FamilyCare - Physicians Health Plan

2013FamilyCare Provider Prescription Drug List

FB43346Y_PHP FAMILYCARE PROVIDER BOOK_v4_FB43346Y_PHP FAMILYCARE PROVIDER BOOK_v4 4/11/13 2:43 PM

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Table of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-3Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Key to Symbols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Medicaid Notification Table . . . . . . . . . . . . . . . . . . . . . 7-9CHAPTERS1. Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.1 Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.2 Tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.3 Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.3.1 First Generation Cephalosporins 1.3.2 Second Generation Cephalosporins 1.3.3 Third Generation Cephalosporins

1.4 Erythromycins & Other Macrolides . . . . . . . . . . . . . 111.4.1 Erythromycins & Other Macrolides

1.5 Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.5.1 Fluoroquinolones

1.6 Sulfas & Related Agents . . . . . . . . . . . . . . . . . . . . . . 111.7 Urinary Tract Agents . . . . . . . . . . . . . . . . . . . . . . . . 111.8 Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.8.1 Miscellaneous Antivirals 1.8.2 HIV/AIDS Therapy

1.9 Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.10 Vancomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.11 Miscellaneous Anti-Infectives . . . . . . . . . . . . . . . . . . 12

1.11.1 Miscellaneous Anti-Infectives1.11.2 Antiparasitics1.11.3 Antimalarials1.11.4 Antimycobacterials

2. Antineoplastic & Immunosuppressant Drugs. . . . . . 132.1 Antineoplastic & Immunosuppressant Drugs . . . . . . 13

2.1.1 Alkylating Agents 2.1.2 Antimetabolites 2.1.3 Androgens, Estrogens, Hormones & Related Drugs

2.1.3.3 Hormones2.1.3.4 Antiestrogens2.1.3.5 Antiandrogens

2.1.5 Immunosuppressant Drugs 2.1.6 Miscellaneous Antineoplastic Drugs

2.2 Adjunctive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . 132.2.1 Adjunctive Agents

3. Autonomic & CNS Drugs, Neurology & Psych . . . . . 143.1 Narcotic Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.1.1 Narcotics 3.1.2 Combination Narcotic/Analgesics

3.3 Non-Narcotic Analgesics . . . . . . . . . . . . . . . . . . . . . 143.3.1 NSAIDs3.3.2 Salicylates 3.3.3 Miscellaneous Analgesics 3.3.4 Narcotic Antagonists

3.4 Migraine & Cluster Headache Therapy . . . . . . . . . . 153.4.1 Headache Therapy 3.4.2 Antivertigo & Antiemetic Drugs

3.5 Antiparkinsonism Agents . . . . . . . . . . . . . . . . . . . . . 153.6 Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.7 Miscellaneous Neurological Therapy . . . . . . . . . . . . 153.8 Muscle Relaxants & Antispasmodic Therapy . . . . . . 15

3.8.1 Muscle Relaxants & Antispasmodic Agents 3.8.2 Myasthenia Gravis

3.9 Psychotherapeutic Drugs . . . . . . . . . . . . . . . . . . . . . 153.9.1 Hypnotic Agents

3.9.2 Antidepressant Agents 3.9.2.1 Tricyclics 3.9.2.2 Miscellaneous Antidepressants 3.9.2.3 MAOI Inhibitors 3.9.2.4 Selective Serotonin Reuptake Inhibitors

3.9.3 Antipsychotics 3.9.3.1 Phenothiazines 3.9.3.2 Butyrophenones 3.9.3.3 Miscellaneous Antipsychotics

3.9.4 Miscellaneous Psychotherapeutic Agents 3.9.5 Anxiolytics

4. Cardiovascular, Hypertension & Lipids. . . . . . . . . . . 164.1 Antiarrhythmic Agents . . . . . . . . . . . . . . . . . . . . . . . 164.2 Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . 164.3 Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

4.3.1 Rapid Acting Nitrates 4.3.2 Long Acting Nitrates

4.4 Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . 164.4.1 Anticoagulants4.4.2 Antiplatelet Drugs 4.4.3 Heparin 4.4.4 Vitamin K 4.4.6 Miscellaneous Coagulation Agents

4.5 Antihypertensive Therapy . . . . . . . . . . . . . . . . . . 16-174.5.1 Thiazide & Related Diuretics 4.5.2 Beta Blockers 4.5.3 Calcium Channel Blockers

4.5.3.1 Calcium Channel Blockers/Non-Dihydropyridines

4.5.3.2 Calcium Channel Blockers/Dihydropyridines

4.5.4 ACE Inhibitors 4.5.5 Adrenergic Antagonists & Related Drugs 4.5.7 Vasodilators 4.5.8 Other Antihypertensive Combinations 4.5.9 Angiotensin II Receptor Blockers

4.6 Lipid/Cholesterol Lowering Agents . . . . . . . . . . . . . 175. Dermatologicals/Topical Therapy . . . . . . . . . . . . . . 18

5.1 Topical Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . 185.1.1 Topical Corticosteroids Very High Potency5.1.2 Topical Corticosteroids High Potency5.1.3 Topical Corticosteroids Medium Potency5.1.4 Topical Corticosteroids Low Potency

5.2 Topical Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . 185.3 Therapy for Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.4 Topical Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . 185.5 Topical Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . 185.6 Topical Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.7 Burn Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.8 Topical Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.10 Antipsoriatic/Antiseborrheic . . . . . . . . . . . . . . . . . . . 195.11 Topical Scabicides/Pediculicides . . . . . . . . . . . . . . . . 195.12 Miscellaneous Dermatologicals . . . . . . . . . . . . . . . . . 19

6. Ear, Nose & Throat Medications . . . . . . . . . . . . . . . 206.1 Intranasal Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . 206.2 Miscellaneous Otic Preparations . . . . . . . . . . . . . . . . 206.3 Otic Steroid/Antibiotic . . . . . . . . . . . . . . . . . . . . . . . 206.4 Miscellaneous Agents . . . . . . . . . . . . . . . . . . . . . . . 20

7. Endocrine/Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 217.1 Antithyroid Agents . . . . . . . . . . . . . . . . . . . . . . . . . . 217.2 Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . 217.3 Adrenal Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . 217.4 Miscellaneous Hormones . . . . . . . . . . . . . . . . . . . . . 21

7.4.1 Androgens 7.4.3 Miscellaneous Agents

7.5 Diabetes Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


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7.5.1 Insulin Therapy 7.5.2 Oral Hypoglycemic Agents 7.5.3 Glucose Elevating Agents 7.5.4 Insulin Syringes/Miscellaneous Durable

Medical Equipment7.5.5 Blood Glucose Monitoring Devices & Supplies

8. Gastroenterology. . . . . . . . . . . . . . . . . . . . . . . . . . 228.1 Ulcer Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

8.1.1 H2 Antagonists 8.1.2 Prostaglandins 8.1.3 Other Ulcer Therapy 8.1.4 Proton Pump Inhibitors

8.2 Antidiarrheals & Antispasmodics . . . . . . . . . . . . . . . 228.2.1 Antidiarrheals 8.2.2 Antispasmodics

8.3 Miscellaneous Gastrointestinal Agents . . . . . . . . . . . 228.3.1 Bile Acids 8.3.2 Digestive Enzymes 8.3.3 Miscellaneous Gastrointestinal Agents 8.3.4 Antivertigo & Antiemetic Agents 8.3.5 Bowel Evacuants

9. Immunology, Vaccines & Biotechnology . . . . . . . . . 239.1 Biotechnology Drugs . . . . . . . . . . . . . . . . . . . . . . . . 23

9.1.1 Erythroid Stimulants9.1.2 Myeloid Stimulants9.1.3 Interferons 9.1.4 Growth Hormones 9.1.5 Interleukins

10.Musculoskeletal & Rheumatology. . . . . . . . . . . . . . 2410.1 NSAID Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

10.1.2 Salicylates 10.2 Gout Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2410.3 Other Rheumatologicals . . . . . . . . . . . . . . . . . . . . . . 24

10.3.1 Corticosteroids 10.3.2 Miscellaneous Rheumatological Agents 10.3.3 Muscle Relaxants & Antispasmodic Therapy

10.4 Osteoporosis Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2411.Obstetrics & Gynecology . . . . . . . . . . . . . . . . . . . . 25

11.1 Oral Contraceptives & Related Agents . . . . . . . . . . . 2511.1.1 Monophasic/Biphasic/Triphasic Agents 11.1.2 Progestin Only

11.2 Oxytocics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2511.3 Estrogens & Progestins . . . . . . . . . . . . . . . . . . . . . . . 25

11.3.1 Progestins 11.3.2 Estrogens 11.3.3 Estrogen Combinations

11.4 Miscellaneous OB/GYN . . . . . . . . . . . . . . . . . . . . . . 2611.4.2 Vaginal Cleanser/Anti-Infectives 11.4.3 Vaginal Antifungals 11.4.4 Specialized OB/GYN Drugs 11.4.5 Diaphragms and Other Non-Oral Contraceptives

12.Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712.1 Beta Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712.2 Cholinesterase Inhibitor Miotics . . . . . . . . . . . . . . . 2712.3 Direct Acting Miotics . . . . . . . . . . . . . . . . . . . . . . . 2712.4 Other Glaucoma Drugs . . . . . . . . . . . . . . . . . . . . . 2712.5 Oral Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . 2712.6 Cycloplegic Mydriatics . . . . . . . . . . . . . . . . . . . . . . 2712.7 Non-Steroidal Anti-Inflammatory Agents . . . . . . . . 2712.8 Vasoconstrictor Decongestants . . . . . . . . . . . . . . . . 2712.9 Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712.10 Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712.11 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712.12 Steroid-Antibiotic Combinations . . . . . . . . . . . . . . 2712.13 Steroid-Sulfonamide Combinations . . . . . . . . . . . . 2812.14 Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . . . . 28

12.15 Miscellaneous Ophthalmologics . . . . . . . . . . . . . . . 2812.16 Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

13.Respiratory, Allergy, Cough & Cold. . . . . . . . . . . . . 2913.1 Antihistamine & Antiallergenic Agents . . . . . . . . . . 29

13.1.1 Antihistamines 13.1.2 Adrenergics 13.1.3 Corticosteroids

13.2 Cough & Cold Therapy . . . . . . . . . . . . . . . . . . . . . . 2913.2.1 Antitussive Combinations 13.2.2 Expectorant Combinations 13.2.3 Decongestant/Antihistamines

13.3 Pulmonary Agents . . . . . . . . . . . . . . . . . . . . . . . . . . 3013.3.1 Xanthines 13.3.2 Beta Agonists Oral 13.3.3 Beta Agonist Inhalers 13.3.4 Inhaled Corticosteroids 13.3.5 Intranasal Steroids 13.3.6 Miscellaneous Pulmonary Agents

14. Urologicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3114.1 Cholinergic Stimulants . . . . . . . . . . . . . . . . . . . . . . . 3114.2 Anticholinergic & Antispasmodics . . . . . . . . . . . . . . 3114.3 Urinary Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . 3114.4 Miscellaneous Urologicals . . . . . . . . . . . . . . . . . . . . . 3114.5 Benign Prostatic Hyperplasia (BPH) Therapy . . . . . . 31

15. Vitamins, Hematinics & Electrolytes . . . . . . . . . . . 3215.1 Vitamins & Hematinics . . . . . . . . . . . . . . . . . . . . . 3215.2 Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . 32

15.2.1 Anticoagulants 15.2.2 Antiplatelet Drugs15.2.3 Heparin15.2.4 Vitamin K15.2.6 Miscellaneous Coagulation Agents

15.3 Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3215.3.1 Potassium

16. Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 3316.1 Miscellaneous Agents . . . . . . . . . . . . . . . . . . . . . . . . 3316.2 Smoking Deterrents . . . . . . . . . . . . . . . . . . . . . . . . . 33

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34


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IntroductionThe Prescription Drug List is a compilation of drugs in various therapeutic classes for use in meeting the prescription therapy needs ofenrollees in Physicians Health Plan (PHP) FamilyCare (Medicaid).The Medicaid PDL is organized into five sections:Section PagesTable of Contents. . . . . . . . . . . . . . . . . . . . . . 1-2Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Keys to Symbols . . . . . . . . . . . . . . . . . . . . . . . . 4Drug Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

OverviewThe Medicaid PDL is intended for use by physicians and other health care professionals in the consideration of drug therapy to treat theconditions of our customers. The list in this volume is current as of December 1, 2008. It is, however, subject to periodic revision. Certain classes of CNS medications (Psychotropic Carve-out) and HIV/AIDS therapies follow the Michigan Department of CommunityHealth Preferred Drug List.The list applies to prescriptions dispensed at network pharmacies. It does not include inpatient medications or drugs obtained from oradministered in a physician’s office. Within a class of drugs, there is a TIER 1 section and a TIER 2 section. Generic medications are listed by generic names and brandnames are included for reference. Brand medications are listed by brand name and generic names are included for reference. Medications listed in ( ) only indicate the trade name/generic name of the medications. Coverage is determined by the member’s prescription drug benefit plan.Billing for Anti-Retroviral, Detoxification, Anticonvulsant and Psychotherapeutic Drug ClassesEffective October 1, 2004, the Michigan Department of Community Health (MDCH) instituted service delivery changes for certainmedications for beneficiaries enrolled in Michigan Medicaid Health Plans. The claims will be adjudicated directly for MDCH throughFirst Health Pharmacy Benefit Manager (PBM) at point of sale by the dispensing pharmacy instead of through PBM.The member will need to present their MIHealth card for these claims. To ensure coverage, members are instructed to always presentboth MIHealth and PHP FamilyCare Card for pharmacy claims. If an attempt is made to run these medications through the PHP FamilyCare pharmacy benefit, the claims will reject, this may lead to the erroneous conclusion that these agents are not covered at all.The pharmacies need to run claims for these medications through the First Health PBM using the member’s MIHealth card.The following medication classes are adjudicated at point of sale by First Health:•Psychotherapeutic drug classes that correspond to the “psych carve out,” which are reimbursed to the MHPs at 100%. Anticonvulsants-all medications within this class of drugs.•Anti-retroviral drug classes, including all NDCs associated with the following categories: protease inhibitors, protease inhibitor combinations, nucleotide analog reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, nucleoside analog reversetranscriptase inhibitor combination, non-nucleoside reverse transcriptase inhibitors, fusion inhibitors.

•Detoxification Agents - Antabuse, Compral, ReVia, Depade and Suboxone all require a price authorization from First Health.Refer to the First Health Website at: www.michigan.fhsc.com for a complete list of medications that must be billed with MIHealth card.Please call Customer Service if you have any questions. Generic Drugs For the drugs listed in the TIER 1 section, the dispensing of generic drugs is required, whenever available. The brand version of the samedrug is non-preferred. In some instances, certain brand drugs, which have generic equivalents may be covered at an established genericreimbursement level. We classify a drug product as a generic or brand, based on commercially available data resources. The classificationis not made by the manufacturer or the pharmacy. The classification of a drug as generic or brand may change from time to time, basedon a variety of factors. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approvalfrom the prescribing physician to substitute the generic equivalent. If you are over 21 years of age, a copy maybe required for certaingeneric and preferred brand name drugs.Over-the-Counter (OTC) DrugsPrescriber Information: PHP FamilyCare provides benefit coverage for certain over-the-counter (OTC) medications. The OTC medications must be:1. medically necessary for treating a current medical condition2. ordered by prescription from a licensed prescriber3. filled at a network pharmacy4. the pharmacy claim filed and adjudicated via the online pharmacy claim system.Mandatory generic substitution is in effect. PHP FamilyCare does not provide benefit coverage for members seeking “stock bottles” fortheir home medicine cabinet. The quantity ordered should be sufficient for length of therapy but not to exceed a 30-day supply, whenpractical.


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Medications Requiring Notification and Other Pharmacy ProgramsSelected medications may require notification to be eligible for coverage under the enrollee’s benefit plan. Such medications have a notation, N(for “notification”), in this booklet. The pharmacy benefit may exclude coverage of medications for certain uses. Quantity limitations are basedon FDA-approved dosing recommendations, common and accepted uses, and package size. Such medications have a notation, “ql,” for quantity limitation. The purpose of these quantity limitations is to align the enrollee’s cost with FDA-approved dosing guidelines. They aredesigned to define the maximum supply of medication per copayment, as specified by the benefit plan. Other medications on the PrescriptionDrug List have a defined maximum amount that can be covered in a one month period. These are called “Quantity Per Duration Limits” andhave the notation, “qd.” The list of the medications requiring notification and a summary of criteria is provided below. The list and criteriareflect the PHP Pharmacy and Therapeutics Committee clinical decisions. For an enrollee to receive benefit coverage for a medication requiring notification, the physician must provide information via PHP “Medical Exception for Medication” fax form. For general questions,or to receive a form, call PHP Customer Service.

Prescriptions for Non-Preferred MedicationsPhysicians are encouraged to use the Medicaid PDL when prescribing medications for our customers. Physicians may request a non-preferred drug; requests for non-preferred drugs are subject to the prior notification process outlined in the previous section. Theserequests will be considered for our customers under the following circumstances (provided the customer’s benefit includes coverage forthe requested non-preferred drugs).• Customer has documented treatment failure with the preferred drugs.• Preferred drugs are contraindicated for treatment.• Customer experienced an allergic reaction to the preferred drugs.• The requested non-preferred drug is documented to be safe and effective for treatment of the condition for which it is requested.Physicians should contact PHP Customer Service to determine the request procedure for non-preferred medications.

Key to SymbolsWeigh risk of birth defects or other adverse outcomes.

Do not use in pregnancy.N Prior Notification is required to be eligible for coverage. Contact PHP Customer Service to determine request procedure.ql Quantity limit.qd Quantity per duration limit.OTC Over-the-counter (non-prescription) drug. Written prescription required. Mandatory generic substitution required.A Prior notification may be required to be eligible for coverage depending on patient age. Contact PHP Customer Service to

determine request procedure.ST Step therapy.


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MEDICAID NOTIFICATION TABLE

# Chapter Therapeutic Class or Medication

Summary Of Notification Criteria (Coverage is provided for treatment of )

1.0 Anti-Infectives

1.8.1 Miscellaneous Antiviral Copegus RebetolRibavirin

Broad range of indications, such as chronic hepatitis, hairycell leukemia, and non-Hodgkin’s lymphoma.

1.9 Antifungal Agents (ql) DiflucanLamisilSporanox

Onychomycosis for >one treatment course. Other fungal infections with unlimited treatment courses.

1.11 Miscellaneous Anti-infectives Tobi Cystic Fibrosis pulmonary infections

2.0 Antineoplastic & Immunosuppressant Drugs

2.2 Adjunctive Agents LeukineNeulasta

Neutropenia for approved indications or prevention of neutropenia for approved indications.

2.1.6 Miscellaneous Antineoplastic Drugs Tykerb Combination treatment of advanced or metastic breast cancer.

Erivedge Metastatic Basal Cell carcinoma or locally advanced BasalCell Carcinoma that recurred following surgery; not a candidate for surgery or radiation.

Inlyta Advanced renal cell carcinoma after failure of one prior systemic therapy.

Jakafi Intermediate of high-risk Myelofibrosis.

Zelboraf Unresectable Metastatic Melanoma with BRAFV600E mutation as detected by a FDA approved test

3.0 Autonomic & CNS Drugs, Neurology & Psych

Cometriq Progressive, metastatic medullary thyroid cancer

3.1 Narcotic Analgesics ActiqFentoraOxycontin

Pain in cancer patients.

Lazanda Breakthrough pain in cancer patients who are receiving &tolerant to opioid therapy for underlying persistent cancerpain & who had a trial of formulary agents & failed or hadsignificant adverse effects.

3.4.2 Antivertigo & Antiemetic Drugs (ql) AnzemetKytrilZofranEmend

Chemotherapy-induced N/V; radiation therapy inducedN/V; prevention of postoperative N/V; & N/V associatedwith pregnancy.

3.7 Miscellaneous Neurological Therapy Aricept 23mg Patients who had a trial of a lower-strength donepezil &other formulary NMDA receptor antagonists & failed orhad significant adverse effects.

3.9.4 Miscellaneous PsychotherapeuticAgents

ProvigilNuvigil

Sleep apnea only after attempts at CPAP have been maximized. Must have a sleep study positive for the diagnosis of sleep apnea.

5.0 Dermatology/Topical Therapy

5.3 Therapy for Acne AvitaDifferinRetin-ATasoracTretinoin TopicalEpiduo

Medical skin conditions (i.e., acne vulgaris, actinic keratosis, precancerous skin lesion). Notification requiredfor members older than 29 years.


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MEDICAID NOTIFICATION TABLE, CONTINUED

# Chapter Therapeutic Class or Medication

Summary Of Notification Criteria (Coverage is provided for treatment of )

5.0 Dermatology/Topical Therapy (continued)

5.12 Miscellaneous Dermatologicals Regranex Treatment of diabetic foot ulcers.

ElidelProtopic

Atopic dermatitis or eczema and if treatment with a topicalcorticosteroid is deemed inadvisable.

7.0 Endocrine/Diabetes

7.4.3 Miscellaneous Agents Kuvan Phenylketonuria (PKU) in patients on a phenylalanine restricted diet.

7.5.2 Non-Insulin Hypoglycemic Agents Bydureon Type 2 diabetic patients who had a trial of Byetta & failedor had significant adverse effects.

8.0 Gastroenterology

8.3.3 Miscellaneous GastrointestinalAgents

Giazo Ulcerative Colitis in patients who have had a trial of for-mulary agents & failed or had significant adverse effects

8.4.3 Antivertigo & Antiemetic Agents Marinol Appetite stimulation in AIDS & chemotherapy inducedN/V patients who had a trial of megestrol (Megace) failedor had significant adverse effects.

9.0 Immunology/Vaccines/Biotech

9.1.1 Erythroid Stimulants AranespEpogenProcrit

Anemia associated with chronic renal failure (CRF) orchemotherapy in patient with malignancies.

9.1.3 Interferons InfergenIntron-APegasysPeg-IntronRoferonRebetron

Broad range of indications, such as chronic hepatitis, hairycell leukemia, and non-Hodgkin’s lymphoma.

Actimmune Chronic Granulomatous Disease (CGD) to reduce the frequency & severity of infections or delaying time to disease progression in severe malignant osteoporosis.

9.1.4 Growth Hormones GenotropinHumatropeNorditropinNutropinNutropin/AQNutropin DepotSaizen

Documented pediatric or adult growth hormone deficiency& other disorders affecting growth in children, (e.g.gonadal dysgenesis), Growth failure secondary to chronicrenal failure/insufficiency without renal transplant, Prader-Willi syndrome, & growth failure in children born smallfor gestational age.

Serostim Wasting associated with AIDS.

Zorbtive Short bowel syndrome.

9.1.5 Interleukins ArcalystIlaris

Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Autoinflammatory Syndrome(FCAS) and Muckle-Wells Syndrome (MWS).

10.0 Musculoskeletal & Rheumatology

10.3.2 Miscellaneous RheumatologicalAgents

EnbrelHumiraKineretSimponi

Rheumatoid arthritis (RA), moderate to severe polyarticular juvenile RA, psoriatic arthritis, ankylosingspondylitis & moderate to severe plaque psoriasis.

Orencia SQ RA in patients who had a trial of Humira & Enbrel &failed or who had a trial of formulary agents & failed orhad significant adverse effects.


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MEDICAID NOTIFICATION TABLE, CONTINUED

# Chapter TherapeuticClass or Medication

Summary Of Notification Criteria(Coverage is provided for treatment of )

11.0 Obstetrics & Gynecology

11.1.1 Monophasic, Biphasic & TriphasicAgents

Beyaz Patients who had a trial formulary oral contraceptives &who had a trial of formulary agents & failed or had significant adverse effects.

13.0 Respiratory, Allergy, Cough & Cold

13.3.6 Miscellaneous Pulmonary Agents Tracleer Thelin,LetairisTyvaso

Pulmonary arterial hypertension (PAH).

Kalydeco Cystic Fibrosis (CF) in patients > 6 years old who haveG551D mutation in the CF Transmembrane ConductanceRegulator (CFTR) gene.

14.0 Urologicals

14.5 BPH Therapy AvodartProscar (g)

Benign prostatic hyperplasia in males.


10


11

1.5 Quinolones PREFERRED PRODUCTS

DRUG NAME

1.5.1 FLUOROQUINOLONESTIER 1Ciprofloxacin ER (Cipro XR)

Ciprofloxacin HCl (Cipro) Levofloxacin (Levaquin) Ofloxacin (Floxin)

1.6 Sulfas & Related Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)

Sulfadiazine Sulfamethoxazole/Trimethoprim (Bactrim, DS, Septra, DS)

1.7 Urinary Tract Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Methenamine Mandelate (Mandelamine)

Nitrofurantoin (Furadantin) Nitrofurantoin Macrocrystal (MacroBid) Nitrofurantoin Macrocrystal (Macrodantin 50, 100mg) Phenazopyridine (Pyridium) Phenazopyridine/Hyoscyamine/Butalbital (Pyridium Plus) Trimethoprim (Proloprim)

1.8 Antivirals PREFERRED PRODUCTS

DRUG NAME

1.8.1 MISCELLANEOUS ANTIVIRALSHIV/AIDS medications are covered but must be billed using the patient’s MIHealth card. See information on page 3.

PREFERRED PRODUCTSDRUG NAME

1.8.2 HIV/AIDS THERAPYHIV/AIDS medications are covered but must be billed using the patient’s MIHealth card. See information on page 3.

1.9 Antifungal Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Clotrimazole Troche (Mycelex)

Ketoconazole ql (Nizoral) Fluconazole N (Diflucan 50, 100, 150, 200mg ql N) Flucytosine (Ancobon) Griseofulvin Ultramicrosize (Gris-Peg) Itraconazole (Sporanox N) Nystatin (Mycostatin) Terbinafine HCl (Lamisil qd N) Voriconazole N (Vfend N)

Weigh risk of birth defects or other adverse outcomes.

Do not use in pregnancy.N Prior Notification is required to be eligible for coverage. Contact PHP Customer Service to determine request

procedure.ql Quantity limit.qd Quantity per duration limit.

OTC Over-the-counter (non-prescription) drug. Written prescription required. Mandatory generic substitutionrequired.

A Prior notification may be required to be eligible for coverage depending on patient age. Contact PHP CustomerService to determine request procedure.

ST Step therapy.

1.1 Penicillins PREFERRED PRODUCTS

DRUG NAME

TIER 1Amoxicillin Trihydrate/Potassium Clavulanate ql

(Augmentin 200, 400mg Suspension, 500, 875mg Tablet, Augmentin ES) Amoxicillin Trihydrate Suspension (Amoxil) Dicloxacillin Sodium Capsule (Dynapen) Penicillin V Potassium (Pen-Vee K)

TIER 2Amoxil Pediatric Drops (Amoxicillin Trihydrate)

1.2 Tetracyclines PREFERRED PRODUCTS

DRUG NAME

TIER 1 Doxycycline Hyclate (Vibra-Tabs, Vibramycin, Vibramycin Suspension) Minocycline HCl (Dynacin) Minocycline HCl (Minocin) Tetracycline HCl (Achromycin V)

1.3 Cephalosporins PREFERRED PRODUCTS

DRUG NAME

1.3.1 FIRST GENERATION CEPHALOSPORINSTIER 1Cefadroxil (Duricef Tablet, Capsule, Suspension)

Cefalexin Monohydrate (Keflex)


1.3.2 SECOND GENERATION CEPHALOSPORINSTIER 1Cefaclor (Ceclor)

Cefaclor Extended Release ql (Ceclor CD) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cefuroxime Axetil (Ceftin Tablet, Suspension)


1.3.3 THIRD GENERATION CEPHALOSPORINSTIER 1Cefdinir ql (Omnicef)

1.4 Erythromycins & Other Macrolides PREFERRED PRODUCTS

DRUG NAME

1.4.1 ERYTHROMYCINS & OTHER MACROLIDESTIER 1Azithromycin (Zithromax Packet, Suspension, Tablet)

Clarithromycin (Biaxin, Biaxin XL) Erythromycin Base Tablet, Enteric Coated (E-Mycin) Erythromycin Ethylsuccinate (E.E.S.) Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) Erythromycin Stearate (Erythrocin Stearate)

1. ANTI-INFECTIVES


12






ST Step therapy.

1.10 Vancomycin PREFERRED PRODUCTS

DRUG NAME

TIER 1Vancomycin HCl Cap (Vancocin)

1.11 Miscellaneous Anti-infectives PREFERRED PRODUCTS

DRUG NAME

1.11.1 MISCELLANEOUS ANTI-INFECTIVESTIER 1Clindamycin HCl (Cleocin HCl 150, 300mg)

Neomycin Sulfate (Neomycin Sulfate) TIER 2Dapsone (Dapsone)


1.11.2 ANTIPARASITICSTIER 1Mebendazole (Vermox)

Metronidazole (Flagyl) Tinidazole (Tindamax)

TIER 2NebuPent ql (Pentamidine Isethionate)


1.11.3 ANTIMALARIALSTIER 1Atovaquone/Proguanil (Malarone)

Chloroquine Phosphate (Aralen Phosphate) Mefloquine HCl ql (Lariam) Hydroxychloroquine Sulfate (Plaquenil) Quinine Sulfate (Qualaquin)

TIER 2Daraprim (Pyrimethamine)

Primaquine (Primaquine Phosphate)


1.11.4 ANTIMYCOBACTERIALSTIER 1Ethambutol HCl (Myambutol)

Isoniazid (Isoniazid) Pyrazinamide (Pyrazinamide) Rifampin (Rifadin)

TIER 2Mycobutin ql (Rifabutin)

Rifamate (Rifampin/Isoniazid) Rifater (Rifampin/Isoniazid/Pyrazinamide)


13


2.1.6 MISCELLANEOUS ANTINEOPLASTIC DRUGSTIER 1

Etoposide (VePesid) Hydroxyurea (Hydrea) Tretinoin (Vesanoid)

TIER 2 Droxia (Hydroxyurea) Emcyt (Estramustine Phosphate Sodium) Gleevec ql N (Imatinib Mesylate) Hexalen (Altretamine) Matulane (Procarbazine HCl) Lysodren (Mitotane) Tykerb Tablet N (Lapatinib)

2.2 Adjunctive Agents PREFERRED PRODUCTS

DRUG NAME

2.2.1 ADJUNCTIVE AGENTSTIER 1Leucovorin Calcium (Leucovorin) TIER 2Mesnex (Mesna)






ST Step therapy.

2.1 Antineoplastic & Immunosuppressant Drugs PREFERRED PRODUCTS

DRUG NAME

2.1.1 ALKYLATING AGENTSTIER 1Cyclophosphamide (Cytoxan) TIER 2

Alkeran (Melphalan) CeeNu (Lomustine) Leukeran (Chlorambucil) Myleran (Busulfan)


2.1.2 ANTIMETABOLITESTIER 1

Mercaptopurine (Purinethol) Methotrexate Sodium (Methotrexate) Methotrexate Sodium (Rheumatrex)


2.1.3 ANDROGENS, ESTROGENS, HORMONES & RELATED DRUGS2.1.3.3 HORMONES

TIER 1 Megestrol Acetate (Megace) 2.1.3.4 ANTIESTROGENS

TIER 1 Anastrozole (Arimidex) Exemestane (Aromasin) Letrozole (Femara) Tamoxifen Citrate Tablet (Nolvadex) 2.1.3.5 ANTIANDROGENS

TIER 1 Bicalutamide (Casodex) Flutamide (Eulexin)


2.1.5 IMMUNOSUPPRESSANT DRUGSTIER 1

Azathioprine (Imuran) Cyclosporine (Sandimmune) Cyclosporine, Modified (Gengraf) Cyclosporine, Modified (Neoral) Mycophenolate Mofetil HCl (CellCept) Tacrolimus Anhydrous (Prograf)

TIER 2Neoral (Cyclosporine, Modified)

Rapamune (Sirolimus) Sandimmune (Cyclosporine)

2. ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS


14

3.3 Non-narcotic Analgesics PREFERRED PRODUCTS

DRUG NAME

OTC ANALGESICSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications. Acetaminophen (Tylenol) Aspirin Aspirin (Ascriptin A/D) Aspirin Enteric Coated (Ecotrin) Ibuprofen (Advil) Ibuprofen (Children’s Advil) Ketoprofen (Orudis KT) Naproxen Sodium (Aleve) 3.3.1 NSAIDS

TIER 1Diclofenac Potassium (Cataflam)

Diclofenac Sodium (Voltaren) Diclofenac Sodium XR (Voltaren XR) Etodolac (Lodine) Etodolac XR (Lodine XL) Fenoprofen Calcium Tablet (Nalfon) Flurbiprofen (Ansaid) Ibuprofen (Motrin, Rufen, Children’s Advil) Ibuprofen Suspension, Oral (Final Dose Form) (Children’s Advil) Indomethacin (Indocin) Indomethacin Capsule, Sustained Action (Indocin SR) Meloxicam (Mobic ql) Nabumetone (Relafen) Naproxen (EC-Naprosyn, Naprosyn) Naproxen Sodium (Anaprox, DS, Aleve) Naproxen Sodium (Anaprox 275, 550 mg) Oxaprozin (Daypro) Piroxicam ql (Feldene) Sulindac (Clinoril) Tolmetin Sodium (Tolectin) Tolmetin Sodium (Tolectin DS)


OTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.3.3.2 SALICYLATES

TIER 1Aspirin (Aspirin OTC)

Choline Sal/MagnesiumSalicylate (Trilisate) Diflunisal 500mg ql (Dolobid 500mg) Salsalate (Salflex)


OTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.3.3.3 MISCELLANEOUS ANALGESICS

TIER 1Acetaminophen (Tylenol OTC)

Butorphanol Tartrate Aerosol, Spray ql (Stadol) Pentazocine HCl/Acetaminophen (Talacen) Phenazopyridine (Pyridium) Tramadol/Acetaminophen (Ultracet) Tramadol HCl (Ultram, Ultram ER ql)


3.3.4 NARCOTIC ANTAGONISTSThese medications are covered with prior authorization from First Health and must be billed usingpatient’s MIHealth Card. See information on page 3.






ST Step therapy.

3.1 Narcotic Analgesics PREFERRED PRODUCTS

DRUG NAME

3.1.1 NARCOTICSTIER 1Codeine Sulfate (Codeine Sulfate)

Fentanyl Patch (Duragesic) Hydromorphone HCl (Dilaudid) Meperidine HCl (Demerol) Methadone HCl (Dolophine HCl) Morphine Sulfate Controlled Release (MS Contin qd) Morphine Sulfate Soln Concentrate, Tabs (MSIR, Oms) Oxycodone HCl Concentrate (OxyFAST) Oxycodone HCl Concentrate (Roxicodone 20mg/ml) Oxycodone HCl Solution, Oral (Roxicodone 5mg/5ml) Oxycodone SR ql (Oxycontin qd)


3.1.2 COMBINATION NARCOTIC/ANALGESICSTIER 1

Acetaminophen/Butalbital (Phrenilin) Acetaminophen/Caffeine/Butalbital (Fioricet) Aspirin/Caffeine/Butalbital (Fiorinal) Codeine Phosphate/Acetaminophen (Tylenol w/Codeine) Codeine Phosphate/Aspirin/Caffeine/Butalbital (Fiorinal w/Codeine 30mg) Hydrocodone Bit/Acetaminophen (Hycet) Hydrocodone Bit/Acetaminophen (Norco) Oxycodone/Aspirin (Percodan) Oxycodone/Ibuprofen (Combunox) Oxycodone HCl/Acetaminophen (Tylox) Oxycodone HCl/Acetaminophen Tablet (Percocet 5-325mg, 7.5-500mg, 10-650mg)

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH


15

3.8 Muscle Relaxants & Antispasmodic Therapy PREFERRED PRODUCTS

DRUG NAME

3.8.1 MUSCLE RELAXANTS & ANTISPASMODIC AGENTSTIER 1Baclofen (Lioresal)

Chlorzoxazone (Parafon Forte DSC) Cyclobenzaprine (Flexeril) Dantrolene Sodium (Dantrium) Diazepam (Valium A) Methocarbamol (Robaxin) Oxybutynin Chloride (Ditropan) Oxybutynin Chloride (Ditropan XL ql) Tizanidine HCl (Zanaflex)


3.8.2 MYASTHENIA GRAVISTIER 1Pyridostigmine Bromide (Mestinon) TIER 2Prostigmin (Neostigmine Bromide)

3.9 Psychotherapeutic Drugs PREFERRED PRODUCTS

DRUG NAME

Psychotherapeutic medications are covered but must be billed using the patient’s MIHealth card. See information on page 3.3.9.1 HYPNOTIC AGENTS3.9.2 ANTIDEPRESSANT AGENTS

3.9.2.1 TRICYCLICS3.9.2.2 MISCELLANEOUS ANTIDEPRESSANT3.9.2.3 MAOI INHIBITORS3.9.2.4 SELECTIVE SEROTONIN REUPTAKE INHIBITORS

3.9.3 ANTIPSYCHOTICS3.9.3.1 PHENOTHIAZINES3.9.3.2 BUTYROPHENONES3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS

3.9.4 MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS 3.9.5 ANXIOLYTICS






ST Step therapy.

3.4 Migraine & Cluster Headache Therapy PREFERRED PRODUCTS

DRUG NAME

3.4.1 HEADACHE THERAPYTIER 1

Acetaminophen/Butalbital (Phrenilin) Acetaminophen/Caffeine/Butalbital (Fioricet) Aspirin/Caffeine/Butalbital (Fiorinal) Dihydroergotamine Mesylate (D.H.E.45) Ergotamine Tartrate/Caffeine (Cafergot Tabs) Naratriptan (Amerge ql qd) Rizatriptan Benzoate (Maxalt, MLT ql qd) Sumatriptan Spray, Non-Aerosol (Imitrex ql qd) Sumatriptan Succinate Tablet (Imitrex ql qd) Sumatriptan Succinate Vial (Imitrex ql qd)

TIER 2 Relpax ql qd (Eletriptan) Ergomar (Ergotamine Tartrate)


3.4.2 ANTIVERTIGO & ANTIEMETIC DRUGSTIER 1Granisetron HCl (Kytril qd)

Meclizine HCl Tablet (Antivert 12.5, 25mg OTC) Prochlorperazine Maleate Tablet, Suppository, Rectal (Compazine) Promethazine HCl (Phenergan 6.25/5mg, Tablet, Syrup, Suppository) Ondansetron HCl Solution, Oral, Tablet (Zofran qd) Ondansetron, Orally Disintegrating Tablet (Zofran ODT qd) Trimethobenzamide (Tigan Caps)

3.5 Antiparkinsonism Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Amantadine HCl Syrup (Symmetrel)

Benztropine Mesylate (Cogentin) Bromocriptine Mesylate (Parlodel 2.5mg) Carbidopa/Levodopa (Sinemet, Parcopa) Carbidopa/Levodopa Tablet, Sustained Action (Sinemet CR) Diphenhydramine HCl A (Benadryl) Entacapone (Comtan) Pramipexole (Mirapex) Ropinirole HCl (Requip) Selegiline HCl (Eldepryl) Trihexyphenidyl HCl (Artane)

3.6 Anticonvulsants PREFERRED PRODUCTS

DRUG NAME

Anticonvulsant medications are covered but must be billed using the patient’s MIHealth card. See information on page 3.

3.7 Miscellaneous Neurological Therapy PREFERRED PRODUCTS

DRUG NAME

TIER 1Donepezil HCl (Aricept ql)

Galantamine (Razadyne Tablet 4mg, Razadyne ER) TIER 2Exelon ql (Rivastigmine Tartrate)


16


4.4.3 HEPARINTIER 1Enoxaparin Sodium (Lovenox ql) TIER 2Fragmin Subcutaneous Injection (Dalteparin ql)

Heparin Inj. Syringe (Heparin)


4.4.4 VITAMIN KTIER 2Mephyton (Phytonadione)


4.4.6 MISCELLANEOUS COAGULATION AGENTSTIER 1Pentoxifylline Tablet, Sustained Action (Trental)

4.5 Antihypertensive Therapy PREFERRED PRODUCTS

DRUG NAME

4.5.1 THIAZIDE & RELATED DIURETICSTIER 1Amiloride HCl (Midamor)

Amiloride HCl/Hydrochlorothiazide (Moduretic) Bumetanide (Bumex) Chlorothiazide Tablet (Diuril) Chlorthalidone (Hygroton) Eplerenone (Inspra) Furosemide (Lasix) Hydrochlorothiazide (HydroDIURIL) Indapamide (Lozol) Methyclothiazide (Enduron) Metolazone (Zaroxolyn) Spironolactone (Aldactone) Spironolactone/Hydrochlorothiazide (Aldactazide 25-25mg) Triamterene/Hydrochlorothiazide (Dyazide, Maxzide) Torsemide Tablet (Demadex)


4.5.2 BETA BLOCKERSTIER 1Acebutolol HCl (Sectral)

Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (Zebeta) Carvedilol (Coreg) Labetalol HCl (Normodyne) Metoprolol Succinate (Toprol XL) Metoprolol Tartrate (Lopressor) Nadolol (Corgard) Pindolol (Visken) Propranolol (Inderal) Sotalol (Betapace) Timolol Maleate (Blocadren)






ST Step therapy.

4.1 Antiarrhythmic Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1 Amiodarone HCl (Pacerone) Disopyramide Phosphate Capsule (Norpace 100mg) Disopyramide Phosphate Capsule, Sustained Action (Norpace CR 150mg) Flecainide Acetate (Tambocor) Mexiletine HCl (Mexitil) Propafenone HCl (Rythmol, Rythmol SR) Quinidine Sulfate (Quinidex) Quinidine Sulfate Tablet, Sustained Action (Quinidex) Sotalol HCl (Betapace, Betapace AF)

TIER 2Tikosyn (Dofetilide)

4.2 Cardiac Glycosides PREFERRED PRODUCTS

DRUG NAME

TIER 1Digoxin Tablet (Lanoxin)

4.3 Nitrates PREFERRED PRODUCTS

DRUG NAME

4.3.1 RAPID ACTING NITRATESTIER 1Nitroglycerin (Nitrolingual)

Nitroglycerin (Nitrostat)


4.3.2 LONG ACTING NITRATESTIER 1Isosorbide Dinitrate Tablet (Isordil 5, 10, 20, 30mg)

Isosorbide Dinitrate Tablet, Sublingual (Isordil 2.5, 5mg) Isosorbide Dinitrate Tablet, Sustained Action (Isorbide Tembid) Isosorbide Mononitrate (ISMO) Isosorbide Mononitrate Tablet, Sustained Release 24hr (Imdur) Nitroglycerin Capsule, Sustained Action (Nitro-Bid) Nitroglycerin Ointment (Nitrol) Nitroglycerin Patch, Transdermal 24 Hours ql (Transderm-Nitro)

TIER 2Minitran (Nitroglycerin)

4.4 Coagulation Therapy PREFERRED PRODUCTS

DRUG NAME

4.4.1 ANTICOAGULANTSTIER 1

Warfarin Sodium (Coumadin) TIER 2

Coumadin (Warfarin Sodium)


4.4.2 ANTIPLATELET DRUGSTIER 1Cilostazol (Pletal)

Clopidogrel Bisulfate (Plavix) Dipyridamole (Persantine) Ticlopidine HCl (Ticlid)

4. CARDIOVASCULAR, HYPTERTENSION & LIPIDS


17


4.5.7 VASODILATORSTIER 1Hydralazine HCl (Apresoline)

Minoxidil (Loniten)


4.5.8 OTHER ANTIHYPERTENSIVE COMBINATIONSTIER 1Amlodipine Besylate/Benzapril (Lotrel, Tarka)

Atenolol/Chlorthalidone (Tenoretic) Benazepril/HCTZ (tab/caps) (Lotensin) Bisoprolol Fumarate/HCTZ (Ziac) Captopril/Hydrochlorothiazide (Capozide) Enalapril Maleate/Hydrochlorothiazide (Vaseretic) Fosinopril/HCTZ (tab/caps) (Monopril HCT) Lisinopril/Hydrochlorothiazide (Prinzide) Methyldopa/Hydrochlorothiazide (Aldoril) Metoprolol HCT (Lopressor HCT) Moexipril/HCTZ (tab/caps) (Uniretic) Propranolol HCl/Hydrochlorothiazide (Inderide) Quinapril HCT (Accuretic)


4.5.9 ANGIOTENSIN II RECEPTOR BLOCKERSTIER 1Candesartan/HCTZ (Atacand HCT)

Eprosartan 600mg (Teveten) Irbesartan (Avapro) Losartan (Cozaar qd) Losartan/Hydrochlorothiazide (Hyzaar qd) Valsartan/HCTZ (Diovan HCT qd)

TIER 2 Diovan qd (Valsartan) Tekturna (Aliskiren Hemifumarate)

4.6 Lipid/Cholesterol Lowering Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1 Atorvastatin Calcium (Lipitor ql qd) Cholestyramine/Aspartame (Questran Light) Cholestyramine/Sucrose (Questran) Colestipol (Colestid) Fenofibrate, Micronized (Lofibra, Tricor) Fenofibric Acid (Fibricor) Gemfibrozil (Lopid) Lovastatin ql (Mevacor qd) Pravastatin ql (Pravachol qd) Simvastatin ql (Zocor qd)

TIER 2Niaspan (Niacin Tablet, Sustained Action Sequential)






ST Step therapy.


4.5.3 CALCIUM CHANNEL BLOCKERS4.5.3.1 CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES

TIER 1Diltiazem HCl (Cardizem)

Diltiazem HCl (Tiazac) Diltiazem HCl Capsule, Sustained Release 12 hr (Cardizem SR) Diltiazem HCl Capsule, Sustained Release 24 hr

(Cardizem CD 120, 180, 240, 300mg) Nimodipine (Nimotop) Verapamil HCl ql (Calan, SR) Verapamil HCl ql (Verelan, Verelan PM)

TIER 2Cardizem LA (Diltiazem LA)

4.5.3.2 CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES

TIER 1Amlodipine Besylate (Norvasc)

Felodipine ql (Plendil) Nifedipine ql (Procardia) Nifedipine Extended Release Tablet ql (Adalat CC) Nifedipine Extended Release Tablet ql (Procardia XL) Nisoldipine 8.5mg, 17mg, 20mg, 25.5mg, 30mg, 34mg, 40mg (Sular)


4.5.4 ACE INHIBITORSTIER 1Benazepril (Lotensin)

Captopril (Capoten) Enalapril (Vasotec) Fosinopril Sodium (Monopril) Lisinopril ql (Prinivil, Zestril) Moexipril (Univasc) Quinapril (Accupril) Perindopril (tab/caps) (Aceon) Ramipril (Altace) Trandolapril (tab/caps) (Mavik)


4.5.5 ADRENERGIC ANTAGONISTS & RELATED DRUGSTIER 1Clonidine HCl (Catapres)

Clonidine HCl Patch, Transdermal Weekly (Catapres-TTS ql) Doxazosin Mesylate (Cardura) Prazosin HCl (Minipress) Guanfacine HCl (Tenex) Methyldopa (Aldomet) Reserpine (Reserpine) Terazosin HCl ql (Hytrin)


18

5.3 Therapy For Acne PREFERRED PRODUCTS

DRUG NAME

OTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Adapalene (Differin)

Benzoyl Peroxide (Benzoyl Peroxide OTC) Benzoyl Peroxide/Urea, Pads, Gel, Cleanser, Cream (ZoDerm) Clindamycin Phosphate (Cleocin T) Clindamycin Phosphate/Benzoyl Peroxide (Benzaclin) Clindamycin Phosphate/Benzoyl Peroxide (Duac) Erythromycin Base/Benzoyl Peroxide (Benzamycin) Erythromycin Base/Ethyl Alcohol (Emgel, Erygel) Erythromycin Base/Ethyl Alcohol Gel (A/T/S) Erythromycin Base/Ethyl Alcohol Solution, Non-Oral (A/T/S) Erythromycin Base/Ethyl Alcohol Swab, Medicated (Erycette, T-Stat) Metronidazole (Metrocream, Metrolotion) Sulfacetamide Sodium/Sulfur (Sulfacet-R) Tretinoin Cream N (Retin A A)

5.4 Topical Antibacterials PREFERRED PRODUCTS

DRUG NAME

TIER 1Gentamicin Sulfate (Garamycin)

Mupirocin Ointment (Bactroban) Sulfacetamide Sodium (Klaron) Triple Antibiotic (Neomycin/Bacitracin/Polymyxin B)

5.5 Topical Antifungals PREFERRED PRODUCTS

DRUG NAME


TIER 1Clotrimazole (Clotrimazole OTC)

Clotrimazole/Betamethasone Dipropionate Cream ql (Lotrisone) Econazole Nitrate (Spectazole) Ketoconazole ql (Nizoral-AD OTC) Ketoconazole Cream ql (Nizoral 2%) Miconazole Nitrate (Micatin) Nystatin (Mycostatin) Nystatin/Triamcinolone Acetonide (Mycolog II) Tolnaftate (Tinactin)

5.6 Topical Antivirals PREFERRED PRODUCTS

DRUG NAME

TIER 2Zovirax (Acyclovir Ointment)

5.7 Burn Therapy PREFERRED PRODUCTS

DRUG NAME

TIER 1Silver Sulfadiazine (Silvadene)

5.8 Topical Enzymes PREFERRED PRODUCTS

DRUG NAME

TIER 1Trypsin/Balsam Peru/Castor Oil (Granulex, Granulsol)






ST Step therapy.

5.1 Topical Corticosteroids PREFERRED PRODUCTS

DRUG NAME

5.1.1 TOPICAL CORTICOSTEROIDS VERY HIGH POTENCYTIER 1Betamethasone Dipropionate/Propylene Glycol Ointment (Diprolene 0.05%)

Clobetasol Propionate ql (Clobex) Clobetasol Propionate ql (Olux) Clobetasol Propionate ql (Temovate) Diflorasone (Psorcon)


5.1.2 TOPICAL CORTICOSTEROIDS HIGH POTENCYTIER 1Betamethasone Dipropionate (Diprosone 0.05%, Maxivate 0.05%)

Betamethasone Dipropionate Ointment (Maxivate 0.05%) Betamethasone Valerate Ointment (Valisone 0.10%) Desoximetasone (Topicort 0.25%) Diflorasone Diacetate (Psorcon-E) Fluocinonide Cream (Lidex 0.05%, Gel, Solution, Ointment) Fluocinonide/Emollient Cream, Ointment (Lidex-E 0.05%)


5.1.3 TOPICAL CORTICOSTEROIDS MEDIUM POTENCYTIER 1Betamethasone Valerate (Valisone Cream)

Desoximetasone Cream (Topicort 0.05%) Diflorasone Diacetate (Psorcon-E Cream) Fluocinolone Acetonide Cream, Ointment ql (Synalar 0.03%) Fluticasone Propionate (Cutivate) Hydrocortisone Butyrate (Locoid) Hydrocortisone Valerate Cream, Ointment (Westcort 0.20%) Mometasone Furoate Ointment (Elocon 0.10%) Triamcinolone Acetonide (Aristocort 0.03, 0.10%) Triamcinolone Acetonide (Kenalog 0.03, 0.10%)


5.1.4 TOPICAL CORTICOSTEROIDS LOW POTENCYOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Fluocinolone Acetonide (Derma-Smoothe FS)

Fluocinolone Acetonide Solution, Non-Oral (Synalar 0.01%) Hydrocortisone OTC Hydrocortisone Cream, Ointment (Hytone 2.50%) Hydrocortisone Lotion (Hytone 2.50%)

5.2 Topical Anesthetics PREFERRED PRODUCTS

DRUG NAME

TIER 1Dibucaine Ointment OTC

Lidocaine HCl Jel (Xylocaine) Lidocaine HCl Ointment Solution (Xylocaine) Lidocaine/Prilocaine (Emla)

5. DERMATOLOGICALS/TOPICAL THERAPY


19






ST Step therapy.

5.10 Antipsoriatic/Antiseborrheic PREFERRED PRODUCTS

DRUG NAME

TIER 1Anthralin (Drithocreme)

Calcipotriene (Dovonex) Hydrocortisone-Pramoxine Cream (Pramasone HC) Sulfacetamide Sodium Cleanser (Ovace) Selenium Sulfide (Selsun Rx)

TIER 2Psoriatec Cream (Anthralin 1%)

5.11 Topical Scabicides/Pediculicides PREFERRED PRODUCTS

DRUG NAME


TIER 1Lice Treatment OTC

Lindane (Lindane) Malathion (Ovide) Permethrin ql (Elimite) Spinosad (Natroba)

TIER 2Eurax (Crotamiton)

Ulesfia (Benzyl Alcohol Lotion 5%)

5.12 Miscellaneous Dermatologicals PREFERRED PRODUCTS

DRUG NAME


TIER 1Amlactin ql (Ammonium Lactate OTC)

Ammonium Lactate Cream ql (Lac-Hydrin) Calamine (Calamine OTC) Capsaicin (Zostrix OTC) Fluorouracil (all forms, topical) (Efudex) Imiquimod N (Aldara) Podofilox (Condylox)

TIER 2Elidel qd N (Pimecrolimus Cream)


20






ST Step therapy.

6.1 Intranasal Steroids PREFERRED PRODUCTS

DRUG NAME

TIER 1Flunisolide Spray (Nasalide ql)

Fluticasone Propionate Aerosol, Spray (Flonase ql) Triamcinolone Acetonide (Nasacort AQ)

TIER 2Nasonex ql (Mometasone Furoate Spray, Non-Aerosol)

6.2 Miscellaneous Otic Preparations PREFERRED PRODUCTS

DRUG NAME


TIER 1Acetic Acid (VoSol)

Acetic Acid/Hydrocortisone (VoSol HC) Antipyrine/Benzocaine/Glycerin (Auralgan) Ciprofloxacin (Cetraxal) Fluocinolone Acetonide Oil (Dermotic) Ofloxacin (Floxin OTIC)

6.3 Otic Steroid/Antibiotic PREFERRED PRODUCTS

DRUG NAME

TIER 1Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone (Cortisporin) TIER 2Ciprodex (Ciprofloxacin HCl/Dexamethasone)

6.4 Miscellaneous Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Azelastine (spray/drops) (Astelin ql)

Chlorhexidine Gluconate (Peridex) Lidocaine HCl Jel (Xylocaine) Lidocaine Solution (Xylocaine) Saline Nasal Spray OTC (Sodium Chloride) Sodium Fluoride (Phos-Flur) Triamcinolone Acetonide (Kenalog in Orabase) Triamcinolone Acetonide Paste (Oralone)

6. EAR, NOSE & THROAT MEDICATIONS


21

7.5 Diabetes Therapy PREFERRED PRODUCTS

DRUG NAME

7.5.1 INSULIN THERAPYPens and Cartridges are non-preferred.TIER 2

All Humulin, Humalog, Novolin and Novalog Vials are Tier 2. Apidra (Insulin Glulisine Vial) Lantus (Insulin Glargine, Human Recombinant Analog) Levemir (Insulin Detemir Vial)


7.5.2 ORAL HYPOGLYCEMIC AGENTSTIER 1Acarbose (Precose)

Chlorpropamide (Diabinese) Glimepiride (Amaryl) Glipizide (Glucotrol) Glipizide Extended Release Tablet (Glucotrol XL) Glipizide/Metformin (Metaglip) Glyburide (DiaBeta) Glyburide (Micronase) Glyburide, Micronized (Glynase) Glyburide/Metformin (Glucovance) Metformin HCl (Glucophage) Metformin HCl ER (Glucophage XR) Nateglinide (Starlix) Pioglitazone HCl (Actos ql) Pioglitazone HCl/Metformin (Actoplus Met XR ql) Tolazamide (Tolinase) Tolbutamide (Orinase)

TIER 2Avandia ql (Rosiglitazone Maleate)

Janumet (Sitagliptin/Metformin) Januvia (Sitagliptin Phosphate)


7.5.3 GLUCOSE ELEVATING AGENTSTIER 2Glucagon Emergency Kit ql (Glucagon Kit ql)


7.5.4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQUIPMENTTIER 2Accu-Chek, B-D Lancet Device, Lancets, OneTouch, Softclix, Soft Touch

(Diabetes Supplies, Miscellaneous)


7.5.5 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIESTIER 2Accu-Chek, Fast Take, OneTouch, Surestep (Blood Sugar Diagnostic Strip)






ST Step therapy.

7.1 Antithyroid Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1 Methimazole (Tapazole) Propylthiouracil (Propylthiouracil)

7.2 Thyroid Hormones PREFERRED PRODUCTS

DRUG NAME

TIER 1Levothyroxine Sodium (Levoxyl)

Liothyronine Sodium (Cytomel) TIER 2Armour Thyroid (Thyroid)Synthroid (Levothyroxine Sodium)

7.3 Adrenal Hormones PREFERRED PRODUCTS

DRUG NAME

TIER 1Dexamethasone (Decadron)

Fludrocortisone Acetate (Florinef Acetate) Hydrocortisone (Hydrocortone) Hydrocortisone Tablet (Cortef 5mg, 10mg, 20mg) Methylprednisolone Tablet, Dose Pack (Medrol) Prednisolone Syrup (Prelone 15mg/5ml) Prednisolone Sodium Phosphate (Orapred, Pediapred) Prednisone (Meticorten) Prednisone Tablet (Deltasone 50mg)

7.4 Miscellaneous Hormones PREFERRED PRODUCTS

DRUG NAME

7.4.1 ANDROGENSTIER 1

Danazol (Danocrine) TIER 2

Androderm (Testosterone Patch, Transdermal 24 Hours) Androgel (Testosterone) Methitest (Methyltestosterone)


7.4.3 MISCELLANEOUS AGENTSTIER 1Cabergoline (Dostinex)

Calcitonin, Salmon, Synthetic ql (Miacalcin ql) Calcitonin, Salmon, Synthetic Aerosol, Spray w/Pump ql (Miacalcin ql) Calcitriol Capsule (Rocaltrol) Desmopressin Acetate Solution, Non-Oral ql (DDAVP and Tablet)

TIER 2Kuvan N (Sapropterin Dihydrochloride)

Synarel (Nafarelin Acetate)

7. ENDOCRINE/DIABETES


22

8.3 Miscellaneous Gastrointestinal Agents PREFERRED PRODUCTS

DRUG NAME

8.3.1 BILE ACIDSTIER 1Ursodiol (Actigall)

Ursodiol (Urso, Urso Forte)


8.3.2 DIGESTIVE ENZYMESTIER 1Amylase/Lipase/Protease 5000 units (Zenpep) TIER 2Creon (Amylase/Lipase/Protease)

Ultrase (Amylase/Lipase/Protease)


8.3.3 MISCELLANEOUS GASTROINTESTINAL AGENTSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Balsalazide (Colazal)

Bisacodyl (Bisacodyl OTC) Budesonide (Entocort EC) Cromolyn Sodium (Gastrocrom) Docusate Calcium (Surfak OTC) Docusate Sodium (Colace OTC) Hydrocortisone (Cortenema, Colocort) Hydrocortisone Acetate (Hydrocortisone) Hydrocortisone/Pramoxine (Analpram-HC) Lactulose ql (Cephulac, Chronulac) Magnesium Hydroxide (Milk of Magnesia OTC) Magnesium Oxide (Mag-Ox OTC) Mesalamine Enema (Rowasa) Metoclopramide (Reglan) Miralax OTC (Polyethylene Glycol) Sennosides (Natural Senna Laxative OTC) Sulfasalazine Tablet (Azulfidine) Sulfasalazine Tablet, Enteric Coated (Azulfidine)

TIER 2Asacol (Mesalamine)

Pentasa (Mesalamine)


8.3.4 ANTIVERTIGO & ANTIEMETIC AGENTSTIER 1Granisetron HCl (Kytril qd)

Meclizine HCl Tablet (Antivert 12.5, 25mg OTC) Ondansetron HCl Solution, Oral, Tablet (Zofran qd) Ondansetron, Orally Disintegrating Tablet (Zofran ODT qd) Promethazine HCl (Phenergan) Prochlorperazine Maleate Tablet, Capsule, Suppository, Rectal (Compazine) Trimethobenzamide (Tigan)


8.3.5 BOWEL EVACUANTSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols

(Colyte) Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols

Solution, Reconstituted, Oral (GoLYTELY)






ST Step therapy.

8.1 Ulcer Therapy PREFERRED PRODUCTS

DRUG NAME

8.1.1 H2 ANTAGONISTSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Cimetidine OTC

Cimetidine 200mg (Tagamet) Cimetidine HCl Liquid (Tagamet) Cimetidine Tablet (Tagamet 800mg) Famotidine (Pepcid 10, 20mg OTC) Famotidine (Pepcid 40mg) Ranitidine 300mg (Zantac) Ranitidine HCl ql (Zantac Rx 75, 150mg OTC) Ranitidine HCl Syrup (Zantac)


8.1.2 PROSTAGLANDINSTIER 1

Misoprostol (Cytotec)


8.1.3 OTHER ULCER THERAPYTIER 1Sucralfate (Carafate)


8.1.4 PROTON PUMP INHIBITORSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1First-Lansoprazole Suspension (Lansoprazole)

First-Omeprazole Suspension (Omeprazole) Omeprazole OTC (Prilosec OTC)

8.2 Antidiarrheals & Antispasmodics PREFERRED PRODUCTS

DRUG NAME

8.2.1 ANTIDIARRHEALSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Diphenoxylate HCl/Atropine Sulfate (Lomotil)

Loperamide (Imodium AD OTC)


8.2.2 ANTISPASMODICSTIER 1Dicyclomine (Bentyl)

Glycopyrrolate (Robinul, Robinul Forte) Hyoscyamine Sulfate (Levbid, Levsin) Hyoscyamine Sulfate (Levsin/SL, Nulev) Hyoscyamine Sulfate Capsule, Sustained Release 12 hr (Levsinex) Hyoscyamine Sulfate Drops (Gastrosed)

8. GASTROENTEROLOGY


23






ST Step therapy.

9.1 Biotechnology Drugs PREFERRED PRODUCTS

DRUG NAME

9.1.1 ERYTHROID STIMULANTSTIER 2Epogen qd (Epoetin Alfa N)

Procrit qd (Epoetin Alfa N)


9.1.2 MYELOID STIMULANTSTIER 2Leukine (Sargramostim N)

Neupogen (Filgrastim N)


9.1.3 INTERFERONSTIER 2Actimmune (Interferon Gamma-1b, Recombinant)

Betaseron (Interferon Beta-1B) Avonex Administration Pack ql N (Interferon Beta-1A/Albumin Human) Copaxone ql N (Glatiramer Acetate) Intron A N (Interferon Alfa-2b, Recombinant Kit, Vial) Pegasys ql N (Peginterferon Alfa-2A) Peg-Intron ql N (Peginterferon Alfa-2b) Rebif (Interferon Beta-1A/Albumin Human)


9.1.4 GROWTH HORMONESTIER 2Humatrope qd N (Somatropin N)

Nutropin, Nutropin AQ, Depot qd N (Somatropin N)


9.1.5 INTERLEUKINSTIER 2Neumega ql (Oprelvekin)

9. IMMUNOLOGY, VACCINES & BIOTECHNOLOGY


24


10.3.2 MISCELLANEOUS RHEUMATOLOGICAL AGENTSTIER 1

Azathioprine (Imuran) Hydroxychloroquine Sulfate (Plaquenil) Leflunomide (Arava ql) Methotrexate Sodium (Rheumatrex) Sulfasalazine Tablet (Azulfidine) Sulfasalazine Tablet, Enteric Coated (Azulfidine)

TIER 2 Cuprimine (Penicillamine) Ridaura (Auranofin)


10.3.3 MUSCLE RELAXANTS & ANTISPASMODIC THERAPYTIER 1Baclofen (Lioresal)

Chlorzoxazone (Paraflex) Chlorzoxazone (Parafon Forte DSC) Cyclobenzaprine (Flexeril) Dantrolene Sodium (Dantrium) Methocarbamol (Robaxin) Oxybutynin Chloride (Ditropan) Oxybutynin Chloride (Ditropan XL ql) Tizanidine HCl (Zanaflex)

10.4 Osteoporosis Therapy PREFERRED PRODUCTS

DRUG NAME

TIER 1Alendronate Sodium (Fosamax ql)

Calcitonin, Salmon, Synthetic Aerosol, Spray w/Pump ql (Miacalcin ql) Estradiol ql (Estrace) Estradiol/Norethindrone Acetate (Activella) Estradiol Patch, Transdermal Weekly ql

(Climara 0.025, 0.0375, 0.05, 0.06, 0.075, 0.1mg) Estropipate Tablet ql (Ogen) Ibandronate Sodium (Boniva)

TIER 2 Evista (Raloxifene HCl) Fosamax Plus D ql (Alendronate Sodium Cholecalciferol) Premarin (Estrogens, Conjugated) Vivelle ql (Estradiol Patch, Transdermal Biweekly ql) Vivelle-Dot ql (Estradiol Patch, Transdermal Biweekly ql)






ST Step therapy.

10.1 NSAID Agents PREFERRED PRODUCTS

DRUG NAME


TIER 1Diclofenac Potassium (Cataflam)

Diclofenac Sodium (Voltaren) Diclofenac Sodium (Voltaren XR) Etodolac (Lodine) Etodolac (Lodine XL) Fenoprofen Calcium (Nalfon) Flurbiprofen (Ansaid) Ibuprofen (Children’s Advil) Ibuprofen (Motrin, Rufen) Ibuprofen Suspension, Oral (Children’s Advil) Indomethacin (Indocin) Indomethacin Capsule, Sustained Action (Indocin SR) Ketoprofen (Orudis) Meloxicam (Mobic ql) Nabumetone (Relafen) Naproxen (EC-Naprosyn) Naproxen (Naprosyn) Naproxen Sodium (Anaprox, DS) Oxaprozin (Daypro) Piroxicam ql (Feldene) Sulindac (Clinoril) Tolmetin Sodium (Tolectin) Tolmetin Sodium (Tolectin DS)


10.1.2 SALICYLATESOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Diflunisal ql (Dolobid)

Salsalate (Salflex)

10.2 Gout Therapy PREFERRED PRODUCTS

DRUG NAME

TIER 1Allopurinol (Zyloprim)

Probenecid (Probenecid)

10.3 Other Rheumatologicals PREFERRED PRODUCTS

DRUG NAME

10.3.1 CORTICOSTEROIDSTIER 1Cortisone (Cortone)

Dexamethasone (Decadron) Fludrocortisone Acetate (Florinef Acetate) Hydrocortisone (Hydrocortone) Hydrocortisone Tablet (Cortef) Methylprednisolone Tablet, Dose Pack (Medrol) Prednisolone Sodium Phosphate (Orapred, Pediapred) Prednisolone Syrup (Prelone 15mg/5ml) Prednisone (Meticorten) Prednisone Tablet (Deltasone 50mg)

10. MUSCULOSKELETAL & RHEUMATOLOGY


25

11.2 Oxytocics PREFERRED PRODUCTS

DRUG NAME

TIER 1 Methylergonovine Maleate (Methergine)

11.3 Estrogens & Progestins PREFERRED PRODUCTS

DRUG NAME

11.3.1 PROGESTINSTIER 1

Medroxyprogesterone Acetate ql (Provera) Norethindrone ql (Camila) Norethindrone (Nor-Q-D ql) Norethindrone (Ortho Micronor ql) Norethindrone Acetate ql (Aygestin) Norgestrel (Ovrette ql) Progesterone, Micronized (Prometrium)


11.3.2 ESTROGENSTIER 1

Estradiol ql (Estrace) Estradiol Patch, Transdermal Weekly ql

(Climara 0.025, 0.0375, 0.05, 0.06, 0.075, 0.1mg) Estropipate Tablet ql (Ogen)

TIER 2 Premarin (Estrogens, Conjugated) Premarin ql (Estrogens, Conjugated Cream) Vivelle ql (Estradiol Patch, Transdermal Biweekly ql)


11.3.3 ESTROGEN COMBINATIONSTIER 1

Estradiol/Norethindrone Acetate (Activella) Estrogens, Conjugated/Medroxyprogesterone Acetate (Premphase) Estrogens, Conjugated/Medroxyprogesterone Acetate (Prempro)






ST Step therapy.

11.1 Oral Contraceptives & Related Agents PREFERRED PRODUCTS

DRUG NAME

11.1.1 MONOPHASIC/BIPHASIC/TRIPHASIC AGENTSTIER 1

Desogestrel-Ethinyl Estradiol (Apri, Desogen, Ortho-Cept, Mircette) Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol (Kariva) Ethinyl Estradiol/Drospirenone (Ocella) Ethinyl Estradiol/Drospirenone (Yasmin) Ethynodiol D-Ethinyl Estradiol (Demulen) Ethynodiol D-Ethinyl Estradiol (Zovia) Levonorgestrel (Plan B) Levonorgestrel-Ethinyl Estradiol (Alesse) Levonorgestrel-Ethinyl Estradiol (Levlen) Levonorgestrel-Ethinyl Estradiol (Levlite) Levonorgestrel-Ethinyl Estradiol (Lybrel) Levonorgestrel-Ethinyl Estradiol (Nordette) Levonorgestrel-Ethinyl Estradiol (Seasonale) Levonorgestrel-Ethinyl Estradiol (Tri-Levlen) Levonorgestrel-Ethinyl Estradiol (Triphasil, Trivora) Levonorgestrel-Ethinyl Estradiol (Aviane, Levora) Levonorgestrel-Ethinyl Estradiol/Ethinyl Estradiol (LoSeasonique) Norethindrone A-E Estradiol (Loestrin) Norethindrone A-E Estradiol/Ferrous Fumarate (Estrostep FE) Norethindrone A-E Estradiol/Ferrous Fumarate (Loestrin FE) Norethindrone A-E Estradiol/Ferrous Fumarate (Microgestin FE) Norethindrone-Ethinyl Estradiol (Brevicon, Nelova, Necon, Ovcon, Genora,

Nortrel) Norethindrone-Ethinyl Estradiol (Modicon) Norethindrone-Ethinyl Estradiol (Norinyl) Norethindrone-Ethinyl Estradiol (Ortho-Novum 1-0.035mg) Norethindrone-Ethinyl Estradiol (Ortho-Novum 10/11) Norethindrone-Ethinyl Estradiol (Ortho-Novum 7/7/7) Norethindrone-Mestranol (Norinyl, Nelova, Necon, Genora 1/50) Norethindrone-Mestranol (Ortho-Novum 1-0.05mg) Norgestimate-Ethinyl Estradiol (Ortho-Cyclen) Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen) Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen Lo) Norgestrel-Ethinyl Estradiol (Lo-Ovral) Norgestrel-Ethinyl Estradiol (Low-Ogestrel) Norgestrel-Ethinyl Estradiol (Ogestrel) Norgestrel-Ethinyl Estradiol (Ovral)

TIER 2 Ella (Ulipristal Acetate)


11.1.2 PROGESTIN ONLYTIER 1

Norethindrone ql (Camila) Norethindrone ql (Ortho Micronor) Norgestrel (Ovrette ql)

11. OBSTETRICS & GYNECOLOGY


26






ST Step therapy.

11.4 Miscellaneous OB/GYN PREFERRED PRODUCTS

DRUG NAME

11.4.2 VAGINAL CLEANSER/ANTI-INFECTIVESTIER 1Clindamycin Phosphate Cream with Applicator (Cleocin Phosphate)

Clindamycin Phosphate Suppository, Vaginal (Cleocin Phosphate) Metronidazole (Metrogel)


11.4.3 VAGINAL ANTIFUNGALSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Clotrimazole Cream, Solution, Non-Oral (Lotrimin AF)

Fluconazole (Diflucan) Miconazole (Micatin) Terconazole (Terazol Cream)


11.4.4 SPECIALIZED OB/GYN DRUGSTIER 1Isoxsuprine HCl (Vasodilan)

Terbutaline Sulfate (Brethine) TIER 2

Synarel (Nafarelin Acetate)


11.4.5 DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVESTIER 2

NuvaRing (Etonogestrel-Ethinyl Estradiol)


27

12.7 Non-steroidal Anti-inflammatory Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Bromfenac Sodium (Xibrom)

Diclofenac (Voltaren Drops) Flurbiprofen Sodium (Ocufen) Ketorolac Tromethamine (Acular, Acular LS)

12.8 Vasoconstrictor Decongestants PREFERRED PRODUCTS

DRUG NAME


TIER 1Naphazoline HCl (Albalon, Naphcon)

Phenylephrine HCl (Neo-Synephrine)

12.9 Antibiotics PREFERRED PRODUCTS

DRUG NAME

TIER 1Bacitracin Ointment (Bacitracin)

Ciprofloxacin HCl Drops (Ciloxin) Erythromycin Base (Ilotycin) Gentamicin Sulfate (Garamycin) Levofloxacin Drops (Quixin) Neomycin Sulfate/Gramicidin D/Polymyxin B Drops (Neosporin) Ofloxacin (Ocuflox) Polymyxin B Sulfate/Trimethoprim (Polytrim) Tobramycin Sulfate, Drops ql (Tobrex)

12.10 Sulfonamides PREFERRED PRODUCTS

DRUG NAME

TIER 1Sulfacetamide Sodium (Bleph-10, Sodium Sulamyd)

12.11 Steroids PREFERRED PRODUCTS

DRUG NAME

TIER 1Dexamethasone Sodium Phosphate Drops

Fluorometholone (FML, Flarex) Prednisolone Acetate (Pred Forte) Prednisolone Sodium Phosphate (Inflamase Forte)

12.12 Steroid-antibiotic Combinations PREFERRED PRODUCTS

DRUG NAME

TIER 1Neomycin/Polymyxin B Sulfate/Dexamethasone (Maxitrol)

Neomycin Sulfate/Bacitracin Zinc/Polymyxin B/Hydrocortisone Ointment(Cortisporin)

Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone Suspension, Drops(Cortisporin)

Tobramycin Sulfate/Dexamethasone (TobraDex)






ST Step therapy.

12.1 Beta-blockers PREFERRED PRODUCTS

DRUG NAME

TIER 1Betaxolol HCl ql (Betoptic)

Carteolol HCl (Ocupress) Levobunolol HCl ql (Betagan) Metipranolol (OptiPranolol) Timolol Maleate (Timoptic) Timolol Maleate Gel-Forming Solution (Timoptic-XE)

TIER 2Betimol (Timolol)

Betoptic S ql (Betaxolol HCl)

12.2 Cholinesterase Inhibitor Miotics PREFERRED PRODUCTS

DRUG NAME

TIER 2Phospholine Iodide (Echothiophate Iodide)

12.3 Direct Acting Miotics PREFERRED PRODUCTS

DRUG NAME

TIER 1Pilocarpine HCl (Pilocar 2%) TIER 2Pilopine HS (Pilocarpine HCl)

12.4 Other Glaucoma Drugs PREFERRED PRODUCTS

DRUG NAME

TIER 1Dorzolamide (Trusopt)

Latanoprost (Xalatan ql) Timolol Maleate/Dorzolamide (Cosopt ql)

TIER 2Isopto Carbachol (Carbachol)

Lumigan ql (Bimatoprost)

12.5 Oral Drugs For Glaucoma PREFERRED PRODUCTS

DRUG NAME

TIER 1Acetazolamide (Diamox)

Acetazolamide (Diamox Sequels) Methazolamide (Neptazane)

12.6 Cycloplegic Mydriatics PREFERRED PRODUCTS

DRUG NAME

TIER 1Atropine Sulfate (Isopto Atropine)

Homatropine HBr 5% (Isopto Homatropine) Tropicamide (Mydriacyl)

12. OPHTHALMOLOGY


28






ST Step therapy.

12.13 Steroid-sulfonamide Combinations PREFERRED PRODUCTS

DRUG NAME

TIER 1Sulfacetamide Sodium/Prednisolone Sodium Phosphate (Vasocidin)

12.14 Sympathomimetics PREFERRED PRODUCTS

DRUG NAME

TIER 1Brimonidine Tartrate (Alphagan P)Epinephrine (Epifrin 1%)

12.15 Miscellaneous Ophthalmologics PREFERRED PRODUCTS

DRUG NAME

TIER 1Azelastine HCl (Optivar)

Cromolyn Sodium (Crolom) Epinastine HCl (Elestat)

TIER 2Zaditor OTC (Ketotifen Fumarate)

12.16 Antivirals PREFERRED PRODUCTS

DRUG NAME

TIER 1Trifluridine ql (Viroptic)


29

13.2 Cough & Cold Therapy PREFERRED PRODUCTS

DRUG NAME

13.2.1 ANTITUSSIVE COMBINATIONSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Codeine/Promethazine HCl ql (Phenergan w/Codeine)

Dextromethorphan HB/P-Ephed HCl (Pediatric Cough & Cold) Dextromethorphan HBr/Pseudoephedrine HCl/Brompheniramine

(Bromfed-DM, Rondec-DM) Guaifenesin/Codeine Phosphate ql (Robitussin A-C) Guaifenesin/Dextromethorphan HBr (Duratuss DM) Guaifenesin/Dextromethorphan HBr Tablet, Sustained Release 12hr (Humibid DM) Phenylephrine HCl/Codeine/Promethazine (Phenergan VC w/Codeine) Pseudoephedrine HCl/Codeine/Chlorpheniramine (Novahistine DH)


13.2.2 EXPECTORANT COMBINATIONSOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Guaifenesin Tablet, Sustained Action (Liquibid)

Guaifenesin/Phenylephrine HCl (Sinuvent PE) Guaifenesin/Pseudoephedrine HCl Capsule (Maxifed)


13.2.3 DECONGESTANT/ANTIHISTAMINESOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Loratadine D (Alavert-D OTC)

Pseudoephedrine HCl/Brompheniramine Maleate (Bromfed) Pseudoephedrine HCl/Carbinoxamine Maleate Tablet (Rondec) Pseudoephedrine HCl/Chlorpheniramine Maleate (Deconamine) Pseudoephedrine HCl/Chlorpheniramine Maleate Capsule, Sustained Release 12 hr

(Deconamine SR)






ST Step therapy.

13.1 Antihistamine & Antiallergenic Agents PREFERRED PRODUCTS

DRUG NAME

13.1.1 ANTIHISTAMINESOTC therapeutic equivalents to many PDL medications are covered with a prescription. See page 3 for information on prescribing OTC medications.

TIER 1Azelastine HCl Aerosol, Spray w/Pump (Astelin ql)

Cetirizine HCl (Zyrtec OTC) Clemastine Fumarate (Tavist) Cyproheptadine HCl (Periactin) Dexchlorpheniramine Maleate Syrup (Polaramine) Dexchlorpheniramine Maleate Tablet, Sustained Action (Polaramine) Dexchlorpheniramine Maleate Tablet, Sustained Action (Polaramine Repetab 6mg) Diphenhydramine HCl A (Benadryl) Fexofenadine (Allegra) Hydroxyzine HCl (Atarax) Hydroxyzine Pamoate Capsule (Vistaril A) Loratadine ql (Alavert OTC) Loratadine ql (Loratadine OTC) Promethazine HCl (Phenergan)


13.1.2 ADRENERGICSTIER 2Twinject (Epinephrine)


13.1.3 CORTICOSTEROIDSTIER 1Dexamethasone (Decadron)

Fludrocortisone Acetate (Florinef Acetate) Hydrocortisone (Hydrocortone) Hydrocortisone Tablet (Cortef) Methylprednisolone Tablet, Dose Pack (Medrol) Prednisolone Sodium Phosphate (Orapred, Pediapred) Prednisolone Syrup (Prelone 15mg/5ml) Prednisone (Meticorten) Prednisone Tablet (Deltasone 50mg)

13. RESPIRATORY, ALLERGY COUGH & COLD


30


13.3.5 INTRANASAL STEROIDSTIER 1Flunisolide ql (Nasarel)

Fluticasone Propionate ql (Flonase ql) Triamcinolone Acetonide (Nasacort AQ)

TIER 2Nasonex ql (Mometasone Furoate Spray, Non-Aerosol)


13.3.6 MISCELLANEOUS PULMONARY AGENTSTIER 1Acetylcysteine Vial (Mucomyst)

Cromolyn Sodium Ampul for Nebulization ql (Intal) Montelukast Sodium (Singulair ST ql) Sodium Chloride for Inhalation (Sodium Chloride) Zafirlukast (Accolate ST)

TIER 2Advair Diskus ql

(Fluticasone Propionate/Salmeterol Xinafoate Disk, with Inhalation Device) Advair HFA (Fluticasone Propionate/Salmeterol) Atrovent HFA ql (Ipratropium Bromide) Combivent ql (Ipratropium Bromide/Albuterol Sulfate) Dulera (Mometasone/Formoterol) Intal Inhaler ql (Cromolyn Sodium) Pulmozyme ql (Dornase Alfa Solution, Non-Oral N) Spiriva ql (Tiotropium) Symbicort (Budesonide/Formoterol Fumarate)






ST Step therapy.

13.3 Pulmonary Agents PREFERRED PRODUCTS

DRUG NAME

13.3.1 XANTHINESTIER 1Theophylline Anhydrous Tablet, Sustained Release 12hr (Theo-Dur)


13.3.2 BETA AGONISTS ORALTIER 1Albuterol Sulfate (Proventil, Ventolin)

Albuterol Sulfate (Vospire ER) Metaproterenol Sulfate (Alupent ql) Terbutaline Sulfate (Brethine)


13.3.3 BETA AGONISTS INHALERSTIER 1Albuterol Sulfate (Accuneb)

Metaproterenol Sulfate Solution, Non-Oral ql (Alupent ql)ProAir HFA (Albuterol Sulfate) TIER 2Foradil ql (Formoterol Fumarate)

Serevent Diskus ql (Salmeterol Xinafoate Disk, with Inhalation Device)


13.3.4 INHALED CORTICOSTEROIDSTIER 1Budesonide Ampules (Pulmicort Respules) TIER 2Azmacort ql (Triamcinolone Acetonide Aerosol w/Adapter)

Flovent HFA ql (Fluticasone Propionate Aerosol w/Adapter) Flovent Rotadisk ql (Fluticasone Propionate Disk, with Inhalation Device) Qvar ql (Beclomethasone Dipropionate)


31






ST Step therapy.

14.1 Cholinergic Stimulants PREFERRED PRODUCTS

DRUG NAME

TIER 1Bethanechol Chloride (Urecholine)

14.2 Anticholinergics & Antispasmodics PREFERRED PRODUCTS

DRUG NAME

TIER 1Dicyclomine HCl (Bentyl)

Hyoscyamine Sulfate (Levsin, Levbid) Hyoscyamine Sulfate (Levsin/SL) Hyoscyamine Sulfate Capsule, Sustained Release 12 hr Oxybutynin Chloride (Ditropan) Oxybutynin Chloride (Ditropan XL ql) Tolterodine Tartrate (Detrol) Trospium, tabs (Sanctura, Sanctura XR)

14.3 Urinary Anesthetics PREFERRED PRODUCTS

DRUG NAME

TIER 1Phenazopyridine HCl (Pyridium, Pyridium Plus)

14.4 Miscellaneous Urologicals PREFERRED PRODUCTS

DRUG NAME

TIER 1Citric Acid/Potassium Citrate Packet Solution (Polycitra-K)

Citric Acid/Sodium Citrate (Bicitra) Potassium Citrate Tablet, Sustained Action (Urocit-K) Sodium/Potassium/Potassium Citrate/Sodium Citrate/Citric Acid (Cytra-3)

TIER 2Elmiron (Pentosan Polysulfate Sodium)

14.5 Benign Prostatic Hyperplasia (BPH) Therapy PREFERRED PRODUCTS

DRUG NAME

TIER 1Doxazosin Mesylate (Cardura)

Finasteride ql (Proscar) Tamsulosin HCl (Flomax) Terazosin HCl ql (Hytrin)

14. UROLOGICALS


32


15.2.6 MISCELLANEOUS COAGULATION AGENTSTIER 1Pentoxifylline Tablet, Sustained Action (Trental)

15.3 Electrolytes PREFERRED PRODUCTS

DRUG NAME

15.3.1 POTASSIUMTIER 1Potassium Chloride (K-Dur)

Potassium Chloride Capsule, Sustained Action (Micro-K 8mEq) Potassium Chloride Capsule, Sustained Action (Micro-K 10mEq) Potassium Chloride Liquid (Kay Ciel) Potassium Chloride Packet (K-Lor) Potassium Chloride Tablet, Sustained Action (K-Tab 10mEq) Potassium Chloride Tablet, Sustained Action (Slow-K 8mEq) Potassium Gluconate (Kaon) Potassium Gluconate Elixir (Kaon)


15.3.2 OTHER ELECTROLYTESTIER 1Calcium Acetate (Phoslo)

Calcium Carbonate (Calcium Carbonate) Electrolyte Oral (Electrolyte) Phosphorus, Potassium, Sodium (NeutraPhos) Sodium Bicarbonate






ST Step therapy.

15.1 Vitamins & Hematinics PREFERRED PRODUCTS

DRUG NAME


TIER 1Calcium Carbonate (Calcium Carbonate)

Cyanocobalamin (Vitamin B-12) Ergocalciferol (Calciferol) Ferrous Gluconate (Ferrous Gluconate) Ferrous Sulfate (Ferrous Sulfate) Fluoride Ion/Iron/Vitamins A, C, and D ql (Tri-Vi-Flor w/Iron) Fluoride Ion/Multivitamins ql (Poly-Vi-Flor) Fluoride Ion/Vitamins A, C, and D ql (Tri-Vi-Flor) Folic Acid (Folvite) Multivitamins (Multivitamins) Multivitamins w/Iron (Multivitamins w/Iron) Prenatal Vitamins/Ca/Iron/Folic Acid/DHA (Prenate Essential) Prenatal Vitamins/Iron, Carbonyl/Docusate/Folic Acid (Prenate Advance) Prenatal Vitamins/Iron, Carbonyl/Docusate/Folic Acid (Prenate GT) Prenatal Vitamins/Iron, Carbonyl/Docusate/Folic Acid (Prenate Ultra) Prenatal Vitamins/Iron/Folic Acid (Venatal-FA) Prenatal Vitamins/Iron/Folic Acid/Omega 3 Combo (Duet DHA StuartNatal) PR Natal EC400 Pyridoxine (Vitamin B-6) Sodium Fluoride (Luride) Thiamine (Vitamin B-1) Vitamin A (Aquasol A) Vitamin E (Vitamin E)

15.2 Coagulation Therapy PREFERRED PRODUCTS

DRUG NAME

15.2.1 ANTICOAGULANTSTIER 1

Warfarin Sodium (Coumadin) TIER 2

Coumadin (Warfarin Sodium)


15.2.2 ANTIPLATELET DRUGSTIER 1Cilostazol (Pletal)

Clopidogrel Bisulfate (Plavix) Dipyridamole (Persantine) Ticlopidine HCl (Ticlid)


15.2.3 HEPARINTIER 1Enoxaparin Sodium (Lovenox ql) TIER 2Fragmin Subcutaneous Injection (Dalteparin ql)


15.2.4 VITAMIN KTIER 2Mephyton (Phytonadione)

15. VITAMINS, HEMATINICS & ELECTROLYTES


33






ST Step therapy.

16.1 Miscellaneous Agents PREFERRED PRODUCTS

DRUG NAME

TIER 1Alendronate Sodium (Fosamax ql)

Bacteriostatic Sodium Chloride (Sodium Chloride) Etidronate Disodium (Didronel) Pilocarpine HCl (Salagen) Sodium Chloride 0.9% (Sodium Chloride) Sodium Polystyrene Sulfonate (Kayexalate) Sorbitol (Sorbitol)

TIER 2Renagel ql (Sevelamer HCl)

Rilutek (Riluzole)

16.2 Smoking Deterrents PREFERRED PRODUCTS

DRUG NAME

TIER 1Bupropion HCl ER Tab (Zyban)

Nicotine Gum OTC qd Nicotine Patch OTC qd

TIER 2Chantix (Varenicline Tartrate qd)

16. MISCELLANEOUS


34

AA/T/S ...........................................................................18Acarbose .......................................................................21Accolate ST...................................................................30Accu-Chek, B-D Lancet Device, Lancets,

OneTouch, Softclix, Soft Touch ................................21Accu-Chek, Fast Take, OneTouch, Surestep..................21Accuneb .......................................................................30Accupril........................................................................17Accuretic ......................................................................17Ace Inhibitors ..............................................................17Acebutolol HCl .............................................................16Aceon ...........................................................................17Acetaminophen .............................................................14Acetaminophen/Butalbital ........................................14,15Acetaminophen/Caffeine/Butalbital ...........................14,15Acetazolamide ...............................................................27Acetic Acid ...................................................................20Acetic Acid/Hydrocortisone .............................................20Acetylcysteine Vial .........................................................30Achromycin V ..............................................................11Actigall .........................................................................22Actimmune ..................................................................23Activella...................................................................24,25Actoplus Met XR ql .....................................................21Actos ql ........................................................................21Acular, Acular LS..........................................................27Acyclovir Ointment .......................................................18Adalat CC ....................................................................17Adapalene ....................................................................18Adjunctive Agents.........................................................13Adrenal Hormones .......................................................21Adrenergic Antagonists & Related Drugs .....................17Adrenergics ..................................................................29Advair Diskus ql...........................................................30Advair HFA..................................................................30Advil.............................................................................14Alavert OTC ................................................................29Alavert-D OTC ............................................................29Albalon, Naphcon ........................................................27Albuterol Sulfate ...........................................................30Aldactazide 25-25mg....................................................16Aldactone .....................................................................16Aldara...........................................................................19Aldomet .......................................................................17Aldoril ..........................................................................17Alendronate Sodium .................................................24,33Alendronate Sodium Cholecalciferol ...............................24Alesse............................................................................25Aleve ............................................................................14Aliskiren Hemifumarate ................................................17Alkeran.........................................................................13Alkylating Agents ........................................................13Allegra ..........................................................................29Allopurinol ...................................................................24Alphagan P...................................................................28Altace ...........................................................................17Altretamine ..................................................................13Alupent ql ....................................................................30Amantadine HCl Syrup ................................................15Amaryl .........................................................................21Amerge ql qd ...............................................................15Amiloride HCl .............................................................16Amiloride HCl/Hydrochlorothiazide ..............................16Amiodarone HCl ..........................................................16Amlactin ql ..................................................................19Amlodipine Besylate ......................................................17Amlodipine Besylate/Benzapril .......................................17Ammonium Lactate Cream ql .......................................19Ammonium Lactate OTC ............................................19Amoxicillin Trihydrate ..................................................11Amoxicillin Trihydrate Suspension ..................................11Amoxicillin Trihydrate/Potassium

Clavulanate ql ..........................................................11Amoxil .........................................................................11Amoxil Pediatric Drops ................................................11Amylase/Lipase/Protease .................................................22Amylase/Lipase/Protease 5000 units ................................22Analpram-HC ..............................................................22Anaprox 275, 550 mg...................................................14Anaprox, DS.................................................................24Anaprox, DS, Aleve ......................................................14Anastrozole ...................................................................13Ancobon.......................................................................11Androderm...................................................................21Androgel.......................................................................21Androgens ...................................................................21Androgens, Estrogens, Hormones & Related

Drugs .......................................................................13Angiotensin II Receptor Blockers .................................17Ansaid .....................................................................14,24Anthralin .....................................................................19Anthralin 1% ...............................................................19Antiandrogens .............................................................13

Antiarrhythmic Agents .................................................16Antibiotics....................................................................27Anticholinergics & Antispasmodics ..............................31Anticoagulants ........................................................16,32Anticonvulsants ............................................................15Antidepressant Agents .................................................15Antidiarrheals ..............................................................22Antidiarrheals & Antispasmodics..................................22Antiestrogens ...............................................................13Antifungal Agents.........................................................11Antihistamine & Antiallergenic Agents.........................29Antihistamines .............................................................29Antihypertensive Therapy.............................................16Antimalarials ...............................................................12Antimetabolites ...........................................................13Antimycobacterials ......................................................12Antineoplastic & Immunosuppressant Drugs ...............13Antiparasitics ...............................................................12Antiparkinsonism Agents..............................................15Antiplatelet Drugs ..................................................16,32Antipsoriatic/Antiseborrheic .........................................19Antipsychotics .............................................................15Antipyrine/Benzocaine/Glycerin .....................................20Antispasmodics ............................................................22Antithyroid Agents .......................................................21Antitussive Combinations ............................................29Antivert 12.5, 25mg OTC.......................................15,22Antivertigo & Antiemetic Agents .................................22Antivertigo & Antiemetic Drugs .................................15Antivirals .................................................................11,28Anxiolytics ...................................................................15Apidra ..........................................................................21Apresoline.....................................................................17Apri ..............................................................................25Aquasol A .....................................................................32Aralen Phosphate..........................................................12Arava ql........................................................................24Aricept ql .....................................................................15Arimidex ......................................................................13Aristocort 0.03, 0.10%.................................................18Armour Thyroid ...........................................................21Aromasin......................................................................13Artane ..........................................................................15Asacol ...........................................................................22Ascriptin A/D...............................................................14Aspirin .........................................................................14Aspirin Enteric Coated ..................................................14Aspirin OTC ................................................................14Aspirin/Caffeine/Butalbital .......................................14,15Astelin ql.................................................................20,29Atacand HCT ..............................................................17Atarax...........................................................................29Atenolol ........................................................................16Atenolol/Chlorthalidone ................................................17Atorvastatin Calcium ....................................................17Atovaquone/Proguanil ...................................................12Atropine Sulfate ............................................................27Atrovent HFA ql ..........................................................30Augmentin 200, 400mg Suspension, 500,

875mg Tablet, Augmentin ES ...................................11Auralgan.......................................................................20Auranofin .....................................................................24Avandia ql ....................................................................21Avapro..........................................................................17Aviane, Levora ..............................................................25Avonex Administration Pack ql N.................................23Aygestin........................................................................25Azathioprine ............................................................13,24Azelastine (spray/drops) .................................................20Azelastine HCl .............................................................28Azelastine HCl Aerosol, Spray w/Pump ..........................29Azithromycin ................................................................11Azmacort ql .................................................................30Azulfidine................................................................22,24

BBacitracin .....................................................................27Bacitracin Ointment .....................................................27Baclofen ..................................................................15,24Bacteriostatic Sodium Chloride ......................................33Bactrim, DS .................................................................11Bactroban .....................................................................18Balsalazide ...................................................................22Beclomethasone Dipropionate ........................................30Benadryl ..................................................................15,29Benazepril ....................................................................17Benazepril/HCTZ (tab/caps) .........................................17Benign Prostatic Hyperplasia (BPH) Therapy ...............31Bentyl......................................................................22,31Benzaclin......................................................................18Benzamycin ..................................................................18Benzoyl Peroxide ...........................................................18Benzoyl Peroxide OTC .................................................18

Benzoyl Peroxide/Urea, Pads, Gel, Cleanser,Cream .......................................................................18

Benztropine Mesylate ....................................................15Benzyl Alcohol Lotion 5% .............................................19Beta Agonists Inhalers ..................................................30Beta Agonists Oral .......................................................30Beta Blockers ...............................................................16Beta-blockers ................................................................27Betagan ........................................................................27Betamethasone Dipropionate .........................................18Betamethasone Dipropionate Ointment ..........................18Betamethasone Dipropionate/Propylene

Glycol Ointment ........................................................18Betamethasone Valerate .................................................18Betamethasone Valerate Ointment ..................................18Betapace .......................................................................16Betapace, Betapace AF..................................................16Betaseron......................................................................23Betaxolol ......................................................................16Betaxolol HCl ...............................................................27Betaxolol HCl ql ..........................................................27Bethanechol Chloride ....................................................31Betimol ........................................................................27Betoptic........................................................................27Betoptic S ql ................................................................27Biaxin, Biaxin XL .........................................................11Bicalutamide ................................................................13Bicitra...........................................................................31Bile Acids ....................................................................22Bimatoprost ..................................................................27Biotechnology Drugs ....................................................23Bisacodyl ......................................................................22Bisacodyl OTC.............................................................22Bisoprolol .....................................................................16Bisoprolol Fumarate/HCTZ ...........................................17Bleph-10, Sodium Sulamyd..........................................27Blocadren .....................................................................16Blood Glucose Monitoring Devices &

Supplies ....................................................................21Blood Sugar Diagnostic Strip .........................................21Boniva ..........................................................................24Bowel Evacuants ..........................................................22Brethine...................................................................26,30Brevicon .......................................................................25Brimonidine Tartrate ....................................................28Bromfed .......................................................................29Bromfed-DM ...............................................................29Bromfenac Sodium ........................................................27Bromocriptine Mesylate .................................................15Budesonide ...................................................................22Budesonide Ampules ......................................................30Budesonide/Formoterol Fumarate ...................................30Bumetanide ..................................................................16Bumex..........................................................................16Bupropion HCl ER Tab .................................................33Burn Therapy ...............................................................18Busulfan .......................................................................13Butorphanol Tartrate Aerosol, Spray ql ...........................14Butyrophenones ..........................................................15

CCabergoline ..................................................................21Cafergot Tabs ...............................................................15Calamine .....................................................................19Calamine OTC.............................................................19Calan, SR .....................................................................17Calciferol......................................................................32Calcipotriene ................................................................19Calcitonin, Salmon, Synthetic Aerosol,

Spray w/Pump ql ..................................................21,24Calcitonin, Salmon, Synthetic ql ...................................21Calcitriol Capsule .........................................................21Calcium Acetate ............................................................32Calcium Carbonate ......................................................32Calcium Carbonate .......................................................32Calcium Channel Blockers ..........................................17Calcium Channel Blockers/Dihydropyridines...............17Calcium Channel Blockers/

Non-Dihydropyridines .............................................17Camila..........................................................................25Candesartan/HCTZ .....................................................17Capoten........................................................................17Capozide ......................................................................17Capsaicin .....................................................................19Captopril ......................................................................17Captopril/Hydrochlorothiazide .......................................17Carafate........................................................................22Carbachol .....................................................................27Carbidopa/Levodopa .....................................................15Carbidopa/Levodopa Tablet, Sustained Action ................15Cardiac Glycosides .......................................................16Cardizem......................................................................17Cardizem CD 120, 180, 240, 300mg ...........................17

INDEX


35

Cardizem LA ................................................................17Cardizem SR ................................................................17Cardura ...................................................................17,31Carteolol HCl ...............................................................27Cartridges.....................................................................21Carvedilol ....................................................................16Casodex........................................................................13Cataflam..................................................................14,24Catapres .......................................................................17Catapres-TTS ql ..........................................................17Ceclor...........................................................................11Ceclor CD....................................................................11CeeNu..........................................................................13Cefaclor ........................................................................11Cefaclor Extended Release ql .........................................11Cefadroxil ....................................................................11Cefalexin Monohydrate .................................................11Cefdinir ql ...................................................................11Cefpodoxime .................................................................11Cefprozil ......................................................................11Ceftin Tablet, Suspension .............................................11Cefuroxime Axetil .........................................................11Cefzil............................................................................11CellCept.......................................................................13Cephalosporins.............................................................11Cephulac ......................................................................22Cetirizine HCl .............................................................29Cetraxal ........................................................................20Chantix ........................................................................33Children’s Advil .......................................................14,24Chlorambucil ...............................................................13Chlorhexidine Gluconate ...............................................20Chloroquine Phosphate ..................................................12Chlorothiazide Tablet ....................................................16Chlorpropamide ............................................................21Chlorthalidone .............................................................16Chlorzoxazone .........................................................15,24Cholestyramine/Aspartame .............................................17Cholestyramine/Sucrose ..................................................17Choline Sal/MagnesiumSalicylate ...................................14Cholinergic Stimulants .................................................31Cholinesterase Inhibitor Miotics...................................27Chronulac ....................................................................22Cilostazol ................................................................16,32Ciloxin .........................................................................27Cimetidine 200mg ........................................................22Cimetidine HCl Liquid ................................................22Cimetidine OTC ..........................................................22Cimetidine Tablet .........................................................22Cipro............................................................................11Cipro XR......................................................................11Ciprodex ......................................................................20Ciprofloxacin ................................................................20Ciprofloxacin ER ..........................................................11Ciprofloxacin HCl ........................................................11Ciprofloxacin HCl Drops ..............................................27Ciprofloxacin HCl/Dexamethasone ................................20Citric Acid/Potassium Citrate Packet

Solution ....................................................................31Citric Acid/Sodium Citrate ............................................31Clarithromycin .............................................................11Clemastine Fumarate ....................................................29Cleocin HCl 150, 300mg.............................................12Cleocin Phosphate........................................................26Cleocin T .....................................................................18Climara 0.025, 0.0375, 0.05, 0.06, 0.075,

0.1mg...................................................................24,25Clindamycin HCl .........................................................12Clindamycin Phosphate .................................................18Clindamycin Phosphate Cream with

Applicator .................................................................26Clindamycin Phosphate Suppository, Vaginal ...................26Clindamycin Phosphate/Benzoyl Peroxide .......................18Clinoril....................................................................14,24Clobetasol Propionate ql ...............................................18Clobex..........................................................................18Clonidine HCl .............................................................17Clonidine HCl Patch, Transdermal Weekly .....................17Clopidogrel Bisulfate ................................................16,32Clotrimazole .................................................................18Clotrimazole Cream, Solution, Non-Oral .......................26Clotrimazole OTC .......................................................18Clotrimazole Troche ......................................................11Clotrimazole/Betamethasone Dipropionate

Cream ql ..................................................................18Coagulation Therapy...............................................16,32Codeine Phosphate/Acetaminophen ................................14Codeine Phosphate/Aspirin/Caffeine/

Butalbital ..................................................................14Codeine Sulfate ............................................................14Codeine Sulfate .............................................................14Codeine/Promethazine HCl ql ......................................29Cogentin ......................................................................15Colace OTC.................................................................22Colazal .........................................................................22Colestid ........................................................................17

Colestipol ......................................................................17Colocort .......................................................................22Colyte...........................................................................22Combination Narcotic/Analgesics ...............................14Combivent ql ...............................................................30Combunox ...................................................................14Compazine ..............................................................15,22Comtan ........................................................................15Condylox......................................................................19Copaxone ql N .............................................................23Coreg ...........................................................................16Corgard ........................................................................16Cortef......................................................................24,29Cortef 5mg, 10mg, 20mg.............................................21Cortenema ...................................................................22Corticosteroids .......................................................24,29Cortisone ......................................................................24Cortisporin..............................................................20,27Cortone........................................................................24Cosopt ql .....................................................................27Cough & Cold Therapy ...............................................29Coumadin ...............................................................16,32Cozaar qd ....................................................................17Creon ...........................................................................22Crolom.........................................................................28Cromolyn Sodium ...............................................22,28,30Cromolyn Sodium Ampul for Nebulization ql .................30Crotamiton ...................................................................19Cuprimine....................................................................24Cutivate........................................................................18Cyanocobalamin ...........................................................32Cyclobenzaprine .......................................................15,24Cyclophosphamide .........................................................13Cycloplegic Mydriatics .................................................27Cyclosporine ..................................................................13Cyclosporine, Modified ..................................................13Cyproheptadine HCl .....................................................29Cytomel .......................................................................21Cytotec.........................................................................22Cytoxan........................................................................13Cytra-3 .........................................................................31

DD.H.E.45 .....................................................................15Dalteparin ql ..........................................................16,32Danazol .......................................................................21Danocrine ....................................................................21Dantrium ................................................................15,24Dantrolene Sodium ..................................................15,24Dapsone .......................................................................12Dapsone .......................................................................12Daraprim......................................................................12Daypro ....................................................................14,24DDAVP and Tablet ......................................................21Decadron............................................................21,24,29Deconamine .................................................................29Deconamine SR ...........................................................29Decongestant/Antihistamines ......................................29Deltasone 50mg .................................................21,24,29Demadex ......................................................................16Demerol .......................................................................14Demulen ......................................................................25Derma-Smoothe FS......................................................18Dermotic......................................................................20Desmopressin Acetate Solution, Non-Oral ql ...................21Desogen .......................................................................25Desogestrel-Ethinyl Estradiol ..........................................25Desogestrel-Ethinyl Estradiol/Ethinyl

Estradiol ...................................................................25Desoximetasone .............................................................18Desoximetasone Cream ..................................................18Detrol...........................................................................31Dexamethasone ...................................................21,24,29Dexamethasone Sodium Phosphate Drops .......................27Dexchlorpheniramine Maleate Syrup ..............................29Dexchlorpheniramine Maleate Tablet,

Sustained Action ........................................................29Dextromethorphan HB/P-Ephed HCl ............................29Dextromethorphan HBr/Pseudoephedrine HCl/

Brompheniramine ......................................................29DiaBeta ........................................................................21Diabetes Supplies, Miscellaneous ....................................21Diabetes Therapy..........................................................21Diabinese .....................................................................21Diamox ........................................................................27Diamox Sequels ............................................................27Diaphragms And Other Non-Oral

Contraceptives .........................................................26Diazepam ....................................................................15Dibucaine Ointment OTC ............................................18Diclofenac ....................................................................27Diclofenac Potassium ................................................14,24Diclofenac Sodium ...................................................14,24Diclofenac Sodium XR ..................................................14Dicloxacillin Sodium Capsule ........................................11

Dicyclomine ..................................................................22Dicyclomine HCl ..........................................................31Didronel.......................................................................33Differin ........................................................................18Diflorasone ...................................................................18Diflorasone Diacetate ....................................................18Diflucan .......................................................................26Diflucan 50, 100, 150, 200mg ql N .............................11Diflunisal 500mg ql .....................................................14Diflunisal ql ................................................................24Digestive Enzymes .......................................................22Digoxin Tablet ..............................................................16Dihydroergotamine Mesylate ..........................................15Dilaudid .......................................................................14Diltiazem HCl .............................................................17Diltiazem HCl Capsule, Sustained Release

12 hr ........................................................................17Diltiazem HCl Capsule, Sustained Release

24 hr ........................................................................17Diltiazem LA ...............................................................17Diovan HCT qd ..........................................................17Diovan qd....................................................................17Diphenhydramine HCl A .........................................15,29Diphenoxylate HCl/Atropine Sulfate ..............................22Diprolene 0.05%..........................................................18Diprosone 0.05% .........................................................18Dipyridamole ..........................................................16,32Direct Acting Miotics ...................................................27Disopyramide Phosphate Capsule ...................................16Disopyramide Phosphate Capsule, Sustained

Action .......................................................................16Ditropan ............................................................15,24,31Ditropan XL ql ..................................................15,24,31Diuril ...........................................................................16Docusate Calcium .........................................................22Docusate Sodium ..........................................................22Dofetilide .....................................................................16Dolobid........................................................................24Dolobid 500mg............................................................14Dolophine HCl ............................................................14Donepezil HCl .............................................................15Dornase Alfa Solution, Non-Oral N ...............................30Dorzolamide .................................................................27Dostinex.......................................................................21Dovonex.......................................................................19Doxazosin Mesylate ..................................................17,31Doxycycline Hyclate ......................................................11Drithocreme.................................................................19Droxia ..........................................................................13Duac ............................................................................18Duet DHA StuartNatal ................................................32Dulera ..........................................................................30Duragesic .....................................................................14Duratuss DM ...............................................................29Duricef Tablet, Capsule, Suspension .............................11Dyazide ........................................................................16Dynacin .......................................................................11Dynapen ......................................................................11

EE-Mycin .......................................................................11E.E.S. ...........................................................................11EC-Naprosyn ..........................................................14,24Echothiophate Iodide .....................................................27Econazole Nitrate ..........................................................18Ecotrin .........................................................................14Efudex ..........................................................................19Eldepryl........................................................................15Electrolyte ....................................................................32Electrolyte Oral .............................................................32Electrolytes ...................................................................32Elestat...........................................................................28Eletriptan .....................................................................15Elidel qd N...................................................................19Elimite..........................................................................19Ella ...............................................................................25Elmiron ........................................................................31Elocon 0.10%...............................................................18Emcyt...........................................................................13Emgel ...........................................................................18Emla.............................................................................18Enalapril ......................................................................17Enalapril Maleate/Hydrochlorothiazide ..........................17Enduron .......................................................................16Enoxaparin Sodium .................................................16,32Entacapone ...................................................................15Entocort EC.................................................................22Epifrin 1% ...................................................................28Epinastine HCl .............................................................28Epinephrine .............................................................28,29Eplerenone ....................................................................16Epoetin Alfa N ..............................................................23Epogen qd ...................................................................23Eprosartan 600mg ........................................................17Ergocalciferol ................................................................32


36

Ergomar .......................................................................15Ergotamine Tartrate ......................................................15Ergotamine Tartrate/Caffeine .........................................15Erycette ........................................................................18Erygel ...........................................................................18Erythrocin Stearate .......................................................11Erythroid Stimulants ...................................................23Erythromycin Base ........................................................27Erythromycin Base Tablet, Enteric Coated .......................11Erythromycin Base/Benzoyl Peroxide ...............................18Erythromycin Base/Ethyl Alcohol ....................................18Erythromycin Base/Ethyl Alcohol Gel ..............................18Erythromycin Base/Ethyl Alcohol Solution,

Non-Oral ..................................................................18Erythromycin Base/Ethyl Alcohol Swab,

Medicated .................................................................18Erythromycin Ethylsuccinate ..........................................11Erythromycin Ethylsuccinate/Sulfisoxazole

Acetyl ........................................................................11Erythromycin Stearate ...................................................11Erythromycins & Other Macrolides .............................11Estrace.....................................................................24,25Estradiol Patch, Transdermal Biweekly ql ...................24,25Estradiol Patch, Transdermal Weekly ql .....................24,25Estradiol ql .............................................................24,25Estradiol/Norethindrone Acetate ................................24,25Estramustine Phosphate Sodium .....................................13Estrogen Combinations ...............................................25Estrogens .....................................................................25Estrogens & Progestins .................................................25Estrogens, Conjugated ...............................................24,25Estrogens, Conjugated Cream .........................................25Estrogens, Conjugated/Medroxyprogesterone

Acetate ......................................................................25Estropipate Tablet ql ................................................24,25Estrostep FE .................................................................25Ethambutol HCl ...........................................................12Ethinyl Estradiol/Drospirenone ......................................25Ethynodiol D-Ethinyl Estradiol ......................................25Etidronate Disodium .....................................................33Etodolac ..................................................................14,24Etodolac XR ..................................................................14Etonogestrel-Ethinyl Estradiol ........................................26Etoposide ......................................................................13Eulexin .........................................................................13Eurax............................................................................19Evista............................................................................24Exelon ql......................................................................15Exemestane ...................................................................13Expectorant Combinations ..........................................29

FFamotidine ...................................................................22Feldene ....................................................................14,24Felodipine ql ................................................................17Femara .........................................................................13Fenofibrate, Micronized ................................................17Fenofibric Acid .............................................................17Fenoprofen Calcium ......................................................24Fenoprofen Calcium Tablet ............................................14Fentanyl Patch ..............................................................14Ferrous Gluconate ........................................................32Ferrous Gluconate .........................................................32Ferrous Sulfate..............................................................32Ferrous Sulfate ..............................................................32Fexofenadine .................................................................29Fibricor.........................................................................17Filgrastim N .................................................................23Finasteride ql ..............................................................31Fioricet ....................................................................14,15Fiorinal....................................................................14,15Fiorinal w/Codeine 30mg.............................................14First Generation Cephalosporins .................................11First-Lansoprazole Suspension ........................................22First-Omeprazole Suspension .........................................22Flagyl............................................................................12Flarex............................................................................27Flecainide Acetate .........................................................16Flexeril.....................................................................15,24Flomax .........................................................................31Flonase ql................................................................20,30Florinef Acetate ..................................................21,24,29Flovent HFA ql ............................................................30Flovent Rotadisk ql ......................................................30Floxin ...........................................................................11Floxin OTIC ................................................................20Fluconazole ..................................................................26Fluconazole N ...............................................................11Flucytosine ....................................................................11Fludrocortisone Acetate ........................................21,24,29Flunisolide ql ...............................................................30Flunisolide Spray ..........................................................20Fluocinolone Acetonide ..................................................18Fluocinolone Acetonide Cream, Ointment ql ...................18Fluocinolone Acetonide Oil ............................................20

Fluocinolone Acetonide Solution, Non-Oral .....................18Fluocinonide Cream ......................................................18Fluocinonide/Emollient Cream, Ointment ......................18Fluoride Ion/Iron/Vitamins A, C, and D ql.....................32Fluoride Ion/Multivitamins ql .......................................32Fluoride Ion/Vitamins A, C, and D ql ...........................32Fluorometholone ...........................................................27Fluoroquinolones ........................................................11Fluorouracil (all forms, topical) ......................................19Flurbiprofen ............................................................14,24Flurbiprofen Sodium .....................................................27Flutamide .....................................................................13Fluticasone Propionate ..................................................18Fluticasone Propionate Aerosol w/Adapter........................30Fluticasone Propionate Aerosol, Spray .............................20Fluticasone Propionate Disk, with

Inhalation Device ......................................................30Fluticasone Propionate ql ..............................................30Fluticasone Propionate/Salmeterol ..................................30Fluticasone Propionate/Salmeterol

Xinafoate Disk, with Inhalation Device ......................30FML.............................................................................27Folic Acid .....................................................................32Folvite ..........................................................................32Foradil ql .....................................................................30Formoterol Fumarate .....................................................30Fosamax Plus D ql .......................................................24Fosamax ql ..............................................................24,33Fosinopril Sodium .........................................................17Fosinopril/HCTZ (tab/caps) ..........................................17Fragmin Subcutaneous Injection..............................16,32Furadantin....................................................................11Furosemide ...................................................................16

GGalantamine ................................................................15Garamycin...............................................................18,27Gastrocrom ..................................................................22Gastrosed......................................................................22Gemfibrozil ..................................................................17Gengraf ........................................................................13Genora .........................................................................25Genora 1/50 .................................................................25Gentamicin Sulfate ..................................................18,27Glatiramer Acetate ........................................................23Gleevec ql N ................................................................13Glimepiride ..................................................................21Glipizide ......................................................................21Glipizide Extended Release Tablet ..................................21Glipizide/Metformin .....................................................21Glucagon Emergency Kit ql .........................................21Glucagon Kit ql ............................................................21Glucophage ..................................................................21Glucophage XR ............................................................21Glucose Elevating Agents .............................................21Glucotrol......................................................................21Glucotrol XL ................................................................21Glucovance...................................................................21Glyburide .....................................................................21Glyburide, Micronized ..................................................21Glyburide/Metformin ....................................................21Glycopyrrolate ...............................................................22Glynase.........................................................................21GoLYTELY ..................................................................22Gout Therapy...............................................................24Granisetron HCl ......................................................15,22Granulex, Granulsol .....................................................18Gris-Peg........................................................................11Griseofulvin Ultramicrosize ...........................................11Growth Hormones ......................................................23Guaifenesin Tablet, Sustained Action ..............................29Guaifenesin/Codeine Phosphate ql .................................29Guaifenesin/Dextromethorphan HBr ..............................29Guaifenesin/Dextromethorphan HBr Tablet,

Sustained Release 12hr ...............................................29Guaifenesin/Phenylephrine HCl .....................................29Guaifenesin/Pseudoephedrine HCl Capsule .....................29Guanfacine HCl ...........................................................17

HH2 Antagonists ...........................................................22Headache Therapy .......................................................15Heparin ..................................................................16,32Heparin .......................................................................16Heparin Inj. Syringe .....................................................16Hexalen ........................................................................13HIV/AIDS Therapy ....................................................11Homatropine HBr 5% ..................................................27Hormones ...................................................................13Humalog Vials..............................................................21Humatrope qd N .........................................................23Humibid DM...............................................................29Humulin Vials..............................................................21Hycet............................................................................14Hydralazine HCl ..........................................................17

Hydrea .........................................................................13Hydrochlorothiazide ......................................................16Hydrocodone Bit/Acetaminophen ...................................14Hydrocortisone.............................................................22Hydrocortisone ...............................................21,22,24,29Hydrocortisone Acetate ..................................................22Hydrocortisone Butyrate ................................................18Hydrocortisone Cream, Ointment ..................................18Hydrocortisone Lotion ...................................................18Hydrocortisone OTC .....................................................18Hydrocortisone Tablet ..........................................21,24,29Hydrocortisone Valerate Cream, Ointment ......................18Hydrocortisone-Pramoxine Cream ..................................19Hydrocortisone/Pramoxine .............................................22Hydrocortone.....................................................21,24,29HydroDIURIL .............................................................16Hydromorphone HCl ....................................................14Hydroxychloroquine Sulfate ......................................12,24Hydroxyurea .................................................................13Hydroxyzine HCl ..........................................................29Hydroxyzine Pamoate Capsule .......................................29Hygroton......................................................................16Hyoscyamine Sulfate .................................................22,31Hyoscyamine Sulfate Capsule, Sustained

Release 12 hr ........................................................22,31Hyoscyamine Sulfate Drops ............................................22Hypnotic Agents ..........................................................15Hytone 2.50%..............................................................18Hytrin .....................................................................17,31Hyzaar qd ....................................................................17

IIbandronate Sodium .....................................................24Ibuprofen ................................................................14,24Ibuprofen Suspension, Oral ............................................24Ibuprofen Suspension, Oral (Final Dose Form) ...............14Ilotycin.........................................................................27Imatinib Mesylate .........................................................13Imdur ...........................................................................16Imiquimod N ...............................................................19Imitrex ql qd ...............................................................15Immunosuppressant Drugs ..........................................13Imodium AD OTC ......................................................22Imuran ....................................................................13,24Indapamide ..................................................................16Inderal..........................................................................16Inderide........................................................................17Indocin....................................................................14,24Indocin SR ..............................................................14,24Indomethacin ..........................................................14,24Indomethacin Capsule, Sustained Action ...................14,24Inflamase Forte.............................................................27Inhaled Corticosteroids ................................................30Inspra ...........................................................................16Insulin Detemir Vial .....................................................21Insulin Glargine, Human Recombinant Analog ...............21Insulin Glulisine Vial ....................................................21Insulin Syringes/Miscellaneous Durable

Medical Equipment ..................................................21Insulin Therapy ...........................................................21Intal..............................................................................30Intal Inhaler ql .............................................................30Interferon Alfa-2b, Recombinant Kit, Vial.......................23Interferon Beta-1A/Albumin Human .............................23Interferon Beta-1B ........................................................23Interferon Gamma-1b, Recombinant ..............................23Interferons ...................................................................23Interleukins .................................................................23Intranasal Steroids ...................................................20,30Intron A N....................................................................23Ipratropium Bromide ....................................................30Ipratropium Bromide/Albuterol Sulfate ...........................30Irbesartan .....................................................................17ISMO...........................................................................16Isoniazid .......................................................................12Isoniazid ......................................................................12Isopto Atropine ............................................................27Isopto Carbachol ..........................................................27Isopto Homatropine .....................................................27Isorbide Tembid............................................................16Isordil 2.5, 5mg ............................................................16Isordil 5, 10, 20, 30mg .................................................16Isosorbide Dinitrate Tablet .............................................16Isosorbide Dinitrate Tablet, Sublingual ...........................16Isosorbide Dinitrate Tablet, Sustained

Action .......................................................................16Isosorbide Mononitrate ..................................................16Isosorbide Mononitrate Tablet, Sustained

Release 24hr ..............................................................16Isoxsuprine HCl ............................................................26Itraconazole ..................................................................11

JJanumet........................................................................21Januvia .........................................................................21


37

KK-Dur ..........................................................................32K-Lor ...........................................................................32K-Tab 10mEq...............................................................32Kaon ............................................................................32Kariva...........................................................................25Kay Ciel .......................................................................32Kayexalate ....................................................................33Keflex ...........................................................................11Kenalog 0.03, 0.10%....................................................18Kenalog in Orabase ......................................................20Kerlone.........................................................................16Ketoconazole Cream ql ..................................................18Ketoconazole ql .......................................................11,18Ketoprofen ...............................................................14,24Ketorolac Tromethamine ................................................27Ketotifen Fumarate .......................................................28Klaron ..........................................................................18Kuvan N .......................................................................21Kytril qd .................................................................15,22

LLabetalol HCl ..............................................................16Lac-Hydrin...................................................................19Lactulose ql ..................................................................22Lamisil qd N ................................................................11Lanoxin ........................................................................16Lansoprazole.................................................................22Lantus ..........................................................................21Lapatinib .....................................................................13Lariam..........................................................................12Lasix .............................................................................16Latanoprost ..................................................................27Leflunomide .................................................................24Letrozole .......................................................................13Leucovorin ...................................................................13Leucovorin Calcium ......................................................13Leukeran ......................................................................13Leukine ........................................................................23Levaquin.......................................................................11Levbid .....................................................................22,31Levemir ........................................................................21Levlen...........................................................................25Levlite ..........................................................................25Levobunolol HCl ql ......................................................27Levofloxacin .................................................................11Levofloxacin Drops ........................................................27Levonorgestrel ...............................................................25Levonorgestrel-Ethinyl Estradiol .....................................25Levonorgestrel-Ethinyl Estradiol/Ethinyl

Estradiol ...................................................................25Levothyroxine Sodium ...................................................21Levoxyl .........................................................................21Levsin, .....................................................................22,31Levsin/SL ................................................................22,31Levsinex........................................................................22Lice Treatment OTC .....................................................19Lidex 0.05%, Gel, Solution, Ointment.........................18Lidex-E 0.05% .............................................................18Lidocaine HCl Jel ....................................................18,20Lidocaine HCl Ointment Solution .................................18Lidocaine Solution ........................................................20Lidocaine/Prilocaine ......................................................18Lindane ........................................................................19Lindane .......................................................................19Lioresal ....................................................................15,24Liothyronine Sodium .....................................................21Lipid/Cholesterol Lowering Agents ..............................17Lipitor ql qd ................................................................17Liquibid .......................................................................29Lisinopril ql .................................................................17Lisinopril/Hydrochlorothiazide .......................................17Lo-Ovral.......................................................................25Locoid ..........................................................................18Lodine.....................................................................14,24Lodine XL ...............................................................14,24Loestrin ........................................................................25Loestrin FE...................................................................25Lofibra..........................................................................17Lomotil ........................................................................22Lomustine ....................................................................13Long Acting Nitrates ...................................................16Loniten.........................................................................17Loperamide ..................................................................22Lopid............................................................................17Lopressor ......................................................................16Lopressor HCT ............................................................17Loratadine D ................................................................29Loratadine OTC...........................................................29Loratadine ql ...............................................................29Losartan .......................................................................17Losartan/Hydrochlorothiazide ........................................17LoSeasonique................................................................25Lotensin .......................................................................17Lotrel............................................................................17

Lotrimin AF .................................................................26Lotrisone ......................................................................18Lovastatin ql ................................................................17Lovenox ql ..............................................................16,32Low-Ogestrel ................................................................25Lozol ............................................................................16Lumigan ql ..................................................................27Luride...........................................................................32Lybrel ...........................................................................25Lysodren.......................................................................13

MMacroBid .....................................................................11Macrodantin 50, 100mg...............................................11Mag-Ox OTC ..............................................................22Magnesium Hydroxide ..................................................22Magnesium Oxide .........................................................22Malarone ......................................................................12Malathion ....................................................................19Mandelamine ...............................................................11Maoi Inhibitors ...........................................................15Matulane ......................................................................13Mavik...........................................................................17Maxalt, MLT ql qd ......................................................15Maxifed ........................................................................29Maxitrol .......................................................................27Maxivate 0.05% ...........................................................18Maxzide........................................................................16Mebendazole ................................................................12Meclizine HCl Tablet ...............................................15,22Medrol ...............................................................21,24,29Medroxyprogesterone Acetate ql .....................................25Mefloquine HCl ql .......................................................12Megace .........................................................................13Megestrol Acetate ..........................................................13Meloxicam ...............................................................14,24Melphalan ....................................................................13Meperidine HCl ...........................................................14Mephyton................................................................16,32Mercaptopurine ............................................................13Mesalamine ..................................................................22Mesalamine Enema .......................................................22Mesna ..........................................................................13Mesnex .........................................................................13Mestinon ......................................................................15Metaglip .......................................................................21Metaproterenol Sulfate ..................................................30Metaproterenol Sulfate Solution, Non-Oral ql ................30Metformin HCl ............................................................21Metformin HCl ER .......................................................21Methadone HCl ............................................................14Methazolamide .............................................................27Methenamine Mandelate ...............................................11Methergine ...................................................................25Methimazole .................................................................21Methitest ......................................................................21Methocarbamol ........................................................15,24Methotrexate ................................................................13Methotrexate Sodium ...............................................13,24Methyclothiazide ...........................................................16Methyldopa ..................................................................17Methyldopa/Hydrochlorothiazide ...................................17Methylergonovine Maleate .............................................25Methylprednisolone Tablet, Dose Pack ...................21,24,29Methyltestosterone .........................................................21Meticorten..........................................................21,24,29Metipranolol .................................................................27Metoclopramide ............................................................22Metolazone ...................................................................16Metoprolol HCT ...........................................................17Metoprolol Succinate .....................................................16Metoprolol Tartrate .......................................................16Metrocream..................................................................18Metrogel.......................................................................26Metrolotion ..................................................................18Metronidazole .....................................................12,18,26Mevacor qd ..................................................................17Mexiletine HCl .............................................................16Mexitil..........................................................................16Miacalcin ql ............................................................21,24Micatin....................................................................18,26Miconazole ...................................................................26Miconazole Nitrate .......................................................18Micro-K 10mEq...........................................................32Micro-K 8mEq.............................................................32Microgestin FE.............................................................25Micronase.....................................................................21Midamor ......................................................................16Migraine & Cluster Headache Therapy ........................15Milk of Magnesia OTC ................................................22Minipress......................................................................17Minitran.......................................................................16Minocin .......................................................................11Minocycline HCl ..........................................................11Minoxidil .....................................................................17

Miralax OTC ...............................................................22Mirapex........................................................................15Mircette........................................................................25Miscellaneous Agents..........................................20,21,33Miscellaneous Analgesics .............................................14Miscellaneous Anti-infectives........................................12Miscellaneous Antidepressant ......................................15Miscellaneous Antineoplastic Drugs ............................13Miscellaneous Antipsychotics .......................................15Miscellaneous Antivirals ..............................................11Miscellaneous Coagulation Agents ..........................16,32Miscellaneous Dermatologicals .....................................19Miscellaneous Gastrointestinal Agents ..........................22Miscellaneous Hormones..............................................21Miscellaneous Neurological Therapy ............................15Miscellaneous OB/GYN...............................................26Miscellaneous Ophthalmologics ...................................28Miscellaneous Otic Preparations ...................................20Miscellaneous Psychotherapeutic Agents ......................15Miscellaneous Pulmonary Agents .................................30Miscellaneous Rheumatological Agents ........................24Miscellaneous Urologicals.............................................31Misoprostol ...................................................................22Mitotane ......................................................................13Mobic ql .................................................................14,24Modicon.......................................................................25Moduretic ....................................................................16Moexipril .....................................................................17Moexipril/HCTZ (tab/caps) ..........................................17Mometasone Furoate Ointment ......................................18Mometasone Furoate Spray, Non-Aerosol ...................20,30Mometasone/Formoterol ................................................30Monophasic/Biphasic/Triphasic Agents .......................25Monopril ......................................................................17Monopril HCT ............................................................17Montelukast Sodium .....................................................30Morphine Sulfate Controlled Release ..............................14Morphine Sulfate Soln Concentrate, Tabs .......................14Motrin.....................................................................14,24MS Contin qd .............................................................14MSIR ...........................................................................14Mucomyst ....................................................................30Multivitamins...............................................................32Multivitamins ..............................................................32Multivitamins w/Iron ...................................................32Multivitamins w/Iron ...................................................32Mupirocin Ointment .....................................................18Muscle Relaxants & Antispasmodic Agents ..................15Muscle Relaxants & Antispasmodic Therapy ...........15,24Myambutol...................................................................12Myasthenia Gravis .......................................................15Mycelex ........................................................................11Mycobutin ql ...............................................................12Mycolog II....................................................................18Mycophenolate Mofetil HCl ...........................................13Mycostatin...............................................................11,18Mydriacyl .....................................................................27Myeloid Stimulants .....................................................23Myleran........................................................................13

NNabumetone ............................................................14,24Nadolol ........................................................................16Nafarelin Acetate .....................................................21,26Nalfon .....................................................................14,24Naphazoline HCl .........................................................27Naprosyn.................................................................14,24Naproxen ................................................................14,24Naproxen Sodium ....................................................14,24Naratriptan ..................................................................15Narcotic Analgesics.......................................................14Narcotic Antagonists ...................................................14Narcotics .....................................................................14Nasacort AQ............................................................20,30Nasalide ql ...................................................................20Nasarel .........................................................................30Nasonex ql ..............................................................20,30Nateglinide ...................................................................21Natroba ........................................................................19Natural Senna Laxative OTC........................................22NebuPent ql .................................................................12Necon...........................................................................25Nelova ..........................................................................25Neo-Synephrine............................................................27Neomycin Sulfate .........................................................12Neomycin Sulfate ..........................................................12Neomycin Sulfate/Bacitracin Zinc/Polymyxin B/

Hydrocortisone Ointment ...........................................27Neomycin Sulfate/Gramicidin D/Polymyxin B

Drops ........................................................................27Neomycin Sulfate/Polymyxin B Sulfate/

Hydrocortisone ...........................................................20Neomycin Sulfate/Polymyxin B Sulfate/

Hydrocortisone Suspension, Drops ...............................27Neomycin/Bacitracin/Polymyxin B...............................18


38

Neomycin/Polymyxin B Sulfate/Dexamethasone ...............27Neoral ..........................................................................13Neosporin.....................................................................27Neostigmine Bromide ....................................................15Neptazane.....................................................................27Neumega ql..................................................................23Neupogen.....................................................................23NeutraPhos...................................................................32Niacin Tablet, Sustained Action Sequential .....................17Niaspan ........................................................................17Nicotine Gum OTC qd ................................................33Nicotine Patch OTC qd ................................................33Nifedipine Extended Release Tablet ql ............................17Nifedipine ql ................................................................17Nimodipine ..................................................................17Nimotop ......................................................................17Nisoldipine 8.5mg, 17mg, 20mg, 25.5mg,

30mg, 34mg, 40mg ...................................................17Nitrates ........................................................................16Nitro-Bid......................................................................16Nitrofurantoin ..............................................................11Nitrofurantoin Macrocrystal ..........................................11Nitroglycerin .................................................................16Nitroglycerin Capsule, Sustained Action .........................16Nitroglycerin Ointment .................................................16Nitroglycerin Patch, Transdermal 24 Hours ql ................16Nitrol ...........................................................................16Nitrolingual..................................................................16Nitrostat .......................................................................16Nizoral .........................................................................11Nizoral 2%...................................................................18Nizoral-AD OTC .........................................................18Nolvadex ......................................................................13Non-narcotic Analgesics ...............................................14Non-steroidal Anti-inflammatory Agents......................27Nor-Q-D ql .................................................................25Norco ...........................................................................14Nordette .......................................................................25Norethindrone ..............................................................25Norethindrone A-E Estradiol .........................................25Norethindrone A-E Estradiol/Ferrous

Fumarate ..................................................................25Norethindrone Acetate ql ..............................................25Norethindrone ql ..........................................................25Norethindrone-Ethinyl Estradiol ....................................25Norethindrone-Mestranol ..............................................25Norgestimate-Ethinyl Estradiol ......................................25Norgestrel .....................................................................25Norgestrel-Ethinyl Estradiol ...........................................25Norinyl.........................................................................25Normodyne ..................................................................16Norpace 100mg............................................................16Norpace CR 150mg .....................................................16Nortrel .........................................................................25Norvasc ........................................................................17Novahistine DH...........................................................29Novalog Vials ...............................................................21Novolin Vials................................................................21NSAID Agents .............................................................24NSAIDs ......................................................................14Nulev ...........................................................................22Nutropin, Nutropin AQ, Depot qd N..........................23NuvaRing .....................................................................26Nystatin ..................................................................11,18Nystatin/Triamcinolone Acetonide ..................................18

OOcella ...........................................................................25Ocufen .........................................................................27Ocuflox ........................................................................27Ocupress.......................................................................27Ofloxacin ...........................................................11,20,27Ogen .......................................................................24,25Ogestrel ........................................................................25Olux.............................................................................18Omeprazole ..................................................................22Omeprazole OTC .........................................................22Omnicef .......................................................................11Oms .............................................................................14Ondansetron HCl Solution, Oral, Tablet ...................15,22Ondansetron, Orally Disintegrating Tablet .................15,22Oprelvekin ...................................................................23OptiPranolol ................................................................27Optivar.........................................................................28Oral Contraceptives & Related Agents .........................25Oral Drugs For Glaucoma............................................27Oral Hypoglycemic Agents ..........................................21Oralone ........................................................................20Orapred..............................................................21,24,29Orinase.........................................................................21Ortho Micronor ...........................................................25Ortho Micronor ql.......................................................25Ortho Tri-Cyclen..........................................................25Ortho Tri-Cyclen Lo.....................................................25Ortho-Cept ..................................................................25

Ortho-Cyclen ...............................................................25Ortho-Novum 1-0.035mg............................................25Ortho-Novum 1-0.05mg..............................................25Ortho-Novum 10/11....................................................25Ortho-Novum 7/7/7 ....................................................25Orudis ..........................................................................24Orudis KT....................................................................14Osteoporosis Therapy ...................................................24Otc Analgesics .............................................................14Other Antihypertensive Combinations ........................17Other Electrolytes ........................................................32Other Glaucoma Drugs ................................................27Other Rheumatologicals ...............................................24Other Ulcer Therapy ...................................................22Otic Steroid/Antibiotic.................................................20Ovace ...........................................................................19Ovcon ..........................................................................25Ovide ...........................................................................19Ovral ............................................................................25Ovrette ql.....................................................................25Oxaprozin ...............................................................14,24Oxybutynin Chloride ..........................................15,24,31Oxycodone HCl Concentrate ..........................................14Oxycodone HCl Solution, Oral ......................................14Oxycodone HCl/Acetaminophen .....................................14Oxycodone HCl/Acetaminophen Tablet ...........................14Oxycodone SR ql ..........................................................14Oxycodone/Aspirin ........................................................14Oxycodone/Ibuprofen ....................................................14Oxycontin qd...............................................................14OxyFAST .....................................................................14Oxytocics .....................................................................25

PPacerone .......................................................................16Paraflex.........................................................................24Parafon Forte DSC ..................................................15,24Parcopa.........................................................................15Parlodel 2.5mg .............................................................15Pediapred............................................................21,24,29Pediatric Cough & Cold...............................................29Pediazole.......................................................................11Peg-Intron ql N ............................................................23Pegasys ql N .................................................................23Peginterferon Alfa-2A ....................................................23Peginterferon Alfa-2b ....................................................23Pen-Vee K.....................................................................11Penicillamine ................................................................24Penicillin V Potassium ...................................................11Penicillins .....................................................................11Pens..............................................................................21Pentamidine Isethionate ................................................12Pentasa .........................................................................22Pentazocine HCl/Acetaminophen ...................................14Pentosan Polysulfate Sodium ..........................................31Pentoxifylline Tablet, Sustained Action ......................16,32Pepcid 10, 20mg OTC .................................................22Pepcid 40mg.................................................................22Percocet 5-325mg, 7.5-500mg, 10-650mg ...................14Percodan.......................................................................14Periactin .......................................................................29Peridex..........................................................................20Perindopril (tab/caps) ....................................................17Permethrin ql ...............................................................19Persantine ................................................................16,32Phenazopyridine ......................................................11,14Phenazopyridine HCl ....................................................31Phenazopyridine/Hyoscyamine/Butalbital .......................11Phenergan ...............................................................22,29Phenergan 6.25/5mg, Tablet, Syrup,

Suppository ...............................................................15Phenergan VC w/Codeine ............................................29Phenergan w/Codeine ..................................................29Phenothiazines ............................................................15Phenylephrine HCl .......................................................27Phenylephrine HCl/Codeine/Promethazine .....................29Phos-Flur......................................................................20Phoslo ..........................................................................32Phospholine Iodide.......................................................27Phosphorus, Potassium, Sodium .....................................32Phrenilin .................................................................14,15Phytonadione ...........................................................16,32Pilocar 2%....................................................................27Pilocarpine HCl .......................................................27,33Pilopine HS..................................................................27Pimecrolimus Cream .....................................................19Pindolol .......................................................................16Pioglitazone HCl ..........................................................21Pioglitazone HCl/Metformin .........................................21Piroxicam ql ...........................................................14,24Plan B...........................................................................25Plaquenil .................................................................12,24Plavix.......................................................................16,32Plendil ..........................................................................17Pletal .......................................................................16,32

Podofilox ......................................................................19Polaramine ...................................................................29Polaramine Repetab 6mg ..............................................29Poly-Vi-Flor..................................................................32Polycitra-K ...................................................................31Polyethylene Glycol ......................................................22Polymyxin B Sulfate/Trimethoprim ................................27Polytrim .......................................................................27Potassium ....................................................................32Potassium Chloride .......................................................32Potassium Chloride Capsule, Sustained Action ................32Potassium Chloride Liquid ............................................32Potassium Chloride Packet .............................................32Potassium Chloride Tablet, Sustained Action ...................32Potassium Citrate Tablet, Sustained Action ......................31Potassium Gluconate .....................................................32Potassium Gluconate Elixir ............................................32PR Natal EC400 ..........................................................32Pramasone HC .............................................................19Pramipexole ..................................................................15Pravachol qd ................................................................17Pravastatin ql ...............................................................17Prazosin HCl ................................................................17Precose .........................................................................21Pred Forte.....................................................................27Prednisolone Acetate ......................................................27Prednisolone Sodium Phosphate ......................21,24,27,29Prednisolone Syrup ..............................................21,24,29Prednisone ..........................................................21,24,29Prednisone Tablet ................................................21,24,29Prelone 15mg/5ml..............................................21,24,29Premarin..................................................................24,25Premarin ql ..................................................................25Premphase ....................................................................25Prempro .......................................................................25Prenatal Vitamins/Ca/Iron/Folic Acid/DHA ....................32Prenatal Vitamins/Iron, Carbonyl/Docusate/

Folic Acid ..................................................................32Prenatal Vitamins/Iron/Folic Acid ..................................32Prenatal Vitamins/Iron/Folic Acid/Omega 3

Combo ......................................................................32Prenate Advance ...........................................................32Prenate Essential ...........................................................32Prenate GT...................................................................32Prenate Ultra ................................................................32Prilosec OTC................................................................22Primaquine...................................................................12Primaquine Phosphate ..................................................12Prinivil .........................................................................17Prinzide ........................................................................17ProAir HFA..................................................................30Probenecid....................................................................24Probenecid ....................................................................24Procarbazine HCl .........................................................13Procardia ......................................................................17Procardia XL.................................................................17Prochlorperazine Maleate Tablet, Capsule,

Suppository, Rectal .....................................................22Prochlorperazine Maleate Tablet,

Suppository, Rectal .....................................................15Procrit qd.....................................................................23Progesterone, Micronized ...............................................25Progestin Only ............................................................25Progestins ....................................................................25Prograf..........................................................................13Proloprim .....................................................................11Promethazine HCl ..............................................15,22,29Prometrium..................................................................25Propafenone HCl ..........................................................16Propranolol ...................................................................16Propranolol HCl/Hydrochlorothiazide ............................17Propylthiouracil ............................................................21Propylthiouracil ............................................................21Proscar..........................................................................31Prostaglandins .............................................................22Prostigmin....................................................................15Proton Pump Inhibitors ...............................................22Proventil, Ventolin........................................................30Provera .........................................................................25Pseudoephedrine HCl/Brompheniramine

Maleate .....................................................................29Pseudoephedrine HCl/Carbinoxamine Maleate

Tablet .......................................................................29Pseudoephedrine HCl/Chlorpheniramine

Maleate .....................................................................29Pseudoephedrine HCl/Chlorpheniramine

Maleate Capsule, Sustained Release 12 hr ....................29Pseudoephedrine HCl/Codeine/

Chlorpheniramine .....................................................29Psorcon.........................................................................18Psorcon-E .....................................................................18Psorcon-E Cream..........................................................18Psoriatec Cream............................................................19Psychotherapeutic Drugs ..............................................15Pulmicort Respules .......................................................30Pulmonary Agents ........................................................30


39

Pulmozyme ql ..............................................................30Purinethol ....................................................................13Pyrazinamide................................................................12Pyrazinamide ...............................................................12Pyridium ............................................................11,14,31Pyridium Plus..........................................................11,31Pyridostigmine Bromide ................................................15Pyridoxine ....................................................................32Pyrimethamine .............................................................12

QQualaquin ....................................................................12Questran ......................................................................17Questran Light .............................................................17Quinapril .....................................................................17Quinapril HCT ............................................................17Quinidex ......................................................................16Quinidine Sulfate .........................................................16Quinidine Sulfate Tablet, Sustained Action......................16Quinine Sulfate ............................................................12Quinolones...................................................................11Quixin..........................................................................27Qvar ql.........................................................................30

RRaloxifene HCl .............................................................24Ramipril ......................................................................17Ranitidine 300mg .........................................................22Ranitidine HCl ql ........................................................22Ranitidine HCl Syrup ...................................................22Rapamune ....................................................................13Rapid Acting Nitrates ..................................................16Razadyne Tablet 4mg, Razadyne ER.............................15Rebif ............................................................................23Reglan ..........................................................................22Relafen ....................................................................14,24Relpax ql qd ................................................................15Renagel ql ....................................................................33Requip..........................................................................15Reserpine......................................................................17Reserpine ......................................................................17Retin A A .....................................................................18Rheumatrex .............................................................13,24Ridaura.........................................................................24Rifabutin .....................................................................12Rifadin .........................................................................12Rifamate.......................................................................12Rifampin ......................................................................12Rifampin/Isoniazid .......................................................12Rifampin/Isoniazid/Pyrazinamide ..................................12Rifater ..........................................................................12Rilutek .........................................................................33Riluzole ........................................................................33Rivastigmine Tartrate ....................................................15Rizatriptan Benzoate ....................................................15Robaxin...................................................................15,24Robinul, Robinul Forte ................................................22Robitussin A-C.............................................................29Rocaltrol.......................................................................21Rondec .........................................................................29Rondec-DM.................................................................29Ropinirole HCl .............................................................15Rosiglitazone Maleate ....................................................21Rowasa .........................................................................22Roxicodone 20mg/ml ...................................................14Roxicodone 5mg/5ml ...................................................14Rufen ...........................................................................14Rythmol, Rythmol SR ..................................................16

SSalagen .........................................................................33Salflex......................................................................14,24Salicylates ...............................................................14,24Saline Nasal Spray OTC ...............................................20Salmeterol Xinafoate Disk, with Inhalation

Device .......................................................................30Salsalate ..................................................................14,24Sanctura, Sanctura XR..................................................31Sandimmune ................................................................13Sapropterin Dihydrochloride ..........................................21Sargramostim N ............................................................23Seasonale ......................................................................25Second Generation Cephalosporins .............................11Sectral...........................................................................16Selective Serotonin Reuptake Inhibitors .......................15Selegiline HCl ..............................................................15Selenium Sulfide ...........................................................19Selsun Rx......................................................................19Sennosides ....................................................................22Septra, DS ....................................................................11Serevent Diskus ql........................................................30Sevelamer HCl .............................................................33Silvadene ......................................................................18Silver Sulfadiazine ........................................................18

Simvastatin ql ..............................................................17Sinemet ........................................................................15Sinemet CR..................................................................15Singulair ST ql .............................................................30Sinuvent PE..................................................................29Sirolimus ......................................................................13Sitagliptin Phosphate .....................................................21Sitagliptin/Metformin ...................................................21Slow-K 8mEq...............................................................32Smoking Deterrents......................................................33Sodium Bicarbonate ......................................................32Sodium Chloride ................................................20,30,33Sodium Chloride 0.9% .................................................33Sodium Chloride for Inhalation .....................................30Sodium Fluoride ......................................................20,32Sodium Polystyrene Sulfonate .........................................33Sodium Sulfate/Sodium/Sodium Bicarbonate/

Potassium Chloride/Polyethylene Glycols ......................22Sodium Sulfate/Sodium/Sodium Bicarbonate/

Potassium Chloride/Polyethylene GlycolsSolution, Reconstituted, Oral ......................................22

Sodium/Potassium/Potassium Citrate/SodiumCitrate/Citric Acid .....................................................31

Somatropin N ...............................................................23Sorbitol ........................................................................33Sorbitol ........................................................................33Sotalol ..........................................................................16Sotalol HCl ..................................................................16Specialized Ob/Gyn Drugs ..........................................26Spectazole .....................................................................18Spinosad .......................................................................19Spiriva ql......................................................................30Spironolactone ..............................................................16Spironolactone/Hydrochlorothiazide ...............................16Sporanox N...................................................................11Stadol ...........................................................................14Starlix ...........................................................................21Steroid-antibiotic Combinations...................................27Steroid-sulfonamide Combinations ..............................28Steroids.........................................................................27Sucralfate .....................................................................22Sular .............................................................................17Sulfacet-R.....................................................................18Sulfacetamide Sodium ..............................................18,27Sulfacetamide Sodium Cleanser .....................................19Sulfacetamide Sodium/Prednisolone Sodium

Phosphate ..................................................................28Sulfacetamide Sodium/Sulfur .........................................18Sulfadiazine .................................................................11Sulfamethoxazole/Trimethoprim .....................................11Sulfas & Related Agents................................................11Sulfasalazine Tablet ..................................................22,24Sulfasalazine Tablet, Enteric Coated ..........................22,24Sulfonamides ................................................................27Sulindac ..................................................................14,24Sumatriptan Spray, Non-Aerosol ....................................15Sumatriptan Succinate Tablet ........................................15Sumatriptan Succinate Vial ...........................................15Surfak OTC .................................................................22Symbicort.....................................................................30Symmetrel ....................................................................15Sympathomimetics .......................................................28Synalar 0.01% ..............................................................18Synalar 0.03% ..............................................................18Synarel.....................................................................21,26Synthroid .....................................................................21

TTacrolimus Anhydrous ...................................................13Tagamet........................................................................22Tagamet 800mg............................................................22Talacen .........................................................................14Tambocor .....................................................................16Tamoxifen Citrate Tablet ...............................................13Tamsulosin HCl ............................................................31Tapazole .......................................................................21Tarka ............................................................................17Tavist............................................................................29Tekturna.......................................................................17Temovate ......................................................................18Tenex............................................................................17Tenoretic ......................................................................17Tenormin .....................................................................16Terazol Cream ..............................................................26Terazosin HCl ql .....................................................17,31Terbinafine HCl ...........................................................11Terbutaline Sulfate ...................................................26,30Terconazole ...................................................................26Testosterone ...................................................................21Testosterone Patch, Transdermal 24 Hours .......................21Tetracycline HCl ...........................................................11Tetracyclines .................................................................11Teveten.........................................................................17Theo-Dur.....................................................................30

Theophylline Anhydrous Tablet, SustainedRelease 12hr ..............................................................30

Therapy For Acne.........................................................18Thiamine .....................................................................32Thiazide & Related Diuretics ......................................16Third Generation Cephalosporins ...............................11Thyroid ........................................................................21Thyroid Hormones.......................................................21Tiazac ...........................................................................17Ticlid.......................................................................16,32Ticlopidine HCl ......................................................16,32Tigan............................................................................22Tigan Caps ...................................................................15Tikosyn ........................................................................16Timolol ........................................................................27Timolol Maleate ......................................................16,27Timolol Maleate Gel-Forming Solution ..........................27Timolol Maleate/Dorzolamide .......................................27Timoptic ......................................................................27Timoptic-XE ................................................................27Tinactin........................................................................18Tindamax .....................................................................12Tinidazole ....................................................................12Tiotropium ...................................................................30Tizanidine HCl .......................................................15,24TobraDex .....................................................................27Tobramycin Sulfate, Drops ql ........................................27Tobramycin Sulfate/Dexamethasone ...............................27Tobrex ..........................................................................27Tolazamide ...................................................................21Tolbutamide .................................................................21Tolectin ...................................................................14,24Tolectin DS .............................................................14,24Tolinase ........................................................................21Tolmetin Sodium .....................................................14,24Tolnaftate .....................................................................18Tolterodine Tartrate .......................................................31Topical Anesthetics .......................................................18Topical Antibacterials ...................................................18Topical Antifungals.......................................................18Topical Antivirals..........................................................18Topical Corticosteroids.................................................18Topical Corticosteroids High Potency ..........................18Topical Corticosteroids Low Potency ...........................18Topical Corticosteroids Medium Potency ....................18Topical Corticosteroids Very High Potency...................18Topical Enzymes...........................................................18Topical Scabicides/Pediculicides....................................19Topicort 0.05% ............................................................18Topicort 0.25% ............................................................18Toprol XL.....................................................................16Torsemide Tablet ...........................................................16Tramadol HCl ..............................................................14Tramadol/Acetaminophen ..............................................14Trandolapril (tab/caps) ..................................................17Transderm-Nitro ..........................................................16Trental .....................................................................16,32Tretinoin ......................................................................13Tretinoin Cream N ........................................................18Tri-Levlen.....................................................................25Tri-Vi-Flor....................................................................32Tri-Vi-Flor w/Iron ........................................................32Triamcinolone Acetonide .....................................18,20,30Triamcinolone Acetonide Aerosol w/Adapter.....................30Triamcinolone Acetonide Paste .......................................20Triamterene/Hydrochlorothiazide ...................................16Tricor ...........................................................................17Tricyclics ......................................................................15Trifluridine ql ..............................................................28Trihexyphenidyl HCl .....................................................15Trilisate.........................................................................14Trimethobenzamide .................................................15,22Trimethoprim ...............................................................11Triphasil .......................................................................25Triple Antibiotic ...........................................................18Trivora..........................................................................25Tropicamide .................................................................27Trospium, tabs ..............................................................31Trusopt.........................................................................27Trypsin/Balsam Peru/Castor Oil .....................................18T-Stat ...........................................................................18Twinject .......................................................................29Tykerb Tablet N ............................................................13Tylenol .........................................................................14Tylenol OTC................................................................14Tylenol w/Codeine .......................................................14Tylox ............................................................................14

UUlcer Therapy...............................................................22Ulesfia ..........................................................................19Ulipristal Acetate ..........................................................25Ultracet ........................................................................14Ultram, Ultram ER ql ..................................................14Ultrase..........................................................................22


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Uniretic ........................................................................17Univasc.........................................................................17Urecholine....................................................................31Urinary Anesthetics ......................................................31Urinary Tract Agents.....................................................11Urocit-K.......................................................................31Urso, Urso Forte...........................................................22Ursodiol .......................................................................22

VVaginal Antifungals .....................................................26Vaginal Cleanser/Anti-Infectives ..................................26Valisone 0.10%.............................................................18Valisone Cream.............................................................18Valium A ......................................................................15Valsartan ......................................................................17Valsartan/HCTZ ..........................................................17Vancocin ......................................................................12Vancomycin..................................................................12Vancomycin HCl Cap ...................................................12Vantin ..........................................................................11Varenicline Tartrate qd .................................................33Vaseretic .......................................................................17Vasocidin......................................................................28Vasoconstrictor Decongestants......................................27Vasodilan......................................................................26Vasodilators .................................................................17Vasotec .........................................................................17Venatal-FA....................................................................32VePesid .........................................................................13Verapamil HCl ql .........................................................17Verelan, Verelan PM .....................................................17Vermox.........................................................................12Vesanoid.......................................................................13Vfend N........................................................................11Vibra-Tabs....................................................................11Vibramycin, Vibramycin Suspension ............................11Viroptic ........................................................................28Visken ..........................................................................16Vistaril A ......................................................................29Vitamin A ....................................................................32Vitamin B-1 .................................................................32Vitamin B-12 ...............................................................32Vitamin B-6 .................................................................32Vitamin E.....................................................................32Vitamin E ....................................................................32Vitamin K ..............................................................16,32Vitamins & Hematinics................................................32Vivelle ql .................................................................24,25Vivelle-Dot ql ..............................................................24Voltaren...................................................................14,24Voltaren Drops .............................................................27Voltaren XR.............................................................14,24Voriconazole N ..............................................................11VoSol............................................................................20VoSol HC.....................................................................20Vospire ER ...................................................................30

WWarfarin Sodium .....................................................16,32Westcort 0.20%............................................................18

XXalatan ql.....................................................................27Xanthines ....................................................................30Xibrom.........................................................................27Xylocaine.................................................................18,20

YYasmin..........................................................................25

ZZaditor OTC................................................................28Zafirlukast ...................................................................30Zanaflex ..................................................................15,24Zantac ..........................................................................22Zantac Rx 75, 150mg OTC .........................................22Zaroxolyn .....................................................................16Zebeta ..........................................................................16Zenpep.........................................................................22Zestril...........................................................................17Ziac ..............................................................................17Zithromax Packet, Suspension, Tablet...........................11Zocor qd ......................................................................17ZoDerm .......................................................................18Zofran ODT qd......................................................15,22Zofran qd................................................................15,22Zostrix OTC ................................................................19Zovia ............................................................................25Zovirax .........................................................................18Zyban...........................................................................33Zyloprim ......................................................................24Zyrtec OTC .................................................................29


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