDE-HC
116
verapamil hcl
VANTAS
140
VERDESO
21
VAPRISOL-5% DEXTROSE
176
VEREGEN
116
VAQTA
146
VERELAN
91
VARIBAR HONEY
157
VERELAN PM
91
VARIBAR NECTAR
157
VERIPRED 20
21
PAGE 246
88,91
VERSACLOZ
VESICARE
VEXA
66
VISIPAQUE
157
125
VISTARIL
45
17
VISTIDE
69
VEXOL
163
VISUDYNE
162
VFEND
48
VITA-RESPA
194
VFEND IV
48
VITAFOL
194
VIAGRA
127
VITAFOL NANO
194
VIBATIV
26
VITAFOL ULTRA
194
VIBRAMYCIN
33
VITAFOL-OB
194
VICOPROFEN
13
VITAFOL-OB+DHA
194
VICTOZA 2-PAK
77
VITAFOL-ONE
194
VICTOZA 3-PAK
77
VITAFOL-PN
194
VICTRELIS
71
VITAL-D RX
194
VIDAZA
54
VITAMEDMD ONE RX
194
VIDEX
68
VITAMEDMD PLUS RX
194
VIDEX EC
68
VITAMEDMD REDICHEW RX
194
VIEKIRA PAK
71
vitamin b complex & vitamin c no.20/folic acid
194
VIGAMOX
32
vitamin b complx no.3/folic acid/ascorbic acid/biotin 194
VIIBRYD
40
vitamin e acet (dl,tocopheryl)/grape/hyaluronic acid 117
VIMIZIM
118
VIMOVO
7
VITEKTA
69
VIMPAT
38
VITRASE
157
VITAPEARL
194
VINATE CARE
194
VITUZ
VINATE DHA RF
194
VIVA CT
194
vinblastine sulfate
57
VIVA DHA
194
vincristine sulfate
57
VIVACTIL
43
vinorelbine tartrate
57
VIVELLE-DOT
136
VIOKACE
118
VIRACEPT
69
VIVOTIF BERNA
146
VIRAMUNE
67
VOGELXO
133
VIRAMUNE XR
67
VOLTAREN
117
VIRASAL
117
VIVITROL
13
VOLTAREN-XR
17
7
VIRAZOLE
71
VOLUMEN
157
VIREAD
68
VOLUVEN
81
157
VORAXAZE
57
72
voriconazole
48
VIRT-BAL DHA
194
VOSOL HC
26
VIRT-BAL DHA PLUS
194
VOSPIRE ER
VIRT-VITE PLUS
194
VOTRIENT
VISCOAT
162
VP CH ULTRA
194
VISIONBLUE
162
VP-PNV-DHA
194
VIRGINIA LIVE OAK
VIROPTIC
PAGE 247
170
58
VPRIV
118
XEOMIN
67
VSL#3 DS
121
XERESE
72
VUSION
117
XGEVA
60
VYTONE
117
XIAFLEX
158
VYTORIN
100
XIFAXAN
26
VYVANSE
102
XIGDUO XR
77
XIZFLUS
W
warfarin sodium
water for inj.,bacteriostatic
80
157
water for
158
XODOL 10-300
13
XODOL 5-300
13
XODOL 7.5-300
13
XOFIGO
57
173
inj.,bacteriostatic/methylparaben/propylparaben
157
XOLAIR
water for injection,sterile
157
XOLEGEL
48
water for irrigation,sterile
157
XOPENEX
170
WELCHOL
77
XOPENEX CONCENTRATE
170
WELLBUTRIN
40
XOPENEX HFA
170
WELLBUTRIN SR
40
XTANDI
141
WELLBUTRIN XL
40
XYLOCAINE
17
WESTCORT
130
XYLOCAINE DENTAL-EPINEPHRINE
17
WESTHROID
139
XYLOCAINE IV
17
WESTHROID-P
139
XYLOCAINE WITH EPINEPHRINE
17
WHITE ASH
158
XYLOCAINE-MPF
17
WHITE OAK EXTRACT
158
XYLOCAINE-MPF WITH EPINEPHRINE
17
WHYTEDERM TDPAK
108
XYNTHA
83
XYNTHA SOLOFUSE
83
WILATE
83
WINRHO SDF
144
XYREM
175
WP THYROID
139
XYZAL
167
X
Y
XALATAN
160
YASMIN 28
136
XALKORI
60
YAZ
136
XANAX
73
YERVOY
60
XANAX XR
73
YF-VAX
146
XARELTO
80
YODOXIN
XARTEMIS XR
10
62
XCLAIR
117
Z
XELJANZ
144
zafirlukast
167
XELODA
54
zaleplon
175
XENADERM
117
ZALTRAP
60
XENAZINE
105
ZAMICET
13
XENICAL
121
ZANAFLEX
67
PAGE 248
ZANOSAR
53
ZANTAC
122
ZITHRANOL
117
ZITHRANOL-RR
117
ZARONTIN
34
ZITHROMAX
31
ZAROXOLYN
97
ZITHROMAX TRI-PAK
31
ZARXIO
81
ZMAX
31
ZAVESCA
118
ZEBETA
ZN-DTPA
158
90
ZOCOR
99
ZEBUTAL
105
ZOFRAN
45
ZECUITY
50
ZOFRAN ODT
46
ZEGERID
124
ZOHYDRO ER
10
ZELAPAR
64
ZOLADEX
140
ZELBORAF
58
zoledronic acid
159
159
ZEMAIRA
173
zoledronic acid in mannitol & water for injection
ZEMPLAR
139
ZOLINZA
60
ZEMURON
105
zolmitriptan
50
ZENPEP
118
ZOLOFT
43
ZENZEDI
102
zolpidem tartrate
175
175
ZERIT
68
ZOLPIMIST
ZESTORETIC
96
ZOLVIT
ZESTRIL
87
ZOMACTON
132
159
13
ZETIA
100
ZOMETA
ZETONNA
166
ZOMIG
50
50
ZEVALIN
60
ZOMIG ZMT
ZIAC
96
ZONALON
117
ZIAGEN
68
ZONATUSS
173
117
ZONEGRAN
34
ZIANA
zidovudine
68
zonisamide
34
ZINACEF
28
ZONTIVITY
84
ZINACEF ISO-OSMOTIC DEXTROSE
28
ZORBTIVE
132
zinc chloride
195
ZORTRESS
143
zinc sulfate
195
ZORVOLEX
7
ZOSTAVAX
146
zinc sulfate heptahydrate/cuso4 phyd/manganese/chromium/se
195
zinc sulfate/cupric sulfate/manganese sulf/chromic
ZOSYN
30
ZOTEX-C
173
195
ZOVIRAX
72
ZINECARD
57
ZUBSOLV
18
ZINGO
17
ZUPLENZ
46
164
ZUTRIPRO
173
chloride
ZIOPTAN
ziprasidone hcl
38,66
ZYBAN
18
ZIPSOR
7
ZYCLARA
57
ZIRGAN
70
ZYDELIG
60
PAGE 249
ZYDONE
13
ZYFLO
167
ZYFLO CR
167
ZYKADIA
ZYLET
60
162
ZYLOPRIM
48
ZYMAXID
32
ZYPRAM
121
ZYPREXA
66
ZYPREXA RELPREVV
66
ZYPREXA ZYDIS
66
ZYTAZE
195
ZYTIGA
58
ZYVOX
26
PAGE 250

Drug Formulary

Transcription

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