‘Ohana Health Plan...choline & mag trisalicylate oral tablet 1000 mg . P choline-mag trisalicylate...

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2014 ‘Ohana Medicaid Comprehensive Preferred Drug List (Quest)(List of Covered Drugs)

‘Ohana Health Plan

Please read: This document contains information about the drugs we cover in this plan.

Please note that the ‘Ohana Health Plan Preferred Drug List (Quest) is updated quarterly.

Providers, please visit our website at https://www.ohanahealthplan.com/member/QUEST/pharmacy to view updates to the preferred drug list.

Members, please visit our website at https://ohanahealthplan.com/member/quest to view updates to the preferred drug list.

Last updated (10/01/2014)

https://www.ohanahealthplan.com/member/QUEST/pharmacy

https://ohanahealthplan.com/member/quest

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Last updated 07/31/14 Page 1 of 2

Hawaii Medicaid Cough & Cold Drug List

Non-Preferred Drugs Preferred Drugs ANTITUSSIVES,NON NARCOTIC

Benzonatate TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE

Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION

Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP

Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE

NON-NARC ANTITUSS 1ST GEN. ANTIHISTAMINE DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl

ALLANHIST PDX DROPS BROMFED DM SYRUP

BROMHIST PDX DROPS ENDACOF-PD DROPS

BROTAPP DM LIQUID Q-TAPP DM ELIXIR

Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAPHEN DM ELIXIR

Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP

RONDEX-DM SYRUP SILDEC PE-DM SYRUP

DE-CHLOR DM LIQUID CORFEN DM

NOHIST-DM TRI-DEX PE

Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD

MESEHIST DM

Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID

Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID

Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP

NON-NARC ANTITUSS 1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine

DELSYM NIGHTTIME MULTI-SYMPTOM EXPECTORANTS

DECONGESTANT EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl

DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID RESCON-GG LIQUID

NON NARCOTIC DECONGESTANT EXPECTORANT ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine

ROBAFEN CF SYRUP

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Hawaii Medicaid Cough & Cold Drug List

Last updated 07/31/14 Page 2 of 2

Non-Preferred Drugs Preferred Drugs NON NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.

Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR

SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID GUAIFENESIN DM SYRUP EXTRA ACTION COUGH REFENESEN DM MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID

DIABETIC TUSSIN DM LIQUID Q-TUSSIN-DM SYRUP SILTUSSIN DM COUGH SYRUP SILTUSSIN DM DAS COUGH SYRUP

NARCOTIC ANTITUSSIVE 1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex

TUSSIONEX PENNKINETIC SUSP TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old)

Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old)

NARCOTIC ANTITUSSIVE 1ST GEN. ANTIHISTAMINE DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl Codeine/Phenylephrine HCl/Promethazine

CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP

HC/PE/DBROM SYRUP PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP

Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH

NARCOTIC ANTITUSSIVE ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine

HYDROMET SYRUP HYDROCODONE-HOMATROPINE

NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine Phosphate/Guaifenesin

HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP TUSSICLEAR DH SYRUP

CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR

NARCOTIC ANTITUSSIVE-DECONGESTANT EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl

CHERATUSSIN DAC SYRUP

1

Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the PA process.

This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit.

Drug Name Preference Details Coverage Details

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts*

*Amphetamines**-*Amphetamine Mixtures***

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG

P

amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

P

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

P

*Amphetamines**-*Amphetamines***

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

P

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

P

methamphetamine hcl oral tablet 5 mg P

PROCENTRA ORAL SOLUTION 5 MG/5ML

P

VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

P

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

P

*Anti-Obesity Agents**-*Lipase Inhibitors***

XENICAL ORAL CAPSULE 120 MG P PA

*Attention-Deficit/Hyperactivity Disorder (Adhd) Agents**-*Adhd Agent - Selective Alpha Adrenergic Agonists***

clonidine hcl er oral tablet extended release 12 hr* 0.1 mg

P

P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs


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INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR* 1 MG, 2 MG, 3 MG, 4 MG

P

*Attention-Deficit/Hyperactivity Disorder (Adhd) Agents**-*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

P

*Stimulants - Misc.**-*Stimulants - Misc.***

DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

P

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

P

dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg

P

FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 25 MG, 35 MG, 5 MG

P

METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG

P

methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml

P

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

P

methylphenidate hcl er oral tablet extendedrelease* 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

P

methylphenidate hcl er (cd) oral capsule extended release* 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

P

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg

P

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

P

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG

P

*Alternative Medicines*

*Alternative Medicine - M's**-*Alternative Medicine - Me's***


3


melatonin maximum strength oral tablet 5 mg P OTC

*Aminoglycosides*

*Aminoglycosides**-*Aminoglycosides***

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

P PA

neomycin sulfate oral tablet 500 mg P

*Analgesics - Anti-Inflammatory*

*Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies***

HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML

P PA

HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML

P PA

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML

P PA

SIMPONI SUBCUTANEOUS* SOLUTION 100 MG/ML, 50 MG/0.5ML

P PA

*Gold Compounds**-*Gold Compounds***

RIDAURA ORAL CAPSULE 3 MG P

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors***

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG

P

ST; Notes (Must fail 2 preferred, generic PDL NSAIDs within the past 100 days.); QL (31 EA per 31 days)

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***

childrens ibuprofen oral suspension 40 mg/ml P OTC

diclofenac potassium oral tablet 50 mg P

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

P

diclofenac sodium er oral tablet extended release 24 hr* 100 mg

P

etodolac oral capsule 200 mg, 300 mg P

etodolac oral tablet 400 mg, 500 mg P


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fenoprofen calcium oral tablet 600 mg P

flurbiprofen oral tablet 100 mg, 50 mg P

ibuprofen oral suspension 100 mg/5ml P OTC

ibuprofen oral tablet 200 mg P OTC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg P

ibuprofen junior strength oral tablet chewable 100 mg

P OTC

indomethacin oral capsule 25 mg, 50 mg P

ketoprofen oral capsule 50 mg, 75 mg P

ketorolac tromethamine oral tablet 10 mg P Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days)

meloxicam oral tablet 15 mg, 7.5 mg P

nabumetone oral tablet 500 mg, 750 mg P

naproxen oral suspension 125 mg/5ml P QL (2000 ML per 31 days)

naproxen oral tablet 250 mg, 375 mg, 500 mg P

naproxen dr oral tablet delayed release 500 mg P

naproxen sodium oral tablet 275 mg, 550 mg P

oxaprozin oral tablet 600 mg P

piroxicam oral capsule 10 mg, 20 mg P

sulindac oral tablet 150 mg, 200 mg P

tolmetin sodium oral capsule 400 mg P

*Pyrimidine Synthesis Inhibitors**-*Pyrimidine Synthesis Inhibitors***

leflunomide oral tablet 10 mg, 20 mg P

*Analgesics - Nonnarcotic*

*Analgesic Combinations**-*Analgesics-Sedatives***

butalbital-acetaminophen oral tablet 50-325 mg P QL (186 EA per 31 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg

P QL (186 EA per 31 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg


butalbital-asa-caffeine oral capsule 50-325-40 mg

P

*Analgesics Other**-*Analgesics Other***


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ACEPHEN SUPPOSITORY 120 MG, 325 MG, 650 MG

P OTC

acetaminophen oral solution 160 mg/5ml P OTC

acetaminophen oral tablet 325 mg P OTC; QL (279 EA per 31 days)

acetaminophen oral tablet 500 mg P OTC; QL (186 EA per 31 days)

childrens non-aspirin oral tablet chewable 80 mg P OTC

childrens silapap oral liquid† 160 mg/5ml P OTC

infants silapap oral solution 100 mg/ml P OTC

JUNIOR MAPAP ORAL TABLET DISPERSIBLE 160 MG

P OTC

mapap oral capsule 500 mg P OTC; QL (186 EA per 31 days)

mapap oral liquid† 160 mg/5ml P OTC

mapap arthritis pain oral tablet extendedrelease* 650 mg

P OTC; QL (93 EA per 31 days)

MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML

P OTC

nortemp infants oral suspension 80 mg/0.8ml P OTC

pain & fever childrens oral solution 160 mg/5ml P OTC

*Salicylates**-*Salicylate Combinations***

choline & mag trisalicylate oral tablet 1000 mg P

choline-mag trisalicylate oral liquid† 500 mg/5ml

P

tri-buffered aspirin oral tablet 325 mg P OTC

*Salicylates**-*Salicylates***

aspirin oral tablet 325 mg, 81 mg P OTC

aspirin oral tablet chewable 81 mg P OTC

aspirin suppository 300 mg, 600 mg P OTC

aspirin adult low strength oral tablet delayed release 81 mg

P OTC

aspirin ec oral tablet delayed release 325 mg P OTC

aspirin low dose oral tablet 81 mg P OTC

diflunisal oral tablet 500 mg P

salsalate oral tablet 500 mg, 750 mg P

*Analgesics - Opioid*

*Opioid Agonists**-*Opioid Agonists***

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg P QL (248 EA per 31 days)


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fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

P PA; QL (10 EA per 30 days)

hydromorphone hcl oral liquid† 1 mg/ml P

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg P QL (248 EA per 31 days)

hydromorphone hcl suppository 3 mg P

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

P

methadone hcl oral tablet 10 mg, 5 mg P QL (248 EA per 31 days)

METHADOSE ORAL TABLET 10 MG P QL (248 EA per 31 days)

morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 5 mg/ml, 8 mg/ml

P

morphine sulfate intravenous* solution 1 mg/ml, 25 mg/ml, 50 mg/ml

P

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

P

morphine sulfate oral tablet 15 mg, 30 mg P QL (248 EA per 31 days)

morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg

P

morphine sulfate (concentrate) oral solution 20 mg/ml

P

morphine sulfate (pf) injection solution 0.5 mg/ml

P

morphine sulfate (pf) intravenous* solution 2 mg/ml, 4 mg/ml, 8 mg/ml

P

morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg


oxycodone hcl oral capsule 5 mg P QL (248 EA per 31 days)

oxycodone hcl oral solution 5 mg/5ml P

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 5 mg


oxycodone hcl oral tablet 30 mg P

tramadol hcl oral tablet 50 mg P QL (248 EA per 31 days)

*Opioid Combinations**-*Codeine Combinations***

acetaminophen-codeine oral solution 120-12 mg/5ml

P

acetaminophen-codeine #2 oral tablet 300-15 mg P QL (248 EA per 31 days)



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ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG

P

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg


butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

P

*Opioid Combinations**-*Hydrocodone Combinations***

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

P QL (3720 ML per 31 days)

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 7.5-200 mg P QL (155 EA per 31 days)

*Opioid Combinations**-*Opioid Combinations***

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 4.8355-325 mg P QL (186 EA per 31 days)

ROXICET ORAL TABLET 5-325 MG P QL (248 EA per 31 days)

*Opioid Partial Agonists**-*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

P PA

butorphanol tartrate nasal solution 10 mg/ml P QL (2.5 ML per 31 days)

pentazocine-naloxone hcl oral tablet 50-0.5 mg P

zubsolv sublingual tablet sublingual 1.4-0.36 mg, 5.7-1.4 mg

P PA

*Androgens-Anabolic*

*Anabolic Steroids**-*Anabolic Steroids***

oxandrolone oral tablet 10 mg, 2.5 mg P PA

*Androgens**-*Androgens***

danazol oral capsule 100 mg, 200 mg, 50 mg P

methitest oral tablet 10 mg P

TESTIM TRANSDERMAL 50 MG/5GM P PA


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testosterone transdermal 12.5 mg/act (1%), 50 mg/5gm

P PA

testosterone cypionate intramuscular* oil 100 mg/ml, 200 mg/ml

P

testosterone enanthate intramuscular* oil 200 mg/ml

P

*Anorectal Agents*

*Intrarectal Steroids**-*Intrarectal Steroids***

hydrocortisone enema 100 mg/60ml P

*Rectal Steroids**-*Rectal Steroids***

PROCTOSOL HC CREAM 2.5 % P

PROCTOZONE-HC CREAM 2.5 % P

*Antacids*

*Antacid Combinations**-*Antacid & Simethicone***

antacid oral suspension 200-200-20 mg/5ml P OTC

*Antacids - Aluminum Salts**-*Antacids -Aluminum Salts***

aluminum hydroxide gel oral suspension 320 mg/5ml

P OTC

*Antacids - Bicarbonate**-*Antacids -Bicarbonate***

sodium bicarbonate oral tablet 325 mg, 650 mg P OTC

*Antacids - Calcium Salts**-*Antacids -Calcium Salts***

antacid oral tablet chewable 500 mg P OTC

calcium antacid extra strength oral tablet chewable 750 mg

P OTC

calcium carbonate antacid oral tablet 648 mg P OTC

calcium carbonate antacid oral tablet chewable 500 mg

P OTC

*Antacids - Magnesium Salts**-*Antacids -Magnesium Salts***

magnesium oxide oral tablet 250 mg, 400 mg, 420 mg

P OTC

*Anthelmintics*

*Anthelmintics**-*Anthelmintics***


9


ALBENZA ORAL TABLET 200 MG P PA

BILTRICIDE ORAL TABLET 600 MG P PA

reeses pinworm medicine oral suspension 144 mg/ml

P OTC

STROMECTOL ORAL TABLET 3 MG P QL (10 EA per 31 days)

*Antianginal Agents*

*Nitrates**-*Nitrates***

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

P

isosorbide dinitrate er oral tablet extendedrelease* 40 mg

P

isosorbide mononitrate oral tablet 10 mg, 20 mg P

isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg

P

NITRO-BID TRANSDERMAL OINTMENT 2 %

P

nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

P

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

P

*Antianxiety Agents*

*Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.***

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

P

hydroxyzine hcl oral solution 10 mg/5ml P QL (450 ML per 31 days)

hydroxyzine hcl oral syrup 10 mg/5ml P QL (450 ML per 31 days)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg P

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

P

meprobamate oral tablet 200 mg, 400 mg P

*Benzodiazepines**-*Benzodiazepines***

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

P

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

P

alprazolam er oral tablet extended release 24 hr* 0.5 mg, 1 mg, 2 mg, 3 mg

P


10


alprazolam xr oral tablet extended release 24 hr* 0.5 mg, 1 mg, 2 mg, 3 mg

P

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

P

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

P AL (Min 9 Years)

diazepam injection solution 5 mg/ml P

diazepam oral solution 1 mg/ml P QL (1240 ML per 31 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg P

lorazepam injection solution 2 mg/ml, 4 mg/ml P

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg P

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

P

oxazepam oral capsule 10 mg, 15 mg, 30 mg P

*Antiarrhythmics*

*Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A***

disopyramide phosphate oral capsule 100 mg, 150 mg

P

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

P

quinidine gluconate injection solution 80 mg/ml P

quinidine gluconate er oral tablet extendedrelease* 324 mg

P

quinidine sulfate oral tablet 300 mg P

*Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B***

lidocaine hcl (cardiac) intravenous* solution 20 mg/ml

P

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

P

*Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C***

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

P

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

P


11


*Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii***

amiodarone hcl intravenous* solution 150 mg/3ml

P

amiodarone hcl oral tablet 200 mg, 400 mg P

PACERONE ORAL TABLET 200 MG, 400 MG

P

*Antiasthmatic And Bronchodilator Agents*

*Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies***

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG

P PA

*Anti-Inflammatory Agents**-*Anti-Inflammatory Agents***

cromolyn sodium inhalation nebulization solution 20 mg/2ml

P

*Bronchodilators -Anticholinergics**-*Bronchodilators -Anticholinergics***

ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT

P QL (25.8 GM per 31 days)

ipratropium bromide inhalation solution 0.02 % P QL (480 ML per 31 days)

TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT


*Leukotriene Modulators**-*Leukotriene Receptor Antagonists***

montelukast sodium oral packet 4 mg P AL (Min 1 Months and Max 2 Years)

montelukast sodium oral tablet 10 mg P

montelukast sodium oral tablet chewable 4 mg, 5 mg

P

zafirlukast oral tablet 10 mg, 20 mg P

*Steroid Inhalants**-*Steroid Inhalants***

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH



12


ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH


ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH


budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

P QL (120 ML per 31 days); AL (Max 8 Years)

FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT

P QL (12 GM per 30 days)

FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT


PULMICORT INHALATION SUSPENSION 1 MG/2ML


*Sympathomimetics**-*Adrenergic Combinations***

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT


DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT


ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml


SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT


*Sympathomimetics**-*Beta Adrenergics***

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%



13


albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%

P

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml


albuterol sulfate oral syrup 2 mg/5ml P QL (2480 ML per 31 days)

albuterol sulfate oral tablet 2 mg, 4 mg P

FORADIL AEROLIZER INHALATION CAPSULE 12 MCG


metaproterenol sulfate oral syrup 10 mg/5ml P

SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE


terbutaline sulfate injection solution 1 mg/ml P

terbutaline sulfate oral tablet 2.5 mg, 5 mg P

VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT


*Xanthines**-*Xanthines***

aminophylline intravenous* solution 25 mg/ml P

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

P

theophylline oral solution 80 mg/15ml P

theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg

P

theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg

P

*Anticoagulants*

*Coumarin Anticoagulants**-*Coumarin Anticoagulants***

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

P

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

P

*Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors***

XARELTO ORAL TABLET 10 MG P QL (35 EA per 365 days)


14


*Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins***

enoxaparin sodium injection solution 300 mg/3ml


enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml


enoxaparin sodium subcutaneous* solution 120 mg/0.8ml, 80 mg/0.8ml

P QL (22.4 ML per 31 days)

enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml


enoxaparin sodium subcutaneous* solution 60 mg/0.6ml


*Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents***

fondaparinux sodium subcutaneous* solution 10 mg/0.8ml


fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml


fondaparinux sodium subcutaneous* solution 5 mg/0.4ml


fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml


*Anticonvulsants*

*Ampa Glutamate Receptor Antagonists**-*Ampa Glutamate Receptor Antagonists***

FYCOMPA ORAL TABLET 8 MG P

*Anticonvulsants -Benzodiazepines**-*Anticonvulsants -Benzodiazepines***

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg P

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

P

diazepam 10 mg, 2.5 mg, 20 mg P

ONFI ORAL SUSPENSION 2.5 MG/ML P

ONFI ORAL TABLET 10 MG, 20 MG P

*Anticonvulsants - Misc.**-*Anticonvulsants -Misc.***


15


APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

P

BANZEL ORAL SUSPENSION 40 MG/ML P

BANZEL ORAL TABLET 200 MG P QL (310 EA per 31 days)

BANZEL ORAL TABLET 400 MG P QL (248 EA per 31 days)

carbamazepine oral suspension 100 mg/5ml P QL (2480 ML per 31 days)

carbamazepine oral tablet 200 mg P QL (248 EA per 31 days)

carbamazepine oral tablet chewable 100 mg P QL (310 EA per 31 days)

carbamazepine er oral capsule extended release 12 hour 100 mg





P

carbamazepine er oral tablet extended release 12 hr* 200 mg


carbamazepine er oral tablet extended release 12 hr* 400 mg

P

EPITOL ORAL TABLET 200 MG P QL (248 EA per 31 days)

gabapentin oral capsule 100 mg P QL (310 EA per 31 days)



gabapentin oral solution 250 mg/5ml P QL (2230 ML per 31 days)

gabapentin oral tablet 600 mg, 800 mg P

LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG

P

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG

P

LAMICTAL ODT ORAL TABLET DISPERSIBLE 25 MG, 50 MG


LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-100 (7) MG, 25 (84)-100(14) MG

P

LAMICTAL XR ORAL KIT 25 (21)-50 (7) MG

P

lamotrigine oral tablet 100 mg, 150 mg, 200 mg P

lamotrigine oral tablet 25 mg P QL (310 EA per 31 days)

lamotrigine oral tablet chewable 25 mg, 5 mg P QL (310 EA per 31 days)


16


lamotrigine er oral tablet extended release 24 hr* 100 mg, 200 mg, 250 mg, 300 mg

P

lamotrigine er oral tablet extended release 24 hr* 25 mg, 50 mg


levetiracetam intravenous* solution 500 mg/5ml P

levetiracetam oral solution 100 mg/ml P QL (1000 ML per 31 days)

levetiracetam oral tablet 1000 mg, 500 mg, 750 mg

P

levetiracetam oral tablet 250 mg P QL (372 EA per 31 days)

levetiracetam er oral tablet extended release 24 hr* 500 mg, 750 mg

P

levetiracetam in nacl intravenous* solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

P

oxcarbazepine oral suspension 300 mg/5ml P QL (1240 ML per 31 days)

oxcarbazepine oral tablet 150 mg P QL (310 EA per 31 days)

oxcarbazepine oral tablet 300 mg P QL (248 EA per 31 days)

oxcarbazepine oral tablet 600 mg P

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG, 600 MG

P

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG

P

primidone oral tablet 250 mg P QL (248 EA per 31 days)

primidone oral tablet 50 mg P QL (310 EA per 31 days)

QUDEXY XR ORAL 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

P

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG


topiramate oral capsule sprinkle 15 mg, 25 mg P QL (310 EA per 31 days)

topiramate oral tablet 100 mg, 25 mg, 50 mg P QL (310 EA per 31 days)

topiramate oral tablet 200 mg P QL (248 EA per 31 days)

TOPIRAMATE ER ORAL 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

P

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

P

VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML

P


17


VIMPAT ORAL SOLUTION 10 MG/ML P

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

P

zonisamide oral capsule 100 mg P QL (186 EA per 31 days)



*Carbamates**-*Carbamates***

felbamate oral suspension 600 mg/5ml P QL (1000 ML per 31 days)

felbamate oral tablet 400 mg P QL (279 EA per 31 days)

felbamate oral tablet 600 mg P

*Gaba Modulators**-*Gaba Modulators***

GABITRIL ORAL TABLET 12 MG, 16 MG P

SABRIL ORAL PACKET 500 MG P

SABRIL ORAL TABLET 500 MG P

tiagabine hcl oral tablet 2 mg, 4 mg P

*Hydantoins**-*Hydantoins***

DILANTIN ORAL CAPSULE 30 MG P QL (310 EA per 31 days)

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml

P

PEGANONE ORAL TABLET 250 MG P QL (372 EA per 31 days)

phenytoin oral suspension 125 mg/5ml P QL (930 ML per 31 days)

phenytoin oral tablet chewable 50 mg P QL (372 EA per 31 days)

phenytoin sodium injection solution 50 mg/ml P

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

P

*Succinimides**-*Succinimides***

CELONTIN ORAL CAPSULE 300 MG P

ethosuximide oral capsule 250 mg P

ethosuximide oral solution 250 mg/5ml P QL (930 ML per 31 days)

*Valproic Acid**-*Valproic Acid***

divalproex sodium oral capsule sprinkle 125 mg P QL (310 EA per 31 days)

divalproex sodium oral tablet delayed release 125 mg, 250 mg


divalproex sodium oral tablet delayed release 500 mg



18


divalproex sodium er oral tablet extended release 24 hr* 250 mg


divalproex sodium er oral tablet extended release 24 hr* 500 mg


STAVZOR ORAL CAPSULE DELAYED RELEASE 125 MG, 250 MG


STAVZOR ORAL CAPSULE DELAYED RELEASE 500 MG


valproate sodium intravenous* solution 100 mg/ml

P

valproic acid oral capsule 250 mg P QL (310 EA per 31 days)

valproic acid oral solution 250 mg/5ml P QL (2790 ML per 31 days)

valproic acid oral syrup 250 mg/5ml P QL (2790 ML per 31 days)

*Antidepressants*

*Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)***

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

P

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

P

*Antidepressants - Misc.**-*Antidepressants -Misc.***

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 348 MG, 522 MG

P

bupropion hcl oral tablet 100 mg, 75 mg P

bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg

P

bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg

P

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR* 450 MG

P

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg P

*Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)***

EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

P

MARPLAN ORAL TABLET 10 MG P


19


phenelzine sulfate oral tablet 15 mg P

tranylcypromine sulfate oral tablet 10 mg P

*Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)***

citalopram hydrobromide oral solution 10 mg/5ml

P

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

P

escitalopram oxalate oral solution 5 mg/5ml P

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

P

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg P

fluoxetine hcl oral capsule delayed release 90 mg P

fluoxetine hcl oral solution 20 mg/5ml P

fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg P

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

P

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

P

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

P

paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg

P

PAXIL ORAL SUSPENSION 10 MG/5ML P

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

P

sertraline hcl oral concentrate 20 mg/ml P

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg P

*Serotonin Modulators**-*Serotonin Modulators***

BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

P

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

P

OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG

P


20


trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

P

VIIBRYD ORAL KIT 10 & 20 & 40 MG P

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

P

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***

desvenlafaxine er oral tablet extended release 24 hr* 100 mg, 50 mg

P

desvenlafaxine fumarate er oral tablet extended release 24 hr* 50 mg

P

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

P

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

P

FETZIMA TITRATION ORAL 20 & 40 MG P

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG

P

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG

P

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

P

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

P

venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 225 mg, 37.5 mg, 75 mg

P

*Tricyclic Agents**-*Tricyclic Agents***

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

P

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

P

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

P

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

P

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

P


21


doxepin hcl oral concentrate 10 mg/ml P

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg P

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

P

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

P

nortriptyline hcl oral solution 10 mg/5ml P

protriptyline hcl oral tablet 10 mg, 5 mg P

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

P

*Antidiabetics*

*Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors***

acarbose oral tablet 100 mg, 25 mg, 50 mg P

*Antidiabetic Combinations**-*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG

P ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG


JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG

P

ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days)

*Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations***

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

P

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

P

*Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedion e Combinations***

AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4 MG, 8-4 MG



22


*Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations***

AVANDAMET ORAL TABLET 2-1000 MG, 2-500 MG, 4-500 MG


pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg


*Biguanides**-*Biguanides***

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

P

metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg

P

metformin hcl er (osm) oral tablet extended release 24 hr* 500 mg

P

RIOMET ORAL SOLUTION 500 MG/5ML P QL (900 ML per 31 days)

*Diabetic Other**-*Diabetic Other***

GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG


GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG


GLUCAGON EMERGENCY INJECTION KIT 1 MG


glucose oral tablet chewable 4 gm P OTC

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


TRADJENTA ORAL TABLET 5 MG P

ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days)

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***


23


BYDUREON SUBCUTANEOUS* 2 MG P ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)

BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG

P ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)

*Insulin Sensitizing Agents**-*Thiazolidinediones***

AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG


pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg P ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)

*Insulin**-*Human Insulin***

APIDRA INJECTION SOLUTION 100 UNIT/ML


APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML


HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML


HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML

P OTC; QL (60 ML per 31 days)

HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML


HUMULIN N KWIKPEN SUBCUTANEOUS* 100 UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML



24


LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML


*Sulfonylureas**-*Sulfonylureas***

chlorpropamide oral tablet 100 mg, 250 mg P

glimepiride oral tablet 1 mg, 2 mg, 4 mg P

glipizide oral tablet 10 mg, 5 mg P

glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg

P

GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG

P

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg P

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

P

*Antidiarrheals*

*Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.***

bismatrol oral suspension 262 mg/15ml P OTC

pink bismuth oral tablet chewable 262 mg P OTC

stomach relief plus oral suspension 525 mg/15ml P OTC

*Antiperistaltic Agents**-*Antiperistaltic Agents***

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml

P

diphenoxylate-atropine oral tablet 2.5-0.025 mg P

loperamide hcl oral capsule 2 mg P

loperamide hcl oral liquid† 1 mg/5ml P OTC

*Antidotes*

*Antidotes - Chelating Agents**-*Antidotes -Chelating Agents***

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

P PA

*Antidotes**-*Antidotes***

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

P

*Opioid Antagonists**-*Opioid Antagonists***

naltrexone hcl oral tablet 50 mg P


25


*Antiemetics*

*5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists***

ondansetron oral tablet dispersible 4 mg, 8 mg P

ondansetron hcl oral solution 4 mg/5ml P

ondansetron hcl oral tablet 4 mg, 8 mg P

*Antiemetics - Anticholinergic**-*Antiemetics -Anticholinergic***

dimenhydrinate oral tablet 50 mg P OTC

meclizine hcl oral tablet 12.5 mg, 25 mg P OTC

meclizine hcl oral tablet chewable 25 mg P OTC

travel sickness oral tablet chewable 25 mg P OTC

*Antifungals*

*Antifungals**-*Antifungals***

griseofulvin microsize oral suspension 125 mg/5ml


griseofulvin microsize oral tablet 500 mg P

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

P

nystatin oral tablet 500000 unit P

terbinafine hcl oral tablet 250 mg P

*Imidazole-Related Antifungals**-*Imidazoles***

ketoconazole oral tablet 200 mg P

*Imidazole-Related Antifungals**-*Triazoles***

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

P

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

P

*Antihistamines*

*Antihistamines -Alkylamines**-*Antihistamines -Alkylamines***

allergy oral tablet 4 mg P OTC


26


*Antihistamines -Ethanolamines**-*Antihistamines -Ethanolamines***

aler-dryl oral tablet 50 mg P OTC

BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML

P OTC

diphenhist oral liquid† 12.5 mg/5ml P OTC

diphenhydramine hcl oral capsule 25 mg, 50 mg P OTC

diphenhydramine hcl oral tablet 25 mg P OTC

*Antihistamines -Non-Sedating**-*Antihistamines -Non-Sedating***

allergy oral tablet dispersible 10 mg P OTC

cetirizine hcl oral syrup 1 mg/ml, 5 mg/5ml P OTC; QL (300 ML per 31 days)

cetirizine hcl oral tablet 10 mg, 5 mg P OTC

cetirizine hcl childrens oral solution 1 mg/ml P OTC; QL (300 ML per 31 days)

childrens loratadine oral syrup 5 mg/5ml P OTC; QL (310 ML per 31 days)

fexofenadine hcl oral tablet 180 mg, 60 mg P OTC

fexofenadine hcl childrens oral suspension 30 mg/5ml

P OTC

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

P ST; Notes (Must fail preferred loratadine solution, cetirizine syrup within the past 100 days)

levocetirizine dihydrochloride oral tablet 5 mg P

loratadine oral tablet 10 mg P OTC

loratadine hives relief oral solution 5 mg/5ml P OTC

*Antihistamines -Phenothiazines**-*Antihistamines -Phenothiazines***

promethazine hcl injection solution 25 mg/ml P

promethazine hcl oral syrup 6.25 mg/5ml P

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

P

promethazine hcl suppository 25 mg P

PROMETHEGAN SUPPOSITORY 25 MG, 50 MG

P

*Antihistamines - Piperidines**-*Antihistamines - Piperidines***


27


cyproheptadine hcl oral syrup 2 mg/5ml P QL (300 ML per 31 days)

cyproheptadine hcl oral tablet 4 mg P

*Antihyperlipidemics*

*Antihyperlipidemics - Combinations**-*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb***

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG

P PA

*Bile Acid Sequestrants**-*Bile Acid Sequestrants***

cholestyramine oral packet 4 gm P

cholestyramine oral powder 4 gm/dose P

cholestyramine light oral packet 4 gm P

cholestyramine light oral powder 4 gm/dose P

*Fibric Acid Derivatives**-*Fibric Acid Derivatives***

fenofibrate oral tablet 160 mg, 54 mg P

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

P

gemfibrozil oral tablet 600 mg P

*Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors***

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

P

ST; Notes (Must fail preferred pravastatin, simvastatin, or lovastatin within the past 100 days.)

lovastatin oral tablet 10 mg, 20 mg, 40 mg P

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

P

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

P

*Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors***

ZETIA ORAL TABLET 10 MG P PA

*Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives***

NIACOR ORAL TABLET 500 MG P


28


*Antihypertensives*

*Ace Inhibitors**-*Ace Inhibitors***

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

P

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

P

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

P

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg

P

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

P

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

P

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

P

*Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists***

losartan potassium oral tablet 100 mg, 25 mg, 50 mg


*Antiadrenergic Antihypertensives**-*Antiadrenergics -Centrally Acting***

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg P

guanfacine hcl oral tablet 1 mg, 2 mg P

methyldopa oral tablet 250 mg, 500 mg P

*Antiadrenergic Antihypertensives**-*Antiadrenergics -Peripherally Acting***

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

P

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg P

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

P

*Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like***

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

P


29


captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

P

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

P

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

P

*Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg


*Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations***

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

P

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

P

propranolol-hctz oral tablet 40-25 mg, 80-25 mg P

*Vasodilators**-*Vasodilators***

hydralazine hcl injection solution 20 mg/ml P

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

P

minoxidil oral tablet 10 mg, 2.5 mg P

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.***

metronidazole oral tablet 250 mg, 500 mg P

trimethoprim oral tablet 100 mg P

vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg

P

vancomycin hcl oral capsule 125 mg, 250 mg P PA

*Anti-Infective Misc. -Combinations**-*Anti-Infective Misc. -Combinations***

sulfamethoxazole-tmp ds oral tablet 800-160 mg P

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml



30


sulfamethoxazole-trimethoprim oral tablet 400-80 mg

P

*Antiprotozoal Agents**-*Antiprotozoal Agents***

atovaquone oral suspension 750 mg/5ml P

*Lincosamides**-*Lincosamides***

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

P

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml


clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml

P

clindamycin phosphate intravenous* solution 300 mg/2ml

P

*Antimalarials*

*Antimalarial Combinations**-*Antimalarial Combinations***

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

P

*Antimalarials**-*Antimalarials***

DARAPRIM ORAL TABLET 25 MG P

hydroxychloroquine sulfate oral tablet 200 mg P

mefloquine hcl oral tablet 250 mg P

primaquine phosphate oral tablet 26.3 mg P

*Antimyasthenic/Cholinergic Agents*

*Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents***

MESTINON ORAL SYRUP 60 MG/5ML P

MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG

P

pyridostigmine bromide oral tablet 60 mg P

*Antineoplastics And Adjunctive Therapies*

*Alkylating Agents**-*Alkylating Agents***

HEXALEN ORAL CAPSULE 50 MG P PA

MYLERAN ORAL TABLET 2 MG P PA

*Alkylating Agents**-*Imidazotetrazines***


31


temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

P PA

*Alkylating Agents**-*Nitrogen Mustards***

ALKERAN ORAL TABLET 2 MG P PA

cyclophosphamide oral capsule 25 mg, 50 mg P

cyclophosphamide oral tablet 25 mg, 50 mg P

LEUKERAN ORAL TABLET 2 MG P PA

*Alkylating Agents**-*Nitrosoureas***

lomustine oral capsule 10 mg, 100 mg, 40 mg P PA

*Antimetabolites**-*Antimetabolites***

ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML

P PA

capecitabine oral tablet 150 mg, 500 mg P PA

fluorouracil intravenous* solution 500 mg/10ml P PA

gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml

P PA

gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg

P PA

mercaptopurine oral tablet 50 mg P

methotrexate oral tablet 2.5 mg P

methotrexate sodium injection solution 25 mg/ml P

methotrexate sodium injection solution reconstituted 1 gm

P

methotrexate sodium (pf) injection solution 1 gm/40ml, 25 mg/ml, 250 mg/10ml, 50 mg/2ml

P

TABLOID ORAL TABLET 40 MG P PA

*Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors***

AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML

P PA

*Antineoplastic - Hedgehog Pathway Inhibitors**-*Antineoplastic - Hedgehog Pathway Inhibitors***

ERIVEDGE ORAL CAPSULE 150 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Antiadrenals***


32


LYSODREN ORAL TABLET 500 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Antiandrogens***

XTANDI ORAL CAPSULE 40 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Antiestrogens***

tamoxifen citrate oral tablet 10 mg, 20 mg P

*Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors***

anastrozole oral tablet 1 mg P

letrozole oral tablet 2.5 mg P

*Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic***

EMCYT ORAL CAPSULE 140 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs***

TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG

P PA

TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG

P PA

TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG

P PA

TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG

P PA

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG

P PA

*Antineoplastic - Hormonal And Related Agents**-*Progestins-Antineoplastic***

megestrol acetate oral suspension 40 mg/ml P QL (600 ML per 31 days)

megestrol acetate oral tablet 20 mg, 40 mg P

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors***

ZELBORAF ORAL TABLET 240 MG P PA


33


*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors***

ZOLINZA ORAL CAPSULE 100 MG P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors***

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors***

STIVARGA ORAL TABLET 40 MG P PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors***

BOSULIF ORAL TABLET 100 MG, 500 MG P PA

CAPRELSA ORAL TABLET 100 MG, 300 MG

P PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

P PA

GLEEVEC ORAL TABLET 100 MG, 400 MG

P PA

ICLUSIG ORAL TABLET 15 MG, 45 MG P PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

P PA

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

P PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG

P PA

TYKERB ORAL TABLET 250 MG P PA

XALKORI ORAL CAPSULE 200 MG, 250 MG

P PA

ZYKADIA ORAL CAPSULE 150 MG P PA; QL (155 EA per 31 days)

*Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors***


34


JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

P PA

*Antineoplastic Enzymes**-*Antineoplastic Enzymes***

ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT

P PA

*Antineoplastics Misc.**-*Antineoplastics Misc.***

hydroxyurea oral capsule 500 mg P

INTRON-A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

P

INTRON-A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

P

*Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents***

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg

P

leucovorin calcium intravenous* solution 10 mg/ml

P

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

P

*Mitotic Inhibitors**-*Mitotic Inhibitors***

etoposide oral capsule 50 mg P PA

*Antiparkinson Agents*

*Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics***

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

P

trihexyphenidyl hcl oral elixir 0.4 mg/ml P

trihexyphenidyl hcl oral tablet 2 mg, 5 mg P

*Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics***

amantadine hcl oral capsule 100 mg P

amantadine hcl oral syrup 50 mg/5ml P


35


amantadine hcl oral tablet 100 mg P

bromocriptine mesylate oral capsule 5 mg P

bromocriptine mesylate oral tablet 2.5 mg P

*Antiparkinson Dopaminergics**-*Levodopa Combinations***

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

P

carbidopa-levodopa er oral tablet extendedrelease* 50-200 mg

P

*Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists***

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

P ST; Notes (Must fail preferred ropinirole within the past 100 days.)

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

P

*Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors***

selegiline hcl oral capsule 5 mg P

selegiline hcl oral tablet 5 mg P

*Antipsychotics/Antimanic Agents*

*Antimanic Agents**-*Antimanic Agents***

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

P

lithium carbonate oral tablet 300 mg P

lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg

P

lithium citrate oral solution 8 meq/5ml P

*Antipsychotics - Misc.**-*Antipsychotics -Misc.***

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

P

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG

P

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

P


36


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

P

*Benzisoxazoles**-*Benzisoxazoles***

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

P

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG

P

INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG

P

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML

P

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

P

risperidone oral solution 1 mg/ml P

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

P

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

P

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

P

*Butyrophenones**-*Butyrophenones***

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

P

haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml

P

haloperidol lactate injection solution 5 mg/ml P

haloperidol lactate oral concentrate 2 mg/ml P

*Dibenzapines**-*Dibenzodiazepines***

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

P

clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg

P


37


FAZACLO ORAL TABLET DISPERSIBLE 150 MG, 200 MG

P

VERSACLOZ ORAL SUSPENSION 50 MG/ML

P

*Dibenzapines**-*Dibenzo-Oxepino Pyrroles***

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG

P

*Dibenzapines**-*Dibenzothiazepines***

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

P

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

P ST

*Dibenzapines**-*Dibenzoxazepines***

ADASUVE INHALATION AEROSOL POWDER, BREATH ACTIVATED 10 MG

P

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

P

*Dibenzapines**-*Thienbenzodiazepines***

olanzapine intramuscular* solution reconstituted 10 mg

P

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

P

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

P

ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG

P ST

*Phenothiazines**-*Phenothiazines***

chlorpromazine hcl injection solution 25 mg/ml P

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

P

fluphenazine decanoate injection solution 25 mg/ml

P

fluphenazine hcl injection solution 2.5 mg/ml P

fluphenazine hcl oral concentrate 5 mg/ml P

fluphenazine hcl oral elixir 2.5 mg/5ml P


38


fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

P

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

P

prochlorperazine suppository 25 mg P

prochlorperazine edisylate injection solution 5 mg/ml

P

prochlorperazine maleate oral tablet 10 mg, 5 mg

P

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

P

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

P

*Quinolinone Derivatives**-*Quinolinone Derivatives***

ABILIFY INTRAMUSCULAR* SOLUTION 9.75 MG/1.3ML

P

ABILIFY ORAL SOLUTION 1 MG/ML P ST

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

P ST

ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG, 15 MG

P ST

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG

P

*Thioxanthenes**-*Thioxanthenes***

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

P

*Antiseptics & Disinfectants*

*Chlorine Antiseptics**-*Chlorine Antiseptics***

chlorhexidine gluconate external liquid† 4 % P OTC; QL (480 ML per 31 days)

*Iodine Antiseptics**-*Iodine Antiseptics***

povidone-iodine external solution 10 % P OTC

*Antivirals*

*Antiretrovirals**-*Antiretroviral Combinations***


39


abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg


ATRIPLA ORAL TABLET 600-200-300 MG P

COMPLERA ORAL TABLET 200-25-300 MG

P

EPZICOM ORAL TABLET 600-300 MG P

KALETRA ORAL SOLUTION 400-100 MG/5ML

P

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

P

lamivudine-zidovudine oral tablet 150-300 mg P

STRIBILD ORAL TABLET 150-150-200-300 MG

P

TRUVADA ORAL TABLET 200-300 MG P

*Antiretrovirals**-*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***

SELZENTRY ORAL TABLET 150 MG, 300 MG

P

*Antiretrovirals**-*Antiretrovirals - Fusion Inhibitors***

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG

P

*Antiretrovirals**-*Antiretrovirals - Integrase Inhibitors***

ISENTRESS ORAL PACKET 100 MG P

ISENTRESS ORAL TABLET 400 MG P

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

P

TIVICAY ORAL TABLET 50 MG P

*Antiretrovirals**-*Antiretrovirals - Protease Inhibitors***

APTIVUS ORAL CAPSULE 250 MG P

APTIVUS ORAL SOLUTION 100 MG/ML P

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

P

INVIRASE ORAL CAPSULE 200 MG P

INVIRASE ORAL TABLET 500 MG P

LEXIVA ORAL SUSPENSION 50 MG/ML P


40


LEXIVA ORAL TABLET 700 MG P

NORVIR ORAL CAPSULE 100 MG P

NORVIR ORAL SOLUTION 80 MG/ML P

NORVIR ORAL TABLET 100 MG P

PREZISTA ORAL SUSPENSION 100 MG/ML

P

PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG

P

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

P

VIRACEPT ORAL TABLET 250 MG, 625 MG

P

*Antiretrovirals**-*Antiretrovirals -Rti-Non-Nucleoside Analogues***

EDURANT ORAL TABLET 25 MG P

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

P

nevirapine oral suspension 50 mg/5ml P

nevirapine oral tablet 200 mg P

nevirapine er oral tablet extended release 24 hr* 400 mg

P

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

P

SUSTIVA ORAL CAPSULE 200 MG, 50 MG P

SUSTIVA ORAL TABLET 600 MG P

viramune xr oral tablet extended release 24 hr* 100 mg

P

*Antiretrovirals**-*Antiretrovirals -Rti-Nucleoside Analogues-Purines***

abacavir sulfate oral tablet 300 mg P

didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg

P

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

P

ZIAGEN ORAL SOLUTION 20 MG/ML P

*Antiretrovirals**-*Antiretrovirals -Rti-Nucleoside Analogues-Pyrimidines***

EMTRIVA ORAL CAPSULE 200 MG P


41


EMTRIVA ORAL SOLUTION 10 MG/ML P

EPIVIR ORAL SOLUTION 10 MG/ML P

EPIVIR HBV ORAL SOLUTION 5 MG/ML P

lamivudine oral tablet 100 mg, 150 mg, 300 mg P

*Antiretrovirals**-*Antiretrovirals -Rti-Nucleoside Analogues-Thymidines***

retrovir intravenous* solution 10 mg/ml P

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

P

stavudine oral solution reconstituted 1 mg/ml P

zidovudine oral capsule 100 mg P

zidovudine oral syrup 50 mg/5ml P QL (1860 ML per 31 days)

zidovudine oral tablet 300 mg P

*Antiretrovirals**-*Antiretrovirals -Rti-Nucleotide Analogues***

viread oral powder 40 mg/gm P

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

P

*Hepatitis Agents**-*Hepatitis B Agents***

adefovir dipivoxil oral tablet 10 mg P

BARACLUDE ORAL SOLUTION 0.05 MG/ML


entecavir oral tablet 0.5 mg, 1 mg P

TYZEKA ORAL TABLET 600 MG P

*Hepatitis Agents**-*Hepatitis C Agents***

INCIVEK ORAL TABLET 375 MG P

OLYSIO ORAL CAPSULE 150 MG P PA; QL (28 EA per 28 days)

PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

P

PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

P

PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

P


42


PEGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML

P

PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML

P

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

P

REBETOL ORAL SOLUTION 40 MG/ML P QL (1000 ML per 31 days)

RIBASPHERE ORAL TABLET 200 MG P

ribavirin oral tablet 200 mg P

SOVALDI ORAL TABLET 400 MG P PA; QL (28 EA per 28 days)

VICTRELIS ORAL CAPSULE 200 MG P QL (336 EA per 28 days)

*Herpes Agents**-*Herpes Agents - Purine Analogues***

acyclovir oral capsule 200 mg P

acyclovir oral suspension 200 mg/5ml P QL (3500 ML per 31 days)

acyclovir oral tablet 400 mg, 800 mg P

valacyclovir hcl oral tablet 1 gm, 500 mg P

*Influenza Agents**-*Influenza Agents***

rimantadine hcl oral tablet 100 mg P

*Influenza Agents**-*Neuraminidase Inhibitors***

RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER

P QL (40 EA per 365 days); AL (Min 7 Years)

TAMIFLU ORAL CAPSULE 30 MG P QL (40 EA per 365 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG P QL (20 EA per 365 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML


*Assorted Classes*

*Immunomodulators**-*Antileprotics***

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

P PA

*Immunomodulators**-*Immunomodulators For Myelodysplastic Syndromes***

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

P PA


43


*Immunosuppressive Agents**-*Cyclosporine Analogs***

cyclosporine intravenous* solution 50 mg/ml P

cyclosporine oral capsule 100 mg, 25 mg P

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

P

cyclosporine modified oral solution 100 mg/ml P

GENGRAF ORAL CAPSULE 100 MG, 25 MG

P

GENGRAF ORAL SOLUTION 100 MG/ML P

SANDIMMUNE ORAL SOLUTION 100 MG/ML

P

*Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors***

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

P

CELLCEPT INTRAVENOUS INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

P

mycophenolate mofetil oral capsule 250 mg P

mycophenolate mofetil oral tablet 500 mg P

mycophenolic acid oral tablet delayed release 180 mg, 360 mg

P

*Immunosuppressive Agents**-*Macrolide Immunosuppressants***

HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

P

PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML

P

RAPAMUNE ORAL SOLUTION 1 MG/ML P

RAPAMUNE ORAL TABLET 1 MG, 2 MG P

sirolimus oral tablet 0.5 mg P

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg P

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

P

*Immunosuppressive Agents**-*Monoclonal Antibodies***


44


SIMULECT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG, 20 MG

P

*Immunosuppressive Agents**-*Purine Analogs***

azathioprine oral tablet 50 mg P

azathioprine sodium injection solution reconstituted 100 mg

P

*Immunosuppressive Agents**-*Selective T-Cell Costimulation Blockers***

NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG

P

*Potassium Removing Resins**-*Potassium Removing Resins***

sodium polystyrene sulfonate oral powder P QL (454 GM per 31 days)

SPS ORAL SUSPENSION 15 GM/60ML P

*Beta Blockers*

*Alpha-Beta Blockers**-*Alpha-Beta Blockers***

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

P

labetalol hcl intravenous* solution 5 mg/ml P

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg P

*Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective***

atenolol oral tablet 100 mg, 25 mg, 50 mg P

bisoprolol fumarate oral tablet 10 mg, 5 mg P

metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg

P

metoprolol tartrate intravenous* solution 1 mg/ml

P

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

P

*Beta Blockers Non-Selective**-*Beta Blockers Non-Selective***

nadolol oral tablet 20 mg, 40 mg, 80 mg P

pindolol oral tablet 10 mg, 5 mg P

propranolol hcl intravenous* solution 1 mg/ml P


45


propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

P

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

P

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

P

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

P

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

P

timolol maleate oral tablet 10 mg, 20 mg, 5 mg P

*Calcium Channel Blockers*

*Calcium Channel Blockers**-*Calcium Channel Blockers***

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

P

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

P

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

P

diltiazem hcl intravenous* solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml

P

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

P

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

P

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

P

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

P

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

P

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

P


46


NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

P

nifedipine oral capsule 10 mg P

nifedipine er oral tablet extended release 24 hr* 90 mg

P

nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg

P

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg P

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

P

verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg

P

*Cardiotonics*

*Cardiac Glycosides**-*Cardiac Glycosides***

digoxin injection solution 0.25 mg/ml P

digoxin oral solution 0.05 mg/ml P

digoxin oral tablet 0.125 mg, 0.25 mg P

*Cardiovascular Agents - Misc.*

*Pulmonary Hypertension - Endothelin Receptor Antagonists**-*Pulmonary Hypertension - Endothelin Receptor Antagonists***

LETAIRIS ORAL TABLET 10 MG, 5 MG P PA

*Pulmonary Hypertension - Phosphodiesterase Inhibitors**-*Pulmonary Hypertension -Phosphodiesterase Inhibitors***

sildenafil citrate oral tablet 20 mg P PA

*Cephalosporins*

*Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation***

cefadroxil oral capsule 500 mg P

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

P

cefadroxil oral tablet 1 gm P

cephalexin oral capsule 250 mg, 500 mg, 750 mg P


47


cephalexin oral suspension reconstituted 125 mg/5ml

P

cephalexin oral suspension reconstituted 250 mg/5ml


*Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation***

cefaclor oral capsule 250 mg, 500 mg P

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

cefprozil oral tablet 250 mg, 500 mg P

cefuroxime axetil oral suspension reconstituted 125 mg/5ml

P

cefuroxime axetil oral tablet 250 mg, 500 mg P

*Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation***

cefdinir oral capsule 300 mg P

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

P

cefpodoxime proxetil oral tablet 100 mg, 200 mg P

*Contraceptives*

*Combination Contraceptives -Oral**-*Biphasic Contraceptives - Oral***

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

P

*Combination Contraceptives -Oral**-*Combination Contraceptives - Oral***

ALTAVERA ORAL TABLET 0.15-30 MG-MCG

P

APRI ORAL TABLET 0.15-30 MG-MCG P

AVIANE ORAL TABLET 0.1-20 MG-MCG P

BALZIVA ORAL TABLET 0.4-35 MG-MCG P

briellyn oral tablet 0.4-35 mg-mcg P

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

P


48


EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

P

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

P

GIANVI ORAL TABLET 3-0.02 MG P

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG P

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG

P

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG

P

LESSINA ORAL TABLET 0.1-20 MG-MCG P

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

P

LORYNA ORAL TABLET 3-0.02 MG P

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG

P

LUTERA ORAL TABLET 0.1-20 MG-MCG P

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

P

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

P

MONONESSA ORAL TABLET 0.25-35 MG-MCG

P

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

P

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG

P

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG

P

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

P


49


NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

P

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

P

OCELLA ORAL TABLET 3-0.03 MG P

OGESTREL ORAL TABLET 0.5-50 MG-MCG

P

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG

P

PREVIFEM ORAL TABLET 0.25-35 MG-MCG

P

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG

P

SOLIA ORAL TABLET 0.15-30 MG-MCG P

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

P

SRONYX ORAL TABLET 0.1-20 MG-MCG P

SYEDA ORAL TABLET 3-0.03 MG P

VESTURA ORAL TABLET 3-0.02 MG P

ZARAH ORAL TABLET 3-0.03 MG P

ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG

P

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

P

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG

P

*Combination Contraceptives -Oral**-*Extended-Cycle Contraceptives -Oral***

QUASENSE ORAL TABLET 0.15-0.03 MG P QL (91 EA per 91 days)

*Combination Contraceptives -Oral**-*Triphasic Contraceptives - Oral***

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG

P

ENPRESSE-28 ORAL TABLET P

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

P


50


NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

P

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRIVORA (28) ORAL TABLET P

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

P

*Combination Contraceptives -Vaginal**-*Combination Contraceptives -Vaginal***

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

P

*Emergency Contraceptives**-*Emergency Contraceptives***

levonorgestrel oral tablet 0.75 mg P QL (4 EA per 31 days)

NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG

P OTC

PLAN B ONE-STEP ORAL TABLET 1.5 MG

P OTC

*Progestin Contraceptives -Injectable**-*Progestin Contraceptives -Injectable***

medroxyprogesterone acetate intramuscular* suspension 150 mg/ml


*Progestin Contraceptives - Oral**-*Progestin Contraceptives - Oral***

CAMILA ORAL TABLET 0.35 MG P

ERRIN ORAL TABLET 0.35 MG P

JOLIVETTE ORAL TABLET 0.35 MG P

NOR-QD ORAL TABLET 0.35 MG P

NORA-BE ORAL TABLET 0.35 MG P

*Corticosteroids*


51


*Glucocorticosteroids**-*Glucocorticosteroids* **

A-METHAPRED INJECTION SOLUTION RECONSTITUTED 125 MG, 40 MG

P

cortisone acetate oral tablet 25 mg P

dexamethasone oral elixir 0.5 mg/5ml P

dexamethasone oral solution 0.5 mg/5ml P

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

P

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml

P

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg P

methylprednisolone oral tablet 16 mg, 32 mg, 8 mg

P

methylprednisolone (pak) oral tablet 4 mg P

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

P

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

P

prednisolone oral solution 15 mg/5ml P

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

P

prednisone oral solution 5 mg/5ml P

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

P

*Mineralocorticoids**-*Mineralocorticoids***

fludrocortisone acetate oral tablet 0.1 mg P

*Cough/Cold/Allergy*

*Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine***

ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

P OTC

ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG

P OTC


52


allergy relief/nasal decongest oral tablet extended release 24 hr* 10-240 mg

P OTC

BROTAPP ORAL LIQUID† 1-15 MG/5ML P OTC

cetirizine-pseudoephedrine er oral tablet extended release 12 hr* 5-120 mg

P OTC

cold & allergy oral elixir 1-2.5 mg/5ml P OTC

DELSYM NGHT TIME CGH/CLD CHILD ORAL LIQUID† 12.5-5 MG/5ML

P OTC

DELSYM NIGHT TIME COUGH/COLD ORAL LIQUID† 6.25-2.5 MG/5ML

P OTC

fexofenadine-pseudoephed er oral tablet extended release 24 hr* 180-240 mg

P OTC

Q-TAPP ORAL ELIXIR 1-15 MG/5ML P OTC

triprolidine-pse oral tablet 2.5-60 mg P OTC

*Expectorants**-*Expectorants***

guaifenesin oral solution 100 mg/5ml P OTC

mucus relief oral tablet 400 mg P OTC

refenesen oral tablet 200 mg P OTC

refenesen 400 oral tablet 400 mg P OTC

robafen oral syrup 100 mg/5ml P OTC

*Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants***

BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 %

P OTC

sodium chloride inhalation nebulization solution 0.9 %

P OTC

*Mucolytics**-*Mucolytics***

acetylcysteine inhalation solution 10 %, 20 % P

*Dermatologicals*

*Acne Products**-*Acne Antibiotics***

clindamycin phosphate external 1 % P

clindamycin phosphate external lotion 1 % P

clindamycin phosphate external solution 1 % P

ery external pad 2 % P

erythromycin external 2 % P

erythromycin external solution 2 % P

sulfacetamide sodium external suspension 10 % P


53


*Acne Products**-*Acne Combinations***

benzoyl peroxide-erythromycin external 5-3 % P

*Acne Products**-*Acne Products***

acne medication external lotion 10 % P OTC

acne medication 5 external lotion 5 % P OTC

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG

P

ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)

AVITA EXTERNAL 0.025 % P QL (45 GM per 31 days); AL (Max 20 Years)

AVITA EXTERNAL CREAM 0.025 % P QL (45 GM per 31 days); AL (Max 20 Years)

benzoyl peroxide external 10 %, 5 % P OTC

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

P

ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)

LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID† 4 %

P

LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID† 8 %

P

tretinoin external 0.01 %, 0.025 % P QL (45 GM per 31 days); AL (Max 20 Years)

tretinoin external cream 0.025 %, 0.05 %, 0.1 % P QL (45 GM per 31 days); AL (Max 20 Years)

*Antibiotics - Topical**-*Antibiotic Mixtures Topical***

double antibiotic external ointment 500-10000 unit/gm

P OTC

triple antibiotic external ointment 3.5-400-5000 , 5-400-5000

P OTC

*Antibiotics - Topical**-*Antibiotic Steroid Combinations - Topical***

CORTISPORIN EXTERNAL OINTMENT 1 %

P


54


*Antibiotics - Topical**-*Antibiotics -Topical***

bacitracin external ointment 500 unit/gm P OTC

bacitracin zinc external ointment 500 unit/gm P OTC

gentamicin sulfate external cream 0.1 % P

gentamicin sulfate external ointment 0.1 % P

mupirocin external ointment 2 % P

*Antifungals - Topical**-*Antifungals -Topical***

ciclopirox external solution 8 % P

ciclopirox olamine external cream 0.77 % P

ciclopirox olamine external suspension 0.77 % P

nystatin external cream 100000 unit/gm P

nystatin external ointment 100000 unit/gm P

nystatin external powder 100000 unit/gm P

terbinafine hcl external cream 1 % P OTC

*Antifungals - Topical**-*Imidazole-Related Antifungals - Topical***

baza antifungal external cream 2 % P OTC

clotrimazole external cream 1 % P OTC

clotrimazole external solution 1 % P OTC

econazole nitrate external cream 1 % P

ketoconazole external cream 2 % P

ketoconazole external shampoo 2 % P

*Anti-Inflammatory Agents -Topical**-*Anti-Inflammatory Agents -Topical***

VOLTAREN TRANSDERMAL 1 % P QL (300 GM per 31 days)

*Antineoplastic Or Premalignant Lesion Agents - Topical**-*Antineoplastic Antimetabolites -Topical***

fluorouracil external cream 5 % P PA

fluorouracil external solution 2 %, 5 % P PA

*Antipsoriatics**-*Antipsoriatics***

calcipotriene external cream 0.005 % P

calcipotriene external ointment 0.005 % P


55


calcipotriene external solution 0.005 % P

DRITHO-CREME HP EXTERNAL CREAM 1 %

P

TAZORAC EXTERNAL 0.05 %, 0.1 % P QL (30 GM per 31 days); AL (Max 20 Years)

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %

P QL (30 GM per 31 days); AL (Max 20 Years)

*Antiseborrheic Products**-*Antiseborrheic Products***

selenium sulfide external lotion 2.5 % P

*Antivirals - Topical**-*Antivirals - Topical***

DENAVIR EXTERNAL CREAM 1 % P ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)

ZOVIRAX EXTERNAL CREAM 5 % P ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)

*Burn Products**-*Burn Products***

silver sulfadiazine external cream 1 % P QL (400 GM per 31 days)

SSD EXTERNAL CREAM 1 % P QL (400 GM per 31 days)

*Corticosteroids - Topical**-*Corticosteroids -Topical***

alclometasone dipropionate external cream 0.05 %

P

alclometasone dipropionate external ointment 0.05 %

P

betamethasone dipropionate external cream 0.05 %

P

betamethasone dipropionate external lotion 0.05 %

P

betamethasone dipropionate external ointment 0.05 %

P

betamethasone dipropionate aug external cream 0.05 %

P

betamethasone valerate external cream 0.1 % P

betamethasone valerate external lotion 0.1 % P

betamethasone valerate external ointment 0.1 % P

clobetasol propionate external 0.05 % P


56


clobetasol propionate external cream 0.05 % P

clobetasol propionate external ointment 0.05 % P

DEMAREST DRICORT EXTERNAL CREAM 1 %

P OTC

desonide external cream 0.05 % P

fluocinolone acetonide external cream 0.01 %, 0.025 %

P

fluocinolone acetonide external ointment 0.025 %

P

fluocinolone acetonide external solution 0.01 % P

fluocinolone acetonide body external oil 0.01 % P

fluocinolone acetonide scalp external oil 0.01 % P

fluocinonide external 0.05 % P

fluocinonide external cream 0.05 % P

fluocinonide external ointment 0.05 % P

fluocinonide external solution 0.05 % P

fluocinonide-e external cream 0.05 % P

fluticasone propionate external cream 0.05 % P

fluticasone propionate external ointment 0.005 %

P

halobetasol propionate external cream 0.05 % P

halobetasol propionate external ointment 0.05 % P

hydrocortisone external cream 0.5 %, 1 % P OTC

hydrocortisone external lotion 1 % P OTC

hydrocortisone external lotion 2.5 % P

hydrocortisone external ointment 0.5 %, 1 % P OTC

hydrocortisone external ointment 2.5 % P

hydrocortisone valerate external cream 0.2 % P

hydrocortisone valerate external ointment 0.2 % P

mometasone furoate external cream 0.1 % P

mometasone furoate external ointment 0.1 % P

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

P

triamcinolone acetonide external ointment 0.1 % P

*Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents***


57


REMEVEN EXTERNAL CREAM 50 % P

urea external cream 40 % P

X-VIATE EXTERNAL CREAM 40 % P

*Emollients**-*Emollients***

AMLACTIN EXTERNAL LOTION 12 % P OTC; QL (400 GM per 31 days)

ammonium lactate external cream 12 % P OTC; QL (400 GM per 31 days)

ammonium lactate external lotion 12 % P OTC; QL (400 GM per 31 days)

*Enzymes - Topical**-*Enzymes - Topical***

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

P PA

*Immunosuppressive Agents -Topical**-*Macrolide Immunosuppressants -Topical***

ELIDEL EXTERNAL CREAM 1 % P

ST; Notes (Must fail preferred topical corticosteroid with use for at least 4 weeks or with 90 days of history.); QL (30 GM per 31 days)

*Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents***

CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 %

P OTC

COMPOUND W EXTERNAL LIQUID† 17 %

P OTC

COMPOUND W MAXIMUM STRENGTH EXTERNAL 17 %

P OTC

CONDYLOX EXTERNAL 0.5 % P PA

FREEZONE EXTERNAL LIQUID† 17.6 % P OTC

podofilox external solution 0.5 % P

SALACTIC FILM EXTERNAL SOLUTION 17 %

P OTC

*Local Anesthetics - Topical**-*Local Anesthetics - Topical***

capsaicin external cream 0.025 % P OTC

lidocaine external ointment 5 % P

lidocaine hcl external 2 % P

lidocaine hcl external solution 4 % P


58


*Local Anesthetics - Topical**-*Topical Anesthetic Combinations***

lidocaine-prilocaine external cream 2.5-2.5 % P

lidocaine-prilocaine external kit 2.5-2.5 % P

*Misc. Topical**-*Misc. Topical***

HYPERCARE EXTERNAL SOLUTION 20 %

P

PREPARATION H EXTERNAL PAD 50 % P OTC

*Rosacea Agents**-*Rosacea Agents***

metronidazole external 1 % P

metronidazole external cream 0.75 % P

*Scabicides & Pediculicides**-*Scabicides & Pediculicides***

ACTICIN EXTERNAL CREAM 5 % P QL (60 GM per 31 days)

malathion external lotion 0.5 % P QL (118 ML per 31 days); AL (Min 6 Years)

permethrin external cream 5 % P QL (60 GM per 31 days)

permethrin external lotion 1 % P OTC; QL (60 ML per 31 days)

spinosad external suspension 0.9 % P AL (Min 4 Years)

*Diagnostic Products*

*Diagnostic Drugs**-*Diagnostic Drugs***

dipyridamole intravenous* solution 5 mg/ml P

*Diagnostic Tests**-*Diagnostic Tests***

ACCU-CHEK ACTIVE IN VITRO STRIP P

Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC

ACCU-CHEK AVIVA PLUS IN VITRO STRIP

P


ACCU-CHEK COMFORT CURVE IN VITRO STRIP

P



59


ACCU-CHEK COMPACT TEST DRUM IN VITRO STRIP

P


ACCU-CHEK SMARTVIEW IN VITRO STRIP

P


CLINISTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)

DIASTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)

FREESTYLE INSULINX TEST IN VITRO STRIP

P


FREESTYLE LITE TEST IN VITRO STRIP P


FREESTYLE TEST IN VITRO STRIP P


KETOSTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

P


PRECISION XTRA KETONE IN VITRO STRIP

P OTC

*Digestive Aids*

*Digestive Enzymes**-*Digestive Enzymes***

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

P


60


PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT

P

*Diuretics*

*Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors***

acetazolamide oral tablet 125 mg, 250 mg P

methazolamide oral tablet 25 mg, 50 mg P

*Diuretic Combinations**-*Diuretic Combinations***

amiloride-hydrochlorothiazide oral tablet 5-50 mg

P

spironolactone-hctz oral tablet 25-25 mg P

triamterene-hctz oral capsule 37.5-25 mg P

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg

P

*Loop Diuretics**-*Loop Diuretics***

bumetanide injection solution 0.25 mg/ml P

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg P

furosemide oral solution 10 mg/ml, 8 mg/ml P

furosemide oral tablet 20 mg, 40 mg, 80 mg P

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

P

*Potassium Sparing Diuretics**-*Potassium Sparing Diuretics***

spironolactone oral tablet 100 mg, 25 mg, 50 mg P

*Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics***

chlorothiazide oral tablet 250 mg, 500 mg P

chlorthalidone oral tablet 25 mg, 50 mg P

hydrochlorothiazide oral capsule 12.5 mg P

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

P

indapamide oral tablet 1.25 mg, 2.5 mg P

metolazone oral tablet 10 mg, 2.5 mg, 5 mg P

*Endocrine And Metabolic Agents - Misc.*


61


*Bone Density Regulators**-*Bisphosphonates***

alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

P

*Bone Density Regulators**-*Calcitonins***

calcitonin (salmon) nasal solution 200 unit/act P

FORTICAL NASAL SOLUTION 200 UNIT/ACT

P

*Bone Density Regulators**-*Rank Ligand (Rankl) Inhibitors***

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML

P PA

*Growth Hormones**-*Growth Hormones***

TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG

P PA

*Hormone Receptor Modulators**-*Selective Estrogen Receptor Modulators (Serms)***

raloxifene hcl oral tablet 60 mg P

*Metabolic Modifiers**-*Carnitine Replenisher - Agents***

levocarnitine intravenous* solution 200 mg/ml P

levocarnitine oral solution 1 gm/10ml P QL (900 ML per 31 days)

levocarnitine oral tablet 330 mg P

*Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents***

LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

P PA

*Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs***

calcitriol intravenous* solution 1 mcg/ml P

calcitriol oral capsule 0.25 mcg, 0.5 mcg P

calcitriol oral solution 1 mcg/ml P

*Posterior Pituitary Hormones**-*Vasopressin***

desmopressin ace rhinal tube nasal solution 0.01 %

P

desmopressin ace spray refrig nasal solution 0.01 %

P


62


desmopressin acetate oral tablet 0.1 mg, 0.2 mg P

desmopressin acetate spray nasal solution 0.01 %

P

*Estrogens*

*Estrogen Combinations**-*Estrogen & Progestin***

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

P

PREMPHASE ORAL TABLET 0.625-5 MG P

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

P

*Estrogens**-*Estrogens***

estradiol oral tablet 0.5 mg, 1 mg, 2 mg P

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

P

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg P

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

P

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

P

*Fluoroquinolones*

*Fluoroquinolones**-*Fluoroquinolones***

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

P

levofloxacin oral tablet 250 mg, 500 mg, 750 mg P

*Gastrointestinal Agents - Misc.*

*Antiflatulents**-*Antiflatulents***

simethicone oral suspension 40 mg/0.6ml P OTC

simethicone oral tablet chewable 80 mg P OTC

*Gallstone Solubilizing Agents**-*Gallstone Solubilizing Agents***

ursodiol oral capsule 300 mg P

*Gastrointestinal Stimulants**-*Gastrointestinal Stimulants***

metoclopramide hcl oral solution 5 mg/5ml P QL (1500 ML per 31 days)

metoclopramide hcl oral tablet 10 mg, 5 mg P


63


*Inflammatory Bowel Agents**-*Inflammatory Bowel Agents***

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

P

balsalazide disodium oral capsule 750 mg P

mesalamine enema 4 gm P QL (1800 ML per 31 days)

sulfasalazine oral tablet 500 mg P

sulfasalazine oral tablet delayed release 500 mg P

*Intestinal Acidifiers**-*Intestinal Acidifiers***

generlac oral solution 10 gm/15ml P QL (4185 ML per 31 days)

*Phosphate Binder Agents**-*Phosphate Binder Agents***

calcium acetate oral capsule 667 mg P QL (372 EA per 31 days)

ELIPHOS ORAL TABLET 667 MG P QL (372 EA per 31 days)

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

P

RENVELA ORAL TABLET 800 MG P

*Genitourinary Agents - Miscellaneous*

*Alkalinizers**-*Citrates***

cytra-2 oral solution 500-334 mg/5ml P QL (3600 ML per 31 days)

CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML


*Genitourinary Irrigants**-*Genitourinary Irrigants***

ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 %


sodium chloride irrigation solution 0.9 % P QL (1000 ML per 31 days)

*Prostatic Hypertrophy Agents**-*5-Alpha Reductase Inhibitors***

AVODART ORAL CAPSULE 0.5 MG P

finasteride oral tablet 5 mg P

*Prostatic Hypertrophy Agents**-*Alpha 1-Adrenoceptor Antagonists***

tamsulosin hcl oral capsule 0.4 mg P

*Urinary Analgesics**-*Urinary Analgesics***

phenazopyridine hcl oral tablet 100 mg, 200 mg P


64


*Gout Agents*

*Gout Agent Combinations**-*Gout Agent Combinations***

colchicine-probenecid oral tablet 0.5-500 mg P

*Gout Agents**-*Gout Agents***

allopurinol oral tablet 100 mg, 300 mg P

COLCRYS ORAL TABLET 0.6 MG P

*Uricosurics**-*Uricosurics***

probenecid oral tablet 500 mg P

*Hematological Agents - Misc.*

*Bradykinin B2 Receptor Antagonists**-*Bradykinin B2 Receptor Antagonists***

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML

P PA

*Hematorheologic Agents**-*Hematorheologic Agents***

pentoxifylline er oral tablet extendedrelease* 400 mg

P

*Platelet Aggregation Inhibitors**-*Phosphodiesterase Iii Inhibitors***

cilostazol oral tablet 100 mg, 50 mg P

*Platelet Aggregation Inhibitors**-*Platelet Aggregation Inhibitors***

dipyridamole oral tablet 25 mg, 50 mg, 75 mg P

*Platelet Aggregation Inhibitors**-*Quinazoline Agents***

anagrelide hcl oral capsule 0.5 mg, 1 mg P

*Platelet Aggregation Inhibitors**-*Thienopyridine Derivatives***

clopidogrel bisulfate oral tablet 75 mg P

*Hematopoietic Agents*

*Cobalamins**-*Cobalamins***

cyanocobalamin injection solution 1000 mcg/ml P

vitamin b-12 oral tablet 1000 mcg, 250 mcg, 500 mcg

P OTC


65


vitamin b-12 sublingual tablet sublingual 1000 mcg

P OTC

vitamin b-12 er oral tablet extendedrelease* 1000 mcg

P OTC

*Folic Acid/Folates**-*Folic Acid/Folates***

folic acid oral tablet 1 mg, 400 mcg, 800 mcg P OTC

*Hematopoietic Growth Factors**-*Erythropoiesis-Stimulating Agents (Esas)***

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

P PA

*Hematopoietic Growth Factors**-*Granulocyte Colony-Stimulating Factors (G-Csf)***

NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML

P PA

*Hematopoietic Mixtures**-*Iron Combinations***

CENTRATEX ORAL CAPSULE 106-1 MG P

FE C PLUS ORAL TABLET 100-250-0.025-1 MG

P

MULTIGEN ORAL TABLET 70 MG P

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

P

*Iron**-*Iron***

ferrous gluconate oral tablet 324 (38 fe) mg P OTC

ferrous sulfate oral elixir 220 (44 fe) mg/5ml P OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml P OTC

ferrous sulfate oral tablet 325 (65 fe) mg P OTC

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

P OTC

POLY-IRON 150 ORAL CAPSULE 150 MG P OTC

slow release iron oral tablet extendedrelease* 160 (50 fe) mg

P OTC

*Hypnotics*


66


*Barbiturate Hypnotics**-*Barbiturate Hypnotics***

phenobarbital oral elixir 20 mg/5ml P QL (2000 ML per 31 days)

phenobarbital oral tablet 100 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

P

phenobarbital oral tablet 15 mg P QL (310 EA per 31 days)

phenobarbital oral tablet 16.2 mg P QL (383 EA per 31 days)

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

P

*Non-Barbiturate Hypnotics**-*Benzodiazepine Hypnotics***

estazolam oral tablet 1 mg, 2 mg P

flurazepam hcl oral capsule 15 mg, 30 mg P

temazepam oral capsule 15 mg, 30 mg P

triazolam oral tablet 0.125 mg, 0.25 mg P AL (Min 18 Years)

*Non-Barbiturate Hypnotics**-*Non-Benzodiazepine -Gaba-Receptor Modulators***

zolpidem tartrate oral tablet 10 mg, 5 mg P QL (31 EA per 31 days); AL (Min 18 Years)

*Laxatives*

*Bulk Laxatives**-*Bulk Laxatives***

METAMUCIL ORAL CAPSULE 0.52 GM P OTC

METAMUCIL ORAL WAFER P OTC

METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 %

P OTC

natural fiber therapy oral powder 30.9 %, 48.57 %

P OTC

*Laxative Combinations**-*Bowel Evacuant Combinations***

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM


GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM


GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM



67


peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm


peg 3350/electrolytes oral solution reconstituted 240 gm


peg-3350/electrolytes oral solution reconstituted 236 gm


TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM


*Laxative Combinations**-*Laxatives & Dss***

senna-docusate sodium oral tablet 8.6-50 mg P OTC

*Laxatives - Miscellaneous**-*Laxatives -Miscellaneous***

glycerin (adult) suppository 2.1 gm P OTC

glycerin (pediatric) suppository 1.2 gm P OTC

lactulose oral solution 10 gm/15ml P QL (4185 ML per 31 days)

polyethylene glycol 3350 oral powder P OTC; QL (527 GM per 31 days)

sorbitol oral solution 70 % P OTC; QL (1500 ML per 31 days)

*Lubricant Laxatives**-*Lubricant Laxatives***

mineral oil oral oil P OTC

mineral oil heavy oral oil P

*Saline Laxatives**-*Saline Laxative Mixtures***

FLEET PEDIATRIC ENEMA 3.5-9.5 GM/59ML

P OTC

ra saline enema enema 19-7 gm/118ml P OTC

*Saline Laxatives**-*Saline Laxatives***

magnesium citrate oral solution 1.745 gm/30ml P OTC

milk of magnesia oral suspension 400 mg/5ml, 7.75 %

P OTC

*Stimulant Laxatives**-*Stimulant Laxatives***

EX-LAX ORAL TABLET CHEWABLE 15 MG

P OTC

laxative suppository 10 mg P OTC

senna oral syrup 8.8 mg/5ml P OTC


68


senna oral tablet 8.6 mg P OTC

stimulant laxative oral tablet delayed release 5 mg

P OTC

*Surfactant Laxatives**-*Surfactant Laxatives***

docusate sodium oral tablet 100 mg P OTC

ENEMEEZ MINI ENEMA 283 MG P OTC

silace oral liquid† 150 mg/15ml P OTC

stool softener oral capsule 100 mg, 250 mg P OTC

stool softener laxative dc oral capsule 240 mg P OTC

*Local Anesthetics-Parenteral*

*Local Anesthetics - Amides**-*Local Anesthetics - Amides***

lidocaine hcl injection solution 0.5 %, 1 %, 1.5 % P

lidocaine hcl (pf) injection solution 2 % P

*Macrolides*

*Azithromycin**-*Azithromycin***

azithromycin intravenous* solution reconstituted 500 mg

P

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

P

azithromycin oral tablet 250 mg P QL (6 EA per 31 days)

azithromycin oral tablet 500 mg, 600 mg P

azithromycin hydrogencitrate intravenous* solution reconstituted 2.5 gm

P

*Clarithromycin**-*Clarithromycin***

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

clarithromycin oral tablet 250 mg, 500 mg P

*Erythromycins**-*Erythromycins***

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

P

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

P

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

P


69


ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

P

ERYTHROCIN STEARATE ORAL TABLET 250 MG

P

erythromycin base oral capsule delayed release particles 250 mg

P

erythromycin base oral tablet 250 mg, 500 mg P

erythromycin ethylsuccinate oral tablet 400 mg P

*Medical Devices*

*Diabetic Supplies**-*Glucose Monitoring Test Supplies***

ACCU-CHEK AVIVA PLUS KIT W/DEVICE


ACCU-CHEK COMPACT PLUS CARE KIT P OTC; QL (1 EA per 365 days)

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE


FREESTYLE FREEDOM LITE KIT W/DEVICE


FREESTYLE INSULINX SYSTEM KIT W/DEVICE


FREESTYLE LITE DEVICE P OTC; QL (1 EA per 365 days)

glucose control in vitro solution P OTC

lancet device P OTC

lancets P

Notes (Accu-Chek Multiclix lancets: QL (204.00 per 31 days); All other lancets:QL (200.00 per 31 days)); OTC

PRECISION XTRA DEVICE P OTC; QL (1 EA per 365 days)

*Misc. Devices**-*Applicators,Cotton Balls,Etc***

alcohol pads pad 70 % P OTC

*Parenteral Therapy Supplies**-*Needles & Syringes***

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

P Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)

EXEL PEN NEEDLES 1/3" 31G X 8 MM P Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)


70


insulin syringe 29g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml

P Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)

*Respiratory Therapy Supplies**-*Peak Flow Meters***

peak flow meter device P OTC; QL (2 EA per 365 days)

*Respiratory Therapy Supplies**-*Respiratory Therapy Supplies***

ACE AEROSOL CLOUD ENHANCER P QL (2 EA per 365 days)

IN-CHECK DIAL FLOW TRAINER DEVICE


PFLEX P QL (2 EA per 365 days)

THRESHOLD IMT P QL (2 EA per 365 days)

THRESHOLD PEP DEVICE P QL (2 EA per 365 days)

WINDMILL TRAINER P QL (2 EA per 365 days)

*Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies***

AEROCHAMBER MV P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU W/MASK


AEROCHAMBER W/FLOWSIGNAL P QL (2 EA per 365 days)

AEROCHAMBER Z-STAT PLUS P QL (2 EA per 365 days)

AEROCHAMBER Z-STAT PLUS CHAMBR


E-Z SPACER DEVICE P QL (2 EA per 365 days)

EASIVENT P QL (2 EA per 365 days)

MICROCHAMBER P QL (2 EA per 365 days)

MICROSPACER P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-LG MASK P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-MED MASK



71


OPTICHAMBER ADVANTAGE-SM MASK


OPTICHAMBER FACE MASK-LARGE P OTC; QL (2 EA per 365 days)

OPTICHAMBER FACE MASK-MEDIUM P OTC; QL (2 EA per 365 days)

OPTICHAMBER FACE MASK-SMALL P OTC; QL (2 EA per 365 days)

OPTIHALER P QL (2 EA per 365 days)

OPTIHALER DEVICE P QL (2 EA per 365 days)

POCKET CHAMBER DEVICE P QL (2 EA per 365 days)

POCKET SPACER DEVICE P QL (2 EA per 365 days)

WATCHHALER DEVICE P QL (2 EA per 365 days)

*Migraine Products*

*Serotonin Agonists**-*Selective Serotonin Agonists 5-Ht(1)***

naratriptan hcl oral tablet 1 mg, 2.5 mg P

ST; Notes (Must fail preferred sumatriptan tablets within the past 100 days.); QL (9 EA per 31 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act P QL (12 EA per 31 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate subcutaneous* 6 mg/0.5ml P QL (4 ML per 31 days)

sumatriptan succinate subcutaneous* solution 4 mg/0.5ml, 6 mg/0.5ml


*Minerals & Electrolytes*

*Calcium**-*Calcium Combinations***

CALCITRATE ORAL TABLET 315-250 MG-UNIT

P OTC

calcium carbonate-vitamin d oral tablet 600-400 mg-unit

P OTC

calcium citrate + d oral tablet 315-200 mg-unit P OTC

oyst-cal d oral tablet 250-125 mg-unit P OTC

oyster shell calcium + d oral tablet 500-400 mg-unit

P OTC

oyster shell calcium/d oral tablet 250-125 mg-unit, 500-200 mg-unit

P OTC

*Calcium**-*Calcium***

cal-lac oral capsule 500 mg P OTC


72


calcium acetate (phos binder) oral tablet 667 mg


calcium carbonate oral suspension 1250 mg/5ml P OTC

calcium carbonate oral tablet 1250 mg, 600 mg P OTC

calcium lactate oral tablet 648 mg P OTC

*Electrolyte Mixtures**-*Electrolytes Oral***

ORALYTE ORAL SOLUTION P OTC; QL (4000 ML per 31 days)

ORALYTE FREEZER POPS ORAL SOLUTION


*Fluoride**-*Fluoride Combinations***

FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG

P

*Fluoride**-*Fluoride***

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP

P

sodium fluoride oral solution 1.1 (0.5 f) mg/ml P

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

P

*Iodine Products**-*Iodine Products***

SSKI ORAL SOLUTION 1 GM/ML P

*Magnesium**-*Magnesium***

mag-delay oral tablet extendedrelease* 535 (64 mg) mg

P OTC

mag-sr oral tablet extendedrelease* 535 (64 mg) mg

P OTC

MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG

P OTC

magnesium oral tablet 250 mg P OTC

magnesium oxide oral tablet 400 (240 mg) mg, 500 mg

P OTC

*Phosphate**-*Phosphate***

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG

N/A

*Potassium**-*Potassium***

KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ

P


73


KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ

P

KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ

P

KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ

P

potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 2 meq/ml, 40 meq/100ml

P

potassium chloride oral liquid† 20 meq/15ml (10%), 40 meq/15ml (20%)

P

potassium chloride oral solution 20 meq/15ml (10%)

P

potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq

P

potassium chloride er oral tablet extendedrelease* 10 meq, 8 meq

P

*Sodium**-*Sodium***

normal saline flush intravenous* solution 0.9 % P QL (310 ML per 31 days)

saline flush intravenous* solution 0.9 % P QL (310 ML per 31 days)

sodium chloride injection solution 0.9 % P QL (310 ML per 31 days)

sodium chloride intravenous* solution 0.9 % P

sodium chloride oral tablet 1 gm P OTC

*Zinc**-*Zinc***

zinc sulfate oral capsule 220 mg P OTC

zinc sulfate oral tablet 220 (50 zn) mg P OTC

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral**-*Anesthetics Topical Oral***

lidocaine viscous mouth/throat solution 2 % P

*Anti-Infectives - Throat**-*Anti-Infectives -Throat***

clotrimazole mouth/throat lozenge 10 mg P

clotrimazole mouth/throat troche 10 mg P

nystatin mouth/throat suspension 100000 unit/ml P QL (300 ML per 31 days)

*Antiseptics - Mouth/Throat**-*Antiseptics -Mouth/Throat***


74


chlorhexidine gluconate mouth/throat solution 0.12 %


PERIOGARD MOUTH/THROAT SOLUTION 0.12 %


*Dental Products**-*Fluoride Dental Products***

CAVAREST DENTAL 1.1 % P

CONTROLRX DENTAL CREAM 1.1 % P

DENTA 5000 PLUS DENTAL CREAM 1.1 %

P

DENTAGEL DENTAL 1.1 % P

FLUORIDEX DAILY DEFENSE DENTAL 1.1 %

P

KARIGEL DENTAL 1.1 % P

KARIGEL-N DENTAL 1.1 % P

NEUTRAGARD ADVANCED DENTAL 1.1 %

P

PHOS-FLUR DENTAL 1.1 % P

sf dental 1.1 % P

sf 5000 plus dental cream 1.1 % P

*Steroids - Mouth/Throat**-*Steroids -Mouth/Throat***

triamcinolone acetonide mouth/throat paste 0.1 %

P

*Throat Products - Misc.**-*Saliva Stimulants***

pilocarpine hcl oral tablet 5 mg, 7.5 mg P

*Multivitamins*

*B-Complex Vitamins**-*B-Complex Vitamins***

b complex oral tablet P OTC

b complex 50 oral tablet P OTC

b complex vitamins oral capsule P OTC

b-complex/b-12 oral tablet P OTC

vitamin b complex oral tablet P OTC

vitamin-b complex oral tablet P OTC


75


*B-Complex W/ C**-*B-Complex W/ C & E + Zn***

stress formula/zinc oral tablet P OTC

stress plus zinc oral tablet P OTC

*B-Complex W/ C**-*B-Complex W/ C***

better b complex oral tablet P OTC

vitamin b complex-c oral capsule P OTC

*B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid***

NEPHRONEX ORAL TABLET P

rena-vite oral tablet P OTC

RENAL ORAL CAPSULE 1 MG P

reno caps oral capsule 1 mg P

virt-caps oral capsule 1 mg P

*B-Complex W/ Folic Acid**-*B-Complex W/Biotin & Folic Acid***

b complete oral tablet P OTC

balanced b complex oral tablet P OTC

BIG 100 ORAL TABLET P OTC

SUPER B-50 B COMPLEX ORAL CAPSULE

P OTC

SUPER QUINTS B-50 ORAL TABLET P OTC

yl balanced b-100 oral tablet P OTC

*Bioflavonoid Products**-*Bioflavonoid Products***

vitamin c er oral tablet extendedrelease* 1000-100 mg

P OTC

*Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals***

centavite a-z complete-mineral oral tablet P OTC

CEROVITE ADVANCED FORMULA ORAL TABLET

P OTC

CERTAVITE SENIOR/ANTIOXIDANT ORAL TABLET

P OTC

CERTAVITE/ANTIOXIDANTS ORAL LIQUID†

P OTC

formula twenty-one oral tablet P OTC


76


gerivite complete oral tablet P OTC

golden age vitamin/minerals oral liquid† P OTC

multivitamin & mineral oral liquid† P OTC

thera vital m oral tablet P OTC

therabasic-m oral tablet P OTC

therapeutic liquid oral solution P OTC

therapeutic-m oral tablet P OTC

THERATRUM COMPLETE ORAL TABLET

P OTC

vision vitamins oral tablet P OTC

VITRUM SENIOR ORAL TABLET P OTC

*Multivitamins**-*Multivitamins***

daily multiple vitamins oral tablet P OTC

multi-vitamin oral tablet P OTC

multi-vitamins oral tablet P OTC

once daily oral tablet P OTC

thera-tabs oral tablet P OTC

*Ped Multi Vitamins W/Fl & Fe**-*Ped Multi Vitamins W/Fl & Fe***

multi-vit/fluoride/iron oral solution 0.25-10 mg/ml

P

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

P

*Ped Multi Vitamins W/Fl & Fe**-*Ped Vitamins Acd Fluoride & Iron***

tri-vit/fluoride/iron oral solution 0.25-10 mg/ml P

*Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride***

multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

P

multi-vitamin/fluoride oral tablet chewable 0.5 mg

P

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

P

*Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/ Fluoride***

tri-vit/fluoride oral solution 0.25 mg/ml P


77


tri-vitamin/fluoride oral solution 0.5 mg/ml P

vitamins acd-fluoride oral solution 0.25 mg/ml P

*Ped Mv W/ Iron**-*Ped Mv W/ Iron***

polyvitamin/iron oral solution 10 mg/ml P OTC

*Pediatric Multiple Vitamins**-*Pediatric Multiple Vitamins W/ C***

poly-vitamin oral solution 35 mg/ml P OTC

*Pediatric Vitamins**-*Pediatric Vitamins A & D W/ C***

tri-vitamin oral solution 1500-400-35 P OTC

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa***

ELITE-OB ORAL TABLET 50-1.25 MG P

MYNATAL ADVANCE ORAL TABLET P

mynatal-z oral tablet P

mynate 90 plus oral tablet extendedrelease* P

PRENATABS RX ORAL TABLET 29-1 MG P

prenatal oral tablet 28-0.8 mg P OTC

prenatal 19 oral tablet chewable P

prenatal low iron oral tablet 27-0.8 mg P OTC

prenatal plus oral tablet 27-1 mg P

prenatal plus iron oral tablet 29-1 mg P

PRENATAL-U ORAL CAPSULE 106.5-1 MG

P

trinatal rx 1 oral tablet 60-1 mg P

TRINATE ORAL TABLET P

VINATE AZ EXTRA ORAL TABLET 29-1 MG

P

VINATE II ORAL TABLET 29-1 MG P

VINATE M ORAL TABLET 27-1 MG P

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***

PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR)

P

*Specialty Vitamins Products**-*Specialty Vitamins Products***

vitamins for hair oral tablet P OTC


78


*Vitamins W/ Lipotropics**-*Vitamins W/ Lipotropics***

b complex formula 1 oral tablet P OTC

b-100 oral tablet P OTC

balance b-100 oral tablet P OTC

balance b-50 oral tablet P Notes (OTC-Covered w/Rx); OTC

balanced b-100 oral tablet P OTC

balanced b-50 oral tablet P OTC

balanced b-50 complex oral capsule P OTC

balanced b-50 complex oral tablet P OTC

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants**-*Central Muscle Relaxants***

baclofen oral tablet 10 mg, 20 mg P

carisoprodol oral tablet 350 mg P QL (124 EA per 31 days)

chlorzoxazone oral tablet 500 mg P

cyclobenzaprine hcl oral tablet 10 mg, 5 mg P QL (93 EA per 31 days)

methocarbamol oral tablet 500 mg, 750 mg P

tizanidine hcl oral tablet 2 mg, 4 mg P ST; Notes (Must fail preferred baclofen, cyclobenzaprine within the past 100 days)

*Direct Muscle Relaxants**-*Direct Muscle Relaxants***

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

P

*Viscosupplements**-*Viscosupplements***

SUPARTZ INTRA-ARTICULAR* SOLUTION 25 MG/2.5ML

P PA

*Nasal Agents - Systemic And Topical*

*Nasal Agents - Misc.**-*Nasal Agents -Misc.***

saline nasal spray nasal solution 0.65 % P OTC

*Nasal Antiallergy**-*Nasal Antihistamines***

azelastine hcl nasal solution 137 mcg/spray P

*Nasal Antiallergy**-*Nasal Mast Cell Stabilizers***


79


cromolyn sodium nasal aerosol, solution 5.2 mg/act

P OTC

*Nasal Anticholinergics**-*Nasal Anticholinergics***

ipratropium bromide nasal solution 0.03 %, 0.06 %

P

*Nasal Steroids**-*Nasal Steroids***

flunisolide nasal solution 25 mcg/act (0.025%) P

fluticasone propionate nasal suspension 50 mcg/act

P

*Sympathomimetic Decongestants**-*Systemic Decongestants***

childrens silfedrine oral liquid† 15 mg/5ml P OTC

nasal decongestant oral liquid† 30 mg/5ml P OTC

pseudoephedrine hcl oral tablet 30 mg, 60 mg P OTC

SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG

P OTC

*Ophthalmic Agents*

*Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations***

artificial tears ophthalmic ointment 83-15 % P OTC

HYPOTEARS OPHTHALMIC SOLUTION 1-1 %

P OTC

*Artificial Tears And Lubricants**-*Artificial Tear Ointments***

tears again ophthalmic ointment P OTC

*Artificial Tears And Lubricants**-*Artificial Tears And Lubricants***

artificial tears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 days)

*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic Combinations***

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

P

*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic***

betaxolol hcl ophthalmic solution 0.5 % P

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

P


80


carteolol hcl ophthalmic solution 1 % P

levobunolol hcl ophthalmic solution 0.25 %, 0.5 %

P

metipranolol ophthalmic solution 0.3 % P

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

P

timolol maleate ophthalmic solution 0.25 %, 0.5 %

P

*Cycloplegic Mydriatics**-*Cycloplegic Mydriatic Combinations***

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 %


*Cycloplegic Mydriatics**-*Cycloplegic Mydriatics***

atropine sulfate ophthalmic ointment 1 % P

atropine sulfate ophthalmic solution 1 % P

atropine-care ophthalmic solution 1 % P

ISOPTO HYOSCINE OPHTHALMIC SOLUTION 0.25 %

P

*Miotics**-*Miotics - Direct Acting***

pilocarpine hcl ophthalmic solution 2 % P

*Ophthalmic Adrenergic Agents**-*Ophthalmic Selective Alpha Adrenergic Agonists***

brimonidine tartrate ophthalmic solution 0.2 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Antibiotics***

ciprofloxacin hcl ophthalmic solution 0.3 % P

erythromycin ophthalmic ointment 5 mg/gm P

gentamicin sulfate ophthalmic ointment 0.3 % P

gentamicin sulfate ophthalmic solution 0.3 % P

ofloxacin ophthalmic solution 0.3 % P

tobramycin ophthalmic solution 0.3 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Anti-Infective Combinations***

ak-poly-bac ophthalmic ointment 500-10000 unit/gm

P


81


bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

P

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

P

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25

P

polycin b ophthalmic ointment 500-10000 unit/gm

P

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

P

*Ophthalmic Anti-Infectives**-*Ophthalmic Antivirals***

trifluridine ophthalmic solution 1 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Sulfonamides***

sulfacetamide sodium ophthalmic solution 10 % P

*Ophthalmic Immunomodulators**-*Ophthalmic Immunomodulators***

RESTASIS OPHTHALMIC EMULSION 0.05 %

P

*Ophthalmic Steroids**-*Ophthalmic Steroid Combinations***

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

P

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

P

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

P

poly-dex ophthalmic ointment 3.5-10000-0.1 P

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

P

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

P

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

P

*Ophthalmic Steroids**-*Ophthalmic Steroids***


82


dexamethasone sodium phosphate ophthalmic solution 0.1 %

P

fluorometholone ophthalmic suspension 0.1 % P

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

P

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

P

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

P

prednisolone acetate ophthalmic suspension 1 % P

VEXOL OPHTHALMIC SUSPENSION 1 % P

*Ophthalmics - Misc.**-*Ophthalmic Antiallergic***

cromolyn sodium ophthalmic solution 4 % P

ketotifen fumarate ophthalmic solution 0.025 % P OTC

*Ophthalmics - Misc.**-*Ophthalmic Carbonic Anhydrase Inhibitors***

AZOPT OPHTHALMIC SUSPENSION 1 % P

dorzolamide hcl ophthalmic solution 2 % P

*Ophthalmics - Misc.**-*Ophthalmic Irrigation Solutions***

OPTICS EYE WASH OPHTHALMIC SOLUTION 0.9 %

P OTC

*Ophthalmics - Misc.**-*Ophthalmic Nonsteroidal Anti-Inflammatory Agents***

diclofenac sodium ophthalmic solution 0.1 % P

flurbiprofen sodium ophthalmic solution 0.03 % P

*Prostaglandins -Ophthalmic**-*Prostaglandins -Ophthalmic***

latanoprost ophthalmic solution 0.005 % P QL (5 ML per 31 days)

*Otic Agents*

*Otic Agents - Miscellaneous**-*Otic Agents -Miscellaneous***

acetic acid-aluminum acetate otic solution 2 % P

earwax treatment drops otic solution 6.5 % P OTC

*Otic Anti-Infectives**-*Otic Anti-Infectives***


83


ofloxacin otic solution 0.3 % P

*Otic Combinations**-*Otic Analgesic Combinations***

antipyrine-benzocaine otic solution 5.4-1.4 %, 5.5-1.4 %, 54-14 mg/ml

P

oticin otic liquid† 1-0.1 % P

*Otic Combinations**-*Otic Steroid-Anti-Infective Combinations***

CIPRODEX OTIC SUSPENSION 0.3-0.1 % P

ST; Notes (Preferred for members 8 years old and younger; Members 9 years old and older: Covered w/step edit: Must fail ofloxacin 0.3% ear drops within the past 100 days.); AL (Max 8 Years)

neomycin-polymyxin-hc otic solution 3.5-10000-1

P

neomycin-polymyxin-hc otic suspension 3.5-10000-1

P

*Oxytocics*

*Oxytocics**-*Oxytocics***

methylergonovine maleate injection solution 0.2 mg/ml

P

methylergonovine maleate oral tablet 0.2 mg P

*Passive Immunizing Agents*

*Monoclonal Antibodies**-*Antiviral Monoclonal Antibodies***

SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML

P PA

*Penicillins*

*Aminopenicillins**-*Aminopenicillins***

amoxicillin oral capsule 250 mg, 500 mg P

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml


amoxicillin oral tablet 500 mg, 875 mg P

amoxicillin oral tablet chewable 125 mg, 250 mg P

ampicillin oral capsule 250 mg, 500 mg P


84


ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

*Natural Penicillins**-*Natural Penicillins***

BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

P

penicillin g procaine intramuscular* suspension 600000 unit/ml

P

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml


penicillin v potassium oral tablet 250 mg, 500 mg P

PFIZERPEN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT

P

*Penicillin Combinations**-*Penicillin Combinations***

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml


amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

P

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

P

BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML

P

BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML

P

*Penicillinase-Resistant Penicillins**-*Penicillinase-Resistant Penicillins***

dicloxacillin sodium oral capsule 250 mg, 500 mg

P

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

P

*Progestins*

*Progestins**-*Progestins***

MAKENA INTRAMUSCULAR* OIL 250 MG/ML

P PA


85


medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

P

norethindrone acetate oral tablet 5 mg P

*Psychotherapeutic And Neurological Agents -Misc.*

*Agents For Chemical Dependency**-*Alcohol Deterrents***

acamprosate calcium oral tablet delayed release 333 mg


disulfiram oral tablet 250 mg, 500 mg P

*Antidementia Agents**-*Cholinomimetics -Ache Inhibitors***

donepezil hcl oral tablet 10 mg, 5 mg P

EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

P

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

P

*Antidementia Agents**-*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***

NAMENDA ORAL SOLUTION 10 MG/5ML

P

NAMENDA ORAL TABLET 10 MG, 5 MG P

NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG

P

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

P

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

P

*Combination Psychotherapeutics**-*Benzodiazepines & Tricyclic Agents***

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

P

*Combination Psychotherapeutics**-*Phenothiazines & Tricyclic Agents***


86


perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

P

*Combination Psychotherapeutics**-*Thienbenzodiazepines & Ssris***

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

P

*Fibromyalgia Agents**-*Fibromyalgia Agent -Snris***

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

P

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

P

*Multiple Sclerosis Agents**-*Ms Agents -Pyrimidine Synthesis Inhibitors***

AUBAGIO ORAL TABLET 14 MG, 7 MG P PA

*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents - Interferons***

EXTAVIA SUBCUTANEOUS* KIT 0.3 MG P PA

REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML

P PA

REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML

P PA

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG

P PA

REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG

P PA

*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents***

COPAXONE SUBCUTANEOUS* 40 MG/ML

P PA; QL (12 ML per 28 days)

COPAXONE SUBCUTANEOUS* KIT 20 MG/ML

P PA

*Psychotherapeutic And Neurological Agents -Misc.**-*Psychotherapeutic And Neurological Agents - Misc.***

ORAP ORAL TABLET 1 MG, 2 MG P


87


*Smoking Deterrents**-*Smoking Deterrents***

BUPROBAN ORAL TABLET EXTENDED RELEASE 12 HR* 150 MG

P

CHANTIX ORAL TABLET 0.5 MG, 1 MG P QL (112 EA per 365 days)

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG


CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42


nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr


nicotine polacrilex mouth/throat gum 2 mg, 4 mg P OTC; QL (2016 EA per 365 days)

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg


NICOTROL INHALATION INHALER 10 MG


NICOTROL NS NASAL SOLUTION 10 MG/ML


*Vasomotor Symptom Agents**-*Vasomotor Symptom Agents - Ssris***

BRISDELLE ORAL CAPSULE 7.5 MG P

*Respiratory Agents - Misc.*

*Cystic Fibrosis Agents**-*Cftr Potentiators***

KALYDECO ORAL TABLET 150 MG P PA

*Cystic Fibrosis Agents**-*Hydrolytic Enzymes***

PULMOZYME INHALATION SOLUTION 1 MG/ML

P PA

*Tetracyclines*

*Tetracyclines**-*Tetracyclines***

doxycycline hyclate oral capsule 100 mg, 50 mg P PA

doxycycline hyclate oral tablet 100 mg P PA

doxycycline hyclate oral tablet 20 mg P

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

P

tetracycline hcl oral capsule 250 mg, 500 mg P


88


*Thyroid Agents*

*Antithyroid Agents**-*Antithyroid Agents***

methimazole oral tablet 10 mg, 5 mg P

propylthiouracil oral tablet 50 mg P QL (558 EA per 31 days)

*Thyroid Hormones**-*Thyroid Hormones***

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

P

levothyroxine sodium intravenous* solution reconstituted 100 mcg, 500 mcg

P

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

P

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

P

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

P

np thyroid oral tablet 30 mg, 60 mg, 90 mg P

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)

P

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)

P

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)

P

THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)

P

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)

P

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

P

UNITHROID DIRECT ORAL TABLET 150 MCG

P

WESTHROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

P


89


*Ulcer Drugs*

*Antispasmodics**-*Antispasmodics***

dicyclomine hcl oral capsule 10 mg P

dicyclomine hcl oral solution 10 mg/5ml P

dicyclomine hcl oral tablet 20 mg P

*Antispasmodics**-*Quaternary Anticholinergics***

glycopyrrolate oral tablet 1 mg, 2 mg P

propantheline bromide oral tablet 15 mg P

*H-2 Antagonists**-*H-2 Antagonists***

cimetidine oral tablet 200 mg P OTC

cimetidine oral tablet 300 mg, 400 mg, 800 mg P

cimetidine hcl oral solution 300 mg/5ml P

famotidine oral tablet 10 mg P OTC

famotidine oral tablet 20 mg, 40 mg P

famotidine premixed intravenous* solution 20-0.9 mg/50ml-%

P

ranitidine acid reducer oral tablet 75 mg P OTC

ranitidine hcl injection solution 1000 mg/40ml, 150 mg/6ml, 50 mg/2ml

P

ranitidine hcl oral capsule 150 mg, 300 mg P

ranitidine hcl oral syrup 15 mg/ml P QL (620 ML per 31 days)

ranitidine hcl oral tablet 150 mg P OTC

ranitidine hcl oral tablet 300 mg P

*Misc. Anti-Ulcer**-*Misc. Anti-Ulcer***

CARAFATE ORAL SUSPENSION 1 GM/10ML


sucralfate oral tablet 1 gm P

*Proton Pump Inhibitors**-*Proton Pump Inhibitors***

lansoprazole oral capsule delayed release 15 mg P ST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.); OTC

lansoprazole oral capsule delayed release 30 mg P ST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.)


90


omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

P

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

P

*Ulcer Drugs - Prostaglandins**-*Ulcer Drugs -Prostaglandins***

misoprostol oral tablet 100 mcg, 200 mcg P

*Urinary Anti-Infectives*

*Urinary Anti-Infective Combinations**-*Urinary Antiseptic-Antispasmodic &/Or Analgesics***

URETRON D/S ORAL TABLET P

uticap oral capsule 120 mg P

*Urinary Anti-Infectives**-*Urinary Anti-Infectives***

MACRODANTIN ORAL CAPSULE 25 MG P AL (Max 8 Years)

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

P

nitrofurantoin monohyd macro oral capsule 100 mg

P

*Urinary Antispasmodics*

*Urinary Antispasmodics**-*Urinary Antispasmodics***

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

P

oxybutynin chloride oral syrup 5 mg/5ml P

oxybutynin chloride oral tablet 5 mg P

oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg

P

trospium chloride oral tablet 20 mg P

*Vaginal Products*

*Vaginal Anti-Infectives**-*Imidazole-Related Antifungals***

3 day vaginal vaginal cream 2 % P OTC

clotrimazole vaginal cream 1 % P OTC

miconazole 3 vaginal suppository 200 mg P

miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm)

P OTC


91


miconazole nitrate vaginal cream 2 % P OTC

miconazole nitrate vaginal suppository 100 mg P OTC

MONISTAT 1 COMBO PACK VAGINAL KIT 1200-2 MG-%

P OTC

MONISTAT 3 VAGINAL CREAM 4 % P OTC

terconazole vaginal cream 0.4 %, 0.8 % P

terconazole vaginal suppository 80 mg P

*Vaginal Anti-Infectives**-*Vaginal Anti-Infectives***

clindamycin phosphate vaginal cream 2 % P

metronidazole vaginal 0.75 % P

VANDAZOLE VAGINAL 0.75 % P

*Vaginal Estrogens**-*Vaginal Estrogens***

PREMARIN VAGINAL CREAM 0.625 MG/GM

P

*Vaginal Progestins**-*Vaginal Progestins***

ENDOMETRIN VAGINAL INSERT 100 MG

P

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG

P


P


P


P


P

*Vasopressors*

*Anaphylaxis Therapy Agents**-*Anaphylaxis Therapy Agents***

EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML P

EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML

P

*Vasopressors**-*Vasopressors***

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg P

*Vitamins*


92


*Oil Soluble Vitamins**-*Vitamin A***

vitamin a oral capsule 10000 unit, 8000 unit P OTC

*Oil Soluble Vitamins**-*Vitamin D***

vitamin d (ergocalciferol) oral capsule 50000 unit

P QL (4 EA per 28 Days)

vitamin d3 oral capsule 2000 unit P OTC

vitamin d3 oral tablet 1000 unit, 400 unit P OTC

*Oil Soluble Vitamins**-*Vitamin E***

e-400 oral capsule 400 unit P OTC

*Oil Soluble Vitamins**-*Vitamin K***

MEPHYTON ORAL TABLET 5 MG P

vitamin k (phytonadione) oral tablet 100 mcg P OTC

*Water Soluble Vitamins**-*Biotin***

biotin oral capsule 5 mg, 5000 mcg P OTC

biotin 5000 oral capsule 5 mg P OTC

biotin maximum strength oral capsule 5000 mcg P OTC

*Water Soluble Vitamins**-*Vitamin B-1***

thiamine hcl injection solution 100 mg/ml P

vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg P OTC


niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg

P OTC

niacin er oral capsule extended release* 500 mg P OTC

niacin er oral tablet extendedrelease* 500 mg P OTC

NIACOR ORAL TABLET 500 MG P


pyridoxine hcl injection solution 100 mg/ml P

vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg

P OTC

vitamin b-6 er oral tablet extendedrelease* 200 mg

P OTC

*Water Soluble Vitamins**-*Vitamin C***

c-500 oral tablet chewable 500 mg P OTC

vitamin c oral syrup 500 mg/5ml P OTC

vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg

P OTC


93


vitamin c oral tablet chewable 100 mg, 250 mg P OTC

vitamin c er oral capsule extended release* 500 mg

P OTC

vitamin c er oral tablet extendedrelease* 1000 mg, 1500 mg, 500 mg

P OTC

vitamin c-rose hips oral tablet 1000 mg, 250 mg, 500 mg

P OTC

vitamin c-rose hips oral tablet chewable 500 mg P OTC

vitamin c-rose hips er oral tablet extendedrelease* 1000 mg, 1500 mg, 500 mg

P OTC


94


95

Index

3 day vaginal ............................................................................................... 90 abacavir sulfate ............................................................................................... 40 abacavir-lamivudine-zidovudine ............................................................................................... 39 ABILIFY .............................................................. 38 ABILIFY DISCMELT ............................................................................................... 38 ABILIFY MAINTENA ............................................................................................... 38 acamprosate calcium ............................................................................................... 85 acarbose .................................................................. 21 ACCU-CHEK ACTIVE ............................................................................................... 58 ACCU-CHEK AVIVA PLUS .................................................................................... 58, 69 ACCU-CHEK COMFORT CURVE ................................................................... 58 ACCU-CHEK COMPACT PLUS CARE ............................................................................................... 69 ACCU-CHEK COMPACT TEST DRUM ............................................................................................... 59 ACCU-CHEK NANO SMARTVIEW ............................................................................................... 69 ACCU-CHEK SMARTVIEW ............................................................................................... 59 ACE AEROSOL CLOUD ENHANCER ............................................................................................... 70 ACEPHEN ............................................................. 5 acetaminophen ................................................................................................... 5 acetaminophen-codeine ................................................................................................... 6 acetaminophen-codeine #2 ................................................................................................... 6 acetaminophen-codeine #3 ................................................................................................... 6 acetaminophen-codeine #4 ................................................................................................... 7 acetazolamide ............................................................................................... 60 acetic acid-aluminum acetate ............................................................................................... 82

acetylcysteine ............................................................................................... 52 acne medication ............................................................................................... 53 acne medication 5 ............................................................................................... 53 ACTICIN ............................................................. 58 acyclovir ................................................................. 42 ADASUVE ........................................................ 37 ADDERALL XR ................................................................................................... 1 adefovir dipivoxil ............................................................................................... 41 ADRUCIL .......................................................... 31 ADVAIR DISKUS ............................................................................................... 12 ADVAIR HFA ............................................................................................... 12 AEROCHAMBER MV ............................................................................................... 70 AEROCHAMBER PLUS FLO-VU ................................................................. 70 AEROCHAMBER PLUS FLO-VU LARGE ............................................................................................... 70 AEROCHAMBER PLUS FLO-VU SMALL ............................................................................................... 70 AEROCHAMBER PLUS FLO-VU W/MASK ............................................................................................... 70 AEROCHAMBER W/FLOWSIGNAL ............................................................................................... 70 AEROCHAMBER Z-STAT PLUS ........................................................................... 70 AEROCHAMBER Z-STAT PLUS CHAMBR ............................................................................................... 70 AFINITOR ............................................................................................... 33 ak-poly-bac ........................................................ 80 ALAVERT ALLERGY/SINUS ............................................................................................... 51 ALBENZA ............................................................. 9 albuterol sulfate .................................................................................... 12, 13 alclometasone dipropionate ............................................................................................... 55

alcohol pads ............................................................................................... 69alendronate sodium ............................................................................................... 61aler-dryl .................................................................. 26ALKERAN............................................................................................... 31ALLEGRA-D ALLERGY & CONGESTION............................................................................................... 51allergy ............................................................ 25, 26allergy relief/nasal decongest ............................................................................................... 52allopurinol ........................................................... 64alprazolam .............................................................. 9alprazolam er................................................................................................... 9alprazolam xr............................................................................................... 10ALTAVERA............................................................................................... 47aluminum hydroxide gel................................................................................................... 8amantadine hcl .................................................................................... 34, 35A-METHAPRED............................................................................................... 51amiloride-hydrochlorothiazide............................................................................................... 60aminophylline ............................................................................................... 13amiodarone hcl ............................................................................................... 11amitriptyline hcl............................................................................................... 20AMLACTIN............................................................................................... 57amlodipine besylate ............................................................................................... 45ammonium lactate ............................................................................................... 57AMNESTEEM............................................................................................... 53amoxapine ........................................................... 20amoxicillin .......................................................... 83amoxicillin-pot clavulanate ............................................................................................... 84amphetamine-dextroamphet er ................................................................................................... 1


96

amphetamine-dextroamphetamine.................................................................................................. 1 ampicillin ................................................... 83, 84 anagrelide hcl ............................................................................................... 64 anastrozole ......................................................... 32 antacid .......................................................................... 8 antipyrine-benzocaine ............................................................................................... 83 APIDRA ................................................................ 23 APIDRA SOLOSTAR ............................................................................................... 23 APLENZIN ............................................................................................... 18 APRI ............................................................................ 47 APRISO .................................................................. 63 APTIOM ............................................................... 15 APTIVUS ............................................................. 39 ARGYLE STERILE SALINE ............................................................................................... 63 ARMOUR THYROID ............................................................................................... 88 artificial tears ............................................................................................... 79 ASCOMP-CODEINE ................................................................................................... 7 ASMANEX 120 METERED DOSES ..................................................................... 11 ASMANEX 30 METERED DOSES ..................................................................... 12 ASMANEX 60 METERED DOSES ..................................................................... 12 aspirin ........................................................................... 5 aspirin adult low strength ................................................................................................... 5 aspirin ec ................................................................... 5 aspirin low dose ................................................................................................... 5 atenolol .................................................................... 44 atenolol-chlorthalidone ............................................................................................... 29 atorvastatin calcium ............................................................................................... 27 atovaquone .......................................................... 30 atovaquone-proguanil hcl ............................................................................................... 30 ATRIPLA ............................................................ 39 atropine sulfate ............................................................................................... 80 atropine-care ............................................................................................... 80

ATROVENT HFA ............................................................................................... 11 AUBAGIO ......................................................... 86 AVANDAMET ............................................................................................... 22 AVANDARYL ............................................................................................... 21 AVANDIA ......................................................... 23 AVASTIN ............................................................ 31 AVIANE ................................................................ 47 AVITA ...................................................................... 53 AVODART ............................................................................................... 63 azathioprine ............................................................................................... 44 azathioprine sodium ............................................................................................... 44 azelastine hcl ............................................................................................... 78 azithromycin ............................................................................................... 68 azithromycin hydrogencitrate ............................................................................................... 68 AZOPT ..................................................................... 82 b complete ............................................................ 75 b complex ............................................................. 74 b complex 50 ............................................................................................... 74 b complex formula 1 ............................................................................................... 78 b complex vitamins ............................................................................................... 74 b-100 ........................................................................... 78 bacitracin .............................................................. 54 bacitracin zinc ............................................................................................... 54 bacitracin-polymyxin b ............................................................................................... 81 baclofen ................................................................... 78 balance b-100 ............................................................................................... 78 balance b-50 ............................................................................................... 78 balanced b complex ............................................................................................... 75 balanced b-100 ............................................................................................... 78 balanced b-50 ............................................................................................... 78 balanced b-50 complex ............................................................................................... 78

balsalazide disodium ............................................................................................... 63BALZIVA ............................................................ 47BANZEL ............................................................... 15BARACLUDE............................................................................................... 41baza antifungal............................................................................................... 54b-complex/b-12............................................................................................... 74BD INSULIN SYRINGE ULTRAFINE............................................................................................... 69BENADRYL ALLERGY CHILDRENS............................................................................................... 26benazepril hcl............................................................................................... 28benazepril-hydrochlorothiazide............................................................................................... 28benzoyl peroxide............................................................................................... 53benzoyl peroxide-erythromycin............................................................................................... 53benztropine mesylate............................................................................................... 34betamethasone dipropionate............................................................................................... 55betamethasone dipropionate aug............................................................................................... 55betamethasone valerate............................................................................................... 55betaxolol hcl............................................................................................... 79bethanechol chloride............................................................................................... 90BETHKIS ................................................................ 3BETOPTIC-S............................................................................................... 79better b complex............................................................................................... 75BICILLIN C-R............................................................................................... 84BICILLIN C-R 900/300............................................................................................... 84BICILLIN L-A............................................................................................... 84BIG 100 .................................................................... 75BILTRICIDE................................................................................................... 9biotin ........................................................................... 92biotin 5000 .......................................................... 92


97

biotin maximum strength ............................................................................................... 92bismatrol ................................................................ 24bisoprolol fumarate ............................................................................................... 44bisoprolol-hydrochlorothiazide ............................................................................................... 29BOSULIF ............................................................. 33briellyn ..................................................................... 47brimonidine tartrate ............................................................................................... 80BRINTELLIX ............................................................................................... 19BRISDELLE ............................................................................................... 87bromocriptine mesylate ............................................................................................... 35BRONCHO SALINE ............................................................................................... 52BROTAPP .......................................................... 52budesonide ........................................................... 12bumetanide ......................................................... 60buprenorphine hcl ................................................................................................... 7BUPROBAN ............................................................................................... 87bupropion hcl ............................................................................................... 18bupropion hcl er (sr) ............................................................................................... 18bupropion hcl er (xl) ............................................................................................... 18buspirone hcl ................................................................................................... 9butalbital-acetaminophen ................................................................................................... 4butalbital-apap-caff-cod ................................................................................................... 7butalbital-apap-caffeine ................................................................................................... 4butalbital-asa-caff-codeine ................................................................................................... 7butalbital-asa-caffeine ................................................................................................... 4butorphanol tartrate ................................................................................................... 7BYDUREON ............................................................................................... 23c-500 ............................................................................ 92calcipotriene .................................................................................... 54, 55

calcitonin (salmon) ............................................................................................... 61CALCITRATE ............................................................................................... 71calcitriol ................................................................. 61calcium acetate ............................................................................................... 63calcium acetate (phos binder) ............................................................................................... 72calcium antacid extra strength ................................................................................................... 8calcium carbonate ............................................................................................... 72calcium carbonate antacid ................................................................................................... 8calcium carbonate-vitamin d ............................................................................................... 71calcium citrate + d ............................................................................................... 71calcium lactate ............................................................................................... 72cal-lac ........................................................................ 71CAMILA ............................................................... 50capecitabine ............................................................................................... 31CAPRELSA ............................................................................................... 33capsaicin ................................................................ 57captopril ................................................................. 28captopril-hydrochlorothiazide ............................................................................................... 29CARAFATE ............................................................................................... 89carbamazepine ............................................................................................... 15carbamazepine er ............................................................................................... 15carbidopa-levodopa ............................................................................................... 35carbidopa-levodopa er ............................................................................................... 35carisoprodol ............................................................................................... 78carteolol hcl ............................................................................................... 80CARTIA XT ............................................................................................... 45carvedilol ............................................................... 44CAVAREST ............................................................................................... 74CAZIANT ........................................................... 49cefaclor .................................................................... 47

cefadroxil .............................................................. 46cefdinir ..................................................................... 47cefpodoxime proxetil............................................................................................... 47cefprozil .................................................................. 47cefuroxime axetil............................................................................................... 47CELEBREX ................................................................................................... 3CELLCEPT ............................................................................................... 43CELLCEPT INTRAVENOUS ............................................................................................... 43CELONTIN ............................................................................................... 17centavite a-z complete-mineral ............................................................................................... 75CENTRATEX ............................................................................................... 65cephalexin ................................................. 46, 47CEROVITE ADVANCED FORMULA ............................................................................................... 75CERTAVITE SENIOR/ANTIOXIDANT ............................................................................................... 75CERTAVITE/ANTIOXIDANT S .......................................................................................... 75cetirizine hcl ............................................................................................... 26cetirizine hcl childrens ............................................................................................... 26cetirizine-pseudoephedrine er ............................................................................................... 52CHANTIX .......................................................... 87CHANTIX CONTINUING MONTH PAK ............................................................................................... 87CHANTIX STARTING MONTH PAK ............................................................................................... 87childrens ibuprofen ................................................................................................... 3childrens loratadine ............................................................................................... 26childrens non-aspirin ................................................................................................... 5childrens silapap ................................................................................................... 5childrens silfedrine ............................................................................................... 79


98

chlordiazepoxide hcl ............................................................................................... 10chlordiazepoxide-amitriptyline ............................................................................................... 85chlorhexidine gluconate .................................................................................... 38, 74chlorothiazide ............................................................................................... 60chlorpromazine hcl ............................................................................................... 37chlorpropamide ............................................................................................... 24chlorthalidone ............................................................................................... 60chlorzoxazone ............................................................................................... 78cholestyramine ............................................................................................... 27cholestyramine light ............................................................................................... 27choline & mag trisalicylate ................................................................................................... 5choline-mag trisalicylate ................................................................................................... 5ciclopirox .............................................................. 54ciclopirox olamine............................................................................................... 54cilostazol ................................................................ 64cimetidine ............................................................. 89cimetidine hcl............................................................................................... 89CIPRODEX ............................................................................................... 83ciprofloxacin hcl .................................................................................... 62, 80citalopram hydrobromide ............................................................................................... 19CLARAVIS ............................................................................................... 53clarithromycin ............................................................................................... 68CLEAR AWAY 1-STEP WART REMOVER ............................................................................................... 57clindamycin hcl ............................................................................................... 30clindamycin palmitate hcl ............................................................................................... 30clindamycin phosphate ......................................................................... 30, 52, 91CLINISTIX ............................................................................................... 59

clobetasol propionate .................................................................................... 55, 56clomipramine hcl ............................................................................................... 20clonazepam ......................................................... 14clonidine hcl............................................................................................... 28clonidine hcl er ................................................................................................... 1clopidogrel bisulfate ............................................................................................... 64clorazepate dipotassium ............................................................................................... 10clotrimazole ......................................................................... 54, 73, 90clozapine ................................................................ 36codeine sulfate................................................................................................... 5colchicine-probenecid ............................................................................................... 64COLCRYS .......................................................... 64cold & allergy ............................................................................................... 52COMBIVENT RESPIMAT ............................................................................................... 12COMPLERA ............................................................................................... 39COMPOUND W ............................................................................................... 57COMPOUND W MAXIMUM STRENGTH ............................................................................................... 57CONDYLOX ............................................................................................... 57CONTROLRX ............................................................................................... 74COPAXONE ............................................................................................... 86cortisone acetate ............................................................................................... 51CORTISPORIN ............................................................................................... 53CREON ................................................................... 59CRIXIVAN ............................................................................................... 39cromolyn sodium ......................................................................... 11, 79, 82CRYSELLE-28............................................................................................... 47cyanocobalamin ............................................................................................... 64

cyclobenzaprine hcl ............................................................................................... 78CYCLOMYDRIL ............................................................................................... 80cyclophosphamide ............................................................................................... 31cyclosporine ............................................................................................... 43cyclosporine modified ............................................................................................... 43cyproheptadine hcl ............................................................................................... 27cytra-2 ...................................................................... 63CYTRA-3 ............................................................. 63daily multiple vitamins ............................................................................................... 76danazol ........................................................................ 7dantrolene sodium............................................................................................... 78DARAPRIM ............................................................................................... 30DAYTRANA ................................................................................................... 2deferoxamine mesylate ............................................................................................... 24DELSYM NGHT TIME CGH/CLD CHILD ............................................................................................... 52DELSYM NIGHT TIME COUGH/COLD ............................................................................................... 52DEMAREST DRICORT ............................................................................................... 56DENAVIR .......................................................... 55DENTA 5000 PLUS ............................................................................................... 74DENTAGEL ............................................................................................... 74desipramine hcl ............................................................................................... 20desmopressin ace rhinal tube ............................................................................................... 61desmopressin ace spray refrig ............................................................................................... 61desmopressin acetate ............................................................................................... 62desmopressin acetate spray ............................................................................................... 62desonide .................................................................. 56desvenlafaxine er............................................................................................... 20


99

desvenlafaxine fumarate er ............................................................................................... 20 dexamethasone ............................................................................................... 51 dexamethasone sodium phosphate .................................................................................... 51, 82 dexmethylphenidate hcl ................................................................................................... 2 dexmethylphenidate hcl er ................................................................................................... 2 dextroamphetamine sulfate ................................................................................................... 1 dextroamphetamine sulfate er ................................................................................................... 1 DIASTIX .............................................................. 59 diazepam .................................................... 10, 14 diclofenac potassium ................................................................................................... 3 diclofenac sodium ........................................................................................ 3, 82 diclofenac sodium er ................................................................................................... 3 dicloxacillin sodium ............................................................................................... 84 dicyclomine hcl ............................................................................................... 89 didanosine ............................................................ 40 diflunisal .................................................................... 5 digoxin ...................................................................... 46 DILANTIN ............................................................................................... 17 diltiazem hcl ............................................................................................... 45 diltiazem hcl er ............................................................................................... 45 diltiazem hcl er beads ............................................................................................... 45 diltiazem hcl er coated beads ............................................................................................... 45 dilt-xr ......................................................................... 45 dimenhydrinate ............................................................................................... 25 diphenhist ............................................................. 26 diphenhydramine hcl ............................................................................................... 26 diphenoxylate-atropine ............................................................................................... 24 dipyridamole .................................................................................... 58, 64 disopyramide phosphate ............................................................................................... 10 disulfiram .............................................................. 85

divalproex sodium ............................................................................................... 17 divalproex sodium er ............................................................................................... 18 docusate sodium ............................................................................................... 68 donepezil hcl ............................................................................................... 85 dorzolamide hcl ............................................................................................... 82 dorzolamide hcl-timolol mal ............................................................................................... 79 double antibiotic ............................................................................................... 53 doxazosin mesylate ............................................................................................... 28 doxepin hcl .............................................. 20, 21 doxycycline hyclate ............................................................................................... 87 DRITHO-CREME HP ............................................................................................... 55 DULERA ............................................................. 12 duloxetine hcl ............................................................................................... 20 E.E.S. GRANULES ............................................................................................... 68 e-400 ............................................................................ 92 earwax treatment drops ............................................................................................... 82 EASIVENT ............................................................................................... 70 econazole nitrate ............................................................................................... 54 EDURANT ............................................................................................... 40 ELIDEL .................................................................. 57 ELIPHOS ............................................................. 63 ELITE-OB ........................................................... 77 ELIXOPHYLLIN ............................................................................................... 13 EMCYT .................................................................. 32 EMOQUETTE ............................................................................................... 48 EMSAM ................................................................. 18 EMTRIVA .............................................. 40, 41 enalapril maleate ............................................................................................... 28 enalapril-hydrochlorothiazide ............................................................................................... 29 ENDOCET ............................................................ 7 ENDOMETRIN ............................................................................................... 91

ENEMEEZ MINI ............................................................................................... 68enoxaparin sodium ............................................................................................... 14ENPRESSE-28............................................................................................... 49entecavir ................................................................. 41EPIPEN 2-PAK............................................................................................... 91EPIPEN JR 2-PAK............................................................................................... 91EPITOL ................................................................... 15EPIVIR .................................................................... 41EPIVIR HBV............................................................................................... 41EPZICOM ........................................................... 39EQUETRO ........................................................ 35ERIVEDGE............................................................................................... 31ERRIN ..................................................................... 50ERWINAZE............................................................................................... 34ery ................................................................................... 52ERYPED 200............................................................................................... 68ERYPED 400............................................................................................... 69ERY-TAB ............................................................ 68ERYTHROCIN STEARATE............................................................................................... 69erythromycin.................................................................................... 52, 80erythromycin base............................................................................................... 69erythromycin ethylsuccinate............................................................................................... 69escitalopram oxalate............................................................................................... 19ESTARYLLA............................................................................................... 48estazolam .............................................................. 66estradiol .................................................................. 62estradiol-norethindrone acet............................................................................................... 62estropipate ........................................................... 62ethosuximide ............................................................................................... 17etodolac ...................................................................... 3etoposide ................................................................ 34EXEL PEN NEEDLES 1/3"............................................................................................... 69EXELON .............................................................. 85


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EXJADE ................................................................ 24EX-LAX ................................................................. 67EXTAVIA ........................................................... 86E-Z SPACER ............................................................................................... 70famotidine ............................................................ 89famotidine premixed ............................................................................................... 89FANAPT ............................................................... 36FANAPT TITRATION PACK ............................................................................................... 36FAZACLO ......................................................... 37FE C PLUS ........................................................ 65felbamate .............................................................. 17fenofibrate ........................................................... 27fenofibrate micronized ............................................................................................... 27fenoprofen calcium ................................................................................................... 4fentanyl ....................................................................... 6ferrous gluconate ............................................................................................... 65ferrous sulfate ............................................................................................... 65FETZIMA ........................................................... 20FETZIMA TITRATION ............................................................................................... 20fexofenadine hcl ............................................................................................... 26fexofenadine hcl childrens ............................................................................................... 26fexofenadine-pseudoephed er ............................................................................................... 52finasteride ............................................................ 63FIRAZYR ........................................................... 64FIRST-PROGESTERONE VGS 100 .................................................................. 91FIRST-PROGESTERONE VGS 200 .................................................................. 91FIRST-PROGESTERONE VGS 25 ...................................................................... 91FIRST-PROGESTERONE VGS 400 .................................................................. 91FIRST-PROGESTERONE VGS 50 ...................................................................... 91flecainide acetate ............................................................................................... 10FLEET PEDIATRIC ............................................................................................... 67FLOVENT DISKUS ............................................................................................... 12

FLOVENT HFA ............................................................................................... 12fluconazole .......................................................... 25fludrocortisone acetate ............................................................................................... 51flunisolide ............................................................. 79fluocinolone acetonide ............................................................................................... 56fluocinolone acetonide body ............................................................................................... 56fluocinolone acetonide scalp ............................................................................................... 56fluocinonide ............................................................................................... 56fluocinonide-e ............................................................................................... 56FLUOR-A-DAY ............................................................................................... 72FLUORIDEX DAILY DEFENSE .......................................................... 74fluorometholone ............................................................................................... 82fluorouracil ............................................. 31, 54fluoxetine hcl ............................................................................................... 19fluphenazine decanoate ............................................................................................... 37fluphenazine hcl .................................................................................... 37, 38flurazepam hcl ............................................................................................... 66flurbiprofen ............................................................ 4flurbiprofen sodium ............................................................................................... 82fluticasone propionate .................................................................................... 56, 79fluvoxamine maleate ............................................................................................... 19fluvoxamine maleate er ............................................................................................... 19FML FORTE ............................................................................................... 82FOCALIN XR ................................................................................................... 2folic acid ................................................................. 65fondaparinux sodium ............................................................................................... 14FORADIL AEROLIZER ............................................................................................... 13FORFIVO XL ............................................................................................... 18

formula twenty-one ............................................................................................... 75FORTICAL ............................................................................................... 61fosinopril sodium ............................................................................................... 28fosphenytoin sodium ............................................................................................... 17FREESTYLE FREEDOM LITE ............................................................................. 69FREESTYLE INSULINX SYSTEM ............................................................... 69FREESTYLE INSULINX TEST ........................................................................... 59FREESTYLE LITE ............................................................................................... 69FREESTYLE LITE TEST ............................................................................................... 59FREESTYLE TEST ............................................................................................... 59FREEZONE ............................................................................................... 57furosemide ........................................................... 60FUZEON .............................................................. 39FYCOMPA ............................................................................................... 14gabapentin ........................................................... 15GABITRIL ........................................................ 17GAVILYTE-G ............................................................................................... 66GAVILYTE-N WITH FLAVOR PACK ............................................................................................... 66gemcitabine hcl ............................................................................................... 31gemfibrozil .......................................................... 27generlac ................................................................... 63GENGRAF ............................................................................................... 43gentamicin sulfate .................................................................................... 54, 80GEODON ............................................................ 35gerivite complete ............................................................................................... 76GIANVI ................................................................. 48GILOTRIF ........................................................ 33GLEEVEC .......................................................... 33glimepiride .......................................................... 24glipizide ................................................................... 24glipizide er ........................................................... 24GLIPIZIDE XL ............................................................................................... 24


101

glipizide-metformin hcl ............................................................................................... 21GLUCAGEN ............................................................................................... 22GLUCAGEN HYPOKIT ............................................................................................... 22GLUCAGON EMERGENCY ............................................................................................... 22glucose ...................................................................... 22glucose control ............................................................................................... 69glyburide ................................................................ 24glyburide micronized ............................................................................................... 24glyburide-metformin ............................................................................................... 21glycerin (adult) ............................................................................................... 67glycerin (pediatric) ............................................................................................... 67glycopyrrolate ............................................................................................... 89golden age vitamin/minerals ............................................................................................... 76GOLYTELY ............................................................................................... 66griseofulvin microsize ............................................................................................... 25griseofulvin ultramicrosize ............................................................................................... 25guaifenesin .......................................................... 52guanfacine hcl ............................................................................................... 28halobetasol propionate ............................................................................................... 56haloperidol .......................................................... 36haloperidol decanoate ............................................................................................... 36haloperidol lactate ............................................................................................... 36HECORIA .......................................................... 43HEXALEN ........................................................ 30HUMALOG ............................................................................................... 23HUMALOG KWIKPEN ............................................................................................... 23HUMALOG MIX 50/50 ............................................................................................... 23HUMALOG MIX 75/25 ............................................................................................... 23HUMALOG MIX 75/25 KWIKPEN ......................................................... 23

HUMIRA ................................................................ 3HUMIRA PEN ................................................................................................... 3HUMIRA PEN-CROHNS STARTER .............................................................. 3HUMULIN 70/30 ............................................................................................... 23HUMULIN N ............................................................................................... 23HUMULIN N KWIKPEN ............................................................................................... 23HUMULIN R ............................................................................................... 23HUMULIN R U-500 (CONCENTRATED)............................................................................................... 23hydralazine hcl ............................................................................................... 29hydrochlorothiazide ............................................................................................... 60hydrocodone-acetaminophen ................................................................................................... 7hydrocodone-ibuprofen ................................................................................................... 7hydrocortisone ............................................................................ 8, 51, 56hydrocortisone valerate ............................................................................................... 56hydromorphone hcl ................................................................................................... 6hydroxychloroquine sulfate ............................................................................................... 30hydroxyurea ............................................................................................... 34hydroxyzine hcl ................................................................................................... 9hydroxyzine pamoate ................................................................................................... 9HYPERCARE ............................................................................................... 58HYPOTEARS ............................................................................................... 79ibuprofen ................................................................... 4ibuprofen junior strength................................................................................................... 4ICLUSIG .............................................................. 33imipramine hcl ............................................................................................... 21imipramine pamoate ............................................................................................... 21IN-CHECK DIAL FLOW TRAINER .......................................................... 70

INCIVEK ............................................................. 41indapamide ......................................................... 60indomethacin ................................................................................................... 4infants silapap ................................................................................................... 5insulin syringe ............................................................................................... 70INTELENCE ............................................................................................... 40INTRON-A ............................................................................................... 34INTUNIV ................................................................ 2INVEGA ............................................................... 36INVEGA SUSTENNA ............................................................................................... 36INVIRASE ......................................................... 39ipratropium bromide .................................................................................... 11, 79ipratropium-albuterol ............................................................................................... 12ISENTRESS ............................................................................................... 39ISOPTO HYOSCINE ............................................................................................... 80isosorbide dinitrate ................................................................................................... 9isosorbide dinitrate er ................................................................................................... 9isosorbide mononitrate ................................................................................................... 9isosorbide mononitrate er ................................................................................................... 9JAKAFI .................................................................. 34JANTOVEN ............................................................................................... 13JANUMET ........................................................ 21JANUMET XR ............................................................................................... 21JANUVIA ........................................................... 22JENTADUETO ............................................................................................... 21JOLIVETTE ............................................................................................... 50JUNEL 1.5/30 ............................................................................................... 48JUNEL 1/20 ............................................................................................... 48JUNEL FE 1.5/30 ............................................................................................... 48JUNEL FE 1/20 ............................................................................................... 48


102

JUNIOR MAPAP ................................................................................................... 5KALETRA ........................................................ 39KALYDECO ............................................................................................... 87KARIGEL .......................................................... 74KARIGEL-N ............................................................................................... 74KARIVA ............................................................... 47KELNOR 1/35 ............................................................................................... 48ketoconazole .................................................................................... 25, 54ketoprofen ............................................................... 4ketorolac tromethamine ................................................................................................... 4KETOSTIX ............................................................................................... 59ketotifen fumarate ............................................................................................... 82KHEDEZLA ............................................................................................... 20KLOR-CON ............................................................................................... 72KLOR-CON 10............................................................................................... 73KLOR-CON M10 ............................................................................................... 73KLOR-CON M20 ............................................................................................... 73K-PHOS-NEUTRAL ............................................................................................... 72labetalol hcl ............................................................................................... 44lactulose .................................................................. 67LAMICTAL ODT ............................................................................................... 15LAMICTAL STARTER ............................................................................................... 15LAMICTAL XR ............................................................................................... 15lamivudine ............................................................ 41lamivudine-zidovudine ............................................................................................... 39lamotrigine ......................................................... 15lamotrigine er ............................................................................................... 16lancet device ............................................................................................... 69lancets ....................................................................... 69lansoprazole ............................................................................................... 89

LANTUS ............................................................... 24latanoprost .......................................................... 82LATUDA ............................................................. 35LAVOCLEN-4 CREAMY WASH ....................................................................... 53LAVOCLEN-8 CREAMY WASH ....................................................................... 53laxative .................................................................... 67leflunomide ............................................................. 4LESSINA .............................................................. 48LETAIRIS .......................................................... 46letrozole .................................................................. 32leucovorin calcium ............................................................................................... 34LEUKERAN ............................................................................................... 31levetiracetam ............................................................................................... 16levetiracetam er ............................................................................................... 16levetiracetam in nacl ............................................................................................... 16levobunolol hcl ............................................................................................... 80levocarnitine ............................................................................................... 61levocetirizine dihydrochloride ............................................................................................... 26levofloxacin ............................................................................................... 62levonorgestrel ............................................................................................... 50LEVORA 0.15/30 (28) ............................................................................................... 48levothyroxine sodium ............................................................................................... 88LEXIVA ...................................................... 39, 40lidocaine ................................................................. 57lidocaine hcl .................................................................................... 57, 68lidocaine hcl (cardiac) ............................................................................................... 10lidocaine hcl (pf) ............................................................................................... 68lidocaine viscous ............................................................................................... 73lidocaine-prilocaine ............................................................................................... 58liothyronine sodium ............................................................................................... 88lisinopril .................................................................. 28

lisinopril-hydrochlorothiazide ............................................................................................... 29lithium carbonate ............................................................................................... 35lithium carbonate er ............................................................................................... 35lithium citrate ............................................................................................... 35lomustine ............................................................... 31loperamide hcl ............................................................................................... 24loratadine ............................................................. 26loratadine hives relief ............................................................................................... 26lorazepam ............................................................. 10LORAZEPAM INTENSOL ............................................................................................... 10LORYNA ............................................................. 48losartan potassium ............................................................................................... 28losartan potassium-hctz ............................................................................................... 29LOTEMAX ............................................................................................... 82lovastatin ............................................................... 27LOW-OGESTREL ............................................................................................... 48loxapine succinate ............................................................................................... 37LUMIZYME ............................................................................................... 61LUTERA .............................................................. 48LYSODREN ............................................................................................... 32MACRODANTIN ............................................................................................... 90MAG64 .................................................................... 72mag-delay ............................................................. 72magnesium .......................................................... 72magnesium citrate ............................................................................................... 67magnesium oxide ........................................................................................ 8, 72mag-sr ....................................................................... 72MAKENA ........................................................... 84malathion .............................................................. 58mapap ............................................................................ 5mapap arthritis pain ................................................................................................... 5MAPAP CHILDRENS ................................................................................................... 5


103

maprotiline hcl ............................................................................................... 18 MARPLAN ............................................................................................... 18 MATZIM LA ............................................................................................... 45 MAXIDEX ........................................................ 82 meclizine hcl ............................................................................................... 25 medroxyprogesterone acetate .................................................................................... 50, 85 mefloquine hcl ............................................................................................... 30 megestrol acetate ............................................................................................... 32 melatonin maximum strength ................................................................................................... 3 meloxicam ............................................................... 4 MEPHYTON ............................................................................................... 92 meprobamate ................................................................................................... 9 mercaptopurine ............................................................................................... 31 mesalamine ......................................................... 63 MESTINON ............................................................................................... 30 METAMUCIL ............................................................................................... 66 METAMUCIL SMOOTH TEXTURE ......................................................... 66 metaproterenol sulfate ............................................................................................... 13 metformin hcl ............................................................................................... 22 metformin hcl er ............................................................................................... 22 metformin hcl er (osm) ............................................................................................... 22 methadone hcl ................................................................................................... 6 METHADOSE ................................................................................................... 6 methamphetamine hcl ................................................................................................... 1 methazolamide ............................................................................................... 60 methimazole ............................................................................................... 88 methitest .................................................................... 7 methocarbamol ............................................................................................... 78

methotrexate ............................................................................................... 31 methotrexate sodium ............................................................................................... 31 methotrexate sodium (pf) ............................................................................................... 31 methyldopa ......................................................... 28 methylergonovine maleate ............................................................................................... 83 METHYLIN ................................................................................................... 2 methylphenidate hcl ................................................................................................... 2 methylphenidate hcl er ................................................................................................... 2 methylphenidate hcl er (cd) ................................................................................................... 2 methylphenidate hcl er (la) ................................................................................................... 2 methylprednisolone ............................................................................................... 51 methylprednisolone (pak) ............................................................................................... 51 methylprednisolone acetate ............................................................................................... 51 methylprednisolone sodium succ ............................................................................................... 51 metipranolol ............................................................................................... 80 metoclopramide hcl ............................................................................................... 62 metolazone .......................................................... 60 metoprolol succinate er ............................................................................................... 44 metoprolol tartrate ............................................................................................... 44 metronidazole ......................................................................... 29, 58, 91 mexiletine hcl ............................................................................................... 10 miconazole 3 ............................................................................................... 90 miconazole 3 combo pack ............................................................................................... 90 miconazole nitrate ............................................................................................... 91 MICROCHAMBER ............................................................................................... 70 MICROGESTIN 1.5/30 ............................................................................................... 48 MICROGESTIN 1/20 ............................................................................................... 48

MICROGESTIN FE 1.5/30 ............................................................................................... 48MICROGESTIN FE 1/20 ............................................................................................... 48MICROSPACER ............................................................................................... 70midodrine hcl............................................................................................... 91milk of magnesia............................................................................................... 67mineral oil ............................................................ 67mineral oil heavy ............................................................................................... 67minocycline hcl ............................................................................................... 87minoxidil ................................................................ 29mirtazapine ........................................................ 18misoprostol ......................................................... 90mometasone furoate............................................................................................... 56MONISTAT 1 COMBO PACK............................................................................................... 91MONISTAT 3............................................................................................... 91MONONESSA............................................................................................... 48montelukast sodium............................................................................................... 11morphine sulfate................................................................................................... 6morphine sulfate (concentrate)................................................................................................... 6morphine sulfate (pf)................................................................................................... 6morphine sulfate er................................................................................................... 6mucus relief ........................................................ 52MULTIGEN............................................................................................... 65multi-vit/fluoride............................................................................................... 76multi-vit/fluoride/iron............................................................................................... 76multi-vitamin............................................................................................... 76multivitamin & mineral............................................................................................... 76multivitamin/fluoride............................................................................................... 76multi-vitamin/fluoride............................................................................................... 76


104

multi-vitamin/fluoride/iron ............................................................................................... 76multi-vitamins ............................................................................................... 76mupirocin .............................................................. 54mycophenolate mofetil ............................................................................................... 43mycophenolic acid ............................................................................................... 43MYLERAN ............................................................................................... 30MYNATAL ADVANCE ............................................................................................... 77mynatal-z .............................................................. 77mynate 90 plus ............................................................................................... 77nabumetone ........................................................... 4nadolol ...................................................................... 44NAFRINSE DROPS ............................................................................................... 72naltrexone hcl ............................................................................................... 24NAMENDA ............................................................................................... 85NAMENDA TITRATION PAK .............................................................................. 85NAMENDA XR ............................................................................................... 85NAMENDA XR TITRATION PACK ......................................................................... 85naproxen .................................................................... 4naproxen dr ................................................................................................... 4naproxen sodium ................................................................................................... 4naratriptan hcl ............................................................................................... 71nasal decongestant ............................................................................................... 79natural fiber therapy ............................................................................................... 66NATURE-THROID ............................................................................................... 88NECON 0.5/35 (28) ............................................................................................... 48NECON 1/35 (28) ............................................................................................... 48NECON 1/50 (28) ............................................................................................... 48NECON 7/7/7 ............................................................................................... 49

nefazodone hcl ............................................................................................... 19neomycin sulfate ................................................................................................... 3neomycin-bacitracin zn-polymyx ............................................................................................... 81neomycin-polymyxin-dexameth ............................................................................................... 81neomycin-polymyxin-gramicidin ............................................................................................... 81neomycin-polymyxin-hc .................................................................................... 81, 83NEPHRONEX ............................................................................................... 75NEUPOGEN ............................................................................................... 65NEUTRAGARD ADVANCED ............................................................................................... 74nevirapine ............................................................. 40nevirapine er ............................................................................................... 40NEXT CHOICE ONE DOSE ............................................................................................... 50niacin .......................................................................... 92niacin er .................................................................. 92NIACOR .................................................... 27, 92nicotine .................................................................... 87nicotine polacrilex ............................................................................................... 87NICOTROL ............................................................................................... 87NICOTROL NS ............................................................................................... 87NIFEDIAC CC ............................................................................................... 45NIFEDICAL XL ............................................................................................... 46nifedipine ............................................................... 46nifedipine er ............................................................................................... 46nifedipine er osmotic ............................................................................................... 46NITRO-BID ................................................................................................... 9nitrofurantoin macrocrystal ............................................................................................... 90nitrofurantoin monohyd macro ............................................................................................... 90nitroglycerin ................................................................................................... 9NITROSTAT ................................................................................................... 9

NORA-BE ........................................................... 50norethindrone acetate ............................................................................................... 85normal saline flush ............................................................................................... 73NOR-QD ............................................................... 50nortemp infants ................................................................................................... 5NORTREL 0.5/35 (28) ............................................................................................... 48NORTREL 1/35 (21) ............................................................................................... 49NORTREL 1/35 (28) ............................................................................................... 49NORTREL 7/7/7 ............................................................................................... 50nortriptyline hcl ............................................................................................... 21NORVIR ............................................................... 40np thyroid ............................................................. 88NULOJIX ............................................................ 44NUVARING ............................................................................................... 50nystatin .............................................. 25, 54, 73OCELLA ............................................................... 49ofloxacin ..................................................... 80, 83OGESTREL ............................................................................................... 49olanzapine ............................................................ 37olanzapine-fluoxetine hcl............................................................................................... 86OLEPTRO .......................................................... 19OLYSIO ................................................................. 41omeprazole ......................................................... 90once daily .............................................................. 76ondansetron............................................................................................... 25ondansetron hcl ............................................................................................... 25ONFI ........................................................................... 14OPTICHAMBER ADVANTAGE ............................................................................................... 70OPTICHAMBER ADVANTAGE-LG MASK ............................................................................................... 70OPTICHAMBER ADVANTAGE-MED MASK ............................................................................................... 70OPTICHAMBER ADVANTAGE-SM MASK ............................................................................................... 71


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OPTICHAMBER FACE MASK-LARGE ............................................................................................... 71OPTICHAMBER FACE MASK-MEDIUM ............................................................................................... 71OPTICHAMBER FACE MASK-SMALL ............................................................................................... 71OPTICS EYE WASH ............................................................................................... 82OPTIHALER ............................................................................................... 71ORALYTE ......................................................... 72ORALYTE FREEZER POPS ............................................................................................... 72ORAP ......................................................................... 86oticin ........................................................................... 83oxacillin sodium............................................................................................... 84oxandrolone ................................................................................................... 7oxaprozin .................................................................. 4oxazepam ............................................................. 10oxcarbazepine............................................................................................... 16OXTELLAR XR ............................................................................................... 16oxybutynin chloride ............................................................................................... 90oxybutynin chloride er ............................................................................................... 90oxycodone hcl ................................................................................................... 6oxycodone-acetaminophen ................................................................................................... 7oxycodone-aspirin ................................................................................................... 7oyst-cal d ............................................................... 71oyster shell calcium + d............................................................................................... 71oyster shell calcium/d ............................................................................................... 71PACERONE ............................................................................................... 11pain & fever childrens ................................................................................................... 5pantoprazole sodium ............................................................................................... 90paroxetine hcl ............................................................................................... 19

paroxetine hcl er ............................................................................................... 19PAXIL ....................................................................... 19peak flow meter ............................................................................................... 70peg 3350/electrolytes ............................................................................................... 67peg 3350-kcl-na bicarb-nacl ............................................................................................... 67peg-3350/electrolytes ............................................................................................... 67PEGANONE ............................................................................................... 17PEGASYS ........................................................... 42PEGASYS PROCLICK ............................................................................................... 42PEG-INTRON ............................................................................................... 41PEG-INTRON REDIPEN ............................................................................................... 41PEG-INTRON REDIPEN PAK 4 ........................................................................................... 41penicillin g procaine ............................................................................................... 84penicillin v potassium ............................................................................................... 84pentazocine-naloxone hcl ................................................................................................... 7pentoxifylline er ............................................................................................... 64PERIOGARD ............................................................................................... 74permethrin ........................................................... 58perphenazine ............................................................................................... 38perphenazine-amitriptyline ............................................................................................... 86PERTZYE ........................................................... 60PEXEVA ............................................................... 19PFIZERPEN-G ............................................................................................... 84PFLEX ..................................................................... 70phenazopyridine hcl ............................................................................................... 63phenelzine sulfate ............................................................................................... 19phenobarbital ............................................................................................... 66phenobarbital sodium ............................................................................................... 66phenytoin ............................................................... 17

phenytoin sodium ............................................................................................... 17phenytoin sodium extended ............................................................................................... 17PHOS-FLUR ............................................................................................... 74pilocarpine hcl .................................................................................... 74, 80pindolol .................................................................... 44pink bismuth ............................................................................................... 24pioglitazone hcl ............................................................................................... 23pioglitazone hcl-metformin hcl ............................................................................................... 22piroxicam ................................................................. 4PLAN B ONE-STEP ............................................................................................... 50POCKET CHAMBER ............................................................................................... 71POCKET SPACER ............................................................................................... 71podofilox ............................................................... 57polycin b ................................................................. 81poly-dex .................................................................. 81polyethylene glycol 3350............................................................................................... 67POLY-IRON 150............................................................................................... 65poly-iron 150 forte ............................................................................................... 65polymyxin b-trimethoprim ............................................................................................... 81poly-vitamin ............................................................................................... 77polyvitamin/iron ............................................................................................... 77PORTIA-28............................................................................................... 49potassium chloride ............................................................................................... 73potassium chloride crys er ............................................................................................... 73potassium chloride er ............................................................................................... 73POTIGA ................................................................. 16povidone-iodine ............................................................................................... 38PR NATAL 400 EC ............................................................................................... 77pramipexole dihydrochloride ............................................................................................... 35


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pravastatin sodium ............................................................................................... 27prazosin hcl ........................................................ 28PRECISION XTRA ............................................................................................... 69PRECISION XTRA BLOOD GLUCOSE ......................................................... 59PRECISION XTRA KETONE ............................................................................................... 59PRED-G ................................................................. 81prednisolone ............................................................................................... 51prednisolone acetate ............................................................................................... 82prednisolone sodium phosphate ............................................................................................... 51prednisone ............................................................ 51PREMARIN .................................................................................... 62, 91PREMPHASE ............................................................................................... 62PREMPRO ........................................................ 62PRENATABS RX ............................................................................................... 77prenatal ................................................................... 77prenatal 19 .......................................................... 77prenatal low iron ............................................................................................... 77prenatal plus ............................................................................................... 77prenatal plus iron ............................................................................................... 77PRENATAL-U ............................................................................................... 77PREPARATION H ............................................................................................... 58PREVIFEM ............................................................................................... 49PREZISTA ......................................................... 40primaquine phosphate ............................................................................................... 30primidone .............................................................. 16PRISTIQ ................................................................ 20probenecid ........................................................... 64procainamide hcl ............................................................................................... 10PROCENTRA ................................................................................................... 1prochlorperazine ............................................................................................... 38prochlorperazine edisylate ............................................................................................... 38

prochlorperazine maleate ............................................................................................... 38PROCRIT ............................................................ 65PROCTOSOL HC ................................................................................................... 8PROCTOZONE-HC ................................................................................................... 8PROGRAF ........................................................ 43PROLIA ................................................................. 61promethazine hcl ............................................................................................... 26PROMETHEGAN ............................................................................................... 26propafenone hcl ............................................................................................... 10propantheline bromide ............................................................................................... 89propranolol hcl .................................................................................... 44, 45propranolol hcl er ............................................................................................... 45propranolol-hctz ............................................................................................... 29propylthiouracil ............................................................................................... 88protriptyline hcl ............................................................................................... 21pseudoephedrine hcl ............................................................................................... 79PULMICORT ............................................................................................... 12PULMOZYME ............................................................................................... 87pyridostigmine bromide ............................................................................................... 30pyridoxine hcl ............................................................................................... 92Q-TAPP ................................................................... 52QUASENSE ............................................................................................... 49QUDEXY XR ............................................................................................... 16quetiapine fumarate ............................................................................................... 37QUILLIVANT XR ................................................................................................... 2quinapril hcl ............................................................................................... 28quinidine gluconate ............................................................................................... 10quinidine gluconate er ............................................................................................... 10

quinidine sulfate ............................................................................................... 10ra saline enema ............................................................................................... 67raloxifene hcl ............................................................................................... 61ramipril .................................................................... 28ranitidine acid reducer............................................................................................... 89ranitidine hcl ............................................................................................... 89RAPAMUNE ............................................................................................... 43REBETOL .......................................................... 42REBIF ....................................................................... 86REBIF REBIDOSE ............................................................................................... 86REBIF REBIDOSE TITRATION PACK ............................................................................................... 86REBIF TITRATION PACK ............................................................................................... 86RECLIPSEN ............................................................................................... 49reeses pinworm medicine ................................................................................................... 9refenesen ................................................................ 52refenesen 400............................................................................................... 52RELENZA DISKHALER ............................................................................................... 42REMEVEN ............................................................................................... 57RENAL ................................................................... 75rena-vite .................................................................. 75reno caps ................................................................ 75RENVELA ......................................................... 63RESCRIPTOR ............................................................................................... 40RESTASIS .......................................................... 81retrovir ..................................................................... 41REVLIMID ............................................................................................... 42REYATAZ ......................................................... 40RIBASPHERE ............................................................................................... 42ribavirin .................................................................. 42RIDAURA ............................................................ 3rimantadine hcl ............................................................................................... 42RIOMET ............................................................... 22


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RISPERDAL CONSTA ............................................................................................... 36risperidone ........................................................... 36RISPERIDONE M-TAB ............................................................................................... 36RITALIN LA ................................................................................................... 2rivastigmine tartrate ............................................................................................... 85robafen ..................................................................... 52ropinirole hcl ............................................................................................... 35ROXICET ............................................................... 7SABRIL .................................................................. 17SALACTIC FILM ............................................................................................... 57saline flush .......................................................... 73saline nasal spray ............................................................................................... 78salsalate ...................................................................... 5SANDIMMUNE ............................................................................................... 43SANTYL ............................................................... 57SAPHRIS ............................................................. 37SAVELLA ........................................................... 86SAVELLA TITRATION PACK ............................................................................................... 86selegiline hcl ............................................................................................... 35selenium sulfide ............................................................................................... 55SELZENTRY ............................................................................................... 39senna ................................................................ 67, 68senna-docusate sodium ............................................................................................... 67SEREVENT DISKUS ............................................................................................... 13SEROQUEL XR ............................................................................................... 37sertraline hcl ............................................................................................... 19sf ....................................................................................... 74sf 5000 plus ........................................................ 74silace ........................................................................... 68sildenafil citrate ............................................................................................... 46silver sulfadiazine ............................................................................................... 55simethicone ......................................................... 62SIMPONI ................................................................. 3

SIMULECT ............................................................................................... 44simvastatin .......................................................... 27sirolimus ................................................................. 43slow release iron ............................................................................................... 65sodium bicarbonate ................................................................................................... 8sodium chloride ......................................................................... 52, 63, 73sodium fluoride ............................................................................................... 72sodium polystyrene sulfonate ............................................................................................... 44SOLIA ....................................................................... 49sorbitol ..................................................................... 67SORINE ................................................................. 45sotalol hcl ............................................................. 45sotalol hcl (af) ............................................................................................... 45SOVALDI ............................................................ 42spinosad .................................................................. 58spironolactone ............................................................................................... 60spironolactone-hctz ............................................................................................... 60SPRINTEC 28............................................................................................... 49SPRYCEL ........................................................... 33SPS .................................................................................. 44SRONYX ............................................................. 49SSD ................................................................................ 55SSKI ............................................................................. 72stavudine ................................................................ 41STAVZOR .......................................................... 18stimulant laxative ............................................................................................... 68STIVARGA ............................................................................................... 33stomach relief plus ............................................................................................... 24stool softener ............................................................................................... 68stool softener laxative dc ............................................................................................... 68STRATTERA ................................................................................................... 2stress formula/zinc ............................................................................................... 75stress plus zinc ............................................................................................... 75STRIBILD .......................................................... 39

STROMECTOL ................................................................................................... 9sucralfate .............................................................. 89SUDAFED 12 HOUR ............................................................................................... 79sulfacetamide sodium .................................................................................... 52, 81sulfacetamide-prednisolone ............................................................................................... 81sulfamethoxazole-tmp ds ............................................................................................... 29sulfamethoxazole-trimethoprim .................................................................................... 29, 30sulfasalazine ............................................................................................... 63sulindac ....................................................................... 4sumatriptan ........................................................ 71sumatriptan succinate ............................................................................................... 71SUPARTZ .......................................................... 78SUPER B-50 B COMPLEX ............................................................................................... 75SUPER QUINTS B-50............................................................................................... 75SURMONTIL ............................................................................................... 21SUSTIVA ............................................................. 40SUTENT ............................................................... 33SYEDA .................................................................... 49SYMBICORT ............................................................................................... 12SYNAGIS ............................................................ 83TABLOID ........................................................... 31tacrolimus ............................................................ 43TAMIFLU .......................................................... 42tamoxifen citrate ............................................................................................... 32tamsulosin hcl ............................................................................................... 63TARCEVA ......................................................... 33TASIGNA ........................................................... 33TAZORAC ........................................................ 55tears again ........................................................... 79TEGRETOL-XR ............................................................................................... 16temazepam .......................................................... 66temozolomide ............................................................................................... 31terazosin hcl ............................................................................................... 28terbinafine hcl .................................................................................... 25, 54


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terbutaline sulfate ............................................................................................... 13terconazole ......................................................... 91TESTIM ..................................................................... 7testosterone ........................................................... 8testosterone cypionate ................................................................................................... 8testosterone enanthate ................................................................................................... 8tetracycline hcl ............................................................................................... 87TEV-TROPIN ............................................................................................... 61THALOMID ............................................................................................... 42theophylline ............................................................................................... 13theophylline er ............................................................................................... 13thera vital m ............................................................................................... 76therabasic-m ............................................................................................... 76therapeutic liquid ............................................................................................... 76therapeutic-m ............................................................................................... 76thera-tabs ............................................................. 76THERATRUM COMPLETE ............................................................................................... 76thiamine hcl ............................................................................................... 92thioridazine hcl ............................................................................................... 38thiothixene .......................................................... 38THRESHOLD IMT ............................................................................................... 70THRESHOLD PEP ............................................................................................... 70THYROLAR-1............................................................................................... 88THYROLAR-1/2 ............................................................................................... 88THYROLAR-1/4 ............................................................................................... 88THYROLAR-2............................................................................................... 88THYROLAR-3............................................................................................... 88tiagabine hcl ............................................................................................... 17

timolol maleate .................................................................................... 45, 80TIVICAY .............................................................. 39tizanidine hcl ............................................................................................... 78TOBRADEX ............................................................................................... 81tobramycin .......................................................... 80tolmetin sodium ................................................................................................... 4topiramate ........................................................... 16TOPIRAMATE ER ............................................................................................... 16torsemide ............................................................... 60TRADJENTA ............................................................................................... 22tramadol hcl ................................................................................................... 6tranylcypromine sulfate ............................................................................................... 19travel sickness ............................................................................................... 25trazodone hcl ............................................................................................... 20TRELSTAR DEPOT ............................................................................................... 32TRELSTAR DEPOT MIXJECT ............................................................................................... 32TRELSTAR LA ............................................................................................... 32TRELSTAR LA MIXJECT ............................................................................................... 32TRELSTAR MIXJECT ............................................................................................... 32tretinoin .................................................................. 53triamcinolone acetonide .................................................................................... 56, 74triamterene-hctz ............................................................................................... 60triazolam ............................................................... 66tri-buffered aspirin ................................................................................................... 5TRI-ESTARYLLA ............................................................................................... 50trifluoperazine hcl ............................................................................................... 38trifluridine ............................................................ 81trihexyphenidyl hcl ............................................................................................... 34TRILYTE ............................................................ 67trimethoprim ............................................................................................... 29

trinatal rx 1............................................................................................... 77TRINATE ........................................................... 77TRINESSA (28) ............................................................................................... 50triple antibiotic ............................................................................................... 53TRI-PREVIFEM ............................................................................................... 50triprolidine-pse ............................................................................................... 52TRI-SPRINTEC ............................................................................................... 50tri-vit/fluoride ............................................................................................... 76tri-vit/fluoride/iron ............................................................................................... 76tri-vitamin ............................................................ 77tri-vitamin/fluoride ............................................................................................... 77TRIVORA (28) ............................................................................................... 50TROKENDI XR ............................................................................................... 16trospium chloride ............................................................................................... 90TRUVADA ............................................................................................... 39TUDORZA PRESSAIR ............................................................................................... 11TYKERB .............................................................. 33TYZEKA .............................................................. 41UNITHROID ............................................................................................... 88UNITHROID DIRECT ............................................................................................... 88urea ............................................................................... 57URETRON D/S ............................................................................................... 90ursodiol .................................................................... 62uticap .......................................................................... 90valacyclovir hcl ............................................................................................... 42valproate sodium ............................................................................................... 18valproic acid ............................................................................................... 18vancomycin hcl ............................................................................................... 29VANDAZOLE ............................................................................................... 91VELIVET ............................................................. 50


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venlafaxine hcl ............................................................................................... 20venlafaxine hcl er ............................................................................................... 20VENTOLIN HFA ............................................................................................... 13verapamil hcl ............................................................................................... 46verapamil hcl er ............................................................................................... 46VERSACLOZ ............................................................................................... 37VESTURA .......................................................... 49VEXOL .................................................................... 82VICTRELIS ............................................................................................... 42VIDEX ..................................................................... 40VIIBRYD ............................................................. 20VIMPAT ..................................................... 16, 17

............................................................................................... 77VINATE AZ EXTRA

VINATE II ......................................................... 77VINATE M ............................................................................................... 77VIRACEPT ............................................................................................... 40viramune xr ............................................................................................... 40VIREAD ................................................................ 41viread .......................................................................... 41virt-caps .................................................................. 75vision vitamins ............................................................................................... 76vitamin a ................................................................ 92vitamin b complex ............................................................................................... 74

............................................................................................... 75vitamin b complex-c

vitamin b-1 .......................................................... 92vitamin b-12 .................................................................................... 64, 65vitamin b-12 er ............................................................................................... 65vitamin b-6 .......................................................... 92vitamin b-6 er ............................................................................................... 92vitamin c ..................................................... 92, 93vitamin c er ............................................. 75, 93vitamin c-rose hips ............................................................................................... 93vitamin c-rose hips er ............................................................................................... 93

............................................................................................... 92vitamin d (ergocalciferol)

vitamin d3 ............................................................ 92vitamin k (phytonadione) ............................................................................................... 92vitamin-b complex ............................................................................................... 74vitamins acd-fluoride ............................................................................................... 77vitamins for hair ............................................................................................... 77VITRUM SENIOR ............................................................................................... 76VOLTAREN ............................................................................................... 54VYTORIN .......................................................... 27VYVANSE ............................................................. 1warfarin sodium ............................................................................................... 13WATCHHALER ............................................................................................... 71WESTHROID ............................................................................................... 88

............................................................................................... 70WINDMILL TRAINER

XALKORI .......................................................... 33XARELTO ......................................................... 13XENICAL ............................................................... 1XOLAIR ................................................................ 11XTANDI ............................................................... 32X-VIATE .............................................................. 57

............................................................................................... 75yl balanced b-100

zafirlukast ............................................................ 11ZARAH .................................................................. 49ZELBORAF ............................................................................................... 32

............................................................................................... 49ZENCHENT FE

ZENZEDI ............................................................... 1ZETIA ....................................................................... 27ZIAGEN ................................................................ 40zidovudine ............................................................ 41zinc sulfate .......................................................... 73ziprasidone hcl ............................................................................................... 36ZOLINZA ........................................................... 33

............................................................................................... 66zolpidem tartrate

zonisamide ........................................................... 17ZORTRESS ............................................................................................... 43

ZOVIA 1/35E (28) ............................................................................................... 49

............................................................................................... 49ZOVIA 1/50E (28)

ZOVIRAX .......................................................... 55zubsolv .......................................................................... 7ZYKADIA ......................................................... 33ZYPREXA RELPREVV ............................................................................................... 37

‘Ohana Health Plan...choline & mag trisalicylate oral tablet 1000 mg . P choline-mag trisalicylate...

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Transcript of ‘Ohana Health Plan...choline & mag trisalicylate oral tablet 1000 mg . P choline-mag trisalicylate...