2015 Abridged Formulary (Partial List of Covered Drugs) · 2014-09-25 · H2986_PD_200 "-1"! × Õ...

P.O. Box 21420 El Sobrante, CA 94820www.UHCAmedicare.org

University H

ealth Care Advantage2015 Abridged Form

ulary (Partial List of Covered Drugs)

2015 Abridged Formulary (Partial List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

00015942, 5 This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact UHCA Member Services at 1-855-996-8422, or, for TTY users, 711, 7 days a week, 8:00 a.m. to 8:00 p.m., or visit www.UHCAmedicare.org.

H2986_PD_200 Accepted 2015

This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact UHCA Member Services at 1-855-996-8422, or, for TTY users, 711, 7 days a week, 8:00 a.m. to 8:00 p.m., or visit www.UHCAmedicare.org.

H2986_PD_200 Accepted 2015

H2986_PD_200 !==?JN?> ȕȓȔȘ Abridged Formulary Page 1

UNIVERSITY HEALTH CARE ADVANTAGE (HMO)

2015 ABRIDGED FORMULARY

(PARTIAL LIST OF COVERED DRUGS)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

00015492, 5

This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our

plan. For a complete listing or other questions, please contact University Health Care Advantage Member Services at 1-855-996-8422 or, for TTY users, Toll-free 711, Monday through Sunday from 8:00 a.m. to 8:00

p.m. (Pacific Standard Time), or visit www.UHCAmedicare.org.

University Health Care Advantage is an HMO plan with a Medicare contract. Enrollment in University Health

Care Advantage depends on contract renewal.

This information is available for free in other languages. Please contact Member Services at 1-855-996-8422 for additional information. TTY users should call 711. Hours are: 8:00 a.m. until 8:00 p.m., Pacific Standard

Time, 7 days a week. Member Services also has free language interpreter services available for non-English

speakers. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente 1-855-996-8422, 8:00 a.m. a 8:00 p.m., hora estándar del pacífico, siete días a la semana. Los usuarios de TTY deben

llamar al 711.

Thông tin này có sẵn miễn phí bằng các ngôn ngữ khác. Xin vui lòng gọi Dịch Vụ Hội Viên của chúng tôi tại số 1-855-996-8422, 8:00 sáng đến 8:00 chiều, giờ Chuẩn Thái Bình Dương, 7 ngày một tuần. Người dùng TTY gọi số 711.

8點至晚上8點之間致電我們的會員服務號碼 1-855-996-8422，時間為太平洋標準時間。TTY 使用者請撥打

711。

http://www.uhcamedicare.org/


Note to existing members: This formulary has changed since last year. Please review this document to

make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means University Health Care Advantage.

When it refers to “plan” or “our plan,” it means University Health Care Advantage (HMO).

This document includes a partial list of the drugs (formulary) for our plan which is current as of August 8, 2014. For a complete updated formulary, please contact us. Our contact information, along with the date

we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.


What is the University Health Care Advantage (HMO) Abridged Formulary?

A formulary is a list of covered drugs selected by University Health Care Advantage (HMO) 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. University Health Care Advantage (HMO) will generally cover the drugs

listed in our formulary as long as the drug is medically necessary, the prescription is filled at a University Health Care Advantage (HMO) network pharmacy, and other plan rules are followed. For more information

on how to fill your prescriptions, please review your Evidence of Coverage.

This document is a partial formulary and includes only some of the drugs covered by University Health Care

Advantage (HMO). For a complete listing of all prescription drugs covered by University Health Care Advantage (HMO), please visit our website or call us. Our contact information, along with the date we last

updated the formulary, appears on the front and back cover pages.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we

will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less

expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our

formulary, will not affect members who are currently taking the drug. It will remain available at the same

cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were

available when you chose our plan, except for cases in which you can save additional money or we can

ensure your safety.

If we remove drugs from our formulary, or 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 August 8, 2014. To get updated information about the drugs covered by University Health Care Advantage (HMO), please contact us. Our contact

information appears on the front and back cover pages. In the event we make a non-maintenance change

to the formulary, we will post an errata sheet to our website and mail a letter to members. Members will

also receive notification via the normal member explanation of benefits process.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 15. The drugs in this formulary are grouped into categories depending on

the type of medical conditions that they are used to treat. For example, drugs used to treat a heart

condition are listed under the category “Cardiovascular Agents.” If you know what your drug is used for,

H2986_PD_200 !==?JN?> ȕȓȔȘ Abridged FormularS 0age 4

look for the category name in the list that begins on page 15. Then look under the category name for

your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on

page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to

your drug, you will see the page number where you can find coverage information. Turn to the page

listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

University Health Care Advantage (HMO) 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:

Prior Authorization: University Health Care Advantage (HMO) requires you or your physician to get

prior authorization for certain drugs. This means that you will need to get approval from University

Health Care Advantage (HMO) before you fill your prescriptions. If you don’t get approval, University Health Care Advantage (HMO) may not cover the drug.

Quantity Limits: For certain drugs, University Health Care Advantage (HMO) limits the amount of

the drug that our plan will cover. For example, University Health Care Advantage (HMO) provides 30 pills per prescription for Ambien. This may be in addition to a standard one-month or three-month

supply.

Step Therapy: In some cases, University Health Care Advantage (HMO) requires you to first try

certain drugs to treat your medical condition before we will cover another drug for that condition.

For example, if Drug A and Drug B both treat your medical condition, University Health Care

Advantage (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on Formulary Page 15. You can also get more information about the restrictions applied to specific

covered drugs by visiting our Web site. We have posted on line documents that explain our prior

authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask University Health Care Advantage (HMO) to make an exception to these restrictions or limits or

for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an


exception to the University Health Care Advantage (HMO) formulary?” on page 5 (below) for information

about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member

Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so University Health Care Advantage (HMO) may cover your drug. For more information, please contact us. Our

contact information, along with the date we last updated the formulary, appears on the front and back

cover pages.

If you learn that University Health Care Advantage (HMO) does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by University Health Care

Advantage (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a

similar drug that is covered by our plan.

You can ask University Health Care Advantage (HMO) to make an exception and cover your drug. See

below for information about how to request an exception.

How do I request an exception to the University Health Care Advantage (HMO)’s

Formulary?

You can ask University Health Care Advantage (HMO) to make an exception to our coverage rules. There are

several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered

at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the

specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

University Health Care Advantage (HMO) limits the amount of the drug that we will cover. If your

drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, University Health Care Advantage (HMO) will only approve your request for an exception if the

alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization

restrictions would not be as effective in treating your condition and/or would cause you to have adverse

medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization

restriction exception. When you request a formulary, tiering or utilization restriction exception, you

should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request

an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by

waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.


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

exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you

may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need

a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will

cover the drug you take. While you talk to your doctor to determine the right course of action for you, we

may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover

a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network

pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of

the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have

provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing

increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our

formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in

our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer

days) while you pursue a formulary exception.

In circumstances where a member is changing from one treatment setting to another, University Health

Care Advantage (HMO) will ensure a transition process for approving non-formulary Part D drugs. This

process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes include: members who are discharged from a hospital to a home;

members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D

plan formulary; members who end a long-term care facility stay and return to the community; and, members who are discharged from psychiatric hospitals with medication regimens that are highly

individualized.

The pharmacy benefit manager for University Health Care Advantage (HMO) will provide pharmacies with access to representatives of the plan who have the ability to override pharmacy claims processing issues.

This access will allow pharmacies to obtain prescription claims overrides at the point-of-sale and ensure

that members receive reliable access to medications.


For more information

For more detailed information about your University Health Care Advantage (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about University Health Care Advantage (HMO), please contact us. Our contact

information, along with the date we last updated the formulary, appears on the front and back cover pages.

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 users should call 1-877-486-2048. Or, visit

http://www.medicare.gov.


University Health Care Advantage (HMO)’s Formulary

The abridged formulary that begins page 15 provides coverage information about some of the drugs covered by University Health Care Advantage (HMO). If you have trouble finding your drug in the list, turn to

the Index that begins on Index Page I-1.

Remember: This is only a partial list of drugs covered by University Health Care Advantage (HMO). If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date

we last updated the formulary, appears on the front and back cover pages.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AVINZA) and

generic drugs are listed in lower-case italics (e.g., acetaminophen).

The information in the Requirements/Limits column tells you if University Health Care Advantage (HMO) has

any special requirements for coverage of your drug

The second column of the chart lists the drug tier. Every drug on the plan’s Drug List is in one of six cost-sharing tiers. The tables below provide an explanation of each tier.

Network Retail Pharmacy Drug Tier Copayment Levels

Tier Copay for up to a

one-month supply

Copay for up to a

three-month supply

Tier 1 (Preferred Generic) $2 $6

Tier 2 (NON-Preferred Generic) $15 $45

Tier 3 (Preferred Brand) $45 $135

Tier 4 (NON-Preferred Brand Name) $95 $285

Tier 5 (Specialty) 33% of cost 33% of cost

Tier 6 (Select Diabetic Drugs) $2 $6

Network Mail Order Drug Tier Copayment Levels

Tier Copay for up to a

one-month supply

Copay for up to a

three-month supply

Tier 1 (Preferred Generic) $2 $4

Tier 2 (NON-Preferred Generic) $15 $30

Tier 3 (Preferred Brand) $45 $90

Tier 4 (NON-Preferred Brand Name) $95 $190

Tier 5 (Specialty) 33% of cost 33% of cost

Tier 6 (Select Diabetic Drugs) $2 $4


The following coverage abbreviations appear in the Requirements/Limits column:

COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization

Restriction

You (or your physician) are required to get prior

authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior

approval, University Health Care Advantage (HMO) may not

cover this drug.

PA BvD

Prior Authorization

Restriction

for

Part B vs Part D

Determination

This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior

authorization from University Health Care Advantage (HMO)

to determine whether this drug is covered under Medicare Part D before you fill your prescription for this drug.

Without prior approval, University Health Care Advantage

(HMO) may not cover this drug.

PA-HRM

Prior Authorization

Restriction

for High Risk Medications

This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare

beneficiaries 65 years or older. Members age 65 years or

older are required to get prior authorization from University

Health Care Advantage (HMO) before filling your prescription for this drug. Without prior approval,

University Health Care Advantage (HMO) may not cover this

drug.

PA NSO

Prior Authorization

Restriction

for New Starts Only

If you are a new member or if you have not taken this drug

previously, you (or your physician) are required to get prior

authorization from University Health Care Advantage (HMO)

before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not

cover this drug.

QL Quantity Limit

Restriction

University Health Care Advantage (HMO) limits the amount

of this drug that is covered per prescription, or within a specific time frame.

ST Step Therapy

Restriction

Before University Health Care Advantage (HMO) will provide

coverage for this drug, you must first try another drug(s) to

treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.


OTHER COVERAGE ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

LA Limited Access Drug

This prescription may be available only at certain

pharmacies. For more information consult your Pharmacy Directory or call Member Services at number at 1-855-996-

8422, 8:00 a.m. to 8:00 p.m., Pacific Standard Time, 7 days a

week. TTY users call 711.

GC Gap Coverage We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for

more information about this coverage.

STRENGTH AND DOSAGE FORM ABBREVIATIONS

ABBREVIATION DESCRIPTION

adh. patch adhesive patch

aer br act aerosol, breath activated

aer pow aerosol, powder

aer pow ba aerosol powder, breath activated

aer refill aerosol refill

aer w/adap aerosol with adapter

ampul ampule

blkbaginj bulk bag injection

cap dr mp capsule, delayed release multiphasic

cap ds pk capsule, dose pack

cap er 12h capsule, 12 hour extended release

cap er 24h capsule, 24 hour extended release

cap er deg capsule, extended release degradable

cap er pel capsule, extended release pellets

cap mphase capsule, multiphasic

cap.sa 24h capsule, 24 hour sustained action

cap.sr 12h capsule, 12 hour sustained release



cap.sr 24h capsule, 24 hour sustained release

cap24h pct capsule, 24 hour controlled-onset pellets

cap24h pel capsule, 24 hour sustained release pellets

cap sprink capsule, sprinkle

cap sr pel capsule sustained release pellets

cap w/dev capsule with device

capsule dr capsule, delayed release

capsule er capsule, extended release

capsule sa capsule, sustained action

cmb cappad combination: capsule, pad

cmb ont fm combination: ointment, foam

cmb ont lt combination: ointment, lotion

cmb tabpad combination: tablet, pad

combo. pkg combination package

cpmp 12hr capsule, 12 hour multiphasic

cpmp 24hr capsule, 24 hour multiphasic

cpmp 30-70 capsule, multiphasic, 30%-70%

cpmp 50-50 capsule, multiphasic, 50%-50%

cream(g), cream(gm) cream (grams)

cream(ml) cream (milliliters)

cream/appl cream with applicator

cream, er (g) cream, extended release (grams)

cream pack cream, package

dehp fr bg di(2-ethylhexyl)phthalate free bag

dis needle disposable needle

disk w/dev disk with inhalation device

disp syrin disposable syringe

drops susp drops, suspension

drps hpvis drops, hyperviscous

emul adhes emulsion adhesive

H2986_PD_200 !==?JN?> ȕȓȔȘ Abridged FILGOF;LS 0age 12


emul packt emulsion packet

emulsn(g) emulsion (grams)

foam/appl. foam with applicator

froz.piggy frozen piggyback

g gram

gel/pf app gel with prefilled applicator

gel (gm) gel (grams)

gel (ml) gel (milliliters)

gel md pmp gel in metered dose pump

gel w/appl gel with applicator

gel w/pump gel with pump

gran pack granule pack

hfa aer ad hfa aerosol adapter

infus. Btl infusion bottle

insuln pen insulin pen

ip soln intraperitoneal solution

irrig soln irrigating solution

iv soln. intravenous solution

jel jelly

jelly/app jelly with applicator

jel/pf app jelly with pre-filled applicator

kit cl&crm kit: cleanser and cream

kt crm le kit: cream, lotion emollient

kt lotn ce kit: lotion, cream emollient

kt oint le kit: ointment, lotion emollient

lotion, er lotion, extended release

lozenge hd lozenge handle

m.ht patch medicated heated patch

ma buc tab mucoadhesive buccal tablet

mcg microgram



med. pad medicated pad

med. swab medicated swab

med. tape medicated tape

mg milligram

ml milliliter

muc er 12h mucoadhesive system, 12 hour extended release

ndl fr inj needle for injection

nl fm susp nail film suspension

oint. (g), oint.(gm) ointment (grams)

oral conc oral concentrate

oral susp oral suspension

paste (g) paste (grams)

patch td24 patch, 24 hour transdermal

patch td72 patch, 72 hour transdermal

patch tdsw patch, biweekly transdermal

patch tdwk patch, weekly transdermal

pca syring patient-controlled analgesic syringe

pca vial patient-controlled analgesic vial

pellet(ea) pellet (each)

pen ij kit pen injector kit

pen injctr pen injector

pggybk btl piggyback bottle

plast. Bag plastic bag

powd pack powder pack

sol md pmp solution with multi-dose pump

sol w/appl solution with applicator

sol/pf app solution with pre-filled applicator

sol-gel solution, gel-forming

soln recon solution, reconstituted

soln(gram) solution (grams)



spray susp spray, suspension

spray/pump spray with pump

stick(ea) stick (each)

supp.rect suppository, rectal

supp.vag suppository, vaginal

suppos. suppository

sus er 24h suspension, 24 hour extended release

sus er rec suspension, extended release reconstituted

sus mc rec suspension, microcapsule reconstituted

suspdr pkt suspension, delayed release packet

susp recon suspension, reconstituted

syringekit syringe kit

tab chew tablet, chewable

tab er 12h tablet, 12 hour extended release

tab er 24h tablet, 24 hour extended release

tab er prt tablet, extended release particles

tab er seq tablet, extended release sequels

tab disper tablet, dispersible

tab ds pk tablet, dose pack

tab er 24 tablet, 24 hour extended release

tab mphase tablet, multiphasic

tab part tablet, particles

tab rap dr tablet, rapid disintegrating delayed release

tab rapdis tablet, rapid disintegrating

tab subl tablet, sublingual

tab.sr 12h tablet, 12 hour sustained release

tab.sr 24h tablet, 24 hour sustained release

tabergr24hr tablet, 24 hour gradual extended release

tablet dr tablet, delayed release

tablet, er tablet, extended release

H2986_PD_200 !==?JN?> ȕȓȔȘ Abridged Formulary 0age 15


tablet eff tablet, effervescent

tablet sa tablet, sustained action

tablet sol tablet, soluble

tb er dspk tablet, extended release dose pack

tb mp dspk tablet, multiphasic dose pack

tb rd dspk tablet, rapid disintegrating dose pack

tbdspk 3mo tablet, 3-month dose pack

tbmp 12hr tablet, 12 hour multiphasic

tbmp 24hr tablet, 24 hour multiphasic

u Unit

vag ring vaginal ring

You can find information on what the symbols and abbreviations in this table mean by going to the introduction

pages of this document

16

University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015

Formulary ID: 15492.000, Version: 5

Drug Name Drug Tier Requirements/Limits

Analgesics Analgesics, Miscellaneous

acetaminophen with codeine solution (Acetaminophen with

Codeine)

2 GC, QL: 2700 in 30 days

acetaminophen with codeine tablet: 300mg-

60mg

(Vopac) 2 GC, QL: 180 in 30 days

acetaminophen with codeine tablet: 300mg-

15mg, 300mg-30mg

(Vopac) 2 GC, QL: 360 in 30 days

AVINZA cpmp 24hr: 30mg, 45mg, 60mg,

75mg, 120mg

4 ST, QL: 30 in 30 days

AVINZA cpmp 24hr: 90mg 4 ST, QL: 60 in 30 days

butalb/acetaminophen/caffeine solution (Dolgic Lq) 2 GC, PA-HRM, QL: 2700

in 30 days

butalb/acetaminophen/caffeine tablet (Esgic) 2 GC, PA-HRM, QL: 180

in 30 days

CAPITAL W-CODEINE 4 QL: 2500 in 30 days

CONZIP 4 QL: 30 in 30 days

DILAUDID liquid 4 QL: 1200 in 30 days

DILAUDID tablet: 2mg, 4mg 4 QL: 180 in 30 days

DILAUDID tablet: 8mg 4 QL: 240 in 30 days

DURAGESIC patch td72: 12mcg/hr,

25mcg/hr, 50mcg/hr, 75mcg/hr

4 PA, QL: 10 in 30 days

DURAGESIC patch td72: 100mcg/hr 4 PA, QL: 20 in 30 days

ESGIC tablet 4 PA-HRM, QL: 180 in 30

days

EXALGO tab er 24h: 8mg, 12mg, 16mg 4 PA, QL: 30 in 30 days

EXALGO tab er 24h: 32mg 4 PA, QL: 60 in 30 days

fentanyl patch td72: 12mcg/hr, 25mcg/hr,

50mcg/hr, 75mcg/hr

(Duragesic) 2 GC, PA, QL: 10 in 30

days

fentanyl patch td72: 100mcg/hr (Duragesic) 2 GC, PA, QL: 20 in 30

days

HYCET 4 QL: 2700 in 30 days

hydrocodone/acetaminophen solution: 7.5-

325/15

(Hycet) 2 GC, QL: 2700 in 30 days

hydrocodone/acetaminophen tablet: 5mg-

325mg, 7.5-325mg, 10mg-325mg

(Norco) 2 GC, QL: 360 in 30 days

hydrocodone/acetaminophen tablet: 5mg-

300mg, 7.5-300mg, 10mg-300mg

(Norco) 2 GC, QL: 390 in 30 days

hydromorphone hcl liquid (Dilaudid) 2 GC, QL: 1200 in 30 days



17




hydromorphone hcl tablet: 2mg, 4mg (Dilaudid) 2 GC, QL: 180 in 30 days

hydromorphone hcl tablet: 8mg (Dilaudid) 2 GC, QL: 240 in 30 days

hydromorphone hcl tab er 24h (Exalgo) 2 GC, PA, QL: 30 in 30

days

KADIAN cap er pel: 10mg, 20mg, 30mg,

40mg, 50mg, 60mg, 70mg, 80mg


KADIAN cap er pel: 200mg 5 ST, QL: 120 in 30 days

KADIAN cap er pel: 100mg, 130mg,

150mg


LORTAB solution 4 QL: 2025 in 30 days

LORTAB tablet 4 QL: 360 in 30 days

morphine sulfate cpmp 24hr: 30mg, 45mg,

60mg, 75mg, 120mg

(Avinza) 2 GC, ST, QL: 30 in 30

days

morphine sulfate cap er pel: 10mg, 20mg,

30mg, 50mg, 60mg, 80mg; cpmp 24hr:

90mg

(Kadian) 2 GC, ST, QL: 60 in 30

days

morphine sulfate cap er pel: 100mg (Kadian) 5 ST, QL: 60 in 30 days

morphine sulfate cartridge: 2mg/ml, 4mg/

ml

(Morphine Sulfate) 2 GC

morphine sulfate tablet er: 30mg, 60mg,

100mg

(MS Contin) 2 GC, QL: 120 in 30 days

morphine sulfate tablet er: 15mg, 200mg (MS Contin) 2 GC, QL: 180 in 30 days

morphine sulfate solution: 100mg/5ml (MSIR) 2 GC, QL: 200 in 30 days



MORPHINE SULFATE 2 GC, QL: 180 in 30 days

MS CONTIN tablet er: 30mg, 60mg,

100mg

4 QL: 120 in 30 days

MS CONTIN tablet er: 15mg, 200mg 4 QL: 180 in 30 days

NORCO 4 QL: 360 in 30 days

OXECTA tablet orl: 7.5mg 4 QL: 360 in 30 days

OXECTA tablet orl: 5mg 4 QL: 540 in 30 days

oxycodone hcl capsule, oral conc, tablet (Dazidox) 2 GC, QL: 180 in 30 days

oxycodone hcl solution (Oxycodone HCl) 2 GC, QL: 1300 in 30 days

oxycodone hcl/acetaminophen tablet: 2.5-

325mg, 5mg-325mg, 7.5-325mg, 10mg-

325mg

(Alcet) 2 GC, QL: 360 in 30 days

oxycodone hcl/acetaminophen solution (Oxycodone HCl/

acetaminophen)

2 GC, QL: 1800 in 30 days



18




OXYCONTIN tab er 12h: 80mg 3 QL: 120 in 30 days

OXYCONTIN tab er 12h: 10mg, 15mg,

20mg, 30mg, 40mg, 60mg

3 QL: 60 in 30 days

PERCOCET 4 QL: 360 in 30 days

PRIMLEV 4 QL: 390 in 30 days

ROXICODONE 4 QL: 180 in 30 days

SUBSYS 5 PA, QL: 120 in 30 days

tramadol hcl tab er 24h: 200mg, 300mg (Ultram ER) 2 GC, QL: 30 in 30 days

tramadol hcl tab er 24h: 100mg (Ultram ER) 2 GC, QL: 90 in 30 days

tramadol hcl tablet (Ultram) 2 GC, QL: 240 in 30 days

TYLENOL-CODEINE NO.3 4 QL: 360 in 30 days

TYLENOL-CODEINE NO.4 4 QL: 180 in 30 days

ULTRAM ER tab er 24h: 200mg, 300mg 4 QL: 30 in 30 days

ULTRAM ER tab er 24h: 100mg 4 QL: 90 in 30 days

ULTRAM 4 QL: 240 in 30 days

XARTEMIS XR 4 QL: 360 in 30 days

XODOL 10-300 4 QL: 390 in 30 days

XODOL 5-300 4 QL: 390 in 30 days

XODOL 7.5-300 4 QL: 390 in 30 days

ZAMICET 4 QL: 2700 in 30 days

Nonsteroidal Anti-inflammatory Agents

CELEBREX 3 ST, QL: 60 in 30 days

diclofenac sodium gel (gram) (Solaraze) 5

diclofenac sodium drops, tab er 24h, tablet

dr

(Voltaren) 2 GC

EC-NAPROSYN 4

ibuprofen oral susp (Ibuprofen) 2 GC

ibuprofen tablet (Motrin) 1 GC

INDOCIN oral susp 4 PA-HRM

indomethacin capsule er (Indocin SR) 2 GC, PA-HRM, QL: 60 in

30 days

indomethacin capsule: 50mg (Indomethacin) 2 GC, PA-HRM, QL: 120

in 30 days

indomethacin capsule: 25mg (Indomethacin) 2 GC, PA-HRM, QL: 240

in 30 days

meloxicam tablet (Mobic) 1 GC

meloxicam oral susp (Mobic) 2 GC

MOBIC 4

nabumetone (Relafen) 2 GC



19




NAPROSYN 4

naproxen tablet (Naprosyn) 1 GC

naproxen oral susp, tablet dr (Naprosyn) 2 GC

PENNSAID 4

SOLARAZE 5

VOLTAREN 3 (Topical Gel)

VOLTAREN-XR 4

Anesthetics Local Anesthetics

lidocaine hcl vial (Xylocaine) 2 GC, PA BvD (PA for

ESRD Only)

lidocaine hcl jel (ml), jel/pf app, solution:

2%, 40mg/ml

(Xylocaine) 2 GC

lidocaine oint. (g) (Lidocaine) 2 GC, PA BvD (PA for

ESRD Only)

lidocaine adh. patch (Lidoderm) 4 PA

LIDODERM 4 PA

XYLOCAINE solution, vial: 20mg/ml 4

Anti-addiction/substance Abuse Treatment Agents Anti-addiction/substance Abuse Treatment Agents

buprenorphine hcl (Subutex) 2 GC, PA, QL: 90 in 30

days

buprenorphine hcl/naloxone hcl (Suboxone) 2 GC, PA, QL: 90 in 30

days

CHANTIX tablet: 0.5mg, 1mg 3 QL: 168 in 84 days

CHANTIX tab ds pk 3 QL: 53 in 28 days

SUBOXONE film: 12mg-3mg 4 PA, QL: 60 in 30 days

SUBOXONE film: 2mg-0.5mg, 4mg-1mg,

8mg-2mg


ZUBSOLV 3 PA, QL: 90 in 30 days

Antianxiety Agents Benzodiazepines

ALPRAZOLAM INTENSOL 4 QL: 180 in 30 days

alprazolam tab er 24h: 1mg, 2mg, 3mg (Xanax XR) 2 GC, QL: 60 in 30 days

alprazolam tab er 24h: 0.5mg; tab rapdis,

tablet

(Xanax) 2 GC, QL: 90 in 30 days

ATIVAN tablet 4 QL: 90 in 30 days

clonazepam tab rapdis: 2mg; tablet: 2mg (Klonopin) 2 GC, QL: 300 in 30 days



20




clonazepam tab rapdis: 0.125mg, 0.25mg,

0.5mg, 1mg; tablet: 0.5mg, 1mg

(Klonopin) 2 GC, QL: 90 in 30 days

KLONOPIN tablet: 2mg 4 QL: 300 in 30 days

KLONOPIN tablet: 0.5mg, 1mg 4 QL: 90 in 30 days

lorazepam tablet (Ativan) 2 GC, QL: 90 in 30 days

lorazepam oral conc (Lorazepam) 2 GC, QL: 150 in 30 days

XANAX XR tab er 24h: 1mg, 2mg, 3mg 4 QL: 60 in 30 days

XANAX XR tab er 24h: 0.5mg 4 QL: 90 in 30 days

XANAX 4 QL: 90 in 30 days

Antibacterials Aminoglycosides

gentamicin sulfate (Garamycin) 2 GC

neomycin sulfate (Neomycin Sulfate) 2 GC

TOBI 5 PA BvD

tobramycin in 0.225% nacl (Tobi) 5 PA BvD

Antibacterials, Miscellaneous

CLEOCIN HCL 4

CLEOCIN PALMITATE 4

clindamycin hcl (Cleocin HCl) 2 GC

clindamycin palmitate hcl (Cleocin Palmitate) 2 GC

MACRODANTIN capsule: 25mg, 100mg 4 PA-HRM, QL: 120 in 30

days (High Risk Med.

QL applies to all

members; PA required

for 65 years and older

with over 90 days

cumulative use of

nitrofurantoin drugs)

nitrofurantoin macrocrystal (Macrodantin) 2 GC, PA-HRM, QL: 120

in 30 days (High Risk

Med. QL applies to all



with over 90 days

cumulative use of

nitrofurantoin drugs)

PRIMSOL 4

trimethoprim (Trimethoprim) 2 GC

VANCOCIN HCL 5



21




vancomycin hcl capsule (Vancocin HCl) 5

vancomycin hcl vial: 5g, 10g (Vancomycin HCl) 2 GC, PA BvD (PA for

ESRD Only)

XIFAXAN tablet: 200mg 5 PA, QL: 9 in 30 days

XIFAXAN tablet: 550mg 5 ST, QL: 60 in 30 days

Cephalosporins

cefadroxil (Cefadroxil) 2 GC

cefdinir (Omnicef) 2 GC

cefprozil (Cefzil) 2 GC

CEFTIN 4

cefuroxime axetil (Ceftin) 2 GC

cephalexin (Keflex) 1 GC

KEFLEX 4

SUPRAX 4

Macrolides

azithromycin (Zithromax) 2 GC

BIAXIN XL 4

BIAXIN 4

clarithromycin (Biaxin) 2 GC

ZITHROMAX TRI-PAK 4

ZITHROMAX 4

ZMAX 4

Miscellaneous B-lactam Antibiotics

CAYSTON 5 LA

INVANZ vial 4

Penicillins

amoxicillin (Amoxil) 1 GC

amoxicillin/potassium clav (Augmentin) 2 GC

ampicillin trihydrate (Ampicillin Trihydrate) 1 GC

AUGMENTIN susp recon: 125-31.25/ 4

dicloxacillin sodium (Dicloxacillin Sodium) 2 GC

MOXATAG 4

nafcillin sodium vial (Unipen) 2 GC

penicillin v potassium (Veetids 500) 2 GC

Quinolones

AVELOX ABC PACK 4

AVELOX 4

CIPRO tablet: 250mg, 500mg 4

ciprofloxacin hcl (Cipro) 1 GC



22




LEVAQUIN solution, tablet: 250mg,

500mg, 750mg

4

levofloxacin tablet (Levaquin) 1 GC

levofloxacin solution, vial (Levaquin) 2 GC

moxifloxacin hcl (Avelox) 2 GC

Sulfonamides

AZULFIDINE 4

BACTRIM DS 4

BACTRIM 4

sulfamethoxazole/trimethoprim tablet (Septra) 1 GC

sulfamethoxazole/trimethoprim oral susp,

vial

(Sulfamethoxazole/

trimethoprim)

2 GC

sulfasalazine (Azulfidine) 2 GC

Tetracyclines

ADOXA capsule 4

doxycycline monohydrate (Adoxa) 2 GC

minocycline hcl (Dynacin) 2 GC

ORACEA 4

SOLODYN 5

VIBRAMYCIN susp recon 4

Anticancer Agents Anticancer Agents

AFINITOR DISPERZ 5 PA NSO, QL: 112 in 28

days

AFINITOR tablet: 2.5mg, 5mg, 7.5mg 5 PA NSO, QL: 28 in 28

days

AFINITOR tablet: 10mg 5 PA NSO, QL: 56 in 28

days

anastrozole (Arimidex) 2 GC

ARIMIDEX 4

AROMASIN 4

cyclophosphamide tablet (Cyclophosphamide) 2 GC, PA BvD, ST

CYCLOPHOSPHAMIDE 4 PA BvD, ST

DROXIA 3

ELIGARD syringe: 30mg 4 QL: 1 in 112 days

ELIGARD syringe: 7.5mg 4 QL: 1 in 28 days

ELIGARD syringe: 22.5mg 4 QL: 1 in 84 days

ELIGARD syringe: 45mg 5 QL: 1 in 168 days

exemestane (Aromasin) 2 GC



23




FEMARA 4

GLEEVEC tablet: 400mg 5 PA NSO, QL: 60 in 30

days

GLEEVEC tablet: 100mg 5 PA NSO, QL: 90 in 30

days

HYDREA 4

hydroxyurea (Hydrea) 2 GC

IMBRUVICA 5 PA NSO, QL: 120 in 30

days

INLYTA tablet: 1mg 5 PA NSO, QL: 180 in 30

days

INLYTA tablet: 5mg 5 PA NSO, QL: 60 in 30

days

JAKAFI 5 PA NSO, QL: 60 in 30

days

letrozole (Femara) 2 GC

LEUKERAN 4

leuprolide acetate (Leuprolide Acetate) 2 GC

LUPRON DEPOT syringekit: 45mg 5 QL: 1 in 168 days

LUPRON DEPOT syringekit: 3.75mg 5 QL: 1 in 28 days

LUPRON DEPOT syringekit: 11.25mg,

22.5mg

5 QL: 1 in 84 days

LUPRON DEPOT-PED syringekit 5 QL: 1 in 112 days

LUPRON DEPOT-PED kit 5 QL: 1 in 28 days

LYSODREN 3

MEGACE ES 5

MEGACE 4

megestrol acetate (Megestrol Acetate) 2 GC

mercaptopurine (Purinethol) 2 GC

methotrexate sodium (Methotrexate Sodium) 2 GC, PA BvD, ST

methotrexate sodium/pf (Methotrexate Sodium/

PF)

2 GC, PA BvD

NEXAVAR 5 PA NSO, QL: 120 in 30

days

POMALYST 5 PA NSO, QL: 21 in 28

days

PURINETHOL 4

REVLIMID 5 LA, PA NSO, QL: 21 in

28 days



24




RHEUMATREX 4 PA BvD, ST

SOLTAMOX 4

SPRYCEL tablet: 50mg, 70mg, 80mg,

100mg, 140mg

5 PA NSO, QL: 30 in 30

days

SPRYCEL tablet: 20mg 5 PA NSO, QL: 60 in 30

days

SUTENT 5 PA NSO, QL: 30 in 30

days

tamoxifen citrate (Nolvadex) 2 GC

TARCEVA tablet: 25mg, 100mg 5 PA NSO, QL: 60 in 30

days

TARCEVA tablet: 150mg 5 PA NSO, QL: 90 in 30

days

TASIGNA 5 PA NSO, QL: 112 in 28

days

TREXALL 4 PA BvD, ST

TYKERB 5

VOTRIENT 5 PA NSO, QL: 120 in 30

days

XALKORI 5 PA NSO, QL: 60 in 30

days

XTANDI 5 PA NSO, QL: 120 in 30

days

ZYTIGA 5 PA NSO, QL: 120 in 30

days

Anticholinergic Agents Antimuscarinics/Antispasmodics

atropine sulfate syringe (Atropine Sulfate) 2 GC

propantheline bromide (Propantheline

Bromide)

2 GC

Anticonvulsants Anticonvulsants

carbamazepine (Tegretol) 2 GC

CARBATROL 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLE 4

DEPAKOTE 4

DILANTIN capsule: 30mg 3

DILANTIN capsule: 100mg 4



25




divalproex sodium (Depakote ER) 2 GC

EQUETRO 4

gabapentin (Neurontin) 2 GC

GRALISE tab er 24h: 300-600mg 4 ST, QL: 78 in 30 days

GRALISE tab er 24h: 300mg, 600mg 4 ST, QL: 90 in 30 days

KEPPRA XR 4

KEPPRA solution, tablet 4

LAMICTAL (BLUE) 4

LAMICTAL (GREEN) 4

LAMICTAL (ORANGE) 4

LAMICTAL ODT 4

LAMICTAL XR (BLUE) 4

LAMICTAL XR (GREEN) 4

LAMICTAL XR (ORANGE) 4

LAMICTAL XR 4

LAMICTAL tablet, tb chw dsp: 5mg,

25mg

4

lamotrigine tab er 24, tablet, tb chw dsp (Lamictal) 2 GC

levetiracetam (Keppra) 2 GC

LYRICA capsule 3 QL: 90 in 30 days

LYRICA solution 3 QL: 900 in 30 days

NEURONTIN 4

PHENYTEK 3

phenytoin sodium extended (Dilantin) 2 GC

QUDEXY XR 4

TEGRETOL XR tab er 12h: 100mg 3

TEGRETOL XR tab er 12h: 200mg,

400mg

4

TEGRETOL 4

TOPAMAX 4

topiramate cap sprink, tablet (Topamax) 2 GC

TROKENDI XR 4

Antidementia Agents Antidementia Agents

ARICEPT ODT 4 QL: 30 in 30 days

ARICEPT 4 QL: 30 in 30 days

donepezil hcl (Aricept) 2 GC, QL: 30 in 30 days

NAMENDA XR cap24 dspk 3 QL: 28 in 28 days

NAMENDA XR cap spr 24 3 QL: 30 in 30 days



26




NAMENDA 3 QL: 360 in 30 days

Antidepressants Antidepressants

amitriptyline hcl (Amitriptyline HCl) 2 GC, PA-HRM

bupropion hcl (Wellbutrin XL) 2 GC

CELEXA 4 QL: 30 in 30 days

citalopram hydrobromide tablet (Celexa) 1 GC, QL: 30 in 30 days

citalopram hydrobromide solution (Celexa) 2 GC

CYMBALTA capsule dr: 30mg 4 QL: 30 in 30 days

CYMBALTA capsule dr: 20mg, 60mg 4 QL: 60 in 30 days

duloxetine hcl capsule dr: 30mg (Cymbalta) 2 GC, QL: 30 in 30 days

duloxetine hcl capsule dr: 20mg, 60mg (Cymbalta) 2 GC, QL: 60 in 30 days

EFFEXOR XR 4

escitalopram oxalate (Lexapro) 2 GC

fluoxetine hcl capsule (Prozac) 1 GC

fluoxetine hcl capsule dr, solution, tablet (Rapiflux) 2 GC

FORFIVO XL 4

LEXAPRO tablet 4

LEXAPRO solution 4 QL: 697 in 30 days

paroxetine hcl (Paxil) 2 GC

PAXIL CR 4

PAXIL 4

PROZAC WEEKLY 4

PROZAC 4

SARAFEM 4

sertraline hcl tablet (Zoloft) 1 GC

sertraline hcl oral conc (Zoloft) 2 GC

trazodone hcl (Trazodone HCl) 1 GC

VENLAFAXINE HCL ER 3

venlafaxine hcl (Effexor XR) 2 GC

WELLBUTRIN SR 4

WELLBUTRIN XL 4

WELLBUTRIN 4

ZOLOFT 4

Antidiabetic Agents Antidiabetic Agents, Miscellaneous

ACTOS 4 QL: 30 in 30 days

BYDUREON 3 ST, QL: 4 in 28 days

FORTAMET tab er 24: 500mg 4 QL: 120 in 30 days



27




FORTAMET tab er 24: 1000mg 4 QL: 60 in 30 days

GLUCOPHAGE XR tab er 24h: 500mg 4 QL: 120 in 30 days

GLUCOPHAGE XR tab er 24h: 750mg 4 QL: 60 in 30 days

GLUCOPHAGE tablet: 500mg 4 QL: 120 in 30 days



GLUMETZA tabergr24h: 500mg 4 QL: 120 in 30 days

GLUMETZA tabergr24h: 1000mg 4 QL: 60 in 30 days

INVOKANA tablet: 300mg 3 ST, QL: 30 in 30 days

INVOKANA tablet: 100mg 3 ST, QL: 60 in 30 days

JANUMET XR tbmp 24hr: 50mg-500mg,

100-1000mg

3 QL: 30 in 30 days

JANUMET XR tbmp 24hr: 50-1000mg 3 QL: 60 in 30 days

JANUMET 3 QL: 60 in 30 days

JANUVIA 3 QL: 30 in 30 days

metformin hcl tab er 24h: 500mg (Fortamet) 2 GC, QL: 120 in 30 days

metformin hcl tab er 24 (Fortamet) 2 GC, QL: 60 in 30 days

metformin hcl tab er 24h: 750mg (Fortamet) 2 GC, QL: 90 in 30 days

metformin hcl tablet: 500mg (Glucophage) 1 GC, QL: 120 in 30 days



pioglitazone hcl (Actos) 2 GC, QL: 30 in 30 days

RIOMET 4 QL: 765 in 30 days

TRADJENTA 3 QL: 30 in 30 days

VICTOZA 3-PAK 4 PA, QL: 9 in 28 days

Insulins

HUMALOG insuln pen 6 QL: 30 in 28 days

HUMALOG vial 6 QL: 40 in 28 days

HUMULIN N KWIKPEN 6 QL: 30 in 28 days

HUMULIN N 6 QL: 40 in 28 days

LANTUS SOLOSTAR 6 QL: 30 in 28 days

LANTUS 6 QL: 40 in 28 days

NOVOLIN N vial 6 QL: 40 in 28 days

Sulfonylureas

AMARYL tablet: 1mg, 2mg 4 QL: 30 in 30 days

AMARYL tablet: 4mg 4 QL: 60 in 30 days

DIABETA tablet: 5mg 4 PA-HRM, QL: 120 in 30

days



28




DIABETA tablet: 2.5mg 4 PA-HRM, QL: 240 in 30

days

DIABETA tablet: 1.25mg 4 PA-HRM, QL: 280 in 30

days

glimepiride tablet: 1mg, 2mg (Amaryl) 1 GC, QL: 30 in 30 days

glimepiride tablet: 4mg (Amaryl) 1 GC, QL: 60 in 30 days

glipizide tab er 24: 2.5mg, 5mg (Glucotrol XL) 2 GC, QL: 30 in 30 days

glipizide tab er 24: 10mg (Glucotrol XL) 2 GC, QL: 60 in 30 days

glipizide tablet: 10mg (Glucotrol) 1 GC, QL: 120 in 30 days

glipizide tablet: 5mg (Glucotrol) 1 GC, QL: 60 in 30 days

GLUCOTROL XL tab er 24: 2.5mg, 5mg 4 QL: 30 in 30 days

GLUCOTROL XL tab er 24: 10mg 4 QL: 60 in 30 days

GLUCOTROL tablet: 10mg 4 QL: 120 in 30 days

GLUCOTROL tablet: 5mg 4 QL: 30 in 30 days

glyburide tablet: 5mg (Micronase) 2 GC, PA-HRM, QL: 120

in 30 days

glyburide tablet: 2.5mg (Micronase) 2 GC, PA-HRM, QL: 240

in 30 days

glyburide tablet: 1.25mg (Micronase) 2 GC, PA-HRM, QL: 280

in 30 days

Antifungals Antifungals

clotrimazole (Mycelex) 2 GC

clotrimazole/betamethasone dip (Lotrisone) 2 GC

DIFLUCAN 4

econazole nitrate (Spectazole) 2 GC

EXTINA 4

fluconazole (Diflucan) 2 GC

ketoconazole (Kuric) 2 GC

KETODAN 4

LAMISIL 4

LOTRISONE 4

NIZORAL 4

nystatin (Nystatin) 2 GC

nystatin/triamcin (Mycogen II) 2 GC

terbinafine hcl (Lamisil) 2 GC

Antihistamines Antihistamines

CLARINEX 4



29




cyproheptadine hcl (Cyproheptadine HCl) 2 GC, PA-HRM

desloratadine (Clarinex) 2 GC

levocetirizine dihydrochloride (Xyzal) 2 GC

XYZAL 4

Anti-infectives (Skin and Mucous Membrane) Anti-infectives (Skin and Mucous Membrane)

METROGEL-VAGINAL 4

metronidazole (Metrogel-vaginal) 2 GC

TERAZOL 3 4

TERAZOL 7 4

terconazole (Terazol 3) 2 GC

VANDAZOLE 4

Antimigraine Agents Antimigraine Agents

ALSUMA 4 QL: 4 in 28 days

AMERGE 4 QL: 18 in 28 days

IMITREX tablet 4 QL: 18 in 28 days

IMITREX cartridge, pen injctr, vial 4 QL: 4 in 28 days

MAXALT MLT 4 QL: 18 in 28 days

MAXALT 4 QL: 18 in 28 days

naratriptan hcl (Amerge) 2 GC, QL: 18 in 28 days

rizatriptan benzoate (Maxalt Mlt) 2 GC, QL: 18 in 28 days

sumatriptan succinate tablet (Imitrex) 2 GC, QL: 18 in 28 days

sumatriptan succinate pen injctr, vial (Imitrex) 2 GC, QL: 4 in 28 days

SUMAVEL DOSEPRO 4 QL: 4 in 28 days

Antimycobacterials Antimycobacterials

dapsone (Dapsone) 2 GC

ethambutol hcl (Myambutol) 2 GC

isoniazid tablet (Isoniazid) 1 GC

isoniazid solution, vial (Isoniazid) 2 GC

MYAMBUTOL 4

RIFADIN 4

rifampin (Rifadin) 2 GC

Antinausea Agents Antinausea Agents

meclizine hcl (Antivert) 2 GC

ondansetron hcl (Zofran) 2 GC, PA BvD



30




ondansetron (Zofran Odt) 2 GC, PA BvD

PHENERGAN 4 PA-HRM

prochlorperazine maleate tablet (Compazine) 1 GC

prochlorperazine maleate supp.rect (Compazine) 2 GC

promethazine hcl ampul, supp.rect, tablet,

vial: 25mg/ml

(Promethazine HCl) 2 GC, PA-HRM

ZOFRAN ODT 5 PA BvD

ZOFRAN vial 4

ZOFRAN solution 4 PA BvD

ZOFRAN tablet 5 PA BvD

Antiparasite Agents Antiparasite Agents

ALBENZA 4

atovaquone/proguanil hcl (Malarone) 2 GC

FLAGYL ER 4

FLAGYL 4

hydroxychloroquine sulfate (Plaquenil) 2 GC

MALARONE 4

mefloquine hcl (Lariam) 2 GC

metronidazole (Flagyl) 2 GC

PLAQUENIL 4

Antiparkinsonian Agents Antiparkinsonian Agents

benztropine mesylate (Benztropine Mesylate) 2 GC, PA-HRM

carbidopa/levodopa (Sinemet 10-100) 2 GC

COGENTIN 4 PA-HRM

MIRAPEX ER 4

MIRAPEX 4

pramipexole di-hcl (Mirapex) 2 GC

REQUIP XL 4

REQUIP 4

ropinirole hcl (Requip) 2 GC

SINEMET 10-100 4

SINEMET 25-100 4

SINEMET 25-250 4

SINEMET CR 4



31




Antipsychotic Agents Antipsychotic Agents

ABILIFY DISCMELT tab rapdis: 15mg 3 QL: 60 in 30 days

ABILIFY DISCMELT tab rapdis: 10mg 3 QL: 90 in 30 days

ABILIFY MAINTENA 5 QL: 1 in 28 days

ABILIFY vial 3 QL: 161.2 in 28 days

ABILIFY tablet: 5mg, 10mg, 15mg, 20mg,

30mg

3 QL: 30 in 30 days

ABILIFY tablet: 2mg 3 QL: 60 in 30 days

ABILIFY solution 3 QL: 900 in 30 days

clozapine tablet: 200mg (Clozaril) 2 GC, QL: 135 in 30 days

clozapine tablet: 100mg (Clozaril) 2 GC, QL: 270 in 30 days

clozapine tablet: 25mg, 50mg (Clozaril) 2 GC, QL: 90 in 30 days

CLOZARIL tablet: 100mg 4 QL: 270 in 30 days

CLOZARIL tablet: 25mg 4 QL: 90 in 30 days

FAZACLO tab rapdis: 200mg 4 ST, QL: 120 in 30 days

FAZACLO tab rapdis: 150mg 4 ST, QL: 180 in 30 days

FAZACLO tab rapdis: 12.5mg, 25mg,

100mg


GEODON capsule 4 QL: 60 in 30 days

haloperidol (Haloperidol) 2 GC

olanzapine tab rapdis: 20mg (Zyprexa Zydis) 2 GC, QL: 31 in 30 days

olanzapine tab rapdis: 5mg, 10mg, 15mg;

tablet, vial

(Zyprexa) 2 GC, QL: 30 in 30 days

quetiapine fumarate (Seroquel) 2 GC, QL: 90 in 30 days

RISPERDAL M-TAB tab rapdis: 3mg,

4mg

4 QL: 120 in 30 days

RISPERDAL M-TAB tab rapdis: 0.5mg,

1mg, 2mg

4 QL: 60 in 30 days

RISPERDAL solution 4 QL: 480 in 30 days

RISPERDAL tablet 4 QL: 60 in 30 days

risperidone tab rapdis: 3mg, 4mg (Risperdal M-tab) 2 GC, QL: 120 in 30 days

risperidone solution (Risperdal) 2 GC, QL: 480 in 30 days

risperidone tab rapdis: 0.25mg, 0.5mg,

1mg, 2mg; tablet

(Risperdal) 2 GC, QL: 60 in 30 days

SEROQUEL XR tab er 24h: 200mg 4 ST, QL: 30 in 30 days

SEROQUEL XR tab er 24h: 50mg,

150mg, 300mg, 400mg


SEROQUEL 4 QL: 90 in 30 days



32




VERSACLOZ 5 ST, QL: 540 in 30 days

ziprasidone hcl (Geodon) 2 GC, QL: 60 in 30 days

ZYPREXA ZYDIS 4 QL: 30 in 30 days

ZYPREXA 4 QL: 30 in 30 days

Antivirals (Systemic) Antiretrovirals

ATRIPLA 5

EPZICOM 5

ISENTRESS powd pack, tab chew 3

ISENTRESS tablet 5

NORVIR 4

PREZISTA tablet: 75mg, 150mg 3

PREZISTA oral susp 4

PREZISTA tablet: 600mg, 800mg 5

REYATAZ 5

STRIBILD 5

TRUVADA 5

VIREAD 5

Antivirals, Miscellaneous

SYNAGIS 5

TAMIFLU 3

Hcv Antivirals

OLYSIO 5 PA, QL: 28 in 28 days

SOVALDI 5 PA, QL: 28 in 28 days

Interferons

PEGASYS PROCLICK 5 PA

PEGASYS 5 PA

PEGINTRON REDIPEN 5 PA

PEGINTRON 5 PA

SYLATRON 4-PACK 5 PA NSO, QL: 4 in 28

days

Nucleosides and Nucleotides

acyclovir (Zovirax) 2 GC

famciclovir (Famvir) 2 GC

FAMVIR 4

valacyclovir hcl (Valtrex) 2 GC

VALTREX 4

ZOVIRAX oral susp 4



33




Blood Products/modifiers/volume Expanders Anticoagulants

COUMADIN 4

enoxaparin sodium syringe: 40mg/0.4ml (Lovenox) 2 GC, QL: 13.6 in 30 days

enoxaparin sodium syringe: 30mg/0.3ml (Lovenox) 2 GC, QL: 18 in 30 days



enoxaparin sodium vial (Lovenox) 2 GC, QL: 36 in 30 days

enoxaparin sodium syringe: 120mg/.8ml (Lovenox) 5 QL: 27.2 in 30 days

enoxaparin sodium syringe: 150mg/ml (Lovenox) 5 QL: 34 in 30 days

enoxaparin sodium syringe: 100mg/ml (Lovenox) 5 QL: 36 in 30 days

LOVENOX syringe: 40mg/0.4ml 4 QL: 13.6 in 30 days

LOVENOX syringe: 30mg/0.3ml 4 QL: 18 in 30 days

LOVENOX syringe: 60mg/0.6ml 4 QL: 20.4 in 30 days

LOVENOX syringe: 80mg/0.8ml, 120mg/

.8ml

4 QL: 27.2 in 30 days

LOVENOX syringe: 150mg/ml 4 QL: 34 in 30 days

LOVENOX syringe: 100mg/ml; vial 4 QL: 36 in 30 days

warfarin sodium (Coumadin) 1 GC

XARELTO tablet: 10mg, 20mg 3 QL: 30 in 30 days

XARELTO tablet: 15mg 3 QL: 42 in 21 days

Blood Formation Modifiers

EPOGEN 3 PA, QL: 12 in 28 days

NEULASTA 5

NEUPOGEN 5

PROCRIT vial: 2000/ml, 3000/ml, 4000/

ml, 20000/2ml


PROCRIT vial: 20000/ml 5 PA, QL: 12 in 28 days

PROCRIT vial: 40000/ml 5 PA, QL: 6 in 28 days

Hematologic Agents, Miscellaneous

AGRYLIN 4

anagrelide hcl (Agrylin) 2 GC

CYKLOKAPRON 4

LYSTEDA 4 QL: 30 in 30 days

tranexamic acid tablet (Lysteda) 2 GC, QL: 30 in 30 days

tranexamic acid vial (Tranexamic Acid) 2 GC

Platelet-aggregation Inhibitors

clopidogrel bisulfate (Plavix) 2 GC

EFFIENT 3 QL: 30 in 30 days



34




PLAVIX 4

Caloric Agents Caloric Agents

CLINIMIX E iv soln: 4.25% 4 PA BvD

CLINIMIX E iv soln: 5% 4 PA BvD

CLINISOL 4 PA BvD

dextrose 10 % in water (Dextrose 10 % in

Water)

2 GC, PA BvD

dextrose 5 % and 0.9 % nacl (Dextrose 5 % and 0.9

% NaCl)

2 GC

dextrose 5 % in water (Dextrose 5 % in

Water)

2 GC

dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 %

NaCl)

2 GC

dextrose 5%-lactated ringers (Dextrose 5%-Lactated

Ringers)

2 GC

INTRALIPID emulsion: 20%, 30% 4 PA BvD

LIPOSYN III emulsion: 10%, 20% 4 PA BvD

PROSOL 4 PA BvD

TRAVASOL iv soln: 10% 4 PA BvD

TROPHAMINE iv soln: 10% 4 PA BvD

Cardiovascular Agents Alpha-adrenergic Agents

CARDURA XL 4

CARDURA 4

CATAPRES 4

clonidine hcl (Catapres) 1 GC

doxazosin mesylate (Cardura) 2 GC

guanfacine hcl (Tenex) 2 GC, PA-HRM

TENEX 4 PA-HRM

Angiotensin II Receptor Antagonists

AVAPRO 4 ST

COZAAR 4

DIOVAN HCT 4 ST

DIOVAN 3 ST

HYZAAR 4

irbesartan (Avapro) 2 GC

losartan potassium (Cozaar) 1 GC

losartan/hydrochlorothiazide (Hyzaar) 2 GC



35




valsartan/hydrochlorothiazide (Diovan HCT) 2 GC

Angiotensin-Converting Enzyme Inhibitors

ALTACE 4

benazepril hcl (Lotensin) 1 GC

enalapril maleate (Vasotec) 1 GC

EPANED 4

lisinopril (Zestril) 1 GC

lisinopril/hydrochlorothiazide (Prinzide) 1 GC

LOTENSIN 4

PRINIVIL tablet: 5mg, 10mg, 20mg 4

ramipril (Altace) 2 GC

VASOTEC 4

ZESTORETIC 4

ZESTRIL 4

Antiarrhythmic Agents

amiodarone hcl tablet, vial (Cordarone) 2 GC

flecainide acetate (Tambocor) 2 GC

propafenone hcl (Rythmol) 2 GC

RYTHMOL SR 4

RYTHMOL 4

Beta-Adrenergic Blocking Agents

atenolol (Tenormin) 1 GC

BYSTOLIC 3

carvedilol (Coreg) 1 GC

COREG 4

INDERAL LA 4

INNOPRAN XL 4

LOPRESSOR 4

metoprolol succinate (Toprol XL) 2 GC

metoprolol tartrate tablet (Lopressor) 1 GC

metoprolol tartrate vial (Metoprolol Tartrate) 2 GC

propranolol hcl (Propranolol HCl) 2 GC

TENORMIN 4

TOPROL XL 4

Calcium-channel Blocking Agents

CALAN SR 4

CALAN 4

CARDIZEM CD 4

CARDIZEM LA 4



36




CARDIZEM 4

DILACOR XR 4

diltiazem hcl tablet (Cardizem CD) 1 GC

diltiazem hcl cap er 12h, cap er 24h, cap er

deg, capsule er, tab er 24h, vial, vial port

(Cardizem CD) 2 GC

TIAZAC 4

verapamil hcl tablet (Calan) 1 GC

verapamil hcl cap24h pct, cap24h pel,

tablet er, vial

(Calan) 2 GC

VERELAN PM 4

VERELAN 4

Cardiovascular Agents, Miscellaneous

AUVI-Q 4

epinephrine ampul (Epinephrine) 2 GC

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

hydralazine hcl (Apresoline) 2 GC

Dihydropyridines

ADALAT CC 4

amlodipine besylate (Norvasc) 1 GC

amlodipine besylate/benazepril (Lotrel) 2 GC

LOTREL 4

nifedipine tab er 24, tablet er (Procardia XL) 2 GC

nifedipine capsule (Procardia) 2 GC, PA-HRM

NORVASC 4

PROCARDIA XL 4

PROCARDIA 4 PA-HRM

Diuretics

chlorthalidone (Chlorthalidone) 1 GC

DYAZIDE 4

furosemide solution, vial (Furosemide) 2 GC

furosemide tablet (Lasix) 1 GC

hydrochlorothiazide (Microzide) 1 GC

LASIX 4

MAXZIDE-25 MG 4

MAXZIDE 4

MICROZIDE 4

triamterene/hydrochlorothiazid (Maxzide) 2 GC



37




Dyslipidemics

ALTOPREV 4

atorvastatin calcium (Lipitor) 2 GC

CRESTOR 3

fenofibrate (Lofibra) 2 GC

FENOGLIDE 4

gemfibrozil (Lopid) 2 GC

LIPITOR 4

LIPOFEN 4

LOFIBRA tablet 4

LOPID 4

lovastatin (Mevacor) 1 GC

PRAVACHOL 4

pravastatin sodium (Pravachol) 1 GC

simvastatin (Zocor) 1 GC, QL: 30 in 30 days

ZOCOR 4 QL: 30 in 30 days

Renin-Angiotensin-Aldosterone System Inhibitors

ALDACTAZIDE 4

ALDACTONE 4

spironolact/hydrochlorothiazid (Aldactazide) 2 GC

spironolactone (Aldactone) 2 GC

Vasodilators

isosorbide mononitrate (Imdur) 2 GC

NITRO-BID 3

NITRO-DUR patch td24: 0.3mg/hr,

0.8mg/hr

4

NITRO-DUR patch td24: 0.1mg/hr,

0.2mg/hr, 0.4mg/hr, 0.6mg/hr

4 QL: 30 in 30 days

nitroglycerin patch td24: 0.1mg/hr, 0.2mg/

hr, 0.6mg/hr

(Nitro-dur) 2 GC, QL: 30 in 30 days

nitroglycerin patch td24: 0.4mg/hr (Nitro-dur) 2 GC, QL: 60 in 30 days

nitroglycerin spray, vial: 50mg/10ml (Nitromist) 2 GC

NITROLINGUAL 4

NITROMIST 4

NITROSTAT 3

Central Nervous System Agents Central Nervous System Agents

ADDERALL XR cap er 24h: 5mg, 10mg,

15mg

4 QL: 30 in 30 days



38




ADDERALL XR cap er 24h: 20mg, 25mg,

30mg

4 QL: 60 in 30 days

ADDERALL tablet: 20mg 4 QL: 60 in 30 days

CONCERTA tab er 24: 18mg, 27mg,

54mg

4 QL: 30 in 30 days

CONCERTA tab er 24: 36mg 4 QL: 60 in 30 days

dexmethylphenidate hcl cpbp 50-50 (Focalin XR) 2 GC, QL: 30 in 30 days

dexmethylphenidate hcl tablet (Focalin) 2 GC, QL: 60 in 30 days

dextroamphetamine/amphetamine cap er

24h: 5mg, 10mg, 15mg

(Adderall XR) 2 GC, QL: 30 in 30 days

dextroamphetamine/amphetamine cap er

24h: 20mg, 25mg, 30mg; tablet

(Adderall) 2 GC, QL: 60 in 30 days

FOCALIN XR 4 QL: 30 in 30 days

FOCALIN 4 QL: 60 in 30 days

lithium carbonate (Eskalith) 2 GC

LITHOBID 4

METADATE CD cpbp 30-70: 10mg,

20mg, 40mg, 50mg, 60mg

4 QL: 30 in 30 days

METADATE CD cpbp 30-70: 30mg 4 QL: 60 in 30 days

METADATE ER 4 QL: 90 in 30 days

METHYLIN tab chew: 10mg 4 QL: 180 in 30 days

METHYLIN tab chew: 2.5mg, 5mg 4 QL: 90 in 30 days

METHYLIN solution 4 QL: 900 in 30 days

methylphenidate hcl cpbp 30-70: 10mg,

20mg, 40mg, 50mg, 60mg; tab er 24:

18mg, 27mg, 54mg

(Concerta) 2 GC, QL: 30 in 30 days

methylphenidate hcl cpbp 30-70: 30mg; tab

er 24: 36mg

(Concerta) 2 GC, QL: 60 in 30 days

methylphenidate hcl solution (Methylin) 2 GC, QL: 900 in 30 days

methylphenidate hcl tablet, tablet er (Ritalin) 2 GC, QL: 90 in 30 days

QUILLIVANT XR 3 QL: 360 in 30 days

RITALIN LA cpbp 50-50: 10mg, 20mg,

40mg

4 QL: 30 in 30 days

RITALIN LA cpbp 50-50: 30mg 4 QL: 60 in 30 days

RITALIN 4 QL: 90 in 30 days

RITALIN-SR 4 QL: 90 in 30 days

VYVANSE 4 QL: 30 in 30 days



39




Contraceptives Contraceptives

AMETHYST 4

ESTROSTEP FE 4

ethinyl estradiol/drospirenone (Yaz) 2 GC

levonorgestrel-ethin estradiol tablet (Nordette-28) 2 GC

levonorgestrel-ethin estradiol tbdspk 3mo (Seasonale) 2 GC, QL: 91 in 84 days

LO LOESTRIN FE 4

MINASTRIN 24 FE 4

MODICON 4

norethindrone-e.estradiol-iron (Loestrin Fe) 2 GC

norethindrone-ethinyl estrad tablet: 0.4-

0.035, 0.5-0.035, 1mg-35mcg, 7-9-5,

7daysx3, 10-11

(Modicon) 2 GC

norethindrone-ethinyl estrad tablet: 0.5-

0.035, 1mg-35mcg

(Modicon) 4

norgestimate-ethinyl estradiol (Ortho-cyclen) 2 GC

ORTHO TRI-CYCLEN LO 4

ORTHO TRI-CYCLEN 4

ORTHO-CYCLEN 4

ORTHO-NOVUM tablet: 1mg-35mcg,

7daysx3

4

OVCON-35 4

TRI-NORINYL 4

YASMIN 28 4

YAZ 4

Dental And Oral Agents Dental And Oral Agents

chlorhexidine gluconate (Peridex) 2 GC

triamcinolone acetonide (Kenalog In Orabase) 2 GC

Dermatological Agents Dermatological Agents, Other

ABSORICA 4

acyclovir (Zovirax) 2 GC, QL: 30 in 30 days

ALDARA 4 PA NSO, QL: 24 in 30

days

ammonium lactate (Lac-hydrin) 2 GC

AZELEX 4

calcipotriene (Dovonex) 2 GC



40




CARAC 4

DOVONEX 4

EFUDEX 4

FINACEA 4

fluorouracil (Efudex) 2 GC

imiquimod (Aldara) 2 GC, PA NSO, QL: 24 in

30 days

isotretinoin (Accutane) 2 GC

LAC-HYDRIN 4

SORILUX 4

ZOVIRAX cream (g) 3 QL: 15 in 30 days

ZOVIRAX oint. (g) 4 QL: 30 in 30 days

ZYCLARA crm md pmp: 2.5% 4 PA NSO, QL: 15 in 28

days

ZYCLARA crm md pmp: 3.75% 4 PA NSO

Dermatological Antibacterials

ACANYA 4

BACTROBAN oint. (g) 4

CLEOCIN T 4

CLINDACIN P 4

clindamycin phos/benzoyl perox (Benzaclin) 2 GC

clindamycin phosphate (Cleocin T) 2 GC

METROCREAM 4

METROGEL 4

METROLOTION 4

metronidazole (Nydamax) 2 GC

mupirocin (Centany) 2 GC

NORITATE 4

SILVADENE 4

silver sulfadiazine (Silvadene) 2 GC

Dermatological Anti-inflammatory Agents

ANUSOL-HC 4

betamethasone dipropionate (Del-beta) 2 GC

CAPEX SHAMPOO 4

clobetasol propionate (Temovate) 2 GC

CLOBEX 4

DESONATE 4

desonide (Desowen) 2 GC

ELOCON 4



41




fluocinolone acetonide (Derma-smoothe-fs) 2 GC

fluocinonide (Vanos) 2 GC

hydrocortisone cream (g), cream/appl,

enema, lotion, oint. (g)

(Hytone) 2 GC

KENALOG aerosol 4

mometasone furoate (Elocon) 2 GC

OLUX 4

SYNALAR cream (g) 4

TEMOVATE 4

triamcinolone acetonide cream (g), lotion,

oint. (g): 0.025%, 0.1%, 0.5%

(Triamcinolone

Acetonide)

2 GC

VANOS 5

Dermatological Retinoids

adapalene (Differin) 2 GC

ATRALIN 4 PA

DIFFERIN cream (g), gel (gram), lotion 4

RETIN-A 4 PA

tretinoin cream (g): 0.025%, 0.05%, 0.1%;

gel (gram): 0.01%, 0.025%

(Retin-A) 2 GC, PA

tretinoin cream (g): 0.025%; gel (gram):

0.025%

(Retin-A) 4 PA

Scabicides and Pediculicides

malathion (Ovide) 2 GC

OVIDE 4

permethrin (Elimite) 2 GC

Devices Devices

syring w-ndl,disp,insul,0.5ml (Syring W-

ndl,disp,insul,0.5ml)

2 GC

syringe & needle,insulin,1 ml (Syringe &

Needle,insulin,1 Ml)

2 GC

Enzyme Replacement/modifiers Enzyme Replacement/modifiers

CIMZIA 5 PA

CREON 3

KUVAN 5

LINZESS 3 QL: 30 in 30 days

LOTRONEX 5

PANCREAZE 4



42




PERTZYE 4

PULMOZYME 5 PA BvD

ULTRESA 4

VIOKACE 4

ZENPEP 3

Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous

ASTEPRO 4 QL: 30 in 25 days

ATROVENT spray: 42mcg 4 QL: 15 in 10 days

ATROVENT spray: 21mcg 4 QL: 30 in 28 days

azelastine hcl spray/pump (Astelin) 2 GC, QL: 30 in 25 days

azelastine hcl drops (Optivar) 2 GC

cromolyn sodium (Cromolyn Sodium) 2 GC

ipratropium bromide spray: 42mcg (Atrovent) 2 GC, QL: 15 in 10 days

ipratropium bromide spray: 21mcg (Atrovent) 2 GC, QL: 30 in 28 days

OPTIVAR 4

PATADAY 3 ST

PATANASE 4 QL: 30.5 in 30 days

PATANOL 3 ST

Eye, Ear, Nose, Throat Anti-infectives Agents

CILOXAN 4

CIPRODEX 4

ciprofloxacin hcl drops (Ciloxan) 2 GC

CORTISPORIN solution 4

erythromycin base (Ilotycin) 2 GC

gentamicin sulfate (Garamycin) 2 GC

MAXITROL 4

neo/polymyx b sulf/dexameth (Maxitrol) 2 GC

neomycin/polymyxin b sulf/hc (Oticin HC) 2 GC

OCUFLOX 4

ofloxacin (Floxin) 2 GC

polymyxin b sulf/trimethoprim (Polytrim) 2 GC

POLYTRIM 4

TOBRADEX ST 3

TOBRADEX 4

tobramycin/dexamethasone (Tobradex) 2 GC

Eye, Ear, Nose, Throat Anti-inflammatory Agents

ACULAR LS 4

ACULAR 4



43




FLONASE 4 QL: 16 in 30 days

flunisolide (Nasarel) 2 GC, QL: 50 in 25 days

fluticasone propionate (Flonase) 2 GC, QL: 16 in 30 days

ketorolac tromethamine (Acular) 2 GC

NASACORT AQ 4 QL: 16.5 in 30 days

NASONEX 4 QL: 34 in 28 days

OMNIPRED 4

PRED FORTE 4

PRED MILD 4

prednisolone acetate (Omnipred) 2 GC

RESTASIS 3 QL: 60 in 30 days

triamcinolone acetonide (Nasacort Aq) 2 GC, QL: 16.5 in 30 days

Gastrointestinal Agents Antiulcer Agents And Acid Suppressants

famotidine tablet (Pepcid) 1 GC (Rx Product Only)

famotidine tablet (Pepcid) 1 GC

famotidine oral susp (Pepcid) 2 GC (Rx Product Only)

lansoprazole (Prevacid) 2 GC (Rx Product Only)

NEXIUM 4 ST

omeprazole (Prilosec) 2 GC

pantoprazole sodium (Protonix) 2 GC

PEPCID 4 (Rx Product Only)

PREVACID 4 ST (Rx Product Only)

PRILOSEC capsule dr 4 (Rx Product Only)

PROTONIX IV 4

PROTONIX 4

ranitidine hcl capsule, syrup, vial (Taladine) 2 GC (Rx Product Only)

ranitidine hcl tablet (Zantac) 1 GC (Rx Product Only)

ranitidine hcl capsule, syrup, vial (Zantac) 2 GC

ZANTAC 4 (Rx Product Only)

ZANTAC 4

Gastrointestinal Agents, Other

ACTIGALL 4

BENTYL 4

dicyclomine hcl (Bentyl) 2 GC

diphenoxylate hcl/atropine (Lomotil) 2 GC

KRISTALOSE 4

lactulose solution: 10g/15ml (Lactulose) 2 GC

LOMOTIL 4



44




metoclopramide hcl solution, vial (Metoclopramide HCl) 2 GC

metoclopramide hcl tablet (Reglan) 1 GC

METOZOLV ODT 4

REGLAN 4

URSO FORTE 4

URSO 4

ursodiol (Actigall) 2 GC

Laxatives

COLYTE with FLAVOR PACKETS 4

GOLYTELY 4

peg 3350/na sulf,bicarb,cl/kcl (Golytely) 2 GC

polyethylene glycol 3350 (Miralax) 2 GC

Phosphate Binders

calcium acetate (Phoslo) 2 GC

PHOSLO 4

PHOSLYRA 4

RENVELA 3

Genitourinary Agents Antispasmodics, Urinary

DETROL LA 4

DETROL 4

DITROPAN XL 4

GELNIQUE gel packet 4 QL: 30 in 30 days

oxybutynin chloride (Ditropan) 2 GC

tolterodine tartrate (Detrol LA) 2 GC

VESICARE 3

Genitourinary Agents, Miscellaneous

FLOMAX 4

tamsulosin hcl (Flomax) 2 GC

terazosin hcl (Hytrin) 1 GC

Heavy Metal Antagonists Heavy Metal Antagonists

CUPRIMINE 4

DEPEN 4

EXJADE tab disper: 125mg 4

EXJADE tab disper: 250mg, 500mg 5



45




Hormonal Agents, Stimulant/replacement/modifying Androgens

ANDRODERM 3 PA, QL: 30 in 30 days

ANDROGEL gel md pmp: 20.25/1.25 3 PA, QL: 150 in 30 days

ANDROGEL gel md pmp: 1.25g(1%) 3 PA, QL: 300 in 30 days

AXIRON 4 PA, QL: 180 in 28 days

DEPO-TESTOSTERONE 4 PA

FORTESTA 4 PA, QL: 120 in 30 days

STRIANT 4 PA, QL: 60 in 30 days

TESTIM 4 PA, QL: 300 in 30 days

testosterone cypionate (Depo-testosterone) 2 GC, PA

VOGELXO 4 PA, QL: 300 in 30 days

Estrogens and Antiestrogens

ACTIVELLA 4 PA-HRM

ALORA 4 PA-HRM, QL: 8 in 28

days

CLIMARA 4 PA-HRM, QL: 4 in 28

days

COMBIPATCH 3 PA-HRM, QL: 8 in 28

days

DIVIGEL 4 PA-HRM, QL: 30 in 30

days

ESTRACE cream/appl 3

ESTRACE tablet 4 PA-HRM

estradiol patch tdwk (Climara) 2 GC, PA-HRM, QL: 4 in

28 days

estradiol tablet (Estrace) 2 GC, PA-HRM

estradiol/norethindrone acet (Activella) 2 GC, PA-HRM

ESTRASORB 4 PA-HRM, QL: 97.44 in

28 days

ESTRING 4 QL: 1 in 84 days

EVAMIST 4 PA-HRM, QL: 8.1 in 25

days

FEMHRT 4 PA-HRM

MENOSTAR 4 PA-HRM, QL: 4 in 28

days

MINIVELLE 4 PA-HRM, QL: 8 in 28

days

norethindrone ac-eth estradiol (Femhrt) 2 GC, PA-HRM



46




PREMARIN cream/appl, vial 3

PREMARIN tablet 3 PA-HRM

PREMPHASE 3 PA-HRM

PREMPRO 3 PA-HRM

VAGIFEM 3 QL: 18 in 28 days

VIVELLE-DOT 3 PA-HRM, QL: 8 in 28

days

Glucocorticoids/mineralocorticoids

CORTEF 4 PA BvD

DEXAMETHASONE INTENSOL 4

dexamethasone tablet (Dexamethasone) 1 GC, PA BvD

dexamethasone elixir (Dexamethasone) 2 GC, PA BvD

DEXPAK tab ds pk: 1.5mg(51) 4

hydrocortisone (Cortef) 2 GC, PA BvD

MILLIPRED solution 4

ORAPRED ODT tab rapdis: 15mg, 30mg 4

ORAPRED 4 PA BvD

prednisolone sod phosphate (Orapred) 2 GC, PA BvD

PREDNISONE INTENSOL 3 PA BvD

prednisone tablet (Prednisone) 1 GC, PA BvD

prednisone solution (Prednisone) 2 GC, PA BvD

RAYOS 4 PA BvD

VERIPRED 20 4 PA BvD

Pituitary

DDAVP solution, tablet, vial 4

desmopressin acetate tablet, vial (DDAVP) 2 GC

desmopressin acetate spray/pump (Desmopressin Acetate) 2 GC, QL: 15 in 30 days

GENOTROPIN syringe: 0.2mg/0.25 4 PA

GENOTROPIN various dosage and/or

strengths are available

5 PA

HUMATROPE 5 PA

NORDITROPIN FLEXPRO 5 PA

NORDITROPIN NORDIFLEX 5 PA

NUTROPIN AQ NUSPIN 5 PA

OMNITROPE cartridge: 10mg/1.5ml 4 PA

OMNITROPE cartridge: 5mg/1.5ml; vial 5 PA

SAIZEN cartridge, vial: 5mg 5 PA

SEROSTIM 5 PA

STIMATE 4



47




TEV-TROPIN 4 PA

ZORBTIVE 5 PA

Progestins

CRINONE gel/pf app: 4% 4

DEPO-PROVERA vial: 150mg/ml 4 QL: 1 in 84 days

DEPO-PROVERA vial: 400mg/ml 4 QL: 10 in 28 days

DEPO-SUBQ PROVERA 104 4 QL: 1 in 84 days

ENDOMETRIN 4

medroxyprogesterone acetate vial (Depo-provera) 2 GC, QL: 1 in 84 days

medroxyprogesterone acetate tablet (Provera) 2 GC

progesterone,micronized (Prometrium) 2 GC

PROMETRIUM 4

PROVERA 4

Thyroid and Antithyroid Agents

CYTOMEL 4

levothyroxine sodium vial: 100mcg (Levothyroxine

Sodium)

2 GC

levothyroxine sodium tablet (Levoxyl) 1 GC

LEVOXYL 4

liothyronine sodium (Cytomel) 2 GC

SYNTHROID 4

TIROSINT 4

UNITHROID 4

Immunological Agents Immunological Agents

ARAVA 4

ASTAGRAF XL 4 PA BvD

AZASAN 4 PA BvD

azathioprine (Imuran) 2 GC, PA BvD

CELLCEPT capsule 4 PA BvD

CELLCEPT susp recon, tablet 5 PA BvD

cyclosporine, modified (Neoral) 2 GC, PA BvD

ENBREL pen injctr 5 PA, QL: 3.92 in 28 days

ENBREL vial 5 PA, QL: 8 in 28 days

ENBREL syringe 5 PA, QL: 8.16 in 28 days

HUMIRA kit 5 PA, QL: 2 in 28 days

HUMIRA pen ij kit: 40mg/0.8ml 5 PA, QL: 6 in 28 days

(Starter Kit)

HUMIRA pen ij kit: 40mg/0.8ml 5 PA



48




IMURAN 4 PA BvD

leflunomide (Arava) 2 GC

mycophenolate mofetil (Cellcept) 2 GC, PA BvD

NEORAL 4 PA BvD

PROGRAF 4 PA BvD

tacrolimus (Hecoria) 2 GC, PA BvD

Vaccines

ADACEL TDAP vial 3

BOOSTRIX TDAP 3

ENGERIX-B ADULT 3 PA BvD

ENGERIX-B PEDIATRIC-

ADOLESCENT

3 PA BvD

HAVRIX vial 3 PA BvD

MENACTRA 3

MENVEO A-C-Y-W-135-DIP 3

RECOMBIVAX HB vial: 10mcg/ml,

40mcg/ml

3 PA BvD

TWINRIX vial 3

TYPHIM VI 3

VAQTA vial: 50unit/ml 3 PA BvD

ZOSTAVAX 3 QL: 1 in 365 days

Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents

APRISO 3

ASACOL HD 3 ST

balsalazide disodium (Colazal) 2 GC

CANASA 4

COLAZAL 4

DELZICOL 3 ST

GIAZO 4 ST

LIALDA 4 ST

PENTASA 4 ST

Irrigating Solutions Irrigating Solutions

sodium chloride irrig solution (Sodium Chloride Irrig

Solution)

2 GC

water for irrigation,sterile (Water for Irrigation,

Sterile)

2 GC



49




Metabolic Bone Disease Agents Metabolic Bone Disease Agents

ACTONEL tablet: 5mg, 30mg 3 QL: 30 in 30 days

ACTONEL tablet: 35mg 3 QL: 4 in 28 days

ACTONEL tablet: 150mg 4 QL: 1 in 28 days

alendronate sodium tablet: 35mg, 70mg (Fosamax) 1 GC, QL: 4 in 28 days

alendronate sodium tablet: 5mg, 10mg,

40mg

(Fosamax) 1 GC

alendronate sodium solution (Fosamax) 2 GC, QL: 300 in 28 days

ATELVIA 4 QL: 4 in 28 days

BINOSTO 4 QL: 4 in 28 days

BONIVA syringe 4 PA BvD, QL: 3 in 84

days (PA for ESRD

Only)

BONIVA tablet 4 QL: 1 in 28 days

calcitriol (Rocaltrol) 2 GC, PA BvD (PA for

ESRD Only)

FOSAMAX 4

ibandronate sodium tablet (Boniva) 2 GC, QL: 1 in 28 days

ibandronate sodium vial (Ibandronate Sodium) 2 GC, PA BvD, QL: 3 in

84 days (PA for ESRD

Only)

risedronate sodium (Actonel) 2 GC, QL: 1 in 28 days

ROCALTROL 4 PA BvD (PA for ESRD

Only)

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

allopurinol (Zyloprim) 1 GC

AVODART 3

AVONEX ADMINISTRATION PACK 5 ST

AVONEX 5 ST

buspirone hcl (Buspar) 2 GC

COLCRYS 3

COPAXONE 5

ELMIRON 4

finasteride (Proscar) 2 GC

GLUCAGEN 3

GLUCAGON EMERGENCY KIT 4

hydroxyzine hcl (Hydroxyzine HCl) 2 GC, PA-HRM



50




hydroxyzine pamoate (Vistaril) 2 GC, PA-HRM

MESTINON 4

PROSCAR 4

pyridostigmine bromide (Mestinon) 2 GC

REBIF 5

SENSIPAR tablet: 30mg 3

SENSIPAR tablet: 60mg, 90mg 5

TECFIDERA capsule dr: 120mg 5 PA, QL: 14 in 30 days

TECFIDERA capsule dr: 120-240mg,

240mg


ULORIC 3 ST, QL: 30 in 30 days

VISTARIL 4 PA-HRM

ZYLOPRIM 4

Ophthalmic Agents Antiglaucoma Agents

ALPHAGAN P drops: 0.1% 3

ALPHAGAN P drops: 0.15% 4

brimonidine tartrate (Alphagan P) 2 GC (drops: 0.15%,

0.20%)

COSOPT 4

dorzolamide hcl/timolol maleat (Cosopt) 2 GC

ISTALOL 4

latanoprost (Xalatan) 2 GC

LUMIGAN 3 QL: 2.5 in 25 days

timolol maleate (Timoptic) 2 GC

TIMOPTIC-XE 4

TRAVATAN Z 3 QL: 2.5 in 25 days

XALATAN 4 QL: 2.5 in 25 days

Replacement Preparations Replacement Preparations

0.9 % sodium chloride (0.9 % Sodium

Chloride)

2 GC

K-TAB ER 4

LACTATED RINGERS 4

potassium chloride in 0.9%nacl (Potassium Chloride In

0.9%NaCl)

2 GC

potassium chloride capsule er, piggyback:

10meq/0.1l, 10meq/50ml, 20meq/50ml; tab

er prt, tablet er, vial

(K-dur) 2 GC



51




potassium chloride/d5-0.45nacl (Potassium Chloride/

d5-0.45NaCl)

2 GC

potassium chloride/d5-0.9%nacl (Potassium Chloride/

d5-0.9%NaCl)

2 GC

potassium citrate tablet er: 5meq, 10meq (Urocit-K) 2 GC

sodium chloride 0.45 % (Sodium Chloride 0.45

%)

2 GC

sodium chloride vial: 2.5meq/ml (Sodium Chloride) 2 GC

UROCIT-K 4

Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS 3 QL: 60 in 30 days

ADVAIR HFA 3 QL: 12 in 28 days

FLOVENT DISKUS blst w/dev: 250mcg 3 QL: 120 in 30 days

FLOVENT DISKUS blst w/dev: 50mcg,

100mcg

3 QL: 60 in 30 days

FLOVENT HFA aer w/adap: 110mcg 3 QL: 12 in 28 days

FLOVENT HFA aer w/adap: 44mcg 3 QL: 21.2 in 28 days

FLOVENT HFA aer w/adap: 220mcg 3 QL: 24 in 28 days

QVAR 3 QL: 17.4 in 25 days

Antileukotrienes

ACCOLATE 4

montelukast sodium (Singulair) 2 GC

SINGULAIR 4

zafirlukast (Accolate) 2 GC

Bronchodilators

albuterol sulfate solution, vial-neb:

0.63mg/3ml, 1.25mg/3ml, 2.5mg/3ml

(Accuneb) 2 GC, PA BvD

albuterol sulfate syrup, tab er 12h, tablet (Albuterol Sulfate) 2 GC

ATROVENT HFA 3 QL: 25.8 in 28 days

COMBIVENT RESPIMAT 3 QL: 8 in 30 days

PROAIR HFA 3 QL: 17 in 25 days

PROVENTIL HFA 4 QL: 13.4 in 25 days

SPIRIVA 3 QL: 30 in 30 days

VENTOLIN HFA hfa aer ad: 90mcg 3 QL: 36 in 25 days

VOSPIRE ER 4

Respiratory Tract Agents, Other

DALIRESP 3 QL: 30 in 30 days

XOLAIR 5 PA, QL: 6 in 28 days



52




Skeletal Muscle Relaxants Skeletal Muscle Relaxants

AMRIX 4 PA-HRM

baclofen (Baclofen) 2 GC

cyclobenzaprine hcl (Fexmid) 2 GC, PA-HRM

FEXMID 4 PA-HRM

methocarbamol (Robaxin) 2 GC, PA-HRM

Sleep Disorder Agents Sleep Disorder Agents

AMBIEN CR 4 PA-HRM, QL: 30 in 30


QL applies to all



with over 90 days

cumulative use with any

non-benzodiazepine

hypnotic drug)

AMBIEN 4 PA-HRM, QL: 30 in 30


QL applies to all



with over 90 days


non-benzodiazepine

hypnotic drug)

EDLUAR 4 PA-HRM, QL: 30 in 30


QL applies to all



with over 90 days


non-benzodiazepine

hypnotic drug)



53




INTERMEZZO 4 PA-HRM, QL: 30 in 30


QL applies to all



with over 90 days


non-benzodiazepine

hypnotic drug)

modafinil (Provigil) 2 GC, PA, QL: 60 in 30

days

NUVIGIL tablet: 150mg, 250mg 3 PA, QL: 30 in 30 days

NUVIGIL tablet: 50mg 3 PA, QL: 90 in 30 days

PROVIGIL 4 PA, QL: 60 in 30 days

zolpidem tartrate (Ambien) 2 GC, PA-HRM, QL: 30 in

30 days (High Risk

Med. QL applies to all



with over 90 days


non-benzodiazepine

hypnotic drug)

ZOLPIMIST 4 PA-HRM, QL: 7.7 in 30


QL applies to all



with over 90 days


non-benzodiazepine

hypnotic drug)

Vasodilating Agents Vasodilating Agents

ADCIRCA 5 PA, QL: 60 in 30 days

CIALIS tablet: 2.5mg, 5mg 4 PA, QL: 30 in 30 days

LETAIRIS 5 PA, QL: 30 in 30 days

REVATIO vial 5 PA, QL: 37.5 in 1 day

REVATIO tablet 5 PA, QL: 90 in 30 days



54




sildenafil citrate (Revatio) 2 GC, PA, QL: 90 in 30

days

Vitamins and Minerals Vitamins and Minerals

ped mv a,c,d3 #21 w-fluoride (Ped Mv A,c,d3 #21

W-fluoride)

2 GC

pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/

iron/fa)

3 (All Rx Prenatal

Vitamins Covered)

I-1



INDEX

0.9 % sodium chloride .......... 49

ABILIFY ............................... 30

ABILIFY DISCMELT .......... 30

ABILIFY MAINTENA ........ 30

ABSORICA .......................... 38

ACANYA ............................. 39

ACCOLATE ......................... 50

acetaminophen with codeine . 15

ACTIGALL........................... 42

ACTIVELLA ........................ 44

ACTONEL ............................ 48

ACTOS ................................. 25

ACULAR .............................. 41

ACULAR LS ........................ 41

acyclovir .......................... 31, 38

ADACEL TDAP ................... 47

ADALAT CC ........................ 35

adapalene .............................. 40

ADCIRCA............................. 52

ADDERALL ......................... 37

ADDERALL XR ............ 36, 37

ADOXA ................................ 21

ADVAIR DISKUS................ 50

ADVAIR HFA ...................... 50

AFINITOR ............................ 21

AFINITOR DISPERZ ........... 21

AGRYLIN............................. 32

ALBENZA ............................ 29

albuterol sulfate .................... 50

ALDACTAZIDE .................. 36

ALDACTONE ...................... 36

ALDARA .............................. 38

alendronate sodium ............... 48

allopurinol............................. 48

ALORA ................................. 44

ALPHAGAN P ..................... 49

alprazolam ............................ 18

ALPRAZOLAM INTENSOL18

ALSUMA .............................. 28

ALTACE ............................... 34

ALTOPREV .......................... 36

AMARYL ............................. 26

AMBIEN ............................... 51

AMBIEN CR ........................ 51

AMERGE .............................. 28

AMETHYST ......................... 38

amiodarone hcl ..................... 34

amitriptyline hcl .................... 25

amlodipine besylate .............. 35

amlodipine besylate/benazepril

........................................... 35

ammonium lactate ................. 38

amoxicillin............................. 20

amoxicillin/potassium clav.... 20

ampicillin trihydrate ............. 20

AMRIX ................................. 51

anagrelide hcl ....................... 32

anastrozole ............................ 21

ANDRODERM ..................... 44

ANDROGEL......................... 44

ANUSOL-HC ....................... 39

APRISO ................................ 47

ARAVA ................................ 46

ARICEPT .............................. 24

ARICEPT ODT ..................... 24

ARIMIDEX........................... 21

AROMASIN ......................... 21

ASACOL HD ........................ 47

ASTAGRAF XL ................... 46

ASTEPRO ............................. 41

ATELVIA ............................. 48

atenolol ................................. 34

ATIVAN ............................... 18

atorvastatin calcium.............. 36

atovaquone/proguanil hcl ..... 29

ATRALIN ............................. 40

ATRIPLA .............................. 31

atropine sulfate ..................... 23

ATROVENT ......................... 41

ATROVENT HFA ................ 50

AUGMENTIN ...................... 20

AUVI-Q ................................ 35

AVAPRO .............................. 33

AVELOX .............................. 20

AVELOX ABC PACK ......... 20

AVINZA ............................... 15

AVODART ........................... 48

AVONEX .............................. 48

AVONEX

ADMINISTRATION PACK

........................................... 48

AXIRON ............................... 44

AZASAN .............................. 46

azathioprine .......................... 46

azelastine hcl ......................... 41

AZELEX ............................... 38

azithromycin .......................... 20

AZULFIDINE ....................... 21

baclofen ................................. 51

BACTRIM ............................ 21

BACTRIM DS ...................... 21

BACTROBAN ...................... 39

balsalazide disodium ............. 47

benazepril hcl ........................ 34

BENTYL ............................... 42

benztropine mesylate ............. 29

betamethasone dipropionate . 39

BIAXIN................................. 20

BIAXIN XL .......................... 20

BINOSTO ............................. 48

BONIVA ............................... 48

BOOSTRIX TDAP ............... 47

brimonidine tartrate .............. 49

buprenorphine hcl ................. 18

buprenorphine hcl/naloxone hcl

........................................... 18

bupropion hcl ........................ 25

I-2



buspirone hcl ......................... 48

butalb/acetaminophen/caffeine

........................................... 15

BYDUREON ........................ 25

BYSTOLIC ........................... 34

CALAN ................................. 34

CALAN SR ........................... 34

calcipotriene ......................... 38

calcitriol ................................ 48

calcium acetate ..................... 43

CANASA .............................. 47

CAPEX SHAMPOO ............. 39

CAPITAL W-CODEINE ...... 15

CARAC ................................. 39

carbamazepine ...................... 23

CARBATROL ...................... 23

carbidopa/levodopa .............. 29

CARDIZEM .......................... 35

CARDIZEM CD ................... 34

CARDIZEM LA ................... 34

CARDURA ........................... 33

CARDURA XL ..................... 33

carvedilol .............................. 34

CATAPRES .......................... 33

CAYSTON ............................ 20

cefadroxil .............................. 20

cefdinir .................................. 20

cefprozil................................. 20

CEFTIN................................. 20

cefuroxime axetil ................... 20

CELEBREX .......................... 17

CELEXA ............................... 25

CELLCEPT ........................... 46

cephalexin ............................. 20

CHANTIX............................. 18

chlorhexidine gluconate ........ 38

chlorthalidone ....................... 35

CIALIS .................................. 52

CILOXAN............................. 41

CIMZIA ................................ 40

CIPRO ................................... 20

CIPRODEX........................... 41

ciprofloxacin hcl ............. 20, 41

citalopram hydrobromide ..... 25

CLARINEX .......................... 27

clarithromycin ....................... 20

CLEOCIN HCL .................... 19

CLEOCIN PALMITATE...... 19

CLEOCIN T .......................... 39

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

CLINDACIN P ..................... 39

clindamycin hcl ..................... 19

clindamycin palmitate hcl ..... 19

clindamycin phos/benzoyl perox

........................................... 39

clindamycin phosphate.......... 39

CLINIMIX E ......................... 33

CLINISOL ............................ 33

clobetasol propionate............ 39

CLOBEX............................... 39

clonazepam ..................... 18, 19

clonidine hcl .......................... 33

clopidogrel bisulfate ............. 32

clotrimazole........................... 27

clotrimazole/betamethasone dip

........................................... 27

clozapine ............................... 30

CLOZARIL ........................... 30

COGENTIN .......................... 29

COLAZAL ............................ 47

COLCRYS ............................ 48

COLYTE with FLAVOR

PACKETS ......................... 43

COMBIPATCH .................... 44

COMBIVENT RESPIMAT .. 50

CONCERTA ......................... 37

CONZIP ................................ 15

COPAXONE ......................... 48

COREG ................................. 34

CORTEF ............................... 45

CORTISPORIN .................... 41

COSOPT ............................... 49

COUMADIN......................... 32

COZAAR .............................. 33

CREON ................................. 40

CRESTOR............................. 36

CRINONE ............................. 46

cromolyn sodium ................... 41

CUPRIMINE......................... 43

cyclobenzaprine hcl .............. 51

cyclophosphamide ................. 21

CYCLOPHOSPHAMIDE..... 21

cyclosporine, modified .......... 46

CYKLOKAPRON ................ 32

CYMBALTA ........................ 25

cyproheptadine hcl ................ 28

CYTOMEL ........................... 46

DALIRESP ........................... 50

dapsone ................................. 28

DDAVP ................................. 45

DELZICOL ........................... 47

DEPAKOTE ......................... 23

DEPAKOTE ER ................... 23

DEPAKOTE SPRINKLE ..... 23

DEPEN .................................. 43

DEPO-PROVERA ................ 46

DEPO-SUBQ PROVERA 104

........................................... 46

DEPO-TESTOSTERONE .... 44

desloratadine......................... 28

desmopressin acetate ............ 45

DESONATE ......................... 39

desonide ................................ 39

DETROL ............................... 43

DETROL LA ........................ 43

dexamethasone ...................... 45

DEXAMETHASONE

INTENSOL ....................... 45

dexmethylphenidate hcl ......... 37

DEXPAK .............................. 45

dextroamphetamine/

amphetamine ..................... 37

dextrose 10 % in water ......... 33

dextrose 5 % and 0.9 % nacl 33

dextrose 5 % in water ........... 33

dextrose 5 %-0.45 % nacl ..... 33

I-3



dextrose 5%-lactated ringers 33

DIABETA ....................... 26, 27

diclofenac sodium ................. 17

dicloxacillin sodium .............. 20

dicyclomine hcl ..................... 42

DIFFERIN............................. 40

DIFLUCAN .......................... 27

DILACOR XR ...................... 35

DILANTIN ........................... 23

DILAUDID ........................... 15

diltiazem hcl .......................... 35

DIOVAN ............................... 33

DIOVAN HCT ...................... 33

diphenoxylate hcl/atropine .... 42

DITROPAN XL .................... 43

divalproex sodium ................. 24

DIVIGEL .............................. 44

donepezil hcl ......................... 24

dorzolamide hcl/timolol maleat

........................................... 49

DOVONEX ........................... 39

doxazosin mesylate................ 33

doxycycline monohydrate ...... 21

DROXIA ............................... 21

duloxetine hcl ........................ 25

DURAGESIC ........................ 15

DYAZIDE ............................. 35

EC-NAPROSYN................... 17

econazole nitrate ................... 27

EDLUAR .............................. 51

EFFEXOR XR ...................... 25

EFFIENT............................... 32

EFUDEX ............................... 39

ELIGARD ............................. 21

ELMIRON ............................ 48

ELOCON .............................. 39

enalapril maleate .................. 34

ENBREL ............................... 46

ENDOMETRIN .................... 46

ENGERIX-B ADULT .......... 47

ENGERIX-B PEDIATRIC-

ADOLESCENT ................ 47

enoxaparin sodium ................ 32

EPANED ............................... 34

epinephrine ........................... 35

EPIPEN 2-PAK ..................... 35

EPIPEN JR 2-PAK ............... 35

EPOGEN ............................... 32

EPZICOM ............................. 31

EQUETRO ............................ 24

erythromycin base ................. 41

escitalopram oxalate ............. 25

ESGIC ................................... 15

ESTRACE ............................. 44

estradiol ................................ 44

estradiol/norethindrone acet . 44

ESTRASORB ....................... 44

ESTRING .............................. 44

ESTROSTEP FE ................... 38

ethambutol hcl ....................... 28

ethinyl estradiol/drospirenone

........................................... 38

EVAMIST ............................. 44

EXALGO .............................. 15

exemestane ............................ 21

EXJADE ............................... 43

EXTINA ................................ 27

famciclovir ............................ 31

famotidine ............................. 42

FAMVIR ............................... 31

FAZACLO ............................ 30

FEMARA .............................. 22

FEMHRT .............................. 44

fenofibrate ............................. 36

FENOGLIDE ........................ 36

fentanyl .................................. 15

FEXMID ............................... 51

FINACEA ............................. 39

finasteride ............................. 48

FLAGYL ............................... 29

FLAGYL ER ......................... 29

flecainide acetate .................. 34

FLOMAX .............................. 43

FLONASE............................. 42

FLOVENT DISKUS ............. 50

FLOVENT HFA ................... 50

fluconazole ............................ 27

flunisolide .............................. 42

fluocinolone acetonide .......... 40

fluocinonide........................... 40

fluorouracil ........................... 39

fluoxetine hcl ......................... 25

fluticasone propionate .......... 42

FOCALIN ............................. 37

FOCALIN XR ....................... 37

FORFIVO XL ....................... 25

FORTAMET ................... 25, 26

FORTESTA .......................... 44

FOSAMAX ........................... 48

furosemide ............................. 35

gabapentin............................. 24

GELNIQUE .......................... 43

gemfibrozil ............................ 36

GENOTROPIN ..................... 45

gentamicin sulfate ........... 19, 41

GEODON .............................. 30

GIAZO .................................. 47

GLEEVEC ............................ 22

glimepiride ............................ 27

glipizide ................................. 27

GLUCAGEN......................... 48

GLUCAGON EMERGENCY

KIT .................................... 48

GLUCOPHAGE ................... 26

GLUCOPHAGE XR ............. 26

GLUCOTROL ...................... 27

GLUCOTROL XL ................ 27

GLUMETZA......................... 26

glyburide ............................... 27

GOLYTELY ......................... 43

GRALISE .............................. 24

guanfacine hcl ....................... 33

haloperidol ............................ 30

HAVRIX ............................... 47

HUMALOG .......................... 26

HUMATROPE ...................... 45

I-4



HUMIRA .............................. 46

HUMULIN N ........................ 26

HUMULIN N KWIKPEN .... 26

HYCET ................................. 15

hydralazine hcl ...................... 35

HYDREA .............................. 22

hydrochlorothiazide .............. 35

hydrocodone/acetaminophen 15

hydrocortisone ................ 40, 45

hydromorphone hcl ......... 15, 16

hydroxychloroquine sulfate ... 29

hydroxyurea .......................... 22

hydroxyzine hcl ..................... 48

hydroxyzine pamoate ............ 49

HYZAAR .............................. 33

ibandronate sodium .............. 48

ibuprofen ............................... 17

IMBRUVICA ........................ 22

imiquimod ............................. 39

IMITREX .............................. 28

IMURAN .............................. 47

INDERAL LA ....................... 34

INDOCIN .............................. 17

indomethacin ......................... 17

INLYTA ................................ 22

INNOPRAN XL.................... 34

INTERMEZZO ..................... 52

INTRALIPID ........................ 33

INVANZ ............................... 20

INVOKANA ......................... 26

ipratropium bromide ............. 41

irbesartan .............................. 33

ISENTRESS .......................... 31

isoniazid ................................ 28

isosorbide mononitrate ......... 36

isotretinoin ............................ 39

ISTALOL .............................. 49

JAKAFI ................................. 22

JANUMET ............................ 26

JANUMET XR ..................... 26

JANUVIA ............................. 26

KADIAN ............................... 16

KEFLEX ............................... 20

KENALOG ........................... 40

KEPPRA ............................... 24

KEPPRA XR ......................... 24

ketoconazole .......................... 27

KETODAN ........................... 27

ketorolac tromethamine ........ 42

KLONOPIN .......................... 19

KRISTALOSE ...................... 42

K-TAB ER ............................ 49

KUVAN ................................ 40

LAC-HYDRIN ...................... 39

LACTATED RINGERS ....... 49

lactulose ................................ 42

LAMICTAL .......................... 24

LAMICTAL BLUE .............. 24

LAMICTAL GREEN............ 24

LAMICTAL ODT ................. 24

LAMICTAL ORANGE ........ 24

LAMICTAL XR ................... 24

LAMICTAL XR BLUE ........ 24

LAMICTAL XR GREEN ..... 24

LAMICTAL XR ORANGE .. 24

LAMISIL .............................. 27

lamotrigine ............................ 24

lansoprazole .......................... 42

LANTUS ............................... 26

LANTUS SOLOSTAR ......... 26

LASIX ................................... 35

latanoprost ............................ 49

leflunomide ............................ 47

LETAIRIS ............................. 52

letrozole................................. 22

LEUKERAN ......................... 22

leuprolide acetate.................. 22

LEVAQUIN .......................... 21

levetiracetam ......................... 24

levocetirizine dihydrochloride

........................................... 28

levofloxacin ........................... 21

levonorgestrel-ethin estradiol 38

levothyroxine sodium ............ 46

LEVOXYL ............................ 46

LEXAPRO ............................ 25

LIALDA ................................ 47

lidocaine ................................ 18

lidocaine hcl .......................... 18

LIDODERM ......................... 18

LINZESS............................... 40

liothyronine sodium .............. 46

LIPITOR ............................... 36

LIPOFEN .............................. 36

LIPOSYN III ......................... 33

lisinopril ................................ 34

lisinopril/hydrochlorothiazide

........................................... 34

lithium carbonate .................. 37

LITHOBID ............................ 37

LO LOESTRIN FE ............... 38

LOFIBRA ............................. 36

LOMOTIL............................. 42

LOPID ................................... 36

LOPRESSOR ........................ 34

lorazepam .............................. 19

LORTAB............................... 16

losartan potassium ................ 33

losartan/hydrochlorothiazide 33

LOTENSIN ........................... 34

LOTREL ............................... 35

LOTRISONE ........................ 27

LOTRONEX ......................... 40

lovastatin ............................... 36

LOVENOX ........................... 32

LUMIGAN ............................ 49

LUPRON DEPOT ................. 22

LUPRON DEPOT-PED ........ 22

LYRICA ................................ 24

LYSODREN ......................... 22

LYSTEDA ............................ 32

MACRODANTIN................. 19

MALARONE ........................ 29

malathion .............................. 40

MAXALT ............................. 28

MAXALT MLT .................... 28

I-5



MAXITROL ......................... 41

MAXZIDE ............................ 35

MAXZIDE-25 MG ............... 35

meclizine hcl.......................... 28

medroxyprogesterone acetate 46

mefloquine hcl ....................... 29

MEGACE .............................. 22

MEGACE ES ........................ 22

megestrol acetate .................. 22

meloxicam ............................. 17

MENACTRA ........................ 47

MENOSTAR......................... 44

MENVEO A-C-Y-W-135-DIP

........................................... 47

mercaptopurine ..................... 22

MESTINON .......................... 49

METADATE CD .................. 37

METADATE ER .................. 37

metformin hcl ........................ 26

methocarbamol ..................... 51

methotrexate sodium ............. 22

methotrexate sodium/pf ......... 22

METHYLIN .......................... 37

methylphenidate hcl .............. 37

metoclopramide hcl ............... 43

metoprolol succinate ............. 34

metoprolol tartrate ................ 34

METOZOLV ODT ............... 43

METROCREAM .................. 39

METROGEL ......................... 39

METROGEL-VAGINAL ..... 28

METROLOTION .................. 39

metronidazole ............ 28, 29, 39

MICROZIDE ........................ 35

MILLIPRED ......................... 45

MINASTRIN 24 FE .............. 38

MINIVELLE ......................... 44

minocycline hcl ..................... 21

MIRAPEX............................. 29

MIRAPEX ER ...................... 29

MOBIC ................................. 17

modafinil ............................... 52

MODICON ........................... 38

mometasone furoate .............. 40

montelukast sodium ............... 50

morphine sulfate.................... 16

MORPHINE SULFATE ....... 16

MOXATAG .......................... 20

moxifloxacin hcl .................... 21

MS CONTIN ......................... 16

mupirocin .............................. 39

MYAMBUTOL .................... 28

mycophenolate mofetil .......... 47

nabumetone ........................... 17

nafcillin sodium ..................... 20

NAMENDA .......................... 25

NAMENDA XR.................... 24

NAPROSYN ......................... 18

naproxen ............................... 18

naratriptan hcl ...................... 28

NASACORT AQ .................. 42

NASONEX ........................... 42

neo/polymyx b sulf/dexameth 41

neomycin sulfate.................... 19

neomycin/polymyxin b sulf/hc 41

NEORAL .............................. 47

NEULASTA ......................... 32

NEUPOGEN ......................... 32

NEURONTIN ....................... 24

NEXAVAR ........................... 22

NEXIUM............................... 42

nifedipine............................... 35

NITRO-BID .......................... 36

NITRO-DUR......................... 36

nitrofurantoin macrocrystal .. 19

nitroglycerin .......................... 36

NITROLINGUAL................. 36

NITROMIST ......................... 36

NITROSTAT ........................ 36

NIZORAL ............................. 27

NORCO................................. 16

NORDITROPIN FLEXPRO . 45

NORDITROPIN NORDIFLEX

........................................... 45

norethindrone ac-eth estradiol

........................................... 44

norethindrone-e.estradiol-iron

........................................... 38

norethindrone-ethinyl estrad 38

norgestimate-ethinyl estradiol

........................................... 38

NORITATE........................... 39

NORVASC ........................... 35

NORVIR ............................... 31

NOVOLIN N ........................ 26

NUTROPIN AQ NUSPIN .... 45

NUVIGIL .............................. 52

nystatin .................................. 27

nystatin/triamcin ................... 27

OCUFLOX ............................ 41

ofloxacin ................................ 41

olanzapine ............................. 30

OLUX ................................... 40

OLYSIO ................................ 31

omeprazole ............................ 42

OMNIPRED .......................... 42

OMNITROPE ....................... 45

ondansetron........................... 29

ondansetron hcl ..................... 28

OPTIVAR ............................. 41

ORACEA .............................. 21

ORAPRED ............................ 45

ORAPRED ODT ................... 45

ORTHO TRI-CYCLEN ........ 38

ORTHO TRI-CYCLEN LO .. 38

ORTHO-CYCLEN ............... 38

ORTHO-NOVUM ................ 38

OVCON-35 ........................... 38

OVIDE .................................. 40

OXECTA .............................. 16

oxybutynin chloride ............... 43

oxycodone hcl........................ 16

oxycodone hcl/acetaminophen

........................................... 16

OXYCONTIN ....................... 17

PANCREAZE ....................... 40

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pantoprazole sodium ............. 42

paroxetine hcl........................ 25

PATADAY ........................... 41

PATANASE .......................... 41

PATANOL ............................ 41

PAXIL ................................... 25

PAXIL CR ............................ 25

ped mv a,c,d3 #21 w-fluoride 53

peg 3350/na sulf,bicarb,cl/kcl 43

PEGASYS ............................. 31

PEGASYS PROCLICK ........ 31

PEGINTRON ........................ 31

PEGINTRON REDIPEN ...... 31

penicillin v potassium ........... 20

PENNSAID ........................... 18

PENTASA............................. 47

PEPCID ................................. 42

PERCOCET .......................... 17

permethrin ............................. 40

PERTZYE ............................. 41

PHENERGAN ...................... 29

PHENYTEK ......................... 24

phenytoin sodium extended ... 24

PHOSLO ............................... 43

PHOSLYRA ......................... 43

pioglitazone hcl ..................... 26

PLAQUENIL ........................ 29

PLAVIX ................................ 33

pnv with ca,no.72/iron/fa ...... 53

polyethylene glycol 3350....... 43

polymyxin b sulf/trimethoprim

........................................... 41

POLYTRIM .......................... 41

POMALYST ......................... 22

potassium chloride ................ 49

potassium chloride in 0.9%nacl

........................................... 49

potassium chloride/d5-0.45nacl

........................................... 50

potassium chloride/d5-

0.9%nacl ........................... 50

potassium citrate ................... 50

pramipexole di-hcl ................ 29

PRAVACHOL ...................... 36

pravastatin sodium ................ 36

PRED FORTE ....................... 42

PRED MILD ......................... 42

prednisolone acetate ............. 42

prednisolone sod phosphate .. 45

prednisone ............................. 45

PREDNISONE INTENSOL . 45

PREMARIN .......................... 45

PREMPHASE ....................... 45

PREMPRO ............................ 45

PREVACID........................... 42

PREZISTA ............................ 31

PRILOSEC ............................ 42

PRIMLEV ............................. 17

PRIMSOL ............................. 19

PRINIVIL ............................. 34

PROAIR HFA ....................... 50

PROCARDIA ....................... 35

PROCARDIA XL ................. 35

prochlorperazine maleate ..... 29

PROCRIT .............................. 32

progesterone,micronized ....... 46

PROGRAF ............................ 47

promethazine hcl ................... 29

PROMETRIUM .................... 46

propafenone hcl .................... 34

propantheline bromide .......... 23

propranolol hcl ..................... 34

PROSCAR ............................ 49

PROSOL ............................... 33

PROTONIX .......................... 42

PROTONIX IV ..................... 42

PROVENTIL HFA ............... 50

PROVERA ............................ 46

PROVIGIL ............................ 52

PROZAC ............................... 25

PROZAC WEEKLY ............. 25

PULMOZYME ..................... 41

PURINETHOL ..................... 22

pyridostigmine bromide ........ 49

QUDEXY XR ....................... 24

quetiapine fumarate .............. 30

QUILLIVANT XR................ 37

QVAR ................................... 50

ramipril ................................. 34

ranitidine hcl ......................... 42

RAYOS ................................. 45

REBIF ................................... 49

RECOMBIVAX HB ............. 47

REGLAN .............................. 43

RENVELA ............................ 43

REQUIP ................................ 29

REQUIP XL .......................... 29

RESTASIS ............................ 42

RETIN-A............................... 40

REVATIO ............................. 52

REVLIMID ........................... 22

REYATAZ ............................ 31

RHEUMATREX ................... 23

RIFADIN .............................. 28

rifampin ................................. 28

RIOMET ............................... 26

risedronate sodium................ 48

RISPERDAL ......................... 30

RISPERDAL M-TAB ........... 30

risperidone ............................ 30

RITALIN............................... 37

RITALIN LA ........................ 37

RITALIN-SR ........................ 37

rizatriptan benzoate .............. 28

ROCALTROL....................... 48

ropinirole hcl ........................ 29

ROXICODONE .................... 17

RYTHMOL ........................... 34

RYTHMOL SR ..................... 34

SAIZEN ................................ 45

SARAFEM ............................ 25

SENSIPAR ............................ 49

SEROQUEL .......................... 30

SEROQUEL XR ................... 30

SEROSTIM ........................... 45

sertraline hcl ......................... 25

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sildenafil citrate .................... 53

SILVADENE ........................ 39

silver sulfadiazine ................. 39

simvastatin ............................ 36

SINEMET 10-100 ................. 29

SINEMET 25-100 ................. 29

SINEMET 25-250 ................. 29

SINEMET CR ....................... 29

SINGULAIR ......................... 50

sodium chloride ..................... 50

sodium chloride 0.45 % ........ 50

sodium chloride irrig solution

........................................... 47

SOLARAZE .......................... 18

SOLODYN ........................... 21

SOLTAMOX ........................ 23

SORILUX ............................. 39

SOVALDI ............................. 31

SPIRIVA ............................... 50

spironolact/hydrochlorothiazid

........................................... 36

spironolactone....................... 36

SPRYCEL ............................. 23

STIMATE ............................. 45

STRIANT .............................. 44

STRIBILD............................. 31

SUBOXONE ......................... 18

SUBSYS ............................... 17

sulfamethoxazole/trimethoprim

........................................... 21

sulfasalazine .......................... 21

sumatriptan succinate ........... 28

SUMAVEL DOSEPRO ........ 28

SUPRAX ............................... 20

SUTENT ............................... 23

SYLATRON 4-PACK .......... 31

SYNAGIS ............................. 31

SYNALAR ............................ 40

SYNTHROID ....................... 46

syring w-ndl,disp,insul,0.5ml 40

syringe & needle,insulin,1 ml 40

tacrolimus ............................. 47

TAMIFLU ............................. 31

tamoxifen citrate ................... 23

tamsulosin hcl ....................... 43

TARCEVA ............................ 23

TASIGNA ............................. 23

TECFIDERA......................... 49

TEGRETOL .......................... 24

TEGRETOL XR ................... 24

TEMOVATE......................... 40

TENEX ................................. 33

TENORMIN ......................... 34

TERAZOL 3 ......................... 28

TERAZOL 7 ......................... 28

terazosin hcl .......................... 43

terbinafine hcl ....................... 27

terconazole ............................ 28

TESTIM ................................ 44

testosterone cypionate ........... 44

TEV-TROPIN ....................... 46

TIAZAC ................................ 35

timolol maleate...................... 49

TIMOPTIC-XE ..................... 49

TIROSINT ............................ 46

TOBI ..................................... 19

TOBRADEX ......................... 41

TOBRADEX ST ................... 41

tobramycin in 0.225% nacl ... 19

tobramycin/dexamethasone ... 41

tolterodine tartrate ................ 43

TOPAMAX ........................... 24

topiramate ............................. 24

TOPROL XL ......................... 34

TRADJENTA ....................... 26

tramadol hcl .......................... 17

tranexamic acid ..................... 32

TRAVASOL ......................... 33

TRAVATAN Z ..................... 49

trazodone hcl ......................... 25

tretinoin ................................. 40

TREXALL ............................ 23

triamcinolone acetonide. 38, 40,

42

triamterene/hydrochlorothiazid

........................................... 35

trimethoprim ......................... 19

TRI-NORINYL ..................... 38

TROKENDI XR.................... 24

TROPHAMINE .................... 33

TRUVADA ........................... 31

TWINRIX ............................. 47

TYKERB............................... 23

TYLENOL-CODEINE NO.3 17

TYLENOL-CODEINE NO.4 17

TYPHIM VI .......................... 47

ULORIC ................................ 49

ULTRAM .............................. 17

ULTRAM ER........................ 17

ULTRESA............................. 41

UNITHROID ........................ 46

UROCIT-K ........................... 50

URSO .................................... 43

URSO FORTE ...................... 43

ursodiol ................................. 43

VAGIFEM ............................ 45

valacyclovir hcl ..................... 31

valsartan/hydrochlorothiazide

........................................... 34

VALTREX ............................ 31

VANCOCIN HCL ................ 19

vancomycin hcl...................... 20

VANDAZOLE ...................... 28

VANOS ................................. 40

VAQTA................................. 47

VASOTEC ............................ 34

venlafaxine hcl ...................... 25

VENLAFAXINE HCL ER ... 25

VENTOLIN HFA ................. 50

verapamil hcl ........................ 35

VERELAN ............................ 35

VERELAN PM ..................... 35

VERIPRED 20 ...................... 45

VERSACLOZ ....................... 31

VESICARE ........................... 43

VIBRAMYCIN ..................... 21

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VICTOZA 3-PAK ................. 26

VIOKACE............................. 41

VIREAD ............................... 31

VISTARIL ............................ 49

VIVELLE-DOT .................... 45

VOGELXO ........................... 44

VOLTAREN ......................... 18

VOLTAREN-XR .................. 18

VOSPIRE ER ........................ 50

VOTRIENT........................... 23

VYVANSE ........................... 37

warfarin sodium .................... 32

water for irrigation,sterile .... 47

WELLBUTRIN..................... 25

WELLBUTRIN SR ............... 25

WELLBUTRIN XL .............. 25

XALATAN ........................... 49

XALKORI............................. 23

XANAX ................................ 19

XANAX XR.......................... 19

XARELTO ............................ 32

XARTEMIS XR.................... 17

XIFAXAN............................. 20

XODOL 10-300 .................... 17

XODOL 5-300 ...................... 17

XODOL 7.5-300 ................... 17

XOLAIR ............................... 50

XTANDI ............................... 23

XYLOCAINE ....................... 18

XYZAL ................................. 28

YASMIN 28 .......................... 38

YAZ ...................................... 38

zafirlukast .............................. 50

ZAMICET ............................. 17

ZANTAC .............................. 42

ZENPEP ................................ 41

ZESTORETIC....................... 34

ZESTRIL............................... 34

ziprasidone hcl ...................... 31

ZITHROMAX....................... 20

ZITHROMAX TRI-PAK ...... 20

ZMAX ................................... 20

ZOCOR ................................. 36

ZOFRAN............................... 29

ZOFRAN ODT ..................... 29

ZOLOFT ............................... 25

zolpidem tartrate ................... 52

ZOLPIMIST .......................... 52

ZORBTIVE ........................... 46

ZOSTAVAX ......................... 47

ZOVIRAX....................... 31, 39

ZUBSOLV ............................ 18

ZYCLARA ............................ 39

ZYLOPRIM .......................... 49

ZYPREXA ............................ 31

ZYPREXA ZYDIS ............... 31

ZYTIGA ................................ 23

This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by

our plan. For a complete listing or other questions, please contact University Health Care Advantage Member Services at 1-855-996-8422 or, for TTY users, Toll-free 711, Monday through Sunday from

8:00 a.m. to 8:00 p.m. (Pacific Standard Time), or visit www.UHCAmedicare.org.

http://www.uhcamedicare.org/

2015 Abridged Formulary (Partial List of Covered Drugs) · 2014-09-25 · H2986_PD_200 "-1"! × Õ...

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