Southern Colorado Commercial HMO Drug...

Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)

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Southern Colorado Commercial HMO Drug Formulary

The following is a listing of the drugs on the Southern Colorado Commercial HMO Drug Formulary This formulary applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.

How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug. You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share.

Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, budesonide (oral), generic for Entocort EC®, a drug used for colitis, is restricted to physicians specialized in Gastroenterology.

Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.

Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day


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supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.

Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them.

Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.

Restricted to a specific age: Some medications may be restricted to a certain age or age range.

Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests:

o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations

Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.

Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand

drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878. The medications on this list are subject to change at any time throughout the year


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Drug Name Drug Tier Requirements /

Limits ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

cyproheptadine hcl Generic

promethazine hcl Generic *

ANTIHISTAMINE DRUGS

SECOND GENERATION ANTIHISTAMINES

None

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ALBENZA Brand

BILTRICIDE Brand

ivermectin Generic


ANTIBACTERIALS

amoxicillin Generic

amoxicillin & potassium clavulanate Generic/Brand †

ampicillin Generic/Brand †

azithromycin Generic/Brand †

BACTOCILL/DEXTROSE Brand *

CAYSTON Brand PA

cefaclor Generic

cefadroxil Generic

cefdinir Generic

cefixime Generic

cefprozil Generic

CEFTRIAXONE SODIUM/DEXTROSE Brand *

cefuroxime axetil Generic/Brand †

cephalexin Generic

ciprofloxacin hcl Generic/Brand †

ciprofloxacin-ciprofloxacin hcl Generic

clarithromycin Generic

clindamycin hcl Generic/Brand †

dicloxacillin Generic

doxycycline Generic

doxycycline (monohydrate) Generic

erythromycin & sulfisoxazole Generic

erythromycin base Generic/Brand †

erythromycin ethylsuccinate Generic/Brand †

erythromycin stearate Brand

levofloxacin Generic

linezolid Brand * MD, PA, QL

minocycline Generic

moxifloxacin Generic


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Limits neomycin sulfate Generic/Brand †

penicillin v potassium Generic

SPECTRACEF Brand

sulfadiazine Generic

sulfamethoxazole & trimethoprim Generic

sulfasalazine Generic

SUPRAX Brand

tetracycline Generic/Brand †

TOBI Podhaler Brand QL

tobramycin neb Generic QL

vancomycin Generic QL

ZYVOX Brand * MD, PA, QL


ANTIFUNGALS

fluconazole Generic

griseofulvin microsize Generic

griseofulvin ultramicrosize Generic

itraconazole Generic/Brand † MD

ketoconazole Generic

nystatin Generic/Brand †

terbinafine Generic

voriconazole Generic MD


ANTIMYCOBACTERIALS

DAPSONE Brand

ethambutol Generic

isoniazid Generic

pyrazinamide Generic

rifabutin Generic

rifampin Generic


ANTIVIRALS

abacavir sulfate-lamivudine-zidovudine Generic

abacavir sulfate Generic

acyclovir Generic

adefovir dipivoxil Generic QL

APTIVUS Brand

ATRIPLA Brand

BARACLUDE Brand

CRIXIVAN Brand

didanosine Generic/Brand †

EMTRIVA Brand

entecavir Generic †


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Limits EPIVIR HBV Brand

EPZICOM Brand

famciclovir Generic

GANCYCLOVIR Brand QL

HARVONI Brand PA, QL

INTELENCE Brand

INVIRASE Brand

ISENTRESS Brand

KALETRA Brand

lamivudine Generic

lamivudine-zidovudine Generic

LEXIVA Brand

nevirapine Generic

NORVIR Brand

PEGASYS Brand * PA, QL

PEG-INTRON Brand * PA, QL

PREZISTA Brand

RELENZA Brand PA, QL

RESCRIPTOR Brand

REYATAZ Brand

ribavirin Generic PA, QL

rimantadine Generic/Brand †

SELZENTRY Brand

SOVALDI Brand PA, QL

stavudine Generic

SUSTIVA Brand

TAMIFLU Brand QL

TRUVADA Brand

TYZEKA Brand QL

valacyclovir Generic

valganciclovir Generic QL

VICTRELIS Brand PA, QL

VIRACEPT Brand

VIRAZOLE Brand PA, QL

VIREAD Brand

zidovudine Generic


ANTIPROTOZOALS

atovaquone/proguanil Generic

chloroquine phosphate Generic

DARAPRIM Brand

hydroxychloroquine sulfate Generic

mefloquine hcl Generic


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Limits metronidazole Generic

NEBUPENT Brand

paromomycin sulfate Generic

PRIMAQUINE PHOSPHATE Brand

YODOXIN Generic


URINARY ANTI-INFECTIVES

belladonna alkaloids, methenamine,

methylene blue & phenyl salicylate Generic

methenamine hippurate Generic

methenamine mandelate Generic

nitrofurantoin macrocrystals Generic/Brand †

nitrofurantoin monohydrate macrocystals Generic

nitrofurantoin suspension Generic

trimethoprim Generic/Brand †

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

AFINITOR Brand MD, QL

ALKERAN Brand *

anastrozole Generic

bicalutamide Generic

capecitabine Generic

CEENU Brand

CYCLOPHOSPHAMIDE Brand

ELIGARD Brand * PA

EMCYT Brand QL

ETOPOSIDE Brand

exemestane Generic

flutamide Generic

GLEEVEC Brand MD, QL

HEXALEN Brand

hydroxyurea Generic

IMBRUVICA Brand PA, QL

INTRON-A Brand * PA, QL

IRESSA Brand QL

letrozole Generic PA

LEUKERAN Brand

leuprolide acetate Generic/Brand *† PA

LUPRON DEPOT Brand * PA

LUPRON DEPOT-PED Brand * PA

LYSODREN Brand QL

MATULANE Brand QL

megestrol acetate Generic


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Limits mercaptopurine Generic

methotrexate Generic/Brand *†

MYLERAN Brand

NEXAVAR Brand MD, QL

NILANDRON Brand

SPRYCEL Brand QL

SUTENT Brand MD, QL

TABLOID Brand

tamoxifen citrate Generic

TARCEVA Brand QL

TARGRETIN Brand QL

temozolomide Generic QL

tretinoin (chemo) Generic QL

TYKERB Brand QL

VOTRIENT Brand MD, QL

XTANDI Brand PA, QL

ZELBORAF Brand PA, QL

ZOLINZA Brand QL

ZYDELIG Brand PA, QL

ZYTIGA Brand PA, QL

AUTONOMIC DRUGS

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

bethanechol chloride Generic

cevimeline hcl Generic

donepezil Generic

galantamine hbr Generic

galantamine hbr (extended release) Generic

pilocarpine hcl (oral) Generic

pyridostigmine bromide Generic/Brand †

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

belladonna alkaloids & phenobarbital Generic/Brand †

chlordiazepoxide & clidinium Generic

dicyclomine hcl Generic

DONNATAL EXTENTABS Brand

glycopyrrolate Generic

hyoscyamine sulfate Generic

ipratropium bromide (inhaled) Generic/Brand †

ipratropium bromide (nasal) Generic

SPIRIVA RESPIMAT Brand QL

AUTONOMIC DRUGS

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ADVAIR DISKUS Brand ST


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Limits ADVAIR HFA Brand ST

albuterol sulfate Generic

COMBIVENT RESPIMAT Brand

DULERA Brand

ELIXOPHYLLIN Brand

epinephrine hcl Generic/Brand *† QL

ergoloid mesylates Generic

levalbuterol hcl solution Generic ST

metaproterenol sulfate Generic/Brand †

midodrine hcl Generic

SEREVENT DISKUS Brand

terbutaline sulfate Generic

VENTOLIN HFA Brand

XOPENEX HFA Brand ST

AUTONOMIC DRUGS

SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS

dihydroergotamine mesylate Generic/Brand *† QL

ERGOMAR Brand QL

phenoxybenzamine hcl Generic

tamsulosin hcl Generic

AUTONOMIC DRUGS

SKELETAL MUSCLE RELAXANTS

baclofen Generic

carisoprodol Generic

carisoprodol & aspirin Generic

cyclobenzaprine hcl Generic

dantrolene sodium Generic

methocarbamol Generic/Brand *†

tizanidine hcl Generic

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

ANTITHROMBOTIC AGENTS

anagrelide hcl Generic

BRILINTA Brand

cilostazol Generic

clopidogrel Generic

EFFIENT Brand * QL

fondaparinux Generic* QL

FRAGMIN Brand * QL

heparin sodium Generic/Brand *†

LOVENOX Brand * QL

PRADAXA Brand

warfarin sodium Generic

BLOOD FORMATION, COAGULATION AND THROMBOSIS


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Limits HEMATOPOIETIC AGENTS

EPOGEN Brand * PA, QL

LEUKINE Brand * MD, QL

NEULASTA Brand * PA, QL

PROCRIT Brand * PA, QL

ZARXIO Brand * QL


HEMORRHEOLOGIC AGENTS

pentoxifylline Generic


ANTIHEMORRHAGIC AGENTS

aminocaproic acid Generic/Brand †

CARDIOVASCULAR DRUGS

CARDIAC DRUGS

amiodarone hcl Generic/Brand †

digoxin Generic/Brand †

disopyramide phosphate Generic/Brand †

flecainide acetate Generic

mexiletine hcl Generic

propafenone hcl Generic

quinidine gluconate Generic

quinidine sulfate Generic

TIKOSYN Brand


ANTILIPEMIC AGENTS

atorvastatin calcium Generic

cholestyramine Generic

cholestyramine light Generic

colestipol Generic

CRESTOR Brand

fenofibrate Generic

fenofibrate (micronized) Generic

gemfibrozil Generic

lovastatin Generic

NIASPAN Brand PA

pravastatin Generic

simvastatin Generic


HYPOTENSIVE AGENTS

clonidine hcl Generic

guanfacine hcl Generic

hydralazine hcl Generic

methyldopa Generic


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Limits minoxidil Generic

RESERPINE Brand


VASODILATING AGENTS

ADCIRCA Brand MD, QL

alprostadil Generic * PA, QL, RB

CAVERJECT Brand * PA, QL, RB

CIALIS Brand PA, QL, RB

dipyridamole Generic

EDEX Brand * PA, QL, RB

isosorbide dinitrate Generic/Brand †

isosorbide mononitrate Generic

LETAIRIS Brand MD, QL

LEVITRA Brand PA, QL, RB

MUSE Brand PA, QL, RB

nitroglycerin Generic/Brand †

OSPHENA Brand PA, QL, RB

sildenafil citrate (pulmonary hypertension) Generic MD

TRACLEER Brand MD, QL

VIAGRA Brand PA, QL, RB


ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Generic

prazosin hcl Generic

terazosin hcl Generic


BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl Generic

atenolol Generic

atenolol & chlorthalidone Generic

bisoprolol fumarate Generic

bisoprolol fumarate & hydrochlorothiazide Generic

BYSTOLIC Brand

carvedilol Generic

COREG CR Brand

labetalol hcl Generic

metoprolol succinate Generic

metoprolol tartrate Generic

nadolol Generic

pindolol Generic

propranolol hcl Generic

sotalol hcl Generic



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Limits CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine besylate Generic

amlodipine besylate & benazepril hcl Generic

amlodipine besylate & valsartan Generic ST

CARDENE SR Brand

diltiazem hcl Generic/Brand †

diltiazem hcl coated beads Generic

diltiazem hcl extended release beads Generic

EXFORGE HCT Brand ST

felodipine Generic

isradipine Generic/Brand †

nifedipine Generic

nimodipined Generic

TARKA Brand

verapamil hcl Generic


RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

benazepril & hydrochlorothiazide Generic

benazepril hcl Generic

captopril Generic

CAPTOPRIL & HYDROCHLOROTHIAZIE Brand

enalapril maleate Generic

fosinopril sodium Generic

fosinopril sodium & hydrochlorothiazide Generic

lisinopril Generic

lisinopril & hydrochlorothiazide Generic

losartan potassium Generic

losartan potassium & hydrochlorothiazide Generic

moexipril & hydrochlorothiazide Generic

moexipril hcl Generic

quinapril & hydrochlorothiazide Generic

quinapril hcl Generic

ramipril Generic

spironolactone Generic

spironolactone & hydrochlorothiazide Generic

valsartan Generic ST

valsartan & hydrochlorothiazide Generic ST

CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS AND ANTIPYRETICS

acetaminophen with codeine Generic

buprenorphine HCl & naloxone HCl Generic/Brand † PA, QL

butalbital & acetaminophen Generic

butalbital, acetaminophen & caffeine Generic


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Limits butalbital, acetaminophen, caffeine & codeine Generic

butalbital, aspirin & caffeine Generic

butalbital, aspirin, caffeine & codeine Generic

celecoxib Generic QL, ST

choline magnesium trisalicylate Generic

diclofenac sodium Generic

etodolac Generic

fenoprofen calcium Generic/Brand †

fentanyl Generic MD, PA, QL

fentanyl citrate Generic MD, PA, QL

hydrocodone & acetaminophen Generic QL

hydromorphone hcl Generic/Brand † QL

ibuprofen Generic

indomethacin Generic/Brand †

ketoprofen Generic

KETOPROFEN (extended release) Brand

ketorolac tromethamine Generic QL

meclofenamate sodium Generic

meloxicam Generic

methadone hcl Generic QL

morphine sulfate Generic/Brand † QL

morphine sulfate (extended release) Generic QL

nabumetone Generic

naproxen Generic

naproxen sodium Generic

oxaprozin Generic

oxycodone & acetaminophen Generic QL

oxycodone & aspirin Generic QL

oxycodone hcl Generic QL

salsalate Generic

sulindac Generic

tramadol hcl Generic


OPIATE ANTAGONISTS

naltrexone hcl Generic


ANTICONVULSANTS

carbamazepine Generic

carbamazepine (extended release) Generic

CELONTIN Brand

clonazepam Generic

divalproex sodium Generic

divalproex sodium (extended release) Generic


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Limits ethosuximide Generic

felbamate Brand MD

gabapentin Generic/Brand †

lamotrigine Generic QL

levetiracetam Generic

oxcarbazepine Generic

phenytoin Generic/Brand †

phenytoin sodium (extended release) Generic/Brand †

primidone Generic

tiagabine Generic

topiramate Generic

valproate sodium Generic

valproic acid Generic

zonisamide Generic MD


PSYCHOTHERAPEUTIC AGENTS

ABILIFY Brand MD, QL

ABILIFY DISCMELT Brand MD, QL

amitriptyline hcl Generic

AMOXAPINE Brand

aripiprazole Generic MD, QL

bupropion hcl Generic

bupropion hcl (smoking deterrent) Generic

bupropion hcl xl Generic QL

chlordiazepoxide & amitriptyline Generic

chlorpromazine hcl Generic

citalopram hydrobromide Generic QL

clomipramine hcl Generic

clozapine Generic MD, QL

desipramine hcl Generic

doxepin hcl Generic

duloxetine hcl Generic

escitalopram oxalate Generic QL, ST

fluoxetine hcl Generic

fluoxetine hcl weekly Generic QL

fluphenazine hcl Generic

fluvoxamine maleate Generic

haloperidol Generic

haloperidol lactate Generic

imipramine hcl Generic

imipramine pamoate Generic/Brand †

loxapine succinate Generic

maprotiline hcl Generic


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Limits mirtazapine Generic

NEFAZODONE HCL Brand MD

nortriptyline hcl Generic

olanzapine Generic MD, QL

olanzapine odt Generic MD, QL

paroxetine hcl Generic

paroxetine hcl (extended release) Generic/Brand † QL

perphenazine Generic

phenelzine sulfate Generic

prochlorperazine maleate Generic

protriptyline hcl Generic MD

quetiapine fumarate Generic MD, QL

risperidone Generic MD, QL

sertraline hcl Generic

SURMONTIL Brand MD

thioridazine hcl Generic

thiothixene Generic/Brand †

tranylcypromine sulfate Generic

trazodone hcl Generic QL

trifluoperazine hcl Generic

venlafaxine hcl Generic

venlafaxine hcl (extended release) Generic/Brand †

ziprasidone hcl Generic MD, QL


ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL

STIMULANTS, MISCELLANEOUS

amphetamine & dextroamphetamine Generic QL

dexmethylphenidate hcl Generic QL

dextroamphetamine sulfate Generic QL

methylphenidate hcl Generic QL

methylphenidate hcl (extended release) Generic/Brand † QL

modafinil Generic PA, QL

phentermine Generic QL, RB

QSYMIA Brand PA, QL, RB


ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

alprazolam Generic

buspirone hcl Generic QL (7.5mg, 30mg)

chlordiazepoxide hcl Generic

clorazepate dipotassium Generic

diazepam Generic/Brand *†

estazolam Generic

flurazepam hcl Generic


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Limits hydroxyzine hcl Generic

hydroxyzine pamoate Generic

lorazepam Generic

oxazepam Generic

phenobarbital Generic

temazepam Generic/Brand † MD

triazolam Generic

zaleplon Generic QL

zolpidem tartrate Generic QL


ANTIMANIC AGENTS

lithium carbonate Generic/Brand †

lithium carbonate (extended release) Generic/Brand †


ANTIMIGRAINE AGENTS

CAFERGOT Brand QL

naratriptan Generic QL, ST

rizatriptan Generic QL, ST

sumatriptan succinate Generic/Brand *† QL

zolmitriptan Generic/Brand QL, ST

zolmitriptan ODT Generic QL, ST


ANTIPARKINSONIAN AGENTS

amantadine hcl Generic

APOKYN Brand * MD, QL

benztropine mesylate Generic

bromocriptine mesylate Generic

cabergoline Generic MD

carbidopa & levodopa Generic

carbidopa & levodopa (extended release) Generic

entacapone Generic

pramipexole dihydrochloride Generic

ropinirole hcl Generic

selegiline hcl Generic

trihexyphenidyl hcl Generic


CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS

acamprosate calcium Generic

riluzole Generic MD

NARCAN Brand

nemantine hcl Generic

pramipexole dihydrochloride Generic

selegiline hcl Generic


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Limits SAVELLA Brand QL

ELECTROLYTIC, CALORIC AND WATER BALANCE

ALKALINIZING AGENTS

potassium & sodium citrates w/ citric acid Generic

potassium citrate Generic

potassium citrate-citric acid Generic

sodium citrate & citric acid Generic


AMMONIA DETOXICANTS

lactulose Generic


DIURETICS

amiloride & hydrochlorothiazide Generic

amiloride Generic

bumetanide Generic

chlorothiazide Generic

chlorthalidone Generic

furosemide Generic

hydrochlorothiazide Generic

indapamide Generic

metolazone Generic

torsemide Generic

triamterene & hydrochlorothiazide Generic


ION-REMOVING AGENTS

RENAGEL Brand

RENVELA Brand

RENVELA PAK Brand

sodium polystyrene sulfonate Generic


IRRIGATING SOLUTIONS

lactated ringer’s (irrigation)) Generic

ringer’s (irrigation) Generic

sodium chloride (gu irrigant) Generic

water for irrigation (sterile) Generic


REPLACEMENT PREPARATIONS

ADDAMEL N Brand *

calcium acetate (phosphate binder) Generic/Brand †

potassium bicarb & potassium chloride Generic/Brand †

potassium chloride Generic

pot phosphate monobasic w/ sod phosphate dibasic & monobasic Generic

zinc sulfate Generic


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Limits ELECTROLYTIC, CALORIC AND WATER BALANCE

URICOSURIC AGENTS

colchicine Generic

probenecid Generic

probenecid & colchicine Generic

ENZYMES

ENZYMES

PULMOZYME Brand QL

RESPIRATORY TRACT AGENTS

ANTITUSSIVES

benzonatate Generic

guaifenesin & codeine Generic

hydrocodone & homatropine Generic QL

hydrocodone polistirex & chlorpheniramine polistirex Generic QL


RESPIRATORY TRACT ANTI-INFLAMMATORY AGENTS

cromolyn sodium Generic/Brand †

montelukast sodium Generic

montelukast sodium (packets) Generic QL, ST

STRIVERDI RESPIMAT

zafirlukast Generic


RESPIRATORY TRACT AGENTS, MISCELLANEOUS

sodium chloride for nebulization Generic

EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

EENT ANTI-ALLERGIC AGENTS

ALAMAST Brand

ALOCRIL (ophthalmic) Brand QL

ALOMIDE (ophthalmic) Brand

azelastine hcl spray Generic

azelastine hcl (ophthalmic) Generic/Brand †

cromolyn sodium (ophthalmic) Generic

PATANOL Brand QL, ST


EENT ANTI-INFECTIVES

bacitracin & polymyxin B (ophthalmic) Generic

bacitracin (ophthalmic) Brand

chlorhexidine gluconate (dental) Generic

ciprofloxacin hcl (ophthalmic) Generic

dexamthasone sod phosphate (ophthalmic) Generic

erythromycin (ophthalmic) Generic

gatifloxacin (ophthalmic) Generic MD

gentamicin sulfate (ophthalmic) Generic


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Limits neomycin, bacitracin & polymyxin B (ophth) Generic

neomycin, polymyxin & dexamethasone (ophth) Generic

ofloxacin (ophthalmic) Generic

ofloxacin (otic) Generic

polymyxin B & trimethoprim Generic

sulfacetamide sodium (ophthalmic) Generic/Brand †

tobramycin sulfate (ophthalmic) Generic/Brand †

trifluridine (ophthalmic) Generic

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

EENT ANTI-INFLAMMATORY AGENTS

BLEPHAMIDE (ophthalmic) Brand

BLEPHAMIDE S.O.P. Brand

CIPRO HC (otic) Brand

CIPRODEX Brand

COLY-MYCIN-S (otic) Brand

diclofenac sodium (ophthalmic) Generic

FLAREX Brand

flunisolide (nasal) Generic

fluorometholone (ophthalmic) Generic

flurbiprofen sodium (ophthalmic) Generic

fluticasone propionate (nasal) Generic

FML FORTE Brand

hydrocortisone & acetic acid (otic) Generic

ketorolac tromethamine (ophthalmic) Generic/Brand †

NASONEX Brand

neomycin, polymyxin, bacitracin

& hydrocortisone (ophthalmic) Generic/Brand †

neomycin, polymyxin &

dexamethasone (ophthalmic) Generic

NEOMYCIN, POLYMYXIN &

DEXAMETHASONE (ophthalmic) Brand

neomycin, polymyxin &

hydrocortisone (otic) Generic

PRED-G (ophthalmic) Brand

PRED-G S.O.P. (ophthalmic) Brand

prednisolone acetate (ophthalmic) Generic/Brand †

prednisolone sodium phosphate (ophth) Generic

sulfacetamide sodium &

prednisolone sodium phosphate (ophth) Generic

tobramycin sulfate & dexamethasone (ophth) Generic/Brand †


EENT ANTIGLAUCOMA AGENTS

acetazolamide Generic

AZOPT (ophthalmic) Brand


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Limits betaxolol hcl (ophthalmic) Generic/Brand †

BETIMOL Brand

brimonidine tartrate Generic/Brand †

carteolol hcl (ophthalmic) Generic

dorzolamide hcl & timolol maleate (ophth) Generic

dorzolamide hcl (ophthalmic) Generic

latanoprost Generic

levobunolol hcl (ophthalmic) Generic

methazolamide Generic

METIPRANOLOL (ophthalmic) Brand

PHOSPHOLINE IODIDE (ophthalmic) Brand

pilocarpine hcl (ophthalmic) Generic

timolol maleate (ophthalmic) Generic


EENT DRUGS, MISCELLANEOUS

acetic acid & aluminum acetate Generic

acetic acid (otic) Generic

fluorescein sodium Generic

fluorescein w/ benoxinate Generic

fluorescein w/ proparacaine Generic

ophthalmic irrigation Generic

phenylephrine (ophth) Generic


EENT LOCAL ANESTHETICS

antipyrine, benzocaine & polycosanol Generic/Brand

benzocaine & antipyrine (otic) Generic

lidocaine hcl (mouth-throat) Generic

proparacaine Generic

tetracaine hcl (ophth) Generic


EENT MYDRIATICS

atropine sulfate (ophthalmic) Generic

cyclopentolate hcl (ophthalmic) Generic

tropicamide (ophthalmic) Generic

GASTROINTESTINAL DRUGS

ANTIDIARRHEA AGENTS

diphenoxylate & atropine Generic


CATHARTICS AND LAXATIVES

polyethylene glycol 3350,

potassium chloride, sodium

bicarbonate, sodium chloride &

sodium sulfate

Generic/Brand †

polyethylene glycol 3350, Generic


- 20 -


Limits potassium chloride, sodium

bicarbonate & sodium chloride


CHOLELITHOLYTIC AGENTS

ursodiol Generic/Brand †


DIGESTANTS

amylase 27,000 units; lipase

5,000 units; protease 17,000 units Generic/Brand †








ANTIEMETICS

ANTIVERT Brand

dronabinol Generic QL

EMEND Brand MD, QL

ondansetron hcl Generic QL


ANTIULCER AGENTS AND ACID SUPPRESSANTS

cimetidine hcl Generic

famotidine Generic

misoprostol Generic

omeprazole Generic

pantoprazole sodium Generic

PREVACID SOLUTAB Brand ST

ranitidine hcl Generic

sucralfate Generic/Brand †


PROKINETIC AGENTS

metoclopramide hcl Generic


GI ANTI-INFLAMMATORY AGENTS

APRISO Brand

balsalazine disodium Generic

LIALDA Brand

mesalamine Generic

sulfasalazine Generic

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA Brand


- 21 -


Limits HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CUPRIMINE Brand PA, QL

DEPEN Brand QL

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

ASMANEX Brand

ASMANEX HFA Brand

budesonide (oral) Generic MD, QL

budesonide (nebulized) Generic

CORTISONE ACETATE Brand

dexamethazone Generic/Brand

FLOVENT DISKUS Brand

FLOVENT HFA Brand

fludrocortisone acetate Generic

hydrocortisone Generic

methylprednisolone Generic/Brand †

prednisolone Generic

prednisolone sodium phosphate Generic

prednisone Generic/Brand †

PULMICORT FLEXHALER Brand

QVAR Brand


ANDROGENS

ANDRODERM Brand PA, QL

ANDROXY Brand QL

AXIRON Brand PA, QL

danazol Generic

METHITEST Brand

testosterone Generic/Brand *† PA, QL

testosterone cypionate Generic/Brand *† PA, QL

testosterone enanthate Brand/Generic *† PA, QL


CONTRACEPTIVES Possible Brands

desogestrel & ethinyl estradiol (monophasic) Generic/Brand †

APRI,

DESOGEN,

KARIVA,

MIRCETTE,

ORTHO-CEPT

desogestrel & ethinyl estradiol (triphasic) Generic

CESIA,

CYCLESSA,

VELIVET

drospirenone & ethinyl estradiol Brand YASMIN

ELLA Brand


- 22 -


Limits

ethynodiol diacetate & ethinyl estradiol Generic

KELNOR,

ZOVIA 1/35E,

ZOVIA 1/50E

levonorgestrel & ethinyl estradiol (91-day) Generic/Brand † JOLESSA,

SEASONIQUE

levonorgestrel & ethinyl estradiol (monophasic) Generic/Brand †

LESSINA,

NORDETTE,

PORTIA

levonorgestrel & ethinyl estradiol (triphasic) Generic ENPRESSE,

TRIVORA

levonorgestrel (emergency oral contraceptive) Generic/Brand † AG

norethindrone & ethinyl estradiol (biphasic) Brand NECON 10/11

norethindrone & ethinyl estradiol (monophasic) Generic/Brand †

MODICON,

NORTREL 0.5/35,

NORTREL 1/35,

ORTHO-NOVUM

1/35

norethindrone & ethinyl estradiol (triphasic) Generic/Brand †

NECON 7/7/7,

NORTREL 7/7/7,

ORTHO-NOVUM

7/7/7,

TRI-NORINYL

norethindrone & mestranol Generic/Brand †

NECON 1/50,

ORTHO-NOVUM

1/50

norethindrone (contraceptive) Generic/Brand †

NOR-QD,

NORA-BE,

ORTHO-

MICRONOR

norethindrone acetate & ethinyl estradiol Generic/Brand †

LOESTRIN 1/20,

MICROGESTIN

1/20,

LOESTRIN 1.5/30,

MICROGESTIN

1.5/30

norethindrone acetate, estradiol & iron Generic/Brand †

LOESTRIN FE 1/20,

MICROGESTIN FE

1/20,

LOESTRIN FE

1.5/30,

MICROGESTIN FE

1.5/30

norgestimate & ethinyl estradiol (monophasic) Generic/Brand †

PREVIFEM,

SPRINTEC,

ORTHO-CYCLEN

norgestimate & ethinyl estradiol (triphasic) Generic/Brand †

ORTHO TRI-

CYCLEN,

TRI-PREVIFEM,

TRI-SPRINTEC

norgestrel & ethinyl estradiol Generic/Brand † CRYSELLE,


- 23 -


Limits LO/OVRAL,

LOW-OGESTREL,

OGESTREL

NUVARING Brand PA, QL

PLAN B Brand AG

XULANE Brand PA, QL


ANTIDIABETIC AGENTS

acarbose Generic

glimepiride Generic

glipizide Generic

glipizide (extended release) Generic

glyburide Generic

glyburide & metformin hcl Generic

HUMALOG Brand PA

HUMALOG KWIKPEN Brand PA

HUMALOG MIX 50/50 Brand

HUMALOG MIX 50/50 PEN Brand PA

HUMALOG MIX 75/25 Brand

HUMALOG MIX 75/25 PEN Brand PA

HUMULIN R U-500 Brand

INSULIN ISOPHANE &

REGULAR (HUMAN) PEN Brand PA

INSULIN ISOPHANE &

REGULAR (HUMAN) Brand

INSULIN ISOPHANE (HUMAN) Brand

INSULIN ISOPHANE (HUMAN) PEN Brand PA

INSULIN REGULAR (HUMAN) Brand

LANTUS Brand

LANTUS SOLOSTAR Brand PA

LEVEMIR Brand

LEVEMIR FLEXTOUCH Brand PA

metformin hcl Generic

metformin hcl (extended release) Generic

NOVOLOG Brand

NOVOLOG FLEXPEN Brand PA

NOVOLOG MIX 70/30 FLEXPEN Brand PA

NOVOLOG MIX 70/30 Brand

pioglitazone hcl Generic

tolazamide Generic

TOLBUTAMIDE Brand


ANTIHYPOGLYCEMIC AGENTS

GLUCAGON HCL Brand † QL


- 24 -


Limits HORMONES AND SYNTHETIC SUBSTITUTES

ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS

COMBIPATCH Brand

clomiphene citrate Generic PA, RB

esterified estrogens & methyltestosterone Generic

ESTRACE VAGINAL Brand

estradiol (oral) Generic/Brand †

estradiol (transdermal) Generic/Brand † QL

estradiol valerate Generic *

estropipate Generic

FEMHRT LOW DOSE Brand

PREMARIN Brand

PREMPHASE Brand

PREMPRO Brand

raloxifene Generic

VAGIFEM Brand


GONADOTROPINS

BRAVELLE Brand * PA. RB

chorionic gonadotropin Generic * PA. RB FOLLISTIM AQ Brand * PA. RB GONAL-F Brand * PA. RB MENOPUR Brand * PA. RB OVIDREL Brand * PA. RB


PARATHYROID

calcitonin (salmon) Generic QL

FORTEO Brand * PA, QL


PITUITARY

ACTHAR HP Brand * PA, QL

desmopressin acetate Generic *


SOMATROPIN AGONISTS AND ANTAGONISTS

OMNITROPE Brand * PA, QL


PROGESTINS

medroxyprogesterone acetate Generic

norethindrone acetate Generic

progesterone, micronized Generic PA, RB


THYROID AND ANTITHYROID AGENTS

levothyroxine sodium Generic/Brand †


- 25 -


Limits liothyronine Generic

methimazole Generic

propylthiouracil Generic

SSKI Brand

thyroid Generic/Brand †

THYROLAR Brand

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

finasteride Generic MD


ALCOHOL DETERRENTS

disulfiram Generic


ANTIDOTES

acetylcysteine Generic

leucovorin calcium Generic/Brand *†


ANTIGOUT AGENTS

allopurinol Generic

colchicine Generic


BIOLOGIC RESPONSE MODIFIERS

GLATOPA Generic * MD, QL

REBIF Brand * MD, QL

REVLIMID Brand QL

THALOMID Brand QL


BONE RESORPTION INHIBITORS

alendronate sodium Generic

ETIDRONATE DISODIUM Brand

FOSAMAX PLUS D Brand


CARIOSTATIC AGENTS

sodium fluoride Generic


DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

ENBREL Brand * MD, QL

HUMIRA Brand * MD, QL

leflunomide Generic MD


IMMUNOSUPPRESSIVE AGENTS

azathioprine Generic

cyclosporine Generic/Brand †


- 26 -


Limits cyclosporine modified (for microemulsion) Generic/Brand †

mycophenolate mofetil Generic

mycophenolate sodium Generic

RAPAMUNE Brand

tacrolimus Generic

sirolimus Generic


OTHER MISCELLANEOUS THERAPEUTIC AGENTS

acitretin Generic

CYSTAGON Brand PA

FIRAZYR Brand * QL

KINERET Brand * QL

levocarnitine Generic/Brand †

lidocaine-prilocaine Generic


PROTECTIVE AGENTS

ELMIRON Brand

OXYTOCICS

OXYTOCICS

methylergonovine Generic

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)

acyclovir Generic

AVC Brand

BACTROBAN NASAL Brand

benzoyl peroxide & erythromycin Generic

ciclopirox Generic

ciclopiroxolamine Generic

clindamycin phosphate (topical) Generic

clindamycin phosphate (vaginal) Generic

clotrimazole Generic

clotrimazole & betamethasone dipropionate Generic

clotrimazole (topical) Generic

erythromycin (topical) Generic

EURAX Brand

EXELDERM Brand

GENTAMICIN SULFATE (topical) Brand

ketoconazole (topical) Generic

lindane Generic

metronidazole (topical) Generic/Brand † MD

metronidazole (vaginal) Generic

MICONAZOLE 3 Brand

mupirocin (topical) Generic


- 27 -


Limits NAFTIN Brand

nystatin (topical) Generic

permethrin Generic

selenium sulfide Generic

silver sulfadiazine Generic

sulfacetamide sodium (topical) Generic


ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)

alclometasone dipropionate Generic

APEXICON E Brand

augmented betamethasone dipropionate Generic

betamethasone dipropionate (topical) Generic

betamethasone valerate Generic

clobetasol propionate Generic MD

clobetasol propionate emollient base Generic MD

CLODERM Brand

CORDRAN Brand

CORTIFOAM Brand

CORTISPORIN Brand

desonide Generic

desoximetasone Generic

diflorasone diacetate Generic

EPIFOAM Brand

fluocinolone acetonide Generic

fluocinonide Generic

fluocinonide emulsified base Generic

fluticasone propionate Generic/Brand †

halobetasol propionate Generic

hydrocortisone butyrate Generic

hydrocortisone butyrate hydrophilic lipo base Generic

hydrocortisone (intrarectal) Generic

hydrocortisone (rectal) Generic

hydrocortisone (topical) Generic

hydrocortisone acetate (rectal) Generic

hydrocortisone valerate Generic

iodoquinol-hc Generic

KENALOG Brand

mometasone furoate Generic

nystatin & triamcinolone Generic

triamcinolone acetonide (mouth) Generic

triamcinolone acetonide (topical) Generic


ANTIPRURITICS AND LOCAL ANESTHETICS


- 28 -


Limits hydrocortisone acetate & pramoxine Generic/Brand †

lidocaine hcl Generic ST

phenazopyridine hcl Generic


CELL STIMULANTS AND PROLIFERANTS

tretinoin Generic AG, QL


PIGMENTING AND DEPIGMENTING AGENTS

OXSORALEN Brand


SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS

adapalene Generic MD

aluminum chloride Generic

AMEVIVE Brand * PA, QL

calcipotriene Generic/Brand †

DRITHO-CREME HP Brand

ELIDEL Brand MD, PA, QL

FINACEA Brand MD

fluorouracil (topical) Generic/Brand †

imiquimod Generic

isotretinoin Generic QL

podofilox Generic/Brand †

REGRANEX Brand PA, QL

tacrolimus (topical) Generic MD

TARGRETIN Brand QL

TAZORAC Brand QL

VECTICAL (topical) Brand ST

SMOOTH MUSCLE RELAXANTS

GENITOURINARY SMOOTH MUSCLE RELAXANTS

flavoxate hcl Generic

oxybutynin chloride Generic

oxybutynin chloride (extended release) Generic

tolterodine tartrate Generic

tolterodine tartrate (extended release) Generic

trospium chloride Generic

SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE Brand

theophylline Generic/Brand †

VITAMINS

VITAMIN B COMPLEX

folic acid Generic

VITAMINS


- 29 -


Limits VITAMIN D

calcitriol Generic

ergocalciferol Generic

VITAMINS

VITAMIN K ACTIVITY

MEPHYTON Brand

VITAMINS

PRENATAL VITAMINS

PRENATAL VITAMIN WITH DOCUSATE, FERROUS

FUMARATE & FOLIC ACID Brand

PRENATAL VITAMIN WITH DOCUSATE, IRON

CARBONYL & FOLIC ACID Brand

PRENATAL VITAMIN WITH FERROUS FUMARATE &

FOLIC ACID Brand

PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC

ACID Brand

PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC

ACID Brand

PRENATAL VITAMIN WITH SELENIUM, FERROUS

FUMARATE & FOLIC ACID Brand

VITAMINS

PEDIATRIC MULTIVITAMINS

pediatric multivitamins with fluoride Generic/Brand †

pediatric vitamins A, C, D, with fluoride Generic/Brand †


- 30 -

INDEX OF DRUGS

Kaiser Permanente Southern Colorado

Commercial HMO Comprehensive Formulary Index

5

5-ALPHA-REDUCTASE INHIBITORS 25

A

abacavir sulfate 4

abacavir sulfate-lamivudine-zidovudine 4

ABILIFY 13

ABILIFY DISCMELT 13

acamprosate calcium 15

acarbose 23

acebutolol hcl 10

acetaminophen with codeine 11

acetazolamide 18

acetic acid & aluminum acetate 19

acetic acid (otic) 19

acetylcysteine 25

acitretin 26

ACTHAR HP 24

acyclovir 4, 26

adapalene 28

ADCIRCA 10

ADDAMEL N 16

adefovir dipivoxil 4

adenovir dipivoxil 4

ADRENALS 21

ADVAIR DISKUS 7

ADVAIR HFA 8

AFINITOR 6

ALAMAST 17

ALBENZA 3

albuterol sulfate 8

alclometasone dipropionate 27

ALCOHOL DETERRENTS 25

alendronate sodium 25

ALKALINIZING AGENTS 16

ALKERAN 6

allopurinol 25

ALOCRIL (ophthalmic) 17

ALOMIDE (ophthalmic) 17

ALPHA-ADRENERGIC BLOCKING AGENTS 10

alprazolam 14

alprostadil 10

aluminum chloride 28

amantadine hcl 15

AMEVIVE 28

amiloride 16

amiloride & hydrochlorothiazide 16

aminocaproic acid 9

AMINOPHYLLINE 28

amiodarone hcl 9

amitriptyline hcl 13

amlodipine besylate 11

amlodipine besylate & benazepril hcl 11

amlodipine besylate & valsartan 11

AMMONIA DETOXICANTS 16

AMOXAPINE 13

amoxicillin 3

amoxicillin & potassium 3

amphetamine & dextroamphetamine 14

ampicillin 3

amylase 109,000 units; lipase 20,000 units; protease

68,000 units 20

amylase 27,000 units; lipase 5,000 units; protease 17,000

units 20


units 20


units 20

anagrelide hcl 8

ANALGESICS AND ANTIPYRETICS 11

anastrozole 6

ANDRODERM 21

ANDROGENS 21

ANDROXY 21

ANOREXIGENIC AGENTS AND RESPIRATORY

AND CEREBRAL 14

ANTHELMINTICS 3

ANTIALLERGIC AGENTS 17

ANTIBACTERIALS 3

ANTICHOLINERGIC AGENTS 7

ANTICONVULSANTS 12

ANTIDIARRHEA AGENTS 19

ANTIDOTES 25

ANTIEMETICS 20

ANTIFUNGALS 4

ANTIGOUT AGENTS 25

ANTIHEMORRHAGIC AGENTS 9

ANTIHISTAMINE DRUGS 3

ANTIHYPOGLYCEMIC AGENTS 23

ANTI-INFECTIVE AGENTS 3, 4, 5, 6

ANTI-INFECTIVES (SKIN AND MUCOUS

MEMBRANE) 26

ANTI-INFLAMMATORY AGENTS (SKIN AND

MUCOUS MEMBRANE) 27

ANTILIPEMIC AGENTS 9

ANTIMANIC AGENTS 15

ANTIMIGRAINE AGENTS 15

ANTIMYCOBACTERIALS 4

ANTINEOPLASTIC AGENTS 6

ANTIPARKINSONIAN AGENTS 15

ANTIPROTOZOALS 5


- 31 -

ANTIPRURITICS AND LOCAL ANESTHETICS 27

antipyrine, benzocaine & polycosanol 19

ANTITHROMBOTIC AGENTS 8

ANTITUSSIVES 17

ANTIULCER AGENTS AND ACID SUPPRESSANTS

20

ANTIVERT 20

ANTIVIRALS 4

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS 14

APEXICON E 27

APOKYN 15

APRI 21

APRISO 20

APTIVUS 4

aripiprazole 13

ASMANEX 21

ASMANEX HFA 21

atenolol 10

atenolol & chlorthalidone 10

atorvastatin calcium 9

atovaquone/proguanil 5

ATRIPLA 4

atropine sulfate (ophthalmic) 19

augmented betamethasone dipropionate 27

AUTONOMIC DRUGS 7, 8

AVC 26

AXIRON 21

azathioprine 25

azelastine hcl (ophthalmic) 17

azelastine hcl spray 17

azithromycin 3

AZOPT (ophthalmic) 18

B

bacitracin & polymyxin B (ophthalmic) 17

bacitracin (ophthalmic) 17

baclofen 8

BACTOCILL/DEXTROSE 3

BACTROBAN NASAL 26

balsalazine disodium 20

BARACLUDE 4

belladonna alkaloids & phenobarbital 7

belladonna alkaloids, 6

benazepril & hydrochlorothiazide 11

benazepril hcl 11

benzocaine & antipyrine (otic) 19

benzonatate 17

benzoyl peroxide & erythromycin 26

benztropine mesylate 15

BETA-ADRENERGIC BLOCKING AGENTS 10

betamethasone dipropionate (topical) 27

betamethasone valerate 27

betaxolol hcl (ophthalmic) 19

bethanechol chloride 7

BETIMOL 19

bicalutamide 6

BILTRICIDE 3

BIOLOGIC RESPONSE MODIFIERS 25

bisoprolol fumarate 10

bisoprolol fumarate & hydrochlorothiazide 10

BLEPHAMIDE (ophthalmic) 18

BLEPHAMIDE S.O.P. 18

BLOOD FORMATION, COAGULATION AND

THROMBOSIS 8

BLOOD FORMATION, COAGULATION, AND

THROMBOSIS 8, 9

BONE RESORPTION INHIBITORS 25

BRAVELLE 24

BRILINTA 8

brimonidine tartrate 19

bromocriptine mesylate 15

budesonide (nebulized) 21

budesonide (oral) 21

bumetanide 16

buprenorphine HCl & naloxone HCL 11

bupropion hcl 13

bupropion hcl (smoking deterrent) 13

bupropion hcl xl 13

buspirone hcl 14

butalbital & acetaminophen 11

butalbital, acetaminophen & caffeine 11

butalbital, acetaminophen, caffeine & codeine 12

butalbital, aspirin & caffeine 12

butalbital, aspirin, caffeine & codeine 12

BYSTOLIC 10

C

cabergoline 15

CAFERGOT 15

calcipotriene 28

calcitonin (salmon) 24

calcitriol 29

calcium acetate (phosphate binde)r 16

CALCIUM-CHANNEL BLOCKING AGENTS 11

capecitabine 6

captopril 11

CAPTOPRIL & HYDROCHLOROTHIAZIE 11

carbamazepine 12

carbamazepine (extended release) 12

carbidopa & levodopa 15

carbidopa & levodopa (extended release) 15

CARDENE SR 11

CARDIAC DRUGS 9

CARDIOVASCULAR DRUGS 9, 10, 11

CARIOSTATIC AGENTS 25

carisoprodol 8

carisoprodol & aspirin 8

carteolol hcl (ophthalmic) 19

carvedilol 10

CATHARTICS AND LAXATIVES 19

CAVERJECT 10

CAYSTON 3

CEENU 6

cefaclor 3

cefadroxil 3

cefdinir 3


- 32 -

cefixime 3

cefprozil 3

CEFTRIAXONE SODIUM/DEXTROSE 3

cefuroxime axetil 3

celecoxib 12

CELL STIMULANTS AND PROLIFERANTS 28

CELONTIN 12

CENTRAL NERVOUS SYSTEM AGENTS 11, 12, 13,

14, 15

CENTRAL NERVOUS SYSTEM AGENTS,

MISCELLANEOUS 15

cephalexin 3

CESIA 21

cevimeline hcl 7

chlordiazepoxide & amitriptyline 13

chlordiazepoxide & clidinium 7

chlordiazepoxide hcl 14

chlorhexidine gluconate (dental) 17

chloroquine phosphate 5

chlorothiazide 16

chlorpromazine hcl 13

chlorthalidone 16

CHOLELITHOLYTIC AGENTS 20

cholestyramine 9

cholestyramine light 9

choline magnesium trisalicylate 12

chorionic gonadotropin 24

CIALIS 10

ciclopiroxolamine 26

cilostazol 8

cimetidine hcl 20

CIPRO HC (otic) 18

CIPRODEX 18

ciprofloxacin hcl 3

ciprofloxacin hcl (ophthalmic) 17

ciprofloxacin-ciprofloxacin hcl 3

citalopram hydrobromide 13

clarithromycin 3

clindamycin hcl 3

clindamycin phosphate (topical) 26

clindamycin phosphate (vaginal) 26

clobetasol propionate 27

clobetasol propionate emollient base 27

CLODERM 27

clomipramine hcl 13

clonazepam 12

clonidine hcl 9

clopidogrel 8

clorazepate dipotassium 14

clotrimazole 26

clotrimazole & betamethasone dipropionate 26

clotrimazole (topical) 26

clozapine 13

colchicine 17, 25

colestipol 9

COLY-MYCIN-S (otic) 18

COMBIPATCH 24

COMBIVENT RESPIMAT 8

CONTRACEPTIVES 21

CORDRAN 27

COREG CR 10

CORTIFOAM 27

CORTISONE ACETATE 21

CORTISPORIN 27

CRESTOR 9

CRIXIVAN 4

cromolyn sodium 17

cromolyn sodium (ophthalmic) 17

CRYSELLE 22

CUPRIMINE 21

CYCLESSA 21

cyclobenzaprine hcl 8

cyclopentolate hcl (ophthalmic) 19

cyclophosphamide 6

cyclosporine 25

cyclosporine modified (for microemulsion) 26

cyproheptadine hcl 3

CYSTAGON 26

D

danazol 21

dantrolene sodium 8

dapsone 4

DARAPRIM 5

DEPEN 21

desipramine hcl 13

desmopressin acetate 24

DESOGEN 21

desogestrel & ethinyl estradiol (monophasic) 21

desogestrel & ethinyl estradiol (triphasic) 21

desonide 27

desoximetasone 27

dexamethasone 21

dexamthasone sod phosphate (ophthalmic) 17

dexmethylphenidate hcl 14

dextroamphetamine sulfate 14

diazepam 14

diclofenac sodium 12

diclofenac sodium (ophthalmic) 18

dicloxacillin 3

dicyclomine hcl 7

didanosine 4

diflorasone diacetate 27

DIGESTANTS 20

digoxin 9

dihydroergotamine mesylate 8

diltiazem hcl 11

diltiazem hcl coated beads 11

diltiazem hcl extended release beads 11

diphenoxylate & atropine 19

dipyridamole 10

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

25

disopyramide phosphate 9

disulfiram 25

DIURETICS 16

divalproex sodium 12


- 33 -

divalproex sodium (extended release) 12

donepezil 7

DONNATAL EXTENTABS 7

dorzolamide hcl & timolol maleate (ophthalmic) 19

dorzolamide hcl (ophthalmic) 19

doxazosin mesylate 10

doxepin hcl 13

doxycycline 3

doxycycline (monohydrate) 3

DRITHO-CREME HP 28

dronabinol 20

drospirenone & ethinyl estradiol 21

DULERA 8

duloxetine 13

E

EDEX 10

EENT ANTIGLAUCOMA AGENTS 18

EENT ANTI-INFECTIVES 17

EENT ANTI-INFLAMMATORY AGENTS 18

EENT DRUGS, MISCELLANEOUS 19

EENT MYDRIATICS 19

EFFIENT 8

ELECTROLYTIC, CALORIC AND WATER

BALANCE 16, 17

ELIDEL 28

ELIGARD 6

ELIXOPHYLLIN 8

ELLA 21

ELMIRON 26

EMCYT 6

EMEND 20

EMTRIVA 4

enalapril maleate 11

ENBREL 25

ENPRESSE 22

entacapone 15

ENZYMES 17

epinephrine hcl 8

EPIVIR HBV 5

EPOGEN 9

EPZICOM 5

ergocalciferol 29

ergoloid mesylates 8

ERGOMAR 8

erythromycin (ophthalmic) 17

erythromycin (topical) 26

erythromycin base 3

erythromycin ethylsuccinate 3

erythromycin stearate 3

erythromycin sulfisoxazole 3

escitalopram oxalate 13

estazolam 14

esterified estrogens & methyltestosterone 24

ESTRACE VAGINAL 24

estradiol (oral) 24

estradiol (transdermal) 24

estradiol valerate 24

ESTROGENS AND ESTROGEN AGONISTS-

ANTAGONISTS 24

estropipate 24

ethambutol 4

ethosuximide 13

ethynodiol diacetate & ethinyl estradiol 22

etidronate disodium 25

etodolac 12

etoposide 6

EURAX 26

EXELDERM 26

exemestane 6

EXFORGE HCT 11

EYE, EAR, NOSE AND THROAT (EENT)

PREPARATIONS 17

EYE, EAR, NOSE, AND THROAT (EENT)

PREPARATIONS 17, 18, 19

F

famciclovir 4, 5

famotidine 20

felbamate 13

felodipine 11

FEMHRT 24

FEMHRT LOW DOSE 24

fenofibrate 9

fenofibrate (micronized) 9

fenoprofen calcium 12

fentanyl 12

fentanyl citrate 12

FINACEA 28

finasteride 25

FIRAZYR 26

FIRST GENERATION ANTIHISTAMINES 3

FLAREX 18

flavoxate hcl 28

flecainide acetate 9

FLOVENT DISKUS 21

FLOVENT HFA 21

fluconazole 4

fludrocortisone acetate 21

flunisolide (nasal) 18

fluocinolone acetonide 27

fluocinonide 27

fluocinonide emulsified base 27

fluorescein sodium 19

fluorescein w/ benoxinate 19

fluorescein w/ proparacaine 19

fluorometholone (ophthalmic) 18

fluorouracil (topical) 28

fluoxetine hcl 13

fluphenazine hcl 13

flurazepam hcl 14

flurbiprofen sodium (ophthalmic) 18

flutamide 6

fluticasone propionate 27

fluticasone propionate (nasal) 18

fluvoxamine maleate 13


- 34 -

FML FORTE 18

folic acid 28

FOLLISTIM AQ 24

fondaparinux 8

FORTEO 24

FOSAMAX PLUS D 25

fosinopril sodium 11

fosinopril sodium & hydrochlorothiazide 11

FRAGMIN 8

furosemide 16

G

gabapentin 13

galantamine hbr 7

galantamine hbr (extended release) 7

GANCYCLOVIR 5

GASTROINTESTINAL DRUGS 19, 20

gatifloxacin (ophthalmic) 17

gemfibrozil 9

GENITOURINARY SMOOTH MUSCLE

RELAXANTS 28

GENTAMICIN SULFATE 26

gentamicin sulfate (ophthalmic) 17

GENTAMICIN SULFATE (topical) 26

GI ANTI-INFLAMMATORY AGENTS 20

GLATOPA 25

GLEEVEC 6

glimepiride 23

glipizide 23

glipizide (extended release) 23

GLUCAGON HCL 23

glyburide 23

glyburide & metformin hcl 23

glycopyrrolate 7

GOLD COMPOUNDS 20

GONADOTROPINS 24

GONAL-F 24

griseofulvin ultramicrosize 4

guaifenesin & codeine 17

guanfacine hcl 9

H

halobetasol propionate 27

haloperidol 13

haloperidol lactate 13

HARVONI 5

HEAVY METAL ANTAGONISTS 21

HEMATOPOIETIC AGENTS 9

HEMORRHEOLOGIC AGENTS 9

heparin sodium 8

HEXALEN 6

HORMONES AND SYNTHETIC SUBSTITUTES 21,

23, 24

HUMALOG 23

HUMALOG KWIKPEN 23

HUMALOG MIX 50/50 23

HUMALOG MIX 50/50 PEN 23

HUMALOG MIX 75/25 23

HUMALOG MIX 75/25 PEN 23

HUMIRA 25

HUMULIN R U-500 23

hydralazine hcl 9

hydrochlorothiazide 16

hydrocodone & acetaminophen 12

hydrocodone & homatropine 17

hydrocodone polistirex & chlorpheniramine polistirex 17

hydrocortisone 21

hydrocortisone & acetic acid (otic) 18

hydrocortisone (intrarectal) 27

hydrocortisone (rectal) 27

hydrocortisone (topical) 27

hydrocortisone acetate & pramoxine 28

hydrocortisone acetate (rectal) 27

hydrocortisone butyrate 27

hydrocortisone butyrate hydrophilic lipo base 27

hydrocortisone valerate 27

hydromorphone hcl 12

hydroxychloroquine sulfate 5

hydroxyurea 6

hydroxyzine hcl 15

hydroxyzine pamoate 15

hyoscyamine sulfate 7

HYPOTENSIVE AGENTS 9

I

ibuprofen 12

IMBRUVICA 6

imipramine hcl 13

imipramine pamoate 13

imiquomod 28

IMMUNOSUPPRESSIVE AGENTS 25

indapamide 16

indomethacin 12

INSULIN ISOPHANE & 23

INSULIN ISOPHANE (HUMAN) 23

INSULIN REGULAR (HUMAN) 23

INTELENCE 5

INTRON-A 6

INVIRASE 5

iodoquinol-hc 27

ION-REMOVING AGENTS 16

ipratropium bromide (inhaled 7

ipratropium bromide (nasal) 7

IRESSA 6

ISENTRESS 5

isoniazid 4

isosorbide dinitrate 10

isosorbide mononitrate 10

isotretinoin 28

isradipine 11

itraconazole 4

ivermectin 3


- 35 -

J

JOLESSA 22

K

KALETRA 5

KARIVA 21

KELNOR 22

KENALOG 27

ketoconazole 4, 26

ketoprofen 12

ketoprofen (extended release) 12

ketorolac tromethamine 12

ketorolac tromethamine (ophthalmic)) 18

KINERET 26

L

labetalol hcl 10

lactated ringer’s (irrigation) 16

lactulose 16

lamivudine 5

lamivudine-zidovudine 5

lamotrigine 13

LANTUS 23

LANTUS SOLOSTAR 23

latanoprost 19

leflunomide 25

LESSINA 22

LETAIRIS 10

letrozole 6

leucovorin calcium 25

LEUKERAN 6

LEUKINE 9

leuprolide acetate 6

levalbuterol hcl solution 8

LEVEMIR 23

LEVEMIR FLEXTOUCH 23

levetiracetam 13

LEVITRA 10

levobunolol hcl (ophthalmic) 19

levocarnitine 26

levofloxacin 3

levonorgestrel & ethinyl estradiol (91-day) 22

levonorgestrel & ethinyl estradiol (monophasic) 22

levonorgestrel & ethinyl estradiol (triphasic) 22

levonorgestrel (emergency oral contraceptive 22

levothyroxine sodium 24

LEXIVA 5

LIALDA 20

lidocaine hcl 28

lidocaine hcl (mouth-throat) 19

lidocaine-prilocaine 26

lindane 26

linezolid 3

liothyronine 25

lisinopril 11

lisinopril & hydrochlorothiazide 11

lithium carbonate 15

lithium carbonate (extended release) 15

LO/OVRAL 23

LOCAL ANESTHETICS 19

LOESTRIN 1.5/30 22

LOESTRIN 1/20 22

LOESTRIN FE 1.5/30 22

LOESTRIN FE 1/20 22

lorazepam 15

losartan potassium 11

losartan potassium & hydrochlorothiazide 11

lovastatin 9

LOVENOX 8

LOW-OGESTREL 23

loxapine succinate 13

LUPRON DEPOT 6

LUPRON DEPOT-PED 6

LYSODREN 6

M

maprotiline hcl 13

MATULANE 6

meclofenamate sodium 12

medroxyprogesterone acetate 24

mefloquine hcl 5

megestrol acetate 6

meloxicam 12

MENOPUR 24

MEPHYTON 29

mercaptopurine 7

mesalamine 20

metaproterenol sulfate 8

metformin hcl 23

metformin hcl (extended release) 23

methadone hcl 12

methazolamide 19

methenamine hippurate 6

methenamine mandelate 6

methimazole 25

METHITEST 21

methocarbamol 8

methotrexate 7

methyldopa 9

methylergonovine 26

methylphenidate hcl 14

methylphenidate hcl (extended release) 14

methylprednisolone 21

metipranolol (ophthalmic) 19

metoclopramide hcl 20

metolazone 16

metoprolol succinate 10

metoprolol tartrate 10

metronidazole 6

metronidazole (topical) 26

metronidazole (vaginal) 26

mexiletine hcl 9

MICONAZOLE 3 26

miconazole nitrate 26


- 36 -

MICROGESTIN 1.5/30 22

MICROGESTIN 1/20 22

MICROGESTIN FE 1.5/30 22

MICROGESTIN FE 1/20 22

midodrine hcl 8

minocycline 3

minoxidil 10

MIRCETTE 21

mirtazapine 14

MISCELLANEOUS THERAPEUTIC AGENTS 25, 26

misoprostol 20

modafinil 14

MODICON 22

moexipril & hydrochlorothiazide 11

moexipril hcl 11

mometasone furoate 27

montelukast sodium 17

montelukast sodium(packets) 17

morphine sulfate 12

morphine sulfate (extended release) 12

moxifloxacin 3

mupirocin (topical) 26

MUSE 10

mycophenolate mofetil 26

mycophenolate sodium 26

MYLERAN 7

N

nabumetone 12

nadolol 10

NAFTIN 27

naltrexone hcl 12

naproxen 12

naproxen sodium 12

naratriptan 15

NARCAN 15

NASONEX 18

NEBUPENT 6

NECON 1/50 22

NECON 10/11 22

NECON 7/7/7 22

NEFAZODONE HCL 14

nemantine hcl 15

neomycin sulfate 4

neomycin, bacitracin & polymyxin B (ophthalmic) 18

NEOMYCIN, POLYMYXIN & 18

neomycin, polymyxin & dexamethasone (ophth) 18

neomycin, polymyxin & dexamethasone (ophthalmic) 18

neomycin, polymyxin & hydrocortisone (otic) 18

neomycin, polymyxin, bacitracin & hydrocortisone

(ophthalmic) 18

NEULASTA 9

nevirapine 5

NEXAVAR 7

NIASPAN 9

nifedipine 11

NILANDRON 7

nimodipine 11

nitrofurantoin macrocrystals 6

nitrofurantoin monohydrate macrocystals 6

nitrofurantoin suspension 6

nitroglycerin 10

NORA-BE 22

NORDETTE 22

norethindrone & ethinyl estradiol (biphasic) 22

norethindrone & ethinyl estradiol (monophasic) 22

norethindrone & ethinyl estradiol (triphasic) 22

norethindrone & mestranol 22

norethindrone (contraceptive) 22

norethindrone acetate 24

norethindrone acetate & ethinyl estradiol 22

norethindrone acetate, estradiol, & iron 22

norgestimate & ethinyl estradiol (monophasic) 22

norgestimate & ethinyl estradiol (triphasic) 22

norgestrel & ethinyl estradiol 22

NOR-QD 22

NORTREL 0.5/35 22

NORTREL 1/35, 22

NORTREL 7/7/7 22

nortriptyline hcl 14

NORVIR 5

NOVOLOG 23

NOVOLOG FLEXPEN 23

NOVOLOG MIX 70/30 23

NOVOLOG MIX 70/30 FLEXPEN 23

NUVARING 23

nystatin 4

nystatin & triamcinolone 27

nystatin (topical) 27

O

ofloxacin (ophthalmic) 18

ofloxacin (otic) 18

OGESTREL 23

olanzapine 14

olanzapine odt 14

omeprazole 20

OMNITROPE 24

ondansetron hcl 20

ophthalmic irrigation 19

OPIATE ANTAGONISTS 12

ORTHO TRI-CYCLEN 22

ORTHO-CEPT 21

ORTHO-CYCLEN 22

ORTHO-MICRONOR 22

ORTHO-NOVUM 1/35 22

ORTHO-NOVUM 1/50 22

ORTHO-NOVUM 7/7/7 22

OSPHENA 10

OTHER MISCELLANEOUS THERAPEUTIC

AGENTS 26

OVIDREL 24

oxaprozin 12

oxazepam 15

oxcarbazepine 13

OXSORALEN 28


- 37 -

oxybutynin chloride 28

oxybutynin chloride (extended release) 28

oxycodone & acetaminophen 12

oxycodone & aspirin 12

oxycodone hcl 12

OXYTOCICS 26

P

pantoprazole sodium 20

PARASYMPATHOMIMETIC (CHOLINERGIC)

AGENTS 7

PARATHYROID 24

paromomycin sulfate 6

paroxetine hcl 14

paroxetine hcl (extended release) 14

PATANOL 17

PEDIATRIC MULTIVITAMINS 29

pediatric multivitamins with fluoride 29

pediatric vitamins A, C, D, with fluoride 29

PEGASYS 5

PEG-INTRON 5

penicillin V potassium 4

pentoxifylline 9

permethrin 27

perphenazine 14

phenazopyridine hcl 28

phenelzine 14

phenobarbital 15

phenoxybenzamine 8

phentermine 14

phenylephrine (ophth) 19

phenytoin 13

phenytoin sodium (extended release) 13

PHOSPHOLINE IODIDE (ophthalmic) 19

PIGMENTING AND DEPIGMENTING AGENTS 28

pilocarpine hcl (ophthalmic) 19

pilocarpine hcl (oral) 7

pindolol 10

pioglitazone hcl 23

PITUITARY 24

PLAN B 23

podofilox 28

polyethylene glycol 3350, 19

polyethylene glycol 3350, potassium chloride, sodium

bicarbonate & sodium chloride 19

polymyxin B & trimethoprim 18

PORTIA 22

pot phosphate monobasic w/ sod phosphate dibasic &

monobasic 16

potassium and sodium citrates with citric acid 16

potassium bicarbonate & potassium chloride 16

potassium chloride 16

potassium citrate 16

potassium citrate-citric acid 16

PRADAXA 8

pramipexole dihydrochloride 15

pramipexole dihydrochloride 15

PRAMOXINE-HC 27

pravastatin 9

prazosin hcl 10

PRED-G (ophthalmic) 18

PRED-G S.O.P. (ophthalmic) 18

prednisolone 21

prednisolone acetate (ophthalmic) 18

prednisolone sodium phosphate 21

prednisolone sodium phosphate (ophthalmic) 18

prednisone 21

PREMARIN 24

PREMPHASE 24

PREMPRO 24

prenatal vitamin with docusate, ferrous fumarate, & folic

acid 29

PRENATAL VITAMIN WITH DOCUSATE, IRON

CARBONYL & FOLIC ACID 29

PRENATAL VITAMIN WITH FERROUS FUMARATE

& FOLIC ACID 29

PRENATAL VITAMIN WITH IRON CARBONYL &

FOLIC ACID 29

PRENATAL VITAMIN WITH MINERALS, IRON &

FOLIC ACID 29

PRENATAL VITAMIN WITH SELENIUM, FERROUS

FUMARATE & FOLIC ACID 29

PRENATAL VITAMINS 29

PREVACID SOLUTAB 20

PREVIFEM 22

PREZISTA 5

PRIMAQUINE PHOSPHATE 6

primidone 13

probenecid 17

probenecid & colchicine 17

prochlorperazine maleate 14

PROCRIT 9

progesterone, micronized 24

PROGESTINS 24

PROKINETIC AGENTS 20

promethazine hcl 3

propafenone hcl 9

proparacaine 19

propranolol hcl 10

propylthiouracil 25

PROTECTIVE AGENTS 26

protriptyline hcl 14

PSYCHOTHERAPEUTIC AGENTS 13

PULMICORT FLEXHALER 21

PULMOZYME 16, 17

pyrazinamide 4

pyridostigmine bromide 7

Q

QSYMIA 14

quetiapine fumarate 14

quinapril & hydrochlorothiazide 11

quinapril hcl 11

quinidine gluconate 9

quinidine sulfate 9

QVAR 21


- 38 -

R

raloxifene 24

ramipril 11

ranitidine hcl 20

RAPAMUNE 26

REBIF 25

REGRANEX 28

RELENZA 5

RENAGEL 16

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM

INHIBITORS 11

RENVELA 16

RENVELA PAK 16

REPLACEMENT PREPARATIONS 16

RESCRIPTOR 5

reserpine 10

RESPIRATORY SMOOTH MUSCLE RELAXANTS28

RESPIRATORY TRACT AGENTS 17

RESPIRATORY TRACT AGENTS,

MISCELLANEOUS 17

RESPIRATORY TRACT ANTI-INFLAMMATORY

AGENTS 17

REVLIMID 25

REYATAZ 5

ribavirin 5

RIDAURA 20

rifabutin 4

rifampin 4

riluzole 15

rimantadine 5

ringer’s (irrigation) 16

risperidone 14

rizatriptan 15

ropinirole hcl 15

S

salsalate 12

SAVELLA 16

SEASONIQUE 22

SECOND GENERATION ANTIHISTAMINES 3

selegiline hcl 15

selenium sulfide 27

SELZENTRY 5

SEREVENT DISKUS 8

sertraline hcl 14

sildenafil citrate (REVATIO) 10

silver sulfadiazine 27

simvastatin 9

sirolimus 26

SKELETAL MUSCLE RELAXANTS 8

SKIN AND MUCOUS MEMBRANE AGENTS 26, 27,

28

SKIN AND MUCOUS MEMBRANE AGENTS,

MISCELLANEOUS 28

SMOOTH MUSCLE RELAXANTS 28

sodium chloride (gu irrigant) 16

sodium chloride for nebulization 17

sodium citrate & citric acid 16

sodium fluoride 25

sodium polystyrene sulfonate 16

SOMATROPIN AGONISTS AND ANTAGONISTS 24

sotalol hcl 10

SOVALDI 5

SPECTRACEF 4

SPIRIVA RESPIMAT 7

spironolactone 11

spironolactone & hydrochlorothiazide 11

SPRINTEC 22

SPRYCEL 7

SSKI 25

stavudine 5

STRIVERDI RESPIMAT 17

sucralfate 20

sulfacetamide sodium & prednisolone sodium phosphate

(ophthalmic) 18

sulfacetamide sodium (ophthalmic) 18

sulfacetamide sodium (topical) 27

sulfadiazine 4

sulfamethoxazole & trimethoprim 4

sulfasalazine 4, 20

sulindac 12

sumatriptan succinate 15

SUPRAX 4

SUSTIVA 5

SUTENT 7

SYMPATHOLYTIC (ADRENERGIC BLOCKING)

AGENTS 8

SYMPATHOMIMETIC (ADRENERGIC) AGENTS 7

T

TABLOID 7

tacrolimus 26

tacrolimus (topical) 28

TAMIFLU 5

tamoxifen citrate 7

tamsulosin hcl 8

TARCEVA 7

TARGRETIN 7, 28

TARKA 11

TAZORAC 28

temazepam 15

temozolomide 7

terazosin hcl 10

terbinafine 4

terbutaline sulfate 8

testosterone 21

testosterone cypionate 21

testosterone enanthate 21

tetracaine hcl (ophth) 19

tetracycline 4

THALOMID 25

theophylline 28

thioridazine hcl 14

thiothixene 14

thyroid 25


- 39 -

THYROID AND ANTITHYROID AGENTS 24

THYROLAR 25

tiagabine 13

TIKOSYN 9

timolol maleate (ophthalmic) 19

tizanidine hcl 8

TOBI Podhaler 4

tobramycin neb 4

tobramycin sulfate & dexamethasone (ophth) 18

tobramycin sulfate (ophthalmic) 18

tolazamide 23

TOLBUTAMIDE 23

tolterodine tartrate 28

tolterodine tartrate (extended release) 28

topiramate 13

torsemide 16

TRACLEER 10

tramadol hcl 12

tranylcypromine sulfate 14

trazodone hcl 14

tretinoin 28

tretinoin (chemo) 7

triamcinolone acetonide (mouth) 27

triamcinolone acetonide (topical) 27

triamterene & hydrochlorothiazide 16

triazolam 15

trifluoperazine hcl 14

trifluridine (ophth) 18

trihexyphenidyl hcl 15

trimethoprim 6

TRI-NORINYL 22

TRI-PREVIFEM 22

TRI-SPRINTEC 22

TRIVORA 22

tropicamide (ophthalmic) 19

trospium chloride 28

TRUVADA 5

TYKERB 7

TYZEKA 5

U

URICOSURIC AGENTS 17

URINARY ANTI-INFECTIVES 6

ursodiol 20

V

VAGIFEM 24

valacyclovir 5

valganciclovir 5

valproic acid 13

valsartan 11

valsartan & hydrochlorothiazide 11

vancomycin 4

VASODILATING AGENTS 10

VECTICAL 28

VELIVET 21

venlafaxine hcl 14

venlafaxine hcl (extended release) 14

VENTOLIN HFA 8

verapamil hcl 11

VIAGRA 10

VICTRELIS 5

VIRACEPT 5

VIREAD 5

VITAMIN B COMPLEX 28

VITAMIN D 29

VITAMIN K ACTIVITY 29

VITAMINS 28, 29

voriconazole 4

VOTRIENT 7

W

warfarin sodium 8

water for irrigation (sterile) 16

X

XOPENEX HFA 8

XTANDI 7

XULANE 23

Y

YASMIN 21

YODOXIN 6

Z

zafirlukast 17

zaleplon 15

ZARXIO 9

ZELBORAF 7

zidovudine 5

zinc sulfate 16

ziprasidone hcl 14

ZOLINZA 7

zolmitriptan 15

zolmitriptan ODT 15

zolpidem tartrate 15

zonisamide 13

ZOVIA 1/35E 22

ZOVIA 1/50E 22

ZYDELIG 7

ZYTIGA 7

ZYVOX 4


- 40 -

Southern Colorado Commercial HMO Drug...

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