2016 632 3t platinum comm eff 05/01/2016 · 2016-04-25 · tramadol hcl cp24 200mg ql (60 caps / 30...

2016 632 3T Platinum Comm eff 05/01/2016

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

MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol

(generic of ARTHROTEC 75) 1

DUEXIS 3 NM

VIMOVO 3 NM

NSAIDS celecoxib (generic of

CELEBREX) CAPS 1

diclofenac potassium 1 diclofenac sodium TB24;

TBEC 1

diflunisal 1 etodolac 1

etodolac er 1

FENOPROFEN CALCIUM CAPS

1

fenoprofen calcium TABS 1

flurbiprofen TABS 1 ibuprofen SUSP 1

ibuprofen TABS 400mg,

600mg, 800mg 1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of

PONSTEL) CAPS 1

MELOXICAM SUSP 1 meloxicam tabs (generic of

MOBIC) 1

nabumetone TABS 1

NAPRELAN 375mg, 750mg 3 NM

naproxen SUSP 1

naproxen (generic of

NAPROSYN) TABS 250mg, 500mg

1

Drug Name Drug Tier

Requirements/Limits

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 3 NM

NAPROXEN SODIUM TB24 500mg

3 NM

oxaprozin (generic of

DAYPRO) 1

piroxicam (generic of

FELDENE) CAPS 1

sulindac TABS 1

tolmetin sodium 1

VIVLODEX 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

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS

QL (400 tabs / 30 days)

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



2

Drug Name Drug Tier

Requirements/Limits

BELBUCA 75mcg, 150mcg, 300mcg, 450mcg

QL (120 buccal films / 30 days)

3 QL PA

BELBUCA 600mcg, 750mcg, 900mcg

QL (60 buccal films / 30 days)

3 QL PA

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

TRAMADOL HCL CP24 100mg


1 QL



1 QL



1 QL

tramadol hcl er (generic of

ULTRAM ER) TB24 100mg QL (90 tabs / 30 days)

1 QL

tramadol hcl er (generic of

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

1 QL

Drug Name Drug Tier

Requirements/Limits

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

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 3 QL NM PA

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

1 QL


1 QL


1 QL

DILAUDID-HP INJ 250MG 3 B/D

DURAMORPH 1 B/D

EMBEDA QL (60 caps / 30 days)

3 QL

endocet (generic of

PERCOCET) QL (360 tabs / 30 days)

1 QL

fentanyl citrate (generic of

ACTIQ) LPOP QL (120 lozenges / 30 days)

3 QL NM PA

fentanyl patch 12 mcg/hr

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

1 QL



3

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL



1 QL

FENTORA QL (120 tabs / 30 days)

3 QL NM PA

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) QL (400 tabs / 30 days)

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


1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)


1 QL

Drug Name Drug Tier

Requirements/Limits

hydrocodone-ibuprofen tab 2.5-200mg


1 QL

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

hydromorphone hcl (generic

of DILAUDID-HP) SOLN 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS


1 QL

hydromorphone tab 8mg er

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

1 QL



1 QL



3 QL NM

HYDROMORPHONE TABS 32MG


3 QL NM

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


3 QL

HYSINGLA ER 80mg, 100mg, 120mg


3 QL NM

ibudone tab 5-200mg (generic

of REPREXAIN) QL (150 tabs / 30 days)

1 QL

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

1 QL



4

Drug Name Drug Tier

Requirements/Limits

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 40mg, 200mg QL (60 caps / 30 days)

3 QL NM

LAZANDA QL (30 bottles / 30 days)

3 QL NM PA

levorphanol tartrate TABS

QL (180 tabs / 30 days) 1 QL

lorcet hd tab 10-325mg (generic of NORCO)


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of


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)


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


1 QL

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

MORPHINE SUL INJ 1MG/ML

1 B/D


3 B/D


1 B/D


1 B/D

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


3 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

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

OPANA ER (CRUSH RESISTANT


2 QL

oxycodone hcl CAPS

QL (180 caps / 30 days) 1 QL

oxycodone hcl CONC 1

OXYCODONE HCL SOLN 1



5

Drug Name Drug Tier

Requirements/Limits

oxycodone hcl (generic of

ROXICODONE) TABS 5mg, 15mg, 30mg


1 QL

oxycodone hcl TABS 10mg,

20mg QL (180 tabs / 30 days)

1 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of


1 QL

oxycodone w/ acetaminophen 5-325mg (generic of


1 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of


1 QL

oxycodone w/ acetaminophen 10-325mg (generic of


1 QL

oxycodone-aspirin (generic of

PERCODAN) QL (360 tabs / 30 days)

1 QL

oxycodone-ibuprofen


OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS


1 QL

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

1 QL

roxicet soln

QL (1800 mL / 30 days) 2 QL

roxicet tab 5-325mg (generic

of PERCOCET) QL (360 tabs / 30 days)

1 QL

SUBSYS QL (120 sprays / 30 days)

3 QL NM PA

vicodin (generic of XODOL)


vicodin es (generic of


1 QL

Drug Name Drug Tier

Requirements/Limits

vicodin hp (generic of


1 QL

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

xylon tab 10-200mg


zamicet QL (5400 mL / 30 days)

1 QL

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


3 QL

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


XYLOCAINE) 2% 1 B/D


XYLOCAINE-MPF) 2% 1 B/D

ANTI-INFECTIVES

ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 3 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




6

Drug Name Drug Tier

Requirements/Limits

gentamicin in saline 1.4mg/ml 3


gentamicin in saline 2 mg/ml 1 gentamicin sulfate SOLN 1

neomycin sulfate TABS 1 paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI PODHALER 3 NM LA PA

tobramycin (generic of TOBI)

NEBU 3 B/D NM

tobramycin sulfate SOLN; SOLR

1

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

atovaquone (generic of

MEPRON) SUSP 3 NM

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3 NM

aztreonam (generic of

AZACTAM) 1

BILTRICIDE 2

CAYSTON 2 NM LA PA

clindamycin hcl (generic of

CLEOCIN) CAPS 1

clindamycin palmitate hydrochloride (generic of

CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate

SOLN 150mg/ml 1

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

CUBICIN 3 NM

DALVANCE 3 NM

Drug Name Drug Tier

Requirements/Limits

dapsone TABS 1

DARAPRIM 3

DORIBAX 3 imipenem-cilastatin (generic

of PRIMAXIN IV) 1

INVANZ 3 ivermectin (generic of

STROMECTOL) TABS 1

linezolid (generic of ZYVOX)

SOLN 3 NM

LINEZOLID SUSR; TABS 3 NM

LINEZOLID IN SODIUM CHLORIDE

3 NM

MACRODANTIN 25mg PA applies if 65 years and older after a 90 day supply in a calendar year

3 PA

meropenem (generic of MERREM)

1

MEROPENEM/SODIUM CHLORIDE

1

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

PRIMSOL SOL 50MG/5ML 3



7

Drug Name Drug Tier

Requirements/Limits

SIVEXTRO 3 NM

sulfamethoxazole-trimethop

SUSP 1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop

(generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3 NM

trimethoprim TABS 1

TYGACIL 3 NM

vancomycin hcl (generic of

VANCOCIN HCL) CAPS 3 NM

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

vancomycin hcl inj 500mg 1

vancomycin hcl inj 750mg 3 vancomycin hcl inj 1000mg 1

XIFAXAN TAB 200MG 3 NM

ZYVOX SUSR; TABS 3 NM

ANTIFUNGALS ABELCET 3 B/D NM

AMBISOME 3 B/D NM

amphotericin b SOLR 1 B/D

CANCIDAS 3 NM

CRESEMBA 3 NM

ERAXIS 3 NM

fluconazole (generic of

DIFLUCAN) SUSR; TABS 1

fluconazole in dextrose 1 fluconazole in nacl 1

flucytosine (generic of

ANCOBON) CAPS 3 NM

griseofulvin microsize 1

griseofulvin ultramicrosize

(generic of GRIS-PEG) 1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1 PA

LAMISIL PACK 3

MYCAMINE 3 NM

NOXAFIL 3 NM

nystatin TABS 1

Drug Name Drug Tier

Requirements/Limits

ONMEL 3 NM PA

SPORANOX SOL 10MG/ML 3 NM

terbinafine hcl (generic of

LAMISIL) TABS QL (90 tabs / 365 days)

1 QL

voriconazole (generic of

VFEND) SUSR; TABS 3 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS 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

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

quinine sulfate (generic of

QUALAQUIN) CAPS 1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of

ZIAGEN) 1

APTIVUS 3 NM

CRIXIVAN 3

didanosine (generic of VIDEX

EC) 1

EDURANT 3 NM

EMTRIVA 2

FUZEON 2 NM

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 3 NM

INVIRASE 3 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 3 NM

ISENTRESS PACK 2

ISENTRESS TABS 3 NM

lamivudine (generic of

EPIVIR) 1

LEXIVA SUSP 3



8

Drug Name Drug Tier

Requirements/Limits

LEXIVA TABS 3 NM

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of

VIRAMUNE XR) TB24 1

NORVIR 2

PREZISTA SUSP 3 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

3 NM

RESCRIPTOR 2

RETROVIR IV INFUSION 3

REYATAZ 3 NM

SELZENTRY 3 NM

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 2

SUSTIVA TABS 3 NM

TIVICAY 3 NM

TYBOST 2

VIDEX PEDIATRIC 3

VIRACEPT 3 NM

VIRAMUNE XR 100mg 2

VIREAD 3 NM

VITEKTA 3 NM

ZIAGEN SOLN 2

zidovudine (generic of

RETROVIR) CAPS; SYRP 1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine

(generic of TRIZIVIR)

3 NM

ATRIPLA 3 NM

COMPLERA 3 NM

EPZICOM 3 NM

EVOTAZ 3 NM

GENVOYA 3 NM

KALETRA SOL 3 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 3 NM

lamivudine-zidovudine

(generic of COMBIVIR) 3 NM

Drug Name Drug Tier

Requirements/Limits

PREZCOBIX 3 NM

STRIBILD 3 NM

TRIUMEQ 3 NM

TRUVADA QL (30 tabs / 30 days)

3 QL NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

cycloserine CAPS 3 NM

ethambutol hcl (generic of

MYAMBUTOL) TABS 1

isoniazid SOLN; SYRP 1

isoniazid tabs 1 paser d/r 3

PRIFTIN 3 pyrazinamide TABS 1

rifabutin (generic of

MYCOBUTIN) 1

rifamate 3 rifampin (generic of RIFADIN)

CAPS; SOLR 1

RIFATER 3

SIRTURO 3 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) 3 NM

BARACLUDE SOLN 2 cidofovir (generic of VISTIDE) 3 NM

DAKLINZA 3 NM PA

entecavir (generic of BARACLUDE)

3 NM

EPIVIR HBV SOLN 2

famciclovir (generic of

FAMVIR) TABS 1

ganciclovir inj 500mg (generic

of CYTOVENE) 1 B/D

HARVONI 3 NM PA

lamivudine (hbv) (generic of

EPIVIR HBV) 1



9

Drug Name Drug Tier

Requirements/Limits

moderiba pak MISC 3 NM

moderiba pak TABS 400mg 3 NM

MODERIBA PAK TABS 600mg

3 NM

moderiba tab 200mg (generic

of COPEGUS) 1 NM

PEG-INTRON 3 NM PA

PEG-INTRON REDIPEN 3 NM PA

PEGASYS 3 NM PA

PEGASYS PROCLICK 3 NM PA

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

3 NM PA

REBETOL SOLN 3 NM

RELENZA DISKHALER 2 ribapak mis 600/day 3 NM

ribasphere (generic of

REBETOL) CAPS 1 NM

ribasphere (generic of COPEGUS) TABS 200mg

1 NM

ribasphere TABS 400mg 1 NM

ribasphere TABS 600mg 3 NM

ribasphere ribapak 800 3 NM



ribavirin 200mg (generic of

REBETOL) CAPS 1 NM

ribavirin 200mg (generic of

COPEGUS) TABS 1 NM

rimantadine hydrochloride

(generic of FLUMADINE) 1

SOVALDI 3 NM PA

TAMIFLU 2

TYZEKA 3 NM

valacyclovir hcl (generic of

VALTREX) TABS 1

VALCYTE SOLR 3 NM

valganciclovir hcl (generic of VALCYTE)

3 NM

CEPHALOSPORINS AVYCAZ 3 NM

cefaclor 1 cefaclor er tab 500mg 3

cefadroxil 1 cefazolin in dextrose 1gm/50ml-5%

3

Drug Name Drug Tier

Requirements/Limits

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 (generic of

CEFOTAN) 1gm, 2gm 1

cefotetan disodium 10gm 1

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1 cefprozil 1

ceftazidime (generic of

FORTAZ) 1

CEFTAZIDIME/DEXTROSE 3

CEFTIBUTEN 1

CEFTIN SUSR 3 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



10

Drug Name Drug Tier

Requirements/Limits

claforan 1gm, 2gm 3

CLAFORAN/D5W 3

FORTAZ SOLN 3

FORTAZ SOLR 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

SUPRAX SUSR 500mg/5ml 2 tazicef (generic of FORTAZ)

SOLR 1

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZERBAXA 3 NM

ZINACEF SOLR 750mg 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR; SUSR; TABS

1

clarithromycin SUSR

125mg/5ml 1

clarithromycin (generic of

BIAXIN) SUSR 250mg/5ml 1


BIAXIN) TABS 1


BIAXIN XL) TB24 1

DIFICID 3 NM

e.e.s. 400 tab 400mg 1

E.E.S. GRANULES 3

ery-tab 1

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 3

erythrocin stearate 1 erythromycin base 1

erythromycin cap 250mg ec 1 erythromycin ethylsuccinate 1

PCE 3

ZMAX 3

FLUOROQUINOLONES AVELOX SOLN 3

Drug Name Drug Tier

Requirements/Limits

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

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


(generic of AUGMENTIN) SUSR

1


(generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate TABS

1


(generic of AUGMENTIN) TABS

1


(generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1 ampicillin & sulbactam sodium

(generic of UNASYN) 1



11

Drug Name Drug Tier

Requirements/Limits

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

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3 NM

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

nafcillin sodium 1gm 1 nafcillin sodium 2gm, 10gm 3 NM

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3 oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 3 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

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

doxy 1

doxycycline (monohydrate) CAPS 50mg

1

doxycycline (monohydrate)

(generic of MONODOX) CAPS 75mg, 100mg

1

Drug Name Drug Tier

Requirements/Limits


(generic of ADOXA) CAPS 150mg

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

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

1


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

1

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

minocycline hcl (generic of

MINOCIN) CAPS 1

minocycline hcl TABS; TB24 1

SOLODYN 3 NM

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 3 B/D NM

BICNU 3 B/D

BUSULFEX 3 B/D NM

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR

1gm, 500mg 3 B/D NM

cyclophosphamide SOLR 2gm

1 B/D

dacarbazine 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 3 NM

IFEX INJ 3GM 3 B/D

ifosfamide inj 1gm (generic of

IFEX) 1 B/D

ifosfamide inj 1gm/20ml 1 B/D



12

Drug Name Drug Tier

Requirements/Limits

IFOSFAMIDE INJ 3GM 3 B/D

ifosfamide inj 3gm/60ml 1 B/D

LEUKERAN 2

melphalan hcl (generic of ALKERAN)

3 B/D NM

MUSTARGEN 3 B/D

thiotepa SOLR 3 B/D NM

TREANDA 3 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES daunorubicin hcl 1 B/D

doxorubicin hcl 50mg 1 B/D

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

(generic of DOXIL)

3 B/D NM

doxorubicin inj 50mg 1 B/D

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

1 B/D

epirubicin inj 200mg (generic

of ELLENCE) 1 B/D

idarubicin hcl (generic of

IDAMYCIN PFS) 3 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D NM

mitomycin SOLR 1 B/D

VALSTAR 3 NM PA

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D NM

ARRANON 3 B/D NM

azacitidine (generic of

VIDAZA) 3 B/D NM

cladribine 3 B/D NM

CLOLAR 3 B/D NM

cytarabine inj 1 B/D

decitabine (generic of

DACOGEN) 3 B/D NM

fludarabine phosphate

SOLN 1 B/D

fludarabine phosphate

(generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 3 NM PA

GEMCITABINE 3 B/D NM

Drug Name Drug Tier

Requirements/Limits

gemcitabine hcl (generic of

GEMZAR) SOLR 1gm, 200mg

3 B/D NM

gemcitabine hcl SOLR 2gm 3 B/D NM

mercaptopurine TABS 1

METHOTREXATE SODIUM 50mg/2ml

1 B/D

methotrexate sodium 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml

1 B/D

methotrexate sodium inj 1 B/D

NIPENT 3 B/D NM

PURIXAN 3 NM

TABLOID 2

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM

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

3 B/D NM

docetaxel CONC 140mg/7ml 3 B/D NM

DOCETAXEL SOLN 20mg/2ml

1 B/D

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

3 B/D NM

DOCETAXEL SOLN 80MG/8ML

3 B/D NM

JEVTANA 3 NM PA

paclitaxel 1 B/D

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 3 B/D NM

AVASTIN 3 B/D NM LA

BELEODAQ 3 NM PA

CYRAMZA 3 NM PA

DARZALEX 3 NM PA

EMPLICITI 3 NM LA PA

ERBITUX 3 B/D NM

ERIVEDGE 3 NM LA PA

FARYDAK 3 NM LA PA

GAZYVA 3 NM PA

HERCEPTIN 3 B/D NM

IBRANCE 3 NM LA PA



13

Drug Name Drug Tier

Requirements/Limits

ISTODAX 3 B/D NM

KADCYLA 3 B/D NM

KEYTRUDA 3 NM PA

LYNPARZA 3 NM LA PA

NINLARO 3 NM PA

OPDIVO 3 NM PA

PERJETA 3 NM PA

PORTRAZZA 3 NM LA PA

PROLEUKIN 3 B/D NM

RITUXAN 2 NM LA PA

TORISEL 3 B/D NM

VECTIBIX 3 B/D NM

VELCADE 3 B/D NM

YERVOY 3 NM PA

ZALTRAP 3 NM PA

ZOLINZA 3 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of

ARIMIDEX) TABS 1

bicalutamide (generic of CASODEX)

1

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 3 NM

FASLODEX 3 B/D NM

FIRMAGON 3 B/D NM

flutamide 1

letrozole (generic of

FEMARA) TABS 1

leuprolide acetate KIT 1 NM PA

LUPRON DEP INJ 11.25MG 3 NM PA

LUPRON DEP-PED INJ 7.5MG

3 NM PA

LUPRON DEP-PED INJ 11.25MG

3 NM PA

LUPRON DEP-PED INJ 15MG

3 NM PA

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

3 NM PA

LUPRON DEPOT 3 NM PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT INJ 22.5MG (3-MONTH)

3 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

3 NM PA

LYSODREN 2

MEGACE ES 3 NM 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

3 NM PA

NILANDRON 3 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 3 NM PA

VANTAS 3 NM PA

XTANDI 3 NM LA PA

ZOLADEX 3 NM PA

ZYTIGA 3 NM LA PA

KINASE INHIBITORS AFINITOR 3 NM PA

AFINITOR DISPERZ 3 NM PA

ALECENSA 3 NM LA PA

BOSULIF 3 NM PA

CAPRELSA 3 NM LA PA

COMETRIQ 3 NM LA PA

COTELLIC 3 NM LA PA

GILOTRIF TAB 20MG 3 NM LA PA



GLEEVEC 2 NM PA

ICLUSIG 3 NM LA PA

imatinib mesylate (generic of

GLEEVEC) 2 NM PA

IMBRUVICA CAP 140MG 3 NM LA PA

INLYTA 3 NM LA PA

IRESSA 3 NM LA PA

JAKAFI 3 NM LA PA

LENVIMA 10MG DAILY DOSE

3 NM LA PA


3 NM LA PA



14

Drug Name Drug Tier

Requirements/Limits


3 NM LA PA


3 NM LA PA

MEKINIST 3 NM LA PA

NEXAVAR 3 NM LA PA

SPRYCEL 3 NM PA

STIVARGA 3 NM LA PA

SUTENT 3 NM PA

TAFINLAR 3 NM LA PA

TAGRISSO 3 NM LA PA

TARCEVA 3 NM LA PA

TASIGNA 3 NM PA

TYKERB 3 NM LA PA

VOTRIENT 3 NM LA PA

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

ZYDELIG 3 NM LA PA

ZYKADIA 3 NM LA PA

MISCELLANEOUS bexarotene (generic of

TARGRETIN) 3 NM PA

DROXIA 3

ERWINAZE 3 NM PA

HALAVEN 3 B/D NM

hydroxyurea (generic of

HYDREA) CAPS 1

IXEMPRA KIT 3 B/D NM

LONSURF 3 NM PA

MATULANE 3 NM LA

mitoxantrone hcl 1 B/D NM

ODOMZO 3 NM LA PA

ONCASPAR 3 NM PA

POMALYST 3 NM LA PA

SYLATRON KIT 200MCG 3 NM PA



SYLVANT 3 NM PA

SYNRIBO 3 NM PA

TARGRETIN CAPS 3 NM PA

tretinoin CAPS 2 NM

TRISENOX 3 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

Drug Name Drug Tier

Requirements/Limits

ELOXATIN 3 B/D NM

oxaliplatin 3 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

3 B/D NM

dexrazoxane (generic of

ZINECARD) 250mg 3 B/D NM

ELITEK 3 B/D NM

FUSILEV 3 B/D NM

KEPIVANCE 3 B/D NM

leucovorin calcium TABS 1

leucovorin calcium inj 50mg 1 B/D





levoleucovorin calcium 3 B/D NM

mesna (generic of MESNEX) 1 B/D

MESNEX TABS 3 NM

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

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 3 B/D NM

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS 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



15

Drug Name Drug Tier

Requirements/Limits

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic

of ZESTORETIC)

1

moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide

(generic of ACCURETIC) 1

trandolapril-verapamil hcl

(generic of TARKA) 1

ACE INHIBITORS 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

moexipril hcl 1 perindopril erbumine 2mg 1

perindopril erbumine (generic

of ACEON) 4mg, 8mg 1

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of

INSPRA) 1

spironolactone (generic of

ALDACTONE) TABS 1

ALPHA BLOCKERS doxazosin mesylate (generic

of CARDURA) 1

Drug Name Drug Tier

Requirements/Limits

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

amlodipine besylate-valsartan tab 10-160 mg (generic of EXFORGE)

1

amlodipine besylate-valsartan tab 10-320 mg (generic of

EXFORGE)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

(generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg


1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)

1



1



1

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

ENTRESTO 3 PA

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide

(generic of HYZAAR) 1

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1



16

Drug Name Drug Tier

Requirements/Limits

TEVETEN HCT 3

TRIBENZOR 2

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

EDARBI 3

eprosartan mesylate 1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of

COZAAR) 1

telmisartan (generic of MICARDIS)

1

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 disopyramide phosphate

(generic of NORPACE) PA if 65 years and older

3 PA

flecainide acetate 1 mexiletine hcl 1

MULTAQ 3

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

Drug Name Drug Tier

Requirements/Limits

propafenone hcl 12hr (generic

of RYTHMOL) TABS 1

quinidine gluconate TBCR 1 quinidine sulfate TABS 1

sorine (generic of

BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of

BETAPACE) 80mg, 120mg, 160mg

1

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 XL 3

LIVALO 3

lovastatin 10mg, 20mg 1 lovastatin (generic of

MEVACOR) 40mg 1

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

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3



17

Drug Name Drug Tier

Requirements/Limits

cholestyramine (generic of

QUESTRAN) 1

cholestyramine light 1 choline fenofibrate (generic of

TRILIPIX) 1

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 gemfibrozil (generic of LOPID)

TABS 1

JUXTAPID 3 NM LA PA

KYNAMRO 3 NM PA

niacin er (antihyperlipidemic)

(generic of NIASPAN) 1

niacor 1 omega-3-acid ethyl esters

(generic of LOVAZA) 1

PRALUENT 3 NM PA

prevalite (generic of

QUESTRAN LIGHT) 1

SIMCOR 2

TRIGLIDE 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone

(generic of TENORETIC 50) 1

Drug Name Drug Tier

Requirements/Limits

atenolol & chlorthalidone

(generic of TENORETIC 100) 1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

DUTOPROL 3

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

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 CR 2 labetalol hcl SOLN; TABS 1

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



18

Drug Name Drug Tier

Requirements/Limits

propranolol sol 1

propranolol tab 1

SOTYLIZE 3 NM

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv

(generic of CADUET) 1

CALCIUM CHANNEL BLOCKERS afeditab cr (generic of

ADALAT CC) 1

amlodipine besylate (generic of NORVASC) TABS

1

CARDIZEM LA 120mg 3

cartia xt (generic of

CARDIZEM CD) 1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

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

Drug Name Drug Tier

Requirements/Limits

nimodipine CAPS 3 NM

nisoldipine (generic of

SULAR) 8.5mg, 17mg, 34mg 1

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NYMALIZE 3 NM

taztia xt (generic of TIAZAC) 1

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

verapamil hcl SOLN 1 verapamil hcl TABS 40mg 1


CALAN) TABS 80mg, 120mg

1


CALAN SR) TBCR 1

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 TABS 62.5mcg QL (60 tabs / 30 days)

2 QL



19

Drug Name Drug Tier

Requirements/Limits

LANOXIN TABS 187.5mcg PA if 65 years and older

2 PA

LANOXIN PEDIATRIC 3

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of

DIAMOX) CP12 1

acetazolamide TABS 1

acetazolamide sodium 1

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

DIURIL SUS 250/5ML 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 1 hydrochlorothiazide (generic

of MICROZIDE) CAPS 1

hydrochlorothiazide TABS 1 indapamide 1

methazolamide (generic of

NEPTAZANE) TABS 1

methyclothiazide 1 metolazone 1

spironolactone & hydrochlorothiazide (generic

of ALDACTAZIDE)

1

torsemide inj 50mg/5ml 3

Drug Name Drug Tier

Requirements/Limits

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

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 3 NM

DIBENZYLINE 3 NM

hydralazine hcl SOLN; TABS 1 midodrine hcl 1

minoxidil TABS 1

phenoxybenzamine hcl (generic of DIBENZYLINE) CAPS

3 NM

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 2 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



20

Drug Name Drug Tier

Requirements/Limits

minitran (generic of

NITRO-DUR) 1

nitro-bid 3

NITRO-DUR .3mg/hr, .8mg/hr

2

nitroglycerin (generic of

NITROLINGUAL PUMPSPRAY) .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 3 NM PA

ADEMPAS 3 NM LA PA

epoprostenol sodium (generic

of FLOLAN) 3 B/D NM LA

FLOLAN 3 B/D NM LA

LETAIRIS 3 NM LA PA

OPSUMIT 3 NM LA PA

ORENITRAM TAB 0.25MG 3 NM LA PA


ORENITRAM TAB 1MG 3 NM LA PA


REMODULIN 3 B/D NM LA

REVATIO SUSR 3 NM PA

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

3 NM PA

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

1 NM PA

TRACLEER 3 NM LA PA

TYVASO 3 B/D NM

UPTRAVI 3 NM LA PA

VELETRI 3 B/D NM LA

VENTAVIS 3 B/D NM

CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of

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

1 QL

Drug Name Drug Tier

Requirements/Limits

alprazolam (generic of

XANAX) TABS 2mg QL (150 tabs / 30 days)

1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of XANAX) TABS .25mg


1 QL

buspirone hcl TABS 1

fluvoxamine maleate 25mg, 50mg


1 QL

fluvoxamine maleate 100mg 1 fluvoxamine maleate er

100mg QL (90 caps / 30 days)

1 QL

fluvoxamine maleate er 150mg


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

ANTICONVULSANTS APTIOM 200mg 3

APTIOM 400mg, 600mg, 800mg

3 NM

BANZEL SUS 40MG/ML 3 NM PA

BANZEL TAB 200MG 3 PA

BANZEL TAB 400MG 3 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

CELONTIN 3 clonazepam (generic of

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

1 QL



21

Drug Name Drug Tier

Requirements/Limits

clonazepam (generic of

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

1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg QL (120 tabs / 30 days)

1 QL

clonazepam TBDP 2mg


clonazepam TBDP .5mg






clorazepate dipotassium

(generic of TRANXENE T) 3.75mg, 7.5mg


1 QL PA

clorazepate dipotassium

(generic of TRANXENE T) 15mg


1 QL PA

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) CSDR

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

Drug Name Drug Tier

Requirements/Limits

felbamate (generic of

FELBATOL) SUSP 3 NM

felbamate (generic of

FELBATOL) TABS 1

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 12mg, 16mg 2

LAMICTAL ODT KIT 3

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

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



22

Drug Name Drug Tier

Requirements/Limits

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


2 QL

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

2 QL

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946 mL / 30 days)

2 QL

ONFI SUSP 3 NM PA

ONFI TABS 10mg 3 PA

ONFI TABS 20mg 3 NM PA

oxcarbazepine (generic of

TRILEPTAL) 1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS


PHENOBARBITAL SODIUM SOLN 65mg/ml

PA if 65 years and older

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

POTIGA 200mg QL (180 tabs / 30 days)

3 QL NM

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

3 QL NM

primidone (generic of

MYSOLINE) TABS 1

Drug Name Drug Tier

Requirements/Limits

SABRIL PACK QL (180 packets / 30 days)

3 QL NM LA PA

SABRIL TABS QL (180 tabs / 30 days)

3 QL NM LA PA

SPRITAM 3

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of

GABITRIL) 1

topiramate (generic of

TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1 topiramate (generic of

TOPAMAX) TABS 1

TROKENDI XR 25mg, 50mg, 100mg

3

TROKENDI XR 200mg 3 NM

valproate sodium (generic of

DEPACON) SOLN 1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of

DEPAKENE) 1

VIMPAT SOLN 2

VIMPAT TABS 50mg 2

VIMPAT TABS 100mg, 150mg, 200mg

3 NM

zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA 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 PATCHES 2

galantamine hydrobromide SOLN

1



23

Drug Name Drug Tier

Requirements/Limits

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

rivastigmine tartrate (generic of EXELON)

1

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

APLENZIN 3 NM

BRINTELLIX 2

bupropion hcl TABS 75mg 1 bupropion hcl (generic of

WELLBUTRIN) TABS 100mg

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of

WELLBUTRIN XL) TB24 1

citalopram hydrobromide SOLN

1

citalopram hydrobromide

(generic of CELEXA) TABS 1

Drug Name Drug Tier

Requirements/Limits

clomipramine hcl (generic of

ANAFRANIL) CAPS PA if 65 years and older

3 PA

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC


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

1

EMSAM 3 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

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


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

nefazodone hcl 1

nortriptyline hcl (generic of PAMELOR) CAPS

1



24

Drug Name Drug Tier

Requirements/Limits

nortriptyline hcl SOLN 1

paroxetine er tab (generic of

PAXIL CR) 1

paroxetine hcl tabs (generic of

PAXIL) 1

PAXIL SUSP 3

PEXEVA 3 phenelzine sulfate (generic of

NARDIL) TABS 1

PRISTIQ 2 protriptyline hcl 1

sertraline hcl (generic of

ZOLOFT) CONC; TABS 1

SURMONTIL 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 tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

VIIBRYD STARTER PACK 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS;

SYRP; TABS 1

APOKYN 3 NM LA PA

AZILECT 2

BENZTROPINE MESYLATE SOLN

1

benztropine mesylate TABS PA if 65 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

bromocriptine mesylate

(generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of

LODOSYN) TABS 3 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

DUOPA 3 B/D NM

ENTACAPONE 1

MIRAPEX .75mg 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

ropinirole hydrochloride

(generic of REQUIP) TABS 1

ropinirole hydrochloride

(generic of REQUIP XL) TB24

1

RYTARY 3

selegiline hcl (generic of

ELDEPRYL) CAPS 1

selegiline hcl TABS 1

ZELAPAR 3 NM

ANTIPSYCHOTICS



25

Drug Name Drug Tier

Requirements/Limits

ABILIFY DISCMELT TAB 10MG


3 QL NM

ABILIFY MAINTENA QL (1 injection / 28 days)

3 QL NM

aripiprazole odt QL (60 tabs / 30 days)

3 QL NM

aripiprazole oral solution 1 mg/ml

QL (900ml / 30 days)

3 QL NM

aripiprazole tabs (generic of ABILIFY)


3 QL NM

ARISTADA QL (1 syringe / 28 days)

3 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)

3 QL NM PA

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

3 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

FANAPT QL (60 tabs / 30 days)

3 QL ST

FANAPT TITRATION PACK 3 ST

FAZACLO 150mg QL (180 tabs / 30 days)

3 QL NM PA

FAZACLO 200mg QL (135 tabs / 30 days)

3 QL NM PA

fluphenazine decanoate

SOLN 1

fluphenazine hcl 1

GEODON INJ QL (6 mL / 3 days)

3 QL

haloperidol TABS 1

Drug Name Drug Tier

Requirements/Limits

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



3 QL NM



3 QL NM

INVEGA SUST INJ 156MG/ML


3 QL NM



3 QL NM

INVEGA TRINZA QL (1 syringe / 90 days)

3 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



26

Drug Name Drug Tier

Requirements/Limits

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 QL (30 tabs / 30 days)

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 QL (60 tabs / 30 days)

1 QL

perphenazine TABS 1 pimozide (generic of ORAP) 1

quetiapine fumarate (generic

of SEROQUEL) QL (90 tabs / 30 days)

1 QL

REXULTI 1mg QL (90 tabs / 30 days)

3 QL NM ST

REXULTI 2mg QL (60 tabs / 30 days)

3 QL NM ST

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

3 QL NM ST

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

3 QL NM ST

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

3 QL NM ST

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

2 QL

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

2 QL

Drug Name Drug Tier

Requirements/Limits

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

3 QL NM

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

3 QL NM

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

1 QL

risperidone (generic of

RISPERDAL) TABS 1mg, 2mg, 3mg


1 QL


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

1 QL


RISPERDAL) TABS .25mg, .5mg


1 QL

risperidone odt (generic of

RISPERDAL M-TAB) 1mg, 2mg, 3mg


1 QL


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

1 QL


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

1 QL

risperidone odt .25mg QL (90 tabs / 30 days)

1 QL

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 XR 50mg QL (120 tabs / 30 days)

2 QL

SEROQUEL XR 150mg, 200mg


2 QL

SEROQUEL XR 300mg, 400mg


2 QL



27

Drug Name Drug Tier

Requirements/Limits

thioridazine hcl TABS


thiothixene 1 trifluoperazine hcl 1

VERSACLOZ QL (600 mL / 30 days)

3 QL NM PA

VRAYLAR CAPS 1.5mg QL (120 caps / 30 days)

3 QL NM ST

VRAYLAR CAPS 3mg QL (60 caps / 30 days)

3 QL NM ST

VRAYLAR CAPS 4.5mg, 6mg


3 QL NM ST

VRAYLAR CPPK 3 ST

ziprasidone hcl (generic of GEODON) 20mg, 40mg


1 QL

ziprasidone hcl (generic of

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

1 QL

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

3 QL NM PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

3 QL NM PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

3 QL NM PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 10mg er

(generic of ADDERALL XR) QL (90 caps / 30 days)

1 QL

amphetamine cap 15mg er


1 QL



1 QL

amphetamine cap 25mg er (generic of ADDERALL XR)


1 QL



1 QL

Drug Name Drug Tier

Requirements/Limits

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

amphetamine-dextroamphetamine tab 10 mg (generic of


1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 15 mg (generic of ADDERALL)


1 QL



1 QL



1 QL

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


3 QL

APTENSIO XR 40mg, 50mg, 60mg


3 QL

DAYTRANA QL (30 patches / 30 days)

2 QL

guanfacine er (adhd) (generic of INTUNIV)


3 PA

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

1 QL



28

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

Drug Name Drug Tier

Requirements/Limits

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

3 QL

RITALIN LA 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 HETLIOZ 3 NM LA 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

temazepam (generic of

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


1 QL PA

temazepam (generic of

RESTORIL) 15mg QL (60 caps / 30 days)


1 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

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

3 QL PA

MIGRAINE



29

Drug Name Drug Tier

Requirements/Limits

almotriptan malate (generic of

AXERT) QL (12 tabs / 30 days)

1 QL

ALSUMA QL (12 injections / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 3

dihydroergotamine mesylate

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

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

3 QL NM

ergomar 3

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

3 QL

migergot 3 NM

naratriptan hcl (generic of

AMERGE) QL (9 tabs / 30 days)

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 QL (18 tabs / 30 days)

1 QL

SUMATRIPTAN INJ 4MG/0.5ML

QL (12 injections / 30 days)

1 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


1 QL

SUMATRIPTAN INJ 6MG/0.5ML SOCT


1 QL

Drug Name Drug Tier

Requirements/Limits

sumatriptan inj 6mg/0.5ml

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

1 QL

sumatriptan inj 6mg/0.5ml

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)

3 QL NM

TREXIMET QL (9 tabs / 30 days)

3 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 NASAL SPRAY QL (12 inhalers / 30 days)

2 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



30

Drug Name Drug Tier

Requirements/Limits

lithium carbonate TBCR

450mg 1

LITHIUM SOLN 8MEQ/5ML 3

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2 pyridostigmine bromide

(generic of MESTINON) TABS

1

pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR

1

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)

3 QL NM PA

tetrabenazine (generic of

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

3 QL NM PA

XENAZINE 12.5mg QL (240 tabs / 30 days)

3 QL NM LA PA

XENAZINE 25mg QL (120 tabs / 30 days)

3 QL NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO QL (30 tabs / 30 days)

3 QL NM LA PA

AVONEX QL (4 injections / 28 days)

3 QL NM PA

AVONEX PEN QL (4 injections / 28 days)

3 QL NM PA

BETASERON QL (14 syringes / 28 days)

3 QL NM PA

Drug Name Drug Tier

Requirements/Limits

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

3 QL NM PA

EXTAVIA QL (15 syringes / 30 days)

3 QL NM PA

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

3 QL NM PA

glatopa (generic of

COPAXONE) QL (30 syringes / 30 days)

3 QL NM PA

LEMTRADA 3 NM LA PA

PLEGRIDY SOPN QL (2 pens / 28 days)

3 QL NM PA

PLEGRIDY SOSY QL (2 syringes / 28 days)

3 QL NM PA

PLEGRIDY STARTER PACK SOPN

QL (2 pens / 28 days)

3 QL NM PA

PLEGRIDY STARTER PACK SOSY

QL (2 syringes / 28 days)

3 QL NM PA

REBIF QL (6 mL / 28 days)

3 QL NM PA

REBIF REBIDOSE QL (6 mL / 28 days)

3 QL NM PA

REBIF REBIDOSE TITRATION

QL (6 mL / 28 days)

3 QL NM PA

REBIF TITRATION PACK QL (6 mL / 30 days)

3 QL NM PA

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

3 QL NM LA PA

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

3 QL NM LA PA

TECFIDERA MIS STARTER 3 NM LA PA

TYSABRI 3 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX INJ 100UNIT 3 NM PA

BOTOX INJ 200UNIT 3 NM PA

cyclobenzaprine hcl TABS

5mg, 10mg PA if 65 years and older

3 PA



31

Drug Name Drug Tier

Requirements/Limits

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 50UNIT 3 NM PA



NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg


1 QL PA

modafinil (generic of

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

3 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

XYREM QL (540 mL / 30 days)

3 QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

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

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

Drug Name Drug Tier

Requirements/Limits

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)

2 QL PA

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

2 QL PA


2 QL PA


2 QL PA

VIVITROL 3 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

ENDOCRINE AND METABOLIC

ANDROGENS ANDRODERM


2 QL PA

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

QL (150 grams / 30 days)

3 QL PA



32

Drug Name Drug Tier

Requirements/Limits

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

AVEED 3 NM PA

AXIRON QL (440 mL / 30 days)

2 QL PA

depo-testosterone 100mg/ml 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 3 NM PA

STRIANT QL (60 buccal systems / 30 days)

3 QL PA

TESTIM QL (300 grams / 30 days)

3 QL PA

TESTOSTERONE GEL 1% QL (300 grams / 30 days)

1 QL PA

TESTOSTERONE GEL 1% QL (300 grams / 30 days)

1 QL PA

TESTOSTERONE GEL 10mg/act


1 QL PA

TESTOSTERONE GEL 25mg/2.5gm


1 QL PA

testosterone cypionate

SOLN 100mg/ml 1 PA

testosterone cypionate

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

1 PA

Drug Name Drug Tier

Requirements/Limits

testosterone enanthate

SOLN 1 PA

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 SRER 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 VIAL (CONCENTRATE)

3 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



33

Drug Name Drug Tier

Requirements/Limits

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

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 3 NM PA

TANZEUM QL (4 pens / 28 days)

3 QL

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

TRULICITY QL (4 pens / 28 days)

2 QL

VICTOZA QL (3 pens / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of

PRECOSE) 1

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

FARXIGA 5mg QL (60 tabs / 30 days)

2 QL

FARXIGA 10mg QL (30 tabs / 30 days)

2 QL

glimepiride (generic of

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

1 QL

glimepiride (generic of AMARYL) 2mg


1 QL

glimepiride (generic of

AMARYL) 4mg QL (60 tabs / 30 days)

1 QL

glipizide (generic of

GLUCOTROL) TABS 5mg QL (240 tabs / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

glipizide (generic of

GLUCOTROL) TABS 10mg QL (120 tabs / 30 days)

1 QL

glipizide er (generic of GLUCOTROL XL) 2.5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 5mg


1 QL

glipizide er (generic of

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 QL (120 tabs / 30 days)

1 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



34

Drug Name Drug Tier

Requirements/Limits

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)

2 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

2 QL

JENTADUETO QL (60 tabs / 30 days)

2 QL

KAZANO QL (60 tabs / 30 days)

3 QL

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


1 QL

metformin hcl (generic of

GLUCOPHAGE) TABS 500mg


1 QL




1 QL




1 QL


GLUMETZA) TB24 500mg QL (120 tabs / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits


GLUMETZA) TB24 1000mg QL (60 tabs / 30 days)

1 QL

metformin hcl osmotic 500mg (generic of FORTAMET)


1 QL

metformin hcl osmotic 1000mg (generic of

FORTAMET) QL (75 tabs / 30 days)

1 QL

nateglinide (generic of STARLIX)


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

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)


1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

repaglinide (generic of PRANDIN) 2mg


1 QL



35

Drug Name Drug Tier

Requirements/Limits

repaglinide (generic of

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

1 QL

repaglinide-metformin hcl QL (150 tabs / 30 days)

1 QL

RIOMET QL (946 mL / 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)

2 QL


2 QL


2 QL


2 QL

BISPHOSPHONATES 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

BINOSTO 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

RISEDRONATE SODIUM TABS 5mg, 30mg

1

Drug Name Drug Tier

Requirements/Limits

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 SOLN 3 B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 2 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 3 NM

EXJADE 3 NM LA PA

FERRIPROX 3 NM LA PA

JADENU 3 NM PA

kionex (generic of

KAYEXALATE) 1

sodium polystyrene sulfonate

(generic of KAYEXALATE) POWD

1

sodium polystyrene sulfonate SUSP

1

sps susp 15gm/60ml 1

SYPRINE 3 NM

VELTASSA 3 NM LA

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



36

Drug Name Drug Tier

Requirements/Limits

blisovi 21 fe 1.5/30 28 day pack (generic of LOESTRIN

FE 1.5/30)

1

blisovi 21 fe 1/20 28 day pack (generic of LOESTRIN FE 1/20)

1

blisovi 24 fe 1/20 28 day 1 briellyn 28 day (generic of

OVCON-35) 1

camila 28 day (generic of

NOR-QD) 1

CAMRESE LO TAB 1

cryselle 28 1

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

cyred tab (generic of

DESOGEN) 1

deblitane 28 day (generic of

NOR-QD) 1

delyla 28 day 1

DEPO-SUBQ PROVERA 104 2

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

falmina 28 day 1

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

Drug Name Drug Tier

Requirements/Limits

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

juleber 28 day (generic of DESOGEN)

1

junel 1.5/30 21 day (generic of

LOESTRIN 1.5/30-21) 1

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

kaitlib fe 28 day (generic of

GENERESS FE) 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



37

Drug Name Drug Tier

Requirements/Limits

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

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

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 nikki 28 day (generic of YAZ) 1

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

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO

TRI-CYCLEN)

1

Drug Name Drug Tier

Requirements/Limits

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO

TRI-CYCLEN LO)

1

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 TRI-CYCLEN LO 2 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

setlakin tab 1

sharobel 28 day (generic of ORTHO MICRONOR)

1

sprintec 28 day (generic of

ORTHO-CYCLEN) 1

sronyx 28 day 1 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-lo- estarylla 28 day (generic

of ORTHO TRI-CYCLEN LO) 1

tri-lo- tab marzia (generic of

ORTHO TRI-CYCLEN LO) 1



38

Drug Name Drug Tier

Requirements/Limits

tri-lo-sprintec 28 day (generic

of ORTHO TRI-CYCLEN LO) 1

tri-previfem 28 day (generic of

ORTHO TRI-CYCLEN) 1

tri-sprintec 28 day (generic of

ORTHO TRI-CYCLEN) 1

TRINESSA 1

TRINESSA LO TAB 1 trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

vienva 28 day 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

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 3 NM PA

SYNAREL 3 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA

ALDURAZYME 3 NM LA PA

CARBAGLU 3 NM LA PA

CERDELGA 3 NM PA

CEREZYME 3 NM LA PA

CYSTADANE 3 NM LA

CYSTAGON 3 NM LA PA

ELAPRASE 3 NM LA PA

ELELYSO 3 NM PA

FABRAZYME 3 NM LA PA

KANUMA 3 NM LA PA

KUVAN 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

levocarnitine (metabolic modifiers) (generic of

CARNITOR)

1 B/D

LUMIZYME 3 NM LA PA

MYOZYME 3 NM LA PA

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM LA PA

PROCYSBI 3 NM LA PA

RAVICTI 3 NM PA

sodium phenylbutyrate

(generic of BUPHENYL) 3 NM

STRENSIQ 3 NM LA PA

VIMIZIM 3 NM PA

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGENS ALORA


DELESTROGEN 10mg/ml 3

depo-estradiol 3

estrace CREA 2 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

fyavolv tab 1 mg-5 mcg


jinteli


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



39

Drug Name Drug Tier

Requirements/Limits

PREMARIN INJ 3

VAGIFEM 2

GLUCOCORTICOIDS a-hydrocort 1

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak 6 day 2 dexpak 10 day 2

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

fludrocortisone acetate

TABS 1

hydrocortisone (generic of

CORTEF) TABS 1

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

methylpr ss inj 125mg

(generic of SOLU-MEDROL) 1 B/D

methylpred pak 4mg (generic

of MEDROL DOSEPAK) 1

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

millipred dp 3

pred sod pho sol 5mg/5ml

(generic of PEDIAPRED) 1 B/D

Drug Name Drug Tier

Requirements/Limits

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 prednisone pak 10mg 1

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





RAYOS TAB 1MG 3 B/D NM



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 2GM 3 B/D

veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

KORLYM 3 NM LA PA

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 3 NM LA PA

GENOTROPIN MINIQUICK 3 NM LA PA

HUMATROPE 3 NM LA PA

HUMATROPE COMBO PACK 3 NM LA PA

NORDITROPIN FLEXPRO 3 NM PA

NUTROPIN AQ INJ 20MG/2ML

3 NM LA PA

NUTROPIN AQ NUSPIN 5 3 NM LA PA



NUTROPIN AQ PEN 3 NM LA PA

OMNITROPE 5.8MG 3 NM LA PA

OMNITROPE 5MG 3 NM LA PA



40

Drug Name Drug Tier

Requirements/Limits

OMNITROPE 10MG 3 NM LA PA

SAIZEN 3 NM LA PA

SAIZEN CLICK.EASY 3 NM LA PA

SEROSTIM 3 NM LA PA

ZOMACTON 3 NM PA

ZORBTIVE 3 NM PA

MISCELLANEOUS AFREZZA 3 cabergoline 1

calcitonin (salmon) nasal spray (generic of

MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 1mg 3 NM LA PA

FORTICAL SPR 200/ACT 3

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

3 QL NM LA PA

INCRELEX 3 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 3 B/D NM

MYALEPT 3 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

3 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 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM LA PA

SIGNIFOR LAR 3 NM LA PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 3 NM LA PA

XGEVA 3 NM PA

Drug Name Drug Tier

Requirements/Limits

PARATHYROID HORMONES FORTEO 3 NM PA

NATPARA 3 NM PA

PHOSPHATE BINDER AGENTS AURYXIA 3 NM

calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS)

TABS

1

FOSRENOL 3 NM

PHOSLYRA 2

RENAGEL 400mg 3

RENAGEL 800mg 3 NM

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 3 NM

PROGESTINS CRINONE 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate

(generic of AYGESTIN) TABS

1

progesterone micronized

(generic of PROMETRIUM) CAPS

1

THYROID AGENTS 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

TIROSINT 3

UNITHROID 1

VASOPRESSINS DESMOPRESSIN ACETATE SOLN

1



41

Drug Name Drug Tier

Requirements/Limits

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 3 NM

GASTROINTESTINAL

ANTIEMETICS AKYNZEO 3 B/D

ALOXI 3 NM

CESAMET QL (60 caps / 30 days)

3 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)

3 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

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

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

Drug Name Drug Tier

Requirements/Limits

ondansetron odt (generic of

ZOFRAN ODT) 1 B/D

phenadoz


phenergan SUPP


prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1 promethazine hcl (generic of

PHENERGAN) SOLN PA if 65 years and older

3 PA

promethazine hcl SUPP; SYRP; TABS


3 PA

promethegan


SANCUSO QL (4 patches / 30 days)

3 QL NM

TRANSDERM-SCOP QL (10 patches / 30 days)


3 QL PA

VARUBI 3 B/D

ZUPLENZ 3 B/D NM

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

1

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



42

Drug Name Drug Tier

Requirements/Limits

methscopolamine bromide

(generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

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

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl SYRP 1

ranitidine hcl (generic of

ZANTAC) TABS 150mg, 300mg

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

balsalazide disodium (generic

of COLAZAL) 1

budesonide (generic of

ENTOCORT EC) CPEP 3 NM

CANASA 3 NM

colocort (generic of

CORTENEMA) 1

DELZICOL 3

DIPENTUM 3 NM

ENTYVIO 3 NM PA

GIAZO 3 NM

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1 mesalamine enema (generic

of ROWASA) KIT 1

Drug Name Drug Tier

Requirements/Limits

PENTASA 2

SF-ROWASA 3 NM

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of

AZULFIDINE) 1

UCERIS AER 2MG/ACT 3

UCERIS TAB 9MG 3 NM

LAXATIVES COLYTE-FLAVOR PACKS 227.1 GM

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

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

1

polyethylene glycol 3350

PACK; POWD 1

PREPOPIK 3

RELISTOR 3 NM PA

SUCLEAR 2

SUPREP BOWEL PREP 2



43

Drug Name Drug Tier

Requirements/Limits

trilyte (generic of

NULYTELY/FLAVOR PACKS) 1

MISCELLANEOUS alosetron hcl (generic of

LOTRONEX) 3 NM PA

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of

PREVPAC)

1

CARAFATE SUSP 2 cromolyn sodium (mastocytosis) (generic of

GASTROCROM)

3 NM

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine

(generic of LOMOTIL) TABS 1

GATTEX 3 NM LA PA

LINZESS 2 loperamide hcl CAPS 1

misoprostol (generic of

CYTOTEC) TABS 1

MOVANTIK 2

OMECLAMOX-PAK 3

PYLERA 3 NM

SUCRAID 3 NM LA

sucralfate (generic of

CARAFATE) TABS 1

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO

250) TABS 250mg 1

ursodiol (generic of URSO

FORTE) TABS 500mg 1

VIBERZI 3 NM PA

XIFAXAN TAB 550MG 3 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 3 NM

ZENPEP 2

PROTON PUMP INHIBITORS

Drug Name Drug Tier

Requirements/Limits

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



omeprazole (generic of

PRILOSEC) CPDR 10mg, 40mg


1 QL

omeprazole (generic of

PRILOSEC) CPDR 20mg 1

OMEPRAZOLE-SODIUM BICARBONATE


1 QL

pantoprazole sodium (generic of PROTONIX) TBEC


1 QL

PREVACID SOLUTAB QL (30 tabs / 30 days)

3 QL

PRILOSEC PACK 3

PROTONIX PACK QL (30 packets / 30 days)

3 QL

rabeprazole sodium (generic

of ACIPHEX) QL (30 tabs / 30 days)

1 QL

ZEGERID PACK QL (30 packets / 30 days)

3 QL

GENITOURINARY



44

Drug Name Drug Tier

Requirements/Limits

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

JALYN 3

RAPAFLO 2 tamsulosin hcl (generic of

FLOMAX) 1

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

URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDE

1

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

Drug Name Drug Tier

Requirements/Limits

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES AVC 3

CLEOCIN VAG SUPP 100MG 3 clindamycin cre 2% vag

(generic of CLEOCIN) 1

CLINDESSE 3

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole 3 sup 200mg 1

NUVESSA 3

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 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

3 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

3 NM

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

2



45

Drug Name Drug Tier

Requirements/Limits

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

3 NM

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

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

PRADAXA 2

SAVAYSA 3

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 NM PA

EPOGEN 3 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MIRCERA 3 NM PA

MOZOBIL 3 NM PA

NEULASTA 3 NM PA

NEULASTA ONPRO KIT 3 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 3 NM PA

NPLATE 3 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS anagrelide hcl 1mg 1

Drug Name Drug Tier

Requirements/Limits

anagrelide hcl (generic of

AGRYLIN) .5mg 1

BERINERT 3 NM PA

cilostazol 1

CINRYZE 3 NM LA PA

FIRAZYR 2 NM PA

KALBITOR 3 NM PA

pentoxifylline TBCR 1

PROMACTA 12.5mg QL (360 tabs / 30 days)

3 QL NM LA PA

PROMACTA 25mg QL (180 tabs / 30 days)

3 QL NM LA PA


3 QL NM LA PA


3 QL NM LA PA

RUCONEST 3 NM PA

SOLIRIS 3 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

DURLAZA 3

EFFIENT 2

ZONTIVITY 3

IMMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 NM PA

CIMZIA 3 NM PA

ENBREL 3 NM PA

ENBREL SURECLICK 3 NM PA

HUMIRA 3 NM PA

HUMIRA PEDIATRIC CROHNS

3 NM PA

HUMIRA PEN 3 NM PA

HUMIRA PEN-CROHNS STARTER KIT

3 NM PA



46

Drug Name Drug Tier

Requirements/Limits

HUMIRA PEN-PSORIASIS STARTER KIT

3 NM PA

hydroxychloroquine sulfate

(generic of PLAQUENIL) 1

KINERET 3 NM PA

leflunomide (generic of

ARAVA) TABS 1

methotrexate sodium tabs 1

ORENCIA 3 NM PA

OTEZLA 3 NM PA

OTREXUP 7.5mg/0.4ml, 10mg/0.4ml, 15mg/0.4ml, 20mg/0.4ml, 25mg/0.4ml

3 NM PA

RASUVO 3 NM PA

REMICADE 3 NM PA

RHEUMATREX 2

SIMPONI 3 NM PA

SIMPONI ARIA 3 NM PA

trexall 2 B/D

XELJANZ 3 NM PA

XELJANZ XR 3 NM PA

IMMUNOGLOBULINS BIVIGAM 3 NM PA

CARIMUNE NANOFILTERED 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAGARD S/D IGA LESS TH

3 NM PA

GAMMAKED 3 NM PA

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

3 NM PA

GAMUNEX-C 3 NM PA

HIZENTRA 3 NM PA

HYQVIA 3 NM PA

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

3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

GRASTEK 2 PA

Drug Name Drug Tier

Requirements/Limits

ILARIS 3 NM PA

INTRON-A INJ 10MU 3 B/D NM




RAGWITEK 2 PA

REVLIMID 3 NM LA PA

THALOMID 2 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 3 B/D NM

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

ATGAM 3 B/D NM

azasan 2 B/D

azathioprine (generic of

IMURAN) TABS 1 B/D

BENLYSTA 3 NM PA

CELLCEPT INTRAVENOUS 3 B/D

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

ENVARSUS XR 3 B/D

gengraf (generic of NEORAL) 1 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil

(generic of CELLCEPT) SUSR

3 B/D NM

mycophenolate sodium

(generic of MYFORTIC) 180mg

1 B/D

mycophenolate sodium

(generic of MYFORTIC) 360mg

3 B/D NM

NEORAL 2 B/D

NULOJIX 3 B/D NM

PROGRAF CAPS 5mg 3 B/D NM



47

Drug Name Drug Tier

Requirements/Limits

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 3 B/D NM

SANDIMMUNE SOLN 2 B/D

SIMULECT 10mg 3 B/D

SIMULECT 20mg 3 B/D NM

SIROLIMUS TABS 2mg 3 B/D NM

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

1 B/D

tacrolimus (generic of

PROGRAF) CAPS 5mg 3 B/D NM

tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg

1 B/D

THYMOGLOBULIN 3 B/D NM

ZORTRESS TAB 0.5MG 3 B/D NM

ZORTRESS TAB 0.25MG 3 B/D

ZORTRESS TAB 0.75MG 3 B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

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

Drug Name Drug Tier

Requirements/Limits

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 3 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

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



48

Drug Name Drug Tier

Requirements/Limits

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

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

Drug Name Drug Tier

Requirements/Limits

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 III 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID INJ 20% 1 B/D

plenamine 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

TRAVASOL 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







49

Drug Name Drug Tier

Requirements/Limits

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

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

Drug Name Drug Tier

Requirements/Limits

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

3 B/D NM

doxercalciferol (generic of

HECTOROL) CAPS .5mcg 1 B/D

doxercalciferol (generic of HECTOROL) SOLN

1 B/D

HECTOROL SOLN 2mcg/ml 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

ZEMPLAR SOLN 2mcg/ml 3 B/D

OPHTHALMIC

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

blephamide OINT 3

BLEPHAMIDE SUSP 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



50

Drug Name Drug Tier

Requirements/Limits

TOBRADEX OINT 2

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

CILOXAN OIN 0.3% OP 3 ciprofloxacin hcl (ophth)

(generic of CILOXAN) 1

erythromycin (ophth) 1

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) 1 ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 3

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

ofloxacin (ophth) (generic of

OCUFLOX) 1

polymyxin b-trimethoprim

(generic of POLYTRIM) 1

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 trifluridine (generic of

VIROPTIC) SOLN 1

VIGAMOX 2

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

Drug Name Drug Tier

Requirements/Limits

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

ILEVRO 3 ketorolac tromethamine (ophth) (generic of ACULAR

LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR)

.5%

1

LOTEMAX 2

MAXIDEX 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

EMADINE 3 epinastine hcl (ophth) (generic

of ELESTAT) 1

LASTACAFT 3

olopatadine hcl (generic of PATANOL)

1

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA



51

Drug Name Drug Tier

Requirements/Limits

ALPHAGAN P 2

ALPHAGAN P 0.1% 2

AZOPT 2 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 PF 2

dorzolamide hcl (generic of

TRUSOPT) 1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of

BETAGAN) .5% 1

LUMIGAN 3 metipranolol 1

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 OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS CYSTARAN 3 NM LA PA

EYLEA 3 NM PA

LACRISERT 3

LUCENTIS 3 NM PA

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of

ALCAINE) SOLN 1

RESTASIS 2

RESPIRATORY

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

Drug Name Drug Tier

Requirements/Limits

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

UTIBRON NEOHALER QL (60 caps / 30 days)

3 QL

ANTICHOLINERGICS 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

SEEBRI NEOHALER QL (60 caps / 30 days)

3 QL

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

cetirizine syrup 1

CLARINEX SYRP 3 desloratadine (generic of

CLARINEX) TABS 1

desloratadine (generic of

CLARINEX REDITABS) TBDP

1



52

Drug Name Drug Tier

Requirements/Limits

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

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

SEREVENT DISKUS QL (60 inhalations / 30 days)

2 QL

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

3 QL

terbutaline sulfate SOLN 3 NM

terbutaline sulfate TABS 1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

XOPENEX HFA QL (2 inhalers / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic

of SINGULAIR) CHEW; PACK; TABS

1

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%,

20% 1 B/D

ARALAST NP 3 NM LA PA

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 3 NM PA

GLASSIA 3 NM LA PA

KALYDECO 3 NM PA

NUCALA 3 NM LA PA

OFEV 3 NM PA

ORKAMBI 3 NM PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 3 B/D NM

tyzine .05% 3

XOLAIR 3 NM LA PA

ZEMAIRA 3 NM LA PA

NASAL STEROIDS BECONASE AQ


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)

(generic of FLONASE) QL (1 bottle / 30 days)

1 QL

NASONEX QL (2 inhalers / 30 days)

2 QL

OMNARIS QL (1 inhaler / 30 days)

3 QL



53

Drug Name Drug Tier

Requirements/Limits

QNASL QL (1 inhaler / 30 days)

3 QL

QNASL CHILDRENS QL (1 inhaler / 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


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

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

QL (120 inhalations / 30 days)

2 QL

FLOVENT DISKUS 250mcg/blist

QL (240 inhalations / 30 days)

2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 1MG/2ML

3 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

Drug Name Drug Tier

Requirements/Limits

ADVAIR DISKUS QL (60 inhalations / 30 days)

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 3 NM

ACANYA 2

ACZONE 5% 3

adapalene (generic of DIFFERIN) CREA; GEL

1

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3 benzoyl peroxide-erythromycin

(generic of BENZAMYCIN)

1

claravis 1

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



54

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate-benzoyl peroxide

(generic of BENZACLIN WITH PUMP)

1

clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of DUAC)

1

DIFFERIN LOTN 2

EPIDUO 2

EPIDUO FORTE 3

ery pad 2% 1

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid)

SOLN 1

FABIOR 3 myorisan 1

neuac gel 1.2-5% (generic of

DUAC) 1

ONEXTON 3

RETIN-A MICRO PUMP .08%

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 NASAL 3

CENTANY 3

CORTISPORIN 3

gentamicin sulfate (topical) 1 mupirocin (generic of

BACTROBAN) OINT 1

Drug Name Drug Tier

Requirements/Limits

mupirocin calcium (topical)

(generic of BACTROBAN) 1

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

SULFAMYLON PACK 3 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

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) CREA 1 ketoconazole (topical)

(generic of EXTINA) FOAM 1

ketodan aer 2% (generic of EXTINA)

1

LUZU 2

MENTAX 3

NAFTIFINE HCL 1% 1 naftifine hcl (generic of

NAFTIN) 2% 1

NAFTIN 2 nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1 nystop 1

oxiconazole nitrate cream (generic of OXISTAT)

1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

DOXEPIN HCL (ANTIPRURITIC)

1

procto-pak 1 proctosol hc 2.5 % (generic of

ANUSOL-HC) 1



55

Drug Name Drug Tier

Requirements/Limits

proctozone hc (generic of

ANUSOL-HC) 1

PRUDOXIN CRE 5% 1

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of

SORIATANE) 3 NM PA

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 3 NM PA

COSENTYX SENSOREADY PEN

3 NM PA

methoxsalen rapid (generic of

OXSORALEN ULTRA) 3 NM

8-MOP 3

SORILUX 2

STELARA 3 NM PA

TAZORAC 2 PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo

(generic of NIZORAL) 1

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate

OINT 1

amcinonide CREA; LOTN 1 amcinonide OINT 3

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

Drug Name Drug Tier

Requirements/Limits

betamethasone valerate

CREA; LOTN; OINT 1

betamethasone valerate

(generic of LUXIQ) FOAM 1

calcipotriene/betamethasone

(generic of TACLONEX) 3 NM

CAPEX 2

clobetasol e cream 0.05% (generic of TEMOVATE E)

1

clobetasol propionate (generic

of TEMOVATE) CREA; GEL; OINT; SOLN

1


of OLUX) FOAM 1


of CLOBEX) LIQD; LOTN; SHAM

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOCORTOLONE PIVALATE 1 clodan sha 0.05% (generic of

CLOBEX) 1

CORDRAN TAPE 3 cormax (generic of

TEMOVATE) 1

DESONATE 3

DESONIDE CREA 1

desonide (generic of

DESOWEN) LOTN; OINT 1

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

ENSTILAR 3 NM

fluocinolone acetonide

CREA .01% 1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1



56

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% 3 NM

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1 fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA

1

fluticasone propionate

(generic of CUTIVATE) 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

LOCOID LOTN 2

lokara (generic of DESOWEN)

1

mometasone furoate (generic

of ELOCON) CREA 1

Drug Name Drug Tier

Requirements/Limits


of ELOCON) OINT 1


of ELOCON) SOLN 1

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

psorcon 3

TACLONEX SUSP 3 NM

texacort 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

DERMATOLOGY, LOCAL ANESTHETICS 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

SYNERA 3

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

ZOVIRAX) 1

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

1

CONDYLOX GEL 2

DENAVIR 3 NM

diclofenac sodium (actinic keratoses) (generic of

SOLARAZE)

3 NM PA

diclofenac sodium (topical) 1

DOXYCYCLINE (ROSACEA) 1

ELIDEL 2 PA

FINACEA AER 15% 2

FINACEA GEL 15% 2



57

Drug Name Drug Tier

Requirements/Limits

fluorouracil (topical) (generic

of EFUDEX) CREA 5% 1

FLUOROURACIL (TOPICAL) CREA .5%

3 NM

fluorouracil (topical) SOLN 1

imiquimod (generic of

ALDARA) CREA 1

metronidazole (topical) (generic of METROCREAM) CREA

1

metronidazole (topical) (generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL

.75% 1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 3 NM

ORACEA 2

PANRETIN 3 NM

PENNSAID 3

PICATO 3 NM

podofilox (generic of

CONDYLOX) SOLN 1

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1 PA

TARGRETIN GEL 3 NM PA

TOLAK 3

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

XERESE 3 NM

ZOVIRAX CREA 3 NM

ZYCLARA 3 NM

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

permethrin (generic of

ELIMITE) 1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS

Drug Name Drug Tier

Requirements/Limits

acetic acid .25% 1

neomycin/polymyxin b gu

(generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 3 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

lidocaine hcl (mouth-throat) 1 nystatin (mouth-throat) 1

ORAVIG 3 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

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

fluocinolone acetonide (otic)

(generic of DERMOTIC) 1

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

1

neomycin-polymyxin-hc (otic)

SUSP 1



58

Drug Name Drug Tier

Requirements/Limits

ofloxacin (otic) 1


59

Index 8 8-MOP...............................55 A abacavir sulfate ...................7 abacavir sulfate-lamivudine-zidovudine ..........................................8 ABELCET............................7 ABILIFY

see aripiprazole tabs .....25 ABILIFY DISCMELT TAB 10MG ................................25 ABILIFY MAINTENA .........25 ABRAXANE ......................12 ABSORICA .......................53 ABSTRAL............................2 acamprosate calcium ........31 ACANYA ...........................53 acarbose ...........................33 ACCOLATE

see zafirlukast ...............52 ACCUPRIL

see quinapril hcl ............15 ACCURETIC

see quinapril-hydrochlorothiazide ..................................15

acebutolol hcl ....................17 ACEON

see perindopril erbumine ......................................15

acetaminophen w/ codeine .1 acetaminophen-caff-dihydrocod ........................................1 acetasol hc ........................57 acetazolamide ...................19 acetazolamide sodium ......19 acetic acid .........................57 acetic acid (otic) ................57 acetic acid sol/hc ...............57 acetic acid-aluminum acetate ..........................................57 acetylcysteine ...................52 ACIPHEX

see rabeprazole sodium 43 ACIPHEX SPR CAP 10MG ..........................................43

ACIPHEX SPR CAP 5MG . 43 acitretin ............................. 55 ACLOVATE

see alclometasone dipropionate .................. 55

ACTEMRA ........................ 45 ACTHIB ............................. 47 ACTIGALL

see ursodiol ................... 43 ACTIMMUNE .................... 46 ACTIQ

see fentanyl citrate .......... 2 ACTONEL

see risedronate sodium . 35 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 34

ACTOPLUS MET XR 15-1000MG ....................... 33 ACTOPLUS MET XR 30-1000MG ....................... 33 ACTOS

see pioglitazone hcl ....... 34 ACULAR

see ketorolac tromethamine (ophth) .... 50

ACULAR LS see ketorolac tromethamine (ophth) .... 50

ACUVAIL .......................... 50 acyclovir .............................. 8 acyclovir sodium ................. 8 acyclovir topical ................ 56 ACZONE ........................... 53 ADACEL ........................... 47 ADAGEN ........................... 38 ADALAT CC

see afeditab cr ............... 18 see nifedipine ................ 18

adapalene ......................... 53 ADCIRCA .......................... 20 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg......... 27 see amphetamine-dextroamph

etamine tab 12.5 mg ..... 27 see amphetamine-dextroamphetamine tab 15 mg ........ 27 see amphetamine-dextroamphetamine tab 20 mg ........ 27 see amphetamine-dextroamphetamine tab 30 mg ........ 27 see amphetamine-dextroamphetamine tab 5 mg .......... 27 see amphetamine-dextroamphetamine tab 7.5 mg ....... 27

ADDERALL XR see amphetamine cap 10mg er ......................... 27 see amphetamine cap 15mg er ......................... 27 see amphetamine cap 20mg er ......................... 27 see amphetamine cap 25mg er ......................... 27 see amphetamine cap 30mg er ......................... 27 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 27

adefovir dipivoxil ................. 8 ADEMPAS ........................ 20 ADOXA

see doxycycline (monohydrate) ............... 11

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 11

adrucil ............................... 12 ADVAIR DISKUS .............. 53 ADVAIR HFA .................... 53 ADVICOR ......................... 16 AEROSPAN ...................... 53 afeditab cr ......................... 18 AFINITOR ......................... 13 AFINITOR DISPERZ ........ 13


60

AFREZZA..........................40 AGGRENOX .....................45 AGRYLIN

see anagrelide hcl .........45 a-hydrocort ........................39 AKYNZEO .........................41 ala-cort ..............................55 ALBENZA............................6 albuterol sulfate .................52 albuterol sulfate er ............52 ALCAINE

see proparacaine hcl .....51 alclometasone dipropionate ..........................................55 ALCOHOL SWABS ...........32 ALDACTAZIDE

see spironolactone & hydrochlorothiazide .......19

ALDACTAZIDE TAB 50/50 ..........................................19 ALDACTONE

see spironolactone ........15 ALDARA

see imiquimod ...............57 ALDURAZYME .................38 ALECENSA .......................13 alendronate sodium ..........35 alfuzosin hcl ......................44 ALIMTA .............................12 ALINIA.................................6 ALKERAN

see melphalan hcl .........12 allopurinol tab ......................1 almotriptan malate ............29 ALOCRIL...........................50 ALOMIDE ..........................50 ALOPRIM ............................1 ALORA ..............................38 alosetron hcl ......................43 ALOXI ...............................41 ALPHAGAN P ...................51 ALPHAGAN P 0.1% ..........51 alprazolam ........................20 ALREX ..............................50 ALSUMA ...........................29 ALTABAX ..........................54 ALTACE

see ramipril ....................15

altavera ............................. 35 ALTOPREV ....................... 16 ALVESCO ......................... 53 amantadine hcl ................. 24 AMARYL

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

see zolpidem tartrate ..... 28 AMBISOME ........................ 7 amcinonide ....................... 55 AMERGE

see naratriptan hcl ......... 29 amethia 91 day ................. 35 amethyst 28 day ............... 35 amifostine crystalline......... 14 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 19 amiloride hcl ...................... 19 aminophylline inj ............... 53 AMINOSYN ....................... 48 AMINOSYN 7%/ELECTROLYTES ....... 48 AMINOSYN II .................... 48 AMINOSYN II 8.5%/ELECTROL .............. 48 AMINOSYN INJ 8.5/LYTE 48 AMINOSYN M ................... 48 AMINOSYN-HBC .............. 48 AMINOSYN-PF 7% ........... 48 AMINOSYN-PF INJ 10% .. 48 AMINOSYN-RF ................. 48 amiodarone hcl ................. 16 amiodarone inj 50mg/ml.... 16 AMITIZA ............................ 43 amitriptyline hcl ................. 23 amlodipine besylate .......... 18 amlodipine besylate/atorv . 18 amlodipine besylate-benazepril hcl ..... 14 amlodipine besylate-valsartan tab 10-160 mg ......................... 15 amlodipine besylate-valsartan tab 10-320 mg ......................... 15 amlodipine besylate-valsartan tab 5-160

mg ..................................... 15 amlodipine besylate-valsartan tab 5-320 mg ..................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 15 ammonium chloride .......... 47 ammonium lactate ............ 56 amnesteem ....................... 53 amoxapine ........................ 23 amoxicillin ......................... 10 amoxicillin & pot clavulanate.......................................... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 43 amphetamine cap 10mg er.......................................... 27 amphetamine cap 15mg er.......................................... 27 amphetamine cap 20mg er.......................................... 27 amphetamine cap 25mg er.......................................... 27 amphetamine cap 30mg er.......................................... 27 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 27 amphetamine-dextroamphetamine tab 10 mg ............... 27 amphetamine-dextroamphetamine tab 12.5 mg ............ 27 amphetamine-dextroamphetamine tab 15 mg ............... 27 amphetamine-dextroamphetamine tab 20 mg ............... 27 amphetamine-dextroamphet


61

amine tab 30 mg ...............27 amphetamine-dextroamphetamine tab 5 mg .................27 amphetamine-dextroamphetamine tab 7.5 mg ..............27 amphotericin b ....................7 ampicillin & sulbactam sodium ........................ 10, 11 ampicillin cap 250mg ........11 ampicillin cap 500 mg .......11 ampicillin inj .......................11 ampicillin sodium ...............11 ampicillin susp ...................11 AMPYRA ...........................30 ANAFRANIL

see clomipramine hcl .....23 anagrelide hcl ....................45 ANAPROX DS

see naproxen sodium ......1 anastrozole .......................13 ANCOBON

see flucytosine .................7 ANDRODERM ..................31 ANDROGEL ................ 31, 32 ANDROGEL 1% ................32 ANDROGEL 1.62% ...........32 ANORO ELLIPT AER 62.5-25 ..............................51 ANTABUSE

see disulfiram ................31 ANTARA ...........................16 ANUSOL-HC

see proctosol hc 2.5 % ..54 see proctozone hc .........55

apexicon e cream ..............55 APIDRA.............................32 APIDRA SOLOSTAR ........32 APLENZIN ........................23 APOKYN ...........................24 apri 28 day ........................35 APRISO ............................42 APTENSIO XR ..................27 APTIOM ............................20 APTIVUS.............................7 ARALAST NP ....................52 ARALEN

see chloroquine phosphate........................7

aranelle 28 ........................ 35 ARANESP ALBUMIN FREE .......................................... 45 ARAVA

see leflunomide ............. 46 ARCALYST ....................... 46 ARCAPTA NEOHALER .... 52 ARICEPT

see donepezil tab hcl 23mg ............................. 22 see donepezil tabs 10mg ...................................... 22 see donepezil tabs 5mg 22

ARIMIDEX see anastrozole ............. 13

aripiprazole odt ................. 25 aripiprazole oral solution 1 mg/ml ................................ 25 aripiprazole tabs ............... 25 ARISTADA ........................ 25 ARIXTRA

see fondaparinux sodium ...................................... 44

ARNUITY ELLIPTA ........... 53 AROMASIN

see exemestane ............ 13 ARRANON ........................ 12 ARTHROTEC 50

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

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

ARZERRA ......................... 12 ASACOL HD ..................... 42 ashlyna 91 day .................. 35 ASMANEX ........................ 53 ASMANEX HFA ................ 53 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG .................. 1 ASPIRIN-DIPYRIDAMOLE .......................................... 45 ASTAGRAF XL ................. 46 ASTEPRO ......................... 51

see azelastine spr 0.15% ...................................... 51

ATACAND

see candesartan cilexetil ...................................... 16

ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 15

ATELVIA see risedronate sodium . 35

atenolol ............................. 17 atenolol & chlorthalidone .. 17 ATGAM ............................. 46 ATIVAN

see lorazepam............... 20 atorvastatin calcium .......... 16 atovaquone ......................... 6 atovaquone-proguanil hcl tab 250-100 mg ........................ 7 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 7 ATRALIN .......................... 53

see tretinoin................... 54 ATRIPLA ............................. 8 ATROPINE SULFATE ...... 41 ATROVENT

see ipratropium bromide (nasal) ........................... 51

ATROVENT HFA .............. 51 AUBAGIO ......................... 30 aubra 28 day ..................... 35 AUGMENTIN .................... 11

see amoxicillin & pot clavulanate .................... 10

AUGMENTIN ES-600 see amoxicillin & pot clavulanate .................... 10

AUGMENTIN XR see amoxicillin & pot clavulanate .................... 10

AURYXIA .......................... 40 AVALIDE

see irbesartan-hydrochlorothiazide ............................... 15

AVAPRO see irbesartan ............... 16

AVASTIN .......................... 12 AVC .................................. 44 AVEED ............................. 32


62

AVELOX............................10 see moxifloxacin hcl ......10

aviane 28 ..........................35 AVITA................................53 AVODART.........................44

see dutasteride ..............44 AVONEX ...........................30 AVONEX PEN ...................30 AVYCAZ..............................9 AXERT ..............................29

see almotriptan malate ..29 AXID

see nizatidine ................42 AXIRON ............................32 AYGESTIN

see norethindrone acetate ......................................40

azacitidine .........................12 AZACTAM

see aztreonam .................6 AZACTAM/DEX INJ 1GM ...6 AZACTAM/DEX INJ 2GM ...6 azasan ..............................46 AZASITE ...........................50 azathioprine ......................46 azelastine drop 0.05% ......50 azelastine spr 0.1% ...........51 azelastine spr 0.15% .........51 AZELEX ............................53 AZILECT ...........................24 azithromycin ......................10 AZITHROMYCIN ...............10 AZOPT ..............................51 AZOR ................................15 aztreonam ...........................6 AZULFIDINE

see sulfasalazine ir ........42 AZULFIDINE EN-TABS

see sulfasalazine dr .......42 B bacitracin (ophthalmic) ......50 bacitracin-polymyxin b (ophth)...............................50 bacitracin-poly-neomycin-hc ..........................................49 baclofen ............................30 BACTOCILL INJ DEX 1GM ..........................................11

BACTOCILL INJ DEX 2GM .......................................... 11 BACTRIM

see sulfamethoxazole-trimethop ...................................... 7

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

BACTROBAN see mupirocin ................ 54 see mupirocin calcium (topical) ......................... 54

BACTROBAN NASAL ....... 54 balsalazide disodium......... 42 balziva 28 day ................... 35 BANZEL SUS 40MG/ML ... 20 BANZEL TAB 200MG ....... 20 BANZEL TAB 400MG ....... 20 BARACLUDE ...................... 8

see entecavir ................... 8 BCG VACCINE ................. 47 BECONASE AQ ................ 52 bekyree 28 day ................. 35 BELBUCA ........................... 2 BELEODAQ ...................... 12 benazepril & hydrochlorothiazide ........... 14 benazepril hcl .................... 15 BENDEKA ......................... 11 BENICAR .......................... 16 BENICAR HCT ................. 15 BENLYSTA ....................... 46 BENTYL ............................ 41

see dicyclomine hcl ....... 41 BENZACLIN WITH PUMP

see clindamycin phosphate-benzoyl peroxide ........................ 54

BENZAMYCIN see benzoyl peroxide-erythromycin ... 53

benzoyl peroxide-erythromycin ...... 53 benztropine mesylate ........ 24 BENZTROPINE MESYLATE .......................................... 24

BEPREVE ......................... 50 BERINERT ....................... 45 BESIVANCE ..................... 50 BETAGAN

see levobunolol hcl ........ 51 betamethasone dipropionate (topical) ............................. 55 betamethasone dipropionate augmented ........................ 55 betamethasone valerate ... 55 BETAPACE

see sorine ..................... 16 see sotalol hcl ............... 16

BETAPACE AF see sotalol hcl (afib/afl) . 16

BETASERON.................... 30 betaxolol hcl ...................... 17 betaxolol hcl (ophth) ......... 51 bethanechol chloride ......... 44 BETHKIS ............................ 5 BETIMOL .......................... 51 BETOPTIC-S .................... 51 bexarotene ........................ 14 BEXSERO ........................ 47 BEYAZ .............................. 35 BIAXIN

see clarithromycin ......... 10 BIAXIN XL

see clarithromycin ......... 10 bicalutamide ..................... 13 BICILLIN C-R .................... 11 BICILLIN L-A .................... 11 BICNU .............................. 11 BIDIL ................................. 19 BILTRICIDE ........................ 6 BINOSTO ......................... 35 bisoprolol & hydrochlorothiazide........... 17 bisoprolol fumarate ........... 17 BIVIGAM ........................... 46 bleomycin sulfate .............. 12 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 50

blephamide ....................... 49 BLEPHAMIDE................... 49 blisovi 21 fe 1.5/30 28 day pack .................................. 36


63

blisovi 21 fe 1/20 28 day pack ..................................36 blisovi 24 fe 1/20 28 day ...36 BONIVA

see ibandronate sodium 35 see ibandronate tab 150mg ...........................35

BOOSTRIX .......................47 BOSULIF...........................13 BOTOX INJ 100UNIT ........30 BOTOX INJ 200UNIT ........30 BREO ELLIPTA ................53 BREVICON-28

see necon 0.5/35 28 day ......................................37 see nortrel 0.5/35 28 day ......................................37

briellyn 28 day ...................36 BRILINTA ..........................45 BRIMONIDINE SOL 0.15% ..........................................51 brimonidine sol 0.2% .........51 BRINTELLIX .....................23 BRISDELLE ......................29 bromfenac sodium (ophth) 50 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ...50 bromocriptine mesylate .....24 BROVANA ........................52 budesonide .......................42 budesonide (inhalation) .....53 budesonide (nasal) ...........52 bumetanide .......................19 BUMEX

see bumetanide .............19 BUNAVAIL MIS 2.1-0.3MG ..........................................31 BUNAVAIL MIS 4.2-0.7MG ..........................................31 BUNAVAIL MIS 6.3-1MG ..31 BUPHENYL

see sodium phenylbutyrate ......................................38

buprenorphine hcl .............31 buprenorphine hcl-naloxone hcl sl ..................................31 buproban ...........................31 bupropion hcl ....................23

bupropion hcl (smoking deterrent) .......................... 31 buspirone hcl .................... 20 BUSULFEX ....................... 11 butorphanol nasal spray...... 2 butorphanol tartrate............. 2 BUTRANS ........................... 2 BYDUREON ..................... 32 BYETTA ............................ 32 BYSTOLIC ........................ 17 C cabergoline ....................... 40 CADUET

see amlodipine besylate/atorv ................ 18

cafergot tab 1-100mg ........ 29 CALAN

see verapamil hcl .......... 18 CALAN SR

see verapamil hcl .......... 18 calcipotriene ...................... 55 calcipotriene/betamethasone .......................................... 55 calcitonin (salmon) nasal spray ................................. 40 calcitrene oin 0.005%........ 55 calcitriol ............................. 49 CALCITRIOL ..................... 55 calcium acetate (phosphate binder)............................... 40 camila 28 day .................... 36 CAMPTOSAR ................... 14

see irinotecan inj 100/5ml ...................................... 14 see irinotecan inj 40mg/2ml ...................... 14

CAMRESE LO TAB .......... 36 CANASA ........................... 42 CANCIDAS ......................... 7 candesartan cilexetil ......... 16 candesartan cilexetil-hydrochlorothiazide .......................................... 15 CANTIL ............................. 41 CAPASTAT SULFATE ........ 8 CAPEX .............................. 55 capital

and codeine ..................... 2

CAPRELSA ...................... 13 captopril ............................ 15 captopril & hydrochlorothiazide........... 14 CARAFATE ...................... 43

see sucralfate ................ 43 CARBAGLU ...................... 38 carbamazepine ................. 20 CARBATROL

see carbamazepine ....... 20 carbidopa .......................... 24 CARBIDOPA/LEVODOPA/ENTACAPONE ................... 24 carbidopa-levodopa .......... 24 carboplatin ........................ 14 CARDIZEM

see diltiazem hcl............ 18 CARDIZEM CD

see cartia xt ................... 18 see diltiazem hcl coated beads ............................ 18

CARDIZEM LA.................. 18 see matzim la ................ 18

CARDURA see doxazosin mesylate 15

CARDURA XL................... 44 CARIMUNE NANOFILTERED .............. 46 CARNITOR

see levocarnitine (metabolic modifiers) ..... 38

carteolol hcl (ophth) .......... 51 cartia xt ............................. 18 carvedilol .......................... 17 CASODEX

see bicalutamide ........... 13 CATAPRES

see clonidine hcl............ 19 CATAPRES-TTS-1



see clonidine hcl............ 19 CAYSTON .......................... 6 cefaclor ............................... 9 cefaclor er tab 500mg ......... 9 cefadroxil ............................ 9


64

cefazolin in dextrose 1gm/50ml-5% ......................9 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................9 cefazolin inj .........................9 cefazolin sodium .................9 cefdinir ................................9 CEFEPIME 1GM SOLN ......9 CEFEPIME 2GM SOLN ......9 CEFEPIME HCL AND DEXTROSE ........................9 cefepime inj 1gm .................9 cefepime inj 2gm .................9 cefixime ...............................9 CEFOTAN

see cefotetan disodium....9 cefotaxime sodium ..............9 cefotetan disodium ..............9 cefoxitin sodium ..................9 CEFOXITIN SODIUM IN DEXTROSE ........................9 cefpodoxime proxetil ...........9 cefprozil...............................9 ceftazidime ..........................9 CEFTAZIDIME/DEXTROSE ............................................9 CEFTIBUTEN .....................9 CEFTIN ...............................9

see cefuroxime axetil .......9 ceftriaxone sodium ..............9 cefuroxime axetil .................9 cefuroxime sodium ..............9 CELEBREX

see celecoxib ...................1 celecoxib .............................1 CELEXA

see citalopram hydrobromide ................23

CELLCEPT see mycophenolate mofetil ......................................46

CELLCEPT INTRAVENOUS ..........................................46 CELONTIN ........................20 CENTANY .........................54 cephalexin ...........................9 CERDELGA ......................38 CEREZYME ......................38

CERVARIX ....................... 47 CESAMET ........................ 41 cetirizine syrup .................. 51 cevimeline hcl ................... 57 CHANTIX .......................... 31 CHANTIX CONTINUING MONTH ............................. 31 CHANTIX STARTER PACK .......................................... 31 CHEMET ........................... 35 chlorhexidine gluconate (mouth-throat) ................... 57 chloroquine phosphate........ 7 chlorothiazide tabs ............ 19 chlorpromazine hcl ............ 25 chlorpromazine inj ............. 25 chlorthalidone ................... 19 cholestyramine .................. 17 cholestyramine light .......... 17 choline fenofibrate ............ 17 CHORIONIC GONADOTROPIN ............ 40 ciclopirox ........................... 54 ciclopirox cre 0.77% .......... 54 ciclopirox shampoo 1% ..... 54 ciclopirox sus 0.77% ......... 54 cidofovir .............................. 8 cilostazol ........................... 45 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 50

CILOXAN OIN 0.3% OP ... 50 cimetidine .......................... 42 cimetidine sol 300/5ml ...... 42 CIMZIA .............................. 45 CINRYZE .......................... 45 CIPRO

see ciprofloxacin............ 10 see ciprofloxacin hcl ...... 10

CIPRO HC ........................ 57 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w 10 CIPRO XR

see ciprofloxacin er ....... 10 CIPRODEX ....................... 57 ciprofloxacin ...................... 10 ciprofloxacin er .................. 10 ciprofloxacin hcl ................ 10

ciprofloxacin hcl (ophth) .... 50 ciprofloxacin in d5w .......... 10 ciprofloxacn inj 400mg/40ml.......................................... 10 cisplatin ............................. 14 citalopram hydrobromide .. 23 cladribine .......................... 12 claforan ............................. 10 CLAFORAN

see cefotaxime sodium ... 9 CLAFORAN/D5W ............. 10 claravis ............................. 53 CLARINEX ........................ 51

see desloratadine .......... 51 CLARINEX REDITABS

see desloratadine .......... 51 CLARINEX-D TAB 2.5-120.......................................... 51 clarithromycin.................... 10 CLEOCIN

see clindamycin cre 2% vag ................................ 44 see clindamycin hcl ......... 6

CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 6

CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride................... 6

CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 6

CLEOCIN VAG SUPP 100MG .............................. 44 CLEOCIN-T

see clindamax ............... 53 see clindamycin phosphate (topical) ........ 53

CLIMARA see estradiol .................. 38

CLINDAGEL ..................... 53 clindamax ......................... 53 clindamycin cre 2% vag .... 44 clindamycin hcl ................... 6 clindamycin palmitate hydrochloride ...................... 6 clindamycin phosphate ....... 6


65

clindamycin phosphate (topical) .............................53 clindamycin phosphate in d5w .....................................6 clindamycin phosphate-benzoyl peroxide ..........................................54 clindamycin phosphate-benzoyl peroxide (refrigerate) .......................54 CLINDESSE ......................44 CLINIMIX 2.75%/DEXTROSE 5% .....48 CLINIMIX 4.25%/DEXTROSE 10% ...48 CLINIMIX 4.25%/DEXTROSE 20% ...48 CLINIMIX 4.25%/DEXTROSE 25% ...48 CLINIMIX 4.25%/DEXTROSE 5% .....48 CLINIMIX 5%/DEXTROSE 15% ...................................48 CLINIMIX 5%/DEXTROSE 20% ...................................48 CLINIMIX 5%/DEXTROSE 25% ...................................48 CLINIMIX E 2.75%/DEXTROSE 10% ...48 CLINIMIX E 2.75%/DEXTROSE 5% .....48 CLINIMIX E 4.25%/D10 ....48 CLINIMIX E 4.25%/DEXTROSE 25% ...48 CLINIMIX E 4.25%/DEXTROSE 5% .....48 CLINIMIX E 5%/DEXTROSE 15% ...................................48 CLINIMIX E 5%/DEXTROSE 20% ...................................48 CLINIMIX E 5%/DEXTROSE 25% ...................................48 clinisol 15 ..........................48 clobetasol e cream 0.05% .55 clobetasol propionate ........55 clobetasol propionate emulsion............................55 CLOBEX

see clobetasol propionate ...................................... 55 see clodan sha 0.05% ... 55

CLOCORTOLONE PIVALATE ......................... 55 clodan sha 0.05% ............. 55 CLOLAR ........................... 12 clomipramine hcl ............... 23 clonazepam ................ 20, 21 clonidine hcl ...................... 19 clopidogrel bisulfate .......... 45 clorazepate dipotassium ... 21 clorpres ............................. 19 clotrimazole ....................... 57 clotrimazole (topical) ......... 54 clozapine ........................... 25 CLOZAPINE ..................... 25 CLOZAPINE ODT ............. 25 CLOZARIL

see clozapine ................ 25 COARTEM .......................... 7 codeine

and capital ....................... 2 CODEINE SULFATE .......... 2 COLAZAL

see balsalazide disodium ...................................... 42

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

see colestipol hcl ........... 17 colestipol hcl ..................... 17 colistimethate sodium ......... 6 colocort ............................. 42 COLY-MYCIN M

see colistimethate sodium ........................................ 6

COLY-MYCIN S ................ 57 COLYTE-FLAVOR PACKS

see gavilyte-c ................ 42 COLYTE-FLAVOR PACKS 227.1 GM .......................... 42 COMBIGAN ...................... 51 COMBIVENT RESPIMAT . 51 COMBIVIR

see lamivudine-zidovudine ........................................ 8

COMETRIQ ...................... 13

COMPAZINE see prochlorperazine maleate ......................... 41

COMPLERA ....................... 8 compro supp ..................... 41 COMVAX .......................... 47 CONDYLOX ..................... 56

see podofilox ................. 57 constulose ........................ 42 CONZIP .............................. 2 COPAXONE

see glatopa ................... 30 COPAXONE INJ 40MG/ML.......................................... 30 COPEGUS

see moderiba tab 200mg 9 see ribasphere ................ 9 see ribavirin 200mg ......... 9

CORDARONE see amiodarone hcl ....... 16 see pacerone ................ 16

CORDRAN ....................... 55 COREG

see carvedilol ................ 17 COREG CR ...................... 17 CORGARD

see nadolol .................... 17 CORLANOR ..................... 19 cormax .............................. 55 CORTEF

see hydrocortisone ........ 39 CORTENEMA

see colocort ................... 42 CORTIFOAM .................... 54 cortisone acetate .............. 39 CORTISPORIN ................. 54

see neomycin-polymyxin-hc (otic) .............................. 57

CORTISPORIN-TC ........... 57 CORZIDE

see nadolol & bendroflumethiazide ...... 17

COSENTYX ...................... 55 COSENTYX SENSOREADY PEN .................................. 55 COSMEGEN ..................... 12 COSOPT


66

see dorzolamide hcl-timolol maleate ........51

COSOPT PF .....................51 COTELLIC ........................13 COUMADIN ......................44

see jantoven ..................45 see warfarin sodium ......45

COZAAR see losartan potassium..16

CREON .............................43 CRESEMBA ........................7 CRESTOR ........................16 CRINONE .........................40 CRIXIVAN ...........................7 cromolyn sodium ...............52 cromolyn sodium (mastocytosis) ...................43 cromolyn sodium (ophth)...50 cryselle 28 .........................36 CUBICIN .............................6 CUTIVATE

see fluticasone propionate ......................................56

CUVPOSA ........................41 cyclafem 1/35 28 day ........36 cyclafem 7/7/7 28 day .......36 CYCLESSA

see velivet 28 day ..........38 cyclobenzaprine hcl ..........30 cyclophosphamide ............11 CYCLOPHOSPHAMIDE ...11 cycloserine ..........................8 cyclosporine ......................46 cyclosporine modified (for microemulsion) ..................46 CYKLOKAPRON

see tranexamic acid ......45 CYMBALTA

see duloxetine hcl ..........23 CYRAMZA ........................12 cyred tab ...........................36 CYSTADANE ....................38 CYSTAGON ......................38 CYSTARAN ......................51 cytarabine inj .....................12 CYTOMEL

see liothyronine sodium .40 CYTOTEC

see misoprostol ............. 43 CYTOVENE

see ganciclovir inj 500mg 8 D D.H.E. 45

see dihydroergotamine mesylate ........................ 29

dacarbazine ...................... 11 DACOGEN

see decitabine ............... 12 DAKLINZA .......................... 8 DALIRESP ........................ 52 DALVANCE ........................ 6 danazol ............................. 38 DANTRIUM

see dantrolene sodium .. 31 dantrolene sodium ............ 31 dapsone .............................. 6 DAPTACEL ....................... 47 DARAPRIM ......................... 6 DARIFENACIN HYDROBROMIDE ............ 44 DARZALEX ....................... 12 daunorubicin hcl ................ 12 DAYPRO

see oxaprozin .................. 1 DAYTRANA ...................... 27 DDAVP

see desmopressin acetate ...................................... 41 see desmopressin acetate inj................................... 41 see desmopressin acetate spray ............................. 41

deblitane 28 day ............... 36 decitabine ......................... 12 DELESTROGEN ............... 38

see estradiol valerate .... 38 delyla 28 day ..................... 36 DELZICOL ........................ 42 DEMADEX

see torsemide tabs ........ 19 demeclocycline hcl ............ 11 DEMSER .......................... 19 DENAVIR .......................... 56 DEPACON

see valproate sodium .... 22 DEPAKENE

see valproate sodium .... 22 see valproic acid ........... 22

DEPAKOTE see divalproex sodium .. 21

DEPAKOTE ER see divalproex sodium .. 21

DEPAKOTE SPRINKLES see divalproex sodium .. 21

DEPEN TITRATABS ......... 35 depo-estradiol ................... 38 DEPO-MEDROL

see methylpr ace inj 40mg/ml ........................ 39 see methylpr ace inj 80mg/ml ........................ 39

DEPO-MEDROL INJ 20MG/ML .......................... 39 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 37

DEPO-PROVERA INJ 400/ML .............................. 13 DEPO-SUBQ PROVERA 104 .................................... 36 depo-testosterone ............. 32 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 32

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 56

DERMA-SMOOTHE/FS SCALP

see fluocinolone acetonide ...................................... 56

DERMATOP see prednicarbate ......... 56

DERMOTIC see fluocinolone acetonide (otic) .............................. 57

desipramine hcl................. 23 desloratadine .................... 51 desmopressin acetate ....... 41 DESMOPRESSIN ACETATE.......................................... 40 desmopressin acetate inj .. 41


67

desmopressin acetate spray ..........................................41 desmopressin acetate spray refrigerated........................41 DESOGEN

see apri 28 day ..............35 see cyred tab .................36 see emoquette ...............36 see juleber 28 day .........36 see reclipsen 28 day .....37

desogestrel-ethinyl estradiol (biphasic) ..........................36 DESONATE ......................55 desonide ...........................55 DESONIDE .......................55 DESOWEN

see desonide .................55 see lokara ......................56

desoximetasone ................55 DESOXIMETASONE ........55 DETROL

see tolterodine tartrate tab 1 mg ..............................44 see tolterodine tartrate tab 2 mg ..............................44

DETROL LA see tolterodine tartrate er ......................................44

dexamethasone ................39 dexamethasone sodium phosphate .........................39 dexamethasone sodium phosphate (ophth) .............50 DEXILANT ........................43 dexpak 10 day ...................39 dexpak 6 day .....................39 dexpak taperpak 13 day ....39 dexrazoxane .....................14 DEXTROSE ......................48 DEXTROSE 10% FLEX CONTAIN ..........................49 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ..........................................49 DEXTROSE 10%/NACL 0.45% ................................49 DEXTROSE 2.5%/NACL 0.45% ................................48

DEXTROSE 5% ................ 48 DEXTROSE 5% /ELECTROLYTE ............... 48 DEXTROSE 5%/LACTATED RING ................................. 48 DEXTROSE 5%/NACL 0.2% .......................................... 48 DEXTROSE 5%/NACL 0.225%.............................. 49 DEXTROSE 5%/NACL 0.3% .......................................... 48 DEXTROSE 5%/NACL 0.33%................................ 48 DEXTROSE 5%/NACL 0.45%................................ 48 DEXTROSE 5%/NACL 0.9% .......................................... 48 DEXTROSE 5%/POTASSIUM CHL ...... 49 DIAMOX

see acetazolamide ........ 19 diazepam .......................... 21 DIAZEPAM GEL (ANTICONVULSANT) ....... 21 DIBENZYLINE .................. 19

see phenoxybenzamine hcl.................................. 19

diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 56 diclofenac sodium (ophth) . 50 diclofenac sodium (topical)56 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 11 dicyclomine hcl ................. 41 didanosine .......................... 7 DIFFERIN ......................... 54

see adapalene ............... 53 DIFICID ............................. 10 diflorasone diacetate ......... 55 DIFLUCAN

see fluconazole ............... 7 diflunisal .............................. 1 digitek ............................... 18 digox ................................. 18 digoxin .............................. 18 digoxin inj .......................... 18

DIGOXIN SOL 50MCG/ML.......................................... 18 dihydroergotamine mesylate.......................................... 29 DIHYDROERGOTAMINE MESYLATE ...................... 29 dilantin .............................. 21 DILANTIN

see phenytoin sodium extended ....................... 22

DILANTIN INFATABS see phenytoin ................ 22

DILANTIN-125 .................. 21 see phenytoin ................ 22

DILATRATE SR ................ 19 DILAUDID

see hydromorphone hcl ... 3 DILAUDID-HP

see hydromorphone hcl ... 3 DILAUDID-HP INJ 250MG .. 2 diltiazem cap 120mg/24hr . 18 diltiazem cap 240mg/24hr . 18 diltiazem cap er/12hr ........ 18 diltiazem hcl ...................... 18 diltiazem hcl coated beads 18 diltiazem hcl er .................. 18 diltiazem hcl extended release beads ................... 18 diltiazem inj 100mg ........... 18 diltiazem inj 125/25ml ....... 18 diltiazem inj 25mg/5ml ...... 18 diltiazem inj 50/10ml ......... 18 dilt-xr cap .......................... 18 DIOVAN

see valsartan ................. 16 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 16

DIPENTUM ....................... 42 diphenhydram inj 50mg/ml 52 diphenoxylate w/ atropine . 43 DIPHTHERIA/TETANUS TOXOID ............................ 47 DIPROLENE

see betamethasone dipropionate augmented 55

DIPROLENE AF


68

see betamethasone dipropionate augmented 55

disopyramide phosphate ...16 disulfiram...........................31 DITROPAN XL

see oxybutynin chloride .44 DIURIL SUS 250/5ML .......19 divalproex sodium .............21 docetaxel...........................12 DOCETAXEL ....................12 DOCETAXEL SOLN 80MG/8ML ........................12 DOLOPHINE

see methadone hcl ..........4 donepezil odt 10mg ...........22 donepezil odt 5mg .............22 donepezil tab hcl 23mg .....22 donepezil tabs 10mg .........22 donepezil tabs 5mg ...........22 DORIBAX ............................6 dorzolamide hcl .................51 dorzolamide hcl-timolol maleate .............................51 DOVONEX

see calcipotriene ...........55 doxazosin mesylate ..........15 doxepin hcl ........................23 DOXEPIN HCL (ANTIPRURITIC) ..............54 doxercalciferol ...................49 DOXIL

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ...........12

doxorubicin hcl ..................12 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .....12 doxorubicin inj 50mg .........12 doxy ..................................11 doxycycline (monohydrate) ..........................................11 DOXYCYCLINE (ROSACEA) ......................56 doxycycline hyclate ...........11 dronabinol .........................41 drospirenone-ethinyl estradiol ............................36 DROXIA ............................14

DUAC see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 54 see neuac gel 1.2-5%.... 54

DUETACT see pioglitazone hcl-glimepiride ............... 34

DUEXIS .............................. 1 DULERA ........................... 53 duloxetine hcl .................... 23 DUOPA ............................. 24 DURAGESIC

see fentanyl patch 100 mcg/hr ............................. 3 see fentanyl patch 12 mcg/hr ............................. 2 see fentanyl patch 25 mcg/hr ............................. 3 see fentanyl patch 50 mcg/hr ............................. 3 see fentanyl patch 75 mcg/hr ............................. 3

DURAMORPH .................... 2 DUREZOL ......................... 50 DURLAZA ......................... 45 dutasteride ........................ 44 dutasteride-tamsulosin hcl 44 DUTOPROL ...................... 17 DYAZIDE

see triamt/hctz cap 37.5-25 .......................... 19

DYMISTA SPR 137-50 ..... 51 DYRENIUM ....................... 19 DYSPORT ........................ 31 E e.e.s. 400 tab 400mg ........ 10 E.E.S. GRANULES ........... 10 EC-NAPROSYN

see naproxen .................. 1 econazole nitrate .............. 54 EDARBI ............................ 16 EDARBYCLOR ................. 15 EDECRIN .......................... 19 EDURANT .......................... 7 EFFEXOR XR

see venlafaxine cap er .. 24 EFFIENT ........................... 45

EFUDEX see fluorouracil (topical) 57

EGRIFTA .......................... 40 ELAPRASE ....................... 38 ELDEPRYL

see selegiline hcl ........... 24 ELECTROLYTE-R IN DEXTROSE ...................... 49 ELELYSO ......................... 38 ELESTAT

see epinastine hcl (ophth) ...................................... 50

ELIDEL ............................. 56 ELIGARD INJ 22.5MG ...... 13 ELIGARD INJ 30MG ......... 13 ELIGARD INJ 45MG ......... 13 ELIGARD INJ 7.5MG ........ 13 ELIMITE

see permethrin .............. 57 ELIPHOS

see calcium acetate (phosphate binder) ........ 40

ELIQUIS TAB 2.5MG ........ 44 ELIQUIS TAB 5MG ........... 44 ELITEK ............................. 14 elixophyllin ........................ 53 ELLA ................................. 36 ELLENCE

see epirubicin inj 200mg 12 see epirubicin inj 50mg/25ml .................... 12

ELMIRON ......................... 44 ELOCON

see mometasone furoate ...................................... 56

ELOXATIN ........................ 14 EMADINE ......................... 50 EMBEDA ............................ 2 EMCYT ............................. 11 EMEND CAP 125MG ........ 41 EMEND CAP 40MG .......... 41 EMEND CAP 80MG .......... 41 EMEND PAK 80 & 125 ..... 41 EMLA

see lidocaine-prilocaine . 56 emoquette ......................... 36 EMPLICITI ........................ 12 EMSAM ............................ 23


69

EMTRIVA ............................7 ENABLEX .........................44 enalapril maleate ...............15 enalapril maleate & hydrochlorothiazide ...........15 ENBREL............................45 ENBREL SURECLICK ......45 endocet ...............................2 ENGERIX-B ......................47 enoxaparin sodium ............44 enpresse 28 day ...............36 ENSTILAR ........................55 ENTACAPONE .................24 entecavir .............................8 ENTOCORT EC

see budesonide .............42 ENTRESTO ......................15 ENTYVIO ..........................42 enulose .............................42 ENVARSUS XR ................46 EPIDUO ............................54 EPIDUO FORTE ...............54 epinastine hcl (ophth) ........50 EPINEPHRINE ..................52 EPIPEN 2-PAK .................52 EPIPEN-JR 2-PAK ............52 epirubicin inj 200mg ..........12 epirubicin inj 50mg/25ml ...12 epitol .................................21 EPIVIR

see lamivudine ................7 EPIVIR HBV ........................8

see lamivudine (hbv) .......8 eplerenone ........................15 EPOGEN...........................45 epoprostenol sodium .........20 eprosartan mesylate .........16 EPZICOM............................8 EQUETRO ........................29 ERAXIS ...............................7 ERBITUX ..........................12 ergomar.............................29 ERIVEDGE .......................12 errin 28 day .......................36 ERTACZO .........................54 ERWINAZE .......................14 ery pad 2% ........................54 ERYGEL

see erythromycin (acne aid) ................................ 54

ERYPED 200 .................... 10 ERYPED 400 .................... 10 ery-tab............................... 10 erythrocin lactobionate ...... 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 54 erythromycin (ophth) ......... 50 erythromycin base............. 10 erythromycin cap 250mg ec .......................................... 10 erythromycin ethylsuccinate .......................................... 10 ESBRIET .......................... 52 escitalopram oxalate ......... 23 esomeprazole magnesium 43 esomeprazole sodium inj .. 43 estarylla tab 0.25-35 ......... 36 estrace .............................. 38 ESTRACE

see estradiol .................. 38 estradiol ............................ 38 estradiol valerate .............. 38 ESTRING .......................... 38 ESTROSTEP FE

see tri-legest 28 day ...... 37 ethambutol hcl .................... 8 ethosuximide ..................... 21 ETHYOL

see amifostine crystalline ...................................... 14

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 14 etoposide .......................... 14 EURAX ............................. 57 EVISTA

see raloxifene hcl .......... 40 EVOCLIN

see clindamycin phosphate (topical) ........ 53

EVOTAZ ............................. 8 EVOXAC

see cevimeline hcl ......... 57 EXALGO

see hydromorphone tab 12mg er ........................... 3

see hydromorphone tab 16mg er ........................... 3 see hydromorphone tab 8mg er ............................. 3

EXELDERM ...................... 54 EXELON

see rivastigmine tartrate 23 see rivastigmine td patch 24hr 13.3 mg/24hr ......... 23 see rivastigmine td patch 24hr 4.6 mg/24hr ........... 23 see rivastigmine td patch 24hr 9.5 mg/24hr ........... 23

EXELON PATCHES ......... 22 exemestane ...................... 13 EXFORGE

see amlodipine besylate-valsartan tab 10-160 mg ..................... 15 see amlodipine besylate-valsartan tab 10-320 mg ..................... 15 see amlodipine besylate-valsartan tab 5-160 mg ....................... 15 see amlodipine besylate-valsartan tab 5-320 mg ....................... 15

EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 15 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 15 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 15 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 15 see amlodipine-valsartan-hydrochlorothiazide


70

5-160-25mg ...................15 EXJADE ............................35 EXTAVIA ...........................30 EXTINA

see ketoconazole (topical) ......................................54 see ketodan aer 2% ......54

EYLEA ..............................51 F FABIOR.............................54 FABRAZYME ....................38 falmina 28 day ...................36 famciclovir ...........................8 famotidine .........................42 famotidine inj .....................42 FAMVIR

see famciclovir .................8 FANAPT ............................25 FANAPT TITRATION PACK ..........................................25 FARESTON ......................13 FARXIGA ..........................33 FARYDAK .........................12 FASLODEX .......................13 FAZACLO .........................25 felbamate ..........................21 FELBATOL

see felbamate ................21 FELDENE

see piroxicam ..................1 felodipine...........................18 FEMARA

see letrozole ..................13 FEMCON FE

see wymzya fe ...............38 see zenchent fe 28 day .38

FEMRING .........................38 fenofibrate .........................17 FENOFIBRATE .................17 fenofibrate micronized .......17 FENOFIBRIC ACID ...........17 FENOGLIDE .....................17 fenoprofen calcium ..............1 FENOPROFEN CALCIUM ..1 fentanyl citrate .....................2 fentanyl patch 100 mcg/hr ...3 fentanyl patch 12 mcg/hr .....2 fentanyl patch 25 mcg/hr .....3

fentanyl patch 50 mcg/hr ..... 3 fentanyl patch 75 mcg/hr ..... 3 FENTORA ........................... 3 FERRIPROX ..................... 35 FETZIMA .......................... 23 FETZIMA TITRATION PACK .......................................... 23 FINACEA AER 15% .......... 56 FINACEA GEL 15% .......... 56 finasteride ......................... 44 FIRAZYR .......................... 45 FIRMAGON ...................... 13 FLAGYL

see metronidazole ........... 6 FLAREX ............................ 50 FLEBOGAMMA ................ 46 FLEBOGAMMA DIF .......... 46 flecainide acetate .............. 16 FLOLAN ............................ 20

see epoprostenol sodium ...................................... 20

FLOMAX see tamsulosin hcl ......... 44

FLONASE see fluticasone propionate (nasal) ........................... 52

FLO-PRED SUS ............... 39 FLOVENT DISKUS ........... 53 FLOVENT HFA ................. 53 fluconazole .......................... 7 fluconazole in dextrose ....... 7 fluconazole in nacl .............. 7 flucytosine ........................... 7 FLUDARA

see fludarabine phosphate ...................................... 12

fludarabine phosphate ...... 12 fludrocortisone acetate...... 39 FLUMADINE

see rimantadine hydrochloride ................... 9

flunisolide (nasal) .............. 52 fluocinolone acetonide 55, 56 fluocinolone acetonide (otic) .......................................... 57 fluocinonide ....................... 56 fluocinonide emulsified base .......................................... 56

FLUOROMETHOLONE (OPHTH) ........................... 50 fluorouracil ........................ 12 fluorouracil (topical) .......... 57 FLUOROURACIL (TOPICAL) ........................ 57 fluoxetine cap 10mg .......... 23 fluoxetine cap 20mg .......... 23 fluoxetine cap 40mg .......... 23 fluoxetine hcl ..................... 23 FLUOXETINE HCL ........... 23 fluphenazine decanoate .... 25 fluphenazine hcl ................ 25 flurbiprofen .......................... 1 flurbiprofen sodium ........... 50 flutamide ........................... 13 fluticasone propionate ....... 56 fluticasone propionate (nasal) ............................... 52 fluvastatin sodium cap 20 mg.......................................... 16 fluvastatin sodium cap 40 mg.......................................... 16 fluvastatin sodium tab sr 24 hr 80 mg ........................... 16 fluvoxamine maleate ......... 20 fluvoxamine maleate er ..... 20 FML .................................. 50 FML FORTE ..................... 50 FOLOTYN ......................... 12 fondaparinux sodium ........ 44 FORADIL AEROLIZER ..... 52 FORFIVO XL .................... 23 FORTAMET

see metformin hcl osmotic 1000mg ......................... 34 see metformin hcl osmotic 500mg ........................... 34

FORTAZ ........................... 10 see ceftazidime ............... 9 see tazicef ..................... 10 see tazicef vial............... 10

FORTEO ........................... 40 FORTESTA ...................... 32 FORTICAL SPR 200/ACT 40 FOSAMAX

see alendronate sodium 35 FOSAMAX PLUS D .......... 35


71

fosinopril sodium ...............15 fosinopril sodium & hydrochlorothiazide ...........15 FOSRENOL ......................40 FRAGMIN ................... 44, 45 FREAMINE HBC 6.9% ......48 FREAMINE III ...................48 FROVA TAB 2.5MG ..........29 FURADANTIN

see nitrofurantoin .............6 furosemide ........................19 furosemide inj ....................19 FUROSEMIDE INJ ............19 furosemide oral soln 8 mg/ml ..........................................19 FUSILEV ...........................14 FUZEON .............................7 fyavolv tab 1 mg-5 mcg .....38 FYCOMPA ........................21 G gabapentin ........................21 GABITRIL..........................21

see tiagabine hcl ...........22 galantamine hydrobromide .................................... 22, 23 galantamine hydrobromide er .......................................23 GAMASTAN S/D ...............46 GAMMAGARD LIQUID .....46 GAMMAGARD S/D ...........46 GAMMAGARD S/D IGA LESS TH ...........................46 GAMMAKED .....................46 GAMMAPLEX ...................46 GAMUNEX-C ....................46 ganciclovir inj 500mg ..........8 GARDASIL ........................47 GARDASIL 9 .....................47 GASTROCROM

see cromolyn sodium (mastocytosis) ...............43

gatifloxacin (ophth) ............50 GATTEX............................43 GAUZE PADS 2X2 ...........32 gaviltye-g...........................42 gavilyte-c ...........................42 gavilyte-h...........................42 gavilyte-n...........................42

GAZYVA ........................... 12 GELNIQUE ....................... 44 GEMCITABINE ................. 12 gemcitabine hcl ................. 12 gemfibrozil ........................ 17 GEMZAR

see gemcitabine hcl....... 12 GENERESS FE

see kaitlib fe 28 day....... 36 see norethindrone & ethinyl estradiol-fe ......... 37

generlac ............................ 42 gengraf.............................. 46 GENOTROPIN .................. 39 GENOTROPIN MINIQUICK .......................................... 39 gentak ............................... 50 gentamicin in saline 0.8 mg/ml .................................. 5 gentamicin in saline 0.9mg/ml ............................. 5 gentamicin in saline 1 mg/ml ............................................ 5 gentamicin in saline 1.2 mg/ml .................................. 5 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) . 50 gentamicin sulfate (topical) .......................................... 54 GENVOYA .......................... 8 GEODON

see ziprasidone hcl........ 27 GEODON INJ ................... 25 GIANVI TAB 3-0.02MG ..... 36 GIAZO............................... 42 gildagia ............................. 36 gildess 1.5/30 21 day ........ 36 gildess 24 fe 28 day .......... 36 GILENYA CAP 0.5MG ...... 30 GILOTRIF TAB 20MG....... 13 GILOTRIF TAB 30MG....... 13 GILOTRIF TAB 40MG....... 13

GLASSIA .......................... 52 glatopa .............................. 30 GLEEVEC ......................... 13

see imatinib mesylate .... 13 GLEOSTINE ..................... 11 glimepiride ........................ 33 glipizide ............................. 33 glipizide er ........................ 33 GLIPIZIDE XL TB24 2.5MG.......................................... 33 GLIPIZIDE XL TB24 5MG . 33 glipizide-metformin 2.5-250 mg ..................................... 33 glipizide-metformin 2.5-500 mg ..................................... 33 glipizide-metformin 5-500mg.......................................... 33 GLUCAGEN HYPOKIT ..... 39 GLUCAGON EMERGENCY KIT .................................... 39 GLUCOPHAGE

see metformin hcl .......... 34 GLUCOPHAGE XR

see metformin er ........... 34 GLUCOTROL

see glipizide .................. 33 GLUCOTROL XL

see glipizide er .............. 33 GLUMETZA ...................... 33

see metformin hcl .......... 34 glycate .............................. 41 glycopyrrolate ................... 41 GLYSET ........................... 33 GLYXAMBI ....................... 33 GOLYTELY ....................... 42

see gaviltye-g ................ 42 GRALISE .......................... 29 GRALISE STARTER ........ 29 granisetron hcl .................. 41 GRANIX ............................ 45 GRASTEK ........................ 46 griseofulvin microsize ......... 7 griseofulvin ultramicrosize .. 7 GRIS-PEG

see griseofulvin ultramicrosize .................. 7

guanfacine er (adhd) ......... 27


72

H H.P. ACTHAR ...................40 HALAVEN .........................14 HALDOL

see haloperidol lactate inj 5 mg/ml..........................25

HALDOL DECANOATE 100 see haloperidol decanoate ......................................25

HALDOL DECANOATE 50 see haloperidol decanoate ......................................25

halobetasol propionate ......56 HALOG .............................56 haloperidol ........................25 haloperidol decanoate .......25 haloperidol lactate .............25 haloperidol lactate inj 5 mg/ml ................................25 HARVONI............................8 HAVRIX.............................47 heather ..............................36 HECTOROL ......................49

see doxercalciferol ........49 HEP SOD/NACL INJ 25000 ..........................................45 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ...........................45 heparin sod inj 10000u/ml .45 heparin sod inj 1000u/ml ...45 heparin sod inj 20000u/ml .45 HEPARIN SOD INJ 2000U/ML .........................45 HEPARIN SOD INJ 2500U/ML .........................45 heparin sod inj 5000u/0.5ml ..........................................45 heparin sod inj 5000u/ml ...45 HEPARIN SODIUM/D5W ..45 HEPARIN SODIUM/NACL 0.45% ................................45 HEPATAMINE ...................48 HEPSERA

see adefovir dipivoxil .......8 HERCEPTIN .....................12 HETLIOZ ...........................28 HEXALEN .........................11

HIBERIX ........................... 47 HIPREX

see methenamine hippurate ......................... 6

HIZENTRA ........................ 46 HORIZANT ....................... 29 HUMALOG ........................ 32 HUMALOG KWIKPEN ...... 32 HUMALOG MIX 50/50 ...... 32 HUMALOG MIX 50/50 KWIKPEN ......................... 32 HUMALOG MIX 75/25 ...... 32 HUMALOG MIX 75/25 KWIKPEN ......................... 32 HUMATROPE ................... 39 HUMATROPE COMBO PACK ................................ 39 HUMIRA ............................ 45 HUMIRA PEDIATRIC CROHNS .......................... 45 HUMIRA PEN ................... 45 HUMIRA PEN-CROHNS STARTER KIT .................. 45 HUMIRA PEN-PSORIASIS STARTER KIT .................. 46 HUMULIN 70/30 ............... 32 HUMULIN 70/30 KWIKPEN .......................................... 32 HUMULIN N ...................... 32 HUMULIN N KWIKPEN .... 32 HUMULIN R ...................... 32 HUMULIN R U-500 VIAL (CONCENTRATE) ............ 32 HYCAMTIN

see topotecan hcl .......... 14 HYCET

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

hydralazine hcl .................. 19 HYDREA

see hydroxyurea ............ 14 hydrochlorothiazide ........... 19 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 ........................... 3 hydrocodone-ibuprofen tab 2.5-200mg .......................... 3 hydrocodone-ibuprofen tab 5-200mg ............................. 3 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 3 hydrocortisone .................. 39 HYDROCORTISONE (INTRARECTAL) .............. 42 hydrocortisone (topical) .... 56 hydrocortisone butyrate .... 56 hydrocortisone butyrate hydrophilic lipo base ......... 56 hydrocortisone valerate .... 56 hydromorphone hcl ............. 3 HYDROMORPHONE HCL . 3 hydromorphone tab 12mg er............................................ 3 hydromorphone tab 16mg er............................................ 3 hydromorphone tab 8mg er 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate.......................................... 46 hydroxyurea ...................... 14 hydroxyzine hcl ................. 52 HYQVIA ............................ 46 HYSINGLA ER.................... 3 HYZAAR

see losartan-hydrochlorothiazide .................................. 15

I ibandronate sodium .......... 35


73

ibandronate tab 150mg .....35 IBRANCE ..........................12 ibudone tab 10-200mg ........3 ibudone tab 5-200mg ..........3 ibuprofen .............................1 ICLUSIG............................13 IDAMYCIN PFS

see idarubicin hcl ...........12 idarubicin hcl .....................12 IFEX

see ifosfamide inj 1gm ...11 IFEX INJ 3GM ...................11 ifosfamide inj 1gm .............11 ifosfamide inj 1gm/20ml ....11 IFOSFAMIDE INJ 3GM .....12 ifosfamide inj 3gm/60ml ....12 ILARIS...............................46 ILEVRO .............................50 ilotycin ...............................50 imatinib mesylate ..............13 IMBRUVICA CAP 140MG .13 imipenem-cilastatin .............6 imipramine hcl ...................23 imipramine pamoate .........23 imiquimod..........................57 IMITREX

see sumatriptan inj 6mg/0.5ml ......................29 see sumatriptan succinate ......................................29

IMITREX STATDOSE SYSTEM

see sumatriptan inj 6mg/0.5ml ......................29

IMOVAX RABIES (H.D.C.V.) ..........................................47 IMURAN

see azathioprine ............46 INCRELEX ........................40 INCRUSE ELLIPTA ..........51 indapamide .......................19 INDERAL LA

see propranolol hcl er ....17 INFANRIX .........................47 INFUMORPH 200 ...............4 INFUMORPH 500 ...............4 INLYTA .............................13 INSPRA

see eplerenone ............. 15 INSULIN PEN NEEDLES .. 32 INSULIN SAFETY NEEDLES ......................... 32 INSULIN SYRINGES ........ 32 INTELENCE ........................ 7 INTRALIPID INJ 20%........ 48 INTRALIPID INJ 30%........ 48 INTRON-A INJ 10MU........ 46 INTRON-A INJ 18MU........ 46 INTRON-A INJ 25MU........ 46 INTRON-A INJ 50MU........ 46 introvale 91 day ................ 36 INTUNIV

see guanfacine er (adhd) ...................................... 27

INVANZ ............................... 6 INVEGA ............................ 25

see paliperidone ............ 26 INVEGA SUST INJ 117 MG/0.75 ML ...................... 25 INVEGA SUST INJ 156MG/ML ........................ 25 INVEGA SUST INJ 234 MG/1.5 ML ........................ 25 INVEGA SUST INJ 39 MG/0.25 ML ...................... 25 INVEGA SUST INJ 78 MG/0.5 ML ........................ 25 INVEGA TRINZA .............. 25 INVIRASE ........................... 7 INVOKAMET TAB 150-1000 .......................................... 33 INVOKAMET TAB 150-500 .......................................... 33 INVOKAMET TAB 50-1000 .......................................... 33 INVOKAMET TAB 50-500MG ......................... 33 INVOKANA TAB 100MG ... 33 INVOKANA TAB 300MG ... 33 IONOSOL-B/DEXTROSE 5%..................................... 49 IONOSOL-MB/DEXTROSE 5%..................................... 49 IPOL INACTIVATED IPV .. 47 ipratropium bromide (nasal) .......................................... 51

ipratropium sol inhal .......... 51 ipratropium-albuterol ......... 51 irbesartan .......................... 16 irbesartan-hydrochlorothiazide........................................ 15 IRESSA ............................ 13 irinotecan inj 100/5ml ........ 14 irinotecan inj 40mg/2ml ..... 14 irinotecan inj 500mg/25ml . 14 ISENTRESS ....................... 7 ISOLYTE P ....................... 49 ISOLYTE S ....................... 49 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISORDIL TITRADOSE ...... 19

see isosorbide dinitrate . 19 isosorbide dinitrate............ 19 isosorbide dinitrate er ....... 19 isosorbide mononitrate ..... 19 isosorbide mononitrate er . 19 isradipine .......................... 18 ISTALOL ........................... 51 ISTODAX .......................... 13 itraconazole ........................ 7 ivermectin ........................... 6 IXEMPRA KIT ................... 14 IXIARO ............................. 47 J JADENU ........................... 35 JAKAFI ............................. 13 JALYN .............................. 44

see dutasteride-tamsulosin hcl ................................. 44

jantoven ............................ 45 JANUMET ......................... 33 JANUMET XR TAB 100-1000 .......................... 34 JANUMET XR TAB 50-1000.......................................... 34 JANUMET XR TAB 50-500MG ......................... 34 JANUVIA .......................... 34 JARDIANCE ..................... 34 JENTADUETO .................. 34 JEVTANA ......................... 12 jinteli ................................. 38 JOLESSA TAB 0.15-0.03 MG .................................... 36


74

JOLIVETTE .......................36 juleber 28 day ...................36 junel 1.5/30 21 day ............36 junel 1/20 21 day ...............36 junel fe 1.5/30 28 day ........36 junel fe 1/20 28 day ...........36 junel fe 24 1/20 28 day ......36 JUXTAPID.........................17 K KADCYLA .........................13 KADIAN...............................4

see morphine sulfate .......4 kaitlib fe 28 day .................36 KALBITOR ........................45 KALETRA SOL ...................8 KALETRA TAB 100-25MG ..8 KALETRA TAB 200-50MG ..8 KALYDECO ......................52 KANUMA...........................38 kariva 28 day .....................36 KAYEXALATE

see kionex .....................35 see sodium polystyrene sulfonate ........................35

KAZANO ...........................34 KCL 0.075%/D5W/NACL 0.45% ................................49 KCL 0.15%/D5W/LR .........49 KCL 0.15%/D5W/NACL 0.9% ..................................49 KCL 0.3%/D5W/LR IV LAC RI ......................................49 KCL 0.3%/D5W/NACL 0.45% ................................49 KCL 0.3%/D5W/NACL 0.9% ..........................................49 KCL IN NACL INJ .15-0.45 ..........................................49 KCL/D5W/NACL INJ .15/.33% ............................49 KCL/D5W/NACL INJ .15/.45% ............................49 KCL/D5W/NACL INJ 0.22%/0.45% .....................49 KCL/NACL INJ 0.15%-0.9% ..........................................49 KCL0.15%/D5W/NACL0.2% ..........................................49

KCL0.15%/D5W/NACL0.225%....................................... 49 KEFLEX

see cephalexin ................ 9 kelnor 1/35 28 day ............ 36 KENALOG

see triamcinolone acetonide (topical) ......... 56

KEPIVANCE ..................... 14 KEPPRA

see levetiracetam .......... 21 see levetiracetam oral soln 100 mg/ml ..................... 21

KEPPRA XR see levetiracetam .......... 21

KERLONE see betaxolol hcl............ 17

ketoconazole ....................... 7 ketoconazole (topical) ....... 54 ketoconazole shampoo ..... 55 ketodan aer 2% ................. 54 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 50 KEYTRUDA ...................... 13 kimidess 28 day ................ 36 KINERET .......................... 46 KINRIX .............................. 47 kionex ............................... 35 KLARON

see sulfacetamide sodium (acne) ............................ 54

KLONOPIN see clonazepam ...... 20, 21

KLOR-CON 10 .................. 47 KLOR-CON 8 .................... 47 klor-con m10 ..................... 47 klor-con m15 ..................... 47 klor-con m20 ..................... 47 klor-con pow 20meq.......... 47 klor-con spr cap 10meq .... 47 klor-con spr cap 8meq ...... 47 KOMBIGLYZE XR 2.5-1000MG ...................... 34 KOMBIGLYZE XR 5-1000MG ......................... 34 KOMBIGLYZE XR 5-500MG .......................................... 34

KORLYM .......................... 39 kristalose .......................... 42 KUVAN ............................. 38 KYNAMRO ....................... 17 L labetalol hcl ....................... 17 LAC-HYDRIN

see ammonium lactate .. 56 LACRISERT ..................... 51 LACTATED RINGERS VIAFLEX ........................... 49 lactulose ........................... 42 lactulose (encephalopathy).......................................... 42 LAMICTAL

see lamotrigine .............. 21 LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 21 LAMICTAL ODT................ 21

see lamotrigine .............. 21 LAMICTAL STARTER ...... 21 LAMICTAL XR .................. 21

see lamotrigine .............. 21 LAMISIL .............................. 7

see terbinafine hcl ........... 7 lamivudine .......................... 7 lamivudine (hbv) ................. 8 lamivudine-zidovudine ........ 8 lamotrigine ........................ 21 LANOXIN .................... 18, 19

see digitek ..................... 18 see digox ....................... 18 see digoxin .................... 18 see digoxin inj ............... 18

LANOXIN PEDIATRIC ...... 19 lansoprazole ..................... 43 LANTUS ........................... 32 LANTUS SOLOSTAR ....... 32 larin 1.5/30 ........................ 36 larin 1/20 ........................... 36 larin fe 1.5/30 .................... 36 larin fe 1/20 ....................... 36 LASIX

see furosemide.............. 19 LASTACAFT ..................... 50 latanoprost ........................ 51 LATUDA ........................... 25


75

LAYOLIS FE CHW ............36 LAZANDA ...........................4 LEENA TAB ......................36 leflunomide........................46 LEMTRADA ......................30 LENVIMA 10MG DAILY DOSE ................................13 LENVIMA 14MG DAILY DOSE ................................13 LENVIMA 20MG DAILY DOSE ................................14 LENVIMA 24MG DAILY DOSE ................................14 LESCOL

see fluvastatin sodium cap 20 mg ............................16

LESCOL XL ......................16 see fluvastatin sodium tab sr 24 hr 80 mg ...............16

lessina 28 day ...................36 LETAIRIS ..........................20 letrozole ............................13 leucovorin calcium ............14 leucovorin calcium inj 100mg ..........................................14 leucovorin calcium inj 200mg ..........................................14 leucovorin calcium inj 350mg ..........................................14 leucovorin calcium inj 500mg ..........................................14 leucovorin calcium inj 50mg ..........................................14 LEUKERAN .......................12 LEUKINE...........................45 leuprolide acetate ..............13 levalbuterol conc 1.25mg/0.5ml ....................52 levalbuterol hcl ..................52 LEVALBUTEROL HCL ......52 LEVAQUIN

see levofloxacin .............10 LEVEMIR ..........................32 LEVEMIR FLEXTOUCH....32 levetiracetam .....................21 LEVETIRACETAM IV ........21 levetiracetam oral soln 100 mg/ml ................................21

levobunolol hcl .................. 51 levocarnitine (metabolic modifiers) .......................... 38 levocetirizine soln 2.5mg/5ml .......................................... 52 levocetirizine tab 5 mg ...... 52 levofloxacin ....................... 10 levofloxacin (ophth) ........... 50 levofloxacin in d5w ............ 10 levoleucovorin calcium ...... 14 levonest 28 day ................. 36 levonor/ethi tab ................. 36 levonorgestrel & eth estradiol .......................................... 36 levonorgestrel (emergency oc) ..................................... 36 levonorgestrel-ethinyl estradiol (91-day) .............. 36 levonorgestrel-ethinyl estradiol (continuous)........ 37 levora 0.15/30 28 day ....... 37 levorphanol tartrate ............. 4 levothyroxine sodium ........ 40 LEVOXYL ......................... 40 LEXAPRO

see escitalopram oxalate ...................................... 23

LEXIVA ........................... 7, 8 LIALDA ............................. 42 lidocaine ............................ 56 lidocaine hcl ...................... 56 lidocaine hcl (local anesth.) . 5 lidocaine hcl (mouth-throat) .......................................... 57 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5% ................ 5 lidocaine inj 2% ................... 5 lidocaine-prilocaine ........... 56 LIDODERM

see lidocaine ................. 56 linezolid ............................... 6 LINEZOLID ......................... 6 LINEZOLID IN SODIUM CHLORIDE ......................... 6 LINZESS ........................... 43 liothyronine sodium ........... 40 LIPITOR

see atorvastatin calcium 16 LIPOSYN III ...................... 48 lisinopril ............................. 15 lisinopril & hydrochlorothiazide........... 15 lithium carbonate ........ 29, 30 LITHIUM SOLN 8MEQ/5ML.......................................... 30 LITHOBID

see lithium carbonate .... 29 LIVALO ............................. 16 LO LOESTRIN FE ............ 37 LOCOID ............................ 56

see hydrocortisone butyrate ......................... 56

LOCOID LIPOCREAM see hydrocortisone butyrate hydrophilic lipo base .............................. 56

LODOSYN see carbidopa................ 24

LOESTRIN 1.5/30-21 see gildess 1.5/30 21 day ...................................... 36 see junel 1.5/30 21 day . 36 see larin 1.5/30.............. 36

LOESTRIN 1/20-21 see junel 1/20 21 day .... 36 see larin 1/20................. 36

LOESTRIN FE 1.5/30 see blisovi 21 fe 1.5/30 28 day pack ........................ 36 see junel fe 1.5/30 28 day ...................................... 36 see larin fe 1.5/30 .......... 36

LOESTRIN FE 1/20 see blisovi 21 fe 1/20 28 day pack ........................ 36 see junel fe 1/20 28 day 36 see larin fe 1/20............. 36 see tarina fe 1/20 28 day ...................................... 37

LOFIBRA see fenofibrate .............. 17 see fenofibrate micronized ...................................... 17

lokara ................................ 56 lomedia 24 fe .................... 37


76

LOMOTIL see diphenoxylate w/ atropine .........................43

LONSURF .........................14 loperamide hcl ...................43 LOPID

see gemfibrozil ..............17 LOPRESSOR

see metoprolol tartrate...17 LOPRESSOR HCT

see metoprolol & hctz tab 100-25mg ......................17 see metoprolol & hctz tab 50-25mg ........................17

LOPROX SHAMPOO see ciclopirox shampoo 1% .................................54

lorazepam .........................20 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 ....................37 losartan potassium ............16 losartan-hydrochlorothiazide ..........................................15 LOTEMAX .........................50 LOTENSIN

see benazepril hcl .........15 LOTENSIN HCT

see benazepril & hydrochlorothiazide .......14

LOTREL see amlodipine besylate-benazepril hcl ..14

LOTRONEX see alosetron hcl ...........43

lovastatin ...........................16 LOVAZA

see omega-3-acid ethyl esters.............................17

LOVENOX see enoxaparin sodium .44

low-ogestrel.......................37 loxapine succinate ............25 LUCENTIS ........................51

LUMIGAN ......................... 51 LUMIZYME ....................... 38 LUPANETA PACK ............ 38 LUPRON DEP INJ 11.25MG .......................................... 13 LUPRON DEPOT.............. 13 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 13 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 13 LUPRON DEP-PED INJ 11.25MG ........................... 13 LUPRON DEP-PED INJ 15MG ................................ 13 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 13 LUPRON DEP-PED INJ 7.5MG ............................... 13 lutera 28 day ..................... 37 LUXIQ

see betamethasone valerate ......................... 55

LUZU ................................ 54 LYNPARZA ....................... 13 LYRICA ............................. 22 LYSODREN ...................... 13 LYSTEDA

see tranexamic acid ...... 45 lyza ................................... 37 M MACROBID

see nitrofurantoin monohyd macro............... 6

MACRODANTIN ................. 6 see nitrofurantoin macrocrystal .................... 6

magnesium sulfate ............ 47 MAGNESIUM SULFATE ... 47 MAGNESIUM SULFATE IN D5W .................................. 47 MAGNESIUM SULFATE INJ 50%................................... 47 MALARONE

see atovaquone-proguanil hcl tab 250-100 mg.......... 7 see atovaquone-proguanil hcl tab 62.5-25 mg........... 7

malathion .......................... 57

maprotiline hcl................... 23 MARINOL

see dronabinol............... 41 marlissa 28 day................. 37 MARPLAN ........................ 23 MATULANE ...................... 14 matzim la .......................... 18 MAVIK

see trandolapril.............. 15 MAXALT

see rizatriptan benzoate 29 MAXALT-MLT

see rizatriptan benzoate 29 MAXIDEX ......................... 50 MAXIPIME ........................ 10

see cefepime inj 1gm ...... 9 see cefepime inj 2gm ...... 9

MAXITROL see neomycin-polymy-dexameth .................................... 49

MAXZIDE see triamt/hctz tab 75-50mg ........................ 19

MAXZIDE-25 see triamt/hctz tab 37.5-25 ...................................... 19

meclizine hcl ..................... 41 MEDROL

see methylpred tab 16mg ...................................... 39 see methylpred tab 32mg ...................................... 39 see methylpred tab 4mg 39 see methylpred tab 8mg 39

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 39

MEDROL TAB 2MG .......... 39 medroxyprogesterone acetate .............................. 40 medroxyprogesterone acetate (contraceptive) ..... 37 mefenamic acid................... 1 mefloquine hcl..................... 7 MEGACE ES .................... 13 MEGACE ORAL

see megestrol ac sus


77

40mg/ml.........................13 megestrol ac sus 40mg/ml 13 megestrol ac tab 20mg .....13 megestrol ac tab 40mg .....13 MEGESTROL SUS 625MG/5ML ......................13 MEKINIST .........................14 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl ....................12 memantine hcl ...................23 MENACTRA ......................47 MENOMUNE-A/C/Y/W-135 ..........................................47 MENOSTAR ......................38 MENTAX ...........................54 MENVEO ..........................47 MEPRON

see atovaquone ...............6 mercaptopurine .................12 meropenem .........................6 MEROPENEM/SODIUM CHLORIDE .........................6 MERREM

see meropenem ..............6 mesalamine enema ...........42 mesna ...............................14 MESNEX ...........................14

see mesna .....................14 MESTINON

see pyridostigmine bromide .........................30

MESTINON SYRUP ..........30 MESTINON TIMESPAN ....30

see pyridostigmine bromide .........................30

METADATE CD see methylphenidate hcl 28

metadate er tab 20mg .......27 metformin er ......................34 metformin hcl ....................34 metformin hcl osmotic 1000mg .............................34 metformin hcl osmotic 500mg ...............................34 methadone hcl ....................4 METHADONE INJ 10MG/ML ............................................4

METHADOSE see methadone hcl .......... 4

methazolamide ................. 19 methenamine hippurate ...... 6 METHERGINE

see methylergonovine maleate ......................... 40

methimazole ..................... 40 methotrexate sodium ........ 12 METHOTREXATE SODIUM .......................................... 12 methotrexate sodium inj .... 12 methotrexate sodium tabs . 46 methoxsalen rapid ............ 55 methscopolamine bromide 42 methyclothiazide ............... 19 methylergonovine maleate 40 METHYLIN

see methylphenidate hcl 28 methylphenidate hcl .......... 28 METHYLPHENIDATE HCL .......................................... 28 methylphenidate hcl er ...... 28 methylpr ace inj 40mg/ml .. 39 methylpr ace inj 80mg/ml .. 39 methylpr ss inj 125mg ....... 39 methylpr ss inj 1gm ........... 39 methylpr ss inj 40mg ......... 39 methylpred pak 4mg ......... 39 methylpred tab 16mg ........ 39 methylpred tab 32mg ........ 39 methylpred tab 4mg .......... 39 methylpred tab 8mg .......... 39 metipranolol ...................... 51 metoclopramide hcl ........... 41 metoclopramide hcl inj 5 mg/ml ................................ 41 metoclopramide odt .......... 41 metolazone ....................... 19 metoprolol & hctz tab 100-25mg .......................... 17 metoprolol & hctz tab 100-50mg .......................... 17 metoprolol & hctz tab 50-25mg ............................ 17 metoprolol succinate ......... 17 metoprolol tartrate ............. 17 METOZOLV ODT

see metoclopramide hcl 41 METRO IV .......................... 6 METROCREAM

see metronidazole (topical) ......................... 57 see rosadan cre 0.75% . 57

METROGEL see metronidazole (topical) ......................... 57

METROGEL-VAGINAL see metronidazole vaginal ...................................... 44

METROLOTION see metronidazole (topical) ......................... 57

metronidazole ..................... 6 metronidazole (topical) ..... 57 metronidazole inj................. 6 metronidazole vaginal ....... 44 MEVACOR

see lovastatin ................ 16 mexiletine hcl .................... 16 MIACALCIN

see calcitonin (salmon) nasal spray .................... 40

MIACALCIN INJ 200U/ML 40 MICARDIS

see telmisartan .............. 16 MICARDIS HCT

see telmisartan-hydrochlorothiazide ............................. 15

miconazole 3 sup 200mg .. 44 MICROGESTIN 1.5/30 ..... 37 MICROGESTIN 1/20 ........ 37 MICROGESTIN FE 1.5/30 37 MICROGESTIN FE 1/20 ... 37 MICRO-K

see klor-con spr cap 10meq ........................... 47 see klor-con spr cap 8meq ...................................... 47 see potassium chloride caps er .......................... 48

MICROZIDE see hydrochlorothiazide 19

midodrine hcl .................... 19 migergot ............................ 29


78

millipred.............................39 millipred dp........................39 MINASTRIN 24 FE ............37 MINIPRESS

see prazosin hcl ............15 minitran .............................20 MINIVELLE .......................38 MINOCIN

see minocycline hcl .......11 minocycline hcl ..................11 minoxidil ............................19 MIRAPEX ..........................24

see pramipexole dihydrochloride ..............24

MIRAPEX ER ....................24 see pramipexole dihydrochloride ..............24

MIRCERA .........................45 MIRCETTE

see bekyree 28 day .......35 see desogestrel-ethinyl estradiol (biphasic) ........36 see kariva 28 day ..........36 see kimidess 28 day ......36 see pimtrea pack ...........37 see viorele .....................38

mirtazapine .......................23 misoprostol........................43 mitomycin ..........................12 mitoxantrone hcl ................14 M-M-R II ............................47 MOBIC

see meloxicam tabs .........1 modafinil............................31 moderiba pak ......................9 MODERIBA PAK .................9 moderiba tab 200mg ...........9 moexipril hcl ......................15 moexipril-hydrochlorothiazide ........................................15 molindone hcl ....................25 mometasone furoate .........56 MONODOX

see doxycycline (monohydrate) ...............11

mono-linyah tab 0.25-35 ...37 MONONESSA ...................37 montelukast sodium ..........52

MORPHINE SUL 20MG/ML ORAL SOL .......................... 4 MORPHINE SUL INJ 10MG/ML ............................ 4 MORPHINE SUL INJ 15MG/ML ............................ 4 MORPHINE SUL INJ 1MG/ML .............................. 4 MORPHINE SUL INJ 4MG/ML .............................. 4 morphine sulfate ................. 4 MORPHINE SULFATE ....... 4 morphine sulfate beads....... 4 morphine sulfate ext-rel tab 4 MOVANTIK ....................... 43 MOVIPREP ....................... 42 MOXEZA ........................... 50 moxifloxacin hcl ................ 10 MOXIFLOXACIN HCL....... 10 MOZOBIL .......................... 45 MS CONTIN

see morphine sulfate ext-rel tab ........................ 4

MULTAQ ........................... 16 mupirocin .......................... 54 mupirocin calcium (topical)54 MUSTARGEN ................... 12 MYALEPT ......................... 40 MYAMBUTOL

see ethambutol hcl .......... 8 MYCAMINE ........................ 7 MYCOBUTIN

see rifabutin ..................... 8 mycophenolate mofetil ...... 46 mycophenolate sodium ..... 46 MYFORTIC

see mycophenolate sodium ........................... 46

myorisan ........................... 54 MYOZYME ........................ 38 MYRBETRIQ .................... 44 MYSOLINE

see primidone ................ 22 myzilra .............................. 37 N nabumetone ........................ 1 nadolol .............................. 17 nadolol &

bendroflumethiazide ......... 17 nafcillin sodium ................. 11 naftifine hcl ....................... 54 NAFTIFINE HCL ............... 54 NAFTIN ............................. 54

see naftifine hcl ............. 54 NAGLAZYME.................... 38 nalbuphine hcl..................... 2 NALLPEN ISO-OSMOTIC IN DE ..................................... 11 NALLPEN/DEXTROSE ..... 11 naloxone hcl ..................... 31 naltrexone hcl ................... 31 NAMENDA

see memantine hcl ........ 23 NAMENDA SOL 10MG/5ML.......................................... 23 NAMENDA TAB ................ 23 NAMENDA XR .................. 23 NAMENDA XR TITRATION PACK ................................ 23 NAMZARIC ....................... 23 naphazoline 0.1% ............. 51 NAPRELAN ........................ 1

see naproxen sodium ...... 1 NAPROSYN

see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 NAPROXEN SODIUM ........ 1 naratriptan hcl ................... 29 NARDIL

see phenelzine sulfate .. 24 NASONEX ........................ 52 NATACYN ........................ 50 nateglinide ........................ 34 NATPARA ......................... 40 NAVELBINE

see vinorelbine tartrate .. 12 NEBUPENT ........................ 6 necon 0.5/35 28 day ......... 37 necon 1/35 28 day ............ 37 necon 10/11 28 day .......... 37 NECON 7/7/7 .................... 37 NECON TAB 1/50-28 ........ 37 nefazodone hcl ................. 23 neomycin sulfate ................. 6 neomycin/polymyxin b gu . 57


79

neomycin-bacitracin zn-polymyxin .....................50 neomycin-polymy-dexameth ..........................................49 neomycin-polymyxin-gramicidin .....................................50 neomycin-polymyxin-hc (ophth)...............................49 neomycin-polymyxin-hc (otic) ..........................................57 NEORAL ...........................46

see cyclosporine modified (for microemulsion) ........46 see gengraf ...................46

NEOSPORIN see neomycin-polymyxin-gramicidin ...............................50

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu ..................................57

NEPHRAMINE ..................48 NEPTAZANE

see methazolamide .......19 NESINA.............................34 neuac gel 1.2-5% ..............54 NEULASTA .......................45 NEULASTA ONPRO KIT ..45 NEUMEGA ........................45 NEUPOGEN .....................45 NEUPRO...........................24 NEURONTIN

see gabapentin ..............21 nevirapine ...........................8 NEVIRAPINE ......................8 NEXAVAR .........................14 NEXIUM

see esomeprazole magnesium ....................43

NEXIUM CAP 20MG .........43 NEXIUM CAP 40MG .........43 NEXIUM GRA 10MG DR ..43 NEXIUM GRA 2.5MG DR .43 NEXIUM GRA 20MG DR ..43 NEXIUM GRA 40MG DR ..43 NEXIUM GRA 5MG DR ....43 NEXIUM I.V.

see esomeprazole sodium

inj................................... 43 niacin er (antihyperlipidemic) .......................................... 17 niacor ................................ 17 NIASPAN

see niacin er (antihyperlipidemic) ....... 17

nicardipine hcl ................... 18 NICOTROL INHALER ....... 31 NICOTROL NS ................. 31 nifedical ............................. 18 nifedipine .......................... 18 nifedipine er ...................... 18 nikki 28 day ....................... 37 NILANDRON ..................... 13 nimodipine ........................ 18 NINLARO .......................... 13 NIPENT ............................. 12 nisoldipine ......................... 18 nitro-bid ............................. 20 NITRO-DUR ...................... 20

see minitran ................... 20 nitrofurantoin ....................... 6 nitrofurantoin macrocrystal .. 6 nitrofurantoin monohyd macro .................................. 6 nitroglycerin ...................... 20 NITROGLYCERIN LINGUAL .......................................... 20 nitroglycerin patches ......... 20 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............ 20 NITROSTAT ..................... 20 nizatidine ........................... 42 NIZORAL

see ketoconazole shampoo ....................... 55

NORA-BE TAB ................. 37 NORCO

see hydrocodone-acetaminophen 5-325mg ..................... 3 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see hydrocodone-acetaminoph

en 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.......................................... 39 norethin acet & estrad-fe .. 37 norethindrone & ethinyl estradiol-fe ........................ 37 norethindrone (contraceptive) .................. 37 norethindrone acetate ....... 40 norethindrone acetate-ethinyl estradiol ............................ 38 norgest/ethi tab 0.25/35 .... 37 norgestimate-ethinyl estradiol (triphasic) ........... 37 NORINYL 1+35

see cyclafem 1/35 28 day ...................................... 36 see necon 1/35 28 day .. 37 see nortrel 1/35 21 day . 37 see nortrel 1/35 28 day . 37 see pirmella 1/35 28 day ...................................... 37

NORITATE ....................... 57 norlyroc 28 day ................. 37 NORMOSOL-M IN D5W ... 49 NORMOSOL-R ................. 49 NORPACE

see disopyramide phosphate ..................... 16

NORPACE CR .................. 16 NORPRAMIN

see desipramine hcl ...... 23 NOR-QD

see camila 28 day ......... 36 see deblitane 28 day ..... 36 see heather ................... 36 see norethindrone (contraceptive) .............. 37 see norlyroc 28 day ....... 37

nortrel 0.5/35 28 day ......... 37


80

nortrel 1/35 21 day ............37 nortrel 1/35 28 day ............37 nortrel 7/7/7 28 day ...........37 nortriptyline hcl ............ 23, 24 NORVASC

see amlodipine besylate 18 NORVIR ..............................8 NOVAREL INJ 10000UNT 40 NOVOLIN 70/30 ................32 NOVOLIN 70/30 RELION..32 NOVOLIN N ......................32 NOVOLIN N RELION ........33 NOVOLIN R ......................33 NOVOLIN R RELION ........33 NOVOLOG ........................33 NOVOLOG FLEXPEN ......33 NOVOLOG MIX 70/30 ......33 NOVOLOG MIX 70/30 PREFILL ...........................33 NOVOLOG PENFILL ........33 NOXAFIL.............................7 NPLATE ............................45 NUBAIN

see nalbuphine hcl ..........2 NUCALA ...........................52 NUCYNTA...........................4 NUCYNTA ER .....................4 NUEDEXTA ......................30 NULOJIX ...........................46 NULYTELY/FLAVOR PACKS ..............................42

see gavilyte-n ................42 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ......................................42 see trilyte .......................43

NUTRILIPID INJ 20% .......48 NUTROPIN AQ INJ 20MG/2ML ........................39 NUTROPIN AQ NUSPIN 10 ..........................................39 NUTROPIN AQ NUSPIN 20 ..........................................39 NUTROPIN AQ NUSPIN 539 NUTROPIN AQ PEN .........39 NUVARING .......................37 NUVESSA .........................44

NUVIGIL ........................... 31 nyamyc ............................. 54 NYMALIZE ........................ 18 nystatin ............................... 7 nystatin (mouth-throat) ...... 57 nystatin (topical) ................ 54 nystatin pow 100000 ......... 54 nystop ............................... 54 O OCELLA TAB 3-0.03MG ... 37 OCTAGAM ........................ 46 octreotide acetate ............. 40 OCUFEN

see flurbiprofen sodium . 50 OCUFLOX

see ofloxacin (ophth) ..... 50 ODOMZO .......................... 14 OFEV ................................ 52 ofloxacin (ophth) ............... 50 ofloxacin (otic) ................... 58 ogestrel 28 day ................. 37 olanzapine ........................ 26 olanzapine odt .................. 26 olopatadine hcl .................. 50 olopatadine hcl (nasal) ...... 52 OLUX

see clobetasol propionate ...................................... 55

OLUX-E see clobetasol propionate emulsion ........................ 55

OMECLAMOX-PAK .......... 43 omega-3-acid ethyl esters . 17 omeprazole ....................... 43 OMEPRAZOLE-SODIUM BICARBONATE ................ 43 OMNARIS ......................... 52 OMNITROPE 10MG ......... 40 OMNITROPE 5.8MG ........ 39 OMNITROPE 5MG ........... 39 ONCASPAR ...................... 14 ondansetron hcl ................ 41 ondansetron hcl inj ............ 41 ondansetron hcl oral soln .. 41 ondansetron odt ................ 41 ONEXTON ........................ 54 ONFI ................................. 22 ONGLYZA ......................... 34

ONMEL ............................... 7 OPANA

see oxymorphone hcl ...... 5 OPANA ER (CRUSH RESISTANT ....................... 4 OPDIVO ............................ 13 OPSUMIT ......................... 20 ORACEA .......................... 57 ORAP ............................... 26

see pimozide ................. 26 ORAPRED ODT

see prednisolone sodium phosphate ..................... 39

ORAVIG ............................ 57 ORENCIA ......................... 46 ORENITRAM TAB 0.125MG.......................................... 20 ORENITRAM TAB 0.25MG.......................................... 20 ORENITRAM TAB 1MG ... 20 ORENITRAM TAB 2.5MG 20 ORFADIN ......................... 38 ORKAMBI ......................... 52 orsythia 28 day ................. 37 ORTHO MICRONOR

see errin 28 day ............ 36 see lyza ......................... 37 see sharobel 28 day ...... 37

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 37 see tri-previfem 28 day .. 38 see tri-sprintec 28 day ... 38

ORTHO TRI-CYCLEN LO 37 see norgestimate-ethinyl estradiol (triphasic) ........ 37 see tri-lo- estarylla 28 day ...................................... 37 see tri-lo- tab marzia ..... 37 see tri-lo-sprintec 28 day ...................................... 38

ORTHO-CYCLEN see estarylla tab 0.25-35 ...................................... 36 see mono-linyah tab 0.25-35 .......................... 37 see norgest/ethi tab 0.25/35 .......................... 37


81

see previfem 28 day ......37 see sprintec 28 day .......37

ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ......................................36 see nortrel 7/7/7 28 day .37

OSENI TAB 12.5-15MG ....34 OSENI TAB 12.5-30MG ....34 OSENI TAB 12.5-45MG ....34 OSENI TAB 25-15MG .......34 OSENI TAB 25-30MG .......34 OSENI TAB 25-45MG .......34 OSMOPREP .....................42 OTEZLA ............................46 OTREXUP.........................46 OVCON-35

see balziva 28 day .........35 see briellyn 28 day ........36 see gildagia ...................36 see philith ......................37 see vyfemla 28 day .......38 see zenchent tab ...........38

OVIDE see malathion ................57

oxacillin sodium .................11 oxaliplatin ..........................14 OXANDRIN

see oxandrolone ............32 oxandrolone ......................32 oxaprozin ............................1 oxcarbazepine ...................22 oxiconazole nitrate cream .54 OXISTAT...........................54

see oxiconazole nitrate cream ............................54

OXSORALEN ULTRA see methoxsalen rapid ..55

OXTELLAR XR .................22 oxybutynin chloride ...........44 oxycodone hcl ................. 4, 5 OXYCODONE HCL ............4 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 oxycodone-ibuprofen .......... 5 OXYCONTIN ...................... 5 oxymorphone hcl ................ 5 OXYTROL ......................... 44 P pacerone ........................... 16 paclitaxel ........................... 12 paliperidone ...................... 26 PAMELOR

see nortriptyline hcl ....... 23 pamidronate disodium....... 35 PAMINE

see methscopolamine bromide ......................... 42

PAMINE FORTE see methscopolamine bromide ......................... 42

PANCREAZE .................... 43 PANDEL ........................... 56 PANRETIN ........................ 57 pantoprazole sodium......... 43 paricalcitol ......................... 49 PARICALCITOL ................ 49 PARLODEL

see bromocriptine mesylate ........................ 24

PARNATE see tranylcypromine sulfate ............................ 24

paroex sol 0.12% .............. 57 paromomycin sulfate ........... 6 paroxetine er tab ............... 24 paroxetine hcl tabs ............ 24 paser d/r .............................. 8 PATADAY ......................... 50 PATANASE

see olopatadine hcl (nasal) ...................................... 52

PATANOL ......................... 50 see olopatadine hcl ....... 50

PAXIL................................ 24 see paroxetine hcl tabs . 24

PAXIL CR see paroxetine er tab..... 24

PAZEO .............................. 50 PCE .................................. 10

PEDIAPRED see pred sod pho sol 5mg/5ml ........................ 39

PEDIARIX ......................... 47 PEDVAX HIB .................... 47 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE.......................................... 42 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 42 PEGANONE ..................... 22 PEGASYS .......................... 9 PEGASYS PROCLICK ....... 9 PEGINTRON ...................... 9 PEG-INTRON ..................... 9 PEG-INTRON REDIPEN .... 9 PENICILLIN G POT IN DEXTROSE ...................... 11 PENICILLIN G POTASSIUM IN ...................................... 11 penicillin g procaine .......... 11 penicillin g sodium ............ 11 penicillin v potassium ........ 11 penicilln gk inj 20mu ......... 11 penicilln gk inj 5mu ........... 11 PENNSAID ....................... 57 PENTACEL ....................... 47 PENTAM 300 ...................... 6 PENTASA ......................... 42 pentoxifylline ..................... 45 PEPCID

see famotidine ............... 42 PERCOCET

see endocet..................... 2 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 .. 5


82

PERCODAN see oxycodone-aspirin.....5

PERFOROMIST ................52 PERIDEX

see chlorhexidine gluconate (mouth-throat) ......................................57 see paroex sol 0.12% ....57 see periogard soln 0.12% ......................................57

perindopril erbumine .........15 periogard soln 0.12% ........57 PERJETA ..........................13 permethrin .........................57 perphenazine ....................26 PERTZYE .........................43 PEXEVA............................24 pfizerpen g inj 5mu ............11 pfizerpen-g inj 20mu .........11 phenadoz ..........................41 phenelzine sulfate .............24 phenergan .........................41 PHENERGAN

see promethazine hcl ....41 phenobarbital ....................22 phenobarbital sodium ........22 PHENOBARBITAL SODIUM ..........................................22 phenoxybenzamine hcl .....19 phenytek ...........................22 PHENYTEK

see phenytoin sodium extended........................22

phenytoin ..........................22 phenytoin inj 50mg/ml .......22 phenytoin sodium extended ..........................................22 philith ................................37 PHOSLO

see calcium acetate (phosphate binder) ........40

PHOSLYRA ......................40 PHOSPHOLINE IODIDE ...51 PICATO.............................57 PILOCARPINE HCL ..........51 pilocarpine hcl (oral) ..........57 PILOCARPINE HCL (ORAL) ..........................................57

pimozide ........................... 26 pimtrea pack ..................... 37 pindolol ............................. 17 pioglitazone hcl ................. 34 pioglitazone hcl-glimepiride .......................................... 34 pioglitazone hcl-metformin hcl ..................................... 34 piperacillin sodium-tazobactam sodium .......................................... 11 pirmella 1/35 28 day.......... 37 piroxicam ............................ 1 PLAN B ONE-STEP

see levonorgestrel (emergency oc) ............. 36

PLAQUENIL see hydroxychloroquine sulfate ............................ 46

PLASMA-LYTE A .............. 49 PLASMA-LYTE-148 .......... 49 PLASMA-LYTE-56/D5W ... 49 PLAVIX

see clopidogrel bisulfate 45 PLEGRIDY ........................ 30 PLEGRIDY STARTER PACK ................................ 30 plenamine ......................... 48 podofilox ........................... 57 polyethylene glycol 3350... 42 polymyxin b sulfate ............. 6 polymyxin b-trimethoprim .. 50 POLYTRIM

see polymyxin b-trimethoprim ............... 50

POMALYST ...................... 14 PONSTEL

see mefenamic acid ........ 1 portia 28 day ..................... 37 PORTRAZZA .................... 13 pot chloride inj 2meq/ml .... 49 potassium chloride ............ 48 POTASSIUM CHLORIDE 48, 49 POTASSIUM CHLORIDE 0.3%/D .............................. 49 potassium chloride caps er .......................................... 48

potassium chloride in nacl 49 POTASSIUM CHLORIDE IN NACL ................................ 49 potassium chloride microencapsulated crystals cr....................................... 48 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 48 potassium citrate (alkalinizer).......................................... 44 POTASSIUM CITRATE (ALKALINIZER) ................ 44 POTIGA ............................ 22 PRADAXA ........................ 45 PRALUENT ...................... 17 pramipexole dihydrochloride.......................................... 24 PRANDIMET..................... 34 PRANDIN

see repaglinide ........ 34, 35 PRAVACHOL

see pravastatin sodium . 16 pravastatin sodium............ 16 prazosin hcl ...................... 15 PRECOSE

see acarbose................. 33 PRED MILD ...................... 50 pred sod pho sol 5mg/5ml 39 PRED-G ............................ 49 PRED-G S.O.P. ................ 49 prednicarbate .................... 56 PREDNICARBATE ........... 56 PREDNISOLONE ACETATE (OPHTH) ........................... 50 prednisolone sodium phosphate ......................... 39 prednisolone sodium phosphate (ophth)............. 50 prednisolone sol 15mg/5ml.......................................... 39 prednisolone sol 25mg/5ml.......................................... 39 prednisolone syrup 15 mg/5ml .............................. 39 prednisone con 5mg/ml .... 39 prednisone pak 10mg ....... 39 prednisone pak 5mg ......... 39 prednisone sol 5mg/5ml .... 39


83

prednisone tab 10mg ........39 prednisone tab 1mg ..........39 prednisone tab 2.5mg .......39 prednisone tab 20mg ........39 prednisone tab 50mg ........39 prednisone tab 5mg ..........39 PREGNYL W/DILUENT BENZYL ............................40 PREMARIN CREAM .........38 PREMARIN INJ .................39 premasol 10% ...................48 premasol 6% .....................48 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ..........................................49 PREPOPIK........................42 PREVACID

see lansoprazole ...........43 PREVACID SOLUTAB ......43 prevalite ............................17 previfem 28 day ................37 PREVPAC

see amoxicillin-clarithromycin w/ lansoprazole .............43

PREZCOBIX .......................8 PREZISTA ..........................8 PRIFTIN ..............................8 PRILOSEC

see omeprazole .............43 PRILOSEC PACK .............43 PRIMAQUINE PHOSPHATE ............................................7 PRIMAXIN IV

see imipenem-cilastatin ...6 primidone ..........................22 PRIMSOL SOL 50MG/5ML .6 PRINIVIL

see lisinopril ...................15 PRISTIQ............................24 PRIVIGEN .........................46 PROAIR HFA ....................52 PROAIR RESPICLICK ......52 probenecid ..........................1 PROCALAMINE ................48 PROCARDIA XL

see nifedical ..................18 see nifedipine er ............18

prochlorperazine inj 5 mg/ml .......................................... 41 prochlorperazine maleate . 41 prochlorperazine supp ...... 41 PROCRIT .......................... 45 procto-pak ......................... 54 proctosol hc 2.5 % ............ 54 proctozone hc ................... 55 PROCYSBI ....................... 38 progesterone micronized .. 40 PROGLYCEM SUS 50MG/ML .......................... 39 PROGRAF .................. 46, 47

see tacrolimus ............... 47 PROLASTIN-C .................. 52 PROLENSA ...................... 51 PROLEUKIN ..................... 13 PROLIA ............................. 40 PROMACTA ..................... 45 promethazine hcl .............. 41 promethegan ..................... 41 PROMETRIUM

see progesterone micronized ..................... 40

propafenone hcl ................ 16 propafenone hcl 12hr ........ 16 proparacaine hcl ............... 51 propranolol & hydrochlorothiazide ........... 17 propranolol hcl er .............. 17 propranolol inj 1mg/ml....... 17 propranolol sol .................. 18 propranolol tab .................. 18 propylthiouracil .................. 40 PROQUAD ........................ 47 PROSCAR

see finasteride ............... 44 PROSOL ........................... 48 PROTONIX ....................... 43

see pantoprazole sodium ...................................... 43

PROTOPIC see tacrolimus (topical) . 57

protriptyline hcl .................. 24 PROVENTIL HFA ............. 52 PROVERA

see medroxyprogesterone acetate .......................... 40

PROVIGIL see modafinil ................. 31

PROZAC see fluoxetine cap 10mg23 see fluoxetine cap 20mg23 see fluoxetine cap 40mg23

PROZAC WEEKLY see fluoxetine hcl .......... 23

PRUDOXIN CRE 5% ........ 55 psorcon ............................. 56 PULMICORT

see budesonide (inhalation) .................... 53

PULMICORT FLEXHALER.......................................... 53 PULMICORT INH SUSP 1MG/2ML .......................... 53 PULMOZYME ................... 52 PURIXAN .......................... 12 PYLERA ........................... 43 pyrazinamide ...................... 8 pyridostigmine bromide ..... 30 Q QNASL ............................. 53 QNASL CHILDRENS ........ 53 QUADRACEL ................... 47 QUALAQUIN

see quinine sulfate .......... 7 QUARTETTE .................... 37 quasense 91 day .............. 37 QUESTRAN

see cholestyramine ....... 17 QUESTRAN LIGHT

see prevalite .................. 17 quetiapine fumarate .......... 26 QUILLIVANT XR ............... 28 quinapril hcl ...................... 15 quinapril-hydrochlorothiazide.......................................... 15 quinidine gluconate ........... 16 quinidine sulfate ................ 16 quinine sulfate..................... 7 QVAR ............................... 53 R RABAVERT ...................... 47 rabeprazole sodium .......... 43 RAGWITEK ...................... 46 raloxifene hcl .................... 40


84

ramipril ..............................15 RANEXA ...........................19 ranitidine hcl ......................42 RAPAFLO .........................44 RAPAMUNE ......................47

see sirolimus .................47 RASUVO ...........................46 RAVICTI ............................38 RAYOS TAB 1MG .............39 RAYOS TAB 2MG .............39 RAYOS TAB 5MG .............39 RAZADYNE

see galantamine hydrobromide ................23

RAZADYNE ER see galantamine hydrobromide er ............23

REBETOL ...........................9 see ribasphere .................9 see ribavirin 200mg .........9

REBIF ...............................30 REBIF REBIDOSE ............30 REBIF REBIDOSE TITRATION .......................30 REBIF TITRATION PACK .30 RECLAST

see zoledronic inj 5/100ml ......................................35

reclipsen 28 day ................37 RECOMBIVAX HB ............47 RECTIV .............................57 REGLAN

see metoclopramide hcl.41 REGRANEX ......................57 RELENZA DISKHALER ......9 RELISTOR ........................42 RELPAX ............................29 REMERON

see mirtazapine .............23 REMERON SOLTAB

see mirtazapine .............23 REMICADE .......................46 REMODULIN ....................20 RENAGEL .........................40 RENVELA PAK .................40 RENVELA TAB 800MG.....40 repaglinide .................. 34, 35 repaglinide-metformin hcl ..35

REPREXAIN see hydrocodone-ibuprofen tab 5-200mg .......................... 3 see ibudone tab 5-200mg 3

reprexain tab 10-200mg ...... 5 REQUIP

see ropinirole hydrochloride ................. 24

REQUIP XL see ropinirole hydrochloride ................. 24

RESCRIPTOR .................... 8 RESTASIS ........................ 51 RESTORIL

see temazepam ............. 28 RETIN-A

see tretinoin ................... 54 RETIN-A MICRO PUMP ... 54 RETROVIR

see zidovudine ................ 8 RETROVIR IV INFUSION ... 8 REVATIO .......................... 20

see sildenafil citrate (pulmonary hypertension) ...................................... 20

REVIA see naltrexone hcl ......... 31

REVLIMID ......................... 46 REXULTI ........................... 26 REYATAZ ........................... 8 RHEUMATREX ................. 46 RHINOCORT AQUA

see budesonide (nasal) . 52 ribapak mis 600/day ............ 9 ribasphere ........................... 9 ribasphere ribapak 1000 ..... 9 ribasphere ribapak 1200 ..... 9 ribasphere ribapak 800 ....... 9 ribavirin 200mg ................... 9 rifabutin ............................... 8 RIFADIN

see rifampin ..................... 8 rifamate ............................... 8 rifampin ............................... 8 RIFATER ............................ 8 RILUTEK

see riluzole .................... 30

riluzole .............................. 30 rimantadine hydrochloride .. 9 RINGER'S ......................... 49 RIOMET ............................ 35 risedronate sodium ........... 35 RISEDRONATE SODIUM 35 RISPERDAL

see risperidone.............. 26 RISPERDAL INJ 12.5MG . 26 RISPERDAL INJ 25MG .... 26 RISPERDAL INJ 37.5MG . 26 RISPERDAL INJ 50MG .... 26 RISPERDAL M-TAB

see risperidone odt ........ 26 risperidone ........................ 26 risperidone odt .................. 26 RITALIN

see methylphenidate hcl 28 RITALIN LA ...................... 28

see methylphenidate hcl 28 RITUXAN .......................... 13 rivastigmine tartrate .......... 23 rivastigmine td patch 24hr 13.3 mg/24hr .................... 23 rivastigmine td patch 24hr 4.6 mg/24hr ...................... 23 rivastigmine td patch 24hr 9.5 mg/24hr ...................... 23 rizatriptan benzoate .......... 29 ROBINUL

see glycopyrrolate ......... 41 ROBINUL FORTE

see glycopyrrolate ......... 41 ROCALTROL

see calcitriol .................. 49 ROCEPHIN

see ceftriaxone sodium ... 9 ropinirole hydrochloride .... 24 rosadan cre 0.75%............ 57 ROTARIX .......................... 47 ROTATEQ ........................ 47 ROWASA

see mesalamine enema 42 roxicet soln ......................... 5 roxicet tab 5-325mg ............ 5 ROXICODONE

see oxycodone hcl .......... 5 ROZEREM ........................ 28


85

RUCONEST ......................45 RYTARY ...........................24 RYTHMOL

see propafenone hcl ......16 see propafenone hcl 12hr ......................................16

RYTHMOL SR see propafenone hcl ......16 see propafenone hcl 12hr ......................................16

S SABRIL .............................22 SAIZEN .............................40 SAIZEN CLICK.EASY .......40 SALAGEN

see pilocarpine hcl (oral) ......................................57

SAMSCA ...........................40 SANCUSO ........................41 SANDIMMUNE

see cyclosporine ............46 SANDIMMUNE SOLN .......47 SANDOSTATIN

see octreotide acetate ...40 SANDOSTATIN LAR DEPOT..............................40 SANTYL ............................57 SAPHRIS ..........................26 SARAFEM.........................31 SAVAYSA .........................45 SAVELLA ..........................30 SAVELLA TITRATION PACK ................................30 SEASONIQUE

see amethia 91 day .......35 see ashlyna 91 day .......35 see levonorgestrel-ethinyl estradiol (91-day) ..........36

SECTRAL see acebutolol hcl ..........17

SEEBRI NEOHALER ........51 selegiline hcl .....................24 selenium sulfide ................55 SELZENTRY .......................8 SEMPREX-D .....................51 SENSIPAR ........................35 SEREVENT DISKUS ........52 SEROQUEL

see quetiapine fumarate 26 SEROQUEL XR ................ 26 SEROSTIM ....................... 40 sertraline hcl ..................... 24 setlakin tab ........................ 37 SF-ROWASA .................... 42 sharobel 28 day ................ 37 SIGNIFOR ........................ 40 SIGNIFOR LAR ................ 40 sildenafil citrate (pulmonary hypertension) .................... 20 SILENOR .......................... 28 SILVER SULFADIAZINE .. 54 SIMBRINZA SUS 1-0.2% .. 51 SIMCOR ........................... 17 SIMPONI ........................... 46 SIMPONI ARIA ................. 46 SIMULECT ........................ 47 simvastatin ........................ 16 SINEMET

see carbidopa-levodopa 24 SINEMET CR

see carbidopa-levodopa 24 SINGULAIR

see montelukast sodium 52 sirolimus ............................ 47 SIROLIMUS ...................... 47 SIRTURO ............................ 8 SIVEXTRO .......................... 7 SKLICE ............................. 57 SODIUM CHLORIDE .. 48, 49 SODIUM CHLORIDE 0.45% VIA .................................... 49 SODIUM CHLORIDE 0.9% .......................................... 57 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 48 sodium phenylbutyrate ...... 38 sodium polystyrene sulfonate .......................................... 35 SOLARAZE

see diclofenac sodium (actinic keratoses) ......... 56

SOLIRIS ............................ 45 SOLODYN ........................ 11 SOLTAMOX ...................... 13 SOLU-CORTEF 1000MG . 39

SOLU-CORTEF 100MG ... 39 SOLU-CORTEF 250MG ... 39 SOLU-CORTEF 500MG ... 39 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 39 see methylpr ss inj 1gm 39 see methylpr ss inj 40mg ...................................... 39

SOLU-MEDROL INJ 2GM 39 SOMATULINE DEPOT ..... 40 SOMAVERT ..................... 40 SOOLANTRA.................... 57 SORIATANE

see acitretin ................... 55 SORILUX .......................... 55 sorine ................................ 16 sotalol hcl .......................... 16 sotalol hcl (afib/afl) ............ 16 SOTYLIZE ........................ 18 SOVALDI ............................ 9 SPIRIVA HANDIHALER ... 51 SPIRIVA RESPIMAT ........ 51 spironolactone .................. 15 spironolactone & hydrochlorothiazide........... 19 SPORANOX

see itraconazole .............. 7 SPORANOX SOL 10MG/ML............................................ 7 sprintec 28 day ................. 37 SPRITAM .......................... 22 SPRYCEL ......................... 14 sps susp 15gm/60ml ......... 35 sronyx 28 day ................... 37 SSD .................................. 54 STARLIX

see nateglinide .............. 34 stavudine ............................ 8 STELARA ......................... 55 STERILE WATER IRRIGATION ..................... 57 STIMATE .......................... 41 STIOLTO RESPIMAT ....... 51 STIVARGA ....................... 14 STRATTERA .................... 28 STRENSIQ ....................... 38 streptomycin sulfate ............ 6


86

STRIANT...........................32 STRIBILD ............................8 STRIVERDI RESPIMAT....52 STROMECTOL

see ivermectin .................6 SUBOXONE MIS 12-3MG 31 SUBOXONE MIS 2-0.5MG ..........................................31 SUBOXONE MIS 4-1MG ..31 SUBOXONE MIS 8-2MG ..31 SUBSYS .............................5 SUCLEAR .........................42 SUCRAID ..........................43 sucralfate ..........................43 SULAR

see nisoldipine ...............18 sulfacet sod oin 10% op ....50 sulfacetamide sodium (acne) ..........................................54 sulfacetamide sodium (ophth)...............................50 sulfacetamide sod-prednisolone ..............49 sulfadiazine .........................6 sulfamethoxazole-trimethop 7 sulfamethoxazole-trimethoprim inj ....................................7 SULFAMYLON ..................54 sulfasalazine dr .................42 sulfasalazine ir ..................42 sulindac ...............................1 SUMATRIPTAN INJ 4MG/0.5ML .......................29 sumatriptan inj 6mg/0.5ml .29 SUMATRIPTAN INJ 6MG/0.5ML .......................29 sumatriptan succinate .......29 SUMATRIPTAN SUCCINATE .....................29 SUMAVEL DOSEPRO ......29 suprax ...............................10 SUPRAX ...........................10

see cefixime ....................9 SUPREP BOWEL PREP...42 SURMONTIL .....................24

see trimipramine maleate ......................................24

SUSTIVA.............................8

SUTENT ........................... 14 syeda ................................ 37 SYLATRON KIT 200MCG . 14 SYLATRON KIT 300MCG . 14 SYLATRON KIT 600MCG . 14 SYLVANT ......................... 14 SYMBICORT .................... 53 SYMLINPEN 120 .............. 33 SYMLINPEN 60 ................ 33 SYNAGIS .......................... 47 SYNALAR

see fluocinolone acetonide ................................ 55, 56

SYNAREL ......................... 38 SYNERA ........................... 56 SYNERCID ......................... 7 SYNJARDY TAB 12.5-1000 .......................................... 35 SYNJARDY TAB 12.5-500 35 SYNJARDY TAB 5-1000MG .......................................... 35 SYNJARDY TAB 5-500MG .......................................... 35 SYNRIBO .......................... 14 SYNTHROID ..................... 40

see levothyroxine sodium ...................................... 40

SYPRINE .......................... 35 T TABLOID .......................... 12 TACLONEX ...................... 56

see calcipotriene/betamethasone .................................. 55

tacrolimus ......................... 47 tacrolimus (topical) ............ 57 TAFINLAR ........................ 14 TAGRISSO ....................... 14 TAMIFLU ............................ 9 tamoxifen citrate ............... 13 tamsulosin hcl ................... 44 TANZEUM ........................ 33 TAPAZOLE

see methimazole ........... 40 TARCEVA ......................... 14 TARGRETIN ............... 14, 57

see bexarotene ............. 14 tarina fe 1/20 28 day ......... 37

TARKA see trandolapril-verapamil hcl ................................. 15

TASIGNA .......................... 14 tazicef ............................... 10 tazicef vial ......................... 10 TAZORAC ........................ 55 taztia xt ............................. 18 TECFIDERA CAP 120MG 30 TECFIDERA CAP 240MG 30 TECFIDERA MIS STARTER.......................................... 30 TEFLARO ......................... 10 TEGRETOL ...................... 22

see carbamazepine ....... 20 see epitol ....................... 21

TEGRETOL-XR ................ 22 see carbamazepine ....... 20

TEKTURNA ...................... 19 TEKTURNA HCT .............. 19 telmisartan ........................ 16 telmisartan-amlodipine ...... 15 telmisartan-hydrochlorothiazide...................................... 15 temazepam ....................... 28 TEMOVATE

see clobetasol propionate ...................................... 55 see cormax.................... 55

TEMOVATE E see clobetasol e cream 0.05% ............................ 55

TENIVAC .......................... 47 TENORETIC 100

see atenolol & chlorthalidone ................ 17

TENORETIC 50 see atenolol & chlorthalidone ................ 17

TENORMIN see atenolol ................... 17

TERAZOL 3 see terconazole vaginal 44

TERAZOL 7 see terconazole vaginal 44 see zazole ..................... 44

terazosin hcl ..................... 15 terbinafine hcl ..................... 7


87

terbutaline sulfate ..............52 terconazole vaginal ...........44 TESTIM .............................32 TESTOSTERONE .............32 testosterone cypionate ......32 testosterone enanthate .....32 TETANUS/DIPHTHERIA TOXOID ............................47 tetrabenazine ....................30 TETRACYCLINE HCL.......11 TEVETEN HCT .................16 texacort .............................56 THALOMID .......................46 theo-24 ..............................53 theophylline .......................53 thioridazine hcl ..................27 thiotepa .............................12 thiothixene.........................27 THYMOGLOBULIN ...........47 tiagabine hcl ......................22 TIAZAC

see diltiazem hcl er ........18 see diltiazem hcl extended release beads ................18 see taztia xt ...................18

TIKOSYN ..........................16 timolol maleate ..................18 timolol maleate (ophth)......51 TIMOLOL MALEATE GEL 51 TIMOPTIC

see timolol maleate (ophth) ...........................51

TIMOPTIC OCUDOSE ......51 TIROSINT .........................40 TIVICAY ..............................8 tizanidine ...........................31 TOBI

see tobramycin ................6 TOBI PODHALER ...............6 TOBRADEX ......................50

see tobramycin-dexamethasone ....................................50

TOBRADEX ST .................50 tobramycin ..........................6 tobramycin (ophth) ............50 tobramycin sulfate ...............6 tobramycin-dexamethasone

.......................................... 50 TOBREX

see tobramycin (ophth) .. 50 TOBREX OINT 0.3% ........ 50 TOFRANIL

see imipramine hcl ........ 23 TOLAK .............................. 57 tolmetin sodium ................... 1 tolterodine tartrate er......... 44 tolterodine tartrate tab 1 mg .......................................... 44 tolterodine tartrate tab 2 mg .......................................... 44 TOPAMAX

see topiramate .............. 22 TOPAMAX SPRINKLE

see topiramate .............. 22 TOPICORT

see desoximetasone ..... 55 TOPICORT SPRAY 0.25% .......................................... 56 topiramate ......................... 22 TOPIRAMATE .................. 22 toposar .............................. 14 topotecan hcl .................... 14 TOPROL XL

see metoprolol succinate ...................................... 17

TORISEL .......................... 13 torsemide inj 50mg/5ml ..... 19 torsemide tabs .................. 19 TOUJEO SOLOSTAR ....... 33 TOVIAZ ............................. 44 TPN ELECTROLYTES ..... 48 TRACLEER ....................... 20 TRADJENTA ..................... 35 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 trandolapril ........................ 15

trandolapril-verapamil hcl .. 15 tranexamic acid................. 45 TRANSDERM-SCOP ........ 41 TRANXENE T

see clorazepate dipotassium ................... 21

tranylcypromine sulfate ..... 24 TRAVASOL ...................... 48 TRAVATAN Z ................... 51 trazodone hcl .................... 24 TREANDA ........................ 12 TRECATOR ........................ 8 TRELSTAR MIXJECT ....... 13 TRESIBA FLEXTOUCH .... 33 tretinoin ....................... 14, 54 TRETINOIN ...................... 54 TRETINOIN MICROSPHERE ............... 54 tretin-x ............................... 54 trexall ................................ 46 TREXIMET ....................... 29 trezix ................................... 2 triamcinolone acetonide (mouth) ............................. 57 TRIAMCINOLONE ACETONIDE (NASAL) ...... 53 triamcinolone acetonide (topical) ............................. 56 triamt/hctz cap 37.5-25 ..... 19 triamt/hctz cap 50-25mg ... 19 triamt/hctz tab 37.5-25 ...... 19 triamt/hctz tab 75-50mg .... 19 trianex ............................... 56 TRIBENZOR ..................... 16 TRICOR

see fenofibrate .............. 17 triderm .............................. 56 trifluoperazine hcl.............. 27 trifluridine .......................... 50 TRIGLIDE ......................... 17 tri-legest 28 day ................ 37 TRILEPTAL

see oxcarbazepine ........ 22 TRILIPIX

see choline fenofibrate .. 17 tri-lo- estarylla 28 day ....... 37 tri-lo- tab marzia ................ 37 tri-lo-sprintec 28 day ......... 38


88

trilyte .................................43 trimethoprim ........................7 trimipramine maleate ........24 TRINESSA ........................38 TRINESSA LO TAB ..........38 TRI-NORINYL 28

see aranelle 28 ..............35 TRIOSTAT

see liothyronine sodium .40 tri-previfem 28 day ............38 TRISENOX........................14 tri-sprintec 28 day .............38 TRIUMEQ ...........................8 trivora 28 day ....................38 TRIZIVIR

see abacavir sulfate-lamivudine-zidovudine ...................................8

TROKENDI XR .................22 TROPHAMINE INJ 10%....48 trospium chloride ...............44 trospium chloride er ..........44 TRULICITY .......................33 TRUMENBA ......................47 TRUSOPT

see dorzolamide hcl ......51 TRUVADA ...........................8 TUDORZA PRESSAIR......51 TUDORZA PRESSAIR (INSTITUTIONAL PACK) ..51 TWINRIX INJ ....................47 TWYNSTA

see telmisartan-amlodipine ......................................15

TYBOST..............................8 TYGACIL.............................7 TYKERB............................14 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................1

TYPHIM VI ........................47 TYSABRI...........................30 TYVASO ...........................20 TYZEKA ..............................9 tyzine ................................52

U UCERIS AER 2MG/ACT ... 42 UCERIS TAB 9MG............ 42 ULORIC .............................. 1 ULTRACET

see tramadol-acetaminophen . 2

ULTRAM see tramadol hcl tab 50 mg ................................... 2

ULTRAM ER see tramadol hcl er .......... 2

ULTRAVATE see halobetasol propionate ..................... 56

ULTRESA ......................... 43 UNASYN

see ampicillin & sulbactam sodium ........................... 10

UNASYN BULK PACK see ampicillin & sulbactam sodium ........................... 11

UNITHROID ...................... 40 UPTRAVI .......................... 20 URECHOLINE

see bethanechol chloride ...................................... 44

UROCIT-K 15 see potassium citrate (alkalinizer) .................... 44

UROXATRAL see alfuzosin hcl ............ 44

URSO 250 see ursodiol ................... 43

URSO FORTE see ursodiol ................... 43

ursodiol ............................. 43 UTIBRON NEOHALER ..... 51 UVADEX ........................... 14 V VAGIFEM .......................... 39 valacyclovir hcl .................... 9 VALCHLOR ...................... 57 VALCYTE ........................... 9

see valganciclovir hcl ...... 9 valganciclovir hcl ................. 9 VALIUM

see diazepam ................ 21

valproate sodium .............. 22 valproic acid ...................... 22 valsartan ........................... 16 valsartan-hydrochlorothiazide........................................ 16 VALSTAR ......................... 12 VALTREX

see valacyclovir hcl ......... 9 VANCOCIN HCL

see vancomycin hcl ......... 7 vancomycin hcl ................... 7 vancomycin hcl inj 1000mg . 7 vancomycin hcl inj 10gm ..... 7 vancomycin hcl inj 500mg ... 7 vancomycin hcl inj 5gm ....... 7 vancomycin hcl inj 750mg ... 7 VANDAZOLE .................... 44 VANOS

see fluocinonide ............ 56 VANTAS ........................... 13 VAQTA ............................. 47 VARIVAX .......................... 47 VARUBI ............................ 41 VASCEPA ......................... 17 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 15

VASOTEC see enalapril maleate .... 15

VECTIBIX ......................... 13 VELCADE ......................... 13 VELETRI ........................... 20 velivet 28 day .................... 38 VELPHORO ...................... 40 VELTASSA ....................... 35 VELTIN ............................. 54 venlafaxine cap er............. 24 venlafaxine hcl .................. 24 VENLAFAXINE HCL ER

see venlafaxine tab er ... 24 venlafaxine tab.................. 24 VENLAFAXINE TAB 225MG ER ..................................... 24 venlafaxine tab er ............. 24 VENTAVIS ........................ 20 VENTOLIN HFA................ 52 VERAMYST ...................... 53 verapamil hcl .................... 18


89

VERAPAMIL HCL .............18 VERELAN

see verapamil hcl ..........18 VERELAN PM

see verapamil hcl ..........18 veripred .............................39 VERSACLOZ ....................27 VESICARE ........................44 vestura ..............................38 VEXOL ..............................50 VFEND

see voriconazole .............7 VFEND IV

see voriconazole inj 200mg .............................7

VIBERZI ............................43 VIBRAMYCIN ....................11

see doxycycline (monohydrate) ...............11 see doxycycline hyclate .11

vicodin .................................5 vicodin es ............................5 vicodin hp ............................5 VICOPROFEN

see hydrocodone-ibuprofen tab 7.5-200 mg ......................3

VICTOZA ..........................33 VIDAZA

see azacitidine ...............12 VIDEX EC

see didanosine ................7 VIDEX PEDIATRIC .............8 vienva 28 day ....................38 VIGAMOX .........................50 VIIBRYD............................24 VIIBRYD STARTER PACK ..........................................24 VIMIZIM ............................38 VIMOVO..............................1 VIMPAT.............................22 vinblastine sulfate .............12 vincasar.............................12 vincristine sulfate ..............12 vinorelbine tartrate ............12 VIOKACE 10 .....................43 VIOKACE 20 .....................43 viorele ...............................38

VIRACEPT .......................... 8 VIRAMUNE

see nevirapine ................. 8 VIRAMUNE XR ................... 8

see nevirapine ................. 8 VIREAD .............................. 8 VIROPTIC

see trifluridine ................ 50 VISTIDE

see cidofovir .................... 8 VITEKTA ............................. 8 VIVELLE-DOT

see estradiol .................. 38 VIVITROL ......................... 31 VIVLODEX .......................... 1 VOGELXO ........................ 32 VOGELXO PUMP ............. 32 VOLTAREN GEL 1% ........ 57 voriconazole ........................ 7 voriconazole inj 200mg ....... 7 VOSPIRE ER

see albuterol sulfate er .. 52 VOTRIENT ........................ 14 VPRIV ............................... 38 VRAYLAR ......................... 27 vyfemla 28 day .................. 38 VYTORIN .......................... 17 VYVANSE ......................... 28 W warfarin sodium ................ 45 WELCHOL ........................ 17 WELLBUTRIN

see bupropion hcl .......... 23 WELLBUTRIN SR

see bupropion hcl .......... 23 WELLBUTRIN XL

see bupropion hcl .......... 23 WESTCORT

see hydrocortisone valerate ......................... 56

wymzya fe ......................... 38 X XALATAN

see latanoprost .............. 51 XALKORI .......................... 14 XANAX

see alprazolam .............. 20 XARELTO ......................... 45

XARELTO STARTER PACK.......................................... 45 XARTEMIS XR ................... 5 XELJANZ .......................... 46 XELJANZ XR .................... 46 XENAZINE ........................ 30

see tetrabenazine .......... 30 XEOMIN 100UNIT ............ 31 XEOMIN 200UNIT ............ 31 XEOMIN 50UNIT .............. 31 XERESE ........................... 57 XGEVA ............................. 40 XIFAXAN TAB 200MG ........ 7 XIFAXAN TAB 550MG ...... 43 XIGDUO XR TAB 10-1000MG ....................... 35 XIGDUO XR TAB 10-500MG.......................................... 35 XIGDUO XR TAB 5-1000MG.......................................... 35 XIGDUO XR TAB 5-500MG.......................................... 35 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 3 see hydrocodone-acetaminophen 5-300mg ..................... 3 see hydrocodone-acetaminophen 7.5-300mg .................. 3 see vicodin ...................... 5 see vicodin es ................. 5 see vicodin hp ................. 5

XOLAIR ............................ 52 XOPENEX

see levalbuterol hcl ....... 52 XOPENEX CONCENTRATE

see levalbuterol conc 1.25mg/0.5ml ................ 52

XOPENEX HFA ................ 52 XTANDI ............................ 13 xulane dis 150-35 ............. 38 XYLOCAINE

see lidocaine hcl............ 56 see lidocaine hcl (local anesth.) ........................... 5


90

see lidocaine inj 1% .........5 see lidocaine inj 2% .........5

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ...........................5 see lidocaine inj 0.5% ......5 see lidocaine inj 1.5% ......5 see lidocaine inj 2% .........5

xylon tab 10-200mg ............5 XYREM .............................31 XYZAL

see levocetirizine soln 2.5mg/5ml ......................52 see levocetirizine tab 5 mg ......................................52

Y YASMIN 28

see drospirenone-ethinyl estradiol .........................36 see syeda ......................37 see zarah.......................38

YAZ see drospirenone-ethinyl estradiol .........................36 see loryna 28 day ..........37 see nikki 28 day .............37 see vestura ....................38

YERVOY ...........................13 YF-VAX .............................47 Z zafirlukast ..........................52 ZALTRAP ..........................13 zamicet................................5 ZANAFLEX

see tizanidine ................31 ZANOSAR.........................12 ZANTAC

see ranitidine hcl ...........42 zarah .................................38 ZARONTIN

see ethosuximide ..........21 ZAVESCA .........................38 zazole ...............................44 ZAZOLE ............................44 ZEBETA

see bisoprolol fumarate .17 ZEGERID ..........................43 ZELAPAR..........................24

ZELBORAF ....................... 14 ZEMAIRA .......................... 52 ZEMPLAR ......................... 49

see paricalcitol .............. 49 zenatane ........................... 54 zenchent fe 28 day............ 38 zenchent tab ..................... 38 ZENPEP ........................... 43 ZERBAXA ......................... 10 ZERIT

see stavudine .................. 8 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 15

ZESTRIL see lisinopril .................. 15

ZETIA TAB 10MG ............. 17 ZETONNA ......................... 53 ZIAC

see bisoprolol & hydrochlorothiazide ....... 17

ZIAGEN .............................. 8 see abacavir sulfate ........ 7

ZIANA ............................... 54 zidovudine ........................... 8 ZINACEF .......................... 10

see cefuroxime sodium ... 9 ZINECARD

see dexrazoxane ........... 14 ZIOPTAN .......................... 51 ziprasidone hcl .................. 27 ZIPSOR .............................. 1 ZIRGAN ............................ 50 ZITHROMAX

see azithromycin ........... 10 ZMAX ................................ 10 ZOCOR

see simvastatin ............. 16 ZOFRAN

see ondansetron hcl ...... 41 see ondansetron hcl inj . 41 see ondansetron hcl oral soln................................ 41

ZOFRAN ODT see ondansetron odt...... 41

ZOHYDRO ER (ABUSE DETERRENT) ..................... 5 ZOLADEX ......................... 13

zoledronic inj 4mg/5ml ...... 35 zoledronic inj 5/100ml ....... 35 ZOLINZA .......................... 13 zolmitriptan ....................... 29 zolmitriptan odt ................. 29 ZOLOFT

see sertraline hcl ........... 24 zolpidem tartrate ............... 28 ZOMACTON ..................... 40 ZOMETA ........................... 35

see zoledronic inj 4mg/5ml ...................................... 35

ZOMIG see zolmitriptan ............. 29

ZOMIG NASAL SPRAY .... 29 ZOMIG ZMT

see zolmitriptan odt ....... 29 ZONEGRAN

see zonisamide ............. 22 zonisamide ....................... 22 ZONTIVITY ....................... 45 ZORBTIVE ........................ 40 ZORTRESS TAB 0.25MG 47 ZORTRESS TAB 0.5MG .. 47 ZORTRESS TAB 0.75MG 47 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 47 ZOSYN ............................. 11

see piperacillin sodium-tazobactam sodium .......................... 11

zovia 1/35e 28 day............ 38 zovia 1/50e 28 day............ 38 ZOVIRAX .......................... 57

see acyclovir ................... 8 see acyclovir topical ...... 56

ZUBSOLV SUB 1.4-0.36MG.......................................... 31 ZUBSOLV SUB 11.4-2.9MG.......................................... 31 ZUBSOLV SUB 2.9-0.71MG.......................................... 31 ZUBSOLV SUB 5.7-1.4MG.......................................... 31 ZUBSOLV SUB 8.6-2.1MG.......................................... 31 ZUPLENZ ......................... 41 ZYBAN


91

see buproban ................31 see bupropion hcl (smoking deterrent) .......31

ZYCLARA .........................57 ZYDELIG...........................14 ZYFLO CR ........................52 ZYKADIA...........................14 ZYLET ...............................50

ZYLOPRIM see allopurinol tab ........... 1

ZYMAXID see gatifloxacin (ophth) . 50

ZYPREXA see olanzapine .............. 26

ZYPREXA RELPREVV ..... 27 ZYPREXA RELPREVV INJ

210MG .............................. 27 ZYPREXA ZYDIS

see olanzapine odt ........ 26 ZYTIGA ............................. 13 ZYVOX ............................... 7

see linezolid .................... 6

2016 632 3t platinum comm eff 05/01/2016 · 2016-04-25 · tramadol hcl cp24 200mg ql (60 caps / 30...

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