2016 601 4t copper comm eff 03/01/2016€¦ · tramadol hcl cp24 100mg ql (90 caps / 30 days) 1...

2016 601 4T Copper Comm eff 03/01/2016

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS

GOUT allopurinol tab (generic of

ZYLOPRIM) 1

ALOPRIM 3 colchicine w/ probenecid 1

COLCRYS QL (120 tabs / 30 days)

2 QL

probenecid 1

ULORIC 2 ST

ZYLOPRIM 3

MISCELLANEOUS ARTHROTEC 50 3

ARTHROTEC 75 3

diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol

(generic of ARTHROTEC 75) 1

DUEXIS 4 NM

VIMOVO 4 NM

NSAIDS ANAPROX 2

ANAPROX DS 2

CELEBREX CAP 50MG 3

CELEBREX CAP 100MG 3



celecoxib (generic of CELEBREX) CAPS

1

DAYPRO 2

diclofenac potassium 1 diclofenac sodium TB24;

TBEC 1

diflunisal 1

EC-NAPROSYN 3

etodolac 1

etodolac er 1

FELDENE 3

FENOPROFEN CALCIUM CAPS

1

fenoprofen calcium TABS 1 flurbiprofen TABS 1

ibuprofen SUSP 1 ibuprofen TABS 400mg,

600mg, 800mg 1

Drug Name Drug Tier

Requirements/Limits

ketoprofen CAPS; CP24 1

mefenamic acid (generic of

PONSTEL) CAPS 1

MELOXICAM SUSP 1

meloxicam tabs (generic of

MOBIC) 1

MOBIC 2 nabumetone TABS 1

NAPRELAN 4 NM

NAPROSYN TABS 2 naproxen SUSP 1

naproxen (generic of

NAPROSYN) TABS 250mg, 500mg

1

naproxen TABS 375mg 1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium TABS

275mg 1

naproxen sodium (generic of

ANAPROX DS) TABS 550mg

1

naproxen sodium (generic of

NAPRELAN) TB24 375mg 4 NM

NAPROXEN SODIUM TB24 500mg

4 NM

oxaprozin (generic of

DAYPRO) 1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 4 NM

sulindac TABS 1

tolmetin sodium 1

VIVLODEX 3

VOLTAREN-XR 3

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine

SOLN QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

2016 601 4T Copper Comm eff 03/01/2016


2

Drug Name Drug Tier

Requirements/Limits

acetaminophen w/ codeine

(generic of TYLENOL/CODEINE #3) TABS


1 QL

acetaminophen w/ codeine

(generic of TYLENOL/CODEINE #4) TABS


1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG


1 QL

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 5mcg/hr QL (16 patches / 28 days)

2 QL

BUTRANS 7.5mcg/hr, 10mcg/hr

QL (8 patches / 28 days)

2 QL

BUTRANS 15mcg/hr, 20mcg/hr


2 QL

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 100mg QL (90 caps / 30 days)

3 QL


3 QL


3 QL

nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml

1

nalbuphine hcl SOLN

20mg/ml 1

SYNALGOS-DC QL (360 caps / 30 days)

3 QL

TRAMADOL HCL CP24 100mg


1 QL

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL

tramadol hcl er (generic of ULTRAM ER) TB24 100mg


1 QL

tramadol hcl er (generic of

ULTRAM ER) TB24 200mg QL (30 tabs / 30 days)

1 QL

TRAMADOL HCL ER TB24 300mg


1 QL

tramadol hcl er (biphasic) 100mg


1 QL



1 QL



1 QL

tramadol hcl tab 50 mg

(generic of ULTRAM) QL (240 tabs / 30 days)

1 QL

tramadol-acetaminophen

(generic of ULTRACET) QL (240 tabs / 30 days)

1 QL

trezix QL (360 caps / 30 days)

3 QL

tylenol with codeine

QL (400 tabs / 30 days) 3 QL

ULTRACET QL (240 tabs / 30 days)

3 QL

ULTRAM QL (240 tabs / 30 days)

2 QL

ULTRAM ER 100mg QL (90 tabs / 30 days)

3 QL

ULTRAM ER 200mg, 300mg QL (30 tabs / 30 days)

3 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 4 QL NM PA

ACTIQ QL (120 lozenges / 30 days)

4 QL NM PA

2016 601 4T Copper Comm eff 03/01/2016


3

Drug Name Drug Tier

Requirements/Limits

CODEINE SULFATE 15mg QL (720 tabs / 30 days)

1 QL


1 QL


1 QL

DILAUDID INJ 3 B/D

DILAUDID TAB QL (270 tabs / 30 days)

3 QL

DILAUDID-5 ORAL LIQD 3

DILAUDID-HP INJ 10MG/ML 3 B/D

DILAUDID-HP INJ 250MG 3 B/D

DOLOPHINE QL (240 tabs / 30 days)

3 QL

DURAGESIC 12mcg/hr, 25mcg/hr


3 QL

DURAGESIC 50mcg/hr, 75mcg/hr, 100mcg/hr


4 QL NM

DURAMORPH 1 B/D

EMBEDA QL (60 caps / 30 days)

3 QL

endocet (generic of

PERCOCET) QL (360 tabs / 30 days)

1 QL

ENDODAN TAB QL (360 tabs / 30 days)

1 QL

EXALGO 8mg, 12mg QL (60 tabs / 30 days)

3 QL

EXALGO 16mg, 32mg QL (60 tabs / 30 days)

4 QL NM

fentanyl citrate (generic of

ACTIQ) LPOP QL (120 lozenges / 30 days)

4 QL NM PA

fentanyl patch 12 mcg/hr

(generic of DURAGESIC) QL (10 patches / 30 days)

1 QL



1 QL

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL

FENTORA QL (120 tabs / 30 days)

4 QL NM PA

hycet QL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of HYCET)

QL (5400 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of

NORCO) QL (360 tabs / 30 days)

1 QL

hydrocodone-acetaminophen 10-300mg (generic of

XODOL) QL (400 tabs / 30 days)

1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of


1 QL

hydrocodone-ibuprofen tab 2.5-200mg


1 QL

2016 601 4T Copper Comm eff 03/01/2016


4

Drug Name Drug Tier

Requirements/Limits

hydrocodone-ibuprofen tab 5-200mg (generic of

REPREXAIN) QL (150 tabs / 30 days)

1 QL

hydrocodone-ibuprofen tab 7.5-200 mg (generic of

VICOPROFEN) QL (150 tabs / 30 days)

1 QL

hydrocodone-ibuprofen tab 10-200mg


1 QL

hydromorphone hcl (generic

of DILAUDID) LIQD 1

HYDROMORPHONE HCL SOLN 1mg/ml, 2mg/ml, 4mg/ml

1 B/D


of DILAUDID-HP) SOLN 500mg/50ml

1 B/D


of DILAUDID) TABS QL (270 tabs / 30 days)

1 QL

hydromorphone tab 8mg er (generic of EXALGO)


1 QL

hydromorphone tab 12mg er

(generic of EXALGO) QL (60 tabs / 30 days)

1 QL

hydromorphone tab 16mg er

(generic of EXALGO) QL (60 tabs / 30 days)

4 QL NM

HYDROMORPHONE TABS 32MG


4 QL NM

HYSINGLA ER 20mg, 30mg, 40mg, 60mg


3 QL

HYSINGLA ER 80mg, 100mg, 120mg


4 QL NM

ibudone tab 5-200mg (generic

of REPREXAIN) QL (150 tabs / 30 days)

1 QL

ibudone tab 10-200mg


INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

Drug Name Drug Tier

Requirements/Limits

KADIAN 10mg, 20mg, 30mg QL (60 caps / 30 days)

3 QL

KADIAN 40mg, 50mg, 60mg, 80mg, 100mg, 200mg


4 QL NM

LAZANDA QL (30 bottles / 30 days)

4 QL NM PA

levorphanol tartrate TABS QL (180 tabs / 30 days)

1 QL

lorcet hd tab 10-325mg

(generic of NORCO) QL (360 tabs / 30 days)

1 QL

lorcet plus tab 7.5-325

(generic of NORCO) QL (360 tabs / 30 days)

1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

lortab tab 5-325mg (generic of


1 QL

lortab tab 7.5-325 (generic of


1 QL

lortab tab 10-325mg (generic

of NORCO) QL (360 tabs / 30 days)

1 QL

methadone hcl (generic of METHADOSE) CONC

QL (120 mL / 30 days)

1 QL

methadone hcl SOLN QL (600 mL / 30 days)

1 QL

methadone hcl (generic of

DOLOPHINE) TABS QL (240 tabs / 30 days)

1 QL

METHADONE INJ 10MG/ML 3

METHADOSE CONC QL (120 mL / 30 days)

3 QL

MORPHINE SUL 20MG/ML ORAL SOL

1

MORPHINE SUL INJ 1MG/ML

1 B/D


3 B/D


1 B/D


1 B/D

2016 601 4T Copper Comm eff 03/01/2016


5

Drug Name Drug Tier

Requirements/Limits

morphine sulfate (generic of

KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg


1 QL

morphine sulfate (generic of

KADIAN) CP24 80mg, 100mg


4 QL NM

MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

1

morphine sulfate SOLN

.5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml

1 B/D

MORPHINE SULFATE TABS


1 QL

morphine sulfate beads QL (60 caps / 30 days)

1 QL

morphine sulfate ext-rel tab

(generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg


1 QL

morphine sulfate ext-rel tab

(generic of MS CONTIN) 200mg


1 QL

MS CONTIN 15mg, 30mg QL (90 tabs / 30 days)

3 QL

MS CONTIN 60mg, 100mg QL (90 tabs / 30 days)

4 QL NM

MS CONTIN 200mg QL (60 tabs / 30 days)

4 QL NM

norco QL (360 tabs / 30 days)

3 QL

NUCYNTA 50mg QL (360 tabs / 30 days)

2 QL


2 QL


2 QL

NUCYNTA ER 50mg, 100mg


2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

Drug Name Drug Tier

Requirements/Limits

OPANA TABS QL (180 tabs / 30 days)

3 QL

OPANA ER (CRUSH RESISTANT


2 QL

oxycodone hcl CAPS

QL (180 caps / 30 days) 1 QL

oxycodone hcl CONC 1

OXYCODONE HCL SOLN 1

oxycodone hcl (generic of

ROXICODONE) TABS 5mg, 15mg, 30mg


1 QL

oxycodone hcl TABS 10mg, 20mg


1 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)


1 QL

oxycodone-aspirin (generic of PERCODAN)


1 QL

oxycodone-ibuprofen


OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of

OPANA) TABS QL (180 tabs / 30 days)

1 QL

percocet 2.5/325


percocet 7.5/325

QL (360 tabs / 30 days) 4 QL NM

percocet 10/325


2016 601 4T Copper Comm eff 03/01/2016


6

Drug Name Drug Tier

Requirements/Limits

percocet tab 5-325mg


PERCODAN QL (360 tabs / 30 days)

3 QL

reprexain tab 2.5-200mg


reprexain tab 5-200mg


reprexain tab 10-200mg


roxicet soln

QL (1800 mL / 30 days) 2 QL

roxicet tab 5-325mg (generic

of PERCOCET) QL (360 tabs / 30 days)

1 QL

ROXICODONE 5mg, 15mg QL (180 tabs / 30 days)

3 QL

ROXICODONE 30mg QL (180 tabs / 30 days)

4 QL NM

SUBSYS QL (120 sprays / 30 days)

4 QL NM PA

vicodin (generic of XODOL)


vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

VICOPROFEN QL (150 tabs / 30 days)

3 QL

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

xodol tab 5-300mg


xodol tab 7.5-300 QL (400 tabs / 30 days)

3 QL

xodol tab 10-300mg


xylon tab 10-200mg QL (150 tabs / 30 days)

1 QL

zamicet

QL (5400 mL / 30 days) 1 QL

ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg


3 QL

Drug Name Drug Tier

Requirements/Limits

ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg


3 QL

ANESTHETICS

LOCAL ANESTHETICS lidocaine hcl (local anesth.)

(generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%

1

lidocaine hcl (local anesth.)

(generic of XYLOCAINE) .5%

1 B/D

lidocaine inj 0.5% (generic of

XYLOCAINE-MPF) 1 B/D

lidocaine inj 1% (generic of XYLOCAINE)

1 B/D

lidocaine inj 1.5% (generic of

XYLOCAINE-MPF) 1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of

XYLOCAINE-MPF) 2% 1 B/D

XYLOCAINE .5%, 1%, 2% 3 B/D

XYLOCAINE-MPF 4% 3

XYLOCAINE-MPF .5%, 1%, 1.5%, 2%

3 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 4 B/D NM

gentamicin in saline 0.8 mg/ml 1

gentamicin in saline 0.9mg/ml 3 gentamicin in saline 1 mg/ml 1

gentamicin in saline 1.2 mg/ml 1

gentamicin in saline 1.4mg/ml 3 gentamicin in saline 1.6 mg/ml 1

gentamicin in saline 2 mg/ml 1

gentamicin sulfate SOLN 1

KITABIS PAK 4 B/D NM

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1 streptomycin sulfate SOLR 1

sulfadiazine TABS 3

2016 601 4T Copper Comm eff 03/01/2016


7

Drug Name Drug Tier

Requirements/Limits

TOBI NEB 4 B/D NM

TOBI PODHALER 4 NM LA PA

tobramycin (generic of TOBI)

NEBU 4 B/D NM

tobramycin sulfate SOLN;

SOLR 1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2 atovaquone (generic of

MEPRON) SUSP 4 NM

AZACTAM 1gm 3

AZACTAM 2gm 4 NM

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 4 NM

aztreonam (generic of

AZACTAM) 1

BACTRIM 2

BACTRIM DS 2

BILTRICIDE 2

CAYSTON 4 NM LA PA

cleocin SOLR 2

CLEOCIN CAP 75MG 2

CLEOCIN CAP 150MG 2

CLEOCIN CAP 300MG 2

CLEOCIN IN D5W 3

CLEOCIN INJ 3

CLEOCIN PHOSPHATE 9gm/60ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

3

cleocin phosphate

150mg/ml, 600mg/4ml 3

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of

CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate

SOLN 150mg/ml 1

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate

(generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium

(generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3

CUBICIN 4 NM

DALVANCE 4 NM

dapsone TABS 1

DARAPRIM 3

DORIBAX 3

FLAGYL 3

FLAGYL ER 3

FURADANTIN PA applies if 65 years and older after a 90 day supply in a calendar year

4 NM PA

HIPREX 3

imipenem-cilastatin (generic

of PRIMAXIN IV) 1

INVANZ 3 ivermectin (generic of

STROMECTOL) TABS 1

linezolid (generic of ZYVOX) SOLN

4 NM

LINEZOLID SUSR; TABS 4 NM

MACROBID PA applies if 65 years and older after a 90 day supply in a calendar year

3 PA

MACRODANTIN PA applies if 65 years and older after a 90 day supply in a calendar year

3 PA

MEPRON 4 NM

meropenem (generic of

MERREM) 1

MEROPENEM/SODIUM CHLORIDE

1

MERREM 3

2016 601 4T Copper Comm eff 03/01/2016


8

Drug Name Drug Tier

Requirements/Limits

methenamine hippurate

(generic of HIPREX) 1

METRO IV 3 metronidazole (generic of

FLAGYL) CAPS; TABS 1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin (generic of

FURADANTIN) SUSP PA applies if 65 years and older after a 90 day supply in a calendar year

1 PA

nitrofurantoin macrocrystal

(generic of MACRODANTIN) PA applies if 65 years and older after a 90 day supply in a calendar year

3 PA

nitrofurantoin monohyd macro (generic of MACROBID)

PA applies if 65 years and older after a 90 day supply in a calendar year

3 PA

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMAXIN 3

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO 4 NM

STROMECTOL 3 sulfamethoxazole-trimethop

SUSP 1

sulfamethoxazole-trimethop

(generic of BACTRIM) TABS 1

sulfamethoxazole-trimethop

(generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 4 NM

trimethoprim TABS 1

TYGACIL 4 NM

VANCOCIN HCL 4 NM

vancomycin hcl (generic of

VANCOCIN HCL) CAPS 4 NM

vancomycin hcl inj 5gm 1 vancomycin hcl inj 10gm 1

vancomycin hcl inj 500mg 1


Drug Name Drug Tier

Requirements/Limits


XIFAXAN TAB 200MG 4 NM

ZYVOX 4 NM

ANTIFUNGALS ABELCET 4 B/D NM

AMBISOME 4 B/D NM

amphotericin b SOLR 1 B/D

ANCOBON 4 NM

CANCIDAS 4 NM

CRESEMBA 4 NM

DIFLUCAN 3

ERAXIS 4 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole in nacl 1 flucytosine (generic of

ANCOBON) CAPS 4 NM

GRIS-PEG 2

griseofulvin microsize 1 griseofulvin ultramicrosize

(generic of GRIS-PEG) 1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1 PA

LAMISIL PACK 3

LAMISIL TABS QL (90 tabs / 365 days)

3 QL

MYCAMINE 4 NM

NOXAFIL 4 NM

nystatin TABS 1

ONMEL 4 NM PA

SPORANOX 4 NM PA

SPORANOX PULSEPAK 4 NM PA

SPORANOX SOL 10MG/ML 4 NM

terbinafine hcl (generic of LAMISIL) TABS


1 QL

VFEND IV 3

VFEND SUS 40MG/ML 4 NM

VFEND TAB 4 NM

voriconazole (generic of

VFEND) SUSR; TABS 4 NM

voriconazole inj 200mg

(generic of VFEND IV) 1

ANTIMALARIALS

2016 601 4T Copper Comm eff 03/01/2016


9

Drug Name Drug Tier

Requirements/Limits

atovaquone-proguanil hcl tab 62.5-25 mg (generic of

MALARONE)

1

atovaquone-proguanil hcl tab 250-100 mg (generic of

MALARONE)

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate

(generic of ARALEN) TABS 500mg

1

COARTEM 2

MALARONE 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3 PA

quinine sulfate (generic of

QUALAQUIN) CAPS 1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of

ZIAGEN) 1

APTIVUS 4 NM

CRIXIVAN 3

didanosine (generic of VIDEX

EC) 1

EDURANT 4 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 3

EPIVIR TABS 3

FUZEON 4 NM

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 4 NM

INVIRASE 4 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 4 NM

ISENTRESS PACK 2

ISENTRESS TABS 4 NM

lamivudine (generic of

EPIVIR) 1

LEXIVA SUSP 3

LEXIVA TABS 4 NM

NEVIRAPINE SUSP 1

nevirapine (generic of

VIRAMUNE) TABS 1

nevirapine (generic of

VIRAMUNE XR) TB24 1

Drug Name Drug Tier

Requirements/Limits

NORVIR 2

PREZISTA SUSP 4 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

4 NM

RESCRIPTOR 2

RETROVIR CAPS 2

RETROVIR IV INFUSION 3

RETROVIR SYRP 2

REYATAZ 4 NM

SELZENTRY 4 NM

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 2

SUSTIVA TABS 4 NM

TIVICAY 4 NM

TYBOST 2

VIDEX EC 2

VIDEX PEDIATRIC 3

VIRACEPT 4 NM

VIRAMUNE SUSP 2

VIRAMUNE TABS 4 NM

VIRAMUNE XR 100mg 2

VIRAMUNE XR 400mg 4 NM

VIREAD 4 NM

VITEKTA 4 NM

ZERIT CAPS 2

ZERIT SOLR 4 NM

ZIAGEN SOLN 2

ZIAGEN TABS 3

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

4 NM

ATRIPLA 4 NM

COMBIVIR 4 NM

COMPLERA 4 NM

EPZICOM 4 NM

EVOTAZ 4 NM

GENVOYA 4 NM

KALETRA SOL 4 NM

2016 601 4T Copper Comm eff 03/01/2016


10

Drug Name Drug Tier

Requirements/Limits

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 4 NM

lamivudine-zidovudine (generic of COMBIVIR)

4 NM

PREZCOBIX 4 NM

STRIBILD 4 NM

TRIUMEQ 4 NM

TRIZIVIR 4 NM

TRUVADA QL (30 tabs / 30 days)

4 QL NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3 cycloserine CAPS 4 NM

ethambutol hcl (generic of

MYAMBUTOL) TABS 1

isoniazid SOLN; SYRP 1 isoniazid tabs 1

MYAMBUTOL 2

MYCOBUTIN 3 paser d/r 3

PRIFTIN 3 pyrazinamide TABS 1

rifabutin (generic of

MYCOBUTIN) 1

rifadin CAPS 150mg 2

RIFADIN CAPS 300mg 2

RIFADIN SOLR 3 rifamate 3

rifampin (generic of RIFADIN)

CAPS; SOLR 1

RIFATER 3

SIRTURO 4 NM LA PA

TRECATOR 3

ANTIVIRALS acyclovir (generic of

ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium SOLN 1 B/D

acyclovir sodium SOLR

500mg 1 B/D

adefovir dipivoxil (generic of

HEPSERA) 4 NM

BARACLUDE SOLN 2

BARACLUDE TABS 4 NM

cidofovir (generic of VISTIDE) 4 NM

COPEGUS 4 NM

Drug Name Drug Tier

Requirements/Limits

CYTOVENE 3 B/D

DAKLINZA 4 NM PA

entecavir (generic of

BARACLUDE) 4 NM

EPIVIR HBV 2

famciclovir (generic of

FAMVIR) TABS 1

FAMVIR 3

FLUMADINE 3

ganciclovir inj 500mg (generic

of CYTOVENE) 1 B/D

HARVONI 4 NM PA

HEPSERA 4 NM

lamivudine (hbv) (generic of

EPIVIR HBV) 1

moderiba pak MISC 4 NM

moderiba pak TABS 400mg 4 NM

MODERIBA PAK TABS 600mg

4 NM

moderiba tab 200mg (generic of COPEGUS)

1 NM

PEG-INTRON 4 NM PA

PEG-INTRON REDIPEN 4 NM PA

PEGASYS 4 NM PA

PEGASYS PROCLICK 4 NM PA

PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml

4 NM PA

REBETOL 4 NM

RELENZA DISKHALER 2

ribapak mis 600/day 4 NM

ribasphere (generic of

REBETOL) CAPS 1 NM

ribasphere (generic of

COPEGUS) TABS 200mg 1 NM

ribasphere TABS 400mg 1 NM

ribasphere TABS 600mg 4 NM

ribasphere ribapak 800 4 NM



ribavirin 200mg (generic of REBETOL) CAPS

1 NM

ribavirin 200mg (generic of

COPEGUS) TABS 1 NM

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 4 NM PA

TAMIFLU 2

2016 601 4T Copper Comm eff 03/01/2016


11

Drug Name Drug Tier

Requirements/Limits

TYZEKA 4 NM

valacyclovir hcl (generic of

VALTREX) TABS 1

VALCYTE 4 NM

valganciclovir hcl (generic of

VALCYTE) 4 NM

VALTREX 3

ZOVIRAX CAPS; SUSP; TABS

3

CEPHALOSPORINS AVYCAZ 4 NM

CEDAX CAPS 3

CEDAX SUSR 180mg/5ml 3

cefaclor 1 cefaclor er tab 500mg 3

cefadroxil 1

cefazolin in dextrose 1gm/50ml-5%

3

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 1 cefazolin sodium 1gm, 20gm 1

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

CEFEPIME HCL AND DEXTROSE

3

cefepime inj 1gm (generic of

MAXIPIME) 1

cefepime inj 2gm (generic of

MAXIPIME) 1

cefixime (generic of SUPRAX) 1

cefotaxime sodium (generic of

CLAFORAN) 1gm, 2gm, 500mg

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1 ceftazidime (generic of

FORTAZ) 1

CEFTAZIDIME/DEXTROSE 3

CEFTIBUTEN 1

CEFTIN 3

Drug Name Drug Tier

Requirements/Limits

ceftriaxone sodium SOLR

1gm, 2gm, 10gm, 250mg 1

ceftriaxone sodium (generic of

ROCEPHIN) SOLR 1gm, 500mg

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1

cefuroxime sodium (generic of

ZINACEF) 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium 7.5gm 3

cephalexin (generic of

KEFLEX) CAPS 1

cephalexin SUSR; TABS 1 claforan 1gm, 2gm 3

CLAFORAN 1gm, 2gm, 10gm, 500mg

3

CLAFORAN/D5W 3

FORTAZ 3

KEFLEX 3

MAXIPIME 3

rocephin 3

SUPRAX CAPS 2

suprax CHEW 2

suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2

tazicef (generic of FORTAZ)

SOLR 1

tazicef vial (generic of

FORTAZ) 1

TEFLARO 3

ZERBAXA 4 NM

ZINACEF SOLR 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1 azithromycin (generic of

ZITHROMAX) SOLR 500mg 1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of

ZITHROMAX) TABS 1

BIAXIN 3 clarithromycin SUSR

125mg/5ml 1

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Drug Name Drug Tier

Requirements/Limits

clarithromycin (generic of

BIAXIN) SUSR 250mg/5ml 1


BIAXIN) TABS 1


BIAXIN XL) TB24 1

DIFICID 4 NM

e.e.s. 400 tab 400mg 1

E.E.S. GRANULES 3

ery-tab 1

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate

500mg 3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1 erythromycin ethylsuccinate 1

PCE 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

FLUOROQUINOLONES AVELOX 3

AVELOX ABC PACK 3

CIPRO SUSP 3

CIPRO TABS 3

CIPRO XR 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin (generic of

CIPRO) SUSR 1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS

100mg, 750mg 1

ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg

1

ciprofloxacin in d5w (generic

of CIPRO I.V.-IN D5W) 1

ciprofloxacn inj 400mg/40ml 1

FACTIVE 3

LEVAQUIN 3

Drug Name Drug Tier

Requirements/Limits

levofloxacin SOLN 1

levofloxacin (generic of

LEVAQUIN) TABS 1

levofloxacin in d5w 1

MOXIFLOXACIN HCL SOLN 3

moxifloxacin hcl (generic of AVELOX) TABS

1

PENICILLINS amoxicillin 1 amoxicillin & pot clavulanate

CHEW 1

amoxicillin & pot clavulanate

SUSR 1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate

TABS 1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium

(generic of UNASYN BULK PACK)

1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1 ampicillin sodium 1

ampicillin susp 1

AUGMENTIN SUSR 3

AUGMENTIN TABS 4 NM

AUGMENTIN ES-600 3

AUGMENTIN XR 4 NM

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 4 NM

BICILLIN C-R 3

BICILLIN L-A 3

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Drug Name Drug Tier

Requirements/Limits

dicloxacillin sodium 1

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 4 NM

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1gm, 2gm 1 oxacillin sodium 10gm 4 NM

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM IN

3

penicillin g procaine 3

penicillin g sodium 1 penicillin v potassium 1

penicilln gk inj 5mu 1

penicilln gk inj 20mu 1 pfizerpen g inj 5mu 1

pfizerpen-g inj 20mu 1 piperacillin sodium-tazobactam sodium

(generic of ZOSYN)

1

UNASYN 3

UNASYN BULK PACK 3

ZOSYN 3

TETRACYCLINES adoxa CAPS 3

demeclocycline hcl 1 doxy 1

doxycycline (monohydrate)

CAPS 50mg 1


(generic of MONODOX) CAPS 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg

1


(generic of VIBRAMYCIN) SUSR

1


(generic of ADOXA) TABS 50mg, 75mg, 100mg

1


(generic of ADOXA PAK 1/150) TABS 150mg

1

Drug Name Drug Tier

Requirements/Limits

doxycycline hyclate CAPS

50mg 1

doxycycline hyclate (generic

of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1 doxycycline hyclate TBEC 1

MINOCIN CAPS 3

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 4 NM

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN CAPS 3

VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS ALKERAN SOLR 3 B/D

BICNU 3 B/D

BUSULFEX 4 B/D NM

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR

1gm, 500mg 4 B/D NM

cyclophosphamide SOLR

2gm 1 B/D

dacarbazine 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 4 NM

IFEX INJ 1GM 3 B/D

IFEX INJ 3GM 3 B/D

ifosfamide inj 1gm/20ml,

3gm/60ml 3 B/D

ifosfamide inj (generic of IFOSFAMIDE) 1gm/20ml, 3gm/60ml

1 B/D

ifosfamide inj 1gm (generic of

IFEX) 1 B/D

IFOSFAMIDE INJ 3GM 3 B/D

LEUKERAN 2

LOMUSTINE 1 melphalan hcl (generic of

ALKERAN) 4 B/D NM

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Drug Name Drug Tier

Requirements/Limits

MUSTARGEN 3 B/D

TREANDA 4 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES daunorubicin hcl 1 B/D

DOXIL 4 B/D NM

doxorubicin hcl 50mg 1 B/D

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml (generic of DOXIL)

4 B/D NM

doxorubicin inj 50mg 1 B/D

ELLENCE 4 B/D NM

epirubicin inj 50mg/25ml (generic of ELLENCE)

1 B/D

epirubicin inj 200mg (generic

of ELLENCE) 1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

4 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 4 B/D NM

mitomycin SOLR 1 B/D

VALSTAR 4 NM PA

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 4 B/D NM

ARRANON 4 B/D NM

azacitidine (generic of

VIDAZA) 4 B/D NM

cladribine 4 B/D NM

CLOLAR 4 B/D NM

cytarabine inj 1 B/D

DACOGEN 4 B/D NM

decitabine (generic of

DACOGEN) 4 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate

(generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 4 NM PA

GEMCITABINE 4 B/D NM

gemcitabine hcl (generic of

GEMZAR) 1gm, 200mg 4 B/D NM

gemcitabine hcl 2gm 4 B/D NM

Drug Name Drug Tier

Requirements/Limits

GEMZAR 4 B/D NM

mercaptopurine TABS 1

methotrexate sodium inj 1 B/D

NIPENT 4 B/D NM

PURIXAN 4 NM

TABLOID 2

VIDAZA 4 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 4 B/D NM

DOCETAXEL CONC 20mg/ml, 80mg/4ml

4 B/D NM

docetaxel CONC 140mg/7ml 4 B/D NM

DOCETAXEL SOLN 20mg/2ml

1 B/D

DOCETAXEL SOLN 160mg/16ml, 200mg/20ml

4 B/D NM

DOCETAXEL SOLN 80MG/8ML

4 B/D NM

JEVTANA 4 NM PA

paclitaxel 1 B/D

TAXOTERE 4 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS ARZERRA 4 B/D NM

AVASTIN 4 B/D NM LA

BELEODAQ 4 NM PA

CYRAMZA 4 NM PA

ERBITUX 4 B/D NM

ERIVEDGE 4 NM LA PA

FARYDAK 4 NM LA PA

GAZYVA 4 NM PA

HERCEPTIN 4 B/D NM

IBRANCE 4 NM LA PA

ISTODAX 4 B/D NM

KADCYLA 4 B/D NM

KEYTRUDA 4 NM PA

LYNPARZA 4 NM LA PA

NINLARO 4 NM PA

OPDIVO 4 NM PA

PERJETA 4 NM PA

PROLEUKIN 4 B/D NM

RITUXAN 4 NM LA PA

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15

Drug Name Drug Tier

Requirements/Limits

TORISEL 4 B/D NM

VECTIBIX 4 B/D NM

VELCADE 4 B/D NM

YERVOY 4 NM PA

ZALTRAP 4 NM PA

ZOLINZA 4 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of

ARIMIDEX) TABS 1

ARIMIDEX 2

AROMASIN 2

bicalutamide (generic of CASODEX)

1

CASODEX 2

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 3 B/D NM

ELIGARD INJ 22.5MG 3 B/D NM

ELIGARD INJ 30MG 3 B/D NM

ELIGARD INJ 45MG 3 B/D NM

exemestane (generic of

AROMASIN) 1

FARESTON 4 NM

FASLODEX 4 B/D NM

FEMARA 4 NM

FIRMAGON 80mg 3 B/D NM

FIRMAGON 120mg 4 B/D NM

flutamide 1 letrozole (generic of

FEMARA) TABS 1

leuprolide acetate KIT 1 NM PA

LUPRON DEP INJ 11.25MG 4 NM PA

LUPRON DEP-PED INJ 7.5MG

4 NM PA

LUPRON DEP-PED INJ 11.25MG

4 NM PA

LUPRON DEP-PED INJ 15MG

4 NM PA

LUPRON DEP-PED INJ 30MG (3-MONTH)

4 NM PA

LUPRON DEPOT 4 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

4 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

4 NM PA

LYSODREN 2

MEGACE ES 4 NM PA

Drug Name Drug Tier

Requirements/Limits

MEGACE ORAL PA if 65 years and older

3 PA

megestrol ac sus 40mg/ml

(generic of MEGACE ORAL) PA if 65 years and older

3 PA

megestrol ac tab 20mg

PA if 65 years and older 3 PA

megestrol ac tab 40mg PA if 65 years and older

3 PA

MEGESTROL SUS 625MG/5ML

4 NM PA

NILANDRON 4 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 4 NM PA

VANTAS 3 NM PA

XTANDI 4 NM LA PA

ZOLADEX 3 NM PA

ZYTIGA 4 NM LA PA

KINASE INHIBITORS AFINITOR 4 NM PA

AFINITOR DISPERZ 4 NM PA

ALECENSA 4 NM LA PA

BOSULIF 4 NM PA

CAPRELSA 4 NM LA PA

COMETRIQ 4 NM LA PA

COTELLIC 4 NM LA PA

GILOTRIF TAB 20MG 4 NM LA PA



GLEEVEC 4 NM PA

ICLUSIG 4 NM LA PA

IMBRUVICA CAP 140MG 4 NM LA PA

INLYTA 4 NM LA PA

IRESSA 4 NM LA PA

JAKAFI 4 NM LA PA

LENVIMA 10MG DAILY DOSE

4 NM LA PA


4 NM LA PA


4 NM LA PA


4 NM LA PA

MEKINIST 4 NM LA PA

NEXAVAR 4 NM LA PA

SPRYCEL 4 NM PA

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16

Drug Name Drug Tier

Requirements/Limits

STIVARGA 4 NM LA PA

SUTENT 4 NM PA

TAFINLAR 4 NM LA PA

TAGRISSO 4 NM LA PA

TARCEVA 4 NM LA PA

TASIGNA 4 NM PA

TYKERB 4 NM LA PA

VOTRIENT 4 NM LA PA

XALKORI 4 NM LA PA

ZELBORAF 4 NM LA PA

ZYDELIG 4 NM LA PA

ZYKADIA 4 NM LA PA

MISCELLANEOUS bexarotene (generic of

TARGRETIN) 4 NM PA

DROXIA 3

ERWINAZE 4 NM PA

HALAVEN 4 B/D NM

HYDREA 2 hydroxyurea (generic of

HYDREA) CAPS 1

IXEMPRA KIT 4 B/D NM

LONSURF 4 NM PA

MATULANE 4 NM LA

mitoxantrone hcl 1 B/D NM

ODOMZO 4 NM LA PA

ONCASPAR 4 NM PA

POMALYST 4 NM LA PA

SYLATRON KIT 200MCG 4 NM PA



SYLVANT 4 NM PA

SYNRIBO 4 NM PA

TARGRETIN CAPS 4 NM PA

tretinoin CAPS 4 NM

TRISENOX 4 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

ELOXATIN 4 B/D NM

oxaliplatin 4 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

4 B/D NM

dexrazoxane (generic of

ZINECARD) 250mg 4 B/D NM

Drug Name Drug Tier

Requirements/Limits

ELITEK 4 B/D NM

FUSILEV 4 B/D NM

KEPIVANCE 4 B/D NM

leucovorin calcium TABS 1 leucovorin calcium inj 50mg 1 B/D

leucovorin calcium inj 100mg 1 B/D




levoleucovorin calcium 4 B/D NM

mesna (generic of MESNEX) 1 B/D

MESNEX SOLN 3 B/D

MESNEX TABS 4 NM

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN

500mg/25ml 1 B/D

HYCAMTIN SOLR 4 B/D NM

irinotecan inj 40mg/2ml

(generic of CAMPTOSAR) 1 B/D

irinotecan inj 100/5ml (generic

of CAMPTOSAR) 1 B/D

irinotecan inj 500mg/25ml 1 B/D

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of

HYCAMTIN) SOLR 4 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS ACCURETIC 3 amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic

of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

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Drug Name Drug Tier

Requirements/Limits

enalapril maleate & hydrochlorothiazide (generic

of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTREL 2

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

trandolapril-verapamil hcl (generic of TARKA)

1

VASERETIC 3

ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3

ALTACE 3 benazepril hcl TABS 5mg 1

benazepril hcl (generic of

LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

lisinopril (generic of ZESTRIL)

TABS 2.5mg, 30mg, 40mg 1

lisinopril (generic of PRINIVIL)

TABS 5mg, 10mg, 20mg 1

LOTENSIN 20mg, 40mg 3

MAVIK 3 moexipril hcl 1

perindopril erbumine 2mg 1 perindopril erbumine (generic

of ACEON) 4mg, 8mg 1

PRINIVIL 3

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of

MAVIK) 1

VASOTEC 3

ZESTRIL 3

Drug Name Drug Tier

Requirements/Limits

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2

eplerenone (generic of

INSPRA) 1

INSPRA 2

spironolactone (generic of

ALDACTONE) TABS 1

ALPHA BLOCKERS CARDURA 3

doxazosin mesylate (generic

of CARDURA) 1

MINIPRESS 1mg, 2mg 3

MINIPRESS 5mg 4 NM

prazosin hcl (generic of

MINIPRESS) 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)

1

amlodipine besylate-valsartan tab 5-320 mg (generic of

EXFORGE)

1


EXFORGE)

1


EXFORGE)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

(generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg


1

amlodipine-valsartan-hydrochlorothiazide 10-160-25mg


1

amlodipine-valsartan-hydrochlorothiazide 10-320-25mg (generic of EXFORGE HCT)

1

ATACAND HCT 3

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Drug Name Drug Tier

Requirements/Limits

AVALIDE 3

AZOR 2

BENICAR HCT 2 candesartan cilexetil-hydrochlorothiazide

(generic of ATACAND HCT)

1

DIOVAN HCT 3

EDARBYCLOR 3

ENTRESTO 3 PA

EXFORGE 3

EXFORGE HCT 3

HYZAAR 3 irbesartan-hydrochlorothiazide

(generic of AVALIDE) 1

losartan-hydrochlorothiazide

(generic of HYZAAR) 1

MICARDIS HCT 3

telmisartan-amlodipine

(generic of TWYNSTA) 1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TEVETEN HCT 3

TRIBENZOR 2

TWYNSTA 3

valsartan-hydrochlorothiazide

(generic of DIOVAN HCT) 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3

AVAPRO 3

BENICAR 2 candesartan cilexetil (generic

of ATACAND) 1

COZAAR 3

DIOVAN 3

EDARBI 3

eprosartan mesylate 1 irbesartan (generic of

AVAPRO) 1

losartan potassium (generic of

COZAAR) 1

MICARDIS 3 telmisartan (generic of

MICARDIS) 1

TEVETEN 3

Drug Name Drug Tier

Requirements/Limits

valsartan (generic of

DIOVAN) 1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS

100mg, 400mg 1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

BETAPACE 2

BETAPACE AF 2

disopyramide phosphate (generic of NORPACE)

PA if 65 years and older

3 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE PA if 65 years and older

3 PA

NORPACE CR PA if 65 years and older

3 PA

pacerone 100mg, 400mg 1 pacerone (generic of

CORDARONE) 200mg 1

propafenone hcl (generic of

RYTHMOL SR) CP12 1

propafenone hcl (generic of RYTHMOL) TABS 225mg

1

propafenone hcl TABS

300mg 1

propafenone hcl 12hr (generic of RYTHMOL SR) CP12

1

propafenone hcl 12hr (generic

of RYTHMOL) TABS 1

quinidine gluconate TBCR 1 quinidine sulfate TABS 1

RYTHMOL 2

RYTHMOL SR 2 sorine (generic of

BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of

BETAPACE) 80mg, 120mg, 160mg

1

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19

Drug Name Drug Tier

Requirements/Limits

sotalol hcl 240mg 1

sotalol hcl (afib/afl) (generic of

BETAPACE AF) 1

TIKOSYN 2 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic

of LIPITOR) TABS 1

CRESTOR 2 fluvastatin sodium cap 20 mg

(generic of LESCOL) 1

fluvastatin sodium cap 40 mg 1 fluvastatin sodium tab sr 24 hr 80 mg (generic of LESCOL

XL)

1

LESCOL 3

LESCOL XL 3

LIPITOR 3

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

PRAVACHOL 3

pravastatin sodium 10mg 1 pravastatin sodium (generic of

PRAVACHOL) 20mg, 40mg, 80mg

1

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin (generic of

ZOCOR) TABS 80mg QL (30 tabs / 30 days)

1 QL

ZOCOR 5mg, 10mg, 20mg, 40mg

3

ZOCOR 80mg QL (30 tabs / 30 days)

3 QL

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3

cholestyramine (generic of

QUESTRAN) 1

cholestyramine light 1 choline fenofibrate (generic of

TRILIPIX) 1

Drug Name Drug Tier

Requirements/Limits

COLESTID 3

colestipol hcl (generic of

COLESTID) 1

FENOFIBRATE CAPS 1

FENOFIBRATE TABS 40mg, 120mg

1

fenofibrate (generic of TRICOR) TABS 48mg, 145mg

1

fenofibrate (generic of

LOFIBRA) TABS 54mg, 160mg

1

fenofibrate micronized

43mg, 130mg 1

fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1

FENOGLIDE 3

FIBRICOR 3

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 4 NM LA PA

KYNAMRO 4 NM PA

LIPOFEN 3

lofibra 3

LOPID 3

LOVAZA CAP 1GM 3 niacin er (antihyperlipidemic)

(generic of NIASPAN) 1

niacor 1

NIASPAN 3 omega-3-acid ethyl esters

(generic of LOVAZA) 1

prevalite (generic of QUESTRAN LIGHT)

1

questran 3

questran light 3

SIMCOR 2

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

2016 601 4T Copper Comm eff 03/01/2016


20

Drug Name Drug Tier

Requirements/Limits

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone

(generic of TENORETIC 50) 1

atenolol & chlorthalidone

(generic of TENORETIC 100) 1

bisoprolol & hydrochlorothiazide (generic

of ZIAC)

1

CORZIDE 3

DUTOPROL 3

LOPRESSOR HCT 2 metoprolol & hctz tab 50-25mg (generic of

LOPRESSOR HCT)

1

metoprolol & hctz tab 100-25mg (generic of

LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide

(generic of CORZIDE) 1

propranolol & hydrochlorothiazide

1

TENORETIC 50 2

TENORETIC 100 2

ZIAC 2

BETA-BLOCKERS acebutolol hcl (generic of

SECTRAL) CAPS 1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of

KERLONE) 1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG 3

COREG CR 2

CORGARD 3

INDERAL LA 3

labetalol hcl SOLN; TABS 1

LOPRESSOR 3

Drug Name Drug Tier

Requirements/Limits

metoprolol succinate (generic

of TOPROL XL) 1

metoprolol tartrate SOLN 1 metoprolol tartrate TABS

25mg 1

metoprolol tartrate (generic of

LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of

CORGARD) TABS 1

pindolol 1 propranolol hcl er (generic of

INDERAL LA) 1

propranolol inj 1mg/ml 1

propranolol sol 1 propranolol tab 1

SECTRAL 3

SOTYLIZE 4 NM

TENORMIN 3

timolol maleate TABS 1

TOPROL XL 3

TRANDATE 3

ZEBETA 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv

(generic of CADUET) 1

CADUET 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

afeditab cr (generic of

ADALAT CC) 1

amlodipine besylate (generic

of NORVASC) TABS 1

CALAN 3

CALAN SR 3

CARDIZEM 60mg, 120mg 3

CARDIZEM CD 120mg 3

CARDIZEM CD 180mg, 240mg, 300mg, 360mg

4 NM

CARDIZEM LA 3

cartia xt (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

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21

Drug Name Drug Tier

Requirements/Limits

diltiazem cap 240mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg

1

diltiazem hcl TABS 90mg 1 diltiazem hcl coated beads

(generic of CARDIZEM CD) 1

diltiazem hcl er (generic of

TIAZAC) 1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1 diltiazem inj 100mg 3

diltiazem inj 125/25ml 1 felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of

PROCARDIA XL) 1

nifedipine (generic of ADALAT

CC) TB24 1

nifedipine er (generic of

PROCARDIA XL) 1

nimodipine CAPS 4 NM

nisoldipine (generic of

SULAR) 8.5mg, 17mg, 34mg 1

nisoldipine 20mg, 25.5mg,

30mg, 40mg 1

NORVASC 3

NYMALIZE 4 NM

PROCARDIA XL 3

SULAR 3

taztia xt (generic of TIAZAC) 1

TIAZAC 3 verapamil hcl (generic of

VERELAN PM) CP24 100mg, 200mg, 300mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

VERAPAMIL HCL CP24 360mg

1

Drug Name Drug Tier

Requirements/Limits

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

verapamil hcl (generic of CALAN) TABS 80mg, 120mg

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN)

.25mg PA if 65 years and older

1 PA

digitek (generic of LANOXIN)

.125mg QL (30 tabs / 30 days)

1 QL

digox (generic of LANOXIN) 125mcg


1 QL

digox (generic of LANOXIN)

250mcg PA if 65 years and older

1 PA

digoxin (generic of LANOXIN)

TABS 125mcg QL (30 tabs / 30 days)

1 QL

digoxin (generic of LANOXIN)

TABS 250mcg PA if 65 years and older

1 PA

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML PA if 65 years and older

1 PA

LANOXIN 62.5mcg QL (60 tabs / 30 days)

2 QL

LANOXIN 187.5mcg PA if 65 years and older

2 PA

LANOXIN INJ 0.25MG/ML 3

LANOXIN PEDIATRIC 3

LANOXIN TAB 125mcg QL (30 tabs / 30 days)

2 QL

LANOXIN TAB 250mcg PA if 65 years and older

2 PA

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2

TEKTURNA HCT 2

DIURETICS

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Drug Name Drug Tier

Requirements/Limits

acetazolamide (generic of

DIAMOX) CP12 1

acetazolamide TABS 1 acetazolamide sodium 1

ALDACTAZIDE 3

ALDACTAZIDE TAB 50/50 3 amiloride & hydrochlorothiazide

1

amiloride hcl TABS 1 bumetanide SOLN 1

bumetanide (generic of

BUMEX) TABS 1

chlorothiazide tabs 1 chlorthalidone 25mg, 50mg 1

DEMADEX TAB 5MG 3

DEMADEX TAB 10MG 3

DEMADEX TAB 20MG 3

DIAMOX 2

DIURIL SUS 250/5ML 3

DYAZIDE 3

DYRENIUM 3

EDECRIN 3

furosemide SOLN 1 furosemide (generic of LASIX)

TABS 1

furosemide inj 10mg/ml 1

FUROSEMIDE INJ 10mg/ml 1 furosemide oral soln 8 mg/ml 2

hydrochlorothiazide (generic

of MICROZIDE) CAPS 1

hydrochlorothiazide TABS 1

indapamide 1

LASIX 3

MAXZIDE 3

MAXZIDE-25 3 methazolamide (generic of

NEPTAZANE) TABS 1

methyclothiazide 1

metolazone 1

MICROZIDE 3

neptazane 3

SODIUM DIURIL 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

Drug Name Drug Tier

Requirements/Limits

torsemide inj 50mg/5ml 3

torsemide tabs (generic of

DEMADEX) 5mg, 10mg, 20mg

1

torsemide tabs 100mg 1

triamt/hctz cap 37.5-25 (generic of DYAZIDE)

1

triamt/hctz cap 50-25mg 1

triamt/hctz tab 37.5-25

(generic of MAXZIDE-25) 1

triamt/hctz tab 75-50mg

(generic of MAXZIDE) 1

MISCELLANEOUS BIDIL 2

CATAPRES TAB 2

CATAPRES-TTS DIS 0.1/24HR

2


2


2

clonidine hcl (generic of

CATAPRES-TTS-1) PTWK .1mg/24hr

1

clonidine hcl (generic of CATAPRES-TTS-2) PTWK .2mg/24hr

1


CATAPRES-TTS-3) PTWK .3mg/24hr

1


CATAPRES) TABS 1

clorpres 1

CORLANOR 3

DEMSER 4 NM

DIBENZYLINE 4 NM

hydralazine hcl SOLN; TABS 1 midodrine hcl 1

minoxidil TABS 1 phenoxybenzamine hcl

(generic of DIBENZYLINE) CAPS

4 NM

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 2

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Drug Name Drug Tier

Requirements/Limits

isosorbide dinitrate (generic of

ISORDIL TITRADOSE) 5mg 1

isosorbide dinitrate 10mg,

20mg, 30mg 1

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1 minitran (generic of

NITRO-DUR) 1

nitro-bid 3

NITRO-DUR 2

nitroglycerin (generic of

NITROLINGUAL PUMPSPRAY) .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 4 NM PA

ADEMPAS 4 NM LA PA

epoprostenol sodium (generic

of FLOLAN) 4 B/D NM LA

FLOLAN 4 B/D NM LA

LETAIRIS 4 NM LA PA

OPSUMIT 4 NM LA PA

ORENITRAM TAB 0.25MG 4 NM LA PA


ORENITRAM TAB 1MG 4 NM LA PA


REMODULIN 4 B/D NM LA

REVATIO 4 NM PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO) SOLN

4 NM PA

sildenafil citrate (pulmonary hypertension) (generic of

REVATIO) TABS

1 NM PA

TRACLEER 4 NM LA PA

TYVASO 4 B/D NM

VELETRI 4 B/D NM LA

VENTAVIS 4 B/D NM

CENTRAL NERVOUS SYSTEM

Drug Name Drug Tier

Requirements/Limits

ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of

XANAX) TABS 1mg QL (120 tabs / 30 days)

1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of

XANAX) TABS .25mg QL (480 tabs / 30 days)

1 QL

ATIVAN SOLN 3

ATIVAN TABS QL (150 tabs / 30 days)

4 QL NM

buspirone hcl TABS 1

fluvoxamine maleate 25mg,

50mg QL (45 tabs / 30 days)

1 QL

fluvoxamine maleate 100mg 1

fluvoxamine maleate er

100mg QL (90 caps / 30 days)

1 QL

fluvoxamine maleate er

150mg QL (60 caps / 30 days)

1 QL

lorazepam CONC

QL (150 mL / 30 days) 1 QL

lorazepam (generic of

ATIVAN) SOLN 1

lorazepam (generic of

ATIVAN) TABS QL (150 tabs / 30 days)

1 QL

XANAX TAB 0.5MG QL (240 tabs / 30 days)

2 QL

XANAX TAB 0.25MG QL (480 tabs / 30 days)

2 QL

XANAX TAB 1MG QL (120 tabs / 30 days)

2 QL

XANAX TAB 2MG QL (150 tabs / 30 days)

2 QL

ANTICONVULSANTS APTIOM 200mg 3

APTIOM 400mg, 600mg, 800mg

4 NM

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Drug Name Drug Tier

Requirements/Limits

BANZEL SUS 40MG/ML 4 NM PA

BANZEL TAB 200MG 3 PA

BANZEL TAB 400MG 4 NM PA

carbamazepine CHEW 1 carbamazepine (generic of

CARBATROL) CP12 1

carbamazepine (generic of

TEGRETOL) SUSP; TABS 1

carbamazepine (generic of

TEGRETOL-XR) TB12 1

CARBATROL 3

CELONTIN 3 clonazepam (generic of

KLONOPIN) TABS 1mg QL (120 tabs / 30 days)

1 QL

clonazepam (generic of

KLONOPIN) TABS 2mg QL (300 tabs / 30 days)

1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg


clonazepam TBDP 2mg


clonazepam TBDP .5mg


clonazepam TBDP .25mg QL (480 tabs / 30 days)

1 QL

clonazepam TBDP .125mg


clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg


1 QL PA

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL PA

DEPACON 4 NM

DEPAKENE CAPS 4 NM

DEPAKENE SYRP 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

Drug Name Drug Tier

Requirements/Limits

diazepam CONC

QL (240 mL / 30 days) 1 QL PA

diazepam SOLN 1mg/ml

QL (1200 mL / 30 days) 1 QL PA

diazepam SOLN 5mg/ml 1

diazepam (generic of

VALIUM) TABS QL (120 tabs / 30 days)

1 QL PA

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium (generic of

DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of

DEPAKOTE ER) TB24 1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of

ZARONTIN) CAPS; SOLN 1

felbamate (generic of

FELBATOL) SUSP 4 NM

felbamate (generic of

FELBATOL) TABS 1

FELBATOL 4 NM

FYCOMPA 3 PA

gabapentin (generic of

NEURONTIN) CAPS 100mg QL (1080 caps / 30 days)

1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

1 QL


NEURONTIN) TABS 600mg QL (180 tabs / 30 days)

1 QL


NEURONTIN) TABS 800mg QL (120 tabs / 30 days)

1 QL

GABITRIL 2

2016 601 4T Copper Comm eff 03/01/2016


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Drug Name Drug Tier

Requirements/Limits

KEPPRA SOLN 4 NM

KEPPRA TABS 250mg 3

KEPPRA TABS 500mg, 750mg, 1000mg

4 NM

KEPPRA XR 4 NM

KLONOPIN 1mg QL (120 tabs / 30 days)

2 QL

KLONOPIN 2mg QL (300 tabs / 30 days)

2 QL

KLONOPIN .5mg QL (240 tabs / 30 days)

2 QL

LAMICTAL TABS 4 NM

LAMICTAL CHEWABLE DISPERS 5mg

3

LAMICTAL CHEWABLE DISPERS 25mg

4 NM

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

LAMICTAL XR TB24 25mg, 50mg

2

LAMICTAL XR TB24 100mg, 200mg, 250mg, 300mg

4 NM

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine KIT 1 lamotrigine (generic of

LAMICTAL) TABS 1

lamotrigine (generic of

LAMICTAL XR) TB24 1

lamotrigine (generic of

LAMICTAL ODT) TBDP 1

levetiracetam (generic of

KEPPRA) SOLN; TABS 1

levetiracetam (generic of

KEPPRA XR) TB24 1

LEVETIRACETAM IV 3

levetiracetam oral soln 100 mg/ml (generic of KEPPRA)

1

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL

LYRICA CAPS 200mg QL (90 caps / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946 mL / 30 days)

2 QL

MYSOLINE 4 NM

NEURONTIN CAPS 100mg QL (1080 caps / 30 days)

3 QL


3 QL


3 QL

NEURONTIN SOLN QL (2160 mL / 30 days)

3 QL

NEURONTIN TABS 600mg QL (180 tabs / 30 days)

3 QL

NEURONTIN TABS 800mg QL (120 tabs / 30 days)

3 QL

ONFI SUSP 4 NM PA

ONFI TABS 10mg 3 PA

ONFI TABS 20mg 4 NM PA

oxcarbazepine (generic of

TRILEPTAL) 1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS


PHENOBARBITAL SODIUM SOLN 65mg/ml


3 PA

phenobarbital sodium SOLN

130mg/ml PA if 65 years and older

3 PA

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of

DILANTIN-125) SUSP 1

phenytoin inj 50mg/ml 1

phenytoin sodium extended

(generic of DILANTIN) 100mg

1

phenytoin sodium extended

(generic of PHENYTEK) 200mg, 300mg

1

POTIGA 50mg 3

2016 601 4T Copper Comm eff 03/01/2016


26

Drug Name Drug Tier

Requirements/Limits

POTIGA 200mg QL (180 tabs / 30 days)

4 QL NM

POTIGA 300mg, 400mg QL (90 tabs / 30 days)

4 QL NM

primidone (generic of

MYSOLINE) TABS 1

QUDEXY XR 3

SABRIL PACK QL (180 packets / 30 days)

4 QL NM LA PA

SABRIL TABS QL (180 tabs / 30 days)

4 QL NM LA PA

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 25mg, 50mg 3

TOPAMAX 100mg, 200mg 4 NM

TOPAMAX SPRINKLE 15mg

3

TOPAMAX SPRINKLE 25mg

4 NM

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1 topiramate (generic of

TOPAMAX) TABS 1

TRANXENE T 3.75mg, 7.5mg


3 QL PA

TRANXENE T 15mg QL (180 tabs / 30 days)

3 QL PA

TRILEPTAL SUSP 3

TRILEPTAL TABS 3

TROKENDI XR 25mg, 50mg, 100mg

3

TROKENDI XR 200mg 4 NM

VALIUM QL (120 tabs / 30 days)

2 QL PA

valproate sodium (generic of

DEPACON) SOLN 1

valproate sodium (generic of

DEPAKENE) SYRP 1

valproic acid (generic of

DEPAKENE) 1

VIMPAT SOLN 2

Drug Name Drug Tier

Requirements/Limits

VIMPAT TABS 50mg 2

VIMPAT TABS 100mg, 150mg, 200mg

4 NM

ZARONTIN CAPS 3

zarontin SOLN 3

ZONEGRAN 25mg 3

ZONEGRAN 100mg 4 NM

zonisamide (generic of

ZONEGRAN) CAPS 25mg, 100mg

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA ARICEPT 3 donepezil odt 5mg 1

donepezil odt 10mg 1 donepezil tab hcl 23mg

(generic of ARICEPT) 1

donepezil tabs 5mg (generic

of ARICEPT) 1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON CAPS 3

EXELON PATCHES 2 galantamine hydrobromide

SOLN 1

galantamine hydrobromide

(generic of RAZADYNE) TABS

1

galantamine hydrobromide er

(generic of RAZADYNE ER) 1

memantine hcl (generic of NAMENDA)

PA if < 30 yrs

1 PA

NAMENDA SOL 10MG/5ML PA if < 30 yrs

2 PA

NAMENDA TAB PA if < 30 yrs

2 PA

NAMENDA XR PA if < 30 yrs

2 PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

2 PA

NAMZARIC 3

RAZADYNE 3

RAZADYNE ER 3

rivastigmine tartrate (generic of EXELON)

1

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Drug Name Drug Tier

Requirements/Limits

rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)

1

rivastigmine td patch 24hr 9.5 mg/24hr (generic of EXELON)

1

rivastigmine td patch 24hr 13.3 mg/24hr (generic of

EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS


amoxapine 1

ANAFRANIL PA if 65 years and older

3 PA

APLENZIN 4 NM

BRINTELLIX 2 bupropion hcl (generic of

WELLBUTRIN) TABS 1

bupropion hcl (generic of

WELLBUTRIN SR) TB12 1

bupropion hcl (generic of

WELLBUTRIN XL) TB24 1

CELEXA 3

citalopram hydrobromide SOLN

1

citalopram hydrobromide

(generic of CELEXA) TABS 1

clomipramine hcl (generic of ANAFRANIL) CAPS


3 PA

CYMBALTA 3 desipramine hcl (generic of

NORPRAMIN) TABS 1

doxepin hcl CAPS; CONC


duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg

1

EFFEXOR XR 3

EMSAM 4 NM PA

escitalopram oxalate (generic

of LEXAPRO) 1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine cap 10mg (generic

of PROZAC) 1

fluoxetine cap 20mg (generic of PROZAC)

1

Drug Name Drug Tier

Requirements/Limits

fluoxetine cap 40mg (generic

of PROZAC) 1

fluoxetine hcl (generic of

PROZAC WEEKLY) CPDR 1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg,

20mg 1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL QL (30 tabs / 30 days)

3 QL

imipramine hcl (generic of TOFRANIL) TABS


3 PA

imipramine pamoate (generic

of TOFRANIL-PM) PA if 65 years and older

3 PA

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

mirtazapine TABS 7.5mg 1

mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

NARDIL 2

nefazodone hcl 1

NORPRAMIN 2 nortriptyline hcl (generic of

PAMELOR) CAPS 1

nortriptyline hcl SOLN 1

PAMELOR 4 NM

PARNATE 4 NM

paroxetine er tab (generic of

PAXIL CR) 1

paroxetine hcl tabs (generic of

PAXIL) 1

PAXIL 3

PAXIL CR 3

PEXEVA 3

phenelzine sulfate (generic of

NARDIL) TABS 1

PRISTIQ 2

protriptyline hcl 1

PROZAC 3

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Drug Name Drug Tier

Requirements/Limits

PROZAC WEEKLY 3

REMERON 3

REMERON SOLTAB 3 sertraline hcl (generic of

ZOLOFT) CONC; TABS 1

SURMONTIL PA if 65 years and older

3 PA

tofranil


TOFRANIL-PM PA if 65 years and older

3 PA

tranylcypromine sulfate

(generic of PARNATE) 1

trazodone hcl TABS 1 trimipramine maleate CAPS

25mg, 50mg PA if 65 years and older

3 PA

trimipramine maleate (generic of SURMONTIL) CAPS 100mg


3 PA

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl 1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of

VENLAFAXINE HCL ER) 1

VIIBRYD 2

VIIBRYD STARTER PACK 2

WELLBUTRIN 3

WELLBUTRIN SR 3

WELLBUTRIN XL 4 NM

ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 4 NM LA PA

AZILECT 2

BENZTROPINE MESYLATE SOLN

1

benztropine mesylate TABS


Drug Name Drug Tier

Requirements/Limits

bromocriptine mesylate

(generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of

LODOSYN) TABS 4 NM

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic

of SINEMET CR) TBCR 1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1


1


1


1


1


1

COGENTIN 3

COMTAN 3

DUOPA 3 B/D NM

ELDEPRYL 3

ENTACAPONE 1

LODOSYN 4 NM

MIRAPEX 3

MIRAPEX ER .75mg, 1.5mg 3

MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg

2

NEUPRO 2

pramipexole dihydrochloride

(generic of MIRAPEX) TABS 1

pramipexole dihydrochloride (generic of MIRAPEX ER) TB24

1

REQUIP 3

REQUIP XL 3

ropinirole hydrochloride

(generic of REQUIP) TABS 1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

2016 601 4T Copper Comm eff 03/01/2016


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Drug Name Drug Tier

Requirements/Limits

RYTARY 3

selegiline hcl (generic of

ELDEPRYL) CAPS 1

selegiline hcl TABS 1

SINEMET 3

SINEMET CR 3

STALEVO 3

ZELAPAR 4 NM

ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG


4 QL NM

ABILIFY MAINTENA QL (1 injection / 28 days)

4 QL NM

ABILIFY TABS QL (30 tabs / 30 days)

4 QL NM

aripiprazole odt


aripiprazole oral solution 1 mg/ml

QL (900ml / 30 days)

4 QL NM

aripiprazole tabs (generic of

ABILIFY) QL (30 tabs / 30 days)

4 QL NM

chlorpromazine hcl TABS 1

chlorpromazine inj 3

clozapine (generic of CLOZARIL) TABS 25mg

1

clozapine TABS 50mg 1

clozapine (generic of CLOZARIL) TABS 100mg


1 QL

clozapine TABS 200mg


CLOZAPINE TBDP 150mg QL (180 tabs / 30 days)

4 QL NM PA

CLOZAPINE TBDP 200mg QL (135 tabs / 30 days)

4 QL NM PA

CLOZAPINE ODT 12.5mg 1 PA

CLOZAPINE ODT 25mg 1 PA

CLOZAPINE ODT 100mg QL (270 tabs / 30 days)

1 QL PA

CLOZARIL 25mg 3

CLOZARIL 100mg QL (270 tabs / 30 days)

4 QL NM

Drug Name Drug Tier

Requirements/Limits

FANAPT QL (60 tabs / 30 days)

3 QL ST

FANAPT TITRATION PACK 3 ST

FAZACLO 12.5mg, 25mg 3 PA

FAZACLO 100mg QL (270 tabs / 30 days)

4 QL NM PA


4 QL NM PA


4 QL NM PA

fluphenazine decanoate

SOLN 1

fluphenazine hcl 1

GEODON 20mg, 40mg QL (60 caps / 30 days)

3 QL

GEODON 60mg, 80mg QL (90 caps / 30 days)

4 QL NM

GEODON INJ QL (6 mL / 3 days)

3 QL

HALDOL 3

HALDOL DECANOATE 50 3

HALDOL DECANOATE 100 3

haloperidol TABS 1 haloperidol decanoate

(generic of HALDOL DECANOATE 50) SOLN 50mg/ml

1

haloperidol decanoate

(generic of HALDOL DECANOATE 100) SOLN 100mg/ml

1

haloperidol lactate 1

haloperidol lactate inj 5 mg/ml

(generic of HALDOL) 1

INVEGA 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)

3 QL

INVEGA 6mg QL (60 tabs / 30 days)

3 QL

INVEGA SUST INJ 39 MG/0.25 ML

QL (1 injection / 28 days)

3 QL



4 QL NM

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Drug Name Drug Tier

Requirements/Limits



4 QL NM

INVEGA SUST INJ 156MG/ML


4 QL NM



4 QL NM

INVEGA TRINZA QL (1 syringe / 90 days)

4 QL NM

LATUDA 20mg QL (240 tabs / 30 days)

2 QL

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

2 QL

LATUDA 60mg, 80mg QL (60 tabs / 30 days)

2 QL

loxapine succinate 1

molindone hcl 1 olanzapine (generic of

ZYPREXA) SOLR QL (3 vials / 1 day)

1 QL

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg


1 QL

olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg


1 QL

olanzapine odt (generic of

ZYPREXA ZYDIS) 10mg, 15mg, 20mg


1 QL

ORAP 3 paliperidone (generic of

INVEGA) 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)

1 QL

paliperidone (generic of INVEGA) 6mg


1 QL

perphenazine TABS 1

Drug Name Drug Tier

Requirements/Limits

pimozide (generic of ORAP) 1

quetiapine fumarate (generic

of SEROQUEL) QL (90 tabs / 30 days)

1 QL

REXULTI 1mg QL (90 tabs / 30 days)

4 QL NM ST

REXULTI 2mg QL (60 tabs / 30 days)

4 QL NM ST

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

4 QL NM ST

REXULTI .5mg QL (180 tabs / 30 days)

4 QL NM ST

REXULTI .25mg QL (360 tabs / 30 days)

4 QL NM ST

RISPERDAL SOLN QL (240 mL / 30 days)

4 QL NM

RISPERDAL TABS 1mg, 2mg


3 QL

RISPERDAL TABS 3mg QL (60 tabs / 30 days)

4 QL NM

RISPERDAL TABS 4mg QL (120 tabs / 30 days)

4 QL NM

RISPERDAL TABS .25mg, .5mg


3 QL

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 25MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

4 QL NM

RISPERDAL INJ 50MG QL (2 injections / 28 days)

4 QL NM

RISPERDAL M-TAB 1mg QL (60 tabs / 30 days)

3 QL

RISPERDAL M-TAB 2mg, 3mg


4 QL NM

RISPERDAL M-TAB 4mg QL (120 tabs / 30 days)

4 QL NM

RISPERDAL M-TAB .5mg QL (90 tabs / 30 days)

4 QL NM

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Drug Name Drug Tier

Requirements/Limits

risperidone (generic of

RISPERDAL) SOLN QL (240 mL / 30 days)

1 QL

risperidone (generic of RISPERDAL) TABS 1mg, 2mg, 3mg


1 QL

risperidone (generic of

RISPERDAL) TABS 4mg QL (120 tabs / 30 days)

1 QL

risperidone (generic of RISPERDAL) TABS .25mg, .5mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) 1mg, 2mg, 3mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) 4mg


1 QL

risperidone odt (generic of

RISPERDAL M-TAB) .5mg QL (90 tabs / 30 days)

1 QL

risperidone odt .25mg


SAPHRIS 2.5mg QL (240 tabs / 30 days)

3 QL

SAPHRIS 5mg QL (120 tabs / 30 days)

3 QL

SAPHRIS 10mg QL (60 tabs / 30 days)

3 QL

SEROQUEL 25mg, 50mg, 100mg


3 QL

SEROQUEL 200mg, 300mg, 400mg


4 QL NM

SEROQUEL XR 50mg QL (120 tabs / 30 days)

2 QL

SEROQUEL XR 150mg, 200mg


2 QL

SEROQUEL XR 300mg, 400mg


2 QL

thioridazine hcl TABS PA if 65 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ QL (600 mL / 30 days)

4 QL NM PA

ziprasidone hcl (generic of

GEODON) 20mg, 40mg QL (60 caps / 30 days)

1 QL

ziprasidone hcl (generic of

GEODON) 60mg, 80mg QL (90 caps / 30 days)

1 QL

ZYPREXA SOLR QL (3 vials / 1 day)

3 QL

ZYPREXA TABS 2.5mg, 5mg, 7.5mg


3 QL

ZYPREXA TABS 10mg QL (60 tabs / 30 days)

3 QL

ZYPREXA TABS 15mg, 20mg


4 QL NM

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

4 QL NM PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

4 QL NM PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL NM PA

ZYPREXA ZYDI TAB 10MG QL (60 tabs / 30 days)

4 QL NM

ZYPREXA ZYDIS 5mg QL (30 tabs / 30 days)

3 QL

ZYPREXA ZYDIS 15mg, 20mg


4 QL NM

ATTENTION DEFICIT HYPERACTIVITY DISORDER adderall tab 5mg


adderall tab 7.5mg QL (240 tabs / 30 days)

3 QL

adderall tab 10mg


adderall tab 12.5mg QL (144 tabs / 30 days)

3 QL

adderall tab 15mg


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Drug Name Drug Tier

Requirements/Limits

adderall tab 20mg


adderall tab 30mg


ADDERALL XR CAP 5MG QL (90 caps / 30 days)

3 QL


3 QL


3 QL


3 QL


3 QL


3 QL

amphetamine cap 10mg er (generic of ADDERALL XR)


1 QL

amphetamine cap 15mg er (generic of ADDERALL XR)


1 QL

amphetamine cap 20mg er

(generic of ADDERALL XR) QL (30 caps / 30 days)

1 QL



1 QL



1 QL

amphetamine-dextroamphetamine cap sr 24hr 5 mg


1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of

ADDERALL) QL (360 tabs / 30 days)

1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of


1 QL



1 QL

Drug Name Drug Tier

Requirements/Limits

amphetamine-dextroamphetamine tab 12.5 mg (generic of


1 QL



1 QL



1 QL



1 QL

APTENSIO XR 10mg, 15mg, 20mg, 30mg


3 QL

APTENSIO XR 40mg, 50mg, 60mg


3 QL

CONCERTA 18mg, 27mg, 36mg


3 QL

CONCERTA 54mg QL (30 tabs / 30 days)

3 QL

DAYTRANA QL (30 patches / 30 days)

2 QL

guanfacine er (adhd) (generic of INTUNIV)


3 PA

INTUNIV PA if 65 years and older

3 PA

METADATE CD 10mg, 20mg, 30mg


3 QL

METADATE CD 40mg, 50mg, 60mg


3 QL

metadate er tab 20mg QL (90 tabs / 30 days)

1 QL

METHYLIN 5mg/5ml QL (1800 mL / 30 days)

3 QL

METHYLIN 10mg/5ml QL (900 mL / 30 days)

3 QL

METHYLIN CHEW TAB QL (180 tabs / 30 days)

2 QL

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Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl (generic

of METHYLIN) CHEW QL (180 tabs / 30 days)

1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 20mg


1 QL

METHYLPHENIDATE HCL CP24 30mg


1 QL


of RITALIN LA) CP24 40mg QL (30 caps / 30 days)

1 QL


of METADATE CD) CPCR 10mg, 20mg, 30mg


1 QL


of METADATE CD) CPCR 40mg, 50mg, 60mg


1 QL


of METHYLIN) SOLN 5mg/5ml

QL (1800 mL / 30 days)

1 QL


of METHYLIN) SOLN 10mg/5ml

QL (900 mL / 30 days)

1 QL


of RITALIN) TABS 5mg, 10mg


1 QL


of RITALIN) TABS 20mg QL (90 tabs / 30 days)

1 QL

methylphenidate hcl TB24


methylphenidate hcl TBCR QL (90 tabs / 30 days)

1 QL

methylphenidate hcl er TB24

27mg, 36mg QL (60 tabs / 30 days)

1 QL

methylphenidate hcl er TB24

54mg QL (30 tabs / 30 days)

1 QL

QUILLIVANT XR QL (360 mL / 30 days)

2 QL

RITALIN 5mg, 10mg QL (180 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

RITALIN 20mg QL (90 tabs / 30 days)

3 QL

RITALIN LA 10mg QL (180 tabs / 30 days)

3 QL

RITALIN LA 20mg, 30mg QL (60 caps / 30 days)

3 QL

RITALIN LA 40mg, 60mg QL (30 caps / 30 days)

3 QL

STRATTERA 10mg, 18mg, 25mg


2 QL

STRATTERA 40mg QL (60 caps / 30 days)

2 QL

STRATTERA 60mg, 80mg, 100mg


2 QL

VYVANSE 10mg, 20mg, 30mg


2 QL

VYVANSE 40mg, 50mg, 60mg, 70mg


2 QL

HYPNOTICS AMBIEN

QL (30 tabs / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

3 QL PA

HETLIOZ 4 NM LA PA

RESTORIL 7.5mg QL (30 caps / 30 days)


3 QL PA

RESTORIL 15mg QL (60 caps / 30 days)


3 QL PA

ROZEREM QL (30 tabs / 30 days)

3 QL

SILENOR 3mg QL (60 tabs / 30 days)

2 QL

SILENOR 6mg QL (30 tabs / 30 days)

2 QL

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Drug Name Drug Tier

Requirements/Limits

temazepam (generic of

RESTORIL) 7.5mg QL (30 caps / 30 days)


1 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

1 QL PA

zolpidem tartrate (generic of

AMBIEN) TABS QL (30 tabs / 30 days)


3 QL PA

MIGRAINE almotriptan malate (generic of

AXERT) QL (12 tabs / 30 days)

1 QL

ALSUMA QL (12 injections / 30 days)

3 QL

AMERGE QL (9 tabs / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 3

D.H.E. 45 4 NM

dihydroergotamine mesylate

(generic of D.H.E. 45) 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

4 QL NM

ergomar 3

FROVA TAB 2.5MG QL (18 tabs / 30 days)

3 QL

IMITREX SOLN 5mg/act QL (24 inhalers / 30 days)

3 QL

IMITREX SOLN 20mg/act QL (12 inhalers / 30 days)

3 QL

IMITREX TABS QL (9 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

IMITREX STATDOSE REFILL QL (12 injections / 30 days)

4 QL NM

IMITREX STATDOSE SYSTEM SOAJ

QL (12 injections / 30 days)

4 QL NM

IMITREX STATDOSE SYSTEM SOLN

QL (6 mL / 30 days)

3 QL

MAXALT 5mg QL (18 tabs / 30 days)

4 QL NM

MAXALT 10mg QL (18 tabs / 30 days)

3 QL

MAXALT-MLT QL (18 tabs / 30 days)

3 QL

migergot 4 NM

MIGRANAL QL (8 mL / 30 days)

4 QL NM

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic

of MAXALT) TABS QL (18 tabs / 30 days)

1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

SUMATRIPTAN INJ 4MG/0.5ML


1 QL

sumatriptan inj 6mg/0.5ml

(generic of IMITREX STATDOSE SYSTEM) SOAJ


1 QL

SUMATRIPTAN INJ 6MG/0.5ML SOCT


1 QL


(generic of IMITREX) SOLN QL (12 injections / 30 days)

1 QL

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Drug Name Drug Tier

Requirements/Limits


SOSY QL (12 injections / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 20mg/act


1 QL

sumatriptan succinate

(generic of IMITREX) TABS QL (9 tabs / 30 days)

1 QL

SUMAVEL DOSEPRO QL (12 injections / 30 days)

4 QL NM

TREXIMET QL (9 tabs / 30 days)

4 QL NM

zolmitriptan (generic of

ZOMIG) TABS QL (12 tabs / 30 days)

1 QL

zolmitriptan odt (generic of

ZOMIG ZMT) QL (12 tabs / 30 days)

1 QL

ZOMIG QL (12 tabs / 30 days)

3 QL

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

2 QL

ZOMIG ZMT QL (12 tabs / 30 days)

3 QL

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 300mg QL (180 tabs / 30 days)

2 QL

GRALISE 600mg QL (90 tabs / 30 days)

2 QL

GRALISE STARTER 2

HORIZANT 3

lithium carbonate CAPS 1

lithium carbonate TABS 1 lithium carbonate (generic of

LITHOBID) TBCR 300mg 1

lithium carbonate TBCR

450mg 1

Drug Name Drug Tier

Requirements/Limits

LITHIUM SOLN 8MEQ/5ML 3

LITHOBID 3

MESTINON 4 NM

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2 pyridostigmine bromide

(generic of MESTINON) TABS

1

pyridostigmine bromide

(generic of MESTINON TIMESPAN) TBCR

1

RILUTEK 4 NM

riluzole (generic of RILUTEK) 1

SAVELLA 12.5mg QL (480 tabs / 30 days)

2 QL

SAVELLA 25mg QL (240 tabs / 30 days)

2 QL


2 QL


2 QL

SAVELLA TITRATION PACK 2

tetrabenazine (generic of

XENAZINE) 12.5mg QL (240 tabs / 30 days)

4 QL NM PA

tetrabenazine (generic of

XENAZINE) 25mg QL (120 tabs / 30 days)

4 QL NM PA

XENAZINE 12.5mg QL (240 tabs / 30 days)

4 QL NM LA PA

XENAZINE 25mg QL (120 tabs / 30 days)

4 QL NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 4 NM LA PA

AUBAGIO QL (30 tabs / 30 days)

4 QL NM LA PA

AVONEX QL (4 injections / 28 days)

4 QL NM PA

AVONEX PEN QL (4 injections / 28 days)

4 QL NM PA

BETASERON QL (14 syringes / 28 days)

4 QL NM PA

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Drug Name Drug Tier

Requirements/Limits

COPAXONE INJ 40MG/ML QL (12 syringes / 28 days)

4 QL NM PA

COPAXONE KIT 20MG/ML QL (30 syringes / 30 days)

4 QL NM PA

EXTAVIA QL (15 syringes / 30 days)

4 QL NM PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

4 QL NM PA

glatopa (generic of COPAXONE)

QL (30 syringes / 30 days)

4 QL NM PA

LEMTRADA 4 NM LA PA

PLEGRIDY SOPN QL (2 pens / 28 days)

4 QL NM PA

PLEGRIDY SOSY QL (2 syringes / 28 days)

4 QL NM PA

PLEGRIDY STARTER PACK SOPN

QL (2 pens / 28 days)

4 QL NM PA

PLEGRIDY STARTER PACK SOSY

QL (2 syringes / 28 days)

4 QL NM PA

REBIF QL (6 mL / 28 days)

4 QL NM PA

REBIF REBIDOSE QL (6 mL / 28 days)

4 QL NM PA

REBIF REBIDOSE TITRATION

QL (6 mL / 28 days)

4 QL NM PA

REBIF TITRATION PACK QL (6 mL / 30 days)

4 QL NM PA

TECFIDERA CAP 120MG QL (14 caps / 7 days)

4 QL NM LA PA

TECFIDERA CAP 240MG QL (60 caps / 30 days)

4 QL NM LA PA

TECFIDERA MIS STARTER 4 NM LA PA

TYSABRI 4 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX INJ 100UNIT 4 NM PA

BOTOX INJ 200UNIT 4 NM PA

Drug Name Drug Tier

Requirements/Limits

cyclobenzaprine hcl TABS

5mg, 10mg PA if 65 years and older

3 PA

DANTRIUM 2 dantrolene sodium (generic of

DANTRIUM) CAPS 25mg, 50mg

1

dantrolene sodium CAPS

100mg 1

DYSPORT 3 NM PA

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of

ZANAFLEX) TABS 4mg 1

XEOMIN INJ 50 UNIT 3 NM PA

XEOMIN INJ 100 UNIT 4 NM PA

ZANAFLEX CAPS 3

ZANAFLEX TABS 2

NARCOLEPSY/CATAPLEXY modafinil (generic of

PROVIGIL) 100mg QL (30 tabs / 30 days)

1 QL PA

modafinil (generic of

PROVIGIL) 200mg QL (60 tabs / 30 days)

4 QL NM PA

NUVIGIL 50mg QL (150 tabs / 30 days)

2 QL PA

NUVIGIL 150mg QL (60 tabs / 30 days)

2 QL PA

NUVIGIL 200mg, 250mg QL (30 tabs / 30 days)

2 QL PA

PROVIGIL 100mg QL (30 tabs / 30 days)

4 QL NM PA

PROVIGIL 200mg QL (60 tabs / 30 days)

4 QL NM PA

XYREM QL (540 mL / 30 days)

4 QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

antabuse 2

BUNAVAIL MIS 2.1-0.3MG QL (120 buccal films / 30 days)

3 QL PA

BUNAVAIL MIS 4.2-0.7MG QL (120 buccal films / 30 days)

3 QL PA

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Drug Name Drug Tier

Requirements/Limits

BUNAVAIL MIS 6.3-1MG QL (60 buccal films / 30 days)

3 QL PA

buprenorphine hcl SUBL 1 PA

buprenorphine hcl-naloxone hcl sl


1 QL PA

buproban (generic of ZYBAN) 1 bupropion hcl (smoking deterrent) (generic of ZYBAN)

1

CHANTIX 2 PA

CHANTIX CONTINUING MONTH

2 PA

CHANTIX STARTER PACK 2 PA

disulfiram (generic of

ANTABUSE) TABS 1

naloxone hcl SOLN 1

naltrexone hcl (generic of

REVIA) TABS 1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG QL (120 SL films / 30 days)

3 QL PA

SUBOXONE MIS 4-1MG QL (120 SL films / 30 days)

3 QL PA


3 QL PA


3 QL PA

VIVITROL 4 NM PA

ZUBSOLV SUB 1.4-0.36MG QL (120 tabs / 30 days)

3 QL PA


3 QL PA


3 QL PA


3 QL PA


3 QL PA

ZYBAN 2

ENDOCRINE AND METABOLIC

Drug Name Drug Tier

Requirements/Limits

ANDROGENS ANDRODERM


2 QL PA

ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm

QL (150 grams / 30 days)

3 QL PA

ANDROGEL 25mg/2.5gm QL (300 grams / 30 days)

3 QL PA

ANDROGEL 1% QL (300 grams / 30 days)

3 QL PA

ANDROGEL 1.62% QL (150 grams / 30 days)

3 QL PA

ANDROGEL PUMP QL (300 grams / 30 days)

3 QL PA

AVEED 3 NM PA

AXIRON QL (440 mL / 30 days)

2 QL PA

depo-testosterone 3 PA

FORTESTA QL (120 grams / 30 days)

3 QL PA

oxandrolone (generic of

OXANDRIN) TABS 2.5mg 1 PA

oxandrolone (generic of OXANDRIN) TABS 10mg

4 NM PA

STRIANT QL (60 buccal systems / 30 days)

3 QL PA

TESTIM QL (300 grams / 30 days)

3 QL PA

testosterone cypionate SOLN 100mg/ml

1 PA

testosterone cypionate

(generic of DEPO-TESTOSTERONE) SOLN 200mg/ml

1 PA

testosterone enanthate

SOLN 1 PA

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Drug Name Drug Tier

Requirements/Limits

VOGELXO QL (300 grams / 30 days)

3 QL PA

VOGELXO PUMP QL (300 grams / 30 days)

3 QL PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 3

APIDRA SOLOSTAR 3

BYDUREON PEN QL (4 pens / 28 days)

3 QL

BYDUREON SUSR QL (4 vials / 28 days)

3 QL

BYETTA QL (1 pen / 30 days)

3 QL

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

4 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

Drug Name Drug Tier

Requirements/Limits

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2 PA

SYMLINPEN 120 4 NM PA

TANZEUM QL (4 pens / 28 days)

3 QL

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

TRULICITY QL (4 pens / 28 days)

3 QL

VICTOZA QL (3 pens / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of

PRECOSE) 1

ACTOPLUS MET TAB 15-500MG


3 QL

ACTOPLUS MET TAB 15-850MG


3 QL

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

ACTOS QL (30 tabs / 30 days)

3 QL

AMARYL 1mg QL (240 tabs / 30 days)

3 QL


3 QL


3 QL

DUETACT QL (30 tabs / 30 days)

3 QL

FARXIGA 5mg QL (60 tabs / 30 days)

3 QL

FARXIGA 10mg QL (30 tabs / 30 days)

3 QL

FORTAMET 500mg QL (150 tabs / 30 days)

4 QL NM

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Drug Name Drug Tier

Requirements/Limits

FORTAMET 1000mg QL (75 tabs / 30 days)

4 QL NM

glimepiride (generic of

AMARYL) 1mg QL (240 tabs / 30 days)

1 QL



1 QL



1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide er (generic of

GLUCOTROL XL) 2.5mg QL (240 tabs / 30 days)

1 QL


GLUCOTROL XL) 5mg QL (120 tabs / 30 days)

1 QL


GLUCOTROL XL) 10mg QL (60 tabs / 30 days)

1 QL

GLIPIZIDE XL TB24 2.5MG QL (240 tabs / 30 days)

1 QL

GLIPIZIDE XL TB24 5MG QL (120 tabs / 30 days)

1 QL

glipizide-metformin 2.5-250 mg


1 QL

glipizide-metformin 2.5-500 mg


1 QL

glipizide-metformin 5-500mg


GLUCOPHAGE 500mg QL (150 tabs / 30 days)

3 QL


3 QL


3 QL

GLUCOPHAGE XR 500mg QL (120 tabs / 30 days)

3 QL

GLUCOPHAGE XR 750mg QL (60 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

GLUCOTROL 5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL 10mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 2.5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL XL 5mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 10mg QL (60 tabs / 30 days)

3 QL

GLUMETZA 500mg QL (120 tabs / 30 days)

3 QL

GLUMETZA 1000mg QL (60 tabs / 30 days)

3 QL

GLYSET 3

GLYXAMBI QL (30 tabs / 30 days)

3 QL

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

3 QL

INVOKAMET TAB 50-1000 QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

INVOKANA TAB 100MG QL (90 tabs / 30 days)

3 QL

INVOKANA TAB 300MG QL (30 tabs / 30 days)

3 QL

JANUMET QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 50-500MG


2 QL

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

2 QL

JANUVIA QL (30 tabs / 30 days)

2 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL

JENTADUETO QL (60 tabs / 30 days)

2 QL

KAZANO QL (60 tabs / 30 days)

3 QL

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Drug Name Drug Tier

Requirements/Limits

KOMBIGLYZE XR 2.5-1000MG


3 QL

KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)

3 QL

KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)

3 QL

metformin er (generic of GLUCOPHAGE XR) 500mg


1 QL

metformin er (generic of

GLUCOPHAGE XR) 750mg QL (60 tabs / 30 days)

1 QL

metformin hcl (generic of

GLUCOPHAGE) TABS 500mg


1 QL




1 QL




1 QL


FORTAMET) TB24 500mg QL (150 tabs / 30 days)

1 QL


FORTAMET) TB24 1000mg QL (75 tabs / 30 days)

1 QL

nateglinide (generic of

STARLIX) QL (90 tabs / 30 days)

1 QL

NESINA 6.25mg QL (120 tabs / 30 days)

3 QL

NESINA 12.5mg QL (60 tabs / 30 days)

3 QL

NESINA 25mg QL (30 tabs / 30 days)

3 QL

ONGLYZA QL (30 tabs / 30 days)

3 QL

OSENI TAB 12.5-15MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

Drug Name Drug Tier

Requirements/Limits

OSENI TAB 25-15MG QL (30 tabs / 30 days)

3 QL


3 QL


3 QL

pioglitazone hcl (generic of

ACTOS) QL (30 tabs / 30 days)

1 QL

pioglitazone hcl-glimepiride

(generic of DUETACT) QL (30 tabs / 30 days)

1 QL

pioglitazone hcl-metformin hcl

(generic of ACTOPLUS MET) QL (90 tabs / 30 days)

1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

PRANDIN 2mg QL (240 tabs / 30 days)

3 QL

PRANDIN .5mg, 1mg QL (120 tabs / 30 days)

3 QL

PRECOSE 2

repaglinide (generic of

PRANDIN) 2mg QL (240 tabs / 30 days)

1 QL

repaglinide (generic of

PRANDIN) .5mg, 1mg QL (120 tabs / 30 days)

1 QL

repaglinide-metformin hcl


RIOMET QL (946 mL / 30 days)

3 QL

STARLIX QL (90 tabs / 30 days)

3 QL

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

3 QL

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

3 QL

SYNJARDY TAB 12.5-500 QL (60 tabs / 30 days)

3 QL

SYNJARDY TAB 12.5-1000 QL (60 tabs / 30 days)

3 QL

TRADJENTA QL (30 tabs / 30 days)

2 QL

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL


3 QL

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Drug Name Drug Tier

Requirements/Limits


3 QL


3 QL

BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

3

ACTONEL 150mg 2 alendronate sodium SOLN

QL (300 mL / 28 days) 1 QL

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

alendronate sodium (generic

of FOSAMAX) TABS 70mg 1

ATELVIA 3

BINOSTO 3

BONIVA SOLN QL (1 injection / 90 days)

3 B/D QL

BONIVA TABS 3 B/D

FOSAMAX 3

FOSAMAX PLUS D 3 ibandronate sodium (generic

of BONIVA) QL (1 injection / 90 days)

1 B/D QL

ibandronate tab 150mg

(generic of BONIVA) 1 B/D

pamidronate disodium SOLN 6mg/ml

3 B/D

pamidronate disodium SOLN

30mg/10ml, 90mg/10ml 1 B/D

RECLAST 3 B/D NM

RISEDRONATE SODIUM TABS 5mg, 30mg

1

risedronate sodium (generic

of ACTONEL) TABS 35mg, 150mg

1

risedronate sodium (generic

of ATELVIA) TBEC 1

zoledronic inj 4mg/5ml

(generic of ZOMETA) 1 B/D NM

zoledronic inj 5/100ml

(generic of RECLAST) 1 B/D NM

ZOMETA 4 B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 2 NM

Drug Name Drug Tier

Requirements/Limits

SENSIPAR 60mg, 90mg 4 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 4 NM

EXJADE 4 NM LA PA

FERRIPROX 4 NM LA PA

JADENU 4 NM PA

KAYEXALATE 3 kionex (generic of

KAYEXALATE) 1

sodium polystyrene sulfonate

(generic of KAYEXALATE) POWD

1

sodium polystyrene sulfonate

SUSP 1

sps susp 15gm/60ml 1

SYPRINE 4 NM

CONTRACEPTIVES altavera 1 amethia 91 day (generic of

SEASONIQUE) 1

amethyst 28 day 1 apri 28 day (generic of

DESOGEN) 1

aranelle 28 (generic of

TRI-NORINYL 28) 1

ashlyna 91 day (generic of

SEASONIQUE) 1

aubra 28 day 1

aviane 28 1 balziva 28 day (generic of

OVCON-35) 1

bekyree 28 day (generic of

MIRCETTE) 1

BEYAZ 2

blisovi 21 fe 1/20 28 day pack

(generic of LOESTRIN FE 1/20)

1

blisovi 24 fe 1/20 28 day 1

BREVICON-28 3 briellyn 28 day (generic of

OVCON-35) 1

camila 28 day (generic of

NOR-QD) 1

CAMRESE LO TAB 1

cryselle 28 1

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Drug Name Drug Tier

Requirements/Limits

cyclafem 1/35 28 day (generic

of NORINYL 1+35) 1

cyclafem 7/7/7 28 day

(generic of ORTHO-NOVUM 7/7/7)

1

CYCLESSA 3

cyred tab (generic of DESOGEN)

1

deblitane 28 day (generic of

NOR-QD) 1

delyla 28 day 1

DEPO-PROVERA CONTRACEPTIVE

2

DEPO-SUBQ PROVERA 104 2

DESOGEN 3 desogestrel-ethinyl estradiol (biphasic) (generic of

MIRCETTE)

1

drospirenone-ethinyl estradiol

(generic of YASMIN 28) 1

drospirenone-ethinyl estradiol

(generic of YAZ) 1

ELLA 3

emoquette (generic of

DESOGEN) 1

enpresse 28 day 1 errin 28 day (generic of

ORTHO MICRONOR) 1

estarylla tab 0.25-35 (generic of ORTHO-CYCLEN)

1

ESTROSTEP FE 3

falmina 28 day 1

FEMCON FE 3

GENERESS FE 3

GIANVI TAB 3-0.02MG 1 gildagia (generic of

OVCON-35) 1

gildess 1.5/30 21 day (generic

of LOESTRIN 1.5/30-21) 1

gildess 24 fe 28 day 1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

Drug Name Drug Tier

Requirements/Limits

junel 1/20 21 day (generic of

LOESTRIN 1/20-21) 1

junel fe 1.5/30 28 day (generic

of LOESTRIN FE 1.5/30) 1

junel fe 1/20 28 day (generic

of LOESTRIN FE 1/20) 1

junel fe 24 1/20 28 day 1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

kimidess 28 day (generic of MIRCETTE)

1

larin 1.5/30 (generic of

LOESTRIN 1.5/30-21) 1

larin 1/20 (generic of LOESTRIN 1/20-21)

1

larin fe 1.5/30 (generic of

LOESTRIN FE 1.5/30) 1

larin fe 1/20 (generic of LOESTRIN FE 1/20)

1

LAYOLIS FE CHW 1

LEENA TAB 1

lessina 28 day 1 levonest 28 day 1

levonor/ethi tab 1 levonorgestrel & eth estradiol 1

levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg

1

levonorgestrel (emergency oc) .75mg

1

levonorgestrel-ethinyl estradiol (91-day)

1

levonorgestrel-ethinyl estradiol (91-day) (generic of

SEASONIQUE)

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2 loestrin 1.5/30 21 day 3

loestrin 1/20 21 day 3

loestrin fe 1.5/30 28 day 3 loestrin fe 1/20 28 day 3

lomedia 24 fe 1

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Drug Name Drug Tier

Requirements/Limits

loryna 28 day (generic of

YAZ) 1

LOSEASONIQUE 3 low-ogestrel 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

1

MICROGESTIN 1.5/30 1

MICROGESTIN 1/20 1

MICROGESTIN FE 1.5/30 1

MICROGESTIN FE 1/20 1

MINASTRIN 24 FE 2

mircette 2

MODICON 3

mono-linyah tab 0.25-35

(generic of ORTHO-CYCLEN) 1

MONONESSA 1 myzilra 1

necon 0.5/35 28 day (generic

of BREVICON-28) 1

necon 1/35 28 day (generic of

NORINYL 1+35) 1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

next choice tab 1.5mg

(generic of PLAN B ONE-STEP)

1

nikki 28 day (generic of YAZ) 1

NOR-QD 2

NORA-BE TAB 1

norethin acet & estrad-fe 1

norethindrone & ethinyl estradiol-fe (generic of

GENERESS FE)

1

norethindrone (contraceptive) (generic of NOR-QD)

1

norgest/ethi tab 0.25/35

(generic of ORTHO-CYCLEN) 1

Drug Name Drug Tier

Requirements/Limits

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO

TRI-CYCLEN)

1

NORINYL 1+35 3

NORINYL 1+50 3

norlyroc 28 day (generic of NOR-QD)

1

nortrel 0.5/35 28 day (generic

of BREVICON-28) 1

nortrel 1/35 21 day (generic of

NORINYL 1+35) 1

nortrel 1/35 28 day (generic of

NORINYL 1+35) 1

nortrel 7/7/7 28 day (generic

of ORTHO-NOVUM 7/7/7) 1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1 orsythia 28 day 1

ORTHO MICRONOR 2

ORTHO TRI-CYCLEN LO 2

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

ovcon 35 28 day 3

philith (generic of OVCON-35) 1 pimtrea pack (generic of

MIRCETTE) 1

pirmella 1/35 28 day (generic of NORINYL 1+35)

1

portia 28 day 1

previfem 28 day (generic of

ORTHO-CYCLEN) 1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3

setlakin tab 1 sharobel 28 day (generic of

ORTHO MICRONOR) 1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

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Drug Name Drug Tier

Requirements/Limits

syeda (generic of YASMIN

28) 1

tarina fe 1/20 28 day (generic

of LOESTRIN FE 1/20) 1

tri-legest 28 day (generic of

ESTROSTEP FE) 1

TRI-NORINYL 28 3

tri-previfem 28 day (generic of ORTHO TRI-CYCLEN)

1

tri-sprintec 28 day (generic of

ORTHO TRI-CYCLEN) 1

TRINESSA 1 trivora 28 day 1

velivet 28 day (generic of

CYCLESSA) 1

vestura (generic of YAZ) 1

viorele (generic of

MIRCETTE) 1

vyfemla 28 day (generic of

OVCON-35) 1

wymzya fe (generic of

FEMCON FE) 1

xulane dis 150-35 1

YASMIN 28 3

YAZ 3 zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of

FEMCON FE) 1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 4 NM PA

SYNAREL 4 NM

ENZYME REPLACEMENTS ADAGEN 4 NM LA PA

ALDURAZYME 4 NM LA PA

CARBAGLU 4 NM LA PA

CARNITOR SOLN 1gm/10ml

2 B/D

CARNITOR SOLN 200mg/ml

3 B/D

CARNITOR TABS 2 B/D

CERDELGA 4 NM PA

Drug Name Drug Tier

Requirements/Limits

CEREZYME 4 NM LA PA

CYSTADANE 4 NM LA

CYSTAGON 3 NM LA PA

ELAPRASE 4 NM LA PA

ELELYSO 4 NM PA

FABRAZYME 4 NM LA PA

KUVAN 4 NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 4 NM LA PA

MYOZYME 4 NM LA PA

NAGLAZYME 4 NM LA PA

ORFADIN 4 NM LA PA

PROCYSBI 4 NM LA PA

RAVICTI 4 NM PA

sodium phenylbutyrate

(generic of BUPHENYL) 4 NM

VIMIZIM 4 NM PA

VPRIV 4 NM PA

ZAVESCA 4 NM LA PA

ESTROGENS ALORA


CLIMARA PA if 65 years and older

3 PA

DELESTROGEN 3

depo-estradiol 3 estrace CREA 2

estrace TABS


estradiol (generic of

VIVELLE-DOT) PTTW PA if 65 years and older

3 PA

estradiol (generic of CLIMARA) PTWK


3 PA

estradiol (generic of

ESTRACE) TABS PA if 65 years and older

3 PA

estradiol valerate (generic of

DELESTROGEN) OIL 1

ESTRING 3

FEMRING 3

jinteli


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Drug Name Drug Tier

Requirements/Limits

MENOSTAR PA if 65 years and older

3 PA

MINIVELLE PA if 65 years and older

3 PA

norethindrone acetate-ethinyl estradiol


3 PA

PREMARIN CREAM 2

PREMARIN INJ 3

VAGIFEM 2

VIVELLE-DOT PA if 65 years and older

3 PA

GLUCOCORTICOIDS a-hydrocort 1

CORTEF 3

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D


3 B/D


3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

fludrocortisone acetate

TABS 1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL PAK 4MG 3 B/D

MEDROL TAB 2MG 3 B/D





methylpr ace inj 40mg/ml

(generic of DEPO-MEDROL) 1 B/D

methylpr ace inj 80mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ss inj 1gm (generic

of SOLU-MEDROL) 1 B/D

methylpr ss inj 40mg (generic

of SOLU-MEDROL) 1 B/D

Drug Name Drug Tier

Requirements/Limits

methylpr ss inj 125mg

(generic of SOLU-MEDROL) 1 B/D

methylpred pak 4mg (generic

of MEDROL DOSEPAK) 1 B/D

methylpred tab 4mg (generic

of MEDROL) 1 B/D


of MEDROL) 1 B/D


of MEDROL) 1 B/D


of MEDROL) 1 B/D

millipred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D



pediapred sol 6.7/5ml 3 B/D

pred sod pho sol 5mg/5ml (generic of PEDIAPRED)

1 B/D

prednisolone sodium phosphate (generic of

ORAPRED ODT)

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml 1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





RAYOS TAB 1MG 4 B/D NM



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 1GM 3 B/D

SOLU-MEDROL INJ 2GM 3 B/D

SOLU-MEDROL INJ 40MG 3 B/D



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Drug Name Drug Tier

Requirements/Limits

veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

KORLYM 4 NM LA PA

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 4 NM LA PA

GENOTROPIN MINIQUICK .2mg

3 NM LA PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

4 NM LA PA

HUMATROPE 4 NM LA PA

HUMATROPE COMBO PACK 4 NM LA PA

NORDITROPIN FLEXPRO 4 NM PA

NUTROPIN AQ INJ 20MG/2ML

4 NM LA PA

NUTROPIN AQ NUSPIN 5 4 NM LA PA

NUTROPIN AQ PEN 4 NM LA PA

OMNITROPE 5.8MG 4 NM LA PA

OMNITROPE 5MG 4 NM LA PA

OMNITROPE 10MG 4 NM LA PA

SAIZEN 4 NM LA PA

SAIZEN CLICK.EASY 4 NM LA PA

SEROSTIM 4 NM LA PA

ZOMACTON 4 NM PA

ZORBTIVE 4 NM PA

MISCELLANEOUS AFREZZA 3

cabergoline 1 calcitonin (salmon) nasal spray (generic of

MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 1mg 4 NM LA PA

EVISTA 3

FORTICAL SPR 200/ACT 3

H.P. ACTHAR QL (1.5 ml / 1 day)

4 QL NM LA PA

INCRELEX 4 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

Drug Name Drug Tier

Requirements/Limits

MIACALCIN INJ 200U/ML 4 B/D NM

MIACALCIN SPR 200/ACT 3

MYALEPT 4 NM LA PA

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of

SANDOSTATIN) 50mcg/ml, 100mcg/ml

1 NM PA

octreotide acetate (generic of SANDOSTATIN) 200mcg/ml, 500mcg/ml, 1000mcg/ml

4 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA QL (1 syringe / 180 days)

3 QL NM

raloxifene hcl (generic of

EVISTA) 1

SAMSCA 4 NM PA

SANDOSTATIN 4 NM PA

SANDOSTATIN LAR DEPOT 4 NM PA

SIGNIFOR 4 NM LA PA

SIGNIFOR LAR 4 NM LA PA

SOMATULINE DEPOT 4 NM PA

SOMAVERT 4 NM LA PA

XGEVA 4 NM PA

PARATHYROID HORMONES FORTEO 4 NM PA

NATPARA 4 NM PA

PHOSPHATE BINDER AGENTS AURYXIA 4 NM

calcium acetate (phosphate binder) (generic of PHOSLO)

CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS)

TABS

1

eliphos 3

FOSRENOL 4 NM

PHOSLO 3

PHOSLYRA 2

RENAGEL 400mg 3

RENAGEL 800mg 4 NM

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 4 NM

PROGESTINS

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Drug Name Drug Tier

Requirements/Limits

aygestin 3

CRINONE 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate

(generic of AYGESTIN) TABS

1

progesterone micronized

(generic of PROMETRIUM) CAPS

1

PROMETRIUM 3

PROVERA 3

THYROID AGENTS CYTOMEL 2

levothyroxine sodium (generic

of SYNTHROID) TABS 1

LEVOXYL 1 liothyronine sodium (generic

of TRIOSTAT) SOLN 1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of

TAPAZOLE) TABS 1

propylthiouracil TABS 1

SYNTHROID 2

tapazole 2

TIROSINT 3

TRIOSTAT 3

UNITHROID 1

VASOPRESSINS DDAVP SOLN 4mcg/ml 4 NM

DDAVP SOLN .01% 2

DDAVP TABS 2

DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj

(generic of DDAVP) 1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 4 NM

GASTROINTESTINAL ANTIEMETICS

Drug Name Drug Tier

Requirements/Limits

AKYNZEO 3 B/D

ALOXI 4 NM

CESAMET QL (60 caps / 30 days)

4 B/D QL NM

compro supp 1

dronabinol (generic of

MARINOL) 2.5mg, 5mg QL (60 caps / 30 days)

1 B/D QL

dronabinol (generic of

MARINOL) 10mg QL (60 caps / 30 days)

4 B/D QL NM

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

MARINOL 2.5mg QL (60 caps / 30 days)

3 B/D QL

MARINOL 5mg, 10mg QL (60 caps / 30 days)

4 B/D QL NM

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl (generic

of METOZOLV ODT) TBDP 1

metoclopramide hcl inj 5 mg/ml

1

metoclopramide odt 1

METOZOLV ODT 3 ondansetron hcl (generic of

ZOFRAN) TABS 4mg, 8mg 1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1 ondansetron hcl inj (generic of

ZOFRAN) 40mg/20ml 1

ondansetron hcl oral soln

(generic of ZOFRAN) 1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz


phenergan PA if 65 years and older

3 PA

phenergan inj


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Drug Name Drug Tier

Requirements/Limits

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate

(generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN


3 PA

promethazine hcl SUPP;

SYRP; TABS PA if 65 years and older

3 PA

promethegan


REGLAN 3

SANCUSO QL (4 patches / 30 days)

4 QL NM

TRANSDERM-SCOP QL (10 patches / 30 days)


3 QL PA

ZOFRAN SOLN 4mg/5ml 4 B/D NM

ZOFRAN TABS 4 B/D NM

ZOFRAN ODT 4 B/D NM

ZUPLENZ 4 B/D NM

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL CAPS; TABS 2

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl (generic of

BENTYL) CAPS; TABS 1

dicyclomine hcl SOLN 1

glycate 3

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of

ROBINUL) TABS 1mg 1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide

(generic of PAMINE) TABS 2.5mg

1

Drug Name Drug Tier

Requirements/Limits

methscopolamine bromide

(generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3

PAMINE FORTE 3

ROBINUL 3

ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1 cimetidine sol 300/5ml 1

famotidine (generic of

PEPCID) SUSR 1

famotidine (generic of

PEPCID) TABS 20mg, 40mg 1

famotidine inj 1

nizatidine CAPS 150mg 1 nizatidine (generic of AXID)

CAPS 300mg 1

nizatidine SOLN 1

PEPCID SUSP 3

pepcid tab 3

ranitidine hcl CAPS 1 ranitidine hcl (generic of

ZANTAC) SOLN 1

ranitidine hcl SYRP 1 ranitidine hcl (generic of

ZANTAC) TABS 150mg, 300mg

1

ZANTAC 3

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

AZULFIDINE 3

AZULFIDINE EN-TABS 3 balsalazide disodium (generic

of COLAZAL) 1

budesonide (generic of

ENTOCORT EC) CP24 4 NM

CANASA 4 NM

COLAZAL 3

colocort (generic of

CORTENEMA) 1

CORTENEMA 3

DELZICOL 3

DIPENTUM 4 NM

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Drug Name Drug Tier

Requirements/Limits

ENTOCORT EC 4 NM

ENTYVIO 4 NM PA

GIAZO 4 NM

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

ROWASA 3

SF-ROWASA 4 NM

sulfasalazine dr (generic of

AZULFIDINE EN-TABS) 1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS AER 2MG/ACT 3

UCERIS TAB 9MG 4 NM

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1 gaviltye-g (generic of

GOLYTELY) 1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-h 1

gavilyte-n (generic of

NULYTELY/FLAVOR PACKS) 1

generlac 1

GOLYTELY 3

kristalose 3 lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

Drug Name Drug Tier

Requirements/Limits

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

1

polyethylene glycol 3350

PACK; POWD 1

PREPOPIK 3

RELISTOR 4 NM PA

SUCLEAR 2

SUPREP BOWEL PREP 2 trilyte (generic of

NULYTELY/FLAVOR PACKS) 1

MISCELLANEOUS ACTIGALL 2 alosetron hcl (generic of

LOTRONEX) 4 NM PA

AMITIZA 2 amoxicillin-clarithromycin w/ lansoprazole (generic of

PREVPAC)

1

CARAFATE 2 cromolyn sodium (mastocytosis) (generic of

GASTROCROM)

4 NM

CYTOTEC 2

diphenoxylate w/ atropine

LIQD 1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GASTROCROM 4 NM

GATTEX 4 NM LA PA

LINZESS 2

LOMOTIL 2

loperamide hcl CAPS 1

LOTRONEX 4 NM PA

misoprostol (generic of

CYTOTEC) TABS 1

MOVANTIK 2

OMECLAMOX-PAK 3

PREVPAC 4 NM

PYLERA 4 NM

SUCRAID 4 NM LA

sucralfate (generic of CARAFATE) TABS

1

URSO 250 2

URSO FORTE 2

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Drug Name Drug Tier

Requirements/Limits

ursodiol (generic of

ACTIGALL) CAPS 1

ursodiol (generic of URSO

250) TABS 250mg 1

ursodiol (generic of URSO

FORTE) TABS 500mg 1

XIFAXAN TAB 550MG 4 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 4 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX


ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG QL (60 caps / 30 days)

3 QL

DEXILANT 2

esomeprazole magnesium

(generic of NEXIUM) 1

esomeprazole sodium inj

20mg 1

esomeprazole sodium inj

(generic of NEXIUM I.V.) 40mg

1

lansoprazole (generic of

PREVACID) CPDR QL (30 caps / 30 days)

1 QL

NEXIUM CAP 20MG 2

NEXIUM CAP 40MG 2

NEXIUM GRA 2.5MG DR 2

NEXIUM GRA 5MG DR 2

NEXIUM GRA 10MG DR 2



NEXIUM I.V. 3 omeprazole (generic of

PRILOSEC) CPDR 10mg, 40mg


1 QL

omeprazole (generic of

PRILOSEC) CPDR 20mg 1

Drug Name Drug Tier

Requirements/Limits

OMEPRAZOLE-SODIUM BICARBONATE


1 QL

pantoprazole sodium (generic of PROTONIX)


1 QL

PREVACID QL (30 caps / 30 days)

3 QL

PREVACID SOLUTAB QL (30 tabs / 30 days)

3 QL

PRILOSEC CPDR 10mg, 40mg


3 QL

PRILOSEC CPDR 20mg QL (60 caps / 30 days)

3 QL

PRILOSEC PACK 3

PROTONIX PACK QL (30 packets / 30 days)

3 QL

PROTONIX TBEC QL (30 tabs / 30 days)

3 QL

PROTONIX INJ 3

rabeprazole sodium (generic of ACIPHEX)


1 QL

ZEGERID CAPS QL (30 caps / 30 days)

3 QL

ZEGERID PACK QL (30 packets / 30 days)

3 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3 dutasteride (generic of

AVODART) 1

dutasteride-tamsulosin hcl

(generic of JALYN) 1

finasteride (generic of PROSCAR) TABS 5mg

1

FLOMAX 3

JALYN 3

PROSCAR 3

RAPAFLO 2

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Drug Name Drug Tier

Requirements/Limits

tamsulosin hcl (generic of

FLOMAX) 1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic

of URECHOLINE) TABS 1

ELMIRON 3 potassium citrate (alkalinizer)

(generic of UROCIT-K 15) 15meq

1

POTASSIUM CITRATE (ALKALINIZER) 540mg

1

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

urecholine 2

UROCIT-K 2

URINARY ANTISPASMODICS DETROL 3

DETROL LA 3

DITROPAN XL 3

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride SYRP;

TABS 1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

tolterodine tartrate er (generic of DETROL LA)

1

tolterodine tartrate tab 1 mg

(generic of DETROL) 1

tolterodine tartrate tab 2 mg

(generic of DETROL) 1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES AVC 3

CLEOCIN CREA 2

CLEOCIN VAG SUPP 100MG 3 clindamycin cre 2% vag

(generic of CLEOCIN) 1

CLINDESSE 3

Drug Name Drug Tier

Requirements/Limits

METROGEL-VAGINAL 2

metronidazole vaginal

(generic of METROGEL-VAGINAL)

1

miconazole 3 sup 200mg 1

NUVESSA 3

TERAZOL 3 2

TERAZOL 7 2

terconazole vaginal (generic of TERAZOL 7) CREA .4%

1

terconazole vaginal (generic

of TERAZOL 3) CREA .8% 1

terconazole vaginal SUPP 1

VANDAZOLE 1

zazole (generic of TERAZOL

7) .4% 1

ZAZOLE .8% 1

HEMATOLOGIC

ANTICOAGULANTS ARIXTRA 4 NM

COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium (generic of

LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium (generic of

LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

fondaparinux sodium (generic

of ARIXTRA) 2.5mg/0.5ml 1

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

4 NM

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

4 NM

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

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Drug Name Drug Tier

Requirements/Limits

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

3 B/D

HEPARIN SOD INJ 2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

jantoven (generic of COUMADIN)

1

LOVENOX 30mg/0.3ml, 40mg/0.4ml, 300mg/3ml

2

LOVENOX 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

PRADAXA 2

SAVAYSA 3 warfarin sodium (generic of

COUMADIN) 1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 10mcg/0.4ml, 25mcg/ml, 40mcg/ml, 60mcg/ml

2 NM PA

ARANESP ALBUMIN FREE SOLN 100mcg/ml, 150mcg/0.75ml, 200mcg/ml, 300mcg/ml

4 NM PA

ARANESP ALBUMIN FREE SOSY 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml

2 NM PA

ARANESP ALBUMIN FREE SOSY 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

4 NM PA

EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 NM PA

EPOGEN 20000unit/ml 4 NM PA

GRANIX 4 NM PA

LEUKINE 4 NM PA

Drug Name Drug Tier

Requirements/Limits

MIRCERA 3 NM PA

MOZOBIL 4 NM PA

NEULASTA 4 NM PA

NEULASTA ONPRO KIT 4 NM PA

NEUMEGA 4 NM PA

NEUPOGEN 4 NM PA

NPLATE 4 NM PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

2 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

4 NM PA

MISCELLANEOUS AGRYLIN 2

anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 4 NM PA

cilostazol 1

CINRYZE 4 NM LA PA

CYKLOKAPRON 3

FIRAZYR 4 NM PA

KALBITOR 4 NM PA

LYSTEDA 3 pentoxifylline TBCR 1

PLETAL 2

PROMACTA 12.5mg QL (360 tabs / 30 days)

4 QL NM LA PA

PROMACTA 25mg QL (180 tabs / 30 days)

4 QL NM LA PA


4 QL NM LA PA


4 QL NM LA PA

RUCONEST 4 NM PA

SOLIRIS 4 NM PA

tranexamic acid (generic of

CYKLOKAPRON) SOLN 1

tranexamic acid (generic of

LYSTEDA) TABS 1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

ASPIRIN-DIPYRIDAMOLE 1

BRILINTA 2

clopidogrel bisulfate (generic

of PLAVIX) 1

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Drug Name Drug Tier

Requirements/Limits

EFFIENT 2

PLAVIX 3

ZONTIVITY 3

IMMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 4 NM PA

ARAVA 4 NM

CIMZIA 4 NM PA

ENBREL 4 NM PA

ENBREL SURECLICK 4 NM PA

HUMIRA 4 NM PA

HUMIRA PEN 4 NM PA

HUMIRA PEN-CROHNS STARTER KIT

4 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

4 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 4 NM PA

leflunomide (generic of

ARAVA) TABS 1

methotrexate sodium tabs 1

ORENCIA 4 NM PA

OTEZLA 4 NM PA

OTREXUP 3 NM PA

PLAQUENIL 2

RASUVO 3 NM PA

REMICADE 4 NM PA

RHEUMATREX 2

SIMPONI 4 NM PA

SIMPONI ARIA 4 NM PA

trexall 2 B/D

XELJANZ 4 NM PA

IMMUNOGLOBULINS BIVIGAM 4 NM PA

CARIMUNE NANOFILTERED 4 NM PA

FLEBOGAMMA 4 NM PA

FLEBOGAMMA DIF 4 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 4 NM PA

GAMMAGARD S/D 4 NM PA

GAMMAGARD S/D IGA LESS TH

4 NM PA

GAMMAKED 4 NM PA

Drug Name Drug Tier

Requirements/Limits

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

4 NM PA

GAMUNEX-C 4 NM PA

HIZENTRA 4 NM PA

HYQVIA 4 NM PA

OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml

4 NM PA

PRIVIGEN 4 NM PA

IMMUNOMODULATORS ACTIMMUNE 4 NM LA PA

ARCALYST 4 NM PA

GRASTEK 2 PA

ILARIS 4 NM PA

INTRON-A INJ 10MU 4 B/D NM




RAGWITEK 2 PA

REVLIMID 4 NM LA PA

THALOMID 4 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 4 B/D NM

ASTAGRAF XL .5mg, 1mg 3 B/D

ATGAM 4 B/D NM

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

BENLYSTA 4 NM PA

CELLCEPT CAP 4 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

CELLCEPT SUSP 4 B/D NM

CELLCEPT TAB 4 B/D NM

cyclosporine (generic of

SANDIMMUNE) CAPS; SOLN

1 B/D

cyclosporine modified (for microemulsion) (generic of

NEORAL) CAPS 25mg, 100mg

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

cyclosporine modified (for microemulsion) (generic of

NEORAL) SOLN

1 B/D

gengraf (generic of NEORAL) 1 B/D

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Drug Name Drug Tier

Requirements/Limits

IMURAN 2 B/D

mycophenolate mofetil

(generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil

(generic of CELLCEPT) SUSR

4 B/D NM

mycophenolate sodium (generic of MYFORTIC) 180mg

1 B/D

mycophenolate sodium

(generic of MYFORTIC) 360mg

4 B/D NM

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 4 B/D NM

NEORAL 2 B/D

NULOJIX 4 B/D NM

PROGRAF CAPS 5mg 4 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 4 B/D NM

RAPAMUNE TABS 1mg, 2mg

4 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 10mg 3 B/D

SIMULECT 20mg 4 B/D NM

SIROLIMUS TABS 2mg 4 B/D NM

sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg

1 B/D

tacrolimus (generic of

PROGRAF) CAPS 5mg 4 B/D NM

tacrolimus (generic of

PROGRAF) CAPS .5mg, 1mg

1 B/D

THYMOGLOBULIN 4 B/D NM

ZORTRESS TAB 0.5MG 4 B/D NM

ZORTRESS TAB 0.25MG 3 B/D

ZORTRESS TAB 0.75MG 4 B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

Drug Name Drug Tier

Requirements/Limits

BEXSERO 3

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 3

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

KINRIX 3

M-M-R II 3

MENACTRA 3

MENOMUNE-A/C/Y/W-135 3

MENVEO 3

PEDVAX HIB 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 4 NM

TENIVAC 3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

K-TAB 8meq, 20meq 3

K-TAB 10meq 2

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Drug Name Drug Tier

Requirements/Limits

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m10 1 klor-con m15 3

klor-con m20 1 klor-con pow 20meq 1

klor-con spr cap 8meq

(generic of MICRO-K) 1

klor-con spr cap 10meq (generic of MICRO-K)

1

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3

magnesium sulfate SOLN

50% 1

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

1

MICRO-K 2

POTASSIUM CHLORIDE SOLN 10%, 20%

1

potassium chloride TBCR 8meq

1

POTASSIUM CHLORIDE TBCR 20meq

1

potassium chloride caps er

(generic of MICRO-K) 1

potassium chloride microencapsulated crystals cr

1

POTASSIUM CHLORIDE TAB CR 10 MEQ

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

Drug Name Drug Tier

Requirements/Limits

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-PF INJ 10% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID INJ 20% 1 B/D

plenamine 1 B/D

premasol 6% 1 B/D

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Drug Name Drug Tier

Requirements/Limits

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

TRAVASOL 3 B/D

TROPHAMINE INJ 6% 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

ISOLYTE S 3

KCL0.15%/D5W/NACL0.2% 1

KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

Drug Name Drug Tier

Requirements/Limits

KCL 0.075%/D5W/NACL 0.45%

1

KCL IN NACL INJ .15-0.45 1

KCL/D5W/NACL INJ 0.22%/0.45%

1

KCL/D5W/NACL INJ .15/.33% 1

KCL/D5W/NACL INJ .15/.45% 1

KCL/NACL INJ 0.15%-0.9% 1

LACTATED RINGERS VIAFLEX

1

NORMOSOL-M IN D5W 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3 pot chloride inj 2meq/ml 1

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

1

POTASSIUM CHLORIDE 0.3%/D

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of

ROCALTROL) CAPS 1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of

ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL) CAPS 1mcg, 2.5mcg

4 B/D NM

doxercalciferol (generic of

HECTOROL) CAPS .5mcg 1 B/D

doxercalciferol (generic of

HECTOROL) SOLN 1 B/D

HECTOROL CAPS 1mcg, 2.5mcg

4 B/D NM

HECTOROL CAPS .5mcg 2 B/D

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Drug Name Drug Tier

Requirements/Limits

HECTOROL SOLN 3 B/D

paricalcitol (generic of

ZEMPLAR) CAPS 1mcg, 2mcg

1 B/D

paricalcitol CAPS 4mcg 1 B/D

PARICALCITOL SOLN 1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ROCALTROL 2 B/D

ZEMPLAR CAPS 1mcg 2 B/D

ZEMPLAR CAPS 2mcg 4 B/D NM

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

blephamide OINT 3

BLEPHAMIDE SUSP 3

MAXITROL 3 neomycin-polymy-dexameth

(generic of MAXITROL) 1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX SUSP 3

TOBRADEX ST 2 tobramycin-dexamethasone

(generic of TOBRADEX) 1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1 bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

BLEPH-10 3

CILOXAN OIN 0.3% OP 3

CILOXAN SOL 0.3% OP 3 ciprofloxacin hcl (ophth)

(generic of CILOXAN) 1

erythromycin (ophth) 1 garamycin 3

Drug Name Drug Tier

Requirements/Limits

gatifloxacin (ophth) (generic of

ZYMAXID) 1

gentak 1 gentamicin sulfate (ophth)

OINT 1

gentamicin sulfate (ophth)

(generic of GARAMYCIN) SOLN

1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 3

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

neosporin solution 3

OCUFLOX 3

ofloxacin (ophth) (generic of

OCUFLOX) 1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3

sulfacet sod oin 10% op 1 sulfacetamide sodium (ophth)

(generic of BLEPH-10) 1

tobramycin (ophth) (generic of

TOBREX) 1

TOBREX OINT 0.3% 3

TOBREX SOL 0.3% OP 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

VIROPTIC 2

ZIRGAN 3

ZYMAXID 3

ANTI-INFLAMMATORIES ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

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Drug Name Drug Tier

Requirements/Limits

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

FML LIQUIFILM 3

ILEVRO 3

ketorolac tromethamine (ophth) (generic of ACULAR

LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

1

LOTEMAX 2

MAXIDEX 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3 azelastine drop 0.05% 1

BEPREVE 3

cromolyn sodium (ophth) 1

ELESTAT 3

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

olopatadine hcl (generic of PATANOL)

1

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA

Drug Name Drug Tier

Requirements/Limits

ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

BETAGAN 3

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT 3

COSOPT PF 2 dorzolamide hcl (generic of

TRUSOPT) 1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of

BETAGAN) .5% 1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth)

(generic of TIMOPTIC) 1

TIMOLOL MALEATE GEL 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 2

TRUSOPT 3

XALATAN 3

ZIOPTAN 2

MISCELLANEOUS alcaine 3

CYSTARAN 4 NM LA PA

EYLEA 4 NM PA

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59

Drug Name Drug Tier

Requirements/Limits

LACRISERT 3

LUCENTIS 4 NM PA

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of

ALCAINE) SOLN 1

RESTASIS 2

RESPIRATORY

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

QL (60 inhalations / 30 days)

2 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

2 QL

ipratropium-albuterol 1 B/D

STIOLTO RESPIMAT QL (1 inhaler / 30 days)

3 QL

ANTICHOLINERGICS ATROVENT 2

ATROVENT HFA QL (2 inhalers / 30 days)

3 QL

INCRUSE ELLIPTA QL (1 inhaler / 30 days)

3 QL

ipratropium bromide (nasal)

(generic of ATROVENT) 1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

SPIRIVA RESPIMAT QL (1 inhaler / 30 days)

2 QL

TUDORZA PRESSAIR QL (1 inhaler / 30 days)

3 QL

TUDORZA PRESSAIR (INSTITUTIONAL PACK)


3 QL

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 QL (1 bottle / 30 days)

3 QL

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 3

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

Drug Name Drug Tier

Requirements/Limits

cetirizine syrup 1

CLARINEX 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of

CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN


levocetirizine soln 2.5mg/5ml

(generic of XYZAL) 1

levocetirizine tab 5 mg

(generic of XYZAL) 1

olopatadine hcl (nasal) (generic of PATANASE)

1

PATANASE 3

XYZAL SOLN 3

XYZAL TABS 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP;

TABS 1

albuterol sulfate er (generic of

VOSPIRE ER) 1

ARCAPTA NEOHALER QL (30 caps / 30 days)

2 QL

BROVANA 3 B/D

FORADIL AEROLIZER QL (60 caps / 30 days)

2 QL

levalbuterol conc 1.25mg/0.5ml (generic of

XOPENEX CONCENTRATE)

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

levalbuterol hcl (generic of

XOPENEX) NEBU .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA QL (2 inhalers / 30 days)

2 QL

PROAIR RESPICLICK QL (2 inhalers / 30 days)

3 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

3 QL

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Drug Name Drug Tier

Requirements/Limits

SEREVENT DISKUS QL (60 inhalations / 30 days)

2 QL

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

3 QL

terbutaline sulfate SOLN 4 NM

terbutaline sulfate TABS 1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

vospire 2

XOPENEX 3 B/D

XOPENEX CONCENTRATE 3 B/D

XOPENEX HFA QL (2 inhalers / 30 days)

3 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3

montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

SINGULAIR 3 zafirlukast (generic of

ACCOLATE) 1

ZYFLO CR 4 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%,

20% 1 B/D

ADRENACLICK 3

ARALAST NP 500mg, 800mg, 1000mg

4 NM LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 4 NM PA

GLASSIA 4 NM LA PA

KALYDECO 4 NM PA

OFEV 4 NM PA

ORKAMBI 4 NM PA

PROLASTIN-C 4 NM LA PA

PULMOZYME 4 B/D NM

tyzine .05% 3

XOLAIR 4 NM LA PA

Drug Name Drug Tier

Requirements/Limits

ZEMAIRA 4 NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 inhalers / 30 days) 3 QL

budesonide (nasal) (generic

of RHINOCORT AQUA) QL (2 bottles / 30 days)

1 QL

flunisolide (nasal)

QL (2 bottles / 30 days) 1 QL

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL

NASONEX QL (2 inhalers / 30 days)

2 QL

OMNARIS QL (1 inhaler / 30 days)

3 QL

QNASL QL (1 inhaler / 30 days)

3 QL

QNASL CHILDRENS QL (1 inhaler / 30 days)

3 QL

RHINOCORT AQUA QL (2 bottles / 30 days)

3 QL

triamcinolone acetonide (nasal)

QL (1 bottle / 30 days)

1 QL

VERAMYST QL (1 bottle / 30 days)

3 QL

ZETONNA QL (1 inhaler / 30 days)

3 QL

STEROID INHALANTS AEROSPAN

QL (2 inhalers / 30 days) 3 QL

ALVESCO QL (2 inhalers / 30 days)

3 QL

ARNUITY ELLIPTA QL (30 inhalations / 30 days)

3 QL

ASMANEX QL (2 inhalers / 30 days)

2 QL

ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)

2 QL

ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)

2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

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61

Drug Name Drug Tier

Requirements/Limits

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 0.5MG/2 ML

3 B/D

PULMICORT INH SUSP 0.25MG/2 ML

3 B/D

PULMICORT INH SUSP 1MG/2ML

4 B/D NM

QVAR 40mcg/act QL (1 inhaler / 30 days)

2 QL

QVAR 80mcg/act QL (2 inhalers / 30 days)

2 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


2 QL

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

BREO ELLIPTA QL (60 blisters / 30 days)

3 QL

DULERA QL (1 inhaler / 30 days)

2 QL

SYMBICORT QL (1 inhaler / 30 days)

3 QL

XANTHINES aminophylline inj 1 elixophyllin 3

theo-24 3

theophylline 1

TOPICAL

DERMATOLOGY, ACNE ABSORICA 4 NM

ACANYA 2

ACZONE 3

Drug Name Drug Tier

Requirements/Limits

adapalene (generic of

DIFFERIN) CREA; GEL 1

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

BENZACLIN 2

BENZAMYCIN 3 benzoyl peroxide-erythromycin

(generic of BENZAMYCIN)

1

claravis 1

CLEOCIN-T 3

CLINDAGEL 3 clindamax (generic of

CLEOCIN-T) 1

clindamycin phosphate (topical) (generic of

EVOCLIN) FOAM

1

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN; SOLN; SWAB

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN WITH PUMP)

1

clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of

DUAC)

1

DIFFERIN 2

DUAC 3

EPIDUO 2

EPIDUO FORTE 3 ery pad 2% 1

erygel 3

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid)

SOLN 1

EVOCLIN 3

FABIOR 3

KLARON 3 myorisan 1

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Drug Name Drug Tier

Requirements/Limits

neuac gel 1.2-5% (generic of

DUAC) 1

ONEXTON 3

RETIN-A 3

RETIN-A MICRO 2

RETIN-A MICRO PUMP 2 sulfacetamide sodium (acne)

(generic of KLARON) 1

tretin-x CREA 3 tretinoin (generic of RETIN-A)

CREA 1

TRETINOIN GEL .01% 1

tretinoin (generic of ATRALIN) GEL .05%

1

tretinoin (generic of RETIN-A)

GEL .025% 1

TRETINOIN MICROSPHERE 1

VELTIN 3

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN 2

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN 3

gentamicin sulfate (topical) 1 mupirocin (generic of

BACTROBAN) OINT 1

mupirocin calcium (topical)

(generic of BACTROBAN) 1

SILVADENE 2

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

SULFAMYLON PACK 4 NM

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1 clotrimazole (topical) 1

Drug Name Drug Tier

Requirements/Limits

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

EXTINA 3

ketoconazole (topical) CREA 1 ketoconazole (topical)

(generic of EXTINA) FOAM 1

ketodan aer 2% (generic of

EXTINA) 1

LOPROX SHAMPOO 3

LUZU 2

MENTAX 3

NAFTIFINE HCL 1

NAFTIN 2

nyamyc 1 nystatin (topical) 1

nystatin pow 100000 1 nystop 1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC anusol hc 2

CORTIFOAM 2

procto-pak 1 proctosol hc 2.5 % (generic of

ANUSOL-HC) 1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of

SORIATANE) 4 NM PA

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 4 NM PA

COSENTYX SENSOREADY PEN

4 NM PA

DOVONEX CRE 0.005% 3

methoxsalen rapid (generic of

OXSORALEN ULTRA) 4 NM

8-MOP 3

OXSORALEN ULTRA 4 NM

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Drug Name Drug Tier

Requirements/Limits

SORIATANE 4 NM PA

SORILUX 2

STELARA 4 NM PA

TAZORAC 2 PA

VECTICAL 4 NM

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo

(generic of NIZORAL) 1

NIZORAL 3

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS aclovate 2

ala-cort 1 ala-scalp 3

alclometasone dipropionate

(generic of ACLOVATE) CREA

1

alclometasone dipropionate

OINT 1

amcinonide CREA; LOTN 1 amcinonide OINT 3

apexicon 1

apexicon e cream 3 betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of

DIPROLENE) LOTN; OINT

1

betamethasone valerate

CREA; LOTN; OINT 1

betamethasone valerate

(generic of LUXIQ) FOAM 1

calcipotriene/betamethasone

(generic of TACLONEX) 4 NM

CAPEX 2

clobetasol e cream 0.05%

(generic of TEMOVATE E) 1

clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN

1

clobetasol propionate (generic

of OLUX) FOAM 1

Drug Name Drug Tier

Requirements/Limits

clobetasol propionate (generic

of CLOBEX) LIQD; LOTN; SHAM

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX 4 NM

CLOCORTOLONE PIVALATE 1

clodan sha 0.05% (generic of CLOBEX)

1

CLODERM PUMP 2

CORDRAN TAPE 3 cormax (generic of

TEMOVATE) 1

CUTIVATE CREA 3

CUTIVATE LOTN 4 NM

DERMA-SMOOTHE/FS BODY

3

DERMA-SMOOTHE/FS SCALP

3

DERMATOP 3

DERMATOP CREAM 0.1% 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of

DESOWEN) LOTN; OINT 1

DESOWEN CREA 2

desowen LOTN 2

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of

TOPICORT) GEL 1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of

TOPICORT) OINT .25% 1

diflorasone diacetate 1

DIPROLENE LOTN 3

DIPROLENE OINT 2

DIPROLENE AF 3

ELOCON CREA; LOTN 3

ELOCON OINT 2 fluocinolone acetonide

CREA .01% 1

fluocinolone acetonide

(generic of SYNALAR) CREA .025%

1

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Drug Name Drug Tier

Requirements/Limits


(generic of DERMA-SMOOTHE/FS BODY) OIL .01%

1


(generic of DERMA-SMOOTHE/FS SCALP) OIL .01%

1


(generic of SYNALAR) OINT 1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of

VANOS) CREA .1% 4 NM

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1 fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN

1

fluticasone propionate OINT 1 halobetasol propionate

(generic of ULTRAVATE) 1

HALOG 3

hydrocortisone (topical) 1 hydrocortisone butyrate

(generic of LOCOID) 1

hydrocortisone butyrate hydrophilic lipo base (generic

of LOCOID LIPOCREAM)

1

hydrocortisone valerate

CREA 1

hydrocortisone valerate

(generic of WESTCORT) OINT

1

KENALOG 3

LOCOID CREA 3

LOCOID LOTN; OINT; SOLN

2

LOCOID LIPOCREAM 4 NM

lokara (generic of

DESOWEN) 1

Drug Name Drug Tier

Requirements/Limits

mometasone furoate (generic

of ELOCON) CREA; OINT; SOLN

1

OLUX 4 NM

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

psorcon 3

SYNALAR CREA; OINT 3

SYNALAR SOLN 2

TACLONEX 4 NM

TEMOVATE CREAM 2

TEMOVATE E CREAM 2

TEMOVATE GEL 2

TEMOVATE OIN 2

TEMOVATE SOLN 3

texacort 2

topicort CREA 3 topicort GEL 2

TOPICORT OINT .05% 2 topicort OINT .25% 2

TOPICORT SPRAY 0.25% 3

triamcinolone acetonide (topical) (generic of

KENALOG) AERS

1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

trianex 3

triderm 1

ULTRAVATE 2

VANOS 4 NM

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

lidocaine OINT 1 lidocaine (generic of

LIDODERM) PTCH 1 PA

lidocaine hcl GEL 1 lidocaine hcl (generic of

XYLOCAINE) SOLN 4% 1

lidocaine-prilocaine (generic

of EMLA) 1 B/D

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 4% 3

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Drug Name Drug Tier

Requirements/Limits

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of

ZOVIRAX) 1

ALDARA 4 NM

ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CARAC 4 NM

CONDYLOX 2

DENAVIR 4 NM

diclofenac sodium (actinic keratoses) (generic of

SOLARAZE)

4 NM PA

diclofenac sodium (topical) 1

DOXYCYCLINE (ROSACEA) 1

EFUDEX 3

ELIDEL 2 PA

FINACEA AER 15% 2

FINACEA GEL 15% 2

fluorouracil (topical) (generic of EFUDEX) CREA 5%

1

FLUOROURACIL (TOPICAL) CREA .5%

4 NM

fluorouracil (topical) SOLN 1 imiquimod (generic of

ALDARA) CREA 1

LAC-HYDRIN 2 laclotion lot 12% (generic of

LAC-HYDRIN) 1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (topical)

(generic of METROCREAM) CREA

1


(generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL

.75% 1


(generic of METROLOTION) LOTN

1

NORITATE 4 NM

ORACEA 2

PANRETIN 4 NM

Drug Name Drug Tier

Requirements/Limits

PENNSAID 3

PICATO 4 NM

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 3 PA

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOLARAZE 4 NM PA

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1 PA

TARGRETIN GEL 4 NM PA

TOLAK 3

VALCHLOR 4 NM LA PA

VOLTAREN GEL 1% 2

XERESE 4 NM

ZOVIRAX CREA; OINT 4 NM

ZYCLARA 4 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3 malathion (generic of OVIDE) 1

ovide 2

permethrin (generic of ELIMITE)

1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu

(generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 4 NM PA

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of

EVOXAC) 1

chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1

clotrimazole TROC 1

EVOXAC 2 lidocaine hcl (mouth-throat) 1

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Drug Name Drug Tier

Requirements/Limits

nystatin (mouth-throat) 1

ORAVIG 4 NM

paroex sol 0.12% (generic of PERIDEX)

1

periogard soln 0.12% (generic

of PERIDEX) 1

PILOCARPINE HCL (ORAL) 5mg

1

pilocarpine hcl (oral) (generic

of SALAGEN) 7.5mg 1

SALAGEN 2 triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1 acetic acid (otic) 1

acetic acid sol/hc 1 acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

DERMOTIC 3 fluocinolone acetonide (otic)

(generic of DERMOTIC) 1

neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN

1

neomycin-polymyxin-hc (otic)

SUSP 1

ofloxacin (otic) 1

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Index 8 8-MOP...............................62 A abacavir sulfate ...................9 abacavir sulfate-lamivudine-zidovudine ..........................................9 ABELCET............................8 ABILIFY

see aripiprazole tabs .....29 ABILIFY DISCMELT TAB 10MG ................................29 ABILIFY MAINTENA .........29 ABILIFY TABS ..................29 ABRAXANE ......................14 ABSORICA .......................61 ABSTRAL............................2 acamprosate calcium ........36 ACANYA ...........................61 acarbose ...........................38 ACCOLATE .......................60

see zafirlukast ...............60 ACCUPRIL ........................17

see quinapril hcl ............17 ACCURETIC .....................16

see quinapril-hydrochlorothiazide ..................................17

acebutolol hcl ....................20 ACEON

see perindopril erbumine ......................................17

acetaminophen w/ codeine 1, 2 acetaminophen-caff-dihydrocod ........................................2 acetasol hc ........................66 acetazolamide ...................22 acetazolamide sodium ......22 acetic acid .........................65 acetic acid (otic) ................66 acetic acid sol/hc ...............66 acetic acid-aluminum acetate ..........................................66 acetylcysteine ...................60 ACIPHEX ..........................50

see rabeprazole sodium 50

ACIPHEX SPR CAP 10MG .......................................... 50 ACIPHEX SPR CAP 5MG . 50 acitretin ............................. 62 aclovate ............................ 63 ACLOVATE

see alclometasone dipropionate .................. 63

ACTEMRA ........................ 53 ACTHIB ............................. 54 ACTIGALL ........................ 49

see ursodiol ................... 50 ACTIMMUNE .................... 53 ACTIQ ................................. 2

see fentanyl citrate .......... 3 ACTONEL ......................... 41

see risedronate sodium . 41 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 40

ACTOPLUS MET TAB 15-500MG ......................... 38 ACTOPLUS MET TAB 15-850MG ......................... 38 ACTOPLUS MET XR 15-1000MG ....................... 38 ACTOPLUS MET XR 30-1000MG ....................... 38 ACTOS ............................. 38

see pioglitazone hcl ....... 40 ACULAR ........................... 57

see ketorolac tromethamine (ophth) .... 58

ACULAR LS ...................... 57 see ketorolac tromethamine (ophth) .... 58

ACUVAIL .......................... 57 acyclovir ............................ 10 acyclovir sodium ............... 10 acyclovir topical ................ 65 ACZONE ........................... 61 ADACEL ........................... 54 ADAGEN ........................... 44 ADALAT CC ...................... 20

see afeditab cr ............... 20 see nifedipine ................ 21

adapalene ......................... 61

ADCIRCA ......................... 23 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg ........ 32 see amphetamine-dextroamphetamine tab 12.5 mg ..... 32 see amphetamine-dextroamphetamine tab 15 mg ........ 32 see amphetamine-dextroamphetamine tab 20 mg ........ 32 see amphetamine-dextroamphetamine tab 30 mg ........ 32 see amphetamine-dextroamphetamine tab 5 mg .......... 32 see amphetamine-dextroamphetamine tab 7.5 mg ....... 32

adderall tab 10mg ............. 31 adderall tab 12.5mg .......... 31 adderall tab 15mg ............. 31 adderall tab 20mg ............. 32 adderall tab 30mg ............. 32 adderall tab 5mg ............... 31 adderall tab 7.5mg ............ 31 ADDERALL XR

see amphetamine cap 10mg er ......................... 32 see amphetamine cap 15mg er ......................... 32 see amphetamine cap 20mg er ......................... 32 see amphetamine cap 25mg er ......................... 32 see amphetamine cap 30mg er ......................... 32 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 32

ADDERALL XR CAP 10MG.......................................... 32

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ADDERALL XR CAP 15MG ..........................................32 ADDERALL XR CAP 20MG ..........................................32 ADDERALL XR CAP 25MG ..........................................32 ADDERALL XR CAP 30MG ..........................................32 ADDERALL XR CAP 5MG 32 adefovir dipivoxil ...............10 ADEMPAS ........................23 adoxa ................................13 ADOXA

see doxycycline (monohydrate) ...............13

ADOXA PAK 1/150 see doxycycline (monohydrate) ...............13

ADRENACLICK ................60 adrucil ...............................14 ADVAIR DISKUS ..............61 ADVAIR HFA ....................61 ADVICOR..........................19 AEROSPAN ......................60 afeditab cr .........................20 AFINITOR .........................15 AFINITOR DISPERZ .........15 AFREZZA..........................46 AGGRENOX .....................52 AGRYLIN ..........................52

see anagrelide hcl .........52 a-hydrocort ........................45 AKYNZEO .........................47 ala-cort ..............................63 ala-scalp............................63 ALBENZA............................7 albuterol sulfate .................59 albuterol sulfate er ............59 alcaine...............................58 ALCAINE

see proparacaine hcl .....59 alclometasone dipropionate ..........................................63 ALCOHOL SWABS ...........38 ALDACTAZIDE .................22

see spironolactone & hydrochlorothiazide .......22

ALDACTAZIDE TAB 50/50

.......................................... 22 ALDACTONE .................... 17

see spironolactone ........ 17 ALDARA ........................... 65

see imiquimod ............... 65 ALDURAZYME ................. 44 ALECENSA ....................... 15 alendronate sodium .......... 41 alfuzosin hcl ...................... 50 ALIMTA ............................. 14 ALINIA ................................ 7 ALKERAN ......................... 13

see melphalan hcl ......... 13 allopurinol tab ..................... 1 almotriptan malate ............ 34 ALOCRIL .......................... 58 ALOMIDE .......................... 58 ALOPRIM ............................ 1 ALORA .............................. 44 alosetron hcl ..................... 49 ALOXI ............................... 47 ALPHAGAN P 0.1% .......... 58 ALPHAGAN P 0.15% ........ 58 alprazolam ........................ 23 ALREX .............................. 57 ALSUMA ........................... 34 ALTABAX .......................... 62 ALTACE ............................ 17

see ramipril .................... 17 altavera ............................. 41 ALTOPREV ....................... 19 ALVESCO ......................... 60 amantadine hcl ................. 28 AMARYL ........................... 38

see glimepiride .............. 39 AMBIEN ............................ 33

see zolpidem tartrate ..... 34 AMBISOME ........................ 8 amcinonide ....................... 63 AMERGE .......................... 34

see naratriptan hcl ......... 34 amethia 91 day ................. 41 amethyst 28 day ............... 41 amifostine crystalline......... 16 amikacin sulfate .................. 6 amiloride & hydrochlorothiazide ........... 22 amiloride hcl ...................... 22

aminophylline inj ............... 61 AMINOSYN ...................... 55 AMINOSYN 7%/ELECTROLYTES ....... 55 AMINOSYN II.................... 55 AMINOSYN II 8.5%/ELECTROL.............. 55 AMINOSYN INJ 8.5/LYTE 55 AMINOSYN M................... 55 AMINOSYN-HBC .............. 55 AMINOSYN-PF 7% ........... 55 AMINOSYN-PF INJ 10% .. 55 AMINOSYN-RF................. 55 amiodarone hcl ................. 18 amiodarone inj 50mg/ml ... 18 AMITIZA ........................... 49 amitriptyline hcl ................. 27 amlodipine besylate .......... 20 amlodipine besylate/atorv . 20 amlodipine besylate-benazepril hcl ..... 16 amlodipine besylate-valsartan tab 10-160 mg ........................ 17 amlodipine besylate-valsartan tab 10-320 mg ........................ 17 amlodipine besylate-valsartan tab 5-160 mg ..................................... 17 amlodipine besylate-valsartan tab 5-320 mg ..................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 17 ammonium chloride .......... 54

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ammonium lactate .............65 amnesteem .......................61 amoxapine ........................27 amoxicillin .........................12 amoxicillin & pot clavulanate ..........................................12 amoxicillin-clarithromycin w/ lansoprazole ......................49 amphetamine cap 10mg er ..........................................32 amphetamine cap 15mg er ..........................................32 amphetamine cap 20mg er ..........................................32 amphetamine cap 25mg er ..........................................32 amphetamine cap 30mg er ..........................................32 amphetamine-dextroamphetamine cap sr 24hr 5 mg ....32 amphetamine-dextroamphetamine tab 10 mg ...............32 amphetamine-dextroamphetamine tab 12.5 mg ............32 amphetamine-dextroamphetamine tab 15 mg ...............32 amphetamine-dextroamphetamine tab 20 mg ...............32 amphetamine-dextroamphetamine tab 30 mg ...............32 amphetamine-dextroamphetamine tab 5 mg .................32 amphetamine-dextroamphetamine tab 7.5 mg ..............32 amphotericin b ....................8 ampicillin & sulbactam sodium ..............................12 ampicillin cap 250mg ........12 ampicillin cap 500 mg .......12 ampicillin inj .......................12 ampicillin sodium ...............12 ampicillin susp ...................12 AMPYRA ...........................35 ANAFRANIL ......................27

see clomipramine hcl .....27 anagrelide hcl ....................52 ANAPROX ..........................1 ANAPROX DS ....................1

see naproxen sodium ...... 1 anastrozole ....................... 15 ANCOBON .......................... 8

see flucytosine ................ 8 ANDRODERM .................. 37 ANDROGEL ...................... 37 ANDROGEL 1% ............... 37 ANDROGEL 1.62%........... 37 ANDROGEL PUMP .......... 37 ANORO ELLIPT AER 62.5-25.............................. 59 antabuse ........................... 36 ANTABUSE

see disulfiram ................ 37 ANTARA ........................... 19 anusol hc .......................... 62 ANUSOL-HC

see proctosol hc 2.5 % .. 62 see proctozone hc ......... 62

apexicon ........................... 63 apexicon e cream ............. 63 APIDRA ............................ 38 APIDRA SOLOSTAR ........ 38 APLENZIN ........................ 27 APOKYN ........................... 28 apri 28 day ........................ 41 APRISO ............................ 48 APTENSIO XR .................. 32 APTIOM ............................ 23 APTIVUS ............................ 9 ARALAST NP ................... 60 ARALEN

see chloroquine phosphate ....................... 9

aranelle 28 ........................ 41 ARANESP ALBUMIN FREE .......................................... 52 ARAVA .............................. 53

see leflunomide ............. 53 ARCALYST ....................... 53 ARCAPTA NEOHALER .... 59 ARICEPT .......................... 26

see donepezil tab hcl 23mg ............................. 26 see donepezil tabs 10mg ...................................... 26 see donepezil tabs 5mg 26

ARIMIDEX ........................ 15

see anastrozole ............. 15 aripiprazole odt ................. 29 aripiprazole oral solution 1 mg/ml ................................ 29 aripiprazole tabs ............... 29 ARIXTRA .......................... 51

see fondaparinux sodium ...................................... 51

ARNUITY ELLIPTA ........... 60 AROMASIN ...................... 15

see exemestane ............ 15 ARRANON ........................ 14 ARTHROTEC 50 ................ 1

see diclofenac w/ misoprostol ...................... 1

ARTHROTEC 75 ................ 1 see diclofenac w/ misoprostol ...................... 1

ARZERRA ........................ 14 ASACOL HD ..................... 48 ashlyna 91 day.................. 41 ASMANEX ........................ 60 ASMANEX HFA ................ 60 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG.................. 2 ASPIRIN-DIPYRIDAMOLE.......................................... 52 ASTAGRAF XL ................. 53 ASTEPRO ........................ 59

see azelastine spr 0.15% ...................................... 59

ATACAND ........................ 18 see candesartan cilexetil ...................................... 18

ATACAND HCT ................ 17 see candesartan cilexetil-hydrochlorothiazide .................................... 18

ATELVIA ........................... 41 see risedronate sodium . 41

atenolol ............................. 20 atenolol & chlorthalidone .. 20 ATGAM ............................. 53 ATIVAN ............................. 23

see lorazepam............... 23 atorvastatin calcium .......... 19 atovaquone ......................... 7

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atovaquone-proguanil hcl tab 250-100 mg .........................9 atovaquone-proguanil hcl tab 62.5-25 mg ..........................9 ATRALIN ...........................61

see tretinoin ...................62 ATRIPLA .............................9 ATROPINE SULFATE.......48 ATROVENT ......................59

see ipratropium bromide (nasal) ...........................59

ATROVENT HFA ..............59 AUBAGIO..........................35 aubra 28 day .....................41 AUGMENTIN ....................12

see amoxicillin & pot clavulanate ....................12

AUGMENTIN ES-600 .......12 see amoxicillin & pot clavulanate ....................12

AUGMENTIN XR ..............12 see amoxicillin & pot clavulanate ....................12

AURYXIA ..........................46 AUVI-Q..............................60 AVALIDE ...........................18

see irbesartan-hydrochlorothiazide ................................18

AVAPRO ...........................18 see irbesartan ................18

AVASTIN...........................14 AVC ..................................51 AVEED ..............................37 AVELOX............................12

see moxifloxacin hcl ......12 AVELOX ABC PACK ........12 aviane 28 ..........................41 AVITA................................61 AVODART.........................50

see dutasteride ..............50 AVONEX ...........................35 AVONEX PEN ...................35 AVYCAZ............................11 AXERT ..............................34

see almotriptan malate ..34 AXID

see nizatidine ................48

AXIRON ............................ 37 aygestin ............................ 47 AYGESTIN

see norethindrone acetate ...................................... 47

azacitidine ......................... 14 AZACTAM ........................... 7

see aztreonam ................ 7 AZACTAM/DEX INJ 1GM ... 7 AZACTAM/DEX INJ 2GM ... 7 azasan .............................. 53 AZASITE ........................... 57 azathioprine ...................... 53 azelastine drop 0.05% ...... 58 azelastine spr 0.1%........... 59 azelastine spr 0.15%......... 59 AZELEX ............................ 61 AZILECT ........................... 28 azithromycin ...................... 11 AZITHROMYCIN............... 11 AZOPT .............................. 58 AZOR ................................ 18 aztreonam ........................... 7 AZULFIDINE ..................... 48

see sulfasalazine ir ........ 49 AZULFIDINE EN-TABS .... 48

see sulfasalazine dr....... 49 B bacitracin (ophthalmic) ...... 57 bacitracin-polymyxin b (ophth) .............................. 57 bacitracin-poly-neomycin-hc .......................................... 57 baclofen ............................ 36 BACTOCILL INJ DEX 1GM .......................................... 12 BACTOCILL INJ DEX 2GM .......................................... 12 BACTRIM ............................ 7

see sulfamethoxazole-trimethop ...................................... 8

BACTRIM DS ...................... 7 see sulfamethoxazole-trimethop ...................................... 8

BACTROBAN ................... 62 see mupirocin ................ 62

see mupirocin calcium (topical) ......................... 62

BACTROBAN NASAL ....... 62 balsalazide disodium ........ 48 balziva 28 day ................... 41 BANZEL SUS 40MG/ML ... 24 BANZEL TAB 200MG ....... 24 BANZEL TAB 400MG ....... 24 BARACLUDE .................... 10

see entecavir ................. 10 BCG VACCINE ................. 54 BECONASE AQ................ 60 bekyree 28 day ................. 41 BELEODAQ ...................... 14 benazepril & hydrochlorothiazide........... 16 benazepril hcl.................... 17 BENICAR .......................... 18 BENICAR HCT ................. 18 BENLYSTA ....................... 53 BENTYL ............................ 48

see dicyclomine hcl ....... 48 BENZACLIN ..................... 61 BENZACLIN WITH PUMP

see clindamycin phosphate-benzoyl peroxide ........................ 61

BENZAMYCIN .................. 61 see benzoyl peroxide-erythromycin ... 61

benzoyl peroxide-erythromycin ...... 61 benztropine mesylate ........ 28 BENZTROPINE MESYLATE.......................................... 28 BEPREVE ......................... 58 BERINERT ....................... 52 BESIVANCE ..................... 57 BETAGAN ........................ 58

see levobunolol hcl ........ 58 betamethasone dipropionate (topical) ............................. 63 betamethasone dipropionate augmented ........................ 63 betamethasone valerate ... 63 BETAPACE ...................... 18

see sorine ..................... 18 see sotalol hcl ............... 18

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BETAPACE AF .................18 see sotalol hcl (afib/afl) ..19

BETASERON ....................35 betaxolol hcl ......................20 betaxolol hcl (ophth) ..........58 bethanechol chloride .........51 BETHKIS.............................6 BETIMOL ..........................58 BETOPTIC-S ....................58 bexarotene ........................16 BEXSERO.........................54 BEYAZ ..............................41 BIAXIN ..............................11

see clarithromycin .........12 BIAXIN XL

see clarithromycin .........12 bicalutamide ......................15 BICILLIN C-R ....................12 BICILLIN L-A .....................12 BICNU ...............................13 BIDIL .................................22 BILTRICIDE ........................7 BINOSTO ..........................41 bisoprolol & hydrochlorothiazide ...........20 bisoprolol fumarate ...........20 BIVIGAM ...........................53 bleomycin sulfate ..............14 BLEPH-10 .........................57

see sulfacetamide sodium (ophth) ...........................57

blephamide .......................57 BLEPHAMIDE ...................57 blisovi 21 fe 1/20 28 day pack ..................................41 blisovi 24 fe 1/20 28 day ...41 BONIVA ............................41

see ibandronate sodium 41 see ibandronate tab 150mg ...........................41

BOOSTRIX .......................54 BOSULIF...........................15 BOTOX INJ 100UNIT ........36 BOTOX INJ 200UNIT ........36 BREO ELLIPTA ................61 BREVICON-28 ..................41

see necon 0.5/35 28 day ......................................43

see nortrel 0.5/35 28 day ...................................... 43

briellyn 28 day ................... 41 BRILINTA .......................... 52 BRIMONIDINE SOL 0.15% .......................................... 58 brimonidine sol 0.2%......... 58 BRINTELLIX ..................... 27 BRISDELLE ...................... 35 bromfenac sodium (ophth) 57 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 57 bromocriptine mesylate ..... 28 BROVANA ........................ 59 budesonide ....................... 48 budesonide (inhalation)..... 60 budesonide (nasal) ........... 60 bumetanide ....................... 22 BUMEX

see bumetanide ............. 22 BUNAVAIL MIS 2.1-0.3MG .......................................... 36 BUNAVAIL MIS 4.2-0.7MG .......................................... 36 BUNAVAIL MIS 6.3-1MG .. 37 BUPHENYL

see sodium phenylbutyrate ...................................... 44

buprenorphine hcl ............. 37 buprenorphine hcl-naloxone hcl sl.................................. 37 buproban ........................... 37 bupropion hcl .................... 27 bupropion hcl (smoking deterrent) .......................... 37 buspirone hcl .................... 23 BUSULFEX ....................... 13 butorphanol nasal spray...... 2 butorphanol tartrate............. 2 BUTRANS ........................... 2 BYDUREON ..................... 38 BYETTA ............................ 38 BYSTOLIC ........................ 20 C cabergoline ....................... 46 CADUET ........................... 20

see amlodipine besylate/atorv ................ 20

cafergot tab 1-100mg ........ 34 CALAN .............................. 20

see verapamil hcl .......... 21 CALAN SR ........................ 20

see verapamil hcl .......... 21 calcipotriene ..................... 62 calcipotriene/betamethasone.......................................... 63 calcitonin (salmon) nasal spray ................................. 46 calcitrene oin 0.005% ....... 62 calcitriol ............................. 56 CALCITRIOL..................... 62 calcium acetate (phosphate binder) .............................. 46 camila 28 day.................... 41 CAMPTOSAR ................... 16

see irinotecan inj 100/5ml ...................................... 16 see irinotecan inj 40mg/2ml ...................... 16

CAMRESE LO TAB .......... 41 CANASA ........................... 48 CANCIDAS ......................... 8 candesartan cilexetil ......... 18 candesartan cilexetil-hydrochlorothiazide.......................................... 18 CANTIL ............................. 48 CAPASTAT SULFATE ...... 10 CAPEX ............................. 63 capital

and codeine..................... 2 CAPRELSA ...................... 15 captopril ............................ 17 captopril & hydrochlorothiazide........... 16 CARAC ............................. 65 CARAFATE ...................... 49

see sucralfate ................ 49 CARBAGLU ...................... 44 carbamazepine ................. 24 CARBATROL .................... 24

see carbamazepine ....... 24 carbidopa .......................... 28 CARBIDOPA/LEVODOPA/ENTACAPONE ................... 28 carbidopa-levodopa .......... 28

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carboplatin ........................16 CARDIZEM .......................20

see diltiazem hcl ............21 CARDIZEM CD .................20

see cartia xt ...................20 see diltiazem hcl coated beads.............................21

CARDIZEM LA ..................20 see matzim la ................21

CARDURA ........................17 see doxazosin mesylate 17

CARDURA XL ...................50 CARIMUNE NANOFILTERED ..............53 CARNITOR .......................44

see levocarnitine (metabolic modifiers) .....44

carteolol hcl (ophth) ..........58 cartia xt .............................20 carvedilol ...........................20 CASODEX ........................15

see bicalutamide ...........15 CATAPRES

see clonidine hcl ............22 CATAPRES TAB ...............22 CATAPRES-TTS DIS 0.1/24HR ...........................22 CATAPRES-TTS DIS 0.2/24HR ...........................22 CATAPRES-TTS DIS 0.3/24HR ...........................22 CATAPRES-TTS-1

see clonidine hcl ............22 CATAPRES-TTS-2

see clonidine hcl ............22 CATAPRES-TTS-3

see clonidine hcl ............22 CAYSTON...........................7 CEDAX..............................11 cefaclor .............................11 cefaclor er tab 500mg .......11 cefadroxil...........................11 cefazolin in dextrose 1gm/50ml-5% ....................11 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ................11 cefazolin inj .......................11 cefazolin sodium ...............11

cefdinir .............................. 11 CEFEPIME 1GM SOLN .... 11 CEFEPIME 2GM SOLN .... 11 CEFEPIME HCL AND DEXTROSE ...................... 11 cefepime inj 1gm ............... 11 cefepime inj 2gm ............... 11 cefixime ............................. 11 cefotaxime sodium ............ 11 cefotetan disodium ............ 11 cefoxitin sodium ................ 11 CEFOXITIN SODIUM IN DEXTROSE ...................... 11 cefpodoxime proxetil ......... 11 cefprozil ............................ 11 ceftazidime ........................ 11 CEFTAZIDIME/DEXTROSE .......................................... 11 CEFTIBUTEN ................... 11 CEFTIN ............................. 11

see cefuroxime axetil..... 11 ceftriaxone sodium ............ 11 cefuroxime axetil ............... 11 cefuroxime sodium ............ 11 CELEBREX

see celecoxib .................. 1 CELEBREX CAP 100MG .... 1 CELEBREX CAP 200MG .... 1 CELEBREX CAP 400MG .... 1 CELEBREX CAP 50MG ...... 1 celecoxib ............................. 1 CELEXA ............................ 27

see citalopram hydrobromide ................ 27

CELLCEPT see mycophenolate mofetil ...................................... 54

CELLCEPT CAP ............... 53 CELLCEPT INTRAVENOUS .......................................... 53 CELLCEPT SUSP............. 53 CELLCEPT TAB ............... 53 CELONTIN ........................ 24 CENTANY ......................... 62 cephalexin ......................... 11 CERDELGA ...................... 44 CEREZYME ...................... 44 CERVARIX ....................... 54

CESAMET ........................ 47 cetirizine syrup .................. 59 cevimeline hcl ................... 65 CHANTIX .......................... 37 CHANTIX CONTINUING MONTH ............................ 37 CHANTIX STARTER PACK.......................................... 37 CHEMET .......................... 41 chlorhexidine gluconate (mouth-throat) ................... 65 chloroquine phosphate ....... 9 chlorothiazide tabs ............ 22 chlorpromazine hcl............ 29 chlorpromazine inj............. 29 chlorthalidone ................... 22 cholestyramine.................. 19 cholestyramine light .......... 19 choline fenofibrate ............ 19 CHORIONIC GONADOTROPIN ............ 46 ciclopirox ........................... 62 ciclopirox cre 0.77% .......... 62 ciclopirox shampoo 1% ..... 62 ciclopirox sus 0.77% ......... 62 cidofovir ............................ 10 cilostazol ........................... 52 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 57

CILOXAN OIN 0.3% OP ... 57 CILOXAN SOL 0.3% OP .. 57 cimetidine ......................... 48 cimetidine sol 300/5ml ...... 48 CIMZIA ............................. 53 CINRYZE .......................... 52 CIPRO

see ciprofloxacin ........... 12 see ciprofloxacin hcl ...... 12

CIPRO HC ........................ 66 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w 12 CIPRO SUSP.................... 12 CIPRO TABS .................... 12 CIPRO XR ........................ 12

see ciprofloxacin er ....... 12 CIPRODEX ....................... 66 ciprofloxacin ...................... 12

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ciprofloxacin er ..................12 ciprofloxacin hcl ................12 ciprofloxacin hcl (ophth) ....57 ciprofloxacin in d5w ...........12 ciprofloxacn inj 400mg/40ml ..........................................12 cisplatin .............................16 citalopram hydrobromide...27 cladribine...........................14 claforan .............................11 CLAFORAN ......................11

see cefotaxime sodium ..11 CLAFORAN/D5W .............11 claravis ..............................61 CLARINEX ........................59

see desloratadine ..........59 CLARINEX REDITABS

see desloratadine ..........59 CLARINEX-D TAB 2.5-120 ..........................................59 clarithromycin .............. 11, 12 cleocin .................................7 CLEOCIN ..........................51

see clindamycin cre 2% vag ................................51 see clindamycin hcl .........7

CLEOCIN CAP 150MG .......7 CLEOCIN CAP 300MG .......7 CLEOCIN CAP 75MG .........7 CLEOCIN IN D5W ..............7

see clindamycin phosphate in d5w ............7

CLEOCIN INJ ......................7 CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ...................7

cleocin phosphate ...............7 CLEOCIN PHOSPHATE .....7

see clindamycin phosphate........................7

CLEOCIN VAG SUPP 100MG ..............................51 CLEOCIN-T .......................61

see clindamax ...............61 see clindamycin phosphate (topical) ........61

CLIMARA ..........................44

see estradiol .................. 44 CLINDAGEL ..................... 61 clindamax .......................... 61 clindamycin cre 2% vag .... 51 clindamycin hcl ................... 7 clindamycin palmitate hydrochloride ...................... 7 clindamycin phosphate ....... 7 clindamycin phosphate (topical) ............................. 61 clindamycin phosphate in d5w ..................................... 7 clindamycin phosphate-benzoyl peroxide .......................................... 61 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 61 CLINDESSE ..................... 51 CLINIMIX 2.75%/DEXTROSE 5% ..... 55 CLINIMIX 4.25%/DEXTROSE 10% ... 55 CLINIMIX 4.25%/DEXTROSE 20% ... 55 CLINIMIX 4.25%/DEXTROSE 25% ... 55 CLINIMIX 4.25%/DEXTROSE 5% ..... 55 CLINIMIX 5%/DEXTROSE 15%................................... 55 CLINIMIX 5%/DEXTROSE 20%................................... 55 CLINIMIX 5%/DEXTROSE 25%................................... 55 CLINIMIX E 2.75%/DEXTROSE 10% ... 55 CLINIMIX E 2.75%/DEXTROSE 5% ..... 55 CLINIMIX E 4.25%/D10 .... 55 CLINIMIX E 4.25%/DEXTROSE 25% ... 55 CLINIMIX E 4.25%/DEXTROSE 5% ..... 55 CLINIMIX E 5%/DEXTROSE 15%................................... 55 CLINIMIX E 5%/DEXTROSE 20%................................... 55

CLINIMIX E 5%/DEXTROSE 25% .................................. 55 clinisol 15 .......................... 55 clobetasol e cream 0.05% 63 clobetasol propionate ........ 63 clobetasol propionate emulsion ........................... 63 CLOBEX ........................... 63

see clobetasol propionate ...................................... 63 see clodan sha 0.05% ... 63

CLOCORTOLONE PIVALATE ........................ 63 clodan sha 0.05% ............. 63 CLODERM PUMP ............ 63 CLOLAR ........................... 14 clomipramine hcl ............... 27 clonazepam ...................... 24 clonidine hcl ...................... 22 clopidogrel bisulfate .......... 52 clorazepate dipotassium ... 24 clorpres ............................. 22 clotrimazole ...................... 65 clotrimazole (topical) ......... 62 clozapine .......................... 29 CLOZAPINE ..................... 29 CLOZAPINE ODT ............. 29 CLOZARIL ........................ 29

see clozapine ................ 29 COARTEM .......................... 9 codeine

and capital ....................... 2 CODEINE SULFATE .......... 3 COGENTIN ....................... 28 COLAZAL ......................... 48

see balsalazide disodium ...................................... 48

colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID ........................ 19

see colestipol hcl ........... 19 colestipol hcl ..................... 19 colistimethate sodium ......... 7 colocort ............................. 48 COLY-MYCIN M ................. 7

see colistimethate sodium ........................................ 7

COLY-MYCIN S ................ 66

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COLYTE-FLAVOR PACKS ..........................................49

see gavilyte-c ................49 COMBIGAN ......................58 COMBIVENT RESPIMAT .59 COMBIVIR ..........................9

see lamivudine-zidovudine ......................................10

COMETRIQ .......................15 COMPAZINE

see prochlorperazine maleate..........................48

COMPLERA ........................9 compro supp .....................47 COMTAN ..........................28 COMVAX ..........................54 CONCERTA ......................32 CONDYLOX ......................65

see podofilox .................65 constulose .........................49 CONZIP ..............................2 COPAXONE

see glatopa ....................36 COPAXONE INJ 40MG/ML ..........................................36 COPAXONE KIT 20MG/ML ..........................................36 COPEGUS ........................10

see moderiba tab 200mg ......................................10 see ribasphere ...............10 see ribavirin 200mg .......10

CORDARONE see amiodarone hcl .......18 see pacerone .................18

CORDRAN ........................63 COREG .............................20

see carvedilol ................20 COREG CR .......................20 CORGARD........................20

see nadolol ....................20 CORLANOR ......................22 cormax ..............................63 CORTEF ...........................45

see hydrocortisone ........45 CORTENEMA ...................48

see colocort ...................48 CORTIFOAM ....................62

cortisone acetate .............. 45 CORTISPORIN ................. 62

see neomycin-polymyxin-hc (otic) .............................. 66

CORTISPORIN-TC ........... 66 CORZIDE .......................... 20

see nadolol & bendroflumethiazide ...... 20

COSENTYX ...................... 62 COSENTYX SENSOREADY PEN .................................. 62 COSMEGEN ..................... 14 COSOPT ........................... 58

see dorzolamide hcl-timolol maleate ........ 58

COSOPT PF ..................... 58 COTELLIC ........................ 15 COUMADIN ...................... 51

see jantoven .................. 52 see warfarin sodium ...... 52

COZAAR ........................... 18 see losartan potassium . 18

CREON ............................. 50 CRESEMBA ........................ 8 CRESTOR ........................ 19 CRINONE ......................... 47 CRIXIVAN ........................... 9 cromolyn sodium ............... 60 cromolyn sodium (mastocytosis) ................... 49 cromolyn sodium (ophth) .. 58 cryselle 28 ......................... 41 CUBICIN ............................. 7 CUTIVATE ........................ 63

see fluticasone propionate ...................................... 64

CUVPOSA ........................ 48 cyclafem 1/35 28 day ........ 42 cyclafem 7/7/7 28 day ....... 42 CYCLESSA ....................... 42

see velivet 28 day.......... 44 cyclobenzaprine hcl .......... 36 cyclophosphamide ............ 13 CYCLOPHOSPHAMIDE ... 13 cycloserine ........................ 10 cyclosporine ...................... 53 cyclosporine modified (for

microemulsion) ................. 53 CYKLOKAPRON .............. 52

see tranexamic acid ...... 52 CYMBALTA ...................... 27

see duloxetine hcl ......... 27 CYRAMZA ........................ 14 cyred tab ........................... 42 CYSTADANE .................... 44 CYSTAGON ..................... 44 CYSTARAN ...................... 58 cytarabine inj .................... 14 CYTOMEL ........................ 47

see liothyronine sodium 47 CYTOTEC ........................ 49

see misoprostol ............. 49 CYTOVENE ...................... 10

see ganciclovir inj 500mg ...................................... 10

D D.H.E. 45 .......................... 34

see dihydroergotamine mesylate ........................ 34

dacarbazine ...................... 13 DACOGEN ....................... 14

see decitabine ............... 14 DAKLINZA ........................ 10 DALIRESP ........................ 60 DALVANCE ........................ 7 danazol ............................. 44 DANTRIUM ....................... 36

see dantrolene sodium .. 36 dantrolene sodium ............ 36 dapsone .............................. 7 DAPTACEL ....................... 54 DARAPRIM ......................... 7 daunorubicin hcl................ 14 DAYPRO ............................ 1

see oxaprozin .................. 1 DAYTRANA ...................... 32 DDAVP ............................. 47

see desmopressin acetate ...................................... 47 see desmopressin acetate inj .................................. 47 see desmopressin acetate spray ............................. 47

deblitane 28 day ............... 42 decitabine ......................... 14

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DELESTROGEN ...............44 see estradiol valerate ....44

delyla 28 day .....................42 DELZICOL ........................48 DEMADEX

see torsemide tabs ........22 DEMADEX TAB 10MG......22 DEMADEX TAB 20MG......22 DEMADEX TAB 5MG .......22 demeclocycline hcl ............13 DEMSER...........................22 DENAVIR ..........................65 DEPACON ........................24

see valproate sodium ....26 DEPAKENE ......................24

see valproate sodium ....26 see valproic acid ............26

DEPAKOTE ......................24 see divalproex sodium ...24

DEPAKOTE ER ................24 see divalproex sodium ...24

DEPAKOTE SPRINKLES .24 see divalproex sodium ...24

DEPEN TITRATABS .........41 depo-estradiol ...................44 DEPO-MEDROL

see methylpr ace inj 40mg/ml.........................45 see methylpr ace inj 80mg/ml.........................45

DEPO-MEDROL INJ 20MG/ML ..........................45 DEPO-MEDROL INJ 40MG/ML ..........................45 DEPO-MEDROL INJ 80MG/ML ..........................45 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) ..43

DEPO-PROVERA CONTRACEPTIVE ...........42 DEPO-PROVERA INJ 400/ML ..............................15 DEPO-SUBQ PROVERA 104 ....................................42 depo-testosterone .............37 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 37

DERMA-SMOOTHE/FS BODY................................ 63

see fluocinolone acetonide ...................................... 64

DERMA-SMOOTHE/FS SCALP .............................. 63

see fluocinolone acetonide ...................................... 64

DERMATOP ..................... 63 see prednicarbate.......... 64

DERMATOP CREAM 0.1% .......................................... 63 DERMOTIC ....................... 66

see fluocinolone acetonide (otic) .............................. 66

desipramine hcl ................. 27 desloratadine .................... 59 desmopressin acetate ....... 47 DESMOPRESSIN ACETATE .......................................... 47 desmopressin acetate inj .. 47 desmopressin acetate spray .......................................... 47 desmopressin acetate spray refrigerated ....................... 47 DESOGEN ........................ 42

see apri 28 day .............. 41 see cyred tab ................. 42 see emoquette .............. 42 see reclipsen 28 day ..... 43

desogestrel-ethinyl estradiol (biphasic) .......................... 42 DESONATE ...................... 63 desonide ........................... 63 DESONIDE ....................... 63 desowen ........................... 63 DESOWEN ....................... 63

see desonide ................. 63 see lokara ...................... 64

desoximetasone ................ 63 DESOXIMETASONE ........ 63 DETROL ........................... 51

see tolterodine tartrate tab 1 mg .............................. 51 see tolterodine tartrate tab 2 mg .............................. 51

DETROL LA ...................... 51 see tolterodine tartrate er ...................................... 51

dexamethasone ................ 45 dexamethasone sodium phosphate ......................... 45 dexamethasone sodium phosphate (ophth)............. 57 DEXILANT ........................ 50 dexpak taperpak 13 day ... 45 dexrazoxane ..................... 16 DEXTROSE ...................... 56 DEXTROSE 10% FLEX CONTAIN ......................... 56 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 56 DEXTROSE 10%/NACL 0.45% ............................... 56 DEXTROSE 2.5%/NACL 0.45% ............................... 56 DEXTROSE 5% ................ 56 DEXTROSE 5% /ELECTROLYTE ............... 56 DEXTROSE 5%/LACTATED RING ................................. 56 DEXTROSE 5%/NACL 0.2%.......................................... 56 DEXTROSE 5%/NACL 0.225% ............................. 56 DEXTROSE 5%/NACL 0.3%.......................................... 56 DEXTROSE 5%/NACL 0.33% ............................... 56 DEXTROSE 5%/NACL 0.45% ............................... 56 DEXTROSE 5%/NACL 0.9%.......................................... 56 DEXTROSE 5%/POTASSIUM CHL ...... 56 DIAMOX ........................... 22

see acetazolamide ........ 22 DIASTAT ACUDIAL .......... 24 DIASTAT PEDIATRIC ...... 24 diazepam .......................... 24 DIAZEPAM GEL (ANTICONVULSANT) ....... 24 DIBENZYLINE .................. 22

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see phenoxybenzamine hcl ..................................22

diclofenac potassium ..........1 diclofenac sodium ...............1 diclofenac sodium (actinic keratoses) .........................65 diclofenac sodium (ophth) .58 diclofenac sodium (topical)65 diclofenac w/ misoprostol ....1 dicloxacillin sodium ...........13 dicyclomine hcl ..................48 didanosine...........................9 DIFFERIN .........................61

see adapalene ...............61 DIFICID .............................12 diflorasone diacetate .........63 DIFLUCAN ..........................8

see fluconazole ...............8 diflunisal ..............................1 digitek ...............................21 digox .................................21 digoxin...............................21 digoxin inj ..........................21 DIGOXIN SOL 50MCG/ML ..........................................21 dihydroergotamine mesylate ..........................................34 DIHYDROERGOTAMINE MESYLATE .......................34 dilantin...............................24 DILANTIN

see phenytoin sodium extended........................25

DILANTIN INFATABS see phenytoin ................25

DILANTIN-125 ..................24 see phenytoin ................25

DILATRATE SR ................22 DILAUDID

see hydromorphone hcl ...4 DILAUDID INJ .....................3 DILAUDID TAB ...................3 DILAUDID-5 ORAL LIQD ....3 DILAUDID-HP

see hydromorphone hcl ...4 DILAUDID-HP INJ 10MG/ML ............................................3 DILAUDID-HP INJ 250MG ..3

diltiazem cap 120mg/24hr . 20 diltiazem cap 240mg/24hr . 21 diltiazem cap er/12hr......... 21 diltiazem hcl ...................... 21 diltiazem hcl coated beads 21 diltiazem hcl er .................. 21 diltiazem hcl extended release beads ................... 21 diltiazem inj 100mg ........... 21 diltiazem inj 125/25ml ....... 21 diltiazem inj 25mg/5ml ...... 21 diltiazem inj 50/10ml ......... 21 dilt-xr cap .......................... 20 DIOVAN ............................ 18

see valsartan ................. 18 DIOVAN HCT .................... 18

see valsartan-hydrochlorothiazide .................................. 18

DIPENTUM ....................... 48 diphenhydram inj 50mg/ml 59 diphenoxylate w/ atropine . 49 DIPHTHERIA/TETANUS TOXOID ............................ 54 DIPROLENE ..................... 63

see betamethasone dipropionate augmented 63

DIPROLENE AF ............... 63 see betamethasone dipropionate augmented 63

disopyramide phosphate ... 18 disulfiram .......................... 37 DITROPAN XL .................. 51

see oxybutynin chloride . 51 DIURIL SUS 250/5ML ....... 22 divalproex sodium ............. 24 docetaxel .......................... 14 DOCETAXEL .................... 14 DOCETAXEL SOLN 80MG/8ML ........................ 14 DOLOPHINE ....................... 3

see methadone hcl .......... 4 donepezil odt 10mg........... 26 donepezil odt 5mg ............ 26 donepezil tab hcl 23mg ..... 26 donepezil tabs 10mg ......... 26 donepezil tabs 5mg ........... 26 DORIBAX ............................ 7

dorzolamide hcl................. 58 dorzolamide hcl-timolol maleate ............................. 58 DOVONEX

see calcipotriene ........... 62 DOVONEX CRE 0.005% .. 62 doxazosin mesylate .......... 17 doxepin hcl ....................... 27 doxercalciferol................... 56 DOXIL ............................... 14

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 14

doxorubicin hcl .................. 14 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .... 14 doxorubicin inj 50mg ......... 14 doxy .................................. 13 doxycycline (monohydrate).......................................... 13 DOXYCYCLINE (ROSACEA) ...................... 65 doxycycline hyclate ........... 13 dronabinol ......................... 47 drospirenone-ethinyl estradiol ............................ 42 DROXIA ............................ 16 DUAC ............................... 61

see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 61 see neuac gel 1.2-5% ... 62

DUETACT ......................... 38 see pioglitazone hcl-glimepiride ............... 40

DUEXIS .............................. 1 DULERA ........................... 61 duloxetine hcl .................... 27 DUOPA ............................. 28 DURAGESIC ...................... 3

see fentanyl patch 100 mcg/hr ............................. 3 see fentanyl patch 12 mcg/hr ............................. 3 see fentanyl patch 25 mcg/hr ............................. 3 see fentanyl patch 50 mcg/hr ............................. 3

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see fentanyl patch 75 mcg/hr .............................3

DURAMORPH ....................3 DUREZOL .........................58 dutasteride ........................50 dutasteride-tamsulosin hcl 50 DUTOPROL ......................20 DYAZIDE ..........................22

see triamt/hctz cap 37.5-25 ..........................22

DYMISTA SPR 137-50......59 DYRENIUM .......................22 DYSPORT.........................36 E e.e.s. 400 tab 400mg ........12 E.E.S. GRANULES ...........12 EC-NAPROSYN ..................1

see naproxen ...................1 econazole nitrate ...............62 EDARBI.............................18 EDARBYCLOR .................18 EDECRIN ..........................22 EDURANT...........................9 EFFEXOR XR ...................27

see venlafaxine cap er...28 EFFIENT ...........................53 EFUDEX ...........................65

see fluorouracil (topical) 65 EGRIFTA ..........................46 ELAPRASE .......................44 ELDEPRYL .......................28

see selegiline hcl ...........29 ELECTROLYTE-R IN DEXTROSE ......................56 ELELYSO..........................44 ELESTAT ..........................58

see epinastine hcl (ophth) ......................................58

ELIDEL..............................65 ELIGARD INJ 22.5MG ......15 ELIGARD INJ 30MG .........15 ELIGARD INJ 45MG .........15 ELIGARD INJ 7.5MG ........15 ELIMITE

see permethrin ..............65 eliphos...............................46 ELIPHOS

see calcium acetate

(phosphate binder) ........ 46 ELIQUIS TAB 2.5MG ........ 51 ELIQUIS TAB 5MG ........... 51 ELITEK ............................. 16 elixophyllin ........................ 61 ELLA ................................. 42 ELLENCE ......................... 14

see epirubicin inj 200mg 14 see epirubicin inj 50mg/25ml .................... 14

ELMIRON ......................... 51 ELOCON ........................... 63

see mometasone furoate ...................................... 64

ELOXATIN ........................ 16 EMADINE ......................... 58 EMBEDA ............................. 3 EMCYT ............................. 13 EMEND CAP 125MG ........ 47 EMEND CAP 40MG .......... 47 EMEND CAP 80MG .......... 47 EMEND PAK 80 & 125 ..... 47 EMLA ................................ 64

see lidocaine-prilocaine . 64 emoquette ......................... 42 EMSAM ............................. 27 EMTRIVA ............................ 9 ENABLEX ......................... 51 enalapril maleate .............. 17 enalapril maleate & hydrochlorothiazide ..... 16, 17 ENBREL ........................... 53 ENBREL SURECLICK ...... 53 endocet ............................... 3 ENDODAN TAB .................. 3 ENGERIX-B ...................... 54 enoxaparin sodium............ 51 enpresse 28 day ............... 42 ENTACAPONE ................. 28 entecavir ........................... 10 ENTOCORT EC ................ 49

see budesonide ............. 48 ENTRESTO ...................... 18 ENTYVIO .......................... 49 enulose ............................. 49 EPIDUO ............................ 61 EPIDUO FORTE ............... 61 epinastine hcl (ophth)........ 58

EPINEPHRINE ................. 60 EPIPEN 2-PAK ................. 60 EPIPEN-JR 2-PAK ............ 60 epirubicin inj 200mg .......... 14 epirubicin inj 50mg/25ml ... 14 epitol ................................. 24 EPIVIR

see lamivudine ................ 9 EPIVIR HBV ..................... 10

see lamivudine (hbv) ..... 10 EPIVIR SOL 10MG/ML ....... 9 EPIVIR TABS...................... 9 eplerenone ........................ 17 EPOGEN .......................... 52 epoprostenol sodium ........ 23 eprosartan mesylate ......... 18 EPZICOM ........................... 9 EQUETRO ........................ 35 ERAXIS .............................. 8 ERBITUX .......................... 14 ergomar ............................ 34 ERIVEDGE ....................... 14 errin 28 day ....................... 42 ERTACZO ........................ 62 ERWINAZE ....................... 16 ery pad 2% ....................... 61 erygel ................................ 61 ERYGEL

see erythromycin (acne aid) ................................ 61

ERYPED 200 .................... 12 ERYPED 400 .................... 12 ery-tab .............................. 12 erythrocin lactobionate ...... 12 erythrocin stearate ............ 12 erythromycin (acne aid) .... 61 erythromycin (ophth) ......... 57 erythromycin base ............ 12 erythromycin cap 250mg ec.......................................... 12 erythromycin ethylsuccinate.......................................... 12 ESBRIET .......................... 60 escitalopram oxalate ......... 27 esomeprazole magnesium 50 esomeprazole sodium inj .. 50 estarylla tab 0.25-35 ......... 42 estrace .............................. 44

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ESTRACE see estradiol ..................44

estradiol ............................44 estradiol valerate ...............44 ESTRING ..........................44 ESTROSTEP FE ...............42

see tri-legest 28 day ......44 ethambutol hcl ...................10 ethosuximide .....................24 ETHYOL

see amifostine crystalline ......................................16

etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS ...................16 etoposide ..........................16 EURAX..............................65 EVISTA .............................46

see raloxifene hcl ..........46 EVOCLIN ..........................61

see clindamycin phosphate (topical) ........61

EVOTAZ..............................9 EVOXAC ...........................65

see cevimeline hcl .........65 EXALGO .............................3

see hydromorphone tab 12mg er ...........................4 see hydromorphone tab 16mg er ...........................4 see hydromorphone tab 8mg er .............................4

EXELDERM ......................62 EXELON

see rivastigmine tartrate 26 see rivastigmine td patch 24hr 13.3 mg/24hr .........27 see rivastigmine td patch 24hr 4.6 mg/24hr ...........27 see rivastigmine td patch 24hr 9.5 mg/24hr ...........27

EXELON CAPS .................26 EXELON PATCHES .........26 exemestane ......................15 EXFORGE ........................18

see amlodipine besylate-valsartan tab 10-160 mg .....................17

see amlodipine besylate-valsartan tab 10-320 mg ..................... 17 see amlodipine besylate-valsartan tab 5-160 mg ....................... 17 see amlodipine besylate-valsartan tab 5-320 mg ....................... 17

EXFORGE HCT ................ 18 see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 17 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 17 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 17

EXJADE ............................ 41 EXTAVIA ........................... 36 EXTINA ............................. 62

see ketoconazole (topical) ...................................... 62 see ketodan aer 2% ...... 62

EYLEA .............................. 58 F FABIOR ............................ 61 FABRAZYME .................... 44 FACTIVE ........................... 12 falmina 28 day .................. 42 famciclovir ......................... 10 famotidine ......................... 48 famotidine inj ..................... 48 FAMVIR ............................ 10

see famciclovir .............. 10 FANAPT ............................ 29

FANAPT TITRATION PACK.......................................... 29 FARESTON ...................... 15 FARXIGA .......................... 38 FARYDAK ......................... 14 FASLODEX ...................... 15 FAZACLO ......................... 29 felbamate .......................... 24 FELBATOL ....................... 24

see felbamate................ 24 FELDENE ........................... 1

see piroxicam .................. 1 felodipine .......................... 21 FEMARA ........................... 15

see letrozole .................. 15 FEMCON FE..................... 42

see wymzya fe .............. 44 see zenchent fe 28 day . 44

FEMRING ......................... 44 fenofibrate ......................... 19 FENOFIBRATE................. 19 fenofibrate micronized ...... 19 FENOFIBRIC ACID .......... 19 FENOGLIDE ..................... 19 fenoprofen calcium ............. 1 FENOPROFEN CALCIUM .. 1 fentanyl citrate .................... 3 fentanyl patch 100 mcg/hr .. 3 fentanyl patch 12 mcg/hr .... 3 fentanyl patch 25 mcg/hr .... 3 fentanyl patch 50 mcg/hr .... 3 fentanyl patch 75 mcg/hr .... 3 FENTORA .......................... 3 FERRIPROX ..................... 41 FETZIMA .......................... 27 FETZIMA TITRATION PACK.......................................... 27 FIBRICOR ........................ 19 FINACEA AER 15% .......... 65 FINACEA GEL 15% .......... 65 finasteride ......................... 50 FIRAZYR .......................... 52 FIRMAGON ...................... 15 FLAGYL .............................. 7

see metronidazole ........... 8 FLAGYL ER ........................ 7 FLAREX ............................ 58 FLEBOGAMMA ................ 53

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FLEBOGAMMA DIF ..........53 flecainide acetate ..............18 FLOLAN ............................23

see epoprostenol sodium ......................................23

FLOMAX ...........................50 see tamsulosin hcl .........51

FLO-PRED SUS ...............45 FLOVENT DISKUS ...........61 FLOVENT HFA .................61 fluconazole ..........................8 fluconazole in dextrose .......8 fluconazole in nacl ..............8 flucytosine ...........................8 FLUDARA

see fludarabine phosphate ......................................14

fludarabine phosphate ......14 fludrocortisone acetate ......45 FLUMADINE .....................10

see rimantadine hydrochloride .................10

flunisolide (nasal) ..............60 fluocinolone acetonide 63, 64 fluocinolone acetonide (otic) ..........................................66 fluocinonide .......................64 fluocinonide emulsified base ..........................................64 FLUOROMETHOLONE (OPHTH) ...........................58 fluorouracil ........................14 fluorouracil (topical) ...........65 FLUOROURACIL (TOPICAL) ........................65 fluoxetine cap 10mg ..........27 fluoxetine cap 20mg ..........27 fluoxetine cap 40mg ..........27 fluoxetine hcl .....................27 FLUOXETINE HCL ...........27 fluphenazine decanoate ....29 fluphenazine hcl ................29 flurbiprofen ..........................1 flurbiprofen sodium ...........58 flutamide ...........................15 fluticasone propionate .......64 fluticasone propionate (nasal) ...............................60

fluvastatin sodium cap 20 mg .......................................... 19 fluvastatin sodium cap 40 mg .......................................... 19 fluvastatin sodium tab sr 24 hr 80 mg ............................ 19 fluvoxamine maleate ......... 23 fluvoxamine maleate er ..... 23 FML................................... 58 FML FORTE ..................... 58 FML LIQUIFILM ................ 58 FOLOTYN ......................... 14 fondaparinux sodium......... 51 FORADIL AEROLIZER ..... 59 FORFIVO XL .................... 27 FORTAMET ................ 38, 39

see metformin hcl .......... 40 FORTAZ ........................... 11

see ceftazidime ............. 11 see tazicef ..................... 11 see tazicef vial ............... 11

FORTEO ........................... 46 FORTESTA ....................... 37 FORTICAL SPR 200/ACT . 46 FOSAMAX ........................ 41

see alendronate sodium 41 FOSAMAX PLUS D .......... 41 fosinopril sodium ............... 17 fosinopril sodium & hydrochlorothiazide ........... 17 FOSRENOL ...................... 46 FRAGMIN ......................... 51 FREAMINE HBC 6.9%...... 55 FREAMINE III ................... 55 FROVA TAB 2.5MG .......... 34 FURADANTIN ..................... 7

see nitrofurantoin............. 8 furosemide ........................ 22 furosemide inj ................... 22 FUROSEMIDE INJ............ 22 furosemide oral soln 8 mg/ml .......................................... 22 FUSILEV ........................... 16 FUZEON ............................. 9 FYCOMPA ........................ 24 G gabapentin ........................ 24 GABITRIL ......................... 24

see tiagabine hcl ........... 26 galantamine hydrobromide26 galantamine hydrobromide er ...................................... 26 GAMASTAN S/D............... 53 GAMMAGARD LIQUID ..... 53 GAMMAGARD S/D ........... 53 GAMMAGARD S/D IGA LESS TH ........................... 53 GAMMAKED ..................... 53 GAMMAPLEX ................... 53 GAMUNEX-C .................... 53 ganciclovir inj 500mg ........ 10 garamycin ......................... 57 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 57

GARDASIL ....................... 54 GARDASIL 9 .................... 54 GASTROCROM................ 49

see cromolyn sodium (mastocytosis) ............... 49

gatifloxacin (ophth) ........... 57 GATTEX ........................... 49 GAUZE PADS 2X2 ........... 38 gaviltye-g .......................... 49 gavilyte-c .......................... 49 gavilyte-h .......................... 49 gavilyte-n .......................... 49 GAZYVA ........................... 14 GELNIQUE ....................... 51 GEMCITABINE ................. 14 gemcitabine hcl ................. 14 gemfibrozil ........................ 19 GEMZAR .......................... 14

see gemcitabine hcl ...... 14 GENERESS FE ................ 42

see norethindrone & ethinyl estradiol-fe ......... 43

generlac ............................ 49 gengraf ............................. 53 GENOTROPIN.................. 46 GENOTROPIN MINIQUICK.......................................... 46 gentak ............................... 57 gentamicin in saline 0.8 mg/ml .................................. 6 gentamicin in saline

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0.9mg/ml .............................6 gentamicin in saline 1 mg/ml ............................................6 gentamicin in saline 1.2 mg/ml ..................................6 gentamicin in saline 1.4mg/ml .............................6 gentamicin in saline 1.6 mg/ml ..................................6 gentamicin in saline 2 mg/ml ............................................6 gentamicin sulfate ...............6 gentamicin sulfate (ophth) .57 gentamicin sulfate (topical) ..........................................62 GENVOYA ..........................9 GEODON ..........................29

see ziprasidone hcl ........31 GEODON INJ ....................29 GIANVI TAB 3-0.02MG .....42 GIAZO ...............................49 gildagia..............................42 gildess 1.5/30 21 day ........42 gildess 24 fe 28 day ..........42 GILENYA CAP 0.5MG ......36 GILOTRIF TAB 20MG .......15 GILOTRIF TAB 30MG .......15 GILOTRIF TAB 40MG .......15 GLASSIA...........................60 glatopa ..............................36 GLEEVEC .........................15 GLEOSTINE .....................13 glimepiride.........................39 glipizide .............................39 glipizide er .........................39 GLIPIZIDE XL TB24 2.5MG ..........................................39 GLIPIZIDE XL TB24 5MG .39 glipizide-metformin 2.5-250 mg .....................................39 glipizide-metformin 2.5-500 mg .....................................39 glipizide-metformin 5-500mg ..........................................39 GLUCAGEN HYPOKIT .....46 GLUCAGON EMERGENCY KIT ....................................46 GLUCOPHAGE .................39

see metformin hcl .......... 40 GLUCOPHAGE XR........... 39

see metformin er ........... 40 GLUCOTROL ................... 39

see glipizide .................. 39 GLUCOTROL XL .............. 39

see glipizide er .............. 39 GLUMETZA ...................... 39 glycate .............................. 48 glycopyrrolate ................... 48 GLYSET ............................ 39 GLYXAMBI ....................... 39 GOLYTELY ....................... 49

see gaviltye-g ................ 49 GRALISE .......................... 35 GRALISE STARTER......... 35 granisetron hcl .................. 47 GRANIX ............................ 52 GRASTEK ......................... 53 griseofulvin microsize.......... 8 griseofulvin ultramicrosize ... 8 GRIS-PEG .......................... 8

see griseofulvin ultramicrosize .................. 8

guanfacine er (adhd) ......... 32 H H.P. ACTHAR ................... 46 HALAVEN ......................... 16 HALDOL ........................... 29

see haloperidol lactate inj 5 mg/ml ......................... 29

HALDOL DECANOATE 100 .......................................... 29

see haloperidol decanoate ...................................... 29

HALDOL DECANOATE 50 .......................................... 29

see haloperidol decanoate ...................................... 29

halobetasol propionate...... 64 HALOG ............................. 64 haloperidol ........................ 29 haloperidol decanoate....... 29 haloperidol lactate ............. 29 haloperidol lactate inj 5 mg/ml ................................ 29 HARVONI ......................... 10 HAVRIX ............................ 54

heather ............................. 42 HECTOROL ................ 56, 57

see doxercalciferol ........ 56 HEP SOD/NACL INJ 25000.......................................... 51 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 51 heparin sod inj 10000u/ml . 52 heparin sod inj 1000u/ml ... 52 heparin sod inj 20000u/ml . 52 HEPARIN SOD INJ 2000U/ML ......................... 52 HEPARIN SOD INJ 2500U/ML ......................... 52 heparin sod inj 5000u/0.5ml.......................................... 52 heparin sod inj 5000u/ml ... 52 HEPARIN SODIUM/D5W . 52 HEPARIN SODIUM/NACL 0.45% ............................... 52 HEPATAMINE .................. 55 HEPSERA ........................ 10

see adefovir dipivoxil ..... 10 HERCEPTIN ..................... 14 HETLIOZ .......................... 33 HEXALEN ......................... 13 HIBERIX ........................... 54 HIPREX .............................. 7

see methenamine hippurate ......................... 8

HIZENTRA ........................ 53 HORIZANT ....................... 35 HUMALOG ....................... 38 HUMALOG KWIKPEN ...... 38 HUMALOG MIX 50/50 ...... 38 HUMALOG MIX 50/50 KWIKPEN ......................... 38 HUMALOG MIX 75/25 ...... 38 HUMALOG MIX 75/25 KWIKPEN ......................... 38 HUMATROPE ................... 46 HUMATROPE COMBO PACK ................................ 46 HUMIRA ........................... 53 HUMIRA PEN ................... 53 HUMIRA PEN-CROHNS STARTER KIT .................. 53

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HUMIRA PEN-PSORIASIS STARTER KIT ...................53 HUMULIN 70/30 ................38 HUMULIN 70/30 KWIKPEN ..........................................38 HUMULIN N ......................38 HUMULIN N KWIKPEN.....38 HUMULIN R ......................38 HUMULIN R U-500 (CONCENTRATE) ............38 HYCAMTIN .......................16

see topotecan hcl ..........16 hycet ...................................3 HYCET

see hydrocodone-acetaminophen 7.5-325 mg/15ml ........3

hydralazine hcl ..................22 HYDREA ...........................16

see hydroxyurea ............16 hydrochlorothiazide ...........22 hydrocodone-acetaminophen 10-300mg ............................3 hydrocodone-acetaminophen 2.5-325mg ...........................3 hydrocodone-acetaminophen 5-300mg ..............................3 hydrocodone-acetaminophen 5-325mg ..............................3 hydrocodone-acetaminophen 7.5-300mg ...........................3 hydrocodone-acetaminophen 7.5-325 mg/15ml .................3 hydrocodone-acetaminophen 7.5-325mg ...........................3 hydrocodone-acetaminophen tab 10-325mg ......................3 hydrocodone-ibuprofen tab 10-200mg ............................4 hydrocodone-ibuprofen tab 2.5-200mg ...........................3 hydrocodone-ibuprofen tab 5-200mg ..............................4 hydrocodone-ibuprofen tab 7.5-200 mg ..........................4 hydrocortisone ..................45 HYDROCORTISONE (INTRARECTAL) ...............49

hydrocortisone (topical)..... 64 hydrocortisone butyrate .... 64 hydrocortisone butyrate hydrophilic lipo base ......... 64 hydrocortisone valerate..... 64 hydromorphone hcl ............. 4 HYDROMORPHONE HCL .. 4 hydromorphone tab 12mg er ............................................ 4 hydromorphone tab 16mg er ............................................ 4 hydromorphone tab 8mg er . 4 HYDROMORPHONE TABS 32MG .................................. 4 hydroxychloroquine sulfate .......................................... 53 hydroxyurea ...................... 16 hydroxyzine hcl ................. 59 HYQVIA ............................ 53 HYSINGLA ER .................... 4 HYZAAR ........................... 18

see losartan-hydrochlorothiazide .................................. 18

I ibandronate sodium .......... 41 ibandronate tab 150mg ..... 41 IBRANCE .......................... 14 ibudone tab 10-200mg ........ 4 ibudone tab 5-200mg .......... 4 ibuprofen ............................. 1 ICLUSIG ........................... 15 IDAMYCIN PFS ................ 14

see idarubicin hcl........... 14 idarubicin hcl ..................... 14 IFEX

see ifosfamide inj 1gm ... 13 IFEX INJ 1GM ................... 13 IFEX INJ 3GM ................... 13 IFOSFAMIDE

see ifosfamide inj........... 13 ifosfamide inj ..................... 13 ifosfamide inj 1gm ............. 13 IFOSFAMIDE INJ 3GM ..... 13 ILARIS .............................. 53 ILEVRO ............................. 58 ilotycin ............................... 57 IMBRUVICA CAP 140MG . 15

imipenem-cilastatin ............. 7 imipramine hcl................... 27 imipramine pamoate ......... 27 imiquimod ......................... 65 IMITREX ........................... 34

see sumatriptan inj 6mg/0.5ml ..................... 34 see sumatriptan succinate ...................................... 35

IMITREX STATDOSE REFILL ............................. 34 IMITREX STATDOSE SYSTEM ........................... 34

see sumatriptan inj 6mg/0.5ml ..................... 34

IMOVAX RABIES (H.D.C.V.).......................................... 54 IMURAN ........................... 54

see azathioprine ............ 53 INCRELEX ........................ 46 INCRUSE ELLIPTA .......... 59 indapamide ....................... 22 INDERAL LA ..................... 20

see propranolol hcl er .... 20 INFANRIX ......................... 54 INFUMORPH 200 ............... 4 INFUMORPH 500 ............... 4 INLYTA ............................. 15 INSPRA ............................ 17

see eplerenone ............. 17 INSULIN PEN NEEDLES . 38 INSULIN SAFETY NEEDLES ......................... 38 INSULIN SYRINGES ........ 38 INTELENCE ....................... 9 INTRALIPID INJ 20% ....... 55 INTRALIPID INJ 30% ....... 55 INTRON-A INJ 10MU ....... 53 INTRON-A INJ 18MU ....... 53 INTRON-A INJ 25MU ....... 53 INTRON-A INJ 50MU ....... 53 introvale 91 day ................ 42 INTUNIV ........................... 32

see guanfacine er (adhd) ...................................... 32

INVANZ .............................. 7 INVEGA ............................ 29

see paliperidone ............ 30

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INVEGA SUST INJ 117 MG/0.75 ML ......................30 INVEGA SUST INJ 156MG/ML ........................30 INVEGA SUST INJ 234 MG/1.5 ML ........................30 INVEGA SUST INJ 39 MG/0.25 ML ......................29 INVEGA SUST INJ 78 MG/0.5 ML ........................29 INVEGA TRINZA ..............30 INVIRASE ...........................9 INVOKAMET TAB 150-1000 ..........................................39 INVOKAMET TAB 150-500 ..........................................39 INVOKAMET TAB 50-1000 ..........................................39 INVOKAMET TAB 50-500MG .........................39 INVOKANA TAB 100MG ...39 INVOKANA TAB 300MG ...39 IONOSOL-B/DEXTROSE 5% .....................................56 IONOSOL-MB/DEXTROSE 5% .....................................56 IPOL INACTIVATED IPV ..54 ipratropium bromide (nasal) ..........................................59 ipratropium sol inhal ..........59 ipratropium-albuterol .........59 irbesartan ..........................18 irbesartan-hydrochlorothiazide ........................................18 IRESSA .............................15 irinotecan inj 100/5ml ........16 irinotecan inj 40mg/2ml .....16 irinotecan inj 500mg/25ml .16 ISENTRESS ........................9 ISOLYTE P .......................56 ISOLYTE S .......................56 isoniazid ............................10 isoniazid tabs ....................10 ISOPTO CARPINE ...........58 ISORDIL TITRADOSE ......22

see isosorbide dinitrate..23 isosorbide dinitrate ............23 isosorbide dinitrate er ........23

isosorbide mononitrate...... 23 isosorbide mononitrate er . 23 isradipine .......................... 21 ISTALOL ........................... 58 ISTODAX .......................... 14 itraconazole ........................ 8 ivermectin ........................... 7 IXEMPRA KIT ................... 16 IXIARO .............................. 54 J JADENU ........................... 41 JAKAFI .............................. 15 JALYN............................... 50

see dutasteride-tamsulosin hcl.................................. 50

jantoven ............................ 52 JANUMET ......................... 39 JANUMET XR TAB 100-1000 ........................... 39 JANUMET XR TAB 50-1000 .......................................... 39 JANUMET XR TAB 50-500MG ......................... 39 JANUVIA ........................... 39 JARDIANCE ..................... 39 JENTADUETO .................. 39 JEVTANA .......................... 14 jinteli.................................. 44 JOLESSA TAB 0.15-0.03 MG .................................... 42 JOLIVETTE ....................... 42 junel 1.5/30 21 day............ 42 junel 1/20 21 day .............. 42 junel fe 1.5/30 28 day........ 42 junel fe 1/20 28 day........... 42 junel fe 24 1/20 28 day...... 42 JUXTAPID ........................ 19 K KADCYLA ......................... 14 KADIAN .............................. 4

see morphine sulfate ....... 5 KALBITOR ........................ 52 KALETRA SOL ................... 9 KALETRA TAB 100-25MG 10 KALETRA TAB 200-50MG 10 KALYDECO ...................... 60 kariva 28 day .................... 42 KAYEXALATE .................. 41

see kionex ..................... 41 see sodium polystyrene sulfonate ....................... 41

KAZANO ........................... 39 KCL 0.075%/D5W/NACL 0.45% ............................... 56 KCL 0.15%/D5W/LR ......... 56 KCL 0.15%/D5W/NACL 0.9% ................................. 56 KCL 0.3%/D5W/LR IV LAC RI ...................................... 56 KCL 0.3%/D5W/NACL 0.45% ............................... 56 KCL 0.3%/D5W/NACL 0.9%.......................................... 56 KCL IN NACL INJ .15-0.45.......................................... 56 KCL/D5W/NACL INJ .15/.33% ........................... 56 KCL/D5W/NACL INJ .15/.45% ........................... 56 KCL/D5W/NACL INJ 0.22%/0.45% .................... 56 KCL/NACL INJ 0.15%-0.9%.......................................... 56 KCL0.15%/D5W/NACL0.2%.......................................... 56 KCL0.15%/D5W/NACL0.225% ...................................... 56 KEFLEX ............................ 11

see cephalexin .............. 11 kelnor 1/35 28 day ............ 42 KENALOG ........................ 64

see triamcinolone acetonide (topical) ......... 64

KEPIVANCE ..................... 16 KEPPRA ........................... 25

see levetiracetam .......... 25 see levetiracetam oral soln 100 mg/ml ..................... 25

KEPPRA XR ..................... 25 see levetiracetam .......... 25

KERLONE see betaxolol hcl ........... 20

ketoconazole ...................... 8 ketoconazole (topical) ....... 62 ketoconazole shampoo ..... 63 ketodan aer 2%................. 62

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ketoprofen ...........................1 ketorolac tromethamine (ophth)...............................58 KEYTRUDA ......................14 kimidess 28 day ................42 KINERET ..........................53 KINRIX ..............................54 kionex ...............................41 KITABIS PAK ......................6 KLARON ...........................61

see sulfacetamide sodium (acne) ............................62

KLONOPIN .......................25 see clonazepam ............24

KLOR-CON 10 ..................55 KLOR-CON 8 ....................55 klor-con m10 .....................55 klor-con m15 .....................55 klor-con m20 .....................55 klor-con pow 20meq ..........55 klor-con spr cap 10meq.....55 klor-con spr cap 8meq ......55 KOMBIGLYZE XR 2.5-1000MG ......................40 KOMBIGLYZE XR 5-1000MG .........................40 KOMBIGLYZE XR 5-500MG ..........................................40 KORLYM ...........................46 kristalose ...........................49 K-TAB ...............................54 KUVAN..............................44 KYNAMRO ........................19 L labetalol hcl .......................20 LAC-HYDRIN ....................65

see ammonium lactate ..65 see laclotion lot 12% .....65

laclotion lot 12% ................65 LACRISERT ......................59 LACTATED RINGERS VIAFLEX ...........................56 lactulose ............................49 lactulose (encephalopathy) ..........................................49 LAMICTAL ........................25

see lamotrigine ..............25 LAMICTAL CHEWABLE

DISPERS .......................... 25 see lamotrigine .............. 25

LAMICTAL ODT ................ 25 see lamotrigine .............. 25

LAMICTAL STARTER....... 25 LAMICTAL XR .................. 25

see lamotrigine .............. 25 LAMISIL .............................. 8

see terbinafine hcl ........... 8 lamivudine ........................... 9 lamivudine (hbv) ............... 10 lamivudine-zidovudine ...... 10 lamotrigine ........................ 25 LANOXIN .......................... 21

see digitek ..................... 21 see digox ....................... 21 see digoxin .................... 21 see digoxin inj ............... 21

LANOXIN INJ 0.25MG/ML 21 LANOXIN PEDIATRIC ...... 21 LANOXIN TAB .................. 21 lansoprazole ..................... 50 LANTUS ............................ 38 LANTUS SOLOSTAR ....... 38 larin 1.5/30 ........................ 42 larin 1/20 ........................... 42 larin fe 1.5/30 .................... 42 larin fe 1/20 ....................... 42 LASIX................................ 22

see furosemide .............. 22 LASTACAFT ..................... 58 latanoprost ........................ 58 LATUDA ............................ 30 LAYOLIS FE CHW ............ 42 LAZANDA ........................... 4 LEENA TAB ...................... 42 leflunomide ....................... 53 LEMTRADA ...................... 36 LENVIMA 10MG DAILY DOSE................................ 15 LENVIMA 14MG DAILY DOSE................................ 15 LENVIMA 20MG DAILY DOSE................................ 15 LENVIMA 24MG DAILY DOSE................................ 15 LESCOL ............................ 19

see fluvastatin sodium cap

20 mg ............................ 19 LESCOL XL ...................... 19

see fluvastatin sodium tab sr 24 hr 80 mg ............... 19

lessina 28 day ................... 42 LETAIRIS .......................... 23 letrozole ............................ 15 leucovorin calcium ............ 16 leucovorin calcium inj 100mg.......................................... 16 leucovorin calcium inj 200mg.......................................... 16 leucovorin calcium inj 350mg.......................................... 16 leucovorin calcium inj 500mg.......................................... 16 leucovorin calcium inj 50mg.......................................... 16 LEUKERAN ...................... 13 LEUKINE .......................... 52 leuprolide acetate ............. 15 levalbuterol conc 1.25mg/0.5ml .................... 59 levalbuterol hcl .................. 59 LEVALBUTEROL HCL ..... 59 LEVAQUIN ....................... 12

see levofloxacin............. 12 LEVEMIR .......................... 38 LEVEMIR FLEXTOUCH ... 38 levetiracetam .................... 25 LEVETIRACETAM IV ....... 25 levetiracetam oral soln 100 mg/ml ................................ 25 levobunolol hcl .................. 58 LEVOBUNOLOL HCL ....... 58 levocarnitine (metabolic modifiers) .......................... 44 levocetirizine soln 2.5mg/5ml.......................................... 59 levocetirizine tab 5 mg ...... 59 levofloxacin ....................... 12 levofloxacin (ophth)........... 57 levofloxacin in d5w............ 12 levoleucovorin calcium ...... 16 levonest 28 day................. 42 levonor/ethi tab ................. 42 levonorgestrel & eth estradiol.......................................... 42

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levonorgestrel (emergency oc) .....................................42 levonorgestrel-ethinyl estradiol (91-day) ..............42 levonorgestrel-ethinyl estradiol (continuous) ........42 levora 0.15/30 28 day .......42 levorphanol tartrate .............4 levothyroxine sodium ........47 LEVOXYL..........................47 LEXAPRO .........................27

see escitalopram oxalate ......................................27

LEXIVA ...............................9 LIALDA..............................49 lidocaine ............................64 lidocaine hcl ......................64 lidocaine hcl (local anesth.) .6 lidocaine hcl (mouth-throat) ..........................................65 lidocaine inj 0.5% ................6 lidocaine inj 1% ...................6 lidocaine inj 1.5% ................6 lidocaine inj 2% ...................6 lidocaine-prilocaine ...........64 LIDODERM .......................64

see lidocaine .................64 linezolid ...............................7 LINEZOLID .........................7 LINZESS ...........................49 liothyronine sodium ...........47 LIPITOR ............................19

see atorvastatin calcium 19 LIPOFEN...........................19 LIPOSYN II .......................55 LIPOSYN III ......................55 lisinopril .............................17 lisinopril & hydrochlorothiazide ...........17 lithium carbonate ...............35 LITHIUM SOLN 8MEQ/5ML ..........................................35 LITHOBID .........................35

see lithium carbonate ....35 LIVALO .............................19 LO LOESTRIN FE .............42 LOCOID ............................64

see hydrocortisone

butyrate ......................... 64 LOCOID LIPOCREAM ...... 64

see hydrocortisone butyrate hydrophilic lipo base .............................. 64

LODOSYN ........................ 28 see carbidopa ................ 28

loestrin 1.5/30 21 day........ 42 LOESTRIN 1.5/30-21

see gildess 1.5/30 21 day ...................................... 42 see junel 1.5/30 21 day . 42 see larin 1.5/30 .............. 42

loestrin 1/20 21 day........... 42 LOESTRIN 1/20-21

see junel 1/20 21 day .... 42 see larin 1/20 ................. 42

LOESTRIN FE 1.5/30 see junel fe 1.5/30 28 day ...................................... 42 see larin fe 1.5/30 .......... 42

loestrin fe 1.5/30 28 day.... 42 LOESTRIN FE 1/20

see blisovi 21 fe 1/20 28 day pack ........................ 41 see junel fe 1/20 28 day 42 see larin fe 1/20 ............. 42 see tarina fe 1/20 28 day ...................................... 44

loestrin fe 1/20 28 day....... 42 lofibra ................................ 19 LOFIBRA

see fenofibrate .............. 19 see fenofibrate micronized ...................................... 19

lokara ................................ 64 lomedia 24 fe .................... 42 LOMOTIL .......................... 49

see diphenoxylate w/ atropine ......................... 49

LOMUSTINE ..................... 13 LONSURF ......................... 16 loperamide hcl .................. 49 LOPID ............................... 19

see gemfibrozil .............. 19 LOPRESSOR ................... 20

see metoprolol tartrate .. 20 LOPRESSOR HCT ........... 20

see metoprolol & hctz tab 100-25mg ...................... 20 see metoprolol & hctz tab 50-25mg ........................ 20

LOPROX SHAMPOO ....... 62 see ciclopirox shampoo 1% ................................. 62

lorazepam ......................... 23 lorcet hd tab 10-325mg ....... 4 lorcet plus tab 7.5-325 ........ 4 lorcet tab 5-325mg .............. 4 lortab tab 10-325mg ............ 4 lortab tab 5-325mg.............. 4 lortab tab 7.5-325................ 4 loryna 28 day .................... 43 losartan potassium............ 18 losartan-hydrochlorothiazide.......................................... 18 LOSEASONIQUE ............. 43 LOTEMAX ........................ 58 LOTENSIN ........................ 17

see benazepril hcl ......... 17 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 16

LOTREL ............................ 17 see amlodipine besylate-benazepril hcl . 16

LOTRONEX ...................... 49 see alosetron hcl ........... 49

lovastatin .......................... 19 LOVAZA

see omega-3-acid ethyl esters ............................ 19

LOVAZA CAP 1GM .......... 19 LOVENOX ........................ 52

see enoxaparin sodium . 51 low-ogestrel ...................... 43 loxapine succinate ............ 30 LUCENTIS ........................ 59 LUMIGAN ......................... 58 LUMIZYME ....................... 44 LUPANETA PACK ............ 44 LUPRON DEP INJ 11.25MG.......................................... 15 LUPRON DEPOT ............. 15 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 15

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LUPRON DEPOT INJ 30MG (3-MONTH) .......................15 LUPRON DEP-PED INJ 11.25MG ...........................15 LUPRON DEP-PED INJ 15MG ................................15 LUPRON DEP-PED INJ 30MG (3-MONTH) ............15 LUPRON DEP-PED INJ 7.5MG ...............................15 lutera 28 day .....................43 LUXIQ

see betamethasone valerate..........................63

LUZU ................................62 LYNPARZA .......................14 LYRICA .............................25 LYSODREN ......................15 LYSTEDA..........................52

see tranexamic acid ......52 lyza ...................................43 M MACROBID .........................7

see nitrofurantoin monohyd macro ...............8

MACRODANTIN .................7 see nitrofurantoin macrocrystal ....................8

magnesium sulfate ............55 MAGNESIUM SULFATE ...55 MAGNESIUM SULFATE IN D5W ..................................55 MAGNESIUM SULFATE INJ 50% ...................................55 MALARONE ........................9

see atovaquone-proguanil hcl tab 250-100 mg ..........9 see atovaquone-proguanil hcl tab 62.5-25 mg ...........9

malathion ..........................65 maprotiline hcl ...................27 MARINOL..........................47

see dronabinol ...............47 marlissa 28 day .................43 MARPLAN.........................27 MATULANE ......................16 matzim la...........................21 MAVIK ...............................17

see trandolapril .............. 17 MAXALT ........................... 34

see rizatriptan benzoate 34 MAXALT-MLT ................... 34

see rizatriptan benzoate 34 MAXIDEX .......................... 58 MAXIPIME ........................ 11

see cefepime inj 1gm .... 11 see cefepime inj 2gm .... 11

MAXITROL ....................... 57 see neomycin-polymy-dexameth .................................... 57

MAXZIDE .......................... 22 see triamt/hctz tab 75-50mg ........................ 22

MAXZIDE-25 ..................... 22 see triamt/hctz tab 37.5-25 ...................................... 22

meclizine hcl ..................... 47 MEDROL

see methylpred tab 16mg ...................................... 45 see methylpred tab 32mg ...................................... 45 see methylpred tab 4mg 45 see methylpred tab 8mg 45

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 45

MEDROL PAK 4MG.......... 45 MEDROL TAB 16MG ........ 45 MEDROL TAB 2MG .......... 45 MEDROL TAB 32MG ........ 45 MEDROL TAB 4MG .......... 45 MEDROL TAB 8MG .......... 45 medroxyprogesterone acetate .............................. 47 medroxyprogesterone acetate (contraceptive) ..... 43 mefenamic acid ................... 1 mefloquine hcl ..................... 9 MEGACE ES .................... 15 MEGACE ORAL ............... 15

see megestrol ac sus 40mg/ml ........................ 15

megestrol ac sus 40mg/ml 15 megestrol ac tab 20mg ..... 15

megestrol ac tab 40mg ..... 15 MEGESTROL SUS 625MG/5ML ...................... 15 MEKINIST ......................... 15 MELOXICAM ...................... 1 meloxicam tabs ................... 1 melphalan hcl.................... 13 memantine hcl .................. 26 MENACTRA ..................... 54 MENOMUNE-A/C/Y/W-135.......................................... 54 MENOSTAR ..................... 45 MENTAX ........................... 62 MENVEO .......................... 54 MEPRON ............................ 7

see atovaquone............... 7 mercaptopurine ................. 14 meropenem ........................ 7 MEROPENEM/SODIUM CHLORIDE ......................... 7 MERREM ............................ 7

see meropenem .............. 7 mesalamine enema .......... 49 mesna ............................... 16 MESNEX .......................... 16

see mesna .................... 16 MESTINON ....................... 35

see pyridostigmine bromide ......................... 35

MESTINON SYRUP ......... 35 MESTINON TIMESPAN ... 35

see pyridostigmine bromide ......................... 35

METADATE CD ................ 32 see methylphenidate hcl 33

metadate er tab 20mg ....... 32 metformin er ..................... 40 metformin hcl .................... 40 methadone hcl .................... 4 METHADONE INJ 10MG/ML............................................ 4 METHADOSE ..................... 4

see methadone hcl .......... 4 methazolamide ................. 22 methenamine hippurate ...... 8 METHERGINE

see methylergonovine maleate ......................... 46

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methimazole ......................47 methotrexate sodium inj ....14 methotrexate sodium tabs .53 methoxsalen rapid .............62 methscopolamine bromide 48 methyclothiazide ...............22 methylergonovine maleate 46 METHYLIN ........................32

see methylphenidate hcl 33 METHYLIN CHEW TAB ....32 methylphenidate hcl ..........33 METHYLPHENIDATE HCL ..........................................33 methylphenidate hcl er ......33 methylpr ace inj 40mg/ml ..45 methylpr ace inj 80mg/ml ..45 methylpr ss inj 125mg .......45 methylpr ss inj 1gm ...........45 methylpr ss inj 40mg .........45 methylpred pak 4mg .........45 methylpred tab 16mg ........45 methylpred tab 32mg ........45 methylpred tab 4mg ..........45 methylpred tab 8mg ..........45 metipranolol ......................58 metoclopramide hcl ...........47 metoclopramide hcl inj 5 mg/ml ................................47 metoclopramide odt ..........47 metolazone .......................22 metoprolol & hctz tab 100-25mg ..........................20 metoprolol & hctz tab 100-50mg ..........................20 metoprolol & hctz tab 50-25mg ............................20 metoprolol succinate .........20 metoprolol tartrate .............20 METOZOLV ODT ..............47

see metoclopramide hcl.47 METRO IV...........................8 METROCREAM ................65

see metronidazole (topical)..........................65 see rosadan cre 0.75%..65

METROGEL ......................65 see metronidazole (topical)..........................65

METROGEL-VAGINAL ..... 51 see metronidazole vaginal ...................................... 51

METROLOTION ............... 65 see metronidazole (topical) ......................... 65

metronidazole ..................... 8 metronidazole (topical)...... 65 metronidazole inj ................. 8 metronidazole vaginal ....... 51 MEVACOR

see lovastatin ................ 19 mexiletine hcl .................... 18 MIACALCIN

see calcitonin (salmon) nasal spray .................... 46

MIACALCIN INJ 200U/ML 46 MIACALCIN SPR 200/ACT .......................................... 46 MICARDIS ........................ 18

see telmisartan .............. 18 MICARDIS HCT ................ 18

see telmisartan-hydrochlorothiazide.............................. 18

miconazole 3 sup 200mg .. 51 MICROGESTIN 1.5/30...... 43 MICROGESTIN 1/20......... 43 MICROGESTIN FE 1.5/30 43 MICROGESTIN FE 1/20 ... 43 MICRO-K .......................... 55

see klor-con spr cap 10meq ........................... 55 see klor-con spr cap 8meq ...................................... 55 see potassium chloride caps er .......................... 55

MICROZIDE ...................... 22 see hydrochlorothiazide 22

midodrine hcl .................... 22 migergot ............................ 34 MIGRANAL ....................... 34 millipred ............................ 45 MINASTRIN 24 FE............ 43 MINIPRESS ...................... 17

see prazosin hcl ............ 17 minitran ............................. 23 MINIVELLE ....................... 45

MINOCIN .......................... 13 see minocycline hcl ....... 13

minocycline hcl ................. 13 minoxidil ............................ 22 MIRAPEX ......................... 28

see pramipexole dihydrochloride .............. 28

MIRAPEX ER.................... 28 see pramipexole dihydrochloride .............. 28

MIRCERA ......................... 52 mircette ............................. 43 MIRCETTE

see bekyree 28 day ....... 41 see desogestrel-ethinyl estradiol (biphasic) ........ 42 see kariva 28 day .......... 42 see kimidess 28 day ...... 42 see pimtrea pack ........... 43 see viorele ..................... 44

mirtazapine ....................... 27 misoprostol ....................... 49 mitomycin ......................... 14 mitoxantrone hcl ............... 16 M-M-R II ............................ 54 MOBIC ................................ 1

see meloxicam tabs ........ 1 modafinil ........................... 36 moderiba pak .................... 10 MODERIBA PAK .............. 10 moderiba tab 200mg ......... 10 MODICON ........................ 43 moexipril hcl ...................... 17 moexipril-hydrochlorothiazide........................................ 17 molindone hcl.................... 30 mometasone furoate ......... 64 MONODOX

see doxycycline (monohydrate) ............... 13

mono-linyah tab 0.25-35 ... 43 MONONESSA .................. 43 montelukast sodium .......... 60 MORPHINE SUL 20MG/ML ORAL SOL .......................... 4 MORPHINE SUL INJ 10MG/ML ............................ 4 MORPHINE SUL INJ

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15MG/ML ............................4 MORPHINE SUL INJ 1MG/ML ..............................4 MORPHINE SUL INJ 4MG/ML ..............................4 morphine sulfate .................5 MORPHINE SULFATE........5 morphine sulfate beads .......5 morphine sulfate ext-rel tab.5 MOVANTIK .......................49 MOVIPREP .......................49 MOXEZA ...........................57 moxifloxacin hcl .................12 MOXIFLOXACIN HCL .......12 MOZOBIL ..........................52 MS CONTIN ........................5

see morphine sulfate ext-rel tab ........................5

MULTAQ ...........................18 mupirocin ..........................62 mupirocin calcium (topical)62 MUSTARGEN ...................14 MYALEPT .........................46 MYAMBUTOL ...................10

see ethambutol hcl ........10 MYCAMINE .........................8 MYCOBUTIN ....................10

see rifabutin ...................10 mycophenolate mofetil ......54 mycophenolate sodium .....54 MYFORTIC .......................54

see mycophenolate sodium ...........................54

myorisan ...........................61 MYOZYME ........................44 MYRBETRIQ .....................51 MYSOLINE .......................25

see primidone ................26 myzilra...............................43 N nabumetone ........................1 nadolol ..............................20 nadolol & bendroflumethiazide ..........20 nafcillin sodium .................13 NAFTIFINE HCL ...............62 NAFTIN .............................62 NAGLAZYME ....................44

nalbuphine hcl ..................... 2 NALLPEN ISO-OSMOTIC IN DE ..................................... 13 NALLPEN/DEXTROSE ..... 13 naloxone hcl ...................... 37 naltrexone hcl ................... 37 NAMENDA

see memantine hcl ........ 26 NAMENDA SOL 10MG/5ML .......................................... 26 NAMENDA TAB ................ 26 NAMENDA XR .................. 26 NAMENDA XR TITRATION PACK ................................ 26 NAMZARIC ....................... 26 naphazoline 0.1% ............. 59 NAPRELAN ........................ 1

see naproxen sodium ...... 1 NAPROSYN

see naproxen .................. 1 NAPROSYN TABS ............. 1 naproxen ............................. 1 naproxen sodium ................ 1 NAPROXEN SODIUM ........ 1 naratriptan hcl ................... 34 NARDIL ............................. 27

see phenelzine sulfate... 27 NASONEX ........................ 60 NATACYN ......................... 57 nateglinide ........................ 40 NATPARA ......................... 46 NAVELBINE

see vinorelbine tartrate .. 14 NEBUPENT ........................ 8 necon 0.5/35 28 day ......... 43 necon 1/35 28 day ............ 43 necon 10/11 28 day .......... 43 NECON 7/7/7 .................... 43 NECON TAB 1/50-28 ........ 43 nefazodone hcl ................. 27 neomycin sulfate ................. 6 neomycin/polymyxin b gu .. 65 neomycin-bacitracin zn-polymyxin ..................... 57 neomycin-polymy-dexameth .......................................... 57 neomycin-polymyxin-gramicidin ..................................... 57

neomycin-polymyxin-hc (ophth) .............................. 57 neomycin-polymyxin-hc (otic).......................................... 66 NEORAL ........................... 54

see cyclosporine modified (for microemulsion) ....... 53 see gengraf ................... 53

NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 57

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 65

neosporin solution............. 57 NEPHRAMINE .................. 55 neptazane ......................... 22 NEPTAZANE

see methazolamide ....... 22 NESINA ............................ 40 neuac gel 1.2-5% .............. 62 NEULASTA ....................... 52 NEULASTA ONPRO KIT .. 52 NEUMEGA ....................... 52 NEUPOGEN ..................... 52 NEUPRO .......................... 28 NEURONTIN .................... 25

see gabapentin.............. 24 nevirapine ........................... 9 NEVIRAPINE ...................... 9 NEXAVAR ........................ 15 NEXIUM

see esomeprazole magnesium.................... 50

NEXIUM CAP 20MG ......... 50 NEXIUM CAP 40MG ......... 50 NEXIUM GRA 10MG DR .. 50 NEXIUM GRA 2.5MG DR . 50 NEXIUM GRA 20MG DR .. 50 NEXIUM GRA 40MG DR .. 50 NEXIUM GRA 5MG DR .... 50 NEXIUM I.V. ..................... 50

see esomeprazole sodium inj .................................. 50

next choice tab 1.5mg ....... 43 niacin er (antihyperlipidemic).......................................... 19

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niacor ................................19 NIASPAN ..........................19

see niacin er (antihyperlipidemic) .......19

nicardipine hcl ...................21 NICOTROL INHALER .......37 NICOTROL NS .................37 nifedical .............................21 nifedipine...........................21 nifedipine er ......................21 nikki 28 day .......................43 NILANDRON .....................15 nimodipine.........................21 NINLARO ..........................14 NIPENT .............................14 nisoldipine .........................21 nitro-bid .............................23 NITRO-DUR ......................23

see minitran ...................23 nitrofurantoin .......................8 nitrofurantoin macrocrystal ..8 nitrofurantoin monohyd macro ..................................8 nitroglycerin.......................23 NITROGLYCERIN LINGUAL ..........................................23 nitroglycerin patches .........23 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............23 NITROLINGUAL SPR PUMPSPRA ......................23 NITROMIST ......................23 NITROSTAT ......................23 nizatidine ...........................48 NIZORAL ..........................63

see ketoconazole shampoo........................63

NORA-BE TAB ..................43 norco ...................................5 NORCO

see hydrocodone-acetaminophen 5-325mg .....................3 see hydrocodone-acetaminophen 7.5-325mg ..................3 see

hydrocodone-acetaminophen tab 10-325mg ............. 3 see lorcet hd tab 10-325mg ........................ 4 see lorcet plus tab 7.5-325 ........................................ 4 see lorcet tab 5-325mg .... 4 see lortab tab 10-325mg . 4 see lortab tab 5-325mg ... 4 see lortab tab 7.5-325 ..... 4

NORDITROPIN FLEXPRO .......................................... 46 norethin acet & estrad-fe ... 43 norethindrone & ethinyl estradiol-fe ........................ 43 norethindrone (contraceptive) .................. 43 norethindrone acetate ....... 47 norethindrone acetate-ethinyl estradiol ............................ 45 norgest/ethi tab 0.25/35 .... 43 norgestimate-ethinyl estradiol (triphasic)............ 43 NORINYL 1+35 ................. 43

see cyclafem 1/35 28 day ...................................... 42 see necon 1/35 28 day .. 43 see nortrel 1/35 21 day .. 43 see nortrel 1/35 28 day .. 43 see pirmella 1/35 28 day ...................................... 43

NORINYL 1+50 ................. 43 NORITATE ........................ 65 norlyroc 28 day ................. 43 NORMOSOL-M IN D5W ... 56 NORMOSOL-R ................. 56 NORPACE ........................ 18

see disopyramide phosphate ..................... 18

NORPACE CR .................. 18 NORPRAMIN .................... 27

see desipramine hcl ...... 27 NOR-QD ........................... 43

see camila 28 day ......... 41 see deblitane 28 day ..... 42 see heather ................... 42 see norethindrone (contraceptive) .............. 43

see norlyroc 28 day ....... 43 nortrel 0.5/35 28 day ......... 43 nortrel 1/35 21 day ............ 43 nortrel 1/35 28 day ............ 43 nortrel 7/7/7 28 day ........... 43 nortriptyline hcl.................. 27 NORVASC ........................ 21

see amlodipine besylate 20 NORVIR .............................. 9 NOVAREL INJ 10000UNT 46 NOVOLIN 70/30................ 38 NOVOLIN 70/30 RELION . 38 NOVOLIN N ...................... 38 NOVOLIN N RELION ........ 38 NOVOLIN R ...................... 38 NOVOLIN R RELION ........ 38 NOVOLOG ....................... 38 NOVOLOG FLEXPEN ...... 38 NOVOLOG MIX 70/30 ...... 38 NOVOLOG MIX 70/30 PREFILL ........................... 38 NOVOLOG PENFILL ........ 38 NOXAFIL ............................ 8 NPLATE ............................ 52 NUBAIN

see nalbuphine hcl .......... 2 NUCYNTA .......................... 5 NUCYNTA ER .................... 5 NUEDEXTA ...................... 35 NULOJIX .......................... 54 NULYTELY/FLAVOR PACKS ............................. 49

see gavilyte-n ................ 49 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 49 see trilyte ....................... 49

NUTRILIPID INJ 20% ....... 55 NUTROPIN AQ INJ 20MG/2ML ........................ 46 NUTROPIN AQ NUSPIN 546 NUTROPIN AQ PEN ........ 46 NUVARING ....................... 43 NUVESSA ........................ 51 NUVIGIL ........................... 36 nyamyc ............................. 62 NYMALIZE ........................ 21

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nystatin................................8 nystatin (mouth-throat) ......66 nystatin (topical) ................62 nystatin pow 100000 .........62 nystop ...............................62 O OCELLA TAB 3-0.03MG ...43 OCTAGAM ........................53 octreotide acetate .............46 OCUFEN ...........................58

see flurbiprofen sodium .58 OCUFLOX.........................57

see ofloxacin (ophth) .....57 ODOMZO ..........................16 OFEV ................................60 ofloxacin (ophth) ...............57 ofloxacin (otic) ...................66 ogestrel 28 day .................43 olanzapine.........................30 olanzapine odt ...................30 olopatadine hcl ..................58 olopatadine hcl (nasal) ......59 OLUX ................................64

see clobetasol propionate ......................................63

OLUX-E see clobetasol propionate emulsion ........................63

OMECLAMOX-PAK ..........49 omega-3-acid ethyl esters .19 omeprazole .......................50 OMEPRAZOLE-SODIUM BICARBONATE ................50 OMNARIS .........................60 OMNIPRED .......................58 OMNITROPE 10MG .........46 OMNITROPE 5.8MG ........46 OMNITROPE 5MG ...........46 ONCASPAR ......................16 ondansetron hcl ................47 ondansetron hcl inj ............47 ondansetron hcl oral soln ..47 ondansetron odt ................47 ONEXTON ........................62 ONFI .................................25 ONGLYZA .........................40 ONMEL ...............................8 OPANA ...............................5

see oxymorphone hcl ...... 5 OPANA ER (CRUSH RESISTANT ........................ 5 OPDIVO ............................ 14 OPSUMIT ......................... 23 OPTIPRANOLOL .............. 58 ORACEA ........................... 65 ORAP................................ 30

see pimozide ................. 30 ORAPRED ODT

see prednisolone sodium phosphate ..................... 45

ORAPRED ODT TAB 10MG .......................................... 45 ORAPRED ODT TAB 15MG .......................................... 45 ORAPRED ODT TAB 30MG .......................................... 45 ORAVIG ............................ 66 ORENCIA ......................... 53 ORENITRAM TAB 0.125MG .......................................... 23 ORENITRAM TAB 0.25MG .......................................... 23 ORENITRAM TAB 1MG .... 23 ORENITRAM TAB 2.5MG . 23 ORFADIN .......................... 44 ORKAMBI ......................... 60 orsythia 28 day ................. 43 ORTHO MICRONOR ........ 43

see errin 28 day............. 42 see lyza ......................... 43 see sharobel 28 day ...... 43

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 43 see tri-previfem 28 day .. 44 see tri-sprintec 28 day ... 44

ORTHO TRI-CYCLEN LO . 43 ORTHO-CYCLEN ............. 43

see estarylla tab 0.25-35 ...................................... 42 see mono-linyah tab 0.25-35 .......................... 43 see norgest/ethi tab 0.25/35 .......................... 43 see previfem 28 day ...... 43 see sprintec 28 day ....... 43

ORTHO-NOVUM 1/35 ...... 43 ORTHO-NOVUM 7/7/7 ..... 43

see cyclafem 7/7/7 28 day ...................................... 42 see nortrel 7/7/7 28 day 43

OSENI TAB 12.5-15MG .... 40 OSENI TAB 12.5-30MG .... 40 OSENI TAB 12.5-45MG .... 40 OSENI TAB 25-15MG ....... 40 OSENI TAB 25-30MG ....... 40 OSENI TAB 25-45MG ....... 40 OSMOPREP ..................... 49 OTEZLA ............................ 53 OTREXUP ........................ 53 ovcon 35 28 day ............... 43 OVCON-35

see balziva 28 day ........ 41 see briellyn 28 day ........ 41 see gildagia ................... 42 see philith ...................... 43 see vyfemla 28 day ....... 44 see zenchent tab ........... 44

ovide ................................. 65 OVIDE

see malathion ................ 65 oxacillin sodium ................ 13 oxaliplatin .......................... 16 OXANDRIN

see oxandrolone............ 37 oxandrolone ...................... 37 oxaprozin ............................ 1 oxcarbazepine .................. 25 OXISTAT .......................... 62 OXSORALEN ULTRA ....... 62

see methoxsalen rapid .. 62 OXTELLAR XR ................. 25 oxybutynin chloride ........... 51 oxycodone hcl ..................... 5 OXYCODONE HCL ............ 5 oxycodone w/ acetaminophen 10-325mg .. 5 oxycodone w/ acetaminophen 2.5-325mg . 5 oxycodone w/ acetaminophen 5-325mg .... 5 oxycodone w/ acetaminophen 7.5-325mg . 5 oxycodone-aspirin............... 5

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oxycodone-ibuprofen ..........5 OXYCONTIN .......................5 oxymorphone hcl .................5 OXYTROL .........................51 P pacerone ...........................18 paclitaxel ...........................14 paliperidone ......................30 PAMELOR ........................27

see nortriptyline hcl .......27 pamidronate disodium .......41 PAMINE ............................48

see methscopolamine bromide .........................48

PAMINE FORTE ...............48 see methscopolamine bromide .........................48

PANCREAZE ....................50 PANDEL............................64 PANRETIN ........................65 pantoprazole sodium .........50 paricalcitol .........................57 PARICALCITOL ................57 PARLODEL

see bromocriptine mesylate ........................28

PARNATE .........................27 see tranylcypromine sulfate ............................28

paroex sol 0.12% ..............66 paromomycin sulfate ...........6 paroxetine er tab ...............27 paroxetine hcl tabs ............27 paser d/r ............................10 PATADAY .........................58 PATANASE .......................59

see olopatadine hcl (nasal) ......................................59

PATANOL .........................58 see olopatadine hcl .......58

PAXIL ................................27 see paroxetine hcl tabs..27

PAXIL CR..........................27 see paroxetine er tab .....27

PAZEO ..............................58 PCE ..................................12 PEDIAPRED

see pred sod pho sol

5mg/5ml ........................ 45 pediapred sol 6.7/5ml........ 45 PEDVAX HIB .................... 54 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 49 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 49 PEGANONE ..................... 25 PEGASYS ......................... 10 PEGASYS PROCLICK ..... 10 PEGINTRON .................... 10 PEG-INTRON ................... 10 PEG-INTRON REDIPEN .. 10 PENICILLIN G POT IN DEXTROSE ...................... 13 PENICILLIN G POTASSIUM IN ...................................... 13 penicillin g procaine .......... 13 penicillin g sodium............. 13 penicillin v potassium ........ 13 penicilln gk inj 20mu.......... 13 penicilln gk inj 5mu............ 13 PENNSAID ....................... 65 PENTAM 300 ...................... 8 PENTASA ......................... 49 pentoxifylline ..................... 52 PEPCID

see famotidine ............... 48 PEPCID SUSP .................. 48 pepcid tab ......................... 48 PERCOCET

see endocet ..................... 3 see oxycodone w/ acetaminophen 10-325mg ........................................ 5 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 5 see oxycodone w/ acetaminophen 5-325mg . 5 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 5 see roxicet tab 5-325mg .. 6

percocet 10/325 .................. 5

percocet 2.5/325 ................. 5 percocet 7.5/325 ................. 5 percocet tab 5-325mg ......... 6 PERCODAN ....................... 6

see oxycodone-aspirin .... 5 PERFOROMIST ............... 59 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 65 see paroex sol 0.12% .... 66 see periogard soln 0.12% ...................................... 66

perindopril erbumine ......... 17 periogard soln 0.12% ........ 66 PERJETA ......................... 14 permethrin ........................ 65 perphenazine .................... 30 PERTZYE ......................... 50 PEXEVA ........................... 27 pfizerpen g inj 5mu ........... 13 pfizerpen-g inj 20mu ......... 13 phenadoz .......................... 47 phenelzine sulfate ............. 27 phenergan ........................ 47 PHENERGAN

see promethazine hcl .... 48 phenergan inj .................... 47 phenobarbital .................... 25 phenobarbital sodium ....... 25 PHENOBARBITAL SODIUM.......................................... 25 phenoxybenzamine hcl ..... 22 phenytek ........................... 25 PHENYTEK

see phenytoin sodium extended ....................... 25

phenytoin .......................... 25 phenytoin inj 50mg/ml ....... 25 phenytoin sodium extended.......................................... 25 philith ................................ 43 PHOSLO ........................... 46

see calcium acetate (phosphate binder) ........ 46

PHOSLYRA ...................... 46 PHOSPHOLINE IODIDE .. 58 PICATO ............................ 65

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PILOCARPINE HCL ..........58 pilocarpine hcl (oral) ..........66 PILOCARPINE HCL (ORAL) ..........................................66 pimozide............................30 pimtrea pack .....................43 pindolol..............................20 pioglitazone hcl .................40 pioglitazone hcl-glimepiride ..........................................40 pioglitazone hcl-metformin hcl .....................................40 piperacillin sodium-tazobactam sodium ..........................................13 pirmella 1/35 28 day ..........43 piroxicam.............................1 PLAN B ONE-STEP

see levonorgestrel (emergency oc) .............42 see next choice tab 1.5mg ......................................43

PLAQUENIL ......................53 see hydroxychloroquine sulfate ............................53

PLASMA-LYTE A ..............56 PLASMA-LYTE-148 ..........56 PLASMA-LYTE-56/D5W ...56 PLAVIX .............................53

see clopidogrel bisulfate 52 PLEGRIDY ........................36 PLEGRIDY STARTER PACK ................................36 plenamine .........................55 PLETAL.............................52 podofilox............................65 polyethylene glycol 3350 ...49 polymyxin b sulfate .............8 polymyxin b-trimethoprim ..57 POLYTRIM........................57

see polymyxin b-trimethoprim ...............57

POMALYST ......................16 PONSTEL ...........................1

see mefenamic acid ........1 portia 28 day .....................43 pot chloride inj 2meq/ml ....56 potassium chloride ............55

POTASSIUM CHLORIDE 55, 56 POTASSIUM CHLORIDE 0.3%/D .............................. 56 potassium chloride caps er .......................................... 55 potassium chloride in nacl . 56 POTASSIUM CHLORIDE IN NACL ................................ 56 potassium chloride microencapsulated crystals cr ....................................... 55 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 55 potassium citrate (alkalinizer) .......................................... 51 POTASSIUM CITRATE (ALKALINIZER) ................ 51 POTIGA ...................... 25, 26 PRADAXA ......................... 52 pramipexole dihydrochloride .......................................... 28 PRANDIMET ..................... 40 PRANDIN .......................... 40

see repaglinide .............. 40 PRAVACHOL .................... 19

see pravastatin sodium . 19 pravastatin sodium ............ 19 prazosin hcl ....................... 17 PRECOSE ........................ 40

see acarbose ................. 38 PRED FORTE ................... 58 PRED MILD ...................... 58 pred sod pho sol 5mg/5ml . 45 PRED-G ............................ 57 PRED-G S.O.P. ................ 57 prednicarbate .................... 64 PREDNICARBATE ........... 64 PREDNISOLONE ACETATE (OPHTH) ........................... 58 prednisolone sodium phosphate ......................... 45 prednisolone sodium phosphate (ophth) ............. 58 prednisolone sol 15mg/5ml .......................................... 45 prednisolone sol 25mg/5ml .......................................... 45

prednisolone syrup 15 mg/5ml .............................. 45 prednisone con 5mg/ml .... 45 prednisone pak 10mg ....... 45 prednisone pak 5mg ......... 45 prednisone sol 5mg/5ml .... 45 prednisone tab 10mg ........ 45 prednisone tab 1mg .......... 45 prednisone tab 2.5mg ....... 45 prednisone tab 20mg ........ 45 prednisone tab 50mg ........ 45 prednisone tab 5mg .......... 45 PREGNYL W/DILUENT BENZYL ............................ 46 PREMARIN CREAM ......... 45 PREMARIN INJ ................ 45 premasol 10% ................... 56 premasol 6% ..................... 55 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC).......................................... 57 PREPOPIK ....................... 49 PREVACID ....................... 50

see lansoprazole ........... 50 PREVACID SOLUTAB ...... 50 prevalite ............................ 19 previfem 28 day ................ 43 PREVPAC ........................ 49

see amoxicillin-clarithromycin w/ lansoprazole ............. 49

PREZCOBIX ..................... 10 PREZISTA .......................... 9 PRIFTIN ............................ 10 PRILOSEC ....................... 50

see omeprazole............. 50 PRIMAQUINE PHOSPHATE............................................ 9 PRIMAXIN .......................... 8 PRIMAXIN IV

see imipenem-cilastatin ... 7 primidone .......................... 26 PRIMSOL SOL 50MG/5ML . 8 PRINIVIL ........................... 17

see lisinopril .................. 17 PRISTIQ ........................... 27 PRIVIGEN ........................ 53 PROAIR HFA .................... 59

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PROAIR RESPICLICK ......59 probenecid ..........................1 PROCALAMINE ................56 PROCARDIA XL ...............21

see nifedical ..................21 see nifedipine er ............21

prochlorperazine inj 5 mg/ml ..........................................48 prochlorperazine maleate..48 prochlorperazine supp ......48 PROCRIT ..........................52 procto-pak .........................62 proctosol hc 2.5 % ............62 proctozone hc ...................62 PROCYSBI .......................44 progesterone micronized...47 PROGLYCEM SUS 50MG/ML ..........................46 PROGRAF ........................54

see tacrolimus ...............54 PROLASTIN-C ..................60 PROLENSA ......................59 PROLEUKIN .....................14 PROLIA .............................46 PROMACTA ......................52 promethazine hcl ...............48 promethegan .....................48 PROMETRIUM .................47

see progesterone micronized .....................47

propafenone hcl ................18 propafenone hcl 12hr ........18 proparacaine hcl ...............59 propranolol & hydrochlorothiazide ...........20 propranolol hcl er ..............20 propranolol inj 1mg/ml .......20 propranolol sol ..................20 propranolol tab ..................20 propylthiouracil ..................47 PROQUAD ........................54 PROSCAR ........................50

see finasteride ...............50 PROSOL ...........................56 PROTONIX .......................50

see pantoprazole sodium ......................................50

PROTONIX INJ .................50

PROTOPIC ....................... 65 see tacrolimus (topical) . 65

protriptyline hcl .................. 27 PROVENTIL HFA ............. 59 PROVERA ........................ 47

see medroxyprogesterone acetate .......................... 47

PROVIGIL ......................... 36 see modafinil ................. 36

PROZAC ........................... 27 see fluoxetine cap 10mg27 see fluoxetine cap 20mg27 see fluoxetine cap 40mg27

PROZAC WEEKLY ........... 28 see fluoxetine hcl........... 27

PRUDOXIN CRE 5% ........ 62 psorcon ............................. 64 PULMICORT

see budesonide (inhalation) .................... 60

PULMICORT FLEXHALER .......................................... 61 PULMICORT INH SUSP 0.25MG/2 ML .................... 61 PULMICORT INH SUSP 0.5MG/2 ML ...................... 61 PULMICORT INH SUSP 1MG/2ML .......................... 61 PULMOZYME ................... 60 PURIXAN .......................... 14 PYLERA ............................ 49 pyrazinamide .................... 10 pyridostigmine bromide ..... 35 Q QNASL .............................. 60 QNASL CHILDRENS ........ 60 QUADRACEL ................... 54 QUALAQUIN ....................... 9

see quinine sulfate .......... 9 QUARTETTE .................... 43 quasense 91 day .............. 43 QUDEXY XR ..................... 26 questran ............................ 19 QUESTRAN

see cholestyramine ....... 19 questran light .................... 19 QUESTRAN LIGHT

see prevalite .................. 19

quetiapine fumarate .......... 30 QUILLIVANT XR ............... 33 quinapril hcl ...................... 17 quinapril-hydrochlorothiazide.......................................... 17 quinidine gluconate ........... 18 quinidine sulfate ................ 18 quinine sulfate..................... 9 QVAR ............................... 61 R RABAVERT ...................... 54 rabeprazole sodium .......... 50 RAGWITEK ...................... 53 raloxifene hcl .................... 46 ramipril .............................. 17 RANEXA ........................... 22 ranitidine hcl ..................... 48 RAPAFLO ......................... 50 RAPAMUNE ..................... 54

see sirolimus ................. 54 RASUVO .......................... 53 RAVICTI ........................... 44 RAYOS TAB 1MG ............ 45 RAYOS TAB 2MG ............ 45 RAYOS TAB 5MG ............ 45 RAZADYNE ...................... 26

see galantamine hydrobromide ................ 26

RAZADYNE ER ................ 26 see galantamine hydrobromide er ............ 26

REBETOL ......................... 10 see ribasphere .............. 10 see ribavirin 200mg ....... 10

REBIF ............................... 36 REBIF REBIDOSE ............ 36 REBIF REBIDOSE TITRATION ....................... 36 REBIF TITRATION PACK 36 RECLAST ......................... 41

see zoledronic inj 5/100ml ...................................... 41

reclipsen 28 day................ 43 RECOMBIVAX HB ............ 54 RECTIV ............................ 65 REGLAN ........................... 48

see metoclopramide hcl 47 REGRANEX ..................... 65

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RELENZA DISKHALER ....10 RELISTOR ........................49 RELPAX ............................34 REMERON........................28

see mirtazapine .............27 REMERON SOLTAB ........28

see mirtazapine .............27 REMICADE .......................53 REMODULIN ....................23 RENAGEL .........................46 RENVELA PAK .................46 RENVELA TAB 800MG.....46 repaglinide ........................40 repaglinide-metformin hcl ..40 REPREXAIN

see hydrocodone-ibuprofen tab 5-200mg ..........................4 see ibudone tab 5-200mg 4

reprexain tab 10-200mg ......6 reprexain tab 2.5-200mg .....6 reprexain tab 5-200mg ........6 REQUIP ............................28

see ropinirole hydrochloride .................28

REQUIP XL .......................28 see ropinirole hydrochloride .................28

RESCRIPTOR ....................9 RESTASIS ........................59 RESTORIL ........................33

see temazepam .............34 RETIN-A............................62

see tretinoin ...................62 RETIN-A MICRO ...............62 RETIN-A MICRO PUMP ...62 RETROVIR

see zidovudine ................9 RETROVIR CAPS ...............9 RETROVIR IV INFUSION ...9 RETROVIR SYRP ...............9 REVATIO ..........................23

see sildenafil citrate (pulmonary hypertension) ......................................23

REVIA see naltrexone hcl .........37

REVLIMID .........................53

REXULTI ........................... 30 REYATAZ ........................... 9 RHEUMATREX ................. 53 RHINOCORT AQUA ......... 60

see budesonide (nasal) . 60 ribapak mis 600/day .......... 10 ribasphere ......................... 10 ribasphere ribapak 1000 ... 10 ribasphere ribapak 1200 ... 10 ribasphere ribapak 800 ..... 10 ribavirin 200mg ................. 10 rifabutin ............................. 10 rifadin ................................ 10 RIFADIN ........................... 10

see rifampin ................... 10 rifamate ............................. 10 rifampin ............................. 10 RIFATER .......................... 10 RILUTEK ........................... 35

see riluzole .................... 35 riluzole .............................. 35 rimantadine hydrochloride . 10 RINGER'S ......................... 56 RIOMET ............................ 40 risedronate sodium ........... 41 RISEDRONATE SODIUM . 41 RISPERDAL ..................... 30

see risperidone .............. 31 RISPERDAL INJ 12.5MG . 30 RISPERDAL INJ 25MG .... 30 RISPERDAL INJ 37.5MG . 30 RISPERDAL INJ 50MG .... 30 RISPERDAL M-TAB ......... 30

see risperidone odt ........ 31 risperidone ........................ 31 risperidone odt .................. 31 RITALIN ............................ 33

see methylphenidate hcl 33 RITALIN LA ....................... 33

see methylphenidate hcl 33 RITUXAN .......................... 14 rivastigmine tartrate .......... 26 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 27 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 27 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 27

rizatriptan benzoate .......... 34 ROBINUL .......................... 48

see glycopyrrolate ......... 48 ROBINUL FORTE............. 48

see glycopyrrolate ......... 48 ROCALTROL .................... 57

see calcitriol .................. 56 rocephin ............................ 11 ROCEPHIN

see ceftriaxone sodium . 11 ropinirole hydrochloride .... 28 rosadan cre 0.75%............ 65 ROTARIX .......................... 54 ROTATEQ ........................ 54 ROWASA .......................... 49

see mesalamine enema 49 roxicet soln ......................... 6 roxicet tab 5-325mg ............ 6 ROXICODONE ................... 6

see oxycodone hcl .......... 5 ROZEREM ........................ 33 RUCONEST ..................... 52 RYTARY ........................... 29 RYTHMOL ........................ 18

see propafenone hcl ...... 18 see propafenone hcl 12hr ...................................... 18

RYTHMOL SR .................. 18 see propafenone hcl ...... 18 see propafenone hcl 12hr ...................................... 18

S SABRIL ............................. 26 SAIZEN ............................. 46 SAIZEN CLICK.EASY ....... 46 SALAGEN ......................... 66

see pilocarpine hcl (oral) ...................................... 66

SAMSCA .......................... 46 SANCUSO ........................ 48 SANDIMMUNE

see cyclosporine ........... 53 SANDIMMUNE CAPS ...... 54 SANDIMMUNE INJ ........... 54 SANDIMMUNE SOLN ...... 54 SANDOSTATIN ................ 46

see octreotide acetate ... 46 SANDOSTATIN LAR

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DEPOT..............................46 SANTYL ............................65 SAPHRIS ..........................31 SARAFEM.........................37 SAVAYSA .........................52 SAVELLA ..........................35 SAVELLA TITRATION PACK ................................35 SEASONIQUE ..................43

see amethia 91 day .......41 see ashlyna 91 day .......41 see levonorgestrel-ethinyl estradiol (91-day) ..........42

SECTRAL .........................20 see acebutolol hcl ..........20

selegiline hcl .....................29 selenium sulfide ................63 SELZENTRY .......................9 SEMPREX-D .....................59 SENSIPAR ........................41 SEREVENT DISKUS ........60 SEROQUEL ......................31

see quetiapine fumarate 30 SEROQUEL XR ................31 SEROSTIM .......................46 sertraline hcl ......................28 setlakin tab ........................43 SF-ROWASA ....................49 sharobel 28 day ................43 SIGNIFOR.........................46 SIGNIFOR LAR .................46 sildenafil citrate (pulmonary hypertension) ....................23 SILENOR ..........................33 SILVADENE ......................62 SILVER SULFADIAZINE...62 SIMBRINZA SUS 1-0.2% ..58 SIMCOR............................19 SIMPONI ...........................53 SIMPONI ARIA .................53 SIMULECT ........................54 simvastatin ........................19 SINEMET ..........................29

see carbidopa-levodopa 28 SINEMET CR ....................29

see carbidopa-levodopa 28 SINGULAIR .......................60

see montelukast sodium 60

sirolimus ............................ 54 SIROLIMUS ...................... 54 SIRTURO .......................... 10 SIVEXTRO .......................... 8 SKLICE ............................. 65 SODIUM CHLORIDE .. 55, 56 SODIUM CHLORIDE 0.45% VIA .................................... 56 SODIUM CHLORIDE 0.9% .......................................... 65 SODIUM DIURIL ............... 22 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 55 sodium phenylbutyrate ...... 44 sodium polystyrene sulfonate .......................................... 41 SOLARAZE ....................... 65

see diclofenac sodium (actinic keratoses) ......... 65

SOLIA ............................... 43 SOLIRIS ............................ 52 SOLODYN ........................ 13 SOLTAMOX ...................... 15 SOLU-CORTEF 1000MG . 45 SOLU-CORTEF 100MG ... 45 SOLU-CORTEF 250MG ... 45 SOLU-CORTEF 500MG ... 45 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 45 see methylpr ss inj 1gm . 45 see methylpr ss inj 40mg ...................................... 45

SOLU-MEDROL INJ 125MG .......................................... 45 SOLU-MEDROL INJ 1GM 45 SOLU-MEDROL INJ 2GM 45 SOLU-MEDROL INJ 40MG .......................................... 45 SOLU-MEDROL INJ 500MG .......................................... 45 SOMATULINE DEPOT ..... 46 SOMAVERT ...................... 46 SOOLANTRA .................... 65 SORIATANE ..................... 63

see acitretin ................... 62 SORILUX .......................... 63

sorine ................................ 18 sotalol hcl .................... 18, 19 sotalol hcl (afib/afl) ............ 19 SOTYLIZE ........................ 20 SOVALDI .......................... 10 SPIRIVA HANDIHALER ... 59 SPIRIVA RESPIMAT ........ 59 spironolactone .................. 17 spironolactone & hydrochlorothiazide........... 22 SPORANOX ....................... 8

see itraconazole .............. 8 SPORANOX PULSEPAK ... 8 SPORANOX SOL 10MG/ML............................................ 8 sprintec 28 day ................. 43 SPRYCEL ......................... 15 sps susp 15gm/60ml ......... 41 sronyx 28 day ................... 43 SSD .................................. 62 STALEVO ......................... 29 STARLIX ........................... 40

see nateglinide .............. 40 stavudine ............................ 9 STELARA ......................... 63 STERILE WATER IRRIGATION ..................... 65 STIMATE .......................... 47 STIOLTO RESPIMAT ....... 59 STIVARGA ....................... 16 STRATTERA .................... 33 streptomycin sulfate ............ 6 STRIANT .......................... 37 STRIBILD ......................... 10 STRIVERDI RESPIMAT ... 60 STROMECTOL ................... 8

see ivermectin ................. 7 SUBOXONE MIS 12-3MG 37 SUBOXONE MIS 2-0.5MG.......................................... 37 SUBOXONE MIS 4-1MG .. 37 SUBOXONE MIS 8-2MG .. 37 SUBSYS ............................. 6 SUCLEAR ......................... 49 SUCRAID ......................... 49 sucralfate .......................... 49 SULAR .............................. 21

see nisoldipine .............. 21

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sulfacet sod oin 10% op ....57 sulfacetamide sodium (acne) ..........................................62 sulfacetamide sodium (ophth)...............................57 sulfacetamide sod-prednisolone ..............57 sulfadiazine .........................6 sulfamethoxazole-trimethop 8 sulfamethoxazole-trimethoprim inj ....................................8 SULFAMYLON ..................62 sulfasalazine dr .................49 sulfasalazine ir ..................49 sulindac ...............................1 SUMATRIPTAN INJ 4MG/0.5ML .......................34 sumatriptan inj 6mg/0.5ml 34, 35 SUMATRIPTAN INJ 6MG/0.5ML .......................34 sumatriptan succinate .......35 SUMATRIPTAN SUCCINATE .....................35 SUMAVEL DOSEPRO ......35 suprax ...............................11 SUPRAX ...........................11

see cefixime ..................11 SUPREP BOWEL PREP...49 SURMONTIL .....................28

see trimipramine maleate ......................................28

SUSTIVA.............................9 SUTENT............................16 syeda ................................44 SYLATRON KIT 200MCG .16 SYLATRON KIT 300MCG .16 SYLATRON KIT 600MCG .16 SYLVANT..........................16 SYMBICORT .....................61 SYMLINPEN 120 ..............38 SYMLINPEN 60 ................38 SYNAGIS ..........................54 SYNALAR .........................64

see fluocinolone acetonide ................................ 63, 64

SYNALGOS-DC ..................2 SYNAREL .........................44

SYNERA ........................... 64 SYNERCID ......................... 8 SYNJARDY TAB 12.5-1000 .......................................... 40 SYNJARDY TAB 12.5-500 40 SYNJARDY TAB 5-1000MG .......................................... 40 SYNJARDY TAB 5-500MG .......................................... 40 SYNRIBO .......................... 16 SYNTHROID ..................... 47

see levothyroxine sodium ...................................... 47

SYPRINE .......................... 41 T TABLOID .......................... 14 TACLONEX ...................... 64

see calcipotriene/betamethasone .................................. 63

tacrolimus ......................... 54 tacrolimus (topical) ............ 65 TAFINLAR ........................ 16 TAGRISSO ....................... 16 TAMIFLU .......................... 10 tamoxifen citrate ............... 15 tamsulosin hcl ................... 51 TANZEUM ........................ 38 tapazole ............................ 47 TAPAZOLE

see methimazole ........... 47 TARCEVA ......................... 16 TARGRETIN ............... 16, 65

see bexarotene ............. 16 tarina fe 1/20 28 day ......... 44 TARKA .............................. 17

see trandolapril-verapamil hcl.................................. 17

TASIGNA .......................... 16 TAXOTERE ...................... 14 tazicef ............................... 11 tazicef vial ......................... 11 TAZORAC ......................... 63 taztia xt ............................. 21 TECFIDERA CAP 120MG 36 TECFIDERA CAP 240MG 36 TECFIDERA MIS STARTER .......................................... 36

TEFLARO ......................... 11 TEGRETOL ...................... 26

see carbamazepine ....... 24 see epitol ....................... 24

TEGRETOL-XR ................ 26 see carbamazepine ....... 24

TEKTURNA ...................... 21 TEKTURNA HCT .............. 21 telmisartan ........................ 18 telmisartan-amlodipine ...... 18 telmisartan-hydrochlorothiazide...................................... 18 temazepam ....................... 34 TEMOVATE

see clobetasol propionate ...................................... 63 see cormax.................... 63

TEMOVATE CREAM ........ 64 TEMOVATE E

see clobetasol e cream 0.05% ............................ 63

TEMOVATE E CREAM ..... 64 TEMOVATE GEL .............. 64 TEMOVATE OIN............... 64 TEMOVATE SOLN ........... 64 TENIVAC .......................... 54 TENORETIC 100 .............. 20

see atenolol & chlorthalidone ................ 20

TENORETIC 50 ................ 20 see atenolol & chlorthalidone ................ 20

TENORMIN ...................... 20 see atenolol ................... 20

TERAZOL 3 ...................... 51 see terconazole vaginal 51

TERAZOL 7 ...................... 51 see terconazole vaginal 51 see zazole ..................... 51

terazosin hcl ..................... 17 terbinafine hcl ..................... 8 terbutaline sulfate ............. 60 terconazole vaginal ........... 51 TESTIM ............................ 37 testosterone cypionate ...... 37 testosterone enanthate ..... 37 TETANUS/DIPHTHERIA TOXOID ............................ 54

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tetrabenazine ....................35 TETRACYCLINE HCL.......13 TEVETEN .........................18 TEVETEN HCT .................18 texacort .............................64 THALOMID .......................53 theo-24 ..............................61 theophylline .......................61 thioridazine hcl ..................31 thiothixene.........................31 THYMOGLOBULIN ...........54 tiagabine hcl ......................26 TIAZAC .............................21

see diltiazem hcl er ........21 see diltiazem hcl extended release beads ................21 see taztia xt ...................21

TIKOSYN ..........................19 timolol maleate ..................20 timolol maleate (ophth)......58 TIMOLOL MALEATE GEL 58 TIMOPTIC .........................58

see timolol maleate (ophth) ...........................58

TIMOPTIC OCUDOSE ......58 TIMOPTIC-XE ...................58 TIROSINT .........................47 TIVICAY ..............................9 tizanidine ...........................36 TOBI

see tobramycin ................7 TOBI NEB ...........................7 TOBI PODHALER ...............7 TOBRADEX ......................57

see tobramycin-dexamethasone ....................................57

TOBRADEX ST .................57 tobramycin ..........................7 tobramycin (ophth) ............57 tobramycin sulfate ...............7 tobramycin sulfate in saline .7 tobramycin-dexamethasone ..........................................57 TOBREX

see tobramycin (ophth) ..57 TOBREX OINT 0.3% ........57 TOBREX SOL 0.3% OP ....57

tofranil ............................... 28 TOFRANIL

see imipramine hcl ........ 27 TOFRANIL-PM ................. 28

see imipramine pamoate ...................................... 27

TOLAK .............................. 65 tolmetin sodium ................... 1 tolterodine tartrate er......... 51 tolterodine tartrate tab 1 mg .......................................... 51 tolterodine tartrate tab 2 mg .......................................... 51 TOPAMAX ........................ 26

see topiramate .............. 26 TOPAMAX SPRINKLE...... 26

see topiramate .............. 26 topicort .............................. 64 TOPICORT ....................... 64

see desoximetasone ..... 63 TOPICORT SPRAY 0.25% .......................................... 64 topiramate ......................... 26 TOPIRAMATE .................. 26 toposar .............................. 16 topotecan hcl .................... 16 TOPROL XL ...................... 20

see metoprolol succinate ...................................... 20

TORISEL .......................... 15 torsemide inj 50mg/5ml ..... 22 torsemide tabs .................. 22 TOUJEO SOLOSTAR ....... 38 TOVIAZ ............................. 51 TPN ELECTROLYTES ..... 55 TRACLEER ....................... 23 TRADJENTA ..................... 40 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 TRAMADOL HCL ER .......... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2

TRANDATE ...................... 20 trandolapril ........................ 17 trandolapril-verapamil hcl .. 17 tranexamic acid................. 52 TRANSDERM-SCOP ........ 48 TRANXENE T ................... 26

see clorazepate dipotassium ................... 24

tranylcypromine sulfate ..... 28 TRAVASOL ...................... 56 TRAVATAN Z ................... 58 trazodone hcl .................... 28 TREANDA ........................ 14 TRECATOR ...................... 10 TRELSTAR MIXJECT ....... 15 TRESIBA FLEXTOUCH .... 38 tretinoin ....................... 16, 62 TRETINOIN ...................... 62 TRETINOIN MICROSPHERE ............... 62 tretin-x ............................... 62 trexall ................................ 53 TREXIMET ....................... 35 trezix ................................... 2 triamcinolone acetonide (mouth) ............................. 66 triamcinolone acetonide (nasal) ............................... 60 triamcinolone acetonide (topical) ............................. 64 triamt/hctz cap 37.5-25 ..... 22 triamt/hctz cap 50-25mg ... 22 triamt/hctz tab 37.5-25 ...... 22 triamt/hctz tab 75-50mg .... 22 trianex ............................... 64 TRIBENZOR ..................... 18 TRICOR ............................ 19

see fenofibrate .............. 19 triderm .............................. 64 trifluoperazine hcl.............. 31 trifluridine .......................... 57 TRIGLIDE ......................... 19 tri-legest 28 day ................ 44 TRILEPTAL

see oxcarbazepine ........ 25 TRILEPTAL SUSP ............ 26 TRILEPTAL TABS ............ 26 TRILIPIX ........................... 19

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see choline fenofibrate ..19 trilyte .................................49 trimethoprim ........................8 trimipramine maleate ........28 TRINESSA ........................44 TRI-NORINYL 28 ..............44

see aranelle 28 ..............41 TRIOSTAT ........................47

see liothyronine sodium .47 tri-previfem 28 day ............44 TRISENOX........................16 tri-sprintec 28 day .............44 TRIUMEQ .........................10 trivora 28 day ....................44 TRIZIVIR ...........................10

see abacavir sulfate-lamivudine-zidovudine ...................................9

TROKENDI XR .................26 TROPHAMINE INJ 10%....56 TROPHAMINE INJ 6%......56 trospium chloride ...............51 trospium chloride er ..........51 TRULICITY .......................38 TRUMENBA ......................54 TRUSOPT .........................58

see dorzolamide hcl ......58 TRUVADA .........................10 TUDORZA PRESSAIR......59 TUDORZA PRESSAIR (INSTITUTIONAL PACK) ..59 TWINRIX INJ ....................54 TWYNSTA ........................18

see telmisartan-amlodipine ......................................18

TYBOST..............................9 TYGACIL.............................8 TYKERB............................16 tylenol with codeine .............2 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................2

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................2

TYPHIM VI ........................54 TYSABRI...........................36 TYVASO ...........................23

TYZEKA ............................ 11 tyzine ................................ 60 U UCERIS AER 2MG/ACT ... 49 UCERIS TAB 9MG............ 49 ULORIC .............................. 1 ULTRACET ......................... 2

see tramadol-acetaminophen . 2

ULTRAM ............................. 2 see tramadol hcl tab 50 mg ................................... 2

ULTRAM ER ....................... 2 see tramadol hcl er .......... 2

ULTRAVATE ..................... 64 see halobetasol propionate ..................... 64

ULTRESA ......................... 50 UNASYN ........................... 13

see ampicillin & sulbactam sodium ........................... 12

UNASYN BULK PACK ...... 13 see ampicillin & sulbactam sodium ........................... 12

UNITHROID ...................... 47 urecholine ......................... 51 URECHOLINE

see bethanechol chloride ...................................... 51

UROCIT-K ........................ 51 UROCIT-K 15

see potassium citrate (alkalinizer) .................... 51

UROXATRAL .................... 51 see alfuzosin hcl ............ 50

URSO 250 ........................ 49 see ursodiol ................... 50

URSO FORTE .................. 49 see ursodiol ................... 50

ursodiol ............................. 50 UVADEX ........................... 16 V VAGIFEM .......................... 45 valacyclovir hcl .................. 11 VALCHLOR ...................... 65 VALCYTE ......................... 11

see valganciclovir hcl .... 11 valganciclovir hcl ............... 11

VALIUM ............................ 26 see diazepam ................ 24

valproate sodium .............. 26 valproic acid ...................... 26 valsartan ........................... 18 valsartan-hydrochlorothiazide........................................ 18 VALSTAR ......................... 14 VALTREX ......................... 11

see valacyclovir hcl ....... 11 VANCOCIN HCL................. 8

see vancomycin hcl ......... 8 vancomycin hcl ................... 8 vancomycin hcl inj 1000mg . 8 vancomycin hcl inj 10gm ..... 8 vancomycin hcl inj 500mg ... 8 vancomycin hcl inj 5gm ....... 8 vancomycin hcl inj 750mg ... 8 VANDAZOLE .................... 51 VANOS ............................. 64

see fluocinonide ............ 64 VANTAS ........................... 15 VAQTA ............................. 54 VARIVAX .......................... 54 VASCEPA ......................... 19 VASERETIC ..................... 17

see enalapril maleate & hydrochlorothiazide ....... 17

VASOTEC ........................ 17 see enalapril maleate .... 17

VECTIBIX ......................... 15 VECTICAL ........................ 63 VELCADE ......................... 15 VELETRI ........................... 23 velivet 28 day .................... 44 VELPHORO ...................... 46 VELTIN ............................. 62 venlafaxine cap er............. 28 venlafaxine hcl .................. 28 VENLAFAXINE HCL ER

see venlafaxine tab er ... 28 VENLAFAXINE HCL ER TAB (VERT) ...................... 28 venlafaxine tab.................. 28 VENLAFAXINE TAB 225MG ER ..................................... 28 venlafaxine tab er ............. 28 VENTAVIS ........................ 23

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VENTOLIN HFA ................60 VERAMYST ......................60 verapamil hcl .....................21 VERAPAMIL HCL .............21 VERELAN .........................21

see verapamil hcl ..........21 VERELAN PM ...................21

see verapamil hcl ..........21 veripred .............................46 VERSACLOZ ....................31 VESICARE ........................51 vestura ..............................44 VEXOL ..............................58 VFEND

see voriconazole .............8 VFEND IV ...........................8

see voriconazole inj 200mg .............................8

VFEND SUS 40MG/ML .......8 VFEND TAB ........................8 VIBRAMYCIN ....................13

see doxycycline (monohydrate) ...............13 see doxycycline hyclate .13

vicodin .................................6 vicodin es ............................6 vicodin hp ............................6 VICOPROFEN ....................6

see hydrocodone-ibuprofen tab 7.5-200 mg ......................4

VICTOZA ..........................38 VIDAZA .............................14

see azacitidine ...............14 VIDEX EC ...........................9

see didanosine ................9 VIDEX PEDIATRIC .............9 VIGAMOX .........................57 VIIBRYD............................28 VIIBRYD STARTER PACK ..........................................28 VIMIZIM ............................44 VIMOVO..............................1 VIMPAT.............................26 vinblastine sulfate .............14 vincasar.............................14 vincristine sulfate ..............14 vinorelbine tartrate ............14

VIOKACE 10 ..................... 50 VIOKACE 20 ..................... 50 viorele ............................... 44 VIRACEPT .......................... 9 VIRAMUNE ......................... 9

see nevirapine ................. 9 VIRAMUNE XR ................... 9

see nevirapine ................. 9 VIREAD .............................. 9 VIROPTIC ......................... 57

see trifluridine ................ 57 VISTIDE

see cidofovir .................. 10 VITEKTA ............................. 9 VIVELLE-DOT .................. 45

see estradiol .................. 44 VIVITROL ......................... 37 VIVLODEX .......................... 1 VOGELXO ........................ 38 VOGELXO PUMP ............. 38 VOLTAREN GEL 1% ........ 65 VOLTAREN-XR .................. 1 voriconazole ........................ 8 voriconazole inj 200mg ....... 8 vospire .............................. 60 VOSPIRE ER

see albuterol sulfate er .. 59 VOTRIENT ........................ 16 VPRIV ............................... 44 vyfemla 28 day .................. 44 VYTORIN .......................... 19 VYVANSE ......................... 33 W warfarin sodium ................ 52 WELCHOL ........................ 19 WELLBUTRIN ................... 28

see bupropion hcl .......... 27 WELLBUTRIN SR ............. 28

see bupropion hcl .......... 27 WELLBUTRIN XL ............. 28

see bupropion hcl .......... 27 WESTCORT

see hydrocortisone valerate ......................... 64

wymzya fe ......................... 44 X XALATAN ......................... 58

see latanoprost .............. 58

XALKORI .......................... 16 XANAX

see alprazolam .............. 23 XANAX TAB 0.25MG ........ 23 XANAX TAB 0.5MG .......... 23 XANAX TAB 1MG ............. 23 XANAX TAB 2MG ............. 23 XARELTO ......................... 52 XARELTO STARTER PACK.......................................... 52 XARTEMIS XR ................... 6 XELJANZ .......................... 53 XENAZINE ........................ 35

see tetrabenazine .......... 35 XEOMIN INJ 100 UNIT ..... 36 XEOMIN INJ 50 UNIT ....... 36 XERESE ........................... 65 XGEVA ............................. 46 XIFAXAN TAB 200MG ........ 8 XIFAXAN TAB 550MG ...... 50 XIGDUO XR TAB 10-1000MG ....................... 41 XIGDUO XR TAB 10-500MG.......................................... 41 XIGDUO XR TAB 5-1000MG.......................................... 40 XIGDUO XR TAB 5-500MG.......................................... 40 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 3 see hydrocodone-acetaminophen 5-300mg ..................... 3 see hydrocodone-acetaminophen 7.5-300mg .................. 3 see vicodin ...................... 6 see vicodin es ................. 6 see vicodin hp ................. 6

xodol tab 10-300mg ............ 6 xodol tab 5-300mg .............. 6 xodol tab 7.5-300 ................ 6 XOLAIR ............................ 60 XOPENEX ........................ 60

see levalbuterol hcl ....... 59 XOPENEX CONCENTRATE

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..........................................60 see levalbuterol conc 1.25mg/0.5ml .................59

XOPENEX HFA ................60 XTANDI .............................15 xulane dis 150-35 ..............44 XYLOCAINE ................. 6, 64

see lidocaine hcl ............64 see lidocaine hcl (local anesth.) ...........................6 see lidocaine inj 1% .........6 see lidocaine inj 2% .........6

XYLOCAINE-MPF ...............6 see lidocaine hcl (local anesth.) ...........................6 see lidocaine inj 0.5% ......6 see lidocaine inj 1.5% ......6 see lidocaine inj 2% .........6

xylon tab 10-200mg ............6 XYREM .............................36 XYZAL...............................59

see levocetirizine soln 2.5mg/5ml ......................59 see levocetirizine tab 5 mg ......................................59

Y YASMIN 28 .......................44

see drospirenone-ethinyl estradiol .........................42 see syeda ......................44 see zarah.......................44

YAZ ...................................44 see drospirenone-ethinyl estradiol .........................42 see loryna 28 day ..........43 see nikki 28 day .............43 see vestura ....................44

YERVOY ...........................15 YF-VAX .............................54 Z zafirlukast ..........................60 ZALTRAP ..........................15 zamicet................................6 ZANAFLEX .......................36

see tizanidine ................36 ZANOSAR.........................14 ZANTAC............................48

see ranitidine hcl ...........48

zarah ................................. 44 zarontin ............................. 26 ZARONTIN ....................... 26

see ethosuximide .......... 24 ZAVESCA ......................... 44 zazole ............................... 51 ZAZOLE ............................ 51 ZEBETA ............................ 20

see bisoprolol fumarate . 20 ZEGERID .......................... 50 ZELAPAR ......................... 29 ZELBORAF ....................... 16 ZEMAIRA .......................... 60 ZEMPLAR ......................... 57

see paricalcitol .............. 57 zenatane ........................... 62 zenchent fe 28 day............ 44 zenchent tab ..................... 44 ZENPEP ........................... 50 ZERBAXA ......................... 11 ZERIT ................................. 9

see stavudine .................. 9 ZESTORETIC ................... 17

see lisinopril & hydrochlorothiazide ....... 17

ZESTRIL ........................... 17 see lisinopril .................. 17

ZETIA TAB 10MG ............. 19 ZETONNA ......................... 60 ZIAC.................................. 20

see bisoprolol & hydrochlorothiazide ....... 20

ZIAGEN .............................. 9 see abacavir sulfate ........ 9

ZIANA ............................... 62 zidovudine ........................... 9 ZINACEF .......................... 11

see cefuroxime sodium . 11 ZINECARD ....................... 16

see dexrazoxane ........... 16 ZIOPTAN .......................... 58 ziprasidone hcl .................. 31 ZIPSOR .............................. 1 ZIRGAN ............................ 57 ZITHROMAX ..................... 12

see azithromycin ........... 11 ZITHROMAX TRI-PAK ...... 12 ZITHROMAX Z-PAK ......... 12

ZMAX ................................ 12 ZOCOR ............................. 19

see simvastatin ............. 19 ZOFRAN ........................... 48

see ondansetron hcl ...... 47 see ondansetron hcl inj . 47 see ondansetron hcl oral soln ............................... 47

ZOFRAN ODT .................. 48 see ondansetron odt ..... 47

ZOHYDRO ER (ABUSE DETERRENT)..................... 6 ZOLADEX ......................... 15 zoledronic inj 4mg/5ml ...... 41 zoledronic inj 5/100ml ....... 41 ZOLINZA .......................... 15 zolmitriptan ....................... 35 zolmitriptan odt ................. 35 ZOLOFT ........................... 28

see sertraline hcl ........... 28 zolpidem tartrate ............... 34 ZOMACTON ..................... 46 ZOMETA ........................... 41

see zoledronic inj 4mg/5ml ...................................... 41

ZOMIG .............................. 35 see zolmitriptan ............. 35

ZOMIG NASAL SPRAY .... 35 ZOMIG ZMT...................... 35

see zolmitriptan odt ....... 35 ZONALON ........................ 62 ZONEGRAN ..................... 26

see zonisamide ............. 26 zonisamide ....................... 26 ZONTIVITY ....................... 53 ZORBTIVE ........................ 46 ZORTRESS TAB 0.25MG 54 ZORTRESS TAB 0.5MG .. 54 ZORTRESS TAB 0.75MG 54 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 54 ZOSYN ............................. 13

see piperacillin sodium-tazobactam sodium .......................... 13

zovia 1/35e 28 day............ 44 zovia 1/50e 28 day............ 44 ZOVIRAX .................... 11, 65

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see acyclovir ..................10 see acyclovir topical ......65

ZUBSOLV SUB 1.4-0.36MG ..........................................37 ZUBSOLV SUB 11.4-2.9MG ..........................................37 ZUBSOLV SUB 2.9-0.71MG ..........................................37 ZUBSOLV SUB 5.7-1.4MG ..........................................37 ZUBSOLV SUB 8.6-2.1MG ..........................................37 ZUPLENZ..........................48

ZYBAN .............................. 37 see buproban ................ 37 see bupropion hcl (smoking deterrent) ....... 37

ZYCLARA ......................... 65 ZYDELIG .......................... 16 ZYFLO CR ........................ 60 ZYKADIA .......................... 16 ZYLET............................... 57 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1 ZYMAXID .......................... 57

see gatifloxacin (ophth) . 57

ZYPREXA ......................... 31 see olanzapine .............. 30

ZYPREXA RELPREVV ..... 31 ZYPREXA RELPREVV INJ 210MG .............................. 31 ZYPREXA ZYDI TAB 10MG.......................................... 31 ZYPREXA ZYDIS ............. 31

see olanzapine odt ........ 30 ZYTIGA ............................. 15 ZYVOX ............................... 8

see linezolid .................... 7

2016 601 4t copper comm eff 03/01/2016€¦ · tramadol hcl cp24 100mg ql (90 caps / 30 days) 1...

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