2012 PROVIDER FORMULARY - My Preferred Provider

P.O. Box 56-5748 · Miami, Florida 33256-5748Toll-Free: 866.231.7201 · TTY Toll-Free: 711 at Florida Relay

www.mypreferredcare.com

Broward, Hernando, Hillsborough, Lake, Manatee, Marion, Miami-Dade, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, Sumter and Volusia counties

2012 PROVIDER FORMULARY

Preferred Care Partners — Formulary 1 –

Preferred Care Partners — 2012 Provider Formulary

What is the Preferred Care Partners Formulary?A formulary is a list of covered drugs selected by Preferred Care Partners in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Preferred Care Partners will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Preferred Care Partners network pharmacy, and other plan rules are followed.Can the Formulary change?Generally, if you have a member taking a drug on our 2012 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2012 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that the member have continued access for the remainder of the coverage year to the formulary drugs that were available when they chose the plan, except for cases in which they can save additional money or we can ensure their safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to

members who take the drug. The enclosed formulary is current as of January 1, 2012. To get updated information about the drugs covered by Preferred Care Partners, please visit our website at www.mypreferredcare.com/mydrugs or call our Pharmacy department at 1-800-591-6144, Monday through Friday from 8:30 am to 5:00 pm. If there are additional changes made to the formulary that are not covered above, you will also be notified of these changes within a reasonable time from when the changes are made.How do I use the Formulary? There are two ways to find your drug within the formulary:Medical Condition

The formulary begins on page 5. The drugs in this formulary are grouped into therapeutic categories depending on the type of medical conditions that they are used to treat. Look for the category name in the list that begins on page number 5. Then look under the category for the drug name.

Alphabetical ListingIf you cannot locate the drug under its proper category, you can search for the drug in the Index that begins on page 36. The Index provides an alphabetical list of all of the brand name and generic drugs included in this document.

What are generic drugs?Preferred Care Partners covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

hh Prior Authorization: Preferred Care Partners requires you to get prior authorization for certain drugs. This means that you will need to request

PLEASE READ:This Document Contains Information About the Drugs We Cover in this PlanNote to Providers: This formulary has changed since last year. Please review this document to make sure it contains the drugs you prefer to prescribe.

Preferred Care Partners — Formulary– 2

a prior authorization from Preferred Care Partners before members fill their prescriptions for these drugs. If you don’t get approval, Preferred Care Partners may not cover the drug.

hh Quantity Limits: For certain drugs, Preferred Care Partners limits the amount of the drug that Preferred Care Partners will cover. For example, Preferred Care Partners provides 30 per prescription for BENICAR. This may be in addition to a standard one month or three month supply

hh Step Therapy: In some cases, Preferred Care Partners requires the member to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member’s medical condition, Preferred Care Partners may not cover drug B unless the member tries Drug A first. If Drug A does not work for the member, Preferred Care Partners will then cover Drug B.

You can find out if a drug has any additional requirements or limits by looking in the formulary that begins on page 5. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at www.mypreferredcare.com/mydrugs.You can ask Preferred Care Partners to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Preferred Care Partners’ formulary?” on page 2 for information on how to request an exception.What if a drug is not on the Formulary?If a drug is not included on this formulary, you should first contact our Pharmacy department to confirm that the drug is not covered. If you learn that Preferred Care Partners does not cover a drug, you have two options:

hh You can ask our Pharmacy department for a list of similar drugs that are covered by Preferred Care Partners. When you receive the list, you may consider prescribing a similar drug that is covered by Preferred Care Partners.

hh You can ask Preferred Care Partners to make an exception and cover the drug. See below for information on how to request an exception.

How do I request an exception to the Preferred Care Partners Formulary?You can ask Preferred Care Partners to make an exception to our coverage rules. There are several types of exceptions that you can request:

hh You can ask us to cover a drug even if it is not on our formulary.

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

hh You can ask us to provide a higher level of coverage for the drug. If the drug is contained in our third tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the second tier instead. This would lower the amount the member must pay for the drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the fourth tier.

Generally, Preferred Care Partners will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating the member’s condition and/or would cause them to have adverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement supporting the request. Generally, we must make our decision within 72 hours of receiving your supporting statement. You can request an expedited (fast) exception if you believe that the member’s health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your supporting statement.What do members do before they can talk to their doctor about changing their drugs or requesting an exception?As a new or continuing member in our plan, your patient may be taking drugs that are not on our formulary. Or, they may be taking a drug that is on our formulary but their ability to get it is limited. For example, you may need a prior authorization from us before the member can fill the prescription. The member should talk with you to decide whether they should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug they take. While the member talks to their


doctor to determine the right course of action, we may cover their drug in certain cases during their first 90 days of membership in our plan.For each drug that is not on our formulary, or if ability to get drugs is limited, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy. After the first 30-day supply, we will not pay for these drugs, even if the member has been with our plan less than 90 days. If the member is a resident of a long-term care facility, we will allow them to refill their prescription until we have provided them with a 91 day transition supply, consistent with the dispensing increment, (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for the first 90 days they are a member of our plan. If the

member needs a drug that is not on our formulary, or if their ability to get their drugs is limited, and they have been with our plan longer than 90 days, we will cover a 31-day emergency supply of that drug (unless the prescription is written for fewer days) while you pursue a formulary exception. For more informationFor more detailed information about Preferred Care Partners’ prescription drug coverage, please contact our Pharmacy department at 1-800-591-6144, Monday through Friday, from 8:30 am to 5:00 pm. Or, visit www.mypreferredcare.com.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

2012 Prescription Drug Benefit

Plan Name County ICL - Initial

CoverageLimit

Tier 1Co-pay

Tier 2Co-pay

Tier 3Co-pay

Tier 4Co-

InsuranceGap

CoverageExcluded

DrugCoverage

Part BDrugCo-

insurance

ChemoDrug

Co-pay

Preferred ChoiceDade (HMO-POS) Miami-Dade $7,000 $0 $0 $20 20% Tier 1 Yes 20% $0

Preferred ChoiceBroward (HMO) Broward $3,750 $0 $15 $30 33% Tier 1 Yes 20% $0

Preferred Complete Care (HMO) Miami-Dade $6,000 $0 $0 $20 20% Tier 1 &

Tier 2 Yes 0% $0

Preferred Special Care Miami-Dade

(HMO-SNP)Miami-Dade $6,000 $0 $0 $20 20% Tier 1 &

Tier 2 Yes 0% $0

Preferred Gold Option (HMO)

Broward, Hernando, Hillsborough, Lake, Manatee, Marion,

Miami-Dade, Orange, Osceola,

Pasco Pinellas, Polk, Seminole, Sumter, &

Volusia

$2,930 $0 $15 $55 33% Tier 1 Yes 20% 20%

Preferred Premium Advantage Miami-Dade (HMO-POS)

Miami-Dade, $2,930 $0 $10 $50 33% Tier 1 Yes 20% 20%

Preferred Select Care (HMO-SNP)

Broward, Hernando, Hillsborough, Lake, Manatee, Marion, Orange, Osceola,

Pasco Pinellas, Polk, Seminole, Sumter, &

Volusia

$3,500 $0 $0 $50 33% Tier 1 Yes 20% 20%

30-Day Supply


2012 Prescription Drug Benefit — continued


CoverageLimit

Tier 1Co-pay

Tier 2 Co-pay

Tier 3Co-pay

GapCoverage

ExcludedDrug

Coverage

Part BDrugCo-

insurance

ChemoDrug

Co-pay

Preferred ChoiceDade (HMO-POS) Miami-Dade $7,000 $0 $0 $40 Tier 1 Yes 20% $0

Preferred ChoiceBroward (HMO) Broward $3,750 $0 $30 $60 Tier 1 Yes 20% $0

Preferred Complete Care (HMO) Miami-Dade $6,000 $0 $0 $40 Tier 1 &

Tier 2 Yes 0% $0

Preferred Special Care Miami-Dade

(HMO-SNP)Miami-Dade $6,000 $0 $0 $40 Tier 1 &

Tier 2 Yes 0% $0

Preferred Gold Option (HMO)

Broward, Hernando, Hillsborough, Lake, Manatee, Marion,

Miami-Dade, Orange, Osceola,

Pasco, Pinellas, Polk, Seminole, Sumter, &

Volusia

$2,930 $0 $30 $110 Tier 1 Yes 20% 20%

Preferred Premium Advantage Miami-Dade(HMO-POS)

Miami-Dade $2,930 $0 $20 $100 Tier 1 Yes 20% 20%

Preferred Select Care (HMO-SNP)

Broward, Hernando, Hillsborough, Lake, Manatee, Marion, Orange, Osceola,

Pasco, Pinellas, Polk, Seminole,

Sumter, & Volusia

$3,500 $0 $0 $100 Tier 1 Yes 20% 20%

90-Day Mail Order Supply


CoverageLimit

GenericDrugs

All OtherDrugs

GapCoverage

ExcludedDrug

Coverage

Part BDrug

Co-insurance

ChemoDrug

Co-pay

Preferred MedicareAssist

(HMO-POS-SNP)

Miami-Dade & Broward $2,930

Up to $1.10, $2.60,

or 15% depending

on Low Income Level

Up to $3.30, $6.50,

or 15% depending

on Low Income Level

Yes Yes 0% $0

Preferred Medicare Assist (HMO-SNP)


B/D = May be Covered Under Medicare Part B or D • ED = Excluded Part D DrugLA = Limited Availability • MO = Available via Mail Order or Retail Pharmacy • PA = Prior Authorization

• QL = Quantity Limit • ST = Step Therapy



The formulary below provides coverage information on some of the drugs covered by Preferred Care Partners. If you have trouble finding a drug in the list, turn to the Index that begins on page 35.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BENICAR) and generic drugs are listed in lower-case italics (e.g., losartan).

The Requirements/Limits column describes any special requirements for coverage of the drug:

Excluded Part D Drug (ED): This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount a member pays when they fill a prescription for this drug does not count towards their total drug costs (that is, the amount they pay does not help them qualify for catastrophic coverage). In addition, if a member is receiving extra help to pay for their prescriptions, they will not get any extra help to pay for this drug.

Limited Availability (LA): ): This drug may be available only at certain pharmacies. For more information consult the Pharmacy Directory or contact our Pharmacy department at 1-800-591-6144, Monday through Friday, from 8:30 am to 5:00 pm.

Mail Order Drug (MO): This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

Preferred Care Partners — 2012 Formulary

Commonly Prescribed Therapeutic Drug Categories Drug Drug Requirements/Name Tier Limits

Drug Drug Requirements/Name Tier Limits

ANALGESICSANALGESICSGenerics

butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg

2 ED

ANTI - INFECTIVESANTIFUNGAL AGENTSGenerics

amphotericin b 3 MOclotrimazole troc 1 MOfluconazole in dextrose inj 0; 400mg/200ml 3

fluconazole susr 1 MOfluconazole tabs 1 MOgriseofulvin microsize 1 MOitraconazole 1 MOketoconazole 1 MOnystatin susp 1 MOnystatin tabs 1 MOterbinafine tabs 3 PA MOBrands

ANCOBON 4 MOERAXIS INJ 100MG 3 PAGRIFULVIN V 3 MOGRIS-PEG 2 MO






ANTIVIRALSGenerics

acyclovir caps 1 MOacyclovir inj 500mg 3 MOacyclovir susp 1 MOacyclovir tabs 1 MOamantadine caps 1 MOamantadine tabs 1 MOdidanosine cpdr 200mg, 250mg, 400mg 2 MO

didanosine cpdr 125mg 1 MOfamciclovir 2 MOganciclovir caps 500mg 4 MOganciclovir inj 3 MOrimantadine hcl 1 MOstavudine 2 MO

valacyclovir hcl 2 QL(30 per 30 days)MO

zidovudine 2 MOBrands

APTIVUS CAPS 4 MOAPTIVUS ORAL SOLN 4

ATRIPLA 4 QL(30 per 30 days)MO

BARACLUDE ORAL SOLN 3 PA QL(630 per

30 days)MO

BARACLUDE TABS 4 PA QL(30 per 30 days)MO

COMBIVIR 4 MOCRIXIVAN CAPS 100MG 2CRIXIVAN CAPS 200MG, 400MG 2 MO

EDURANT 3 MOEMTRIVA 3 MOEPIVIR 3 MOEPIVIR HBV 3 MOEPZICOM 4 MO

FUZEON 4 QL(60 per 30 days)MO

GANCICLOVIR CAPS 250MG 2 MO

HEPSERA 4 PA QL(30 per 30 days)MO

INTELENCE TABS 100MG 4 QL(120 per 30 days)MO

INVIRASE CAPS 3 MOINVIRASE TABS 4 MO

ISENTRESS 4 QL(60 per 30 days)MO

KALETRA ORAL SOLN 4 MOKALETRA TABS 200MG; 50MG 4 MO

KALETRA TABS 100MG; 25MG 3 MO

LEXIVA SUSP 3 MOLEXIVA TABS 4 MONORVIR 3 MOPREZISTA TABS 150MG 3PREZISTA TABS 75MG 3 MOPREZISTA TABS 400MG, 600MG 4 MO

REBETOL ORAL SOLN 2 MO

RELENZA DISKHALER 3 QL(112 per 365 days)MO

RESCRIPTOR 2 MORETROVIR IV INFUSION 3 MOREYATAZ CAPS 100MG 3 MOREYATAZ CAPS 150MG, 200MG, 300MG 4 MO

RIBAPAK 4 MORIBASPHERE CAPS 3 MORIBASPHERE TABS 200MG 3 MO

RIBASPHERE TABS 400MG 4

RIBASPHERE TABS 600MG 4 MO

RIBAVIRIN 3SELZENTRY TABS 150MG 4 QL(60 per 30

days)MO






SELZENTRY TABS 300MG 4 QL(120 per 30 days)MO

SUSTIVA 2 MOTAMIFLU CAPS 45MG, 75MG 2 QL(56 per 365

days)MO

TAMIFLU CAPS 30MG 2 QL(112 per 365 days)MO

TAMIFLU SUSR 12MG/ML 2 MOTRIZIVIR 4 MOTRUVADA 4 MO

TYZEKA 3 QL(30 per 30 days)MO

VALCYTE TABS 4 MOVICTRELIS 4 PA MOVIDEX PEDIATRIC ORAL SOLN 2GM 2 MO

VIRACEPT 3 MOVIRAMUNE 3 MOVIRAMUNE XR 3 MOVIREAD 3 MOZERIT ORAL SOLN 2 MOZIAGEN 3 MO

CEPHALOSPORINScefaclor 1 MOcefaclor er 1 MOcefadroxil 1 MOcefazolin inj 20gm, 500mg 1cefazolin inj 1gm 1 MOcefdinir 1 MOcefepime inj 2gm 2cefepime inj 1gm 2 MOcefotetan inj 1gm, 2gm 1cefpodoxime proxetil 1 MOcefprozil 1 MOceftriaxone sodium inj 10gm 1ceftriaxone sodium inj 1gm, 250mg, 2gm, 500mg 1 MO

cefuroxime axetil 1 MOcefuroxime sodium inj 7.5gm 1

cefuroxime sodium inj 1.5gm, 750mg 1 MO

cephalexin 1 MO

ERYTHROMYCINS / OTHER MACROLIDESGenerics

azithromycin inj 500mg 1 MOazithromycin susr 1 MOazithromycin tabs 1 MOclarithromycin 1 MOclarithromycin er 1 MOe.e.s. 400 1 MOery-tab tbec 333mg 1 MOerythrocin stearate 1 MOerythromycin base 1 MOerythromycin ethylsuccinate 1 MOerythromycin/sulfisoxazole 1 MO

MISCELLANEOUS ANTIINFECTIVESGenerics

amikacin sulfate inj 500mg/2ml 2

amikacin sulfate inj 50mg/ml 2 MOchloroquine 1 MOclindamycin hcl 1 MOclindamycin phosphate add-vantage 2 MO

ethambutol tabs 400mg 2ethambutol tabs 100mg 2 MOhydroxychloroquine 1 MOisoniazid inj 2isoniazid syrp 1 MOisoniazid tabs 1 MOkanamycin sulfate 2mebendazole 1 MOmefloquine hcl 2 MOmetronidazole 1 MOneomycin sulfate 1 MOparomomycin 1 MO






pyrazinamide 1 MOrifampin 1 MOBrands

ALBENZA 3 MO

ALINIA SUSR 3 QL(180 per 30 days)MO

ALINIA TABS 3 QL(6 per 30 days)MO

CAPASTAT SULFATE 3COLISTIMETHATE SODIUM 3 MO

CUBICIN 4 B/D PA MODAPSONE 2 MODARAPRIM 3 MOINVANZ 3 PA MOLINCOCIN 3 MOMEPRON 4 PA MOMYCOBUTIN 3 MOPASER 3 MOPRIFTIN 3PRIMAQUINE 2 MOPRIMAXIN IV 2 MO

QUALAQUIN 3 QL(84 per 180 days)MO

SEROMYCIN 3 MOSTREPTOMYCIN SULFATE 2 MO

STROMECTOL 3 MOTOBI 4 B/D PA MOTRECATOR 3 MOZYVOX INJ 4 MO

ZYVOX SUSR 4 QL(1800 per 28 days)MO

ZYVOX TABS 2 QL(20 per 10 days)MO

PENICILLINSGenerics

amoxicillin 1 MO

amoxicillin/clavulanate potassium 1 MO

amoxicillin/potassium clavulanate tabs 1 MO

ampicillin caps 1 MOampicillin inj 10gm, 125mg, 1gm 1

ampicillin susr 1 MOampicillin-sulbactam inj 10gm; 5gm 1

ampicillin-sulbactam inj 2gm; 1gm 1 MO

dicloxacillin sodium 1 MOnafcillin sodium inj 10gm 1nafcillin sodium inj 1gm 1 MOoxacillin sodium inj 10gm, 1gm 1

penicillin g potassium in iso-osmotic dextrose 3

penicillin g potassium inj 5mu 3

penicillin g procaine 3 MOpenicillin g sodium 3penicillin v potassium 1 MOpiperacillin sodium 1Brands

BACTOCILL IN DEXTROSE 1

NALLPEN/DEXTROSE INJ 0; 1GM/50ML 1

QUINOLONESGenerics

ciprofloxacin er 1 MOciprofloxacin extended- release 1 MO

ciprofloxacin inj 400mg/40ml 1ciprofloxacin tabs 1 MOofloxacin 1 MO






Brands

AVELOX ABC PACK 3 MOAVELOX TABS 3 MOLEVAQUIN ORAL SOLN 3 MO

LEVAQUIN TABS 3 QL(10 per 10 days)MO

SULFA’S / RELATED AGENTSGenerics

sulfadiazine 3 MOsulfamethoxazole/ trimethoprim 1 MO

sulfamethoxazole/ trimethoprim ds 1 MO

TETRACYCLINESGenerics

demeclocycline hcl 3 MOdoxycycline hyclate caps 1 MOdoxycycline hyclate cpep 100mg 1

doxycycline hyclate inj 3 MOdoxycycline hyclate tabs 1 MOdoxycycline monohydrate tabs 150mg, 50mg, 75mg 1 MO

minocycline hcl caps 1 MOtetracycline hcl 1 MOGenerics

DOXYCYCLINE HYCLATE CPEP 75MG 1 MO

URINARY TRACT AGENTSGenerics

methenamine hippurate 1 MOnitrofurantoin macrocrystalline caps 50mg 3 MO

nitrofurantoin monohydrate 3 MOtrimethoprim 1 MO

VANCOMYCINGenerics

vancomycin inj 10gm 3 B/D PAvancomycin inj 1000mg 3 B/D PA MOBrands

VANCOCIN ORAL 2 MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSGenerics

leucovorin calcium tabs 25mg, 5mg 1 MO

Brands

AMIFOSTINE 4 PA MOELITEK INJ 1.5MG 4 PAMESNA 2 B/D PA MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSGenerics

anastrozole 2 QL(30 per 30 days)MO

azathioprine 1 B/D PA MO

bicalutamide 2 QL(30 per 30 days)MO

cyclophosphamide tabs 1 B/D PA MOcyclosporine caps 50mg 2 B/D PAcyclosporine caps 100mg, 25mg 2 B/D PA MO

cyclosporine oral soln 2 B/D PA MOexemestane 1 MOfludarabine phosphate inj 50mg 3 MO

flutamide 2 MOgemcitabine hcl inj 1gm 3 B/D PA MOhydroxyurea 1 MO






letrozole 2 QL(30 per 30 days)MO

leuprolide acetate 2 B/D PA MOmegestrol acetate susp 2 MOmegestrol acetate tabs 1 MOmercaptopurine 1 MOmethotrexate 1 MOmethotrexate sodium inj 1gm 1 B/D PAmethotrexate sodium inj 25mg/ml 1 B/D PA MO

mitoxantrone hcl 1 B/D PA MOmycophenolate mofetil 3 B/D PA MOoctreotide inj 1000mcg/ml, 500mcg/ml 4 PA MO

tacrolimus caps 0.5mg, 1mg 3 B/D PA MOtacrolimus caps 5mg 4 B/D PA MOtamoxifen citrate 1 MOtopotecan hcl inj 4mg 3 B/D PA MOBrands

AFINITOR TABS 10MG, 5MG 4 QL(30 per 30

days)MO

AFINITOR TABS 2.5MG 4 QL(90 per 30 days)MO

ALIMTA INJ 500MG 4 PA MOAROMASIN 2 MOAVASTIN INJ 100MG/4ML 4 LA PA MOBLEOMYCIN SULFATE INJ 30UNIT 3 B/D PA MO

CAMPATH 4 PACEENU 3 MOCELLCEPT 3 B/D PA MODAUNOXOME 3 B/D PA MOEMCYT 3 MOFARESTON 3 MOFASLODEX 4 MO

FEMARA 3 QL(30 per 30 days)MO

GLEEVEC TABS 400MG 2 PA QL(60 per 30 days)MO

GLEEVEC TABS 100MG 2 PA QL(90 per 30 days)MO

HALAVEN 4 B/D PA MOHEXALEN 4 MO

IRESSA 4 PA QL(30 per 30 days)

JEVTANA 4 B/D PA MOLEUKERAN 2 MOLUPRON DEPOT INJ 11.25MG, 22.5MG, 3.75MG, 30MG, 7.5MG

4 B/D PA MO

LUPRON DEPOT-PED INJ 11.25MG, 15MG 4 B/D PA MO

LYSODREN 2 MOMATULANE 4 MO

NEXAVAR 4 PA QL(120 per 30 days)MO

NILANDRON 3 MOOCTREOTIDE INJ 100MCG/ML, 200MCG/ ML, 50MCG/ML

3 PA MO

ONTAK 4 PAPROGRAF CAPS 5MG 4 B/D PA MOPROGRAF CAPS 0.5MG, 1MG 3 B/D PA MO

PROGRAF INJ 3 B/D PARAPAMUNE ORAL SOLN 3 B/D PA MORAPAMUNE TABS 1MG, 2MG 3 B/D PA MO

REVLIMID 4 LA QL(30 per 30 days)MO

RITUXAN 4 B/D PA MOSOMATULINE DEPOT 4 PA MOSPRYCEL TABS 140MG, 70MG, 80MG 4 MO

SPRYCEL TABS 100MG 4 QL(30 per 30 days)MO

SPRYCEL TABS 20MG, 50MG 4 QL(60 per 30

days)MO

SUTENT 4 PA QL(30 per 30 days)MO






TABLOID 3 MO

TARCEVA 4 PA QL(30 per 30 days)MO

TARGRETIN CAPS 4 MO

TARGRETIN GEL 4 QL(60 per 30 days)MO

TASIGNA CAPS 200MG 4 PA QL(120 per 30 days)MO

THALOMID 4 QL(28 per 28 days)MO

TRETINOIN CAPS 4 MOTRISENOX 3 B/D PA MO

TYKERB 4 QL(150 per 30 days)MO

VANDETANIB 4 PAVELCADE 4 PA MOVIDAZA 4 PA MO

VOTRIENT 4 QL(120 per 30 days)MO

ZOLINZA 4 QL(120 per 30 days)MO

ZORTRESS TABS 0.5MG, 0.75MG 4 B/D PA MO

ZORTRESS TABS 0.25MG 3 B/D PA MOZYTIGA 4 PA MO

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSGenerics

carbamazepine 1 MOcarbamazepine er tb12 2 MO

clonazepam 1 ED QL(120 per 30 days)

clonazepam odt 1 ED QL(120 per 30 days)

diazepam tabs 1 ED QL(120 per 30 days)

divalproex sodium cpsp 2 MOdivalproex sodium er 2 MO

divalproex sodium tbec 2 MOepitol 1 MOethosuximide 1 MOgabapentin caps 1 MOgabapentin oral soln 3 MOgabapentin tabs 2 MOlamotrigine chew 1 MOlamotrigine tabs 2 MOlevetiracetam inj 3levetiracetam oral soln 2 MOlevetiracetam tabs 2 MOoxcarbazepine 2 MOphenobarbital tabs 100mg, 15mg, 30mg, 60mg 1 ED

phenytoin 1 MOphenytoin sodium extended caps 100mg 1 MO

primidone 1 MOtopiramate 2 MOvalproate sodium 1 MOvalproic acid 1 MOzonisamide 1 MOBrands

BANZEL SUSP 3 MO

BANZEL TABS 200MG 3 PA QL(240 per 30 days)MO

BANZEL TABS 400MG 4 PA QL(240 per 30 days)MO

CELONTIN 3 MODILANTIN INFATABS 3 MOFELBATOL 3 MOGABITRIL 3 MOLAMICTAL ODT TBDP 3 MO

LYRICA 3 QL(90 per 30 days)MO

PEGANONE 3 MOSABRIL 4 MOTEGRETOL-XR 3 MOTRILEPTAL SUSP 3 MO






VIMPAT INJ 3 QL(1200 per 30 days)

VIMPAT ORAL SOLN 3 MO

VIMPAT TABS 3 QL(60 per 30 days)MO

ANTIPARKINSONISM AGENTSGenerics

benztropine mesylate inj 3benztropine mesylate tabs 1 MObromocriptine mesylate 1 MOcarbidopa/levodopa 1 MOcarbidopa/levodopa cr 1 MOcarbidopa/levodopa sr tbcr 50mg; 200mg 1 MO

pramipexole dihydrochloride 2 MOropinirole 1 MOselegiline 1 MOtrihexyphenidyl 1 MOBrands

APOKYN 3 LA PA MO

AZILECT 3 QL(30 per 30 days) ST MO

COMTAN 2 MOTASMAR 3 MO

MIGRAINE / CLUSTER HEADACHE THERAPYGenerics

ergotamine tartrate/caffeine 1 MOmigergot 1 MO

naratriptan hcl 3 QL(9 per 30 days)MO

sumatriptan succinate inj 4mg/0.5ml 2 QL(8 per 30

days)sumatriptan succinate inj 6mg/0.5ml 2 QL(8 per 30

days)MO

sumatriptan succinate tabs 2 QL(9 per 30 days)MO

MISCELLANEOUS NEUROLOGICAL THERAPYGenerics

donepezil hcl 2 MOgalantamine hydrobromide cp24 2 QL(30 per 30

days)MOgalantamine hydrobromide tabs 2 QL(60 per 30

days)MO

rivastigmine tartrate 2 QL(60 per 30 days)MO

Brands

COPAXONE 4 MO

EXELON PT24 3 QL(30 per 30 days) ST MO

NAMENDA ORAL SOLN 2 QL(380 per 30 days)MO

NAMENDA TABS 2 QL(60 per 30 days)MO

XENAZINE 4 LA PA MO

MUSCLE RELAXANTS / ANTISPASMODIC THERAPYGenerics

baclofen 1 MOchlorzoxazone 1 MOpyridostigmine bromide 1 MOtizanidine hcl 3 MOBrands

MESTINON 3 MOMESTINON TIMESPAN 3 MO

NARCOTIC ANALGESICSGenerics

acetaminophen/codeine oral soln 1 MO

acetaminophen/codeine tabs 300mg; 15mg 1 MO

acetaminophen/codeine #3 1 MOacetaminophen/codeine #4 1 MOascomp/codeine 1 MO






buprenorphine hcl subl 3 MO

fentanyl patches 2 QL(16 per 30 days)MO

hydrocodone bitartrate/ acetaminophen tabs 1 MO

hydrocodone/acetaminophen oral soln 500mg/15ml; 7.5mg/15ml

1 MO

hydrocodone/acetaminophen tabs 1 MO

hydrocodone/ibuprofen 1 MOhydromorphone hcl inj 10mg/ml 2 MO

hydromorphone hcl tabs 1 MOlevorphanol tartrate 1 MOmargesic-h 1 MOmeperidine hcl inj 10mg/ml, 50mg/ml 3

meperidine hcl inj 25mg/ml 3 MOmethadone hcl conc 1 MOmethadone hcl tabs 1 MOmethadose tabs 1 MO

morphine sulfate er 2 QL(90 per 30 days)MO

morphine sulfate inj 0.5mg/ml 1

morphine sulfate inj 1mg/ml 1 MOmorphine sulfate tabs 1 MOoxycodone/acetaminophen caps 1 MO

oxycodone/acetaminophen tabs 325mg; 5mg 1

oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg, 500mg; 7.5mg

1 MO

oxycodone hcl caps 1 MOoxycodone hcl conc 1 MOoxycodone hcl tabs 15mg, 30mg, 5mg 1 MO

oxycodone/aspirin tabs 325mg; 4.835mg 1

oxycodone/aspirin tabs 325mg; 4.5mg; 0.38mg 1 MO

oxycodone/ibuprofen 1 QL(28 per 7 days)MO

roxicet tabs 325mg; 5mg 1 MOstagesic 1 MOzerlor 2 MOBrands

ABSTRAL SUBL 300MCG, 400MCG, 600MCG, 800MCG

3 PA

ABSTRAL SUBL 100MCG, 200MCG

3 PA MO

CO-GESIC 1 MOMETHADONE HCL ORAL SOLN 1 MO

NON-NARCOTIC ANALGESICSGenerics

butorphanol tartrate nasal soln 2 MO

depade 1 MOdiclofenac potassium 1 MOdiclofenac sodium 1 MOdiclofenac sodium ec 1 MOdiclofenac sodium xr 1 MOdiflunisal 1 MOetodolac 1 MOfenoprofen calcium 1 MOflurbiprofen 1 MOibuprofen susp 1 MOibuprofen tabs 400mg, 600mg, 800mg 1 MO

indomethacin caps 1 MOindomethacin er 1 MOketoprofen 1 MOketoprofen er 1 MO

ketorolac tromethamine tabs 1 QL(20 per 5 days)MO

meclofenamate sodium 1 MO






meloxicam 1 MOnabumetone 1 MOnaloxone 3naltrexone 1 MOnaproxen sodium tabs 275mg, 550mg 1 MO

naproxen susp 1 MOnaproxen tabs 250mg, 375mg 1 MO

naproxen tbec 1 MOoxaprozin 1 MOpiroxicam 1 MOsulindac 1 MOtolmetin sodium 1 MOtramadol 1 MOtramadol hcl/acetaminophen 1 MOBrands

ARTHROTEC 50 3 MOARTHROTEC 75 3 MO

CELEBREX CAPS 100MG 2 QL(30 per 30 days)MO

CELEBREX CAPS 200MG, 400MG, 50MG 2 QL(60 per 30

days)MO

VOLTAREN GEL 3 QL(200 per 1 days)MO

PSYCHOTHERAPEUTIC DRUGSGenerics

alprazolam 1 ED QL(120 per 30 days)

alprazolam er 1 ED QL(30 per 30 days)

amitriptyline 1 MOamoxapine 1 MO

amphetamine/ dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg

1 QL(30 per 30 days)MO

amphetamine/ dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 7.5mg


budeprion sr 1 QL(60 per 30 days)MO

budeprion xl 2 QL(60 per 30 days)MO

bupropion hcl 1 MO

bupropion hcl sr 1 QL(60 per 30 days)MO

buspirone hcl 1 MO

chlordiazepoxide hcl 1 ED QL(120 per 30 days)

chlordiazepoxide/ amitriptyline 3 MO

chlorpromazine inj 2 MOchlorpromazine tabs 1 MOcitalopram 1 MOclomipramine 1 MO

clorazepate dipotassium 1 ED QL(120 per 30 days)

clozapine tabs 100mg, 25mg, 50mg 1

desipramine 1 MOdexmethylphenidate 1 MOdextroamphetamine sulfate 1 MOdextroamphetamine sulfate er 1 MOdoxepin 1 MO

estazolam 1 ED QL(30 per 30 days)






fluoxetine 1 MOfluphenazine conc 3fluphenazine decanoate inj 3 MOfluphenazine elix 1 MOfluphenazine inj 3 MOfluphenazine tabs 1 MO

flurazepam hcl 1 ED QL(120 per 30 days)

fluvoxamine 1 MO

folic acid tabs 1mg 1 ED QL(120 per 30 days)

haloperidol 1 MOhaloperidol decanoate inj 3 MOhaloperidol lactate inj 3 MOimipramine 1 MOimipramine pamoate 3 MOlithium carbonate caps 150mg, 300mg 1 MO

lithium carbonate er 1 MOlithium carbonate tabs 1 MOlithium citrate 1 MO

lorazepam tabs 1 ED QL(120 per 30 days)

loxapine 1 MOmaprotiline 1 MOmetadate er 1 MOmethylin er 1 MOmethylin tabs 1 MOmethylphenidate hcl sr 1methylphenidate hcl tabs 20mg 1

methylphenidate hcl tabs 10mg, 5mg 1 MO

methylphenidate hydrochloride 1 MO

mirtazapine 1 MOmirtazapine odt tbdp 30mg, 45mg 1 MO

nefazodone 1 MOnortriptyline 1 MO

oxazepam 1 ED QL(120 per 30 days)

paroxetine er tb24 37.5mg 2 MO

paroxetine er tb24 25mg 2 QL(60 per 30 days)MO

paroxetine er tb24 12.5mg 2 QL(150 per 30 days)MO

paroxetine susp 1 MO

paroxetine tabs 1 QL(60 per 30 days)MO

perphenazine 1 MOperphenazine/amitriptyline 1 MOphenelzine sulfate 1 MOprotriptyline hcl 1 MO

risperidone odt 2 QL(60 per 30 days)MO

risperidone oral soln 2 MOrisperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL(60 per 30

days)MO

risperidone tabs 4mg 2 QL(120 per 30 days)MO

sertraline 1 MOtemazepam caps 15mg, 30mg 1 ED QL(30 per

30 days)thioridazine 1 MOthiothixene 1 MOtranylcypromine 1 MOtrazodone 1 MO

triazolam 1 ED QL(30 per 30 days)

trifluoperazine 1 MOvenlafaxine hcl 1 MOvenlafaxine hcl er cp24 37.5mg, 75mg 3 QL(30 per 30

days)MOvenlafaxine hcl er cp24 150mg 3 QL(60 per 30

days)MOvenlafaxine hcl er tb24 225mg 2 QL(30 per 30

days)venlafaxine hcl er tb24 37.5mg, 75mg 2 QL(30 per 30

days)MO






venlafaxine hcl er tb24 150mg 2 QL(60 per 30

days)MO

zaleplon 1 QL(30 per 30 days)MO

zolpidem 1 QL(30 per 30 days)MO

Brands

ABILIFY DISCMELT 3 QL(60 per 30 days) ST MO

ABILIFY INJ 3 QL(900 per 30 days) ST MO

ABILIFY ORAL SOLN 3 QL(750 per 30 days) ST MO

ABILIFY TABS 3 QL(60 per 30 days) ST MO

CYMBALTA CPEP 60MG 3 QL(30 per 30 days)MO

CYMBALTA CPEP 20MG, 30MG 3 QL(60 per 30

days)MOEMSAM 3 MOFANAPT TABS 1MG, 2MG, 4MG 3 QL(30 per 30

days)MOFANAPT TABS 10MG, 12MG, 6MG, 8MG 3 QL(60 per 30

days)MOFANAPT TITRATION PACK 3 QL(1 per 365

days)MOFAZACLO 3

GEODON CAPS 2 QL(60 per 30 days)MO

GEODON INJ 3 PA MOGUANIDINE HCL 2INTUNIV 2 PA MOINVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ ML, 234MG/1.5ML

4 MO

INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML

3 MO

INVEGA TB24 1.5MG, 3MG, 9MG 3 QL(30 per 30

days) ST MO

INVEGA TB24 6MG 3 QL(60 per 30 days) ST MO

LATUDA 3 ST MO

LEXAPRO ORAL SOLN 2 QL(600 per 30 days)MO

LEXAPRO TABS 2 QL(30 per 30 days)MO

LITHIUM CARBONATE CAPS 600MG 1 MO

MARPLAN 3 MONARDIL 2 MOORAP 3 MO

PRISTIQ 3 QL(30 per 30 days)MO

PROVIGIL 2 PA QL(30 per 30 days)MO

RISPERDAL CONSTA INJ 37.5MG, 50MG 3 PA QL(4 per 28

days)MORISPERDAL CONSTA INJ 25MG 3 PA QL(8 per 28

days)MORISPERDAL CONSTA INJ 12.5MG 3 PA QL(16 per

28 days)MO

SAPHRIS 3 QL(60 per 30 days)MO

SEROQUEL TABS 300MG, 400MG 2 QL(60 per 30

days)MO

SEROQUEL TABS 100MG 2 QL(90 per 30 days)MO

SEROQUEL TABS 200MG 2 QL(120 per 30 days)MO

SEROQUEL TABS 25MG, 50MG 2 QL(180 per 30

days)MOSEROQUEL XR TB24 150MG, 200MG, 50MG 2 QL(30 per 30

days)MOSEROQUEL XR TB24 300MG, 400MG 2 QL(60 per 30

days)MOSURMONTIL 3 MOVIIBRYD 3 MOVIVACTIL 3 MOXYREM 4 LA PA






ZYPREXA 3 QL(30 per 30 days)MO

ZYPREXA ZYDIS 3 QL(30 per 30 days)MO

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSGenerics

amiodarone tabs 1 MOdisopyramide phosphate 1 MOflecainide acetate 1 MOmexiletine 1 MOpacerone tabs 200mg 1 MOprocainamide 1propafenone hcl 1 MOquinidine gluconate er 1 MOquinidine sulfate 1 MOquinidine sulfate er 1 MOsotalol 1 MOBrands

MULTAQ 3 PA QL(60 per 30 days)MO

TIKOSYN 3 MO

ANTIHYPERTENSIVE THERAPYGenerics

acebutolol 1 MOafeditab cr 1 MOamiloride 1 MOamiloride/ hydrochlorothiazide 1 MO

amlodipine 1 MOamlodipine/benazepril caps 10mg; 40mg, 5mg; 40mg 1 MO

amlodipine/benazepril caps 10mg; 20mg, 2.5mg; 10mg, 5mg; 10mg


amlodipine/benazepril caps 5mg; 20mg 1 QL(60 per 30

days)MOatenolol 1 MOatenolol/chlorthalidone 1 MObenazepril 1 MObenazepril/ hydrochlorothiazide 1 MO

betaxolol hcl 1 MObisoprolol fumarate 1 MObisoprolol fumarate/ hydrochlorothiazide 1 MO

bumetanide tabs 1 MOcaptopril 1 MOcaptopril/ hydrochlorothiazide 1 MO

cartia xt 1 MOcarvedilol 1 MOchlorothiazide 1 MOchlorthalidone tabs 25mg, 50mg 1 MO

clonidine tabs 1 MOdilt-cd cp24 120mg, 300mg 1 MOdilt-xr cp24 180mg, 240mg 1diltiazem cd cp24 120mg, 240mg, 300mg 1 MO

diltiazem hcl er cp12 1 MOdiltiazem hcl er cp24 360mg, 420mg 1 MO

diltiazem hcl tabs 1 MOdiltzac cp24 120mg, 180mg, 240mg, 300mg 1 MO

doxazosin 1 MOenalapril 1 MOenalapril/ hydrochlorothiazide 1 MO

felodipine er 1 MOfosinopril 1 MOfosinopril/ hydrochlorothiazide 1 MO

furosemide inj 2 MO






furosemide oral soln 10mg/ml 1 MO

furosemide tabs 1 MOguanfacine hcl 1 MOhydralazine tabs 1 MOhydrochlorothiazide 1 MOindapamide 1 MOisradipine 1 MOlabetalol tabs 1 MOlisinopril 1 MOlisinopril/ hydrochlorothiazide 1 MO

losartan potassium 1 MOlosartan potassium/ hydrochlorothiazide 1 MO

methyclothiazide 1 MOmethyldopa 1 MOmethyldopa/ hydrochlorothiazide 1 MO

metolazone 1 MOmetoprolol succinate er 1metoprolol tartrate tabs 1 MOmetoprolol/ hydrochlorothiazide 1 MO

minoxidil tabs 1 MOmoexipril 1 MOmoexipril/hydrochlorothiazide 1 MO

nadolol 1 MOnadolol/bendroflumethiazide 1 MOnicardipine caps 1 MOnifediac cc 1 MOnifedical xl 1 MOnifedipine er tb24 30mg, 60mg 1

nifedipine er tb24 90mg 1 MOnimodipine 3 MOnisoldipine tb24 20mg, 30mg, 40mg 1 MO

pindolol 1 MO

prazosin 1 MOpropranolol hcl er 1 MOpropranolol hcl oral soln 1 MOpropranolol hcl tabs 1 MOpropranolol/ hydrochlorothiazide 1 MO

quinapril 1 MOquinapril/ hydrochlorothiazide 1 MO

ramipril 1 MOreserpine 1 MOspironolactone 1 MOspironolactone/ hydrochlorothiazide 1 MO

taztia xt 1 MOterazosin hcl 1 MOtimolol maleate 1 MOtorsemide tabs 1 MOtrandolapril 1 MOtriamterene/ hydrochlorothiazide 1 MO

verapamil er cp24 1 MOverapamil er tbcr 120mg, 240mg 1

verapamil er tbcr 180mg 1 MOverapamil tabs 1 MOBrands

ATACAND 3 QL(30 per 30 days)MO

ATACAND HCT 3 QL(30 per 30 days)MO

AVALIDE 3 QL(30 per 30 days)MO

AVAPRO 3 QL(30 per 30 days)MO

BENICAR 2 QL(30 per 30 days)MO

BENICAR HCT 2 QL(30 per 30 days)MO






COREG CR 3 QL(30 per 30 days)MO

DIOVAN HCT 2 QL(60 per 30 days)MO

DIOVAN TABS 320MG 2 QL(30 per 30 days)MO

DIOVAN TABS 160MG, 40MG, 80MG 2 QL(60 per 30

days)MOEXFORGE 2 MOEXFORGE HCT 2 MOFUROSEMIDE ORAL SOLN 8MG/ML 1 MO

MICARDIS 2 QL(30 per 30 days)MO

MICARDIS HCT 2 QL(30 per 30 days)MO

TEKTURNA 2 QL(30 per 30 days)MO

TEKTURNA HCT 2 QL(30 per 30 days)MO

TOPROL XL 3 MO

CARDIAC GLYCOSIDESGenerics

digoxin oral soln 1 MOdigoxin tabs 1 MO

COAGULATION THERAPYGenerics

cilostazol 1 MOenoxaparin sodium 1 PA MOheparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

3 MO

heparin sodium/d5w inj 5%; 40unit/ml 3

jantoven 1 MOpentoxifylline er 1 MOticlopidine hcl 1 MOwarfarin 1 MO

Brands

AGGRENOX 3 MOARIXTRA 1 PA MOCOUMADIN TABS 2 MOCYKLOKAPRON 2 PA MOFRAGMIN INJ 10000UNIT/ ML, 25000UNIT/ ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML

1 PA MO

HEPARIN SODIUM INJ 2000UNIT/ML 3 MO

HEPARIN SODIUM/NACL 0.45% 3

HEPARIN SODIUM/ SODIUM CHLORIDE 0.9% PREMIX

3

PLAVIX TABS 75MG 2 QL(30 per 30 days)MO

PROMACTA TABS 25MG, 50MG 4 LA PA MO

LIPID/CHOLESTEROL LOWERING AGENTSGenerics

cholestyramine light pack 1 MOcolestipol 1 MOfenofibrate 1 MOfenofibrate micronized 1 MOgemfibrozil 1 MOlovastatin 1 MOpravastatin 1 MOprevalite powd 1 MOsimvastatin 1 MOBrands

CADUET 2 QL(30 per 30 days)MO

CRESTOR 2 QL(30 per 30 days)MO

LIPITOR 2 QL(30 per 30 days)MO






LOVAZA 2 PA MONIACOR 2 MO

NIASPAN 3 QL(60 per 30 days)MO

TRICOR 3 QL(30 per 30 days) ST MO

ZETIA 2 QL(30 per 30 days)MO

MISCELLANEOUS CARDIOVASCULAR AGENTSBrands

RANEXA 3 PA QL(60 per 30 days)MO

NITRATESGenerics

isosorbide dinitrate 1 MOisosorbide dinitrate er 1 MOisosorbide mononitrate 1 MOisosorbide mononitrate er 1 MOnitroglycerin pt24 0.2mg/hr, 0.6mg/hr 1

nitroglycerin pt24 0.4mg/hr 1 MOnitroglycerin transdermal pt24 0.1mg/hr 1 MO

nitrostat 1 MOBrands

MINITRAN 2 QL(30 per 30 days)MO

MONOKET 3 MONITROLINGUAL PUMPSPRAY 3 MO

DERMATOLOGICALS/TOPICAL THERAPYANTIPSORIATIC / ANTISEBORRHEICGenerics

calcipotriene external soln 2 MOselenium sulfide lotn 2.5% 1 MO

BURN THERAPYGenerics

silver sulfadiazine 1 MOssd 1 MOthermazene 1 MO

MISCELLANEOUS DERMATOLOGICALSGenerics

ammonium lactate 1 MOfluorouracil cream 2 MOfluorouracil external soln 2 MOimiquimod 3 PA MOlaclotion 1 MOpodofilox 1 MOBrands

CARAC 3 MOELIDEL 3 MOOXSORALEN ULTRA 3 MOPANRETIN 4 PA MO

REGRANEX 4 QL(15 per 30 days)MO

SOLARAZE 3 PA QL(100 per 1 days)MO

ZONALON 3 QL(45 per 30 days)MO

THERAPY FOR ACNEGenerics

clindamycin phosphate external soln 1 MO

clindamycin phosphate gel 1 MOclindamycin phosphate lotn 1 MOclindamycin phosphate swab 1 MOery 1 MOerythromycin/benzoyl peroxide 1 MO

erythromycin external soln 1 MOerythromycin gel 1 MOmetronidazole 1 MO






sotret 2tretinoin cream 1 MOtretinoin gel 1 MOBrands

TAZORAC 3 QL(100 per 30 days)MO

TOPICAL ANESTHETICSGenerics

lidocaine/prilocaine cream 1 MOlidocaine external soln 1 MOlidocaine gel 1 MOlidocaine inj 0.5%, 1% 1lidocaine oint 1 MOBrands

LIDODERM 3 PA MO

TOPICAL ANTIBACTERIALSGenerics

gentamicin sulfate cream 1 MOgentamicin sulfate oint 0.1% 1 MOmupirocin 1 MOsodium sulfacetamide 1 MOBrands

BACTROBAN CREAM 3 MOSULFAMYLON CREAM 3 MO

TOPICAL ANTIFUNGALSGenerics

ciclopirox gel 1 MOciclopirox nail lacquer 1 MOciclopirox olamine 1 MOciclopirox susp 1 MOclotrimazole/betamethasone 1 MOclotrimazole external cream 1 MOclotrimazole external soln 1 MOeconazole nitrate 1 MOketoconazole 1 MO

nyamyc 1 MOnystatin/triamcinolone 1 MOnystatin cream 1 MOnystatin external powd 1nystatin oint 1 MOnystop 1 MOpedi-dri 1 MO

TOPICAL ANTIVIRALSBrands

DENAVIR 3 QL(2 per 30 days)MO

ZOVIRAX CREAM 3 QL(2 per 1 days)MO

TOPICAL CORTICOSTEROIDSGenerics

alclometasone dipropionate 1 MOamcinonide cream 1 MOamcinonide lotn 1 MOamcinonide oint 1augmented betamethasone dipropionate cream 1 MO

augmented betamethasone dipropionate lotn 1 MO

augmented betamethasone dipropionate oint 1 MO

betamethasone dipropionate 1 MObetamethasone valerate 1 MOclobetasol propionate e 1 MOclobetasol propionate external soln 1

clobetasol propionate gel 1 MOclobetasol propionate oint 1 MOdesonide 1 MOdesoximetasone 1 MOdiflorasone diacetate 1 MOfluocinolone acetonide 1 MOfluocinonide emollient base 1fluocinonide external soln 1 MO






fluocinonide gel 1 MOfluocinonide oint 1 MOfluticasone propionate cream 1 MOfluticasone propionate oint 1 MOhalobetasol propionate 1 MOhydrocortisone butyrate 1 MOhydrocortisone cream 1%, 2.5% 1 MO

hydrocortisone lotn 2.5% 1 MOhydrocortisone oint 1%, 2.5% 1 MO

hydrocortisone valerate 1 MOmometasone furoate 1 MOprednicarbate 1 MOtriamcinolone acetonide cream 1 MO

triamcinolone acetonide lotn 1 MOtriamcinolone acetonide oint 1 MOtriderm 1 MO

TOPICAL ENZYMESBrands

SANTYL 2 MO

TOPICAL SCABICIDES / PEDICULICIDESGenerics

acticin 1 MOpermethrin cream 1 MOBrands

LINDANE 3 MO

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSGenerics

lactated ringers irrigation 1 MOneomycin/polymyxin b sulfates 1 MO

ringers irrigation 1 MO

Brands

PHYSIOLYTE 1PHYSIOSOL IRRIGATION 1TIS-U-SOL 1 MO

MISCELLANEOUS AGENTSGenerics

alendronate sodium 1 MOanagrelide hydrochloride 1 MOdextrose 10% flex container 3dextrose 2.5%/sodium chloride 0.45% 3

dextrose 5% 3 MOdextrose 5%/nacl 0.2% 3dextrose 5%/nacl 0.45% 3 MOdextrose 5%/nacl 0.9% 3 MOkionex powd 2 MOlevocarnitine oral soln 1 MOlevocarnitine tabs 1 B/D PA MOmidodrine 2 MOpilocarpine hcl tabs 1 MOsodium chloride 0.9% 1 MOsodium chloride inj 0.9% 1 MOsterile water irrigation 1 MOBrands

ADAGEN 4 PA MOBUPHENYL TABS 4 PA MOCAMPRAL 2 MOCLINIMIX/DEXTROSE 3CLINIMIX E/DEXTROSE 3DEXTROSE 10%/NACL 0.2% 3

DEXTROSE 5%/NACL 0.33% 3

EXJADE TBSO 125MG 3 PA MOEXJADE TBSO 250MG, 500MG 4 PA MO

INCRELEX 4 PA MOLEVOCARNITINE INJ 2 B/D PA MO






ORFADIN 4 LA MOPROLASTIN INJ 500MG 4 LA MOPROLASTIN-C 4RILUTEK 4 MOSODIUM POLYSTYRENE SULFONATE 1 MO

SYPRINE 3 MO

SMOKING DETERRENTSGenerics

buproban 1 MOBrands

CHANTIX 3 ST MONICOTROL INHALER 3 MO

NICOTROL NASAL 3 QL(40 per 30 days)MO

EAR, NOSE / THROAT MEDICATIONSMISCELLANEOUS AGENTSGenerics

azelastine hcl nasal soln 2 MOchlorhexidine gluconate oral rinse 1 MO

ipratropium bromide nasal soln 1 MO

periogard 1 MOtriamcinolone in orabase 1 MOBrands

TYZINE 2 MO

MISCELLANEOUS OTIC PREPARATIONSGenerics

acetasol hc 1 MOacetic acid 1 MOhydrocortisone/acetic acid 1 MOofloxacin 1 MOBrands

DERMOTIC 2 MO

OTIC STEROID / ANTIBIOTICGenerics

neomycin/polymyxin/hc 1 MOneomycin/polymyxin/ hydrocortisone otic susp 1 MO

Brands

CIPRODEX 3 MO

ENDOCRINE/DIABETESADRENAL HORMONESGenerics

cortisone acetate 1 MOdexamethasone elix 1 MOdexamethasone inj 4mg/ml 1 MOdexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg 1 MO

fludrocortisone acetate 1 MOhydrocortisone tabs 1 MOmethylprednisolone acetate inj 40mg/ml 2 MO

methylprednisolone acetate inj 80mg/ml 3 MO

methylprednisolone tabs 32mg 1

methylprednisolone tabs 16mg, 4mg, 8mg 1 MO

prednisolone sodium phosphate 1 MO

prednisone 1 MOBrands

DEXAMETHASONE INTENSOL 1 MO

DEXAMETHASONE TABS 1MG, 2MG 1 MO

PREDNISONE INTENSOL 1 MO

ANTITHYROID AGENTSGenerics

methimazole 1 MO






propylthiouracil 1 MO

DIABETES THERAPYGenerics

acarbose 1 MOglimepiride 1 MOglipizide 1 MOglipizide/metformin 1 MOglipizide er 1glyburide 1 MOglyburide/metformin 1 MOglyburide micronized 1 MOmetformin hcl 1 MOmetformin hcl er 1 MOnateglinide 2 MOnovolog flexpen 1 MOtolazamide 1 MOtolbutamide 2 MOBrands

ACTOPLUS MET 2 QL(90 per 30 days)MO

ACTOS 2 QL(30 per 30 days)MO

ALCOHOL PREPS 2

AVANDAMET 2 QL(60 per 30 days)MO

AVANDARYL 2 QL(60 per 30 days)MO

AVANDIA TABS 8MG 2 QL(30 per 30 days)MO

AVANDIA TABS 2MG, 4MG 2 QL(60 per 30

days)MOBD INSULIN SYRINGE SAFETYGLIDE/1ML/ 29G X 1/2”

1 MO

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”

1 MO

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2”

1 MO

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16”

1 MO

BYETTA INJ 5MCG/0.02ML 2 ST MO

BYETTA INJ 10MCG/0.04ML 2 QL(2.4 per 30

days) ST MOFREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM

1 ED

FREESTYLE LITE TEST STRIPS 1 ED

FREESTYLE TEST STRIPS 1 EDGAUZE PADS 2”X2” 1 MOGLUCAGEN HYPOKIT 2 MOGLUCAGON EMERGENCY KIT 2 MO

GLYSET 3 MOHUMALOG 2 MOHUMALOG KWIKPEN 2 MOHUMALOG MIX 50/50 2 MOHUMALOG MIX 50/50 KWIKPEN 2 MO

HUMALOG MIX 75/25 2 MOHUMALOG MIX 75/25 KWIKPEN 2 MO

HUMULIN 70/30 2 MOHUMULIN 70/30 PEN 2 MOHUMULIN N 2 MOHUMULIN N U-100 PEN 2 MOHUMULIN R 2 MOHUMULIN R U-500 (CONCENTRATED) 2 MO

JANUMET 2 QL(60 per 30 days)MO

JANUVIA 2 QL(30 per 30 days)MO

LANTUS 2 MO






LANTUS SOLOSTAR 2 MOLEVEMIR 1 MOLEVEMIR FLEXPEN 1 MONOVOLIN 70/30 1 MONOVOLIN N 1 MONOVOLIN R 1 MONOVOLOG 1 MONOVOLOG MIX 70/30 1 MONOVOLOG MIX 70/30 PREFILLED FLEXPEN 1 MO

PRECISION XTRA 1 EDPRECISION XTRA BLOOD GLUCOSE TEST STRIPS 1 ED

SYMLIN 2 QL(20 per 30 days)

SYMLINPEN 120 2 MOSYMLINPEN 60 2 MO

MISCELLANEOUS HORMONESGenerics

androxy 3 MOcabergoline 2 MOcalcitonin-salmon 1 MOcalcitriol caps 1 B/D PA MOcalcitriol inj 3 B/D PA MOchorionic gonadotropin 3 MOdanazol 2 MOdesmopressin acetate nasal soln 2 MO

desmopressin acetate tabs 2 MO

fortical 1 QL(3.7 per 30 days)MO

oxandrolone tabs 2.5mg 2 QL(120 per 30 days)MO

pamidronate disodium inj 30mg/10ml, 90mg/10ml 2 B/D PA

testosterone cypionate inj 100mg/ml 2 MO

Brands

ALDURAZYME 4 LA PA MO

ANADROL-50 4 PA MOANDROGEL GEL 50MG/5GM 3 MO

ANDROGEL PUMP GEL 1.62% 3 MO

ANDROID 3 PA MOCEREDASE 4 MO

CEREZYME INJ 200UNIT 4 B/D LA PA MO

ELAPRASE 4 LA MO

FABRAZYME INJ 35MG 4 B/D LA PA MO

HECTOROL CAPS 3 B/D PA MOKUVAN 4 PA MOMIACALCIN INJ 3 B/D PA MOMIACALCIN NASAL SOLN 3 MO

NAGLAZYME 4 LA PA MOOXANDROLONE TABS 10MG 4 QL(60 per 30

days)MOPAMIDRONATE DISODIUM INJ 6MG/ML 2 B/D PA

SENSIPAR TABS 30MG 2 QL(60 per 30 days)MO



SOMAVERT 4 PA QL(30 per 30 days)MO

SYNAREL 4 PA MOZAVESCA 4ZOMETA 4 PA MO

THYROID HORMONESGenerics

levothroid 1 MOlevothyroxine tabs 1levoxyl 1 MOliothyronine sodium tabs 1 MO






unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

1 MO

Brands

SYNTHROID 2 MO

GASTROENTEROLOGYANTIDIARRHEALS / ANTISPASMODICSGenerics

dicyclomine hcl caps 3 MOdicyclomine hcl oral soln 3 MOdicyclomine hcl tabs 3 MOglycopyrrolate tabs 1 MOloperamide hcl caps 1 MOmethscopolamine bromide 1 MO

MISCELLANEOUS GASTROINTESTINAL AGENTSGenerics

balsalazide 2 MOcompro 1 MOconstulose 1 MOcortenema 3 MOdronabinol 3 PA MOenulose 1 MOgavilyte-c 2 MOgavilyte-g 2 MOgavilyte-n/flavor pack 2 MOgolytely oral soln 227.1gm; 2.82gm; 6.36gm; 5.53gm; 21.5gm

3 MO

granisetron inj 0.1mg/ml 3 MOgranisetron tabs 3 MOhydrocortisone enem 1lactulose 1 MOmeclizine hcl 1 MOmesalamine enem 2 MOmetoclopramide inj 3 MO

metoclopramide oral soln 1 MOmetoclopramide tabs 1 MOondansetron hcl oral soln 3 B/D PA MOondansetron hcl tabs 24mg 3 B/D PAondansetron hcl tabs 4mg, 8mg 3 B/D PA MO

ondansetron odt 3 B/D PA MOpolyethylene glycol 3350 powd 1 MO

prochlorperazine 1prochlorperazine edisylate 3 MOprochlorperazine maleate 1 MOprocto-pak 1 MOproctosol hc 1 MOproctozone-hc 1 MOsulfasalazine tabs 1 MOsulfazine ec 1ursodiol caps 3 MOursodiol tabs 3Brands

ASACOL 3 QL(180 per 30 days)MO

COLOCORT 1 MOCORTIFOAM 3 MOCREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT

3 MO

CYSTADANE 3 MO

EMEND CAPS 3B/D PA QL(6 per 30 days)MO

ENTOCORT EC 3 PA MOGASTROCROM 3 MOGOLYTELY ORAL SOLN 236GM; 2.97GM; 6.74GM; 5.86GM; 22.74GM


GRANISETRON INJ 1MG/ML 3 MO






LOTRONEX 2 QL(60 per 30 days)MO

PANCREAZE 3 MOPROCTOCREAM HC 1 MORELISTOR 3 MOREMICADE 4 PA MOTRILYTE 2 MOVISICOL 3 MOZENPEP 2 MO

ULCER THERAPYGenerics

cimetidine 1 MOcimetidine hcl oral soln 1 MOfamotidine tabs 20mg, 40mg 1 MOlansoprazole 1 MOmisoprostol 1 MOnizatidine caps 1 MOomeprazole cpdr 10mg, 20mg 1 MO

pantoprazole 2 MOranitidine hcl caps 1 MOranitidine hcl inj 150mg/6ml 2 MOranitidine hcl syrp 1 MOranitidine hcl tabs 1 MOsucralfate 1 MOBrands

NEXIUM CPDR 3 QL(30 per 30 days) ST MO

NEXIUM PACK 20MG, 40MG 3 QL(30 per 30

days) ST MOPROTONIX INJ 3

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSBrands

ACTIMMUNE 4 LA PA MO

ARCALYST 4 LA PA MO

AVONEX 4 PA QL(4 per 30 days)MO

BETASERON 4 PA MOGENOTROPIN 4 MOGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

4 MO

GENOTROPIN MINIQUICK INJ 0.2MG 3 MO

INTRON-A INJ 3MU/0.2ML 3INTRON-A INJ 6000000UNIT/ML 3 MO

INTRON-A INJ 10MU/0.2ML, 5MU/0.2ML 4

INTRON-A WITH DILUENT INJ 10MU 3 MO

LEUKINE 4 PA MOMOZOBIL 4 MONEUMEGA 4 PA MONEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML

4 PA MO

PEG-INTRON INJ 50MCG/0.5ML 4 PA MO

PEG-INTRON REDIPEN 4 PA MOPEGASYS INJ 180MCG/0.5ML 4 PA MO

PROCRIT INJ 20000UNIT/ ML, 40000UNIT/ML 4 PA MO

PROCRIT INJ 10000UNIT/ ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ ML

2 PA MO

PROLEUKIN 4 PA MO






VACCINES / MISCELLANEOUS IMMUNOLOGICALSGenerics

gammagard liquid inj 2.5gm/25ml 4 B/D PA MO

tetanus toxoid adsorbed 2Brands

ACTHIB 3ADACEL 3 MOATGAM 4BOOSTRIX 3 MOCARIMUNE NANOFILTERED INJ 3GM

4 B/D PA MO

CERVARIX 3COMVAX 3 MODAPTACEL 3 MODECAVAC 3 MODIPHTHERIA/TETANUS TOXOID PEDIATRIC 3 MO

ENGERIX-B INJ 10MCG/0.5ML 3 B/D PA

ENGERIX-B INJ 20MCG/ ML 3 B/D PA MO

GAMASTAN S/D 2 B/D PA MOGARDASIL 3 MOHAVRIX INJ 720ELU/0.5ML 3

HAVRIX INJ 1440ELU/ML 3 MOIMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3 MOIPOL INACTIVATED IPV 3 MOIXIARO 3JE-VAX 3 MOM-M-R II W/DILUENT 10 DOSE 3 MO

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

PEDVAX HIB 3 MOPROQUAD 3RABAVERT 3 MORECOMBIVAX HB INJ 40MCG/ML 3 B/D PA

RECOMBIVAX HB INJ 10MCG/ML 3 B/D PA MO

ROTATEQ 3TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

3 MO

THYMOGLOBULIN 4 B/D PATRIPEDIA 3TWINRIX 2 B/D PA MOTYPHIM VI 3VAQTA 3 MOVARIVAX 2YF-VAX 3

ZOSTAVAX 3 QL(1 per 365 days)

MUSCULOSKELETAL / RHEUMATOLOGYGOUT THERAPYGenerics

allopurinol 1 MOprobenecid 1 MOprobenecid/colchicine 1 MOBrands

COLCRYS 3 MO

OSTEOPOROSIS THERAPYGenerics

alendronate sodium 1 MOBrands

ACTONEL TABS 150MG 2 QL(1 per 30 days)MO

ACTONEL TABS 35MG 2 QL(4 per 30 days)MO






BONIVA TABS 2B/D PA QL(1 per 30 days)MO

EVISTA 2 QL(30 per 30 days)MO

FORTEO 4 PA MO

OTHER RHEUMATOLOGICALSGenerics

leflunomide 2 QL(30 per 30 days)MO

Brands

CUPRIMINE 3 MOHUMIRA INJ 40MG/0.8ML 4 PA MOKINERET 4 PA MO

OBSTETRICS / GYNECOLOGYESTROGENS / PROGESTINSGenerics

camila 1 MOerrin 1 MOestradiol/norethindrone acetate tabs 1mg; 0.5mg 1 MO

estradiol ptwk 1estradiol tabs 1 MOestropipate 1 MOjolivette 1 MOmedroxyprogesterone acetate 1 MOnora-be 1 MOnorethindrone tabs 5mg 1 MOortho-est 1Brands

CLIMARA PRO 2 MO

MENEST 2 QL(30 per 30 days)MO

PREMARIN TABS 2 QL(30 per 30 days)MO

PREMARIN W/ APPLICATOR 2 MO

PREMPHASE 2 QL(30 per 30 days)MO

PREMPRO 2 QL(30 per 30 days)MO

MISCELLANEOUS OB/GYNGenerics

clindamycin phosphate cream 1 MO

metronidazole vaginal 1 MOmiconazole 3 1 MOterconazole 1 MOvandazole 1 MOzazole cream 0.4% 1 MOBrands

ZAZOLE CREAM 0.8% 1 MO

ORAL CONTRACEPTIVES / RELATED AGENTSGenerics

apri 1 MOaranelle 1 MOaviane 1 MObalziva 1 MOcesia 1 MOcryselle-28 1 MOenpresse-28 1 MOjunel 1 MOjunel fe 1.5/30 1 MOjunel fe 1/20 1 MOkariva 1 MOkelnor 1/35 1 MOleena 1 MOlessina-28 1 MOlevora 1 MOlow-ogestrel 1 MOlutera 1 MOmicrogestin 1.5/30 1 MOmicrogestin 1/20 1 MOmicrogestin fe 1 MO






microgestin fe 1.5/30 1 MOmononessa 1 MOnecon 0.5/35-28 1 MOnecon 1/35-28 1 MOnecon 10/11-28 1 MOnecon 7/7/7 1 MOnortrel 0.5/35 (28) 1 MOnortrel 1/35 (21) 1 MOnortrel 1/35 (28) 1 MOnortrel 7/7/7 1 MOogestrel 1 MOportia-28 1 MOprevifem 1 MOquasense 1 MOreclipsen 1 MOsolia 1 MOsprintec 28 1 MOsronyx 1 MOtri-legest fe 1 MOtri-previfem 1 MOtri-sprintec 1 MOtrinessa 1 MOtrivora-28 1 MOvelivet 1 MOzovia 1/35e 1 MOzovia 1/50e 1 MO

OPHTHALMOLOGYANTIBIOTICSGenerics

bacitracin/polymyxin b 1 MObacitracin ophthalmic oint 1 MOciprofloxacin ophthalmic soln 1 MOerythromycin oint 1 MOgentak 1 MOgentamicin sulfate ophthalmic soln 1 MO

gentasol 1 MO

neomycin/bacitracin/ polymyxin 1 MO

neomycin/polymyxin/ gramicidin 1 MO

ofloxacin 1 MOtobramycin ophthalmic soln 1 MOtobrasol 1trimethoprim sulfate/ polymyxin b sulfate 1 MO

Brands

NATACYN 3 MOROMYCIN 1 MOVIGAMOX 3 MO

ANTIVIRALSGenerics

trifluridine 1 MOBrands

ZIRGAN 3 MO

BETA-BLOCKERSGenerics

betaxolol hcl 1 MOcarteolol hcl 1 MOlevobunolol hcl 1 MOmetipranolol 1 MOtimolol maleate 1 MOtimolol maleate ophthalmic gel forming 1 MO

Brands

BETIMOL 3 MOBETOPTIC-S 2 MO

CYCLOPLEGIC MYDRIATICSGenerics

tropicamide 1 MO






DIRECT ACTING MIOTICSBrands

PILOPINE HS 2 MO

MISCELLANEOUS OPHTHALMOLOGICSGenerics

azelastine hcl ophthalmic soln 3 MO

cromolyn sodium ophthalmic soln 1 MO

parcaine 1proparacaine hcl 1Brands

ALAMAST 2 MOALOCRIL 3 MO

RESTASIS 2 QL(60 per 30 days)MO

NON-STEROIDAL ANTI-INFLAMMATORY AGENTSGenerics

diclofenac sodium 1 MOflurbiprofen sodium 1 MOketorolac tromethamine ophthalmic soln 2 MO

ORAL DRUGS FOR GLAUCOMAGenerics

acetazolamide 1 MOmethazolamide 1 MO

OTHER GLAUCOMA DRUGSGenerics

dorzolamide hcl 1 MOdorzolamide hcl/timolol maleate 1 MO

latanoprost 1 MOBrands

AZOPT 2 MO

LUMIGAN 3 MO

TRAVATAN Z 3 QL(5 per 30 days)MO

XALATAN 2 MO

STEROID-ANTIBIOTIC COMBINATIONSGenerics

neomycin/polymyxin/ bacitracin/hydrocortisone 1 MO

neomycin/polymyxin/ dexamethasone 1 MO

neomycin/polymyxin/ hydrocortisone ophthalmic susp

1 MO

poly-dex oint 1 MOpoly-dex susp 1tobramycin/dexamethasone 2 MOBrands

TOBRADEX OINT 3 MO

STEROID-SULFONAMIDE COMBINATIONSGenerics

sulfacetamide sodium/ prednisolone sodium phospha

1 MO

STEROIDSGenerics

dexamethasone ophthalmic soln 1 MO

fluorometholone 1 MOprednisolone acetate 1 MOprednisolone sodium phosphate 1 MO

Brands

ALREX 2 MOLOTEMAX 2 MO






SULFONAMIDESGenerics

sodium sulfacetamide 1 MO

SYMPATHOMIMETICSGenerics

apraclonidine 3 MObrimonidine tartrate ophthalmic soln 0.2% 1 MO

VASOCONSTRICTOR DECONGESTANTSGenerics

ak-con 1 MO

RESPIRATORY AND ALLERGYANTIHISTAMINE / ANTIALLERGENIC AGENTSGenerics

cetirizine hcl syrp 3 MOclemastine fumarate syrp 1 MOclemastine fumarate tabs 2.68mg 1 MO

fexofenadine hcl tabs 180mg 1 QL(30 per 30 days)

fexofenadine hcl tabs 30mg, 60mg 1 QL(60 per 30

days)levocetirizine dihydrochloride 3 MO

palgic liqd 1 MOpromethazine hcl inj 25mg/ ml 3

promethazine hcl inj 50mg/ ml 3 MO

promethazine/codeine 1 ED

PULMONARY AGENTSGenerics

acetylcysteine 1 B/D PA MOalbuterol sulfate er 1 MO

albuterol sulfate nebu 1 B/D PA MOalbuterol sulfate syrp 1 MOalbuterol sulfate tabs 1 MOaminophylline tabs 1 MObudesonide susp 2 B/D PA MOcromolyn sodium nebu 1 B/D PA MOflunisolide nasal soln 0.025% 1 MO

fluticasone propionate susp 1 QL(16 per 30 days)MO

ipratropium bromide inhalation soln 1 B/D PA MO

ipratropium bromide/ albuterol sulfate 1 B/D PA MO

levalbuterol 2B/D PA QL(288 per 30 days)MO

metaproterenol sulfate 1 MOterbutaline sulfate tabs 1 MOtheochron tb12 300mg 1theochron tb12 100mg 1 MOtheophylline er 1 MOzafirlukast 2 MOBrands

ADVAIR DISKUS 2 QL(60 per 30 days)MO

ADVAIR HFA 2 QL(12 per 30 days)MO

ASMANEX 120 METERED DOSES 3 MO


ASMANEX 30 METERED DOSES AEPB 220MCG/ INH

3 MO


ATROVENT HFA 2 QL(25.8 per 30 days)MO

COMBIVENT 3 MOFLOVENT HFA 2 MO






LETAIRIS 4 LA PA MO

NASACORT AQ 3 QL(33 per 30 days)MO

NASONEX 3 QL(34 per 30 days)MO

PROAIR HFA 3 MOPROVENTIL HFA 3 MOPULMICORT FLEXHALER 3 MO

PULMOZYME 4 B/D PA MOQVAR 2 MOREVATIO TABS 4 PA MO

RHINOCORT AQUA 3 QL(17.2 per 30 days)MO

SEREVENT DISKUS 2 MO

SINGULAIR 3 QL(30 per 30 days)MO

SPIRIVA HANDIHALER 3 QL(30 per 30 days)MO

SYMBICORT AERO 80MCG/ACT; 4.5MCG/ ACT

3 QL(20 per 30 days)

SYMBICORT AERO 160MCG/ACT; 4.5MCG/ ACT


TRACLEER 4LA PA QL(60 per 30 days)MO

VENTAVIS INHALATION SOLN 10MCG/ML 4 PA MO

VENTOLIN HFA 2 MOXOLAIR 4 PA MOXOPENEX HFA 3 MOXOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML

3 B/D PA MO

ZYFLO CR 2 QL(120 per 30 days)MO

UROLOGICALSANTICHOLINERGICS / ANTISPASMODICSGenerics

flavoxate hcl 1 MOoxybutynin 1 MO

oxybutynin er tb24 5mg 1 QL(30 per 30 days)MO



Brands

DETROL LA 2 QL(30 per 30 days)MO

DETROL TABS 2MG 2 QL(60 per 30 days)MO

DETROL TABS 1MG 2 QL(120 per 30 days)MO

VESICARE 3 QL(30 per 30 days)MO

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPYGenerics

finasteride 1 MOtamsulosin hcl 1 MOBrands

AVODART 2 QL(30 per 30 days)MO

CHOLINERGIC STIMULANTSGenerics

bethanechol chloride 2 MO

MISCELLANEOUS UROLOGICALSGenerics

potassium citrate extended-release 1 MO






Brands

CIALIS TABS 10MG, 20MG, 5MG 2 ED QL(4 per

30 days)CYSTAGON 2 LAELMIRON 3 MO

LEVITRA 2 ED QL(4 per 30 days)

VIAGRA 2 ED QL(4 per 30 days)

VITAMINS, HEMATINICS / ELECTROLYTESELECTROLYTESGenerics

calcium acetate 1 MOed k+10 1eliphos 1 MOkcl 0.3%/d5w/lr iv lac ring 3klor-con 10 1 MOklor-con 8 1 MOklor-con m20 1 MOlactated ringers 1 MOplasma-lyte inj 3potassium chloride 0.15% d5w/nacl 0.33% 3

potassium chloride 0.15% d5w/nacl 0.45% viaflex 3 MO

potassium chloride 0.15% nacl 0.9% 3

potassium chloride 0.224%/ d5w 3

potassium chloride 0.3%/d5w 3

potassium chloride er cpcr 1 MOpotassium chloride er tbcr 10meq 1

potassium chloride er tbcr 20meq 1 MO

potassium chloride inj 10meq/100ml 3

sodium lactate 2Brands

POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225%

3

POTASSIUM CHLORIDE 0.15%/D5W 3

POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 3

POTASSIUM CHLORIDE 0.3%/ NACL 0.9% 3

POTASSIUM CHLORIDE INJ 0.4MEQ/ML 3

MISCELLANEOUS NUTRITION PRODUCTSGenerics

aminosyn ii inj 3intralipid inj 2.25%; 20% 2Brands

AMINOSYN 3AMINOSYN II INJ 3AMINOSYN M 3AMINOSYN-HBC 3AMINOSYN-HF 3AMINOSYN-PF 3AMINOSYN-PF 7% 3CLINIMIX/DEXTROSE 3CLINIMIX E/DEXTROSE 3DEXTROSE 5% / ELECTROLYTE #48 VIAFLEX

3

FREAMINE III 3HEPATAMINE 2PLASMA-LYTE INJ 3






PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML

2

VITAMINS / HEMATINICSGenerics

prenatal vitamins (generic) 1sodium fluoride tabs 1 MO


AABILIFY DISCMELT .................16ABILIFY INJ ...............................16ABILIFY ORAL SOLN ...............16ABILIFY TABS ...........................16ABSTRAL SUBL 100MCG, 200MCG ....................................13ABSTRAL SUBL 300MCG, 400MCG, 600MCG, 800MCG ....................................13acarbose ........................................24acebutolol .....................................17acetaminophen/codeine #3 ...........12acetaminophen/codeine #4 ...........12acetaminophen/codeine oral soln ......................................12acetaminophen/codeine tabs 300mg; 15mg ......................12acetasol hc ....................................23acetazolamide ...............................31acetic acid .....................................23acetylcysteine ...............................32ACTHIB .......................................28acticin ...........................................22ACTIMMUNE .............................27ACTONEL TABS 35MG .............28ACTONEL TABS 150MG ...........28ACTOPLUS MET ........................24ACTOS ........................................24acyclovir caps .................................6acyclovir inj 500mg .......................6acyclovir susp .................................6acyclovir tabs .................................6ADACEL .....................................28ADAGEN .....................................22ADVAIR DISKUS .......................32ADVAIR HFA ..............................32afeditab cr .....................................17AFINITOR TABS 2.5MG ............10AFINITOR TABS 10MG, 5MG ...........................................10AGGRENOX ...............................19ak-con ...........................................32ALAMAST ..................................31ALBENZA .....................................8albuterol sulfate er ........................32albuterol sulfate nebu ...................32albuterol sulfate syrp ....................32albuterol sulfate tabs ....................32

alclometasone dipropionate .........21ALCOHOL PREPS ......................24ALDURAZYME ..........................25alendronate sodium ................22, 28ALIMTA INJ 500MG ..................10ALINIA SUSR ...............................8ALINIA TABS ...............................8allopurinol ....................................28ALOCRIL ....................................31alprazolam ....................................14alprazolam er ................................14ALREX ........................................31amantadine caps .............................6amantadine tabs ..............................6amcinonide cream ........................21amcinonide lotn ............................21amcinonide oint ............................21AMIFOSTINE ...............................9amikacin sulfate inj 50mg/ml .........7amikacin sulfate inj 500mg/2ml ...................................7amiloride ......................................17amiloride/ hydrochlorothiazide ...................17aminophylline tabs .......................32AMINOSYN ................................34AMINOSYN-HBC ......................34AMINOSYN-HF..........................34aminosyn ii inj..............................34AMINOSYN II INJ ......................34AMINOSYN M ...........................34AMINOSYN-PF ..........................34AMINOSYN-PF 7% ....................34amiodarone tabs ...........................17amitriptyline .................................14amlodipine ....................................17amlodipine/benazepril caps 5mg; 20mg .................................17amlodipine/benazepril caps 10mg; 20mg, 2.5mg; 10mg, 5mg; 10mg .................................17amlodipine/benazepril caps 10mg; 40mg, 5mg; 40mg ...........17ammonium lactate ........................20amoxapine ....................................14amoxicillin .....................................8amoxicillin/clavulanate potassium .....................................8amoxicillin/potassium clavulanate tabs ............................8

amphetamine/ dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg .................14amphetamine/ dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 7.5mg .........................................14amphotericin b ...............................5ampicillin caps ...............................8ampicillin inj 10gm, 125mg, 1gm ..............................................8ampicillin-sulbactam inj 2gm; 1gm .....................................8ampicillin-sulbactam inj 10gm; 5gm ...................................8ampicillin susr ................................8ANADROL-50 .............................25anagrelide hydrochloride .............22anastrozole .....................................9ANCOBON ....................................5ANDROGEL GEL 50MG/5GM................................25ANDROGEL PUMP GEL 1.62% .........................................25ANDROID ...................................25androxy ........................................25APOKYN .....................................12apraclonidine ................................32apri ...............................................29APTIVUS CAPS ............................6APTIVUS ORAL SOLN ...............6aranelle .........................................29ARCALYST .................................27ARIXTRA ....................................19AROMASIN ................................10ARTHROTEC 50 .........................14ARTHROTEC 75 .........................14ASACOL ......................................26ascomp/codeine ............................12ASMANEX 14 METERED DOSES .......................................32ASMANEX 30 METERED DOSES AEPB 220MCG/ INH ............................................32ASMANEX 60 METERED DOSES .......................................32


ASMANEX 120 METERED DOSES .......................................32ATACAND ...................................18ATACAND HCT ..........................18atenolol .........................................17atenolol/chlorthalidone ................17ATGAM .......................................28ATRIPLA .......................................6ATROVENT HFA ........................32augmented betamethasone dipropionate cream .....................21augmented betamethasone dipropionate lotn ........................21augmented betamethasone dipropionate oint ........................21AVALIDE .....................................18AVANDAMET .............................24AVANDARYL ..............................24AVANDIA TABS 2MG, 4MG ...........................................24AVANDIA TABS 8MG ................24AVAPRO ......................................18AVASTIN INJ 100MG/4ML ........10AVELOX ABC PACK ...................9AVELOX TABS .............................9aviane ...........................................29AVODART ...................................33AVONEX .....................................27azathioprine ....................................9azelastine hcl nasal soln ...............23azelastine hcl ophthalmic soln .............................................31AZILECT .....................................12azithromycin inj 500mg .................7azithromycin susr ...........................7azithromycin tabs ...........................7AZOPT .........................................31

Bbacitracin ophthalmic oint ............30bacitracin/polymyxin b ................30baclofen ........................................12BACTOCILL IN DEXTROSE .................................8BACTROBAN Cream .................21balsalazide ....................................26balziva ..........................................29BANZEL SUSP ...........................11BANZEL TABS 200MG ..............11BANZEL TABS 400MG ..............11BARACLUDE ORAL SOLN ........6

BARACLUDE TABS ....................6BD INSULIN SYRINGE SAFETYGLIDE/1ML/ 29G X 1/2” .................................24BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” .......................................24BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” .........................................24BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” .......................................24benazepril .....................................17benazepril/ hydrochlorothiazide ...................17BENICAR ....................................18BENICAR HCT ...........................18benztropine mesylate inj ..............12benztropine mesylate tabs ............12betamethasone dipropionate .........21betamethasone valerate ................21BETASERON ..............................27betaxolol hcl ...........................17, 30bethanechol chloride ....................33BETIMOL ....................................30BETOPTIC-S ...............................30bicalutamide ...................................9bisoprolol fumarate ......................17bisoprolol fumarate/ hydrochlorothiazide ...................17BLEOMYCIN SULFATE INJ 30UNIT ...............................10BONIVA TABS ............................29BOOSTRIX..................................28brimonidine tartrate ophthalmic soln 0.2% .................32bromocriptine mesylate ................12budeprion sr .................................14budeprion xl .................................14budesonide susp ...........................32bumetanide tabs ...........................17BUPHENYL TABS......................22buprenorphine hcl subl .................13buproban ......................................23bupropion hcl ...............................14bupropion hcl sr ...........................14buspirone hcl ................................14butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg ............................................5

butorphanol tartrate nasal soln .............................................13BYETTA INJ 5MCG/0.02ML ..........................24BYETTA INJ 10MCG/0.04ML ........................24

Ccabergoline ...................................25CADUET .....................................19calcipotriene external soln ...........20calcitonin-salmon .........................25calcitriol caps ...............................25calcitriol inj ..................................25calcium acetate .............................34camila ...........................................29CAMPATH ...................................10CAMPRAL ..................................22CAPASTAT SULFATE ..................8captopril .......................................17captopril/ hydrochlorothiazide ...................17CARAC ........................................20carbamazepine ..............................11carbamazepine er tb12 .................11carbidopa/levodopa ......................12carbidopa/levodopa cr ..................12carbidopa/levodopa sr tbcr 50mg; 200mg .............................12CARIMUNE NANOFILTERED INJ 3GM ...........................................28carteolol hcl ..................................30cartia xt .........................................17carvedilol ......................................17CEENU ........................................10cefaclor ...........................................7cefaclor er .......................................7cefadroxil .......................................7cefazolin inj 1gm ............................7cefazolin inj 20gm, 500mg ............7cefdinir ...........................................7cefepime inj 1gm ............................7cefepime inj 2gm ............................7cefotetan inj 1gm, 2gm ..................7cefpodoxime proxetil .....................7cefprozil .........................................7ceftriaxone sodium inj 1gm, 250mg, 2gm, 500mg ....................7ceftriaxone sodium inj 10gm .........7cefuroxime axetil ...........................7

Drug Formulary Index


cefuroxime sodium inj 1.5gm, 750mg ..............................7cefuroxime sodium inj 7.5gm ........7CELEBREX CAPS 100MG ........14CELEBREX CAPS 200MG, 400MG, 50MG ...........................14CELLCEPT ..................................10CELONTIN ..................................11cephalexin ......................................7CEREDASE .................................25CEREZYME INJ 200UNIT .........25CERVARIX ..................................28cesia ..............................................29cetirizine hcl syrp .........................32CHANTIX ....................................23chlordiazepoxide/ amitriptyline ...............................14chlordiazepoxide hcl ....................14chlorhexidine gluconate oral rinse .....................................23chloroquine ....................................7chlorothiazide ...............................17chlorpromazine inj .......................14chlorpromazine tabs .....................14chlorthalidone tabs 25mg, 50mg ..........................................17chlorzoxazone ..............................12cholestyramine light pack ............19chorionic gonadotropin ................25CIALIS TABS 10MG, 20MG, 5MG ...............................34ciclopirox gel ...............................21ciclopirox nail lacquer ..................21ciclopirox olamine .......................21ciclopirox susp .............................21cilostazol ......................................19cimetidine .....................................27cimetidine hcl oral soln ................27CIPRODEX..................................23ciprofloxacin er ..............................8ciprofloxacin extended- release ..........................................8ciprofloxacin inj 400mg/40ml ........8ciprofloxacin ophthalmic soln ......30ciprofloxacin tabs ...........................8citalopram ....................................14clarithromycin ................................7clarithromycin er ............................7clemastine fumarate syrp .............32clemastine fumarate tabs 2.68mg .......................................32CLIMARA PRO...........................29clindamycin hcl ..............................7

clindamycin phosphate add-vantage ..................................7clindamycin phosphate cream ..........................................29clindamycin phosphate external soln ...............................20clindamycin phosphate gel ...........20clindamycin phosphate lotn .........20clindamycin phosphate swab .......20CLINIMIX/DEXTROSE .......22, 34CLINIMIX E/DEXTROSE ....22, 34clobetasol propionate e ................21clobetasol propionate external soln ...............................21clobetasol propionate gel .............21clobetasol propionate oint ............21clomipramine ...............................14clonazepam ..................................11clonazepam odt ............................11clonidine tabs ...............................17clorazepate dipotassium ...............14clotrimazole/betamethasone .........21clotrimazole external cream .........21clotrimazole external soln ............21clotrimazole troc ............................5clozapine tabs 100mg, 25mg, 50mg ..........................................14CO-GESIC ...................................13COLCRYS ...................................28colestipol ......................................19COLISTIMETHATE SODIUM ......................................8COLOCORT ................................26COMBIVENT ..............................32COMBIVIR....................................6compro .........................................26COMTAN.....................................12COMVAX ....................................28constulose .....................................26COPAXONE ................................12COREG CR ..................................19cortenema .....................................26CORTIFOAM ..............................26cortisone acetate ...........................23COUMADIN TABS .....................19CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT ...........26CRESTOR ....................................19CRIXIVAN CAPS 100MG ............6CRIXIVAN CAPS 200MG, 400MG .........................................6

cromolyn sodium nebu .................32cromolyn sodium ophthalmic soln .............................................31cryselle-28 ....................................29CUBICIN .......................................8CUPRIMINE................................29cyclophosphamide tabs ..................9cyclosporine caps 50mg .................9cyclosporine caps 100mg, 25mg ............................................9cyclosporine oral soln ....................9CYKLOKAPRON .......................19CYMBALTA CPEP 20MG, 30MG .........................................16CYMBALTA CPEP 60MG ..........16CYSTADANE ..............................26CYSTAGON ................................34

Ddanazol .........................................25DAPSONE .....................................8DAPTACEL .................................28DARAPRIM ..................................8DAUNOXOME ...........................10DECAVAC ...................................28demeclocycline hcl .........................9DENAVIR ....................................21depade ..........................................13dermotic .......................................23desipramine ..................................14desmopressin acetate nasal soln .............................................25desmopressin acetate tabs ............25desonide .......................................21desoximetasone ............................21DETROL LA ................................33DETROL TABS 1MG ..................33DETROL TABS 2MG ..................33dexamethasone elix ......................23dexamethasone inj 4mg/ml ..........23DEXAMETHASONE INTENSOL ................................23dexamethasone ophthalmic soln .............................................31dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg .........23DEXAMETHASONE TABS 1MG, 2MG ......................23dexmethylphenidate .....................14dextroamphetamine sulfate ..........14dextroamphetamine sulfate er ......14dextrose 2.5%/sodium chloride 0.45% ...........................22dextrose 5% ..................................22


DEXTROSE 5% / ELECTROLYTE #48 VIAFLEX ..................................34dextrose 5%/nacl 0.2% .................22dextrose 5%/nacl 0.9% .................22DEXTROSE 5%/NACL 0.33% .........................................22dextrose 5%/nacl 0.45% ...............22dextrose 10% flex container .........22DEXTROSE 10%/NACL 0.2% ...........................................22diazepam tabs ...............................11diclofenac potassium ....................13diclofenac sodium ..................13, 31diclofenac sodium ec ....................13diclofenac sodium xr ....................13dicloxacillin sodium .......................8dicyclomine hcl caps ....................26dicyclomine hcl oral soln .............26dicyclomine hcl tabs ....................26didanosine cpdr 125mg ..................6didanosine cpdr 200mg, 250mg, 400mg .............................6diflorasone diacetate .....................21diflunisal .......................................13digoxin oral soln ..........................19digoxin tabs ..................................19DILANTIN INFATABS ...............11dilt-cd cp24 120mg, 300mg .........17diltiazem cd cp24 120mg, 240mg, 300mg ...........................17diltiazem hcl er cp12 ....................17diltiazem hcl er cp24 360mg, 420mg ........................................17diltiazem hcl tabs .........................17dilt-xr cp24 180mg, 240mg ..........17diltzac cp24 120mg, 180mg, 240mg, 300mg ...........................17DIOVAN HCT .............................19DIOVAN TABS 160MG, 40MG, 80MG .............................19DIOVAN TABS 320MG ..............19DIPHTHERIA/TETANUS TOXOID PEDIATRIC ...............28disopyramide phosphate ...............17divalproex sodium cpsp ...............11divalproex sodium er ....................11divalproex sodium tbec ................11donepezil hcl ................................12dorzolamide hcl ............................31dorzolamide hcl/timolol maleate .......................................31doxazosin .....................................17doxepin .........................................14

doxycycline hyclate caps ...............9DOXYCYCLINE HYCLATE CPEP 75MG .............9doxycycline hyclate cpep 100mg ..........................................9doxycycline hyclate inj ..................9doxycycline hyclate tabs ................9doxycycline monohydrate tabs 150mg, 50mg, 75mg .............9dronabinol ....................................26

Eeconazole nitrate ..........................21ed k+10.........................................34EDURANT ....................................6e.e.s. 400 ........................................7ELAPRASE .................................25ELIDEL ........................................20eliphos ..........................................34ELITEK INJ 1.5MG ......................9ELMIRON ...................................34EMCYT ........................................10EMEND CAPS ............................26EMSAM .......................................16EMTRIVA ......................................6enalapril ........................................17enalapril/ hydrochlorothiazide ...................17ENGERIX-B INJ 10MCG/0.5ML ..........................28ENGERIX-B INJ 20MCG/ ML ..............................................28enoxaparin sodium .......................19enpresse-28 ..................................29ENTOCORT EC ..........................26enulose .........................................26epitol ............................................11EPIVIR ...........................................6EPIVIR HBV .................................6EPZICOM ......................................6ERAXIS INJ 100MG .....................5ergotamine tartrate/caffeine .........12errin ..............................................29ery ................................................20ery-tab tbec 333mg ........................7erythrocin stearate ..........................7erythromycin base ..........................7erythromycin/benzoyl peroxide ......................................20erythromycin ethylsuccinate ..........7erythromycin external soln ..........20erythromycin gel ..........................20erythromycin oint .........................30erythromycin/sulfisoxazole ............7

estazolam ......................................14estradiol/norethindrone acetate tabs 1mg; 0.5mg .............29estradiol ptwk ...............................29estradiol tabs ................................29estropipate ....................................29ethambutol tabs 100mg ..................7ethambutol tabs 400mg ..................7ethosuximide ................................11etodolac ........................................13EVISTA ........................................29EXELON PT24 ............................12exemestane .....................................9EXFORGE ...................................19EXFORGE HCT ..........................19EXJADE TBSO 125MG ..............22EXJADE TBSO 250MG, 500MG .......................................22

FFABRAZYME INJ 35MG ...........25famciclovir .....................................6famotidine tabs 20mg, 40mg ........27FANAPT TABS 1MG, 2MG, 4MG .................................16FANAPT TABS 10MG, 12MG, 6MG, 8MG ....................16FANAPT TITRATION PACK .........................................16FARESTON .................................10FASLODEX .................................10FAZACLO ...................................16FELBATOL ..................................11felodipine er .................................17FEMARA .....................................10fenofibrate ....................................19fenofibrate micronized .................19fenoprofen calcium ......................13fentanyl patches ...........................13fexofenadine hcl tabs 30mg, 60mg ..........................................32fexofenadine hcl tabs 180mg .......32finasteride .....................................33flavoxate hcl .................................33flecainide acetate ..........................17FLOVENT HFA ...........................32fluconazole in dextrose inj 0; 400mg/200ml ...........................5fluconazole susr ..............................5fluconazole tabs ..............................5fludarabine phosphate inj 50mg ............................................9fludrocortisone acetate .................23flunisolide nasal soln 0.025% ......32


fluocinolone acetonide .................21fluocinonide emollient base .........21fluocinonide external soln ............21fluocinonide gel ............................22fluocinonide oint ..........................22fluorometholone ...........................31fluorouracil cream ........................20fluorouracil external soln .............20fluoxetine ......................................15fluphenazine conc .........................15fluphenazine decanoate inj ...........15fluphenazine elix ..........................15fluphenazine inj ............................15fluphenazine tabs ..........................15flurazepam hcl ..............................15flurbiprofen ..................................13flurbiprofen sodium ......................31flutamide ........................................9fluticasone propionate cream .......22fluticasone propionate oint ...........22fluticasone propionate susp ..........32fluvoxamine ..................................15folic acid tabs 1mg .......................15FORTEO ......................................29fortical ..........................................25fosinopril ......................................17fosinopril/ hydrochlorothiazide ...................17FRAGMIN INJ 10000UNIT/ ML, 25000UNIT/ ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML ......................19FREAMINE III ............................34FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM ....................................24FREESTYLE LITE TEST STRIPS ......................................24FREESTYLE TEST STRIPS .......24furosemide inj ..............................17FUROSEMIDE ORAL SOLN 8MG/ML .........................19furosemide oral soln 10mg/ml .....................................18furosemide tabs ............................18FUZEON ........................................6

Ggabapentin caps ............................11gabapentin oral soln .....................11gabapentin tabs .............................11GABITRIL ...................................11

galantamine hydrobromide cp24 ............................................12galantamine hydrobromide tabs ...12GAMASTAN S/D ........................28gammagard liquid inj 2.5gm/25ml ................................28GANCICLOVIR CAPS 250MG .........................................6ganciclovir caps 500mg .................6ganciclovir inj ................................6GARDASIL .................................28GASTROCROM ..........................26GAUZE PADS 2”X2” ..................24gavilyte-c ......................................26gavilyte-g .....................................26gavilyte-n/flavor pack ..................26gemcitabine hcl inj 1gm .................9gemfibrozil ...................................19GENOTROPIN ............................27GENOTROPIN MINIQUICK INJ 0.2MG ...........27GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG .................................27gentak ...........................................30gentamicin sulfate cream .............21gentamicin sulfate oint 0.1% ........21gentamicin sulfate ophthalmic soln ..........................30gentasol ........................................30GEODON CAPS ..........................16GEODON INJ ..............................16GLEEVEC TABS 100MG ...........10GLEEVEC TABS 400MG ...........10glimepiride ...................................24glipizide ........................................24glipizide er ...................................24glipizide/metformin ......................24GLUCAGEN HYPOKIT .............24GLUCAGON EMERGENCY KIT ...................24glyburide ......................................24glyburide/metformin ....................24glyburide micronized ...................24glycopyrrolate tabs .......................26GLYSET .......................................24golytely oral soln 227.1gm; 2.82gm; 6.36gm; 5.53gm; 21.5gm .......................................26GOLYTELY ORAL SOLN 236GM; 2.97GM; 6.74GM; 5.86GM; 22.74GM.....................26

granisetron inj 0.1mg/ml ..............26GRANISETRON INJ 1MG/ML ....................................26granisetron tabs ............................26GRIFULVIN V ...............................5griseofulvin microsize ....................5GRIS-PEG......................................5guanfacine hcl ..............................18GUANIDINE HCL ......................16

HHALAVEN ...................................10halobetasol propionate .................22haloperidol ...................................15haloperidol decanoate inj .............15haloperidol lactate inj ...................15HAVRIX INJ 720ELU/0.5ML ..........................28HAVRIX INJ 1440ELU/ML ........28HECTOROL CAPS .....................25heparin sodium/d5w inj 5%; 40unit/ml.............................19HEPARIN SODIUM INJ 2000UNIT/ML ...........................19heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml ........19HEPARIN SODIUM/NACL 0.45% .........................................19HEPARIN SODIUM/ SODIUM CHLORIDE 0.9% PREMIX ...........................19HEPATAMINE .............................34HEPSERA ......................................6HEXALEN ...................................10HUMALOG .................................24HUMALOG KWIKPEN ..............24HUMALOG MIX 50/50 ..............24HUMALOG MIX 50/50 KWIKPEN .................................24HUMALOG MIX 75/25 ..............24HUMALOG MIX 75/25 KWIKPEN .................................24HUMIRA INJ 40MG/0.8ML .......29HUMULIN 70/30 .........................24HUMULIN 70/30 PEN ................24HUMULIN N ...............................24HUMULIN N U-100 PEN ...........24HUMULIN R ...............................24HUMULIN R U-500 (CONCENTRATED) .................24hydralazine tabs ...........................18hydrochlorothiazide .....................18


hydrocodone/acetaminophen oral soln 500mg/15ml; 7.5mg/15ml ................................13hydrocodone/acetaminophen tabs .............................................13hydrocodone bitartrate/ acetaminophen tabs ....................13hydrocodone/ibuprofen ................13hydrocortisone/acetic acid ...........23hydrocortisone butyrate ...............22hydrocortisone cream 1%, 2.5% ....................................22hydrocortisone enem ....................26hydrocortisone lotn 2.5% .............22hydrocortisone oint 1%, 2.5% ....................................22hydrocortisone tabs ......................23hydrocortisone valerate ................22hydromorphone hcl inj 10mg/ml .....................................13hydromorphone hcl tabs ...............13hydroxychloroquine .......................7hydroxyurea ...................................9

Iibuprofen susp ..............................13ibuprofen tabs 400mg, 600mg, 800mg ...........................13imipramine ...................................15imipramine pamoate .....................15imiquimod ....................................20IMOVAX RABIES (H.D.C.V.) ....28INCRELEX ..................................22indapamide ...................................18indomethacin caps ........................13indomethacin er ............................13INFANRIX ...................................28INTELENCE TABS 100MG .........6intralipid inj 2.25%; 20% .............34INTRON-A INJ 3MU/0.2ML ......27INTRON-A INJ 10MU/0.2ML, 5MU/0.2ML .......27INTRON-A INJ 6000000UNIT/ML .....................27INTRON-A WITH DILUENT INJ 10MU ................27INTUNIV .....................................16INVANZ .........................................8INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML .............................16INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ ML, 234MG/1.5ML ...................16

INVEGA TB24 1.5MG, 3MG, 9MG .................................16INVEGA TB24 6MG ...................16INVIRASE CAPS ..........................6INVIRASE TABS ..........................6IPOL INACTIVATED IPV ..........28ipratropium bromide/ albuterol sulfate ..........................32ipratropium bromide inhalation soln ............................32ipratropium bromide nasal soln .............................................23IRESSA ........................................10ISENTRESS ...................................6isoniazid inj ....................................7isoniazid syrp .................................7isoniazid tabs ..................................7isosorbide dinitrate .......................20isosorbide dinitrate er ...................20isosorbide mononitrate .................20isosorbide mononitrate er .............20isradipine ......................................18itraconazole ....................................5IXIARO ........................................28

Jjantoven ........................................19JANUMET ...................................24JANUVIA ....................................24JE-VAX ........................................28JEVTANA ....................................10jolivette ........................................29junel ..............................................29junel fe 1.5/30 ..............................29junel fe 1/20 .................................29

KKALETRA ORAL SOLN ..............6KALETRA TABS 100MG; 25MG ...........................................6KALETRA TABS 200MG; 50MG ...........................................6kanamycin sulfate ..........................7kariva ............................................29kcl 0.3%/d5w/lr iv lac ring ...........34kelnor 1/35 ...................................29ketoconazole ............................5, 21ketoprofen ....................................13ketoprofen er ................................13ketorolac tromethamine ophthalmic soln ..........................31ketorolac tromethamine tabs ........13KINERET ....................................29

kionex powd .................................22klor-con 8 .....................................34klor-con 10 ...................................34klor-con m20 ................................34KUVAN ........................................25

Llabetalol tabs ................................18laclotion ........................................20lactated ringers .............................34lactated ringers irrigation .............22lactulose .......................................26LAMICTAL ODT TBDP .............11lamotrigine chew ..........................11lamotrigine tabs ............................11lansoprazole .................................27LANTUS ......................................24LANTUS SOLOSTAR ................25latanoprost ....................................31LATUDA ......................................16leena .............................................29leflunomide ..................................29lessina-28 .....................................29LETAIRIS ....................................33letrozole ........................................10leucovorin calcium tabs 25mg, 5mg ...................................9LEUKERAN ................................10LEUKINE ....................................27leuprolide acetate .........................10levalbuterol ..................................32LEVAQUIN ORAL SOLN ............9LEVAQUIN TABS .........................9LEVEMIR ....................................25LEVEMIR FLEXPEN .................25levetiracetam inj ...........................11levetiracetam oral soln .................11levetiracetam tabs .........................11LEVITRA .....................................34levobunolol hcl .............................30LEVOCARNITINE INJ ...............22levocarnitine oral soln ..................22levocarnitine tabs .........................22levocetirizine dihydrochloride ..........................32levora ............................................29levorphanol tartrate ......................13levothroid .....................................25levothyroxine tabs ........................25levoxyl ..........................................25LEXAPRO ORAL SOLN ............16LEXAPRO TABS ........................16LEXIVA SUSP ...............................6LEXIVA TABS ...............................6


lidocaine external soln .................21lidocaine gel .................................21lidocaine inj 0.5%, 1% .................21lidocaine oint ................................21lidocaine/prilocaine cream ...........21LIDODERM ................................21LINCOCIN ....................................8LINDANE ....................................22liothyronine sodium tabs ..............25LIPITOR ......................................19lisinopril .......................................18lisinopril/ hydrochlorothiazide ...................18lithium carbonate caps 150mg, 300mg ...........................15LITHIUM CARBONATE CAPS 600MG ............................16lithium carbonate er .....................15lithium carbonate tabs ..................15lithium citrate ...............................15loperamide hcl caps ......................26lorazepam tabs .............................15losartan potassium ........................18losartan potassium/ hydrochlorothiazide ...................18LOTEMAX ..................................31LOTRONEX ................................27lovastatin ......................................19LOVAZA ......................................20low-ogestrel ..................................29loxapine ........................................15LUMIGAN ...................................31LUPRON DEPOT INJ 11.25MG, 22.5MG, 3.75MG, 30MG, 7.5MG ............10LUPRON DEPOT-PED INJ 11.25MG, 15MG ........................10lutera ............................................29LYRICA .......................................11LYSODREN .................................10

Mmaprotiline ...................................15margesic-h ....................................13MARPLAN ..................................16MATULANE ................................10mebendazole ..................................7meclizine hcl ................................26meclofenamate sodium ................13medroxyprogesterone acetate .......29mefloquine hcl ................................7megestrol acetate susp ..................10megestrol acetate tabs ..................10meloxicam ....................................14

MENACTRA ...............................28MENEST ......................................29MENOMUNE-A/C/Y/W-135 ......28MENVEO ....................................28meperidine hcl inj 10mg/ml, 50mg/ml .....................................13meperidine hcl inj 25mg/ml .........13MEPRON .......................................8mercaptopurine ............................10mesalamine enem .........................26MESNA ..........................................9MESTINON .................................12MESTINON TIMESPAN ............12metadate er ...................................15metaproterenol sulfate ..................32metformin hcl ...............................24metformin hcl er ...........................24methadone hcl conc ......................13METHADONE HCL ORAL SOLN .............................13methadone hcl tabs .......................13methadose tabs .............................13methazolamide .............................31methenamine hippurate ..................9methimazole .................................23methotrexate .................................10methotrexate sodium inj 1gm .......10methotrexate sodium inj 25mg/ml .....................................10methscopolamine bromide ...........26methyclothiazide ..........................18methyldopa ...................................18methyldopa/ hydrochlorothiazide ...................18methylin er ...................................15methylin tabs ................................15methylphenidate hcl sr .................15methylphenidate hcl tabs 10mg, 5mg .................................15methylphenidate hcl tabs 20mg ..........................................15methylphenidate hydrochloride .............................15methylprednisolone acetate inj 40mg/ml ................................23methylprednisolone acetate inj 80mg/ml ................................23methylprednisolone tabs 16mg, 4mg, 8mg ........................23methylprednisolone tabs 32mg ..........................................23metipranolol .................................30metoclopramide inj ......................26metoclopramide oral soln .............26

metoclopramide tabs ....................26metolazone ...................................18metoprolol/ hydrochlorothiazide ...................18metoprolol succinate er ................18metoprolol tartrate tabs ................18metronidazole ...........................7, 20metronidazole vaginal ..................29mexiletine .....................................17MIACALCIN INJ ........................25MIACALCIN NASAL SOLN .........................................25MICARDIS ..................................19MICARDIS HCT .........................19miconazole 3 ................................29microgestin 1.5/30 ........................29microgestin 1/20 ...........................29microgestin fe ...............................29microgestin fe 1.5/30 ...................30midodrine .....................................22migergot .......................................12MINITRAN ..................................20minocycline hcl caps ......................9minoxidil tabs...............................18mirtazapine ...................................15mirtazapine odt tbdp 30mg, 45mg ..........................................15misoprostol ...................................27mitoxantrone hcl ..........................10M-M-R II W/DILUENT 10 DOSE .........................................28moexipril ......................................18moexipril/hydrochlorothiazide .....18mometasone furoate .....................22MONOKET ..................................20mononessa ....................................30morphine sulfate er ......................13morphine sulfate inj 0.5mg/ml ....................................13morphine sulfate inj 1mg/ml ........13morphine sulfate tabs ...................13MOZOBIL ...................................27MULTAQ .....................................17mupirocin .....................................21MYCOBUTIN ...............................8mycophenolate mofetil .................10

Nnabumetone ..................................14nadolol ..........................................18nadolol/bendroflumethiazide ........18nafcillin sodium inj 1gm ................8nafcillin sodium inj 10gm ..............8NAGLAZYME ............................25


NALLPEN/DEXTROSE INJ 0; 1GM/50ML .......................8naloxone .......................................14naltrexone .....................................14NAMENDA ORAL SOLN ..........12NAMENDA TABS ......................12naproxen sodium tabs 275mg, 550mg ...........................14naproxen susp ...............................14naproxen tabs 250mg, 375mg ........................................14naproxen tbec ...............................14naratriptan hcl ..............................12NARDIL .......................................16NASACORT AQ ..........................33NASONEX ..................................33NATACYN ...................................30nateglinide ....................................24necon 0.5/35-28 ............................30necon 1/35-28 ...............................30necon 7/7/7 ...................................30necon 10/11-28 .............................30nefazodone ...................................15neomycin/bacitracin/ polymyxin ..................................30neomycin/polymyxin/ bacitracin/hydrocortisone ...........31neomycin/polymyxin b sulfates .......................................22neomycin/polymyxin/ dexamethasone ...........................31neomycin/polymyxin/ gramicidin ..................................30neomycin/polymyxin/hc ..............23neomycin/polymyxin/ hydrocortisone ophthalmic susp ............................................31neomycin/polymyxin/ hydrocortisone otic susp ............23neomycin sulfate ............................7NEUMEGA ..................................27NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML ........................27NEXAVAR ...................................10NEXIUM CPDR ..........................27NEXIUM PACK 20MG, 40MG .........................................27NIACOR ......................................20NIASPAN .....................................20nicardipine caps ...........................18NICOTROL INHALER ...............23NICOTROL NASAL ...................23

nifediac cc ....................................18nifedical xl ...................................18nifedipine er tb24 30mg, 60mg ..........................................18nifedipine er tb24 90mg ...............18NILANDRON ..............................10nimodipine ...................................18nisoldipine tb24 20mg, 30mg, 40mg ...............................18nitrofurantoin macrocrystalline caps 50mg .........9nitrofurantoin monohydrate ...........9nitroglycerin pt24 0.2mg/hr, 0.6mg/hr .....................................20nitroglycerin pt24 0.4mg/hr .........20nitroglycerin transdermal pt24 0.1mg/hr .............................20NITROLINGUAL PUMPSPRAY ............................20nitrostat ........................................20nizatidine caps ..............................27nora-be .........................................29norethindrone tabs 5mg ................29nortrel 0.5/35 (28) ........................30nortrel 1/35 (21) ...........................30nortrel 1/35 (28) ...........................30nortrel 7/7/7 ..................................30nortriptyline ..................................15NORVIR.........................................6NOVOLIN 70/30 .........................25NOVOLIN N ...............................25NOVOLIN R ................................25NOVOLOG ..................................25novolog flexpen ............................24NOVOLOG MIX 70/30 ...............25NOVOLOG MIX 70/30 PREFILLED FLEXPEN ............25nyamyc .........................................21nystatin cream ..............................21nystatin external powd .................21nystatin oint ..................................21nystatin susp ...................................5nystatin tabs ...................................5nystatin/triamcinolone ..................21nystop ...........................................21

OOCTREOTIDE INJ 100MCG/ML, 200MCG/ ML, 50MCG/ML .......................10octreotide inj 1000mcg/ml, 500mcg/ml .................................10ofloxacin .............................8, 23, 30ogestrel .........................................30

omeprazole cpdr 10mg, 20mg ..........................................27ondansetron hcl oral soln .............26ondansetron hcl tabs 4mg, 8mg ............................................26ondansetron hcl tabs 24mg ...........26ondansetron odt ............................26ONTAK ........................................10ORAP ...........................................16ORFADIN ....................................23ortho-est .......................................29oxacillin sodium inj 10gm, 1gm ..............................................8oxandrolone tabs 2.5mg ...............25OXANDROLONE TABS 10MG .........................................25oxaprozin ......................................14oxazepam .....................................15oxcarbazepine ..............................11OXSORALEN ULTRA ................20oxybutynin ...................................33oxybutynin er tb24 5mg ...............33oxybutynin er tb24 10mg .............33oxybutynin er tb24 15mg .............33oxycodone/acetaminophen caps ............................................13oxycodone/acetaminophen tabs 325mg; 5mg ........................13oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg, 500mg; 7.5mg ................13oxycodone/aspirin tabs 325mg; 4.5mg; 0.38mg ..............13oxycodone/aspirin tabs 325mg; 4.835mg ........................13oxycodone hcl caps ......................13oxycodone hcl conc ......................13oxycodone hcl tabs 15mg, 30mg, 5mg .................................13oxycodone/ibuprofen ...................13

Ppacerone tabs 200mg ....................17palgic liqd .....................................32PAMIDRONATE DISODIUM INJ 6MG/ML ........25pamidronate disodium inj 30mg/10ml, 90mg/10ml .............25PANCREAZE ..............................27PANRETIN ..................................20pantoprazole .................................27parcaine ........................................31paromomycin .................................7paroxetine er tb24 12.5mg ...........15


paroxetine er tb24 25mg ..............15paroxetine er tb24 37.5mg ...........15paroxetine susp .............................15paroxetine tabs .............................15PASER ...........................................8pedi-dri .........................................21PEDVAX HIB ..............................28PEGANONE ................................11PEGASYS INJ 180MCG/0.5ML ........................27PEG-INTRON INJ 50MCG/0.5ML ..........................27PEG-INTRON REDIPEN ............27penicillin g potassium in iso-osmotic dextrose ....................8penicillin g potassium inj 5mu .......8penicillin g procaine .......................8penicillin g sodium .........................8penicillin v potassium ....................8pentoxifylline er ...........................19periogard ......................................23permethrin cream .........................22perphenazine ................................15perphenazine/amitriptyline ..........15phenelzine sulfate .........................15phenobarbital tabs 100mg, 15mg, 30mg, 60mg ....................11phenytoin ......................................11phenytoin sodium extended caps 100mg ................................11PHYSIOLYTE .............................22PHYSIOSOL IRRIGATION ........22pilocarpine hcl tabs ......................22PILOPINE HS ..............................31pindolol ........................................18piperacillin sodium .........................8piroxicam .....................................14plasma-lyte inj ..............................34PLASMA-LYTE INJ ...................34PLAVIX TABS 75MG .................19podofilox ......................................20poly-dex oint ................................31poly-dex susp ...............................31polyethylene glycol 3350 powd ...........................................26portia-28 .......................................30potassium chloride 0.3%/d5w ...................................34POTASSIUM CHLORIDE 0.3%/ NACL 0.9% .....................34POTASSIUM CHLORIDE 0.15%/D5W ...............................34potassium chloride 0.15% d5w/nacl 0.33% ..........................34

potassium chloride 0.15% d5w/nacl 0.45% viaflex .............34potassium chloride 0.15% nacl 0.9% ....................................34POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% ........34POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% .......................................34potassium chloride 0.224%/ d5w .............................................34potassium chloride er cpcr ...........34potassium chloride er tbcr 10meq .........................................34potassium chloride er tbcr 20meq .........................................34POTASSIUM CHLORIDE INJ 0.4MEQ/ML ........................34potassium chloride inj 10meq/100ml .............................34potassium citrate extended-release .........................33pramipexole dihydrochloride .......12pravastatin ....................................19prazosin ........................................18PRECISION XTRA .....................25PRECISION XTRA BLOOD GLUCOSE TEST STRIPS .........25prednicarbate ................................22prednisolone acetate .....................31prednisolone sodium phosphate .............................23, 31prednisone ....................................23PREDNISONE INTENSOL ........23PREMARIN TABS ......................29PREMARIN W/ APPLICATOR ............................29PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML ..........................35PREMPHASE ..............................29PREMPRO ...................................29prenatal vitamins (generic) ..........35

prevalite powd ..............................19previfem .......................................30PREZISTA TABS 75MG ...............6PREZISTA TABS 150MG .............6PREZISTA TABS 400MG, 600MG .........................................6PRIFTIN ........................................8PRIMAQUINE ..............................8PRIMAXIN IV ...............................8primidone .....................................11PRISTIQ ......................................16PROAIR HFA ..............................33probenecid ....................................28probenecid/colchicine ..................28procainamide ................................17prochlorperazine ..........................26prochlorperazine edisylate ...........26prochlorperazine maleate .............26PROCRIT INJ 10000UNIT/ ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ ML ..............................................27PROCRIT INJ 20000UNIT/ ML, 40000UNIT/ML .................27PROCTOCREAM HC .................27procto-pak ....................................26proctosol hc ..................................26proctozone-hc ...............................26PROGRAF CAPS 0.5MG, 1MG ...........................................10PROGRAF CAPS 5MG ...............10PROGRAF INJ ............................10PROLASTIN-C............................23PROLASTIN INJ 500MG ...........23PROLEUKIN ...............................27PROMACTA TABS 25MG, 50MG .........................................19promethazine/codeine ..................32promethazine hcl inj 25mg/ ml ...............................................32promethazine hcl inj 50mg/ ml ...............................................32propafenone hcl ............................17proparacaine hcl ...........................31propranolol hcl er .........................18propranolol hcl oral soln ..............18propranolol hcl tabs ......................18propranolol/ hydrochlorothiazide ...................18propylthiouracil ............................24PROQUAD ..................................28PROTONIX INJ ...........................27protriptyline hcl ............................15PROVENTIL HFA .......................33


PROVIGIL ...................................16PULMICORT FLEXHALER ............................33PULMOZYME ............................33pyrazinamide ..................................8pyridostigmine bromide ...............12

QQUALAQUIN ................................8quasense .......................................30quinapril .......................................18quinapril/ hydrochlorothiazide ...................18quinidine gluconate er ..................17quinidine sulfate ...........................17quinidine sulfate er .......................17QVAR ...........................................33

RRABAVERT .................................28ramipril .........................................18RANEXA .....................................20ranitidine hcl caps ........................27ranitidine hcl inj 150mg/6ml ........27ranitidine hcl syrp ........................27ranitidine hcl tabs .........................27RAPAMUNE ORAL SOLN ........10RAPAMUNE TABS 1MG, 2MG ...........................................10REBETOL ORAL SOLN ...............6reclipsen .......................................30RECOMBIVAX HB INJ 10MCG/ML ...............................28RECOMBIVAX HB INJ 40MCG/ML ...............................28REGRANEX ................................20RELENZA DISKHALER ..............6RELISTOR ..................................27REMICADE .................................27RESCRIPTOR ...............................6reserpine .......................................18RESTASIS ...................................31RETROVIR IV INFUSION ...........6REVATIO TABS ..........................33REVLIMID ..................................10REYATAZ CAPS 100MG ..............6REYATAZ CAPS 150MG, 200MG, 300MG ...........................6RHINOCORT AQUA ..................33RIBAPAK ......................................6RIBASPHERE CAPS ....................6RIBASPHERE TABS 200MG .........................................6

RIBASPHERE TABS 400MG .........................................6RIBASPHERE TABS 600MG .........................................6RIBAVIRIN ...................................6rifampin ..........................................8RILUTEK ....................................23rimantadine hcl ...............................6ringers irrigation ...........................22RISPERDAL CONSTA INJ 12.5MG ......................................16RISPERDAL CONSTA INJ 25MG .........................................16RISPERDAL CONSTA INJ 37.5MG, 50MG ..........................16risperidone odt .............................15risperidone oral soln .....................15risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg ..............15risperidone tabs 4mg ....................15RITUXAN ....................................10rivastigmine tartrate .....................12ROMYCIN ...................................30ropinirole ......................................12ROTATEQ ....................................28roxicet tabs 325mg; 5mg ..............13

SSABRIL .......................................11SANTYL ......................................22SAPHRIS .....................................16selegiline ......................................12selenium sulfide lotn 2.5% ...........20SELZENTRY TABS 150MG .........................................6SELZENTRY TABS 300MG .........7SENSIPAR TABS 30MG .............25SENSIPAR TABS 60MG .............25SENSIPAR TABS 90MG .............25SEREVENT DISKUS ..................33SEROMYCIN ................................8SEROQUEL TABS 25MG, 50MG .........................................16SEROQUEL TABS 100MG.........16SEROQUEL TABS 200MG.........16SEROQUEL TABS 300MG, 400MG .......................................16SEROQUEL XR TB24 150MG, 200MG, 50MG ............16SEROQUEL XR TB24 300MG, 400MG .........................16sertraline .......................................15silver sulfadiazine ........................20

simvastatin ...................................19SINGULAIR ................................33sodium chloride 0.9% .................22sodium chloride inj 0.9% .............22sodium fluoride tabs .....................35sodium lactate ..............................34SODIUM POLYSTYRENE SULFONATE .............................23sodium sulfacetamide .............21, 32SOLARAZE .................................20solia ..............................................30SOMATULINE DEPOT ..............10SOMAVERT ................................25sotalol ...........................................17sotret .............................................21SPIRIVA HANDIHALER ...........33spironolactone ..............................18spironolactone/ hydrochlorothiazide ...................18sprintec 28 ....................................30SPRYCEL TABS 20MG, 50MG .........................................10SPRYCEL TABS 100MG ............10SPRYCEL TABS 140MG, 70MG, 80MG .............................10sronyx ...........................................30ssd ................................................20stagesic .........................................13stavudine ........................................6sterile water irrigation ..................22STREPTOMYCIN SULFATE .....................................8STROMECTOL .............................8sucralfate ......................................27sulfacetamide sodium/ prednisolone sodium phospha ......................................31sulfadiazine ....................................9sulfamethoxazole/ trimethoprim ................................9sulfamethoxazole/ trimethoprim ds ............................9SULFAMYLON Cream ...............21sulfasalazine tabs .........................26sulfazine ec ...................................26sulindac ........................................14sumatriptan succinate inj 4mg/0.5ml ..................................12sumatriptan succinate inj 6mg/0.5ml ..................................12sumatriptan succinate tabs ...........12SURMONTIL ..............................16SUSTIVA .......................................7


SUTENT ......................................10SYMBICORT AERO 80MCG/ACT; 4.5MCG/ ACT ............................................33SYMBICORT AERO 160MCG/ACT; 4.5MCG/ ACT ............................................33SYMLIN ......................................25SYMLINPEN 60 ..........................25SYMLINPEN 120 ........................25SYNAREL ...................................25SYNTHROID ..............................26SYPRINE .....................................23

TTABLOID ....................................11tacrolimus caps 0.5mg, 1mg ........10tacrolimus caps 5mg ....................10TAMIFLU CAPS 30MG ................7TAMIFLU CAPS 45MG, 75MG ...........................................7TAMIFLU SUSR 12MG/ML .........7tamoxifen citrate ..........................10tamsulosin hcl ..............................33TARCEVA ....................................11TARGRETIN CAPS ....................11TARGRETIN GEL .......................11TASIGNA CAPS 200MG ............11tasmar ...........................................12TAZORAC ...................................21taztia xt .........................................18TEGRETOL-XR ..........................11TEKTURNA ................................19TEKTURNA HCT .......................19temazepam caps 15mg, 30mg ..........................................15terazosin hcl .................................18terbinafine tabs ...............................5terbutaline sulfate tabs .................32terconazole ...................................29testosterone cypionate inj 100mg/ml ...................................25TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT .......................................28tetanus toxoid adsorbed ................28tetracycline hcl ...............................9THALOMID ................................11theochron tb12 100mg .................32theochron tb12 300mg .................32theophylline er .............................32thermazene ...................................20thioridazine ..................................15thiothixene ....................................15

THYMOGLOBULIN ..................28ticlopidine hcl ...............................19TIKOSYN ....................................17timolol maleate .......................18, 30timolol maleate ophthalmic gel forming .................................30TIS-U-SOL ...................................22tizanidine hcl ................................12TOBI ..............................................8TOBRADEX OINT .....................31tobramycin/dexamethasone ..........31tobramycin ophthalmic soln .........30tobrasol .........................................30tolazamide ....................................24tolbutamide ..................................24tolmetin sodium ...........................14topiramate ....................................11topotecan hcl inj 4mg ...................10TOPROL XL ................................19torsemide tabs ..............................18TRACLEER .................................33tramadol .......................................14tramadol hcl/acetaminophen ........14trandolapril ...................................18tranylcypromine ...........................15TRAVATAN Z ..............................31trazodone ......................................15TRECATOR ...................................8TRETINOIN CAPS .....................11tretinoin cream .............................21tretinoin gel ..................................21triamcinolone acetonide cream ..........................................22triamcinolone acetonide lotn ........22triamcinolone acetonide oint ........22triamcinolone in orabase ..............23triamterene/ hydrochlorothiazide ...................18triazolam ......................................15TRICOR .......................................20triderm ..........................................22trifluoperazine ..............................15trifluridine ....................................30trihexyphenidyl ............................12tri-legest fe ...................................30TRILEPTAL SUSP ......................11TRILYTE .....................................27trimethoprim ..................................9trimethoprim sulfate/ polymyxin b sulfate ....................30trinessa .........................................30TRIPEDIA....................................28tri-previfem ..................................30TRISENOX ..................................11

tri-sprintec ....................................30trivora-28 ......................................30TRIZIVIR ......................................7tropicamide ..................................30TRUVADA .....................................7TWINRIX ....................................28TYKERB......................................11TYPHIM VI .................................28TYZEKA ........................................7TYZINE .......................................23

Uunithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg .........................................26ursodiol caps ................................26ursodiol tabs .................................26

Vvalacyclovir hcl ..............................6VALCYTE TABS ...........................7valproate sodium ..........................11valproic acid .................................11VANCOCIN ORAL .......................9vancomycin inj 10gm .....................9vancomycin inj 1000mg .................9vandazole .....................................29VANDETANIB ............................11VAQTA .........................................28VARIVAX ....................................28VELCADE ...................................11velivet ...........................................30venlafaxine hcl .............................15venlafaxine hcl er cp24 37.5mg, 75mg ............................15venlafaxine hcl er cp24 150mg ........................................15venlafaxine hcl er tb24 37.5mg, 75mg ............................15venlafaxine hcl er tb24 150mg ........................................16venlafaxine hcl er tb24 225mg ........................................15VENTAVIS INHALATION SOLN 10MCG/ML ....................33VENTOLIN HFA .........................33verapamil er cp24 .........................18verapamil er tbcr 120mg, 240mg ........................................18verapamil er tbcr 180mg ..............18verapamil tabs ..............................18


VESICARE ..................................33VIAGRA ......................................34VICTRELIS ...................................7VIDAZA ......................................11VIDEX PEDIATRIC ORAL SOLN 2GM ..................................7VIGAMOX ..................................30VIIBRYD .....................................16VIMPAT INJ ................................12VIMPAT ORAL SOLN ................12VIMPAT TABS ............................12VIRACEPT ....................................7VIRAMUNE ..................................7VIRAMUNE XR ...........................7VIREAD ........................................7VISICOL ......................................27VIVACTIL ...................................16VOLTAREN GEL ........................14VOTRIENT ..................................11

Wwarfarin ........................................19

XXALATAN ...................................31XENAZINE .................................12XOLAIR ......................................33XOPENEX HFA ..........................33XOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML .............................33XYREM .......................................16

YYF-VAX .......................................28

Zzafirlukast .....................................32zaleplon ........................................16ZAVESCA ....................................25zazole cream 0.4% .......................29ZAZOLE Cream 0.8% .................29ZENPEP .......................................27ZERIT ORAL SOLN .....................7zerlor ............................................13

ZETIA ..........................................20ZIAGEN .........................................7zidovudine ......................................6ZIRGAN ......................................30ZOLINZA ....................................11zolpidem .......................................16ZOMETA .....................................25ZONALON ..................................20zonisamide ...................................11ZORTRESS TABS 0.5MG, 0.75MG ......................................11ZORTRESS TABS 0.25MG ........11ZOSTAVAX .................................28zovia 1/35e ...................................30zovia 1/50e ...................................30ZOVIRAX CREAM ....................21ZYFLO CR ..................................33ZYPREXA ...................................17ZYPREXA ZYDIS.......................17ZYTIGA .......................................11ZYVOX INJ ...................................8ZYVOX SUSR...............................8ZYVOX TABS ...............................8

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2012 PROVIDER FORMULARY

2012 PROVIDER FORMULARY - My Preferred Provider

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