2016 631 3T Copper Comm BvD Plus with sPA eff 11/01/2016€¦ · 200mg 1 tramadol hcl er (biphasic)...

2016 631 3T Copper Comm BvD Plus with sPA eff 11/01/2016

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

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS 2

probenecid 1

ULORIC 2

ZURAMPIC 3

ZYLOPRIM 3

MISCELLANEOUS ARTHROTEC 50 3

ARTHROTEC 75 3

diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 3 NM

VIMOVO 3 NM

NSAIDS ANAPROX DS 2

CELEBREX CAP 50MG 3

CELEBREX CAP 100MG 3



celecoxib (generic of CELEBREX) CAPS

1

DAYPRO 2

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

EC-NAPROSYN 3

etodolac CAPS 1

etodolac (generic of LODINE) TABS 400mg

1

etodolac TABS 500mg 1

etodolac er 1

FELDENE 3

FENOPROFEN CALCIUM CAPS 400mg

1

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

Drug Name Drug Tier

Requirements/Limits

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

meloxicam tabs (generic of MOBIC)

1

MOBIC TABS 2

nabumetone TABS 1

NALFON 3

NAPRELAN 3 NM

NAPROSYN TAB 500MG 2

naproxen (generic of NAPROSYN) SUSP

1

naproxen (generic of NAPROSYN) TABS 250mg, 500mg

1

naproxen TABS 375mg 1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

naproxen sodium (generic of NAPRELAN) TB24 375mg

3 NM

NAPROXEN SODIUM TB24 500mg

3 NM

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 3 NM

sulindac TABS 1

tolmetin sodium 1

VIVLODEX 3

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL



2

Drug Name Drug Tier

Requirements/Limits

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


1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS


1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

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

1

BELBUCA 3

butorphanol nasal spray 1

butorphanol tartrate SOLN 1

BUTRANS 2

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 3

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

1

nalbuphine hcl SOLN 20mg/ml

1

SYNALGOS-DC 3

TRAMADOL HCL CP24 1

tramadol hcl er TB24 100mg, 200mg

1

TRAMADOL HCL ER TB24 300mg

1

tramadol hcl er (biphasic) 100mg

1


1


1

tramadol hcl tab 50 mg (generic of ULTRAM)

1

tramadol-acetaminophen (generic of ULTRACET)


1 QL

trezix QL (360 caps / 30 days)

3 QL

tylenol with codeine QL (400 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

ULTRACET QL (240 tabs / 30 days)

3 QL

ULTRAM ER TAB 100MG 3



ULTRAM TAB 50MG 2

OPIOID ANALGESICS, CII ABSTRAL 3 NM PA

ACTIQ 3 NM PA

CODEINE SULFATE 1

DILAUDID INJ 3 B/D

DILAUDID TAB 3

DILAUDID-5 ORAL LIQD 3

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

DILAUDID-HP INJ 250MG 3 B/D

DOLOPHINE 3

DURAGESIC 12mcg/hr, 25mcg/hr

3

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

3 NM

DURAMORPH 1 B/D

EMBEDA 3

endocet (generic of PERCOCET)


1 QL

EXALGO 8mg, 12mg 3

EXALGO 16mg, 32mg 3 NM

fentanyl citrate (generic of ACTIQ) LPOP

3 NM PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)

1


1


1


1


1

FENTORA 3 NM PA

hycet QL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL



3

Drug Name Drug Tier

Requirements/Limits

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


1 QL

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


1 QL

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


1 QL

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

QL (5400 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 10-300mg (generic of XODOL)


1 QL

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


1 QL

hydrocodone-ibuprofen tab 2.5-200mg

1

hydrocodone-ibuprofen tab 5-200mg (generic of REPREXAIN)

1

hydrocodone-ibuprofen tab 7.5-200 mg (generic of VICOPROFEN)

1

hydrocodone-ibuprofen tab 10-200mg

1

hydromorphone hcl (generic of DILAUDID) LIQD

1

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

1 B/D

hydromorphone hcl SOLN 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS

1

hydromorphone tab 8mg er (generic of EXALGO)

1


1

Drug Name Drug Tier

Requirements/Limits


3 NM

HYDROMORPHONE TABS 32MG

3 NM

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

2

HYSINGLA ER 80mg, 100mg, 120mg

3 NM

ibudone tab 5-200mg (generic of REPREXAIN)

1

ibudone tab 10-200mg 1

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 10mg, 20mg, 30mg 3

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

3 NM

LAZANDA 3 NM PA

levorphanol tartrate TABS 1

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


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

lortab tab 5-325mg (generic of NORCO)


1 QL

lortab tab 7.5-325 (generic of NORCO)


1 QL

lortab tab 10-325mg (generic of NORCO)


1 QL

methadone hcl (generic of METHADOSE) CONC

1

methadone hcl SOLN 1

methadone hcl (generic of DOLOPHINE) TABS

1

METHADONE INJ 10MG/ML 3

METHADOSE CONC 3

MORPHINE SUL 20MG/ML ORAL SOL

1

MORPHINE SUL INJ 1MG/ML

1 B/D



4

Drug Name Drug Tier

Requirements/Limits


3 B/D


1 B/D


1 B/D

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg

1

morphine sulfate (generic of KADIAN) CP24 80mg, 100mg

3 NM

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

3 B/D

morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml

1 B/D

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

1

morphine sulfate SOLN .5mg/ml, 1mg/ml

1 B/D

MORPHINE SULFATE TABS

1

morphine sulfate beads 1

morphine sulfate ext-rel tab (generic of MS CONTIN)

1

MS CONTIN 15mg, 30mg 3

MS CONTIN 60mg, 100mg, 200mg

3 NM

norco QL (360 tabs / 30 days)

3 QL

NUCYNTA 2

NUCYNTA ER 2

OPANA TABS 3

OPANA ER (CRUSH RESISTANT

2

oxycodone hcl CAPS 1

oxycodone hcl CONC 1

OXYCODONE HCL SOLN 1

oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg

1

oxycodone hcl TABS 10mg, 20mg

1

Drug Name Drug Tier

Requirements/Limits

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


1 QL

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


1 QL

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


1 QL

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


1 QL

oxycodone w/ acetaminophen soln 5-325 mg/5ml

QL (1800 mL / 30 days)

1 QL

oxycodone-aspirin 1

oxycodone-ibuprofen 1

OXYCONTIN 2

oxymorphone hcl (generic of OPANA) TABS

1

percocet 2.5/325 QL (360 tabs / 30 days)

3 QL

percocet 7.5/325 QL (360 tabs / 30 days)

3 QL NM

percocet 10/325 QL (360 tabs / 30 days)

3 QL NM

percocet tab 5-325mg QL (360 tabs / 30 days)

3 QL NM

reprexain tab 2.5-200mg 3

reprexain tab 5-200mg 3

reprexain tab 10-200mg 1

ROXICODONE 5mg, 15mg 3

ROXICODONE 30mg 3 NM

SUBSYS 3 NM PA

vicodin (generic of XODOL) QL (400 tabs / 30 days)

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

XARTEMIS XR QL (120 tabs / 30 days)

3 QL



5

Drug Name Drug Tier

Requirements/Limits

xodol tab 5-300mg QL (400 tabs / 30 days)

3 QL

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

3 QL

xodol tab 10-300mg QL (400 tabs / 30 days)

3 QL NM

XTAMPZA ER 3

xylon tab 10-200mg 1

zamicet QL (5400 mL / 30 days)

1 QL

ZOHYDRO ER (ABUSE DETERRENT)

3

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 1%

1 B/D

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

1

lidocaine hcl (local anesth.) (generic of XYLOCAINE) .5%

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE)

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of XYLOCAINE-MPF) 2%

1 B/D

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

XYLOCAINE-MPF 4% 3

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

3 B/D

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

BETHKIS 3 B/D NM

gentamicin in saline 0.8 mg/ml 1

gentamicin in saline 0.9mg/ml 3

gentamicin in saline 1 mg/ml 1


gentamicin in saline 1.4mg/ml 3


Drug Name Drug Tier

Requirements/Limits

gentamicin in saline 2 mg/ml 1

gentamicin sulfate SOLN 1

KITABIS PAK 3 B/D NM

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI NEB 3 B/D NM

TOBI PODHALER 3 NM LA PA

tobramycin (generic of KITABIS PAK) NEBU

3 B/D NM

tobramycin sulfate SOLN; SOLR

1

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

atovaquone (generic of MEPRON) SUSP

3 NM

AZACTAM 1gm 3

AZACTAM 2gm 3 NM

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3 NM

aztreonam (generic of AZACTAM)

1

BACTRIM 2

BACTRIM DS 2

BILTRICIDE 2

CAYSTON 2 NM LA PA

cleocin SOLR 2

CLEOCIN CAP 75MG 2

CLEOCIN CAP 150MG 2

CLEOCIN CAP 300MG 2

CLEOCIN IN D5W 3

CLEOCIN INJ 3

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

3

cleocin phosphate 300mg/2ml, 600mg/4ml, 900mg/6ml

3

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1



6

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate SOLN 150mg/ml

1

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

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3

CUBICIN 3 NM

DALVANCE 3 NM

dapsone TABS 1

daptomycin (generic of CUBICIN)

3 NM

DARAPRIM 3

DORIBAX 3

emverm 3

FLAGYL 3

FURADANTIN 3 NM

HIPREX 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

ivermectin (generic of STROMECTOL) TABS

1

linezolid (generic of ZYVOX) SOLN

3 NM

LINEZOLID SUSR; TABS 3 NM

LINEZOLID IN SODIUM CHLORIDE

3 NM

MACROBID 3

MACRODANTIN 3

MEPRON 3 NM

meropenem (generic of MERREM)

1

MEROPENEM/SODIUM CHLORIDE

1

MERREM 3

methenamine hippurate (generic of HIPREX)

1

METRO IV 3

Drug Name Drug Tier

Requirements/Limits

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

1

nitrofurantoin macrocrystal (generic of MACRODANTIN)

3

nitrofurantoin monohyd macro (generic of MACROBID)

3

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMAXIN 3

PRIMSOL 3

SIVEXTRO 3 NM

STROMECTOL 3

sulfamethoxazole-trimethop SUSP

1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3 NM

trimethoprim TABS 1

TYGACIL 3 NM

VANCOCIN HCL 3 NM

vancomycin hcl (generic of VANCOCIN HCL) CAPS

3 NM

vancomycin hcl inj 5gm 1

vancomycin hcl inj 10gm 1

vancomycin hcl inj 500mg 1



VANCOMYCIN IN NACL 3

XIFAXAN TAB 200MG 3 NM

ZYVOX 3 NM

ANTIFUNGALS ABELCET 3 B/D NM

AMBISOME 3 B/D NM

amphotericin b SOLR 1 B/D

ANCOBON 3 NM

CANCIDAS 3 NM

CRESEMBA 3 NM



7

Drug Name Drug Tier

Requirements/Limits

DIFLUCAN 3

ERAXIS 3 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole in nacl 1

flucytosine (generic of ANCOBON) CAPS

3 NM

GRIS-PEG 2

griseofulvin microsize 1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1

ketoconazole TABS 1

LAMISIL 3

MYCAMINE 3 NM

NOXAFIL 3 NM

nystatin TABS 1

ONMEL 3 NM

SPORANOX 3 NM

SPORANOX PULSEPAK 3 NM

SPORANOX SOL 10MG/ML 3 NM

terbinafine hcl (generic of LAMISIL) TABS

1

VFEND IV 3

VFEND SUS 40MG/ML 3 NM

VFEND TAB 3 NM

voriconazole (generic of VFEND) SUSR; TABS

3 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)

1

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

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

MALARONE 2

Drug Name Drug Tier

Requirements/Limits

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3

quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 3 NM

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 3 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 3

EPIVIR TABS 3

FUZEON 2 NM

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 3 NM

INVIRASE 3 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 3 NM

ISENTRESS PACK 2

ISENTRESS TABS 3 NM

lamivudine (generic of EPIVIR)

1

LEXIVA SUSP 3

LEXIVA TABS 3 NM

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA SUSP 3 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

3 NM

RESCRIPTOR 2

RETROVIR CAPS 2

RETROVIR IV INFUSION 3

RETROVIR SYRP 2

REYATAZ 3 NM

SELZENTRY 3 NM

stavudine (generic of ZERIT) 1



8

Drug Name Drug Tier

Requirements/Limits

SUSTIVA CAPS 2

SUSTIVA TABS 3 NM

TIVICAY 10mg 2

TIVICAY 25mg, 50mg 3 NM

TYBOST 2

VIDEX EC 2

VIDEX PEDIATRIC 3

VIRACEPT 3 NM

VIRAMUNE SUSP 2

VIRAMUNE TABS 3 NM

VIRAMUNE XR 100mg 2

VIRAMUNE XR 400mg 3 NM

VIREAD 3 NM

VITEKTA 3 NM

ZERIT CAPS 2

ZERIT SOLR 3 NM

ZIAGEN SOLN 2

ZIAGEN TABS 3

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

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

3 NM

ATRIPLA 3 NM

COMBIVIR 3 NM

COMPLERA 3 NM

DESCOVY 3 NM

EPZICOM 3 NM

EVOTAZ 3 NM

GENVOYA 3 NM

KALETRA SOL 3 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 3 NM

lamivudine-zidovudine (generic of COMBIVIR)

3 NM

ODEFSEY 3 NM

PREZCOBIX 3 NM

STRIBILD 3 NM

TRIUMEQ 3 NM

TRIZIVIR 3 NM

TRUVADA TAB 100-150 3 NM



Drug Name Drug Tier

Requirements/Limits


ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

cycloserine CAPS 3 NM

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

MYAMBUTOL 2

MYCOBUTIN 3

paser d/r 3

PRIFTIN 3

pyrazinamide TABS 1

rifabutin (generic of MYCOBUTIN)

1

rifadin CAPS 150mg 2

RIFADIN CAPS 300mg 2

RIFADIN SOLR 3

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

SIRTURO 3 NM LA

TRECATOR 3

ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium SOLN 1 B/D

acyclovir sodium SOLR 500mg

1 B/D

adefovir dipivoxil (generic of HEPSERA)

3 NM

BARACLUDE SOLN 2

BARACLUDE TABS 3 NM

cidofovir 3 NM

COPEGUS 3 NM

CYTOVENE 3 B/D

DAKLINZA 3 NM PA

entecavir (generic of BARACLUDE)

3 NM

EPIVIR HBV 2

famciclovir (generic of FAMVIR) TABS

1

FAMVIR 3



9

Drug Name Drug Tier

Requirements/Limits

FLUMADINE 3

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HARVONI 3 NM PA

HEPSERA 3 NM

lamivudine (hbv) (generic of EPIVIR HBV)

1

moderiba pak MISC 3 NM

moderiba pak TABS 400mg 3 NM

MODERIBA PAK TABS 600mg

3 NM

moderiba tab 200mg (generic of COPEGUS)

1 NM

PEG-INTRON REDIPEN 3 NM PA

PEGASYS 3 NM PA

PEGASYS PROCLICK 3 NM PA

PEGINTRON 3 NM PA

REBETOL 3 NM

RELENZA DISKHALER 2

ribapak mis 600/day 3 NM

ribasphere (generic of REBETOL) CAPS

1 NM

ribasphere (generic of COPEGUS) TABS 200mg

1 NM

ribasphere TABS 400mg 1 NM

ribasphere TABS 600mg 3 NM

ribasphere ribapak 800 3 NM



ribavirin 200mg (generic of REBETOL) CAPS

1 NM

ribavirin 200mg (generic of COPEGUS) TABS

1 NM

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 3 NM PA

TAMIFLU 2

TYZEKA 3 NM

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 3 NM

valganciclovir hcl (generic of VALCYTE)

3 NM

VALTREX 3

ZOVIRAX CAPS; SUSP; TABS

3

CEPHALOSPORINS

Drug Name Drug Tier

Requirements/Limits

AVYCAZ 3 NM

CEDAX 3

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin in dextrose 1gm/50ml-5%

3

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

CEFEPIME HCL AND DEXTROSE

3

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefixime (generic of SUPRAX) 1

CEFOTAN 3

cefotaxime sodium 1gm 1

cefotaxime sodium (generic of CLAFORAN) 2gm, 500mg

1

cefotetan disodium (generic of CEFOTAN) 1gm, 2gm

1

cefotetan disodium 10gm 1

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ)

1

CEFTAZIDIME/DEXTROSE 3

CEFTIBUTEN 1

CEFTIN 3

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm

1

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1



10

Drug Name Drug Tier

Requirements/Limits

cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg

1

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

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

3

CLAFORAN/D5W 3

FORTAZ 3

MAXIPIME 3

rocephin 3

SUPRAX CAPS 2

suprax CHEW 2

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

2

SUPRAX SUSR 500mg/5ml 2

tazicef (generic of FORTAZ) SOLR

1

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZERBAXA 3 NM

ZINACEF SOLR 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR; SUSR; TABS

1

BIAXIN 3

clarithromycin SUSR 125mg/5ml

1

clarithromycin (generic of BIAXIN) SUSR 250mg/5ml

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 3 NM

e.e.s. 400 tab 400mg 1

E.E.S. GRANULES 3

ery-tab 1

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 3

Drug Name Drug Tier

Requirements/Limits

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

FLUOROQUINOLONES AVELOX 3

AVELOX ABC PACK 3

CIPRO SUSP 3

CIPRO TABS 3

CIPRO XR 3

ciprofloxacin (generic of CIPRO) SUSR

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

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

1

ciprofloxacin in d5w 1

ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)

1

ciprofloxacin inj 200mg/20ml 1

ciprofloxacin inj 400mg/40ml 1

LEVAQUIN 3

levofloxacin SOLN 1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 1

MOXIFLOXACIN HCL SOLN 3

moxifloxacin hcl (generic of AVELOX) TABS

1

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate SUSR

1



11

Drug Name Drug Tier

Requirements/Limits

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

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

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN SUSR 3

AUGMENTIN TABS 3 NM

AUGMENTIN ES-600 3

AUGMENTIN XR 3 NM

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3 NM

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

MOXATAG 3

NAFCILLIN 3

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 3 NM

NAFCILLIN SODIUM IN DEXTROSE

3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 3 NM

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM IN

3

Drug Name Drug Tier

Requirements/Limits

penicillin g procaine 3

penicillin g sodium 1

penicillin gk inj 5mu 1

penicillin gk inj 20mu 1

penicillin v potassium 1

pfizerpen-g inj 5mu 1

pfizerpen-g inj 20mu 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

UNASYN 3

UNASYN BULK PACK 3

ZOSYN 3

TETRACYCLINES adoxa CAPS 3

demeclocycline hcl 1

doxy 1

doxycycline (monohydrate) CAPS 50mg

1

doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg

1

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

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

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

1

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

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate (generic of DORYX) TBEC

1

doxycycline hyclate tab 75 mg dr

1



12

Drug Name Drug Tier

Requirements/Limits


1


1

MINOCIN CAPS 3

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

morgidox 1

SOLODYN 3 NM

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN CAPS 3

VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN SOLR 3 B/D NM

BENDEKA 3 B/D NM

BICNU 3 B/D

BUSULFEX 3 B/D NM

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 1gm, 500mg

3 B/D NM

cyclophosphamide SOLR 2gm

1 B/D

dacarbazine 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 3 NM

IFEX INJ 1GM 3 B/D

IFEX INJ 3GM 3 B/D

ifosfamide inj 1 B/D

ifosfamide inj 1gm (generic of IFEX)

1 B/D

IFOSFAMIDE INJ 3GM 3 B/D

LEUKERAN 2

melphalan hcl (generic of ALKERAN)

3 B/D NM

MUSTARGEN 3 B/D

thiotepa SOLR 3 B/D NM

TREANDA 3 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES daunorubicin hcl 1 B/D

DOXIL 3 B/D NM

Drug Name Drug Tier

Requirements/Limits

doxorubicin hcl 50mg 1 B/D

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

3 B/D NM

doxorubicin inj 50mg 1 B/D

ELLENCE 3 B/D NM

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

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

3 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D NM

mitomycin SOLR 1 B/D

VALSTAR 3 NM PA

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D NM

ARRANON 3 B/D NM

azacitidine (generic of VIDAZA)

3 B/D NM

cladribine 3 B/D NM

CLOLAR 3 B/D NM

cytarabine inj 1 B/D

DACOGEN 3 B/D NM

decitabine (generic of DACOGEN)

3 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 3 NM PA

GEMCITABINE HCL SOLN 3 B/D NM

gemcitabine hcl (generic of GEMZAR) SOLR 1gm, 200mg

3 B/D NM

gemcitabine hcl SOLR 2gm 3 B/D NM

GEMZAR 3 B/D NM

mercaptopurine TABS 1

METHOTREXATE SODIUM 50mg/2ml

1 B/D



13

Drug Name Drug Tier

Requirements/Limits

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

1 B/D

methotrexate sodium inj 1 B/D

NIPENT 3 B/D NM

PURIXAN 3 NM

TABLOID 2

VIDAZA 3 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM

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

3 B/D NM

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

DOCETAXEL SOLN 20mg/2ml

1 B/D

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

3 B/D NM

DOCETAXEL SOLN 80MG/8ML

3 B/D NM

JEVTANA 3 NM PA

paclitaxel 1 B/D

TAXOTERE 3 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 B/D NM

AVASTIN 3 B/D NM LA

BELEODAQ 3 NM PA

CYRAMZA 3 NM PA

DARZALEX 3 NM PA

EMPLICITI 3 NM LA PA

ERBITUX 3 B/D NM

ERIVEDGE 3 NM LA PA

FARYDAK 3 NM LA PA

GAZYVA 3 NM PA

HERCEPTIN 3 B/D NM

IBRANCE 3 NM LA PA

ISTODAX 3 B/D NM

KADCYLA 3 B/D NM

KEYTRUDA 3 NM PA

LYNPARZA 3 NM LA PA

NINLARO 3 NM PA

OPDIVO 3 NM PA

Drug Name Drug Tier

Requirements/Limits

PERJETA 3 NM PA

PORTRAZZA 3 NM LA PA

PROLEUKIN 3 B/D NM

RITUXAN 2 NM LA PA

TECENTRIQ 3 NM LA PA

TORISEL 3 B/D NM

VECTIBIX 3 B/D NM

VELCADE 3 B/D NM

VENCLEXTA 3 NM LA PA

VENCLEXTA STARTING PACK

3 NM LA PA

YERVOY 3 NM PA

ZALTRAP 3 NM PA

ZOLINZA 3 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARIMIDEX 2

AROMASIN 2

bicalutamide (generic of CASODEX)

1

CASODEX 2

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 3 B/D NM

ELIGARD INJ 22.5MG 3 B/D NM

ELIGARD INJ 30MG 3 B/D NM

ELIGARD INJ 45MG 3 B/D NM

exemestane (generic of AROMASIN)

1

FARESTON 3 NM

FASLODEX 3 B/D NM

FEMARA 3 NM

FIRMAGON 3 B/D NM

flutamide 1

hydroxyprogesterone caproate (antineoplastic)

3 B/D

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPRON DEP INJ 11.25MG 3 NM PA

LUPRON DEP-PED INJ 7.5MG

3 NM PA

LUPRON DEP-PED INJ 11.25MG

3 NM PA

LUPRON DEP-PED INJ 15MG

3 NM PA



14

Drug Name Drug Tier

Requirements/Limits

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

3 NM PA

LUPRON DEPOT 3 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

3 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

3 NM PA

LYSODREN 2

MEGACE ES 3 NM

MEGACE ORAL 3

megestrol ac sus 40mg/ml (generic of MEGACE ORAL)

3

megestrol ac tab 20mg 3

megestrol ac tab 40mg 3

MEGESTROL SUS 625MG/5ML

3 NM

NILANDRON 3 NM

nilutamide (generic of NILANDRON)

3 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 3 NM PA

VANTAS 3 NM PA

XTANDI 3 NM LA PA

ZOLADEX 3 NM PA

ZYTIGA 3 NM LA PA

KINASE INHIBITORS AFINITOR 3 NM PA

AFINITOR DISPERZ 3 NM PA

ALECENSA 3 NM LA PA

BOSULIF 3 NM PA

CABOMETYX 3 NM LA PA

CAPRELSA 3 NM LA PA

COMETRIQ 3 NM LA PA

COTELLIC 3 NM LA PA

GILOTRIF TAB 20MG 3 NM LA PA



GLEEVEC 2 NM PA

ICLUSIG 3 NM LA PA

imatinib mesylate (generic of GLEEVEC)

2 NM PA

IMBRUVICA CAP 140MG 3 NM LA PA

INLYTA 3 NM LA PA

IRESSA 3 NM LA PA

JAKAFI 3 NM LA PA

LENVIMA 8 MG DAILY DOSE 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

LENVIMA 10 MG DAILY DOSE

3 NM LA PA


3 NM LA PA


3 NM LA PA


3 NM LA PA


3 NM LA PA

MEKINIST 3 NM LA PA

NEXAVAR 3 NM LA PA

SPRYCEL 3 NM PA

STIVARGA 3 NM LA PA

SUTENT 3 NM PA

TAFINLAR 3 NM LA PA

TAGRISSO 3 NM LA PA

TARCEVA 3 NM LA PA

TASIGNA 3 NM PA

TYKERB 3 NM LA PA

VOTRIENT 3 NM LA PA

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

ZYDELIG 3 NM LA PA

ZYKADIA 3 NM LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

3 NM PA

DROXIA 3

ERWINAZE 3 NM PA

HALAVEN 3 B/D NM

HYDREA 2

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 3 B/D NM

LONSURF 3 NM PA

MATULANE 3 NM LA

mitoxantrone hcl 1 B/D NM

ODOMZO 3 NM LA PA

ONCASPAR 3 NM PA

POMALYST 3 NM LA PA

SYLATRON KIT 200MCG 3 NM PA



SYLVANT 3 NM PA

SYNRIBO 3 NM PA

TARGRETIN CAPS 3 NM PA



15

Drug Name Drug Tier

Requirements/Limits

tretinoin CAPS 2 NM

TRISENOX 3 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

ELOXATIN 3 B/D NM

oxaliplatin 3 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

3 B/D NM

dexrazoxane (generic of ZINECARD) 250mg

3 B/D NM

ELITEK 3 B/D NM

ETHYOL 3 B/D NM

FUSILEV 3 B/D NM

KEPIVANCE 3 B/D NM

leucovorin calcium TABS 1

leucovorin calcium inj 50mg 1 B/D





levoleucovorin calcium SOLN

3 B/D NM

levoleucovorin calcium (generic of FUSILEV) SOLR

3 B/D NM

mesna (generic of MESNEX) 1 B/D

MESNEX SOLN 3 B/D

MESNEX TABS 3 NM

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

HYCAMTIN SOLR 3 B/D NM

irinotecan inj 40mg/2ml (generic of CAMPTOSAR)

1 B/D

irinotecan inj 100/5ml (generic of CAMPTOSAR)

1 B/D

irinotecan inj 500mg/25ml 1 B/D

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

3 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS

Drug Name Drug Tier

Requirements/Limits

ACCURETIC 3

amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTREL 2

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

trandolapril-verapamil hcl (generic of TARKA)

1

VASERETIC 3

ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3

ALTACE 3

benazepril hcl TABS 5mg 1

benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

1



16

Drug Name Drug Tier

Requirements/Limits

LOTENSIN 20mg, 40mg 3

MAVIK 3

moexipril hcl 1

perindopril erbumine 2mg 1

perindopril erbumine (generic of ACEON) 4mg, 8mg

1

PRINIVIL 3

QBRELIS 3

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

VASOTEC 3

ZESTRIL 3

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2

eplerenone (generic of INSPRA)

1

INSPRA 2

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS CARDURA 3

doxazosin mesylate (generic of CARDURA)

1

MINIPRESS 1mg, 2mg 3

MINIPRESS 5mg 3 NM

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

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

1

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

1


1


1

Drug Name Drug Tier

Requirements/Limits

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

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)

1

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

1


1


1

ATACAND HCT 3

AVALIDE 3

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

DIOVAN HCT 3

EDARBYCLOR 3

ENTRESTO 3

EXFORGE 3

EXFORGE HCT 3

HYZAAR 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 3

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TRIBENZOR 2

TWYNSTA 3

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3

AVAPRO 3

BENICAR 2



17

Drug Name Drug Tier

Requirements/Limits

candesartan cilexetil (generic of ATACAND)

1

COZAAR 3

DIOVAN 3

EDARBI 3

eprosartan mesylate 1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 3

telmisartan (generic of MICARDIS)

1

valsartan (generic of DIOVAN)

1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg, 400mg

1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

BETAPACE 2

BETAPACE AF 2

disopyramide phosphate (generic of NORPACE)

3

dofetilide (generic of TIKOSYN)

1 NM

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE 3

NORPACE CR 3

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl (generic of RYTHMOL) TABS 225mg

1

propafenone hcl TABS 300mg

1

propafenone hcl 12hr (generic of RYTHMOL SR) CP12

1

propafenone hcl 12hr TABS 1

Drug Name Drug Tier

Requirements/Limits

quinidine gluconate TBCR 1

quinidine sulfate TABS 1

RYTHMOL 2

RYTHMOL SR 2

sorine (generic of BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg

1

sotalol hcl 240mg 1

sotalol hcl (afib/afl) (generic of BETAPACE AF)

1

TIKOSYN 2 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic of LIPITOR) TABS

1

CRESTOR 2

fluvastatin sodium cap 20 mg (generic of LESCOL)

1

fluvastatin sodium cap 40 mg 1

fluvastatin sodium tab sr 24 hr 80 mg (generic of LESCOL XL)

1

LESCOL 3

LESCOL XL 3

LIPITOR 3

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

PRAVACHOL 3

pravastatin sodium 10mg 1

pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg

1

rosuvastatin calcium (generic of CRESTOR)

1

simvastatin (generic of ZOCOR) TABS

1

ZOCOR 3

ANTILIPEMICS, MISCELLANEOUS ANTARA 3



18

Drug Name Drug Tier

Requirements/Limits

cholestyramine (generic of QUESTRAN)

1

cholestyramine light PACK 1

cholestyramine light (generic of QUESTRAN LIGHT) POWD

1

choline fenofibrate (generic of TRILIPIX)

1

COLESTID 3

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

FENOFIBRATE TABS 40mg, 120mg

1

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

1

fenofibrate (generic of LOFIBRA) TABS 54mg, 160mg

1

fenofibrate micronized 43mg, 130mg

1

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

1

FENOFIBRIC ACID 1

FENOGLIDE 3

FIBRICOR 3

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 3 NM LA PA

KYNAMRO 3 NM PA

LIPOFEN 3

lofibra 3

LOPID 3

LOVAZA CAP 1GM 3

niacin er (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

NIASPAN 3

omega-3-acid ethyl esters (generic of LOVAZA)

1

PRALUENT 3 NM PA

prevalite (generic of QUESTRAN LIGHT)

1

questran 3

Drug Name Drug Tier

Requirements/Limits

questran lite 3

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

VASCEPA 1gm 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

CORZIDE 3

DUTOPROL 3

LOPRESSOR HCT 2

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

1

metoprolol & hctz tab 100-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

TENORETIC 50 2

TENORETIC 100 2

ZIAC 2

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2



19

Drug Name Drug Tier

Requirements/Limits

carvedilol (generic of COREG)

1

COREG 3

COREG CR 2

CORGARD 3

INDERAL LA 3

labetalol hcl SOLN; TABS 1

LOPRESSOR 3

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate SOLN 1

metoprolol tartrate TABS 25mg

1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol hcl er 60mg, 80mg

1

propranolol hcl er (generic of INDERAL LA) 120mg, 160mg

1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

SECTRAL 3

SOTYLIZE 3 NM

TENORMIN 3

timolol maleate TABS 1

TOPROL XL 3

ZEBETA 10mg 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv (generic of CADUET)

1

CADUET 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CALAN 3

Drug Name Drug Tier

Requirements/Limits

CALAN SR 3

CARDIZEM 60mg, 120mg 3

CARDIZEM CD 120mg 3

CARDIZEM CD 180mg, 240mg, 360mg

3 NM

CARDIZEM LA 3

cartia xt (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap 240mg/24hr 1

diltiazem cap er/12hr 1

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

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 3

diltiazem inj 125/25ml 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 3 NM

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

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

1

NORVASC 3

NYMALIZE 3 NM

PROCARDIA XL 3

SULAR 3



20

Drug Name Drug Tier

Requirements/Limits

taztia xt (generic of TIAZAC) 1

TIAZAC 3

verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg, 300mg

1

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

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

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

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) 1

digox (generic of LANOXIN) 1

digoxin (generic of LANOXIN) TABS

1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN 2

LANOXIN INJ 0.25MG/ML 3

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

ALDACTAZIDE TAB 50/50 3

amiloride & hydrochlorothiazide

1

amiloride hcl TABS 1

Drug Name Drug Tier

Requirements/Limits

bumetanide SOLN 1

bumetanide (generic of BUMEX) TABS

1

chlorothiazide tabs 1

chlorthalidone 25mg, 50mg 1

DEMADEX TAB 5MG 3

DEMADEX TAB 10MG 3

DEMADEX TAB 20MG 3

DIAMOX 2

DIURIL SUS 250/5ML 3

DYAZIDE 3

DYRENIUM 3

EDECRIN 3

ethacrynic acid (generic of EDECRIN)

1

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 10mg/ml 1

FUROSEMIDE INJ 10mg/ml 1

furosemide oral soln 8 mg/ml 1

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

LASIX 3

MAXZIDE 3

MAXZIDE-25 3

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone 1

MICROZIDE 3

neptazane 3

SODIUM DIURIL 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 50mg/5ml 3

torsemide tabs 5mg, 100mg 1

torsemide tabs (generic of DEMADEX) 10mg, 20mg

1

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

1

triamt/hctz cap 50-25mg 1



21

Drug Name Drug Tier

Requirements/Limits

triamt/hctz tab 37.5-25 (generic of MAXZIDE-25)

1

triamt/hctz tab 75-50mg (generic of MAXZIDE)

1

MISCELLANEOUS BIDIL 2

CATAPRES TAB 2

CATAPRES-TTS DIS 0.1/24HR

2


2


2

clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr

1


1


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

CORLANOR 3

DEMSER 3 NM

DIBENZYLINE 3 NM

hydralazine hcl SOLN; TABS 1

KEVEYIS 3 NM PA

midodrine hcl 1

minoxidil TABS 1

phenoxybenzamine hcl (generic of DIBENZYLINE) CAPS

3 NM

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 2

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

1

isosorbide dinitrate 10mg, 20mg, 30mg

1

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

Drug Name Drug Tier

Requirements/Limits

minitran (generic of NITRO-DUR)

1

nitro-bid 3

NITRO-DUR 2

nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) SOLN .4mg/spray

1

nitroglycerin (generic of NITROSTAT) SUBL

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 3 NM PA

ADEMPAS 3 NM LA PA

epoprostenol sodium (generic of FLOLAN)

3 B/D NM LA

FLOLAN 3 B/D NM LA

LETAIRIS 3 NM LA PA

OPSUMIT 3 NM LA PA

ORENITRAM TAB 0.25MG 3 NM LA PA


ORENITRAM TAB 1MG 3 NM LA PA


REMODULIN 3 B/D NM LA

REVATIO 3 NM PA

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

3 NM PA

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

1 NM PA

TRACLEER 3 NM LA PA

TYVASO 3 B/D NM

UPTRAVI 3 NM LA PA

VELETRI 3 B/D NM LA

VENTAVIS 3 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC 3

alprazolam (generic of XANAX) TABS

1



22

Drug Name Drug Tier

Requirements/Limits

ATIVAN SOLN 3

ATIVAN TABS 3 NM

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

lorazepam CONC 1

lorazepam (generic of ATIVAN) SOLN; TABS

1

XANAX TAB 0.5MG 2

XANAX TAB 0.25MG 2

XANAX TAB 1MG 2

XANAX TAB 2MG 2

ANTICONVULSANTS APTIOM 200mg 3

APTIOM 400mg, 600mg, 800mg

3 NM

BANZEL SUS 40MG/ML 3 NM

BANZEL TAB 200MG 3

BANZEL TAB 400MG 3 NM

BRIVIACT INJ 3

BRIVIACT SOLN 10MG/ML 3 NM

BRIVIACT TABS 3 NM

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CARBATROL 3

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS

1

clonazepam TBDP 1

clorazepate dipotassium 3.75mg, 15mg

1

clorazepate dipotassium (generic of TRANXENE T) 7.5mg

1

DEPACON 3 NM

DEPAKENE CAPS 3 NM

DEPAKENE SYRP 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

Drug Name Drug Tier

Requirements/Limits

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

diazepam CONC; SOLN 1

diazepam (generic of VALIUM) TABS

1

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

3 NM

felbamate (generic of FELBATOL) TABS

1

FELBATOL 3 NM

FYCOMPA 2

gabapentin (generic of NEURONTIN) CAPS; SOLN; TABS

1

GABITRIL 2

KEPPRA SOLN 3 NM

KEPPRA TABS 250mg 3

KEPPRA TABS 500mg, 750mg, 1000mg

3 NM

KEPPRA XR 3 NM

KLONOPIN 2

LAMICTAL TABS 3 NM

LAMICTAL CHEWABLE DISPERS 5mg

3

LAMICTAL CHEWABLE DISPERS 25mg

3 NM

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

LAMICTAL XR TB24 25mg, 50mg

2



23

Drug Name Drug Tier

Requirements/Limits

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

3 NM

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine KIT 1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

lamotrigine (generic of LAMICTAL ODT) TBDP

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LEVETIRACETAM IV 3

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

1

LYRICA 2

MYSOLINE 3 NM

NEURONTIN 3

ONFI SUSP 3 NM

ONFI TABS 10mg 3

ONFI TABS 20mg 3 NM

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 2

PEGANONE 3

phenobarbital ELIX; TABS 3

PHENOBARBITAL SODIUM SOLN 65mg/ml

3

phenobarbital sodium SOLN 130mg/ml

3

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN-125) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

1

Drug Name Drug Tier

Requirements/Limits

POTIGA 50mg 3

POTIGA 200mg, 300mg, 400mg

3 NM

primidone (generic of MYSOLINE) TABS

1

QUDEXY XR 2

roweepra (generic of KEPPRA)

1

SABRIL 3 NM LA PA

SPRITAM 3

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 25mg, 50mg 3

TOPAMAX 100mg, 200mg 3 NM

TOPAMAX SPRINKLE 15mg

3

TOPAMAX SPRINKLE 25mg

3 NM

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1

topiramate (generic of TOPAMAX) TABS

1

TRANXENE T 3

TRILEPTAL SUSP 3

TRILEPTAL TABS 3

TROKENDI XR 25mg, 50mg, 100mg

2

TROKENDI XR 200mg 3 NM

VALIUM 2

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE)

1

VIMPAT SOLN 2

VIMPAT TABS 50mg 2

VIMPAT TABS 100mg, 150mg, 200mg

3 NM

ZARONTIN CAPS 3

zarontin SOLN 3

ZONEGRAN 25mg 3



24

Drug Name Drug Tier

Requirements/Limits

ZONEGRAN 100mg 3 NM

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

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA ARICEPT 3

donepezil odt 5mg 1

donepezil odt 10mg 1

donepezil tab hcl 23mg (generic of ARICEPT)

1

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON CAPS 3

EXELON PATCHES 2

galantamine hydrobromide SOLN

1

galantamine hydrobromide (generic of RAZADYNE) TABS

1

galantamine hydrobromide er (generic of RAZADYNE ER)

1

memantine hcl (generic of NAMENDA)

PA if < 30 yrs

1 PA

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

2 PA

NAMENDA TAB PA if < 30 yrs

2 PA

NAMENDA XR PA if < 30 yrs

2 PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

2 PA

NAMZARIC 3

RAZADYNE 3

RAZADYNE ER 3

rivastigmine tartrate (generic of EXELON)

1

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

1


1

Drug Name Drug Tier

Requirements/Limits


1

ANTIDEPRESSANTS amitriptyline hcl TABS 10mg, 50mg, 75mg, 100mg, 150mg

3

amitriptyline hcl (generic of ELAVIL) TABS 25mg

3

amoxapine 1

ANAFRANIL 3

APLENZIN 3 NM

BRINTELLIX 2

bupropion hcl TABS 1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

CELEXA 3

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

3

CYMBALTA 3

desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg

1

desipramine hcl TABS 50mg, 75mg, 100mg, 150mg

1

doxepin hcl CAPS; CONC 3

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

1

EFFEXOR XR 3

EMSAM 3 NM

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine cap 10mg (generic of PROZAC)

1


1


1



25

Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl (generic of TOFRANIL) TABS

3

imipramine pamoate 3

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

mirtazapine TABS 7.5mg 1

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

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

NARDIL 2

nefazodone hcl 1

NORPRAMIN 2

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

PAMELOR 3 NM

PARNATE 3 NM

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl tabs (generic of PAXIL)

1

PAXIL 3

PAXIL CR 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl 1

PROZAC 3

PROZAC WEEKLY 3

REMERON 3

REMERON SOLTAB 3

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3

Drug Name Drug Tier

Requirements/Limits

tofranil 3

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

trimipramine maleate CAPS 25mg, 50mg

3

trimipramine maleate (generic of SURMONTIL) CAPS 100mg

3

TRINTELLIX 2

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl 1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

VIIBRYD STARTER PACK 2

WELLBUTRIN SR 3

WELLBUTRIN TAB 75MG 3

WELLBUTRIN XL 3 NM

ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 3 NM LA PA

AZILECT 2

BENZTROPINE MESYLATE SOLN

1

benztropine mesylate TABS 3

bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

1

carbidopa (generic of LODOSYN) TABS

3 NM

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1



26

Drug Name Drug Tier

Requirements/Limits


1


1


1


1


1

COGENTIN 3

COMTAN 3

DUOPA 3 B/D NM

ELDEPRYL 3

ENTACAPONE 1

LODOSYN 3 NM

MIRAPEX 3

MIRAPEX ER .75mg, 1.5mg 3

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

2

NEUPRO 2

pramipexole dihydrochloride (generic of MIRAPEX) TABS

1

pramipexole dihydrochloride (generic of MIRAPEX ER) TB24

1

REQUIP 3

REQUIP XL 3

ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

RYTARY 3

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

SINEMET 3

SINEMET CR 3

STALEVO 3

ZELAPAR 3 NM

ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG

3 NM

ABILIFY MAINTENA 3 NM

ABILIFY TABS 3 NM

Drug Name Drug Tier

Requirements/Limits

aripiprazole 3 NM

aripiprazole oral solution 1 mg/ml

3 NM

aripiprazole tabs (generic of ABILIFY)

3 NM

ARISTADA 3 NM

chlorpromazine hcl TABS 1

chlorpromazine inj 3

clozapine (generic of CLOZARIL) 25mg, 100mg

1

clozapine 50mg, 200mg 1

CLOZAPINE ODT 12.5mg 1

CLOZAPINE ODT 25mg, 100mg

1

CLOZAPINE ODT 150mg, 200mg

3 NM

CLOZARIL 25mg 3

CLOZARIL 100mg 3 NM

FANAPT 3

FANAPT TITRATION PACK 3

FAZACLO 12.5mg, 25mg 3

FAZACLO 100mg, 150mg, 200mg

3 NM

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON 20mg, 40mg 3

GEODON 60mg, 80mg 3 NM

GEODON INJ 3

HALDOL 3

HALDOL DECANOATE 50 3

HALDOL DECANOATE 100 3

haloperidol TABS 1

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

1

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

1

haloperidol lactate 1

haloperidol lactate inj 5 mg/ml (generic of HALDOL)

1

INVEGA 3



27

Drug Name Drug Tier

Requirements/Limits

INVEGA SUST INJ 39 MG/0.25 ML

3


3 NM


3 NM

INVEGA SUST INJ 156MG/ML

3 NM


3 NM

INVEGA TRINZA 3 NM

LATUDA 2

loxapine succinate 1

molindone hcl 1

NUPLAZID 3 NM LA PA

olanzapine (generic of ZYPREXA)

1

olanzapine odt (generic of ZYPREXA ZYDIS)

1

ORAP 3

paliperidone (generic of INVEGA)

1

perphenazine TABS 1

pimozide (generic of ORAP) 1

quetiapine fumarate (generic of SEROQUEL)

1

REXULTI 3 NM

RISPERDAL SOLN 3 NM

RISPERDAL TABS 3mg, 4mg

3 NM

RISPERDAL TABS .25mg, .5mg, 1mg, 2mg

3

RISPERDAL INJ 12.5MG 2

RISPERDAL INJ 25MG 2

RISPERDAL INJ 37.5MG 3 NM

RISPERDAL INJ 50MG 3 NM

RISPERDAL M-TAB 1mg 3

RISPERDAL M-TAB .5mg, 2mg, 3mg, 4mg

3 NM

risperidone (generic of RISPERDAL)

1

risperidone odt (generic of RISPERDAL M-TAB) .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone odt .25mg 1

SAPHRIS 3

Drug Name Drug Tier

Requirements/Limits

SEROQUEL 25mg, 50mg, 100mg

3

SEROQUEL 200mg, 300mg, 400mg

3 NM

SEROQUEL XR 2

thioridazine hcl TABS 3

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3 NM

VRAYLAR CAPS 3 NM

VRAYLAR CPPK 3

ziprasidone hcl (generic of GEODON)

1

ZYPREXA SOLR 3

ZYPREXA TABS 2.5mg, 5mg, 7.5mg, 10mg

3

ZYPREXA TABS 15mg, 20mg

3 NM

ZYPREXA RELPREVV 3 NM

ZYPREXA RELPREVV INJ 210MG

3 NM

ZYPREXA ZYDI TAB 10MG 3 NM

ZYPREXA ZYDIS 5mg 3

ZYPREXA ZYDIS 15mg, 20mg

3 NM

ATTENTION DEFICIT HYPERACTIVITY DISORDER adderall tab 5mg 3

adderall tab 7.5mg 3

adderall tab 10mg 3

adderall tab 12.5mg 3

adderall tab 15mg 3

adderall tab 20mg 3

adderall tab 30mg 3

ADDERALL XR CAP 5MG 3






amphetamine cap 10mg er (generic of ADDERALL XR)

1


1



28

Drug Name Drug Tier

Requirements/Limits


1


1


1

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)

1

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)

1

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)

1


1

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)

1


1


1


1

APTENSIO XR 3

CONCERTA 3

DAYTRANA 2

guanfacine er (adhd) (generic of INTUNIV)

3

INTUNIV 3

METADATE CD 3

metadate er tab 20mg 1

METHYLIN 3

METHYLIN CHEW TAB 2

methylphenidate hcl (generic of METHYLIN) CHEW

1

methylphenidate hcl (generic of RITALIN LA) CP24 20mg, 40mg

1

METHYLPHENIDATE HCL CP24 30mg

1

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl (generic of METADATE CD) CPCR

1

methylphenidate hcl (generic of METHYLIN) SOLN

1

methylphenidate hcl (generic of RITALIN) TABS

1

methylphenidate hcl TB24 1

methylphenidate hcl TBCR 1

methylphenidate hcl er TB24 1

QUILLICHEW ER 3

QUILLIVANT XR 2

RITALIN 3

RITALIN LA 3

STRATTERA 2

VYVANSE 2

HYPNOTICS AMBIEN 3

HETLIOZ 3 NM LA PA

RESTORIL 7.5mg, 15mg 3

ROZEREM 3

SILENOR 2

temazepam (generic of RESTORIL) 7.5mg, 15mg

1

zolpidem tartrate (generic of AMBIEN) TABS

3

MIGRAINE almotriptan malate (generic of AXERT)

1

AMERGE 3

AXERT 3

cafergot tab 1-100mg 3

D.H.E. 45 3 NM

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

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

3 NM

ergomar 3

FROVA TAB 2.5MG 3

frovatriptan succinate (generic of FROVA)

1

IMITREX 3

IMITREX STATDOSE REFILL 3 NM

IMITREX STATDOSE SYSTEM SOAJ

3 NM



29

Drug Name Drug Tier

Requirements/Limits

IMITREX STATDOSE SYSTEM SOLN

3

MAXALT 5mg 3 NM

MAXALT 10mg 3

MAXALT-MLT 3

migergot 3 NM

MIGRANAL 3 NM

naratriptan hcl (generic of AMERGE)

1

ONZETRA XSAIL 3

RELPAX 2

rizatriptan benzoate (generic of MAXALT) TABS

1

rizatriptan benzoate (generic of MAXALT-MLT) TBDP

1

sumatriptan inj 4mg/0.5ml SOAJ

1

SUMATRIPTAN INJ 4MG/0.5ML SOCT

1

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

1

SUMATRIPTAN INJ 6MG/0.5ML SOCT

1

sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN

1

sumatriptan inj 6mg/0.5ml SOSY

1

SUMATRIPTAN SUCCINATE SOLN

1

sumatriptan succinate (generic of IMITREX) TABS

1

SUMAVEL DOSEPRO 3 NM

TREXIMET 3 NM

ZEMBRACE SYMTOUCH 3

zolmitriptan (generic of ZOMIG) TABS

1

zolmitriptan odt (generic of ZOMIG ZMT)

1

ZOMIG 3

ZOMIG NASAL SPRAY 2

ZOMIG ZMT 3

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 2

Drug Name Drug Tier

Requirements/Limits

GRALISE STARTER 2

HORIZANT 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM SOLN 8MEQ/5ML 3

LITHOBID 3

MESTINON 3 NM

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide (generic of MESTINON) TABS

1

pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR

1

RILUTEK 3 NM

riluzole (generic of RILUTEK) 1

SAVELLA 2

SAVELLA TITRATION PACK 2

tetrabenazine (generic of XENAZINE)

3 NM PA

XENAZINE 3 NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO 3 NM LA PA

AVONEX 3 NM PA

AVONEX PEN 3 NM PA

BETASERON 3 NM PA

COPAXONE INJ 40MG/ML 3 NM PA

COPAXONE KIT 20MG/ML 3 NM PA

EXTAVIA 3 NM PA

GILENYA CAP 0.5MG 3 NM PA

glatopa (generic of COPAXONE)

3 NM PA

LEMTRADA 3 NM LA PA

PLEGRIDY 3 NM PA

PLEGRIDY STARTER PACK 3 NM PA

REBIF 3 NM PA

REBIF REBIDOSE 3 NM PA

REBIF REBIDOSE TITRATION

3 NM PA



30

Drug Name Drug Tier

Requirements/Limits

REBIF TITRATION PACK 3 NM PA

TECFIDERA CAP 120MG 3 NM LA PA

TECFIDERA CAP 240MG 3 NM LA PA

TECFIDERA MIS STARTER 3 NM LA PA

TYSABRI 3 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX INJ 100UNIT 3 NM PA

BOTOX INJ 200UNIT 3 NM PA

cyclobenzaprine hcl TABS 5mg, 10mg

3

DANTRIUM 2

dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg

1

dantrolene sodium CAPS 100mg

1

DYSPORT 3 NM PA

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

XEOMIN 50UNIT 3 NM PA



ZANAFLEX CAPS 3

ZANAFLEX TABS 2

NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg, 150mg, 250mg

1

ARMODAFINIL 200mg 1

modafinil (generic of PROVIGIL) 100mg

1

modafinil (generic of PROVIGIL) 200mg

3 NM

NUVIGIL 2

PROVIGIL 3 NM

XYREM 3 NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

antabuse 2

BUNAVAIL MIS 2.1-0.3MG 3

BUNAVAIL MIS 4.2-0.7MG 3

BUNAVAIL MIS 6.3-1MG 3

Drug Name Drug Tier

Requirements/Limits

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban tab (smoking deterrent) (generic of ZYBAN)

1

bupropion hcl (smoking deterrent) (generic of ZYBAN)

1

CHANTIX 2

CHANTIX CONTINUING MONTH

2

CHANTIX STARTER PACK 2

disulfiram (generic of ANTABUSE) TABS

1

naloxone inj 0.4mg/ml 1

naloxone inj 1mg/ml 1

naltrexone hcl TABS 1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG 2

SUBOXONE MIS 4-1MG 2



VIVITROL 3 NM PA

ZUBSOLV SUB 1.4-0.36MG 3





ZYBAN 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2 PA

ANDROGEL 3 PA

ANDROGEL 1% 3 PA

ANDROGEL 1.62% 3 PA

AVEED 3 NM PA

AXIRON 2 PA

depo-testosterone 3 PA

FORTESTA 3 PA

oxandrolone (generic of OXANDRIN) TABS 2.5mg

1 PA

oxandrolone (generic of OXANDRIN) TABS 10mg

3 NM PA

STRIANT 3 PA



31

Drug Name Drug Tier

Requirements/Limits

TESTIM 3 PA

TESTOSTERONE GEL 1% 1 PA

TESTOSTERONE GEL 1% 1 PA

TESTOSTERONE GEL 10mg/act

1 PA

TESTOSTERONE GEL 25mg/2.5gm

1 PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

1 PA

testosterone enanthate SOLN

1 PA

VOGELXO 3 PA

VOGELXO PUMP 3 PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 3

APIDRA SOLOSTAR 3

BYDUREON 3

BYDUREON PEN 3

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

HUMULIN R 3

HUMULIN R U-500 KWIKPEN 3 NM

HUMULIN R U-500 VIAL (CONCENTRATE)

3 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

Drug Name Drug Tier

Requirements/Limits

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2

SYMLINPEN 120 3 NM

TANZEUM 3

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

TRULICITY 2

VICTOZA 2

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET TAB 15-500MG

3

ACTOPLUS MET TAB 15-850MG

3

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

ACTOS 3

AMARYL 3

DUETACT 3

FARXIGA 2

FORTAMET 3 NM

glimepiride (generic of AMARYL)

1

glipizide (generic of GLUCOTROL) TABS

1

glipizide er (generic of GLUCOTROL XL)

1

GLIPIZIDE XL TB24 2.5MG 1

GLIPIZIDE XL TB24 5MG 1



32

Drug Name Drug Tier

Requirements/Limits

glipizide-metformin 2.5-250 mg

1

glipizide-metformin 2.5-500 mg

1

glipizide-metformin 5-500mg 1

GLUCOPHAGE 3

GLUCOPHAGE XR 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUMETZA 3

GLYSET 3

GLYXAMBI 3

INVOKAMET TAB 50-500MG 3

INVOKAMET TAB 50-1000 3



INVOKANA TAB 100MG 3

INVOKANA TAB 300MG 3

JANUMET 2

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2.5-1000MG

2

JENTADUETO XR 5-1000MG 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er (generic of GLUCOPHAGE XR)

1

metformin hcl (generic of GLUCOPHAGE) TABS

1

metformin hcl (generic of GLUMETZA) TB24

1

metformin hcl osmotic 500mg (generic of FORTAMET)

1

metformin hcl osmotic 1000mg (generic of FORTAMET)

1

Drug Name Drug Tier

Requirements/Limits

miglitol (generic of GLYSET) 1

nateglinide (generic of STARLIX)

1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl (generic of ACTOS)

1

pioglitazone hcl-glimepiride (generic of DUETACT)

1

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)

1

PRANDIMET 3

PRANDIN 3

PRECOSE 2

repaglinide (generic of PRANDIN)

1

repaglinide-metformin hcl 1

RIOMET 3

STARLIX 3

SYNJARDY 3

TRADJENTA 2

XIGDUO XR TAB 5-500MG 2




BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

3

ACTONEL 150mg 2

alendronate sodium SOLN 1

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

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 3

BINOSTO 3

BONIVA 3 B/D

FOSAMAX 3

FOSAMAX PLUS D 3



33

Drug Name Drug Tier

Requirements/Limits

ibandronate sodium (generic of BONIVA)

1 B/D

ibandronate tab 150mg (generic of BONIVA)

1 B/D

pamidronate disodium SOLN 6mg/ml

3 B/D

pamidronate disodium SOLN 30mg/10ml, 90mg/10ml

1 B/D

RECLAST 3 B/D NM

RISEDRONATE SODIUM TABS 5mg, 30mg

1

risedronate sodium (generic of ACTONEL) TABS 35mg, 150mg

1

risedronate sodium (generic of ATELVIA) TBEC

1

zoledronic inj 4mg/5ml (generic of ZOMETA)

1 B/D NM

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D NM

ZOMETA 3 B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 2 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 3 NM

EXJADE 3 NM LA PA

FERRIPROX 3 NM LA PA

JADENU 3 NM PA

KAYEXALATE 3

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate (generic of KAYEXALATE) POWD

1

sodium polystyrene sulfonate SUSP

1

sps 1

SYPRINE 3 NM

VELTASSA 3 NM LA

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

Drug Name Drug Tier

Requirements/Limits

aranelle 28 (generic of TRI-NORINYL 28)

1

ashlyna 91 day (generic of SEASONIQUE)

1

aubra 28 day 1

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

bekyree 28 day (generic of MIRCETTE)

1

BEYAZ 2

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

1

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

1

blisovi 24 fe 1/20 28 day 1

BREVICON-28 3

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

caziant 28 day (generic of CYCLESSA)

1

cryselle 28 1

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

1

cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

CYCLESSA 3

cyred tab (generic of DESOGEN)

1

deblitane 28 day (generic of NOR-QD)

1

delyla 28 day 1

DEPO-PROVERA CONTRACEPTIVE

2

DEPO-SUBQ PROVERA 104 2

DESOGEN 3

desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)

1

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1



34

Drug Name Drug Tier

Requirements/Limits

drospirenone-ethinyl estradiol (generic of YAZ)

1

ELLA 3

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

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

1

ESTROSTEP FE 3

falmina 28 day 1

FEMCON FE 3

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia (generic of OVCON-35)

1

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

1

gildess 24 fe 28 day 1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

juleber 28 day (generic of DESOGEN)

1

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

1

junel 1/20 21 day (generic of LOESTRIN 1/20-21)

1

junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

junel fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

junel fe 24 1/20 28 day 1

kaitlib fe 28 day (generic of GENERESS FE)

1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

kimidess 28 day (generic of MIRCETTE)

1

larin 1.5/30 (generic of LOESTRIN 1.5/30-21)

1

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

1

Drug Name Drug Tier

Requirements/Limits

larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

1

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

1

larissia 28 day pack 1

LAYOLIS FE CHW 1

leena tab (generic of TRI-NORINYL 28)

1

lessina 28 day 1

levonest 28 day 1

levonor/ethi tab 1

levonorgestrel & eth estradiol 1

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

1

levonorgestrel (emergency oc) .75mg

1

levonorgestrel-ethinyl estradiol (91-day)

1

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

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

loestrin 1.5/30 21 day 3

loestrin 1/20 21 day 3

loestrin fe 1.5/30 28 day 3

loestrin fe 1/20 28 day 3

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

LOSEASONIQUE 3

low-ogestrel 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

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

1

MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSY

1



35

Drug Name Drug Tier

Requirements/Limits

MICROGESTIN 1.5/30 1

MICROGESTIN 1/20 1

MICROGESTIN FE 1.5/30 1

MICROGESTIN FE 1/20 1

MINASTRIN 24 FE 2

mircette 2

MODICON 3

mono-linyah tab 0.25-35 (generic of ORTHO-CYCLEN)

1

MONONESSA 1

myzilra 1

necon 0.5/35 28 day (generic of BREVICON-28)

1

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

1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

nikki 28 day (generic of YAZ) 1

NOR-QD 2

NORA-BE TAB 1

norethin acet & estrad-fe 1

norethindrone & ethinyl estradiol-fe (generic of GENERESS FE)

1

norethindrone (contraceptive) (generic of NOR-QD)

1

norgest/ethi tab 0.25/35 (generic of ORTHO-CYCLEN)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN LO)

1

NORINYL 1+35 3

NORINYL 1+50 3

norlyroc 28 day (generic of NOR-QD)

1

nortrel 0.5/35 28 day (generic of BREVICON-28)

1

nortrel 1/35 21 day (generic of NORINYL 1+35)

1

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

1

Drug Name Drug Tier

Requirements/Limits

nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO MICRONOR 2

ORTHO TRI-CYCLEN LO 2

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

ovcon 35 28 day 3

philith (generic of OVCON-35) 1

pimtrea pack (generic of MIRCETTE)

1

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

1

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3

setlakin tab 1

sharobel 28 day (generic of ORTHO MICRONOR)

1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

tarina fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

tri-linyah tab (generic of ORTHO TRI-CYCLEN)

1

tri-lo- estarylla 28 day (generic of ORTHO TRI-CYCLEN LO)

1

tri-lo- tab marzia (generic of ORTHO TRI-CYCLEN LO)

1

tri-lo-sprintec 28 day (generic of ORTHO TRI-CYCLEN LO)

1

TRI-NORINYL 28 3



36

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

TRINESSA 1

TRINESSA LO TAB 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

vienva 28 day 1

viorele (generic of MIRCETTE)

1

vyfemla 28 day (generic of OVCON-35)

1

wymzya fe (generic of FEMCON FE)

1

xulane dis 150-35 1

YASMIN 28 3

YAZ 3

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 NM PA

SYNAREL 3 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA

ALDURAZYME 3 NM LA PA

BUPHENYL POWD 3 NM

BUPHENYL TABS 3 NM LA PA

CARBAGLU 3 NM LA PA

CARNITOR SOLN 1gm/10ml

2 B/D

CARNITOR SOLN 200mg/ml

3 B/D

CARNITOR TABS 2 B/D

CERDELGA 3 NM PA

CEREZYME 3 NM LA PA

CYSTADANE 3 NM LA

CYSTAGON 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

ELAPRASE 3 NM LA PA

ELELYSO 3 NM PA

FABRAZYME 3 NM LA PA

KANUMA 3 NM LA PA

KUVAN 3 NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 3 NM LA PA

MYOZYME 3 NM LA PA

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM LA PA

PROCYSBI 3 NM LA PA

RAVICTI 3 NM PA

sodium phenylbutyrate (generic of BUPHENYL)

3 NM

STRENSIQ 3 NM LA PA

VIMIZIM 3 NM PA

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGENS ALORA 3

CLIMARA 3

DELESTROGEN 3

depo-estradiol 3

estrace CREA 2

estrace TABS 3

estradiol (generic of VIVELLE-DOT) PTTW

3

estradiol (generic of CLIMARA) PTWK

3

estradiol (generic of ESTRACE) TABS

3

estradiol valerate (generic of DELESTROGEN) OIL

1

ESTRING 3

FEMRING 3

fyavolv tab 1 mg-5 mcg 3

jinteli 3

MENOSTAR 3

MINIVELLE 3

norethindrone acetate-ethinyl estradiol

3

PREMARIN CREAM 2

PREMARIN INJ 3

VAGIFEM 2



37

Drug Name Drug Tier

Requirements/Limits

VIVELLE-DOT 3

GLUCOCORTICOIDS a-hydrocort 1

CORTEF 3

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D


3 B/D


3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak 6 day 2

dexpak 10 day 2

dexpak taperpak 13 day 2

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL PAK 4MG 3

MEDROL TAB 2MG 3 B/D





methylpr ace inj 40mg/ml (generic of DEPO-MEDROL)

1 B/D

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

1 B/D

methylpr ss inj 1gm (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 40mg (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 125mg (generic of SOLU-MEDROL)

1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D

Drug Name Drug Tier

Requirements/Limits


1 B/D

millipred 3 B/D

millipred dp 3

ORAPRED ODT TAB 10MG 2 B/D



pediapred sol 6.7/5ml 3 B/D

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

1 B/D

prednisolone sodium phosphate (generic of ORAPRED ODT)

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml 1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1

prednisone pak 10mg 1

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





RAYOS TAB 1MG 3 B/D NM



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 1GM 3 B/D

SOLU-MEDROL INJ 2GM 3 B/D

SOLU-MEDROL INJ 40MG 3 B/D



veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

KORLYM 3 NM LA PA

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES



38

Drug Name Drug Tier

Requirements/Limits

GENOTROPIN 3 NM PA

GENOTROPIN MINIQUICK 3 NM PA

HUMATROPE 3 NM PA

HUMATROPE COMBO PACK 3 NM PA

NORDITROPIN FLEXPRO 3 NM PA

NUTROPIN AQ INJ 20MG/2ML

3 NM LA PA

NUTROPIN AQ NUSPIN 5 3 NM LA PA



NUTROPIN AQ PEN 3 NM LA PA

OMNITROPE 5.8MG 3 NM LA PA

OMNITROPE 5MG 3 NM LA PA

OMNITROPE 10MG 3 NM LA PA

SAIZEN 3 NM LA PA

SAIZEN CLICK.EASY 3 NM LA PA

SEROSTIM 3 NM LA PA

ZOMACTON 3 NM PA

ZORBTIVE 3 NM PA

MISCELLANEOUS AFREZZA 3

cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 1mg 3 NM LA PA

EVISTA 3

FORTICAL SPR 200/ACT 3

H.P. ACTHAR 3 NM LA PA

INCRELEX 3 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 3 B/D NM

MIACALCIN SPR 200/ACT 3

MYALEPT 3 NM LA PA

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml

1 NM PA

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

3 NM PA

Drug Name Drug Tier

Requirements/Limits

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM

raloxifene hcl (generic of EVISTA)

1

SAMSCA 3 NM PA

SANDOSTATIN 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM LA PA

SIGNIFOR LAR 3 NM LA PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 3 NM LA PA

XGEVA 3 NM PA

PARATHYROID HORMONES FORTEO 3 NM PA

NATPARA 3 NM PA

PHOSPHATE BINDER AGENTS AURYXIA 3 NM

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

1

calcium acetate (phosphate binder) (generic of ELIPHOS) TABS

1

eliphos 3

FOSRENOL 3 NM

PHOSLO 3

PHOSLYRA 2

RENAGEL 400mg 3

RENAGEL 800mg 3 NM

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 3 NM

PROGESTINS aygestin 3

CRINONE 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

PROMETRIUM 3

PROVERA 3



39

Drug Name Drug Tier

Requirements/Limits

THYROID AGENTS CYTOMEL 2

levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

tapazole 2

TIROSINT 3

TRIOSTAT 3

UNITHROID 1

VASOPRESSINS DDAVP SOLN 4mcg/ml 3 NM

DDAVP SOLN .01% 2

DDAVP TABS 2

DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM

GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D

ALOXI 3 NM

CESAMET 3 B/D NM

compro supp 1

dronabinol (generic of MARINOL) 2.5mg, 5mg

1 B/D

dronabinol (generic of MARINOL) 10mg

3 B/D NM

EMEND SUSR 3 B/D

EMEND CAP 40MG 3 B/D



Drug Name Drug Tier

Requirements/Limits

EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

MARINOL 2.5mg 3 B/D

MARINOL 5mg, 10mg 3 B/D NM

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl (generic of METOZOLV ODT) TBDP

1

metoclopramide hcl inj 5 mg/ml

1

metoclopramide odt 1

METOZOLV ODT 3

ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1

ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml

1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz 3

phenergan 3

phenergan inj 3

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

3

promethazine hcl SUPP; SYRP; TABS

3

promethegan 3

REGLAN 3

SANCUSO 3 NM

SUSTOL 3

TRANSDERM-SCOP 3

VARUBI 2 B/D

ZOFRAN SOLN 4mg/5ml 3 B/D NM

ZOFRAN TABS 3 B/D NM

ZOFRAN ODT 3 B/D NM

ZUPLENZ 3 B/D NM



40

Drug Name Drug Tier

Requirements/Limits

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

1

BENTYL CAPS; TABS 2

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl (generic of BENTYL) CAPS

1

dicyclomine hcl SOLN 10mg/5ml

1

dicyclomine hcl (generic of BENTYL) SOLN 10mg/ml

1

dicyclomine hcl (generic of BENTYL) TABS

1

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3

PAMINE FORTE 3

ROBINUL 3

ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine (generic of PEPCID) SUSR

1

famotidine (generic of PEPCID) TABS 20mg, 40mg

1

famotidine inj 1

nizatidine 1

PEPCID SUSP 3

pepcid tab 3

ranitidine hcl CAPS 1

ranitidine hcl SOLN 1

ranitidine hcl SYRP 1

Drug Name Drug Tier

Requirements/Limits

ranitidine hcl (generic of ZANTAC) TABS 150mg, 300mg

1

ranitidine hcl inj 1

ZANTAC 3

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CPEP

3 NM

CANASA 3 NM

COLAZAL 3

colocort (generic of CORTENEMA)

1

CORTENEMA 3

DELZICOL 3

DIPENTUM 3 NM

ENTOCORT EC 3 NM

ENTYVIO 3 NM PA

GIAZO 3 NM

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

MESALAMINE TBEC 1

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

ROWASA 3

SF-ROWASA 3 NM

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS AER 2MG/ACT 3

UCERIS TAB 9MG 3 NM

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1



41

Drug Name Drug Tier

Requirements/Limits

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-h 1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

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

1

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

1

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

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR SOLN 3 NM

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS ACTIGALL 2

alosetron hcl (generic of LOTRONEX)

3 NM

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1

CARAFATE 2

CHOLBAM 3 NM LA PA

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

3 NM

CYTOTEC 2

Drug Name Drug Tier

Requirements/Limits

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GASTROCROM 3 NM

GATTEX 3 NM LA PA

LINZESS 2

LOMOTIL 2

loperamide hcl CAPS 1

LOTRONEX 3 NM

misoprostol (generic of CYTOTEC) TABS

1

MOVANTIK 2

OCALIVA 3 NM LA PA

OMECLAMOX-PAK 3

PREVPAC 3 NM

PYLERA 3 NM

SUCRAID 3 NM LA

sucralfate (generic of CARAFATE) TABS

1

URSO 250 2

URSO FORTE 2

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

VIBERZI 3 NM

XIFAXAN TAB 550MG 3 NM

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 3 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX 3

ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG 3

DEXILANT 2

esomeprazole magnesium (generic of NEXIUM)

1



42

Drug Name Drug Tier

Requirements/Limits

esomeprazole sodium inj 20mg

1

esomeprazole sodium inj (generic of NEXIUM I.V.) 40mg

1

lansoprazole (generic of PREVACID) CPDR

1

NEXIUM CAP 20MG 2

NEXIUM CAP 40MG 2

NEXIUM GRA 2.5MG DR 2

NEXIUM GRA 5MG DR 2

NEXIUM GRA 10MG DR 2



NEXIUM I.V. 3

omeprazole (generic of PRILOSEC) CPDR

1

OMEPRAZOLE-SODIUM BICARBONATE CAPS

1

OMEPRAZOLE-SODIUM BICARBONATE PACK

3

pantoprazole sodium (generic of PROTONIX)

1

PREVACID 3

PREVACID SOLUTAB 3

PRILOSEC PACK 3

PROTONIX 3

PROTONIX INJ 3

rabeprazole sodium (generic of ACIPHEX)

1

ZEGERID 3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3

dutasteride (generic of AVODART)

1

dutasteride-tamsulosin hcl (generic of JALYN)

1

finasteride (generic of PROSCAR) TABS 5mg

1

FLOMAX 3

JALYN 3

PROSCAR 3

Drug Name Drug Tier

Requirements/Limits

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 3

potassium citrate (alkalinizer) (generic of UROCIT-K 15) 15meq

1

POTASSIUM CITRATE (ALKALINIZER) 540mg

1

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

urecholine 2

UROCIT-K 2

URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDE

1

DETROL 3

DETROL LA 3

DITROPAN XL 3

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

tolterodine tartrate er (generic of DETROL LA)

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES AVC 3

CLEOCIN CREA 2

CLEOCIN VAG SUPP 100MG 3



43

Drug Name Drug Tier

Requirements/Limits

clindamycin cre 2% vag (generic of CLEOCIN)

1

CLINDESSE 3

METROGEL-VAGINAL 2

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole 3 sup 200mg 1

NUVESSA 3

TERAZOL 3 2

TERAZOL 7 2

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

1

terconazole vaginal (generic of TERAZOL 3) CREA .8%

1

terconazole vaginal SUPP 1

VANDAZOLE 1

ZAZOLE CRE 0.8% 1

HEMATOLOGIC ANTICOAGULANTS ARIXTRA 3 NM

COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml

3 NM

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

1

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

3 NM

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

2

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

3 NM

HEP SOD/NACL INJ 25000 1

Drug Name Drug Tier

Requirements/Limits

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

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




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

jantoven (generic of COUMADIN)

1

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

2

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

3 NM

PRADAXA 2

SAVAYSA 3

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 NM PA

EPOGEN 3 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MIRCERA 3 NM PA

MOZOBIL 3 NM PA

NEULASTA 3 NM PA

NEULASTA ONPRO KIT 3 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 3 NM PA

NPLATE 3 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS AGRYLIN 2

anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 3 NM PA

cilostazol 1

CINRYZE 3 NM LA PA

CYKLOKAPRON 3



44

Drug Name Drug Tier

Requirements/Limits

FIRAZYR 2 NM PA

KALBITOR 3 NM PA

LYSTEDA 3

pentoxifylline TBCR 1

PLETAL TAB 50MG 2

PROMACTA 3 NM LA PA

RUCONEST 3 NM PA

SOLIRIS 3 NM PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

ASPIRIN-DIPYRIDAMOLE 1

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

DURLAZA 3

EFFIENT 2

PLAVIX 3

ZONTIVITY 3

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

ARAVA 3 NM

CIMZIA 3 NM PA

ENBREL 3 NM PA

ENBREL SURECLICK 3 NM PA

HUMIRA INJ 10MG/0.2ML 3 NM PA

HUMIRA KIT 20MG/0.4ML 3 NM PA

HUMIRA KIT 40MG/0.8ML 3 NM PA

HUMIRA PEDIATRIC CROHNS

3 NM PA

HUMIRA PEN 3 NM PA

HUMIRA PEN-CROHNS STARTER KIT

3 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

3 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 3 NM PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

Drug Name Drug Tier

Requirements/Limits

ORENCIA 3 NM PA

ORENCIA CLICKJECT 3 NM PA

OTEZLA 3 NM PA

OTREXUP 3 NM PA

PLAQUENIL 2

RASUVO 3 NM PA

REMICADE 3 NM PA

RHEUMATREX 2

SIMPONI 3 NM PA

SIMPONI ARIA 3 NM PA

trexall 2 B/D

XELJANZ 3 NM PA

XELJANZ XR 3 NM PA

IMMUNOGLOBULINS BIVIGAM 3 NM PA

CARIMUNE NANOFILTERED 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAGARD S/D IGA LESS TH

3 NM PA

GAMMAKED 3 NM PA

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

3 NM PA

GAMUNEX-C 3 NM PA

HIZENTRA 3 NM PA

HYQVIA 3 NM PA

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

3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

GRASTEK 2

ILARIS 3 NM PA

INTRON-A INJ 10MU 3 B/D NM




RAGWITEK 2

REVLIMID 3 NM LA PA

THALOMID 2 NM PA



45

Drug Name Drug Tier

Requirements/Limits

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 3 B/D NM

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

ATGAM 3 B/D NM

azasan 2 B/D

azathioprine SOLR 1 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

BENLYSTA 3 NM PA

CELLCEPT CAP 3 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

CELLCEPT SUSP 3 B/D NM

CELLCEPT TAB 3 B/D NM

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

1 B/D

ENVARSUS XR 3 B/D

gengraf (generic of NEORAL) CAPS 25mg, 100mg

1 B/D

gengraf CAPS 50mg 1 B/D

gengraf (generic of NEORAL) SOLN

1 B/D

IMURAN 2 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil (generic of CELLCEPT) SUSR

3 B/D NM

mycophenolate sodium (generic of MYFORTIC) 180mg

1 B/D

mycophenolate sodium (generic of MYFORTIC) 360mg

3 B/D NM

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 3 B/D NM

NEORAL 2 B/D

NULOJIX 3 B/D NM

Drug Name Drug Tier

Requirements/Limits

PROGRAF CAPS 5mg 3 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 3 B/D NM

RAPAMUNE TABS 1mg, 2mg

3 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 10mg 3 B/D

SIMULECT 20mg 3 B/D NM

SIROLIMUS TABS 2mg 3 B/D NM

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

1 B/D

tacrolimus (generic of PROGRAF) CAPS 5mg

3 B/D NM

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

1 B/D

THYMOGLOBULIN 3 B/D NM

ZORTRESS TAB 0.5MG 3 B/D NM

ZORTRESS TAB 0.25MG 3 B/D

ZORTRESS TAB 0.75MG 3 B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 3

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

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

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3



46

Drug Name Drug Tier

Requirements/Limits

KINRIX 3

M-M-R II 3

MENACTRA 3

MENHIBRIX 3

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

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 3 NM

TENIVAC 3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

K-TAB 8meq, 20meq 3

K-TAB 10meq 2

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20meq 1

klor-con spr cap 8meq (generic of MICRO-K)

1

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

1

magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml

1

Drug Name Drug Tier

Requirements/Limits

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

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

1

MICRO-K 2

POTASSIUM CHLORIDE SOLN 10%, 20%

1

potassium chloride TBCR 8meq

1

POTASSIUM CHLORIDE TBCR 20meq

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

POTASSIUM CHLORIDE TAB CR 10 MEQ

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

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

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-PF INJ 10% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D



47

Drug Name Drug Tier

Requirements/Limits


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID INJ 20% 1 B/D

plenamine 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

SMOFLIPID 3 B/D

TRAVASOL 3 B/D

TROPHAMINE INJ 6% 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 1

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

ISOLYTE S 3

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

KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

KCL IN NACL INJ .15-0.45 1

KCL/D5W/NACL INJ 0.22%/0.45%

1

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

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

KCL/NACL INJ 0.15%-0.9% 1



48

Drug Name Drug Tier

Requirements/Limits

LACTATED RINGERS VIAFLEX

1

NORMOSOL-M IN D5W 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

pot chloride inj 2meq/ml 1

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

1

POTASSIUM CHLORIDE 0.3%/D

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

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

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

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

3 B/D NM

doxercalciferol (generic of HECTOROL) CAPS .5mcg

1 B/D

doxercalciferol (generic of HECTOROL) SOLN

1 B/D

HECTOROL CAPS 1mcg, 2.5mcg

3 B/D NM

HECTOROL CAPS .5mcg 2 B/D

HECTOROL SOLN 3 B/D

paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg

1 B/D

paricalcitol CAPS 4mcg 1 B/D

PARICALCITOL SOLN 1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

Drug Name Drug Tier

Requirements/Limits

ROCALTROL 2 B/D

ZEMPLAR CAPS 1mcg 2 B/D

ZEMPLAR CAPS 2mcg 3 B/D NM

ZEMPLAR SOLN 3 B/D

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

blephamide OINT 3

BLEPHAMIDE SUSP 3

MAXITROL 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX SUSP 3

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

BLEPH-10 3

CILOXAN OIN 0.3% OP 3

CILOXAN SOL 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

garamycin 3

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) 1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 3



49

Drug Name Drug Tier

Requirements/Limits

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

neosporin solution 3

OCUFLOX 3

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3

sulfacet sod oin 10% op 1

sulfacetamide sodium (ophth) (generic of BLEPH-10)

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

TOBREX SOL 0.3% OP 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

VIROPTIC 2

ZIRGAN 3

ZYMAXID 3

ANTI-INFLAMMATORIES ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

FML LIQUIFILM 3

ILEVRO 3

Drug Name Drug Tier

Requirements/Limits

ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

1

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

1

LOTEMAX 2

MAXIDEX 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine drop 0.05% 1

BEPREVE 3

cromolyn sodium (ophth) 1

ELESTAT 3

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

olopatadine hcl (generic of PATANOL)

1

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

BETAGAN 3

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1



50

Drug Name Drug Tier

Requirements/Limits

COMBIGAN 2

COSOPT 3

COSOPT PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of BETAGAN)

1

LUMIGAN 3

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 2

TRUSOPT 3

XALATAN 3

ZIOPTAN 2

MISCELLANEOUS alcaine 3

CYSTARAN 3 NM LA PA

EYLEA 3 NM PA

LACRISERT 3

LUCENTIS 3 NM PA

naphazoline hcl SOLN 1

PROLENSA 2

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25 2

COMBIVENT RESPIMAT 2

Drug Name Drug Tier

Requirements/Limits

ipratropium-albuterol 1 B/D

STIOLTO RESPIMAT 3

UTIBRON NEOHALER 3

ANTICHOLINERGICS ATROVENT 2

ATROVENT HFA 3

INCRUSE ELLIPTA 3

ipratropium bromide (nasal) 1

ipratropium sol inhal 1 B/D

SEEBRI NEOHALER 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3

TUDORZA PRESSAIR (INSTITUTIONAL PACK)

3

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 3

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 3

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine TBDP 1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN 3

levocetirizine soln 2.5mg/5ml (generic of XYZAL)

1

levocetirizine tab 5 mg (generic of XYZAL)

1

olopatadine hcl (nasal) (generic of PATANASE)

1

PATANASE 3

XYZAL SOLN 3

XYZAL TABS 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1



51

Drug Name Drug Tier

Requirements/Limits

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER 2

BROVANA 3 B/D

FORADIL AEROLIZER 2

levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

levalbuterol hcl (generic of XOPENEX) NEBU .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA 2

PROAIR RESPICLICK 3

PROVENTIL HFA 3

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 3

terbutaline sulfate SOLN 3 NM

terbutaline sulfate TABS 1

VENTOLIN HFA 3

vospire 2

XOPENEX 3 B/D

XOPENEX CONCENTRATE 3 B/D

XOPENEX HFA 3

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3

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

1

SINGULAIR 3

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 3 NM LA PA

CINQAIR 3 NM LA PA

DALIRESP 2

EPINEPHRINE SOAJ 1

Drug Name Drug Tier

Requirements/Limits

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 3 NM PA

GLASSIA 3 NM LA PA

KALYDECO 3 NM PA

NUCALA 3 NM LA PA

OFEV 3 NM PA

ORKAMBI 3 NM PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 3 B/D NM

tyzine .05% 3

XOLAIR 3 NM LA PA

ZEMAIRA 3 NM LA PA

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) (generic of RHINOCORT AQUA)

1

flunisolide (nasal) 1

fluticasone propionate (nasal) 1

mometasone furoate (nasal) (generic of NASONEX)

1

NASONEX 2

OMNARIS 3

QNASL 3

QNASL CHILDRENS 3

RHINOCORT AQUA 3

TRIAMCINOLONE ACETONIDE (NASAL)

1

VERAMYST 3

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ARNUITY ELLIPTA 3

ASMANEX 2

ASMANEX HFA 2

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

PULMICORT INH SUSP 0.5MG/2 ML

3 B/D

PULMICORT INH SUSP 0.25MG/2 ML

3 B/D



52

Drug Name Drug Tier

Requirements/Limits

PULMICORT INH SUSP 1MG/2ML

3 B/D NM

QVAR 2

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 3

DULERA 2

SYMBICORT 3

XANTHINES aminophylline inj 1

elixophyllin 3

theo-24 3

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NM

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA; GEL

1

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

BENZACLIN 2

BENZAMYCIN 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLEOCIN-T 3

clindacin-p (generic of CLEOCIN-T)

1

CLINDAGEL 3

clindamax (generic of CLEOCIN-T)

1

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

Drug Name Drug Tier

Requirements/Limits

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

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

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

1

clindamycin phosphate-tretinoin (generic of ZIANA)

1

DIFFERIN 2

DUAC 3

EPIDUO 2

EPIDUO FORTE 3

ery pad 2% 1

erygel 3

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

EVOCLIN 3

FABIOR 3

KLARON 3

myorisan 1

neuac gel 1.2-5% (generic of DUAC)

1

ONEXTON 3

RETIN-A 3

RETIN-A MICRO 2

RETIN-A MICRO PUMP 2

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA 3

tretinoin (generic of RETIN-A) CREA

1

TRETINOIN GEL .01% 1

tretinoin (generic of ATRALIN) GEL .05%

1

tretinoin (generic of RETIN-A) GEL .025%

1

TRETINOIN MICROSPHERE 1

VELTIN 3



53

Drug Name Drug Tier

Requirements/Limits

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS BACTROBAN CREAM 2

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN 3

gentamicin sulfate (topical) 1

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVADENE 2

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

SULFAMYLON PACK 3 NM

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% (generic of LOPROX)

1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

EXTINA 3

ketoconazole (topical) CREA 1

ketoconazole (topical) (generic of EXTINA) FOAM

1

ketodan aer 2% (generic of EXTINA)

1

LOPROX CREA 3

LOPROX SHAMPOO 3

LUZU 2

MENTAX 3

NAFTIFINE HCL 1% 1

naftifine hcl (generic of NAFTIN) 2%

1

NAFTIN 2

nyamyc 1

Drug Name Drug Tier

Requirements/Limits

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

oxiconazole nitrate cream (generic of OXISTAT)

1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC anusol hc 2

CORTIFOAM 2

DOXEPIN HCL (ANTIPRURITIC)

1

procto-med (generic of ANUSOL-HC)

1

procto-pak 1

proctosol hc 2.5 % (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

3 NM

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 3 NM PA

COSENTYX SENSOREADY PEN

3 NM PA

DOVONEX CRE 0.005% 3

methoxsalen rapid (generic of OXSORALEN ULTRA)

3 NM

8-MOP 3

OXSORALEN ULTRA 3 NM

SORIATANE 3 NM

SORILUX 2

STELARA SOSY 3 NM PA

TALTZ 3 NM LA PA

TAZORAC 2

VECTICAL 3 NM

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

NIZORAL 3



54

Drug Name Drug Tier

Requirements/Limits

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS aclovate 2

ala-cort 1

ala-scalp 3

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon e cream 3

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotriene/betamethasone (generic of TACLONEX)

3 NM

CAPEX 2

clobetasol e cream 0.05% (generic of TEMOVATE E)

1

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

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LIQD; LOTN; SHAM

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX 3 NM

CLOCORTOLONE PIVALATE 1

clodan sha 0.05% (generic of CLOBEX)

1

CLODERM PUMP 2

Drug Name Drug Tier

Requirements/Limits

CORDRAN TAPE 3

cormax (generic of TEMOVATE)

1

CUTIVATE CREA 3

CUTIVATE LOTN 3 NM

DERMA-SMOOTHE/FS BODY

3

DERMA-SMOOTHE/FS SCALP

3

DERMATOP 3

DERMATOP CREAM 0.1% 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN

1

desonide OINT 1

DESOWEN CREA 2

desowen LOTN 2

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

DIPROLENE LOTN 3

DIPROLENE OINT 2

DIPROLENE AF 3

ELOCON CREA; LOTN 3

ELOCON OINT 2

ENSTILAR 3 NM

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

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

1

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

1



55

Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of VANOS) CREA .1%

3 NM

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide-e 0.05% cream 1

flurandrenolide (generic of CORDRAN) CREA

1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN

1

fluticasone propionate OINT 1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOCOID CREA 3

LOCOID LOTN; OINT; SOLN

2

LOCOID LIPOCREAM 3 NM

lokara (generic of DESOWEN)

1

mometasone furoate (generic of ELOCON) CREA; OINT; SOLN

1

OLUX 3 NM

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

Drug Name Drug Tier

Requirements/Limits

psorcon 3

SERNIVO 3 NM

SYNALAR CREA; OINT 3

SYNALAR SOLN 2

TACLONEX 3 NM

TEMOVATE CREAM 2

TEMOVATE E CREAM 2

TEMOVATE GEL 2

TEMOVATE OIN 2

TEMOVATE SOLN 3

texacort 2

topicort CREA 3

topicort GEL 2

TOPICORT OINT .05% 2

topicort OINT .25% 2

TOPICORT SPRAY 0.25% 3

triamcinolone acetonide (topical) (generic of KENALOG) AERS

1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

trianex 3

triderm 1

ULTRAVATE CREA; OINT 2

ULTRAVATE LOTN 3

VANOS 3 NM

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine 1 B/D

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 4% 3

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

1

ALDARA 3 NM

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

1



56

Drug Name Drug Tier

Requirements/Limits

CARAC 3 NM

CONDYLOX 2

DENAVIR 3 NM

diclofenac sodium (actinic keratoses) (generic of SOLARAZE)

3 NM

diclofenac sodium (topical) 1% gel (generic of VOLTAREN)

1

diclofenac sodium (topical) 1.5% soln

1

DOXYCYCLINE (ROSACEA) 1

EFUDEX 3

ELIDEL 2

FINACEA AER 15% 2

FINACEA GEL 15% 2

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

1

FLUOROURACIL (TOPICAL) CREA .5%

3 NM

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

LAC-HYDRIN 2

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (topical) (generic of METROCREAM) CREA

1

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

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 3 NM

ORACEA 2

PANRETIN 3 NM

PENNSAID SOL 2% 3

PICATO 3 NM

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 3

Drug Name Drug Tier

Requirements/Limits

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOLARAZE 3 NM

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1

TARGRETIN GEL 3 NM PA

TOLAK 3

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

XERESE 3 NM

ZOVIRAX CREA; OINT 3 NM

ZYCLARA 3 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES ELIMITE 3

EURAX 3

malathion (generic of OVIDE) 1

ovide 2

permethrin (generic of ELIMITE)

1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 3 NM

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

1

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

1

clotrimazole TROC 1

EVOXAC 2

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

ORAVIG 3 NM

paroex sol 0.12% (generic of PERIDEX)

1



57

Drug Name Drug Tier

Requirements/Limits

periogard soln 0.12% (generic of PERIDEX)

1

PILOCARPINE HCL (ORAL) 5mg

1

pilocarpine hcl (oral) (generic of SALAGEN) 7.5mg

1

SALAGEN 2

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

DERMOTIC 3

floxin otic 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

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

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) (generic of FLOXIN OTIC)

1

OTOVEL 3


58

Index 8 8-MOP .............................. 53 A abacavir sulfate ...................7 abacavir sulfate-lamivudine-zidovudine ..........................................8 ABELCET............................6 ABILIFY

see aripiprazole tabs ..... 26 ABILIFY DISCMELT TAB 10MG ................................ 26 ABILIFY MAINTENA ......... 26 ABILIFY TABS .................. 26 ABRAXANE ...................... 13 ABSORICA ....................... 52 ABSTRAL............................2 acamprosate calcium ........ 30 ACANYA ........................... 52 acarbose ........................... 31 ACCOLATE ....................... 51

see zafirlukast ............... 51 ACCUPRIL ........................ 15

see quinapril hcl ............ 16 ACCURETIC ..................... 15

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

acebutolol hcl .................... 18 ACEON

see perindopril erbumine ...................................... 16

acetaminophen w/ codeine 1, 2 acetaminophen-caff-dihydrocod ........................................2 acetasol hc ........................ 57 acetazolamide ................... 20 acetazolamide sodium ...... 20 acetic acid ......................... 56 acetic acid (otic) ................ 57 acetic acid sol/hc ............... 57 acetic acid-aluminum acetate .......................................... 57 acetylcysteine ................... 51 ACIPHEX .......................... 41

see rabeprazole sodium 42

ACIPHEX SPR CAP 10MG .......................................... 41 ACIPHEX SPR CAP 5MG . 41 acitretin ............................. 53 aclovate ............................ 54 ACLOVATE

see alclometasone dipropionate .................. 54

ACTEMRA ........................ 44 ACTHIB ............................. 45 ACTIGALL ........................ 41

see ursodiol ................... 41 ACTIMMUNE .................... 44 ACTIQ ................................. 2

see fentanyl citrate .......... 2 ACTONEL ......................... 32

see risedronate sodium . 33 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 32

ACTOPLUS MET TAB 15-500MG ......................... 31 ACTOPLUS MET TAB 15-850MG ......................... 31 ACTOPLUS MET XR 15-1000MG ....................... 31 ACTOPLUS MET XR 30-1000MG ....................... 31 ACTOS ............................. 31

see pioglitazone hcl ....... 32 ACULAR ........................... 49

see ketorolac tromethamine (ophth) .... 49

ACULAR LS ...................... 49 see ketorolac tromethamine (ophth) .... 49

ACUVAIL .......................... 49 acyclovir .............................. 8 acyclovir sodium ................. 8 acyclovir topical ................ 55 ACZONE ........................... 52 ADACEL ........................... 45 ADAGEN ........................... 36 ADALAT CC ...................... 19

see afeditab cr ............... 19 see nifedipine ................ 19

adapalene ......................... 52

ADCIRCA ......................... 21 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg ........ 28 see amphetamine-dextroamphetamine tab 12.5 mg ..... 28 see amphetamine-dextroamphetamine tab 15 mg ........ 28 see amphetamine-dextroamphetamine tab 20 mg ........ 28 see amphetamine-dextroamphetamine tab 30 mg ........ 28 see amphetamine-dextroamphetamine tab 5 mg .......... 28 see amphetamine-dextroamphetamine tab 7.5 mg ....... 28

adderall tab 10mg ............. 27 adderall tab 12.5mg .......... 27 adderall tab 15mg ............. 27 adderall tab 20mg ............. 27 adderall tab 30mg ............. 27 adderall tab 5mg ............... 27 adderall tab 7.5mg ............ 27 ADDERALL XR

see amphetamine cap 10mg er ......................... 27 see amphetamine cap 15mg er ......................... 27 see amphetamine cap 20mg er ......................... 28 see amphetamine cap 25mg er ......................... 28 see amphetamine cap 30mg er ......................... 28 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 28

ADDERALL XR CAP 10MG.......................................... 27


59

ADDERALL XR CAP 15MG .......................................... 27 ADDERALL XR CAP 20MG .......................................... 27 ADDERALL XR CAP 25MG .......................................... 27 ADDERALL XR CAP 30MG .......................................... 27 ADDERALL XR CAP 5MG 27 adefovir dipivoxil .................8 ADEMPAS ........................ 21 adoxa ................................ 11 ADOXA

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

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

ADRENACLICK ................ 51 adrucil ............................... 12 ADVAIR DISKUS .............. 52 ADVAIR HFA .................... 52 AEROSPAN ...................... 51 afeditab cr ......................... 19 AFINITOR ......................... 14 AFINITOR DISPERZ ......... 14 AFREZZA.......................... 38 AGGRENOX ..................... 44 AGRYLIN .......................... 43

see anagrelide hcl ......... 43 a-hydrocort ........................ 37 AKYNZEO ......................... 39 ala-cort .............................. 54 ala-scalp............................ 54 ALBENZA............................5 albuterol sulfate ................. 50 albuterol sulfate er ............ 51 alcaine .............................. 50 ALCAINE

see proparacaine hcl ..... 50 alclometasone dipropionate .......................................... 54 ALCOHOL SWABS ........... 31 ALDACTAZIDE ................. 20

see spironolactone & hydrochlorothiazide ....... 20

ALDACTAZIDE TAB 50/50 .......................................... 20

ALDACTONE .................... 16 see spironolactone ........ 16

ALDARA ........................... 55 see imiquimod ............... 56

ALDURAZYME ................. 36 ALECENSA ....................... 14 alendronate sodium .......... 32 alfuzosin hcl ...................... 42 ALIMTA ............................. 12 ALINIA ................................ 5 ALKERAN ......................... 12

see melphalan hcl ......... 12 allopurinol tab ..................... 1 almotriptan malate ............ 28 ALOCRIL .......................... 49 ALOMIDE .......................... 49 ALOPRIM ............................ 1 ALORA .............................. 36 alosetron hcl ..................... 41 ALOXI ............................... 39 ALPHAGAN P 0.1% .......... 49 ALPHAGAN P 0.15% ........ 49 alprazolam ........................ 21 ALREX .............................. 49 ALTACE ............................ 15

see ramipril .................... 16 altavera ............................. 33 ALTOPREV ....................... 17 ALVESCO ......................... 51 amantadine hcl ................. 25 AMARYL ........................... 31

see glimepiride .............. 31 AMBIEN ............................ 28

see zolpidem tartrate ..... 28 AMBISOME ........................ 6 amcinonide ....................... 54 AMERGE .......................... 28

see naratriptan hcl ......... 29 amethia 91 day ................. 33 amethyst 28 day ............... 33 amifostine crystalline......... 15 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 20 amiloride hcl ...................... 20 aminophylline inj ............... 52 AMINOSYN ....................... 46 AMINOSYN

7%/ELECTROLYTES ....... 46 AMINOSYN II ................... 46 AMINOSYN II 8.5%/ELECTROL.............. 46 AMINOSYN INJ 8.5/LYTE 46 AMINOSYN M .................. 46 AMINOSYN-HBC .............. 46 AMINOSYN-PF 7% ........... 46 AMINOSYN-PF INJ 10% .. 46 AMINOSYN-RF................. 46 amiodarone hcl ................. 17 amiodarone inj 50mg/ml ... 17 AMITIZA ........................... 41 amitriptyline hcl ................. 24 amlodipine besylate .......... 19 amlodipine besylate/atorv . 19 amlodipine besylate-benazepril hcl ..... 15 amlodipine besylate-valsartan tab 10-160 mg ........................ 16 amlodipine besylate-valsartan tab 10-320 mg ........................ 16 amlodipine besylate-valsartan tab 5-160 mg ..................................... 16 amlodipine besylate-valsartan tab 5-320 mg ..................................... 16 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 16 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 16 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 16 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 16 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 16 ammonium chloride .......... 46 ammonium lactate ............ 55 amnesteem ....................... 52 amoxapine ........................ 24


60

amoxicillin ......................... 10 amoxicillin & pot clavulanate .................................... 10, 11 amoxicillin-clarithromycin w/ lansoprazole ...................... 41 amphetamine cap 10mg er .......................................... 27 amphetamine cap 15mg er .......................................... 27 amphetamine cap 20mg er .......................................... 28 amphetamine cap 25mg er .......................................... 28 amphetamine cap 30mg er .......................................... 28 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 28 amphetamine-dextroamphetamine tab 10 mg ............... 28 amphetamine-dextroamphetamine tab 12.5 mg ............ 28 amphetamine-dextroamphetamine tab 15 mg ............... 28 amphetamine-dextroamphetamine tab 20 mg ............... 28 amphetamine-dextroamphetamine tab 30 mg ............... 28 amphetamine-dextroamphetamine tab 5 mg ................. 28 amphetamine-dextroamphetamine tab 7.5 mg .............. 28 amphotericin b ....................6 ampicillin & sulbactam sodium .............................. 11 ampicillin cap 250mg ........ 11 ampicillin cap 500 mg ....... 11 ampicillin inj ....................... 11 ampicillin sodium ............... 11 ampicillin susp ................... 11 AMPYRA ........................... 29 ANAFRANIL ...................... 24

see clomipramine hcl ..... 24 anagrelide hcl .................... 43 ANAPROX DS ....................1

see naproxen sodium ......1 anastrozole ....................... 13 ANCOBON ..........................6

see flucytosine .................7

ANDRODERM .................. 30 ANDROGEL ...................... 30 ANDROGEL 1% ............... 30 ANDROGEL 1.62% .......... 30 ANORO ELLIPT AER 62.5-25 .............................. 50 antabuse ........................... 30 ANTABUSE

see disulfiram ................ 30 ANTARA ........................... 17 anusol hc .......................... 53 ANUSOL-HC

see procto-med ............. 53 see proctosol hc 2.5 % .. 53 see proctozone hc ......... 53

apexicon e cream ............. 54 APIDRA ............................ 31 APIDRA SOLOSTAR ........ 31 APLENZIN ........................ 24 APOKYN ........................... 25 apri 28 day ........................ 33 APRISO ............................ 40 APTENSIO XR .................. 28 APTIOM ............................ 22 APTIVUS ............................ 7 ARALAST NP ................... 51 ARALEN

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

aranelle 28 ........................ 33 ARANESP ALBUMIN FREE .......................................... 43 ARAVA .............................. 44

see leflunomide ............. 44 ARCALYST ....................... 44 ARCAPTA NEOHALER .... 51 ARICEPT .......................... 24

see donepezil tab hcl 23mg ............................. 24 see donepezil tabs 10mg ...................................... 24 see donepezil tabs 5mg 24

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

aripiprazole ....................... 26 aripiprazole oral solution 1 mg/ml ................................ 26 aripiprazole tabs ............... 26

ARISTADA ........................ 26 ARIXTRA .......................... 43

see fondaparinux sodium ...................................... 43

armodafinil ........................ 30 ARMODAFINIL ................. 30 ARNUITY ELLIPTA ........... 51 AROMASIN ...................... 13

see exemestane ............ 13 ARRANON ........................ 12 ARTHROTEC 50 ................ 1

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

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

ARZERRA ........................ 13 ASACOL HD ..................... 40 ashlyna 91 day ................. 33 ASMANEX ........................ 51 ASMANEX HFA ................ 51 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG.................. 2 ASPIRIN-DIPYRIDAMOLE.......................................... 44 ASTAGRAF XL ................. 45 ASTEPRO ........................ 50

see azelastine spr 0.15% ...................................... 50

ATACAND ........................ 16 see candesartan cilexetil ...................................... 17

ATACAND HCT ................ 16 see candesartan cilexetil-hydrochlorothiazide .................................... 16

ATELVIA ........................... 32 see risedronate sodium . 33

atenolol ............................. 18 atenolol & chlorthalidone .. 18 ATGAM ............................. 45 ATIVAN ............................. 22

see lorazepam............... 22 atorvastatin calcium .......... 17 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ........................ 7


61

atovaquone-proguanil hcl tab 62.5-25 mg ..........................7 ATRALIN ........................... 52

see tretinoin ................... 52 ATRIPLA .............................8 ATROPINE SULFATE ...... 40 ATROVENT ...................... 50 ATROVENT HFA .............. 50 AUBAGIO.......................... 29 aubra 28 day ..................... 33 AUGMENTIN .................... 11

see amoxicillin & pot clavulanate .................... 11

AUGMENTIN ES-600 ....... 11 see amoxicillin & pot clavulanate .................... 11

AUGMENTIN XR .............. 11 see amoxicillin & pot clavulanate .................... 11

AURYXIA .......................... 38 AVALIDE ........................... 16

see irbesartan-hydrochlorothiazide ................................ 16

AVAPRO ........................... 16 see irbesartan ................ 17

AVASTIN........................... 13 AVC .................................. 42 AVEED .............................. 30 AVELOX............................ 10

see moxifloxacin hcl ...... 10 AVELOX ABC PACK ........ 10 aviane 28 .......................... 33 AVITA ............................... 52 AVODART ......................... 42

see dutasteride .............. 42 AVONEX ........................... 29 AVONEX PEN ................... 29 AVYCAZ..............................9 AXERT .............................. 28

see almotriptan malate .. 28 AXIRON ............................ 30 aygestin............................. 38 AYGESTIN

see norethindrone acetate ...................................... 38

azacitidine ......................... 12 AZACTAM ...........................5

see aztreonam ................ 5 AZACTAM/DEX INJ 1GM ... 5 AZACTAM/DEX INJ 2GM ... 5 azasan .............................. 45 AZASITE ........................... 48 azathioprine ...................... 45 azelastine drop 0.05% ...... 49 azelastine spr 0.1% .......... 50 azelastine spr 0.15%......... 50 AZELEX ............................ 52 AZILECT ........................... 25 azithromycin ...................... 10 AZITHROMYCIN .............. 10 AZOPT .............................. 49 AZOR ................................ 16 aztreonam ........................... 5 AZULFIDINE ..................... 40

see sulfasalazine ir ........ 40 AZULFIDINE EN-TABS .... 40

see sulfasalazine dr....... 40 B bacitracin (ophthalmic) ...... 48 bacitracin-polymyxin b (ophth) .............................. 48 bacitracin-poly-neomycin-hc .......................................... 48 baclofen ............................ 30 BACTOCILL INJ DEX 1GM .......................................... 11 BACTOCILL INJ DEX 2GM .......................................... 11 BACTRIM ............................ 5

see sulfamethoxazole-trimethop ...................................... 6

BACTRIM DS ...................... 5 see sulfamethoxazole-trimethop ...................................... 6

BACTROBAN see mupirocin ................ 53 see mupirocin calcium (topical) ......................... 53

BACTROBAN CREAM ...... 53 BACTROBAN NASAL ....... 53 balsalazide disodium......... 40 balziva 28 day ................... 33 BANZEL SUS 40MG/ML ... 22

BANZEL TAB 200MG ....... 22 BANZEL TAB 400MG ....... 22 BARACLUDE ...................... 8

see entecavir ................... 8 BCG VACCINE ................. 45 BECONASE AQ................ 51 bekyree 28 day ................. 33 BELBUCA ........................... 2 BELEODAQ ...................... 13 benazepril & hydrochlorothiazide ........... 15 benazepril hcl ................... 15 BENDEKA ........................ 12 BENICAR .......................... 16 BENICAR HCT ................. 16 BENLYSTA ....................... 45 BENTYL ............................ 40

see dicyclomine hcl ....... 40 BENZACLIN ..................... 52

see clindamycin phosphate-benzoyl peroxide ........................ 52

BENZAMYCIN .................. 52 see benzoyl peroxide-erythromycin ... 52

benzoyl peroxide-erythromycin ...... 52 benztropine mesylate ........ 25 BENZTROPINE MESYLATE.......................................... 25 BEPREVE ......................... 49 BERINERT ....................... 43 BESIVANCE ..................... 48 BETAGAN ........................ 49

see levobunolol hcl ........ 50 betamethasone dipropionate (topical) ............................. 54 betamethasone dipropionate augmented ........................ 54 betamethasone valerate ... 54 BETAPACE ...................... 17

see sorine ..................... 17 see sotalol hcl ............... 17

BETAPACE AF ................. 17 see sotalol hcl (afib/afl) . 17

BETASERON ................... 29 betaxolol hcl ...................... 18 betaxolol hcl (ophth) ......... 49


62

bethanechol chloride ......... 42 BETHKIS.............................5 BETIMOL .......................... 49 BETOPTIC-S .................... 49 bexarotene ........................ 14 BEXSERO......................... 45 BEYAZ .............................. 33 BIAXIN .............................. 10

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

see clarithromycin ......... 10 bicalutamide ...................... 13 BICILLIN C-R .................... 11 BICILLIN L-A ..................... 11 BICNU ............................... 12 BIDIL ................................. 21 BILTRICIDE ........................5 BINOSTO .......................... 32 bisoprolol & hydrochlorothiazide ........... 18 bisoprolol fumarate ........... 18 BIVIGAM ........................... 44 bleomycin sulfate .............. 12 BLEPH-10 ......................... 48

see sulfacetamide sodium (ophth) ........................... 49

blephamide ....................... 48 BLEPHAMIDE ................... 48 blisovi 21 fe 1.5/30 28 day pack .................................. 33 blisovi 21 fe 1/20 28 day pack .................................. 33 blisovi 24 fe 1/20 28 day ... 33 BONIVA ............................ 32

see ibandronate sodium 33 see ibandronate tab 150mg ........................... 33

BOOSTRIX ....................... 45 BOSULIF........................... 14 BOTOX INJ 100UNIT ........ 30 BOTOX INJ 200UNIT ........ 30 BREO ELLIPTA ................ 52 BREVICON-28 .................. 33

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

briellyn 28 day ................... 33

BRILINTA .......................... 44 BRIMONIDINE SOL 0.15% .......................................... 49 brimonidine sol 0.2%......... 49 BRINTELLIX ..................... 24 BRISDELLE ...................... 29 BRIVIACT INJ ................... 22 BRIVIACT SOLN 10MG/ML .......................................... 22 BRIVIACT TABS ............... 22 bromfenac sodium (ophth) 49 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 49 bromocriptine mesylate ..... 25 BROVANA ........................ 51 budesonide ....................... 40 budesonide (inhalation) ..... 51 budesonide (nasal) ........... 51 bumetanide ....................... 20 BUMEX

see bumetanide ............. 20 BUNAVAIL MIS 2.1-0.3MG .......................................... 30 BUNAVAIL MIS 4.2-0.7MG .......................................... 30 BUNAVAIL MIS 6.3-1MG .. 30 BUPHENYL ...................... 36

see sodium phenylbutyrate ...................................... 36

buprenorphine hcl ............. 30 buprenorphine hcl-naloxone hcl sl.................................. 30 buproban tab (smoking deterrent) .......................... 30 bupropion hcl .................... 24 bupropion hcl (smoking deterrent) .......................... 30 buspirone hcl .................... 22 BUSULFEX ....................... 12 butorphanol nasal spray ...... 2 butorphanol tartrate ............ 2 BUTRANS ........................... 2 BYDUREON ..................... 31 BYDUREON PEN ............. 31 BYETTA ............................ 31 BYSTOLIC ........................ 18 C cabergoline ....................... 38

CABOMETYX ................... 14 CADUET ........................... 19

see amlodipine besylate/atorv ................ 19

cafergot tab 1-100mg ........ 28 CALAN .............................. 19

see verapamil hcl .......... 20 CALAN SR ........................ 19

see verapamil hcl .......... 20 calcipotriene ..................... 53 calcipotriene/betamethasone.......................................... 54 calcitonin (salmon) nasal spray ................................. 38 calcitrene oin 0.005% ....... 53 calcitriol ............................. 48 CALCITRIOL .................... 53 calcium acetate (phosphate binder) .............................. 38 camila 28 day ................... 33 CAMPTOSAR ................... 15

see irinotecan inj 100/5ml ...................................... 15 see irinotecan inj 40mg/2ml ...................... 15

CAMRESE LO TAB .......... 33 CANASA ........................... 40 CANCIDAS ......................... 6 candesartan cilexetil ......... 17 candesartan cilexetil-hydrochlorothiazide.......................................... 16 CANTIL ............................. 40 CAPASTAT SULFATE ........ 8 CAPEX ............................. 54 capital

and codeine .................... 2 CAPRELSA ...................... 14 captopril ............................ 15 captopril & hydrochlorothiazide ........... 15 CARAC ............................. 56 CARAFATE ...................... 41

see sucralfate ................ 41 CARBAGLU ...................... 36 carbamazepine ................. 22 CARBATROL .................... 22

see carbamazepine ....... 22


63

carbidopa .......................... 25 CARBIDOPA/LEVODOPA/ENTACAPONE .............. 25, 26 carbidopa-levodopa .......... 25 carboplatin ........................ 15 CARDIZEM ....................... 19

see diltiazem hcl ............ 19 CARDIZEM CD ................. 19

see cartia xt ................... 19 see diltiazem hcl coated beads............................. 19

CARDIZEM LA .................. 19 see matzim la ................ 19

CARDURA ........................ 16 see doxazosin mesylate 16

CARDURA XL ................... 42 CARIMUNE NANOFILTERED .............. 44 CARNITOR ....................... 36

see levocarnitine (metabolic modifiers) ..... 36

carteolol hcl (ophth) .......... 49 cartia xt ............................. 19 carvedilol ........................... 19 CASODEX ........................ 13

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

see clonidine hcl ............ 21 CATAPRES TAB ............... 21 CATAPRES-TTS DIS 0.1/24HR ........................... 21 CATAPRES-TTS DIS 0.2/24HR ........................... 21 CATAPRES-TTS DIS 0.3/24HR ........................... 21 CATAPRES-TTS-1

see clonidine hcl ............ 21 CATAPRES-TTS-2

see clonidine hcl ............ 21 CATAPRES-TTS-3

see clonidine hcl ............ 21 CAYSTON ...........................5 caziant 28 day ................... 33 CEDAX ...............................9 cefaclor ...............................9 cefaclor er tab 500mg .........9 cefadroxil.............................9 cefazolin in dextrose

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

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

see cefuroxime axetil ....... 9 ceftriaxone sodium .............. 9 cefuroxime axetil ................. 9 cefuroxime sodium ............ 10 CELEBREX

see celecoxib .................. 1 CELEBREX CAP 100MG .... 1 CELEBREX CAP 200MG .... 1 CELEBREX CAP 400MG .... 1 CELEBREX CAP 50MG ...... 1 celecoxib ............................. 1 CELEXA ............................ 24

see citalopram hydrobromide ................ 24

CELLCEPT see mycophenolate mofetil ...................................... 45

CELLCEPT CAP ............... 45 CELLCEPT INTRAVENOUS .......................................... 45 CELLCEPT SUSP ............ 45

CELLCEPT TAB ............... 45 CELONTIN ....................... 22 CENTANY ........................ 53 cephalexin ........................ 10 CERDELGA ...................... 36 CEREZYME ...................... 36 CERVARIX ....................... 45 CESAMET ........................ 39 cetirizine syrup .................. 50 cevimeline hcl ................... 56 CHANTIX .......................... 30 CHANTIX CONTINUING MONTH ............................ 30 CHANTIX STARTER PACK.......................................... 30 CHEMET .......................... 33 chlorhexidine gluconate (mouth-throat) ................... 56 chloroquine phosphate ....... 7 chlorothiazide tabs ............ 20 chlorpromazine hcl ............ 26 chlorpromazine inj............. 26 chlorthalidone ................... 20 CHOLBAM ........................ 41 cholestyramine ................. 18 cholestyramine light .......... 18 choline fenofibrate ............ 18 CHORIONIC GONADOTROPIN ............ 38 ciclopirox ........................... 53 ciclopirox cre 0.77% .......... 53 ciclopirox shampoo 1% ..... 53 ciclopirox sus 0.77% ......... 53 cidofovir .............................. 8 cilostazol ........................... 43 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 48

CILOXAN OIN 0.3% OP ... 48 CILOXAN SOL 0.3% OP .. 48 cimetidine ......................... 40 cimetidine sol 300/5ml ...... 40 CIMZIA ............................. 44 CINQAIR ........................... 51 CINRYZE .......................... 43 CIPRO

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


64

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

see ciprofloxacin in d5w 10 CIPRO SUSP .................... 10 CIPRO TABS .................... 10 CIPRO XR ......................... 10

see ciprofloxacin er ....... 10 CIPRODEX ....................... 57 ciprofloxacin ...................... 10 ciprofloxacin er .................. 10 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 48 ciprofloxacin in d5w ........... 10 ciprofloxacin inj 200mg/20ml .......................................... 10 ciprofloxacin inj 400mg/40ml .......................................... 10 cisplatin ............................. 15 citalopram hydrobromide... 24 cladribine........................... 12 claforan ............................. 10 CLAFORAN ...................... 10

see cefotaxime sodium ....9 CLAFORAN/D5W ............. 10 claravis .............................. 52 CLARINEX ........................ 50

see desloratadine .......... 50 CLARINEX-D TAB 2.5-120 .......................................... 50 clarithromycin .................... 10 cleocin .................................5 CLEOCIN .......................... 42

see clindamycin cre 2% vag ................................ 43 see clindamycin hcl .........5

CLEOCIN CAP 150MG .......5 CLEOCIN CAP 300MG .......5 CLEOCIN CAP 75MG .........5 CLEOCIN IN D5W ..............5

see clindamycin phosphate in d5w ............6

CLEOCIN INJ ......................5 CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ...................5

cleocin phosphate ...............5 CLEOCIN PHOSPHATE .....5

see clindamycin phosphate ....................... 6

CLEOCIN VAG SUPP 100MG .............................. 42 CLEOCIN-T ...................... 52

see clindacin-p .............. 52 see clindamax ............... 52 see clindamycin phosphate (topical) ........ 52

CLIMARA .......................... 36 see estradiol .................. 36

clindacin-p ......................... 52 CLINDAGEL ..................... 52 clindamax .......................... 52 clindamycin cre 2% vag .... 43 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 6 clindamycin phosphate (topical) ............................. 52 clindamycin phosphate in d5w ..................................... 6 clindamycin phosphate-benzoyl peroxide .......................................... 52 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 52 clindamycin phosphate-tretinoin ........... 52 CLINDESSE ..................... 43 CLINIMIX 2.75%/DEXTROSE 5% ..... 46 CLINIMIX 4.25%/DEXTROSE 10% ... 46 CLINIMIX 4.25%/DEXTROSE 20% ... 47 CLINIMIX 4.25%/DEXTROSE 25% ... 47 CLINIMIX 4.25%/DEXTROSE 5% ..... 46 CLINIMIX 5%/DEXTROSE 15%................................... 47 CLINIMIX 5%/DEXTROSE 20%................................... 47 CLINIMIX 5%/DEXTROSE 25%................................... 47

CLINIMIX E 2.75%/DEXTROSE 10% ... 47 CLINIMIX E 2.75%/DEXTROSE 5% ..... 47 CLINIMIX E 4.25%/D10 .... 47 CLINIMIX E 4.25%/DEXTROSE 25% ... 47 CLINIMIX E 4.25%/DEXTROSE 5% ..... 47 CLINIMIX E 5%/DEXTROSE 15% .................................. 47 CLINIMIX E 5%/DEXTROSE 20% .................................. 47 CLINIMIX E 5%/DEXTROSE 25% .................................. 47 clinisol 15 .......................... 47 clobetasol e cream 0.05% 54 clobetasol propionate ........ 54 clobetasol propionate emulsion ........................... 54 CLOBEX ........................... 54

see clobetasol propionate ...................................... 54 see clodan sha 0.05% ... 54

CLOCORTOLONE PIVALATE ........................ 54 clodan sha 0.05% ............. 54 CLODERM PUMP ............ 54 CLOLAR ........................... 12 clomipramine hcl ............... 24 clonazepam ...................... 22 clonidine hcl ...................... 21 clopidogrel bisulfate .......... 44 clorazepate dipotassium ... 22 clorpres ............................. 21 clotrimazole ...................... 56 clotrimazole (topical) ......... 53 clozapine .......................... 26 CLOZAPINE ODT ............. 26 CLOZARIL ........................ 26

see clozapine ................ 26 COARTEM .......................... 7 codeine

and capital ....................... 2 CODEINE SULFATE .......... 2 COGENTIN ....................... 26 COLAZAL ......................... 40

see balsalazide disodium


65

...................................... 40 colchicine w/ probenecid .....1 COLCRYS ...........................1 COLESTID ........................ 18

see colestipol hcl ........... 18 colestipol hcl ..................... 18 colistimethate sodium .........6 colocort ............................. 40 COLY-MYCIN M .................6

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

COLY-MYCIN S ................ 57 COLYTE-FLAVOR PACKS .......................................... 40

see gavilyte-c ................ 41 COMBIGAN ...................... 50 COMBIVENT RESPIMAT . 50 COMBIVIR ..........................8

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

COMETRIQ ....................... 14 COMPLERA ........................8 compro supp ..................... 39 COMTAN .......................... 26 COMVAX .......................... 45 CONCERTA ...................... 28 CONDYLOX ...................... 56

see podofilox ................. 56 constulose ......................... 40 CONZIP ..............................2 COPAXONE

see glatopa .................... 29 COPAXONE INJ 40MG/ML .......................................... 29 COPAXONE KIT 20MG/ML .......................................... 29 COPEGUS ..........................8

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

CORDARONE see amiodarone hcl ....... 17 see pacerone ................. 17

CORDRAN ........................ 54 see flurandrenolide ........ 55

COREG ............................. 19 see carvedilol ................ 19

COREG CR ....................... 19

CORGARD ....................... 19 see nadolol .................... 19

CORLANOR ..................... 21 cormax .............................. 54 CORTEF ........................... 37

see hydrocortisone ........ 37 CORTENEMA ................... 40

see colocort ................... 40 CORTIFOAM .................... 53 cortisone acetate .............. 37 CORTISPORIN ................. 53

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

CORTISPORIN-TC ........... 57 CORZIDE .......................... 18

see nadolol & bendroflumethiazide ...... 18

COSENTYX ...................... 53 COSENTYX SENSOREADY PEN .................................. 53 COSMEGEN ..................... 12 COSOPT ........................... 50

see dorzolamide hcl-timolol maleate ........ 50

COSOPT PF ..................... 50 COTELLIC ........................ 14 COUMADIN ...................... 43

see jantoven .................. 43 see warfarin sodium ...... 43

COZAAR ........................... 17 see losartan potassium . 17

CREON ............................. 41 CRESEMBA ........................ 6 CRESTOR ........................ 17

see rosuvastatin calcium ...................................... 17

CRINONE ......................... 38 CRIXIVAN ........................... 7 cromolyn sodium ............... 51 cromolyn sodium (mastocytosis) ................... 41 cromolyn sodium (ophth) .. 49 cryselle 28 ......................... 33 CUBICIN ............................. 6

see daptomycin ............... 6 CUTIVATE ........................ 54

see fluticasone propionate

...................................... 55 CUVPOSA ........................ 40 cyclafem 1/35 28 day ........ 33 cyclafem 7/7/7 28 day ....... 33 CYCLESSA ...................... 33

see caziant 28 day ........ 33 see velivet 28 day ......... 36

cyclobenzaprine hcl .......... 30 cyclophosphamide ............ 12 CYCLOPHOSPHAMIDE ... 12 cycloserine .......................... 8 cyclosporine ...................... 45 cyclosporine modified (for microemulsion) ................. 45 CYKLOKAPRON .............. 43

see tranexamic acid ...... 44 CYMBALTA ...................... 24

see duloxetine hcl ......... 24 CYRAMZA ........................ 13 cyred tab ........................... 33 CYSTADANE .................... 36 CYSTAGON ..................... 36 CYSTARAN ...................... 50 cytarabine inj .................... 12 CYTOMEL ........................ 39

see liothyronine sodium 39 CYTOTEC ........................ 41

see misoprostol ............. 41 CYTOVENE ........................ 8

see ganciclovir inj 500mg 9 D D.H.E. 45 .......................... 28

see dihydroergotamine mesylate ........................ 28

dacarbazine ...................... 12 DACOGEN ....................... 12

see decitabine ............... 12 DAKLINZA .......................... 8 DALIRESP ........................ 51 DALVANCE ........................ 6 danazol ............................. 36 DANTRIUM ....................... 30

see dantrolene sodium .. 30 dantrolene sodium ............ 30 dapsone .............................. 6 DAPTACEL ....................... 45 daptomycin ......................... 6 DARAPRIM ......................... 6


66

DARIFENACIN HYDROBROMIDE ............ 42 DARZALEX ....................... 13 daunorubicin hcl ................ 12 DAYPRO .............................1

see oxaprozin ..................1 DAYTRANA ...................... 28 DDAVP ............................. 39

see desmopressin acetate ...................................... 39 see desmopressin acetate inj ................................... 39 see desmopressin acetate spray ............................. 39

deblitane 28 day ................ 33 decitabine.......................... 12 DELESTROGEN ............... 36

see estradiol valerate .... 36 delyla 28 day ..................... 33 DELZICOL ........................ 40 DEMADEX

see torsemide tabs ........ 20 DEMADEX TAB 10MG ..... 20 DEMADEX TAB 20MG ..... 20 DEMADEX TAB 5MG ....... 20 demeclocycline hcl ............ 11 DEMSER........................... 21 DENAVIR .......................... 56 DEPACON ........................ 22

see valproate sodium .... 23 DEPAKENE ...................... 22

see valproate sodium .... 23 see valproic acid ............ 23

DEPAKOTE ...................... 22 see divalproex sodium ... 22

DEPAKOTE ER ................ 22 see divalproex sodium ... 22

DEPAKOTE SPRINKLES . 22 see divalproex sodium ... 22

DEPEN TITRATABS ......... 33 depo-estradiol ................... 36 DEPO-MEDROL

see methylpr ace inj 40mg/ml ......................... 37 see methylpr ace inj 80mg/ml ......................... 37

DEPO-MEDROL INJ 20MG/ML .......................... 37

DEPO-MEDROL INJ 40MG/ML .......................... 37 DEPO-MEDROL INJ 80MG/ML .......................... 37 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 34

DEPO-PROVERA CONTRACEPTIVE ........... 33 DEPO-PROVERA INJ 400/ML .............................. 13 DEPO-SUBQ PROVERA 104 .................................... 33 depo-testosterone ............. 30 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 31

DERMA-SMOOTHE/FS BODY ................................ 54

see fluocinolone acetonide ...................................... 54

DERMA-SMOOTHE/FS SCALP .............................. 54

see fluocinolone acetonide ...................................... 54

DERMATOP ..................... 54 see prednicarbate ......... 55

DERMATOP CREAM 0.1% .......................................... 54 DERMOTIC ....................... 57

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

DESCOVY .......................... 8 desipramine hcl ................. 24 desloratadine .................... 50 desmopressin acetate ....... 39 DESMOPRESSIN ACETATE .......................................... 39 desmopressin acetate inj .. 39 desmopressin acetate spray .......................................... 39 desmopressin acetate spray refrigerated ....................... 39 DESOGEN ........................ 33

see apri 28 day .............. 33 see cyred tab ................. 33 see emoquette .............. 34

see juleber 28 day ......... 34 see reclipsen 28 day ..... 35

desogestrel-ethinyl estradiol (biphasic) .......................... 33 DESONATE ...................... 54 desonide ........................... 54 DESONIDE ....................... 54 desowen ........................... 54 DESOWEN ....................... 54

see desonide ................. 54 see lokara ..................... 55

desoximetasone................ 54 DESOXIMETASONE ........ 54 DETROL ........................... 42

see tolterodine tartrate tab 1 mg .............................. 42 see tolterodine tartrate tab 2 mg .............................. 42

DETROL LA ...................... 42 see tolterodine tartrate er ...................................... 42

dexamethasone ................ 37 dexamethasone sodium phosphate ......................... 37 dexamethasone sodium phosphate (ophth)............. 49 DEXILANT ........................ 41 dexpak 10 day .................. 37 dexpak 6 day .................... 37 dexpak taperpak 13 day ... 37 dexrazoxane ..................... 15 DEXTROSE ...................... 47 DEXTROSE 10% FLEX CONTAIN ......................... 47 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 47 DEXTROSE 10%/NACL 0.45% ............................... 47 DEXTROSE 2.5%/NACL 0.45% ............................... 47 DEXTROSE 5% ................ 47 DEXTROSE 5% /ELECTROLYTE ............... 47 DEXTROSE 5%/LACTATED RING ................................. 47 DEXTROSE 5%/NACL 0.2%.......................................... 47


67

DEXTROSE 5%/NACL 0.225% .............................. 47 DEXTROSE 5%/NACL 0.3% .......................................... 47 DEXTROSE 5%/NACL 0.33% ................................ 47 DEXTROSE 5%/NACL 0.45% ................................ 47 DEXTROSE 5%/NACL 0.9% .......................................... 47 DEXTROSE 5%/POTASSIUM CHL ...... 47 DIAMOX ............................ 20

see acetazolamide ........ 20 DIASTAT ACUDIAL .......... 22 DIASTAT PEDIATRIC ....... 22 diazepam .......................... 22 DIAZEPAM GEL (ANTICONVULSANT) ....... 22 DIBENZYLINE .................. 21

see phenoxybenzamine hcl .................................. 21

diclofenac potassium ..........1 diclofenac sodium ...............1 diclofenac sodium (actinic keratoses) ......................... 56 diclofenac sodium (ophth) . 49 diclofenac sodium (topical) 1% gel ............................... 56 diclofenac sodium (topical) 1.5% soln .......................... 56 diclofenac w/ misoprostol ....1 dicloxacillin sodium ........... 11 dicyclomine hcl .................. 40 didanosine...........................7 DIFFERIN ......................... 52

see adapalene ............... 52 DIFICID ............................. 10 diflorasone diacetate ......... 54 DIFLUCAN ..........................7

see fluconazole ...............7 diflunisal ..............................1 digitek ............................... 20 digox ................................. 20 digoxin .............................. 20 digoxin inj .......................... 20 DIGOXIN SOL 50MCG/ML .......................................... 20

dihydroergotamine mesylate .......................................... 28 DIHYDROERGOTAMINE MESYLATE ....................... 28 dilantin .............................. 22 DILANTIN

see phenytoin sodium extended ....................... 23

DILANTIN INFATABS see phenytoin ................ 23

DILANTIN-125 .................. 22 see phenytoin ................ 23

DILATRATE SR ................ 21 DILAUDID

see hydromorphone hcl ... 3 DILAUDID INJ ..................... 2 DILAUDID TAB ................... 2 DILAUDID-5 ORAL LIQD .... 2 DILAUDID-HP INJ 10MG/ML ............................................ 2 DILAUDID-HP INJ 250MG .. 2 diltiazem cap 120mg/24hr . 19 diltiazem cap 240mg/24hr . 19 diltiazem cap er/12hr......... 19 diltiazem hcl ...................... 19 diltiazem hcl coated beads 19 diltiazem hcl er .................. 19 diltiazem hcl extended release beads ................... 19 diltiazem inj 100mg ........... 19 diltiazem inj 125/25ml ....... 19 diltiazem inj 25mg/5ml ...... 19 diltiazem inj 50/10ml ......... 19 dilt-xr cap .......................... 19 DIOVAN ............................ 17

see valsartan ................. 17 DIOVAN HCT .................... 16

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

DIPENTUM ....................... 40 diphenhydram inj 50mg/ml 50 diphenoxylate w/ atropine . 41 DIPHTHERIA/TETANUS TOXOID ............................ 45 DIPROLENE ..................... 54

see betamethasone dipropionate augmented 54

DIPROLENE AF ............... 54 see betamethasone dipropionate augmented 54

disopyramide phosphate ... 17 disulfiram .......................... 30 DITROPAN XL .................. 42

see oxybutynin chloride . 42 DIURIL SUS 250/5ML ....... 20 divalproex sodium ............. 22 docetaxel .......................... 13 DOCETAXEL .................... 13 DOCETAXEL SOLN 80MG/8ML ........................ 13 dofetilide ........................... 17 DOLOPHINE ...................... 2

see methadone hcl .......... 3 donepezil odt 10mg .......... 24 donepezil odt 5mg ............ 24 donepezil tab hcl 23mg ..... 24 donepezil tabs 10mg ......... 24 donepezil tabs 5mg ........... 24 DORIBAX ........................... 6 DORYX

see doxycycline hyclate 11 dorzolamide hcl................. 50 dorzolamide hcl-timolol maleate ............................. 50 DOVONEX

see calcipotriene ........... 53 DOVONEX CRE 0.005% .. 53 doxazosin mesylate .......... 16 doxepin hcl ....................... 24 DOXEPIN HCL (ANTIPRURITIC) .............. 53 doxercalciferol .................. 48 DOXIL ............................... 12

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

doxorubicin hcl .................. 12 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .... 12 doxorubicin inj 50mg ......... 12 doxy .................................. 11 doxycycline (monohydrate).......................................... 11 DOXYCYCLINE (ROSACEA) ...................... 56


68

doxycycline hyclate ........... 11 doxycycline hyclate tab 100 mg dr ................................. 12 doxycycline hyclate tab 150 mg dr ................................. 12 doxycycline hyclate tab 75 mg dr ................................. 11 dronabinol ......................... 39 drospirenone-ethinyl estradiol ...................... 33, 34 DROXIA ............................ 14 DUAC ................................ 52

see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 52 see neuac gel 1.2-5% .... 52

DUETACT ......................... 31 see pioglitazone hcl-glimepiride ............... 32

DUEXIS...............................1 DULERA ........................... 52 duloxetine hcl .................... 24 DUOPA ............................. 26 DURAGESIC .......................2

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

DURAMORPH ....................2 DUREZOL ......................... 49 DURLAZA ......................... 44 dutasteride ........................ 42 dutasteride-tamsulosin hcl 42 DUTOPROL ...................... 18 DYAZIDE .......................... 20

see triamt/hctz cap 37.5-25 .......................... 20

DYMISTA SPR 137-50 ..... 50 DYRENIUM ....................... 20 DYSPORT ......................... 30 E e.e.s. 400 tab 400mg ........ 10

E.E.S. GRANULES ........... 10 EC-NAPROSYN ................. 1

see naproxen .................. 1 econazole nitrate .............. 53 EDARBI ............................ 17 EDARBYCLOR ................. 16 EDECRIN .......................... 20

see ethacrynic acid........ 20 EDURANT .......................... 7 EFFEXOR XR ................... 24

see venlafaxine cap er .. 25 EFFIENT ........................... 44 EFUDEX ........................... 56

see fluorouracil (topical) 56 EGRIFTA .......................... 38 ELAPRASE ....................... 36 ELAVIL

see amitriptyline hcl ....... 24 ELDEPRYL ....................... 26

see selegiline hcl ........... 26 ELECTROLYTE-R IN DEXTROSE ...................... 47 ELELYSO ......................... 36 ELESTAT .......................... 49

see epinastine hcl (ophth) ...................................... 49

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

see permethrin .............. 56 eliphos .............................. 38 ELIPHOS

see calcium acetate (phosphate binder) ........ 38

ELIQUIS TAB 2.5MG ........ 43 ELIQUIS TAB 5MG ........... 43 ELITEK ............................. 15 elixophyllin ........................ 52 ELLA ................................. 34 ELLENCE ......................... 12

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

ELMIRON ......................... 42 ELOCON ........................... 54

see mometasone furoate ...................................... 55

ELOXATIN ........................ 15 EMADINE ......................... 49 EMBEDA ............................ 2 EMCYT ............................. 12 EMEND ............................. 39 EMEND CAP 125MG ........ 39 EMEND CAP 40MG .......... 39 EMEND CAP 80MG .......... 39 EMEND PAK 80 & 125 ..... 39 EMLA ................................ 55 emoquette ......................... 34 EMPLICITI ........................ 13 EMSAM ............................ 24 EMTRIVA ............................ 7 emverm ............................... 6 ENABLEX ......................... 42 enalapril maleate .............. 15 enalapril maleate & hydrochlorothiazide ........... 15 ENBREL ........................... 44 ENBREL SURECLICK ...... 44 endocet ............................... 2 ENGERIX-B ...................... 45 enoxaparin sodium ........... 43 enpresse 28 day ............... 34 ENSTILAR ........................ 54 ENTACAPONE ................. 26 entecavir ............................. 8 ENTOCORT EC................ 40

see budesonide ............. 40 ENTRESTO ...................... 16 ENTYVIO .......................... 40 enulose ............................. 40 ENVARSUS XR ................ 45 EPIDUO ............................ 52 EPIDUO FORTE ............... 52 epinastine hcl (ophth) ....... 49 EPINEPHRINE ................. 51 EPIPEN 2-PAK ................. 51 EPIPEN-JR 2-PAK ............ 51 epirubicin inj 200mg .......... 12 epirubicin inj 50mg/25ml ... 12 epitol ................................. 22 EPIVIR

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


69

see lamivudine (hbv) .......9 EPIVIR SOL 10MG/ML .......7 EPIVIR TABS ......................7 eplerenone ........................ 16 EPOGEN........................... 43 epoprostenol sodium ......... 21 eprosartan mesylate ......... 17 EPZICOM............................8 EQUETRO ........................ 29 ERAXIS ...............................7 ERBITUX .......................... 13 ergomar............................. 28 ERIVEDGE ....................... 13 errin 28 day ....................... 34 ERTACZO ......................... 53 ERWINAZE ....................... 14 ery pad 2% ........................ 52 erygel ................................ 52 ERYGEL

see erythromycin (acne aid) ................................ 52

ERYPED 200 .................... 10 ERYPED 400 .................... 10 ery-tab ............................... 10 erythrocin lactobionate ...... 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 52 erythromycin (ophth) ......... 48 erythromycin base ............. 10 erythromycin cap 250mg ec .......................................... 10 erythromycin ethylsuccinate .......................................... 10 ESBRIET........................... 51 escitalopram oxalate ......... 24 esomeprazole magnesium 41 esomeprazole sodium inj .. 42 estarylla tab 0.25-35 ......... 34 estrace .............................. 36 ESTRACE

see estradiol .................. 36 estradiol ............................ 36 estradiol valerate ............... 36 ESTRING .......................... 36 ESTROSTEP FE ............... 34

see tri-legest 28 day ...... 35 ethacrynic acid .................. 20 ethambutol hcl .....................8

ethosuximide ..................... 22 ETHYOL ........................... 15

see amifostine crystalline ...................................... 15

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 15 etoposide .......................... 15 EURAX ............................. 56 EVISTA ............................. 38

see raloxifene hcl .......... 38 EVOCLIN .......................... 52

see clindamycin phosphate (topical) ........ 52

EVOTAZ ............................. 8 EVOXAC ........................... 56

see cevimeline hcl ......... 56 EXALGO ............................. 2

see hydromorphone tab 12mg er ........................... 3 see hydromorphone tab 16mg er ........................... 3 see hydromorphone tab 8mg er ............................. 3

EXELDERM ...................... 53 EXELON

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

EXELON CAPS ................ 24 EXELON PATCHES ......... 24 exemestane ...................... 13 EXFORGE ........................ 16

see amlodipine besylate-valsartan tab 10-160 mg ..................... 16 see amlodipine besylate-valsartan tab 10-320 mg ..................... 16 see amlodipine besylate-valsartan tab 5-160 mg ....................... 16 see amlodipine besylate-valsartan tab

5-320 mg ....................... 16 EXFORGE HCT ................ 16

see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 16 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 16 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 16 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 16 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 16

EXJADE ............................ 33 EXTAVIA .......................... 29 EXTINA ............................. 53

see ketoconazole (topical) ...................................... 53 see ketodan aer 2% ...... 53

EYLEA .............................. 50 F FABIOR ............................ 52 FABRAZYME .................... 36 falmina 28 day .................. 34 famciclovir ........................... 8 famotidine ......................... 40 famotidine inj .................... 40 FAMVIR .............................. 8

see famciclovir ................ 8 FANAPT ........................... 26 FANAPT TITRATION PACK.......................................... 26 FARESTON ...................... 13 FARXIGA .......................... 31 FARYDAK ......................... 13 FASLODEX ...................... 13 FAZACLO ......................... 26 felbamate .......................... 22 FELBATOL ....................... 22


70

see felbamate ................ 22 FELDENE ...........................1

see piroxicam ..................1 felodipine........................... 19 FEMARA ........................... 13

see letrozole .................. 13 FEMCON FE ..................... 34

see wymzya fe ............... 36 see zenchent fe 28 day . 36

FEMRING ......................... 36 fenofibrate ......................... 18 FENOFIBRATE ................. 18 fenofibrate micronized ....... 18 FENOFIBRIC ACID ........... 18 FENOGLIDE ..................... 18 fenoprofen calcium ..............1 FENOPROFEN CALCIUM ..1 fentanyl citrate .....................2 fentanyl patch 100 mcg/hr ...2 fentanyl patch 12 mcg/hr .....2 fentanyl patch 25 mcg/hr .....2 fentanyl patch 50 mcg/hr .....2 fentanyl patch 75 mcg/hr .....2 FENTORA ...........................2 FERRIPROX ..................... 33 FETZIMA........................... 24 FETZIMA TITRATION PACK .......................................... 24 FIBRICOR ......................... 18 FINACEA AER 15% .......... 56 FINACEA GEL 15% .......... 56 finasteride ......................... 42 FIRAZYR........................... 44 FIRMAGON ....................... 13 FLAGYL ..............................6

see metronidazole ...........6 FLAREX ............................ 49 FLEBOGAMMA ................. 44 FLEBOGAMMA DIF .......... 44 flecainide acetate .............. 17 FLOLAN ............................ 21

see epoprostenol sodium ...................................... 21

FLOMAX ........................... 42 see tamsulosin hcl ......... 42

FLOVENT DISKUS ........... 51 FLOVENT HFA ................. 51 floxin otic ........................... 57

FLOXIN OTIC see ofloxacin (otic) ........ 57

fluconazole .......................... 7 fluconazole in dextrose ....... 7 fluconazole in nacl .............. 7 flucytosine ........................... 7 FLUDARA

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

fludarabine phosphate ...... 12 fludrocortisone acetate...... 37 FLUMADINE ....................... 9

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

flunisolide (nasal) .............. 51 fluocinolone acetonide 54, 55 fluocinolone acetonide (otic) .......................................... 57 fluocinonide ....................... 55 fluocinonide-e 0.05% cream .......................................... 55 FLUOROMETHOLONE (OPHTH) ........................... 49 fluorouracil ........................ 12 fluorouracil (topical) .......... 56 FLUOROURACIL (TOPICAL) ........................ 56 fluoxetine cap 10mg .......... 24 fluoxetine cap 20mg .......... 24 fluoxetine cap 40mg .......... 24 fluoxetine hcl ..................... 25 FLUOXETINE HCL ........... 25 fluphenazine decanoate .... 26 fluphenazine hcl ................ 26 flurandrenolide .................. 55 flurbiprofen .......................... 1 flurbiprofen sodium ........... 49 flutamide ........................... 13 fluticasone propionate ....... 55 fluticasone propionate (nasal) ............................... 51 fluvastatin sodium cap 20 mg .......................................... 17 fluvastatin sodium cap 40 mg .......................................... 17 fluvastatin sodium tab sr 24 hr 80 mg ............................ 17 fluvoxamine maleate ......... 22

fluvoxamine maleate er ..... 22 FML .................................. 49 FML FORTE ..................... 49 FML LIQUIFILM ................ 49 FOLOTYN ......................... 12 fondaparinux sodium ........ 43 FORADIL AEROLIZER ..... 51 FORFIVO XL .................... 25 FORTAMET ...................... 31

see metformin hcl osmotic 1000mg ......................... 32 see metformin hcl osmotic 500mg ........................... 32

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

FORTEO ........................... 38 FORTESTA ...................... 30 FORTICAL SPR 200/ACT 38 FOSAMAX ........................ 32

see alendronate sodium 32 FOSAMAX PLUS D .......... 32 fosinopril sodium ............... 15 fosinopril sodium & hydrochlorothiazide ........... 15 FOSRENOL ...................... 38 FRAGMIN ......................... 43 FREAMINE HBC 6.9% ..... 47 FREAMINE III ................... 47 FROVA

see frovatriptan succinate ...................................... 28

FROVA TAB 2.5MG .......... 28 frovatriptan succinate ........ 28 FURADANTIN..................... 6

see nitrofurantoin ............ 6 furosemide ........................ 20 furosemide inj ................... 20 FUROSEMIDE INJ ........... 20 furosemide oral soln 8 mg/ml.......................................... 20 FUSILEV ........................... 15

see levoleucovorin calcium ...................................... 15

FUZEON ............................. 7 fyavolv tab 1 mg-5 mcg ..... 36 FYCOMPA ........................ 22


71

G gabapentin ........................ 22 GABITRIL.......................... 22

see tiagabine hcl ........... 23 galantamine hydrobromide 24 galantamine hydrobromide er ....................................... 24 GAMASTAN S/D ............... 44 GAMMAGARD LIQUID ..... 44 GAMMAGARD S/D ........... 44 GAMMAGARD S/D IGA LESS TH ........................... 44 GAMMAKED ..................... 44 GAMMAPLEX ................... 44 GAMUNEX-C .................... 44 ganciclovir inj 500mg ..........9 garamycin ......................... 48 GARDASIL ........................ 45 GARDASIL 9 ..................... 45 GASTROCROM ................ 41

see cromolyn sodium (mastocytosis) ............... 41

gatifloxacin (ophth) ............ 48 GATTEX............................ 41 GAUZE PADS 2X2 ........... 31 gaviltye-g........................... 40 gavilyte-c ........................... 41 gavilyte-h........................... 41 gavilyte-n........................... 41 GAZYVA ........................... 13 GELNIQUE ....................... 42 gemcitabine hcl ................. 12 GEMCITABINE HCL ......... 12 gemfibrozil......................... 18 GEMZAR........................... 12

see gemcitabine hcl ....... 12 GENERESS FE ................ 34

see kaitlib fe 28 day ....... 34 see norethindrone & ethinyl estradiol-fe ......... 35

generlac ............................ 41 gengraf .............................. 45 GENOTROPIN .................. 38 GENOTROPIN MINIQUICK .......................................... 38 gentak ............................... 48 gentamicin in saline 0.8 mg/ml ..................................5

gentamicin in saline 0.9mg/ml ............................. 5 gentamicin in saline 1 mg/ml ............................................ 5 gentamicin in saline 1.2 mg/ml .................................. 5 gentamicin in saline 1.4mg/ml ............................. 5 gentamicin in saline 1.6 mg/ml .................................. 5 gentamicin in saline 2 mg/ml ............................................ 5 gentamicin sulfate ............... 5 gentamicin sulfate (ophth) . 48 gentamicin sulfate (topical) .......................................... 53 GENVOYA .......................... 8 GEODON .......................... 26

see ziprasidone hcl........ 27 GEODON INJ ................... 26 GIANVI TAB 3-0.02MG ..... 34 GIAZO ............................... 40 gildagia ............................. 34 gildess 1.5/30 21 day ........ 34 gildess 24 fe 28 day .......... 34 GILENYA CAP 0.5MG ...... 29 GILOTRIF TAB 20MG....... 14 GILOTRIF TAB 30MG....... 14 GILOTRIF TAB 40MG....... 14 GLASSIA .......................... 51 glatopa .............................. 29 GLEEVEC ......................... 14

see imatinib mesylate .... 14 GLEOSTINE ..................... 12 glimepiride ........................ 31 glipizide ............................. 31 glipizide er ......................... 31 GLIPIZIDE XL TB24 2.5MG .......................................... 31 GLIPIZIDE XL TB24 5MG . 31 glipizide-metformin 2.5-250 mg ..................................... 32 glipizide-metformin 2.5-500 mg ..................................... 32 glipizide-metformin 5-500mg .......................................... 32 GLUCAGEN HYPOKIT ..... 37 GLUCAGON EMERGENCY

KIT .................................... 37 GLUCOPHAGE ................ 32

see metformin hcl .......... 32 GLUCOPHAGE XR .......... 32

see metformin er ........... 32 GLUCOTROL ................... 32

see glipizide .................. 31 GLUCOTROL XL .............. 32

see glipizide er .............. 31 GLUMETZA ...................... 32

see metformin hcl .......... 32 glycopyrrolate ................... 40 GLYSET ........................... 32

see miglitol .................... 32 GLYXAMBI ....................... 32 GOLYTELY ....................... 41

see gaviltye-g ................ 40 GRALISE .......................... 29 GRALISE STARTER ........ 29 granisetron hcl .................. 39 GRANIX ............................ 43 GRASTEK ........................ 44 griseofulvin microsize ......... 7 griseofulvin ultramicrosize .. 7 GRIS-PEG .......................... 7

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

guanfacine er (adhd) ......... 28 H H.P. ACTHAR ................... 38 HALAVEN ......................... 14 HALDOL ........................... 26

see haloperidol lactate inj 5 mg/ml ......................... 26

HALDOL DECANOATE 100.......................................... 26

see haloperidol decanoate ...................................... 26

HALDOL DECANOATE 50.......................................... 26

see haloperidol decanoate ...................................... 26

halobetasol propionate ..... 55 HALOG ............................. 55 haloperidol ........................ 26 haloperidol decanoate ...... 26 haloperidol lactate............. 26 haloperidol lactate inj 5


72

mg/ml ................................ 26 HARVONI............................9 HAVRIX............................. 45 heather .............................. 34 HECTOROL ...................... 48

see doxercalciferol ........ 48 HEP SOD/NACL INJ 25000 .......................................... 43 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 43 heparin sod inj 10000u/ml . 43 heparin sod inj 1000u/ml ... 43 heparin sod inj 20000u/ml . 43 heparin sod inj 5000u/0.5ml .......................................... 43 heparin sod inj 5000u/ml ... 43 HEPARIN SODIUM/D5W .. 43 HEPARIN SODIUM/NACL 0.45% ................................ 43 HEPATAMINE ................... 47 HEPSERA ...........................9

see adefovir dipivoxil .......8 HERCEPTIN ..................... 13 HETLIOZ ........................... 28 HEXALEN ......................... 12 HIBERIX............................ 45 HIPREX...............................6

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

HIZENTRA ........................ 44 HORIZANT ........................ 29 HUMALOG ........................ 31 HUMALOG KWIKPEN ...... 31 HUMALOG MIX 50/50 ...... 31 HUMALOG MIX 50/50 KWIKPEN ......................... 31 HUMALOG MIX 75/25 ...... 31 HUMALOG MIX 75/25 KWIKPEN ......................... 31 HUMATROPE ................... 38 HUMATROPE COMBO PACK ................................ 38 HUMIRA INJ 10MG/0.2ML 44 HUMIRA KIT 20MG/0.4ML 44 HUMIRA KIT 40MG/0.8ML 44 HUMIRA PEDIATRIC CROHNS .......................... 44

HUMIRA PEN ................... 44 HUMIRA PEN-CROHNS STARTER KIT .................. 44 HUMIRA PEN-PSORIASIS STARTER KIT .................. 44 HUMULIN 70/30 ............... 31 HUMULIN 70/30 KWIKPEN .......................................... 31 HUMULIN N ...................... 31 HUMULIN N KWIKPEN .... 31 HUMULIN R ...................... 31 HUMULIN R U-500 KWIKPEN ......................... 31 HUMULIN R U-500 VIAL (CONCENTRATE) ............ 31 HYCAMTIN ....................... 15

see topotecan hcl .......... 15 hycet ................................... 2 HYCET

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

hydralazine hcl .................. 21 HYDREA ........................... 14

see hydroxyurea ............ 14 hydrochlorothiazide ........... 20 hydrocodone-acetaminophen 10-300mg ............................ 3 hydrocodone-acetaminophen 2.5-325mg ........................... 2 hydrocodone-acetaminophen 5-300mg .............................. 3 hydrocodone-acetaminophen 5-325mg .............................. 3 hydrocodone-acetaminophen 7.5-300mg ........................... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 3 hydrocodone-acetaminophen 7.5-325mg ........................... 3 hydrocodone-acetaminophen tab 10-325mg ...................... 3 hydrocodone-ibuprofen tab 10-200mg ............................ 3 hydrocodone-ibuprofen tab 2.5-200mg ........................... 3 hydrocodone-ibuprofen tab 5-200mg .............................. 3

hydrocodone-ibuprofen tab 7.5-200 mg ......................... 3 hydrocortisone .................. 37 HYDROCORTISONE (INTRARECTAL) .............. 40 hydrocortisone (topical) .... 55 hydrocortisone butyrate .... 55 hydrocortisone butyrate hydrophilic lipo base ......... 55 hydrocortisone valerate .... 55 hydromorphone hcl ............. 3 HYDROMORPHONE HCL . 3 hydromorphone tab 12mg er............................................ 3 hydromorphone tab 16mg er............................................ 3 hydromorphone tab 8mg er 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate.......................................... 44 hydroxyprogesterone caproate (antineoplastic) .. 13 hydroxyurea ...................... 14 hydroxyzine hcl ................. 50 HYQVIA ............................ 44 HYSINGLA ER.................... 3 HYZAAR ........................... 16

see losartan-hydrochlorothiazide .................................. 16

I ibandronate sodium .......... 33 ibandronate tab 150mg ..... 33 IBRANCE .......................... 13 ibudone tab 10-200mg ........ 3 ibudone tab 5-200mg .......... 3 ibuprofen ............................. 1 ICLUSIG ........................... 14 IDAMYCIN PFS ................ 12

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

see ifosfamide inj 1gm .. 12 IFEX INJ 1GM .................. 12 IFEX INJ 3GM .................. 12 ifosfamide inj ..................... 12 ifosfamide inj 1gm ............. 12


73

IFOSFAMIDE INJ 3GM ..... 12 ILARIS .............................. 44 ILEVRO ............................. 49 ilotycin ............................... 48 imatinib mesylate .............. 14 IMBRUVICA CAP 140MG . 14 imipenem-cilastatin .............6 imipramine hcl ................... 25 imipramine pamoate ......... 25 imiquimod.......................... 56 IMITREX ........................... 28

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

IMITREX STATDOSE REFILL .............................. 28 IMITREX STATDOSE SYSTEM ..................... 28, 29

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

IMOVAX RABIES (H.D.C.V.) .......................................... 45 IMURAN ............................ 45

see azathioprine ............ 45 INCRELEX ........................ 38 INCRUSE ELLIPTA .......... 50 indapamide ....................... 20 INDERAL LA ..................... 19

see propranolol hcl er .... 19 INFANRIX ......................... 45 INFUMORPH 200 ...............3 INFUMORPH 500 ...............3 INLYTA ............................. 14 INSPRA............................. 16

see eplerenone .............. 16 INSULIN PEN NEEDLES .. 31 INSULIN SAFETY NEEDLES ......................... 31 INSULIN SYRINGES ........ 31 INTELENCE ........................7 INTRALIPID INJ 20% ........ 47 INTRALIPID INJ 30% ........ 47 INTRON-A INJ 10MU ........ 44 INTRON-A INJ 18MU ........ 44 INTRON-A INJ 25MU ........ 44 INTRON-A INJ 50MU ........ 44 introvale 91 day ................. 34

INTUNIV ........................... 28 see guanfacine er (adhd) ...................................... 28

INVANZ ............................... 6 INVEGA ............................ 26

see paliperidone ............ 27 INVEGA SUST INJ 117 MG/0.75 ML ...................... 27 INVEGA SUST INJ 156MG/ML ........................ 27 INVEGA SUST INJ 234 MG/1.5 ML ........................ 27 INVEGA SUST INJ 39 MG/0.25 ML ...................... 27 INVEGA SUST INJ 78 MG/0.5 ML ........................ 27 INVEGA TRINZA .............. 27 INVIRASE ........................... 7 INVOKAMET TAB 150-1000 .......................................... 32 INVOKAMET TAB 150-500 .......................................... 32 INVOKAMET TAB 50-1000 .......................................... 32 INVOKAMET TAB 50-500MG ......................... 32 INVOKANA TAB 100MG ... 32 INVOKANA TAB 300MG ... 32 IONOSOL-B/DEXTROSE 5% .................................... 47 IONOSOL-MB/DEXTROSE 5% .................................... 47 IPOL INACTIVATED IPV .. 45 ipratropium bromide (nasal) .......................................... 50 ipratropium sol inhal .......... 50 ipratropium-albuterol ......... 50 irbesartan .......................... 17 irbesartan-hydrochlorothiazide ........................................ 16 IRESSA ............................. 14 irinotecan inj 100/5ml ........ 15 irinotecan inj 40mg/2ml ..... 15 irinotecan inj 500mg/25ml . 15 ISENTRESS ....................... 7 ISOLYTE P ....................... 47 ISOLYTE S ....................... 47 isoniazid .............................. 8

isoniazid tabs ...................... 8 ISOPTO CARPINE ........... 50 ISORDIL TITRADOSE ...... 21

see isosorbide dinitrate . 21 isosorbide dinitrate ............ 21 isosorbide dinitrate er ....... 21 isosorbide mononitrate ..... 21 isosorbide mononitrate er . 21 isradipine .......................... 19 ISTALOL ........................... 50 ISTODAX .......................... 13 itraconazole ........................ 7 ivermectin ........................... 6 IXEMPRA KIT ................... 14 IXIARO ............................. 45 J JADENU ........................... 33 JAKAFI ............................. 14 JALYN .............................. 42

see dutasteride-tamsulosin hcl ................................. 42

jantoven ............................ 43 JANUMET ......................... 32 JANUMET XR TAB 100-1000 .......................... 32 JANUMET XR TAB 50-1000.......................................... 32 JANUMET XR TAB 50-500MG ......................... 32 JANUVIA .......................... 32 JARDIANCE ..................... 32 JENTADUETO .................. 32 JENTADUETO XR 2.5-1000MG ...................... 32 JENTADUETO XR 5-1000MG ......................... 32 JEVTANA ......................... 13 jinteli ................................. 36 JOLESSA TAB 0.15-0.03 MG .................................... 34 JOLIVETTE ...................... 34 juleber 28 day ................... 34 junel 1.5/30 21 day ........... 34 junel 1/20 21 day .............. 34 junel fe 1.5/30 28 day ....... 34 junel fe 1/20 28 day .......... 34 junel fe 24 1/20 28 day ..... 34 JUXTAPID ........................ 18


74

K KADCYLA ......................... 13 KADIAN...............................3

see morphine sulfate .......4 kaitlib fe 28 day ................. 34 KALBITOR ........................ 44 KALETRA SOL ...................8 KALETRA TAB 100-25MG ..8 KALETRA TAB 200-50MG ..8 KALYDECO ...................... 51 KANUMA........................... 36 kariva 28 day ..................... 34 KAYEXALATE ................... 33

see kionex ..................... 33 see sodium polystyrene sulfonate ........................ 33

KAZANO ........................... 32 KCL 0.075%/D5W/NACL 0.45% ................................ 47 KCL 0.15%/D5W/LR ......... 47 KCL 0.15%/D5W/NACL 0.9% .................................. 47 KCL 0.3%/D5W/LR IV LAC RI ...................................... 47 KCL 0.3%/D5W/NACL 0.45% ................................ 47 KCL 0.3%/D5W/NACL 0.9% .......................................... 47 KCL IN NACL INJ .15-0.45 .......................................... 47 KCL/D5W/NACL INJ .15/.33% ............................ 47 KCL/D5W/NACL INJ .15/.45% ............................ 47 KCL/D5W/NACL INJ 0.22%/0.45% ..................... 47 KCL/NACL INJ 0.15%-0.9% .......................................... 47 KCL0.15%/D5W/NACL0.2% .......................................... 47 KCL0.15%/D5W/NACL0.225% ....................................... 47 KEFLEX

see cephalexin .............. 10 kelnor 1/35 28 day ............ 34 KENALOG......................... 55

see triamcinolone acetonide (topical) ......... 55

KEPIVANCE ..................... 15 KEPPRA ........................... 22

see levetiracetam .......... 23 see levetiracetam oral soln 100 mg/ml ..................... 23 see roweepra ................ 23

KEPPRA XR ..................... 22 see levetiracetam .......... 23

KERLONE see betaxolol hcl ........... 18

ketoconazole ....................... 7 ketoconazole (topical) ....... 53 ketoconazole shampoo ..... 53 ketodan aer 2% ................. 53 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 49 KEVEYIS .......................... 21 KEYTRUDA ...................... 13 kimidess 28 day ................ 34 KINERET .......................... 44 KINRIX .............................. 46 kionex ............................... 33 KITABIS PAK ...................... 5

see tobramycin ................ 5 KLARON ........................... 52

see sulfacetamide sodium (acne) ............................ 52

KLONOPIN ....................... 22 see clonazepam ............ 22

KLOR-CON 10 .................. 46 KLOR-CON 8 .................... 46 klor-con m10 ..................... 46 klor-con m15 ..................... 46 klor-con m20 ..................... 46 klor-con pow 20meq ......... 46 klor-con spr cap 10meq .... 46 klor-con spr cap 8meq ...... 46 KOMBIGLYZE XR 2.5-1000MG ...................... 32 KOMBIGLYZE XR 5-1000MG ......................... 32 KOMBIGLYZE XR 5-500MG .......................................... 32 KORLYM ........................... 37 kristalose ........................... 41 K-TAB ............................... 46 KUVAN ............................. 36

KYNAMRO ....................... 18 L labetalol hcl ....................... 19 LAC-HYDRIN .................... 56

see ammonium lactate .. 55 LACRISERT ..................... 50 LACTATED RINGERS VIAFLEX ........................... 48 lactulose ........................... 41 lactulose (encephalopathy).......................................... 41 LAMICTAL ........................ 22

see lamotrigine .............. 23 LAMICTAL CHEWABLE DISPERS .......................... 22

see lamotrigine .............. 23 LAMICTAL ODT................ 22

see lamotrigine .............. 23 LAMICTAL STARTER ...... 22 LAMICTAL XR ............ 22, 23

see lamotrigine .............. 23 LAMISIL .............................. 7

see terbinafine hcl ........... 7 lamivudine .......................... 7 lamivudine (hbv) ................. 9 lamivudine-zidovudine ........ 8 lamotrigine ........................ 23 LANOXIN .......................... 20

see digitek ..................... 20 see digox ....................... 20 see digoxin .................... 20 see digoxin inj ............... 20

LANOXIN INJ 0.25MG/ML 20 LANOXIN PEDIATRIC ...... 20 LANOXIN TAB .................. 20 lansoprazole ..................... 42 LANTUS ........................... 31 LANTUS SOLOSTAR ....... 31 larin 1.5/30 ........................ 34 larin 1/20 ........................... 34 larin fe 1.5/30 .................... 34 larin fe 1/20 ....................... 34 larissia 28 day pack .......... 34 LASIX ............................... 20

see furosemide.............. 20 LASTACAFT ..................... 49 latanoprost ........................ 50 LATUDA ........................... 27


75

LAYOLIS FE CHW ............ 34 LAZANDA ...........................3 leena tab ........................... 34 leflunomide ........................ 44 LEMTRADA ...................... 29 LENVIMA 10 MG DAILY DOSE ................................ 14 LENVIMA 14 MG DAILY DOSE ................................ 14 LENVIMA 18 MG DAILY DOSE ................................ 14 LENVIMA 20 MG DAILY DOSE ................................ 14 LENVIMA 24 MG DAILY DOSE ................................ 14 LENVIMA 8 MG DAILY DOSE ................................ 14 LESCOL ............................ 17

see fluvastatin sodium cap 20 mg ............................ 17

LESCOL XL ...................... 17 see fluvastatin sodium tab sr 24 hr 80 mg ............... 17

lessina 28 day ................... 34 LETAIRIS .......................... 21 letrozole ............................ 13 leucovorin calcium ............ 15 leucovorin calcium inj 100mg .......................................... 15 leucovorin calcium inj 200mg .......................................... 15 leucovorin calcium inj 350mg .......................................... 15 leucovorin calcium inj 500mg .......................................... 15 leucovorin calcium inj 50mg .......................................... 15 LEUKERAN ....................... 12 LEUKINE........................... 43 leuprolide acetate .............. 13 levalbuterol conc 1.25mg/0.5ml .................... 51 levalbuterol hcl .................. 51 LEVALBUTEROL HCL ...... 51 LEVAQUIN ........................ 10

see levofloxacin ............. 10 LEVEMIR .......................... 31 LEVEMIR FLEXTOUCH.... 31

levetiracetam .................... 23 LEVETIRACETAM IV........ 23 levetiracetam oral soln 100 mg/ml ................................ 23 levobunolol hcl .................. 50 levocarnitine (metabolic modifiers) .......................... 36 levocetirizine soln 2.5mg/5ml .......................................... 50 levocetirizine tab 5 mg ...... 50 levofloxacin ....................... 10 levofloxacin (ophth) ........... 48 levofloxacin in d5w ............ 10 levoleucovorin calcium ...... 15 levonest 28 day ................. 34 levonor/ethi tab ................. 34 levonorgestrel & eth estradiol .......................................... 34 levonorgestrel (emergency oc) ..................................... 34 levonorgestrel-ethinyl estradiol (91-day) .............. 34 levonorgestrel-ethinyl estradiol (continuous)........ 34 levora 0.15/30 28 day ....... 34 levorphanol tartrate ............. 3 levothyroxine sodium ........ 39 LEVOXYL ......................... 39 LEXAPRO ......................... 25

see escitalopram oxalate ...................................... 24

LEXIVA ............................... 7 LIALDA ............................. 40 lidocaine ............................ 55 lidocaine hcl ...................... 55 lidocaine hcl (local anesth.) . 5 lidocaine hcl (mouth-throat) .......................................... 56 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5% ................ 5 lidocaine inj 2% ................... 5 lidocaine-prilocaine ........... 55 LIDODERM ....................... 55

see lidocaine ................. 55 linezolid ............................... 6 LINEZOLID ......................... 6 LINEZOLID IN SODIUM

CHLORIDE ......................... 6 LINZESS ........................... 41 liothyronine sodium ........... 39 LIPITOR ............................ 17

see atorvastatin calcium 17 LIPOFEN .......................... 18 LIPOSYN II ....................... 47 LIPOSYN III ...................... 47 lisinopril ............................. 15 lisinopril & hydrochlorothiazide ........... 15 lithium carbonate .............. 29 LITHIUM SOLN 8MEQ/5ML.......................................... 29 LITHOBID ......................... 29

see lithium carbonate .... 29 LIVALO ............................. 17 LO LOESTRIN FE ............ 34 LOCOID ............................ 55

see hydrocortisone butyrate ......................... 55

LOCOID LIPOCREAM ...... 55 see hydrocortisone butyrate hydrophilic lipo base .............................. 55

LODINE see etodolac .................... 1

LODOSYN ........................ 26 see carbidopa................ 25

loestrin 1.5/30 21 day ....... 34 LOESTRIN 1.5/30-21

see gildess 1.5/30 21 day ...................................... 34 see junel 1.5/30 21 day . 34 see larin 1.5/30.............. 34

loestrin 1/20 21 day .......... 34 LOESTRIN 1/20-21

see junel 1/20 21 day .... 34 see larin 1/20................. 34

LOESTRIN FE 1.5/30 see blisovi 21 fe 1.5/30 28 day pack ........................ 33 see junel fe 1.5/30 28 day ...................................... 34 see larin fe 1.5/30 .......... 34

loestrin fe 1.5/30 28 day ... 34 LOESTRIN FE 1/20

see blisovi 21 fe 1/20 28


76

day pack ........................ 33 see junel fe 1/20 28 day 34 see larin fe 1/20 ............. 34 see tarina fe 1/20 28 day ...................................... 35

loestrin fe 1/20 28 day ....... 34 lofibra ................................ 18 LOFIBRA

see fenofibrate ............... 18 see fenofibrate micronized ...................................... 18

lokara ................................ 55 lomedia 24 fe .................... 34 LOMOTIL .......................... 41

see diphenoxylate w/ atropine ......................... 41

LONSURF ......................... 14 loperamide hcl ................... 41 LOPID ............................... 18

see gemfibrozil .............. 18 LOPRESSOR .................... 19

see metoprolol tartrate .. 19 LOPRESSOR HCT ........... 18

see metoprolol & hctz tab 100-25mg ...................... 18 see metoprolol & hctz tab 50-25mg ........................ 18

LOPROX ........................... 53 see ciclopirox cre 0.77% 53

LOPROX SHAMPOO ........ 53 see ciclopirox shampoo 1% ................................. 53

lorazepam ......................... 22 lorcet hd tab 10-325mg .......3 lorcet plus tab 7.5-325 ........3 lorcet tab 5-325mg ..............3 lortab tab 10-325mg ............3 lortab tab 5-325mg ..............3 lortab tab 7.5-325 ................3 loryna 28 day .................... 34 losartan potassium ............ 17 losartan-hydrochlorothiazide .......................................... 16 LOSEASONIQUE ............. 34 LOTEMAX ......................... 49 LOTENSIN ........................ 16

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

see benazepril & hydrochlorothiazide ....... 15

LOTREL ............................ 15 see amlodipine besylate-benazepril hcl .. 15

LOTRONEX ...................... 41 see alosetron hcl ........... 41

lovastatin ........................... 17 LOVAZA

see omega-3-acid ethyl esters ............................ 18

LOVAZA CAP 1GM .......... 18 LOVENOX ........................ 43

see enoxaparin sodium . 43 low-ogestrel ...................... 34 loxapine succinate ............ 27 LUCENTIS ........................ 50 LUMIGAN ......................... 50 LUMIZYME ....................... 36 LUPANETA PACK ............ 36 LUPRON DEP INJ 11.25MG .......................................... 13 LUPRON DEPOT ............. 14 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 14 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 14 LUPRON DEP-PED INJ 11.25MG ........................... 13 LUPRON DEP-PED INJ 15MG ................................ 13 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 14 LUPRON DEP-PED INJ 7.5MG ............................... 13 lutera 28 day ..................... 34 LUXIQ

see betamethasone valerate ......................... 54

LUZU ................................ 53 LYNPARZA ....................... 13 LYRICA ............................. 23 LYSODREN ...................... 14 LYSTEDA ......................... 44

see tranexamic acid ...... 44 lyza ................................... 34 M MACROBID ........................ 6

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

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

magnesium sulfate ............ 46 MAGNESIUM SULFATE .. 46

see magnesium sulfate . 46 MAGNESIUM SULFATE IN D5W .................................. 46 MAGNESIUM SULFATE INJ 50% .................................. 46 MALARONE ....................... 7

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

malathion .......................... 56 maprotiline hcl .................. 25 MARINOL ......................... 39

see dronabinol............... 39 marlissa 28 day................. 34 MARPLAN ........................ 25 MATULANE ...................... 14 matzim la .......................... 19 MAVIK .............................. 16

see trandolapril.............. 16 MAXALT ........................... 29

see rizatriptan benzoate 29 MAXALT-MLT ................... 29

see rizatriptan benzoate 29 MAXIDEX ......................... 49 MAXIPIME ........................ 10

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

MAXITROL ....................... 48 see neomycin-polymy-dexameth .................................... 48

MAXZIDE .......................... 20 see triamt/hctz tab 75-50mg ........................ 21

MAXZIDE-25 .................... 20 see triamt/hctz tab 37.5-25 ...................................... 21

meclizine hcl ..................... 39 MEDROL

see methylpred tab 16mg


77

...................................... 37 see methylpred tab 32mg ...................................... 37 see methylpred tab 4mg 37 see methylpred tab 8mg 37

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 37

MEDROL PAK 4MG .......... 37 MEDROL TAB 16MG ........ 37 MEDROL TAB 2MG .......... 37 MEDROL TAB 32MG ........ 37 MEDROL TAB 4MG .......... 37 MEDROL TAB 8MG .......... 37 medroxyprogesterone acetate .............................. 38 medroxyprogesterone acetate (contraceptive) ..... 34 MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) ......... 34 mefenamic acid ...................1 mefloquine hcl .....................7 MEGACE ES ..................... 14 MEGACE ORAL ................ 14

see megestrol ac sus 40mg/ml ......................... 14

megestrol ac sus 40mg/ml 14 megestrol ac tab 20mg ..... 14 megestrol ac tab 40mg ..... 14 MEGESTROL SUS 625MG/5ML ...................... 14 MEKINIST ......................... 14 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 12 memantine hcl ................... 24 MENACTRA ...................... 46 MENHIBRIX ...................... 46 MENOMUNE-A/C/Y/W-135 .......................................... 46 MENOSTAR ...................... 36 MENTAX ........................... 53 MENVEO .......................... 46 MEPRON ............................6

see atovaquone ...............5 mercaptopurine ................. 12 meropenem .........................6

MEROPENEM/SODIUM CHLORIDE ......................... 6 MERREM ............................ 6

see meropenem .............. 6 MESALAMINE .................. 40 mesalamine enema .......... 40 mesna ............................... 15 MESNEX ........................... 15

see mesna ..................... 15 MESTINON ....................... 29

see pyridostigmine bromide ......................... 29

MESTINON SYRUP.......... 29 MESTINON TIMESPAN .... 29

see pyridostigmine bromide ......................... 29

METADATE CD ................ 28 see methylphenidate hcl 28

metadate er tab 20mg ....... 28 metformin er ...................... 32 metformin hcl .................... 32 metformin hcl osmotic 1000mg ............................. 32 metformin hcl osmotic 500mg ............................... 32 methadone hcl .................... 3 METHADONE INJ 10MG/ML ............................................ 3 METHADOSE ..................... 3

see methadone hcl .......... 3 methazolamide ................. 20 methenamine hippurate ...... 6 METHERGINE

see methylergonovine maleate ......................... 38

methimazole ..................... 39 methotrexate sodium ........ 13 METHOTREXATE SODIUM .......................................... 12 methotrexate sodium inj .... 13 methotrexate sodium tabs . 44 methoxsalen rapid ............ 53 methscopolamine bromide 40 methyclothiazide ............... 20 methylergonovine maleate 38 METHYLIN ........................ 28

see methylphenidate hcl 28 METHYLIN CHEW TAB .... 28

methylphenidate hcl .......... 28 METHYLPHENIDATE HCL.......................................... 28 methylphenidate hcl er ...... 28 methylpr ace inj 40mg/ml .. 37 methylpr ace inj 80mg/ml .. 37 methylpr ss inj 125mg ....... 37 methylpr ss inj 1gm ........... 37 methylpr ss inj 40mg ......... 37 methylpred pak 4mg ......... 37 methylpred tab 16mg ........ 37 methylpred tab 32mg ........ 37 methylpred tab 4mg .......... 37 methylpred tab 8mg .......... 37 metipranolol ...................... 50 metoclopramide hcl ........... 39 metoclopramide hcl inj 5 mg/ml ................................ 39 metoclopramide odt .......... 39 metolazone ....................... 20 metoprolol & hctz tab 100-25mg ......................... 18 metoprolol & hctz tab 100-50mg ......................... 18 metoprolol & hctz tab 50-25mg ........................... 18 metoprolol succinate ......... 19 metoprolol tartrate............. 19 METOZOLV ODT ............. 39

see metoclopramide hcl 39 METRO IV .......................... 6 METROCREAM ................ 56

see metronidazole (topical) ......................... 56 see rosadan cre 0.75% . 56

METROGEL ..................... 56 see metronidazole (topical) ......................... 56

METROGEL-VAGINAL ..... 43 see metronidazole vaginal ...................................... 43

METROLOTION ............... 56 see metronidazole (topical) ......................... 56

metronidazole ..................... 6 metronidazole (topical) ..... 56 metronidazole inj................. 6 metronidazole vaginal ....... 43


78

MEVACOR see lovastatin ................ 17

mexiletine hcl .................... 17 MIACALCIN

see calcitonin (salmon) nasal spray .................... 38

MIACALCIN INJ 200U/ML. 38 MIACALCIN SPR 200/ACT .......................................... 38 MICARDIS ........................ 17

see telmisartan .............. 17 MICARDIS HCT ................ 16

see telmisartan-hydrochlorothiazide .............................. 16

miconazole 3 sup 200mg .. 43 MICROGESTIN 1.5/30 ...... 35 MICROGESTIN 1/20 ......... 35 MICROGESTIN FE 1.5/30 35 MICROGESTIN FE 1/20 ... 35 MICRO-K .......................... 46

see klor-con spr cap 10meq ........................... 46 see klor-con spr cap 8meq ...................................... 46 see potassium chloride caps er........................... 46

MICROZIDE ...................... 20 see hydrochlorothiazide 20

midodrine hcl ..................... 21 migergot ............................ 29 miglitol ............................... 32 MIGRANAL ....................... 29 millipred............................. 37 millipred dp ........................ 37 MINASTRIN 24 FE ............ 35 MINIPRESS ...................... 16

see prazosin hcl ............ 16 minitran ............................. 21 MINIVELLE ....................... 36 MINOCIN .......................... 12

see minocycline hcl ....... 12 minocycline hcl .................. 12 minoxidil ............................ 21 MIRAPEX .......................... 26

see pramipexole dihydrochloride .............. 26

MIRAPEX ER .................... 26

see pramipexole dihydrochloride .............. 26

MIRCERA ......................... 43 mircette ............................. 35 MIRCETTE

see bekyree 28 day ....... 33 see desogestrel-ethinyl estradiol (biphasic) ........ 33 see kariva 28 day .......... 34 see kimidess 28 day ...... 34 see pimtrea pack ........... 35 see viorele ..................... 36

mirtazapine ....................... 25 misoprostol ....................... 41 mitomycin .......................... 12 mitoxantrone hcl ............... 14 M-M-R II ............................ 46 MOBIC

see meloxicam tabs......... 1 MOBIC TABS ...................... 1 modafinil ........................... 30 moderiba pak ...................... 9 MODERIBA PAK ................ 9 moderiba tab 200mg ........... 9 MODICON ........................ 35 moexipril hcl ...................... 16 moexipril-hydrochlorothiazide ........................................ 15 molindone hcl .................... 27 mometasone furoate ......... 55 mometasone furoate (nasal) .......................................... 51 MONODOX

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

mono-linyah tab 0.25-35 ... 35 MONONESSA .................. 35 montelukast sodium .......... 51 morgidox ........................... 12 MORPHINE SUL 20MG/ML ORAL SOL .......................... 3 MORPHINE SUL INJ 10MG/ML ............................ 4 MORPHINE SUL INJ 15MG/ML ............................ 4 MORPHINE SUL INJ 1MG/ML .............................. 3 MORPHINE SUL INJ

4MG/ML .............................. 4 morphine sulfate ................. 4 MORPHINE SULFATE ....... 4

see morphine sulfate ....... 4 morphine sulfate beads ...... 4 morphine sulfate ext-rel tab 4 MOVANTIK ....................... 41 MOVIPREP ....................... 41 MOXATAG ........................ 11 MOXEZA .......................... 48 moxifloxacin hcl ................ 10 MOXIFLOXACIN HCL ...... 10 MOZOBIL ......................... 43 MS CONTIN ....................... 4

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

MULTAQ ........................... 17 mupirocin .......................... 53 mupirocin calcium (topical) 53 MUSTARGEN ................... 12 MYALEPT ......................... 38 MYAMBUTOL ..................... 8

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

see rifabutin .................... 8 mycophenolate mofetil ...... 45 mycophenolate sodium ..... 45 MYFORTIC ....................... 45

see mycophenolate sodium .......................... 45

myorisan ........................... 52 MYOZYME ....................... 36 MYRBETRIQ .................... 42 MYSOLINE ....................... 23

see primidone................ 23 myzilra .............................. 35 N nabumetone ........................ 1 nadolol .............................. 19 nadolol & bendroflumethiazide ......... 18 NAFCILLIN ....................... 11 nafcillin sodium ................. 11 NAFCILLIN SODIUM IN DEXTROSE ...................... 11 naftifine hcl ....................... 53 NAFTIFINE HCL ............... 53


79

NAFTIN ............................. 53 see naftifine hcl ............. 53

NAGLAZYME .................... 36 nalbuphine hcl .....................2 NALFON .............................1 naloxone inj 0.4mg/ml ....... 30 naloxone inj 1mg/ml .......... 30 naltrexone hcl .................... 30 NAMENDA

see memantine hcl ........ 24 NAMENDA SOL 10MG/5ML .......................................... 24 NAMENDA TAB ................ 24 NAMENDA XR .................. 24 NAMENDA XR TITRATION PACK ................................ 24 NAMZARIC ....................... 24 naphazoline hcl ................. 50 NAPRELAN .........................1

see naproxen sodium ......1 NAPROSYN

see naproxen ...................1 NAPROSYN TAB 500MG ...1 naproxen .............................1 naproxen sodium ................1 NAPROXEN SODIUM ........1 naratriptan hcl ................... 29 NARDIL ............................. 25

see phenelzine sulfate ... 25 NASONEX ........................ 51

see mometasone furoate (nasal) ........................... 51

NATACYN ......................... 48 nateglinide......................... 32 NATPARA ......................... 38 NAVELBINE

see vinorelbine tartrate .. 13 NEBUPENT ........................6 necon 0.5/35 28 day ......... 35 necon 1/35 28 day ............ 35 necon 10/11 28 day .......... 35 NECON 7/7/7 .................... 35 NECON TAB 1/50-28 ........ 35 nefazodone hcl .................. 25 neomycin sulfate .................5 neomycin/polymyxin b gu .. 56 neomycin-bacitracin zn-polymyxin ..................... 49

neomycin-polymy-dexameth .......................................... 48 neomycin-polymyxin-gramicidin ..................................... 49 neomycin-polymyxin-hc (ophth) .............................. 48 neomycin-polymyxin-hc (otic) .......................................... 57 NEORAL ........................... 45

see cyclosporine modified (for microemulsion)........ 45 see gengraf ................... 45

NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 49

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 56

neosporin solution ............. 49 NEPHRAMINE .................. 47 neptazane ......................... 20 NEPTAZANE

see methazolamide ....... 20 NESINA ............................ 32 neuac gel 1.2-5% .............. 52 NEULASTA ....................... 43 NEULASTA ONPRO KIT .. 43 NEUMEGA ........................ 43 NEUPOGEN ..................... 43 NEUPRO .......................... 26 NEURONTIN .................... 23

see gabapentin .............. 22 nevirapine ........................... 7 NEVIRAPINE ...................... 7 NEXAVAR ......................... 14 NEXIUM

see esomeprazole magnesium .................... 41

NEXIUM CAP 20MG ......... 42 NEXIUM CAP 40MG ......... 42 NEXIUM GRA 10MG DR .. 42 NEXIUM GRA 2.5MG DR . 42 NEXIUM GRA 20MG DR .. 42 NEXIUM GRA 40MG DR .. 42 NEXIUM GRA 5MG DR .... 42 NEXIUM I.V. ..................... 42

see esomeprazole sodium

inj .................................. 42 niacin er (antihyperlipidemic).......................................... 18 niacor ................................ 18 NIASPAN .......................... 18

see niacin er (antihyperlipidemic) ....... 18

nicardipine hcl ................... 19 NICOTROL INHALER ....... 30 NICOTROL NS ................. 30 nifedical ............................ 19 nifedipine .......................... 19 nifedipine er ...................... 19 nikki 28 day ....................... 35 NILANDRON .................... 14

see nilutamide ............... 14 nilutamide ......................... 14 nimodipine ........................ 19 NINLARO .......................... 13 NIPENT ............................ 13 nisoldipine ......................... 19 nitro-bid ............................. 21 NITRO-DUR ..................... 21

see minitran .................. 21 nitrofurantoin ....................... 6 nitrofurantoin macrocrystal . 6 nitrofurantoin monohyd macro .................................. 6 nitroglycerin ...................... 21 NITROGLYCERIN LINGUAL.......................................... 21 nitroglycerin patches ......... 21 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............ 21 NITROLINGUAL SPR PUMPSPRA ..................... 21 NITROMIST ...................... 21 NITROSTAT ..................... 21

see nitroglycerin ............ 21 nizatidine .......................... 40 NIZORAL .......................... 53

see ketoconazole shampoo ....................... 53

NORA-BE TAB ................. 35 norco ................................... 4 NORCO

see


80

hydrocodone-acetaminophen 5-325mg .....................3 see hydrocodone-acetaminophen 7.5-325mg ..................3 see hydrocodone-acetaminophen tab 10-325mg .............3 see lorcet hd tab 10-325mg ........................3 see lorcet plus tab 7.5-325 ........................................3 see lorcet tab 5-325mg ....3 see lortab tab 10-325mg..3 see lortab tab 5-325mg ...3 see lortab tab 7.5-325 .....3

NORDITROPIN FLEXPRO .......................................... 38 norethin acet & estrad-fe ... 35 norethindrone & ethinyl estradiol-fe ........................ 35 norethindrone (contraceptive) .................. 35 norethindrone acetate ....... 38 norethindrone acetate-ethinyl estradiol ............................ 36 norgest/ethi tab 0.25/35 .... 35 norgestimate-ethinyl estradiol (triphasic) ............ 35 NORINYL 1+35 ................. 35

see cyclafem 1/35 28 day ...................................... 33 see necon 1/35 28 day .. 35 see nortrel 1/35 21 day .. 35 see nortrel 1/35 28 day .. 35 see pirmella 1/35 28 day ...................................... 35

NORINYL 1+50 ................. 35 NORITATE ........................ 56 norlyroc 28 day ................. 35 NORMOSOL-M IN D5W ... 48 NORMOSOL-R ................. 48 NORPACE ........................ 17

see disopyramide phosphate ...................... 17

NORPACE CR .................. 17 NORPRAMIN .................... 25

see desipramine hcl ...... 24

NOR-QD ........................... 35 see camila 28 day ......... 33 see deblitane 28 day ..... 33 see heather ................... 34 see norethindrone (contraceptive) .............. 35 see norlyroc 28 day ....... 35

nortrel 0.5/35 28 day ......... 35 nortrel 1/35 21 day ............ 35 nortrel 1/35 28 day ............ 35 nortrel 7/7/7 28 day ........... 35 nortriptyline hcl .................. 25 NORVASC ........................ 19

see amlodipine besylate 19 NORVIR .............................. 7 NOVAREL INJ 10000UNT 38 NOVOLIN 70/30 ................ 31 NOVOLIN 70/30 RELION . 31 NOVOLIN N ...................... 31 NOVOLIN N RELION ........ 31 NOVOLIN R ...................... 31 NOVOLIN R RELION ........ 31 NOVOLOG ........................ 31 NOVOLOG FLEXPEN ...... 31 NOVOLOG MIX 70/30 ...... 31 NOVOLOG MIX 70/30 PREFILL ........................... 31 NOVOLOG PENFILL ........ 31 NOXAFIL ............................ 7 NPLATE ............................ 43 NUBAIN

see nalbuphine hcl .......... 2 NUCALA ........................... 51 NUCYNTA .......................... 4 NUCYNTA ER .................... 4 NUEDEXTA ...................... 29 NULOJIX ........................... 45 NULYTELY/FLAVOR PACKS .............................. 41

see gavilyte-n ................ 41 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 41 see trilyte ....................... 41

NUPLAZID ........................ 27 NUTRILIPID INJ 20% ....... 47 NUTROPIN AQ INJ

20MG/2ML ........................ 38 NUTROPIN AQ NUSPIN 10.......................................... 38 NUTROPIN AQ NUSPIN 20.......................................... 38 NUTROPIN AQ NUSPIN 5 38 NUTROPIN AQ PEN ........ 38 NUVARING ....................... 35 NUVESSA ........................ 43 NUVIGIL ........................... 30

see armodafinil .............. 30 nyamyc ............................. 53 NYMALIZE ........................ 19 nystatin ............................... 7 nystatin (mouth-throat) ...... 56 nystatin (topical)................ 53 nystatin pow 100000 ......... 53 nystop ............................... 53 O OCALIVA .......................... 41 OCELLA TAB 3-0.03MG ... 35 OCTAGAM ....................... 44 octreotide acetate ............. 38 OCUFEN .......................... 49

see flurbiprofen sodium . 49 OCUFLOX ........................ 49

see ofloxacin (ophth) ..... 49 ODEFSEY .......................... 8 ODOMZO ......................... 14 OFEV ................................ 51 ofloxacin (ophth) ............... 49 ofloxacin (otic) .................. 57 ogestrel 28 day ................. 35 olanzapine ........................ 27 olanzapine odt .................. 27 olopatadine hcl ................. 49 olopatadine hcl (nasal) ...... 50 OLUX ................................ 55

see clobetasol propionate ...................................... 54

OLUX-E see clobetasol propionate emulsion ........................ 54

OMECLAMOX-PAK .......... 41 omega-3-acid ethyl esters 18 omeprazole ....................... 42 OMEPRAZOLE-SODIUM BICARBONATE ................ 42


81

OMNARIS ......................... 51 OMNIPRED ....................... 49 OMNITROPE 10MG ......... 38 OMNITROPE 5.8MG ........ 38 OMNITROPE 5MG ........... 38 ONCASPAR ...................... 14 ondansetron hcl ................ 39 ondansetron hcl inj ............ 39 ondansetron hcl oral soln .. 39 ondansetron odt ................ 39 ONEXTON ........................ 52 ONFI ................................. 23 ONGLYZA ......................... 32 ONMEL ...............................7 ONZETRA XSAIL .............. 29 OPANA ...............................4

see oxymorphone hcl ......4 OPANA ER (CRUSH RESISTANT ........................4 OPDIVO ............................ 13 OPSUMIT.......................... 21 OPTIPRANOLOL .............. 50 ORACEA ........................... 56 ORAP ................................ 27

see pimozide ................. 27 ORAPRED ODT

see prednisolone sodium phosphate ...................... 37

ORAPRED ODT TAB 10MG .......................................... 37 ORAPRED ODT TAB 15MG .......................................... 37 ORAPRED ODT TAB 30MG .......................................... 37 ORAVIG ............................ 56 ORENCIA.......................... 44 ORENCIA CLICKJECT ..... 44 ORENITRAM TAB 0.125MG .......................................... 21 ORENITRAM TAB 0.25MG .......................................... 21 ORENITRAM TAB 1MG .... 21 ORENITRAM TAB 2.5MG . 21 ORFADIN .......................... 36 ORKAMBI ......................... 51 orsythia 28 day .................. 35 ORTHO MICRONOR ........ 35

see errin 28 day ............. 34

see lyza ......................... 34 see sharobel 28 day ...... 35

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 35 see tri-linyah tab ............ 35 see tri-previfem 28 day .. 36 see tri-sprintec 28 day ... 36

ORTHO TRI-CYCLEN LO . 35 see norgestimate-ethinyl estradiol (triphasic) ........ 35 see tri-lo- estarylla 28 day ...................................... 35 see tri-lo- tab marzia ...... 35 see tri-lo-sprintec 28 day ...................................... 35

ORTHO-CYCLEN ............. 35 see estarylla tab 0.25-35 ...................................... 34 see mono-linyah tab 0.25-35 .......................... 35 see norgest/ethi tab 0.25/35 .......................... 35 see previfem 28 day ...... 35 see sprintec 28 day ....... 35

ORTHO-NOVUM 1/35 ...... 35 ORTHO-NOVUM 7/7/7 ..... 35

see cyclafem 7/7/7 28 day ...................................... 33 see nortrel 7/7/7 28 day . 35

OSENI TAB 12.5-15MG .... 32 OSENI TAB 12.5-30MG .... 32 OSENI TAB 12.5-45MG .... 32 OSENI TAB 25-15MG ....... 32 OSENI TAB 25-30MG ....... 32 OSENI TAB 25-45MG ....... 32 OSMOPREP ..................... 41 OTEZLA ............................ 44 OTOVEL ........................... 57 OTREXUP ........................ 44 ovcon 35 28 day ............... 35 OVCON-35

see balziva 28 day......... 33 see briellyn 28 day ........ 33 see gildagia ................... 34 see philith ...................... 35 see vyfemla 28 day ....... 36 see zenchent tab ........... 36

ovide ................................. 56 OVIDE

see malathion ................ 56 oxacillin sodium ................ 11 oxaliplatin .......................... 15 OXANDRIN

see oxandrolone............ 30 oxandrolone ...................... 30 oxaprozin ............................ 1 oxcarbazepine .................. 23 oxiconazole nitrate cream . 53 OXISTAT .......................... 53

see oxiconazole nitrate cream ............................ 53

OXSORALEN ULTRA ....... 53 see methoxsalen rapid .. 53

OXTELLAR XR ................. 23 oxybutynin chloride ........... 42 oxycodone hcl ..................... 4 OXYCODONE HCL ............ 4 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 4 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone w/ acetaminophen soln 5-325 mg/5ml ................................ 4 oxycodone-aspirin............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone hcl ................ 4 OXYTROL ........................ 42 P pacerone ........................... 17 paclitaxel ........................... 13 paliperidone ...................... 27 PAMELOR ........................ 25

see nortriptyline hcl ....... 25 pamidronate disodium ...... 33 PAMINE ............................ 40

see methscopolamine bromide ......................... 40

PAMINE FORTE ............... 40 see methscopolamine


82

bromide ......................... 40 PANCREAZE .................... 41 PANDEL............................ 55 PANRETIN ........................ 56 pantoprazole sodium ......... 42 paricalcitol ......................... 48 PARICALCITOL ................ 48 PARLODEL

see bromocriptine mesylate ........................ 25

PARNATE ......................... 25 see tranylcypromine sulfate ............................ 25

paroex sol 0.12% .............. 56 paromomycin sulfate ...........5 paroxetine er tab ............... 25 paroxetine hcl tabs ............ 25 paser d/r ..............................8 PATADAY ......................... 49 PATANASE ....................... 50

see olopatadine hcl (nasal) ...................................... 50

PATANOL ......................... 49 see olopatadine hcl ....... 49

PAXIL ................................ 25 see paroxetine hcl tabs.. 25

PAXIL CR.......................... 25 see paroxetine er tab ..... 25

PAZEO .............................. 49 PCE .................................. 10 PEDIAPRED

see pred sod pho sol 5mg/5ml ......................... 37

pediapred sol 6.7/5ml ........ 37 PEDIARIX ......................... 46 PEDVAX HIB .................... 46 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 41 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 41 PEGANONE ...................... 23 PEGASYS ...........................9 PEGASYS PROCLICK .......9 PEGINTRON .......................9 PEG-INTRON REDIPEN.....9

PENICILLIN G POT IN DEXTROSE ...................... 11 PENICILLIN G POTASSIUM IN ...................................... 11 penicillin g procaine .......... 11 penicillin g sodium ............ 11 penicillin gk inj 20mu ......... 11 penicillin gk inj 5mu ........... 11 penicillin v potassium ........ 11 PENNSAID SOL 2% ......... 56 PENTACEL ....................... 46 PENTAM 300 ...................... 6 PENTASA ......................... 40 pentoxifylline ..................... 44 PEPCID

see famotidine ............... 40 PEPCID SUSP .................. 40 pepcid tab ......................... 40 PERCOCET

see endocet ..................... 2 see oxycodone w/ acetaminophen 10-325mg ........................................ 4 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 4 see oxycodone w/ acetaminophen 5-325mg . 4 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 4

percocet 10/325 .................. 4 percocet 2.5/325 ................. 4 percocet 7.5/325 ................. 4 percocet tab 5-325mg ......... 4 PERFOROMIST ............... 51 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 56 see paroex sol 0.12% .... 56 see periogard soln 0.12% ...................................... 57

perindopril erbumine ......... 16 periogard soln 0.12% ........ 57 PERJETA .......................... 13 permethrin ......................... 56 perphenazine .................... 27

PERTZYE ......................... 41 PEXEVA ........................... 25 pfizerpen-g inj 20mu ......... 11 pfizerpen-g inj 5mu ........... 11 phenadoz .......................... 39 phenelzine sulfate ............. 25 phenergan ........................ 39 PHENERGAN

see promethazine hcl .... 39 phenergan inj .................... 39 phenobarbital .................... 23 phenobarbital sodium ....... 23 PHENOBARBITAL SODIUM.......................................... 23 phenoxybenzamine hcl ..... 21 phenytek ........................... 23 PHENYTEK

see phenytoin sodium extended ....................... 23

phenytoin .......................... 23 phenytoin inj 50mg/ml ....... 23 phenytoin sodium extended.......................................... 23 philith ................................ 35 PHOSLO ........................... 38

see calcium acetate (phosphate binder) ........ 38

PHOSLYRA ...................... 38 PHOSPHOLINE IODIDE .. 50 PICATO ............................ 56 PILOCARPINE HCL ......... 50 pilocarpine hcl (oral) ......... 57 PILOCARPINE HCL (ORAL).......................................... 57 pimozide ........................... 27 pimtrea pack ..................... 35 pindolol ............................. 19 pioglitazone hcl ................. 32 pioglitazone hcl-glimepiride.......................................... 32 pioglitazone hcl-metformin hcl ..................................... 32 piperacillin sodium-tazobactam sodium.......................................... 11 pirmella 1/35 28 day ......... 35 piroxicam ............................ 1 PLAN B ONE-STEP


83

see levonorgestrel (emergency oc) ............. 34

PLAQUENIL ...................... 44 see hydroxychloroquine sulfate ............................ 44

PLASMA-LYTE A .............. 48 PLASMA-LYTE-148 .......... 48 PLASMA-LYTE-56/D5W ... 48 PLAVIX ............................. 44

see clopidogrel bisulfate 44 PLEGRIDY ........................ 29 PLEGRIDY STARTER PACK ................................ 29 plenamine ......................... 47 PLETAL TAB 50MG .......... 44 podofilox............................ 56 polyethylene glycol 3350 ... 41 polymyxin b sulfate .............6 polymyxin b-trimethoprim .. 49 POLYTRIM ........................ 49

see polymyxin b-trimethoprim ............... 49

POMALYST ...................... 14 PONSTEL ...........................1

see mefenamic acid ........1 portia 28 day ..................... 35 PORTRAZZA .................... 13 pot chloride inj 2meq/ml .... 48 potassium chloride ............ 46 POTASSIUM CHLORIDE 46, 48 POTASSIUM CHLORIDE 0.3%/D .............................. 48 potassium chloride caps er .......................................... 46 potassium chloride in nacl . 48 POTASSIUM CHLORIDE IN NACL ................................ 48 potassium chloride microencapsulated crystals cr ....................................... 46 POTASSIUM CHLORIDE TAB CR 10 MEQ ............... 46 potassium citrate (alkalinizer) .......................................... 42 POTASSIUM CITRATE (ALKALINIZER) ................. 42 POTIGA ............................ 23

PRADAXA ......................... 43 PRALUENT ....................... 18 pramipexole dihydrochloride .......................................... 26 PRANDIMET ..................... 32 PRANDIN .......................... 32

see repaglinide .............. 32 PRAVACHOL .................... 17

see pravastatin sodium . 17 pravastatin sodium ............ 17 prazosin hcl ....................... 16 PRECOSE ........................ 32

see acarbose ................. 31 PRED FORTE ................... 49 PRED MILD ...................... 49 pred sod pho sol 5mg/5ml . 37 PRED-G ............................ 48 PRED-G S.O.P. ................ 48 prednicarbate .................... 55 PREDNICARBATE ........... 55 PREDNISOLONE ACETATE (OPHTH) ........................... 49 prednisolone sodium phosphate ......................... 37 prednisolone sodium phosphate (ophth) ............. 49 prednisolone sol 15mg/5ml .......................................... 37 prednisolone sol 25mg/5ml .......................................... 37 prednisolone syrup 15 mg/5ml .............................. 37 prednisone con 5mg/ml ..... 37 prednisone pak 10mg ....... 37 prednisone pak 5mg ......... 37 prednisone sol 5mg/5ml .... 37 prednisone tab 10mg ........ 37 prednisone tab 1mg .......... 37 prednisone tab 2.5mg ....... 37 prednisone tab 20mg ........ 37 prednisone tab 50mg ........ 37 prednisone tab 5mg .......... 37 PREGNYL W/DILUENT BENZYL ............................ 38 PREMARIN CREAM ......... 36 PREMARIN INJ ................ 36 premasol 10% ................... 47 premasol 6% ..................... 47

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC).......................................... 48 PREPOPIK ....................... 41 PREVACID ....................... 42

see lansoprazole ........... 42 PREVACID SOLUTAB ...... 42 prevalite ............................ 18 previfem 28 day ................ 35 PREVPAC ........................ 41

see amoxicillin-clarithromycin w/ lansoprazole ............. 41

PREZCOBIX ....................... 8 PREZISTA .......................... 7 PRIFTIN .............................. 8 PRILOSEC

see omeprazole............. 42 PRILOSEC PACK ............. 42 PRIMAQUINE PHOSPHATE............................................ 7 PRIMAXIN .......................... 6 PRIMAXIN IV

see imipenem-cilastatin ... 6 primidone .......................... 23 PRIMSOL ........................... 6 PRINIVIL ........................... 16

see lisinopril .................. 15 PRISTIQ ........................... 25 PRIVIGEN ........................ 44 PROAIR HFA .................... 51 PROAIR RESPICLICK ...... 51 probenecid .......................... 1 PROCALAMINE................ 47 PROCARDIA XL ............... 19

see nifedical .................. 19 see nifedipine er ............ 19

prochlorperazine inj 5 mg/ml.......................................... 39 prochlorperazine maleate . 39 prochlorperazine supp ...... 39 PROCRIT ......................... 43 procto-med ....................... 53 procto-pak ......................... 53 proctosol hc 2.5 % ............ 53 proctozone hc ................... 53 PROCYSBI ....................... 36 progesterone micronized .. 38


84

PROGLYCEM SUS 50MG/ML .......................... 37 PROGRAF ........................ 45

see tacrolimus ............... 45 PROLASTIN-C .................. 51 PROLENSA ...................... 50 PROLEUKIN ..................... 13 PROLIA ............................. 38 PROMACTA ...................... 44 promethazine hcl ............... 39 promethegan ..................... 39 PROMETRIUM ................. 38

see progesterone micronized ..................... 38

propafenone hcl ................ 17 propafenone hcl 12hr ........ 17 proparacaine hcl ............... 50 propranolol & hydrochlorothiazide ........... 18 propranolol hcl er .............. 19 propranolol inj 1mg/ml ....... 19 propranolol sol .................. 19 propranolol tab .................. 19 propylthiouracil .................. 39 PROQUAD ........................ 46 PROSCAR ........................ 42

see finasteride ............... 42 PROSOL ........................... 47 PROTONIX ....................... 42

see pantoprazole sodium ...................................... 42

PROTONIX INJ ................. 42 PROTOPIC ....................... 56

see tacrolimus (topical).. 56 protriptyline hcl .................. 25 PROVENTIL HFA ............. 51 PROVERA ........................ 38

see medroxyprogesterone acetate........................... 38

PROVIGIL ......................... 30 see modafinil ................. 30

PROZAC ........................... 25 see fluoxetine cap 10mg 24 see fluoxetine cap 20mg 24 see fluoxetine cap 40mg 24

PROZAC WEEKLY ........... 25 see fluoxetine hcl ........... 25

PRUDOXIN CRE 5% ........ 53

psorcon ............................. 55 PULMICORT

see budesonide (inhalation) .................... 51

PULMICORT FLEXHALER .......................................... 51 PULMICORT INH SUSP 0.25MG/2 ML .................... 51 PULMICORT INH SUSP 0.5MG/2 ML ...................... 51 PULMICORT INH SUSP 1MG/2ML .......................... 52 PULMOZYME ................... 51 PURIXAN .......................... 13 PYLERA ............................ 41 pyrazinamide ...................... 8 pyridostigmine bromide ..... 29 Q QBRELIS .......................... 16 QNASL .............................. 51 QNASL CHILDRENS ........ 51 QUADRACEL ................... 46 QUALAQUIN ....................... 7

see quinine sulfate .......... 7 QUARTETTE .................... 35 quasense 91 day .............. 35 QUDEXY XR ..................... 23 questran ............................ 18 QUESTRAN

see cholestyramine ....... 18 QUESTRAN LIGHT

see cholestyramine light 18 see prevalite .................. 18

questran lite ...................... 18 quetiapine fumarate .......... 27 QUILLICHEW ER ............. 28 QUILLIVANT XR ............... 28 quinapril hcl ....................... 16 quinapril-hydrochlorothiazide .......................................... 15 quinidine gluconate ........... 17 quinidine sulfate ................ 17 quinine sulfate ..................... 7 QVAR ................................ 52 R RABAVERT ...................... 46 rabeprazole sodium .......... 42 RAGWITEK ....................... 44

raloxifene hcl .................... 38 ramipril .............................. 16 RANEXA ........................... 21 ranitidine hcl ..................... 40 ranitidine hcl inj ................. 40 RAPAFLO ......................... 42 RAPAMUNE ..................... 45

see sirolimus ................. 45 RASUVO .......................... 44 RAVICTI ........................... 36 RAYOS TAB 1MG ............ 37 RAYOS TAB 2MG ............ 37 RAYOS TAB 5MG ............ 37 RAZADYNE ...................... 24

see galantamine hydrobromide ................ 24

RAZADYNE ER ................ 24 see galantamine hydrobromide er ............ 24

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

REBIF ............................... 29 REBIF REBIDOSE ............ 29 REBIF REBIDOSE TITRATION ....................... 29 REBIF TITRATION PACK 30 RECLAST ......................... 33

see zoledronic inj 5/100ml ...................................... 33

reclipsen 28 day................ 35 RECOMBIVAX HB ............ 46 RECTIV ............................ 56 REGLAN ........................... 39

see metoclopramide hcl 39 REGRANEX ..................... 56 RELENZA DISKHALER ...... 9 RELISTOR ........................ 41 RELPAX ........................... 29 REMERON ....................... 25

see mirtazapine ............. 25 REMERON SOLTAB ........ 25

see mirtazapine ............. 25 REMICADE ....................... 44 REMODULIN .................... 21 RENAGEL ........................ 38 RENVELA PAK ................. 38 RENVELA TAB 800MG .... 38


85

repaglinide ........................ 32 repaglinide-metformin hcl .. 32 REPREXAIN

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

reprexain tab 10-200mg ......4 reprexain tab 2.5-200mg .....4 reprexain tab 5-200mg ........4 REQUIP ............................ 26

see ropinirole hydrochloride ................. 26

REQUIP XL ....................... 26 see ropinirole hydrochloride ................. 26

RESCRIPTOR ....................7 RESTASIS ........................ 50 RESTORIL ........................ 28

see temazepam ............. 28 RETIN-A............................ 52

see tretinoin ................... 52 RETIN-A MICRO ............... 52 RETIN-A MICRO PUMP ... 52 RETROVIR

see zidovudine ................8 RETROVIR CAPS ...............7 RETROVIR IV INFUSION ...7 RETROVIR SYRP ...............7 REVATIO .......................... 21

see sildenafil citrate (pulmonary hypertension) ...................................... 21

REVLIMID ......................... 44 REXULTI ........................... 27 REYATAZ ...........................7 RHEUMATREX ................. 44 RHINOCORT AQUA ......... 51

see budesonide (nasal) . 51 ribapak mis 600/day ............9 ribasphere ...........................9 ribasphere ribapak 1000 .....9 ribasphere ribapak 1200 .....9 ribasphere ribapak 800 .......9 ribavirin 200mg ...................9 rifabutin ...............................8 rifadin ..................................8 RIFADIN..............................8

see rifampin ..................... 8 rifamate ............................... 8 rifampin ............................... 8 RIFATER ............................ 8 RILUTEK ........................... 29

see riluzole .................... 29 riluzole .............................. 29 rimantadine hydrochloride ... 9 RINGER'S ......................... 48 RIOMET ............................ 32 risedronate sodium ........... 33 RISEDRONATE SODIUM . 33 RISPERDAL ..................... 27

see risperidone .............. 27 RISPERDAL INJ 12.5MG . 27 RISPERDAL INJ 25MG .... 27 RISPERDAL INJ 37.5MG . 27 RISPERDAL INJ 50MG .... 27 RISPERDAL M-TAB ......... 27

see risperidone odt ........ 27 risperidone ........................ 27 risperidone odt .................. 27 RITALIN ............................ 28

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

see methylphenidate hcl 28 RITUXAN .......................... 13 rivastigmine tartrate .......... 24 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 24 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 24 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 24 rizatriptan benzoate .......... 29 ROBINUL .......................... 40

see glycopyrrolate ......... 40 ROBINUL FORTE ............. 40

see glycopyrrolate ......... 40 ROCALTROL .................... 48

see calcitriol .................. 48 rocephin ............................ 10 ROCEPHIN

see ceftriaxone sodium ... 9 ropinirole hydrochloride..... 26 rosadan cre 0.75% ............ 56 rosuvastatin calcium ......... 17 ROTARIX .......................... 46

ROTATEQ ........................ 46 ROWASA .......................... 40

see mesalamine enema 40 roweepra ........................... 23 ROXICODONE ................... 4

see oxycodone hcl .......... 4 ROZEREM ........................ 28 RUCONEST ..................... 44 RYTARY ........................... 26 RYTHMOL ........................ 17

see propafenone hcl ...... 17 RYTHMOL SR .................. 17

see propafenone hcl ...... 17 see propafenone hcl 12hr ...................................... 17

S SABRIL ............................. 23 SAIZEN ............................. 38 SAIZEN CLICK.EASY ....... 38 SALAGEN ......................... 57

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

SAMSCA .......................... 38 SANCUSO ........................ 39 SANDIMMUNE

see cyclosporine ........... 45 SANDIMMUNE CAPS ...... 45 SANDIMMUNE INJ ........... 45 SANDIMMUNE SOLN ...... 45 SANDOSTATIN ................ 38

see octreotide acetate ... 38 SANDOSTATIN LAR DEPOT ............................. 38 SANTYL ............................ 56 SAPHRIS .......................... 27 SARAFEM ........................ 30 SAVAYSA ......................... 43 SAVELLA .......................... 29 SAVELLA TITRATION PACK ................................ 29 SEASONIQUE .................. 35

see amethia 91 day ....... 33 see ashlyna 91 day ....... 33 see levonorgestrel-ethinyl estradiol (91-day) .......... 34

SECTRAL ......................... 19 see acebutolol hcl ......... 18

SEEBRI NEOHALER ........ 50


86

selegiline hcl ..................... 26 selenium sulfide ................ 54 SELZENTRY .......................7 SEMPREX-D ..................... 50 SENSIPAR ........................ 33 SEREVENT DISKUS ........ 51 SERNIVO .......................... 55 SEROQUEL ...................... 27

see quetiapine fumarate 27 SEROQUEL XR ................ 27 SEROSTIM ....................... 38 sertraline hcl ...................... 25 setlakin tab ........................ 35 SF-ROWASA .................... 40 sharobel 28 day ................ 35 SIGNIFOR ......................... 38 SIGNIFOR LAR ................. 38 sildenafil citrate (pulmonary hypertension) .................... 21 SILENOR .......................... 28 SILVADENE ...................... 53 SILVER SULFADIAZINE... 53 SIMBRINZA SUS 1-0.2% .. 50 SIMPONI ........................... 44 SIMPONI ARIA ................. 44 SIMULECT ........................ 45 simvastatin ........................ 17 SINEMET .......................... 26

see carbidopa-levodopa 25 SINEMET CR .................... 26

see carbidopa-levodopa 25 SINGULAIR ....................... 51

see montelukast sodium 51 sirolimus ............................ 45 SIROLIMUS ...................... 45 SIRTURO ............................8 SIVEXTRO ..........................6 SKLICE ............................. 56 SMOFLIPID ....................... 47 SODIUM CHLORIDE .. 46, 48 SODIUM CHLORIDE 0.45% VIA .................................... 48 SODIUM CHLORIDE 0.9% .......................................... 56 SODIUM DIURIL ............... 20 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 46

sodium phenylbutyrate ...... 36 sodium polystyrene sulfonate .......................................... 33 SOLARAZE ....................... 56

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

SOLIRIS ............................ 44 SOLODYN ........................ 12 SOLTAMOX ...................... 14 SOLU-CORTEF 1000MG . 37 SOLU-CORTEF 100MG ... 37 SOLU-CORTEF 250MG ... 37 SOLU-CORTEF 500MG ... 37 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 37 see methylpr ss inj 1gm . 37 see methylpr ss inj 40mg ...................................... 37

SOLU-MEDROL INJ 125MG .......................................... 37 SOLU-MEDROL INJ 1GM 37 SOLU-MEDROL INJ 2GM 37 SOLU-MEDROL INJ 40MG .......................................... 37 SOLU-MEDROL INJ 500MG .......................................... 37 SOMATULINE DEPOT ..... 38 SOMAVERT ...................... 38 SOOLANTRA .................... 56 SORIATANE ..................... 53

see acitretin ................... 53 SORILUX .......................... 53 sorine ................................ 17 sotalol hcl .......................... 17 sotalol hcl (afib/afl) ............ 17 SOTYLIZE ........................ 19 SOVALDI ............................ 9 SPIRIVA HANDIHALER .... 50 SPIRIVA RESPIMAT ........ 50 spironolactone .................. 16 spironolactone & hydrochlorothiazide ........... 20 SPORANOX ....................... 7

see itraconazole .............. 7 SPORANOX PULSEPAK .... 7 SPORANOX SOL 10MG/ML ............................................ 7

sprintec 28 day ................. 35 SPRITAM .......................... 23 SPRYCEL ......................... 14 sps .................................... 33 sronyx 28 day ................... 35 SSD .................................. 53 STALEVO ......................... 26 STARLIX ........................... 32

see nateglinide .............. 32 stavudine ............................ 7 STELARA ......................... 53 STERILE WATER IRRIGATION ..................... 56 STIMATE .......................... 39 STIOLTO RESPIMAT ....... 50 STIVARGA ....................... 14 STRATTERA .................... 28 STRENSIQ ....................... 36 streptomycin sulfate ............ 5 STRIANT .......................... 30 STRIBILD ........................... 8 STRIVERDI RESPIMAT ... 51 STROMECTOL ................... 6

see ivermectin ................. 6 SUBOXONE MIS 12-3MG 30 SUBOXONE MIS 2-0.5MG.......................................... 30 SUBOXONE MIS 4-1MG .. 30 SUBOXONE MIS 8-2MG .. 30 SUBSYS ............................. 4 SUCLEAR ......................... 41 SUCRAID ......................... 41 sucralfate .......................... 41 SULAR .............................. 19

see nisoldipine .............. 19 sulfacet sod oin 10% op .... 49 sulfacetamide sodium (acne).......................................... 52 sulfacetamide sodium (ophth) .............................. 49 sulfacetamide sod-prednisolone .............. 48 sulfadiazine ......................... 5 sulfamethoxazole-trimethop 6 sulfamethoxazole-trimethoprim inj .................................... 6 SULFAMYLON ................. 53 sulfasalazine dr ................. 40


87

sulfasalazine ir .................. 40 sulindac ...............................1 sumatriptan inj 4mg/0.5ml . 29 SUMATRIPTAN INJ 4MG/0.5ML ....................... 29 sumatriptan inj 6mg/0.5ml . 29 SUMATRIPTAN INJ 6MG/0.5ML ....................... 29 sumatriptan succinate ....... 29 SUMATRIPTAN SUCCINATE ..................... 29 SUMAVEL DOSEPRO ...... 29 suprax ............................... 10 SUPRAX ........................... 10

see cefixime ....................9 SUPREP BOWEL PREP... 41 SURMONTIL ..................... 25

see trimipramine maleate ...................................... 25

SUSTIVA.............................8 SUSTOL............................ 39 SUTENT............................ 14 syeda ................................ 35 SYLATRON KIT 200MCG . 14 SYLATRON KIT 300MCG . 14 SYLATRON KIT 600MCG . 14 SYLVANT.......................... 14 SYMBICORT ..................... 52 SYMLINPEN 120 .............. 31 SYMLINPEN 60 ................ 31 SYNAGIS .......................... 46 SYNALAR ......................... 55

see fluocinolone acetonide ................................ 54, 55

SYNALGOS-DC ..................2 SYNAREL ......................... 36 SYNERA ........................... 55 SYNERCID .........................6 SYNJARDY ....................... 32 SYNRIBO .......................... 14 SYNTHROID ..................... 39

see levothyroxine sodium ...................................... 39

SYPRINE .......................... 33 T TABLOID........................... 13 TACLONEX ....................... 55

see

calcipotriene/betamethasone .................................. 54

tacrolimus ......................... 45 tacrolimus (topical) ............ 56 TAFINLAR ........................ 14 TAGRISSO ....................... 14 TALTZ ............................... 53 TAMIFLU ............................ 9 tamoxifen citrate ............... 14 tamsulosin hcl ................... 42 TANZEUM ........................ 31 tapazole ............................ 39 TAPAZOLE

see methimazole ........... 39 TARCEVA ......................... 14 TARGRETIN ............... 14, 56

see bexarotene ............. 14 tarina fe 1/20 28 day ......... 35 TARKA .............................. 15

see trandolapril-verapamil hcl.................................. 15

TASIGNA .......................... 14 TAXOTERE ...................... 13 tazicef ............................... 10 tazicef vial ......................... 10 TAZORAC ......................... 53 taztia xt ............................. 20 TECENTRIQ ..................... 13 TECFIDERA CAP 120MG 30 TECFIDERA CAP 240MG 30 TECFIDERA MIS STARTER .......................................... 30 TEFLARO ......................... 10 TEGRETOL ...................... 23

see carbamazepine ....... 22 see epitol ....................... 22

TEGRETOL-XR ................ 23 see carbamazepine ....... 22

TEKTURNA ...................... 20 TEKTURNA HCT .............. 20 telmisartan ........................ 17 telmisartan-amlodipine ...... 16 telmisartan-hydrochlorothiazide ...................................... 16 temazepam ....................... 28 TEMOVATE

see clobetasol propionate ...................................... 54

see cormax ................... 54 TEMOVATE CREAM ........ 55 TEMOVATE E

see clobetasol e cream 0.05% ............................ 54

TEMOVATE E CREAM ..... 55 TEMOVATE GEL .............. 55 TEMOVATE OIN............... 55 TEMOVATE SOLN ........... 55 TENIVAC .......................... 46 TENORETIC 100 .............. 18

see atenolol & chlorthalidone ................ 18

TENORETIC 50 ................ 18 see atenolol & chlorthalidone ................ 18

TENORMIN ...................... 19 see atenolol ................... 18

TERAZOL 3 ...................... 43 see terconazole vaginal 43

TERAZOL 7 ...................... 43 see terconazole vaginal 43

terazosin hcl ..................... 16 terbinafine hcl ..................... 7 terbutaline sulfate ............. 51 terconazole vaginal ........... 43 TESTIM ............................ 31 TESTOSTERONE ............ 31 testosterone cypionate ...... 31 testosterone enanthate ..... 31 TETANUS/DIPHTHERIA TOXOID ............................ 46 tetrabenazine .................... 29 TETRACYCLINE HCL ...... 12 texacort ............................. 55 THALOMID ....................... 44 theo-24 ............................. 52 theophylline ...................... 52 thioridazine hcl .................. 27 thiotepa ............................. 12 thiothixene ........................ 27 THYMOGLOBULIN ........... 45 tiagabine hcl ..................... 23 TIAZAC ............................. 20

see diltiazem hcl er ....... 19 see diltiazem hcl extended release beads................ 19 see taztia xt ................... 20


88

TIKOSYN .......................... 17 see dofetilide ................. 17

timolol maleate .................. 19 timolol maleate (ophth) ..... 50 TIMOLOL MALEATE GEL 50 TIMOPTIC ......................... 50

see timolol maleate (ophth) ........................... 50

TIMOPTIC OCUDOSE ...... 50 TIMOPTIC-XE ................... 50 TIROSINT ......................... 39 TIVICAY ..............................8 tizanidine ........................... 30 TOBI NEB ...........................5 TOBI PODHALER ...............5 TOBRADEX ...................... 48

see tobramycin-dexamethasone .................................... 48

TOBRADEX ST ................. 48 tobramycin ..........................5 tobramycin (ophth) ............ 49 tobramycin sulfate ...............5 tobramycin-dexamethasone .......................................... 48 TOBREX

see tobramycin (ophth) .. 49 TOBREX OINT 0.3% ........ 49 TOBREX SOL 0.3% OP .... 49 tofranil ............................... 25 TOFRANIL

see imipramine hcl ........ 25 TOLAK .............................. 56 tolmetin sodium ...................1 tolterodine tartrate er ......... 42 tolterodine tartrate tab 1 mg .......................................... 42 tolterodine tartrate tab 2 mg .......................................... 42 TOPAMAX ........................ 23

see topiramate ............... 23 TOPAMAX SPRINKLE ...... 23

see topiramate ............... 23 topicort .............................. 55 TOPICORT ....................... 55

see desoximetasone ..... 54 TOPICORT SPRAY 0.25% .......................................... 55

topiramate ......................... 23 TOPIRAMATE .................. 23 toposar .............................. 15 topotecan hcl .................... 15 TOPROL XL ...................... 19

see metoprolol succinate ...................................... 19

TORISEL .......................... 13 torsemide inj 50mg/5ml ..... 20 torsemide tabs .................. 20 TOUJEO SOLOSTAR ....... 31 TOVIAZ ............................. 42 TPN ELECTROLYTES ..... 46 TRACLEER ....................... 21 TRADJENTA ..................... 32 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 TRAMADOL HCL ER .......... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 trandolapril ........................ 16 trandolapril-verapamil hcl .. 15 tranexamic acid ................. 44 TRANSDERM-SCOP ........ 39 TRANXENE T ................... 23

see clorazepate dipotassium ................... 22

tranylcypromine sulfate ..... 25 TRAVASOL ....................... 47 TRAVATAN Z ................... 50 trazodone hcl .................... 25 TREANDA ......................... 12 TRECATOR ........................ 8 TRELSTAR MIXJECT ....... 14 TRESIBA FLEXTOUCH .... 31 tretinoin ....................... 15, 52 TRETINOIN ...................... 52 TRETINOIN MICROSPHERE ............... 52 tretin-x ............................... 52 trexall ................................ 44 TREXIMET ........................ 29

trezix ................................... 2 triamcinolone acetonide (mouth) ............................. 57 TRIAMCINOLONE ACETONIDE (NASAL) ...... 51 triamcinolone acetonide (topical) ............................. 55 triamt/hctz cap 37.5-25 ..... 20 triamt/hctz cap 50-25mg ... 20 triamt/hctz tab 37.5-25 ...... 21 triamt/hctz tab 75-50mg .... 21 trianex ............................... 55 TRIBENZOR ..................... 16 TRICOR ............................ 18

see fenofibrate .............. 18 triderm .............................. 55 trifluoperazine hcl.............. 27 trifluridine .......................... 49 TRIGLIDE ......................... 18 tri-legest 28 day ................ 35 TRILEPTAL

see oxcarbazepine ........ 23 TRILEPTAL SUSP ............ 23 TRILEPTAL TABS ............ 23 tri-linyah tab ...................... 35 TRILIPIX ........................... 18

see choline fenofibrate .. 18 tri-lo- estarylla 28 day ....... 35 tri-lo- tab marzia ................ 35 tri-lo-sprintec 28 day ......... 35 trilyte ................................. 41 trimethoprim ........................ 6 trimipramine maleate ........ 25 TRINESSA ........................ 36 TRINESSA LO TAB .......... 36 TRI-NORINYL 28 .............. 35

see aranelle 28.............. 33 see leena tab ................ 34

TRINTELLIX ..................... 25 TRIOSTAT ........................ 39

see liothyronine sodium 39 tri-previfem 28 day ............ 36 TRISENOX ....................... 15 tri-sprintec 28 day ............. 36 TRIUMEQ ........................... 8 trivora 28 day .................... 36 TRIZIVIR ............................. 8

see abacavir


89

sulfate-lamivudine-zidovudine ...................................8

TROKENDI XR ................. 23 TROPHAMINE INJ 10% ... 47 TROPHAMINE INJ 6% ..... 47 trospium chloride ............... 42 trospium chloride er .......... 42 TRULICITY ....................... 31 TRUMENBA ...................... 46 TRUSOPT ......................... 50

see dorzolamide hcl ...... 50 TRUVADA TAB 100-150 .....8 TRUVADA TAB 133-200 .....8 TRUVADA TAB 167-250 .....8 TRUVADA TAB 200-300 .....8 TUDORZA PRESSAIR ..... 50 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 50 TWINRIX INJ .................... 46 TWYNSTA ........................ 16

see telmisartan-amlodipine ...................................... 16

TYBOST..............................8 TYGACIL.............................6 TYKERB............................ 14 tylenol with codeine .............2 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................2

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................2

TYPHIM VI ........................ 46 TYSABRI........................... 30 TYVASO ........................... 21 TYZEKA ..............................9 tyzine ................................ 51 U UCERIS AER 2MG/ACT ... 40 UCERIS TAB 9MG ............ 40 ULORIC ..............................1 ULTRACET .........................2

see tramadol-acetaminophen .2

ULTRAM see tramadol hcl tab 50 mg ...................................2

ULTRAM ER TAB 100MG...2

ULTRAM ER TAB 200MG .. 2 ULTRAM ER TAB 300MG .. 2 ULTRAM TAB 50MG .......... 2 ULTRAVATE ..................... 55

see halobetasol propionate ..................... 55

ULTRESA ......................... 41 UNASYN ........................... 11

see ampicillin & sulbactam sodium ........................... 11

UNASYN BULK PACK ...... 11 see ampicillin & sulbactam sodium ........................... 11

UNITHROID ...................... 39 UPTRAVI .......................... 21 urecholine ......................... 42 URECHOLINE

see bethanechol chloride ...................................... 42

UROCIT-K ........................ 42 UROCIT-K 15

see potassium citrate (alkalinizer) .................... 42

UROXATRAL .................... 42 see alfuzosin hcl ............ 42

URSO 250 ........................ 41 see ursodiol ................... 41

URSO FORTE .................. 41 see ursodiol ................... 41

ursodiol ............................. 41 UTIBRON NEOHALER ..... 50 UVADEX ........................... 15 V VAGIFEM .......................... 36 valacyclovir hcl .................... 9 VALCHLOR ...................... 56 VALCYTE ........................... 9

see valganciclovir hcl ...... 9 valganciclovir hcl ................. 9 VALIUM ............................ 23

see diazepam ................ 22 valproate sodium .............. 23 valproic acid ...................... 23 valsartan ........................... 17 valsartan-hydrochlorothiazide ........................................ 16 VALSTAR ......................... 12 VALTREX ........................... 9

see valacyclovir hcl ......... 9 VANCOCIN HCL................. 6

see vancomycin hcl ......... 6 vancomycin hcl ................... 6 vancomycin hcl inj 1000mg . 6 vancomycin hcl inj 10gm ..... 6 vancomycin hcl inj 500mg ... 6 vancomycin hcl inj 5gm ....... 6 vancomycin hcl inj 750mg ... 6 VANCOMYCIN IN NACL .... 6 VANDAZOLE .................... 43 VANOS ............................. 55

see fluocinonide ............ 55 VANTAS ........................... 14 VAQTA ............................. 46 VARIVAX .......................... 46 VARUBI ............................ 39 VASCEPA ......................... 18 VASERETIC ..................... 15

see enalapril maleate & hydrochlorothiazide ....... 15

VASOTEC ........................ 16 see enalapril maleate .... 15

VECTIBIX ......................... 13 VECTICAL ........................ 53 VELCADE ......................... 13 VELETRI ........................... 21 velivet 28 day .................... 36 VELPHORO ...................... 38 VELTASSA ....................... 33 VELTIN ............................. 52 VENCLEXTA .................... 13 VENCLEXTA STARTING PACK ................................ 13 venlafaxine cap er............. 25 venlafaxine hcl .................. 25 VENLAFAXINE HCL ER

see venlafaxine tab er ... 25 VENLAFAXINE HCL ER TAB (VERT) ...................... 25 venlafaxine tab ................. 25 VENLAFAXINE TAB 225MG ER ..................................... 25 venlafaxine tab er ............. 25 VENTAVIS ........................ 21 VENTOLIN HFA................ 51 VERAMYST ...................... 51 verapamil hcl .................... 20


90

VERAPAMIL HCL ............. 20 VERELAN ......................... 20

see verapamil hcl .......... 20 VERELAN PM ................... 20

see verapamil hcl .......... 20 veripred ............................. 37 VERSACLOZ .................... 27 VESICARE ........................ 42 vestura .............................. 36 VEXOL .............................. 49 VFEND

see voriconazole .............7 VFEND IV ...........................7

see voriconazole inj 200mg .............................7

VFEND SUS 40MG/ML .......7 VFEND TAB ........................7 VIBERZI ............................ 41 VIBRAMYCIN .................... 12

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

vicodin .................................4 vicodin es ............................4 vicodin hp ............................4 VICOPROFEN

see hydrocodone-ibuprofen tab 7.5-200 mg ......................3

VICTOZA .......................... 31 VIDAZA ............................. 13

see azacitidine ............... 12 VIDEX EC ...........................8

see didanosine ................7 VIDEX PEDIATRIC .............8 vienva 28 day .................... 36 VIGAMOX ......................... 49 VIIBRYD............................ 25 VIIBRYD STARTER PACK .......................................... 25 VIMIZIM ............................ 36 VIMOVO..............................1 VIMPAT............................. 23 vinblastine sulfate ............. 13 vincasar............................. 13 vincristine sulfate .............. 13 vinorelbine tartrate ............ 13 VIOKACE 10 ..................... 41

VIOKACE 20 ..................... 41 viorele ............................... 36 VIRACEPT .......................... 8 VIRAMUNE ......................... 8

see nevirapine ................. 7 VIRAMUNE XR ................... 8

see nevirapine ................. 7 VIREAD .............................. 8 VIROPTIC ......................... 49

see trifluridine ................ 49 VITEKTA ............................. 8 VIVELLE-DOT .................. 37

see estradiol .................. 36 VIVITROL ......................... 30 VIVLODEX .......................... 1 VOGELXO ........................ 31 VOGELXO PUMP ............. 31 VOLTAREN

see diclofenac sodium (topical) 1% gel ............. 56

VOLTAREN GEL 1% ........ 56 voriconazole ........................ 7 voriconazole inj 200mg ....... 7 vospire .............................. 51 VOSPIRE ER

see albuterol sulfate er .. 51 VOTRIENT ........................ 14 VPRIV ............................... 36 VRAYLAR ......................... 27 vyfemla 28 day .................. 36 VYTORIN .......................... 18 VYVANSE ......................... 28 W warfarin sodium ................ 43 WELCHOL ........................ 18 WELLBUTRIN SR ............. 25

see bupropion hcl .......... 24 WELLBUTRIN TAB 75MG 25 WELLBUTRIN XL ............. 25

see bupropion hcl .......... 24 WESTCORT

see hydrocortisone valerate ......................... 55

wymzya fe ......................... 36 X XALATAN ......................... 50

see latanoprost .............. 50 XALKORI .......................... 14

XANAX see alprazolam .............. 21

XANAX TAB 0.25MG ........ 22 XANAX TAB 0.5MG .......... 22 XANAX TAB 1MG ............. 22 XANAX TAB 2MG ............. 22 XARELTO ......................... 43 XARELTO STARTER PACK.......................................... 43 XARTEMIS XR ................... 4 XELJANZ .......................... 44 XELJANZ XR .................... 44 XENAZINE ........................ 29

see tetrabenazine .......... 29 XEOMIN 100UNIT ............ 30 XEOMIN 200UNIT ............ 30 XEOMIN 50UNIT .............. 30 XERESE ........................... 56 XGEVA ............................. 38 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 41 XIGDUO XR TAB 10-1000MG ....................... 32 XIGDUO XR TAB 10-500MG.......................................... 32 XIGDUO XR TAB 5-1000MG.......................................... 32 XIGDUO XR TAB 5-500MG.......................................... 32 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 3 see hydrocodone-acetaminophen 5-300mg ..................... 3 see hydrocodone-acetaminophen 7.5-300mg .................. 3 see vicodin ...................... 4 see vicodin es ................. 4 see vicodin hp ................. 4

xodol tab 10-300mg ............ 5 xodol tab 5-300mg .............. 5 xodol tab 7.5-300 ................ 5 XOLAIR ............................ 51 XOPENEX ........................ 51

see levalbuterol hcl ....... 51


91

XOPENEX CONCENTRATE .......................................... 51

see levalbuterol conc 1.25mg/0.5ml ................. 51

XOPENEX HFA ................ 51 XTAMPZA ER .....................5 XTANDI ............................. 14 xulane dis 150-35 .............. 36 XYLOCAINE ................. 5, 55

see lidocaine hcl ............ 55 see lidocaine hcl (local anesth.) ...........................5 see lidocaine inj 1% .........5 see lidocaine inj 2% .........5

XYLOCAINE-MPF ...............5 see lidocaine hcl (local anesth.) ...........................5 see lidocaine inj 0.5% ......5 see lidocaine inj 1.5% ......5 see lidocaine inj 2% .........5

xylon tab 10-200mg ............5 XYREM ............................. 30 XYZAL .............................. 50

see levocetirizine soln 2.5mg/5ml ...................... 50 see levocetirizine tab 5 mg ...................................... 50

Y YASMIN 28 ....................... 36

see drospirenone-ethinyl estradiol ......................... 33 see syeda ...................... 35 see zarah ....................... 36

YAZ ................................... 36 see drospirenone-ethinyl estradiol ......................... 34 see loryna 28 day .......... 34 see nikki 28 day ............. 35 see vestura .................... 36

YERVOY ........................... 13 YF-VAX ............................. 46 Z zafirlukast .......................... 51 ZALTRAP .......................... 13 zamicet ...............................5 ZANAFLEX ....................... 30

see tizanidine ................ 30 ZANOSAR ......................... 12

ZANTAC ........................... 40 see ranitidine hcl ........... 40

zarah ................................. 36 zarontin ............................. 23 ZARONTIN ....................... 23

see ethosuximide .......... 22 ZAVESCA ......................... 36 ZAZOLE CRE 0.8% .......... 43 ZEBETA ............................ 19

see bisoprolol fumarate . 18 ZEGERID .......................... 42 ZELAPAR ......................... 26 ZELBORAF ....................... 14 ZEMAIRA .......................... 51 ZEMBRACE SYMTOUCH 29 ZEMPLAR ......................... 48

see paricalcitol .............. 48 zenatane ........................... 53 zenchent fe 28 day ........... 36 zenchent tab ..................... 36 ZENPEP ........................... 41 ZERBAXA ......................... 10 ZERIT ................................. 8

see stavudine .................. 7 ZESTORETIC ................... 15

see lisinopril & hydrochlorothiazide ....... 15

ZESTRIL ........................... 16 see lisinopril .................. 15

ZETIA TAB 10MG ............. 18 ZETONNA ......................... 51 ZIAC.................................. 18

see bisoprolol & hydrochlorothiazide ....... 18

ZIAGEN .............................. 8 see abacavir sulfate ........ 7

ZIANA ............................... 53 see clindamycin phosphate-tretinoin........ 52

zidovudine ........................... 8 ZINACEF .......................... 10

see cefuroxime sodium . 10 ZINECARD ....................... 15

see dexrazoxane ........... 15 ZIOPTAN .......................... 50 ziprasidone hcl .................. 27 ZIPSOR .............................. 1 ZIRGAN ............................ 49

ZITHROMAX .................... 10 see azithromycin ........... 10

ZITHROMAX TRI-PAK ..... 10 ZITHROMAX Z-PAK ......... 10 ZMAX ................................ 10 ZOCOR ............................. 17

see simvastatin ............. 17 ZOFRAN ........................... 39

see ondansetron hcl ...... 39 see ondansetron hcl inj . 39 see ondansetron hcl oral soln ............................... 39

ZOFRAN ODT .................. 39 see ondansetron odt ..... 39

ZOHYDRO ER (ABUSE DETERRENT)..................... 5 ZOLADEX ......................... 14 zoledronic inj 4mg/5ml ...... 33 zoledronic inj 5/100ml ....... 33 ZOLINZA .......................... 13 zolmitriptan ....................... 29 zolmitriptan odt ................. 29 ZOLOFT ........................... 25

see sertraline hcl ........... 25 zolpidem tartrate ............... 28 ZOMACTON ..................... 38 ZOMETA ........................... 33

see zoledronic inj 4mg/5ml ...................................... 33

ZOMIG .............................. 29 see zolmitriptan ............. 29

ZOMIG NASAL SPRAY .... 29 ZOMIG ZMT ..................... 29

see zolmitriptan odt ....... 29 ZONALON ........................ 53 ZONEGRAN ............... 23, 24

see zonisamide ............. 24 zonisamide ....................... 24 ZONTIVITY ....................... 44 ZORBTIVE ........................ 38 ZORTRESS TAB 0.25MG 45 ZORTRESS TAB 0.5MG .. 45 ZORTRESS TAB 0.75MG 45 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 46 ZOSYN ............................. 11

see piperacillin sodium-tazobactam


92

sodium ........................... 11 zovia 1/35e 28 day ............ 36 zovia 1/50e 28 day ............ 36 ZOVIRAX ...................... 9, 56

see acyclovir ....................8 see acyclovir topical ...... 55

ZUBSOLV SUB 1.4-0.36MG .......................................... 30 ZUBSOLV SUB 11.4-2.9MG .......................................... 30 ZUBSOLV SUB 2.9-0.71MG .......................................... 30 ZUBSOLV SUB 5.7-1.4MG .......................................... 30 ZUBSOLV SUB 8.6-2.1MG

.......................................... 30 ZUPLENZ ......................... 39 ZURAMPIC ......................... 1 ZYBAN .............................. 30

see buproban tab (smoking deterrent) ....... 30 see bupropion hcl (smoking deterrent) ....... 30

ZYCLARA ......................... 56 ZYDELIG .......................... 14 ZYFLO CR ........................ 51 ZYKADIA .......................... 14 ZYLET ............................... 48 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1

ZYMAXID .......................... 49 see gatifloxacin (ophth) . 48

ZYPREXA ......................... 27 see olanzapine .............. 27

ZYPREXA RELPREVV ..... 27 ZYPREXA RELPREVV INJ 210MG .............................. 27 ZYPREXA ZYDI TAB 10MG.......................................... 27 ZYPREXA ZYDIS ............. 27

see olanzapine odt ........ 27 ZYTIGA ............................. 14 ZYVOX ............................... 6

see linezolid .................... 6

2016 631 3T Copper Comm BvD Plus with sPA eff 11/01/2016€¦ · 200mg 1 tramadol hcl er (biphasic)...

Documents

Transcript of 2016 631 3T Copper Comm BvD Plus with sPA eff 11/01/2016€¦ · 200mg 1 tramadol hcl er (biphasic)...