2008 formulary - unitedhealthcare® medicare solutions - medicare

COMPLETE DRUG LIST EFFECTIVE JANUARY 1 THROUGH DECEMBER 31, 2008

Inside:Tiers and copays.

Drug list.

Lower-cost options.

My Medications worksheet.

Please Read: This document contains information about the drugs we cover in this plan. Note to Existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

UNITEDHEALTH RX BASIC

2008

formulary(COMPLETE LIST OF COVERED DRUGS)

This is a complete drug formulary as of January 1, 2008. For more information, call 1-888-867-5562, 24 hours a day, 7 days a week. TTY users should call 1-877-730-4203. or visit us online at www.UnitedHealthRx.com.

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About this complete drug list.UnitedHealth Rx Basic helps members like you lower prescription drug costs. This complete formulary is a list of drugs covered by UnitedHealth Rx Basic. UnitedHealth Rx Basic selected the drugs in consultation with a team of health care providers with expertise in the prescription drug needs of people on Medicare. For more information, go to www.UnitedHealthRx.com or call Customer Care using the number on the bottom of the next page.

The UnitedHealth Rx Basic drug list includes every brand-name prescription drug, or its generic version, covered by Part D. For your prescription drugs to be covered by this plan, the drugs must be included in the drug list and in most cases the prescriptions must be filled at one of our network pharmacies.

The UnitedHealth Rx Basic includes over 60,000 network pharmacies for your convenience. Some of our network retail pharmacies include:

Plus thousands of independent neighborhood pharmacies! To find a pharmacy location within our network call Customer Care or visit us online at www.UnitedHealthRx.com.

Brooks

Costco

CVS

HEB Pharmacy

Kmart

Kroger

Longs

Medicine Shoppe

Publix

Rite Aid

Safeway

Shopko/Pamida

Target

Walgreens

Wal-Mart

Winn Dixie

and more ...


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There are two ways to find your prescription drugs within the drug list.

1. Look for a drug by name in the Drug Index, which begins on page 45.

2. Look for a drug by the health condition in the category section. For example, if you want to find drugs used to treat chest pain, turn to the category listing and look for “Chest Pain Drugs”.

Brand-name drugs are in bold type (e.g., Lipitor) while generic drugs are not (e.g., Furosemide). If you cannot find your drug in this complete drug list, contact Customer Care for assistance in finding your drug. If your drug is not in the complete drug list, you should talk with your doctor to see if the drug list includes an alternative drug choice that is right for you.

Your copay.During the initial coverage period, UnitedHealth Rx Basic pays part of the costs for your covered drugs and you pay part. Your copayment (copay) depends on the tier (or coverage level) assigned to your prescription drug.

This complete drug list includes four tiers. Each tier has a different copay amount. The Summary of Benefits lists the copays that apply to each tier. If you qualify for extra help in paying for your prescription drugs, your copays may be different than those described in the Summary of Benefits. Please contact Customer Care to find out what your costs are in this situation.

HOW TO FIND OUT IF YOUR DRUG IS COVERED.

TIER 1 Lowest CopayIncludes most generic prescription drugs. Generic drugs usually cost less than brand-name drugs.

TIER 2 Medium CopayIncludes preferred brand-name prescription drugs. Tier 2 drugs offer clinical advantages and/or lower prices than Tier 3 drugs. Brand-name drugs are in bold type (e.g., Lipitor).

TIER 3 Highest CopayTier 3 drugs include non-preferred drugs that have clinical disadvantages and/or higher prices than Tier 1 and/or Tier 2 drugs. If you are taking a Tier 3 drug, ask your doctor if a Tier 1 or Tier 2 drug could be an alternative. See page 62 for a partial listing of lower-cost drug options.

SPECIALTY TIER (SP) CoinsuranceIncludes unique and/or very high-cost drugs. You and the plan share in a percentage of the drug cost.

Generic drugs.UnitedHealth Rx Basic covers both brand-name and generic drugs. A generic drug has the same active ingredient as its brand-name equivalent. Generic drugs usually cost less than brand-name drugs and are approved by the Food and Drug Administration (FDA). If a generic equivalent drug is not available, a generic alternative can be a good option. Generic alternatives contain different active ingredients than brand-name drugs, but come from the same chemical family and can provide similar results.


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STEP THERAPYSTIn some cases, you are required to treat your medical condition with certain drugs before the plan will cover another drug for that condition.

QUANTITY LIMITSQLQuantity limits manage the quantity of certain drugs a member receives for a copay or defined period of time. Quantity limits are based upon FDA-approved dosing and standard professional treatment guidelines.

PRIOR AUTHORIZATIONPAPrior authorization requires certain criteria be met before the plan sponsor covers a particular drug. Some drugs require prior authorization due to coverage, clinical effectiveness or safety considerations. Prior authorization requires you or your doctor to get approval from the plan before you fill your prescription. If you do not get approval, your drug may not be covered by the plan.

MEDICARE PART B/D COVERAGE DETERMINATIONB/DSome drugs may be billed to the Medicare Part B or Part D benefit, depending on the intended use and other factors. Claims for a drug may be stopped at the pharmacy to determine which Medicare benefit should cover the drug. Your doctor may need to supply additional information before a drug is covered by the Part D plan.

To help manage drug costs and what you pay out of pocket, you may want to consult with your doctor to determine whether any of the brand-name drugs you take are available as generics. Using generic drugs may save you money and help keep you out of the coverage gap.

Coverage determination requirements for certain drugs.Some covered drugs may have additional requirements or limits that help ensure safe and effective drug use. These drugs may require a coverage determination by your Medicare Part D plan. You can find out if your drug has any additional requirements or limits by looking for abbreviations next to the drug names within the drug list in this booklet. Please see requirements in the side bar.

Please note: Due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, and Caverject. For more information, call 1-866-863-1406, 24 hours a day, 7 days a week. TTY users should call 1-877-730-4203.

Coverage determination process.A coverage determination allows you to request an exception to waive coverage restrictions or limits on your drug. A coverage determination applies to prior authorization, step therapy, quantity limits and Medicare Part B/Part D. You, your pharmacist, your doctor or your authorized representative can initiate a coverage determination by contacting Customer Care at the number listed below.

These requirements and limits apply to retail and mail order service and may include:


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Part D exception process.You can ask to make an exception to the plan’s coverage rules.

• You can ask to have your drug covered even if it is not on the drug list. If an exception is approved, you would get the prescription drug at the Tier 3 copay level.

You can ask us to waive coverage • restrictions or limits on your drug. For example, for certain drugs, we may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

• You can ask for a higher level of coverage for your drug. If your drug is in Tier 3, you can ask that the plan cover it as a Tier 2 drug instead. This would lower the amount you must pay for your drug. The tier exception process only applies to Tier 3 drugs. If the plan grants your request to cover a drug that is not on the drug list, you may not ask the plan to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, your request for an exception willbe approved only if the alternative drugs included on the plan’s drug list or the lower-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

When requesting a drug list or tiering exception, please submit a statement from your doctor supporting your request. Generally, the coverage decision is made within 72 hours of getting your prescribing physician’s supporting statement. You can

request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your prescribing physician’s supporting statement.

Visit www.UnitedHealthRx.com or call Customer Care at the number below for more information and to access the Exception Request Form.

Transition process for changing the drugs you take.If you are a new member in our plan, you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but a coverage determination may apply. For example, you may need prior authorization before the plan covers the drug.You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or to request an exception so that we may cover the drug you take. While you talk to your doctor to determine the right choice for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written


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for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our drug list or your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception.

There may be unplanned transitions such as hospital discharges or level of care changes that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our drug list or your ability to get your drugs is limited, you are required to use the plan’s exception process. You may request a one-time emergency supply of up to 31 days to allow you time to discuss alternative treatment with your doctor or to pursue a drug list exception.

If you are a continuing member in the plan, you receive an Annual Notice Of Change (ANOC). You may notice that a formulary medication which you are currently taking is either not on the 2008 formulary or its cost sharing or coverage is limited in the upcoming year. For coverage requests we receive by December 15, 2007 and approve, the plan will cover the drug as of January 1, 2008. For coverage requests initiated on or after December 16, 2007, normal time frames for resolution apply: you will receive an answer within 24 hours for urgent requests and 72 hours for all other request. If your request is still in process on January 1, 2008, you may receive a temporary supply of the drug for your current plan cost-sharing until we answer your request.

Drug list changes.UnitedHealth Rx Basic recognizes that drug list stability is important to you. It is our intention to make as few changes to the drug list as possible. From time to time, however, drug list changes are necessary for safety or other reasons. For example, the Food and Drug Administration (FDA) may declare a drug to be unsafe. When that happens, we will immediately remove that drug from our drug list and provide notice to members who take the drug. For other changes, such as if a drug is moved to a higher-cost tier, UnitedHealth Rx Basic will notify affected members at least 60 days before the change becomes effective, or at the time you request a refill of the drug, at which time you will receive a 60-day supply of the drug. If there are any changes to the drugs you take, they will be listed in your Explanation of Benefits.

The drug list may change throughout the year when the plan:

• Modifies the limitations or restrictions for a drug.

• Adds or removes a drug.

• Moves a drug to a lower or higher-cost tier.

Generally, if you are taking a drug on our 2008 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2008 coverage year. Exceptions include the availability of a new, less expensive generic equivalent drug or the release of new adverse information about the safety or effectiveness of a drug. Other types of drug list changes, such as adding prior authorization to a drug, will not affect members


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who are currently taking the drug. It will remain available at the same copay for those members taking it for the remainder of the coverage year.

For more information.For more detailed information about UnitedHealth Rx Basic drug coverage, please review your Evidence of Coverage, Summary of Benefits and other plan materials. You can also contact Customer Care at the numbers and Web site listed below.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

If you have special needs, this document may be available in alternative formats. For more information, call Customer Care at the phone number listed below.

8*See page 62 for a Lower-cost Drug Option(s)PA- Prior Authorization QL- Quantity Limits ST- Step Therapy B/D- Medicare Part B

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DRUGUnitedHealth Rx Basic

Tier Limits

ANTIHISTAMINE DRUGS - DRUGS TO TREAT

ALLERGIES AND ITCHING

Ethanolamine Derivatives - Allergy DrugsClemastine Fumarate 1Diphenhydramine HCl 3Palgic (Liquid) 1Palgic (Tablet) 2Miscellaneous Derivatives - Allergy DrugsCyproheptadine HCl 3Phenothiazine Derivatives - Nausea and Vomiting Drugs Phenadoz 3Promethazine HCl 3Promethazine HCl Plain 3Promethazine VC 3Promethegan 3Propylamine Derivatives - Allergy DrugsDexchlorpheniramine Maleate 3

Second Generation Antihistamines - Allergy Drugs

Allegra (Suspension) 3 QLAllegra-D 12 Hour 3 QLAllegra-D 24 Hour 3 QLClarinex * 3 QLClarinex Reditabs 3 QLClarinex-D 12 Hour 3 QLClarinex-D 24 Hour 3 QLFexofenadine HCl 1 QLSemprex-D 3 QLZyrtec 3 QLZyrtec-D 3 QL


Tier Limits

ANTI-INFECTIVE AGENTS -

DRUGS TO TREAT INFECTIONS

Adamantanes - Flu DrugsAmantadine HCl 1Flumadine (Syrup) 3Rimantadine HCl 1Allylamines - Antifungals

Terbinafine (Tablet) 1AmebicidesParomomycin Sulfate 3Aminoglycosides - AntibioticsAmikacin Sulfate 1Gentamicin Sulfate/0.9% NaCl (0.6mg/ml; 0.9% Solution, 0.8 mg/ml; 0.9% Solution, 1 mg/ml; 0.9% Solution, 1.2 mg/ml; 0.9% Solution, 1.6 mg/ml; 0.9% Solution)

1

Gentamicin Sulfate/0.9% NaCl (0.9 mg/ml; 0.9% Solution,1.4 mg/ml; 0.9% Solution)

3

Gentamicin Sulfate/NaCl 1Gentamicin Sulfate 1Kanamycin Sulfate 1Neo-Fradin 3Neomycin Sulfate 1Streptomycin Sulfate 3Tobi 4 B/D, PATobramycin Sulfate 1Tobramycin Sulfate/NaCl 3

THE DRUG LIST

*See page 62 for a Lower-cost Drug Option(s)PA- Prior Authorization QL- Quantity Limits ST- Step Therapy B/D- Medicare Part B

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Tier Limits

Tobramycin Sulfate Add-Vantage 3

Tobramycin Sulfate Fliptop 1Anthelmintics - Drugs to Treat Worm InfectionsAlbenza 2Biltricide 2Mebendazole 1Mintezol 2Stromectol 2Antimalarials - Malaria DrugsChloroquine Phosphate 1Daraprim 2Fansidar 3Hydroxychloroquine Sulfate 1Malarone 3Mefloquine HCl 1Primaquine Phosphate 2Qualaquin 3 PAAntiretrovirals - HIV DrugsAgenerase 3Aptivus 4Atripla 4 Combivir 4Crixivan 2Didanosine 3Emtriva 3Epivir 2Epivir HBV 2Epzicom 4Fuzeon 4Invirase 4Isentress 4Kaletra 4Lexiva 4Norvir (Capsule) 3


Tier Limits

Norvir (Solution) 4Prezista 4Rescriptor 3Retrovir IV Infusion 3Reyataz 4Selzentry 4Sustiva 3Trizivir 4Truvada 4Videx EC (125 mg Delayed Release Capsule) 3

Videx Pediatric 3Viracept 4Viramune 2Viread 3Zerit 2Ziagen 2Zidovudine (Capsule, Syrup) 3Zidovudine (Tablet) 1Antituberculosis AgentsCapastat Sulfate 4Ethambutol HCl 1Isonarif 1Isoniazid 1Mycobutin 3Paser 3Priftin 3Pyrazinamide 1Rifampin (Capsule) 1Rifampin (Solution for Reconstitution) 3

Rifater 3Seromycin 3Trecator 3


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Tier Limits

Azoles - AntifungalsFluconazole (50 mg Tablet, 100 mg Tablet, 200 mg Tablet, Suspension for Reconstitution)

1

Fluconazole (150 mg Tablet) 1 QLFluconazole in Dextrose 3Fluconazole in NaCl 3Itraconazole 3Ketoconazole (Tablet) 3Noxafil 4Sporanox (Kit) 4Sporanox (Solution) 3 PAVfend 4Vfend IV 4Cephalosporins - AntibioticsCedax 3Cefaclor 1Cefaclor ER 1Cefadroxil 1Cefdinir (Generic for Omnicef) 1

Cefizox in Dextrose 5% 3Cefotaxime Sodium 3Cefotetan 3Cefpodoxime Proxetil 1Cefprozil 1Ceftin (Suspension for Reconstitution) 3

Ceftazidime (1gm Solution for Reconstitution, 2 gm Solution for Reconstitution, 6 gm Solution for Reconstitution)

1

Ceftriaxone in Iso-Osmotic Dextrose 3

Ceftriaxone Sodium 3Ceftriaxone/Dextrose 3


Tier Limits

Cefuroxime Axetil 1Cefuroxime Sodium 1Cefuroxime/Dextrose 1Cephalexin 1Claforan/D5W Galaxy 3Fortaz (500 mg Solution for Reconstitution, Solution) 2

Keflex (750 mg Capsule) 3 QLMaxipime 2Panixine Disperdose 3Raniclor 3Rocephin (1 gm Solution for Reconstitution, 2 gm Solution for Reconstitution)

3

Rocephin in Iso-Osmotic Dextrose 3

Spectracef 2Suprax 3Tazicef (Solution for Reconstitution) 1

Tazicef (Solution) 2Zinacef (7.5 gm Solution for Reconstitution) 1

Zinacef (750 mg Solution for Reconstitution, 1.5 gm Solution for Reconstitution )

3

Zinacef in Iso-Osmotic Dextrose 3

Zinacef in Iso-Osmotic Diluent 3

Zinacef/D5W 3Chloramphenicol - AntibioticsChloramphenicol Sodium Succinate 1

Echinocandins - AntifungalsCancidas 4Eraxis 4Mycamine 4


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Tier Limits

Interferons - Hepatitis DrugsInfergen 4 PAPegasys 4 PAPeg-Intron 4 PAPeg-Intron Redipen 4 PAPeg-Intron Redipen Pak 4 4 PARoferon-A (3MU/0.5ml, 6MU/0.5ml Kit) 3 PA

Roferon-A (9MU/0.5ml Kit) 4 PAMacrolides - Antibiotics Azasite 3Azithromycin (Pack, Suspension for Reconstitution)

1

Azithromycin (Solution for Reconstitution) 3

Azithromycin (Tablet) 1 QLClarithromycin 1Clarithromycin ER 1Dynabac D5-Pak 3E.E.S. 200 1E.E.S. 400 1Eryped 2Eryped 400 2Ery-Tab 2Erythrocin 2Erythrocin Lactobionate 2Erythrocin Stearate 1Erythromycin 1Erythromycin Ethylsuccinate 1Erythromycin Lactobionate 2Erythromycin/Sulfisoxazole 1Ketek 3 PA, QLKetek Pak 3 PA, QLPCE 3Zmax 3 QL


Tier Limits

Miscellaneous AntibacterialsBaciim 1Cleocin (75 mg Capsule, Suppository) 3

Cleocin Galaxy 3Cleocin Pediatric Granules 3Clindamycin HCl 1Clindamycin Phosphate 1Clindamycin Phosphate Add-Vantage 1

Colistimethate Sodium 3Cubicin 4Grifulvin V (Tablet) 2Polymyxin B Sulfate 3Synercid 4Vancocin HCl (Capsule) 4 PAVancocin HCl (Solution) 3Vancocin HCl Iso-Osmotic Dextrose 3

Vancomycin HCl 1Xifaxan 3 QLZyvox (Solution) 4Zyvox (Suspension for Reconstitution, Tablet) 4 PA

Miscellaneous AntifungalsGriseofulvin Microsize 3Gris-Peg 3Miscellaneous Anti-InfectivesHelidac 3 QLPylera 3Miscellaneous Antimycobacterials - Drugs to Treat Miscellaneous InfectionsDapsone 2Miscellaneous Antiprotozoals Alinia 3 QLFlagyl ER 3


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Tier Limits

Mepron 4Metro IV 3Metronidazole 1Metronidazole in NaCl 0.79% 1Nebupent 3 B/D, PANeutrexin 4Pentamidine Isethionate 1Tindamax 2 QLMiscellaneous Antivirals Foscarnet Sodium 1Miscellaneous B-Lactams - AntibioticsAzactam 2Azactam in Dextrose 3Cefoxitin (1 gm Injectable; 2 gm Injectable; 10 gm Injectable)

3

Doribax 4Invanz 3Mefoxin in Dextrose 2.2% 3Mefoxin in Dextrose 3.9% 3Merrem 4Primaxin I.M. 4Primaxin IV 4Primaxin IV Add-Vantage 4Monoclonal Antibodies - Respiratory Syncytial Virus DrugsSynagis 4Neuraminidase Inhibitors - Flu DrugsRelenza Diskhaler 3 QLTamiflu 3 QLNucleosides and Nucleotides - Herpes and Hepatitis DrugsAcyclovir (Capsule, Tablet) 1Acyclovir (Suspension) 3Baraclude 4Cytovene 3Famvir 3


Tier Limits

Ganciclovir 4Hepsera 4Rebetol (Solution) 4 PARibasphere 1 PARibatab (Pack) 4 PARibatab (Tablet) 1 PARibavirin 1 PATyzeka 3Valcyte 4Valtrex 3Virazole 4Vistide 4Penicillins - AntibioticsAmoclan 1Amoxicillin 1Amoxicillin/Clavulanate Potassium 1

Amoxil (50 mg/ml Suspension for Reconstitution)

3

Amoxil (250 mg/5ml Suspension for Reconstitution, Capsule)

1

Ampicillin 1Ampicillin-Sulbactam 3

Augmentin (125 mg/5ml; 31.25 mg/5ml Suspension for Reconstitution, 125 mg;31.25 mg Chewable Tablet, 250 mg/5ml; 62.5 mg/5ml Suspension for Reconstitution, 250 mg; 62.5 mg Chewable Tablet)

3

Augmentin XR 3Bactocill in Dextrose 3Bicillin C-R 3Bicillin L-A 3Dicloxacillin Sodium 1


13


Tier Limits

Dispermox 3Geocillin 3Nafcillin Sodium (1 gm Solution for Reconstitution, 2 gm Solution for Reconstitution, 10 gm Solution for Reconstitution)

3

Nallpen Iso-Osmotic in Dextrose 4

Nallpen/Dextrose 4Oxacillin Sodium 3Penicillin G Potassium 3Penicillin G Potassium in Iso-Osmotic Dextrose 3

Penicillin G Procaine 3Penicillin G Sodium 1Penicillin V Potassium 1Piperacillin Sodium 3Timentin 2Trimox 1Unasyn Add-Vantage 3Unasyn Piggyback Unit 3Veetids 1Zosyn 3Polyenes - AntifungalsAbelcet 4Ambisome 4 B/DAmphocin 1Amphotec 3Amphotericin B 1Bio-Statin 3Nystatin 1Pyrimidines - AntifungalsAncobon 4Quinolones - AntibioticsAvelox (Solution) 3Avelox (Tablet) 2 QL


Tier Limits

Avelox ABC Pack 2 QLCipro (Suspension for Reconstitution) 3

Cipro I.V.-in D5W 3Ciprofloxacin (Injection) 3Ciprofloxacin ER 1Ciprofloxacin HCl 1Factive 3 QLLevaquin (Solution) 2Levaquin (Tablet) 2 QLLevaquin Leva-Pak 2 QLLevaquin Premix 2Noroxin 3 QLOfloxacin 1Proquin XR 3 QLSulfonamides (Systemic) - AntibioticsGantrisin Pediatric 2Sulfadiazine 1Sulfamethoxazole/Trimethoprim 1

Sulfamethoxazole/Trimethoprim DS 1

Sulfasalazine 1Sulfatrim 1Sulfazine 1Sulfazine EC 1Trimethoprim/Sulfamethoxazole DS 1

Tetracyclines - AntibioticsAdoxa Pak 1/150 3Demeclocycline HCl 4Doryx 3Doxy-Caps 1Doxycycline Hyclate (Capsule, Extended Release Capsule, Tablet)

1


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Tier Limits

Doxycycline Hyclate (Solution for Reconstitution) 3

Doxycycline Monohydrate 1Dynacin (100 mg Capsule) 1Minocin PAC 3Minocycline HCl 1Myrac 1Oracea 2Solodyn 3Sumycin (Syrup) 1Sumycin (Tablet) 2Tetracycline HCl 1Tygacil 3Vibramycin (Suspension for Reconstitution, Syrup) 3

Urinary Anti-Infectives - Antibiotics

Furadantin 3Macrodantin (25 mg Capsule) 3

Methenamine Hippurate 1Monurol 3Nitrofurantoin Macrocrystalline 3

Nitrofurantoin Monohydrate 3Primsol 3Trimethoprim 1

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER OR CANCER TREATMENT SIDE

Antineoplastics - Cancer DrugsAbraxane 4Adriamycin 1Alferon N 4Alimta 4 PAAlkeran 3Arimidex 2Aromasin 3


Tier Limits

Arranon 4Avastin 4 PABexxar 4Bicnu w/Diluent Absolute Ethanol 3

Bleomycin Sulfate 1Busulfex 4Campath 4Camptosar 4Carboplatin 3Casodex 3Ceenu 3Cisplatin 1Cisplatin AQ 1Cladribine 3Clolar 4Cosmegen 3Cyclophosphamide (Solution for Reconstitution) 1

Cyclophosphamide (Tablet) 3 B/DCytarabine 1Cytarabine Aqueous 1Dacarbazine (100 mg Solution for Reconstitution) 3

Dacarbazine (200 mg Solution for Reconstitution) 1

Dacogen 4Daunorubicin HCl (Injection) 3Daunorubicin HCl (Solution for Reconstitution) 3

Daunoxome 3Doxil 4 B/DDoxorubicin HCl 1Droxia 2Eligard 3Ellence 4Eloxatin 4


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Tier Limits

Elspar 3Emcyt 2Epirubicin HCl 4 Erbitux 4 PAEtopophos 4Etoposide 1Fareston 3Faslodex 4Femara 2Floxuridine 3Fludarabine Phosphate 4Fluorouracil 1Flutamide 1Gemzar 4Gleevec 4Herceptin 4Hexalen 4Hycamtin 4Hydroxyurea 1Idarubicin 4Ifosfamide 3Ifosfamide/Mesna 4Intron-A 4 PAIntron-A w/Diluent 4 PAIressa 4Ixempra Kit 4 B/DLeukeran 2Leuprolide Acetate 1Lupron Depot 3Lupron Depot-PED 4Lysodren 2Matulane 4Megestrol Acetate (Suspension) 3

Megestrol Acetate (Tablet) 1Mercaptopurine 3


Tier Limits

Methotrexate 1Mitomycin 3Mitoxantrone HCl 1 PAMustargen 3Mylotarg 4Nexavar 4Nilandron 3Nipent 4Oncaspar 4Ontak 4Onxol 4Paclitaxel 4Pentostatin 4Photofrin 4Plenaxis 4Proleukin 4 PARituxan 4 PASoltamox 3Sprycel 4Sutent 4Tabloid 3Tasigna 4 PATamoxifen Citrate 1Tarceva 4Targretin 4Taxotere 4Teslac 3Thiotepa 4Toposar 1Torisel 4Trelstar Depot 3Trelstar LA 3Tretinoin Capsule 4Trexall 3Trisenox 4Tykerb 3 PA


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Tier Limits

Vantas 3Vectibix 4 PAVelcade 4Viadur 3Vidaza 4Vinblastine Sulfate 1Vincasar PFS 1Vincristine Sulfate 1Vinorelbine Tartrate 4Vumon 4Zanosar 3Zoladex 4Zolinza 4 PA

AUTONOMIC DRUGS - DRUGS TO TREAT ORGAN DISORDERS

Antimuscarinics/Antispasmotics - Miscellaneous DisordersAtreza 3Atrovent HFA 2Cantil 3Dicyclomine HCl 3Glycopyrrolate 1Ipratropium Bromide (0.02% Solution) 1 B/D

Ipratropium Bromide (0.03% Solution, 0.06% Solution) 1

Methscopolamine Bromide 3Pamine 3Pro-Banthine 3Propantheline Bromide 3Spiriva Handihaler 2Antiparkinsonian Agents - Drugs to Treat Parkinson’s DiseaseAkineton 3Benztropine Mesylate 1


Tier Limits

Cogentin 2Kemadrin 3Trihexyphenidyl HCl 1Bronchodilators, Combinations - Drugs to Treat Asthma/COPDAdvair Diskus 2 STAlbuterol Sulfate/Ipratropium Bromide 1 B/D

Brovana 3 B/D, PACombivent 2Duoneb 3 B/D, PASymbicort 2 STMiscellaneous Autonomic Drugs - Smoking Cessation DrugsChantix 3 QLNicotine 3Nicotrol Inhaler 3Nicotrol NS 3Parasympathomimetic (Cholinergic) AgentsAricept 2 QLAricept ODT 2 QLBethanechol Chloride 1Cognex 3Enlon-Plus 3Evoxac 3 STExelon * (Capsule, Patch) 3 QLExelon * (Solution) 3Guanidine HCl 3Mestinon (Syrup) 3Mestinon Timespan 3Mytelase 3Pilocarpine HCl 1Pyridostigmine Bromide 1Razadyne (Solution) 2


17


Tier Limits

Razadyne (Tablet) 2 QLRazadyne ER 2 QLRegonol 3Skeletal Muscle Relaxants - Drugs to Treat Muscle SpasmsAmrix 3 STBaclofen 1Carisoprodol 1Carisoprodol/Aspirin 3Carisoprodol/Aspirin/Codeine 3

Chlorzoxazone 3Cyclobenzaprine HCl 3Dantrolene Sodium 1Methocarbamol 3Orphenadrine Citrate 3Orphenadrine Citrate ER 3Orphenadrine/Aspirin/Caffeine 3

Robaxin (Solution) 3Skelaxin 3Soma (250mg Tablet) 3Tizanidine HCl 1Zanaflex (Capsule) 3Sympathomimetic (Adrenergic Blocking) Agents - Miscellaneous DisordersDibenzyline 3Ergoloid Mesylates 1Sympathomimetic (Adrenergic) Agents - Breathing Disorder DrugsAccuneb (0.63 mg/3ml Nebulizer Solution) 3 B/D, PA

Adrenalin (0.1% Solution) 3Advair HFA 2 STAiret 1 B/D, PA


Tier Limits

Albuterol 1 STAlbuterol Sulfate (Nebulizer Solution) 1 B/D, PA

Albuterol Sulfate (Syrup, Extended-Release Tablet, Tablet)

1

Alupent 3Epinephrine HCl 1Epipen 2-Pak 2Epipen-Jr 2-Pak 2Foradil Aerolizer 2 PAIsuprel 3Maxair Autohaler 3Metaproterenol Sulfate (Nebulizer Solution) 1 B/D, PA

Metaproterenol Sulfate (Syrup, Tablet) 1

Proair HFA 2Proventil HFA 2Serevent Diskus 3 PATerbutaline Sulfate (Solution) 3Terbutaline Sulfate (Tablet) 1Ventolin HFA 3Xopenex (Nebulizer Solution) 3 B/D, PA

Xopenex Concentrate (Nebulizer Solution) 3 B/D, PA

Xopenex HFA 3Vasopressors - Heart Regulation DrugsMidodrine HCl 3Twinject 3


18


Tier Limits

BLOOD FORMATION AND COAGULATION - DRUGS TO TREAT BLOOD DISORDERS

Anticoagulants - Blood ThinnersArixtra 4 QLCoumadin 2Fragmin 2 QLHeparin Sodium 1Heparin Sodium DCU 1Heparin Sodium/D5W 1Heparin Sodium/NaCl 1Innohep 4 QLJantoven 1Lovenox 4 QLWarfarin Sodium 1Antihemorrhagic Agents - Drugs to Prevent BleedingCyklokapron 2Antiplatelet Agents - Blood ThinnersAnagrelide HCl 1Aggrenox 2 QLCilostazol 1Dipyridamole 1Plavix 2 QLTiclopidine HCl 1Hematopoietic Agents - Blood Formation DrugsAranesp 4 B/D, PAAranesp Albumin Free 4 B/D, PAAranesp Albumin Free SureClick 4 B/D, PA

Epogen (2000 unit/ml, 3000 unit/ml, 4000 unit/ml Injectable Solution)

3 B/D, PA, QL

Epogen (10000 unit/ml, 20000 unit/ml, 40000 unit/ml Injectable Solution)

3 B/D, PA


Tier Limits

Leukine 4 PANeulasta 4 PANeumega 4 PANeupogen 4 PAProcrit (2000 unit/ml, 3000 unit/ml, 4000 unit/ml Injectable Solution)

3 B/D, PA,QL

Procrit (10000 unit/ml, 20000 unit/ml, 40000 unit/ml Injectable Solution)

3 B/D, PA

Hemorrheologic Agents - Blood ThinnersPentopak 1Pentoxifylline CR 1Pentoxifylline ER 1Pentoxil 1

CARDIOVASCULAR DRUGS - DRUGS TO TREAT HEART OR CIRCULATION CONDITIONS

Alpha-Adrenergic Blocking Agents - Blood Pressure DrugsCardura XL 3Doxazosin Mesylate 1Prazosin HCl 1Terazosin HCl 1Angiotensin II Receptor Antagonists - Blood Pressure DrugsAtacand 3 QL, STAtacand HCT 3 QL, STAvalide * 3 QL, STAvapro * 3 QL, STBenicar 2 QL, STBenicar HCT 2 QL, STCozaar * 3 QL, STDiovan 2 QL, ST


19


Tier Limits

Diovan HCT 2 QL, STHyzaar * 3 QL, STMicardis 3 QL, STMicardis HCT 3 QL, STTeveten 3 QL, STTeveten HCT 3 QL, STAngiotensin-Converting Enzyme Inhibitors - Blood Pressure DrugsAceon 3Altace 3Benazepril HCl 1Benazepril HCl/Hydrochlorothiazide 1

Captopril 1Captopril/Hydrochlorothiazide 1

Enalapril Maleate 1Enalapril Maleate/Hydrochlorothiazide 1

Fosinopril Sodium 1Fosinopril Sodium/Hydrochlorothiazide 1

Lisinopril 1Lisinopril/Hydrochlorothiazide 1

Mavik * (1 mg Tablet) 3Moexipril HCl 1Moexipril HCl/Hydrochlorothiazide 1

Quinapril HCl 1Quinapril/Hydrochlorothiazide 1

Quinaretic 1Trandolapril 1Antiarrhythmic Agents - Heart Regulation DrugsAmiodarone HCl 1Disopyramide Phosphate 1


Tier Limits

Disopyramide Phosphate ER 1Ethmozine 3Flecainide Acetate 3Mexiletine HCl 1Norpace CR (100 mg 12-Hour Capsule) 3

Pacerone (100 mg Tablet, 300 mg Tablet) 3

Pacerone (200 mg Tablet) 1Procainamide HCl 1Procainamide HCl ER 1Procainamide HCl SR 1Procanbid 3Pronestyl (Tablet) 3Propafenone HCl 1Quinidine Gluconate 3Quinidine Gluconate CR 1Quinidine Gluconate ER 1Quinidine Gluconate SA 1Quinidine Sulfate 1Quinidine Sulfate ER 1Rythmol SR 3Tikosyn 3Beta-Adrenergic Blocking Agents - Blood Pressure and Heart Regulation DrugsAcebutolol HCl 1Atenolol 1Atenolol/Chlorthalidone 1Betaxolol HCl 1Bisoprolol Fumarate 1Bisoprolol Fumarate/Hydrochlorothiazide 1

Cartrol 3Carvedilol 1Coreg 2Coreg CR * 3 QL


20


Tier Limits

Corzide 3Innopran XL 3Labetalol HCl 1Levatol 3Metoprolol Succinate ER 1Metoprolol Tartrate 1Metoprolol/Hydrochlorothiazide 1

Nadolol 1Pindolol 1Propranolol HCl 1Propranolol HCl ER 1Propranolol/Hydrochlorothiazide 1

Sorine 1Sotalol HCl 1Sotalol HCl (AF) 1Tenormin (Solution) 3Timolide 10/25 3Timolol Maleate 1Bile Acid Sequestrants - Cholesterol Control DrugsColestipol HCl (Granules) 3Colestipol HCl (Tablet) 1Cholestyramine 1Cholestyramine Light 1Prevalite 1Welchol 3Cardiotonic Agents - Heart Regulation DrugsDigitek 1Digoxin 1Lanoxicaps 2Lanoxin 2Central Alpha-Agonists - Blood Pressure DrugsCatapres-TTS-1 3 QLCatapres-TTS-2 3 QLCatapres-TTS-3 3 QL


Tier Limits

Clonidine HCl 1Clorpres 3Guanabenz Acetate 1Guanfacine HCl 1Methyldopa 1Methyldopa/Hydrochlorothiazide 1

Methyldopate HCl 1Cholesterol Absorption Inhibitors - Cholesterol Control DrugsZetia 2 QLDihydropyridines - Blood Pressure DrugsAfeditab CR 1Amlodipine Besylate (Generic for Norvasc) 1

Amlodipine Besylate/Benazepril HCl 1

Azor 3 QL, STCaduet 3 QLCardene I.V. 3Cardene SR 3 QLDynacirc CR 3 QLExforge 2 QL, STFelodipine ER 1Isradipine 1Lexxel 3 STLotrel (5 mg/40 mg Capsule, 10 mg/40 mg Capsule)

2 QL

Nicardipine HCl 1Nifediac CC 1Nifedical XL 1Nifedipine 3Nifedipine ER 1Nifedipine 4Nimodipine 4Nimotop 4


21


Tier Limits

Sular 2 QLDirect Vasodilators - Blood Pressure DrugsHydralazine HCl 1Minoxidil 1Fibric Acid Derivatives - Cholesterol Control DrugsAntara 3Fenofibrate 1Gemfibrozil 1Tricor 2Triglide (50 mg Tablet) 3HMG-CoA Reductase Inhibitors - Cholesterol Control DrugsAdvicor 2 QLAltoprev 3 QLCrestor * 3 QL, STLescol * 3 QLLescol XL * 3 QLLipitor 2 QLLovastatin 1Pravastatin 1Simvastatin 1Vytorin 2 QLMineralocorticoid (Aldosterone) Receptor Antagonists - Blood Pressure DrugsAldactazide (50/50 mg Tablet) 3

Inspra 3 STSpironolactone 1Spironolactone/Hydrochlorothiazide 1

Miscellaneous Antilipemic Agents - Cholesterol Control Drugs Lovaza 3Niaspan 2Miscellaneous Calcium-Channel Blockers - Blood Pressure DrugsCardizem CD (360 mg 24-Hour Capsule) 3


Tier Limits

Cardizem LA 2 QLCartia XT 1Covera-HS 3 QLDilt-CD 1Dilt-XR 1Diltia XT 1Diltiazem CD 1Diltiazem HCl 1Diltiazem HCl ER 1Tarka 3 STTaztia XT 1Verapamil HCl 1Verapamil HCl ER 1Verelan PM 3Miscellaneous Cardiac Drugs - Chest Pain DrugsRanexa 3 PAMiscellaneous Hypotensive Agents - Blood Pressure DrugsInversine 3Tekturna 2 QL, STMiscellaneous Vasodilating Agents - Pulmonary Hypertension DrugsLetairis 4 PAPapaverine HCl 1Remodulin 4 B/D, PATracleer 4 PAVentavis 4 B/D, PANitrates and Nitrites - Chest Pain DrugsBidil 2Dilatrate SR 3Isochron 1Isordil Titradose (40 mg Tablet) 3

Isosorbide Dinitrate 1Isosorbide Dinitrate ER 1Isosorbide Mononitrate 1


22


Tier Limits

Isosorbide Mononitrate ER 1Minitran 1Nitrek 1Nitrobid 3Nitro-Dur (0.3 mg/hr 24-Hour Patch, 0.8 mg/hr 24-Hour Patch)

3

Nitroglycerin 1Nitroglycerin CR (9 mg Capsules) 1

Nitroglycerin TD 1Nitroglycerin Transdermal 1Nitrolingual Pumpspray 3Nitrostat 3Nitro-Time 1Peripheral Adrenergic Inhibitors - Blood Pressure Drugs Rauwolfia/Bendroflumethiazide 3

Reserpine 1Phosphodiesterase Inhibitors - Pulmonary Hypertension Drugs

Revatio 4 PA

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS TO TREAT NERVE CONDITIONS

Amphetamines - Stimulant DrugsAdderall XR 3 QLAmphetamine Salts Combo 1Dextroamphetamine Sulfate 1Dextroamphetamine Sulfate CR 1

Dextrostat (5 mg Tablet) 1Vyvanse 3 QLAntidepressantsAmitriptyline HCl 1Amoxapine 1Budeprion SR 1


Tier Limits

Budeprion XL 1Buproban 1Bupropion HCl 1Bupropion HCl SR 1Chlordiazepoxide/Amitriptyline 3

Citalopram Hydrobromide (Solution) 3

Citalopram Hydrobromide (Tablet) 1

Clomipramine HCl 1Cymbalta 2Desipramine HCl 1Doxepin HCl 1Effexor XR 2 QLEmsam 3 QLFluoxetine HCl 1Fluvoxamine Maleate 1Imipramine HCl 1Imipramine Pamoate 3Lexapro 2Maprotiline HCl 1Marplan 3Mirtazapine 1Nardil 2Nefazodone HCl 1Nortriptyline HCl 1Paroxetine HCl (Suspension) 3Paroxetine HCl (Tablet) 1Paxil (Suspension) 3Paxil CR 3 QLPerphenazine/Amitriptyline 1Pexeva 3Prozac Weekly 3 QLSarafem 3 QLSertraline HCl 1Surmontil (100 mg Capsule) 3


23


Tier Limits

Symbyax 3Tranylcypromine Sulfate 3Trazodone HCl 1Trimipramine Maleate 1Venlafaxine HCl 1Vivactil 3Wellbutrin XL (150 mg 24-Hour Tablet) 2 QL

Antimanic Agents - Mood StabilizersLithium Carbonate 1Lithium Carbonate ER 1Lithium Citrate (Syrup) 1Lithobid 3Antipsychotic AgentsAbilify 3Abilify Discmelt 3Chlorpromazine HCl 1Clozapine 1Equetro 2Fazaclo 3Fluphenazine Decanoate 1Fluphenazine HCl 1Geodon 3Haloperidol 1Invega 3Loxapine Succinate 1Moban 3Navane (20 mg Capsule) 3Orap 2Perphenazine 1Prochlorperazine 1Prochlorperazine Edisylate 1Prochlorperazine Maleate 1Risperdal 2Risperdal Consta 4Risperdal M-Tab 2


Tier Limits

Seroquel 2Seroquel XR 2Thioridazine HCl 3Thiothixene 1Trifluoperazine HCl 1Zyprexa 2Zyprexa Zydis 2Barbiturates (Anticonvulsants) - Seizure Control DrugsPrimidone 1Hydantoins - Seizure Control DrugsCerebyx 3Dilantin 2Dilantin Infatabs 2Peganone 3Phenytek 2Phenytoin 1Miscellaneous Analgesics - Pain Control DrugsDuraclon 4Miscellaneous Anorexigenic Agents and Cerebral StimulantsConcerta 3 QLDaytrana 3 QLDexmethylphenidate HCL 1Focalin XR 3 QLMetadate CD 3 QLMetadate ER (10 mg Controlled Release Tablet) 1

Methylin (Chewable Tablet) 3

Methylin (Solution) 3Methylin (Tablet) 1Methylin ER 1Methylphenidate HCl 1Methylphenidate HCl ER 1Provigil 2 PA,QLRitalin LA 3 QL


24


Tier Limits

Miscellaneous Anticonvulsants - Seizure Control DrugsCarbamazepine 1Carbatrol 2Depakote 2Depakote Sprinkles 2Epitol 1Felbatol 3Gabapentin 1Gabitril 3Keppra 2Lamictal (Tablet) 2Lamictal Starter Kits 2Lamotrigine Chewable Dispersible 3

Lyrica 3 PANeurontin (Solution) 3Oxcarbazepine (Tablet) 3Tegretol 2Tegretol-XR 2Topamax 3 PATopamax Sprinkle 3 PATrileptal 3Valproate Sodium 3Valproic Acid 1Zonisamide 1Miscellaneous Antimigraine Agents

Depakote ER 2Dihydroergotamine Mesylate 3Ergomar 3Ergotamine Tartrate/Caffeine 1Migergot 3Migranal 3 QL

Miscellaneous Anxiolytics, Sedatives, and Hypnotics - Drugs for Anxiety, Sedation, and Sleep

Ambien CR 2 QL


Tier Limits

Buspirone HCl 1Equagesic 3Hydroxyzine HCl 3Hydroxyzine Pamoate 3Lunesta 2 QLMeprobamate 3Rozerem 3 QLSonata * 3 QLVistaril (Suspension) 3Zolpidem Tartrate (Generic for Ambien) 1

Miscellaneous Central Nervous System AgentsApokyn 4 PAAtamet 1Azilect 2 STCampral 3Carbidopa/Levodopa 1Carbidopa/Levodopa CR 1Carbidopa/Levodopa ER 1Carbidopa/Levodopa SR 1Comtan 2Lodosyn 3Mirapex 2Namenda (Solution) 2Namenda (Tablet) 2 QLNamenda Titration Pak 2 QLNeupro 3 QL, STParcopa 3 STPrialt 4 B/DRequip 2Rilutek 4Selegiline HCl 1Stalevo 50 3 STStalevo 100 3 STStalevo 150 3 STStalevo 200 2


25


Tier Limits

Strattera 3 QL, STTasmar 3 STXyrem 3 QLZelapar 3 STNonsteroidal Anti-Inflammatory AgentsArthrotec 50 3Arthrotec 75 3Celebrex 3 QLDiclofenac Potassium 1Diclofenac Sodium 1Diclofenac Sodium DR 1Diclofenac Sodium EC 1Diclofenac Sodium ER 1Diclofenac Sodium XR 1Diflunisal 1Etodolac 1Etodolac ER 1Fenoprofen Calcium 1Flurbiprofen 1Ibuprofen 1Indomethacin 1Indomethacin ER 1Ketoprofen 1Ketoprofen ER 1Ketorolac Tromethamine 3 QLMeclofenamate Sodium 1Meloxicam (Suspension) 3Meloxicam (Tablet) 1MST 600 1Nabumetone 1Nalfon 3Naprelan (375 mg 24-Hour Tablet) 3

Naproxen 1Naproxen DR 1Orphenadrine Compound 3


Tier Limits

Orphenadrine Compound DS 3Orphengesic 3Orphengesic Forte 3Oxaprozin 1Piroxicam 1Prevacid Naprapac 3 QLSulindac 1Tolmetin Sodium (Capsule) 1Tolmetin Sodium (Tablet) 3Opiate Agonists - Narcotic Pain RelieversAcetaminophen/Codeine 1Acetaminophen/Codeine #2 1Acetaminophen/Codeine #3 1Acetaminophen/Codeine #4 1Anexsia 1Ascomp/Codeine 1Aspirin/Codeine 1Astramorph 1Avinza 2 QLBalacet 325 1Butalbital/Acetaminophen/Caffeine/Codeine 1

Butalbital/Aspirin/Caffeine/Codeine 1

Capital/Codeine 2Co-Gesic 1Combunox 3Darvon-N 3Depodur 4Dilaudid-5 3Dilaudid-HP 250mg (Solution for Reconstitution) 3

Dolacet 1Dolagesic 1Dolorex Forte 1Duramorph 1


26


Tier Limits

Endocet 1Eth-Oxydose 1Fentanyl (Patch) 3 QLFentanyl Citrate (Injectable) 1Fentanyl Citrate Oral Transmucosal 4 PA,QL

Fentora 4 PA,QLHycet 3Hydrocet 1Hydrocodone Bitartrate/Acetaminophen 1

Hydrocodone/Acetaminophen 1

Hydrocodone/Acetaminophen-HS 1

Hydrocodone/Ibuprofen 1Hydromorphone HCl 1Infumorph 200 3Infumorph 500 3Kadian 2 QLLevorphanol Tartrate 1Margesic-H 1Meperidine HCl 1Meperitab 1Methadone HCl (10 mg/5ml Solution, 5 mg/5ml Solution, Concentrate, Tablet)

1

Methadone HCl (10 mg/ml Solution) 3

Methadose 1Morphine/D5W 1Morphine Sulfate Add-Vantage 1

Morphine Sulfate Dilute-A-Jet 1

Morphine Sulfate/D5W 1Morphine Sulfate ER 3 QL


Tier Limits

Morphine Sulfate in Dextrose 5% 1

Morphine Sulfate/NS 1Morphine Sulfate Stick-Gard 1Nalbuphine HCl 1Narvox 1Numorphan 3Opana 3 QLOpana ER 2 QLOxycodone HCl 1Oxycodone HCl CR 3 QLOxycodone HCl ER 3 QLOxycodone/Acetaminophen 1Oxycodone/Aspirin 1Oxycontin 3 QLOxyfast 1Panlor DC 3Percocet (325 mg;2.5 mg Tablet) 3

Percolone 1Perloxx 1Phrenilin w/Caffeine/Codeine 1

Propoxyphene HCl 1Propoxyphene/Acetaminophen 1

Propoxyphene-N/Acetaminophen 1

Reprexain 3Roxicet (Solution) 3Roxicet (Tablet) 1Stagesic 1Suboxone 3Subutex 3Synalgos-DC 3Talwin 2Tramadol HCl 1


27


Tier Limits

Tramadol HCl/Acetaminophen 1

Ultram ER 3Vanacet 1Vopac 2Zerlor 1Zydone 3Opiate Antagonists - Narcotic Pain RelieversDepade 1Naloxone HCl 1Naltrexone HCl 1Revex 3Vivitrol 4Opiate Partial Agonists - Narcotic Pain RelieversBuprenorphine HCl 1Butorphanol Tartrate 1Pentazocine/Acetaminophen 1Pentazocine/Naloxone HCl 1Selective Serotonin Agonists - Migraine and Headache DrugsAmerge 3 QLAxert 3 QLFrova 3 QLImitrex 3 QLImitrex Statdose Pen 3 QLImitrex Statdose Refill 3 QLMaxalt 2 QLMaxalt-MLT 2 QLRelpax 3 QLZomig 3 QLZomig ZMT 3 QLSuccinimides - Seizure Control DrugsCelontin 3Ethosuximide 1


Tier Limits

DEVICES

DevicesAlcohol Swabs 1BD Insulin Needles, Pens, Syringes, Safety Syringes 1

Gauze Pads 1Insulin Needles, Pens, Syringes, Safety Syringes (Non-BD Brand Products)

2

ELECTROLYTIC, CALORIC, AND WATER BALANCE

Acidifying AgentsAmmonium Chloride 3Alkalinizing AgentsPotassium Citrate Extended-Release 1

Ammonia DetoxicantsBuphenyl (Powder) 4Buphenyl (Tablet) 3Constulose 1Enulose 1Generlac 1Kristalose 2Lactulose 1Lithostat 3Diuretics - Drugs for Water BalanceAmiloride/Hydrochlorothiazide 1

Bumetanide 1Chlorothiazide 1Chlorthalidone 1Demadex (Solution) 3Diuril 2Diuril IV 3Dyrenium 3Edecrin Sodium 3


28


Tier Limits

Furosemide 1Hydrochlorothiazide 1Indapamide 1Ismotic 3Methyclothiazide 1Metolazone 1Thalitone 3Torsemide 1Triamterene/Hydrochlorothiazide 1

Irrigating SolutionsBrand Irrigation Solutions 2Generic Irrigation Solutions 1Phosphate-Removing AgentsFosrenol 3Renagel 2Potassium-Removing AgentsKionex 1Sodium Polystyrene Sulfonate 1

Replacement PreparationsBrand Injectable Replacement Therapies 2

Generic Injectable Replacement Therapies 1

Ed K+10 1Kaon-Cl-10 1KCl 1KCl CR 1KCl ER 1KCl SA 1KCl SR 1Klor-Con 8 1Klor-Con 10 1Klor-Con M10 1Klor-Con M15 2


Tier Limits

Klor-Con M20 1K-Vescent 1Magnesium Sulfate in D5W 1Micro-K (8 meq Controlled Release Capsule) 2

NaCl 0.9% 1NaCl Bacteriostatic 1PhosLo 2Uricosuric Agents - Drugs to Decrease Uric AcidProbenecid 1Probenecid/Colchicine 1

ENZYMES

Enzyme Deficiency DrugsAdagen 4Aldurazyme 4Ceredase 4Cerezyme 4Elaprase 4Elitek 4Fabrazyme 4Myozyme 4Naglazyme 4Pulmozyme 4 B/D, PASucraid 4

EYE, EAR, NOSE & THROAT PREPARATIONS - EENT DRUGS

Antiallergic Agents - Drugs to Treat AllergiesAlamast 3Alocril 3Alomide 3Astelin 2 QLCromolyn Sodium (Solution) 1Elestat 3Emadine 3


29


Tier Limits

Ketotifen Fumarate 1Optivar 3Pataday 2Patanol 3Antibacterials (EENT) - Drugs to Treat Bacterial Infections

Ak-Poly-Bac 1Ak-Tob 1Arestin 3Atridox 3Bacitracin (Ointment) 1Bacitracin/Neomycin/Polymyxin 1

Bacitracin/Polymyxin B 1Ciloxan (Ointment) 2Ciprofloxacin HCl 1Erythromycin 1Floxin Otic 3 STFloxin Otic Singles 3 STGenoptic 1Gentak 1Gentamicin Sulfate 1Gentasol 1Neocin 1Neocin-PG 1Neomycin/Bacitracin/Polymyxin 1

Neomycin/Polymyxin/Gramicidin 1

Neomycin/Polymycin/Bacitracin/Hydrocortisone 1

Neomycin/Bacitracin Zinc/Polymyxin 1

Ocusulf-10 1Ofloxacin (Ophthalmic Solution) 1

Ofloxacin (Otic Solution) 1 ST


Tier Limits

Polycin B 1Polymyxin B Sulfate/Trimethoprim Sulfate 1

Quixin 3Romycin 1Sulf-10 1Sulfacetamide Sodium 1Tobramycin Sulfate 1Tobrasol 1Tobrex (Ointment) 3Trimethoprim Sulfate/Polymyxin B Sulfate 1

Vigamox 2Zymar 2Antifungals (EENT) - Drugs to Treat Fungal InfectionsNatacyn 2Antivirals (EENT) - Drugs to Treat Viral InfectionsTrifluridine 1Corticosteroids - Anti-Inflammatory DrugsAcetic Acid/Hydrocortisone 1Alrex 2Antibiotic Ear 1Beconase AQ 3 QLBlephamide 3Blephamide S.O.P. 3Cipro HC 3Ciprodex 3Coly-Mycin-S 3Cortisporin-TC 3Cortomycin 1Dermotic 2Dexamethasone Sodium Phosphate 1

Dexasol 1Dexasporin 1Flarex 2


30


Tier Limits

Flunisolide 1Fluorometholone 1Fluor-Op 1Fluticasone Propionate 1FML Forte 2FML S.O.P. 2Lotemax 2Maxidex 3Nasacort AQ 3 QLNasarel 3 QLNasonex 2 QLNeomycin/Polymyxin/Dexamethasone 1

Neomycin/Polymyxin/Hydrocortisone 1

Neomycin/Polymyxin/Hydrocortisone (1%; 3.5 mg/ml; 10000 unit/ml Suspension)

1

Oticin HC 1Poly-Dex 1Poly-Pred 2Pred-G 2Pred-G S.O.P. 2Prednisol 1Prednisolone 1Prednisolone Acetate 1Prednisolone Sodium Phosphate 1

Rhinocort Aqua 3 QLSulfacetamide Sodium/Prednisolone Sodium Phosphate

1

Tobradex 2Veramyst 3Vexol 3Zylet 2


Tier Limits

EENT - Glaucoma Drugs Acetazolamide (Injectable) 3Acetazolamide (Tablet) 1Alphagan P 3Azopt 2Betaxolol HCl 1Betimol 3Betoptic-S 3Brimonidine Tartrate 1Carteolol HCl 1Cosopt 3Diamox 3Istalol 3Levobunolol HCl 1Lumigan 2 QLMethazolamide 1Metipranolol 1Timolol Maleate 1Timolol Maleate Ophthalmic Gel Forming 1

Travatan 2 QLTravatan Z 2 QLTrusopt * 3Xalatan * 3 QLLocal Anesthetics (EENT) Lidomar Viscous 1Parcaine 1Proparacaine HCl 1Uni-Otic 1MioticsCarbastat 1Phospholine Iodide 2Pilopine HS 2Miscellaneous Anti-InfectivesChlorhexidine Gluconate 1Periogard 1


31


Tier Limits

Miscellaneous Anti-Inflammatory AgentsRestasis 3Miscellaneous EENT DrugsBorofair 1Iopidine 3Lacrisert 2MydriaticsAtropine Sulfate 3Dipivefrin HCl 1Mydral 1Tropicacyl 1Tropicamide 1Nonsteroidal Anti-Inflammatory AgentsAcular 3Acular LS 3Acular PF 3Flurbiprofen Sodium 1Nevanac 3Voltaren (Solution) 3Xibrom 3VasoconstrictorsAk-Con 1Naphazoline HCl 1Tyzine 2Tyzine Pediatric Nasal Drops 2

GASTROINTESTINAL AGENTS - DRUGS TO TREAT BOWEL, INTESTINE OR STOMACH CONDITIONS

5-HT3 Receptor Antagonists - Nausea and Vomiting Prevention DrugsAloxi 4Anzemet (Solution) 3Anzemet (Tablet) 4 B/D, PA, QLKytril (0.1 mg/ml Solution, 1 mg/ml Solution) 4


Tier Limits

Kytril (2 mg/10ml Oral Solution, Tablet) 4 B/D, PA, QL

Ondansetron HCl (2 mg/ml Solution, 32 mg/50ml Solution)

3

Ondansetron HCl (4 mg/5ml Oral Solution, Tablet) 3 B/D, PA, QL

Ondansetron ODT 3 B/D, PA, QLAntidiarrhea Agents Diphenoxylate/Atropine 3Lofene 3Lonox 3Loperamide HCl 1Motofen 3Opium Tincture 3Paregoric 1

Antihistamines (GI Drugs) - Nausea and Vomiting Prevention Drugs

Antivert (50 mg Tablet) 3Meclizine HCl 1Trimethobenzamide HCl 3Anti-Inflammatory Agents - Bowel Treatment DrugsAsacol 2Canasa 3Colazal 3Dipentum 3Lialda 3Mesalamine 1Pentasa 3Cathartics and Laxatives - Bowel Treatment DrugsAmitiza 3 PA,QLGlycolax 1Golytely (236 gm; 2.97 gm; 6.74 gm; 5.86 gm; 22.74 Solution for Reconstitution)

2

Halflytely Bowel Prep Kit 2


32


Tier Limits

Moviprep 2Nulytely 2Osmoprep 2Polyethylene Glycol 3350 1Polyethylene Glycol 3350/Electrolytes 1

Trilyte 2Visicol 2

Cholelitholytic Agents - Drugs to Treat Gall Stones

Urso 250 3Urso Forte 3Ursodiol 3Digestants - Digestive Enzymes

Creon 5 2Creon 10 2Creon 20 2Dygase 3Enzycap 3Enzymax 3Kutrase 3Ku-Zyme 3Ku-Zyme HP 3Lapase 3Lipram 4500 3Lipram-PN10 3Lipram-PN16 3Lipram-PN20 3Lipram-UL12 3Lipram-UL18 3Lipram-UL20 3Palcaps 10 3Palcaps 20 3Palipase 3Palipase MT 16 3Palipase MT 20 3Palpeon DR 10 3


Tier Limits

Palpeon DR 20 3Palpeon MT 20 3Paltrase V8 3Pancrease MT 4 3Pancrease MT 10 3Pancrease MT 16 3Pancrease MT 20 3Pancrecarb MS-4 3Pancrecarb MS-8 3Pancrecarb MS-16 3Pancrelipase 3Pancrelipase MST-16 3Pancron 10 3Pancron 20 3Pangestyme CN 10 3Pangestyme CN 20 3Pangestyme EC 3Pangestyme MT 16 3Pangestyme UL 12 3Pangestyme UL 18 3Pangestyme UL 20 3Panocaps 3Panocaps MT 16 3Panocaps MT 20 3Panokase 3Panokase-16 3Plaretase 8000 3Ultracaps MT 20 3Ultrase 2Ultrase MT 12 2Ultrase MT 18 2Ultrase MT 20 2Viokase 3Viokase 8 3Viokase 16 3


33


Tier Limits

Histamine H2-Antagonists - Ulcer and Stomach Acid DrugsAxid (Solution) 3Cimetidine 1Famotidine 1Famotidine Premixed 1Nizatidine 1Pepcid (Suspension for Reconstitution) 3

Ranitidine HCl (Capsule, Injectable, Tablet) 1

Ranitidine HCl (Syrup) 3Zantac (50 mg/50ml; 0.45% Solution, Effervescent Tablet, Pack)

3

Miscellaneous Antiemetics - Nausea and Vomiting Prevention DrugsCesamet 3 B/D, PA, QLCompro 1Emend 2 B/D, PA, QLMarinol 4 B/D, PATransderm-Scop 3Miscellaneous GI Drugs - Gastrointestinal DrugsLotronex 2 PA, QLProchlorperazine 1Xenical 3Prokinetic Agents - Nausea and Vomiting Prevention DrugsMetoclopramide HCl 1Prostaglandins - Ulcer and Stomach Acid DrugsMisoprostol 1Protectants - Ulcer and Stomach Acid DrugsCarafate (Suspension) 3Sucralfate 1


Tier Limits

Proton-Pump Inhibitors - Ulcer and Stomach Acid DrugsAciphex * 3 QLNexium 2 QLNexium I.V. 3Omeprazole 1 QLPrevacid 2 QLPrevacid I.V. 3Prevacid Solutab 2 QLPrilosec (40 mg Delayed Release Capsule) 3 QL

Protonix (Delayed Release Tablet) 2 QL

Protonix (Solution for Reconstitution) 3

Prevpac 3 QLZegerid 3 QL

GOLD COMPOUNDS

Gold Compounds - Arthritis DrugsRidaura 3

HEAVY METAL ANTAGONISTS

Heavy Metal AntagonistsChemet 3Cuprimine 2Depen Titratabs 3Exjade 4Syprine 3

HORMONES AND SYNTHETIC SUBSTITUTES

Adrenals - Corticosteroids - Anti-Inflammatory DrugsAerobid 3Aerobid-M 3


34


Tier Limits

A-Methapred 1Aristospan Intra-Articular 3Aristospan Intralesional 3Asmanex 14 Metered Doses 2 QL

Asmanex 30 Metered Doses 2 QL



Azmacort 3Celestone 3Cortef (10 mg Tablet, 5 mg Tablet) 3

Cortisone Acetate 1Depo-Medrol (20 mg/ml Suspension) 2

Dexamethasone 1Dexamethasone Intensol 1Dexamethasone Sodium Phosphate 1

Dexpak 13 Day 3Entocort EC 3Flovent HFA 3Fludrocortisone Acetate 1Hydrocortisone (Enema) 3Hydrocortisone (Tablet) 1Kenalog-10 2Kenalog-40 2Medrol (16 mg Tablet, 2 mg Tablet, 32 mg Tablet) 3

Methylprednisolone 1Methylprednisolone Acetate 1Methylprednisolone Sodium Succinate 1

Orapred ODT 3


Tier Limits

Prednisone 1Prednisone Intensol 1Pulmicort Respules 3 B/D, PAPulmicort Flexhaler 3QVAR 2Solu-Cortef 2Solu-Medrol (2 gm Solution for Reconstitution)

2

Alpha-Glucosidase Inhibitors - Diabetes DrugsGlyset 3Precose 2Androgens - Testosterone DrugsAnadrol-50 4 PAAndroderm 2 PAAndrogel 2 PAAndrogel Pump 2 PAAndroid 3Androxy 3Danazol 3Methitest 3Nandrolone Decanoate 2Oxandrolone 4 PAStriant 3 PATestim 3 PATestopel 3Testosterone Cypionate 1Testosterone Enanthate 1Testred 3Antithyroid AgentsMethimazole 1Propylthiouracil 1Biguanides - Diabetes DrugsFortamet 3Glumetza 3


35


Tier Limits

Metformin HCl 1Metformin HCl ER 1Riomet 3Contraceptives - Birth Control DrugsApri 1Aranelle 1Aviane 1Balziva 1Camila 1Cesia 1Cryselle-28 1Enpresse-28 1Errin 1Estrostep Fe 3Femcon Fe 3Jolessa 1Jolivette 1Junel 1.5/30 1Junel 1/20 1Junel Fe 1.5/30 1Junel Fe 1/20 1Kariva 1Kelnor 1/35 1Leena 1Lessina-28 1Levora 0.15/30-28 1Low-Ogestrel 1Lutera 1Microgestin 1.5/30 1Microgestin 1/20 1Microgestin Fe 1Microgestin Fe 1.5/30 1MonoNessa 1Necon 0.5/35-28 1Necon 1/35-28 1


Tier Limits

Necon 1/50-28 1Necon 10/11-28 1Necon 7/7/7 1Nora-BE 1Nortrel 0.5/35 (28) 1Nortrel 1/35 (21) 1Nortrel 1/35 (28) 1Nortrel 7/7/7 1Ogestrel 1Ortho Evra 2Ortho Tri-Cyclen Lo 3Ovcon-50 28 3Plan B 3Portia-28 1Previfem 1Quasense 3Reclipsen 1Seasonale 3Seasonique 3Solia 1Sprintec 28 1Sronyx 1Tri-Legest FE 1TriNessa 1Tri-Previfem 1Tri-Sprintec 1Trivora-28 1Velivet 1Yasmin 28 2Yaz 2Zovia 1/35E 1Zovia 1/50E 1NuvaRing 2Estrogen Agonist-AntagonistsEvista 2 QL


36


Tier Limits

EstrogensActivella 3Alora 2Angeliq 3Cenestin 3Climara Pro 3Combipatch 3Delestrogen 3Depo-Estradiol 3Divigel 3 QLElestrin 3 QLEnjuvia 3Esclim 3Estrace (Cream) 3Estraderm 2Estradiol 1Estrasorb 3Estring 3 QLEstrogel 3 QLEstropipate 1Femhrt 1/5 3Femhrt Low Dose 3Femring 3 QLFemtrace 3Gynodiol (0.5 mg Tablet, 1 mg Tablet, 2 mg Tablet) 1

Gynodiol (1.5 mg Tablet) 2Lybrel 3Menest 2Menostar 3Ortho-Est 1Prefest 3Premarin 2Premarin w/Applicator 2Premphase 3Prempro 3


Tier Limits

Vagifem 2Vivelle 3Vivelle-Dot 2Glycogenolytic Agents - Diabetes DrugsGlucagen Hypokit 3Glucagon Emergency Kit 2Gonadotropins - Hormone Regulation DrugsChorionic Gonadotropin 1Novarel 1Pregnyl w/Diluent Benzyl Alcohol/NaCl 1

Synarel 4InsulinsApidra 3 STExubera Combination Pack 15 3 PA

Exubera Kit 3 PAHumalog 2Humalog Mix 50/50 2Humalog Mix 50/50 Pen 2Humalog Mix 75/25 2Humalog Mix 75/25 Pen 2Humalog Pen 2Humulin 50/50 2Humulin 70/30 2Humulin 70/30 Pen 2Humulin N 2Humulin N U-100 Pen 2Humulin R 2Lantus 2Lantus OptiClik 2Levemir 2Levemir FlexPen 2Novolin 70/30 2Novolin 70/30 Innolet 2Novolin 70/30 Penfill 2


37


Tier Limits

Novolin N 2Novolin N Innolet 2Novolin N U-100 Penfill 2Novolin R 2Novolin R Innolet 2Novolin R U-100 2Novolin R U-100 Penfill 2Novolog 2Novolog FlexPen 2Novolog Mix 70/30 2Novolog Mix 70/30 Penfill 2Novolog Mix 70/30 Prefilled FlexPen 2

Novolog Penfill 2Relion 70/30 3Relion 70/30 Innolet 3Relion N 3Relion N Innolet 3Relion R 3Meglitinides - Diabetes DrugsPrandin 3 QLStarlix 2 QLMiscellaneous Diabetes Drugs

Byetta 3 STJanuvia 3 STJanumet 3 STSymlin 3 PAMiscellaneous Antihypoglycemic Agents

Proglycem 3ParathyroidForteo 4 B/D, PAFortical 2 QLMiacalcin * (200 unit/ml Injectable Solution) 3 B/D, PA

Miacalcin * (200 unit/act Nasal Solution) 3 QL


Tier Limits

Pituitary

Desmopressin Acetate 3Minirin 3Stimate 4ProgestinsCrinone 3Depo-Provera (400 mg/ml Injectable) 3

Depo-Subq Provera 104 3Endometrin 3Medroxyprogesterone Acetate 1

Megace ES 3Norethindrone Acetate 1Prochieve 3Prometrium 3Somatotropin Agonists - Growth Deficiency Drugs

Genotropin 4 PAGenotropin Miniquick 4 PAHumatrope 4 PAHumatrope Combo Pack 4 PAIncrelex 4 PAIplex 4 PANorditropin Cartridge 4 PANorditropin Nordiflex 4 PANorditropin Nordiflex Pen 4 PANutropin 4 PANutropin AQ 4 PANutropin AQ Pen 4 PASaizen 4 PASaizen Click.Easy 4 PASerostim 4 PATev-Tropin 4 PAZorbtive 4 PASomatotropin Antagonists

Somavert 4 PA


38


Tier Limits

Sulfonylureas - Diabetes Drugs

Chlorpropamide 1Glimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glipizide/Metformin HCl 1Glyburide 1Glyburide Micronized 1Glyburide/Metformin HCl 1Glycron (1.5 mg Tablet, 3 mg Tablet, 6 mg Tablet) 1

Glycron (4.5 mg Tablet) 2Tolazamide 1Tolbutamide 1Thiazolidinediones - Diabetes Drugs

Actoplus Met 2 STActos 2 QLAvandamet 2 STAvandaryl 2 STAvandia 2 QLDuetact 2 STThyroid AgentsCytomel 2Levothroid 2Levothyroxine Sodium 1Levoxyl 1Liothyronine Sodium 1Synthroid 2Thyrolar-1/4 2Thyrolar-1/2 2Thyrolar-1 2Thyrolar-2 2Thyrolar-3 2Unithroid 1


Tier Limits

LOCAL ANESTHETICS

Local AnestheticsLidocaine HCl 1

MISCELLANEOUS THERAPEUTIC AGENTS

Miscellaneous Therapeutic AgentsAcetadote 3Actimmune 4Actonel 2 QLActonel With Calcium 2 QLAllopurinol 1Antabuse 2Antizol 4Aphthasol 2Aralast 4 Atgam 4 B/D, PAAvodart 3 QLAvonex 4 PAAzasan 3Azathioprine Sodium 3Betaseron 4 PABoniva * (Kit) 3Boniva * (Tablet) 3 QLBotox 4 PABromocriptine Mesylate 3Cabergoline 3Cellcept 4 B/D, PACellcept Intravenous 4 B/D, PAColchicine (Solution) 3Colchicine (Tablet) 1Copaxone 4 PACyclosporine 3 B/D, PACyclosporine Modified 3 B/D, PACystadane 3


39


Tier Limits

Cystagon 3Demser 3Dexrazoxane 1Didronel (400 mg Tablets) 3Elmiron 3Enbrel 4 PAEnbrel SureClick 4 PAEthyol 4Etidronate Disodium 1Finasteride 1Flomax 2 QLFosamax 2 QLFosamax Plus D 2 QLGastrocrom 3Gengraf 3 B/D, PAHumira 4 PAHumira Pen 4 PAKineret 4 PALeflunomide 1Leucovorin Calcium (Solution for Reconstitution, Tablet)

1

Leucovorin Calcium (Solution) 3

Levocarnitine (Solution) 3Levocarnitine (Tablet) 1Mesna 4Mesnex (Tablet) 4Myfortic 3 B/D, PAMyobloc 3Octreotide Acetate 4 PAOrencia 4 PAOrfadin 4Orthoclone OKT3 4 B/D, PA


Tier Limits

Pamidronate Disodium (30 mg/10ml Solution, 90 mg/10ml Solution, Solution for Reconstitution)

3

Pamidronate Disodium (6 mg/ml Solution) 4

Prograf 4 B/D, PAProlastin 4 Quadramet 4Rapamune 3 B/D, PARebif 4 PARebif Titration Pack 4 PAReclast 4Remicade 4 PARevlimid 4 PASandostatin LAR Depot 4 PASensipar 2Simulect 4 B/D, PASkelid 3Sodium Fluoride 3Somatuline Depot 4 PASoriatane 4Thalomid 4 PAThiola 3Thymoglobulin 4 B/D, PATysabri 4 PAUroxatral * 3 QLZavesca 4Zemaira 4 Zenapax 3 B/D, PAZometa 4

OXYTOCICS

Oxytocics - Drugs for Labor and DeliveryMethergine 2Oxytocin 3


40


Tier Limits

PHARMACEUTICAL AIDS

Pharmaceutical AidsNaCl Bacteriostatic/ Benzyl Alcohol 1

RESPIRATORY AGENTS - DRUGS TO TREAT LUNG CONDITIONS

Antileukotrienes - Asthma DrugsAccolate 3 QL, STSingulair 2 QL, STZyflo 3 STZyflo CR 3 STMast Cell Stabilizers - Asthma DrugsCromolyn Sodium (Nebulizer Solution) 1 B/D

Intal Inhaler 2Tilade 3Miscellaneous Respiratory Agents - Asthma DrugsXolair 4 PAMucolytic Agents - Mucus Dissolving DrugsAcetylcysteine 1 B/D

SERUMS, TOXOIDS AND VACCINES

Serums - Immune System DrugsCarimune 4 B/D, PACarimune Nanofiltered 4 B/D, PAFlebogamma 4 B/D, PAGamastan S/D 3 B/D, PAGammagard Liquid 4 B/D, PAGammagard S/D 4 B/D, PAGamunex 4 B/D, PAImmune Globulin 1 B/D, PAIveegam EN 4 B/D, PAOctagam 4 B/D, PAPanglobulin 4 B/D, PAPanglobulin NF 4 B/D, PA


Tier Limits

Polygam S/D 4 B/D, PAVenoglobulin-S 4 B/D, PAVivaglobin 4 B/D, PAToxoids - VaccinesAdacel 2Boostrix 2Daptacel 2Decavac 2Diptheria/Tetanus Toxoid Pediatric 2

Infanrix 2Tetanus Toxoid 2Tetanus Toxoid Adsorbed 2Tetanus/Diphtheria Toxoids-Absorbed Adult 2

TriHiBit 2Tripedia 2VaccinesActhib 2Attenuvax 3Comvax 2Engerix-B 2 B/D, PAGardasil 2Havrix 2Hibtiter 2Imovax Rabies (H.D.C.V.) 2Ipol Inactivated IPV 2Je-Vax 3Menactra 2Menomune-A/C/Y/W-135 3Meruvax II w/Diluent 1 Dose 2

Meruvax II w/Diluent 10 Dose 2

M-M-R II w/Diluent 1 Dose 2


41


Tier Limits

M-M-R II w/Diluent 10 Dose 2

M-R-Vax II 2Mumpsvax w/Diluent 1 Dose 2

Mumpsvax w/Diluent 10 Dose 2

Pediarix 2Pedvax HIB 2ProQuad 2Rabavert 3Recombivax HB 2 B/D, PARotaTeq 2Theracys 3Tice BCG 3Twinrix 2Typhim Vi 3Vaqta 2Varivax 2Vivotif Berna 3YF-Vax 2Zostavax 2

SKIN AND MUCOUS MEMBRANE PREPARATIONS

Antibacterials (Skin & Mucous Membrane Agents) - Bacterial Infection DrugsAkne-Mycin 3Altabax 3Bactroban (Cream) 3Bactroban Nasal 3Benzaclin 2Clindagel 1Clindamycin Phosphate 1Clindesse 3Clindets 1


Tier Limits

Duac 3Eryderm 1Erythromycin/Benzoyl Peroxide 1

Evoclin 3Gentamicin Sulfate 1Metrogel 3Metronidazole 1Metronidazole Vaginal 1Mupirocin 1Noritate 3Rozex 3Vandazole 1Z-Clinz 5 3Z-Clinz 10 3Antifungals (Skin & Mucous Membrane Agents) - Fungal Infection DrugsCiclopirox (Nail Lacquer) 3Ciclopirox (Suspension) 1Ciclopirox Olamine (Cream) 1Clotrimazole 1Clotrimazole/Betamethasone Dipropionate 1

Econazole Nitrate 1Ertaczo 3Exelderm 3Extina 3Gynazole-1 2Ketoconazole (Cream, Shampoo) 1

Kuric 1Lamisil (Spray) 3Loprox (Gel) 3Loprox Shampoo 3Mentax 3Miconazole 3 1


42


Tier Limits

Monistat 7 Combination Pack 2

Naftin 2Naftin-MP 2Nyamyc 1Nystatin 1Nystop 1Oxistat 3Pedi-Dri 1Penlac Nail Lacquer 3 QLTerconazole 1Xolegel 3Zazole 1Anti-Inflammatory AgentsAla-Cort 1Ala-Scalp 2Alclometasone Dipropionate 1Alphatrex 1Amcinonide 1Augmented Betamethasone Dipropionate 1

Betamethasone Dipropionate 1

Betamethasone Valerate 1Beta-Val 1Capex 3Cetacort 1Clobetasol Propionate 1Clobetasol Propionate Emollient 1

Clobevate 1Clobex 3Cloderm 3Colocort 1Cordran 3Cordran SP 3


Tier Limits

Cordran Tape 3Cormax 1Cortifoam 3Cortisporin (Cream) 2Cortisporin (Ointment) 3Cutivate (Lotion) 3Del-Beta 1Derma-Smoothe/ FS Body Oil 3

Derma-Smoothe/ FS Scalp Oil 3

Desonate 3Desonide 1Desoximetasone 1Diflorasone Diacetate 1Fluocinolone Acetonide 1Fluocinonide 1Fluocinonide Emollient Base 1Fluocinonide-E 1Halog 3Hydrocortisone (Cream, Lotion, Ointment) 1

Hydrocortisone (Enema, Tablet) 3

Hydrocortisone Butyrate 1Hydrocortisone in Absorbase 1

Hydrocortisone Valerate 1Isovate 1Kenalog (Aerosol Solution) 2

Lacticare-HC 1Locoid Lipocream 2Lokara 1Luxiq 3Mometasone Furoate 1Nystatin/Triamcinolone 1


43


Tier Limits

Olux 3Olux-E 3Pandel 3Prednicarbate 1Proctocream-HC 1Procto-Kit 1Procto-Pak 1Proctosol HC 1Proctozone-HC 1Psorcon E 3Taclonex 3Texacort (1% Solution) 1Texacort (2.5% Solution) 3Triamcinolone Acetonide 1Triamcinolone Acetonide in Absorbase 1

Triamcinolone in Orabase 1Triderm 1U-Cort 1Vanos 3Verdeso 3Antipruritics and Local AnestheticsEmla/Tegaderm 3Lidocaine 1Lidocaine HCl Jelly 1Lidocaine/Prilocaine 1Lidoderm 2 QLPhenazopyridine HCl 1Synera 3Antivirals (Skin & Mucous Membrane Agents) - Viral Infection DrugsDenavir 2Zovirax (Cream, Ointment) 3

Basic Lotions and LinimentsAmmonium Lactate 1


Tier Limits

LACcream 1LAClotion 1Cell Stimulants and ProliferantsAvita (Cream) 1Kepivance 4Retin-A Micro 2Tretinoin (Cream, Gel) 1Depigmenting AgentsBenoquin 3Miscellaneous Local Anti-InfectivesSelenium Sulfide 1Silver Sulfadiazine 1SSD 1SSD AF 1Sulfamylon (Cream) 2Sulfamylon (Pack) 3Thermazene 1Miscellaneous Skin and Mucous Membrane AgentsAldara 2Amevive 4 PAAmnesteem 3Azelex 3Carac 2Claravis 3Condylox (Gel) 3Differin 3Dovonex 2Efudex Occlusion Pack 2Elidel 3 STFinacea 3Fluoroplex 2Fluorouracil 1Levulan Kerastick 3Panretin 4


44


Tier Limits

Podocon 25 in Benzoin Tincture 1

Podofilox 1Protopic 3 STRaptiva 4 PARegranex 4 PA,QLSantyl 3Solaraze 3Sotret (10 mg Capsule, 20 mg Capsule, 40 mg Capsule)

3

Sotret (30 mg Capsule) 3Targretin 4Tazorac 3Ziana 3Pigmenting Agents8-Mop 4Oxsoralen 2Oxsoralen Ultra 4Uvadex 3Scabicides and Pediculicides - Scabies and Lice DrugsActicin 1Eurax 2Lindane 1Ovide 3Permethrin 1

SMOOTH MUSCLE RELAXANTS

Genitourinary Smooth Muscle Relaxants - Bladder Control DrugsDetrol 2 QLDetrol LA 2 QLEnablex 2 QLFlavoxate HCl 1


Tier Limits

Oxybutynin Chloride 1Oxybutynin Chloride ER 1Oxytrol 2 QLSanctura * 3 QL, STVesicare * 3 QL, STRespiratory Smooth Muscle - Asthma DrugsAminophylline 1Dilor 3Elixophyllin 2Theo-24 2Theocap 1Theochron 1Theophylline CR 1Theophylline ER 1Theophylline TD 1Uniphyl 2

VITAMINS

Miscellaneous VitaminsBrand Nutritional Supplements 2 B/D

Brand Prenatal Vitamins 2Generic Nutritional Supplements 1 B/D

Generic Prenatal Vitamins 1Vitamin B ComplexNiacor 1Vitamin D - Renal Disease Drugs Calcitriol (Capsules, Solution) 1

Hectorol 3Zemplar (Capsule) 3 ST

45

8-Mop ............................................. 44

A

Abelcet ........................................... 13Abilify ............................................. 23Abilify Discmelt .............................. 23Abraxane ........................................ 14Accolate ......................................... 40Accuneb.......................................... 17Acebutolol HCl ............................... 19Aceon ............................................. 19Acetadote ....................................... 38Acetaminophen/Codeine ............... 25Acetaminophen/Codeine #2 .......... 25Acetaminophen/Codeine #3 .......... 25Acetaminophen/Codeine #4 .......... 25Acetazolamide................................ 30Acetic Acid/Hydrocortisone ........... 29Acetylcysteine ................................ 40Aciphex........................................... 33Acthib ............................................. 40Acticin ............................................ 44Actimmune ..................................... 38Activella ......................................... 36Actonel ........................................... 38Actonel With Calcium .................... 38Actoplus Met.................................. 38Actos .............................................. 38Acular ............................................. 31Acular LS ........................................ 31Acular PF ........................................ 31Acyclovir ......................................... 12Adacel ............................................ 40Adagen ........................................... 28Adderall XR .................................... 22Adoxa Pak 1/150 ............................ 13Adrenalin ........................................ 17Adriamycin ..................................... 14Advair Diskus ................................. 16

Advair HFA ..................................... 17Advicor ........................................... 21Aerobid ........................................... 33Aerobid-M ...................................... 33Afeditab CR .................................... 20Agenerase ........................................ 9Aggrenox ........................................ 18Airet................................................ 17Ak-Con ............................................ 31Akineton ......................................... 16Akne-Mycin .................................... 41Ak-Poly-Bac .................................... 29Ak-Tob ............................................ 29Ala-Cort .......................................... 42Alamast .......................................... 28Ala-Scalp ........................................ 42Albenza............................................. 9Albuterol......................................... 17Albuterol Sulfate ........................... 17Albuterol Sulfate/

Ipratropium Bromide ................... 16Alclometasone Dipropionate ......... 42Alcohol Swabs ............................... 27Aldactazide..................................... 21Aldara ............................................. 43Aldurazyme..................................... 28Alferon N ........................................ 14Alimta ............................................. 14Alinia .............................................. 11Alkeran ........................................... 14Allegra .............................................. 8Allegra-D 12 Hour ............................ 8Allegra-D 24 Hour ............................ 8Allopurinol ...................................... 38Alocril ............................................. 28Alomide .......................................... 28Alora ............................................... 36Aloxi ............................................... 31Alphagan P ..................................... 30

Alphatrex ........................................ 42Alrex ............................................... 29Altabax ........................................... 41Altace ............................................. 19Altoprev .......................................... 21Alupent ........................................... 17Amantadine HCl ............................... 8Ambien CR...................................... 24Ambisome ...................................... 13Amcinonide .................................... 42Amerge ........................................... 27A-Methapred .................................. 34Amevive.......................................... 43Amikacin Sulfate .............................. 8Amiloride/Hydrochlorothiazide ...... 27Aminophylline ................................ 44Amiodarone HCl ............................. 19Amitiza ........................................... 31Amitriptyline HCl ............................ 22Amlodipine Besylate ..................... 20Amlodipine Besylate/

Benazepril HCl ............................ 20Ammonium Chloride....................... 27Ammonium Lactate ........................ 43Amnesteem .................................... 43Amoclan ......................................... 12Amoxapine ..................................... 22Amoxicillin...................................... 12Amoxicillin/Clavulanate

Potassium ................................... 12Amoxil .......................................... 1 2Amphetamine Salts Combo ........... 22Amphocin ....................................... 13Amphotec ....................................... 13Amphotericin B............................... 13Ampicillin ....................................... 12Ampicillin-Sulbactam ..................... 12Amrix .............................................. 17Anadrol-50...................................... 34

DRUG INDEX

4646

Anagrelide HCl ............................... 18Ancobon ......................................... 13Androderm...................................... 34Androgel ......................................... 34Androgel Pump ............................... 34Android ........................................... 34Androxy .......................................... 34Anexsia........................................... 25Angeliq ........................................... 36Antabuse ........................................ 38Antara............................................. 21Antibiotic Ear.................................. 29Antivert........................................... 31Antizol ............................................ 38Anzemet ......................................... 31Aphthasol ....................................... 38Apidra ............................................. 36Apokyn............................................ 24Apri ................................................. 35Aptivus ............................................. 9Aralast ............................................ 38Aranelle .......................................... 35Aranesp .......................................... 18Aranesp Albumin Free.................... 18Aranesp Albumin Free SureClick ... 18Arestin ............................................ 29Aricept ............................................ 16Aricept ODT .................................... 16Arimidex ......................................... 14Aristospan Intra-Articular .............. 34Aristospan Intralesional ................. 34Arixtra............................................. 18Aromasin ........................................ 14Arranon........................................... 14Arthrotec 50 ................................... 25Arthrotec 75 ................................... 25Asacol............................................. 31Ascomp/Codeine ............................ 25Asmanex 14 Metered Doses.......... 34Asmanex 30 Metered Doses.......... 34Asmanex 60 Metered Doses.......... 34Asmanex 120 Metered Doses........ 34

Aspirin/Codeine ............................. 25Astelin ............................................ 28Astramorph..................................... 25Atacand .......................................... 18Atacand HCT .................................. 18Atamet............................................ 24Atenolol .......................................... 19Atenolol/Chlorthalidone................. 19Atgam ............................................. 38Atreza ............................................. 16Atridox ............................................ 29Atripla............................................... 9Atropine Sulfate ............................. 31Atrovent HFA .................................. 16Attenuvax ....................................... 40Augmented Betamethasone

Dipropionate ............................... 42Augmentin ...................................... 12Augmentin XR ................................ 12Avalide ........................................... 18Avandamet ..................................... 38Avandaryl ....................................... 38Avandia .......................................... 38Avapro ............................................ 18Avastin ........................................... 14Avelox ............................................ 13Avelox ABC Pack ............................ 13Aviane ............................................ 35Avinza ............................................. 25Avita ............................................... 43Avodart ........................................... 38Avonex ............................................ 38Axert ............................................... 27Axid ................................................ 33Azactam.......................................... 12Azactam in Dextrose ...................... 12Azasan ............................................ 38Azasite............................................ 11Azathioprine Sodium ...................... 38Azelex ............................................. 43Azilect............................................. 24Azithromycin................................... 11

Azmacort ........................................ 34Azopt .............................................. 30Azor ................................................ 20

B

Baciim............................................. 11Bacitracin ....................................... 29Bacitracin/Neomycin/Polymyxin .... 29Bacitracin/Polymyxin B .................. 29Baclofen ......................................... 17Bactocill in Dextrose ...................... 12Bactroban ....................................... 41Bactroban Nasal............................. 41Balacet 325 .................................... 25Balziva ............................................ 35Baraclude ....................................... 12BD Insulin Needles, Pens, Syringes,

Safety Syringes ........................... 27Beconase AQ .................................. 29Benazepril HCl ................................ 19Benazepril HCl/

Hydrochlorothiazide .................... 19Benicar ........................................... 18Benicar HCT.................................... 18Benoquin ........................................ 43Benzaclin ........................................ 41Benztropine Mesylate .................... 16Betamethasone Dipropionate ........ 42Betamethasone Valerate ............... 42Betaseron ....................................... 38Beta-Val .......................................... 42Betaxolol HCl............................ 19, 30Bethanechol Chloride ..................... 16Betimol ........................................... 30Betoptic-S....................................... 30Bexxar............................................. 14Bicillin C-R ...................................... 12Bicillin L-A ...................................... 12Bicnu w/Diluent Absolute

Ethanol ........................................ 14Bidil ................................................ 21Biltricide ........................................... 9

47

Bio-Statin ....................................... 13Bisoprolol Fumarate ....................... 19Bisoprolol Fumarate/

Hydrochlorothiazide .................... 19Bleomycin Sulfate .......................... 14Blephamide .................................... 29Blephamide S.O.P. .......................... 29Boniva............................................. 38Boostrix .......................................... 40Borofair........................................... 31Botox .............................................. 38Brand Injectable Replacement

Therapies .................................... 28Brand Irrigation Solutions .............. 28Brand Nutritional Supplements ..... 44Brand Prenatal Vitamins ................ 44Brimonidine Tartrate ...................... 30Bromocriptine Mesylate................. 38Brovana .......................................... 16Budeprion SR.................................. 22Budeprion XL .................................. 22Bumetanide .................................... 27Buphenyl......................................... 27Buprenorphine HCl ......................... 27Buproban ........................................ 22Bupropion HCl ................................ 22Bupropion HCl SR ........................... 22Buspirone HCl................................. 24Busulfex.......................................... 14Butalbital/Acetaminophen/

Caffeine/Codeine ........................ 25Butalbital/Aspirin/Caffeine/

Codeine ....................................... 25Butorphanol Tartrate ...................... 27Byetta ............................................. 37

C

Cabergoline .................................... 38Caduet ............................................ 20Calcitriol ......................................... 44Camila ............................................ 35Campath ......................................... 14Campral .......................................... 24

Camptosar ...................................... 14Canasa............................................ 31Cancidas ......................................... 10Cantil .............................................. 16Capastat Sulfate .............................. 9Capex.............................................. 42Capital/Codeine ............................. 25Captopril ......................................... 19Captopril/Hydrochlorothiazide ....... 19Carac .............................................. 43Carafate.......................................... 33Carbamazepine............................... 24Carbastat ........................................ 30Carbatrol......................................... 24Carbidopa/Levodopa ...................... 24Carbidopa/Levodopa CR................. 24Carbidopa/Levodopa ER ................. 24Carbidopa/Levodopa SR................. 24Carboplatin ..................................... 14Cardene I.V. .................................... 20Cardene SR..................................... 20Cardizem CD ................................... 21Cardizem LA ................................... 21Cardura XL ...................................... 18Carimune ........................................ 40Carimune Nanofiltered ................... 40Carisoprodol ................................... 17Carisoprodol/Aspirin ...................... 17Carisoprodol/Aspirin/Codeine ....... 17Carteolol HCl .................................. 30Cartia XT......................................... 21Cartrol............................................. 19Carvedilol ....................................... 19Casodex .......................................... 14Catapres-TTS-1 .............................. 20Catapres-TTS-2 .............................. 20Catapres-TTS-3 .............................. 20Cedax.............................................. 10Ceenu ............................................. 14Cefaclor .......................................... 10Cefaclor ER ..................................... 10Cefadroxil ....................................... 10Cefdinir .......................................... 10

Cefizox in Dextrose 5% .................. 10Cefotaxime Sodium ........................ 10Cefotetan........................................ 10Cefoxitin ......................................... 12Cefpodoxime Proxetil ..................... 10Cefprozil ......................................... 10Ceftazidime .................................... 10Ceftin .............................................. 10Ceftriaxone/Dextrose ..................... 10Ceftriaxone in Iso-Osmotic

Dextrose ...................................... 10Ceftriaxone Sodium........................ 10Cefuroxime Axetil........................... 10Cefuroxime/Dextrose ..................... 10Cefuroxime Sodium ........................ 10Celebrex ......................................... 25Celestone ....................................... 34Cellcept .......................................... 38Cellcept Intravenous ...................... 38Celontin .......................................... 27Cenestin ......................................... 36Cephalexin...................................... 10Cerebyx........................................... 23Ceredase ........................................ 28Cerezyme ........................................ 28Cesamet ......................................... 33Cesia............................................... 35Cetacort .......................................... 42Chantix ........................................... 16Chemet ........................................... 33Chloramphenicol Sodium

Succinate .................................... 10Chlordiazepoxide/Amitriptyline ..... 22Chlorhexidine Gluconate ................ 30Chloroquine Phosphate .................... 9Chlorothiazide ................................ 27Chlorpromazine HCl........................ 23Chlorpropamide .............................. 38Chlorthalidone ................................ 27Chlorzoxazone ................................ 17Cholestyramine .............................. 20Cholestyramine Light ..................... 20Chorionic Gonadotropin ................. 36

4848

Ciclopirox........................................ 41Ciclopirox Olamine ......................... 41Cilostazol ........................................ 18Ciloxan............................................ 29Cimetidine ...................................... 33Ciprodex ......................................... 29Ciprofloxacin................................... 13Ciprofloxacin ER ............................ 13Ciprofloxacin HCl ...................... 13, 29Cipro HC ......................................... 29Cipro I.V.-in D5W ............................ 13Cipro ............................................... 13Cisplatin ......................................... 14Cisplatin AQ ................................... 14Citalopram Hydrobromide .............. 22Cladribine ....................................... 14Claforan/D5W Galaxy .................... 10Claravis........................................... 43Clarinex ............................................ 8Clarinex-D 12 Hour ........................... 8Clarinex-D 24 Hour ........................... 8Clarinex Reditabs ............................. 8Clarithromycin ................................ 11Clarithromycin ER ........................... 11Clemastine Fumarate ....................... 8Cleocin............................................ 11Cleocin Galaxy................................ 11Cleocin Pediatric Granules ............. 11Climara Pro ..................................... 36Clindagel ........................................ 41Clindamycin HCl ............................. 11Clindamycin Phosphate ............ 11, 41Clindamycin Phosphate

Add-Vantage ............................... 11Clindesse ........................................ 41Clindets .......................................... 41Clobetasol Propionate .................... 42Clobetasol Propionate Emollient.... 42Clobevate ....................................... 42Clobex............................................. 42Cloderm .......................................... 42Clolar .............................................. 14Clomipramine HCl .......................... 22

Clonidine HCl.................................. 20Clorpres .......................................... 20Clotrimazole ................................... 41Clotrimazole/Betamethasone

Dipropionate ............................... 41Clozapine ........................................ 23Cogentin ......................................... 16Co-Gesic ......................................... 25Cognex............................................ 16Colazal ............................................ 31Colchicine ....................................... 38Colestipol HCl................................. 20Colistimethate Sodium................... 11Colocort .......................................... 42Coly-Mycin-S .................................. 29Combipatch .................................... 36Combivent ...................................... 16Combivir ........................................... 9Combunox....................................... 25Compro ........................................... 33Comtan ........................................... 24Comvax ........................................... 40Concerta ......................................... 23Condylox ......................................... 43Constulose...................................... 27Copaxone........................................ 38Cordran ........................................... 42Cordran SP...................................... 42Cordran Tape .................................. 42Coreg .............................................. 19Coreg CR ........................................ 19Cormax ........................................... 42Cortef ............................................. 34Cortifoam........................................ 42Cortisone Acetate .......................... 34Cortisporin ...................................... 42Cortisporin-TC ................................ 29Cortomycin ..................................... 29Corzide............................................ 20Cosmegen....................................... 14Cosopt ............................................ 30Coumadin ....................................... 18Covera-HS ...................................... 21

Cozaar............................................. 18Creon 5 ........................................... 32Creon 10 ......................................... 32Creon 20 ......................................... 32Crestor ............................................ 21Crinone ........................................... 37Crixivan............................................. 9Cromolyn Sodium ..................... 40, 28Cryselle-28 ..................................... 35Cubicin............................................ 11Cuprimine ....................................... 33Cutivate .......................................... 42Cyclobenzaprine HCl ...................... 17Cyclophosphamide ......................... 14Cyclosporine ................................... 38Cyclosporine Modified ................... 38Cyklokapron .................................... 18Cymbalta ........................................ 22Cyproheptadine HCl ......................... 8Cystadane....................................... 38Cystagon......................................... 39Cytarabine ...................................... 14Cytarabine Aqueous ....................... 14Cytomel .......................................... 38Cytovene......................................... 12

D

Dacarbazine.................................... 14Dacogen ......................................... 14Danazol........................................... 34Dantrolene Sodium ........................ 17Dapsone ......................................... 11Daptacel ......................................... 40Daraprim........................................... 9Darvon-N ........................................ 25Daunorubicin HCl ........................... 14Daunoxome .................................... 14Daytrana ......................................... 23Decavac .......................................... 40Del-Beta ......................................... 42Delestrogen .................................... 36Demadex ........................................ 27Demeclocycline HCl ....................... 13

49

Demser ........................................... 39Denavir ........................................... 43Depade ........................................... 27Depakote ........................................ 24Depakote ER ................................... 24Depakote Sprinkles ........................ 24Depen Titratabs .............................. 33Depodur .......................................... 25Depo-Estradiol................................ 36Depo-Medrol .................................. 34Depo-Provera.................................. 37Depo-Subq Provera 104 ................. 37Derma-Smoothe/FS Body Oil ......... 42Derma-Smoothe/FS Scalp Oil ........ 42Dermotic ......................................... 29Desipramine HCl ............................ 22Desmopressin Acetate ................... 37Desonate ........................................ 42Desonide ........................................ 42Desoximetasone............................. 42Detrol.............................................. 44Detrol LA ........................................ 44Dexamethasone ............................. 34Dexamethasone Intensol ............... 34Dexamethasone Sodium

Phosphate ............................. 29, 34Dexasol........................................... 29Dexasporin ..................................... 29Dexchlorpheniramine Maleate ........ 8Dexmethylphenidate HCL .............. 23Dexpak 13 Day ............................... 34Dexrazoxane ................................... 39Dextroamphetamine Sulfate .......... 22Dextroamphetamine Sulfate CR .... 22Dextrostat....................................... 22Diamox ........................................... 30Dibenzyline ..................................... 17Diclofenac Potassium..................... 25Diclofenac Sodium ......................... 25Diclofenac Sodium DR ................... 25Diclofenac Sodium EC .................... 25Diclofenac Sodium ER .................... 25Diclofenac Sodium XR.................... 25

Dicloxacillin Sodium....................... 12Dicyclomine HCl ............................. 16Didanosine ....................................... 9Didronel .......................................... 39Differin ........................................... 43Diflorasone Diacetate .................... 42Diflunisal ........................................ 25Digitek ............................................ 20Digoxin ........................................... 20Dihydroergotamine Mesylate ........ 24Dilantin ........................................... 23Dilantin Infatabs............................. 23Dilatrate SR .................................... 21Dilaudid-5 ....................................... 25Dilaudid-HP 250mg ........................ 25Dilor ................................................ 44Dilt-CD ............................................ 21Diltia XT.......................................... 21Diltiazem CD................................... 21Diltiazem HCl.................................. 21Diltiazem HCl ER ............................ 21Dilt-XR ............................................ 21Diovan ............................................ 18Diovan HCT..................................... 19Dipentum ........................................ 31Diphenhydramine HCl ...................... 8Diphenoxylate/Atropine ................. 31Dipivefrin HCl ................................. 31Diptheria/Tetanus

Toxoid Pediatric .......................... 40Dipyridamole .................................. 18Disopyramide Phosphate ............... 19Disopyramide Phosphate ER .......... 19Dispermox ...................................... 13Diuril ............................................... 27Diuril IV........................................... 27Divigel ............................................ 36Dolacet ........................................... 25Dolagesic........................................ 25Dolorex Forte .................................. 25Doribax ........................................... 12Doryx .............................................. 13Dovonex.......................................... 43

Doxazosin Mesylate ....................... 18Doxepin HCl.................................... 22Doxil ............................................... 14Doxorubicin HCl.............................. 14Doxy-Caps ...................................... 13Doxycycline Hyclate ................. 13, 14Doxycycline Monohydrate.............. 14Droxia ............................................. 14Duac ............................................... 41Duetact ........................................... 38Duoneb ........................................... 16Duraclon ......................................... 23Duramorph...................................... 25Dygase............................................ 32Dynabac D5-Pak ............................. 11Dynacin........................................... 14Dynacirc CR .................................... 20Dyrenium ........................................ 27

E

Econazole Nitrate ........................... 41Edecrin Sodium .............................. 27Ed K+10 .......................................... 28E.E.S. 200 ....................................... 11E.E.S. 400 ....................................... 11Effexor XR....................................... 22Efudex Occlusion Pack ................... 43Elaprase.......................................... 28Elestat ............................................ 28Elestrin ........................................... 36Elidel............................................... 43Eligard ............................................ 14Elitek............................................... 28Elixophyllin ..................................... 44Ellence ............................................ 14Elmiron ........................................... 39Eloxatin........................................... 14Elspar.............................................. 15Emadine.......................................... 28Emcyt .............................................. 15Emend............................................. 33Emla/Tegaderm .............................. 43Emsam ............................................ 22

5050

Emtriva ............................................. 9Enablex ........................................... 44Enalapril Maleate........................... 19Enalapril Maleate/

Hydrochlorothiazide .................... 19Enbrel ............................................. 39Enbrel SureClick ............................. 39Endocet........................................... 26Endometrin ..................................... 37Engerix-B ........................................ 40Enjuvia ............................................ 36Enlon-Plus....................................... 16Enpresse-28.................................... 35Entocort EC ..................................... 34Enulose ........................................... 27Enzycap........................................... 32Enzymax.......................................... 32Epinephrine HCl.............................. 17Epipen 2-Pak................................... 17Epipen-Jr 2-Pak .............................. 17Epirubicin HCl ................................. 15Epitol .............................................. 24Epivir................................................. 9Epivir HBV......................................... 9Epogen............................................ 18Epzicom ............................................ 9Equagesic ....................................... 24Equetro ........................................... 23Eraxis .............................................. 10Erbitux ............................................ 15Ergoloid Mesylates ........................ 17Ergomar .......................................... 24Ergotamine Tartrate/Caffeine ........ 24Errin ................................................ 35Ertaczo ............................................ 41Eryderm .......................................... 41Eryped............................................. 11Eryped 400...................................... 11Ery-Tab ............................................ 11Erythrocin ....................................... 11Erythrocin Lactobionate ................. 11Erythrocin Stearate ........................ 11Erythromycin............................. 11, 29

Erythromycin/Benzoyl Peroxide...... 41Erythromycin Ethylsuccinate .......... 11Erythromycin Lactobionate............. 11Erythromycin/Sulfisoxazole ............ 11Esclim ............................................. 36Estrace............................................ 36Estraderm ....................................... 36Estradiol ......................................... 36Estrasorb ........................................ 36Estring ............................................ 36Estrogel .......................................... 36Estropipate ..................................... 36Estrostep Fe.................................... 35Ethambutol HCl ................................ 9Ethmozine ....................................... 19Ethosuximide .................................. 27Eth-Oxydose ................................... 26Ethyol.............................................. 39Etidronate Disodium....................... 39Etodolac.......................................... 25Etodolac ER .................................... 25Etopophos....................................... 15Etoposide........................................ 15Eurax............................................... 44Evista .............................................. 35Evoclin ............................................ 41Evoxac ............................................ 16Exelderm......................................... 41Exelon ............................................. 16Exforge .......................................... 20Exjade ............................................. 33Extina.............................................. 41Exubera Combination Pack 15........ 36Exubera Kit ..................................... 36

F

Fabrazyme ...................................... 28Factive ............................................ 13Famotidine...................................... 33Famotidine Premixed...................... 33Famvir ............................................. 12Fansidar ............................................ 9Fareston.......................................... 15

Faslodex ......................................... 15Fazaclo............................................ 23Felbatol........................................... 24Felodipine ER.................................. 20Femara............................................ 15Femcon Fe ...................................... 35Femhrt 1/5 ...................................... 36Femhrt Low Dose ........................... 36Femring........................................... 36Femtrace......................................... 36Fenofibrate ..................................... 21Fenoprofen Calcium ....................... 25Fentanyl .......................................... 26Fentanyl Citrate .............................. 26Fentanyl Citrate Oral

Transmucosal .............................. 26Fentora ........................................... 26Fexofenadine HCl ............................. 8Finacea ........................................... 43Finasteride...................................... 39Flagyl ER ......................................... 11Flarex .............................................. 29Flavoxate HCl ................................. 44Flebogamma ................................... 40Flecainide Acetate ......................... 19Flomax ............................................ 39Flovent HFA .................................... 34Floxin Otic....................................... 29Floxin Otic Singles.......................... 29Floxuridine ...................................... 15Fluconazole..................................... 10Fluconazole in Dextrose ................. 10Fluconazole in NaCl........................ 10Fludarabine Phosphate................... 15Fludrocortisone Acetate ................. 34Flumadine ......................................... 8Flunisolide ...................................... 30Fluocinolone Acetonide.................. 42Fluocinonide ................................... 42Fluocinonide-E ................................ 42Fluocinonide Emollient Base .......... 42Fluorometholone ............................ 30Fluor-Op .......................................... 30

51

Fluoroplex ....................................... 43Fluorouracil............................... 15, 43Fluoxetine HCl ................................ 22Fluphenazine Decanoate ................ 23Fluphenazine HCl............................ 23Flurbiprofen .................................... 25Flurbiprofen Sodium ....................... 31Flutamide........................................ 15Fluticasone Propionate................... 30Fluvoxamine Maleate..................... 22FML Forte ....................................... 30FML S.O.P. ...................................... 30Focalin XR....................................... 23Foradil Aerolizer ............................. 17Fortamet ......................................... 34Fortaz .............................................. 10Forteo ............................................. 37Fortical............................................ 37Fosamax ......................................... 39Fosamax Plus D .............................. 39Foscarnet Sodium........................... 12Fosinopril Sodium........................... 19Fosinopril Sodium/

Hydrochlorothiazide .................... 19Fosrenol .......................................... 28Fragmin........................................... 18Frova ............................................... 27Furadantin ...................................... 14Furosemide ..................................... 28Fuzeon .............................................. 9

G

Gabapentin ..................................... 24Gabitril............................................ 24Gamastan S/D ................................ 40Gammagard Liquid ......................... 40Gammagard S/D............................. 40Gamunex ........................................ 40Ganciclovir...................................... 12Gantrisin Pediatric.......................... 13Gardasil .......................................... 40Gastrocrom ..................................... 39Gauze Pads ..................................... 27

Gemfibrozil ..................................... 21Gemzar ........................................... 15Generic Injectable Replacement

Therapies .................................... 28Generic Irrigation Solutions ........... 28Generic Nutritional

Supplements ............................... 44Generic Prenatal Vitamins ............. 44Generlac ......................................... 27Gengraf........................................... 39Genoptic ......................................... 29Genotropin...................................... 37Genotropin Miniquick..................... 37Gentak ............................................ 29Gentamicin Sulfate .............. 8, 29, 41Gentamicin Sulfate/0.9% NaCl ....... 8Gentamicin Sulfate/NaCl ................. 8Gentasol ......................................... 29Geocillin ......................................... 13Geodon ........................................... 23Gleevec........................................... 15Glimepiride ..................................... 38Glipizide.......................................... 38Glipizide ER .................................... 38Glipizide/Metformin HCl ................ 38Glipizide XL..................................... 38Glucagen Hypokit ........................... 36Glucagon Emergency Kit ................ 36Glumetza ........................................ 34Glyburide ........................................ 38Glyburide/Metformin HCl............... 38Glyburide Micronized ..................... 38Glycolax .......................................... 31Glycopyrrolate ................................ 16Glycron ........................................... 38Glyset ............................................. 34Golytely .......................................... 31Grifulvin V....................................... 11Griseofulvin Microsize ................... 11Gris-Peg .......................................... 11Guanabenz Acetate ........................ 20Guanfacine HCl .............................. 20Guanidine HCl ................................ 16

Gynazole-1...................................... 41Gynodiol ......................................... 36

H

Halflytely Bowel Prep Kit ............... 31Halog .............................................. 42Haloperidol ..................................... 23Havrix ............................................. 40Hectorol .......................................... 44Helidac ........................................... 11Heparin Sodium.............................. 18Heparin Sodium/D5W .................... 18Heparin Sodium DCU ..................... 18Heparin Sodium/NaCl .................... 18Hepsera .......................................... 12Herceptin ........................................ 15Hexalen .......................................... 15Hibtiter ........................................... 40Humalog ......................................... 36Humalog Mix 50/50 ....................... 36Humalog Mix 50/50 Pen ................ 36Humalog Mix 75/25 ....................... 36Humalog Mix 75/25 Pen ................ 36Humalog Pen .................................. 36Humatrope...................................... 37Humatrope Combo Pack ................. 37Humira ............................................ 39Humira Pen ..................................... 39Humulin 50/50................................ 36Humulin 70/30................................ 36Humulin 70/30 Pen......................... 36Humulin N ...................................... 36Humulin N U-100 Pen..................... 36Humulin R ....................................... 36Hycamtin ........................................ 15Hycet .............................................. 26Hydralazine HCl ............................. 21Hydrocet ......................................... 26Hydrochlorothiazide ....................... 28Hydrocodone/Acetaminophen ....... 26Hydrocodone/

Acetaminophen-HS ..................... 26

5252

Hydrocodone Bitartrate/ Acetaminophen ........................... 26

Hydrocodone/Ibuprofen ................. 26Hydrocortisone ......................... 34, 42Hydrocortisone Butyrate ................ 42Hydrocortisone in Absorbase ......... 42Hydrocortisone Valerate ................ 42Hydromorphone HCl ....................... 26Hydroxychloroquine Sulfate ............. 9Hydroxyurea ................................... 15Hydroxyzine HCl ............................. 24Hydroxyzine Pamoate ..................... 24Hyzaar............................................. 19

I

Ibuprofen ........................................ 25Idarubicin........................................ 15Ifosfamide ...................................... 15Ifosfamide/Mesna.......................... 15Imipramine HCl............................... 22Imipramine Pamoate ...................... 22Imitrex ............................................ 27Imitrex Statdose Pen ...................... 27Imitrex Statdose Refill.................... 27Immune Globulin ............................ 40Imovax Rabies ................................ 40Increlex ........................................... 37Indapamide..................................... 28Indomethacin.................................. 25Indomethacin ER ............................ 25Infanrix ........................................... 40Infergen .......................................... 11Infumorph 200 ................................ 26Infumorph 500 ................................ 26Innohep........................................... 18Innopran XL .................................... 20Inspra.............................................. 21Insulin Needles, Pens, Syringes,

Safety Syringes ........................... 27Intal Inhaler .................................... 40Intron-A .......................................... 15Intron-A w/Diluent ......................... 15Invanz ............................................. 12

Invega ............................................. 23Inversine ......................................... 21Invirase ............................................. 9Iopidine........................................... 31Iplex ................................................ 37Ipol Inactivated IPV ........................ 40Ipratropium Bromide ...................... 16Iressa .............................................. 15Isentress ........................................... 9Ismotic ............................................ 28Isochron .......................................... 21Isonarif ............................................. 9Isoniazid ........................................... 9Isordil Titradose ............................. 21Isosorbide Dinitrate........................ 21Isosorbide Dinitrate ER .................. 21Isosorbide Mononitrate.................. 21Isosorbide Mononitrate ER ............ 22Isovate ............................................ 42Isradipine........................................ 20Istalol.............................................. 30Isuprel............................................. 17Itraconazole .................................... 10Iveegam EN .................................... 40Ixempra Kit ..................................... 15

J

Jantoven......................................... 18Janumet ......................................... 37Januvia ........................................... 37Je-Vax ............................................ 40Jolessa ........................................... 35Jolivette ......................................... 35Junel 1/20 ...................................... 35Junel 1.5/30 ................................... 35Junel Fe 1/20 ................................. 35Junel Fe 1.5/30 .............................. 35

K

Kadian ............................................ 26Kaletra .............................................. 9Kanamycin Sulfate ........................... 8Kaon-Cl-10...................................... 28

Kariva ............................................. 35KCl .................................................. 28KCl CR............................................. 28KCl ER ............................................. 28KCl SA ............................................ 28KCl SR............................................. 28Keflex.............................................. 10Kelnor 1/35..................................... 35Kemadrin ........................................ 16Kenalog .......................................... 42Kenalog-10 ..................................... 34Kenalog-40 ..................................... 34Kepivance ....................................... 43Keppra ............................................ 24Ketek .............................................. 11Ketek Pak........................................ 11Ketoconazole ............................ 10, 41Ketoprofen...................................... 25Ketoprofen ER ................................ 25Ketorolac Tromethamine ................ 25Ketotifen Fumarate ........................ 29Kineret ............................................ 39Kionex............................................. 28Klor-Con 8 ....................................... 28Klor-Con 10 ..................................... 28Klor-Con M10 ................................. 28Klor-Con M15 ................................. 28Klor-Con M20 ................................. 28Kristalose ....................................... 27Kuric ............................................... 41Kutrase ........................................... 32Ku-Zyme ......................................... 32Ku-Zyme HP .................................... 32K-Vescent ....................................... 28Kytril ............................................... 31

L

Labetalol HCl .................................. 20LACcream ....................................... 43LAClotion ........................................ 43Lacrisert.......................................... 31Lacticare-HC ................................... 42Lactulose ........................................ 27

53

Lamictal .......................................... 24Lamictal Starter Kits ...................... 24Lamisil ............................................ 41Lamotrigine Chewable

Dispersible .................................. 24Lanoxicaps...................................... 20Lanoxin ........................................... 20Lantus ............................................. 36Lantus OptiClik ............................... 36Lapase ............................................ 32Leena .............................................. 35Leflunomide .................................... 39Lescol ............................................. 21Lescol XL ........................................ 21Lessina-28 ...................................... 35Letairis............................................ 21Leucovorin Calcium ........................ 39Leukeran ......................................... 15Leukine ........................................... 18Leuprolide Acetate ......................... 15Levaquin ......................................... 13Levaquin Leva-Pak.......................... 13Levaquin Premix ............................. 13Levatol ............................................ 20Levemir ........................................... 36Levemir FlexPen ............................. 36Levobunolol HCl ............................. 30Levocarnitine .................................. 39Levora 0.15/30-28 .......................... 35Levorphanol Tartrate ...................... 26Levothroid....................................... 38Levothyroxine Sodium .................... 38Levoxyl............................................ 38Levulan Kerastick ........................... 43Lexapro ........................................... 22Lexiva ............................................... 9Lexxel ............................................. 20Lialda .............................................. 31Lidocaine ........................................ 43Lidocaine HCl ................................. 38Lidocaine HCl Jelly......................... 43Lidocaine/Prilocaine....................... 43Lidoderm......................................... 43

Lidomar Viscous ............................. 30Lindane ........................................... 44Liothyronine Sodium ...................... 38Lipitor ............................................. 21Lipram 4500.................................... 32Lipram-PN10................................... 32Lipram-PN16................................... 32Lipram-PN20................................... 32Lipram-UL12 ................................... 32Lipram-UL18 ................................... 32Lipram-UL20 ................................... 32Lisinopril ......................................... 19Lisinopril/Hydrochlorothiazide ....... 19Lithium Carbonate .......................... 23Lithium Carbonate ER..................... 23Lithium Citrate................................ 23Lithobid........................................... 23Lithostat ......................................... 27Locoid Lipocream ........................... 42Lodosyn .......................................... 24Lofene............................................. 31Lokara ............................................. 42Lonox .............................................. 31Loperamide HCl .............................. 31Loprox ............................................. 41Loprox Shampoo............................. 41Lotemax .......................................... 30Lotrel .............................................. 20Lotronex.......................................... 33Lovastatin ....................................... 21Lovaza ............................................ 21Lovenox .......................................... 18Low-Ogestrel .................................. 35Loxapine Succinate ........................ 23Lumigan .......................................... 30Lunesta ........................................... 24Lupron Depot .................................. 15Lupron Depot-PED .......................... 15Lutera ............................................. 35Luxiq ............................................... 42Lybrel .............................................. 36Lyrica .............................................. 24Lysodren ......................................... 15

M

Macrodantin ................................... 14Magnesium Sulfate in D5W .......... 28Malarone .......................................... 9Maprotiline HCl .............................. 22Margesic-H..................................... 26Marinol ........................................... 33Marplan .......................................... 22Matulane ........................................ 15Mavik.............................................. 19Maxair Autohaler ........................... 17Maxalt ............................................ 27Maxalt-MLT .................................... 27Maxidex.......................................... 30Maxipime ....................................... 10Mebendazole.................................... 9Meclizine HCl ................................. 31Meclofenamate Sodium................. 25Medrol ............................................ 34Medroxyprogesterone Acetate ...... 37Mefloquine HCl ................................ 9Mefoxin in Dextrose 2.2% ............. 12Mefoxin in Dextrose 3.9% ............. 12Megace ES ..................................... 37Megestrol Acetate ........................ 15Meloxicam...................................... 25Menactra ........................................ 40Menest ........................................... 36Menomune-A/C/Y/W-135 ............. 40Menostar ........................................ 36Mentax ........................................... 41Meperidine HCl .............................. 26Meperitab....................................... 26Meprobamate................................. 24Mepron ........................................... 12Mercaptopurine.............................. 15Merrem........................................... 12Meruvax II w/Diluent 1 Dose ......... 40Meruvax II w/Diluent 10 Dose ....... 40Mesalamine ................................... 31Mesna ............................................ 39Mesnex........................................... 39Mestinon ........................................ 16

5454

Mestinon Timespan ....................... 16Metadate CD .................................. 23Metadate ER .................................. 23Metaproterenol Sulfate ................. 17Metformin HCl................................ 35Metformin HCl ER .......................... 35Methadone HCl .............................. 26Methadose ..................................... 26Methazolamide .............................. 30Methenamine Hippurate ................ 14Methergine..................................... 39Methimazole .................................. 34Methitest........................................ 34Methocarbamol .............................. 17Methotrexate ................................. 15Methscopolamine Bromide ............ 16Methyclothiazide............................ 28Methyldopa .................................... 20Methyldopa/

Hydrochlorothiazide .................... 20Methyldopate HCl .......................... 20Methylin ......................................... 23Methylin ER .................................... 23Methylphenidate HCl ..................... 23Methylphenidate HCl ER ................ 23Methylprednisolone ....................... 34Methylprednisolone Acetate ......... 34Methylprednisolone Sodium

Succinate .................................... 34Metipranolol................................... 30Metoclopramide HCl ...................... 33Metolazone .................................... 28Metoprolol/Hydrochlorothiazide .... 20Metoprolol Succinate ER ............... 20Metoprolol Tartrate ........................ 20Metrogel......................................... 41Metro IV ......................................... 12Metronidazole .......................... 12, 41Metronidazole in NaCl 0.79%........ 12Metronidazole Vaginal ................... 41Mexiletine HCl ............................... 19Miacalcin........................................ 37Micardis ......................................... 19

Micardis HCT.................................. 19Miconazole 3 .................................. 41Microgestin 1/20............................ 35Microgestin 1.5/30......................... 35Microgestin Fe ............................... 35Microgestin Fe 1.5/30 .................... 35Micro-K........................................... 28Midodrine HCl ................................ 17Migergot......................................... 24Migranal ......................................... 24Minirin ............................................ 37Minitran.......................................... 22Minocin PAC ................................... 14Minocycline HCl ............................. 14Minoxidil ........................................ 21Mintezol ........................................... 9Mirapex .......................................... 24Mirtazapine .................................... 22Misoprostol .................................... 33Mitomycin ...................................... 15Mitoxantrone HCl ........................... 15M-M-R II w/Diluent 1 Dose ........... 40M-M-R II w/Diluent 10 Dose ......... 41Moban ............................................ 23Moexipril HCl ................................. 19Moexipril HCl/

Hydrochlorothiazide .................... 19Mometasone Furoate ..................... 42Monistat 7 Combination Pack ........ 42MonoNessa .................................... 35Monurol .......................................... 14Morphine/D5W .............................. 26Morphine Sulfate Add-Vantage ..... 26Morphine Sulfate/D5W ................. 26Morphine Sulfate Dilute-A-Jet ...... 26Morphine Sulfate ER ...................... 26Morphine Sulfate

in Dextrose 5% ........................... 26Morphine Sulfate/NS..................... 26Morphine Sulfate Stick-Gard ......... 26Motofen.......................................... 31Moviprep ........................................ 32M-R-Vax II ...................................... 41

MST 600 ......................................... 25Mumpsvax w/Diluent 1 Dose ........ 41Mumpsvax w/Diluent 10 Dose ...... 41Mupirocin ....................................... 41Mustargen ...................................... 15Mycamine....................................... 10Mycobutin ........................................ 9Mydral ............................................ 31Myfortic .......................................... 39Mylotarg ......................................... 15Myobloc.......................................... 39Myozyme ........................................ 28Myrac ............................................. 14Mytelase ........................................ 16

N

Nabumetone................................... 25NaCl 0.9% ...................................... 28NaCl Bacteriostatic ........................ 28NaCl Bacteriostatic/Benzyl

Alcohol ........................................ 40Nadolol ........................................... 20Nafcillin Sodium............................. 13Naftin ............................................. 42Naftin-MP....................................... 42Naglazyme...................................... 28Nalbuphine HCl .............................. 26Nalfon............................................. 25Nallpen/Dextrose ........................... 13Nallpen Iso-Osmotic in Dextrose ... 13Naloxone HCl ................................. 27Naltrexone HCl ............................... 27Namenda ........................................ 24Namenda Titration Pak .................. 24Nandrolone Decanoate .................. 34Naphazoline HCl............................. 31Naprelan......................................... 25Naproxen ........................................ 25Naproxen DR .................................. 25Nardil.............................................. 22Narvox ............................................ 26Nasacort AQ ................................... 30Nasarel ........................................... 30

55

Nasonex ......................................... 30Natacyn .......................................... 29Navane ........................................... 23Nebupent........................................ 12Necon 0.5/35-28 ............................ 35Necon 1/35-28 ............................... 35Necon 1/50-28 ............................... 35Necon 7/7/7 ................................... 35Necon 10/11-28 ............................. 35Nefazodone HCl ............................. 22Neocin ............................................ 29Neocin-PG ...................................... 29Neo-Fradin........................................ 8Neomycin/Bacitracin/Polymyxin .... 29Neomycin/Bacitracin Zinc/

Polymyxin .................................... 29Neomycin/Polymycin/Bacitracin/

Hydrocortisone ............................ 29Neomycin/Polymyxin/

Dexamethasone .......................... 30Neomycin/Polymyxin/Gramicidin .. 29Neomycin/Polymyxin/

Hydrocortisone ............................ 30Neomycin Sulfate............................. 8Neulasta ......................................... 18Neumega ........................................ 18Neupogen ....................................... 18Neupro............................................ 24Neurontin ....................................... 24Neutrexin........................................ 12Nevanac ......................................... 31Nexavar .......................................... 15Nexium ........................................... 33Nexium I.V. ..................................... 33Niacor ............................................. 44Niaspan .......................................... 21Nicardipine HCl .............................. 20Nicotine .......................................... 16Nicotrol Inhaler .............................. 16Nicotrol NS..................................... 16Nifediac CC .................................... 20Nifedical XL .................................... 20Nifedipine....................................... 20

Nifedipine ER ................................. 20Nilandron........................................ 15Nimodipine ..................................... 20Nimotop.......................................... 20Nipent............................................. 15Nitrek.............................................. 22Nitrobid .......................................... 22Nitro-Dur ........................................ 22Nitrofurantoin Macrocrystalline .... 14Nitrofurantoin Monohydrate .......... 14Nitroglycerin................................... 22Nitroglycerin CR ............................. 22Nitroglycerin TD ............................. 22Nitroglycerin Transdermal .............. 22Nitrolingual Pumpspray.................. 22Nitrostat ......................................... 22Nitro-Time ...................................... 22Nizatidine ....................................... 33Nora-BE .......................................... 35Norditropin Cartridge ..................... 37Norditropin Nordiflex ..................... 37Norditropin Nordiflex Pen .............. 37Norethindrone Acetate .................. 37Noritate .......................................... 41Noroxin ........................................... 13Norpace CR .................................... 19Nortrel 0.5/35................................. 35Nortrel 1/35.................................... 35Nortrel 7/7/7 .................................. 35Nortriptyline HCl ............................ 22Norvir................................................ 9Novarel ........................................... 36Novolin 70/30................................. 36Novolin 70/30 Innolet .................... 36Novolin 70/30 Penfill...................... 36Novolin N ....................................... 37Novolin N Innolet ........................... 37Novolin N U-100 Penfill.................. 37Novolin R ........................................ 37Novolin R Innolet............................ 37Novolin R U-100 ............................. 37Novolin R U-100 Penfill .................. 37Novolog .......................................... 37

Novolog FlexPen............................. 37Novolog Mix 70/30 ........................ 37Novolog Mix 70/30 Penfill ............. 37Novolog Mix 70/30 Prefilled

FlexPen ........................................ 37Novolog Penfill ............................... 37Noxafil ............................................ 10Nulytely .......................................... 32Numorphan..................................... 26Nutropin ......................................... 37Nutropin AQ ................................... 37Nutropin AQ Pen ............................ 37NuvaRing ........................................ 35Nyamyc........................................... 42Nystatin .................................... 13, 42Nystatin/Triamcinolone .................. 42Nystop ............................................ 42

O

Octagam ......................................... 40Octreotide Acetate ......................... 39Ocusulf-10 ...................................... 29Ofloxacin................................... 13, 29Ogestrel .......................................... 35Olux ................................................ 43Olux-E ............................................. 43Omeprazole .................................... 33Oncaspar ........................................ 15Ondansetron HCl ...................... 31, 32Ondansetron ODT ........................... 31Ontak .............................................. 15Onxol .............................................. 15Opana ............................................. 26Opana ER ........................................ 26Opium Tincture ............................... 31Optivar ............................................ 29Oracea ............................................ 14Orap ................................................ 23Orapred ODT................................... 34Orencia ........................................... 39Orfadin............................................ 39Orphenadrine/Aspirin/Caffeine ..... 17Orphenadrine Citrate...................... 17

5656

Orphenadrine Citrate ER ................ 17Orphenadrine Compound ............... 25Orphenadrine Compound DS.......... 25Orphengesic ................................... 25Orphengesic Forte .......................... 25Orthoclone OKT3 ............................ 39Ortho-Est ........................................ 36Ortho Evra....................................... 35Ortho Tri-Cyclen Lo ......................... 35Osmoprep ....................................... 32Oticin HC ........................................ 30Ovcon-50 28 ................................... 35Ovide .............................................. 44Oxacillin Sodium ............................ 13Oxandrolone ................................... 34Oxaprozin........................................ 25Oxcarbazepine ................................ 24Oxistat ............................................ 42Oxsoralen ....................................... 44Oxsoralen Ultra .............................. 44Oxybutynin Chloride ....................... 44Oxybutynin Chloride ER .................. 44Oxycodone/Acetaminophen ........... 26Oxycodone/Aspirin ......................... 26Oxycodone HCl ............................... 26Oxycodone HCl CR.......................... 26Oxycodone HCl ER .......................... 26Oxycontin........................................ 26Oxyfast ........................................... 26Oxytocin.......................................... 39Oxytrol ............................................ 44

P

Pacerone......................................... 19Paclitaxel ........................................ 15Palcaps 10 ...................................... 32Palcaps 20 ...................................... 32Palgic ................................................ 8Palipase .......................................... 32Palipase MT 16 .............................. 32Palipase MT 20 .............................. 32Palpeon DR 10 ................................ 32Palpeon DR 20 ................................ 32

Palpeon MT 20 ............................... 32Paltrase V8 ..................................... 32Pamidronate Disodium ................... 39Pamine............................................ 16Pancrease MT 4 ............................. 32Pancrease MT 10 ........................... 32Pancrease MT 16 ........................... 32Pancrease MT 20 ........................... 32Pancrecarb MS-4............................ 32Pancrecarb MS-8............................ 32Pancrecarb MS-16.......................... 32Pancrelipase ................................... 32Pancrelipase MST-16 ..................... 32Pancron 10...................................... 32Pancron 20...................................... 32Pandel............................................. 43Pangestyme CN 10 ......................... 32Pangestyme CN 20 ......................... 32Pangestyme EC............................... 32Pangestyme MT 16 ........................ 32Pangestyme UL 12.......................... 32Pangestyme UL 18.......................... 32Pangestyme UL 20.......................... 32Panglobulin..................................... 40Panglobulin NF ............................... 40Panixine Disperdose....................... 10Panlor DC........................................ 26Panocaps ........................................ 32Panocaps MT 16............................. 32Panocaps MT 20............................. 32Panokase ........................................ 32Panokase-16 ................................... 32Panretin .......................................... 43Papaverine HCl ............................... 21Parcaine.......................................... 30Parcopa........................................... 24Paregoric ........................................ 31Paromomycin Sulfate ....................... 8Paroxetine HCl................................ 22Paser................................................. 9Pataday........................................... 29Patanol ........................................... 29Paxil CR .......................................... 22

Paxil ................................................ 22PCE ................................................. 11Pediarix........................................... 41Pedi-Dri........................................... 42Pedvax HIB ..................................... 41Peganone........................................ 23Pegasys .......................................... 11Peg-Intron ....................................... 11Peg-Intron Redipen......................... 11Peg-Intron Redipen Pak 4 ............... 11Penicillin G Potassium.................... 13Penicillin G Potassium in

Iso-Osmotic Dextrose ................. 13Penicillin G Procaine ...................... 13Penicillin G Sodium ........................ 13Penicillin V Potassium .................... 13Penlac Nail Lacquer ....................... 42Pentamidine Isethionate ................ 12Pentasa........................................... 31Pentazocine/Acetaminophen ......... 27Pentazocine/Naloxone HCl ............ 27Pentopak......................................... 18Pentostatin ..................................... 15Pentoxifylline CR ............................ 18Pentoxifylline ER ............................ 18Pentoxil........................................... 18Pepcid ............................................. 33Percocet.......................................... 26Percolone........................................ 26Periogard ........................................ 30Perloxx ............................................ 26Permethrin ...................................... 44Perphenazine .................................. 23Perphenazine/Amitriptyline ........... 22Pexeva ............................................ 22Phenadoz .......................................... 8Phenazopyridine HCl ...................... 43Phenytek ......................................... 23Phenytoin........................................ 23PhosLo ............................................ 28Phospholine Iodide ......................... 30Photofrin ......................................... 15Phrenilin w/Caffeine/Codeine ....... 26

57

Pilocarpine HCl ............................... 16Pilopine HS ..................................... 30Pindolol........................................... 20Piperacillin Sodium ........................ 13Piroxicam ........................................ 25Plan B ............................................. 35Plaretase 8000 ............................... 32Plavix .............................................. 18Plenaxis .......................................... 15Podocon 25 in Benzoin Tincture ..... 44Podofilox ......................................... 44Polycin B ......................................... 29Poly-Dex ......................................... 30Polyethylene Glycol 3350 ............... 32Polyethylene Glycol 3350/

Electrolytes ................................. 32Polygam S/D................................... 40Polymyxin B Sulfate ....................... 11Polymyxin B Sulfate/

Trimethoprim Sulfate .................. 29Poly-Pred ........................................ 30Portia-28 ......................................... 35Potassium Citrate

Extended-Release ....................... 27Prandin ........................................... 37Pravastatin ..................................... 21Prazosin HCl ................................... 18Precose ........................................... 34Pred-G............................................. 30Pred-G S.O.P. .................................. 30Prednicarbate ................................. 43Prednisol......................................... 30Prednisolone................................... 30Prednisolone Acetate ..................... 30Prednisolone Sodium Phosphate ... 30Prednisone...................................... 34Prednisone Intensol........................ 34Prefest ............................................ 36Pregnyl w/Diluent Benzyl

Alcohol/NaCl .............................. 36Premarin ......................................... 36Premarin w/Applicator ................... 36Premphase...................................... 36

Prempro .......................................... 36Prevacid .......................................... 33Prevacid I.V. .................................... 33Prevacid Naprapac ......................... 25Prevacid Solutab ............................ 33Prevalite ......................................... 20Previfem ......................................... 35Prevpac ........................................... 33Prezista ............................................. 9Prialt ............................................... 24Priftin ................................................ 9Prilosec ........................................... 33Primaquine Phosphate ..................... 9Primaxin I.M. .................................. 12Primaxin IV ..................................... 12Primaxin IV Add-Vantage ............... 12Primidone ....................................... 23Primsol............................................ 14Proair HFA ...................................... 17Pro-Banthine................................... 16Probenecid...................................... 28Probenecid/Colchicine ................... 28Procainamide HCl ........................... 19Procainamide HCl ER...................... 19Procainamide HCl SR ..................... 19Procanbid........................................ 19Prochieve ........................................ 37Prochlorperazine....................... 23, 33Prochlorperazine Edisylate ............. 23Prochlorperazine Maleate .............. 23Procrit ............................................. 18Proctocream-HC ............................. 43Procto-Kit........................................ 43Procto-Pak ...................................... 43Proctosol HC ................................... 43Proctozone-HC ................................ 43Proglycem ....................................... 37Prograf ............................................ 39Prolastin ......................................... 39Proleukin......................................... 15Promethazine HCl ............................. 8Promethazine HCl Plain .................... 8Promethazine VC .............................. 8

Promethegan .................................... 8Prometrium ..................................... 37Pronestyl......................................... 19Propafenone HCl ............................ 19Propantheline Bromide................... 16Proparacaine HCl............................ 30Propoxyphene/Acetaminophen ...... 26Propoxyphene HCl .......................... 26Propoxyphene-N/

Acetaminophen ........................... 26Propranolol HCl .............................. 20Propranolol HCl ER ......................... 20Propranolol/Hydrochlorothiazide ... 20Propylthiouracil .............................. 34ProQuad .......................................... 41Proquin XR ...................................... 13Protonix .......................................... 33Protopic .......................................... 44Proventil HFA .................................. 17Provigil............................................ 23Prozac Weekly ................................ 22Psorcon E ........................................ 43Pulmicort Flexhaler......................... 34Pulmicort Respules......................... 34Pulmozyme ..................................... 28Pylera.............................................. 11Pyrazinamide .................................... 9Pyridostigmine Bromide ................. 16

Q

Quadramet...................................... 39Qualaquin ......................................... 9Quasense........................................ 35Quinapril HCl .................................. 19Quinapril/Hydrochlorothiazide ....... 19Quinaretic ....................................... 19Quinidine Gluconate....................... 19Quinidine Gluconate CR ................. 19Quinidine Gluconate ER ................. 19Quinidine Gluconate SA ................. 19Quinidine Sulfate ........................... 19Quinidine Sulfate ER ...................... 19Quixin ............................................. 29

5858

QVAR .............................................. 34

R

Rabavert ......................................... 41Ranexa............................................ 21Raniclor .......................................... 10Ranitidine HCl ................................ 33Rapamune ...................................... 39Raptiva ........................................... 44Rauwolfia/Bendroflumethiazide..... 22Razadyne .................................. 16, 17Razadyne ER ................................... 17Rebetol ........................................... 12Rebif ............................................... 39Rebif Titration Pack ........................ 39Reclast............................................ 39Reclipsen ........................................ 35Recombivax HB .............................. 41Regonol .......................................... 17Regranex ........................................ 44Relenza Diskhaler........................... 12Relion 70/30 ................................... 37Relion 70/30 Innolet....................... 37Relion N.......................................... 37Relion N Innolet ............................. 37Relion R .......................................... 37Relpax............................................. 27Remicade........................................ 39Remodulin ...................................... 21Renagel .......................................... 28Reprexain ....................................... 26Requip ............................................ 24Rescriptor ......................................... 9Reserpine ....................................... 22Restasis .......................................... 31Retin-A Micro ................................. 43Retrovir IV Infusion........................... 9Revatio ........................................... 22Revex .............................................. 27Revlimid.......................................... 39Reyataz ............................................. 9Rhinocort Aqua............................... 30

Ribasphere ..................................... 12Ribatab ........................................... 12Ribavirin ......................................... 12Ridaura ........................................... 33Rifampin ........................................... 9Rifater............................................... 9Rilutek ............................................ 24Rimantadine HCl .............................. 8Riomet ............................................ 35Risperdal ........................................ 23Risperdal Consta ............................ 23Risperdal M-Tab ............................. 23Ritalin LA ........................................ 23Rituxan ........................................... 15Robaxin........................................... 17Rocephin......................................... 10Rocephin in Iso-Osmotic

Dextrose ...................................... 10Roferon-A ....................................... 11Romycin .......................................... 29RotaTeq .......................................... 41Roxicet............................................ 26Rozerem.......................................... 24Rozex .............................................. 41Rythmol SR ..................................... 19

S

Saizen ............................................. 37Saizen Click.Easy............................ 37Sanctura ......................................... 44Sandostatin LAR Depot .................. 39Santyl ............................................. 44Sarafem .......................................... 22Seasonale....................................... 35Seasonique..................................... 35Selegiline HCl................................. 24Selenium Sulfide ............................ 43Selzentry........................................... 9Semprex-D........................................ 8Sensipar ......................................... 39Serevent Diskus ............................. 17Seromycin......................................... 9

Seroquel ......................................... 23Seroquel XR ................................... 23Serostim ......................................... 37Sertraline HCl ................................. 22Silver Sulfadiazine ......................... 43Simulect ......................................... 39Simvastatin .................................... 21Singulair ......................................... 40Skelaxin .......................................... 17Skelid.............................................. 39Sodium Fluoride ............................. 39Sodium Polystyrene Sulfonate ....... 28Solaraze.......................................... 44Solia ............................................... 35Solodyn........................................... 14Soltamox ........................................ 15Solu-Cortef ..................................... 34Solu-Medrol ................................... 34Soma .............................................. 17Somatuline Depot .......................... 39Somavert ........................................ 37Sonata ............................................ 24Soriatane ........................................ 39Sorine ............................................. 20Sotalol HCl ..................................... 20Sotret.............................................. 44Spectracef ...................................... 10Spiriva Handihaler.......................... 16Spironolactone ............................... 21Spironolactone/

Hydrochlorothiazide .................... 21Sporanox ........................................ 10Sprintec 28 ..................................... 35Sprycel............................................ 15Sronyx............................................. 35SSD................................................. 43SSD AF ........................................... 43Stagesic.......................................... 26Stalevo 50 ...................................... 24Stalevo 100 .................................... 24Stalevo 150 .................................... 24Stalevo 200 .................................... 24

59

Starlix ............................................. 37Stimate ........................................... 37Strattera ......................................... 25Streptomycin Sulfate ....................... 8Striant............................................. 34Stromectol ........................................ 9Suboxone........................................ 26Subutex .......................................... 26Sucraid ........................................... 28Sucralfate ....................................... 33Sular ............................................... 21Sulf-10 ............................................ 29Sulfacetamide Sodium ................... 29Sulfacetamide Sodium/

Prednisolone Sodium Phosphate ................................... 30

Sulfadiazine.................................... 13Sulfamethoxazole/Trimethoprim .... 13Sulfamethoxazole/

Trimethoprim DS ......................... 13Sulfamylon ..................................... 43Sulfasalazine .................................. 13Sulfatrim......................................... 13Sulfazine......................................... 13Sulfazine EC ................................... 13Sulindac.......................................... 25Sumycin .......................................... 14Suprax ............................................ 10Surmontil ........................................ 22Sustiva.............................................. 9Sutent ............................................. 15Symbicort ....................................... 16Symbyax ......................................... 23Symlin............................................. 37Synagis ........................................... 12Synalgos-DC ................................... 26Synarel ........................................... 36Synera ............................................ 43Synercid.......................................... 11Synthroid ........................................ 38Syprine ........................................... 33

T

Tabloid ............................................ 15Taclonex ......................................... 43Talwin ............................................. 26Tamiflu ............................................ 12Tamoxifen Citrate ........................... 15Tarceva ........................................... 15Targretin ................................... 15, 44Tarka ............................................... 21Tasigna ........................................... 15Tasmar ............................................ 25Taxotere .......................................... 15Tazicef ............................................ 10Tazorac ........................................... 44Taztia XT ......................................... 21Tegretol .......................................... 24Tegretol-XR ..................................... 24Tekturna .......................................... 21Tenormin ......................................... 20Terazosin HCl .................................. 18Terbinafine ........................................ 8Terbutaline Sulfate ......................... 17Terconazole .................................... 42Teslac ............................................. 15Testim ............................................. 34Testopel .......................................... 34Testosterone Cypionate ................. 34Testosterone Enanthate ................. 34Testred ............................................ 34Tetanus/Diphtheria

Toxoids-Absorbed Adult ............. 40Tetanus Toxoid ............................... 40Tetanus Toxoid Adsorbed ............... 40Tetracycline HCl ............................. 14Teveten ........................................... 19Teveten HCT ................................... 19Tev-Tropin ....................................... 37Texacort .......................................... 43Thalitone ........................................ 28Thalomid......................................... 39Theo-24 .......................................... 44Theocap .......................................... 44Theochron....................................... 44

Theophylline CR ............................. 44Theophylline ER.............................. 44Theophylline TD ............................. 44Theracys ......................................... 41Thermazene .................................... 43Thiola.............................................. 39Thioridazine HCl ............................. 23Thiotepa ......................................... 15Thiothixene..................................... 23Thymoglobulin ................................ 39Thyrolar-1 ....................................... 38Thyrolar-1/2 .................................... 38Thyrolar-1/4 .................................... 38Thyrolar-2 ....................................... 38Thyrolar-3 ....................................... 38Tice BCG ......................................... 41Ticlopidine HCl ............................... 18Tikosyn............................................ 19Tilade .............................................. 40Timentin.......................................... 13Timolide 10/25 ............................... 20Timolol Maleate ....................... 20, 30Timolol Maleate Ophthalmic

Gel Forming ................................. 30Tindamax ........................................ 12Tizanidine HCl................................. 17Tobi ................................................... 8Tobradex ......................................... 30Tobramycin Sulfate .................... 8, 29Tobramycin Sulfate Add-Vantage .... 9Tobramycin Sulfate Fliptop .............. 9Tobramycin Sulfate/NaCl ................. 8Tobrasol .......................................... 29Tobrex ............................................. 29Tolazamide ..................................... 38Tolbutamide .................................... 38Tolmetin Sodium ............................ 25Topamax ......................................... 24Topamax Sprinkle ........................... 24Toposar ........................................... 15Torisel ............................................. 15Torsemide ....................................... 28

6060

Tracleer ........................................... 21Tramadol HCl .................................. 26Tramadol HCl/Acetaminophen ....... 27Trandolapril .................................... 19Transderm-Scop ............................. 33Tranylcypromine Sulfate ................ 23Travatan .......................................... 30Travatan Z ....................................... 30Trazodone HCl ................................ 23Trecator ............................................ 9Trelstar Depot ................................. 15Trelstar LA ...................................... 15Tretinoin Capsule ........................... 15Tretinoin ......................................... 43Trexall ............................................. 15Triamcinolone Acetonide ............... 43Triamcinolone Acetonide

in Absorbase ............................... 43Triamcinolone in Orabase .............. 43Triamterene/

Hydrochlorothiazide .................... 28Tricor ............................................... 21Triderm ........................................... 43Trifluoperazine HCl ......................... 23Trifluridine ...................................... 29Triglide ............................................ 21Trihexyphenidyl HCl ........................ 16TriHiBit ............................................ 40Tri-Legest FE ................................... 35Trileptal .......................................... 24Trilyte .............................................. 32Trimethobenzamide HCl ................. 31Trimethoprim .................................. 14Trimethoprim/

Sulfamethoxazole DS ................. 13Trimethoprim Sulfate/

Polymyxin B Sulfate .................... 29Trimipramine Maleate .................... 23Trimox ............................................. 13TriNessa ......................................... 35Tripedia ........................................... 40

Tri-Previfem .................................... 35Trisenox .......................................... 15Tri-Sprintec ..................................... 35Trivora-28 ....................................... 35Trizivir ............................................... 9Tropicacyl ....................................... 31Tropicamide .................................... 31Trusopt ............................................ 30Truvada ............................................. 9Twinject .......................................... 17Twinrix ............................................ 41Tygacil ............................................ 14Tykerb ............................................ 15Typhim Vi ....................................... 41Tysabri ............................................ 39Tyzeka ............................................. 12Tyzine .............................................. 31Tyzine Pediatric Nasal Drops ......... 31

U

U-Cort ............................................. 43Ultracaps MT 20............................. 32Ultram ER ....................................... 27Ultrase ............................................ 32Ultrase MT 12 ................................ 32Ultrase MT 18 ................................ 32Ultrase MT 20 ................................ 32Unasyn Add-Vantage ..................... 13Unasyn Piggyback Unit................... 13Uni-Otic .......................................... 30Uniphyl ........................................... 44Unithroid......................................... 38Uroxatral......................................... 39Urso 250 ......................................... 32Ursodiol .......................................... 32Urso Forte ....................................... 32Uvadex............................................ 44

V

Vagifem .......................................... 36Valcyte ............................................ 12

Valproate Sodium ........................... 24Valproic Acid .................................. 24Valtrex ............................................ 12Vanacet .......................................... 27Vancocin HCl .................................. 11Vancomycin HCl ............................. 11Vandazole ....................................... 41Vanos .............................................. 43Vantas ............................................ 16Vaqta .............................................. 41Varivax ............................................ 41Vectibix ........................................... 16Veetids ........................................... 13Velcade ........................................... 16Velivet ............................................ 35Venlafaxine HCl .............................. 23Venoglobulin-S ............................... 40Ventavis .......................................... 21Ventolin HFA................................... 17Veramyst ........................................ 30Verapamil HCl ................................ 21Verapamil HCl ER ........................... 21Verdeso .......................................... 43Verelan PM ..................................... 21Vesicare .......................................... 44Vexol ............................................... 30Vfend .............................................. 10Vfend IV .......................................... 10Viadur ............................................. 16Vibramycin ...................................... 14Vidaza ............................................. 16Videx EC ........................................... 9Videx Pediatric ................................. 9Vigamox .......................................... 29Vinblastine Sulfate ......................... 16Vincasar PFS ................................... 16Vincristine Sulfate .......................... 16Vinorelbine Tartrate ....................... 16Viokase ........................................... 32Viokase 8 ........................................ 32Viokase 16 ...................................... 32

61

Viracept ............................................ 9Viramune .......................................... 9Virazole ........................................... 12Viread ............................................... 9Visicol ............................................. 32Vistaril ............................................ 24Vistide ............................................ 12Vivactil ............................................ 23Vivaglobin ....................................... 40Vivelle ............................................. 36Vivelle-Dot ...................................... 36Vivitrol ............................................ 27Vivotif Berna ................................... 41Voltaren .......................................... 31Vopac .............................................. 27Vumon ............................................ 16Vytorin ............................................ 21Vyvanse .......................................... 22

W

Warfarin Sodium ............................ 18Welchol .......................................... 20Wellbutrin XL ................................. 23

X

Xalatan ........................................... 30Xenical............................................ 33Xibrom ............................................ 31Xifaxan ........................................... 11Xolair .............................................. 40Xolegel ........................................... 42Xopenex.......................................... 17Xopenex Concentrate ..................... 17Xopenex HFA .................................. 17Xyrem ............................................. 25

Y

Yasmin 28 ....................................... 35Yaz .................................................. 35YF-Vax ............................................ 41

Z

Zanaflex .......................................... 17Zanosar........................................... 16Zantac............................................. 33Zavesca .......................................... 39Zazole ............................................. 42Z-Clinz 5.......................................... 41Z-Clinz 10........................................ 41Zegerid ........................................... 33Zelapar ........................................... 25Zemaira .......................................... 39Zemplar .......................................... 44Zenapax .......................................... 39Zerit .................................................. 9Zerlor .............................................. 27Zetia ............................................... 20Ziagen............................................... 9Ziana............................................... 44Zidovudine ........................................ 9Zinacef............................................ 10Zinacef/D5W .................................. 10Zinacef in Iso-Osmotic Dextrose .... 10Zinacef in Iso-Osmotic Diluent....... 10Zmax ............................................... 11Zoladex ........................................... 16Zolinza ............................................ 16Zolpidem Tartrate ........................... 24Zometa ........................................... 39Zomig.............................................. 27Zomig ZMT ..................................... 27Zonisamide ..................................... 24Zorbtive .......................................... 37Zostavax ......................................... 41Zosyn .............................................. 13Zovia 1/35E .................................... 35Zovia 1/50E .................................... 35Zovirax ............................................ 43Zydone ............................................ 27Zyflo ................................................ 40Zyflo CR .......................................... 40

Zylet................................................ 30Zymar.............................................. 29Zyprexa ........................................... 23Zyprexa Zydis ................................. 23Zyrtec................................................ 8Zyrtec-D ............................................ 8Zyvox .............................................. 11

6262

Tier 3 Drug Lower-cost Option(s)

LOWER-COST OPTION(S)

Talk to your doctor or pharmacist about these lower-cost options.

Aciphex Nexium, Omeprazole, Prevacid, Protonix

Avapro Benicar, Diovan

Avalide Benicar HCT, Diovan HCT

Boniva Actonel, Fosamax

Clarinex Fexofenadine

Coreg CR Carvedilol

Cozaar Benicar, Diovan

Crestor Lipitor, Simvastatin, Vytorin

Exelon Aricept, Razadyne

Hyzaar Benicar HCT, Diovan HCT

Lescol Lovastatin, Pravastatin, Simvastatin

Lescol XL Lovastatin, Pravastatin, Simvastatin

Mavik Benazepril, Enalapril, Lisinopril

Miacalcin Fortical

Sanctura Detrol LA, Enablex, Oxybutynin ER

Sonata Ambien CR, Lunesta, Zolpidem

Trusopt Azopt

Uroxatral Doxazosin, Flomax, Terazosin

Vesicare Detrol LA, Enablex, Oxybutynin ER

Xalatan Travatan

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This Medicare Prescription Drug Plan (PDP) is insured by United HealthCare Insurance Company or United HealthCare Insurance Company of New York for New York residents (together called “UnitedHealthcare”). UnitedHealthcare receives rebates from drug manufacturers that it passes on to its enrollees through reductions in premiums and to Medicare to reduce Medicare program costs. UnitedHealthcare contracts with the Federal government as a PDP sponsor. All decisions about prescription drugs are between you and your physician or other health care provider.

This document includes:

UnitedHealth Rx Basic complete formulary as of January 1, 2008.

For more information, please visit us online at www.UnitedHealthRx.com or call 1-888-867-5562, 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-730-4203.

Or write us at:

UnitedHealth Rx BasicP.O. Box 29350Hot Springs, AR 71903-9350

FLPDP3023181_XUBE004 S5921_PDP3023181_000 CMS 09/2007

2008 formulary - unitedhealthcare® medicare solutions - medicare

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