closed formulary - fallon community health plan

Closed Formulary

List of Covered Drugs

Please read This document contains information

about the drugs we cover in this plan.

1

What is a formulary? A formulary is a listing of prescription drugs that are approved for coverage by Fallon Community Health Plan. These drugs are classified by therapeutic category or disease class. Fallon Community Health Plan uses a closed formulary for Direct Care, Select Care, Fallon Preferred Care and Steward Community Care Premium Saver II and Premium Saver 2000/500 II plans. The covered prescription drugs are listed on the following pages. The formulary list is limited and drugs not on the following list will not be covered by your prescription drug benefit under any circumstances. Can this formulary change? Yes, Fallon Community Health Plan may add or remove drugs from our formulary during the year. If we remove drugs from our formulary during the year, we must notify you of the change at least 60 days before the date that the change becomes effective. What is a drug class? A drug class is the group that a specific drug belongs to based on what the drug is used for. Examples of drug classes are antibiotics, antidepressants or diuretics. What are tiers? This is the classification that applies to each drug or to durable medical equipment (DME). For example: Tier 1: Preferred generic drugs Tier 2: Non-preferred generic and preferred-brand drugs Tier 3: Non-preferred brand-name drugs Tier-1 drugs tend to have lower copayments than Tier-3 drugs. What are quantity limits? For certain drugs, Fallon Community Health Plan limits the amount of the drug per month or day (DY) that FCHP will cover. Are there any other restrictions on prescription drug coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior authorization (PA): Fallon Community Health Plan requires that you obtain prior authorization for certain drugs. This means that you will need to obtain approval from FCHP before you fill your prescriptions. If you do not obtain approval, FCHP may not cover the drug.

Quantity limits (QL): For certain drugs, Fallon Community Health Plan limits the amount of the drug per month that FCHP will cover.

What if my drug is not on the formulary? There may be periodic changes to the drugs listed in this formulary. To determine whether a particular drug is included or excluded from the closed formulary, please call Customer Service. The toll free number for FCHP Direct Care, Select Care and Steward Community Care is 1-800-868-5200. The toll free number for Fallon Preferred Care members is 1-888-468-1541. We are available Monday through Friday, 8 a.m. to 6 p.m. TTY users, please call TRS Relay. You may also access our Web site at fchp.org and click on the “Online Drug Formulary” in our Member’s section for a complete listing of the drugs included in the closed formulary.

2

Tier PA QL

Penicillins

Natural Penicillins

PENICILLIN V POTASSIUM 250MG TABS 1

PENICILLIN V POTASSIUM 500MG TABS 3

PENICILLIN V POTASSIUM 125MG/5ML SOLR 3

PENICILLIN V POTASSIUM 250MG/5ML SOLR 3

Aminopenicillins

AMOXICILLIN 250MG CAPS 1

AMOXICILLIN 500MG CAPS 1

AMOXICILLIN 500MG TABS 1

AMOXICILLIN 875MG TABS 1

AMOXICILLIN 125MG CHEW 1

AMOXICILLIN 250MG CHEW 1

AMOXICILLIN 125MG/5ML SUSR 1




AMPICILLIN 250MG CAPS 1

AMPICILLIN 500MG CAPS 1

AMPICILLIN 125MG/5ML SUSR 1

AMPICILLIN 250MG/5ML SUSR 1

Penicillinase-Resistant Penicillins

DICLOXACILLIN SODIUM 250MG CAPS 1

DICLOXACILLIN SODIUM 500MG CAPS 1

Penicillin Combinations

AMOXICILLIN/CLAVULANATE POTASSIUM 250MG; 125MG TABS 1

AMOXICILLIN/POTASSIUM CLAVULANATE 500MG; 125MG TABS 1

AMOXICILLIN/POTASSIUM CLAVULANATE 875MG; 125MG TABS 1

AMOXICILLIN/POTASSIUM CLAVULANATE 200MG; 28.5MG CHEW 1

AMOXICILLIN/POTASSIUM CLAVULANATE 400MG; 57MG CHEW 1

AMOXICILLIN/POTASSIUM CLAVULANATE 200MG/5ML; 28.5MG/5ML SUSR

1

AMOXICILLIN/CLAVULANATE POTASSIUM 250MG/5ML; 62.5MG/5ML SUSR

1

AMOXICILLIN/POTASSIUM CLAVULANATE 400MG/5ML; 57MG/5ML SUSR

1

AMOXICILLIN/CLAVULANATE POTASSIUM 600MG/5ML; 42.9MG/5ML SUSR

1

3

Tier PA QL

Cephalosporins

Cephalosporins - 1st Generation

CEFADROXIL 500MG CAPS 1

CEFADROXIL 1GM TABS 1

CEFADROXIL 250MG/5ML SUSR 1

CEFADROXIL 500MG/5ML SUSR 1

CEPHALEXIN 250MG CAPS 1

CEPHALEXIN 500MG CAPS 1

CEPHALEXIN 250MG TABS 1

CEPHALEXIN 500MG TABS 1

CEPHALEXIN 125MG/5ML SUSR 1

CEPHALEXIN 250MG/5ML SUSR 1

Cephalosporins - 2nd Generation

CEFACLOR 250MG CAPS 1

CEFACLOR 500MG CAPS 1

CEFPROZIL 250MG TABS 1

CEFPROZIL 500MG TABS 1

CEFPROZIL 125MG/5ML SUSR 1

CEFPROZIL 250MG/5ML SUSR 1

CEFUROXIME AXETIL 250MG TABS 1

CEFUROXIME AXETIL 500MG TABS 1

CEFUROXIME AXETIL 125MG/5ML SUSR 1

Cephalosporins - 3rd Generation

CEFDINIR 300MG CAPS 1

CEFDINIR 125MG/5ML SUSR 1

CEFDINIR 250MG/5ML SUSR 1

CEFPODOXIME PROXETIL 100MG TABS 1

CEFPODOXIME PROXETIL 200MG TABS 1

CEFPODOXIME PROXETIL 50MG/5ML SUSR 1

CEFPODOXIME PROXETIL 100MG/5ML SUSR 1

Macrolides

Erythromycins

ERYTHROMYCIN BASE 250MG TABS 1

ERYTHROMYCIN BASE 500MG TABS 1

ERYTHROCIN STEARATE 250MG TABS 1

E.E.S. 400 400MG TABS 1

Azithromycin

AZITHROMYCIN 250MG TABS 1


4

Tier PA QL

Macrolides

Azithromycin, continued


AZITHROMYCIN 100MG/5ML SUSR 1

AZITHROMYCIN 200MG/5ML SUSR 1

Clarithromycin

CLARITHROMYCIN 250MG TABS 1

CLARITHROMYCIN 500MG TABS 1

CLARITHROMYCIN 125MG/5ML SUSR 1

CLARITHROMYCIN 250MG/5ML SUSR 1

CLARITHROMYCIN ER 500MG TB24 1

Tetracyclines

Tetracyclines

DOXYCYCLINE MONOHYDRATE 50MG CAPS 1

DOXYCYCLINE MONOHYDRATE 100MG CAPS 1

DOXYCYCLINE MONOHYDRATE 50MG TABS 1



DOXYCYCLINE HYCLATE 50MG CAPS 1

DOXYCYCLINE HYCLATE 100MG CAPS 1

DOXYCYCLINE HYCLATE 100MG TABS 1

MINOCYCLINE HCL 50MG CAPS 1



MINOCYCLINE HCL 50MG TABS 1



TETRACYCLINE HCL 250MG CAPS 1

TETRACYCLINE HCL 500MG CAPS 1

Fluoroquinolones

Fluoroquinolones

CIPROFLOXACIN ER 1000MG; 0 TB24 1 3 PER RX

CIPROFLOXACIN HCL 100MG TABS 1




Aminoglycosides

Aminoglycosides

NEOMYCIN SULFATE 500MG TABS 1

5

Tier PA QL

Sulfonamides

Sulfonamides

SULFADIAZINE 500MG TABS 3

Antimycobacterial Agents

Antimycobacterial Agents

ETHAMBUTOL HCL 100MG TABS 1

ETHAMBUTOL HCL 400MG TABS 1

ISONIAZID 300MG TABS 1

RIFAMPIN 150MG CAPS 1

RIFAMPIN 300MG CAPS 1

Antifungals

Antifungals

GRISEOFULVIN MICROSIZE 125MG/5ML SUSP 1

NYSTATIN 500000UNIT TABS 1

BIO-STATIN 0 POWD 1

TERBINAFINE HCL 250MG TABS 1 84 PER 365 DAYS

Imidazole-Related Antifungals

KETOCONAZOLE 200MG TABS 1

FLUCONAZOLE 50MG TABS 1 15 PER RX




FLUCONAZOLE 10MG/ML SUSR 1 75 PER RX

FLUCONAZOLE 40MG/ML SUSR 1 75 PER RX

Antivirals

Hepatitis Agents

BARACLUDE 0.5MG TABS 3 PA

BARACLUDE 1MG TABS 3 PA

BARACLUDE 0.05MG/ML SOLN 3 PA

TYZEKA 600MG TABS 3 PA 30 PER 30 DAYS

PEG-INTRON 50MCG/0.5ML KIT 3 PA Specialty Pharmacy


PEG-INTRON REDIPEN 120MCG/0.5ML KIT 3 PA Specialty Pharmacy



RIBAVIRIN 200MG CAPS 1 PA Specialty Pharmacy

RIBASPHERE 200MG CAPS 1 PA Specialty Pharmacy

RIBAVIRIN 200MG TABS

1 PA Specialty Pharmacy

6

Tier PA QL

Antivirals

Herpes Agents

ACYCLOVIR 200MG CAPS 1

ACYCLOVIR 400MG TABS 1

ACYCLOVIR 800MG TABS 1

ACYCLOVIR 200MG/5ML SUSP 1

VALACYCLOVIR HCL 500MG TABS 1

VALACYCLOVIR HCL 1000MG TABS 1

Influenza Agents

TAMIFLU 75MG CAPS 3 PA 10 PER RX

TAMIFLU 12MG/ML SUSR 3 PA 75 PER RX

Antimalarials

Antimalarials

CHLOROQUINE PHOSPHATE 250MG TABS 1

CHLOROQUINE PHOSPHATE 500MG TABS 1

HYDROXYCHLOROQUINE SULFATE 200MG TABS 1

MEFLOQUINE HCL 250MG TABS 1

Anthelmintics

Anthelmintics

MEBENDAZOLE 100MG CHEW 1

Anti-infective Agents - Misc.

Anti-infective Agents - Misc.

METRONIDAZOLE 375MG CAPS 1

METRONIDAZOLE 250MG TABS 1

METRONIDAZOLE 500MG TABS 1

TRIMETHOPRIM 100MG TABS 1

Lincosamides

CLINDAMYCIN HCL 150MG CAPS 1

CLINDAMYCIN HCL 300MG CAPS 1

Leprostatics

DAPSONE 25MG TABS 1

DAPSONE 100MG TABS 1

Anti-infective Misc. - Combinations

ERYTHROMYCIN/SULFISOXAZOLE 200MG/5ML; 600MG/5ML SUSR 1

SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG; 80MG TABS 1

SULFAMETHOXAZOLE/TRIMETHOPRIM DS 800MG; 160MG TABS 1

SULFAMETHOXAZOLE/TRIMETHOPRIM 200MG/5ML; 40MG/5ML SUSP

1

7

Tier PA QL

Antineoplastics And Adjunctive Therapies

Alkylating Agents

HEXALEN 50MG CAPS 3

MYLERAN 2MG TABS 3

LEUKERAN 2MG TABS 2

CYCLOPHOSPHAMIDE 25MG TABS 1

CYCLOPHOSPHAMIDE 50MG TABS 1

ALKERAN 2MG TABS 3

CEENU 10MG CAPS 3

CEENU 40MG CAPS 3

CEENU 100MG CAPS 3

TEMODAR 5MG CAPS 2 Specialty Pharmacy






Antimetabolites

MERCAPTOPURINE 50MG TABS 1

METHOTREXATE 2.5MG TABS 1

TABLOID 40MG TABS 3

VIDAZA 100MG SUSR 3 PA

XELODA 150MG TABS 3 Specialty Pharmacy

XELODA 500MG TABS 3 Specialty Pharmacy

Antineoplastic - Hormonal Agents

ANASTROZOLE 1MG TABS 1

BICALUTAMIDE 50MG TABS 1

EMCYT 140MG CAPS 2

EXEMESTANE 25MG TABS 1

FARESTON 60MG TABS 3

FLUTAMIDE 125MG CAPS 1

LETROZOLE 2.5MG TABS 1

LYSODREN 500MG TABS 2

MEGESTROL ACETATE 20MG TABS 1

MEGESTROL ACETATE 40MG TABS 1

MEGESTROL ACETATE 40MG/ML SUSP 1

NILANDRON 150MG TABS 3 PA

TAMOXIFEN CITRATE 10MG TABS 1

TAMOXIFEN CITRATE 20MG TABS 1

8

Tier PA QL

Antineoplastics And Adjunctive Therapies

Mitotic Inhibitors

ETOPOSIDE 50MG CAPS 1

Antineoplastic Enzyme Inhibitors

GLEEVEC 100MG TABS 3 Specialty Pharmacy

GLEEVEC 400MG TABS 3 Specialty Pharmacy

HYDROXYUREA 500MG CAPS 1

IRESSA 250MG TABS 3

MATULANE 50MG CAPS 2

NEXAVAR 200MG TABS 3 PA Specialty Pharmacy

SPRYCEL 100MG TABS 3 PA Specialty Pharmacy






SUTENT 12.5MG CAPS 3 PA Specialty Pharmacy

SUTENT 25MG CAPS 3 PA Specialty Pharmacy

SUTENT 50MG CAPS 3 PA Specialty Pharmacy

TARCEVA 100MG TABS 3 PA Specialty Pharmacy



TARGRETIN 75MG CAPS 3 Specialty Pharmacy

TASIGNA 200MG CAPS 3 PA Specialty Pharmacy

TRETINOIN 10MG CAPS 3

TYKERB 250MG TABS 3 PA Specialty Pharmacy

ZOLINZA 100MG CAPS 3 PA Specialty Pharmacy

Chemotherapy Rescue/Antidote Agents

LEUCOVORIN CALCIUM 5MG TABS 1



MESNEX 400MG TABS 3

Corticosteroids

Glucocorticosteroids

DEXAMETHASONE 0.5MG TABS 1


DEXAMETHASONE 1MG TABS 1



9

Tier PA QL

Corticosteroids

Glucocorticosteroids, continued



DEXAMETHASONE 0.5MG/5ML ELIX 1

DEXAMETHASONE 0.5MG/5ML SOLN 1

HYDROCORTISONE 5MG TABS 1



METHYLPREDNISOLONE 4MG TABS 1





PREDNISOLONE 15MG/5ML SOLN 1

PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLN 1

PREDNISOLONE SODIUM PHOSPHATE 5MG/5ML SOLN 1

PREDNISOLONE SODIUM PHOSPHATE 6.7MG/5ML SOLN 1

PREDNISONE 1MG TABS 1

PREDNISONE 2.5MG TABS 1





PREDNISONE 5MG/5ML SOLN 1



Mineralocorticoids

FLUDROCORTISONE ACETATE 0.1MG TABS 1

Estrogens

Estrogens

CENESTIN 0.3MG TABS 3





ENJUVIA 0.3MG TABS 3



10

Tier PA QL

Estrogens

Estrogens, continued



ESTRADIOL 0.025MG/24HR PTWK 1 4 PER 28 DAYS





ESTRADIOL 0.5MG TABS 1

ESTRADIOL 1MG TABS 1

ESTRADIOL 2MG TABS 1

ESTRADIOL 37.5MCG/24HR PTWK 1 4 PER 28 DAYS

ESTROPIPATE 0.75MG TABS 1

ESTROPIPATE 1.5MG TABS 1

ESTROPIPATE 3MG TABS 1

MENEST 0.3MG TABS 2

MENEST 0.625MG TABS 2

MENEST 1.25MG TABS 2

MENEST 2.5MG TABS 2

PREMARIN 0.3MG TABS 3





Estrogen Combinations

ACTIVELLA 0.5MG; 0.1MG TABS 3

ESTRADIOL/NORETHINDRONE ACETATE 1MG; 0.5MG TABS 1

JINTELI 5MCG; 1MG TABS 1

MIMVEY 1MG; 0.5MG TABS 1

PREMPRO 0.3MG; 1.5MG TABS 3



PREMPRO 0.625MG; 5MG TABS 3

Contraceptives

Progestin Contraceptives - Oral

CAMILA 0.35MG TABS 1

ERRIN 0.35MG TABS 1

JOLIVETTE 0.35MG TABS 1

11

Tier PA QL

Contraceptives

Progestin Contraceptives – Oral, continued

NORA-BE 0.35MG TABS 1

Progestin Contraceptives - Injectable

MEDROXYPROGESTERONE ACETATE 150MG/ML SUSP 1 1 PER 90 DAYS

Emergency Contraceptives

NEXT CHOICE 0.75MG TABS 1

Combination Contraceptives - Vaginal

NUVARING 0.015MG/24HR; 0.12MG/24HR RING 3

Combination Contraceptives - Oral

ALTAVERA 0.03MG; 0.15MG TABS 1

APRI 0.15MG; 30MCG TABS 1

ARANELLE 0; 0 TABS 1

AVIANE 20MCG; 0.1MG TABS 1

AZURETTE 0; 0 TABS 1

BALZIVA 35MCG; 0.4MG TABS 1

BRIELLYN 35MCG; 0.4MG TABS 1

CAZIANT 0; 0 TABS 1

CESIA 0; 0 TABS 1

CRYSELLE-28 30MCG; 0.3MG TABS 1

CYCLAFEM 1/35 35MCG; 1MG TABS 1

CYCLAFEM 7/7/7 0; 0 TABS 1

CYCLESSA 0; 0 TABS 3

EMOQUETTE 0.15MG; 30MCG TABS 1

ENPRESSE-28 0; 0 TABS 1

ESTROSTEP FE 0; 75MG; 1MG TABS 3

FEMCON FE 35MCG; 0; 0.4MG CHEW 3

GIANVI 3MG; 0.02MG TABS 1

GILDESS FE 1.5/30 30MCG; 75MG; 1.5MG TABS 1

GILDESS FE 1/20 20MCG; 75MG; 1MG TABS 1

INTROVALE 0.03MG; 0.15MG TABS 1 1 PER 91 DAYS

JOLESSA 0.03MG; 0.15MG TABS 1 1 PER 91 DAYS

JUNEL 1.5/30 30MCG; 1.5MG TABS 1

JUNEL 1/20 20MCG; 1MG TABS 1

JUNEL FE 1.5/30 30MCG; 75MG; 1.5MG TABS 1

JUNEL FE 1/20 20MCG; 75MG; 1MG TABS 1

KARIVA 0; 0 TABS 1

KELNOR 1/35 35MCG; 1MG TABS 1

LEENA 0; 0 TABS 1

12

Tier PA QL

Contraceptives

Combination Contraceptives – Oral, continued

LESSINA-28 20MCG; 0.1MG TABS 1

LEVORA 0.15/30-28 30MCG; 0.15MG TABS 1

LOESTRIN 24 FE 20MCG; 75MG; 1MG TABS 3

LOESTRIN FE 1.5/30 30MCG; 75MG; 1.5MG TABS 3

LOESTRIN FE 1/20 20MCG; 75MG; 1MG TABS 3

LORYNA 3MG; 0.02MG TABS 1

LOW-OGESTREL 30MCG; 0.3MG TABS 1

LUTERA 20MCG; 0.1MG TABS 1

LYBREL 20MCG; 90MCG TABS 3

MICROGESTIN 1.5/30 30MCG; 1.5MG TABS 1

MICROGESTIN 1/20 20MCG; 1MG TABS 1

MICROGESTIN FE 1.5/30 30MCG; 75MG; 1.5MG TABS 1

MICROGESTIN FE 20MCG; 75MG; 1MG TABS 1

MONONESSA 35MCG; 0.25MG TABS 1

NECON 0.5/35-28 35MCG; 0.5MG TABS 1

NECON 1/35-28 35MCG; 1MG TABS 1

NECON 1/50-28 50MCG; 1MG TABS 1

NECON 10/11-28 35MCG; 0 TABS 3

NECON 7/7/7 0; 0 TABS 1

NORGESTREL/ETHINYL ESTRADIOL 30MCG; 0.3MG TABS 1

NORINYL 1+50 50MCG; 1MG TABS 2

NORTREL 0.5/35 (28) 35MCG; 0.5MG TABS 1

NORTREL 1/35 (21) 35MCG; 1MG TABS 1

NORTREL 1/35 (28) 35MCG; 1MG TABS 1

NORTREL 7/7/7 0; 0 TABS 1

OCELLA 3MG; 0.03MG TABS 1

OGESTREL 50MCG; 0.5MG TABS 3

ORTHO TRI-CYCLEN 0; 0 TABS 3

ORTHO TRI-CYCLEN LO 0; 0 TABS 3

ORTHO-CYCLEN 35MCG; 0.25MG TABS 3

ORTHO-NOVUM 7/7/7 0; 0 TABS 3

OVCON-50 28 50MCG; 1MG TABS 3

PORTIA-28 0.03MG; 0.15MG TABS 1

PREVIFEM 35MCG; 0.25MG TABS 1

QUASENSE 0.03MG; 0.15MG TABS 1 1 PER 91 DAYS

RECLIPSEN 0.15MG; 30MCG TABS 1

SEASONALE 0.03MG; 0.15MG TABS 2 1 PER 91 DAYS

SEASONIQUE 0; 0 TABS 2 1 PER 91 DAYS

13

Tier PA QL

Contraceptives

Combination Contraceptives – Oral, continued

SOLIA 0.15MG; 30MCG TABS 1

SPRINTEC 28 35MCG; 0.25MG TABS 1

SRONYX 20MCG; 0.1MG TABS 1

SYEDA 3MG; 0.03MG TABS 1

TILIA FE 0; 75MG; 1MG TABS 1

TRI-LEGEST FE 0; 75MG; 1MG TABS 1

TRINESSA 0; 0 TABS 1

TRI-NORINYL 28 0; 0 TABS 2

TRI-PREVIFEM 0; 0 TABS 1

TRI-SPRINTEC 0; 0 TABS 1

TRIVORA-28 0; 0 TABS 1

VELIVET 0; 0 TABS 1

ZARAH 3MG; 0.03MG TABS 1

ZENCHENT 35MCG; 0.4MG TABS 1

ZEOSA 35MCG; 0; 0.4MG CHEW 1

ZOVIA 1/35E 35MCG; 1MG TABS 1

ZOVIA 1/50E 50MCG; 1MG TABS 1

Progestins

Progestins

MEDROXYPROGESTERONE ACETATE 2.5MG TABS 1

MEDROXYPROGESTERONE ACETATE 5MG TABS 1

MEDROXYPROGESTERONE ACETATE 10MG TABS 1

NORETHINDRONE ACETATE 5MG TABS 1

PROMETRIUM 100MG CAPS 2

PROMETRIUM 200MG CAPS 2

Antidiabetics

Insulin

LANTUS 100UNIT/ML SOLN 2

HUMALOG 100UNIT/ML SOLN 2

LEVEMIR 100UNIT/ML SOLN 3

NOVOLIN R 100UNIT/ML SOLN 3

HUMULIN R 100UNIT/ML SOLN 2

HUMULIN R U-500 (CONCENTRATED) 500UNIT/ML SOLN 2

NOVOLIN N 100UNIT/ML SUSP 3

HUMULIN N 100UNIT/ML SUSP 2

NOVOLIN 70/30 30%; 70% SUSP 3

HUMULIN 70/30 30%; 70% SUSP 2

14

Tier PA QL

Antidiabetics

Sulfonylureas

CHLORPROPAMIDE 100MG TABS 1

CHLORPROPAMIDE 250MG TABS 1

GLIMEPIRIDE 1MG TABS 1



GLIPIZIDE 5MG TABS 1

GLIPIZIDE 10MG TABS 1

GLIPIZIDE ER 2.5MG TB24 1

GLIPIZIDE XL 2.5MG TB24 1

GLIPIZIDE ER 5MG TB24 1

GLIPIZIDE XL 5MG TB24 1

GLIPIZIDE ER 10MG TB24 1

GLIPIZIDE XL 10MG TB24 1

GLYBURIDE 1.25MG TABS 1

GLYBURIDE 2.5MG TABS 1

GLYBURIDE 5MG TABS 1

GLYBURIDE MICRONIZED 1.5MG TABS 1

GLYBURIDE MICRONIZED 3MG TABS 1

GLYBURIDE MICRONIZED 6MG TABS 1

TOLAZAMIDE 250MG TABS 1

TOLAZAMIDE 500MG TABS 1

Biguanides

METFORMIN HCL 500MG TABS 1



METFORMIN HCL ER 500MG TB24 1

METFORMIN HCL ER 750MG TB24 1

Diabetic Other

GLUCAGON EMERGENCY KIT 1MG KIT 2

GLUCAGEN 1MG SOLR 2

Alpha-Glucosidase Inhibitors

ACARBOSE 25MG TABS 1 90 PER 30 DAYS

ACARBOSE 50MG TABS 1

ACARBOSE 100MG TABS 1 90 PER 30 DAYS

Insulin Sensitizing Agents

ACTOS 15MG TABS 2 30 PER 30 DAYS



15

Tier PA QL

Thyroid Agents

Thyroid Hormones

ARMOUR THYROID 120MG TABS 2








BIO-THROID 120MG CAPS 3









LEVOTHROID 100MCG TABS 1












LEVOTHYROXINE SODIUM 100MCG TABS 1









16

Tier PA QL

Thyroid Agents

Thyroid Hormones, continued




LEVOXYL 100MCG TABS 1











LIOTHYRONINE SODIUM 25MCG TABS 1



NATURE-THROID 130MG TABS 3

NATURE-THROID 16.25MG TABS 3







NP THYROID 30 30MG TABS 1



SYNTHROID 100MCG TABS 3










17

Tier PA QL

Thyroid Agents

Thyroid Hormones, continued



THYROLAR-1 60MG TABS 2

THYROLAR-1/2 30MG TABS 2

THYROLAR-1/4 15MG TABS 2



UNITHROID 100MCG TABS 1











WESTHROID 130MG TABS 3

WESTHROID 16.25MG TABS 3







Antithyroid Agents

METHIMAZOLE 5MG TABS 1

METHIMAZOLE 10MG TABS 1

PROPYLTHIOURACIL 50MG TABS 1

Oxytocics

Oxytocics

METHERGINE 0.2MG TABS 3

Endocrine and Metabolic Agents - Misc.

Bone Density Regulators

ALENDRONATE SODIUM 5MG TABS 1


18

Tier PA QL

Endocrine and Metabolic Agents - Misc.

Bone Density Regulators, continued



ALENDRONATE SODIUM 70MG TABS 1 2 PER 28 DAYS

ETIDRONATE DISODIUM 400MG TABS 1

Posterior Pituitary Hormones

DESMOPRESSIN ACETATE 0.1MG TABS 1

DESMOPRESSIN ACETATE 0.2MG TABS 1

DESMOPRESSIN ACETATE 0.01% SOLN 1


MINIRIN 0.1MG/ML SOLN 1


Cardiotonics

Cardiac Glycosides

LANOXIN 0.125MG TABS 3

DIGOXIN 0.125MG TABS 1

LANOXIN 0.25MG TABS 3

DIGOXIN 0.25MG TABS 1

DIGOXIN 0.05MG/ML SOLN 1

Antianginal Agents

Nitrates

ISOSORBIDE DINITRATE 5MG TABS 1




ISOCHRON 40MG TBCR 1

ISOSORBIDE DINITRATE ER 40MG TBCR 1

ISOSORBIDE DINITRATE 2.5MG SUBL 1

ISOSORBIDE DINITRATE 5MG SUBL 1

ISOSORBIDE MONONITRATE 10MG TABS 1

ISOSORBIDE MONONITRATE 20MG TABS 1

ISOSORBIDE MONONITRATE ER 30MG TB24 1



NITROGLYCERIN ER 2.5MG CPCR 1

NITROGLYCERIN ER 6.5MG CPCR 1

NITROGLYCERIN ER 9MG CPCR 1

NITROSTAT 0.3MG SUBL 3

19

Tier PA QL

Antianginal Agents

Nitrates, continued



NITRO-BID 2% OINT 3

NITROGLYCERIN TRANSDERMAL 0.1MG/HR PT24 1




Beta Blockers

Beta Blockers Non-Selective

NADOLOL 20MG TABS 1

NADOLOL 40MG TABS 1

NADOLOL 80MG TABS 1

PINDOLOL 5MG TABS 1

PINDOLOL 10MG TABS 1

PROPRANOLOL HCL 10MG TABS 1





PROPRANOLOL HCL 20MG/5ML SOLN 1

PROPRANOLOL HCL 40MG/5ML SOLN 1

PROPRANOLOL HCL ER 60MG CP24 1




SOTALOL HCL 80MG TABS 1

SORINE 80MG TABS 1


SORINE 120MG TABS 1


SORINE 160MG TABS 1


SORINE 240MG TABS 1

TIMOLOL MALEATE 5MG TABS 1

TIMOLOL MALEATE 10MG TABS 1

TIMOLOL MALEATE 20MG TABS

1

20

Tier PA QL

Beta Blockers

Beta Blockers Cardio-Selective

ATENOLOL 25MG TABS 1



METOPROLOL SUCCINATE ER 25MG TB24 1 30 PER 30 DAYS




METOPROLOL TARTRATE 25MG TABS 1

METOPROLOL TARTRATE 50MG TABS 1 30 PER 30 DAYS

METOPROLOL TARTRATE 100MG TABS 1

Alpha-Beta Blockers

LABETALOL HCL 100MG TABS 1



Calcium Channel Blockers


AFEDITAB CR 30MG TB24 1 30 PER 30 DAYS

AFEDITAB CR 60MG TB24 1 30 PER 30 DAYS

AMLODIPINE BESYLATE 10MG TABS 1 30 PER 30 DAYS

AMLODIPINE BESYLATE 2.5MG TABS 1 30 PER 30 DAYS

AMLODIPINE BESYLATE 5MG TABS 1 30 PER 30 DAYS

CARTIA XT 120MG CP24 1




DILT-CD 120MG CP24 1




DILTIAZEM HCL 120MG CP24 1

DILTIAZEM HCL 120MG TABS 1







21

Tier PA QL


Calcium Channel Blockers, continued


DILTIAZEM HCL ER 120MG CP12 1











FELODIPINE ER 10MG TB24 1

FELODIPINE ER 2.5MG TB24 1

FELODIPINE ER 5MG TB24 1

NICARDIPINE HCL 20MG CAPS 1

NICARDIPINE HCL 30MG CAPS 1

NIFEDIAC CC 30MG TB24 1 30 PER 30 DAYS



NIFEDICAL XL 30MG TB24 1 30 PER 30 DAYS

NIFEDICAL XL 60MG TB24 1 30 PER 30 DAYS

NIFEDIPINE 10MG CAPS 1 30 PER 30 DAYS

NIFEDIPINE ER 30MG TB24 1 30 PER 30 DAYS



NIMODIPINE 30MG CAPS 1

TAZTIA XT 120MG CP24 1





VERAPAMIL HCL 120MG TABS 1



VERAPAMIL HCL ER 100MG CP24 1 PA

VERAPAMIL HCL ER 120MG CP24 1

VERAPAMIL HCL ER 120MG TBCR 1

22

Tier PA QL


Calcium Channel Blockers, continued







VERAPAMIL HCL SR 360MG CP24 1

Antiarrhythmics

Antiarrhythmics Type I-A

QUINIDINE GLUCONATE CR 324MG TBCR 1

QUINIDINE SULFATE 200MG TABS 1

QUINIDINE SULFATE 300MG TABS 1

QUINIDINE SULFATE ER 300MG TBCR 1

Antiarrhythmics Type I-B

MEXILETINE HCL 150MG CAPS 1



Antiarrhythmics Type I-C

FLECAINIDE ACETATE 50MG TABS 1



PROPAFENONE HCL 150MG TABS 1



Antiarrhythmics Type III

AMIODARONE HCL 200MG TABS 1

AMIODARONE HCL 400MG TABS 1

Antihypertensives

ACE Inhibitors

BENAZEPRIL HCL 5MG TABS 1




CAPTOPRIL 12.5MG TABS 1

CAPTOPRIL 25MG TABS 1



23

Tier PA QL

Antihypertensives

ACE Inhibitors, continued

ENALAPRIL MALEATE 2.5MG TABS 1

ENALAPRIL MALEATE 5MG TABS 1



FOSINOPRIL SODIUM 10MG TABS 1



LISINOPRIL 2.5MG TABS 1

LISINOPRIL 5MG TABS 1





MOEXIPRIL HCL 7.5MG TABS 1

MOEXIPRIL HCL 15MG TABS 1

QUINAPRIL HCL 5MG TABS 1 30 PER 30 DAYS




RAMIPRIL 1.25MG CAPS 1

RAMIPRIL 2.5MG CAPS 1

RAMIPRIL 5MG CAPS 1

RAMIPRIL 10MG CAPS 1

TRANDOLAPRIL 1MG TABS 1



Angiotensin II Receptor Antagonists

BENICAR 20MG TABS 2

BENICAR 40MG TABS 2

BENICAR 5MG TABS 2

DIOVAN 160MG TABS 2

DIOVAN 320MG TABS 2

DIOVAN 40MG TABS 2

DIOVAN 80MG TABS 2

LOSARTAN POTASSIUM 100MG TABS 1

LOSARTAN POTASSIUM 25MG TABS 1

LOSARTAN POTASSIUM 50MG TABS

1

24

Tier PA QL

Antihypertensives

Antiadrenergic Antihypertensives

CLONIDINE HCL 0.1MG TABS 1



DOXAZOSIN MESYLATE 1MG TABS 1 30 PER 30 DAYS




GUANFACINE HCL 1MG TABS 1

GUANFACINE HCL 2MG TABS 1

METHYLDOPA 250MG TABS 1

METHYLDOPA 500MG TABS 1

PRAZOSIN HCL 1MG CAPS 1



RESERPINE 0.1MG TABS 1

RESERPINE 0.25MG TABS 1

TERAZOSIN HCL 10MG CAPS 1




Vasodilators

HYDRALAZINE HCL 10MG TABS 1




MINOXIDIL 2.5MG TABS 1

MINOXIDIL 10MG TABS 1

Antihypertensive Combinations

BENICAR HCT 12.5MG; 20MG TABS 2

BENICAR HCT 12.5MG; 40MG TABS 2

BENICAR HCT 25MG; 40MG TABS 2

DIOVAN HCT 12.5MG; 160MG TABS 2



DIOVAN HCT 25MG; 160MG TABS 2

DIOVAN HCT 25MG; 320MG TABS 2

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 12.5MG; 100MG TABS

1

25

Tier PA QL

Antihypertensives

Antihypertensive Combinations, continued

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 12.5MG; 50MG TABS

1

Diuretics

Carbonic Anhydrase Inhibitors

ACETAZOLAMIDE 125MG TABS 1

ACETAZOLAMIDE 250MG TABS 1

ACETAZOLAMIDE 500MG CP12 1

METHAZOLAMIDE 25MG TABS 1

METHAZOLAMIDE 50MG TABS 1

Loop Diuretics

BUMETANIDE 0.5MG TABS 1

BUMETANIDE 1MG TABS 1

BUMETANIDE 2MG TABS 1

FUROSEMIDE 20MG TABS 1



FUROSEMIDE 10MG/ML SOLN 1

TORSEMIDE 5MG TABS 1




Potassium Sparing Diuretics

SPIRONOLACTONE 25MG TABS 1



Thiazides and Thiazide-Like Diuretics

CHLOROTHIAZIDE 250MG TABS 1

CHLOROTHIAZIDE 500MG TABS 1

CHLORTHALIDONE 25MG TABS 1

CHLORTHALIDONE 50MG TABS 1

HYDROCHLOROTHIAZIDE 12.5MG CAPS 1

HYDROCHLOROTHIAZIDE 25MG TABS 1

HYDROCHLOROTHIAZIDE 50MG TABS 1

INDAPAMIDE 1.25MG TABS 1

INDAPAMIDE 2.5MG TABS 1

METHYCLOTHIAZIDE 5MG TABS 1

METOLAZONE 2.5MG TABS 1

METOLAZONE 5MG TABS 1

26

Tier PA QL

Diuretics

Thiazides and Thiazide-Like Diuretics, continued

METOLAZONE 10MG TABS 1

Diuretic Combinations

TRIAMTERENE/HYDROCHLOROTHIAZIDE 25MG; 37.5MG CAPS 1

TRIAMTERENE/HYDROCHLOROTHIAZIDE 25MG; 37.5MG TABS 1

TRIAMTERENE/HYDROCHLOROTHIAZIDE 50MG; 75MG TABS 1

Vasopressors

Vasopressors

MIDODRINE HCL 2.5MG TABS 1 PA

MIDODRINE HCL 5MG TABS 1 PA

MIDODRINE HCL 10MG TABS 1 PA

Anaphylaxis Therapy Agents

EPIPEN-JR 0.15MG/0.3ML DEVI 2 2 PER RX

EPIPEN 0.3MG/0.3ML DEVI 2 2 PER RX

Antihyperlipidemics

Bile Acid Sequestrants

CHOLESTYRAMINE 4GM/DOSE POWD 1

CHOLESTYRAMINE 4GM PACK 1

CHOLESTYRAMINE LIGHT 4GM/DOSE POWD 1

CHOLESTYRAMINE LIGHT 4GM PACK 1

PREVALITE 4GM/DOSE POWD 1

PREVALITE 4GM PACK 1

Fibric Acid Derivatives

FENOFIBRATE 54MG TABS 1

FENOFIBRATE 160MG TABS 1

FENOFIBRATE MICRONIZED 67MG CAPS 1



GEMFIBROZIL 600MG TABS 1

HMG CoA Reductase Inhibitors

LIPITOR 10MG TABS 2 30 PER 30 DAYS




LESCOL 20MG CAPS 2

LOVASTATIN 10MG TABS 1



27

Tier PA QL

Antihyperlipidemics

HMG CoA Reductase Inhibitors, continued

SIMVASTATIN 5MG TABS 1 30 PER 30 DAYS





Nicotinic Acid Derivatives

NIASPAN 500MG TBCR 3



Cardiovascular Agents - Misc.

Peripheral Vasodilators

ISOXSUPRINE HCL 20MG TABS 1

PAPAVERINE HCL CR 150MG CPCR 1

PARA-TIME 150MG CPCR 1

Nasal Agents - Systemic And Topical

Nasal Steroids

FLUNISOLIDE 0.025% SOLN 1

FLUTICASONE PROPIONATE 50MCG/ACT SUSP 1

NASACORT AQ 55MCG/ACT AERS 3

Cough/Cold/Allergy

Antitussives

HYDROCODONE/HOMATROPINE 1.5MG/5ML; 5MG/5ML SYRP 1

BENZONATATE 100MG CAPS 1

BENZONATATE 200MG CAPS 1

Antiasthmatic And Bronchodilator Agents

Bronchodilators - Anticholinergics

IPRATROPIUM BROMIDE 0.02% SOLN 1

Anti-Inflammatory Agents

CROMOLYN SODIUM 20MG/2ML NEBU 1

Sympathomimetics

ADVAIR DISKUS 100MCG/DOSE; 50MCG/DOSE AEPB 3



ADVAIR HFA 115MCG/ACT; 21MCG/ACT AERO 3



ALBUTEROL SULFATE 0.083% NEBU 1

28

Tier PA QL

Antiasthmatic And Bronchodilator Agents

Sympathomimetics, continued

ALBUTEROL SULFATE 0.5% NEBU 1

ALBUTEROL SULFATE 0.63MG/3ML NEBU 1

ALBUTEROL SULFATE 1.25MG/3ML NEBU 1

ALBUTEROL SULFATE 2MG TABS 1

ALBUTEROL SULFATE 2MG/5ML SYRP 1

ALBUTEROL SULFATE 4MG TABS 1

ALBUTEROL SULFATE ER 4MG TB12 1

ALBUTEROL SULFATE ER 8MG TB12 1

COMBIVENT 103MCG/ACT; 18MCG/ACT AERO 2

PROAIR HFA 108MCG/ACT AERS 2

TERBUTALINE SULFATE 2.5MG TABS 1

TERBUTALINE SULFATE 5MG TABS 1

Xanthines

THEOPHYLLINE ER 100MG TB12 1






Steroid Inhalants

QVAR 40MCG/ACT AERS 2

QVAR 80MCG/ACT AERS 2

Leukotriene Modulators

SINGULAIR 10MG TABS 2

SINGULAIR 4MG CHEW 2

SINGULAIR 5MG CHEW 2

SINGULAIR 4MG PACK 2

ZAFIRLUKAST 10MG TABS 1

ZAFIRLUKAST 20MG TABS 1

Antidiarrheals

Antiperistaltic Agents

DIPHENOXYLATE/ATROPINE 0.025MG; 2.5MG TABS 1

DIPHENOXYLATE/ATROPINE 0.025MG/5ML; 2.5MG/5ML LIQD 1

LOFENE 0.025MG; 2.5MG TABS 1

LONOX 0.025MG; 2.5MG TABS

1

29

Tier PA QL

Ulcer Drugs

Antispasmodics

HYOMAX 0.125MG TABS 1

HYOSCYAMINE SULFATE 0.125MG TABS 1

HYOSCYAMINE SULFATE 0.125MG SUBL 1

HYOMAX-SL 0.125MG SUBL 1

SYMAX-SL 0.125MG SUBL 1

HYOSYNE 0.125MG/5ML ELIX 1

HYOSCYAMINE SULFATE 0.125MG/5ML ELIX 1

COLIDROPS PEDIATRIC 0.125MG/ML SOLN 1

HYOSYNE 0.125MG/ML SOLN 1

HYOSCYAMINE SULFATE 0.125MG/ML SOLN 1

DICYCLOMINE HCL 10MG CAPS 1

DICYCLOMINE HCL 20MG TABS 1

Ulcer Drugs - Prostaglandins

MISOPROSTOL 100MCG TABS 1

MISOPROSTOL 200MCG TABS 1

Antiemetics

Antiemetics - Anticholinergic

MECLIZINE HCL 12.5MG TABS 1

MECLIZINE HCL 25MG TABS 1

TRIMETHOBENZAMIDE HCL 300MG CAPS 1

5-HT3 Receptor Antagonists

ONDANSETRON HCL 4MG TABS 1

Gastrointestinal Agents - Misc.

Gastrointestinal Stimulants

METOCLOPRAMIDE HCL 5MG TABS 1

METOCLOPRAMIDE HCL 10MG TABS 1

METOCLOPRAMIDE HCL 5MG/5ML SOLN 1

Intestinal Acidifiers

ENULOSE 10GM/15ML SOLN 1

GENERLAC 10GM/15ML SOLN 1

Inflammatory Bowel Agents

SULFASALAZINE 500MG TABS 1

SULFAZINE EC 500MG TBEC 1

SULFASALAZINE 500MG TBEC 1

Urinary Anti-Infectives

Urinary Anti-infectives

METHENAMINE MANDELATE 0.5GM TABS 1

30

Tier PA QL

Urinary Anti-Infectives

Urinary Anti-infectives, continued

METHENAMINE HIPPURATE 1GM TABS 1

METHENAMINE HIPPURATE 1GM TABS 1

NITROFURANTOIN MACROCRYSTALLINE 50MG CAPS 1

NITROFURANTOIN MACROCRYSTALLINE 100MG CAPS 1

NITROFURANTOIN MONOHYDRATE 100MG CAPS 1

Urinary Antispasmodics

Urinary Antispasmodics

BETHANECHOL CHLORIDE 5MG TABS 1



URECHOLINE 50MG TABS 3


OXYBUTYNIN CHLORIDE 5MG TABS 1

OXYBUTYNIN CHLORIDE 5MG/5ML SYRP 1

OXYBUTYNIN CHLORIDE ER 5MG TB24 1



Urinary Antispasmodic Combinations

URELIEF PLUS 15MG; 0.3MG; 150MG TABS 1

Vaginal Products

Vaginal Anti-infectives

CLINDAMYCIN PHOSPHATE 2% CREA 1

METRONIDAZOLE VAGINAL 0.75% GEL 1

Vaginal Estrogens

PREMARIN W/APPLICATOR 0.625MG/GM CREA 1

Genitourinary Agents - Miscellaneous

Acidifiers

K-PHOS MF 155MG; 350MG TABS 2

K-PHOS NO 2 305MG; 700MG TABS 2

Alkalinizers

CITROLITH 50MG; 950MG TABS 3

CYTRA K CRYSTALS 1002MG; 3300MG PACK 1

CYTRA-2 334MG/5ML; 500MG/5ML SOLN 1

CYTRA-3 334MG/5ML; 550MG/5ML; 500MG/5ML SYRP 1

CYTRA-K 334MG/5ML; 1100MG/5ML SOLN 1

POTASSIUM CITRATE 1080MG TBCR 1

POTASSIUM CITRATE 540MG TBCR 1

31

Tier PA QL

Genitourinary Agents - Miscellaneous

Alkalinizers, continued

TRICITRATES 334MG/5ML; 550MG/5ML; 500MG/5ML SOLN 1

Urinary Analgesics

PHENAZOPYRIDINE HCL 100MG TABS 1

PHENAZOPYRIDINE HCL 200MG TABS 1

Genitourinary Irrigants

SODIUM CHLORIDE 0.9% 0.9% SOLN 1

Prostatic Hypertrophy Agents

FINASTERIDE 5MG TABS 1

Antianxiety Agents

Benzodiazepines

ALPRAZOLAM 0.25MG TABS 1

ALPRAZOLAM 0.5MG TABS 1

ALPRAZOLAM 1MG TABS 1

ALPRAZOLAM 2MG TABS 1

CHLORDIAZEPOXIDE HCL 5MG CAPS 1



DIAZEPAM 2MG TABS 1

DIAZEPAM 5MG TABS 1

DIAZEPAM 10MG TABS 1

DIAZEPAM 1MG/ML SOLN 1

LORAZEPAM 0.5MG TABS 1

LORAZEPAM 1MG TABS 1

LORAZEPAM 2MG TABS 1

OXAZEPAM 10MG CAPS 1



Antianxiety Agents - Misc.

BUSPIRONE HCL 5MG TABS 1

BUSPIRONE HCL 7.5MG TABS 1




HYDROXYZINE HCL 10MG TABS 1



HYDROXYZINE HCL 10MG/5ML SYRP 1

32

Tier PA QL

Antianxiety Agents

Antianxiety Agents - Misc., continued

HYDROXYZINE PAMOATE 25MG CAPS 1



Antidepressants

Alpha-2 Receptor Antagonists (Tetracyclics)

MIRTAZAPINE 7.5MG TABS 1

MIRTAZAPINE 15MG TABS 1



MIRTAZAPINE 15MG TBDP 1

MIRTAZAPINE ODT 30MG TBDP 1

MIRTAZAPINE ODT 45MG TBDP 1

Monoamine Oxidase Inhibitors (MAOIs)

NARDIL 15MG TABS 2

TRANYLCYPROMINE SULFATE 10MG TABS 1

Modified Cyclics

NEFAZODONE HCL 50MG TABS 1





TRAZODONE HCL 50MG TABS 1




Selective Serotonin Reuptake Inhibitors (SSRIs)

CITALOPRAM HYDROBROMIDE 10MG TABS 1



CITALOPRAM HYDROBROMIDE 10MG/5ML SOLN 1

FLUOXETINE HCL 10MG CAPS 1

FLUOXETINE HCL 20MG CAPS 1

FLUOXETINE HCL 40MG CAPS 1 PA

FLUOXETINE HCL 10MG TABS 1

FLUOXETINE HCL 20MG TABS 1

FLUOXETINE HCL 20MG/5ML SOLN 1

FLUVOXAMINE MALEATE 25MG TABS 1

33

Tier PA QL

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs), continued



PAROXETINE HCL 10MG TABS 1




PAROXETINE HCL 10MG/5ML SUSP 1

PAROXETINE HCL ER 12.5MG TB24 1

PAROXETINE HCL ER 25MG TB24 1

SERTRALINE HCL 25MG TABS 1



SERTRALINE HCL 20MG/ML CONC 1

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

VENLAFAXINE HCL 25MG TABS 1

VENLAFAXINE HCL 37.5MG TABS 1




Tricyclic Agents

AMITRIPTYLINE HCL 10MG TABS 1






AMOXAPINE 25MG TABS 3




CLOMIPRAMINE HCL 25MG CAPS 1



DESIPRAMINE HCL 10MG TABS 1





34

Tier PA QL

Antidepressants

Tricyclic Agents, continued


DOXEPIN HCL 10MG CAPS 1






DOXEPIN HCL 10MG/ML CONC 1

IMIPRAMINE HCL 10MG TABS 1



NORTRIPTYLINE HCL 10MG CAPS 1




NORTRIPTYLINE HCL 10MG/5ML SOLN 1

PROTRIPTYLINE HCL 10MG TABS 1

Antidepressants - Misc.

MAPROTILINE HCL 25MG TABS 1



BUPROPION HCL 75MG TABS 1

BUPROPION HCL 100MG TABS 1

BUDEPRION SR 100MG TB12 1

BUPROPION HCL SR 100MG TB12 1

BUDEPRION SR 150MG TB12 1



BUPROPION HCL XL 150MG TB24 1 30 PER 30 DAYS

BUDEPRION XL 300MG TB24 1 30 PER 30 DAYS

BUPROPION HCL XL 300MG TB24 1 30 PER 30 DAYS

Antipsychotics/Antimanic Agents

Benzisoxazoles

RISPERIDONE 0.25MG TABS 1 60 PER 30 DAYS

RISPERIDONE 0.5MG TABS 1 60 PER 30 DAYS

RISPERIDONE 1MG TABS 1 60 PER 30 DAYS


35

Tier PA QL


Benzisoxazoles, continued



Butyrophenones

HALOPERIDOL 0.5MG TABS 1

HALOPERIDOL 1MG TABS 1





HALOPERIDOL 2MG/ML CONC 1

Dibenzapines

CLOZAPINE 25MG TABS 1




LOXAPINE SUCCINATE 5MG CAPS 1




Phenothiazines

CHLORPROMAZINE HCL 100MG TABS 1





COMPRO 25MG SUPP 1

FLUPHENAZINE HCL 10MG TABS 1


FLUPHENAZINE HCL 2.5MG TABS 1

FLUPHENAZINE HCL 2.5MG TABS 1


PERPHENAZINE 16MG TABS 1




PROCHLORPERAZINE MALEATE 10MG TABS 1

PROCHLORPERAZINE MALEATE 5MG TABS 1

THIORIDAZINE HCL 100MG TABS 1

36

Tier PA QL


Phenothiazines, continued




TRIFLUOPERAZINE HCL 10MG TABS 1




Thioxanthenes

THIOTHIXENE 1MG CAPS 1




Antimanic Agents

LITHIUM CARBONATE 150MG CAPS 1



LITHIUM CARBONATE 300MG TABS 3

LITHIUM CARBONATE ER 300MG TBCR 1

LITHIUM CARBONATE ER 450MG TBCR 1

LITHIUM CITRATE 8MEQ/5ML SYRP 3

LITHOBID 300MG TBCR 2

Hypnotics

Barbiturate Hypnotics

BUTISOL SODIUM 30MG TABS 2

BUTISOL SODIUM 50MG TABS 2

BUTISOL SODIUM 30MG/5ML ELIX 2

MEBARAL 32MG TABS 3

MEBARAL 50MG TABS 3

MEBARAL 100MG TABS 3

PHENOBARBITAL 15MG TABS 1

PHENOBARBITAL 16.2MG TABS 1







37

Tier PA QL

Hypnotics

Barbiturate Hypnotics, continued

PHENOBARBITAL 20MG/5ML ELIX 1

SECONAL 100MG CAPS 2

Non-Barbiturate Hypnotics

CHLORAL HYDRATE 500MG/5ML SYRP 1

ESTAZOLAM 1MG TABS 1 9 PER 30 DAYS

ESTAZOLAM 2MG TABS 1 9 PER 30 DAYS

FLURAZEPAM HCL 15MG CAPS 1

FLURAZEPAM HCL 30MG CAPS 1

MIDAZOLAM HCL 2MG/ML SYRP 1

TEMAZEPAM 15MG CAPS 1

TEMAZEPAM 30MG CAPS 1

TRIAZOLAM 0.125MG TABS 1

TRIAZOLAM 0.25MG TABS 1

ZOLPIDEM TARTRATE 5MG TABS 1 30 PER 30 DAYS

ZOLPIDEM TARTRATE 10MG TABS 1 30 PER 30 DAYS

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Amphetamines

DEXTROAMPHETAMINE SULFATE 5MG TABS 1

DEXTROAMPHETAMINE SULFATE 10MG TABS 1

DEXTROAMPHETAMINE SULFATE ER 5MG CP24 1



AMPHETAMINE/DEXTROAMPHETAMINE 1.25MG; 1.25MG; 1.25MG; 1.25MG TABS

1


1


1


1


1

AMPHETAMINE/DEXTROAMPHETAMINE 5MG; 5MG; 5MG; 5MG TABS 1


1

Stimulants - Misc.

DEXMETHYLPHENIDATE HCL 2.5MG TABS 1

DEXMETHYLPHENIDATE HCL 5MG TABS 1

DEXMETHYLPHENIDATE HCL 10MG TABS 1

38

Tier PA QL

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Stimulants - Misc., continued

METHYLIN 5MG TABS 1

METHYLPHENIDATE HCL 5MG TABS 1

METHYLIN 10MG TABS 1


METHYLIN 20MG TABS 1


METHYLIN ER 10MG TBCR 1

METHYLIN ER 20MG TBCR 1

METHYLPHENIDATE HCL SR 20MG TBCR 1

METADATE ER 20MG TBCR 1

Psychotherapeutic And Neurological Agents - Misc.

Antidementia Agents

GALANTAMINE HYDROBROMIDE 4MG TABS 1



GALANTAMINE HYDROBROMIDE 8MG CP24 1



Smoking Deterrents

BUPROBAN 150MG TB12 1


Agents for Chemical Dependency

DISULFIRAM 250MG TABS 1

ANTABUSE 500MG TABS 3

Analgesics - Nonnarcotic

Salicylates

SALSALATE 500MG TABS 1

SALSALATE 750MG TABS 1

CHOLINE MAGNESIUM TRISALICYLATE 500MG TABS 1



CHOLINE MAGNESIUM TRISALICYLATE 500MG/5ML LIQD 1

Analgesic Combinations

BUTALBITAL/ACETAMINOPHEN 325MG; 50MG TABS 1

MARTEN-TAB 325MG; 50MG TABS 1

BUPAP 650MG; 50MG TABS 1

CEPHADYN 650MG; 50MG TABS 1

39

Tier PA QL

Analgesics - Nonnarcotic

Analgesic Combinations, continued

BUTALBITAL/APAP/CAFFEINE 325MG; 50MG; 40MG CAPS 1

MARGESIC 325MG; 50MG; 40MG CAPS 1

ANOLOR 300 325MG; 50MG; 40MG CAPS 1

ZEBUTAL 500MG; 50MG; 40MG CAPS 1

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 325MG; 50MG; 40MG TABS 1

REPAN 325MG; 50MG; 40MG TABS 1

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 500MG; 50MG; 40MG TABS 1

DOLGIC PLUS 750MG; 50MG; 40MG TABS 3

BUTAL/ASA/CAFF 325MG; 50MG; 40MG CAPS 1

BUTALBITAL/ASPIRIN/CAFFEINE 325MG; 50MG; 40MG TABS 1

BUTALBITAL/ASPIRIN/CAFFEINE 325MG; 50MG; 40MG TABS 1

BUTALBITAL COMPOUND 325MG; 50MG; 40MG TABS 1

Analgesics - Opioid

Opioid Agonists

CODEINE SULFATE 15MG TABS 1



HYDROMORPHONE HCL 2MG TABS 1



LEVORPHANOL TARTRATE 2MG TABS 1

MEPERIDINE HCL 50MG TABS 1

MEPERITAB 50MG TABS 1

MEPERIDINE HCL 100MG TABS 1

MEPERITAB 100MG TABS 1

METHADONE HCL 5MG TABS 1

METHADOSE 5MG TABS 1

METHADONE HCL 10MG TABS 1

METHADOSE 10MG TABS 1

METHADOSE 10MG/ML CONC 1

METHADOSE SUGAR-FREE 10MG/ML CONC 1

METHADONE HCL 5MG/5ML SOLN 1

METHADONE HCL 10MG/5ML SOLN 1

METHADOSE 40MG TBSO 1

METHADONE HCL 40MG TBSO 1

MORPHINE SULFATE 15MG TABS 1

MORPHINE SULFATE 30MG TABS 1

40

Tier PA QL

Analgesics - Opioid

Opioid Agonists, continued

MORPHINE SULFATE 5MG SUPP 1



OXYCODONE HCL 5MG TABS 1



OXYCODONE HCL 20MG/ML CONC 1

TRAMADOL HCL 50MG TABS 1

Opioid Combinations

OXYCODONE/ACETAMINOPHEN 500MG; 5MG CAPS 1

ROXICET 325MG; 5MG TABS 1

OXYCODONE/ACETAMINOPHEN 325MG; 5MG TABS 1

OXYCODONE/ASPIRIN 325MG; 4.5MG; 0.38MG TABS 1

ACETAMINOPHEN/CODEINE #3 300MG; 30MG TABS 1

ACETAMINOPHEN/CODEINE 300MG; 60MG TABS 1

ACETAMINOPHEN/CODEINE 120MG/5ML; 12MG/5ML SOLN 1

HYDROCODONE/ACETAMINOPHEN 500MG; 5MG TABS 1

HYDROCODONE/ACETAMINOPHEN 750MG; 7.5MG TABS 1

Analgesics - Anti-Inflammatory

Nonsteroidal Anti-inflammatory Agents (NSAIDs)

DICLOFENAC SODIUM EC 25MG TBEC 1

DICLOFENAC SODIUM EC 50MG TBEC 1

DICLOFENAC SODIUM 75MG TBEC 1

DICLOFENAC SODIUM ER 100MG TB24 1

ETODOLAC 200MG CAPS 1

ETODOLAC 400MG TABS 1

FLURBIPROFEN 50MG TABS 1

FLURBIPROFEN 100MG TABS 1

IBUPROFEN 400MG TABS 1



INDOMETHACIN 25MG CAPS 1

INDOMETHACIN 50MG CAPS 1

INDOMETHACIN ER 75MG CPCR 1

KETOPROFEN 50MG CAPS 1

KETOPROFEN 75MG CAPS 1

NAPROXEN 250MG TABS 1

41

Tier PA QL

Analgesics - Anti-Inflammatory

Nonsteroidal Anti-inflammatory Agents (NSAIDs), continued



NAPROXEN 125MG/5ML SUSP 1

NAPROXEN SODIUM 275MG TABS 1

NAPROXEN SODIUM 550MG TABS 1

OXAPROZIN 600MG TABS 1

PIROXICAM 10MG CAPS 1

PIROXICAM 20MG CAPS 1

SULINDAC 150MG TABS 1

SULINDAC 200MG TABS 1

TOLMETIN SODIUM 400MG CAPS 1

TOLMETIN SODIUM 600MG TABS 1

Pyrimidine Synthesis Inhibitors

LEFLUNOMIDE 10MG TABS 1

LEFLUNOMIDE 20MG TABS 1

Migraine Products

Serotonin Agonists

RELPAX 20MG TABS 2 6 PER 30 DAYS

RELPAX 40MG TABS 2 6 PER 30 DAYS

Migraine Combinations

MIGRALAM 325MG; 100MG; 65MG CAPS 3

ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN 325MG; 100MG; 65MG CAPS

1

EPIDRIN 325MG; 100MG; 65MG CAPS 1

ERGOTAMINE TARTRATE/CAFFEINE 100MG; 1MG TABS 1

Gout Agents

Gout Agents

ALLOPURINOL 100MG TABS 1

ALLOPURINOL 300MG TABS 1

Uricosurics

PROBENECID 500MG TABS 1

Gout Agent Combinations

PROBENECID/COLCHICINE 0.5MG; 500MG TABS 1

Anticonvulsants

Anticonvulsants - Benzodiazepines

CLONAZEPAM 0.5MG TABS 1

CLONAZEPAM 1MG TABS 1

42

Tier PA QL

Anticonvulsants

Anticonvulsants – Benzodiazepines, continued

CLONAZEPAM 2MG TABS 1

Hydantoins

DILANTIN 100MG CAPS 2

DILANTIN 125MG/5ML SUSP 2

DILANTIN 30MG CAPS 2

DILANTIN INFATABS 50MG CHEW 2

PHENYTEK 200MG CAPS 2

PHENYTEK 300MG CAPS 2

PHENYTOIN 125MG/5ML SUSP 1

PHENYTOIN SODIUM EXTENDED 100MG CAPS 1



Succinimides

CELONTIN 300MG CAPS 3

ETHOSUXIMIDE 250MG CAPS 1

ETHOSUXIMIDE 250MG/5ML SOLN 1

ZARONTIN 250MG CAPS 3

ZARONTIN 250MG/5ML SOLN 3 Valproic Acid DIVALPROEX SODIUM 125MG TBEC 1 DIVALPROEX SODIUM 250MG TBEC 1 DIVALPROEX SODIUM 500MG TBEC 1 DIVALPROEX SODIUM 125MG CPSP 1 DIVALPROEX SODIUM ER 250MG TB24 1 DIVALPROEX SODIUM ER 500MG TB24 1 VALPROIC ACID 250MG/5ML SYRP 1 VALPROIC ACID 250MG CAPS 1

Anticonvulsants - Misc.

CARBAMAZEPINE 200MG TABS 1

CARBAMAZEPINE 100MG CHEW 1

CARBAMAZEPINE 100MG/5ML SUSP 1

TEGRETOL-XR 100MG TB12 2

CARBAMAZEPINE ER 200MG TB12 1

CARBAMAZEPINE ER 400MG TB12 1

GABAPENTIN 100MG CAPS 1



GABAPENTIN 600MG TABS 1

GABAPENTIN 800MG TABS 1

43

Tier PA QL

Anticonvulsants

Anticonvulsants - Misc., continued

LAMOTRIGINE 25MG TABS 1




LEVETIRACETAM 250MG TABS 1




OXCARBAZEPINE 150MG TABS 1



PRIMIDONE 50MG TABS 1

PRIMIDONE 250MG TABS 1

TOPIRAMATE 25MG TABS 1




TOPIRAMATE 15MG CPSP 1

TOPIRAMATE 25MG CPSP 1

ZONISAMIDE 25MG CAPS 1



Antiparkinson Agents

Antiparkinson Anticholinergics

BENZTROPINE MESYLATE 0.5MG TABS 1

BENZTROPINE MESYLATE 1MG TABS 1

BENZTROPINE MESYLATE 2MG TABS 1

TRIHEXYPHENIDYL HCL 2MG TABS 1

TRIHEXYPHENIDYL HCL 5MG TABS 1

Antiparkinson Dopaminergics

AMANTADINE HCL 100MG CAPS 1

AMANTADINE HCL 100MG TABS 1

AMANTADINE HCL 50MG/5ML SYRP 1

BROMOCRIPTINE MESYLATE 2.5MG TABS 1

CARBIDOPA/LEVODOPA 10MG; 100MG TABS 1



44

Tier PA QL

Antiparkinson Agents

Antiparkinson Dopaminergics, continued

CARBIDOPA/LEVODOPA ER 25MG; 100MG TBCR 1

CARBIDOPA/LEVODOPA ER 50MG; 200MG TBCR 1

ROPINIROLE HCL 0.25MG TABS 1

ROPINIROLE HCL 0.5MG TABS 1

ROPINIROLE HCL 1MG TABS 1





Antiparkinson Monoamine Oxidase Inhibitors

SELEGILINE HCL 5MG CAPS 1

SELEGILINE HCL 5MG TABS 1

Musculoskeletal Therapy Agents

Central Muscle Relaxants

BACLOFEN 10MG TABS 1

BACLOFEN 20MG TABS 1

CARISOPRODOL 350MG TABS 1

CHLORZOXAZONE 500MG TABS 1

CYCLOBENZAPRINE HCL 5MG TABS 1

CYCLOBENZAPRINE HCL 10MG TABS 1

METHOCARBAMOL 500MG TABS 1

METHOCARBAMOL 750MG TABS 1

ORPHENADRINE CITRATE ER 100MG TB12 1

Direct Muscle Relaxants

DANTROLENE SODIUM 25MG CAPS 1



Antimyasthenic Agents

Antimyasthenic Agents

PYRIDOSTIGMINE BROMIDE 60MG TABS 1

Vitamins

Oil Soluble Vitamins

VITAMIN D 50000UNIT CAPS 1

Multivitamins

Prenatal Vitamins

PRENATAL VITAMINS 100MG; 200MG; 4MCG; 400UNIT; 60MG; 0.8MG; 18MG; 2.6MG; 1.7MG; 1.5MG; 11MG; 4000UNIT; 25MG TABS

3

45

Tier PA QL

Minerals & Electrolytes

Fluoride

FLUORITAB 0.5MG CHEW 1

FLUORITAB 1MG CHEW 1

FLURA-DROPS 0.125MG/DROP SOLN 1

FLURA-DROPS 0.25MG/DROP SOLN 1

LURIDE 0.25MG CHEW 3

LURIDE 0.5MG CHEW 3

LURIDE 0.5MG/ML SOLN 3

LURIDE 1MG CHEW 3

SODIUM FLUORIDE 0.125MG/DROP SOLN 1

SODIUM FLUORIDE 0.25MG CHEW 1

SODIUM FLUORIDE 0.5MG/ML SOLN 1

Iodine Products

SSKI 1GM/ML SOLN 3

Potassium

EFFER-K 25MEQ TBEF 1

EFFERVESCENT POT CHLORIDE 0.55GM; 0.91GM; 0.5GM; 1.5GM TBEF 1

EFFERVESCENT POTASSIUM/CHLORIDE 0.55GM; 0.91GM; 0.5GM; 1.5GM TBEF

1

K-EFFERVESCENT 25MEQ TBEF 1

KLOR-CON 10 10MEQ TBCR 1

KLOR-CON 20MEQ PACK 1

KLOR-CON 8 8MEQ TBCR 1

KLOR-CON M10 10MEQ TBCR 1

KLOR-CON M20 20MEQ TBCR 1

KLOR-CON/EF 25MEQ TBEF 1

K-VESCENT 20MEQ PACK 1

K-VESCENT 25MEQ TBEF 1

POTASSIUM BICARBONATE 25MEQ TBEF 1

POTASSIUM CHLORIDE 10% LIQD 1

POTASSIUM CHLORIDE 20% LIQD 1

POTASSIUM CHLORIDE ER 10MEQ TBCR 1



Hematopoietic Agents

Folic Acid/Folates

FOLIC ACID 1MG TABS

1

46

Tier PA QL

Anticoagulants

Heparins And Heparinoid-Like Agents

ENOXAPARIN SODIUM 30MG/0.3ML SOLN 2 21 DAY SUPPLY PER RX




ENOXAPARIN SODIUM 100MG/ML SOLN 2 21 DAY SUPPLY PER RX


ENOXAPARIN SODIUM 150MG/ML SOLN 2 21 DAY SUPPLY PER RX

Coumarin Anticoagulants

WARFARIN SODIUM 1MG TABS 1


WARFARIN SODIUM 2.5MG TABS 1





WARFARIN SODIUM 7.5MG TABS 1


Hematological Agents - Misc.

Platelet Aggregation Inhibitors

DIPYRIDAMOLE 25MG TABS 1



CILOSTAZOL 50MG TABS 1

CILOSTAZOL 100MG TABS 1

ANAGRELIDE HYDROCHLORIDE 0.5MG CAPS 1 PA

ANAGRELIDE HYDROCHLORIDE 1MG CAPS 1 PA

TICLOPIDINE HCL 250MG TABS 1

Hematorheologic Agents

PENTOXIFYLLINE ER 400MG TBCR 1

Ophthalmic Agents

Ophthalmic Anti-infectives

AK-POLY-BAC 500UNIT/GM; 10000UNIT/GM OINT 1

47

Tier PA QL

Ophthalmic Agents

Ophthalmic Anti-infectives, continued

AK-TOB 0.3% SOLN 1

AZASITE 1% SOLN 3

BLEPH-10 10% SOLN 3

CILOXAN 0.3% OINT 2

CILOXAN 0.3% SOLN 2

CIPROFLOXACIN HCL 0.3% SOLN 1

ERYTHROMYCIN 5MG/GM OINT 1

GARAMYCIN 0.3% OINT 1

GENTAK 0.3% OINT 1

GENTAMICIN SULFATE 0.3% OINT 1

GENTAMICIN SULFATE 0.3% SOLN 1

GENTASOL 0.3% SOLN 1

IQUIX 1.5% SOLN 3

NATACYN 5% SUSP 3

NEOMYCIN/BACITRACIN/POLYMYXIN 400UNIT/GM; 5MG/GM; 10000UNIT/GM OINT

1

NEOMYCIN/POLYMYXIN/GRAMICIDIN 0.025MG/ML; 1.75MG/ML; 10000UNIT/ML SOLN

1

NEOSPORIN 0.025MG/ML; 1.75MG/ML; 10000UNIT/ML SOLN 3

OCUFLOX 0.3% SOLN 3

OFLOXACIN 0.3% SOLN 1

POLYCIN B 500UNIT/GM; 10000UNIT/GM OINT 1

POLYTRIM 10000UNIT/ML; 0.1% SOLN 3

QUIXIN 0.5% SOLN 2

ROMYCIN 5MG/GM OINT 1

SODIUM SULFACETAMIDE 10% SOLN 1

SODIUM SULFACETAMIDE 10% SOLN 1

TOBRASOL 0.3% SOLN 1

TOBREX 0.3% OINT 2

TOBREX 0.3% SOLN 2

TRIFLURIDINE 1% SOLN 1

TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE 10000UNIT/ML; 0.1% SOLN

1

VIGAMOX 0.5% SOLN 3 3 PER 30 DAYS

VIROPTIC 1% SOLN 3

Beta-blockers - Ophthalmic

BETAXOLOL HCL 0.5% SOLN 1

BETIMOL 0.25% SOLN 2

BETIMOL 0.5% SOLN 2

48

Tier PA QL

Ophthalmic Agents

Beta-blockers – Ophthalmic, continued

CARTEOLOL HCL 1% SOLN 1

COMBIGAN 0.2%; 0.5% SOLN 3

ISTALOL 0.5% SOLN 3

LEVOBUNOLOL HCL 0.25% SOLN 1

LEVOBUNOLOL HCL 0.5% SOLN 1

METIPRANOLOL 0.3% SOLN 1

OPTIPRANOLOL 0.3% SOLN 3

TIMOLOL MALEATE 0.25% SOLN 3

TIMOLOL MALEATE 0.5% SOLN 1

TIMOLOL MALEATE OPHTHALMIC GEL FORMING 0.25% SOLG 1

TIMOLOL MALEATE OPHTHALMIC GEL FORMING 0.5% SOLG 1

TIMOPTIC 0.25% SOLN 3

TIMOPTIC 0.5% SOLN 3

TIMOPTIC-XE 0.25% SOLG 3

TIMOPTIC-XE 0.5% SOLG 3 Ophthalmic Steroids ALREX 0.2% SUSP 2 BLEPHAMIDE 0.2%; 10% SUSP 2 BLEPHAMIDE S.O.P. 0.2%; 10% OINT 2 DEXAMETHASONE SODIUM PHOSPHATE 0.1% SOLN 1 DUREZOL 0.05% EMUL 3 FLAREX 0.1% SUSP 3 FLUOROMETHOLONE 0.1% SUSP 1 FML 0.1% OINT 2 FML FORTE 0.25% SUSP 2 FML LIQUIFILM 0.1% SUSP 2 LOTEMAX 0.5% SUSP 3 MAXIDEX 0.1% SUSP 2 MAXITROL 0.1%; 3.5MG/GM; 10000UNIT/GM OINT 3 MAXITROL 0.1%; 3.5MG/ML; 10000UNIT/ML SUSP 3 NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE 400UNIT/GM; 1%; 0.5%; 10000UNIT/GM OINT

1

NEOMYCIN/POLYMYXIN/DEXAMETHASONE 0.1%; 3.5MG/GM; 10000UNIT/GM OINT

1

NEOMYCIN/POLYMYXIN/DEXAMETHASONE 0.1%; 3.5MG/ML; 10000UNIT/ML SUSP

1

POLY-PRED 0.35%; 10000UNIT/ML; 0.5% SUSP 3 PRED FORTE 1% SUSP 3 PRED MILD 0.12% SUSP 3 PRED-G S.O.P. 0.3%; 0.6% OINT 2

49

Tier PA QL

Ophthalmic Agents Ophthalmic Steroids, continued

PREDNISOLONE ACETATE 1% SUSP 1 PREDNISOLONE SODIUM PHOSPHATE 1% SOLN 3 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE 0.23%; 10% SOLN

1

TOBRADEX 0.1%; 0.3% OINT 2 TOBRADEX 0.1%; 0.3% SUSP 2

TOBRAMYCIN/DEXAMETHASONE 0.1%; 0.3% SUSP 1

VEXOL 1% SUSP 2 ZYLET 0.5%; 0.3% SUSP 1

Prostaglandins - Ophthalmic

LATANOPROST 0.005% SOLN 1

Cycloplegic Mydriatics

ATROPINE SULFATE 1% SOLN 1

CYCLOGYL 0.5% SOLN 3

CYCLOGYL 1% SOLN 3

CYCLOGYL 2% SOLN 3

CYCLOMYDRIL 0.2%; 1% SOLN 3

CYCLOPENTOLATE HCL 1% SOLN 1

HOMATROPAIRE 5% SOLN 1

ISOPTO ATROPINE 1% SOLN 3

ISOPTO HOMATROPINE 2% SOLN 3

ISOPTO HOMATROPINE 5% SOLN 3

ISOPTO HYOSCINE 0.25% SOLN 2

MYDRIACYL 1% SOLN 3

TROPICAMIDE 0.5% SOLN 1

Ophthalmic Decongestants

AK-CON 0.1% SOLN 1

MYDFRIN 2.5% SOLN 3

PHENYLEPHRINE HCL 10% SOLN 1

PHENYLEPHRINE HCL 2.5% SOLN 1

Miotics

ISOPTO CARBACHOL 1.5% SOLN 2

ISOPTO CARBACHOL 3% SOLN 2

ISOPTO CARPINE 1% SOLN 3

PILOCARPINE HCL 1% SOLN 1





50

Tier PA QL

Ophthalmic Agents

Miotics, continued

PILOPINE HS 4% GEL 2

PHOSPHOLINE IODIDE 0.125% SOLR 3

Ophthalmic Adrenergic Agents

ALPHAGAN P 0.1% SOLN 2

ALPHAGAN P 0.15% SOLN 2

BRIMONIDINE TARTRATE 0.15% SOLN 1

BRIMONIDINE TARTRATE 0.2% SOLN 1

Ophthalmics - Misc.

CROMOLYN SODIUM 4% SOLN 1

EMADINE 0.05% SOLN 3

ALOMIDE 0.1% SOLN 3

ALOCRIL 2% SOLN 3

PATANOL 0.1% SOLN 3

PATADAY 0.2% SOLN 3

ALAMAST 0.1% SOLN 3

AZOPT 1% SUSP 3

DORZOLAMIDE HCL 2% SOLN 1

VOLTAREN 0.1% SOLN 2

DICLOFENAC SODIUM 0.1% SOLN 1

OCUFEN 0.03% SOLN 3

FLURBIPROFEN SODIUM 0.03% SOLN 1

ACULAR LS 0.4% SOLN 3

KETOROLAC TROMETHAMINE 0.4% SOLN 1

ACULAR 0.5% SOLN 3

KETOROLAC TROMETHAMINE 0.5% SOLN 1

NEVANAC 0.1% SUSP 3

Otic Agents

Otic Anti-infectives

OFLOXACIN 0.3% SOLN 1

Otic Steroids

DERMOTIC 0.01% OIL 3

ACETASOL HC 2%; 1% SOLN 1

Otic Agents - Miscellaneous

ACETIC ACID 2% SOLN 1

ACETIC ACID/ALUMINUM ACETATE 2%; 0 SOLN 1

CRESYLATE 25% SOLN

3

51

Tier PA QL

Otic Agents

Otic Combinations

AERO OTIC HC 1MG/ML; 10MG/ML; 10MG/ML SOLN 1

ANTIPYRINE/BENZOCAINE 5.4%; 1.4% SOLN 1

CIPRO HC 0.2%; 1% SUSP 3

CIPRODEX 0.3%; 0.1% SUSP 3

COLY-MYCIN S 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML SUSP 3

CORTANE-B AQUEOUS 1MG/ML; 10MG/ML; 10MG/ML SOLN 3

CORTANE-B-OTIC 1MG/ML; 10MG/ML; 10MG/ML SOLN 3

CORTIC-ND 1MG/ML; 10MG/ML; 10MG/ML SOLN 1

CORTISPORIN 1%; 3.5MG/ML; 10000UNIT/ML SOLN 3

CORTISPORIN-TC 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML SUSP 3

CORTOMYCIN 1%; 3.5MG/ML; 10000UNIT/ML SUSP 1

CYOTIC 1MG/ML; 10MG/ML; 10MG/ML SOLN 1

EXOTIC-HC 1MG/ML; 10MG/ML; 10MG/ML SOLN 1

NEOMYCIN/POLYMYXIN/HC 1%; 3.5MG/ML; 10000UNIT/ML SOLN 1

NEOMYCIN/POLYMYXIN/HYDROCORTISONE 1%; 3.5MG/ML; 10000UNIT/ML SOLN

1

NEOMYCIN/POLYMYXIN/HYDROCORTISONE 1%; 3.5MG/ML; 10000UNIT/ML SUSP

1

OTICIN 1MG/ML; 10MG/ML LIQD 1

OTOMAR 1MG/ML; 10MG/ML; 10MG/ML SOLN 1

PRAMOTIC 0.1%; 1% LIQD 3

Mouth/Throat/Dental Agents

Anti-infectives - Throat

CLOTRIMAZOLE 10MG TROC 1

NYSTATIN 100000UNIT/ML SUSP 1

Antiseptics - Mouth/Throat

CHLORHEXIDINE GLUCONATE 0.12% SOLN 1

DEBACTEROL 50%; 30% SOLN 3

PERIDEX 0.12% SOLN 3

PERIOGARD 0.12% SOLN 1

Steroids - Mouth/Throat

TRIAMCINOLONE IN ORABASE 0.1% PSTE 1

Antiallergy Agents - Mouth/Throat

APHTHASOL 5% PSTE 3

Anesthetics Topical Oral

FIRST-MOUTHWASH BLM 3.15GM/237ML; 0.2GM/237ML; 1.6GM/237ML; 3.15GM/237ML; 0.315GM/237ML SUSP

3

LIDOCAINE VISCOUS 2% SOLN 1

52

Tier PA QL

Mouth/Throat/Dental Agents

Anesthetics Topical Oral, continued

ORASEP 600MG/30ML; 30MG/30ML; 30MG/30ML; 300MG/30ML SOLN 3

Dental Products

CONTROLRX 1.1% PSTE 1

GEL-KAM ORAL CARE RINSE 0.63% CONC 3

PREVIDENT 0.2% SOLN 3

PREVIDENT 5000 BOOSTER 1.1% PSTE 3

PREVIDENT 5000 PLUS 1.1% CREA 3

PREVIDENT FLUORIDE 1.1% GEL 3

SF 1.1% GEL 1

SF 5000 PLUS 1.1% CREA 1

STANNOUS FLUORIDE ORAL RINSE 0.63% CONC 1

Anorectal Agents

Rectal Steroids

ANUCORT-HC 25MG SUPP 1

HEMRIL-30 30MG SUPP 1

HYDROCORTISONE ACETATE 25MG SUPP 1

HYDROCORTISONE ACETATE 30MG SUPP 1

PROCTOCREAM HC 2.5% CREA 1

PROCTOZONE-HC 2.5% CREA 1

Rectal Combinations

ANALPRAM-HC 1%; 1% CREA 2

ANALPRAM-HC 2.5%; 1% CREA 2

ANALPRAM-HC 2.5%; 1% LOTN 2

HYDROCORTISONE ACETATE/PRAMOXINE 1%; 1% CREA 1

HYDROCORTISONE ACETATE/PRAMOXINE 2.5%; 1% CREA 1

PROCTOFOAM HC 1%; 1% FOAM 2

Dermatologicals

Antibiotics - Topical

GENTAMICIN SULFATE 0.1% CREA 1

GENTAMICIN SULFATE 0.1% OINT 1

MUPIROCIN 2% OINT 1

Antifungals - Topical

ALA QUIN 3%; 0.5% CREA 3

CLOTRIMAZOLE 1% SOLN 1

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.05%; 1% CREA 1

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.05%; 1% LOTN 1

ECONAZOLE NITRATE 1% CREA 1

53

Tier PA QL

Dermatologicals

Antifungals – Topical, continued

HYDROCORTISONE/IODOQUINOL 1%; 1% CREA 1

KETOCONAZOLE 2% CREA 1

KETOCONAZOLE 2% SHAM 1

NYSTATIN 100000UNIT/GM CREA 1

NYSTATIN 100000UNIT/GM OINT 1

NYSTATIN 100000UNIT/GM POWD 1

NYSTATIN/TRIAMCINOLONE 100000UNIT/GM; 0.1% CREA 1

NYSTATIN/TRIAMCINOLONE 100000UNIT/GM; 0.1% OINT 1

Antiseborrheic Products

SELENIUM SULFIDE 2.5% LOTN 1

Antivirals - Topical

DENAVIR 1% CREA 3

Antineoplastic or Premalignant Lesion Agents - Topical

FLUOROURACIL 2% SOLN 1

FLUOROURACIL 5% SOLN 1

Burn Products

SILVER SULFADIAZINE 1% CREA 1

Corticosteroids - Topical

ACLOVATE 0.05% CREA 2

ALCLOMETASONE DIPROPIONATE 0.05% CREA 1

ALCLOMETASONE DIPROPIONATE 0.05% OINT 1

AMCINONIDE 0.1% CREA 1

AMCINONIDE 0.1% LOTN 1

AMCINONIDE 0.1% OINT 3

BETAMETHASONE DIPROPIONATE 0.05% CREA 1

BETAMETHASONE DIPROPIONATE 0.05% LOTN 1

BETAMETHASONE DIPROPIONATE 0.05% OINT 1

BETAMETHASONE VALERATE 0.1% CREA 1

BETAMETHASONE VALERATE 0.1% LOTN 1

BETAMETHASONE VALERATE 0.1% OINT 1

CLOBETASOL PROPIONATE 0.05% CREA 1

CLOBETASOL PROPIONATE 0.05% GEL 1

CLOBETASOL PROPIONATE 0.05% OINT 1

CLOBETASOL PROPIONATE 0.05% SOLN 1

CLOBETASOL PROPIONATE EMOLLIENT 0.05% CREA 1

CORTANE-B 1MG/ML; 10MG/ML; 10MG/ML LOTN 3

CUTIVATE 0.05% LOTN 2

DERMA-SMOOTHE/FS SCALP OIL 0.01% OIL 2

54

Tier PA QL

Dermatologicals

Corticosteroids – Topical, continued

DESONIDE 0.05% CREA 1

DESONIDE 0.05% LOTN 1

DESONIDE 0.05% OINT 1

FLUOCINOLONE ACETONIDE 0.01% CREA 1

FLUOCINOLONE ACETONIDE 0.01% SOLN 1

FLUOCINOLONE ACETONIDE 0.025% CREA 1

FLUOCINOLONE ACETONIDE 0.025% OINT 1

FLUOCINONIDE 0.05% CREA 1

FLUOCINONIDE 0.05% GEL 1

FLUOCINONIDE 0.05% OINT 1

FLUOCINONIDE 0.05% SOLN 1

FLUOCINONIDE-E 0.05% CREA 1

FLUTICASONE PROPIONATE 0.005% OINT 1

FLUTICASONE PROPIONATE 0.05% CREA 1

HALOBETASOL PROPIONATE 0.05% CREA 1

HALOBETASOL PROPIONATE 0.05% OINT 1

HYDROCORTISONE 2.5% CREA 1

HYDROCORTISONE 2.5% OINT 1

HYDROCORTISONE ACETATE/PRAMOXINE 2.5%; 1% CREA 1

HYDROCORTISONE BUTYRATE 0.1% CREA 1

HYDROCORTISONE BUTYRATE 0.1% OINT 1

HYDROCORTISONE BUTYRATE 0.1% SOLN 1

HYDROCORTISONE VALERATE 0.2% CREA 1

HYDROCORTISONE VALERATE 0.2% OINT 1

LOCOID 0.1% CREA 3

LOCOID 0.1% OINT 3

LOCOID 0.1% SOLN 3

MOMETASONE FUROATE 0.1% CREA 1

MOMETASONE FUROATE 0.1% OINT 1

MOMETASONE FUROATE 0.1% SOLN 1

PANDEL 0.1% CREA 3

PREDNICARBATE 0.1% CREA 1

PREDNICARBATE 0.1% OINT 1

TRIAMCINOLONE ACETONIDE 0.025% CREA 1

TRIAMCINOLONE ACETONIDE 0.025% LOTN 1

TRIAMCINOLONE ACETONIDE 0.025% OINT 1


TRIAMCINOLONE ACETONIDE 0.1% LOTN 1

55

Tier PA QL

Dermatologicals

Corticosteroids – Topical, continued




TRIAMCINOLONE ACETONIDE IN ABSORBASE 0.05% OINT 3

U-CORT 1%; 10% CREA 1

WESTCORT 0.2% OINT 3

Enzymes - Topical

GRANULEX 788MG/GM; 87MG/GM; 0.12MG/GM AERS 3

KOVIA 0.83MMU/GM; 100MG/GM OINT 1

SANTYL 250UNIT/GM OINT 2

TBC 650MG/0.82ML; 72.5MG/0.82ML; 0.1MG/0.82ML AERS 1

VASOLEX 788MG/GM; 87MG/GM; 90UNIT/GM OINT 1

Keratolytic/Antimitotic Agents

PODOFILOX 0.5% SOLN 1

Immunosuppressive Agents - Topical

ELIDEL 1% CREA 3

Scabicides & Pediculicides

EURAX 10% CREA 3

EURAX 10% LOTN 3

LINDANE 1% LOTN 1

LINDANE 1% SHAM 3

PERMETHRIN 5% CREA 1

Misc. Topical

XERAC AC 6.25% SOLN 3

Diagnostic Products

Diagnostic Tests

BLOOD GLUCOSE TEST STRIPS (Lifescan only) 2

Medical Devices

Parenteral Therapy Supplies

NEEDLES 2

INSULIN SYRINGE 2

PEN DEVICE 2

PEN NEEDLES 2

Diabetic Supplies

GLUCOSE CONTROL SOLN (Lifescan only) 3

GLUCOSE METER (Lifescan only) DME

LANCETS 1

56

Tier PA QL

Medical Devices

Diabetic Supplies, continued

LANCET DEVICE 2

Respiratory Therapy Supplies

AEROCHAMBER AND SUPPLIES DME

PEAK FLOW METER DME

Contraceptives

ORTHO DIAPHRAGM COIL SPRING KIT 50 KIT 3



ORTHO DIAPHRAGM FLAT SPRING KIT 55 KIT 3









WIDE-SEAL SILICONE DIAPHRAGM KIT 60 2% DPRH 3








Assorted Classes

Immunosuppressive Agents

AZATHIOPRINE 50MG TABS 1

Potassium Removing Resins

KIONEX 15GM/60ML SUSP 1

SODIUM POLYSTYRENE SULFONATE 0 POWD 1

57

Index ACARBOSE ................................................................... 16 ACETAMINOPHEN/CODEINE ..................................... 43 ACETASOL HC .............................................................. 54 ACETAZOLAMIDE ........................................................ 27 ACETIC ACID ................................................................ 54 ACETIC ACID/ALUMINUM ACETATE .......................... 54 ACLOVATE .................................................................... 57 ACTIVELLA .................................................................... 12 ACTOS .......................................................................... 16 ACULAR ........................................................................ 54 ACULAR LS ................................................................... 54 ACYCLOVIR .................................................................... 7 ADVAIR DISKUS ............................................................ 30 ADVAIR HFA ................................................................. 30 AERO OTIC HC ............................................................. 55 AEROCHAMBER AND SUPPLIES ................................. 60 AFEDITAB CR ............................................................... 22 AK-CON ........................................................................ 53 AK-POLY-BAC ............................................................... 50 AK-TOB ......................................................................... 50 ALA QUIN ..................................................................... 57 ALAMAST ...................................................................... 54 ALBUTEROL SULFATE .................................................. 30 ALBUTEROL SULFATE ER ............................................ 30 ALCLOMETASONE DIPROPIONATE ........................... 57 ALENDRONATE SODIUM ............................................ 19 ALKERAN ........................................................................ 8 ALLOPURINOL .............................................................. 45 ALOCRIL ........................................................................ 54 ALOMIDE ...................................................................... 54 ALPHAGAN P ............................................................... 53 ALPRAZOLAM .............................................................. 33 ALREX ........................................................................... 52 ALTAVERA .................................................................... 12 AMANTADINE HCL ...................................................... 47 AMCINONIDE ............................................................... 57 AMIODARONE HCL ..................................................... 24 AMITRIPTYLINE HCL .................................................... 36 AMLODIPINE BESYLATE .............................................. 22 AMOXAPINE ................................................................. 36 AMOXICILLIN.................................................................. 3 AMOXICILLIN/CLAVULANATE POTASSIUM ................. 3 AMOXICILLIN/POTASSIUM CLAVULANATE ................. 3 AMPHETAMINE/DEXTROAMPHETAMINE .................. 40 AMPICILLIN ..................................................................... 3 ANAGRELIDE HYDROCHLORIDE ................................ 50 ANALPRAM-HC ............................................................ 56 ANASTROZOLE .............................................................. 8 ANOLOR 300 ................................................................ 42 ANTABUSE ................................................................... 41 ANTIPYRINE/BENZOCAINE ......................................... 55 ANUCORT-HC .............................................................. 56 APHTHASOL ................................................................. 55 APRI ............................................................................... 12 ARANELLE .................................................................... 12 ARMOUR THYROID ...................................................... 16 ATENOLOL ................................................................... 21 ATROPINE SULFATE .................................................... 53

AVIANE ......................................................................... 12 AZASITE ........................................................................ 50 AZATHIOPRINE ............................................................ 61 AZITHROMYCIN ............................................................. 5 AZOPT .......................................................................... 54 AZURETTE .................................................................... 12 BACLOFEN 10MG TABS .............................................. 47 BALZIVA ........................................................................ 12 BARACLUDE ................................................................... 6 BENAZEPRIL HCL ......................................................... 24 BENICAR ................................................................. 25, 26 BENICAR HCT .............................................................. 26 BENZONATATE ............................................................ 29 BENZTROPINE MESYLATE .......................................... 47 BETAMETHASONE DIPROPIONATE ........................... 57 BETAMETHASONE VALERATE .............................. 57, 58 BETAXOLOL HCL ......................................................... 51 BETHANECHOL CHLORIDE ........................................ 32 BETIMOL ....................................................................... 51 BICALUTAMIDE .............................................................. 8 BIO-STATIN .................................................................... 6 BIO-THROID ........................................................... 16, 17 BLEPH-10 ...................................................................... 50 BLEPHAMIDE ............................................................... 52 BLOOD GLUCOSE TEST STRIPS .................................. 60 BRIELLYN ...................................................................... 12 BRIMONIDINE TARTRATE ........................................... 53 BROMOCRIPTINE MESYLATE ..................................... 47 BUDEPRION SR ............................................................ 37 BUDEPRION XL ............................................................ 37 BUMETANIDE ............................................................... 27 BUPAP .......................................................................... 42 BUPROBAN .................................................................. 41 BUPROPION HCL ................................................... 37, 41 BUPROPION HCL SR .............................................. 37, 41 BUPROPION HCL XL .................................................... 37 BUSPIRONE HCL .......................................................... 34 BUTAL/ASA/CAFF ........................................................ 42 BUTALBITAL COMPOUND .......................................... 42 BUTALBITAL/ACETAMINOPHEN ................................ 42 BUTALBITAL/ACETAMINOPHEN/CAFFEINE .............. 42 BUTALBITAL/APAP/CAFFEINE .................................... 42 BUTALBITAL/ASPIRIN/CAFFEINE ................................ 42 BUTISOL SODIUM ........................................................ 39 CAMILA ........................................................................ 12 CAPTOPRIL ................................................................... 24 CARBAMAZEPINE ........................................................ 46 CARBAMAZEPINE ER .................................................. 46 CARBIDOPA/LEVODOPA ............................................ 47 CARBIDOPA/LEVODOPA ER ....................................... 47 CARISOPRODOL .......................................................... 47 CARTEOLOL HCL ......................................................... 51 CARTIA XT .................................................................... 22 CAZIANT ....................................................................... 12 CEENU ............................................................................ 8 CEFACLOR ..................................................................... 4 CEFADROXIL .................................................................. 4 CEFDINIR ........................................................................ 4

58

CEFPODOXIME PROXETIL ............................................. 4 CEFPROZIL ...................................................................... 4 CEFUROXIME AXETIL .................................................... 4 CELONTIN .................................................................... 45 CENESTIN ..................................................................... 11 CEPHADYN ................................................................... 42 CEPHALEXIN .................................................................. 4 CESIA ............................................................................ 12 CHLORAL HYDRATE .................................................... 40 CHLORDIAZEPOXIDE HCL ........................................... 33 CHLORHEXIDINE GLUCONATE .................................. 55 CHLOROQUINE PHOSPHATE ....................................... 7 CHLOROTHIAZIDE ....................................................... 27 CHLORPROMAZINE HCL ............................................. 38 CHLORPROPAMIDE ..................................................... 15 CHLORTHALIDONE ...................................................... 27 CHLORZOXAZONE ...................................................... 47 CHOLESTYRAMINE ...................................................... 28 CHOLINE MAGNESIUM TRISALICYLATE .................... 41 CILOSTAZOL ................................................................. 50 CILOXAN ...................................................................... 50 CIPRO HC ..................................................................... 55 CIPRODEX .................................................................... 55 CIPROFLOXACIN ER ...................................................... 5 CIPROFLOXACIN HCL .............................................. 5, 50 CITALOPRAM HYDROBROMIDE ................................. 35 CITROLITH .................................................................... 33 CLARITHROMYCIN ......................................................... 5 CLARITHROMYCIN ER ................................................... 5 CLINDAMYCIN HCL ....................................................... 7 CLINDAMYCIN PHOSPHATE ....................................... 33 CLOBETASOL PROPIONATE ....................................... 58 CLOBETASOL PROPIONATE EMOLLIENT .................. 58 CLOMIPRAMINE HCL ................................................... 36CLONAZEPAM ............................................................ 45 CLONIDINE HCL ........................................................... 26 CLOTRIMAZOLE ..................................................... 55, 57 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE........ 57 CLOZAPINE .................................................................. 38 CODEINE SULFATE ...................................................... 42 COLIDROPS PEDIATRIC ............................................... 31 COLY-MYCIN S ............................................................. 55 COMBIGAN .................................................................. 51 COMBIVENT ................................................................. 30 COMPRO ...................................................................... 38 CONTROLRX ................................................................ 56 CORTANE-B ............................................................ 55, 58 CORTANE-B AQUEOUS ............................................... 55 CORTANE-B-OTIC ........................................................ 55 CORTIC-ND .................................................................. 55 CORTISPORIN .............................................................. 55 CORTISPORIN-TC ......................................................... 55 CORTOMYCIN .............................................................. 55 CRESYLATE ................................................................... 54 CROMOLYN SODIUM ............................................ 30, 54 CRYSELLE ...................................................................... 12 CUTIVATE ..................................................................... 58 CYCLAFEM ................................................................... 12 CYCLESSA ..................................................................... 12 CYCLOBENZAPRINE HCL ............................................ 47

CYCLOGYL ................................................................... 53 CYCLOMYDRIL ............................................................. 53 CYCLOPENTOLATE HCL ............................................. 53 CYCLOPHOSPHAMIDE .................................................. 8 CYOTIC ......................................................................... 55 CYTRA K CRYSTALS ..................................................... 33 CYTRA-2 ....................................................................... 33 CYTRA-3 ....................................................................... 33 CYTRA-K ....................................................................... 33 DANTROLENE SODIUM .............................................. 48 DAPSONE ....................................................................... 7 DEBACTEROL ............................................................... 55 DENAVIR ....................................................................... 57 DERMA-SMOOTHE/FS SCALP OIL .............................. 58 DERMOTIC ................................................................... 54 DESIPRAMINE HCL ...................................................... 36 DESMOPRESSIN ACETATE .................................... 19, 20 DESONIDE .................................................................... 58 DEXAMETHASONE ................................................ 10, 52 DEXAMETHASONE SODIUM PHOSPHATE ................ 52 DEXMETHYLPHENIDATE HCL ..................................... 41 DEXTROAMPHETAMINE SULFATE ............................. 40 DEXTROAMPHETAMINE SULFATE ER ........................ 40 DIAZEPAM .............................................................. 33, 34 DICLOFENAC SODIUM.......................................... 43, 54 DICLOFENAC SODIUM EC .......................................... 43 DICLOFENAC SODIUM ER .......................................... 43 DICLOXACILLIN SODIUM .............................................. 3 DICYCLOMINE HCL ..................................................... 31 DIGOXIN ....................................................................... 20 DILANTIN ..................................................................... 45 DILANTIN INFATABS ................................................... 45 DILT-CD ........................................................................ 22 DILTIAZEM HCL ...................................................... 22, 23 DILTIAZEM HCL ER ................................................ 22, 23 DIOVAN .................................................................. 25, 26 DIOVAN HCT ................................................................ 26 DIPHENOXYLATE/ATROPINE ..................................... 31 DIPYRIDAMOLE ............................................................ 50 DISULFIRAM ................................................................. 41 DIVALPROEX SODIUM ................................................. 45 DIVALPROEX SODIUM ER ........................................... 45 DOLGIC PLUS ............................................................... 42 DORZOLAMIDE HCL .................................................... 54 DOXAZOSIN MESYLATE.............................................. 26 DOXEPIN HCL .............................................................. 36 DOXYCYCLINE HYCLATE .............................................. 5 DOXYCYCLINE MONOHYDRATE ................................. 5 DUREZOL ...................................................................... 52 E.E.S. 400 ........................................................................ 4 ECONAZOLE NITRATE ................................................ 57 EFFER-K 25MEQ TBEF ................................................. 48 EFFERVESCENT POT CHLORIDE ................................ 48 EFFERVESCENT POTASSIUM/CHLORIDE ................... 48 ELIDEL ........................................................................... 59 EMADINE ...................................................................... 54 EMCYT ............................................................................ 8 EMOQUETTE ................................................................ 12 ENALAPRIL MALEATE ............................................ 24, 25 ENJUVIA ....................................................................... 11

59

ENOXAPARIN SODIUM ............................................... 49 ENPRESSE ..................................................................... 12 ENULOSE ...................................................................... 32 EPIDRIN ......................................................................... 44 EPIPEN .......................................................................... 28 EPIPEN-JR ..................................................................... 28 ERGOTAMINE TARTRATE/CAFFEINE ......................... 44 ERRIN ............................................................................ 12 ERYTHROCIN STEARATE ............................................... 4 ERYTHROMYCIN .................................................. 4, 8, 50 ERYTHROMYCIN BASE .................................................. 4 ERYTHROMYCIN/SULFISOXAZOLE ............................... 8 ESTAZOLAM ................................................................. 40 ESTRADIOL ....................................................... 11, 12, 13 ESTRADIOL/NORETHINDRONE ACETATE ................. 12 ESTROPIPATE ............................................................... 11 ESTROSTEP ................................................................... 13 ETHAMBUTOL HCL ........................................................ 6 ETHOSUXIMIDE ............................................................ 45 ETIDRONATE DISODIUM ............................................. 19 ETODOLAC ................................................................... 43 ETOPOSIDE .................................................................... 9 EURAX ........................................................................... 59 EXEMESTANE ................................................................. 8 EXOTIC-HC ................................................................... 55 FARESTON ...................................................................... 8 FELODIPINE ER ............................................................ 23 FEMCON ....................................................................... 13 FENOFIBRATE .............................................................. 28 FENOFIBRATE MICRONIZED ....................................... 28 FINASTERIDE ................................................................ 33 FIRST-MOUTHWASH BLM ........................................... 56 FLAREX ......................................................................... 52 FLECAINIDE ACETATE ................................................. 24 FLUCONAZOLE .............................................................. 6 FLUDROCORTISONE ACETATE .................................. 11 FLUNISOLIDE ................................................................ 29 FLUOCINOLONE ACETONIDE .................................... 58 FLUOCINONIDE ........................................................... 58 FLUOCINONIDE-E ........................................................ 58 FLUORITAB ................................................................... 48 FLUOROMETHOLONE ................................................. 52 FLUOROURACIL ........................................................... 57 FLUOXETINE HCL ......................................................... 35 FLUPHENAZINE HCL .................................................... 38 FLURA-DROPS .............................................................. 48 FLURAZEPAM HCL ....................................................... 40 FLURBIPROFEN ...................................................... 43, 54 FLURBIPROFEN SODIUM ............................................. 54 FLUTAMIDE .................................................................... 9 FLUTICASONE PROPIONATE ................................ 29, 58 FLUVOXAMINE MALEATE ........................................... 35 FML ............................................................................... 52 FML FORTE ................................................................... 52 FML LIQUIFILM ............................................................. 52 FOLIC ACID .................................................................. 49 FOSINOPRIL SODIUM .................................................. 25 FUROSEMIDE ............................................................... 27 GABAPENTIN ............................................................... 46 GALANTAMINE HYDROBROMIDE .............................. 41

GARAMYCIN ................................................................ 50 GEL-KAM ORAL CARE RINSE ...................................... 56 GEMFIBROZIL ............................................................... 28 GENERLAC ................................................................... 32 GENTAK ....................................................................... 50 GENTAMICIN SULFATE ......................................... 50, 56 GENTASOL ................................................................... 50 GIANVI .......................................................................... 13 GILDESS ........................................................................ 13 GLEEVEC ........................................................................ 9 GLIMEPIRIDE ................................................................ 15 GLIPIZIDE ...................................................................... 15 GLIPIZIDE ER ................................................................ 15 GLIPIZIDE XL................................................................. 15 GLUCAGEN .................................................................. 16 GLUCAGON EMERGENCY KIT .................................... 16 GLUCOSE CONTROL SOLN (Lifescan only) ................ 60 GLUCOSE METER (Lifescan only) ............................... 60 GLYBURIDE............................................................. 15, 16 GLYBURIDE MICRONIZED ..................................... 15, 16 GRANULEX ................................................................... 59 GRISEOFULVIN MICROSIZE .......................................... 6 GUANFACINE HCL ...................................................... 26 HALOBETASOL PROPIONATE .................................... 58 HALOPERIDOL ............................................................. 37 HEMRIL-30 .................................................................... 56 HEXALEN ........................................................................ 8 HOMATROPAIRE ......................................................... 53 HUMALOG ................................................................... 15 HUMULIN ...................................................................... 15 HUMULIN N .................................................................. 15 HUMULIN R .................................................................. 15 HYDRALAZINE HCL ...................................................... 26 HYDROCHLOROTHIAZIDE .................................... 27, 28 HYDROCODONE/ACETAMINOPHEN ........................ 43 HYDROCODONE/HOMATROPINE ............................. 29 HYDROCORTISONE ....................... 10, 52, 55, 56, 57, 58 HYDROCORTISONE ACETATE.............................. 56, 58 HYDROCORTISONE ACETATE/PRAMOXINE 56, 58 HYDROCORTISONE BUTYRATE .................................. 58 HYDROCORTISONE VALERATE .................................. 58 HYDROCORTISONE/IODOQUINOL ........................... 57 HYDROMORPHONE HCL ............................................ 42 HYDROXYCHLOROQUINE SULFATE ............................ 7 HYDROXYUREA .............................................................. 9 HYDROXYZINE HCL ..................................................... 34 HYDROXYZINE PAMOATE .......................................... 34 HYOMAX ...................................................................... 31 HYOMAX-SL ................................................................. 31 HYOSCYAMINE SULFATE ............................................ 31 HYOSYNE ..................................................................... 31 IBUPROFEN ............................................................ 43, 44 IMIPRAMINE HCL ......................................................... 36 INDAPAMIDE ......................................................... 27, 28 INDOMETHACIN .......................................................... 44 INDOMETHACIN ER .................................................... 44 INSULIN SYRINGE ........................................................ 60 INTROVALE .................................................................. 13 IPRATROPIUM BROMIDE ............................................ 30 IQUIX ............................................................................ 51

60

IRESSA ............................................................................. 9 ISOCHRON ................................................................... 20 ISOMETHEPTENE/DICHLORALPHENAZONE/ ACETAMINOPHEN ....................................................... 44 ISONIAZID ...................................................................... 6 ISOPTO ATROPINE ...................................................... 53 ISOPTO CARBACHOL .................................................. 53 ISOPTO CARPINE ......................................................... 53 ISOPTO HOMATROPINE ............................................. 53 ISOPTO HYOSCINE ...................................................... 53 ISOSORBIDE DINITRATE .............................................. 20 ISOSORBIDE DINITRATE ER ........................................ 20 ISOSORBIDE MONONITRATE ..................................... 20 ISOXSUPRINE HCL ....................................................... 29 ISTALOL ........................................................................ 51 JINTELI .......................................................................... 12 JOLESSA ....................................................................... 13 JOLIVETTE .................................................................... 12 JUNEL ........................................................................... 13 KARIVA .......................................................................... 13 K-EFFERVESCENT ........................................................ 48 KELNOR ........................................................................ 13 KETOCONAZOLE ..................................................... 6, 57 KETOPROFEN ............................................................... 44 KETOROLAC TROMETHAMINE ................................... 54 KIONEX ......................................................................... 61 KLOR-CON .............................................................. 48, 49 KLOR-CON 10 .............................................................. 48 KLOR-CON 8................................................................. 49 KLOR-CON M10 ........................................................... 49 KLOR-CON M20 ........................................................... 49 KLOR-CON/EF .............................................................. 49 KOVIA ........................................................................... 59 K-PHOS MF ................................................................... 33 K-PHOS NO 2 ............................................................... 33 K-VESCENT ................................................................... 49 LABETALOL HCL .......................................................... 22 LAMOTRIGINE .............................................................. 46 LANCET DEVICE ........................................................... 60 LANCETS ...................................................................... 60 LANOXIN ...................................................................... 20 LANTUS ......................................................................... 15 LATANOPROST ............................................................ 53 LEENA ........................................................................... 13 LEFLUNOMIDE ............................................................. 44 LESCOL ......................................................................... 29 LESSINA ........................................................................ 13 LETROZOLE .................................................................... 9 LEUCOVORIN CALCIUM .............................................. 10 LEUKERAN ...................................................................... 8 LEVEMIR ........................................................................ 15 LEVETIRACETAM .......................................................... 46 LEVOBUNOLOL HCL .................................................... 51 LEVORA......................................................................... 13 LEVORPHANOL TARTRATE ......................................... 42 LEVOTHROID ................................................................ 17 LEVOTHYROXINE SODIUM ......................................... 17 LEVOXYL ................................................................. 17, 18 LIDOCAINE VISCOUS ................................................... 56

LINDANE ...................................................................... 59 LIOTHYRONINE SODIUM ............................................ 18 LIPITOR ......................................................................... 29 LISINOPRIL ................................................................... 25 LITHIUM CARBONATE ................................................. 39 LITHIUM CARBONATE ER ........................................... 39 LITHIUM CITRATE ........................................................ 39 LITHOBID ...................................................................... 39 LOCOID ........................................................................ 58 LOESTRIN ..................................................................... 13 LOESTRIN 24 ................................................................ 13 LOFENE ........................................................................ 31 LONOX ......................................................................... 31 LORAZEPAM ................................................................ 34 LORYNA ........................................................................ 13 LOSARTAN POTASSIUM ....................................... 25, 27 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 27 LOTEMAX ..................................................................... 52 LOVASTATIN ................................................................ 29 LOW-OGESTREL .......................................................... 13 LOXAPINE SUCCINATE ............................................... 38 LURIDE .......................................................................... 48 LUTERA ......................................................................... 13 LYBREL .......................................................................... 13 LYSODREN ..................................................................... 9 MAPROTILINE HCL ...................................................... 37 MARGESIC .................................................................... 42 MARTEN-TAB ............................................................... 42 MATULANE .................................................................... 9 MAXIDEX ...................................................................... 52 MAXITROL .................................................................... 52 MEBARAL ..................................................................... 39 MEBENDAZOLE ............................................................. 7 MECLIZINE HCL ........................................................... 31 MEDROXYPROGESTERONE ACETATE ................ 12, 15 MEFLOQUINE HCL ........................................................ 7 MEGESTROL ACETATE ................................................. 9 MENEST ........................................................................ 11 MEPERIDINE HCL ......................................................... 42 MEPERITAB .................................................................. 42 MERCAPTOPURINE ....................................................... 8 MESNEX ....................................................................... 10 METADATE ER ............................................................. 41 METFORMIN HCL ........................................................ 16 METFORMIN HCL ER ................................................... 16 METHADONE HCL ................................................. 42, 43 METHADOSE .......................................................... 42, 43 METHADOSE SUGAR-FREE ......................................... 43 METHAZOLAMIDE ....................................................... 27 METHENAMINE HIPPURATE ....................................... 32 METHENAMINE MANDELATE .................................... 32 METHERGINE ............................................................... 19 METHIMAZOLE ............................................................ 19 METHOCARBAMOL ..................................................... 47 METHOTREXATE ........................................................... 8 METHYCLOTHIAZIDE .................................................. 28 METHYLDOPA .............................................................. 26 METHYLIN .................................................................... 41 METHYLIN ER ............................................................... 41 METHYLPHENIDATE HCL ............................................ 41

61

METHYLPREDNISOLONE ............................................. 10 METIPRANOLOL ........................................................... 51 METOCLOPRAMIDE HCL ............................................. 32 METOLAZONE.............................................................. 28 METOPROLOL SUCCINATE ER ................................... 21 METOPROLOL TARTRATE ..................................... 21, 22 METRONIDAZOLE .................................................... 7, 33 METRONIDAZOLE VAGINAL ....................................... 33 MEXILETINE HCL .......................................................... 24 MICROGESTIN .............................................................. 13 MIDAZOLAM HCL ........................................................ 40 MIDODRINE HCL .......................................................... 28 MIGRALAM ................................................................... 44 MIMVEY ........................................................................ 12 MINIRIN......................................................................... 20 MINOCYCLINE HCL ....................................................... 5 MINOXIDIL .................................................................... 26 MIRTAZAPINE ............................................................... 34 MIRTAZAPINE ODT ...................................................... 34 MISOPROSTOL ............................................................. 31 MOEXIPRIL HCL ............................................................ 25 MOMETASONE FUROATE .......................................... 59 MONONESSA ............................................................... 13 MORPHINE SULFATE ................................................... 43 MUPIROCIN .................................................................. 56 MYDFRIN ...................................................................... 53 MYDRIACYL .................................................................. 53 MYLERAN ....................................................................... 8 NADOLOL ..................................................................... 21 NAPROXEN .................................................................. 44 NAPROXEN SODIUM ................................................... 44 NARDIL ......................................................................... 34 NASACORT AQ ............................................................ 29 NATACYN ..................................................................... 51 NATURE-THROID ......................................................... 18 NECON ......................................................................... 13 NEEDLES ....................................................................... 60 NEFAZODONE HCL ..................................................... 35 NEOMYCIN SULFATE ..................................................... 6 NEOMYCIN/BACITRACIN/POLYMYXIN ...................... 51 NEOMYCIN/POLYMYXIN/BACITRACIN/ HYDROCORTISONE ..................................................... 52 NEOMYCIN/POLYMYXIN/DEXAMETHASONE ........... 52 NEOMYCIN/POLYMYXIN/GRAMICIDIN ...................... 51 NEOMYCIN/POLYMYXIN/HC ...................................... 55 NEOMYCIN/POLYMYXIN/HYDROCORTISONE .......... 55 NEOSPORIN ................................................................. 51 NEVANAC ..................................................................... 54 NEXAVAR ........................................................................ 9 NEXT CHOICE .............................................................. 12 NIASPAN ....................................................................... 29 NICARDIPINE HCL ........................................................ 23 NIFEDIAC CC ................................................................ 23 NIFEDICAL XL ............................................................... 23 NIFEDIPINE ................................................................... 23 NIFEDIPINE ER ............................................................. 23 NILANDRON ................................................................... 9 NIMODIPINE ................................................................. 23 NITRO-BID .................................................................... 20 NITROFURANTOIN MACROCRYSTALLINE ................. 32

NITROFURANTOIN MONOHYDRATE ........................ 32 NITROGLYCERIN ER .................................................... 20 NITROGLYCERIN TRANSDERMAL .............................. 20 NITROSTAT .................................................................. 20 NORA-BE ...................................................................... 12 NORETHINDRONE ACETATE ............................... 12, 15 NORGESTREL/ETHINYL ESTRADIOL .......................... 13 NORINYL ................................................................ 13, 14 NORTREL ................................................................ 13, 14 NORTRIPTYLINE HCL ............................................. 36, 37 NOVOLIN ..................................................................... 15 NOVOLIN N .................................................................. 15 NOVOLIN R .................................................................. 15 NP THYROID 30 ........................................................... 18 NP THYROID 60 ........................................................... 18 NP THYROID 90 ........................................................... 18 NUVARING ................................................................... 12 NYSTATIN ........................................................... 6, 55, 57 NYSTATIN/TRIAMCINOLONE ..................................... 57 OCELLA ........................................................................ 14 OCUFEN ....................................................................... 54 OCUFLOX ..................................................................... 51 OFLOXACIN ........................................................... 51, 54 OGESTREL .............................................................. 13, 14 ONDANSETRON HCL .................................................. 31 OPTIPRANOLOL ........................................................... 51 ORASEP ........................................................................ 56 ORPHENADRINE CITRATE ER ..................................... 47 ORTHO DIAPHRAGM COIL SPRING KIT ..................... 60 ORTHO DIAPHRAGM FLAT SPRING KIT ..................... 60 ORTHO TRI-CYCLEN .................................................... 14 ORTHO-CYCLEN .......................................................... 14 ORTHO-NOVUM .......................................................... 14 OTICIN .......................................................................... 55 OTOMAR ...................................................................... 55 OVCON-50 ................................................................... 14 OXAPROZIN ................................................................. 44 OXAZEPAM .................................................................. 34 OXCARBAZEPINE ........................................................ 46 OXYBUTYNIN CHLORIDE ............................................ 32 OXYBUTYNIN CHLORIDE ER ....................................... 32 OXYCODONE HCL ...................................................... 43 OXYCODONE/ACETAMINOPHEN ............................. 43 OXYCODONE/ASPIRIN ............................................... 43 PANDEL ........................................................................ 59 PAPAVERINE HCL CR .................................................. 29 PARA-TIME ................................................................... 29 PAROXETINE HCL ........................................................ 35 PAROXETINE HCL ER .................................................. 35 PATADAY ..................................................................... 54 PATANOL ..................................................................... 54 PEAK FLOW METER ..................................................... 60 PEG-INTRON .................................................................. 6 PEG-INTRON REDIPEN .................................................. 6 PEN DEVICE ................................................................. 60 PEN NEEDLES .............................................................. 60 PENICILLIN V POTASSIUM ............................................ 3 PENTOXIFYLLINE ER .................................................... 50 PERIDEX ........................................................................ 55 PERIOGARD ................................................................. 55

62

PERMETHRIN ................................................................ 59 PERPHENAZINE ............................................................ 38 PHENAZOPYRIDINE HCL ............................................. 33 PHENOBARBITAL ......................................................... 39 PHENYLEPHRINE HCL .................................................. 53 PHENYTEK .................................................................... 45 PHENYTOIN .................................................................. 45 PHENYTOIN SODIUM EXTENDED .............................. 45 PHOSPHOLINE IODIDE ................................................ 53 PILOCARPINE HCL ....................................................... 53 PILOPINE HS ................................................................. 53 PINDOLOL .................................................................... 21 PIROXICAM ................................................................... 44 PODOFILOX.................................................................. 59 POLYCIN B .................................................................... 51 POLY-PRED ................................................................... 52 POLYTRIM ..................................................................... 51 PORTIA-28 .................................................................... 14 POTASSIUM BICARBONATE ....................................... 49 POTASSIUM CHLORIDE ............................................... 49 POTASSIUM CHLORIDE ER ......................................... 49 POTASSIUM CITRATE .................................................. 33 PRAMOTIC .................................................................... 55 PRAZOSIN HCL ............................................................. 26 PRED FORTE ................................................................. 52 PRED MILD .................................................................... 52 PRED-G S.O.P. .............................................................. 52 PREDNICARBATE ......................................................... 59 PREDNISOLONE ..................................................... 10, 52 PREDNISOLONE ACETATE .......................................... 52 PREDNISOLONE SODIUM PHOSPHATE ............... 10, 52 PREDNISONE................................................................ 10 PREMARIN .............................................................. 11, 33 PREMARIN W/APPLICATOR ........................................ 33 PREMPRO ..................................................................... 12 PRENATAL VITAMINS .................................................. 48 PREVALITE .................................................................... 28 PREVIDENT ................................................................... 56 PREVIDENT 5000 BOOSTER ........................................ 56 PREVIDENT 5000 PLUS ................................................ 56 PREVIDENT FLUORIDE ................................................. 56 PREVIFEM ..................................................................... 14 PRIMIDONE .................................................................. 46 PROAIR HFA ................................................................. 30 PROBENECID................................................................ 45 PROBENECID/COLCHICINE ........................................ 45 PROCHLORPERAZINE MALEATE ................................ 38 PROCTOCREAM HC..................................................... 56 PROCTOFOAM HC ...................................................... 56 PROCTOZONE-HC ....................................................... 56 PROMETRIUM ............................................................... 15 PROPAFENONE HCL ................................................... 24 PROPRANOLOL HCL .................................................... 21 PROPRANOLOL HCL ER .............................................. 21 PROPYLTHIOURACIL .................................................... 19 PROTRIPTYLINE HCL .................................................... 37 PYRIDOSTIGMINE BROMIDE ....................................... 48 QUASENSE ................................................................... 14 QUINAPRIL HCL ........................................................... 25 QUINIDINE GLUCONATE CR ...................................... 24

QUINIDINE SULFATE ................................................... 24 QUINIDINE SULFATE ER .............................................. 24 QUIXIN .......................................................................... 51 QVAR ............................................................................ 30 RAMIPRIL ...................................................................... 25 RECLIPSEN ................................................................... 14 RELPAX ......................................................................... 44 REPAN .......................................................................... 42 RESERPINE ................................................................... 26 RIBASPHERE ................................................................... 7 RIBAVIRIN ....................................................................... 7 RIFAMPIN ....................................................................... 6 RISPERIDONE ............................................................... 37 ROMYCIN ..................................................................... 51 ROPINIROLE HCL ......................................................... 47 ROXICET ....................................................................... 43 SALSALATE ................................................................... 41 SANTYL ......................................................................... 59 SEASONALE ................................................................. 14 SEASONIQUE ............................................................... 14 SECONAL ..................................................................... 39 SELEGILINE HCL ........................................................... 47 SELENIUM SULFIDE ..................................................... 57 SERTRALINE HCL ......................................................... 35 SF .................................................................................. 56 SF 5000 PLUS ............................................................... 56 SILVER SULFADIAZINE ................................................. 57 SIMVASTATIN ............................................................... 29 SINGULAIR ................................................................... 31 SODIUM CHLORIDE ..................................................... 33 SODIUM FLUORIDE ..................................................... 48 SODIUM POLYSTYRENE SULFONATE ........................ 61 SODIUM SULFACETAMIDE ......................................... 51 SOLIA ............................................................................ 14 SORINE ......................................................................... 21 SOTALOL HCL .............................................................. 21 SPIRONOLACTONE ..................................................... 27 SPRINTEC 28 ................................................................ 14 SPRYCEL ......................................................................... 9 SRONYX ........................................................................ 14 SSKI ............................................................................... 48 STANNOUS FLUORIDE ORAL RINSE .......................... 56 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM

PHOSPHATE ............................................................. 52 SULFADIAZINE ......................................................... 6, 57 SULFAMETHOXAZOLE/TRIMETHOPRIM ...................... 8 SULFASALAZINE .......................................................... 32 SULFAZINE EC ............................................................. 32 SULINDAC .................................................................... 44 SUTENT .......................................................................... 9 SYEDA ........................................................................... 14 SYMAX-SL ..................................................................... 31 SYNTHROID .................................................................. 18 TABLOID ......................................................................... 8 TAMIFLU ......................................................................... 7 TAMOXIFEN CITRATE ................................................... 9 TARCEVA ........................................................................ 9 TARGRETIN .................................................................... 9 TASIGNA ........................................................................ 9 TAZTIA XT .................................................................... 23

63

TBC ................................................................................ 59 TEGRETOL-XR .............................................................. 46 TEMAZEPAM ................................................................ 40 TEMODAR ...................................................................... 8 TERAZOSIN HCL ........................................................... 26 TERBINAFINE HCL .......................................................... 6 TERBUTALINE SULFATE ............................................... 30 TETRACYCLINE HCL ...................................................... 5 THEOPHYLLINE ER ....................................................... 30 THIORIDAZINE HCL ..................................................... 38 THIOTHIXENE ............................................................... 39 THYROLAR .................................................................... 18 TICLOPIDINE HCL ........................................................ 50 TILIA .............................................................................. 14 TIMOLOL MALEATE ......................................... 21, 51, 52 TIMOLOL MALEATE OPHTHALMIC GEL FORMING . 51,

52 TIMOPTIC ..................................................................... 52 TIMOPTIC-XE ................................................................ 52 TOBRADEX ................................................................... 52 TOBRAMYCIN/DEXAMETHASONE ............................. 52 TOBRASOL ................................................................... 51 TOBREX ........................................................................ 51 TOLAZAMIDE ............................................................... 16 TOLMETIN SODIUM ..................................................... 44 TOPIRAMATE ............................................................... 46 TORSEMIDE .................................................................. 27 TRAMADOL HCL .......................................................... 43 TRANDOLAPRIL ............................................................ 25 TRANYLCYPROMINE SULFATE 10MG TABS .............. 34 TRAZODONE HCL ........................................................ 35 TRETINOIN ..................................................................... 9 TRIAMCINOLONE ACETONIDE .................................. 59 TRIAMCINOLONE ACETONIDE IN ABSORBASE ....... 59 TRIAMCINOLONE IN ORABASE .................................. 55 TRIAMTERENE/HYDROCHLOROTHIAZIDE ................. 28 TRIAZOLAM .................................................................. 40 TRICITRATES ................................................................. 33 TRIFLUOPERAZINE HCL ............................................... 38 TRIFLURIDINE ............................................................... 51 TRIHEXYPHENIDYL HCL ............................................... 47 TRI-LEGEST ................................................................... 14 TRIMETHOBENZAMIDE HCL ....................................... 31 TRIMETHOPRIM ................................................... 7, 8, 51

TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE .. 51 TRINESSA ..................................................................... 14 TRI-NORINYL ................................................................ 14 TRI-PREVIFEM ............................................................... 14 TRI-SPRINTEC ............................................................... 14 TRIVORA ....................................................................... 14 TROPICAMIDE .............................................................. 53 TYKERB ........................................................................... 9 TYZEKA ........................................................................... 6 U-CORT ........................................................................ 59 UNITHROID ............................................................ 18, 19 URECHOLINE ............................................................... 32 URELIEF PLUS ............................................................... 32 VALACYCLOVIR HCL ...................................................... 7 VALPROIC ACID ........................................................... 45 VASOLEX ...................................................................... 59 VELIVET ......................................................................... 14 VENLAFAXINE HCL ...................................................... 36 VERAPAMIL HCL .................................................... 23, 24 VERAPAMIL HCL ER ............................................... 23, 24 VEXOL ........................................................................... 52 VIDAZA ........................................................................... 8 VIGAMOX ..................................................................... 51 VIROPTIC ...................................................................... 51 VITAMIN D .................................................................... 48 VOLTAREN ................................................................... 54 WARFARIN SODIUM .................................................... 50 WESTCORT ................................................................... 59 WESTHROID ................................................................. 19 WIDE-SEAL SILICONE DIAPHRAGM KIT ..................... 60 XELODA .......................................................................... 8 XERAC AC .................................................................... 59 ZAFIRLUKAST ............................................................... 31 ZARAH .......................................................................... 14 ZARONTIN .................................................................... 45 ZEBUTAL ....................................................................... 42 ZENCHENT ................................................................... 14 ZEOSA .......................................................................... 14 ZOLINZA ......................................................................... 9 ZOLPIDEM TARTRATE ................................................. 40 ZONISAMIDE ................................................................ 46 ZOVIA ........................................................................... 14 ZYLET ............................................................................ 52

11-607-061 Rev. 00 12/11 Commercial Closed Formulary

FCHP Direct Care, Select Care and Steward Community Care members, please call 1-800-868-5200. Fallon Preferred Care members, please call 1-888-468-1541.

TTY users, please call TRS Relay 711. fchp.org

Fallon Health & Life Assurance Company, Inc. is a wholly-owned subsidiary of Fallon Community Health Plan.

closed formulary - fallon community health plan

Documents