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2013 MVP HEALTH CARE MEDICARE PART D COVERED DRUGS (Formulary) For Mid-Hudson Region direct bill members

PLEASE READ This document contains information about the drugs we cover in this plan

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 2014

To receive material in an alternate format or language call MVPrsquos Medicare Customer Care Center at the phone numbers on the back cover (They also are found on the back of your member ID card)

Note to existing members This Formulary has changed since last year Please review this document to make sure that it still contains the drugs you take and to see if they have changed tiers since last year This document is current as of August 2012

For the most up-to-date Formulary listing visit wwwmvphealthcarecom or call MVPrsquos Medicare Customer Care Center at the phone numbers on the back of your MVP member ID card

Y0051_1538R1 CMS Approved 092012 Formulary ID 13250 Version 5

2

3

Prescription drug copayments for Preferred Gold HMO-POS with Part D

ATTENTION

The costs in the chart below may be different for you if you qualify for low income subsidy (Extra Help)

If you qualify for low income subsidy the following information may not apply Please read your Evidence of Coverage (your contract) and other plan materials for details

For Preferred Gold with Part D members who pay directly for their MVP health plan

Tier (drug level) Retail

Pharmacy 30-day supply

Retail Pharmacy

60-day supply

Retail Pharmacy

90-day supply

Mail-Order Pharmacy

90-day supply

Tier 1 ndash Preferred Generic Drugs $10 $20 $30 $20 diamsTier 2 ndash Preferred Brand Name Drugs

$45 $90 $135 $90

diamsTier 3 ndash Non-Preferred Brand Name Drugs and Non-Preferred Generic Drugs

$95 $190 $285 $190

diamsTier 4 ndash Specialty Drugs 25 25 25 25

Tier 5 ndash Select Care Drugs $6 $12 $18 $12

diams Tiers 2 3 and 4 have a deductible of $325

Preferred Gold with Part D Once your total drug costs in 2013 reach $2970 you will pay 79 for generic drugs and 475 for Medicare-contracted brands When your out-of-pocket costs reach $4750 in 2013 your cost for prescriptions is reduced to the greater of 5 or $265 for generics and $660 for brand-name drugs

Total drug costs = your out-of-pocket costs for covered drugs (what you pay) plus what the plan pays for your covered drugs

Certain drugs will be limited to a 30-day supply through retail and not allowed through the mail order pharmacy

Table of Contents

What is the MVP Health Care Medicare Part D Formulary 1

Can the Formulary change 1

MVP Health Carersquos Medicare Part D Formulary Tiers 2

How do I use the Formulary 3

What are generic drugs 3

What programs are in place to promote cost savings and safety 4

What if my drug is not on the Formulary 4

How do I request an exception to MVPrsquos Medicare Part D Formulary 5

What do I do before I talk to my doctor about changing my drugs or requesting an exception 6

For more information 7

Abbreviations and Definitions of Formulary terms 8

MVPrsquos list of covered drugs by category 9

Alphabetical index of covered drugs 38

What is the MVP Health Care Medicare Part D Formulary

The Formulary is a list of Medicare covered drugs selected by MVP Health Care in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MVP Health Care will generally cover the drugs listed in our Formulary as long as the drug is medically necessary the prescription is filled at an MVP Health Care network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage (your contract)

Can the Formulary change

Generally if you are taking a drug on our 2013 Formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of Formulary changes such as removing a drug from our Formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year

to the Formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we need to make a change to ensure your safety

If we remove drugs from our Formulary move a drug to a higher cost-sharing tier add prior authorization quantity limits andor step therapy restrictions on a drug we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our Formulary to be unsafe or a drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our Formulary and provide notice to members who take the drug

The enclosed Formulary is current as of August 2012 To get updated information about the drugs covered by MVP Health Care please visit our website at wwwmvphealthcarecom or call MVPrsquos Medicare Customer Care Center at the phone numbers found on page 7 and on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1

3

Prescription drug copayments for Preferred Gold HMO-POS with Part D

ATTENTION

The costs in the chart below may be different for you if you qualify for low income subsidy (Extra Help)

If you qualify for low income subsidy the following information may not apply Please read your Evidence of Coverage (your contract) and other plan materials for details

For Preferred Gold with Part D members who pay directly for their MVP health plan

Tier (drug level) Retail

Pharmacy 30-day supply

Retail Pharmacy

60-day supply

Retail Pharmacy

90-day supply

Mail-Order Pharmacy

90-day supply

Tier 1 ndash Preferred Generic Drugs $10 $20 $30 $20 diamsTier 2 ndash Preferred Brand Name Drugs

$45 $90 $135 $90

diamsTier 3 ndash Non-Preferred Brand Name Drugs and Non-Preferred Generic Drugs

$95 $190 $285 $190

diamsTier 4 ndash Specialty Drugs 25 25 25 25

Tier 5 ndash Select Care Drugs $6 $12 $18 $12

diams Tiers 2 3 and 4 have a deductible of $325

Preferred Gold with Part D Once your total drug costs in 2013 reach $2970 you will pay 79 for generic drugs and 475 for Medicare-contracted brands When your out-of-pocket costs reach $4750 in 2013 your cost for prescriptions is reduced to the greater of 5 or $265 for generics and $660 for brand-name drugs

Total drug costs = your out-of-pocket costs for covered drugs (what you pay) plus what the plan pays for your covered drugs

Certain drugs will be limited to a 30-day supply through retail and not allowed through the mail order pharmacy

Table of Contents

What is the MVP Health Care Medicare Part D Formulary 1

Can the Formulary change 1

MVP Health Carersquos Medicare Part D Formulary Tiers 2

How do I use the Formulary 3

What are generic drugs 3

What programs are in place to promote cost savings and safety 4

What if my drug is not on the Formulary 4

How do I request an exception to MVPrsquos Medicare Part D Formulary 5

What do I do before I talk to my doctor about changing my drugs or requesting an exception 6

For more information 7

Abbreviations and Definitions of Formulary terms 8

MVPrsquos list of covered drugs by category 9

Alphabetical index of covered drugs 38

What is the MVP Health Care Medicare Part D Formulary

The Formulary is a list of Medicare covered drugs selected by MVP Health Care in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MVP Health Care will generally cover the drugs listed in our Formulary as long as the drug is medically necessary the prescription is filled at an MVP Health Care network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage (your contract)

Can the Formulary change

Generally if you are taking a drug on our 2013 Formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of Formulary changes such as removing a drug from our Formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year

to the Formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we need to make a change to ensure your safety

If we remove drugs from our Formulary move a drug to a higher cost-sharing tier add prior authorization quantity limits andor step therapy restrictions on a drug we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our Formulary to be unsafe or a drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our Formulary and provide notice to members who take the drug

The enclosed Formulary is current as of August 2012 To get updated information about the drugs covered by MVP Health Care please visit our website at wwwmvphealthcarecom or call MVPrsquos Medicare Customer Care Center at the phone numbers found on page 7 and on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1

Table of Contents

What is the MVP Health Care Medicare Part D Formulary 1

Can the Formulary change 1

MVP Health Carersquos Medicare Part D Formulary Tiers 2

How do I use the Formulary 3

What are generic drugs 3

What programs are in place to promote cost savings and safety 4

What if my drug is not on the Formulary 4

How do I request an exception to MVPrsquos Medicare Part D Formulary 5

What do I do before I talk to my doctor about changing my drugs or requesting an exception 6

For more information 7

Abbreviations and Definitions of Formulary terms 8

MVPrsquos list of covered drugs by category 9

Alphabetical index of covered drugs 38

What is the MVP Health Care Medicare Part D Formulary

The Formulary is a list of Medicare covered drugs selected by MVP Health Care in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MVP Health Care will generally cover the drugs listed in our Formulary as long as the drug is medically necessary the prescription is filled at an MVP Health Care network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage (your contract)

Can the Formulary change

Generally if you are taking a drug on our 2013 Formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of Formulary changes such as removing a drug from our Formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year

to the Formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we need to make a change to ensure your safety

If we remove drugs from our Formulary move a drug to a higher cost-sharing tier add prior authorization quantity limits andor step therapy restrictions on a drug we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our Formulary to be unsafe or a drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our Formulary and provide notice to members who take the drug

The enclosed Formulary is current as of August 2012 To get updated information about the drugs covered by MVP Health Care please visit our website at wwwmvphealthcarecom or call MVPrsquos Medicare Customer Care Center at the phone numbers found on page 7 and on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1

What is the MVP Health Care Medicare Part D Formulary

The Formulary is a list of Medicare covered drugs selected by MVP Health Care in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MVP Health Care will generally cover the drugs listed in our Formulary as long as the drug is medically necessary the prescription is filled at an MVP Health Care network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage (your contract)

Can the Formulary change

Generally if you are taking a drug on our 2013 Formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of Formulary changes such as removing a drug from our Formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year

to the Formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we need to make a change to ensure your safety

If we remove drugs from our Formulary move a drug to a higher cost-sharing tier add prior authorization quantity limits andor step therapy restrictions on a drug we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our Formulary to be unsafe or a drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our Formulary and provide notice to members who take the drug

The enclosed Formulary is current as of August 2012 To get updated information about the drugs covered by MVP Health Care please visit our website at wwwmvphealthcarecom or call MVPrsquos Medicare Customer Care Center at the phone numbers found on page 7 and on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1

In the event of a change or changes to the Formulary during the year the changes also will be posted on the MVP website wwwmvphealthcarecom (This updated version of the Formulary will be posted on the MVP website on a monthly basis as needed) To view the list of changes start at our home page and

bull Click on ldquoMedicare Membersrdquo bull Click on the county you live in (if you donrsquot

live in New York state click on the button that applies to you)

bull Under the Part D Prescription Drug Coverage heading click on Covered Formulary Drug List and Updates at the top of the list

bull Click on ldquo2013 Formulary Changesrdquo

Or you may request an errata sheet (a copy of the 2013 Formulary changes) by calling MVPrsquos Medicare Customer Care Center at the phone numbers on the back of your member ID card

MVP Health Carersquos Medicare Part D Formulary Tiers

The Formulary that begins on page 9 provides coverage information about most of the drugs covered by MVP Health Care If you have trouble finding your drug in the list turn to the Index that begins on page 38

The first column of the Formulary chart lists the drug name Brand-name drugs are capitalized (eg NEXIUM) and generic drugs are listed in lower-case italics (eg allopurinol)

The information in the Notes column tells you if MVP Health Care has any special requirements for coverage of your drug See page 8 for abbreviations and definitions of Formulary terms

The 2013 Formulary is divided into five ldquotiersrdquo (or cost groups) that correspond to the drug copays in your Evidence of Coverage (your contract) Copays may vary if you are in the Medicare Part D ldquocoverage gaprdquo if you are in ldquocatastrophic coveragerdquo or if you have qualified for ldquoExtra Helprdquo Refer to your Evidence of Coverage for more details about the different levels of coverage

Here are the five tiers for 2013

Tier 1 - Preferred Generic Drugs

Tier 1 includes preferred generic drugs (Note Not all generic drugs will be a Tier 1 drug) Generic drugs have the same active ingredients strength and effectiveness as the brand-name versions but generally at a much lower cost

diamsTier 2 - Preferred Brand Name Drugs

Tier 2 includes preferred brand drugs that have the lowest cost sharing for brand name drugs If you and your doctor decide that a brand name drug is right for you try using a Tier 2 brand name drug to save money

2

diamsTier 3 - Non-preferred Brand Name and Non-preferred Generic Drugs

Tier 3 non-preferred brand name and non-preferred generic drugs are available at a higher cost In addition Part D drugs excluded from our Formulary must go through an exception process in order for MVP to cover them If they are approved they will be covered in Tier 3

diamsTier 4 - Specialty Drugs

Tier 4 includes drugs (brand name and generic) that cost $600 or more for a 30-day supply Most drugs in this tier are restricted to a 30-day supply at retail and are excluded from the mail order program and tier exception process

Tier 5 ndash Select Care Drugs - $6 cost for each 30-day supply

Tier 5 includes select drugs for diabetes blood pressure control glaucoma gout bone health heartburn and ulcers mental health conditions pain management cholesterol control and thyroid conditions Tier 5 also includes the most common Part D vaccines the shingles vaccine (Zostavax) tetanus vaccines and combination tetanus diphtheria pertussis vaccines (such as Tenivac Adacel and Boostrix) Think about using a Tier 5 drug if you and your doctor decide it is right for you Tier 5 is your lowest priced tier

diamsNOTE Tiers 2 3 and 4 have a deductible of $325

How do I use the Formulary

There are two ways to find your covered drug within the Formulary

Alphabetical Listing

Look for your covered drug in the Index that begins on page 38 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index

1 Look in the Index and find your drug 2 Next to your drug you will see the page

number where you can find coverage information

3 Turn to the page listed in the Index and find the name of your drug

Medical Condition

If you know what your drug is used for look for the category name in the list that begins on page 9 Then look under the category name for your drug For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Hypertension amp Lipidsrdquo

What are generic drugs

MVP Health Care covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs

3

What programs are in place to promote cost savings and safety

For safety reasons andor cost savings some covered drugs may have additional requirements or limits on coverage These requirements and limits may include

bull Prior Authorization MVP Health Care requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from MVP before you fill your prescriptions If you donrsquot get approval first MVP may not cover the drug

bull Quantity Limits For certain drugs MVP Health Care limits the amount of the drug that we will cover For example MVP provides 1 capsule per day for NEXIUM This limit may be applied to a standard one-month or three-month supply

bull Step Therapy In some cases MVP Health Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition MVP may not cover Drug B unless you try Drug A first If Drug A does not work for you MVP will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the Formulary that begins on page 9 You also can get more information about the restrictions applied to specific covered drugs by visiting our website at wwwmvphealthcarecom

You can ask MVP Health Care to make an exception to these restrictions or limits See the section ldquoHow do I request an exception to the MVP Health Care Formularyrdquo on page 5 for information about how to request an exception

What if my drug is not on the Formulary

To find out if your drug is covered but is not listed in this Formulary you should first contact MVPrsquos Customer Care Center to find out if your drug is covered

If you learn that MVP Health Care does not cover your drug you have two options

bull You can ask MVPrsquos Medicare Customer Care Center for a list of similar drugs that are covered by MVP Health Care When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by MVP

bull You can ask MVP Health Care to make an exception and cover your drug See page 5 for information about how to request an exception

Your drug may be available as a generic Many popular brand name drugs have recently become available as generics or will be available as generics in the next few years If you donrsquot see your brand name medication on the formulary look for the drugrsquos generic name If you have questions about the coverage of your brand name drug please call MVPrsquos Medicare Customer Care Center at the phone number on the back of your member ID card

Your drug may be a Part B drug which means that the drug is not covered under your Medicare Part D pharmacy benefit but under your medical benefit If it is a Part B drug you may be responsible to pay a coinsurance (a percentage) These drugs must still be obtained through an MVP network pharmacy The following are examples of Part B drugs and supplies

Temodar (temozolomide) Xeloda (capecitabine) Vepesid (etoposide) Inhalation spacers Diabetic testing supplies like lancets test strips Insulin pump supplies

4

What programs are in place to promote cost savings and safety

For safety reasons andor cost savings some covered drugs may have additional requirements or limits on coverage These requirements and limits may include

bull Prior Authorization MVP Health Care requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from MVP before you fill your prescriptions If you donrsquot get approval first MVP may not cover the drug

bull Quantity Limits For certain drugs MVP Health Care limits the amount of the drug that we will cover For example MVP provides 1 capsule per day for NEXIUM This limit may be applied to a standard one-month or three-month supply

bull Step Therapy In some cases MVP Health Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition MVP may not cover Drug B unless you try Drug A first If Drug A does not work for you MVP will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the Formulary that begins on page 9 You also can get more information about the restrictions applied to specific covered drugs by visiting our website at wwwmvphealthcarecom

You can ask MVP Health Care to make an exception to these restrictions or limits See the section ldquoHow do I request an exception to the MVP Health Care Formularyrdquo on page 5 for information about how to request an exception

What if my drug is not on the Formulary

To find out if your drug is covered but is not listed in this Formulary you should first contact MVPrsquos Customer Care Center to find out if your drug is covered

If you learn that MVP Health Care does not cover your drug you have two options

bull You can ask MVPrsquos Medicare Customer Care Center for a list of similar drugs that are covered by MVP Health Care When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by MVP

bull You can ask MVP Health Care to make an exception and cover your drug See page 5 for information about how to request an exception

Your drug may be available as a generic Many popular brand name drugs have recently become available as generics or will be available as generics in the next few years If you donrsquot see your brand name medication on the formulary look for the drugrsquos generic name If you have questions about the coverage of your brand name drug please call MVPrsquos Medicare Customer Care Center at the phone number on the back of your member ID card

Your drug may be a Part B drug which means that the drug is not covered under your Medicare Part D pharmacy benefit but under your medical benefit If it is a Part B drug you may be responsible to pay a coinsurance (a percentage) These drugs must still be obtained through an MVP network pharmacy The following are examples of Part B drugs and supplies

Temodar (temozolomide) Xeloda (capecitabine) Vepesid (etoposide) Inhalation spacers Diabetic testing supplies like lancets test strips Insulin pump supplies

4

How do I request an exception to MVPrsquos Medicare Part D Formulary

You can ask MVP Health Care to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

bull You can ask us to cover certain drugs even if they are not on our Formulary

bull You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs MVP Health Care limits 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

bull You can ask us to provide a higher level of coverage for your drug If your drug is contained in our Non-preferred Tier 3 you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Tier 2 instead This would lower the amount you must pay for your drug Please note if we grant your request to cover a drug that is not on our Formulary you may not ask us to provide a higher level of coverage for that drug Also you may not ask us to provide a higher level of coverage for drugs that are in Tier 2 or the Specialty Tier (Tier 4)

Generally MVP Health Care will only approve your request for an exception if the alternative drugs included on the planrsquos Formulary or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects

You should contact us to ask us for an initial coverage decision for a formulary tiering or utilization restriction exception When you are requesting a formulary tiering or utilization restriction exception you should submit a statement from your physician supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos 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 get your prescriberrsquos supporting statement

Please note that MVP can not approve a formulary exception request for a Medicare excluded drug If you or your physician believes it meets the definition of a covered Part D drug you may request a coverage determination Examples of Medicare excluded drugs include drugs used for weight loss cough and colds and erectile dysfunction Also excluded are drugs not approved by the Food and Drug Administration and most vitamins

5

What do I do before I talk to my doctor about changing my drugs or requesting an exception

As a new or continuing member in our plan you may be taking drugs that are not on our Formulary Or you may be taking a drug that is on our Formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription Talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days that you are a member of our plan

For each of your drugs that is not on our Formulary or if your ability to get your drugs is limited we will cover a temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy After your first 30-day supply we will not pay for these drugs mdash even if you have been a member of the plan less than 90 days mdash unless your doctor submits a request for your drug and it is approved by the plan

If you are a resident of a long-term care facility we will allow you to refill your prescription until we have provided you with a 93-day transition supply consistent with the dispensing increment (unless you have a prescription written 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 Formulary or if 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 formulary exception

Members who are changing levels of care may be eligible for a transition supply of medication outside of their initial 90-day enrollment transition period Level of care changes may include entering or leaving a long-term care facility discharge from hospital to home and ending a skilled nursing facility stay and reverting to plan Part D Formulary coverage

6

For more information

For more detailed information about your MVP Health Care Medicare Advantage prescription drug coverage please review your Evidence of Coverage (your contract) and other plan materials

If you have questions about MVP Health Care please call MVPrsquos Medicare Customer Care Center at the following phone numbers They also are found on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048

Or visit wwwmedicaregov

7

What do I do before I talk to my doctor about changing my drugs or requesting an exception

As a new or continuing member in our plan you may be taking drugs that are not on our Formulary Or you may be taking a drug that is on our Formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription Talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days that you are a member of our plan

For each of your drugs that is not on our Formulary or if your ability to get your drugs is limited we will cover a temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy After your first 30-day supply we will not pay for these drugs mdash even if you have been a member of the plan less than 90 days mdash unless your doctor submits a request for your drug and it is approved by the plan

If you are a resident of a long-term care facility we will allow you to refill your prescription until we have provided you with a 93-day transition supply consistent with the dispensing increment (unless you have a prescription written 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 Formulary or if 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 formulary exception

Members who are changing levels of care may be eligible for a transition supply of medication outside of their initial 90-day enrollment transition period Level of care changes may include entering or leaving a long-term care facility discharge from hospital to home and ending a skilled nursing facility stay and reverting to plan Part D Formulary coverage

6

For more information

For more detailed information about your MVP Health Care Medicare Advantage prescription drug coverage please review your Evidence of Coverage (your contract) and other plan materials

If you have questions about MVP Health Care please call MVPrsquos Medicare Customer Care Center at the following phone numbers They also are found on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048

Or visit wwwmedicaregov

7

For more information

For more detailed information about your MVP Health Care Medicare Advantage prescription drug coverage please review your Evidence of Coverage (your contract) and other plan materials

If you have questions about MVP Health Care please call MVPrsquos Medicare Customer Care Center at the following phone numbers They also are found on the back of your member ID card Representatives are available to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048

Or visit wwwmedicaregov

7

Abbreviations and Definitions of Formulary Terms

You may find one or more of the following abbreviations in the Formulary under the Notes column next to a drug name

Select Care Drugs ($6)

Tier 5 drugs will have a $6 cost share which is your lowest price tier

Mail Order (MO)

Medicare Part D drugs which are available to be filled through the Medco Pharmacy (Express Scripts mail order) Note You do not have to order these drugs through the mail You may fill them at a retail pharmacy as well if you wish

Prior Authorization (PA)

MVP Health Care requires you or your doctor to get prior authorization for certain drugs This means that you will need to get approval from MVP before you fill your prescriptions If you donrsquot get approval first MVP may not cover the drug

Quantity Limits (QL)

For certain drugs MVP Health Care limits the amount of the drug that we will cover For example MVP provides 1 capsule per day for NEXIUM This limit may be applied to a standard one-month or three-month supply

Step Therapy (ST)

In some cases MVP Health Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition MVP may not cover Drug B unless you try Drug A first If Drug A does not work for you MVP will then cover Drug B

Dispensing Limits (DL)

Certain drugs are limited to a 30-day supply through a retail pharmacy and are not available through the mail order pharmacy

Limited Availability (LA)

Some drugs are available only through a designated Specialty Pharmacy because of manufacturer limited distribution

Part B versus Part D drug coverage (BD)

Some drugs could be covered under the Part B or Part D benefit depending on certain criteria This means that you or your doctor will need to submit a request to MVP Health Care so we can determine based on Medicare guidelines if your drug will be covered as Part B or Part D Your cost sharing will be based on this determination

8

13 13 13

9

ANTI - INFECTIVES ANTIFUNGAL AGENTS

Drug Name

Drug Tier

Notes

amphotericin b 1 BD MO CANCIDAS 4 DL clotrimazole troc 1 MO ERAXIS INJ 100MG 3 DL fluconazole in dextrose inj 0 400mg200ml

1

fluconazole susr 1 MO fluconazole tabs 1 MO flucytosine 1 MO GRIS-PEG 3 MO griseofulvin microsize 1 MO itraconazole 3 PA DL ketoconazole tabs 1 MO NOXAFIL 4 DL nystatin susp 1 MO nystatin tabs 1 MO terbinafine tabs 1 QL(84 per

365 days) DL

VFEND IV 3 DL voriconazole tabs 50mg 3 QL(60 per

30 days) DL voriconazole tabs 200mg 4 QL(60 per

30 days) DL ANTIVIRALS acyclovir caps 5 $6 MO acyclovir inj 500mg 1 BD DL acyclovir susp 1 MO acyclovir tabs 1 MO amantadine 1 MO APTIVUS 4 DL ATRIPLA 4 DL BARACLUDE 3 DL COMPLERA 4 DL CRIXIVAN 2 MO didanosine 1 MO EDURANT 4 DL EMTRIVA 2 MO

Drug Name

Drug Tier

Notes

EPIVIR HBV 2 MO EPIVIR ORAL SOLN 2 MO EPZICOM 4 DL famciclovir 1 MO FUZEON 4 DL ganciclovir caps 1 MO ganciclovir inj 1 BD DL HEPSERA 4 DL INCIVEK 4 PA QL(504

per 365 days) DL

INTELENCE TABS 100MG 200MG

4 DL

INVIRASE 2 MO ISENTRESS 4 DL KALETRA 2 MO lamivudine 1 MO lamivudinezidovudine 1 DL LEXIVA SUSP 3 DL LEXIVA TABS 4 DL nevirapine tabs 200mg 1 MO NORVIR 2 MO PREZISTA TABS 75MG 150MG

3 DL

PREZISTA TABS 400MG 600MG

4 DL

REBETOL ORAL SOLN 2 PA QL(900 per 30 days)

DL RELENZA DISKHALER 3 QL(60 per

180 days) DL

RESCRIPTOR 2 MO RETROVIR IV INFUSION 3 MO REYATAZ CAPS 100MG 3 QL(60 per

30 days) DL REYATAZ CAPS 150MG 200MG 300MG

4 DL

ribapak tabs 4 PA DL ribasphere caps 200mg 3 PA QL(180

per 30 days) DL

ribasphere tabs 400mg 3 PA DL

Commonly Prescribed Therapeutic Drug Categories

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes ribasphere tabs 200mg 3 PA QL(180 cefotaxime sodium inj 10gm 1gm 1

per 30 days) DL

cefotaxime sodium inj 2gm 1 CEFOTETAN 3

MO

ribasphere tabs 600mg ribavirin rimantadine hcl

4 PA DL 3 PA DL 1 MO

CEFOXITIN SODIUM INJ 1GM 4 2GM 22

3

cefoxitin sodium inj 10gm 2gm 1 SELZENTRY 4 DL cefoxitin sodium inj 1gm 1 MO stavudine caps 1 MO cefpodoxime proxetil 1 MO SUSTIVA 2 MO cefprozil 1 MO SYNAGIS INJ 50MG05ML 4 DL ceftazidime inj 1gm 6gm 1 TAMIFLU CAPS 45MG 75MG

TAMIFLU CAPS 30MG

TAMIFLU SUSR

3 QL(28 per 180 days)

DL 3 QL(56 per

180 days) DL

3 QL(360 per 180 days)

DL

ceftazidime inj 2gm 1 CEFTAZIDIMEDEXTROSE 3 ceftriaxone sodium inj 10gm 1 ceftriaxone sodium inj 1gm 250mg 2gm 500mg

1

cefuroxime axetil tabs 1 cefuroxime sodium inj 75gm 1 cefuroxime sodium inj 15gm 1

MO

MO

MO

MO TRIZIVIR 4 DL 750mg TRUVADA 4 DL cephalexin 1 MO TYZEKA 3 MO CLAFORAN INJ 1GM 3 valacyclovir hcl VALCYTE VIDEX PEDIATRIC ORAL SOLN 2GM

1 MO 4 DL 3 MO

FORTAZ INJ 1GM50ML 5 2GM50ML 5 6GM

3

SPECTRACEF 3 SUPRAX TAB 400MG 3

MO

VIRACEPT 2 MO SUPRAX SUSR 3 VIRAMUNE SUSP 2 MO ZINACEF IN ISO-OSMOTIC 3 VIREAD VISTIDE

2 MO 3 MO

DEXTROSE ZINACEF IN ISO-OSMOTIC DILUENT

3

ZERIT ORAL SOLN ZIAGEN zidovudine

3 MO 2 MO 1 MO

ZINACEF INJ 15GM 750MG 3 ERYTHROMYCINS OTHER MACROLIDES

CEPHALOSPORINS CEDAX CAPS 3 MO cefaclor 1 MO cefaclor er 1 MO cefadroxil 1 MO cefazolin inj 1gm 5 500mg 1 cefazolin inj 1gm 1 MO CEFAZOLIN INJ 10GM 3 cefdinir 1 MO cefepime inj 2gm 1 cefepime inj 1gm 1 MO

10

azithromycin inj 500mg 1 MO azithromycin susr 1 MO azithromycin tabs 1 MO BIAXIN XL PAC 3 MO clarithromycin 1 MO clarithromycin er 1 MO DIFICID 4 PA DL ees 400 1 MO ery-tab tbec 250mg 333mg 1 MO ERY-TAB TBEC 500MG 2 MO ERYPED 200 3 MO

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes gentamicin sulfate09 sodium 1 chloride inj GENTAMICIN SULFATE09 3 SODIUM CHLORIDE INJ gentamicin sulfatesodium 1 chloride inj 12mgml 09 hydroxychloroquine 1 imipenemcilastatin 1 INVANZ 3 isoniazid inj 1 ISONIAZID SYRP 3 isoniazid tabs 1 isotonic gentamicin inj 08mgml 1 09 kanamycin sulfate 1 KETEK 3 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 079 1 MYCOBUTIN 3 NEBUPENT 3 neomycin sulfate 1 paromomycin 1 PASER 3 PENTAM 300 3 polymyxin b sulfate 1 PRIFTIN 3 PRIMAQUINE 3 PRIMAXIN IV INJ 500MG 3 500MG QUALAQUIN 3 rifampin 1 RIFATER 3 SEROMYCIN 3 STREPTOMYCIN SULFATE 3 STROMECTOL 3 SYNERCID 4 TOBI 4 tobramycin inj 10mgml 1 80mg2ml TOBRAMYCIN SULFATE 3 SODIUM CHLORIDE

MO MO MO

MO MO

MO PA DL PA DL

MO MO MO MO

BD DL MO MO MO

BD DL MO MO

PA DL MO

PA DL MO MO MO MO MO DL

BD DL BD DL

ERYPED 400 3 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 ERYTHROMYCIN BASE 3 erythromycin ethylsuccinate 1 PCE 3 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES

MO

MO MO MO MO MO

ALBENZA ALINIA amikacin sulfate inj 500mg2ml 50mgml atovaquoneproguanil hcl tabs 250mg 100mg AZACTAM IN ISO-OSMOTIC DEXTROSE aztreonam inj 1gm baciim bacitracin inj BILTRICIDE CAPASTAT SULFATE CHLORAMPHENICOL SODIUM SUCCINATE chloroquine CLEOCIN CAPS 75MG CLEOCIN GALAXY CLEOCIN IN D5W clindamycin hcl caps 150mg 300mg clindamycin phosphate add-vantage COARTEM colistimethate sodium CUBICIN DAPSONE DARAPRIM DORIBAX INJ 500MG ethambutol tabs 400mg ethambutol tabs 100mg FLAGYL ER GENTAMICIN SULFATE INJ 10MGML gentamicin sulfate inj 40mgml

3 3 1

1

3

1 1 1 2 3 3

1 3 3 3 1

1

3 3 4 2 3 3 1 1 3 3

1

DL DL MO

DL

MO

MO DL

DL MO

MO

MO

PA DL MO

BD DL MO

PA DL DL

MO MO

MO

11

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRECATOR 3 MO ZOSYN INJ 5 2GM50ML 3 TYGACIL 3 DL 025GM50ML 5 3GM50ML XIFAXAN TABS 550MG 3 MO 0375GM50ML

XIFAXAN TABS 200MG 3 PA QL(9 per 30 days)

QUINOLONES AVELOX ABC PACK 2 MO

DL AVELOX INJ 3 PA DL ZYVOX 4 PA DL AVELOX TABS 2 MO PENICILLINS CIPRO SUSR 3 amoxicillin 1 amoxicillinclavulanate potassium 1 amoxicillinclavulanate potassium 1 er amoxicillinpotassium clavulanate 1 tabs ampicillin caps 1 ampicillin inj 1gm 125mg 1 ampicillin inj 10gm 1 ampicillin susp 1 ampicillin-sulbactam inj 10gm 1 5gm ampicillin-sulbactam inj 2gm 1 1gm BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium inj 10gm 1 nafcillin sodium inj 1gm 1 NALLPENDEXTROSE INJ 0 3 1GM50ML OXACILLIN SODIUM INJ 3 10GM 1GM PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodiumtazobactam 1 sodium inj 4gm 05gm piperacillin sodiumtazobactam 1 sodium inj 3gm 0375gm TIMENTIN INJ 01GM 3GM 3

MO ciprofloxacin er 1 MO MO ciprofloxacin inj 400mg40ml 1 PA DL MO ciprofloxacin tabs 1 MO

FACTIVE 3 MO MO levofloxacin in d5w inj 5 1 PA DL

MO 500mg100ml levofloxacin inj 1 PA DL levofloxacin oral soln 1 MO

MO levofloxacin tabs 1 MO MO NOROXIN 3 MO

ofloxacin 1 MO

MO SULFAS RELATED AGENTS sulfadiazine 1 MO sulfamethoxazoletrimethoprim 1 MO

MO sulfamethoxazoletrimethoprim ds 1 MO MO TETRACYCLINES MO demeclocycline hcl 1 MO MO doxycycline caps 75mg 1 MO

doxycycline hyclate caps 1 MO MO doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO doxycycline hyclate tbec 100mg 1 MO 75mg 150mg doxycycline monohydrate tabs 1 MO 150mg 50mg 75mg minocycline hcl 1 MO

MO minocycline hcl er 1 tetracycline hcl caps 1

MO MO

VIBRAMYCIN SYRP 3 MO MO URINARY TRACT AGENTS

MACRODANTIN CAPS 25MG 3 MO methenamine hippurate 1 MO

MO MONUROL 3 MO nitrofurantoin susp 25mg5ml 3 MO

MO 12

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13 13 13

9

ANTI - INFECTIVES ANTIFUNGAL AGENTS

Drug Name

Drug Tier

Notes

amphotericin b 1 BD MO CANCIDAS 4 DL clotrimazole troc 1 MO ERAXIS INJ 100MG 3 DL fluconazole in dextrose inj 0 400mg200ml

1

fluconazole susr 1 MO fluconazole tabs 1 MO flucytosine 1 MO GRIS-PEG 3 MO griseofulvin microsize 1 MO itraconazole 3 PA DL ketoconazole tabs 1 MO NOXAFIL 4 DL nystatin susp 1 MO nystatin tabs 1 MO terbinafine tabs 1 QL(84 per

365 days) DL

VFEND IV 3 DL voriconazole tabs 50mg 3 QL(60 per

30 days) DL voriconazole tabs 200mg 4 QL(60 per

30 days) DL ANTIVIRALS acyclovir caps 5 $6 MO acyclovir inj 500mg 1 BD DL acyclovir susp 1 MO acyclovir tabs 1 MO amantadine 1 MO APTIVUS 4 DL ATRIPLA 4 DL BARACLUDE 3 DL COMPLERA 4 DL CRIXIVAN 2 MO didanosine 1 MO EDURANT 4 DL EMTRIVA 2 MO

Drug Name

Drug Tier

Notes

EPIVIR HBV 2 MO EPIVIR ORAL SOLN 2 MO EPZICOM 4 DL famciclovir 1 MO FUZEON 4 DL ganciclovir caps 1 MO ganciclovir inj 1 BD DL HEPSERA 4 DL INCIVEK 4 PA QL(504

per 365 days) DL

INTELENCE TABS 100MG 200MG

4 DL

INVIRASE 2 MO ISENTRESS 4 DL KALETRA 2 MO lamivudine 1 MO lamivudinezidovudine 1 DL LEXIVA SUSP 3 DL LEXIVA TABS 4 DL nevirapine tabs 200mg 1 MO NORVIR 2 MO PREZISTA TABS 75MG 150MG

3 DL

PREZISTA TABS 400MG 600MG

4 DL

REBETOL ORAL SOLN 2 PA QL(900 per 30 days)

DL RELENZA DISKHALER 3 QL(60 per

180 days) DL

RESCRIPTOR 2 MO RETROVIR IV INFUSION 3 MO REYATAZ CAPS 100MG 3 QL(60 per

30 days) DL REYATAZ CAPS 150MG 200MG 300MG

4 DL

ribapak tabs 4 PA DL ribasphere caps 200mg 3 PA QL(180

per 30 days) DL

ribasphere tabs 400mg 3 PA DL

Commonly Prescribed Therapeutic Drug Categories

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes ribasphere tabs 200mg 3 PA QL(180 cefotaxime sodium inj 10gm 1gm 1

per 30 days) DL

cefotaxime sodium inj 2gm 1 CEFOTETAN 3

MO

ribasphere tabs 600mg ribavirin rimantadine hcl

4 PA DL 3 PA DL 1 MO

CEFOXITIN SODIUM INJ 1GM 4 2GM 22

3

cefoxitin sodium inj 10gm 2gm 1 SELZENTRY 4 DL cefoxitin sodium inj 1gm 1 MO stavudine caps 1 MO cefpodoxime proxetil 1 MO SUSTIVA 2 MO cefprozil 1 MO SYNAGIS INJ 50MG05ML 4 DL ceftazidime inj 1gm 6gm 1 TAMIFLU CAPS 45MG 75MG

TAMIFLU CAPS 30MG

TAMIFLU SUSR

3 QL(28 per 180 days)

DL 3 QL(56 per

180 days) DL

3 QL(360 per 180 days)

DL

ceftazidime inj 2gm 1 CEFTAZIDIMEDEXTROSE 3 ceftriaxone sodium inj 10gm 1 ceftriaxone sodium inj 1gm 250mg 2gm 500mg

1

cefuroxime axetil tabs 1 cefuroxime sodium inj 75gm 1 cefuroxime sodium inj 15gm 1

MO

MO

MO

MO TRIZIVIR 4 DL 750mg TRUVADA 4 DL cephalexin 1 MO TYZEKA 3 MO CLAFORAN INJ 1GM 3 valacyclovir hcl VALCYTE VIDEX PEDIATRIC ORAL SOLN 2GM

1 MO 4 DL 3 MO

FORTAZ INJ 1GM50ML 5 2GM50ML 5 6GM

3

SPECTRACEF 3 SUPRAX TAB 400MG 3

MO

VIRACEPT 2 MO SUPRAX SUSR 3 VIRAMUNE SUSP 2 MO ZINACEF IN ISO-OSMOTIC 3 VIREAD VISTIDE

2 MO 3 MO

DEXTROSE ZINACEF IN ISO-OSMOTIC DILUENT

3

ZERIT ORAL SOLN ZIAGEN zidovudine

3 MO 2 MO 1 MO

ZINACEF INJ 15GM 750MG 3 ERYTHROMYCINS OTHER MACROLIDES

CEPHALOSPORINS CEDAX CAPS 3 MO cefaclor 1 MO cefaclor er 1 MO cefadroxil 1 MO cefazolin inj 1gm 5 500mg 1 cefazolin inj 1gm 1 MO CEFAZOLIN INJ 10GM 3 cefdinir 1 MO cefepime inj 2gm 1 cefepime inj 1gm 1 MO

10

azithromycin inj 500mg 1 MO azithromycin susr 1 MO azithromycin tabs 1 MO BIAXIN XL PAC 3 MO clarithromycin 1 MO clarithromycin er 1 MO DIFICID 4 PA DL ees 400 1 MO ery-tab tbec 250mg 333mg 1 MO ERY-TAB TBEC 500MG 2 MO ERYPED 200 3 MO

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes gentamicin sulfate09 sodium 1 chloride inj GENTAMICIN SULFATE09 3 SODIUM CHLORIDE INJ gentamicin sulfatesodium 1 chloride inj 12mgml 09 hydroxychloroquine 1 imipenemcilastatin 1 INVANZ 3 isoniazid inj 1 ISONIAZID SYRP 3 isoniazid tabs 1 isotonic gentamicin inj 08mgml 1 09 kanamycin sulfate 1 KETEK 3 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 079 1 MYCOBUTIN 3 NEBUPENT 3 neomycin sulfate 1 paromomycin 1 PASER 3 PENTAM 300 3 polymyxin b sulfate 1 PRIFTIN 3 PRIMAQUINE 3 PRIMAXIN IV INJ 500MG 3 500MG QUALAQUIN 3 rifampin 1 RIFATER 3 SEROMYCIN 3 STREPTOMYCIN SULFATE 3 STROMECTOL 3 SYNERCID 4 TOBI 4 tobramycin inj 10mgml 1 80mg2ml TOBRAMYCIN SULFATE 3 SODIUM CHLORIDE

MO MO MO

MO MO

MO PA DL PA DL

MO MO MO MO

BD DL MO MO MO

BD DL MO MO

PA DL MO

PA DL MO MO MO MO MO DL

BD DL BD DL

ERYPED 400 3 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 ERYTHROMYCIN BASE 3 erythromycin ethylsuccinate 1 PCE 3 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES

MO

MO MO MO MO MO

ALBENZA ALINIA amikacin sulfate inj 500mg2ml 50mgml atovaquoneproguanil hcl tabs 250mg 100mg AZACTAM IN ISO-OSMOTIC DEXTROSE aztreonam inj 1gm baciim bacitracin inj BILTRICIDE CAPASTAT SULFATE CHLORAMPHENICOL SODIUM SUCCINATE chloroquine CLEOCIN CAPS 75MG CLEOCIN GALAXY CLEOCIN IN D5W clindamycin hcl caps 150mg 300mg clindamycin phosphate add-vantage COARTEM colistimethate sodium CUBICIN DAPSONE DARAPRIM DORIBAX INJ 500MG ethambutol tabs 400mg ethambutol tabs 100mg FLAGYL ER GENTAMICIN SULFATE INJ 10MGML gentamicin sulfate inj 40mgml

3 3 1

1

3

1 1 1 2 3 3

1 3 3 3 1

1

3 3 4 2 3 3 1 1 3 3

1

DL DL MO

DL

MO

MO DL

DL MO

MO

MO

PA DL MO

BD DL MO

PA DL DL

MO MO

MO

11

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRECATOR 3 MO ZOSYN INJ 5 2GM50ML 3 TYGACIL 3 DL 025GM50ML 5 3GM50ML XIFAXAN TABS 550MG 3 MO 0375GM50ML

XIFAXAN TABS 200MG 3 PA QL(9 per 30 days)

QUINOLONES AVELOX ABC PACK 2 MO

DL AVELOX INJ 3 PA DL ZYVOX 4 PA DL AVELOX TABS 2 MO PENICILLINS CIPRO SUSR 3 amoxicillin 1 amoxicillinclavulanate potassium 1 amoxicillinclavulanate potassium 1 er amoxicillinpotassium clavulanate 1 tabs ampicillin caps 1 ampicillin inj 1gm 125mg 1 ampicillin inj 10gm 1 ampicillin susp 1 ampicillin-sulbactam inj 10gm 1 5gm ampicillin-sulbactam inj 2gm 1 1gm BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium inj 10gm 1 nafcillin sodium inj 1gm 1 NALLPENDEXTROSE INJ 0 3 1GM50ML OXACILLIN SODIUM INJ 3 10GM 1GM PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodiumtazobactam 1 sodium inj 4gm 05gm piperacillin sodiumtazobactam 1 sodium inj 3gm 0375gm TIMENTIN INJ 01GM 3GM 3

MO ciprofloxacin er 1 MO MO ciprofloxacin inj 400mg40ml 1 PA DL MO ciprofloxacin tabs 1 MO

FACTIVE 3 MO MO levofloxacin in d5w inj 5 1 PA DL

MO 500mg100ml levofloxacin inj 1 PA DL levofloxacin oral soln 1 MO

MO levofloxacin tabs 1 MO MO NOROXIN 3 MO

ofloxacin 1 MO

MO SULFAS RELATED AGENTS sulfadiazine 1 MO sulfamethoxazoletrimethoprim 1 MO

MO sulfamethoxazoletrimethoprim ds 1 MO MO TETRACYCLINES MO demeclocycline hcl 1 MO MO doxycycline caps 75mg 1 MO

doxycycline hyclate caps 1 MO MO doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO doxycycline hyclate tbec 100mg 1 MO 75mg 150mg doxycycline monohydrate tabs 1 MO 150mg 50mg 75mg minocycline hcl 1 MO

MO minocycline hcl er 1 tetracycline hcl caps 1

MO MO

VIBRAMYCIN SYRP 3 MO MO URINARY TRACT AGENTS

MACRODANTIN CAPS 25MG 3 MO methenamine hippurate 1 MO

MO MONUROL 3 MO nitrofurantoin susp 25mg5ml 3 MO

MO 12

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes ribasphere tabs 200mg 3 PA QL(180 cefotaxime sodium inj 10gm 1gm 1

per 30 days) DL

cefotaxime sodium inj 2gm 1 CEFOTETAN 3

MO

ribasphere tabs 600mg ribavirin rimantadine hcl

4 PA DL 3 PA DL 1 MO

CEFOXITIN SODIUM INJ 1GM 4 2GM 22

3

cefoxitin sodium inj 10gm 2gm 1 SELZENTRY 4 DL cefoxitin sodium inj 1gm 1 MO stavudine caps 1 MO cefpodoxime proxetil 1 MO SUSTIVA 2 MO cefprozil 1 MO SYNAGIS INJ 50MG05ML 4 DL ceftazidime inj 1gm 6gm 1 TAMIFLU CAPS 45MG 75MG

TAMIFLU CAPS 30MG

TAMIFLU SUSR

3 QL(28 per 180 days)

DL 3 QL(56 per

180 days) DL

3 QL(360 per 180 days)

DL

ceftazidime inj 2gm 1 CEFTAZIDIMEDEXTROSE 3 ceftriaxone sodium inj 10gm 1 ceftriaxone sodium inj 1gm 250mg 2gm 500mg

1

cefuroxime axetil tabs 1 cefuroxime sodium inj 75gm 1 cefuroxime sodium inj 15gm 1

MO

MO

MO

MO TRIZIVIR 4 DL 750mg TRUVADA 4 DL cephalexin 1 MO TYZEKA 3 MO CLAFORAN INJ 1GM 3 valacyclovir hcl VALCYTE VIDEX PEDIATRIC ORAL SOLN 2GM

1 MO 4 DL 3 MO

FORTAZ INJ 1GM50ML 5 2GM50ML 5 6GM

3

SPECTRACEF 3 SUPRAX TAB 400MG 3

MO

VIRACEPT 2 MO SUPRAX SUSR 3 VIRAMUNE SUSP 2 MO ZINACEF IN ISO-OSMOTIC 3 VIREAD VISTIDE

2 MO 3 MO

DEXTROSE ZINACEF IN ISO-OSMOTIC DILUENT

3

ZERIT ORAL SOLN ZIAGEN zidovudine

3 MO 2 MO 1 MO

ZINACEF INJ 15GM 750MG 3 ERYTHROMYCINS OTHER MACROLIDES

CEPHALOSPORINS CEDAX CAPS 3 MO cefaclor 1 MO cefaclor er 1 MO cefadroxil 1 MO cefazolin inj 1gm 5 500mg 1 cefazolin inj 1gm 1 MO CEFAZOLIN INJ 10GM 3 cefdinir 1 MO cefepime inj 2gm 1 cefepime inj 1gm 1 MO

10

azithromycin inj 500mg 1 MO azithromycin susr 1 MO azithromycin tabs 1 MO BIAXIN XL PAC 3 MO clarithromycin 1 MO clarithromycin er 1 MO DIFICID 4 PA DL ees 400 1 MO ery-tab tbec 250mg 333mg 1 MO ERY-TAB TBEC 500MG 2 MO ERYPED 200 3 MO

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes gentamicin sulfate09 sodium 1 chloride inj GENTAMICIN SULFATE09 3 SODIUM CHLORIDE INJ gentamicin sulfatesodium 1 chloride inj 12mgml 09 hydroxychloroquine 1 imipenemcilastatin 1 INVANZ 3 isoniazid inj 1 ISONIAZID SYRP 3 isoniazid tabs 1 isotonic gentamicin inj 08mgml 1 09 kanamycin sulfate 1 KETEK 3 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 079 1 MYCOBUTIN 3 NEBUPENT 3 neomycin sulfate 1 paromomycin 1 PASER 3 PENTAM 300 3 polymyxin b sulfate 1 PRIFTIN 3 PRIMAQUINE 3 PRIMAXIN IV INJ 500MG 3 500MG QUALAQUIN 3 rifampin 1 RIFATER 3 SEROMYCIN 3 STREPTOMYCIN SULFATE 3 STROMECTOL 3 SYNERCID 4 TOBI 4 tobramycin inj 10mgml 1 80mg2ml TOBRAMYCIN SULFATE 3 SODIUM CHLORIDE

MO MO MO

MO MO

MO PA DL PA DL

MO MO MO MO

BD DL MO MO MO

BD DL MO MO

PA DL MO

PA DL MO MO MO MO MO DL

BD DL BD DL

ERYPED 400 3 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 ERYTHROMYCIN BASE 3 erythromycin ethylsuccinate 1 PCE 3 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES

MO

MO MO MO MO MO

ALBENZA ALINIA amikacin sulfate inj 500mg2ml 50mgml atovaquoneproguanil hcl tabs 250mg 100mg AZACTAM IN ISO-OSMOTIC DEXTROSE aztreonam inj 1gm baciim bacitracin inj BILTRICIDE CAPASTAT SULFATE CHLORAMPHENICOL SODIUM SUCCINATE chloroquine CLEOCIN CAPS 75MG CLEOCIN GALAXY CLEOCIN IN D5W clindamycin hcl caps 150mg 300mg clindamycin phosphate add-vantage COARTEM colistimethate sodium CUBICIN DAPSONE DARAPRIM DORIBAX INJ 500MG ethambutol tabs 400mg ethambutol tabs 100mg FLAGYL ER GENTAMICIN SULFATE INJ 10MGML gentamicin sulfate inj 40mgml

3 3 1

1

3

1 1 1 2 3 3

1 3 3 3 1

1

3 3 4 2 3 3 1 1 3 3

1

DL DL MO

DL

MO

MO DL

DL MO

MO

MO

PA DL MO

BD DL MO

PA DL DL

MO MO

MO

11

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRECATOR 3 MO ZOSYN INJ 5 2GM50ML 3 TYGACIL 3 DL 025GM50ML 5 3GM50ML XIFAXAN TABS 550MG 3 MO 0375GM50ML

XIFAXAN TABS 200MG 3 PA QL(9 per 30 days)

QUINOLONES AVELOX ABC PACK 2 MO

DL AVELOX INJ 3 PA DL ZYVOX 4 PA DL AVELOX TABS 2 MO PENICILLINS CIPRO SUSR 3 amoxicillin 1 amoxicillinclavulanate potassium 1 amoxicillinclavulanate potassium 1 er amoxicillinpotassium clavulanate 1 tabs ampicillin caps 1 ampicillin inj 1gm 125mg 1 ampicillin inj 10gm 1 ampicillin susp 1 ampicillin-sulbactam inj 10gm 1 5gm ampicillin-sulbactam inj 2gm 1 1gm BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium inj 10gm 1 nafcillin sodium inj 1gm 1 NALLPENDEXTROSE INJ 0 3 1GM50ML OXACILLIN SODIUM INJ 3 10GM 1GM PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodiumtazobactam 1 sodium inj 4gm 05gm piperacillin sodiumtazobactam 1 sodium inj 3gm 0375gm TIMENTIN INJ 01GM 3GM 3

MO ciprofloxacin er 1 MO MO ciprofloxacin inj 400mg40ml 1 PA DL MO ciprofloxacin tabs 1 MO

FACTIVE 3 MO MO levofloxacin in d5w inj 5 1 PA DL

MO 500mg100ml levofloxacin inj 1 PA DL levofloxacin oral soln 1 MO

MO levofloxacin tabs 1 MO MO NOROXIN 3 MO

ofloxacin 1 MO

MO SULFAS RELATED AGENTS sulfadiazine 1 MO sulfamethoxazoletrimethoprim 1 MO

MO sulfamethoxazoletrimethoprim ds 1 MO MO TETRACYCLINES MO demeclocycline hcl 1 MO MO doxycycline caps 75mg 1 MO

doxycycline hyclate caps 1 MO MO doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO doxycycline hyclate tbec 100mg 1 MO 75mg 150mg doxycycline monohydrate tabs 1 MO 150mg 50mg 75mg minocycline hcl 1 MO

MO minocycline hcl er 1 tetracycline hcl caps 1

MO MO

VIBRAMYCIN SYRP 3 MO MO URINARY TRACT AGENTS

MACRODANTIN CAPS 25MG 3 MO methenamine hippurate 1 MO

MO MONUROL 3 MO nitrofurantoin susp 25mg5ml 3 MO

MO 12

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes gentamicin sulfate09 sodium 1 chloride inj GENTAMICIN SULFATE09 3 SODIUM CHLORIDE INJ gentamicin sulfatesodium 1 chloride inj 12mgml 09 hydroxychloroquine 1 imipenemcilastatin 1 INVANZ 3 isoniazid inj 1 ISONIAZID SYRP 3 isoniazid tabs 1 isotonic gentamicin inj 08mgml 1 09 kanamycin sulfate 1 KETEK 3 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 079 1 MYCOBUTIN 3 NEBUPENT 3 neomycin sulfate 1 paromomycin 1 PASER 3 PENTAM 300 3 polymyxin b sulfate 1 PRIFTIN 3 PRIMAQUINE 3 PRIMAXIN IV INJ 500MG 3 500MG QUALAQUIN 3 rifampin 1 RIFATER 3 SEROMYCIN 3 STREPTOMYCIN SULFATE 3 STROMECTOL 3 SYNERCID 4 TOBI 4 tobramycin inj 10mgml 1 80mg2ml TOBRAMYCIN SULFATE 3 SODIUM CHLORIDE

MO MO MO

MO MO

MO PA DL PA DL

MO MO MO MO

BD DL MO MO MO

BD DL MO MO

PA DL MO

PA DL MO MO MO MO MO DL

BD DL BD DL

ERYPED 400 3 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 ERYTHROMYCIN BASE 3 erythromycin ethylsuccinate 1 PCE 3 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES

MO

MO MO MO MO MO

ALBENZA ALINIA amikacin sulfate inj 500mg2ml 50mgml atovaquoneproguanil hcl tabs 250mg 100mg AZACTAM IN ISO-OSMOTIC DEXTROSE aztreonam inj 1gm baciim bacitracin inj BILTRICIDE CAPASTAT SULFATE CHLORAMPHENICOL SODIUM SUCCINATE chloroquine CLEOCIN CAPS 75MG CLEOCIN GALAXY CLEOCIN IN D5W clindamycin hcl caps 150mg 300mg clindamycin phosphate add-vantage COARTEM colistimethate sodium CUBICIN DAPSONE DARAPRIM DORIBAX INJ 500MG ethambutol tabs 400mg ethambutol tabs 100mg FLAGYL ER GENTAMICIN SULFATE INJ 10MGML gentamicin sulfate inj 40mgml

3 3 1

1

3

1 1 1 2 3 3

1 3 3 3 1

1

3 3 4 2 3 3 1 1 3 3

1

DL DL MO

DL

MO

MO DL

DL MO

MO

MO

PA DL MO

BD DL MO

PA DL DL

MO MO

MO

11

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRECATOR 3 MO ZOSYN INJ 5 2GM50ML 3 TYGACIL 3 DL 025GM50ML 5 3GM50ML XIFAXAN TABS 550MG 3 MO 0375GM50ML

XIFAXAN TABS 200MG 3 PA QL(9 per 30 days)

QUINOLONES AVELOX ABC PACK 2 MO

DL AVELOX INJ 3 PA DL ZYVOX 4 PA DL AVELOX TABS 2 MO PENICILLINS CIPRO SUSR 3 amoxicillin 1 amoxicillinclavulanate potassium 1 amoxicillinclavulanate potassium 1 er amoxicillinpotassium clavulanate 1 tabs ampicillin caps 1 ampicillin inj 1gm 125mg 1 ampicillin inj 10gm 1 ampicillin susp 1 ampicillin-sulbactam inj 10gm 1 5gm ampicillin-sulbactam inj 2gm 1 1gm BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium inj 10gm 1 nafcillin sodium inj 1gm 1 NALLPENDEXTROSE INJ 0 3 1GM50ML OXACILLIN SODIUM INJ 3 10GM 1GM PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodiumtazobactam 1 sodium inj 4gm 05gm piperacillin sodiumtazobactam 1 sodium inj 3gm 0375gm TIMENTIN INJ 01GM 3GM 3

MO ciprofloxacin er 1 MO MO ciprofloxacin inj 400mg40ml 1 PA DL MO ciprofloxacin tabs 1 MO

FACTIVE 3 MO MO levofloxacin in d5w inj 5 1 PA DL

MO 500mg100ml levofloxacin inj 1 PA DL levofloxacin oral soln 1 MO

MO levofloxacin tabs 1 MO MO NOROXIN 3 MO

ofloxacin 1 MO

MO SULFAS RELATED AGENTS sulfadiazine 1 MO sulfamethoxazoletrimethoprim 1 MO

MO sulfamethoxazoletrimethoprim ds 1 MO MO TETRACYCLINES MO demeclocycline hcl 1 MO MO doxycycline caps 75mg 1 MO

doxycycline hyclate caps 1 MO MO doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO doxycycline hyclate tbec 100mg 1 MO 75mg 150mg doxycycline monohydrate tabs 1 MO 150mg 50mg 75mg minocycline hcl 1 MO

MO minocycline hcl er 1 tetracycline hcl caps 1

MO MO

VIBRAMYCIN SYRP 3 MO MO URINARY TRACT AGENTS

MACRODANTIN CAPS 25MG 3 MO methenamine hippurate 1 MO

MO MONUROL 3 MO nitrofurantoin susp 25mg5ml 3 MO

MO 12

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

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Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

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13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRECATOR 3 MO ZOSYN INJ 5 2GM50ML 3 TYGACIL 3 DL 025GM50ML 5 3GM50ML XIFAXAN TABS 550MG 3 MO 0375GM50ML

XIFAXAN TABS 200MG 3 PA QL(9 per 30 days)

QUINOLONES AVELOX ABC PACK 2 MO

DL AVELOX INJ 3 PA DL ZYVOX 4 PA DL AVELOX TABS 2 MO PENICILLINS CIPRO SUSR 3 amoxicillin 1 amoxicillinclavulanate potassium 1 amoxicillinclavulanate potassium 1 er amoxicillinpotassium clavulanate 1 tabs ampicillin caps 1 ampicillin inj 1gm 125mg 1 ampicillin inj 10gm 1 ampicillin susp 1 ampicillin-sulbactam inj 10gm 1 5gm ampicillin-sulbactam inj 2gm 1 1gm BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium inj 10gm 1 nafcillin sodium inj 1gm 1 NALLPENDEXTROSE INJ 0 3 1GM50ML OXACILLIN SODIUM INJ 3 10GM 1GM PENICILLIN G POTASSIUM IN 3 ISO-OSMOTIC DEXTROSE penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodiumtazobactam 1 sodium inj 4gm 05gm piperacillin sodiumtazobactam 1 sodium inj 3gm 0375gm TIMENTIN INJ 01GM 3GM 3

MO ciprofloxacin er 1 MO MO ciprofloxacin inj 400mg40ml 1 PA DL MO ciprofloxacin tabs 1 MO

FACTIVE 3 MO MO levofloxacin in d5w inj 5 1 PA DL

MO 500mg100ml levofloxacin inj 1 PA DL levofloxacin oral soln 1 MO

MO levofloxacin tabs 1 MO MO NOROXIN 3 MO

ofloxacin 1 MO

MO SULFAS RELATED AGENTS sulfadiazine 1 MO sulfamethoxazoletrimethoprim 1 MO

MO sulfamethoxazoletrimethoprim ds 1 MO MO TETRACYCLINES MO demeclocycline hcl 1 MO MO doxycycline caps 75mg 1 MO

doxycycline hyclate caps 1 MO MO doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO doxycycline hyclate tbec 100mg 1 MO 75mg 150mg doxycycline monohydrate tabs 1 MO 150mg 50mg 75mg minocycline hcl 1 MO

MO minocycline hcl er 1 tetracycline hcl caps 1

MO MO

VIBRAMYCIN SYRP 3 MO MO URINARY TRACT AGENTS

MACRODANTIN CAPS 25MG 3 MO methenamine hippurate 1 MO

MO MONUROL 3 MO nitrofurantoin susp 25mg5ml 3 MO

MO 12

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes nitrofurantoin macrocrystalline 3 MO caps 50mg nitrofurantoin monohydrate caps 3 MO PRIMSOL 3 MO trimethoprim 1 MO VANCOMYCIN vancomycin caps 4 DL vancomycin inj 10gm 500mg 1 BD vancomycin inj 1000mg 1 BD ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine inj 4 BD DL dexrazoxane inj 500mg 3 BD DL ELITEK INJ 15MG 4 BD DL leucovorin calcium inj 100mg 1 BD DL 350mg leucovorin calcium tabs 25mg 1 MO 5mg LEUCOVORIN CALCIUM 2 MO TABS 10MG 15MG mesna inj 1 BD DL MESNEX TABS 2 DL ZINECARD INJ 250MG 3 BD DL ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 BD DL adriamycin inj 2mgml 1 BD DL AFINITOR TABS 25MG 5MG 4 QL(30 per 75MG 30 days) DL AFINITOR TABS 10MG 4 QL(60 per

30 days) DL ALIMTA INJ 500MG 4 BD DL anastrozole 1 MO ARRANON 4 BD DL ARZERRA 4 BD DL AVASTIN INJ 100MG4ML 4 BD DL AZASAN 3 BD MO azathioprine tabs 1 BD MO azathioprine sodium inj 1 BD DL bicalutamide 1 MO BICNU 3 BD DL bleomycin sulfate inj 30unit 1 BD DL

BUSULFEX 3 BD DL CAMPATH 4 BD DL CAPRELSA TABS 300MG 4 PA QL(30

per 30 days) DL

CAPRELSA TABS 100MG 4 PA QL(60 per 30 days)

DL carboplatin inj 150mg15ml 1 BD DL CEENU 2 MO CELLCEPT INTRAVENOUS 3 BD DL CELLCEPT SUSP 2 BD MO cisplatin inj 100mg100ml 1 BD DL cladribine 3 BD DL cyclophosphamide tabs 1 BD DL cyclosporine caps 100mg 25mg 1 BD MO CYCLOSPORINE CAPS 50MG 3 BD MO cyclosporine inj 1 BD DL cyclosporine oral soln 1 BD MO cytarabine aqueous inj 20mgml 1 BD DL CYTARABINE AQUEOUS INJ 3 BD DL 100MGML cytarabine inj 500mg 1 BD MO dacarbazine inj 200mg 1 BD DL DACOGEN 4 BD DL daunorubicin hcl inj 5mgml 1 BD DL DOCEFREZ 3 BD DL DOCETAXEL INJ 80MG8ML 3 BD DL docetaxel inj 80mg4ml 1 BD DL DOXIL 3 BD DL doxorubicin hcl inj 2mgml 1 BD DL DROXIA 2 MO ELIGARD 3 BD DL ELLENCE INJ 200MG100ML 4 BD DL ELSPAR 3 BD DL EMCYT 2 MO epirubicin hcl inj 50mg25ml 3 BD DL ERBITUX INJ 100MG50ML 4 BD DL ERIVEDGE CAPS 4 LA PA DL ETOPOPHOS 3 BD DL etoposide inj 1 BD DL exemestane 1 MO FARESTON 2 MO

13

13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

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Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

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13

Drug Drug Name Tier Notes FASLODEX FIRMAGON INJ 120MG FIRMAGON INJ 80MG

fludarabine phosphate inj 50mg fluorouracil inj 500mg10ml flutamide gemcitabine hcl inj 1gm gengraf GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea idarubicin hcl inj 10mg10ml IFEX INJ 3GM ifosfamide inj 1gm INLYTA irinotecan inj 100mg5ml ISTODAX IXEMPRA KIT INJ 45MG JAKAFI

JEVTANA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ 375MG

LUPRON DEPOT INJ 225MG 30MG 45MG 75MG LUPRON DEPOT-PED INJ 1125MG 15MG LYSODREN MATULANE MEGACE ES megestrol acetate melphalan hydrochloride inj mercaptopurine methotrexate tabs 25mg methotrexate sodium inj 25mgml

4 4 3

1 1 1 1 1 4 4 4 4 1 1 3 1 4 3 4 4 4

4 1 2 1 3

4

4

2 4 3 1 1 1 5 1

BD DL BD DL

BD QL(4 per 28 days)

DL BD DL BD DL

MO BD DL BD MO

DL BD DL BD DL

DL MO

BD DL BD DL BD DL

PA LA DL BD DL BD DL BD DL

PA QL(60 per 30 days)

DL BD DL

MO MO DL

BD QL(1 per 30 days)

DL BD DL

BD DL

MO DL

PA DL PA DL BD DL

MO $6 MO

DL

Drug Drug Name Tier Notes METHOTREXATE SODIUM 3 BD DL INJ 1GM mitomycin inj 20mg 1 BD DL mitoxantrone hcl inj 1 BD DL MUSTARGEN 3 BD DL mycophenolate mofetil 1 BD MO MYFORTIC 2 BD MO NEORAL 3 BD MO NEXAVAR 4 LA DL NILANDRON 2 MO NIPENT 4 BD DL NULOJIX 4 BD DL octreotide inj 1000mcgml 4 DL 500mcgml octreotide inj 100mcgml 3 DL 200mcgml 50mcgml ONTAK 4 BD DL oxaliplatin inj 100mg20ml 3 BD DL paclitaxel inj 300mg50ml 1 BD DL pentostatin 4 BD DL PROGRAF INJ 3 BD DL RAPAMUNE 3 BD MO REVLIMID CAPS 10MG 4 LA QL(30 15MG 25MG 5MG per 30 days)

DL RHEUMATREX 3 MO RITUXAN 4 BD DL SANDIMMUNE CAPS 2 BD MO SANDIMMUNE INJ 3 BD DL SANDIMMUNE ORAL SOLN 2 BD MO SANDOSTATIN LAR DEPOT 4 BD DL SIMULECT INJ 20MG 3 BD DL SOMATULINE DEPOT 4 PA DL SPRYCEL 4 QL(30 per

30 days) DL SUTENT 4 QL(30 per

30 days) DL TABLOID 3 MO tacrolimus 1 BD MO tamoxifen citrate 1 MO TARCEVA TABS 100MG 4 QL(30 per 150MG 30 days) DL TARCEVA TABS 25MG 4 QL(60 per

30 days) DL

14

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Name

Drug Tier Notes

TARGRETIN 4 DL TASIGNA

THALOMID CAPS 100MG 50MG THALOMID CAPS 150MG 200MG thiotepa topotecan hcl inj 4mg TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin caps TREXALL

4

4

4

1 4 4 4 3 3 4 4 3

QL(112 per 28 days) DL QL(30 per

30 days) DL QL(60 per

30 days) DL BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL MO

TRISENOX TYKERB

3 4

BD DL LA DL

VECTIBIX INJ 100MG5ML VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg5ml VOTRIENT

4 4 4 1 1 1 3 4

BD DL BD DL BD DL BD DL BD DL BD DL BD DL

DL XALKORI 4 LA PA DL YERVOY INJ 50MG10ML ZANOSAR ZELBORAF

4 3 4

PA DL BD DL

LA PA DL ZOLINZA 4 DL ZORTRESS TABS 05MG 075MG

4 BD DL

ZORTRESS TABS 025MG 3 BD QL(60 per 30 days)

DL ZYTIGA 4 PA DL AUTONOMIC CNS DRUGS NEUROLOGY PSYCH ANTICONVULSANTS BANZEL SUSP 4 DL BANZEL TABS 400MG 4 DL BANZEL TABS 200MG 3 QL(60 per

30 days) DL 15

Drug Drug Name Tier Notes carbamazepine 1 MO carbamazepine er cp12 1 MO CELONTIN 2 MO clonazepam 3 DL clonazepam odt 3 DL diazepam gel 1 DL DILANTIN 3 MO DILANTIN INFATABS 3 MO divalproex sodium 1 MO divalproex sodium dr 1 MO divalproex sodium er 1 MO epitol 1 MO EQUETRO 3 MO ethosuximide 1 MO felbamate 1 MO fosphenytoin sodium inj 100mg 1 MO 2ml gabapentin 1 MO GABITRIL 3 MO lamotrigine 1 MO levetiracetam er 1 MO levetiracetam inj 500mg5ml 1 levetiracetam oral soln 1 MO levetiracetam tabs 1 MO LYRICA 3 QL(90 per

30 days) MO

ONFI 3 PA DL oxcarbazepine 1 MO PEGANONE 2 MO phenobarbital elix 1 DL phenobarbital tabs 15mg 162mg 1 DL 30mg 324mg 60mg 648mg 972mg phenytoin 1 MO PHENYTOIN SODIUM 3 phenytoin sodium er 1 MO primidone 1 MO POTIGA TABS 3 PA DL SABRIL 4 LA DL STAVZOR 3 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes TRILEPTAL SUSP 3 MO MAXALT 2 QL(12 per valproate sodium 1 MO 30 days)

MOvalproic acid 1 MO MAXALT-MLT 2 QL(12 per VIMPAT INJ 3 30 days)

VIMPAT ORAL SOLN 3 MO MO VIMPAT TABS 3 MO MIGRANAL 2 QL(8 per 30 zonisamide 1 MO days) MO ANTIPARKINSONISM AGENTS naratriptan hcl tabs 25mg 1 QL(9 per 30

days) MO APOKYN 4 BD LA PA naratriptan hcl tabs 1mg 1 QL(18 per DL

30 days) AZILECT 3 MO MObenztropine mesylate inj 1 RELPAX TABS 40MG 2 QL(8 per 30

benztropine mesylate tabs 1 MO days) MO bromocriptine mesylate 1 MO RELPAX TABS 20MG 2 QL(12 per carbidopalevodopa 1 MO 30 days) carbidopalevodopa er 1 MO MO carbidopalevodopa odt 1 MO sumatriptan succinate inj 1 QL(4 per 30

6mg05ml days) MO COMTAN 3 MO sumatriptan succinate tabs 100mg 1 QL(9 per 30 LODOSYN 3 MO days) MO

pramipexole dihydrochloride 1 MO sumatriptan succinate tabs 25mg 1 QL(18 per ropinirole 1 MO 50mg 30 days) ropinirole er tabs 1 MO MO selegiline 1 MO TREXIMET 3 QL(9 per 30

days) MO STALEVO 100 3 MO ZOMIG NASAL SOLN 3 QL(12 per STALEVO 125 3 MO

30 days) STALEVO 150 3 MO MO STALEVO 200 3 MO ZOMIG TABS 5MG 3 QL(8 per 30 STALEVO 50 3 MO days) MO STALEVO 75 3 MO ZOMIG TABS 25MG 3 QL(12 per TASMAR 3 MO 30 days)

MOtrihexyphenidyl 1 MO ZOMIG ZMT TBDP 5MG 3 QL(8 per 30 ZELAPAR 3 MO days) MO

MIGRAINE CLUSTER HEADACHE ZOMIG ZMT TBDP 25MG 3 QL(12 per THERAPY 30 days) AXERT TABS 125MG 3 QL(8 per 30 MO

days) MO MISCELLANEOUS NEUROLOGICAL AXERT TABS 625MG 3 QL(12 per THERAPY

30 days) AMPYRA 4 PA QL(60 MO per 30 days)

FROVA 3 QL(12 per DL30 days) COPAXONE 4 DL

MO donepezil hcl 1 MO EXELON ORAL SOLN 3 MO

16

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes duramorph endocet endodan fentanyl citrate oral transmucosal lpop 200mcg

fentanyl citrate oral transmucosal lpop 1200mcg 1600mcg 400mcg 600mcg 800mcg fentanyl patches

FENTORA

hydrocodone bitartrateacetaminophen oral soln hydrocodone bitartrateacetaminophen tabs 300mg 10mg 300mg 5mg 300mg 75mg 750mg 10mg hydrocodoneacetaminophen oral soln 500mg15ml 75mg15ml hydrocodoneacetaminophen tabs hydrocodoneibuprofen hydromorphone hcl inj 500mg50ml hydromorphone hcl tabs KADIAN CP24 10MG 200MG

levorphanol tartrate MAGNACET methadone hcl conc methadone hcl inj methadone hcl oral soln 5mg5ml METHADONE HCL ORAL SOLN 10MG5ML methadone hcl tabs methadose tabs morphine sulfate er

morphine sulfate oral soln morphine sulfate tabs

1 1 1 3

4

1

4

1

1

1

1 1 1

1 3

1 3 1 1 1 3

1 1 1

1 1

MO MO MO

PA QL(120 per 30 days)

DL PA QL(120 per 30 days)

DL QL(20 per 30 days)

MO PA QL(120 per 30 days)

DL MO

MO

MO

MO MO

MO QL(90 per 30 days)

MO MO MO MO

MO MO

MO MO

QL(90 per 30 days)

MO MO MO

EXELON PT24 galantamine hydrobromide GILENYA

MYTELASE NAMENDA

3 1 4

2 2

NAMENDA TITRATION PAK 2 rivastigmine tartrate 1 XENAZINE 4 MUSCLE RELAXANTS ANTISPASMODIC THERAPY baclofen tabs cyclobenzaprine hcl er cyclobenzaprine hcl tabs 75mg cyclobenzaprine hcl tabs 10mg 5mg dantrolene sodium caps MESTINON SYRP MESTINON TIMESPAN methocarbamol pyridostigmine bromide regonol tizanidine hcl tabs caps NARCOTIC ANALGESICS acetaminophen codeine acetaminophencaffeinedihydroc odeine bitartrate acetaminophencodeine 3 ascompcodeine AVINZA CP24 120MG 30MG 45MG 60MG 75MG

AVINZA CP24 90MG

BUPRENEX buprenorphine hcl inj buprenorphine hcl subl butalbitalacetaminophencaffeine codeine CAPITALCODEINE codeine sulfate tabs DILAUDID-5

1 1 1 1

1 3 3 1 1 1 1

1 1

1 1 3

3

3 1 1 1

3 1 3

MO MO

PA QL(30 per 30 days)

DL MO MO MO MO

LA PA DL

MO MO

MO

MO MO MO MO MO

MO

MO MO

MO MO

QL(30 per 30 days)

MO QL(120 per

30 days) MO MO

DL MO

MO MO MO

17

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes OPANA ER (CRUSH 3 QL(90 per RESISTANT) 30 days)

MO oxycodone acetaminophen 1 MO oxycodone hcl caps 1 MO oxycodone hcl conc 1 MO oxycodone hcl tabs 15mg 30mg 1 MO 5mg oxycodoneaspirin 1 MO oxycodoneibuprofen 1 MO OXYCONTIN 3 QL(90 per

30 days) MO

oxymorphone hydrochloride 1 MO oxymorphone hydrochloride er 1 QL(90 per

30 days) MO

reprexain tabs 10mg 200mg 1 MO REPREXAIN TABS 25MG 3 MO 200MG 5MG 200MG ROXICET ORAL SOLN 3 MO ROXICET TABS 500MG 5MG 3 MO stagesic 1 MO SYNALGOS-DC 3 MO ZAMICET 3 MO ZYDONE 3 MO NON-NARCOTIC ANALGESICS ARTHROTEC 50 3 MO ARTHROTEC 75 3 MO butorphanol tartrate inj 1 DL butorphanol tartrate nasal soln 1 QL(10 per

30 days) DL CELEBREX 3 MO diclofenac potassium 1 MO diclofenac sodium dr 1 MO diclofenac sodium er 1 MO diflunisal 1 MO etodolac caps 200mg 1 MO etodolac tabs 1 MO etodolac tb24 1 MO fenoprofen calcium 1 MO FLECTOR 3 MO flurbiprofen 1 MO

Drug Drug Name Tier Notes ibuprofen tabs 400mg 600mg 5 $6 MO 800mg indomethacin caps 1 MO indomethacin er 1 MO ketoprofen caps 1 MO ketoprofen er 1 MO meclofenamate sodium 1 MO mefenamic acid 1 MO meloxicam tabs 5 $6 MO nabumetone 1 MO nalbuphine hcl 1 MO NALFON 3 MO naloxone inj 1mgml 1 naltrexone 1 MO naproxen 5 $6 MO naproxen sodium tabs 275mg 5 $6 MO 550mg oxaprozin 1 MO piroxicam 1 MO SUBOXONE 3 DL sulindac 1 MO tolmetin sodium 1 MO tramadol 1 MO tramadol hcl acetaminophen 1 MO tramadol hcl er tb24 100mg 1 MO 200mg 300mg VIMOVO 3 MO VIVITROL 4 BD DL VOLTAREN GEL 3 MO PSYCHOTHERAPEUTIC DRUGS ABILIFY 3 MO ABILIFY DISCMELT 3 MO amitriptyline 1 MO amoxapine 1 MO amphetaminedextroamphetamine 1 MO tabs APLENZIN 3 MO budeprion sr 1 MO budeprion xl tb24 150mg 1 budeprion xl tb24 300mg 1 MO bupropion hcl 1 MO bupropion hcl sr 1 MO buspirone hcl 5 $6 MO

18

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes chlorpromazine citalopram clomipramine clorazepate dipotassium clozapine tabs 100mg 25mg 50mg 200mg CYMBALTA DAYTRANA desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er DIAZEPAM INTENSOL DIAZEPAM ORAL SOLN diazepam tabs doxepin EMSAM escitalopram FANAPT FANAPT TITRATION PACK FAZACLO fluoxetine caps fluoxetine dr fluoxetine oral soln fluoxetine tabs 10mg 20mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR GEODON INJ haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine tabs imipramine pamoate INTUNIV INVEGA INVEGA SUSTENNA INJ 39MG025ML 78MG05ML

1 MO 5 $6 MO 1 MO 3 DL 1

3 MO 3 MO 1 MO 1 MO 1 MO 1 MO 3 DL 3 DL 3 DL 1 MO 3 MO 1 MO 3 DL 3 DL 3 5 $6 MO 5 $6 MO 5 $6 MO 5 $6 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 BD DL 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 3 MO 3 BD DL

INVEGA SUSTENNA INJ 4 BD DL 117MG075ML 156MGML 234MG15ML KAPVAY 3 MO LATUDA TABS 20MG 40MG 3 DL 80MG lithium carbonate 1 MO lithium carbonate er 1 MO lithium citrate 1 MO lorazepam intensol 3 DL lorazepam tabs 3 DL loxapine 1 MO LUVOX CR 3 MO maprotiline 1 MO MARPLAN 3 MO METADATE CD 3 MO metadate er 1 MO methamphetamine hcl 1 MO METHYLIN CHEW 3 MO methylphenidate hcl 1 MO methylphenidate hcl er cp24 1 MO methylphenidate hcl er tbcr 20mg 1 MO methylphenidate hydrochloride 1 MO mirtazapine 1 MO mirtazapine odt tbdp 30mg 45mg 1 MO nefazodone 1 MO nortriptyline caps 1 MO olanzapine odt 1 MO olanzapine tabs 1 MO olanzapine inj 1 DL ORAP 3 MO paroxetine tabs 5 $6 MO paroxetine er 1 MO PAXIL SUSP 3 MO perphenazine 1 MO perphenazineamitriptyline 1 MO phenelzine sulfate 1 MO PRISTIQ 3 MO protriptyline hcl 1 MO PROVIGIL 3 QL(30 per

30 days) MO

quetiapine tabs 1 MO

19

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes RISPERDAL CONSTA 3 risperidone 1 risperidone odt tbdp 05mg 1mg 1 2mg 3mg 4mg RISPERIDONE ODT TBDP 3 025MG ROZEREM 3

SAPHRIS 3 SEROQUEL XR 2 sertraline 5 STRATTERA 3 SYMBYAX 3 thioridazine 3 thiothixene 1 tranylcypromine 1 trazodone 1 trifluoperazine 1 trimipramine caps 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 venlafaxine hcl er tb24 150mg 1 375mg 75mg VENLAFAXINE HCL ER TB24 3 375MG 75MG 150MG 225MG (MULTI-SOURCE BRAND) VIIBRYD TABS 3 VYVANSE 3 XYREM 4 zaleplon 1

ziprasidone caps 1 zolpidem 1

zolpidem tartrate er 1

MO MO MO

MO

QL(180 per 365 days)

ST DL MO MO

$6 MO MO MO MO MO MO MO MO MO MO MO MO

PA MO MO

LA PA DL QL(180 per 365 days)

DL MO

QL(180 per 365 days)

DL QL(180 per 365 days)

DL

CARDIOVASCULAR HYPERTENSION LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mgml 1 amiodarone tabs 1 MO

Drug Drug Name Tier Notes disopyramide phosphate 1 MO flecainide acetate 1 MO mexiletine 1 MO MULTAQ 3 MO NORPACE CR 3 MO PACERONE TABS 100MG 3 MO pacerone tabs 200mg 1 MO procainamide inj 1 propafenone hcl tabs 1 MO propafenone hcl er 1 MO QUINIDINE GLUCONATE INJ 3 quinidine gluconate er 1 MO quinidine sulfate tabs 1 MO quinidine sulfate er 1 MO sorine tabs 240mg 1 sorine tabs 120mg 160mg 80mg 1 MO sotalol tabs 1 MO SOTALOL HCL INJ 3 TIKOSYN CAPS 3 MO ANTIHYPERTENSIVE THERAPY acebutolol caps 1 MO afeditab cr 1 MO ALDACTAZIDE TABS 50MG 3 MO 50MG amiloride tabs 5 $6 MO amiloridehydrochlorothiazide 5 $6 MO amlodipine 1 MO amlodipine benazepril 1 MO ATACAND 3 ST MO ATACAND HCT 3 ST MO atenolol 5 $6 MO atenolol chlorthalidone 5 $6 MO AZOR 3 ST MO benazepril 5 $6 MO benazepril hydrochlorothiazide 5 $6 MO BENICAR 3 ST MO BENICAR HCT 3 ST MO betaxolol hcl tabs 20mg 1 MO bisoprolol fumarate 5 $6 MO bisoprolol fumarate 5 $6 MO hydrochlorothiazide bumetanide 1 MO BYSTOLIC 3 MO

20

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes captopril captoprilhydrochlorothiazide CARDIZEM CD CP24 360MG CARDIZEM LA TB24 120MG cartia xt carvedilol tabs chlorothiazide tabs chlorthalidone tabs 25mg 50mg clonidine ptwk clonidine tabs CLORPRES COREG CR COVERA-HS DEMSER DIBENZYLINE dilt-cd cp24 120mg 300mg dilt-xr cp24 180mg 240mg diltiazem cd cp24 120mg 240mg 300mg diltiazem hcl er cp12 diltiazem hcl er cp24 180mg 360mg DILTIAZEM HCL INJ 100MG diltiazem hcl inj 50mg10ml diltiazem hcl tabs DIOVAN DIOVAN HCT DIURIL doxazosin DYNACIRC CR DYRENIUM EDECRIN enalapril enalapril hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril fosinopril hydrochlorothiazide furosemide inj furosemide oral soln 10mgml

5 5 3 3 1 5 5 5 3 3 3 3 3 2 2 1 1 1

1 1

3 1 1 2 2 3 3 3 3 3 5 5 1 1 3 3 1 1 1 1 1

$6 MO $6 MO

MO MO MO

$6 MO $6 MO $6 MO

MO MO MO MO MO MO MO MO MO MO

MO MO

MO MO MO MO MO MO MO MO

$6 MO $6 MO

MO MO

ST MO ST MO

MO MO MO MO MO

Drug Drug Name Tier Notes FUROSEMIDE ORAL SOLN 3 MO 8MGML furosemide tabs 5 $6 MO guanfacine hcl 3 MO hydralazine inj tabs 1 MO hydrochlorothiazide caps tabs 5 $6 MO indapamide tabs 5 $6 MO INNOPRAN XL 3 MO irbesartan tabs 1 MO irbesartanhydrochlorothiazide 1 MO isradipine 1 MO labetalol inj 1 labetalol tabs 1 MO LEVATOL 3 MO lisinopril 5 $6 MO lisinoprilhydrochlorothiazide 5 $6 MO losartan potassium 5 $6 MO losartan 5 $6 MO potassiumhydrochlorothiazide matzim la 1 MO methyclothiazide tabs 1 MO methyldopa 3 MO methyldopahydrochlorothiazide 3 MO metolazone 1 MO metoprolol succinate er 1 MO metoprolol tartrate inj 1 metoprolol tartrate tabs 5 $6 MO metoprololhydrochlorothiazide 5 $6 MO MICARDIS 3 ST MO MICARDIS HCT 3 ST MO minoxidil tabs 1 MO moexipril 1 MO moexiprilhydrochlorothiazide 1 MO nadolol 5 $6 MO nadololbendroflumethiazide 1 MO nicardipine caps 1 MO nifediac cc tb24 90mg 1 MO nifedical xl 1 MO nifedipine er tb24 30mg 60mg 1 nifedipine er tb24 90mg 1 MO nimodipine caps 3 MO nisoldipine 1 MO nisoldipine er 1 MO

21

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes perindopril erbumine pindolol tabs prazosin caps propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranololhydrochlorothiazide quinapril quinaprilhydrochlorothiazide ramipril caps reserpine tabs spironolactone tabs spironolactonehydrochlorothiazi de TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl TEVETEN HCT TEVETEN TABS 400MG THALITONE timolol maleate tabs TORSEMIDE INJ 20MG2ML torsemide tabs trandolapril triamterenehydrochlorothiazide verapamil er verapamil inj verapamil tabs

1 1 3 1 1 1 5 5 5 1 5 1 5 5

3 1 3 3 3 3 3 3 1 3 1 1 5 1 1 1

MO MO MO MO

MO $6 MO $6 MO $6 MO

MO $6 MO

MO $6 MO $6 MO

MO MO

PA MO PA MO

MO ST MO ST MO

MO MO

MO MO

$6 MO MO

MO

CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ 01MGML LANOXIN TABS COAGULATION THERAPY AGGRENOX cilostazol tabs clopidogrel COUMADIN INJ

1 1 1 3 3

3 1 1 3

MO MO

MO

MO MO MO

22

Drug Drug Name Tier Notes COUMADIN TABS 3 MO dipyridamole tabs 3 MO EFFIENT 3 MO enoxaparin sodium inj 100mgml 3 DL 120mg08ml 150mgml 30mg03ml 40mg04ml 60mg06ml 80mg08ml fondaparinux sodium inj 3 DL 25mg05ml fondaparinux sodium inj 4 DL 10mg08ml 5mg04ml 75mg06ml FRAGMIN INJ 10000UNITML 4 DL 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 7500UNIT03ML FRAGMIN INJ 25000UNITML 3 DL 2500UNIT02ML 5000UNIT02ML heparin sodium inj 10000unitml 1 MO 1000unitml 20000unitml 5000unitml heparin sodiumd5w inj 5 1 40unitml HEPARIN SODIUMNACL 3 045 heparin sodiumsodium chloride 1 09 premix jantoven 1 MO pentoxifylline er 1 MO PRADAXA 3 MO PROMACTA 4 LA PA DL ticlopidine hcl 1 MO tranexamic acid 1 BD DL XARELTO TABS 3 DL warfarin 1 MO LIPIDCHOLESTEROL LOWERING AGENTS ADVICOR 3 MO ALTOPREV 3 MO ANTARA 3 MO atorvastatin calcium 1 MO cholestyramine light pack 1 MO colestipol 1 MO CRESTOR 2 MO

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes fenofibrate tabs 1 MO fenofibrate micronized 1 MO fluvastatin caps 1 MO gemfibrozil tabs 1 MO LESCOL XL 3 MO LIPOFEN 3 MO lovastatin tabs 5 $6 MO LOVAZA 2 MO NIACOR 2 MO NIASPAN 2 MO pravastatin tabs 5 $6 MO prevalite powd 1 MO SIMCOR TB24 1000MG 40MG 3 MO 500MG 20MG 500MG 40MG 750MG 20MG simvastatin tabs 5 $6 MO TRICOR 3 MO TRILIPIX 3 MO WELCHOL TABS 3 MO ZETIA 3 PA MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 MO

NITRATES DILATRATE SR 3 MO ISORDIL TITRADOSE TABS 3 MO 40MG isosorbide dinitrate 1 MO isosorbide dinitrate er 1 MO isosorbide mononitrate er 1 MO isosorbide mononitrate tabs 20mg 1 MO nitro-bid 1 MO nitroglycerin inj 1 nitroglycerin pt24 1 MO nitroglycerin transdermal pt24 1 MO 01mghr NITROLINGUAL PUMPSPRAY 3 MO NITROSTAT 3 MO DERMATOLOGICALSTOPICAL THERAPY ANTIPSORIATIC ANTISEBORRHEIC calcipotriene topical soln 1 MO calcipotriene topical oint 1 MO

Drug Drug Name Tier Notes DOVONEX CREAM 3 MO selenium sulfide lotn 25 1 MO SORIATANE 4 DL TACLONEX 3 MO TACLONEX SCALP 3 MO BURN THERAPY silver sulfadiazine 1 cream 1 MO ssd 1 cream 1 MO thermazene 1 cream 1 MO MISCELLANEOUS DERMATOLOGICALS 8-MOP CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil crea imiquimod OXSORALEN OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE U-CORT UVADEX VEREGEN THERAPY FOR ACNE

2 3 3 2 3 2 1 1 3 4 2 1 3 3 3 3 3 3

MO MO MO MO MO MO MO MO DL DL MO MO MO MO MO MO

MO

ACANYA adapalene AKNE-MYCIN amnesteem caps AZELEX claravis caps CLINDAGEL clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab

3 1 3 1 3 1 3 1

1 1 1 1

MO

MO

MO

MO MO

MO MO MO MO

23

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes clindamycinbenzoyl peroxide gel 1 MO EXELDERM 3 MO 5 1 ketoconazole 2 1 MO DIFFERIN GEL 03 3 MO NAFTIN CREA 1 3 MO DIFFERIN LOTN 3 MO NAFTIN GEL 3 MO ery 2 pads 1 erythromycin benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole topical 1

MO MO MO MO MO MO MO

nyamyc 1 nystatin triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 OXISTAT 3

MO MO MO

MO MO MO

TAZORAC 3 tretinoin crea 1

PA MO PA DL

pedi-dri 1 TOPICAL ANTIVIRALS

MO

tretinoin gel 1 PA DL DENAVIR 3 MO TOPICAL ANESTHETICS ZOVIRAX CREA 3 MO lidocaine prilocaine crea 1 MO ZOVIRAX OINT 3 MO lidocaine external soln 1 MO TOPICAL CORTICOSTEROIDS lidocaine gel 2 1 lidocaine inj 05 1 1

MO alclometasone dipropionate 1 amcinonide 1

MO MO

lidocaine oint 5 1 lidocaine viscous 2 1 LIDODERM 3

MO MO DL

augmented betamethasone dipropionate crea

1

augmented betamethasone 1

MO

MO SYNERA 3 MO dipropionate lotn TOPICAL ANTIBACTERIALS augmented betamethasone 1 MO

ALTABAX 3 BACTROBAN CREA 3 CORTISPORIN CREA 3 CORTISPORIN OINT 3 gentamicin sulfate crea 1 gentamicin sulfate oint 01 1

MO MO MO MO MO MO

dipropionate oint betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 1 clobetasol propionate external soln

1

MO MO MO MO

mupirocin oint 2 1 PHISOHEX 2 sulfacetamide sodium susp 10 1 SULFAMYLON 2

MO MO MO MO

clobetasol propionate foam 1 clobetasol propionate gel 1 clobetasol propionate lotn 1 clobetasol propionate oint 1

MO MO MO

TOPICAL ANTIFUNGALS clobetasol propionate sham 1 MO ciclopirox 077 1 MO CLOBEX LIQD 3 MO ciclopirox 1 CLODERM PUMP 3 MO ciclopirox nail lacquer 8 1 PA DL CORDRAN 3 MO ciclopirox olamine cream 077 1 MO CORDRAN TAPE 3 MO clotrimazole betamethasone 1 MO DESONATE 3 MO econazole nitrate cream 1 1 MO desonide 1 MO ERTACZO 3 MO desoximetasone crea 1 MO

24

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes desoximetasone gel 1 MO ringers irrigation 1 MO desoximetasone oint 025 1 MO MISCELLANEOUS AGENTS diflorasone diacetate 1 MO ACTONEL 3 ST MO fluocinolone acetonide 1 MO ADAGEN 4 LA PA DL fluocinolone acetonide body 1 MO alendronate sodium tabs 40mg 1 MO fluocinonide external soln 1 MO anagrelide hydrochloride 1 MO fluocinonide gel 1 MO ARALAST NP INJ 400MG 4 LA PA DL fluocinonide oint 1 MO BUPHENYL 3 MO fluocinonide-e 1 MO CAMPRAL 3 MO fluticasone propionate crea 1 MO CHEMET 3 DL fluticasone propionate lotn 1 CLINIMIX 425DEXTROSE 3 fluticasone propionate oint 1 MO 5 halobetasol propionate 1 MO CLINIMIX E 275DEXTROSE 3

10HALOG 3 MO CLINIMIX E 275DEXTROSE 3hydrocortisone crea 25 1 MO 5

hydrocortisone lotn 25 1 MO DEXTROSE 10NACL 045 3 hydrocortisone oint 25 1 MO dextrose 10 flex container 1 hydrocortisone valerate 1 MO DEXTROSE 10NACL 02 3 KENALOG AERS 3 MO dextrose 25sodium chloride 1 LUXIQ 3 MO 045 mometasone furoate 1 MO dextrose 5 1 MO PANDEL 3 MO dextrose 5lactated ringers 1 prednicarbate 1 MO dextrose 5nacl 02 1 triamcinolone acetonide crea 1 MO dextrose 5nacl 0225 1 triamcinolone acetonide lotn 1 MO DEXTROSE 5NACL 033 3 triamcinolone acetonide oint 1 MO dextrose 5nacl 045 1 MO triderm 1 MO dextrose 5nacl 09 1 MO VANOS 3 MO disulfiram 1 MO VERDESO 3 MO etidronate disodium 1 MO TOPICAL ENZYMES EVOXAC 2 MO SANTYL 2 MO EXJADE TBSO 250MG 500MG 4 LA PA DL TOPICAL SCABICIDES PEDICULICIDES EXJADE TBSO 125MG 3 LA PA

QL(30 per EURAX 3 MO 30 days) DL lindane 1 MO FOSRENOL 3 MO

malathion 1 MO GLASSIA 4 LA PA DL permethrin crea 1 MO INCRELEX 4 PA DL ULESFIA 3 MO kionex powd 1 MO DIAGNOSTICS MISCELLANEOUS levocarnitine inj 3 BD MO AGENTS levocarnitine oral soln 1 BD MO IRRIGATING SOLUTIONS levocarnitine tabs 1 BD MO lactated ringers irrigation 1 MO midodrine 1 MO neomycinpolymyxin b sulfates 1 MO ORFADIN 4 LA DL

25

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

CIPRO HC 3 MO CIPRODEX 2 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO neomycinpolymyxinhc 1 MO

pilocarpine hcl tabs 1 MO PROLASTIN-C 4 LA PA DL RENAGEL 3 MO RENVELA 3 MO RILUTEK 2 MO SKELID 3 MO sodium chloride 09 irrigation 1 MO sodium chloride inj 09 100ml 1 MO sodium polystyrene sulfonate susp 1 MO sterile water irrigation 1 MO SYPRINE 3 MO ZEMAIRA 4 LA PA DL SMOKING DETERRENTS

ENDOCRINEDIABETES ADRENAL HORMONES a-hydrocort 1 MO CELESTONE 3 MO cortisone acetate 1 MO DEPO-MEDROL 3 MO dexamethasone elix 1 MO

buproban CHANTIX CHANTIX STARTING MONTH PAK NICOTROL INHALER NICOTROL NASAL EAR NOSE THROAT MEDICATIONS

1 3 3

3 3

MO MO MO

MO MO

MISCELLANEOUS AGENTS ASTEPRO azelastine hcl BACTROBAN NASAL chlorhexidine gluconate oral rinse ipratropium bromide nasal soln PATANASE periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS

3 1 3 1

1 3 1 1 2 2

MO MO MO MO

MO MO MO MO MO

dexamethasone inj 4mgml 1 MO DEXAMETHASONE 3 MO INTENSOL dexamethasone tabs 05mg 1 MO 075mg 15mg 4mg 6mg DEXAMETHASONE TABS 3 MO 1MG 2MG fludrocortisone acetate 1 MO hydrocortisone tabs 1 MO MEDROL TABS 32MG 3 MO methylprednisolone acetate inj 1 MO methylprednisolone dose pack 1 MO METHYLPREDNISOLONE 3 MO SODIUMSUCCINATE INJ 1GM methylprednisolone tabs 32mg 1 methylprednisolone tabs 16mg 1 MO 4mg 8mg MILLIPRED ORAL SOLN 3 MO millipred tabs 1 MO ORAPRED ODT TBDP 15MG 3 MO 30MG prednisolone sodium phosphate 1 MO prednisone 1 MO

MISCELLANEOUS OTIC PREDNISONE INTENSOL 3 MO PREPARATIONS acetasol hc 1 acetic acid 1 fluocinolone acetonide 1 hydrocortisoneacetic acid 1 ofloxacin 1 OTIC STEROID ANTIBIOTIC

MO MO MO MO MO

SOLU-CORTEF INJ 100MG 250MG SOLU-MEDROL INJ 2GM SOLU-MEDROL INJ 40MG 500MG VERIPRED 20 ANTITHYROID AGENTS methimazole

3

3 3

3

1

MO

MO

MO

MO

26

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes propylthiouracil 1 MO DIABETES THERAPY acarbose ACTOPLUS MET ACTOS ALCOHOL PREPS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT FORTAMET GAUZE PADS 2X2 glimepiride tabs glipizide tabs glipizide metformin glipizide er tabs glipizide xl tabs GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA TB24 500MG glyburide tabs glyburide metformin glyburide micronized GLYSET HUMALOG HUMALOG KWIKPEN HUMALOG MIX 5050 HUMALOG MIX 5050 KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525 KWIKPEN HUMULIN 7030 HUMULIN 7030 PEN HUMULIN N HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) INSULIN PEN NEEDLE

1 2 2 3 3 3 3 3 2 3 3 5 5 1 5 5 2 2

3 5 1 5 3 2 2 2 2

2 2

2 2 2 2 2 2

2

MO MO MO

MO MO MO MO MO MO MO

$6 MO $6 MO

MO $6 MO $6 MO

MO MO

MO $6 MO

MO $6 MO

MO MO MO MO MO

MO MO

MO MO MO MO MO MO

DL

27

Drug Drug Name Tier Notes INSULIN SYRINGE (DISP) U- 2 100 03 ML INSULIN SYRINGE (DISP) U- 2 100 1 ML INSULIN SYRINGE (DISP) U- 2 100 12 ML JANUMET 2 JANUVIA 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 metformin hcl 5 metformin hcl er tb24 500mg 5 750mg nateglinide 1 NEEDLES INSULIN DISP 2 SAFETY NOVOLIN 7030 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 7030 3 NOVOLOG MIX 7030 3 PREFILLED FLEXPEN ONGLYZA 3 PRANDIMET 3 PRANDIN 3 PROGLYCEM 3 RIOMET 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide 1 tolbutamide 1 TRADJENTA 3 VICTOZA 3 MISCELLANEOUS HORMONES ALDURAZYME 4 LA PA DL ANDROGEL GEL 50MG5GM 2 MO ANDROGEL PUMP GEL 162 2 MO androxy 1 MO cabergoline 1 MO calcitonin-salmon nasal soln 1 MO

DL

DL

DL

MO MO MO MO MO MO

$6 MO $6 MO

MO DL

MO MO MO MO MO MO MO

MO MO MO MO MO MO MO MO MO MO MO

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes calcitriol caps calcitriol inj calcitriol oral soln CEREZYME INJ 200UNIT danazol caps desmopressin acetate inj nasal oral FABRAZYME INJ 35MG fortical HECTOROL KUVAN METHITEST MIACALCIN INJ MYOZYME NAGLAZYME oxandrolone PAMIDRONATE DISODIUM INJ 6MGML pamidronate disodium inj 30mg10ml 90mg10ml SENSIPAR SOMAVERT STIMATE STRIANT SYNAREL testosterone cypionate testosterone enanthate TESTRED VPRIV ZAVESCA ZEMPLAR CAPS ZEMPLAR INJ ZOMETA INJ 4MG5ML

1 BD MO 1 BD MO 1 BD MO 4 LA PA DL 1 MO 1 MO

4 LA PA DL 1 MO 3 BD MO 4 LA PA DL 3 MO 3 BD MO 4 PA DL 4 LA PA DL 1 MO 3 PA DL

3 PA DL

2 DL 4 LA PA DL 3 MO 3 MO 2 MO 1 MO 1 MO 3 MO 4 PA DL 4 LA PA DL 3 BD MO 3 BD DL 4 PA DL

THYROID HORMONES LEVOTHROID 3 MO levothyroxine tabs 5 $6 levoxyl 1 MO liothyronine sodium inj 1 liothyronine sodium tabs 1 MO SYNTHROID 3 MO TIROSINT 3 MO

Drug Drug Name Tier Notes unithroid tabs 100mcg 112mcg 1 MO 125mcg 150mcg 175mcg 200mcg 25mcg 300mcg 50mcg 75mcg 88mcg

GASTROENTEROLOGY ANTIDIARRHEALS ANTISPASMODICS atropine sulfate inj 01mgml 1 ATROPINE SULFATE INJ 3 005MGML CANTIL 3 MO diphenoxylate atropine 1 MO glycopyrrolate 1 MO methscopolamine bromide tabs 1 MO MOTOFEN 3 MO MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI INJ 3 PA DL AMITIZA 2 PA DL ANTIVERT TABS 50MG 3 MO ANZEMET INJ 3 PA DL ANZEMET TABS 100MG 3 BD QL(7

per 30 days) DL

ANZEMET TABS 50MG 3 BD QL(14 per 30 days)

DL APRISO 3 MO ASACOL 2 MO ASACOL HD 2 MO balsalazide caps 1 MO budesonide cp24 1 MO CANASA 2 MO CESAMET 3 MO CIMZIA 4 PA DL colocort enema 1 MO compro 1 MO CORTIFOAM 2 MO CREON CPEP 2 MO cromolyn sodium conc 100mg5ml 1 MO CYSTADANE 3 DL DIPENTUM 3 MO dronabinol 1 QL(60 per

30 days) DL

28

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes EMEND CAPS 40MG

EMEND CAPS 125MG

EMEND CAPS TRIPACK

EMEND CAPS 80MG

enulose gavilyte-c gavilyte-g gavilyte-nflavor pack GOLYTELY ORAL SOLN 2271GM 282GM 636GM 553GM 215GM granisetron inj 01mgml 1mgml granisetron tabs

GRANISOL

HALFLYTELY BOWEL PREPFLAVOR PACKS hydrocortisone enem lactulose LIALDA LOTRONEX mesalamine kit metoclopramide MOVIPREP ondansetron hcl inj 4mg2ml ondansetron hcl oral soln

ondansetron hcl tabs 24mg

ondansetron hcl tabs 4mg 8mg

2

2

2

2

1 1 1 1 3

3 1

3

3

1 1 3 4 1 1 3 3 1

1

1

BD QL(1 per 30 days)

DL BD QL(2

per 30 days) DL

BD QL(6 per 30 days)

DL BD QL(8

per 30 days) DL MO MO MO MO MO

PA DL BD QL(30 per 30 days)

DL BD QL(150 per 30 days)

DL MO

MO MO

PA DL MO MO MO

PA DL BD QL(450 per 30 days)

DL BD QL(7

per 30 days) DL

BD QL(45 per 30 days)

DL

Drug Drug Name Tier Notes ondansetron odt

OSMOPREP PENTASA prochlorperazine supp prochlorperazine edisylate prochlorperazine maleate RELISTOR INJ 12MG06ML REMICADE SANCUSO

SUCRAID sulfasalazine tabs sulfazine ec SUPREP BOWEL PREP trilyte ursodiol ZENPEP CPEP 16000UNIT 3000UNIT 10000UNIT ZENPEP CPEP 109000UNIT 20000UNIT 68000UNIT 136000UNIT 25000UNIT 85000UNIT 55000UNIT 10000UNIT 34000UNIT 82000UNIT 15000UNIT 51000UNIT ULCER THERAPY

1

2 3 1 1 1 3 4 3

4 1 1 3 1 1 3

3

BD QL(45 per 30 days)

DL MO MO

MO MO MO

PA DL QL(2 per 30 days) MO

LA DL MO

MO MO MO

MO

ACIPHEX

CARAFATE SUSP cimetidine tabs cimetidine hcl soln DEXILANT

famotidine inj famotidine premixed famotidine susr famotidine (RX) tabs 20mg 40mg HELIDAC lansoprazole

3

3 1 1 3

1 1 1 5 3 1

PA QL(30 per 30 days)

MO MO MO MO

PA QL(30 per 30 days)

MO MO

MO $6 MO

MO QL(60 per 30 days)

MO

29

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes

Drug Drug Name Tier Notes EPOGEN INJ 10000UNITML

EPOGEN INJ 2000UNITML 3000UNITML 4000UNITML

EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE COMBO PACK HUMATROPE INJ 6MG HUMATROPE INJ 12MG 24MG INFERGEN INJ 15MCG05ML INTRON-A INJ 5MU02ML INTRON-A INJ 10MU02ML 3MU02ML 6000000UNITML INTRON-A WITH DILUENT INJ 10MU LEUKINE MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG05ML 480MCG08ML 480MCG16ML NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN OMNITROPE INJ 58MG OMNITROPE INJ 10MG15ML PEG-INTRON INJ 50MCG05ML PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK INJ 135MCG05ML PROCRIT INJ 20000UNITML 40000UNITML PROCRIT INJ 10000UNITML

3

2

4 4 3 4 3 4

4 4 3

4

4 4 4 4 4

4 4

4 4 3 4

4 4 4

4

3

PA QL(12 per 30 days)

DL PA QL(12

per 30 days) DL

ST DL PA DL PA DL PA DL PA DL PA DL

PA DL DL DL

DL

DL PA DL BD DL

DL DL

PA DL PA DL

PA DL PA DL PA DL PA DL

PA DL PA DL PA DL

PA DL

PA QL(12 per 30 days)

DL

misoprostol tabs 200mcg NEXIUM

NEXIUM IV nizatidine 150mg 300mg nizatidine 15mgml omeprazole (RX) cap dr omeprazolesodium bicarbonate caps 40mg 1100mg

pantoprazole

PREVPAC PYLERA ranitidine hcl caps tabs (RX) 150mg 300mg ranitidine hcl inj 150mg6ml ranitidine hcl syrp sucralfate

1 MO 2 QL(30 per

30 days) MO

3 PA DL 1 MO 1 MO 5 $6 MO 1 QL(30 per

30 days) MO

1 QL(60 per 30 days)

MO 3 MO 3 MO 5 $6 MO

1 PA DL 1 MO 1 MO

IMMUNOLOGY VACCINES BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA PA DL ARANESP INJ 100MCG05ML 4 PA DL 150MCG03ML 200MCG04ML 200MCGML 300MCG06ML 300MCGML 500MCGML ARANESP INJ 25MCG042ML 3 PA QL(1 40MCG04ML per 30 days)

DL ARANESP INJ 100MCGML 3 PA QL(2 25MCGML 40MCGML per 30 days)

DL ARANESP INJ 60MCG03ML 3 PA QL(24

per 30 days) DL

ARANESP INJ 60MCGML 3 PA QL(8 per 30 days)

DL ARCALYST 4 LA PA DL AVONEX 4 DL BETASERON 4 DL EPOGEN INJ 20000UNITML 3 PA DL

30

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes PROCRIT INJ 2000UNITML 2 PA QL(12 3000UNITML 4000UNITML per 30 days)

DL PROLEUKIN 4 DL REBIF 4 DL REBIF TITRATION PACK 4 DL SAIZEN CLICKEASY 4 PA DL SAIZEN INJ 5MG 4 PA DL SYLATRON 4 PA QL(4

per 28 days) DL

TEV-TROPIN 3 PA DL VACCINES MISCELLANEOUS IMMUNOLOGICALS ACTHIB 5 ADACEL 5 ATGAM 4 BOOSTRIX INJ 5 CARIMUNE NANOFILTERED 4 INJ 3GM CERVARIX 3 COMVAX 3 DAPTACEL 5 DECAVAC 5 ENGERIX-B INJ 3 fomepizole 1 GAMMAGARD LIQUID 4 GAMUNEX-C INJ 1GM10ML 4 GARDASIL 3 HAVRIX INJ 3 INFANRIX 5 IPOL INACTIVATED IPV 3 IXIARO 3 M-M-R II WDILUENT 10 3 DOSE MENACTRA 3 MENOMUNE-ACYW-135 3 MENVEO 3 PEDVAX HIB 3 PRIVIGEN INJ 20GM200ML 4 PROQUAD 3 RABAVERT 2 RECOMBIVAX HB INJ 3 40MCGML

$6 $6 DL $6

PA DL

$6 $6

PA DL PA DL

$6

PA

PA DL

BD

31

Drug Drug Name Tier Notes RECOMBIVAX HB INJ 3 10MCGML ROTATEQ 3 TENIVAC 5 $6 TETANUS DIPHTHERIA 5 $6 TOXOIDS-ADSORBED ADULT THYMOGLOBULIN 2 BD DL TWINRIX 3 TYPHIM VI 3 PA DL VAQTA 3 VARIVAX 3 YF-VAX 3 PA ZOSTAVAX 5 $6 MUSCULOSKELETAL RHEUMATOLOGY GOUT THERAPY allopurinol tabs 5 $6 MO ALOPRIM 3 COLCRYS 3 MO probenecid tabs 1 MO probenecid colchicine 1 MO OSTEOPOROSIS THERAPY ACTONEL 3 ST MO alendronate sodium tabs 10mg 1 MO 5mg alendronate sodium tabs 35mg 5 $6 MO 70mg ATELVIA 3 ST MO BONIVA INJ 3 PA MO EVISTA 2 MO FORTEO 4 PA DL OTHER RHEUMATOLOGICALS DEPEN TITRATABS 3 MO ENBREL 4 PA DL HUMIRA 4 PA DL HUMIRA PEN-CROHNS 4 PA DL DISEASE STARTER ibandronate tabs 150mg 1 BD MO leflunomide 1 MO ORENCIA INJ 125MG1ML 4 PA QL(4

per 28 days) DL

RIDAURA 2 MO

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes SAVELLA 2 MO PREMARIN INJ 3 SAVELLA TITRATION PACK 2 MO PREMARIN TABS 2 MO SIMPONI 4 PA DL PREMPHASE 2 MO

PREMPRO 2 MO OBSTETRICS GYNECOLOGY PROGESTERONE CAPS 1 ESTROGENS PROGESTINS ALORA 3 MO

100MG 200MG VAGIFEM 2 MO

ANGELIQ TABS 05MG 1MG 3 MO VIVELLE-DOT 2 MO

camila 1 MO MISCELLANEOUS OBGYN CENESTIN 2 MO CLEOCIN SUPP 3 MO CLIMARA PRO 3 MO clindamycin phosphate crea 1 MO COMBIPATCH 3 MO metronidazole vaginal 1 MO DELESTROGEN INJ 10MGML 3 MO NUVARING 2 MO DEPO-ESTRADIOL 3 MO ORTHO EVRA 2 MO DEPO-PROVERA 3 MO terconazole crea 04 1 MO DEPO-SUBQ PROVERA 104 3 MO terconazole supp 1 MO DIVIGEL GEL 1MGGM 3 MO vandazole 1 MO ELESTRIN 3 MO zazole crea 04 1 MO ENJUVIA 3 MO ORAL CONTRACEPTIVES RELATED errin 1 MO AGENTS ESTRACE CREA 3 MO amethia 1 MO estradiol norethindrone acetate 1 MO amethyst 1 MO tabs 1mg 05mg apri 1 MO estradiol ptwk 1 aranelle 1 MO estradiol tabs 1 MO aviane 1 MO estradiol valerate 1 MO balziva 1 MO ESTRING 2 MO briellyn 1 MO estropipate 1 MO cryselle-28 1 MO EVAMIST 3 MO cyclafem 135 1 MO FEMHRT LOW DOSE 3 MO cyclafem 777 1 MO FEMRING 3 MO emoquette 1 MO FEMTRACE 3 MO enpresse-28 1 MO jinteli 1 MO gianvi 1 MO jolivette 1 MO introvale 1 MO medroxyprogesterone acetate inj 1 MO junel 1 MO medroxyprogesterone acetate tabs 1 MO junel fe 1530 1 MO MENEST 3 MO junel fe 120 1 MO MENOSTAR 3 MO kariva 1 MO nora-be 1 MO kelnor 135 1 MO norethindrone tabs 5mg 1 MO leena 1 MO PREFEST 3 MO lessina-28 1 MO PREMARIN CREA 2 MO levora 1 MO

32

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

LO LOESTRIN FE LOESTRIN 24 FE low-ogestrel lutera marlissa microgestin 1530 microgestin 120 microgestin fe microgestin fe 1530 mononessa necon 0535-28 necon 135-28 necon 1011-28 necon 777 next choice

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO DL

methylergonovine maleate tabs OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin polymyxin b bacitracin ophthalmic oint BESIVANCE CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak oint gentamicin sulfate ophthalmic soln levofloxacin ophthalmic soln NATACYN

1

3 1 1 3 3 1 1 1 1

1 2

MO MO MO MO MO MO MO MO MO

MO MO

nortrel 0535 (28) nortrel 135 (21) nortrel 135 (28) nortrel 777 ocella

1 1 1 1 1

MO MO MO MO MO

neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic soln tobramycin ophthalmic soln TOBREX OINT

1 1 1 1 3

MO MO MO MO MO

ogestrel orsythia ORTHO TRI-CYCLEN LO OVCON-50 28 portia-28 previfem quasense reclipsen SAFYRAL sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet vestura zeosa zovia 135e zovia 150e OXYTOCICS

1 1 2 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

trimethoprim sulfatepolymyxin b sulfate

1

VIGAMOX 2 ZYMAXID 3 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl ophthalmic soln 1 BETIMOL 3 BETOPTIC-S 3 carteolol hcl 1 ISTALOL 3 levobunolol hcl ophthalmic soln 05

1

metipranolol 1 timolol maleate ophthalmic gel forming

1

timolol maleate ophthalmic soln 5 CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 CYCLOPLEGIC MYDRIATICS

MO

MO MO

MO MO

MO MO MO MO MO MO

MO MO

$6 MO

MO

33

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Name Tier Notes tropicamide 1 MO DIRECT ACTING MIOTICS PILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 MO ALOMIDE 3 MO azelastine hcl 1 MO cromolyn sodium ophthalmic soln 1 MO EMADINE 3 MO epinastine hcl 1 MO PATADAY 3 MO PATANOL 2 MO proparacaine hcl 1 RESTASIS 3 MO NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 3 MO BROMDAY 3 MO bromfenac ophthalmic soln 1 MO diclofenac sodium ophthalmic 1 MO soln flurbiprofen sodium 1 MO ketorolac tromethamine 1 MO ophthalmic soln NEVANAC 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide 1 MO acetazolamide er 1 MO acetazolamide sodium 1 methazolamide 1 MO OTHER GLAUCOMA DRUGS AZOPT 3 MO COMBIGAN 3 MO dorzolamide hcl 1 MO dorzolamide hcltimolol maleate 1 MO latanoprost 5 $6 MO LUMIGAN 3 MO TRAVATAN Z 2 MO STEROID-ANTIBIOTIC COMBINATIONS neomycinpolymyxinbacitracinh 1 MO ydrocortisone neomycinpolymyxindexamethaso 1 MO ne

Drug Drug Name Tier Notes neomycinpolymyxinhc 1 MO PRED-G 3 MO PRED-G SOP 3 MO TOBRADEX OINT 2 MO tobramycindexamethasone 1 MO ZYLET 3 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE SOP sulfacetamide sodium prednisolone sodium phospha STEROIDS

3 3 1

MO MO MO

ALREX dexamethasone ophthalmic soln DUREZOL FLAREX FML FML FORTE LOTEMAX MAXIDEX PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL SULFONAMIDES

3 1 3 3 3 3 2 2 3 1 1 3

MO MO MO MO MO MO MO MO MO MO MO MO

BLEPH-10 3 MO sodium sulfacetamide ophthalmic 1 MO soln sulfacetamide sodium ophthalmic 1 oint SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC 2 MO SOLN 01 apraclonidine 1 MO brimonidine tartrate 1 MO IOPIDINE OPHTHALMIC 3 MO SOLN 1 VASOCONSTRICTOR DECONGESTANTS ak-con 1 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE ANTIALLERGENIC AGENTS

34

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes carbinoxamine maleate CLARINEX CLARINEX REDITABS CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clemastine fumarate syrp clemastine fumarate tabs 268mg epinephrine hcl inj 01mgml EPIPEN

EPIPEN-JR

hydroxyzine hcl hydroxyzine pamoate levocetirizine dihydrochloride phenadoz supp 125mg phenadoz supp 25mg promethazine hcl inj 25mgml promethazine hcl inj 50mgml promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine vc promethegan supp 25mg 50mg SEMPREX-D TWINJECT

1 MO 3 MO 3 MO 3 MO 3 MO 1 MO 1 MO 1 2 QL(06 per

30 days) MO

2 QL(06 per 30 days)

MO 1 MO 1 MO 1 MO 1 1 MO 1 1 MO 1 MO 1 MO 1 MO 1 MO 1 MO 3 MO 2 QL(2 per 30

days) MO PULMONARY AGENTS acetylcysteine inh 1 BD DL ADCIRCA 4 PA DL ADVAIR DISKUS 2 MO ADVAIR HFA 2 MO albuterol sulfate er 1 MO albuterol sulfate nebu 1 BD MO albuterol sulfate syrp 1 MO albuterol sulfate tabs 1 MO ALVESCO 3 MO aminophylline 1 ASMANEX 120 METERED 2 MO DOSES ASMANEX 14 METERED 2 MO DOSES

ASMANEX 30 METERED 2 MO DOSES ASMANEX 60 METERED 2 MO DOSES ATROVENT HFA 2 MO BECONASE AQ 3 MO BROVANA 3 BD DL budesonide susp 1 BD MO COMBIVENT 2 MO cromolyn sodium nebu 1 BD MO DALIRESP 3 PA DL DULERA 2 MO ELIXOPHYLLIN 2 MO FLOVENT DISKUS 2 MO FLOVENT HFA 2 MO flunisolide nasal soln 0025 1 MO fluticasone propionate susp 1 MO FORADIL AEROLIZER 2 MO ipratropium bromide inhalation 1 BD MO soln ipratropium bromidealbuterol 1 BD MO sulfate LETAIRIS 4 LA PA DL levalbuterol 1 BD MO LUFYLLIN 3 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 1 MO NASONEX 3 MO OMNARIS 3 MO PERFOROMIST 3 BD DL PROAIR HFA 2 MO PROVENTIL HFA 2 MO PULMICORT FLEXHALER 2 MO PULMICORT SUSP 1MG2ML 3 BD MO PULMOZYME 4 BD DL QVAR 3 MO REVATIO TABS 4 PA QL(90

per 30 days) DL

RHINOCORT AQUA 3 MO SEREVENT DISKUS 2 MO SINGULAIR 3 MO SPIRIVA HANDIHALER 2 MO

35

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Name

Drug Tier Notes

Drug Name

Drug Tier Notes

SYMBICORT AERO 2 MISCELLANEOUS UROLOGICALS 80MCGACT 45MCGACT SYMBICORT AERO 160MCGACT 45MCGACT terbutaline sulfate theophylline cr theophylline er tb12 300mg 450mg theophylline er tb24 TRACLEER triamcinolone acetonide inhaler VENTAVIS INHALATION SOLN 10MCGML VENTOLIN HFA VERAMYST XOLAIR XOPENEX XOPENEX HFA zafirlukast ZYFLO TAB 600MG ZYFLO CR UROLOGICALS

2

1 1 1

1 4 1 4

2 3 4 3 3 1 3 3

AMMONIUM CHLORIDE 3 CIALIS TABS 25MG 3

CIALIS TABS 5MG 3

CYSTAGON 2 ELMIRON 2 VITAMINS HEMATINICS ELECTROLYTES ELECTROLYTES calcium acetate caps 1 DEXTROSE 5POTASSIUM 3 CHLORIDE 015 eliphos 1 K-TABS 3 kcl 0075d5wnacl 045 1 kcl 015d5wlr 1 KCL 015D5WNACL 02 3 KCL 015D5WNACL 0225 3 kcl 015d5wnacl 09 1 kcl 03d5wnacl 045 1 kcl 03d5wnacl 09 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 3 MAGNESIUM SULFATE INJ 3 50 NORMOSOL-R IN D5W 3 POTASSIUM CHLORIDE 015 3 NACL 045 VIAFLEX potassium chloride 015 1 d5wnacl 033 potassium chloride 015 1 d5wnacl 045 viaflex potassium chloride 015 nacl 1 09 POTASSIUM CHLORIDE 022 3 D5WNACL 045 potassium chloride 1 0224dextrose 5 viaflex

PA QL(30 per 30 days)

DL PA QL(30

per 30 days) DL

LA DL MO

MO

MO MO

MO MO MO MO MO

MO

ANTICHOLINERGICS ANTISPASMODICS DETROL 2 MO DETROL LA 2 MO ENABLEX 3 MO flavoxate hcl 1 MO oxybutynin 1 MO oxybutynin er 1 MO TOVIAZ 3 MO trospium chloride 1 MO VESICARE 2 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin hcl er AVODART finasteride JALYN RAPAFLO tamsulosin hcl

1 2 1 2 3 1

MO

MO MO MO

MO LA PA DL

MO PA DL

MO MO

PA DL BD MO

MO MO MO MO

MO MO MO MO MO MO

CHOLINERGIC STIMULANTS bethanechol chloride 1 MO

36

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

13

Drug Drug Drug Drug Name Tier Notes Name Tier Notes POTASSIUM CHLORIDE 03 3 FREAMINE III 3 3 BD NACL 09 potassium chloride 03d5wviaflex

1

potassium chloride er cpcr 1 potassium chloride er tbcr 10meq 1 potassium chloride er tbcr 20meq 1 potassium chloride inj 10meq100ml 10meq50ml 2meqml

1

POTASSIUM CHLORIDE INJ 3

MO

MO

HEPATAMINE 3 HEPATASOL 3 INTRALIPID INJ 17 30 3 intralipid inj 225 20 1 IONOSOL 3 ISOLYTE 3 NEPHRAMINE 3 NORMOSOL-R 3 PLASMA-LYTE 3

BD BD BD BD BD BD BD BD BD

04MEQML 30MEQ100ML PREMASOL INJ 56MEQL 3 BD ringers injection 1 320MG100ML 730MG100ML sodium chloride 045 viaflex 1 MO 190MG100ML 3MEQL sodium chloride inj 3 5 1 sodium chloride inj 25meqml 1 sodium lactate 1 MISCELLANEOUS NUTRITION PRODUCTS

MO 20MG100ML 300MG100ML 220MG100ML 290MG100ML 490MG100ML 840MG100ML 490MG100ML 200MG100ML 290MG100ML 410MG100ML 230MG100ML 5MEQL

AMINOSYN II INJ 3 BD 15MG100ML 250MG100ML aminosyn ii inj AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7 CLINIMIX 275DEXTROSE 5 CLINIMIX 425DEXTROSE 10 CLINIMIX 425DEXTROSE

1 3 3 3 3 3

3

3

BD BD BD BD BD BD

BD

BD

120MG100ML 140MG100ML 470MG100ML premasol inj 52meql 1760mg100ml 880mg100ml 34meql 1760mg100ml 372mg100ml 406mg100ml 526mg100ml 492mg100ml 492mg100ml 526mg100ml 356mg100ml 356mg100ml 390mg100ml 34mg100ml 152mg100ml

1 BD

20 CLINIMIX 5DEXTROSE 15 CLINIMIX 5DEXTROSE 20 CLINIMIX 5DEXTROSE 25 CLINIMIX E 425DEXTROSE 25 CLINIMIX E 425DEXTROSE 5

3 3 3 3

3

BD BD BD BD

BD

PROCALAMINE 3 PROSOL 3 travasol 1 TROPHAMINE 3 VITAMINS HEMATINICS prenatal vitamins (generic) 1 sodium fluoride 1

BD BD BD BD

MO CLINIMIX E 5DEXTROSE 3 BD 15 CLINIMIX E 5DEXTROSE 3 BD 20 CLINIMIX E 5DEXTROSE 3 BD 25 FREAMINE III 3 BD

37

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

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From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

Index of Drugs

8

8-MOP 23

A

ABILIFY18 ABILIFY DISCMELT18 ABRAXANE 13 ACANYA 23 acarbose27 acebutolol20 acetaminophen codeine 17 acetaminophencaffeinedihydrocodeine bitartrate

17 acetaminophencodeine 3 17 acetasol hc 26 acetazolamide 34 acetazolamide er 34 acetazolamide sodium34 acetic acid 26 acetylcysteine 35 ACIPHEX 29 ACTHIB31 ACTIMMUNE30 ACTONEL25 31 ACTOPLUS MET 27 ACTOS 27 ACUVAIL 34 acyclovir9 ADACEL 31 ADAGEN25 adapalene23 ADCIRCA 35 adriamycin 13 ADVAIR DISKUS 35 ADVAIR HFA35 ADVICOR 22 afeditab cr 20 AFINITOR13 AGGRENOX 22 a-hydrocort 26 ak-con34 AKNE-MYCIN23

ALBENZA 11 albuterol sulfate 35 albuterol sulfate er 35 alclometasone dipropionate 24 ALCOHOL PREPS 27 ALDACTAZIDE 20 ALDURAZYME 27 alendronate sodium 25 31 alfuzosin hcl er 36 ALIMTA 13 ALINIA 11 allopurinol 31 ALOCRIL 34 ALOMIDE 34 ALOPRIM 31 ALORA 32 ALOXI 28 ALPHAGAN P 34 ALREX 34 ALTABAX 24 ALTOPREV 22 ALVESCO 35 amantadine 9 amcinonide 24 amethia 32 amethyst 32 amifostine 13 amikacin sulfate 11 amiloride 20 amiloridehydrochlorothiazide 20 aminophylline 35 AMINOSYN II 37 AMINOSYN M 37 AMINOSYN-HBC 37 AMINOSYN-PF 37 AMINOSYN-PF 7 37 amiodarone 20 AMITIZA 28 amitriptyline 18 amlodipine 20 amlodipine benazepril 20 AMMONIUM CHLORIDE 36

38

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

amnesteem23 ATACAND HCT 20 amoxapine 18 amoxicillin 12 amoxicillinclavulanate potassium 12 amoxicillinclavulanate potassium er 12 amoxicillinpotassium clavulanate 12 amphetaminedextroamphetamine 18 amphotericin b 9 ampicillin 12 ampicillin-sulbactam 12 AMPYRA 16 anagrelide hydrochloride 25 anastrozole13 ANDROGEL 27 ANDROGEL PUMP27 androxy 27 ANGELIQ32 ANTARA22 ANTIVERT 28 ANZEMET 28 APLENZIN18 APOKYN16 apraclonidine 34 apri32 APRISO 28 APTIVUS9 ARALAST NP25 aranelle 32 ARANESP 30 ARCALYST 30 ARRANON13 ARTHROTEC 50 18 ARTHROTEC 75 18 ARZERRA13 ASACOL 28 ASACOL HD28 ascompcodeine17 ASMANEX 120 METERED DOSES 35 ASMANEX 14 METERED DOSES 35 ASMANEX 30 METERED DOSES 35 ASMANEX 60 METERED DOSES 35 ASTEPRO26 ATACAND20

ATELVIA 31 atenolol 20 atenolol chlorthalidone 20 ATGAM 31 atorvastatin calcium 22 atovaquoneproguanil hcl 11 ATRIPLA 9 atropine sulfate 28 ATROVENT HFA 35 augmented betamethasone dipropionate 24 AVANDAMET 27 AVANDARYL 27 AVANDIA 27 AVASTIN 13 AVELOX 12 AVELOX ABC PACK 12 aviane 32 AVINZA 17 AVODART 36 AVONEX 30 AXERT 16 AZACTAM IN ISO-OSMOTIC DEXTROSE 11 AZASAN 13 AZASITE 33 azathioprine 13 azathioprine sodium 13 azelastine hcl 26 34 AZELEX 23 AZILECT 16 azithromycin 10 AZOPT 34 AZOR 20 aztreonam 11

B

baciim 11 bacitracin 11 33 bacitracin polymyxin b 33 baclofen 17 BACTOCILL IN DEXTROSE 12 BACTROBAN 24 BACTROBAN NASAL 26

39

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

balsalazide 28 BUPRENEX 17 balziva 32 BANZEL15 BARACLUDE 9 BECONASE AQ35 benazepril20 benazepril hydrochlorothiazide 20 BENICAR20 BENICAR HCT20 benztropine mesylate16 BESIVANCE 33 betamethasone dipropionate24 betamethasone valerate 24 BETASERON30 betaxolol hcl20 33 bethanechol chloride36 BETIMOL33 BETOPTIC-S33 BIAXIN XL PAC 10 bicalutamide13 BICILLIN C-R12 BICILLIN L-A12 BICNU 13 BILTRICIDE 11 bisoprolol fumarate20 bisoprolol fumarate hydrochlorothiazide 20 bleomycin sulfate 13 BLEPH-10 34 BLEPHAMIDE34 BLEPHAMIDE SOP 34 BONIVA31 BOOSTRIX 31 briellyn 32 brimonidine tartrate34 BROMDAY 34 bromfenac 34 bromocriptine mesylate16 BROVANA35 budeprion sr 18 budeprion xl 18 budesonide 28 35 bumetanide20 BUPHENYL 25

buprenorphine hcl 17 buproban 26 bupropion hcl 18 bupropion hcl sr 18 buspirone hcl 18 BUSULFEX 13 butalbitalacetaminophencaffeinecodeine 17 butorphanol tartrate 18 BYETTA 27 BYSTOLIC 20

C

cabergoline 27 calcipotriene 23 calcitonin-salmon 27 calcitriol 28 calcium acetate 36 camila 32 CAMPATH 13 CAMPRAL 25 CANASA 28 CANCIDAS 9 CANTIL 28 CAPASTAT SULFATE 11 CAPEX 24 CAPITALCODEINE 17 CAPRELSA 13 captopril 21 captoprilhydrochlorothiazide 21 CARAC 23 CARAFATE 29 carbamazepine 15 carbamazepine er 15 carbidopa levodopa 16 carbidopa levodopa er 16 carbidopalevodopa odt 16 carbinoxamine maleate 35 carboplatin 13 CARDIZEM CD 21 CARDIZEM LA 21 CARIMUNE NANOFILTERED 31 CARMOL-HC 23

40

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

carteolol hcl 33 cartia xt 21 carvedilol 21 CEDAX10 CEENU 13 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin 10 cefdinir 10 cefepime 10 cefotaxime sodium10 CEFOTETAN 10 CEFOXITIN SODIUM10 cefpodoxime proxetil 10 cefprozil 10 ceftazidime 10 CEFTAZIDIMEDEXTROSE10 ceftriaxone sodium 10 cefuroxime axetil10 cefuroxime sodium 10 CELEBREX18 CELESTONE26 CELLCEPT13 CELLCEPT INTRAVENOUS 13 CELONTIN 15 CENESTIN 32 cephalexin 10 CEREZYME28 CERVARIX 31 CESAMET28 CHANTIX 26 CHANTIX STARTING MONTH PAK 26 CHEMET 25 CHLORAMPHENICOL SODIUM SUCCINATE

11 chlorhexidine gluconate oral rinse 26 chloroquine 11 chlorothiazide 21 chlorpromazine 19 chlorthalidone 21 cholestyramine light22 CIALIS36

ciclopirox 24 ciclopirox nail lacquer 24 ciclopirox olamine 24 cilostazol 22 CILOXAN 33 cimetidine 29 cimetidine hcl 29 CIMZIA 28 CIPRO 12 CIPRO HC 26 CIPRODEX 26 ciprofloxacin 12 33 ciprofloxacin er 12 cisplatin 13 citalopram 19 cladribine 13 CLAFORAN 10 claravis 23 CLARINEX 35 CLARINEX REDITABS 35 CLARINEX-D 12 HOUR 35 CLARINEX-D 24 HOUR 35 clarithromycin 10 clarithromycin er 10 clemastine fumarate 35 CLEOCIN 11 32 CLEOCIN GALAXY 11 CLEOCIN IN D5W 11 CLIMARA PRO 32 CLINDAGEL 23 clindamycin hcl 11 clindamycin phosphate 23 32 clindamycin phosphate add-vantage 11 clindamycinbenzoyl peroxide 24 CLINIMIX 275DEXTROSE 5 37 CLINIMIX 425DEXTROSE 10 37 CLINIMIX 425DEXTROSE 20 37 CLINIMIX 425DEXTROSE 5 25 CLINIMIX 5DEXTROSE 15 37 CLINIMIX 5DEXTROSE 20 37 CLINIMIX 5DEXTROSE 25 37 CLINIMIX E 275DEXTROSE 10 25 CLINIMIX E 275DEXTROSE 5 25

41

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

CLINIMIX E 425DEXTROSE 2537 CLINIMIX E 425DEXTROSE 537 CLINIMIX E 5DEXTROSE 1537 CLINIMIX E 5DEXTROSE 2037 CLINIMIX E 5DEXTROSE 2537 clobetasol propionate 24 CLOBEX 24 CLODERM PUMP 24 clomipramine 19 clonazepam 15 clonazepam odt 15 clonidine21 clopidogrel 22 clorazepate dipotassium 19 CLORPRES 21 clotrimazole 9 clotrimazole betamethasone 24 clozapine 19 COARTEM11 codeine sulfate 17 COLCRYS 31 colestipol 22 colistimethate sodium 11 colocort 28 COLY-MYCIN S26 COMBIGAN34 COMBIPATCH 32 COMBIVENT35 COMPLERA9 compro 28 COMTAN 16 COMVAX31 CONDYLOX 23 COPAXONE16 CORDRAN24 CORDRAN TAPE24 COREG CR21 CORTIFOAM28 cortisone acetate 26 CORTISPORIN 24 CORTISPORIN-TC26 COUMADIN 22 COVERA-HS21

CREON 28 CRESTOR 22 CRIXIVAN 9 cromolyn sodium 28 34 35 cryselle-28 32 CUBICIN 11 cyclafem 135 32 cyclafem 777 32 cyclobenzaprine hcl 17 cyclobenzaprine hcl er 17 cyclophosphamide 13 cyclosporine 13 CYMBALTA 19 CYSTADANE 28 CYSTAGON 36 cytarabine 13 cytarabine aqueous 13

D

dacarbazine 13 DACOGEN 13 DALIRESP 35 danazol 28 dantrolene sodium 17 DAPSONE 11 DAPTACEL 31 DARAPRIM 11 daunorubicin hcl 13 DAYTRANA 19 DECAVAC 31 DELESTROGEN 32 demeclocycline hcl 12 DEMSER 21 DENAVIR 24 DEPEN TITRATABS 31 DEPO-ESTRADIOL 32 DEPO-MEDROL 26 DEPO-PROVERA 32 DEPO-SUBQ PROVERA 104 32 desipramine 19 desmopressin acetate 28 DESONATE 24 desonide 24

42

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

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From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

desoximetasone 24 25 DETROL36 DETROL LA 36 dexamethasone26 34 DEXAMETHASONE INTENSOL 26 DEXILANT 29 dexmethylphenidate 19 dexrazoxane 13 dextroamphetamine sulfate 19 dextroamphetamine sulfate er19 DEXTROSE 10NACL 04525 dextrose 10 flex container 25 DEXTROSE 10NACL 0225 dextrose 25sodium chloride 045 25 dextrose 525 dextrose 5lactated ringers 25 dextrose 5nacl 02 25 dextrose 5nacl 0225 25 DEXTROSE 5NACL 03325 dextrose 5nacl 045 25 dextrose 5nacl 09 25 DEXTROSE 5POTASSIUM CHLORIDE

015 36 diazepam 15 19 DIAZEPAM INTENSOL 19 DIBENZYLINE21 diclofenac potassium18 diclofenac sodium 34 diclofenac sodium dr18 diclofenac sodium er 18 dicloxacillin sodium 12 didanosine 9 DIFFERIN 24 DIFICID10 diflorasone diacetate25 diflunisal 18 digoxin 22 DILANTIN 15 DILANTIN INFATABS15 DILATRATE SR 23 DILAUDID-517 dilt-cd 21 diltiazem cd 21

DILTIAZEM HCL 21 diltiazem hcl er 21 dilt-xr 21 DIOVAN 21 DIOVAN HCT 21 DIPENTUM 28 diphenoxylate atropine 28 dipyridamole 22 disopyramide phosphate 20 disulfiram 25 DIURIL 21 divalproex sodium 15 divalproex sodium dr 15 divalproex sodium er 15 DIVIGEL 32 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 16 DORIBAX 11 dorzolamide hcl 34 dorzolamide hcltimolol maleate 34 DOVONEX 23 doxazosin 21 doxepin 19 DOXIL 13 doxorubicin hcl 13 doxycycline 12 doxycycline hyclate 12 doxycycline monohydrate 12 dronabinol 28 DROXIA 13 DUETACT 27 DULERA 35 duramorph 17 DUREZOL 34 DYNACIRC CR 21 DYRENIUM 21

E

ees 400 10 econazole nitrate 24 EDECRIN 21 EDURANT 9

43

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

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From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

EFFIENT 22 ELESTRIN32 ELIDEL 23 ELIGARD13 eliphos 36 ELITEK 13 ELIXOPHYLLIN 35 ELLENCE13 ELMIRON 36 ELSPAR13 EMADINE 34 EMCYT 13 EMEND 29 emoquette 32 EMSAM19 EMTRIVA 9 ENABLEX36 enalapril21 enalapril hydrochlorothiazide 21 ENBREL31 endocet 17 endodan17 ENGERIX-B31 ENJUVIA32 enoxaparin sodium22 enpresse-28 32 enulose 29 epinastine hcl 34 epinephrine hcl 35 EPIPEN35 EPIPEN-JR 35 epirubicin hcl 13 epitol 15 EPIVIR9 EPIVIR HBV 9 eplerenone21 EPOGEN30 eprosartan mesylate 21 EPZICOM9 EQUETRO15 ERAXIS 9 ERBITUX 13 ERIVEDGE 13

errin 32 ERTACZO 24 ery 24 ERYPED 200 10 ERYPED 400 11 ery-tab 10 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 24 33 erythromycin benzoyl peroxide 24 ERYTHROMYCIN BASE 11 erythromycin ethylsuccinate 11 escitalopram 19 ESTRACE 32 estradiol 32 estradiol norethindrone acetate 32 estradiol valerate 32 ESTRING 32 estropipate 32 ethambutol 11 ethosuximide 15 etidronate disodium 25 etodolac 18 ETOPOPHOS 13 etoposide 13 EURAX 25 EVAMIST 32 EVISTA 31 EVOXAC 25 EXELDERM 24 EXELON 16 17 exemestane 13 EXFORGE 21 EXFORGE HCT 21 EXJADE 25 EXTAVIA 30

F

FABRAZYME 28 FACTIVE 12 famciclovir 9 famotidine 29 famotidine premixed 29

44

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

FANAPT19 FANAPT TITRATION PACK19 FARESTON13 FASLODEX14 FAZACLO 19 felbamate15 felodipine er 21 FEMHRT LOW DOSE32 FEMRING 32 FEMTRACE 32 fenofibrate 23 fenofibrate micronized 23 fenoprofen calcium 18 fentanyl citrate oral transmucosal 17 fentanyl patches 17 FENTORA 17 FINACEA 24 finasteride 36 FIRMAGON 14 FLAGYL ER11 FLAREX34 flavoxate hcl 36 flecainide acetate 20 FLECTOR18 FLOVENT DISKUS35 FLOVENT HFA 35 fluconazole 9 fluconazole in dextrose 9 flucytosine 9 fludarabine phosphate 14 fludrocortisone acetate 26 flunisolide35 fluocinolone acetonide 25 26 fluocinolone acetonide body 25 fluocinonide 25 fluocinonide-e 25 FLUOROPLEX 23 fluorouracil 14 23 fluoxetine19 fluoxetine dr 19 fluphenazine 19 fluphenazine decanoate inj 19 flurbiprofen 18

flurbiprofen sodium 34 flutamide 14 fluticasone propionate 25 35 fluvastatin 23 fluvoxamine 19 FML 34 FML FORTE 34 FOCALIN XR 19 fomepizole 31 fondaparinux sodium 22 FORADIL AEROLIZER 35 FORTAMET 27 FORTAZ 10 FORTEO 31 fortical 28 fosinopril 21 fosinopril hydrochlorothiazide 21 fosphenytoin sodium 15 FOSRENOL 25 FRAGMIN 22 FREAMINE III 37 FREAMINE III 3 37 FROVA 16 furosemide 21 FUZEON 9

G

gabapentin 15 GABITRIL 15 galantamine hydrobromide 17 GAMMAGARD LIQUID 31 GAMUNEX-C 31 ganciclovir 9 GARDASIL 31 GAUZE PADS 2 27 gavilyte-c 29 gavilyte-g 29 gavilyte-nflavor pack 29 gemcitabine hcl 14 gemfibrozil 23 gengraf 14 GENOTROPIN 30 GENOTROPIN MINIQUICK 30

45

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

gentak33 GENTAMICIN SULFATE11 24 33 gentamicin sulfate09 sodium chloride11 gentamicin sulfatesodium chloride 11 GEODON19 gianvi 32 GILENYA17 GLASSIA25 GLEEVEC 14 glimepiride 27 glipizide27 glipizide metformin 27 glipizide er 27 glipizide xl27 GLUCAGEN HYPOKIT27 GLUCAGON EMERGENCY KIT 27 GLUMETZA 27 glyburide 27 glyburide metformin27 glyburide micronized 27 glycopyrrolate 28 GLYSET 27 GOLYTELY 29 granisetron29 GRANISOL 29 griseofulvin microsize 9 GRIS-PEG 9 guanfacine hcl21

H

HALAVEN 14 HALFLYTELY BOWEL PREPFLAVOR

PACKS29 halobetasol propionate 25 HALOG 25 haloperidol19 haloperidol decanoate inj 19 haloperidol lactate inj19 HAVRIX31 HECTOROL 28 HELIDAC29 heparin sodium 22 heparin sodiumd5w22

HEPARIN SODIUMNACL 045 22 heparin sodiumsodium chloride 09 premix 22 HEPATAMINE 37 HEPATASOL 37 HEPSERA 9 HERCEPTIN 14 HEXALEN 14 HUMALOG 27 HUMALOG KWIKPEN 27 HUMALOG MIX 5050 27 HUMALOG MIX 5050 KWIKPEN 27 HUMALOG MIX 7525 27 HUMALOG MIX 7525 KWIKPEN 27 HUMATROPE 30 HUMATROPE COMBO PACK 30 HUMIRA 31 HUMIRA PEN-CROHNS DISEASE STARTER

31 HUMULIN 7030 27 HUMULIN 7030 PEN 27 HUMULIN N 27 HUMULIN N U-100 PEN 27 HUMULIN R 27 HUMULIN R U-500 (CONCENTRATED) 27 hydralazine 21 hydrochlorothiazide 21 hydrocodone bitartrateacetaminophen 17 hydrocodoneacetaminophen 17 hydrocodoneibuprofen 17 hydrocortisone 25 26 29 hydrocortisone valerate 25 hydrocortisoneacetic acid 26 hydromorphone hcl 17 hydroxychloroquine 11 hydroxyurea 14 hydroxyzine hcl 35 hydroxyzine pamoate 35

I

ibandronate 31 ibuprofen 18 idarubicin hcl 14 IFEX 14

46

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

ifosfamide14 isosorbide mononitrate er 23 imipenemcilastatin 11 imipramine 19 imipramine pamoate 19 imiquimod 23 INCIVEK 9 INCRELEX25 indapamide21 indomethacin18 indomethacin er 18 INFANRIX 31 INFERGEN30 INLYTA14 INNOPRAN XL 21 INSULIN PEN NEEDLE 27 INSULIN SYRINGE (DISP) U-100 03 ML27 INSULIN SYRINGE (DISP) U-100 1 ML27 INSULIN SYRINGE (DISP) U-100 12 ML 27 INTELENCE 9 INTRALIPID 37 INTRON-A 30 INTRON-A WITH DILUENT 30 introvale 32 INTUNIV19 INVANZ 11 INVEGA 19 INVEGA SUSTENNA 19 INVIRASE9 IONOSOL37 IOPIDINE 34 IPOL INACTIVATED IPV 31 ipratropium bromide26 35 ipratropium bromidealbuterol sulfate 35 irbesartan21 irbesartanhydrochlorothiazide 21 irinotecan 14 ISENTRESS9 ISOLYTE37 isoniazid 11 ISORDIL TITRADOSE 23 isosorbide dinitrate 23 isosorbide dinitrate er23 isosorbide mononitrate 23

isotonic gentamicin 11 isradipine 21 ISTALOL 33 ISTODAX 14 itraconazole 9 IXEMPRA KIT 14 IXIARO 31

J

JAKAFI 14 JALYN 36 jantoven 22 JANUMET 27 JANUVIA 27 JEVTANA 14 jinteli 32 jolivette 32 junel 32 junel fe 1530 32 junel fe 120 32

K

KADIAN 17 KALETRA 9 kanamycin sulfate 11 KAPVAY 19 kariva 32 kcl 0075d5wnacl 045 36 kcl 015d5wlr 36 KCL 015D5WNACL 02 36 KCL 015D5WNACL 0225 36 kcl 015d5wnacl 09 36 kcl 03d5wnacl 045 36 kcl 03d5wnacl 09 36 kelnor 135 32 KENALOG 25 KETEK 11 ketoconazole 9 24 ketoprofen 18 ketoprofen er 18 ketorolac tromethamine 34 kionex 25 klor-con 10 36

47

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

klor-con 8 36 LEVOTHROID 28 KLOR-CON M15 36 klor-con m20 36 K-TABS 36 KUVAN 28

L

labetalol 21 LACTATED RINGERS 36 lactated ringers irrigation 25 lactulose 29 lamivudine9 lamivudinezidovudine 9 lamotrigine15 LANOXIN 22 lansoprazole29 LANTUS27 LANTUS SOLOSTAR 27 latanoprost 34 LATUDA 19 leena32 leflunomide31 LESCOL XL 23 lessina-28 32 LETAIRIS35 letrozole 14 leucovorin calcium13 LEUKERAN14 LEUKINE 30 leuprolide acetate 14 levalbuterol 35 LEVATOL 21 LEVEMIR27 LEVEMIR FLEXPEN 27 levetiracetam15 levetiracetam er 15 levobunolol hcl33 levocarnitine 25 levocetirizine dihydrochloride 35 levofloxacin 12 33 levofloxacin in d5w 12 levora 32 levorphanol tartrate 17

levothyroxine 28 levoxyl 28 LEXIVA 9 LIALDA 29 lidocaine 24 lidocaine prilocaine 24 lidocaine viscous 24 LIDODERM 24 lindane 25 liothyronine sodium 28 LIPOFEN 23 lisinopril 21 lisinoprilhydrochlorothiazide 21 lithium carbonate 19 lithium carbonate er 19 lithium citrate 19 LO LOESTRIN FE 33 LODOSYN 16 LOESTRIN 24 FE 33 lorazepam 19 lorazepam intensol 19 losartan potassium 21 losartan potassiumhydrochlorothiazide 21 LOTEMAX 34 LOTRONEX 29 lovastatin 23 LOVAZA 23 low-ogestrel 33 loxapine 19 LUFYLLIN 35 LUMIGAN 34 LUPRON DEPOT 14 LUPRON DEPOT-PED 14 lutera 33 LUVOX CR 19 LUXIQ 25 LYRICA 15 LYSODREN 14

M

MACRODANTIN 12 MAGNACET 17

48

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

MAGNESIUM SULFATE 36 malathion 25 maprotiline19 marlissa33 MARPLAN19 MATULANE 14 matzim la21 MAXAIR AUTOHALER35 MAXALT 16 MAXALT-MLT16 MAXIDEX34 meclofenamate sodium18 MEDROL26 medroxyprogesterone acetate 32 mefenamic acid 18 mefloquine hcl11 MEGACE ES14 megestrol acetate 14 meloxicam 18 melphalan hydrochloride 14 MENACTRA 31 MENEST 32 MENOMUNE-ACYW-13531 MENOSTAR 32 MENVEO 31 MEPRON11 mercaptopurine 14 meropenem11 mesalamine 29 mesna 13 MESNEX 13 MESTINON17 MESTINON TIMESPAN17 METADATE CD19 metadate er 19 metaproterenol sulfate 35 metformin hcl 27 metformin hcl er27 methadone hcl 17 methadose 17 methamphetamine hcl 19 methazolamide 34 methenamine hippurate12

methimazole 26 METHITEST 28 methocarbamol 17 methotrexate 14 methotrexate sodium 14 methscopolamine bromide 28 methyclothiazide 21 methyldopa 21 methyldopahydrochlorothiazide 21 methylergonovine maleate 33 METHYLIN 19 methylphenidate hcl 19 methylphenidate hcl er 19 methylphenidate hydrochloride 19 methylprednisolone 26 methylprednisolone acetate 26 methylprednisolone dose pack 26 METHYLPREDNISOLONE

SODIUMSUCCINATE 26 metipranolol 33 metoclopramide 29 metolazone 21 metoprolol succinate er 21 metoprolol tartrate 21 metoprololhydrochlorothiazide 21 METROGEL 24 metronidazole 11 24 metronidazole in nacl 079 11 metronidazole vaginal 32 mexiletine 20 MIACALCIN 28 MICARDIS 21 MICARDIS HCT 21 microgestin 1530 33 microgestin 120 33 microgestin fe 33 microgestin fe 1530 33 midodrine 25 MIGRANAL 16 MILLIPRED 26 minocycline hcl 12 minocycline hcl er 12 minoxidil 21

49

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

mirtazapine 19 mirtazapine odt 19 misoprostol30 mitomycin14 mitoxantrone hcl 14 M-M-R II WDILUENT 10 DOSE31 moexipril 21 moexiprilhydrochlorothiazide21 mometasone furoate 25 mononessa33 MONUROL 12 morphine sulfate 17 morphine sulfate er 17 MOTOFEN 28 MOVIPREP 29 MOXATAG 12 MOZOBIL 30 MULTAQ 20 mupirocin 24 MUSTARGEN14 MYCOBUTIN 11 mycophenolate mofetil 14 MYFORTIC14 MYOZYME28 MYTELASE 17

N

nabumetone 18 nadolol 21 nadololbendroflumethiazide 21 nafcillin sodium12 NAFTIN24 NAGLAZYME 28 nalbuphine hcl18 NALFON 18 NALLPENDEXTROSE 12 naloxone18 naltrexone 18 NAMENDA 17 NAMENDA TITRATION PAK17 naproxen 18 naproxen sodium18 naratriptan hcl 16

NASONEX 35 NATACYN 33 nateglinide 27 NEBUPENT 11 necon 0535-28 33 necon 135-28 33 necon 1011-28 33 necon 777 33 NEEDLES INSULIN DISP SAFETY 27 nefazodone 19 neomycin sulfate 11 neomycinbacitracinpolymyxin 33 neomycinpolymyxin b sulfates 25 neomycinpolymyxinbacitracinhydrocortisone 34 neomycinpolymyxindexamethasone 34 neomycinpolymyxingramicidin 33 neomycinpolymyxinhc 26 34 NEORAL 14 NEPHRAMINE 37 NEULASTA 30 NEUMEGA 30 NEUPOGEN 30 NEVANAC 34 nevirapine 9 NEXAVAR 14 NEXIUM 30 NEXIUM IV 30 next choice 33 NIACOR 23 NIASPAN 23 nicardipine 21 NICOTROL INHALER 26 NICOTROL NASAL 26 nifediac cc 21 nifedical xl 21 nifedipine er 21 NILANDRON 14 nimodipine 21 NIPENT 14 nisoldipine 21 nisoldipine er 21 nitro-bid 23 nitrofurantoin 12

50

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

nitrofurantoin macrocrystalline13 nitrofurantoin monohydrate13 nitroglycerin23 nitroglycerin transdermal 23 NITROLINGUAL PUMPSPRAY23 NITROSTAT 23 nizatidine30 nora-be32 NORDITROPIN FLEXPRO30 NORDITROPIN NORDIFLEX PEN 30 norethindrone32 NORMOSOL-R 37 NORMOSOL-R IN D5W 36 NOROXIN 12 NORPACE CR 20 nortrel 0535 (28)33 nortrel 135 (21)33 nortrel 135 (28)33 nortrel 777 33 nortriptyline 19 NORVIR 9 NOVOLIN 7030 27 NOVOLIN N 27 NOVOLIN R27 NOVOLOG27 NOVOLOG FLEXPEN 27 NOVOLOG MIX 703027 NOVOLOG MIX 7030 PREFILLED FLEXPEN

27 NOXAFIL9 NULOJIX14 NUTROPIN 30 NUVARING 32 nyamyc 24 nystatin9 24 nystatin triamcinolone 24 nystop 24

O

ocella33 octreotide 14 ofloxacin12 26 33 ogestrel33

olanzapine 19 olanzapine odt 19 omeprazole 30 omeprazolesodium bicarbonate 30 OMNARIS 35 OMNITROPE 30 ondansetron hcl 29 ondansetron odt 29 ONFI 15 ONGLYZA 27 ONTAK 14 OPANA ER (CRUSH RESISTANT) 18 ORAP 19 ORAPRED ODT 26 ORENCIA 31 ORFADIN 25 orsythia 33 ORTHO EVRA 32 ORTHO TRI-CYCLEN LO 33 OSMOPREP 29 OVCON-50 28 33 OXACILLIN SODIUM 12 oxaliplatin 14 oxandrolone 28 oxaprozin 18 oxcarbazepine 15 OXISTAT 24 OXSORALEN 23 OXSORALEN ULTRA 23 oxybutynin 36 oxybutynin er 36 oxycodone acetaminophen 18 oxycodone hcl 18 oxycodoneaspirin 18 oxycodoneibuprofen 18 OXYCONTIN 18 oxymorphone hydrochloride 18 oxymorphone hydrochloride er 18

P

PACERONE 20 paclitaxel 14 PAMIDRONATE DISODIUM 28

51

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

PANDEL25 PHOSPHOLINE IODIDE 33 PANRETIN23 pantoprazole 30 paromomycin 11 paroxetine 19 paroxetine er 19 PASER 11 PATADAY 34 PATANASE26 PATANOL34 PAXIL19 PCE 11 pedi-dri24 PEDVAX HIB 31 PEGANONE15 PEGASYS30 PEGASYS PROCLICK30 PEG-INTRON 30 PEG-INTRON REDIPEN30 penicillin g potassium 12 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE12 PENICILLIN G PROCAINE12 PENICILLIN G SODIUM12 penicillin v potassium 12 PENTAM 300 11 PENTASA 29 pentostatin14 pentoxifylline er 22 PERFOROMIST35 perindopril erbumine 22 periogard 26 permethrin25 perphenazine 19 perphenazineamitriptyline 19 pfizerpen-g 12 phenadoz 35 phenelzine sulfate19 phenobarbital15 phenytoin15 PHENYTOIN SODIUM15 phenytoin sodium extended 15 PHISOHEX24

pilocarpine hcl 26 PILOPINE HS 34 pindolol 22 piperacillin sodiumtazobactam sodium 12 piroxicam 18 PLASMA-LYTE 37 podofilox 23 polymyxin b sulfate 11 portia-28 33 potassium chloride 37 POTASSIUM CHLORIDE 015 NACL 045

VIAFLEX 36 potassium chloride 015 d5wnacl 033 36 potassium chloride 015 d5wnacl 045 viaflex

36 potassium chloride 015 nacl 09 36 POTASSIUM CHLORIDE 022 D5WNACL

045 36 potassium chloride 0224dextrose 5 viaflex 36 POTASSIUM CHLORIDE 03 NACL 09 37 potassium chloride 03d5wviaflex 37 potassium chloride er 37 POTIGA 15 PRADAXA 22 pramipexole dihydrochloride 16 PRANDIMET 27 PRANDIN 27 pravastatin 23 prazosin 22 PRED MILD 34 PRED-G 34 PRED-G SOP 34 prednicarbate 25 prednisolone acetate 34 prednisolone sodium phosphate 26 34 prednisone 26 PREDNISONE INTENSOL 26 PREFEST 32 PREMARIN 32 PREMASOL 37 PREMPHASE 32 PREMPRO 32

52

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

prenatal vitamins (generic)37 prevalite 23 previfem 33 PREVPAC 30 PREZISTA9 PRIFTIN 11 PRIMAQUINE 11 PRIMAXIN IV 11 primidone 15 PRIMSOL 13 PRISTIQ 19 PRIVIGEN31 PROAIR HFA35 probenecid 31 probenecid colchicine 31 procainamide 20 PROCALAMINE37 prochlorperazine29 prochlorperazine edisylate 29 prochlorperazine maleate 29 PROCRIT30 31 PROGESTERONE 32 PROGLYCEM27 PROGRAF 14 PROLASTIN-C 26 PROLEUKIN31 PROMACTA 22 promethazine hcl35 promethazine vc 35 promethegan 35 propafenone hcl 20 propafenone hcl er 20 proparacaine hcl34 propranolol hcl 22 propranolol hcl er 22 propranololhydrochlorothiazide22 propylthiouracil 27 PROQUAD 31 PROSOL 37 PROTOPIC 23 protriptyline hcl 19 PROVENTIL HFA 35 PROVIGIL19

PULMICORT 35 PULMICORT FLEXHALER 35 PULMOZYME 35 PYLERA 30 pyridostigmine bromide 17

Q

QUALAQUIN 11 quasense 33 quetiapine 19 quinapril 22 quinaprilhydrochlorothiazide 22 QUINIDINE GLUCONATE 20 quinidine gluconate er 20 quinidine sulfate 20 quinidine sulfate er 20 QVAR 35

R

RABAVERT 31 ramipril 22 RANEXA 23 ranitidine hcl 30 RAPAFLO 36 RAPAMUNE 14 REBETOL 9 REBIF 31 REBIF TITRATION PACK 31 reclipsen 33 RECOMBIVAX HB 31 regonol 17 REGRANEX 23 RELENZA DISKHALER 9 RELISTOR 29 RELPAX 16 REMICADE 29 RENAGEL 26 RENVELA 26 reprexain 18 RESCRIPTOR 9 reserpine 22 RESTASIS 34 RETROVIR IV INFUSION 9 REVATIO 35

53

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

REVLIMID14 REYATAZ9 RHEUMATREX14 RHINOCORT AQUA35 ribapak 9 ribasphere 9 10 ribavirin 10 RIDAURA 31 rifampin11 RIFATER11 RILUTEK 26 rimantadine hcl 10 ringers injection 37 ringers irrigation 25 RIOMET 27 RISPERDAL CONSTA20 risperidone 20 risperidone odt 20 RITUXAN 14 rivastigmine tartrate 17 ropinirole 16 ropinirole er 16 ROTATEQ31 ROXICET 18 ROZEREM 20

S

SABRIL 15 SAFYRAL 33 SAIZEN 31 SAIZEN CLICKEASY31 SANCUSO29 SANDIMMUNE14 SANDOSTATIN LAR DEPOT14 SANTYL25 SAPHRIS 20 SAVELLA 32 SAVELLA TITRATION PACK 32 selegiline 16 selenium sulfide23 SELZENTRY10 SEMPREX-D35 SENSIPAR28

SEREVENT DISKUS 35 SEROMYCIN 11 SEROQUEL XR 20 sertraline 20 silver sulfadiazine 23 SIMCOR 23 SIMPONI 32 SIMULECT 14 simvastatin 23 SINGULAIR 35 SKELID 26 sodium chloride 26 37 sodium chloride 045 viaflex 37 sodium chloride 09 26 sodium fluoride 37 sodium lactate 37 sodium polystyrene sulfonate 26 sodium sulfacetamide 34 SOLARAZE 23 SOLU-CORTEF 26 SOLU-MEDROL 26 SOMATULINE DEPOT 14 SOMAVERT 28 SORIATANE 23 sorine 20 sotalol 20 SPECTRACEF 10 SPIRIVA HANDIHALER 35 spironolactone 22 spironolactonehydrochlorothiazide 22 sprintec 28 33 SPRYCEL 14 sronyx 33 ssd 23 stagesic 18 STALEVO 100 16 STALEVO 125 16 STALEVO 150 16 STALEVO 200 16 STALEVO 50 16 STALEVO 75 16 stavudine 10 STAVZOR 15

54

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

sterile water irrigation26 STIMATE 28 STRATTERA 20 STREPTOMYCIN SULFATE 11 STRIANT28 STROMECTOL11 SUBOXONE18 SUCRAID29 sucralfate 30 sulfacetamide sodium24 sulfacetamide sodium prednisolone sodium

phospha 34 sulfacetamide sodium ophthalmic34 sulfadiazine 12 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim ds 12 SULFAMYLON 24 sulfasalazine29 sulfazine ec29 sulindac 18 sumatriptan succinate 16 SUPRAX10 SUPREP BOWEL PREP 29 SUSTIVA10 SUTENT 14 SYLATRON 31 SYMBICORT 36 SYMBYAX 20 SYMLINPEN 12027 SYMLINPEN 6027 SYNAGIS 10 SYNALGOS-DC 18 SYNAREL 28 SYNERA 24 SYNERCID 11 SYNTHROID 28 SYPRINE26

T

TABLOID14 TACLONEX23 TACLONEX SCALP 23 tacrolimus 14

TAMIFLU 10 tamoxifen citrate 14 tamsulosin hcl 36 TARCEVA 14 TARGRETIN 15 TARKA 22 TASIGNA 15 TASMAR 16 TAZORAC 24 taztia xt 22 TEGRETOL-XR 15 TEKTURNA 22 TEKTURNA HCT 22 TENIVAC 31 terazosin hcl 22 terbinafine 9 terbutaline sulfate 36 terconazole 32 testosterone cypionate 28 testosterone enanthate 28 TESTRED 28 TETANUS DIPHTHERIA TOXOIDS-

ADSORBED ADULT 31 tetracycline hcl 12 TEVETEN 22 TEVETEN HCT 22 TEV-TROPIN 31 THALITONE 22 THALOMID 15 theophylline cr 36 theophylline er 36 thermazene 23 thioridazine 20 thiotepa 15 thiothixene 20 THYMOGLOBULIN 31 ticlopidine hcl 22 TIKOSYN 20 TIMENTIN 12 timolol maleate 22 33 timolol maleate ophthalmic gel forming 33 TIROSINT 28 tizanidine hcl 17

55

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

TOBI 11 TOBRADEX34 tobramycin 11 33 TOBRAMYCIN SULFATE SODIUM

CHLORIDE 11 tobramycindexamethasone 34 TOBREX 33 tolazamide 27 tolbutamide 27 tolmetin sodium18 topiramate 15 topotecan hcl15 TORISEL 15 TORSEMIDE22 TOVIAZ36 TRACLEER36 TRADJENTA 27 tramadol18 tramadol hcl acetaminophen 18 tramadol hcl er18 trandolapril 22 tranexamic acid22 tranylcypromine 20 travasol 37 TRAVATAN Z 34 trazodone 20 TREANDA 15 TRECATOR 12 TRELSTAR DEPOT MIXJECT 15 TRELSTAR LA MIXJECT 15 TRELSTAR MIXJECT 15 tretinoin15 24 TREXALL 15 TREXIMET 16 triamcinolone acetonide 25 36 triamcinolone in orabase 26 triamterenehydrochlorothiazide 22 TRICOR23 triderm 25 trifluoperazine20 trifluridine 33 trihexyphenidyl16 tri-legest fe 33

TRILEPTAL 16 TRILIPIX 23 trilyte 29 trimethoprim 13 trimethoprim sulfatepolymyxin b sulfate 33 trimipramine 20 trinessa 33 tri-previfem 33 TRISENOX 15 tri-sprintec 33 trivora-28 33 TRIZIVIR 10 TROPHAMINE 37 tropicamide 34 trospium chloride 36 TRUVADA 10 TWINJECT 35 TWINRIX 31 TYGACIL 12 TYKERB 15 TYPHIM VI 31 TYZEKA 10 TYZINE 26 TYZINE PEDIATRIC NASAL DROPS 26

U

U-CORT 23 ULESFIA 25 unithroid 28 ursodiol 29 UVADEX 23

V

VAGIFEM 32 valacyclovir hcl 10 VALCYTE 10 valproate sodium 16 valproic acid 16 vancomycin 13 vandazole 32 VANOS 25 VAQTA 31 VARIVAX 31 VECTIBIX 15

56

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

VELCADE15 WELCHOL 23 velivet 33 VENLAFAXINE 20 venlafaxine hcl 20 venlafaxine hcl er20 VENTAVIS 36 VENTOLIN HFA 36 VERAMYST 36 verapamil 22 verapamil er 22 VERDESO 25 VEREGEN23 VERIPRED 2026 VESICARE36 vestura33 VEXOL34 VFEND IV9 VIBRAMYCIN12 VICTOZA27 VIDAZA 15 VIDEX PEDIATRIC 10 VIGAMOX 33 VIIBRYD20 VIMOVO 18 VIMPAT 16 vinblastine sulfate 15 vincasar pfs 15 vincristine sulfate 15 vinorelbine tartrate 15 VIRACEPT10 VIRAMUNE10 VIREAD 10 VISTIDE10 VIVELLE-DOT 32 VIVITROL18 VOLTAREN18 voriconazole9 VOTRIENT 15 VPRIV 28 VYVANSE 20

W

warfarin 22

X

XALKORI 15 XARELTO 22 XENAZINE 17 XIFAXAN 12 XOLAIR 36 XOPENEX 36 XOPENEX HFA 36 XYREM 20

Y

YERVOY 15 YF-VAX 31

Z

zafirlukast 36 zaleplon 20 ZAMICET 18 ZANOSAR 15 ZAVESCA 28 zazole 32 ZELAPAR 16 ZELBORAF 15 ZEMAIRA 26 ZEMPLAR 28 ZENPEP 29 zeosa 33 ZERIT 10 ZETIA 23 ZIAGEN 10 zidovudine 10 ZINACEF 10 ZINACEF IN ISO-OSMOTIC DEXTROSE 10 ZINACEF IN ISO-OSMOTIC DILUENT 10 ZINECARD 13 ziprasidone 20 ZIRGAN 33 ZMAX 11 ZOLINZA 15 zolpidem 20 zolpidem tartrate er 20 ZOMETA 28

57

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

ZOMIG 16 ZOMIG ZMT16 zonisamide 16 ZORTRESS 15 ZOSTAVAX31 ZOSYN 12 zovia 135e 33 zovia 150e 33

ZOVIRAX 24 ZYDONE 18 ZYFLO 36 ZYFLO CR 36 ZYLET 34 ZYMAXID 33 ZYTIGA 15 ZYVOX 12

58

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234

Wersquore here to serve you

Monday ndash Friday 8 am ndash 8 pm and Saturday 8 am ndash 4 pm ET

From Oct 1 ndash Feb 14 call seven days a week 8 am ndash 8 pm

1-800-665-7924

TTY 1-800-662-1220

Or visit our website at wwwmvphealthcarecom for more information about Medicare Part D drug coverage

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copayments coinsurance may change on January 1 of each year MVP Health Plan Inc is a not-for-profit Medicare Advantage organization with a Medicare contract Plan performance Star Ratings are assessed each year and may change from one year to the next

11234