health net cal mediconnect plan (medicare-medicaid …€¦ · health net cal mediconnect plan ......

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)

2015 List ofCovered Drugs (Formulary)

Formulary ID: 15417 Version: Material ID #H3237_2015_0095_A CMS Approved 09112014

This drug list was updated on If you have questions, please call Health Net Cal MediConnect at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711, 24 hours a day, 7 days a week. The call is free. For more information, visit www.healthnet.com/calmediconnect.

12/1/2015.

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? If you have questions, please call Health Net Cal MediConnect at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711, 24 hours a day, 7 days a week. The call is free. For more information, visit www.healthnet.com/calmediconnect.

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This is a list of drugs that members can get in Health Net Cal MediConnect.

• Health Net Cal MediConnect is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

• Benefits, List of Covered Drugs, and pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year.

• You can always check Health Net Cal MediConnect’s up-to-date List of Covered Drugs online at www.healthnet.com/calmediconnect or by calling 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711.

• You can ask for this information in other formats, such as Braille or large print. Call 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711. The call is free.

• Limitations, copays, and restrictions may apply. For more information, call Health Net Cal MediConnect Member Services or read the Health Net Cal MediConnect Member Handbook.

• Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

• You can get this information for free in other languages. Call 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711. The call is free.

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Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1. What prescription drugs are on the List of Covered Drugs?

(We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the Drug List are the drugs covered by Health Net Cal MediConnect. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

Health Net Cal MediConnect will cover all medically necessary drugs on the Drug List if:

• your doctor or other prescriber says you need them to get better or stay healthy, and

• you fill the prescription at a Health Net Cal MediConnect network pharmacy.

In some cases, you have to do something before you can get a drug (see question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at www.healthnet.com/calmediconnect or call Member Services at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711.


2. Does the Drug List ever change?Yes. Health Net Cal MediConnect may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:

• a cheaper drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Health Net Cal MediConnect before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

(For more information on these drug rules, see page iv.)

We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 7 below have more information on what happens when the Drug List changes.

• You can always check Health Net Cal MediConnect’s up-to-date Drug List online at www.healthnet.com/calmediconnect. You can also call Member Services to check the current Drug List at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711.

3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. If we make any other negative changes to the Drug List, we will send you a letter that tells you about these changes. We will also put the changes on our website at www.healthnet.com/calmediconnect.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you get one of these letters, please call your doctor to talk about other drug options.

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5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Health Net Cal MediConnect before you fill your prescription. If you don’t get approval, Health Net Cal MediConnect may not cover the drug.

• Quantity limits: Sometimes Health Net Cal MediConnect limits the amount of a drug you can get.

• Step therapy: Sometimes Health Net Cal MediConnect requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 – Index 1. You can also get more information by visiting our website at www.healthnet.com/calmediconnect. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can also ask for an “exception” from these limits. Please see Question 11 for more information on exceptions.

• If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 34-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Health Net Cal MediConnect member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next.


8. How can you find a drug on the Drug List?

There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it in the Index that begins on page Index 1.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711 and ask about it. If you learn that Health Net Cal MediConnect will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see

question 11 for more information about exceptions.

10. What if you are a new Health Net Cal MediConnect member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Health Net Cal MediConnect. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Health Net Cal MediConnect, or

• you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 98 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception.

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Level of Care ChangesIf your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

• If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.

• If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 34-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 34-day supply.

11. Can you ask for an exception to cover your drug?

Yes. You can ask Health Net Cal MediConnect to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Health Net Cal MediConnect may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

12. How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?To ask for an exception, call Member Services. Member Services will work with you and your provider to help you ask for an exception.

14. What are generic drugs?Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA).

Health Net Cal MediConnect covers both brand name drugs and generic drugs.


15. What are OTC drugs? OTC stands for “over-the-counter”.

Health Net Cal MediConnect covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Health Net Cal MediConnect Drug List to see what OTC drugs are covered.

16. Does Health Net Cal MediConnect cover OTC non-drug products?

Health Net Cal MediConnect covers some OTC non-drug products when they are written as prescriptions by your provider.

You can read the Health Net Cal MediConnect Drug List to see what OTC non-drug products are covered.

17. What is your copay?You can read the Health Net Cal MediConnect Drug List to learn about the copay for each drug.

Health Net Cal MediConnect members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays.

Copays are listed by tiers. Tiers are groups of drugs with the same copay.

• Tier 1 drugs have a low copay. They are generic drugs. The copay will be from $0.00 to $2.65. This depends on your level of Medi-Cal coverage.

• Tier 2 drugs have a higher copay. They are brand name drugs. The copay will be from $0.00 to $6.60. This depends on your level of Medi-Cal coverage.

• Tier 3 drugs have a $0.00 copay. They are prescription and OTC drugs that Medi-Cal covers.

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List of Covered DrugsThe list of covered drugs that begins on page 1 gives you information about the drugs covered by Health Net Cal MediConnect. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., LIPITOR) and generic

drugs are listed in lower-case italics (e.g., atorvastatin calcium).

The information in the “Necessary actions, restrictions, or limits on use” column tells you if Health Net Cal MediConnect has any rules for covering your drug.

Abbreviation What this means How it worksAL Age Limit Some drugs may need prior authorization if

your age does not meet drug maker, FDA or clinical guidelines.

B/D Medicare Part B vs. Part D

Some drugs need prior authorization to decide if the drug should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or other prescriber may need to give more facts to help us make this decision.

GL Gender Limit Some drugs may only be safe for males or females.

LA Limited Access Some drugs may be found at only one or a few pharmacies because:

• The FDA limits the drug to certain facilities, pharmacies or prescribers, or

• Certain drugs need special care, or patient training that cannot be given at a retail pharmacy.

You should talk to your doctor, other prescriber, or pharmacist for details about getting limited access drugs.

MO Mail Order You can get this drug at Health Net Cal MediConnect’s mail order pharmacy.


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Abbreviation What this means How it worksNF Not Covered This drug is not covered on the Drug List. You

can ask for an exception for the drug to be covered.

NT Not Part D This drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

PA Prior Authorization For some drugs, you or your doctor must get approval from Health Net Cal MediConnect before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL Quantity Limit Sometimes Health Net Cal MediConnect limits the amount of a drug you can get.

RX/OTC Prescription and OTC Certain drugs are made in both prescription form and OTC form.

ST Step Therapy Sometimes Health Net Cal MediConnect asks that you do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

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Note: The NT next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it

if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711. You can also read the Member Handbook to learn how to appeal a decision.

List of drugs by medical condition

Name of drug

Whatthe

drugwillcostyou(tier

level)

Necessaryactions,restrictions, orlimits on use

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR (UseAmphetamine-Dextroamphetamine)

NFMO

amphetamine-dextroamphetamine

$0-$2.65(Tier

1)

MO

DESOXYN (UseMethamphetamine HCl) NF MO

DEXEDRINE 10 MG,15MG,5 MG (UseDextroamphetamineSulfate)

NF

MO

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg

$0-$2.65(Tier

1)

MO

dextroamphetamine sulfatetabs 10 mg, 5 mg

$0-$2.65(Tier

1)

MO

methamphetamine hcl$0-

$2.65(Tier

1)

MO

Anorexiants Non-AmphetamineADIPEX-P (UsePhentermine HCl) NF PA; MO; NT

diethylpropion hcl tabs 25mg

$0(Tier

3)

PA; MO; NT

DIETHYLPROPION HCLTABS 25 MG (UseDiethylpropion HCl)

NFPA; MO; NT

diethylpropion hcl tb24 75mg

$0(Tier

3)

PA; MO; NT

Name of drug

Whatthe


level)


phentermine hcl$0

(Tier3)

PA; MO; NT

QSYMIA$0

(Tier3)

PA; NT

REGIMEX$0

(Tier3)

PA; MO; NT

SUPRENZA$0

(Tier3)

PA; MO; NT

Anti-Obesity Agents

ALLI$0

(Tier3)

PA; NT

BELVIQ$0

(Tier3)

PA; MO; NT

CONTRAVE$0

(Tier3)

PA; MO; NT

SAXENDA$0

(Tier3)

PA; MO; NT

Attention-Deficit/Hyperactivity Disorder (ADHD)

clonidine hcl (adhd)$0-

$2.65(Tier

1)

MO

guanfacine hcl (adhd)$0-

$2.65(Tier

1)

AL; MO

INTUNIV (Use GuanfacineHCl (ADHD))

$0-$6.60(Tier

2)

AL; MO

KAPVAY (Use ClonidineHCl (ADHD)) NF MO

You can find information on what the symbols and abbreviations on this table mean by going topage viii.

Health Net Cal MediConnect 2015 Drug List

1

Name of drug

Whatthe


level)


STRATTERA$0-

$6.60(Tier

2)

MO

Stimulants - Misc.CONCERTA 27 MG, 36MG (Use MethylphenidateHCl)

NFMO

dexmethylphenidate hclcp24 15 mg

$0-$2.65(Tier

1)

MO

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg

$0-$2.65(Tier

1)

MO

FOCALIN (UseDexmethylphenidate HCl) NF MO

FOCALIN XR 15 MG (UseDexmethylphenidate HCl) NF MO

METADATE CD (UseMethylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 30 mg, 40 mg

$0-$2.65(Tier

1)

MO

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

$0-$2.65(Tier

1)

MO

methylphenidate hcl tabs or10 mg, 20 mg, 5 mg

$0-$2.65(Tier

1)

MO

methylphenidate hcl tb24or 27 mg, 36 mg

$0-$2.65(Tier

1)

MO

methylphenidate hcl tbcr or20 mg, 27 mg, 36 mg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


modafinil$0-

$2.65(Tier

1)

PA; MO

PROVIGIL (Use Modafinil) NF PA; MO

RITALIN (UseMethylphenidate HCl) NF MO

RITALIN LA 20 MG, 30MG, 40 MG (UseMethylphenidate HCl)

NFMO

RITALIN LA 60 MG$0-

$6.60(Tier

2)RITALIN SR (UseMethylphenidate HCl) NF MO

ALTERNATIVE MEDICINES

Alternative Medicine - A's

ALPHA LIPOIC ACIDCAPS OR 50 MG

$0(Tier

3)

NT

ALPHA-LIPOIC ACID$0

(Tier3)

NT

alpha-lipoic acid (thiocticacid) caps 100 mg

$0(Tier

3)

MO; NT

Alternative Medicine - C's

CHEW Q 100 MG$0

(Tier3)

NT

coenzyme q10(ubidecarenone) caps 10mg, 60 mg

$0(Tier

3)

NT

coenzyme q10(ubidecarenone) caps 150mg, 30 mg

$0(Tier

3)

MO; NT

COENZYME Q10 CHEWOR 60 MG

$0(Tier

3)

NT



2

Name of drug

Whatthe


level)


COENZYME Q10 TABSOR 25 MG

$0(Tier

3)

MO; NT

Alternative Medicine - G's

glucosamine sulfate capsor 500 mg

$0(Tier

3)

MO; NT

glucosamine sulfate tabs or500 mg

$0(Tier

3)

NT

Alternative Medicine - L's

lutein caps or 6 mg$0

(Tier3)

NT

Alternative Medicine Combinations

glucosamine-chondroitincaps 200mg-250mg

$0(Tier

3)

NT

glucosamine-chondroitintabs 200mg-250mg

$0(Tier

3)

MO; NT

LIQ-10 50MG/5ML-15UNIT/5ML

$0(Tier

3)

NT

VITALINECOQ10/VITAMIN E100MG-300UNIT

$0(Tier

3)

NT

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosides

amikacin sulfate soln ij 1gm/4ml, 500 mg/2ml

$0-$2.65(Tier

1)

MO

BETHKIS$0-

$6.60(Tier

2)

B/D

Name of drug

Whatthe


level)


gentamicin in saline 0.9%-0.8mg/ml

$0-$2.65(Tier

1)

MO

gentamicin in saline 0.9%-1.2mg/ml, 0.9%-1.6mg/ml,0.9%-1mg/ml

$0-$2.65(Tier

1)

gentamicin sulfate soln ij 40mg/ml

$0-$2.65(Tier

1)

MO

gentamicin sulfate soln iv10 mg/ml

$0-$2.65(Tier

1)

neomycin sulfate tabs or$0-

$2.65(Tier

1)

MO

paromomycin sulfate$0-

$2.65(Tier

1)

MO

TOBI (Use Tobramycin) NF B/D

TOBI PODHALER$0-

$6.60(Tier

2)

tobramycin nebu in$0-

$2.65(Tier

1)

B/D

tobramycin sulfate soln ij1.2 gm/30ml, 40 mg/ml, 80mg/2ml

$0-$2.65(Tier

1)

MO

tobramycin sulfate soln ij10 mg/ml

$0-$2.65(Tier

1)



3

Name of drug

Whatthe


level)


tobramycin sulfate solr ij1.2 gm

$0-$2.65(Tier

1)

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal Antibodies

HUMIRA$0-

$6.60(Tier

2)

PA

HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK

$0-$6.60(Tier

2)

PA

HUMIRA PEN$0-

$6.60(Tier

2)

PA

HUMIRA PEN-CROHNSDISEASESTARTER

$0-$6.60(Tier

2)

PA

HUMIRA PEN-PSORIASISSTARTER

$0-$6.60(Tier

2)

PA

SIMPONI$0-

$6.60(Tier

2)

PA

SIMPONI ARIA$0-

$6.60(Tier

2)

PA

Antirheumatic - Enzyme Inhibitors

XELJANZ$0-

$6.60(Tier

2)

PA

Antirheumatic Antimetabolites

Name of drug

Whatthe


level)


OTREXUP$0-

$6.60(Tier

2)

PA

RASUVO$0-

$6.60(Tier

2)

PA

Gold Compounds

RIDAURA$0-

$6.60(Tier

2)

MO

Interleukin-1 Blockers

ARCALYST$0-

$6.60(Tier

2)

LA

Interleukin-1 Receptor Antagonist (IL-1Ra)

KINERET$0-

$6.60(Tier

2)

PA

Interleukin-1beta Blockers

ILARIS$0-

$6.60(Tier

2)

LA

Interleukin-6 Receptor Inhibitors

ACTEMRA$0-

$6.60(Tier

2)

PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ADVIL (Use Ibuprofen) NF MO; NT

ADVIL MIGRAINE (UseIbuprofen) NF MO; NT

ALEVE CAPS (UseNaproxen Sodium) NF NT



4

Name of drug

Whatthe


level)


ANAPROX (Use NaproxenSodium) NF MO

ANAPROX DS (UseNaproxen Sodium) NF MO

ARTHROTEC 50 (UseDiclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 (UseDiclofenac w/ Misoprostol) NF MO

CATAFLAM (UseDiclofenac Potassium) NF MO

CELEBREX (UseCelecoxib)

$0-$6.60(Tier

2)

MO

celecoxib$0-

$2.65(Tier

1)

MO

CHILDRENS MOTRINCHEW 50 MG

$0(Tier

3)

NT

CHILDRENS MOTRINJUNIOR STRENGTH (UseIbuprofen)

NFMO; NT

CHILDRENS MOTRINSUSP 40 MG/ML (UseIbuprofen)

NFNT

DAYPRO (Use Oxaprozin) NF MO

diclofenac potassium$0-

$2.65(Tier

1)

MO

diclofenac sodium tb24 or100 mg

$0-$2.65(Tier

1)

MO

diclofenac sodium tbec or25 mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


diclofenac w/ misoprostol$0-

$2.65(Tier

1)

MO

EC-NAPROSYN (UseNaproxen) NF MO

etodolac caps or 200 mg,300 mg

$0-$2.65(Tier

1)

MO

etodolac tabs or 400 mg,500 mg

$0-$2.65(Tier

1)

MO

etodolac tb24 or 400 mg,500 mg, 600 mg

$0-$2.65(Tier

1)

MO

FELDENE (Use Piroxicam) NF MO

flurbiprofen tabs or 100 mg,50 mg

$0-$2.65(Tier

1)

MO

ibuprofen caps or 200 mg$0

(Tier3)

MO; NT

ibuprofen chew or 100 mg$0

(Tier3)

MO; NT

ibuprofen susp or 100mg/5ml

$0-$2.65(Tier

1)

RX/OTC; MO

ibuprofen susp or 40mg/ml, 50 mg/1.25ml

$0(Tier

3)

NT

ibuprofen tabs or 100 mg$0

(Tier3)

NT

ibuprofen tabs or 200 mg$0

(Tier3)

MO; NT



5

Name of drug

Whatthe


level)


ibuprofen tabs or 400 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO


$2.65(Tier

1)

QL(5 ea daily);MO


$2.65(Tier

1)

QL(4 ea daily);MO

indomethacin caps or 25mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

indomethacin cpcr or 75mg

$0-$2.65(Tier

1)

AL; MO

INFANTS ADVIL (UseIbuprofen) NF NT

ketoprofen caps or 50 mg,75 mg

$0-$2.65(Tier

1)

MO

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml

$0-$2.65(Tier

1)

AL; MO

ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

$0-$2.65(Tier

1)

AL; MO

mefenamic acid caps or$0-

$2.65(Tier

1)

MO

meloxicam tabs or 15 mg,7.5 mg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


MOBIC TABS 15 MG, 7.5MG (Use Meloxicam) NF MO

MOTRIN INFANTS (UseIbuprofen) NF NT

MOTRIN INFANTSDROPS (Use Ibuprofen) NF NT

MOTRIN JUNIORSTRENGTH CHEW (UseIbuprofen)

NFMO; NT

MOTRIN JUNIORSTRENGTH TABS (UseIbuprofen)

NFNT

nabumetone$0-

$2.65(Tier

1)

MO

NAPROSYN (UseNaproxen) NF MO

naproxen sodium caps or220 mg

$0(Tier

3)

NT

naproxen sodium tabs or275 mg, 550 mg

$0-$2.65(Tier

1)

MO

naproxen tabs or 250 mg,375 mg, 500 mg

$0-$2.65(Tier

1)

MO

naproxen tbec or 375 mg,500 mg

$0-$2.65(Tier

1)

MO

oxaprozin$0-

$2.65(Tier

1)

MO

piroxicam caps or 10 mg,20 mg

$0-$2.65(Tier

1)

MO



6

Name of drug

Whatthe


level)


PONSTEL (Use MefenamicAcid) NF MO

sulindac tabs or 150 mg,200 mg

$0-$2.65(Tier

1)

MO

tolmetin sodium caps 400mg

$0-$2.65(Tier

1)

MO

tolmetin sodium tabs 200mg

$0-$2.65(Tier

1)

MO

VOLTAREN-XR (UseDiclofenac Sodium) NF MO

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA$0-

$6.60(Tier

2)

PA

Pyrimidine Synthesis InhibitorsARAVA (Use Leflunomide) NF MO

leflunomide tabs or 10 mg,20 mg

$0-$2.65(Tier

1)

MO

Selective Costimulation Modulators

ORENCIA$0-

$6.60(Tier

2)

PA

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL$0-

$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


ENBREL SURECLICK$0-

$6.60(Tier

2)

PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinations

acetaminophen-caffeine-pyrilamine

$0(Tier

3)

NT

BIPHENOX$0

(Tier3)

NT

MIDOL COMPLETE500MG-15MG-60MG (UseAcetaminophen-Caffeine-Pyrilamine)

NF

NT

MIDOL MAXIMUMSTRENGTH MENSTRUAL(Use Acetaminophen-Caffeine-Pyrilamine)

NF

NT

MIDOL MAXIMUMSTRENGTH MENSTRUALFORMULA (UseAcetaminophen-Caffeine-Pyrilamine)

NF

NT

Analgesics Other

acetaminophen chew or160 mg

$0(Tier

3)

NT

acetaminophen chew or 80mg

$0(Tier

3)

MO; NT

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml

$0(Tier

3)

NT

acetaminophen liqd or 160mg/5ml

$0(Tier

3)

MO; NT

acetaminophen soln or 100mg/ml, 160 mg/5ml, 80mg/0.8ml

$0(Tier

3)

MO; NT



7

Name of drug

Whatthe


level)


acetaminophen supp re120 mg

$0(Tier

3)

MO; NT

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml

$0(Tier

3)

MO; NT

acetaminophen susp or 80mg/0.8ml

$0(Tier

3)

NT

acetaminophen tbdp or 160mg

$0(Tier

3)

MO; NT

acetaminophen tbdp or 80mg

$0(Tier

3)

NT

ELIXSURE FEVER/PAIN$0

(Tier3)

NT

FEVERALL INFANTS$0

(Tier3)

NT

TYLENOL CHILDRENS(Use Acetaminophen) NF MO; NT

TYLENOLCHILDRENS/FLAVORCREATOR (UseAcetaminophen)

NF

MO; NT

TYLENOL INFANTS 160MG/5ML (UseAcetaminophen)

NFMO; NT

TYLENOL INFANTS 80MG/0.8ML (UseAcetaminophen)

NFNT

TYLENOL JRMELTAWAYS (UseAcetaminophen)

NFMO; NT

Salicylates

ASCRIPTIN$0

(Tier3)

NT

Name of drug

Whatthe


level)


aspirin buffered (cal carb-mag carb-mag oxide)

$0(Tier

3)

MO; NT

ASPIRIN SUPP RE 120MG, 200 MG

$0(Tier

3)

NT

aspirin supp re 300 mg,600 mg

$0(Tier

3)

NT

aspirin tabs or 325 mg$0

(Tier3)

MO; NT

aspirin tabs or 81 mg$0

(Tier3)

NT

aspirin tbec or 324 mg, 325mg, 500 mg, 81 mg

$0(Tier

3)

MO; NT

BUFFERIN (Use AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))

NFMO; NT

diflunisal$0-

$2.65(Tier

1)

MO

ECOTRIN MAXIMUMSTRENGTH (Use Aspirin) NF MO; NT

ECOTRIN REGULARSTRENGTH (Use Aspirin) NF MO; NT

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsACTIQ 1200 MCG, 1600MCG, 400 MCG, 600 MCG,800 MCG (Use FentanylCitrate)

NF

PA; QL(4 eadaily); MO

ACTIQ 200 MCG (UseFentanyl Citrate) NF PA; QL(6 ea

daily); MODEMEROL SOLN IJ 100MG/ML, 50 MG/ML (UseMeperidine HCl)

NFMO



8

Name of drug

Whatthe


level)


DEMEROL SOLN IJ 25MG/ML (Use MeperidineHCl)

NF

DILAUDID LIQD OR 1MG/ML (UseHydromorphone HCl)

NFQL(30 mldaily); MO

DILAUDID SOLN IJ 2MG/ML

$0-$6.60(Tier

2)

MO

DILAUDID TABS OR 2 MG(Use Hydromorphone HCl) NF QL(29 ea

daily); MODILAUDID TABS OR 4 MG(Use Hydromorphone HCl) NF QL(14 ea

daily); MODILAUDID TABS OR 8 MG(Use Hydromorphone HCl) NF QL(7 ea daily);

MODILAUDID-HP SOLN 10MG/ML (UseHydromorphone HCl)

NFMO

DOLOPHINE 10 MG (UseMethadone HCl) NF QL(19 ea

daily); MODOLOPHINE 5 MG (UseMethadone HCl) NF QL(38 ea

daily); MODURAGESIC 100 MCG/HR(Use Fentanyl) NF QL(1 ea daily);

MODURAGESIC 12 MCG/HR(Use Fentanyl) NF QL(1.44 ea

daily); MODURAGESIC 25 MCG/HR(Use Fentanyl) NF QL(0.7 ea



daily); MO

fentanyl 100 mcg/hr$0-

$2.65(Tier

1)

QL(1 ea daily);MO


$2.65(Tier

1)

QL(1.44 eadaily); MO

Name of drug

Whatthe


level)



$2.65(Tier

1)

QL(0.7 eadaily); MO


$2.65(Tier

1)



$2.65(Tier

1)


fentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

$0-$2.65(Tier

1)


fentanyl citrate lpop bu 200mcg

$0-$2.65(Tier

1)


hydromorphone hcl liqd or1 mg/ml

$0-$2.65(Tier

1)

QL(30 mldaily); MO

hydromorphone hcl soln ij10 mg/ml, 2 mg/ml, 50mg/5ml, 500 mg/50ml

$0-$2.65(Tier

1)

MO

hydromorphone hcl tabs or2 mg

$0-$2.65(Tier

1)

QL(29 eadaily); MO


$0-$2.65(Tier

1)

QL(14 eadaily); MO


$0-$2.65(Tier

1)

QL(7 ea daily);MO



9

Name of drug

Whatthe


level)


HYSINGLA ER 100 MG,120 MG

$0-$6.60(Tier

2)

PA; QL(2 eadaily)

HYSINGLA ER 20 MG, 30MG, 40 MG, 60 MG, 80 MG

$0-$6.60(Tier

2)


KADIAN 100 MG (UseMorphine Sulfate) NF QL(6 ea daily);

MOKADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG (UseMorphine Sulfate)

NFQL(5 ea daily);MO

LAZANDA 100 MCG/ACT$0-

$6.60(Tier

2)


LAZANDA 400 MCG/ACT$0-

$6.60(Tier

2)

PA; QL(4 eadaily)

meperidine hcl soln ij 100mg/ml, 50 mg/ml

$0-$2.65(Tier

1)

MO

meperidine hcl soln ij 25mg/ml

$0-$2.65(Tier

1)

meperidine hcl soln or 50mg/5ml

$0-$2.65(Tier

1)

AL; MO

methadone hcl conc or 10mg/ml

$0-$2.65(Tier

1)

QL(4 ml daily);MO

methadone hcl soln or 10mg/5ml

$0-$2.65(Tier

1)

QL(20 mldaily); MO

Name of drug

Whatthe


level)


methadone hcl soln or 5mg/5ml

$0-$2.65(Tier

1)

QL(40 mldaily); MO

methadone hcl tabs or 10mg

$0-$2.65(Tier

1)

QL(19 eadaily); MO

methadone hcl tabs or 5mg

$0-$2.65(Tier

1)

QL(38 eadaily); MO

METHADOSE 10 MG/ML(Use Methadone HCl) NF QL(4 ml daily);

MOMETHADOSE SUGAR-FREE (Use MethadoneHCl)

NFQL(4 ml daily);MO

morphine sulfate cp24 or100 mg

$0-$2.65(Tier

1)

QL(6 ea daily);MO

morphine sulfate cp24 or20 mg, 30 mg, 50 mg, 60mg, 80 mg

$0-$2.65(Tier

1)

QL(5 ea daily);MO

morphine sulfate soln ij 0.5mg/ml

$0-$2.65(Tier

1)

morphine sulfate soln ij 1mg/ml

$0-$2.65(Tier

1)

MO

morphine sulfate soln or 10mg/5ml

$0-$2.65(Tier

1)

QL(60 mldaily); MO

morphine sulfate soln or100 mg/5ml, 20 mg/ml

$0-$2.65(Tier

1)

QL(6 ml daily);MO



10

Name of drug

Whatthe


level)


morphine sulfate soln or 20mg/5ml

$0-$2.65(Tier

1)

QL(30 mldaily); MO

MORPHINE SULFATETABS OR 15 MG

$0-$6.60(Tier

2)

QL(8 ea daily);MO

MORPHINE SULFATETABS OR 30 MG

$0-$6.60(Tier

2)

QL(14 eadaily); MO

morphine sulfate tbcr or100 mg, 200 mg, 30 mg, 60mg

$0-$2.65(Tier

1)

MO

morphine sulfate tbcr or 15mg

$0-$2.65(Tier

1)

QL(8 ea daily);MO

MS CONTIN 100 MG, 200MG, 30 MG, 60 MG (UseMorphine Sulfate)

NFMO

MS CONTIN 15 MG (UseMorphine Sulfate) NF QL(8 ea daily);

MOOPANA TABS OR 10 MG(Use Oxymorphone HCl) NF QL(4 ea daily);

MOOPANA TABS OR 5 MG(Use Oxymorphone HCl) NF QL(8 ea daily);

MO

oxycodone hcl caps or 5mg

$0-$2.65(Tier

1)

QL(17 eadaily); MO

oxycodone hcl conc or 100mg/5ml, 20 mg/ml

$0-$2.65(Tier

1)

QL(4 ml daily);MO

oxycodone hcl tabs or 15mg

$0-$2.65(Tier

1)

QL(11 eadaily); MO

Name of drug

Whatthe


level)


oxycodone hcl tabs or 30mg

$0-$2.65(Tier

1)

QL(15 eadaily); MO

oxycodone hcl tabs or 5 mg$0-

$2.65(Tier

1)

QL(17 eadaily); MO

oxymorphone hcl tabs 10mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO

oxymorphone hcl tabs 5 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

oxymorphone hcl tb12 15mg

$0-$2.65(Tier

1)


oxymorphone hcl tb12 7.5mg

$0-$2.65(Tier

1)

QL(5 ea daily);MO

ROXICODONE 15 MG(Use Oxycodone HCl) NF QL(11 ea

daily); MOROXICODONE 30 MG(Use Oxycodone HCl) NF QL(15 ea

daily); MOROXICODONE 5 MG (UseOxycodone HCl) NF QL(17 ea

daily); MO

SUBSYS 100 MCG, 200MCG

$0-$6.60(Tier

2)


SUBSYS 1200 MCG, 1600MCG

$0-$6.60(Tier

2)

PA; QL(4 eadaily)

SUBSYS 400 MCG, 600MCG, 800 MCG

$0-$6.60(Tier

2)




11

Name of drug

Whatthe


level)


tramadol hcl tabs or 50 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

tramadol hcl tb24 or 100mg

$0-$2.65(Tier

1)

QL(3 ea daily);MO

tramadol hcl tb24 or 200mg, 300 mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO

ULTRAM (Use TramadolHCl) NF QL(8 ea daily);

MOULTRAM ER 100 MG (UseTramadol HCl) NF QL(3 ea daily);

MOULTRAM ER 200 MG, 300MG (Use Tramadol HCl) NF QL(1 ea daily);

MO

ZOHYDRO ER C12A 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

$0-$6.60(Tier

2)


ZOHYDRO ER CP12 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

$0-$6.60(Tier

2)

PA; QL(2 eadaily)

Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml

$0-$2.65(Tier

1)

QL(166 mldaily); MO

acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg

$0-$2.65(Tier

1)

QL(13 eadaily); MO

butalbital-aspirin-caffeinew/cod

$0-$2.65(Tier

1)

AL; MO

FIORINAL/CODEINE #3(Use Butalbital-Aspirin-Caffeine w/Cod)

NFAL; MO

Name of drug

Whatthe


level)


hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

$0-$2.65(Tier

1)

QL(184 mldaily); MO

hydrocodone-acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

$0-$2.65(Tier

1)

QL(13 eadaily); MO

hydrocodone-acetaminophen tabs 10mg-325mg, 5mg-325mg,7.5mg-325mg

$0-$2.65(Tier

1)

QL(12 eadaily); MO

hydrocodone-ibuprofen$0-

$2.65(Tier

1)

MO

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

$0-$2.65(Tier

1)

QL(61 ml daily)

oxycodone w/acetaminophen tabs 10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg

$0-$2.65(Tier

1)

QL(12 eadaily); MO

oxycodone-aspirin$0-

$2.65(Tier

1)

MO

PERCODAN (UseOxycodone-Aspirin) NF MO

tramadol-acetaminophen$0-

$2.65(Tier

1)

QL(12 eadaily); MO

ULTRACET (UseTramadol-Acetaminophen) NF QL(12 ea

daily); MOVICOPROFEN (UseHydrocodone-Ibuprofen) NF MO

Opioid Partial AgonistsBUPRENEX (UseBuprenorphine HCl) NF MO



12

Name of drug

Whatthe


level)


buprenorphine hcl soln ij0.3 mg/ml

$0-$2.65(Tier

1)

MO

buprenorphine hcl subl sl 2mg

$0-$2.65(Tier

1)


buprenorphine hcl subl sl 8mg

$0-$2.65(Tier

1)


buprenorphine hcl-naloxone hcl dihydrate2mg-0.5mg

$0-$2.65(Tier

1)


buprenorphine hcl-naloxone hcl dihydrate8mg-2mg

$0-$2.65(Tier

1)


butorphanol tartrate soln ij2 mg/ml

$0-$2.65(Tier

1)

MO

butorphanol tartrate soln na10 mg/ml

$0-$2.65(Tier

1)

QL(4.2 mldaily); MO

nalbuphine hcl soln ij 10mg/ml, 20 mg/ml

$0-$2.65(Tier

1)

MO

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic Steroids

ANADROL-50$0-

$6.60(Tier

2)

MO

OXANDRIN (UseOxandrolone) NF MO

Name of drug

Whatthe


level)


oxandrolone tabs or 10 mg,2.5 mg

$0-$2.65(Tier

1)

MO

Androgens

ANDRODERM$0-

$6.60(Tier

2)

GL; MO

ANDROGEL 20.25MG/1.25GM,40.5MG/2.5GM

$0-$6.60(Tier

2)

GL; MO

ANDROGEL 25MG/2.5GM,50 MG/5GM(Use Testosterone)

$0-$6.60(Tier

2)

GL; MO

ANDROGEL PUMP$0-

$6.60(Tier

2)

GL; MO

AVEED$0-

$6.60(Tier

2)

LA

danazol caps or 100 mg,200 mg, 50 mg

$0-$2.65(Tier

1)

MO

fluoxymesterone tabs or$0-

$2.65(Tier

1)

TESTIM$0-

$6.60(Tier

2)

GL; MO

testosterone cypionate$0-

$2.65(Tier

1)

MO



13

Name of drug

Whatthe


level)


testosterone enanthatesoln im

$0-$2.65(Tier

1)

MO

TESTOSTERONE GEL TD1 %, 25 MG/2.5GM, 50MG/5GM

$0-$6.60(Tier

2)

GL; MO

testosterone gel td 25mg/2.5gm, 50 mg/5gm

$0-$2.65(Tier

1)

GL; MO

TESTOSTERONE PUMP$0-

$6.60(Tier

2)

GL; MO

VOGELXO$0-

$6.60(Tier

2)

GL; MO

VOGELXO PUMP$0-

$6.60(Tier

2)

GL; MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA (UseHydrocortisone(Intrarectal))

NFMO

hydrocortisone (intrarectal)$0-

$2.65(Tier

1)

MO

UCERIS FOAM RE 2MG/ACT

$0-$6.60(Tier

2)

Rectal Combinations

phenylephrine-shark liveroil-glycerin-petrolatum

$0(Tier

3)

NT

Name of drug

Whatthe


level)


Rectal Products - Misc.

starch (topical)$0

(Tier3)

MO; NT

TUCKS (Use Starch(topical)) NF MO; NT

Rectal Steroids

hydrocortisone (rectal)$0-

$2.65(Tier

1)

MO

PROCTOCORT CREA 1 %(Use Hydrocortisone(Rectal))

NFMO

Vasodilating Agents

RECTIV$0-

$6.60(Tier

2)

MO

ANTACIDS - Ulcer and Stomach Acid Drugs

Antacid Combinations

ALMACONE$0

(Tier3)

NT

alum & mag hydrox-simethicone chew 200mg-25mg-200mg

$0(Tier

3)

NT

alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT



14

Name of drug

Whatthe


level)


alum & mag hydrox-simethicone susp200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml,200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT

aluminum hydroxide-magtrisil

$0(Tier

3)

NT

GELUSIL 200MG-25MG-200MG (Use Alum & MagHydrox-Simethicone)

NFNT

HYVEE ADVANCEDANTACID MAXIMUMSTRENGTH (Use Alum &Mag Hydrox-Simethicone)

NF

MO; NT

MYLANTA DOUBLE-STRENGTH (Use Alum &Mag Hydrox-Simethicone)

NFMO; NT

MYLANTA SUSP200MG/5ML-20MG/5ML-200MG/5ML (Use Alum &Mag Hydrox-Simethicone)

NF

MO; NT

Antacids - Aluminum Salts

ALUMINUM HYDROXIDE$0

(Tier3)

NT

Antacids - Calcium Salts

calcium carbonate(antacid) 500 mg, 750 mg

$0(Tier

3)

MO; NT

calcium carbonate(antacid) 600 mg

$0(Tier

3)

NT

CALCIUM CARBONATETABS OR 648 MG

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


MAALOX (Use CalciumCarbonate (Antacid)) NF NT

TUMS (Use CalciumCarbonate (Antacid)) NF MO; NT

TUMS E-X 750 (UseCalcium Carbonate(Antacid))

NFMO; NT

TUMS KIDS (Use CalciumCarbonate (Antacid)) NF MO; NT

TUMS LASTING EFFECTS(Use Calcium Carbonate(Antacid))

NFMO; NT

TUMS SMOOTHIES 750MG (Use CalciumCarbonate (Antacid))

NFMO; NT

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelmintics

ALBENZA$0-

$6.60(Tier

2)

MO

ivermectin tabs or$0-

$2.65(Tier

1)

MO

STROMECTOL (UseIvermectin)

$0-$6.60(Tier

2)

MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM (UseAztreonam) NF MO

aztreonam$0-

$2.65(Tier

1)

MO



15

Name of drug

Whatthe


level)


CAYSTON$0-

$6.60(Tier

2)

colistimethate sodium solr ij$0-

$2.65(Tier

1)

MO

COLY-MYCIN M (UseColistimethate Sodium) NF MO

FLAGYL (UseMetronidazole) NF MO

metronidazole caps or 375mg

$0-$2.65(Tier

1)

MO

metronidazole in nacl$0-

$2.65(Tier

1)

metronidazole tabs or 250mg, 500 mg

$0-$2.65(Tier

1)

MO

NEBUPENT$0-

$6.60(Tier

2)

MO; B/D

PENTAM 300$0-

$6.60(Tier

2)

MO

TINDAMAX (UseTinidazole) NF MO

tinidazole tabs or 250 mg,500 mg

$0-$2.65(Tier

1)

MO

trimethoprim tabs or$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


VANCOCIN HCL (UseVancomycin HCl) NF PA; MO

vancomycin hcl caps or125 mg, 250 mg

$0-$2.65(Tier

1)

PA; MO

VANCOMYCIN HCL INDEXTROSE

$0-$6.60(Tier

2)

vancomycin hcl solr iv 10gm, 1000 mg, 5000 mg

$0-$2.65(Tier

1)

vancomycin hcl solr iv 500mg

$0-$2.65(Tier

1)

MO

XIFAXAN$0-

$6.60(Tier

2)

MO

Anti-infective Misc. - CombinationsBACTRIM (UseSulfamethoxazole-Trimethoprim)

NFMO

BACTRIM DS (UseSulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim

$0-$2.65(Tier

1)

MO

Antiprotozoal Agents

ALINIA TABS 500 MG$0-

$6.60(Tier

2)

MO

atovaquone$0-

$2.65(Tier

1)

MO



16

Name of drug

Whatthe


level)


MEPRON (UseAtovaquone) NF MO

Carbapenems

imipenem-cilastatin$0-

$2.65(Tier

1)

MO

INVANZ IJ$0-

$6.60(Tier

2)

MO

meropenem$0-

$2.65(Tier

1)

MO

MERREM (UseMeropenem) NF MO

PRIMAXIN IV (UseImipenem-Cilastatin) NF MO

Chloramphenicols

chloramphenicol sodiumsuccinate

$0-$2.65(Tier

1)

Cyclic Lipopeptides

CUBICIN$0-

$6.60(Tier

2)

Glycylcyclines

TYGACIL$0-

$6.60(Tier

2)

Leprostatics

dapsone tabs or 100 mg,25 mg

$0-$2.65(Tier

1)

MO

Lincosamides

Name of drug

Whatthe


level)


CLEOCIN CAPS OR 150MG, 300 MG, 75 MG (UseClindamycin HCl)

NFMO

CLEOCIN IN D5W (UseClindamycin Phosphate inD5W)

NF

CLEOCIN PHOSPHATE IJ600 MG/4ML, 900 MG/6ML(Use ClindamycinPhosphate)

NF

MO

CLEOCIN PHOSPHATE IV300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% (UseClindamycin Phosphate inD5W)

NF

clindamycin hcl caps or 150mg, 300 mg, 75 mg

$0-$2.65(Tier

1)

MO

clindamycin palmitatehydrochloride

$0-$2.65(Tier

1)

MO

clindamycin phosphate ind5w

$0-$2.65(Tier

1)

clindamycin phosphate solnij 150 mg/ml, 9000 mg/60ml

$0-$2.65(Tier

1)

clindamycin phosphate solnij 600 mg/4ml, 900 mg/6ml

$0-$2.65(Tier

1)

MO

clindamycin phosphate solniv 150 mg/ml, 600 mg/4ml

$0-$2.65(Tier

1)



17

Name of drug

Whatthe


level)


LINCOCIN$0-

$6.60(Tier

2)

MO

Oxazolidinones

linezolid soln iv 2 mg/ml$0-

$2.65(Tier

1)

linezolid tabs or 600 mg$0-

$2.65(Tier

1)

MO

SIVEXTRO SOLR IV$0-

$6.60(Tier

2)

SIVEXTRO TABS OR$0-

$6.60(Tier

2)

MO

ZYVOX SOLN IV 2 MG/ML(Use Linezolid)

$0-$6.60(Tier

2)

ZYVOX SUSR OR 100MG/5ML

$0-$6.60(Tier

2)

MO

ZYVOX TABS OR 600 MG(Use Linezolid)

$0-$6.60(Tier

2)

MO

Polymyxins

polymyxin b sulfate solr ij$0-

$2.65(Tier

1)

Streptogramins

Name of drug

Whatthe


level)


SYNERCID$0-

$6.60(Tier

2)

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Other

RANEXA$0-

$6.60(Tier

2)

PA; MO

NitratesISORDIL TITRADOSE 5MG (Use IsosorbideDinitrate)

NFMO

isosorbide dinitrate tabs or10 mg, 20 mg, 30 mg, 5 mg

$0-$2.65(Tier

1)

MO

isosorbide dinitrate tbcr or40 mg

$0-$2.65(Tier

1)

MO

isosorbide mononitrate tabs10 mg, 20 mg

$0-$2.65(Tier

1)

MO

isosorbide mononitratetb24 120 mg, 30 mg, 60 mg

$0-$2.65(Tier

1)

MO

NITRO-DUR 0.1 MG/HR,0.2 MG/HR, 0.4 MG/HR,0.6 MG/HR (UseNitroglycerin)

NF

MO

NITROGLYCERINLINGUAL

$0-$6.60(Tier

2)

MO



18

Name of drug

Whatthe


level)


nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

$0-$2.65(Tier

1)

MO

nitroglycerin soln tl 0.4mg/spray

$0-$2.65(Tier

1)

MO

NITROLINGUALPUMPSPRAY (UseNitroglycerin)

NFMO

NITROMIST$0-

$6.60(Tier

2)

MO

NITROSTAT$0-

$6.60(Tier

2)

MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 10mg, 15 mg, 30 mg, 5 mg,7.5 mg

$0-$2.65(Tier

1)

MO

hydroxyzine hcl soln im 25mg/ml, 50 mg/ml

$0-$2.65(Tier

1)

AL; MO

hydroxyzine hcl soln or 10mg/5ml

$0-$2.65(Tier

1)

AL; MO

hydroxyzine hcl syrp or 10mg/5ml

$0-$2.65(Tier

1)

AL; MO

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

Name of drug

Whatthe


level)


hydroxyzine pamoate capsor 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

VISTARIL (UseHydroxyzine Pamoate) NF AL; MO

Benzodiazepines

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg

$0-$2.65(Tier

1)

MO

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg

$0-$2.65(Tier

1)

MO

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg

$0-$2.65(Tier

1)

MO

ATIVAN SOLN IJ 2 MG/ML(Use Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Use Lorazepam) NF

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (UseLorazepam)

NFMO

clorazepate dipotassium$0-

$2.65(Tier

1)

MO

diazepam conc or 5 mg/ml$0-

$2.65(Tier

1)

MO

diazepam soln or 1 mg/ml$0-

$2.65(Tier

1)

MO

diazepam tabs or 10 mg, 2mg, 5 mg

$0-$2.65(Tier

1)

MO



19

Name of drug

Whatthe


level)


lorazepam conc or 2 mg/ml$0-

$2.65(Tier

1)

MO

lorazepam soln ij 2 mg/ml,20 mg/10ml

$0-$2.65(Tier

1)

MO

lorazepam soln ij 4 mg/ml$0-

$2.65(Tier

1)

lorazepam tabs or 0.5 mg,1 mg, 2 mg

$0-$2.65(Tier

1)

MO

NIRAVAM (UseAlprazolam) NF MO

oxazepam$0-

$2.65(Tier

1)

MO

TRANXENE T (UseClorazepate Dipotassium) NF MO

VALIUM (Use Diazepam) NF MO

XANAX (Use Alprazolam) NF MO

XANAX XR (UseAlprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-A

disopyramide phosphate$0-

$2.65(Tier

1)

AL; MO

NORPACE (UseDisopyramide Phosphate) NF AL; MO

Name of drug

Whatthe


level)


quinidine gluconate tbcr or324 mg

$0-$2.65(Tier

1)

MO

quinidine sulfate$0-

$2.65(Tier

1)

MO

Antiarrhythmics Type I-B

mexiletine hcl$0-

$2.65(Tier

1)

MO

Antiarrhythmics Type I-C

flecainide acetate 100 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO


$2.65(Tier

1)

QL(2 ea daily);MO


$2.65(Tier

1)

QL(8 ea daily);MO

propafenone hcl$0-

$2.65(Tier

1)

MO

RYTHMOL (UsePropafenone HCl) NF MO

RYTHMOL SR (UsePropafenone HCl) NF MO

Antiarrhythmics Type III

amiodarone hcl tabs or 100mg, 200 mg, 400 mg

$0-$2.65(Tier

1)

MO

CORDARONE (UseAmiodarone HCl) NF MO



20

Name of drug

Whatthe


level)


MULTAQ$0-

$6.60(Tier

2)

MO

TIKOSYN$0-

$6.60(Tier

2)

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agents

cromolyn sodium nebu in$0-

$2.65(Tier

1)

MO; B/D

Antiasthmatic - Monoclonal Antibodies

XOLAIR$0-

$6.60(Tier

2)

PA; LA

Asthma and Bronchodilator Agent Combinations

dyphylline-guaifenesin$0

(Tier3)

NT

Bronchodilators - Anticholinergics

ATROVENT HFA$0-

$6.60(Tier

2)

QL(0.86 gmdaily); MO

INCRUSE ELLIPTA$0-

$6.60(Tier

2)

QL(1 ea daily);MO

ipratropium bromide soln in$0-

$2.65(Tier

1)

MO; B/D

SPIRIVA HANDIHALER$0-

$6.60(Tier

2)

QL(1 ea daily);MO

Name of drug

Whatthe


level)


SPIRIVA RESPIMAT 1.25MCG/ACT

$0-$6.60(Tier

2)

60actuations;QL(0.14 gm daily)


$0-$6.60(Tier

2)

60actuations;QL(0.14 gm daily);MO


$0-$6.60(Tier

2)

28actuations;QL(0.28 gm daily);MO

TUDORZA PRESSAIR$0-

$6.60(Tier

2)


Leukotriene ModulatorsACCOLATE (UseZafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg

$0-$2.65(Tier

1)

MO

montelukast sodium tabs10 mg

$0-$2.65(Tier

1)

MO

SINGULAIR CHEW 4 MG,5 MG (Use MontelukastSodium)

NFMO

SINGULAIR TABS 10 MG(Use Montelukast Sodium) NF MO

zafirlukast$0-

$2.65(Tier

1)

MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP$0-

$6.60(Tier

2)

QL(1 ea daily);MO

Steroid Inhalants



21

Name of drug

Whatthe


level)


AEROSPAN$0-

$6.60(Tier

2)

QL(0.6 gmdaily); MO

ARNUITY ELLIPTA$0-

$6.60(Tier

2)

QL(1 ea daily);MO

budesonide (inhalation)0.25 mg/2ml, 0.5 mg/2ml

$0-$2.65(Tier

1)

MO; B/D

FLOVENT DISKUS 100MCG/BLIST

$0-$6.60(Tier

2)

QL(20 eadaily); MO


$0-$6.60(Tier

2)

QL(8 ea daily);MO


$0-$6.60(Tier

2)

QL(40 eadaily); MO

FLOVENT HFA 110MCG/ACT, 220 MCG/ACT

$0-$6.60(Tier

2)

QL(0.8 gmdaily); MO

FLOVENT HFA 44MCG/ACT

$0-$6.60(Tier

2)


PULMICORT 0.25MG/2ML, 0.5 MG/2ML(Use Budesonide(Inhalation))

NF

MO; B/D

QVAR$0-

$6.60(Tier

2)


Sympathomimetics

Name of drug

Whatthe


level)


ADVAIR DISKUS$0-

$6.60(Tier

2)

MO

ADVAIR HFA$0-

$6.60(Tier

2)

QL(4 gm daily);MO

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

$0-$2.65(Tier

1)

MO; B/D

albuterol sulfate syrp or 2mg/5ml

$0-$2.65(Tier

1)

MO

albuterol sulfate tabs or 2mg, 4 mg

$0-$2.65(Tier

1)

MO

albuterol sulfate tb12 or 4mg, 8 mg

$0-$2.65(Tier

1)

MO

ANORO ELLIPTA$0-

$6.60(Tier

2)

QL(2 ea daily);MO

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0-$6.60(Tier

2)

Limited to 2inhalers permonth(InstitutionalPack);QL(2 eadaily); MO

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0-$6.60(Tier

2)

Limit 1 inhalerper month;QL(2ea daily); MO

COMBIVENT RESPIMAT$0-

$6.60(Tier

2)

MO



22

Name of drug

Whatthe


level)


DULERA$0-

$6.60(Tier

2)

QL(4 gm daily);MO

DUONEB (UseIpratropium-Albuterol) NF MO; B/D

EPHEDRINE HCL TABSOR

$0(Tier

3)

NT

EPHEDRINE SULFATECAPS OR

$0(Tier

3)

MO; NT

epinephrine hcl sosy 0.1mg/ml

$0-$2.65(Tier

1)

MO

FORADIL AEROLIZER$0-

$6.60(Tier

2)

QL(2 ea daily);MO

ipratropium-albuterol$0-

$2.65(Tier

1)

MO; B/D

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/0.5ml, 1.25mg/3ml

$0-$2.65(Tier

1)

MO; B/D

PROAIR HFA$0-

$6.60(Tier

2)

MO

PROAIR RESPICLICK$0-

$6.60(Tier

2)

MO

PROVENTIL HFA$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


SEREVENT DISKUS$0-

$6.60(Tier

2)

QL(2 ea daily);MO

STIOLTO RESPIMAT$0-

$6.60(Tier

2)

Limited to 1inhaler permonth;QL(0.14gm daily); MO

STRIVERDI RESPIMAT$0-

$6.60(Tier

2)


STRIVERDI RESPIMAT$0-

$6.60(Tier

2)

InstitutionalPack;QL(0.28gm daily); MO

terbutaline sulfate tabs or2.5 mg, 5 mg

$0-$2.65(Tier

1)

MO

XOPENEX (UseLevalbuterol HCl) NF MO; B/D

XOPENEXCONCENTRATE (UseLevalbuterol HCl)

NFMO; B/D

Xanthines

aminophylline$0-

$2.65(Tier

1)

MO

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg

$0-$2.65(Tier

1)

MO

theophylline tb24 400 mg,600 mg

$0-$2.65(Tier

1)

MO

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants



23

Name of drug

Whatthe


level)


COUMADIN TABS OR 1MG, 10 MG, 2 MG, 2.5 MG,3 MG, 4 MG, 5 MG, 6 MG,7.5 MG (Use WarfarinSodium)

NF

MO

warfarin sodium$0-

$2.65(Tier

1)

MO

Direct Factor Xa Inhibitors

ELIQUIS$0-

$6.60(Tier

2)

MO

XARELTO$0-

$6.60(Tier

2)

MO

XARELTO STARTERPACK

$0-$6.60(Tier

2)

MO

Heparins And Heparinoid-Like AgentsARIXTRA (UseFondaparinux Sodium) NF MO

enoxaparin sodium$0-

$2.65(Tier

1)

MO

fondaparinux sodium$0-

$2.65(Tier

1)

MO

FRAGMIN 10000 UNIT/ML,12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 2500UNIT/0.2ML, 25000UNIT/ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML

$0-$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


FRAGMIN 95000UNIT/3.8ML

$0-$6.60(Tier

2)

heparin sodium (porcine)$0-

$2.65(Tier

1)

MO

LOVENOX (UseEnoxaparin Sodium) NF MO

Thrombin Inhibitors

argatroban 250 mg/2.5ml$0-

$2.65(Tier

1)

MO

PRADAXA$0-

$6.60(Tier

2)

MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA 10 MG$0-

$6.60(Tier

2)

QL(1.2 eadaily); MO

FYCOMPA 12 MG$0-

$6.60(Tier

2)

QL(1 ea daily);MO

FYCOMPA 2 MG$0-

$6.60(Tier

2)

QL(6 ea daily);MO

FYCOMPA 4 MG$0-

$6.60(Tier

2)

QL(3 ea daily);MO

FYCOMPA 6 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO



24

Name of drug

Whatthe


level)


FYCOMPA 8 MG$0-

$6.60(Tier

2)

QL(1.5 eadaily); MO

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg$0-

$2.65(Tier

1)

QL(40 eadaily); MO

clonazepam tabs or 1 mg$0-

$2.65(Tier

1)

QL(20 eadaily); MO

clonazepam tabs or 2 mg$0-

$2.65(Tier

1)

QL(10 eadaily); MO

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

$0-$2.65(Tier

1)

MO

DIASTAT ACUDIAL$0-

$6.60(Tier

2)

MO

DIASTAT PEDIATRIC$0-

$6.60(Tier

2)

MO

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG

$0-$6.60(Tier

2)

MO

KLONOPIN 0.5 MG (UseClonazepam) NF QL(40 ea

daily); MOKLONOPIN 1 MG (UseClonazepam) NF QL(20 ea

daily); MOKLONOPIN 2 MG (UseClonazepam) NF QL(10 ea

daily); MO

Name of drug

Whatthe


level)


ONFI$0-

$6.60(Tier

2)

MO

Anticonvulsants - Misc.

APTIOM 200 MG$0-

$6.60(Tier

2)

QL(6 ea daily);MO

APTIOM 400 MG$0-

$6.60(Tier

2)

QL(3 ea daily);MO

APTIOM 600 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

APTIOM 800 MG$0-

$6.60(Tier

2)

QL(1 ea daily);MO

BANZEL$0-

$6.60(Tier

2)

MO

carbamazepine chew or100 mg

$0-$2.65(Tier

1)

MO

carbamazepine cp12 or100 mg, 200 mg, 300 mg

$0-$2.65(Tier

1)

MO

carbamazepine susp or100 mg/5ml

$0-$2.65(Tier

1)

MO

carbamazepine tabs or 200mg

$0-$2.65(Tier

1)

MO



25

Name of drug

Whatthe


level)


carbamazepine tb12 or 200mg, 400 mg

$0-$2.65(Tier

1)

MO

CARBATROL (UseCarbamazepine) NF MO

gabapentin caps or 100mg, 300 mg, 400 mg

$0-$2.65(Tier

1)

MO

gabapentin soln or 250mg/5ml

$0-$2.65(Tier

1)

MO

gabapentin tabs or 600 mg,800 mg

$0-$2.65(Tier

1)

MO

KEPPRA (UseLevetiracetam) NF MO

KEPPRA XR (UseLevetiracetam) NF MO

LAMICTAL CHEWABLEDISPERSIBLE (UseLamotrigine)

NFMO

LAMICTAL TABS 100 MG,150 MG, 200 MG, 25 MG(Use Lamotrigine)

NFMO

LAMICTAL XR KIT$0-

$6.60(Tier

2)

MO

LAMICTAL XR TB24 100MG, 200 MG, 25 MG, 250MG, 300 MG, 50 MG (UseLamotrigine)

NF

MO

lamotrigine chew 25 mg, 5mg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg

$0-$2.65(Tier

1)

MO

lamotrigine tb24 100 mg,200 mg, 25 mg, 250 mg,300 mg, 50 mg

$0-$2.65(Tier

1)

MO

LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML,500MG/100ML-820MG/100ML

$0-$6.60(Tier

2)

levetiracetam soln iv 500mg/5ml

$0-$2.65(Tier

1)

MO

levetiracetam soln or 100mg/ml, 500 mg/5ml

$0-$2.65(Tier

1)

MO

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

$0-$2.65(Tier

1)

MO

levetiracetam tb24 or 500mg, 750 mg

$0-$2.65(Tier

1)

MO

LYRICA CAPS 100 MG$0-

$6.60(Tier

2)

QL(6 ea daily);MO


$6.60(Tier

2)

QL(4 ea daily);MO


$6.60(Tier

2)

QL(3 ea daily);MO



26

Name of drug

Whatthe


level)


LYRICA CAPS 225 MG,300 MG

$0-$6.60(Tier

2)

QL(2 ea daily);MO


$6.60(Tier

2)

QL(24 eadaily); MO


$6.60(Tier

2)

QL(12 eadaily); MO


$6.60(Tier

2)

QL(8 ea daily);MO

LYRICA SOLN 20 MG/ML$0-

$6.60(Tier

2)

QL(30 mldaily); MO

MYSOLINE (UsePrimidone) NF MO

NEURONTIN (UseGabapentin) NF MO

oxcarbazepine$0-

$2.65(Tier

1)

MO

POTIGA 200 MG$0-

$6.60(Tier

2)

QL(6 ea daily);MO

POTIGA 300 MG$0-

$6.60(Tier

2)

QL(4 ea daily);MO

POTIGA 400 MG$0-

$6.60(Tier

2)

QL(3 ea daily);MO

Name of drug

Whatthe


level)


POTIGA 50 MG$0-

$6.60(Tier

2)

QL(24 eadaily); MO

primidone tabs or 250 mg,50 mg

$0-$2.65(Tier

1)

MO

TEGRETOL (UseCarbamazepine) NF MO

TEGRETOL-XR 100 MG$0-

$6.60(Tier

2)

MO

TEGRETOL-XR 200 MG,400 MG (UseCarbamazepine)

NFMO

TOPAMAX (UseTopiramate) NF MO

TOPAMAX SPRINKLE(Use Topiramate) NF MO

topiramate cpsp or 15 mg,25 mg

$0-$2.65(Tier

1)

MO

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

TRILEPTAL (UseOxcarbazepine) NF MO

VIMPAT SOLN IV 200MG/20ML

$0-$6.60(Tier

2)

VIMPAT SOLN OR 10MG/ML

$0-$6.60(Tier

2)

MO

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

$0-$6.60(Tier

2)

MO



27

Name of drug

Whatthe


level)


ZONEGRAN (UseZonisamide) NF MO

zonisamide$0-

$2.65(Tier

1)

MO

Carbamates

felbamate$0-

$2.65(Tier

1)

MO

FELBATOL (UseFelbamate) NF MO

GABA Modulators

GABITRIL 12 MG, 16 MG$0-

$6.60(Tier

2)

MO

GABITRIL 2 MG, 4 MG(Use Tiagabine HCl) NF MO

SABRIL$0-

$6.60(Tier

2)

LA

tiagabine hcl$0-

$2.65(Tier

1)

MO

HydantoinsCEREBYX 100 MGPE/2ML (Use FosphenytoinSodium)

NF

CEREBYX 500 MGPE/10ML (UseFosphenytoin Sodium)

NFMO

DILANTIN-125 (UsePhenytoin) NF MO

fosphenytoin sodium 100mg pe/2ml

$0-$2.65(Tier

1)

Name of drug

Whatthe


level)


fosphenytoin sodium 500mg pe/10ml

$0-$2.65(Tier

1)

MO

PEGANONE$0-

$6.60(Tier

2)

MO

phenytoin chew or 50 mg$0-

$2.65(Tier

1)

MO

phenytoin sodium extended$0-

$2.65(Tier

1)

MO

phenytoin sodium soln ij$0-

$2.65(Tier

1)

phenytoin susp or 125mg/5ml

$0-$2.65(Tier

1)

MO

Succinimides

CELONTIN$0-

$6.60(Tier

2)

MO

ethosuximide caps or 250mg

$0-$2.65(Tier

1)

MO

ethosuximide soln or 250mg/5ml

$0-$2.65(Tier

1)

MO

ZARONTIN 250 MG (UseEthosuximide) NF MO

Valproic AcidDEPACON (Use ValproateSodium) NF



28

Name of drug

Whatthe


level)


DEPAKENE (UseValproate Sodium) NF MO

DEPAKENE (Use ValproicAcid) NF MO

DEPAKOTE (UseDivalproex Sodium) NF MO

DEPAKOTE ER (UseDivalproex Sodium) NF MO

DEPAKOTE SPRINKLES(Use Divalproex Sodium) NF MO

divalproex sodium$0-

$2.65(Tier

1)

MO

STAVZOR$0-

$6.60(Tier

2)

valproate sodium soln iv100 mg/ml, 500 mg/5ml

$0-$2.65(Tier

1)

valproate sodium soln or250 mg/5ml

$0-$2.65(Tier

1)

MO

valproate sodium syrp or250 mg/5ml

$0-$2.65(Tier

1)

MO

valproic acid caps or$0-

$2.65(Tier

1)

MO

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


REMERON (UseMirtazapine) NF MO

REMERON SOLTAB (UseMirtazapine) NF MO

Antidepressants - Misc.

bupropion hcl tabs or 100mg

$0-$2.65(Tier

1)

QL(4.5 eadaily); MO

bupropion hcl tabs or 75mg

$0-$2.65(Tier

1)

QL(6 ea daily);MO

bupropion hcl tb12 or 100mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO

bupropion hcl tb12 or 150mg, 200 mg

$0-$2.65(Tier

1)

QL(2 ea daily);MO


$0-$2.65(Tier

1)

QL(3 ea daily);MO


$0-$2.65(Tier

1)

QL(1 ea daily);MO

FORFIVO XL$0-

$6.60(Tier

2)

MO

maprotiline hcl$0-

$2.65(Tier

1)

MO

WELLBUTRIN 100 MG(Use Bupropion HCl) NF QL(4.5 ea

daily); MOWELLBUTRIN 75 MG (UseBupropion HCl) NF QL(6 ea daily);

MO



29

Name of drug

Whatthe


level)


WELLBUTRIN SR 100 MG(Use Bupropion HCl) NF QL(4 ea daily);

MOWELLBUTRIN SR 150 MG,200 MG (Use BupropionHCl)

NFQL(2 ea daily);MO

WELLBUTRIN XL 150 MG(Use Bupropion HCl) NF QL(3 ea daily);

MOWELLBUTRIN XL 300 MG(Use Bupropion HCl) NF QL(1 ea daily);

MOMonoamine Oxidase Inhibitors (MAOIs)

EMSAM$0-

$6.60(Tier

2)

MO

MARPLAN$0-

$6.60(Tier

2)

MO

NARDIL (Use PhenelzineSulfate) NF MO

PARNATE (UseTranylcypromine Sulfate) NF MO

phenelzine sulfate tabs or$0-

$2.65(Tier

1)

MO

tranylcypromine sulfate$0-

$2.65(Tier

1)

MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA 10 MG (UseCitalopram Hydrobromide) NF QL(4 ea daily);

MOCELEXA 20 MG (UseCitalopram Hydrobromide) NF QL(2 ea daily);

MOCELEXA 40 MG (UseCitalopram Hydrobromide) NF QL(1 ea daily);

MO

citalopram hydrobromidesoln 10 mg/5ml

$0-$2.65(Tier

1)

QL(20 mldaily); MO

Name of drug

Whatthe


level)


citalopram hydrobromidetabs 10 mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO


$0-$2.65(Tier

1)

QL(2 ea daily);MO


$0-$2.65(Tier

1)

QL(1 ea daily);MO

escitalopram oxalate$0-

$2.65(Tier

1)

MO

fluoxetine hcl caps or 10mg, 20 mg, 40 mg

$0-$2.65(Tier

1)

MO

fluoxetine hcl cpdr or 90 mg$0-

$2.65(Tier

1)

MO

fluoxetine hcl soln or 20mg/5ml

$0-$2.65(Tier

1)

MO

fluoxetine hcl tabs or 10mg, 20 mg

$0-$2.65(Tier

1)

MO

fluvoxamine maleate$0-

$2.65(Tier

1)

MO

LEXAPRO (UseEscitalopram Oxalate) NF MO

LUVOX CR (UseFluvoxamine Maleate) NF MO



30

Name of drug

Whatthe


level)


paroxetine hcl$0-

$2.65(Tier

1)

MO

PAXIL CR (Use ParoxetineHCl) NF MO

PAXIL SUSP 10 MG/5ML$0-

$6.60(Tier

2)

MO

PAXIL TABS 10 MG, 20MG, 30 MG, 40 MG (UseParoxetine HCl)

NFMO

PROZAC (Use FluoxetineHCl) NF MO

PROZAC WEEKLY (UseFluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml

$0-$2.65(Tier

1)

MO

sertraline hcl tabs or 100mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

ZOLOFT (Use SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX 10 MG$0-

$6.60(Tier

2)

ST; QL(2 eadaily); MO

BRINTELLIX 20 MG$0-

$6.60(Tier

2)


BRINTELLIX 5 MG$0-

$6.60(Tier

2)


Name of drug

Whatthe


level)


nefazodone hcl$0-

$2.65(Tier

1)

MO

trazodone hcl tabs or 100mg, 150 mg, 300 mg, 50mg

$0-$2.65(Tier

1)

MO

VIIBRYD$0-

$6.60(Tier

2)

ST; MO

VIIBRYD STARTER PACK$0-

$6.60(Tier

2)

ST

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA (UseDuloxetine HCl) NF MO

DESVENLAFAXINE ER100 MG, 50 MG

$0-$6.60(Tier

2)

ST; MO

DESVENLAFAXINE ER100 MG, 50 MG

$0-$6.60(Tier

2)

ST; Fumarate

duloxetine hcl 20 mg, 30mg, 60 mg

$0-$2.65(Tier

1)

MO

EFFEXOR XR 150 MG(Use Venlafaxine HCl) NF QL(1 ea daily);

MOEFFEXOR XR 37.5 MG(Use Venlafaxine HCl) NF QL(6 ea daily);

MOEFFEXOR XR 75 MG (UseVenlafaxine HCl) NF QL(3 ea daily);

MO

FETZIMA 120 MG, 40 MG,80 MG

$0-$6.60(Tier

2)




31

Name of drug

Whatthe


level)


FETZIMA 20 MG$0-

$6.60(Tier

2)


FETZIMA TITRATIONPACK

$0-$6.60(Tier

2)

ST; MO

KHEDEZLA$0-

$6.60(Tier

2)

ST; MO

PRISTIQ$0-

$6.60(Tier

2)

ST; MO

venlafaxine hcl cp24 150mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO

venlafaxine hcl cp24 37.5mg

$0-$2.65(Tier

1)

QL(6 ea daily);MO

venlafaxine hcl cp24 75 mg$0-

$2.65(Tier

1)

QL(3 ea daily);MO

VENLAFAXINE HCL ER$0-

$6.60(Tier

2)


venlafaxine hcl tabs 100mg

$0-$2.65(Tier

1)

QL(3.5 eadaily); MO

venlafaxine hcl tabs 25 mg$0-

$2.65(Tier

1)

QL(15 eadaily); MO

Name of drug

Whatthe


level)


venlafaxine hcl tabs 37.5mg

$0-$2.65(Tier

1)

QL(10 eadaily); MO


$2.65(Tier

1)

QL(7.5 eadaily); MO


$2.65(Tier

1)

QL(5 ea daily);MO

venlafaxine hcl tb24 150mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO

venlafaxine hcl tb24 37.5mg

$0-$2.65(Tier

1)

QL(6 ea daily);MO

venlafaxine hcl tb24 75 mg$0-

$2.65(Tier

1)

QL(3 ea daily);MO

Tricyclic Agents

amitriptyline hcl$0-

$2.65(Tier

1)

AL; MO

amoxapine$0-

$2.65(Tier

1)

MO

ANAFRANIL (UseClomipramine HCl) NF AL; MO

clomipramine hcl caps or25 mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

AL; MO

desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

MO



32

Name of drug

Whatthe


level)


doxepin hcl caps or 10 mg,100 mg, 150 mg, 25 mg, 50mg, 75 mg

$0-$2.65(Tier

1)

AL; MO

doxepin hcl conc or 10mg/ml

$0-$2.65(Tier

1)

AL; MO

imipramine hcl tabs or 10mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

imipramine pamoate$0-

$2.65(Tier

1)

AL; MO

NORPRAMIN (UseDesipramine HCl) NF MO

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

MO

nortriptyline hcl soln or 10mg/5ml

$0-$2.65(Tier

1)

MO

PAMELOR (UseNortriptyline HCl) NF MO

protriptyline hcl$0-

$2.65(Tier

1)

MO

SURMONTIL$0-

$6.60(Tier

2)

AL; MO

TOFRANIL-PM (UseImipramine Pamoate) NF AL; MO

trimipramine maleate capsor 100 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

Name of drug

Whatthe


level)


ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose$0-

$2.65(Tier

1)

QL(3 ea daily);MO

GLYSET$0-

$6.60(Tier

2)

QL(3 ea daily);MO

PRECOSE (Use Acarbose) NF QL(3 ea daily);MO

Antidiabetic - Amylin Analogs

SYMLINPEN 120$0-

$6.60(Tier

2)

QL(0.4 mldaily); MO

SYMLINPEN 60$0-

$6.60(Tier

2)

QL(0.4 mldaily); MO

Antidiabetic CombinationsACTOPLUS MET (UsePioglitazone HCl-MetforminHCl)

NFQL(3 ea daily);MO

DUETACT (UsePioglitazone HCl-Glimepiride)

NFQL(1.5 eadaily); MO

glipizide-metformin hcl2.5mg-250mg

$0-$2.65(Tier

1)

QL(8 ea daily);MO

glipizide-metformin hcl2.5mg-500mg, 5mg-500mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO

GLUCOVANCE 1.25MG-250MG (Use Glyburide-Metformin)

NFAL; QL(8 eadaily); MO



33

Name of drug

Whatthe


level)


GLUCOVANCE 2.5MG-500MG, 5MG-500MG (UseGlyburide-Metformin)

NFAL; QL(4 eadaily); MO

glyburide-metformin1.25mg-250mg

$0-$2.65(Tier

1)

AL; QL(8 eadaily); MO

glyburide-metformin 2.5mg-500mg, 5mg-500mg

$0-$2.65(Tier

1)


INVOKAMET 150MG-1000MG, 150MG-500MG,50MG-1000MG

$0-$6.60(Tier

2)

QL(2 ea daily);MO

INVOKAMET 50MG-500MG

$0-$6.60(Tier

2)

QL(4 ea daily);MO

JANUMET$0-

$6.60(Tier

2)

QL(2 ea daily);MO

JANUMET XR 100MG-1000MG

$0-$6.60(Tier

2)

QL(1 ea daily);MO

JANUMET XR 50MG-1000MG, 50MG-500MG

$0-$6.60(Tier

2)

QL(2 ea daily);MO

JENTADUETO$0-

$6.60(Tier

2)

QL(2 ea daily);MO

KAZANO$0-

$6.60(Tier

2)

QL(2 ea daily);MO

KOMBIGLYZE XR 2.5MG-1000MG

$0-$6.60(Tier

2)

QL(2 ea daily);MO

Name of drug

Whatthe


level)


KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG

$0-$6.60(Tier

2)

QL(1 ea daily);MO

OSENI 12.5MG-15MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

OSENI 12.5MG-30MG,12.5MG-45MG, 25MG-15MG, 25MG-30MG,25MG-45MG

$0-$6.60(Tier

2)

QL(1 ea daily);MO

pioglitazone hcl-glimepiride$0-

$2.65(Tier

1)

QL(1.5 eadaily); MO

pioglitazone hcl-metforminhcl

$0-$2.65(Tier

1)

QL(3 ea daily);MO

PRANDIMET$0-

$6.60(Tier

2)

QL(5 ea daily);MO

BiguanidesFORTAMET 1000 MG (UseMetformin HCl) NF QL(2 ea daily);

MOFORTAMET 500 MG (UseMetformin HCl) NF Osmotic;QL(5

ea daily); MOGLUCOPHAGE 1000 MG(Use Metformin HCl) NF QL(2.5 ea

daily); MOGLUCOPHAGE 500 MG(Use Metformin HCl) NF QL(5 ea daily);

MOGLUCOPHAGE 850 MG(Use Metformin HCl) NF QL(3 ea daily);

MOGLUCOPHAGE XR 500MG (Use Metformin HCl) NF QL(4 ea daily);

MOGLUCOPHAGE XR 750MG (Use Metformin HCl) NF QL(2 ea daily);

MO



34

Name of drug

Whatthe


level)


GLUMETZA 1000 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

GLUMETZA 500 MG$0-

$6.60(Tier

2)

QL(4 ea daily);MO

metformin hcl tabs or 1000mg

$0-$2.65(Tier

1)

QL(2.5 eadaily); MO


$0-$2.65(Tier

1)

QL(5 ea daily);MO


$0-$2.65(Tier

1)

QL(3 ea daily);MO

metformin hcl tb24 or 1000mg, 750 mg

$0-$2.65(Tier

1)

QL(2 ea daily);MO

metformin hcl tb24 or 500mg

$0-$2.65(Tier

1)

Osmotic;QL(5ea daily); MO

metformin hcl tb24 or 500mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO

Diabetic Other

BD GLUCOSE$0

(Tier3)

NT

CVS GLUCOSE 4 GM$0

(Tier3)

MO; NT

DEX4 QUICK DISSOLVEGLUCOSE

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


dextrose (diabetic use) gel15 gm/38gm, 40 %

$0(Tier

3)

MO; NT

GLUCAGEN HYPOKIT$0-

$6.60(Tier

2)

MO

glucagon (rdna)$0-

$2.65(Tier

1)

MO

GLUCOSE CHEW 4 GM$0

(Tier3)

MO; NT

GNP GLUCOSE 4 GM$0

(Tier3)

MO; NT

GNP QUICK DISSOLVEGLUCOSE

$0(Tier

3)

MO; NT

LEADER QUICKDISSOLVE GLUCOSE

$0(Tier

3)

MO; NT

MS QUICK DISSOLVEGLUCOSE

$0(Tier

3)

MO; NT

PROGLYCEM$0-

$6.60(Tier

2)

MO

SM GLUCOSE 4 GM$0

(Tier3)

MO; NT

ULTILET GLUCOSE$0

(Tier3)

MO; NT

WALGREENS GLUCOSE4 GM

$0(Tier

3)

MO; NT

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors



35

Name of drug

Whatthe


level)


JANUVIA$0-

$6.60(Tier

2)

MO

NESINA$0-

$6.60(Tier

2)

MO

ONGLYZA$0-

$6.60(Tier

2)

MO

TRADJENTA$0-

$6.60(Tier

2)

MO

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET$0-

$6.60(Tier

2)

QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON$0-

$6.60(Tier

2)

ST; MO

BYETTA$0-

$6.60(Tier

2)

ST; MO

VICTOZA$0-

$6.60(Tier

2)

ST; QL(0.3 mldaily); MO

Insulin Sensitizing AgentsACTOS 15 MG (UsePioglitazone HCl) NF QL(3 ea daily);

MOACTOS 30 MG, 45 MG(Use Pioglitazone HCl) NF QL(1 ea daily);

MO

Name of drug

Whatthe


level)


AVANDIA 2 MG$0-

$6.60(Tier

2)

QL(4 ea daily);LA; MO

AVANDIA 4 MG$0-

$6.60(Tier

2)


AVANDIA 8 MG$0-

$6.60(Tier

2)


pioglitazone hcl 15 mg$0-

$2.65(Tier

1)

QL(3 ea daily);MO

pioglitazone hcl 30 mg, 45mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO

Insulin

HUMALOG$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMALOG KWIKPEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMALOG MIX 50/50$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMALOG MIX 50/50KWIKPEN

$0-$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMALOG MIX 75/25$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO



36

Name of drug

Whatthe


level)


HUMALOG MIX 75/25KWIKPEN

$0-$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN 70/30$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN 70/30 KWIKPEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN 70/30 PEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN N$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN N KWIKPEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN N U-100 PEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN R$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

HUMULIN R U-500(CONCENTRATED)

$0-$6.60(Tier

2)

QL(1.5 mldaily); MO

LANTUS$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

Name of drug

Whatthe


level)


LANTUS SOLOSTAR$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

LEVEMIR$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

LEVEMIR FLEXPEN$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

LEVEMIR FLEXTOUCH$0-

$6.60(Tier

2)

QL(1.5 mldaily); MO

TOUJEO SOLOSTAR$0-

$6.60(Tier

2)

Limited to15mls permonth;QL(0.5ml daily); MO

Meglitinide Analogues

nateglinide$0-

$2.65(Tier

1)

QL(3 ea daily);MO

PRANDIN 0.5 MG (UseRepaglinide) NF QL(32 ea

daily); MOPRANDIN 1 MG (UseRepaglinide) NF QL(16 ea

daily); MOPRANDIN 2 MG (UseRepaglinide) NF QL(8 ea daily);

MO

repaglinide 0.5 mg$0-

$2.65(Tier

1)

QL(32 eadaily); MO

repaglinide 1 mg$0-

$2.65(Tier

1)

QL(16 eadaily); MO



37

Name of drug

Whatthe


level)


repaglinide 2 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

STARLIX (Use Nateglinide) NF QL(3 ea daily);MO

Sodium-Glucose Co-Transporter 2 (SGLT2)

FARXIGA$0-

$6.60(Tier

2)

MO

INVOKANA$0-

$6.60(Tier

2)

MO

JARDIANCE 10 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

JARDIANCE 25 MG$0-

$6.60(Tier

2)

QL(1 ea daily);MO

SulfonylureasAMARYL 1 MG (UseGlimepiride) NF QL(8 ea daily);

MOAMARYL 2 MG (UseGlimepiride) NF QL(4 ea daily);

MOAMARYL 4 MG (UseGlimepiride) NF QL(2 ea daily);

MO

DIABETA 1.25 MG (UseGlyburide)

$0-$6.60(Tier

2)


DIABETA 2.5 MG (UseGlyburide)

$0-$6.60(Tier

2)


DIABETA 5 MG (UseGlyburide)

$0-$6.60(Tier

2)


Name of drug

Whatthe


level)


glimepiride 1 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

glimepiride 2 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

glimepiride 4 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

glipizide tabs or 10 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

glipizide tabs or 5 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

glipizide tb24 or 10 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

glipizide tb24 or 2.5 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

glipizide tb24 or 5 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

GLUCOTROL 10 MG (UseGlipizide) NF QL(4 ea daily);

MOGLUCOTROL 5 MG (UseGlipizide) NF QL(8 ea daily);

MOGLUCOTROL XL 10 MG(Use Glipizide) NF QL(2 ea daily);

MOGLUCOTROL XL 2.5 MG(Use Glipizide) NF QL(8 ea daily);

MOGLUCOTROL XL 5 MG(Use Glipizide) NF QL(4 ea daily);

MO



38

Name of drug

Whatthe


level)


glyburide 1.25 mg$0-

$2.65(Tier

1)


glyburide 2.5 mg$0-

$2.65(Tier

1)


glyburide 5 mg$0-

$2.65(Tier

1)


glyburide micronized 1.5mg

$0-$2.65(Tier

1)


glyburide micronized 3 mg$0-

$2.65(Tier

1)


glyburide micronized 6 mg$0-

$2.65(Tier

1)


GLYNASE 1.5 MG (UseGlyburide Micronized) NF AL; QL(8 ea

daily); MOGLYNASE 3 MG (UseGlyburide Micronized) NF AL; QL(4 ea

daily); MOGLYNASE 6 MG (UseGlyburide Micronized) NF AL; QL(2 ea

daily); MO

tolazamide 250 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

tolazamide 500 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

tolbutamide$0-

$2.65(Tier

1)

QL(6 ea daily);MO

Name of drug

Whatthe


level)


ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal Agents - Misc.

bismuth subsalicylate chewor 262 mg

$0(Tier

3)

MO; NT

bismuth subsalicylate suspor 262 mg/15ml, 525mg/15ml, 527 mg/30ml

$0(Tier

3)

MO; NT

bismuth subsalicylate tabsor 262 mg

$0(Tier

3)

NT

PEPTO BISMOL (UseBismuth Subsalicylate) NF NT

PEPTO-BISMOL (UseBismuth Subsalicylate) NF MO; NT

PEPTO-BISMOLINSTACOOL (Use BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOL MAXSTRENGTH (Use BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOL TO-GO(Use BismuthSubsalicylate)

NFMO; NT

Antiperistaltic Agents

diphenoxylate w/ atropine$0-

$2.65(Tier

1)

MO

LOMOTIL (UseDiphenoxylate w/ Atropine) NF MO

loperamide hcl caps or 2mg

$0-$2.65(Tier

1)

RX/OTC; MO

ANTIDOTES - Drugs to Treat Overdose orToxicityAntidotes - Chelating Agents



39

Name of drug

Whatthe


level)


EXJADE$0-

$6.60(Tier

2)

LA

FERRIPROX$0-

$6.60(Tier

2)

PA; LA

JADENU$0-

$6.60(Tier

2)

Antidotes

IPECAC$0

(Tier3)

NT

SM IPECAC SYRUP$0

(Tier3)

NT

Opioid Antagonists

naloxone hcl soln ij 1mg/ml

$0-$2.65(Tier

1)

MO

naltrexone hcl tabs or$0-

$2.65(Tier

1)

MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonists

granisetron hcl tabs or 1mg

$0-$2.65(Tier

1)

MO; B/D

ondansetron$0-

$2.65(Tier

1)

MO; B/D

Name of drug

Whatthe


level)


ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml

$0-$2.65(Tier

1)

MO

ondansetron hcl soln or 4mg/5ml

$0-$2.65(Tier

1)

MO; B/D

ondansetron hcl tabs or 24mg, 4 mg, 8 mg

$0-$2.65(Tier

1)

MO; B/D

ZOFRAN ODT (UseOndansetron) NF MO; B/D

ZOFRAN SOLN IJ 40MG/20ML (UseOndansetron HCl)

NFMO

ZOFRAN SOLN OR 4MG/5ML (Use OndansetronHCl)

NFMO; B/D

ZOFRAN TABS OR 4 MG,8 MG (Use OndansetronHCl)

NFMO; B/D

Antiemetics - Anticholinergic

meclizine hcl chew 25 mg$0

(Tier3)

MO; NT

meclizine hcl tabs 12.5 mg,25 mg

$0-$2.65(Tier

1)

RX/OTC; MO

TIGAN SOLN IM 100MG/ML

$0-$6.60(Tier

2)

AL; MO

TRANSDERM-SCOP$0-

$6.60(Tier

2)

MO



40

Name of drug

Whatthe


level)


trimethobenzamide hcl solnim 100 mg/ml

$0-$2.65(Tier

1)

AL; MO

Antiemetics - Miscellaneous

CESAMET$0-

$6.60(Tier

2)

MO; B/D

dronabinol$0-

$2.65(Tier

1)

MO; B/D

MARINOL (UseDronabinol) NF MO; B/D

Substance P/Neurokinin 1 (NK1) Receptor

EMEND CAPS OR 125MG, 80 MG

$0-$6.60(Tier

2)

MO; B/D

EMEND CAPS OR 40 MG$0-

$6.60(Tier

2)

PA; MO

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

CANCIDAS 50 MG$0-

$6.60(Tier

2)

CANCIDAS 70 MG$0-

$6.60(Tier

2)

MO

ERAXIS 100 MG$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


MYCAMINE$0-

$6.60(Tier

2)

MO

Antifungals

ABELCET$0-

$6.60(Tier

2)

AMBISOME$0-

$6.60(Tier

2)

amphotericin b solr ij 50 mg$0-

$2.65(Tier

1)

MO

ANCOBON (UseFlucytosine) NF MO

flucytosine$0-

$2.65(Tier

1)

MO

GRIS-PEG (UseGriseofulvin Ultramicrosize) NF MO

griseofulvin microsize$0-

$2.65(Tier

1)

MO

griseofulvin ultramicrosize$0-

$2.65(Tier

1)

MO

LAMISIL TABS 250 MG(Use Terbinafine HCl) NF MO

nystatin tabs or$0-

$2.65(Tier

1)

MO



41

Name of drug

Whatthe


level)


terbinafine hcl tabs or$0-

$2.65(Tier

1)

MO

Imidazole-Related Antifungals

CRESEMBA CAPS OR186 MG

$0-$6.60(Tier

2)

MO

CRESEMBA SOLR IV 372MG

$0-$6.60(Tier

2)DIFLUCAN (UseFluconazole) NF MO

fluconazole in dextrose$0-

$2.65(Tier

1)

fluconazole in nacl200mg/100ml-0.9%,400mg/200ml-0.9%

$0-$2.65(Tier

1)

fluconazole susr or 10mg/ml, 40 mg/ml

$0-$2.65(Tier

1)

MO

fluconazole tabs or 100mg, 150 mg, 200 mg, 50mg

$0-$2.65(Tier

1)

MO

itraconazole caps or$0-

$2.65(Tier

1)

MO

ketoconazole tabs or$0-

$2.65(Tier

1)

MO

NOXAFIL SOLN IV 300MG/16.7ML

$0-$6.60(Tier

2)

Name of drug

Whatthe


level)


NOXAFIL SUSP OR 40MG/ML

$0-$6.60(Tier

2)

MO

NOXAFIL TBEC OR 100MG

$0-$6.60(Tier

2)

MO

SPORANOX CAPS 100MG (Use Itraconazole) NF MO

SPORANOX PULSEPAK(Use Itraconazole) NF MO

VFEND IV (UseVoriconazole) NF

VFEND TABS 200 MG, 50MG (Use Voriconazole) NF MO

voriconazole solr iv 200 mg$0-

$2.65(Tier

1)

voriconazole tabs or 200mg, 50 mg

$0-$2.65(Tier

1)

MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesCHLOR-TRIMETON (UseChlorpheniramine Maleate) NF AL; MO; NT

chlorpheniramine maleatesyrp or 2 mg/5ml

$0(Tier

3)

AL; MO; NT

chlorpheniramine maleatetabs or 4 mg

$0(Tier

3)

AL; MO; NT

ED CHLORPED$0

(Tier3)

AL; NT

Antihistamines - Ethanolamines



42

Name of drug

Whatthe


level)


ALER-DRYL$0

(Tier3)

AL; NT

BENADRYL (UseDiphenhydramine HCl) NF AL; MO; NT

BENADRYL ALLERGY(Use DiphenhydramineHCl)

NFAL; MO; NT

BENADRYL ALLERGYCHILDRENS CHEW 12.5MG (Use DiphenhydramineHCl)

NF

AL; NT

BENADRYL ALLERGYCHILDRENS LIQD 12.5MG/5ML (UseDiphenhydramine HCl)

NF

AL; MO; NT

BENADRYL DYE-FREEALLERGYLIQUID-GELS(Use DiphenhydramineHCl)

NF

AL; MO; NT

carbinoxamine maleate$0-

$2.65(Tier

1)

AL; MO

clemastine fumarate tabsor 2.68 mg

$0-$2.65(Tier

1)

AL; MO

diphenhydramine hcl capsor 25 mg

$0(Tier

3)

AL; MO; NT

diphenhydramine hcl chewor 12.5 mg

$0(Tier

3)

AL; NT

diphenhydramine hcl elix or12.5 mg/5ml

$0-$2.65(Tier

1)

RX/OTC

diphenhydramine hcl liqd or12.5 mg/5ml, 25 mg/10ml,50 mg/20ml

$0(Tier

3)

AL; MO; NT

Name of drug

Whatthe


level)


diphenhydramine hcl soln ij50 mg/ml

$0-$2.65(Tier

1)

AL; MO

diphenhydramine hcl syrpor 12.5 mg/5ml

$0(Tier

3)

AL; RX/OTC;NT

diphenhydramine hcl tabsor 25 mg

$0(Tier

3)

AL; MO; NT

TRIAMINIC COUGH &RUNNY NOSE

$0(Tier

3)

AL; NT

Antihistamines - Non-Sedating

cetirizine hcl soln 1 mg/ml$0-

$2.65(Tier

1)

RX/OTC; MO

cetirizine hcl syrp 1 mg/ml,5 mg/5ml

$0-$2.65(Tier

1)

RX/OTC; MO

CLARINEX REDITABS 5MG (Use Desloratadine) NF MO

CLARINEX TABS 5 MG(Use Desloratadine) NF MO

desloratadine tabs 5 mg$0-

$2.65(Tier

1)

MO

desloratadine tbdp 5 mg$0-

$2.65(Tier

1)

MO

levocetirizinedihydrochloride

$0-$2.65(Tier

1)

MO

XYZAL (Use LevocetirizineDihydrochloride) NF MO

Antihistamines - Phenothiazines



43

Name of drug

Whatthe


level)


promethazine hcl soln ij 25mg/ml, 50 mg/ml

$0-$2.65(Tier

1)

AL; MO

promethazine hcl soln or6.25 mg/5ml

$0-$2.65(Tier

1)

AL; MO

promethazine hcl supp re12.5 mg, 25 mg

$0-$2.65(Tier

1)

AL; MO

promethazine hcl syrp or6.25 mg/5ml

$0-$2.65(Tier

1)

AL; MO

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

Antihistamines - Piperidines

cyproheptadine hcl syrp or2 mg/5ml

$0-$2.65(Tier

1)

AL; MO

cyproheptadine hcl tabs or4 mg

$0-$2.65(Tier

1)

AL; MO

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinations

LIPTRUZET$0-

$6.60(Tier

2)

Antihyperlipidemics - Misc.

KYNAMRO$0-

$6.60(Tier

2)

PA; LA

Name of drug

Whatthe


level)


LOVAZA (Use Omega-3-acid Ethyl Esters)

$0-$6.60(Tier

2)

MO

omega-3-acid ethyl esters$0-

$2.65(Tier

1)

MO

VASCEPA$0-

$6.60(Tier

2)

MO

Bile Acid Sequestrants

cholestyramine light$0-

$2.65(Tier

1)

MO

cholestyramine pack or 4gm

$0-$2.65(Tier

1)

MO

cholestyramine powd or 4gm/dose

$0-$2.65(Tier

1)

MO

COLESTID (Use ColestipolHCl) NF MO

COLESTID FLAVOREDGRAN 5 GM (UseColestipol HCl)

NFMO

colestipol hcl$0-

$2.65(Tier

1)

MO

WELCHOL$0-

$6.60(Tier

2)

MO

Fibric Acid DerivativesANTARA 130 MG, 43 MG(Use FenofibrateMicronized)

NFMO



44

Name of drug

Whatthe


level)


ANTARA 30 MG$0-

$6.60(Tier

2)

QL(3 ea daily);MO

ANTARA 90 MG$0-

$6.60(Tier

2)

QL(1 ea daily);MO

choline fenofibrate$0-

$2.65(Tier

1)

MO

fenofibrate micronized$0-

$2.65(Tier

1)

MO

fenofibrate tabs 145 mg,160 mg, 48 mg, 54 mg

$0-$2.65(Tier

1)

MO

gemfibrozil tabs or$0-

$2.65(Tier

1)

MO

LOPID (Use Gemfibrozil) NF MO

TRICOR (Use Fenofibrate) NF MO

TRIGLIDE$0-

$6.60(Tier

2)

MO

TRILIPIX (Use CholineFenofibrate) NF MO

HMG CoA Reductase Inhibitors

atorvastatin calcium$0-

$2.65(Tier

1)

MO

CRESTOR$0-

$6.60(Tier

2)

ST; MO

Name of drug

Whatthe


level)


fluvastatin sodium caps 20mg, 40 mg

$0-$2.65(Tier

1)

MO

LESCOL (Use FluvastatinSodium) NF MO

LIPITOR (Use AtorvastatinCalcium) NF MO

lovastatin$0-

$2.65(Tier

1)

MO

MEVACOR (UseLovastatin) NF MO

PRAVACHOL (UsePravastatin Sodium) NF MO

pravastatin sodium$0-

$2.65(Tier

1)

MO

simvastatin tabs or 10 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO


$2.65(Tier

1)

QL(4 ea daily);MO


$2.65(Tier

1)

QL(2 ea daily);MO


$2.65(Tier

1)

QL(16 eadaily); MO


$2.65(Tier

1)

QL(1 ea daily);MO

ZOCOR 10 MG (UseSimvastatin) NF QL(8 ea daily);

MO



45

Name of drug

Whatthe


level)


ZOCOR 20 MG (UseSimvastatin) NF QL(4 ea daily);

MOZOCOR 40 MG (UseSimvastatin) NF QL(2 ea daily);

MOZOCOR 5 MG (UseSimvastatin) NF QL(16 ea

daily); MOZOCOR 80 MG (UseSimvastatin) NF QL(1 ea daily);

MOIntestinal Cholesterol Absorption Inhibitors

ZETIA$0-

$6.60(Tier

2)

MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID 10 MG$0-

$6.60(Tier

2)

PA; QL(6 eadaily); LA

JUXTAPID 20 MG$0-

$6.60(Tier

2)


JUXTAPID 30 MG$0-

$6.60(Tier

2)


JUXTAPID 40 MG, 60 MG$0-

$6.60(Tier

2)


JUXTAPID 5 MG$0-

$6.60(Tier

2)


Nicotinic Acid Derivatives

niacin (antihyperlipidemic)$0-

$2.65(Tier

1)

MO

NIASPAN (Use Niacin(Antihyperlipidemic)) NF MO

Name of drug

Whatthe


level)


Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOPN 150MG/ML

$0-$6.60(Tier

2)

PA; QL(0.08 mldaily); MO

PRALUENT SOPN 75MG/ML

$0-$6.60(Tier

2)


PRALUENT SOSY 150MG/ML

$0-$6.60(Tier

2)


PRALUENT SOSY 75MG/ML

$0-$6.60(Tier

2)


ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL (Use QuinaprilHCl) NF MO

ACEON 4 MG (UsePerindopril Erbumine) NF QL(4 ea daily);

MOACEON 8 MG (UsePerindopril Erbumine) NF QL(2 ea daily);

MO

ALTACE (Use Ramipril) NF MO

benazepril hcl tabs or 10mg, 20 mg, 40 mg, 5 mg

$0-$2.65(Tier

1)

MO

captopril tabs or 100 mg,12.5 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

enalapril maleate tabs or10 mg, 2.5 mg, 20 mg, 5mg

$0-$2.65(Tier

1)

MO



46

Name of drug

Whatthe


level)


fosinopril sodium$0-

$2.65(Tier

1)

MO

lisinopril tabs or 10 mg, 2.5mg, 20 mg, 30 mg, 40 mg,5 mg

$0-$2.65(Tier

1)

MO

LOTENSIN (UseBenazepril HCl) NF MO

MAVIK (Use Trandolapril) NF MO

moexipril hcl$0-

$2.65(Tier

1)

MO

perindopril erbumine 2 mg$0-

$2.65(Tier

1)

MO


$2.65(Tier

1)

QL(4 ea daily);MO


$2.65(Tier

1)

QL(2 ea daily);MO

PRINIVIL (Use Lisinopril) NF MO

quinapril hcl$0-

$2.65(Tier

1)

MO

ramipril$0-

$2.65(Tier

1)

MO

trandolapril$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


UNIVASC (Use MoexiprilHCl) NF MO

VASOTEC (Use EnalaprilMaleate) NF MO

ZESTRIL (Use Lisinopril) NF MO

Agents for Pheochromocytoma

DEMSER$0-

$6.60(Tier

2)

MO

DIBENZYLINE (UsePhenoxybenzamine HCl)

$0-$6.60(Tier

2)

MO

phenoxybenzamine hclcaps or

$0-$2.65(Tier

1)

MO

Angiotensin II Receptor AntagonistsATACAND (UseCandesartan Cilexetil) NF MO

AVAPRO (Use Irbesartan) NF MO

candesartan cilexetil$0-

$2.65(Tier

1)

MO

COZAAR (Use LosartanPotassium) NF MO

DIOVAN (Use Valsartan) NF MO

eprosartan mesylate$0-

$2.65(Tier

1)

MO

irbesartan$0-

$2.65(Tier

1)

MO



47

Name of drug

Whatthe


level)


losartan potassium$0-

$2.65(Tier

1)

MO

TEVETEN (Use EprosartanMesylate) NF MO

valsartan$0-

$2.65(Tier

1)

MO

Antiadrenergic AntihypertensivesCARDURA (UseDoxazosin Mesylate) NF MO

CATAPRES (Use ClonidineHCl) NF MO

CATAPRES-TTS-1 (UseClonidine HCl) NF MO



clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

$0-$2.65(Tier

1)

MO

clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg

$0-$2.65(Tier

1)

MO

doxazosin mesylate$0-

$2.65(Tier

1)

MO

guanfacine hcl$0-

$2.65(Tier

1)

AL; MO

MINIPRESS (Use PrazosinHCl) NF MO

Name of drug

Whatthe


level)


prazosin hcl$0-

$2.65(Tier

1)

MO

RESERPINE TABS OR 0.1MG, 0.25 MG

$0-$6.60(Tier

2)

MO

TENEX (Use GuanfacineHCl) NF AL; MO

terazosin hcl$0-

$2.65(Tier

1)

MO

Antihypertensive CombinationsACCURETIC (UseQuinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl

$0-$2.65(Tier

1)

MO

ATACAND HCT (UseCandesartan Cilexetil-Hydrochlorothiazide)

NFMO

atenolol & chlorthalidone$0-

$2.65(Tier

1)

MO

AVALIDE (Use Irbesartan-Hydrochlorothiazide) NF MO

benazepril &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

bisoprolol &hydrochlorothiazide

$0-$2.65(Tier

1)

MO



48

Name of drug

Whatthe


level)


candesartan cilexetil-hydrochlorothiazide

$0-$2.65(Tier

1)

MO

captopril &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

CORZIDE (Use Nadolol &Bendroflumethiazide) NF MO

DIOVAN HCT (UseValsartan-Hydrochlorothiazide)

NFMO

enalapril maleate &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

fosinopril sodium &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

HYZAAR (Use LosartanPotassium &Hydrochlorothiazide)

NFMO

irbesartan-hydrochlorothiazide

$0-$2.65(Tier

1)

MO

lisinopril &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

LOPRESSOR HCT (UseMetoprolol &Hydrochlorothiazide)

NFMO

losartan potassium &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

LOTENSIN HCT (UseBenazepril &Hydrochlorothiazide)

NFMO

Name of drug

Whatthe


level)


LOTREL (Use AmlodipineBesylate-Benazepril HCl) NF MO

methyldopa &hydrochlorothiazide

$0-$2.65(Tier

1)

AL; MO

metoprolol &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

moexipril-hydrochlorothiazide

$0-$2.65(Tier

1)

MO

nadolol &bendroflumethiazide

$0-$2.65(Tier

1)

MO

quinapril-hydrochlorothiazide

$0-$2.65(Tier

1)

MO

TEKTURNA HCT$0-

$6.60(Tier

2)

MO

TENORETIC 100 (UseAtenolol & Chlorthalidone) NF MO

TENORETIC 50 (UseAtenolol & Chlorthalidone) NF MO

UNIRETIC (Use Moexipril-Hydrochlorothiazide) NF MO

valsartan-hydrochlorothiazide

$0-$2.65(Tier

1)

MO

VASERETIC (Use EnalaprilMaleate &Hydrochlorothiazide)

NFMO

ZESTORETIC (UseLisinopril &Hydrochlorothiazide)

NFMO



49

Name of drug

Whatthe


level)


ZIAC (Use Bisoprolol &Hydrochlorothiazide) NF MO

Direct Renin Inhibitors

TEKTURNA$0-

$6.60(Tier

2)

MO

Selective Aldosterone Receptor Antagonists

eplerenone$0-

$2.65(Tier

1)

MO

INSPRA (Use Eplerenone) NF MO

Vasodilators

hydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

minoxidil tabs or 10 mg, 2.5mg

$0-$2.65(Tier

1)

MO

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinations

atovaquone-proguanil hcl250mg-100mg

$0-$2.65(Tier

1)

MO

COARTEM$0-

$6.60(Tier

2)

MO

MALARONE 250MG-100MG (Use Atovaquone-Proguanil HCl)

NFMO

AntimalarialsARALEN (Use ChloroquinePhosphate) NF MO

Name of drug

Whatthe


level)


chloroquine phosphate tabsor 250 mg, 500 mg

$0-$2.65(Tier

1)

MO

DARAPRIM$0-

$6.60(Tier

2)

MO

hydroxychloroquine sulfatetabs or

$0-$2.65(Tier

1)

MO

mefloquine hcl$0-

$2.65(Tier

1)

MO

PLAQUENIL (UseHydroxychloroquineSulfate)

NFMO

PRIMAQUINEPHOSPHATE

$0-$6.60(Tier

2)

MO

QUALAQUIN (Use QuinineSulfate) NF PA; MO

quinine sulfate caps or$0-

$2.65(Tier

1)

PA; MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents

guanidine hcl$0-

$2.65(Tier

1)MESTINON TABS 60 MG(Use PyridostigmineBromide)

NFMO

MESTINON TIMESPAN(Use PyridostigmineBromide)

$0-$6.60(Tier

2)

MO



50

Name of drug

Whatthe


level)


pyridostigmine bromidetabs or 60 mg

$0-$2.65(Tier

1)

MO

pyridostigmine bromidetbcr or 180 mg

$0-$2.65(Tier

1)

MO

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinations

isoniazid & rifampin$0-

$2.65(Tier

1)

MO

RIFATER$0-

$6.60(Tier

2)

MO

Antimycobacterial Agents

aminosalicylic acid pack or$0-

$2.65(Tier

1)

MO

CAPASTAT SULFATE$0-

$6.60(Tier

2)

ethambutol hcl tabs or 100mg, 400 mg

$0-$2.65(Tier

1)

MO

isoniazid tabs or 100 mg,300 mg

$0-$2.65(Tier

1)

MO

MYAMBUTOL (UseEthambutol HCl) NF MO

MYCOBUTIN (UseRifabutin)

$0-$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


PRIFTIN$0-

$6.60(Tier

2)

MO

pyrazinamide$0-

$2.65(Tier

1)

MO

rifabutin$0-

$2.65(Tier

1)

MO

RIFADIN 300 MG,600 MG(Use Rifampin) NF MO

rifampin caps or 150 mg,300 mg

$0-$2.65(Tier

1)

MO

rifampin solr iv 600 mg$0-

$2.65(Tier

1)

MO

TRECATOR$0-

$6.60(Tier

2)

MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Use Melphalan HCl) NF

ALKERAN TABS OR 2 MG$0-

$6.60(Tier

2)

MO; B/D

BICNU$0-

$6.60(Tier

2)



51

Name of drug

Whatthe


level)


BUSULFEX$0-

$6.60(Tier

2)

carboplatin 150 mg/15ml,600 mg/60ml

$0-$2.65(Tier

1)

carboplatin 450 mg/45ml,50 mg/5ml

$0-$2.65(Tier

1)

MO

cisplatin$0-

$2.65(Tier

1)

cyclophosphamide tabs or25 mg, 50 mg

$0-$2.65(Tier

1)

B/D

ELOXATIN (UseOxaliplatin) NF MO

GLEOSTINE$0-

$6.60(Tier

2)

HEXALEN$0-

$6.60(Tier

2)

MO

IFEX 1 GM (UseIfosfamide) NF

IFEX 3 GM$0-

$6.60(Tier

2)

ifosfamide soln 1 gm/20ml,3 gm/60ml

$0-$2.65(Tier

1)

Name of drug

Whatthe


level)


ifosfamide solr 1 gm$0-

$2.65(Tier

1)

IFOSFAMIDE SOLR 3 GM$0-

$6.60(Tier

2)

LEUKERAN$0-

$6.60(Tier

2)

MO

lomustine 10 mg$0-

$2.65(Tier

1)

LOMUSTINE 100 MG, 40MG

$0-$6.60(Tier

2)

melphalan hcl$0-

$2.65(Tier

1)

MUSTARGEN$0-

$6.60(Tier

2)

oxaliplatin soln 100mg/20ml, 50 mg/10ml

$0-$2.65(Tier

1)

MO

oxaliplatin solr 100 mg, 50mg

$0-$2.65(Tier

1)

TEMODAR$0-

$6.60(Tier

2)



52

Name of drug

Whatthe


level)


THIOTEPA SOLR IJ$0-

$6.60(Tier

2)

TREANDA$0-

$6.60(Tier

2)

YONDELIS$0-

$6.60(Tier

2)

ZANOSAR$0-

$6.60(Tier

2)

MO

Antimetabolites

ALIMTA 100 MG$0-

$6.60(Tier

2)

ALIMTA 500 MG$0-

$6.60(Tier

2)

MO

ARRANON$0-

$6.60(Tier

2)

azacitidine$0-

$2.65(Tier

1)

cladribine$0-

$2.65(Tier

1)

MO

CLOLAR$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


cytarabine soln 100 mg/ml$0-

$2.65(Tier

1)

cytarabine soln 20 mg/ml$0-

$2.65(Tier

1)

MO

DACOGEN (UseDecitabine) NF

decitabine$0-

$2.65(Tier

1)FLUDARA (UseFludarabine Phosphate) NF MO

fludarabine phosphate solr50 mg

$0-$2.65(Tier

1)

MO

fluorouracil soln iv 1gm/20ml

$0-$2.65(Tier

1)

fluorouracil soln iv 2.5gm/50ml, 5 gm/100ml, 500mg/10ml

$0-$2.65(Tier

1)

MO

FOLOTYN$0-

$6.60(Tier

2)

GEMCITABINE$0-

$6.60(Tier

2)

gemcitabine hcl 1 gm, 200mg

$0-$2.65(Tier

1)

MO



53

Name of drug

Whatthe


level)


gemcitabine hcl 2 gm$0-

$2.65(Tier

1)GEMZAR (UseGemcitabine HCl) NF MO

mercaptopurine tabs or$0-

$2.65(Tier

1)

MO

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 25 mg/ml, 250mg/10ml, 50 mg/2ml

$0-$2.65(Tier

1)

methotrexate sodium solr ij1 gm

$0-$2.65(Tier

1)

methotrexate sodium tabsor 10 mg, 15 mg, 2.5 mg, 5mg, 7.5 mg

$0-$2.65(Tier

1)

MO

PURINETHOL (UseMercaptopurine) NF MO

PURIXAN$0-

$6.60(Tier

2)

TABLOID$0-

$6.60(Tier

2)

MO

VIDAZA (Use Azacitidine) NF

Antineoplastic - Angiogenesis Inhibitors

AVASTIN$0-

$6.60(Tier

2)

CYRAMZA$0-

$6.60(Tier

2)

LA

Name of drug

Whatthe


level)


ZALTRAP$0-

$6.60(Tier

2)

Antineoplastic - Antibodies

ARZERRA$0-

$6.60(Tier

2)

BLINCYTO$0-

$6.60(Tier

2)

PA

ERBITUX$0-

$6.60(Tier

2)

GAZYVA$0-

$6.60(Tier

2)

LA

HERCEPTIN$0-

$6.60(Tier

2)

KADCYLA$0-

$6.60(Tier

2)

KEYTRUDA$0-

$6.60(Tier

2)

OPDIVO$0-

$6.60(Tier

2)

PERJETA$0-

$6.60(Tier

2)



54

Name of drug

Whatthe


level)


RITUXAN$0-

$6.60(Tier

2)

VECTIBIX$0-

$6.60(Tier

2)

YERVOY$0-

$6.60(Tier

2)

Antineoplastic - Hedgehog Pathway Inhibitors

ERIVEDGE$0-

$6.60(Tier

2)

LA

ODOMZO$0-

$6.60(Tier

2)

PA

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or$0-

$2.65(Tier

1)

MO

ARIMIDEX (UseAnastrozole) NF MO

AROMASIN (UseExemestane) NF MO

bicalutamide$0-

$2.65(Tier

1)

MO

CASODEX (UseBicalutamide) NF MO

DEPO-PROVERA$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


ELIGARD$0-

$6.60(Tier

2)

EMCYT$0-

$6.60(Tier

2)

MO

exemestane$0-

$2.65(Tier

1)

MO

FARESTON$0-

$6.60(Tier

2)

MO

FASLODEX$0-

$6.60(Tier

2)

MO

FEMARA (Use Letrozole) NF MO

FIRMAGON$0-

$6.60(Tier

2)

flutamide$0-

$2.65(Tier

1)

MO

letrozole$0-

$2.65(Tier

1)

MO

leuprolide acetate kit ij$0-

$2.65(Tier

1)

LUPRON DEPOT$0-

$6.60(Tier

2)



55

Name of drug

Whatthe


level)


LYSODREN$0-

$6.60(Tier

2)

MO

MEGACE ORAL (UseMegestrol Acetate) NF AL; MO

megestrol acetate susp or40 mg/ml, 400 mg/10ml

$0-$2.65(Tier

1)

AL; MO

megestrol acetate tabs or20 mg, 40 mg

$0-$2.65(Tier

1)

AL; MO

NILANDRON$0-

$6.60(Tier

2)

MO

SOLTAMOX$0-

$6.60(Tier

2)

MO

tamoxifen citrate tabs or 10mg, 20 mg

$0-$2.65(Tier

1)

MO

TRELSTAR$0-

$6.60(Tier

2)

TRELSTAR MIXJECT$0-

$6.60(Tier

2)

VANTAS$0-

$6.60(Tier

2)

XTANDI$0-

$6.60(Tier

2)

PA; LA

Name of drug

Whatthe


level)


ZOLADEX$0-

$6.60(Tier

2)

ZYTIGA$0-

$6.60(Tier

2)

Antineoplastic - Immunomodulators

POMALYST$0-

$6.60(Tier

2)

LA

Antineoplastic Antibiotics

bleomycin sulfate 15 unit$0-

$2.65(Tier

1)

MO

bleomycin sulfate 30 unit$0-

$2.65(Tier

1)

COSMEGEN$0-

$6.60(Tier

2)

MO

daunorubicin hcl$0-

$2.65(Tier

1)

DAUNOXOME$0-

$6.60(Tier

2)DOXIL (Use DoxorubicinHCl Liposomal) NF

doxorubicin hcl liposomal$0-

$2.65(Tier

1)



56

Name of drug

Whatthe


level)


doxorubicin hcl soln 2mg/ml

$0-$2.65(Tier

1)

MO

doxorubicin hcl solr 10 mg$0-

$2.65(Tier

1)

doxorubicin hcl solr 50 mg$0-

$2.65(Tier

1)

MO

ELLENCE (Use EpirubicinHCl) NF MO

epirubicin hcl soln 200mg/100ml, 50 mg/25ml

$0-$2.65(Tier

1)

MO

IDAMYCIN PFS (UseIdarubicin HCl) NF

idarubicin hcl$0-

$2.65(Tier

1)

mitomycin solr iv 20 mg, 40mg, 5 mg

$0-$2.65(Tier

1)

MO

mitoxantrone hcl$0-

$2.65(Tier

1)

VALSTAR$0-

$6.60(Tier

2)

Antineoplastic Enzyme Inhibitors

AFINITOR$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


AFINITOR DISPERZ$0-

$6.60(Tier

2)

BELEODAQ$0-

$6.60(Tier

2)

BOSULIF$0-

$6.60(Tier

2)

PA

CAPRELSA$0-

$6.60(Tier

2)

LA

COMETRIQ$0-

$6.60(Tier

2)

COMETRIQ$0-

$6.60(Tier

2)

140 MG DoseKit;MO

FARYDAK$0-

$6.60(Tier

2)

PA; LA

GILOTRIF$0-

$6.60(Tier

2)

LA

GLEEVEC$0-

$6.60(Tier

2)

IBRANCE$0-

$6.60(Tier

2)

LA



57

Name of drug

Whatthe


level)


ICLUSIG$0-

$6.60(Tier

2)

LA

IMBRUVICA$0-

$6.60(Tier

2)

PA

INLYTA$0-

$6.60(Tier

2)

PA; LA

IRESSA$0-

$6.60(Tier

2)

LA

ISTODAX$0-

$6.60(Tier

2)

JAKAFI$0-

$6.60(Tier

2)

LA

LENVIMA 10MG DAILYDOSE

$0-$6.60(Tier

2)

PA


$0-$6.60(Tier

2)

PA


$0-$6.60(Tier

2)

PA


$0-$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


LYNPARZA$0-

$6.60(Tier

2)

PA; LA

MEKINIST$0-

$6.60(Tier

2)

NEXAVAR$0-

$6.60(Tier

2)

LA

SPRYCEL$0-

$6.60(Tier

2)

STIVARGA$0-

$6.60(Tier

2)

PA; LA

SUTENT$0-

$6.60(Tier

2)

TAFINLAR$0-

$6.60(Tier

2)

TARCEVA$0-

$6.60(Tier

2)

TASIGNA$0-

$6.60(Tier

2)

TORISEL$0-

$6.60(Tier

2)



58

Name of drug

Whatthe


level)


TYKERB$0-

$6.60(Tier

2)

VELCADE$0-

$6.60(Tier

2)

VOTRIENT$0-

$6.60(Tier

2)

XALKORI$0-

$6.60(Tier

2)

ZELBORAF$0-

$6.60(Tier

2)

LA

ZOLINZA$0-

$6.60(Tier

2)

ZYDELIG$0-

$6.60(Tier

2)

PA

ZYKADIA$0-

$6.60(Tier

2)

PA; LA

Antineoplastic Enzymes

ERWINAZE$0-

$6.60(Tier

2)

ONCASPAR$0-

$6.60(Tier

2)

Antineoplastics Misc.

Name of drug

Whatthe


level)


ACTIMMUNE$0-

$6.60(Tier

2)

LA

bexarotene$0-

$2.65(Tier

1)

dacarbazine 100 mg$0-

$2.65(Tier

1)

dacarbazine 200 mg$0-

$2.65(Tier

1)

MO

HYDREA (UseHydroxyurea) NF MO

hydroxyurea caps or$0-

$2.65(Tier

1)

MO

INTRON A$0-

$6.60(Tier

2)

INTRON A W/DILUENT$0-

$6.60(Tier

2)

MATULANE$0-

$6.60(Tier

2)

LA

PROLEUKIN$0-

$6.60(Tier

2)

SYLATRON$0-

$6.60(Tier

2)



59

Name of drug

Whatthe


level)


SYNRIBO$0-

$6.60(Tier

2)

TARGRETIN 1 %,75 MG$0-

$6.60(Tier

2)

TARGRETIN 75 MG (UseBexarotene)

$0-$6.60(Tier

2)

THERACYS$0-

$6.60(Tier

2)

MO

TICE BCG$0-

$6.60(Tier

2)

MO

tretinoin (chemotherapy)$0-

$2.65(Tier

1)

MO

TRISENOX$0-

$6.60(Tier

2)

MO

UVADEX$0-

$6.60(Tier

2)

Chemotherapy Adjuncts

ELITEK$0-

$6.60(Tier

2)

KEPIVANCE$0-

$6.60(Tier

2)

MO

Chemotherapy Rescue/Antidote Agents

Name of drug

Whatthe


level)


amifostine crystalline$0-

$2.65(Tier

1)

MO

dexrazoxane$0-

$2.65(Tier

1)ETHYOL (Use AmifostineCrystalline) NF MO

FUSILEV$0-

$6.60(Tier

2)

leucovorin calcium solr ij100 mg, 200 mg, 350 mg

$0-$2.65(Tier

1)

MO

leucovorin calcium solr ij 50mg, 500 mg

$0-$2.65(Tier

1)

leucovorin calcium tabs or10 mg, 15 mg, 25 mg, 5 mg

$0-$2.65(Tier

1)

MO

LEVOLEUCOVORIN$0-

$6.60(Tier

2)

levoleucovorin calcium$0-

$2.65(Tier

1)

mesna$0-

$2.65(Tier

1)

MO

MESNEX SOLN IV 100MG/ML (Use Mesna) NF MO



60

Name of drug

Whatthe


level)


MESNEX TABS OR 400MG

$0-$6.60(Tier

2)

MO

TOTECT$0-

$6.60(Tier

2)ZINECARD (UseDexrazoxane) NF

Mitotic Inhibitors

ABRAXANE$0-

$6.60(Tier

2)

MO

DOCEFREZ$0-

$6.60(Tier

2)

docetaxel conc 140mg/7ml, 20 mg/ml, 80mg/4ml

$0-$2.65(Tier

1)

DOCETAXEL CONC 20MG/ML, 80 MG/4ML

$0-$6.60(Tier

2)

DOCETAXEL SOLN 160MG/16ML, 20 MG/2ML,200 MG/20ML, 80 MG/8ML

$0-$6.60(Tier

2)

ETOPOPHOS$0-

$6.60(Tier

2)

MO

etoposide soln iv 1gm/50ml, 100 mg/5ml

$0-$2.65(Tier

1)

MO

etoposide soln iv 500mg/25ml

$0-$2.65(Tier

1)

Name of drug

Whatthe


level)


HALAVEN$0-

$6.60(Tier

2)

IXEMPRA KIT$0-

$6.60(Tier

2)

JEVTANA$0-

$6.60(Tier

2)NAVELBINE (UseVinorelbine Tartrate) NF MO

paclitaxel 100 mg/16.7ml,30 mg/5ml, 300 mg/50ml

$0-$2.65(Tier

1)

MO

paclitaxel 150 mg/25ml$0-

$2.65(Tier

1)

TAXOL (Use Paclitaxel) NF MO

TAXOTERE (UseDocetaxel)

$0-$6.60(Tier

2)

vinblastine sulfate$0-

$2.65(Tier

1)

MO

vincristine sulfate$0-

$2.65(Tier

1)

MO

vinorelbine tartrate$0-

$2.65(Tier

1)

MO

Topoisomerase I Inhibitors



61

Name of drug

Whatthe


level)


CAMPTOSAR 100MG/5ML, 40 MG/2ML (UseIrinotecan HCl)

NFMO

CAMPTOSAR 300MG/15ML

$0-$6.60(Tier

2)HYCAMTIN (UseTopotecan HCl) NF MO

irinotecan hcl 100 mg/5ml,40 mg/2ml

$0-$2.65(Tier

1)

MO

irinotecan hcl 500 mg/25ml$0-

$2.65(Tier

1)

TOPOTECAN HCL SOLN4 MG/4ML

$0-$6.60(Tier

2)

topotecan hcl solr 4 mg$0-

$2.65(Tier

1)

MO

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvants

carbidopa tabs or$0-

$2.65(Tier

1)

MO

LODOSYN (UseCarbidopa) NF MO

Antiparkinson Anticholinergics

benztropine mesylate solnij 1 mg/ml

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg

$0-$2.65(Tier

1)

AL; MO

COGENTIN (UseBenztropine Mesylate) NF MO

trihexyphenidyl hcl$0-

$2.65(Tier

1)

AL; MO

Antiparkinson COMT InhibitorsCOMTAN (UseEntacapone) NF MO

entacapone$0-

$2.65(Tier

1)

MO

TASMAR (Use Tolcapone)

$0-$6.60(Tier

2)

MO

tolcapone$0-

$2.65(Tier

1)

MO

Antiparkinson Dopaminergics

amantadine hcl caps or 100mg

$0-$2.65(Tier

1)

MO

amantadine hcl syrp or 50mg/5ml

$0-$2.65(Tier

1)

MO

amantadine hcl tabs or 100mg

$0-$2.65(Tier

1)

MO

APOKYN$0-

$6.60(Tier

2)

LA



62

Name of drug

Whatthe


level)


bromocriptine mesylatecaps or 5 mg

$0-$2.65(Tier

1)

MO

bromocriptine mesylatetabs or 2.5 mg

$0-$2.65(Tier

1)

MO

carbidopa-levodopa$0-

$2.65(Tier

1)

MO

DUOPA$0-

$6.60(Tier

2)

B/D

MIRAPEX (UsePramipexoleDihydrochloride)

NFMO

NEUPRO$0-

$6.60(Tier

2)

MO

PARLODEL (UseBromocriptine Mesylate) NF MO

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.5 mg, 0.75mg, 1 mg, 1.5 mg

$0-$2.65(Tier

1)

MO

REQUIP (Use RopiniroleHydrochloride) NF MO

REQUIP XL (UseRopinirole Hydrochloride) NF MO

ropinirole hydrochloride$0-

$2.65(Tier

1)

MO

RYTARY$0-

$6.60(Tier

2)

MO

SINEMET (Use Carbidopa-Levodopa) NF MO

Name of drug

Whatthe


level)


SINEMET CR (UseCarbidopa-Levodopa) NF MO

Antiparkinson Monoamine Oxidase Inhibitors

AZILECT$0-

$6.60(Tier

2)

MO

ELDEPRYL (Use SelegilineHCl) NF MO

selegiline hcl caps or$0-

$2.65(Tier

1)

MO

selegiline hcl tabs or$0-

$2.65(Tier

1)

MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agents

lithium$0-

$2.65(Tier

1)

MO

lithium carbonate caps or150 mg, 300 mg, 600 mg

$0-$2.65(Tier

1)

MO

LITHIUM CARBONATECAPS OR 600 MG (UseLithium Carbonate)

NFMO

lithium carbonate tabs or300 mg

$0-$2.65(Tier

1)

MO

lithium carbonate tbcr or300 mg, 450 mg

$0-$2.65(Tier

1)

MO

LITHOBID (Use LithiumCarbonate) NF MO



63

Name of drug

Whatthe


level)


Antipsychotics - Misc.

EQUETRO$0-

$6.60(Tier

2)

MO

GEODON CAPS OR 20MG, 40 MG, 60 MG, 80 MG(Use Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG$0-

$6.60(Tier

2)

MO

LATUDA 120 MG$0-

$6.60(Tier

2)

QL(1 ea daily);MO

LATUDA 20 MG$0-

$6.60(Tier

2)

QL(8 ea daily);MO

LATUDA 40 MG$0-

$6.60(Tier

2)

QL(4 ea daily);MO

LATUDA 60 MG$0-

$6.60(Tier

2)


LATUDA 80 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

ziprasidone hcl$0-

$2.65(Tier

1)

MO

Benzisoxazoles

FANAPT$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


INVEGA 1.5 MG (UsePaliperidone)

$0-$6.60(Tier

2)

QL(8 ea daily);MO

INVEGA 3 MG (UsePaliperidone)

$0-$6.60(Tier

2)

QL(4 ea daily);MO


$0-$6.60(Tier

2)

QL(2 ea daily);MO


$0-$6.60(Tier

2)

QL(1 ea daily);MO

INVEGA SUSTENNA$0-

$6.60(Tier

2)

MO

INVEGA TRINZA$0-

$6.60(Tier

2)

paliperidone 1.5 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

paliperidone 3 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO


$2.65(Tier

1)

QL(2 ea daily);MO


$2.65(Tier

1)

QL(1 ea daily);MO

RISPERDAL (UseRisperidone) NF MO



64

Name of drug

Whatthe


level)


RISPERDAL CONSTA12.5 MG

$0-$6.60(Tier

2)


RISPERDAL CONSTA 25MG

$0-$6.60(Tier

2)


RISPERDAL CONSTA37.5 MG, 50 MG

$0-$6.60(Tier

2)


RISPERDAL M-TAB (UseRisperidone) NF MO

risperidone$0-

$2.65(Tier

1)

MO

ButyrophenonesHALDOL (Use HaloperidolLactate) NF MO

HALDOL DECANOATE100 (Use HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50(Use HaloperidolDecanoate)

NFMO

haloperidol$0-

$2.65(Tier

1)

MO

haloperidol decanoate solnim 100 mg/ml, 50 mg/ml

$0-$2.65(Tier

1)

MO

haloperidol lactate$0-

$2.65(Tier

1)

MO

Dibenzapines

Name of drug

Whatthe


level)


clozapine$0-

$2.65(Tier

1)

CLOZAPINE ODT$0-

$6.60(Tier

2)CLOZARIL (UseClozapine) NF

FAZACLO 100 MG,25 MG(Use Clozapine)

$0-$6.60(Tier

2)

FAZACLO 12.5 MG,150MG,200 MG

$0-$6.60(Tier

2)

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

$0-$2.65(Tier

1)

MO

olanzapine$0-

$2.65(Tier

1)

MO

quetiapine fumarate$0-

$2.65(Tier

1)

MO

SAPHRIS 10 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

SAPHRIS 2.5 MG$0-

$6.60(Tier

2)

QL(8 ea daily);MO

SAPHRIS 5 MG$0-

$6.60(Tier

2)

QL(4 ea daily);MO



65

Name of drug

Whatthe


level)


SEROQUEL (UseQuetiapine Fumarate) NF MO

VERSACLOZ$0-

$6.60(Tier

2)

PA; QL(18 mldaily)

ZYPREXA (UseOlanzapine) NF MO

ZYPREXA RELPREVV 210MG

$0-$6.60(Tier

2)ZYPREXA ZYDIS (UseOlanzapine) NF MO

Phenothiazines

chlorpromazine hcl soln ij25 mg/ml

$0-$2.65(Tier

1)

MO

chlorpromazine hcl soln ij50 mg/2ml

$0-$2.65(Tier

1)

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

$0-$2.65(Tier

1)

MO

fluphenazine decanoatesoln ij

$0-$2.65(Tier

1)

MO

fluphenazine hcl conc or 5mg/ml

$0-$2.65(Tier

1)

MO

fluphenazine hcl soln ij 2.5mg/ml

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg

$0-$2.65(Tier

1)

MO

perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg

$0-$2.65(Tier

1)

MO

prochlorperazine$0-

$2.65(Tier

1)

MO

prochlorperazine edisylatesoln ij

$0-$2.65(Tier

1)

MO

prochlorperazine maleatetabs or 10 mg, 5 mg

$0-$2.65(Tier

1)

MO

thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

trifluoperazine hcl$0-

$2.65(Tier

1)

MO

Quinolinone Derivatives

ABILIFY DISCMELT 10MG

$0-$6.60(Tier

2)

QL(3 ea daily)

ABILIFY DISCMELT 15MG

$0-$6.60(Tier

2)

QL(2 ea daily)

ABILIFY MAINTENA$0-

$6.60(Tier

2)

MO



66

Name of drug

Whatthe


level)


ABILIFY SOLN IM 9.75MG/1.3ML

$0-$6.60(Tier

2)

QL(4 ml daily);MO

ABILIFY SOLN OR 1MG/ML

$0-$6.60(Tier

2)

QL(30 mldaily); MO

ABILIFY TABS OR 10 MG(Use Aripiprazole)

$0-$6.60(Tier

2)

QL(3 ea daily);MO


$0-$6.60(Tier

2)

QL(2 ea daily);MO


$0-$6.60(Tier

2)

QL(15 eadaily); MO

ABILIFY TABS OR 20 MG,30 MG (Use Aripiprazole)

$0-$6.60(Tier

2)

QL(1 ea daily);MO


$0-$6.60(Tier

2)

QL(6 ea daily);MO

ARIPIPRAZOLE ODT 10MG

$0-$6.60(Tier

2)

QL(3 ea daily)

ARIPIPRAZOLE ODT 15MG

$0-$6.60(Tier

2)

QL(2 ea daily)

aripiprazole soln 1 mg/ml$0-

$2.65(Tier

1)

QL(30 mldaily); MO

Name of drug

Whatthe


level)


aripiprazole tabs 10 mg$0-

$2.65(Tier

1)

QL(3 ea daily);MO


$2.65(Tier

1)

QL(2 ea daily);MO


$2.65(Tier

1)

QL(15 eadaily); MO

aripiprazole tabs 20 mg, 30mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO


$2.65(Tier

1)

QL(6 ea daily);MO

REXULTI 0.25 MG$0-

$6.60(Tier

2)


REXULTI 0.5 MG$0-

$6.60(Tier

2)


REXULTI 1 MG$0-

$6.60(Tier

2)


REXULTI 2 MG$0-

$6.60(Tier

2)


REXULTI 3 MG, 4 MG$0-

$6.60(Tier

2)


Thioxanthenes



67

Name of drug

Whatthe


level)


thiothixene$0-

$2.65(Tier

1)

MO

ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin InfectionsChlorine Antiseptics

BENZALKONIUMCHLORIDE SOLN

$0(Tier

3)

RX/OTC; NT

CETAPHILANTIBACTERIAL

$0(Tier

3)

NT

dakin's solution 0.25 %, 0.5%

$0(Tier

3)

MO; NT

PEDI-WHIRLCONCENTRATE

$0(Tier

3)

RX/OTC; NT

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate$0-

$2.65(Tier

1)

MO

abacavir sulfate-lamivudine-zidovudine

$0-$2.65(Tier

1)

MO

APTIVUS CAPS 250 MG$0-

$6.60(Tier

2)

MO

APTIVUS SOLN 100MG/ML

$0-$6.60(Tier

2)

ATRIPLA$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


COMBIVIR (UseLamivudine-Zidovudine) NF MO

COMPLERA$0-

$6.60(Tier

2)

MO

CRIXIVAN$0-

$6.60(Tier

2)

MO

didanosine$0-

$2.65(Tier

1)

MO

EDURANT$0-

$6.60(Tier

2)

MO

EMTRIVA$0-

$6.60(Tier

2)

MO

EPIVIR SOLN 10 MG/ML(Use Lamivudine)

$0-$6.60(Tier

2)

MO

EPIVIR TABS 150 MG, 300MG (Use Lamivudine) NF MO

EPZICOM$0-

$6.60(Tier

2)

MO

EVOTAZ$0-

$6.60(Tier

2)

MO

FUZEON$0-

$6.60(Tier

2)



68

Name of drug

Whatthe


level)


INTELENCE 100 MG, 200MG

$0-$6.60(Tier

2)

MO

INTELENCE 25 MG$0-

$6.60(Tier

2)

INVIRASE$0-

$6.60(Tier

2)

MO

ISENTRESS CHEW 100MG

$0-$6.60(Tier

2)

QL(6 ea daily);MO

ISENTRESS CHEW 25 MG$0-

$6.60(Tier

2)

QL(24 eadaily); MO

ISENTRESS PACK 100MG

$0-$6.60(Tier

2)

QL(2 ea daily)

ISENTRESS TABS 400MG

$0-$6.60(Tier

2)

MO

KALETRA$0-

$6.60(Tier

2)

MO

lamivudine$0-

$2.65(Tier

1)

MO

lamivudine-zidovudine$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


LEXIVA$0-

$6.60(Tier

2)

MO

NEVIRAPINE SUSP 50MG/5ML

$0-$6.60(Tier

2)

MO

nevirapine tabs 200 mg$0-

$2.65(Tier

1)

MO

nevirapine tb24 100 mg$0-

$2.65(Tier

1)

nevirapine tb24 400 mg$0-

$2.65(Tier

1)

MO

NORVIR$0-

$6.60(Tier

2)

MO

PREZCOBIX$0-

$6.60(Tier

2)

MO

PREZISTA SUSP 100MG/ML

$0-$6.60(Tier

2)

MO

PREZISTA TABS 150 MG,600 MG, 800 MG

$0-$6.60(Tier

2)

MO

PREZISTA TABS 400 MG,75 MG

$0-$6.60(Tier

2)



69

Name of drug

Whatthe


level)


RESCRIPTOR$0-

$6.60(Tier

2)

MO

RETROVIR (UseZidovudine) NF MO

RETROVIR IV INFUSION$0-

$6.60(Tier

2)

REYATAZ CAPS 150 MG,200 MG, 300 MG

$0-$6.60(Tier

2)

MO

REYATAZ PACK 50 MG$0-

$6.60(Tier

2)

SELZENTRY$0-

$6.60(Tier

2)

MO

stavudine$0-

$2.65(Tier

1)

MO

STRIBILD$0-

$6.60(Tier

2)

MO

SUSTIVA$0-

$6.60(Tier

2)

MO

TIVICAY$0-

$6.60(Tier

2)

MO

TRIUMEQ$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


TRIZIVIR (Use AbacavirSulfate-Lamivudine-Zidovudine)

NFMO

TRUVADA$0-

$6.60(Tier

2)

MO

TYBOST$0-

$6.60(Tier

2)

MO

VIDEX EC (UseDidanosine) NF MO

VIDEXPEDIATRIC$0-

$6.60(Tier

2)

MO

VIRACEPT$0-

$6.60(Tier

2)

MO

VIRAMUNE SUSP 50MG/5ML

$0-$6.60(Tier

2)

MO

VIRAMUNE TABS 200 MG(Use Nevirapine) NF MO

VIRAMUNE XR 100 MG$0-

$6.60(Tier

2)VIRAMUNE XR 400 MG(Use Nevirapine) NF MO

VIREAD POWD 40 MG/GM$0-

$6.60(Tier

2)

MO

VIREAD TABS 150 MG,200 MG, 300 MG

$0-$6.60(Tier

2)

MO



70

Name of drug

Whatthe


level)


VIREAD TABS 250 MG$0-

$6.60(Tier

2)

VITEKTA$0-

$6.60(Tier

2)

ZERIT (Use Stavudine) NF MO

ZIAGEN SOLN 20 MG/ML$0-

$6.60(Tier

2)

MO

ZIAGEN TABS 300 MG(Use Abacavir Sulfate) NF MO

zidovudine$0-

$2.65(Tier

1)

MO

CMV Agents

cidofovir$0-

$2.65(Tier

1)CYTOVENE (UseGanciclovir Sodium) NF MO

ganciclovir sodium$0-

$2.65(Tier

1)

MO

VALCYTE TABS 450 MG(Use Valganciclovir HCl)

$0-$6.60(Tier

2)

MO

valganciclovir hcl$0-

$2.65(Tier

1)

MO

VISTIDE (Use Cidofovir) NF

Hepatitis Agents

Name of drug

Whatthe


level)


adefovir dipivoxil$0-

$2.65(Tier

1)

MO

BARACLUDE 0.05 MG/ML$0-

$6.60(Tier

2)

MO

BARACLUDE 0.5 MG,1MG (Use Entecavir)

$0-$6.60(Tier

2)

MO

COPEGUS (Use Ribavirin(Hepatitis C)) NF

entecavir$0-

$2.65(Tier

1)

MO

EPIVIR HBV SOLN 5MG/ML

$0-$6.60(Tier

2)

MO

EPIVIR HBV TABS 100MG (Use Lamivudine(HBV))

NFMO

HARVONI$0-

$6.60(Tier

2)

PA

HEPSERA (Use AdefovirDipivoxil) NF MO

INCIVEK$0-

$6.60(Tier

2)

PA

lamivudine (hbv)$0-

$2.65(Tier

1)

MO

OLYSIO$0-

$6.60(Tier

2)

PA



71

Name of drug

Whatthe


level)


PEG-INTRON$0-

$6.60(Tier

2)

PEG-INTRON REDIPEN$0-

$6.60(Tier

2)

PEG-INTRON REDIPENPAK 4

$0-$6.60(Tier

2)

PEGASYS$0-

$6.60(Tier

2)

PEGASYS PROCLICK$0-

$6.60(Tier

2)

PEGINTRON$0-

$6.60(Tier

2)REBETOL CAPS 200 MG(Use Ribavirin (HepatitisC))

NF

ribavirin (hepatitis c)$0-

$2.65(Tier

1)

SOVALDI$0-

$6.60(Tier

2)

PA

TYZEKA$0-

$6.60(Tier

2)

MO

VICTRELIS$0-

$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


VIEKIRA PAK$0-

$6.60(Tier

2)

PA

Herpes Agents

acyclovir caps or 200 mg$0-

$2.65(Tier

1)

MO

acyclovir sodium soln 50mg/ml

$0-$2.65(Tier

1)

acyclovir sodium solr 500mg

$0-$2.65(Tier

1)

MO

acyclovir susp or 200mg/5ml

$0-$2.65(Tier

1)

MO

acyclovir tabs or 400 mg,800 mg

$0-$2.65(Tier

1)

MO

famciclovir$0-

$2.65(Tier

1)

MO

FAMVIR (Use Famciclovir) NF MO

valacyclovir hcl tabs or 1gm, 1000 mg, 500 mg

$0-$2.65(Tier

1)

MO

VALTREX (UseValacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Use Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Use Acyclovir) NF MO



72

Name of drug

Whatthe


level)


ZOVIRAX TABS OR 400MG, 800 MG (UseAcyclovir)

NFMO

Influenza AgentsFLUMADINE (UseRimantadineHydrochloride)

NFMO

RELENZA DISKHALER$0-

$6.60(Tier

2)

MO

rimantadine hydrochloride$0-

$2.65(Tier

1)

MO

TAMIFLU$0-

$6.60(Tier

2)

MO

Respiratory Syncytial Virus (RSV) Agents

VIRAZOLE$0-

$6.60(Tier

2)

ASSORTED CLASSES - Miscellaneous Drugs

Assorted Classes

gelatin caps or 650 mg$0

(Tier3)

NT

NULLO$0

(Tier3)

NT

Chelating Agents

CUPRIMINE$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


DEPEN TITRATABS$0-

$6.60(Tier

2)

MO

SYPRINE$0-

$6.60(Tier

2)

MO

Enzymes

papaya chew 5mg-5mg-3mg-2mg-20mg

$0(Tier

3)

NT

Immunomodulators

REVLIMID$0-

$6.60(Tier

2)

LA

THALOMID$0-

$6.60(Tier

2)

Immunosuppressive Agents

ASTAGRAF XL$0-

$6.60(Tier

2)

MO; B/D

azathioprine tabs or 100mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

MO; B/D

CELLCEPT CAPS 250 MG(Use MycophenolateMofetil)

NFMO; B/D

CELLCEPTINTRAVENOUS

$0-$6.60(Tier

2)

B/D

CELLCEPT SUSR 200MG/ML (UseMycophenolate Mofetil)

$0-$6.60(Tier

2)

MO; B/D



73

Name of drug

Whatthe


level)


CELLCEPT TABS 500 MG(Use MycophenolateMofetil)

NFMO; B/D

cyclosporine caps or 100mg, 25 mg

$0-$2.65(Tier

1)

MO; B/D

cyclosporine modified (formicroemulsion) caps 100mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO; B/D

cyclosporine soln iv 50mg/ml

$0-$2.65(Tier

1)

B/D

IMURAN (UseAzathioprine) NF MO; B/D

mycophenolate mofetil$0-

$2.65(Tier

1)

MO; B/D

mycophenolate sodium$0-

$2.65(Tier

1)

MO; B/D

MYFORTIC (UseMycophenolate Sodium) NF MO; B/D

NEORAL CAPS 100 MG,25 MG (Use CyclosporineModified (ForMicroemulsion))

NF

MO; B/D

NULOJIX$0-

$6.60(Tier

2)

B/D

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG (UseTacrolimus)

NFMO; B/D

PROGRAF SOLN IV 5MG/ML

$0-$6.60(Tier

2)

B/D

Name of drug

Whatthe


level)


RAPAMUNE SOLN 1MG/ML

$0-$6.60(Tier

2)

MO; B/D

RAPAMUNE TABS 0.5 MG(Use Sirolimus) NF MO; B/D

RAPAMUNE TABS 1 MG,2 MG (Use Sirolimus)

$0-$6.60(Tier

2)

MO; B/D

SANDIMMUNE CAPS OR100 MG, 25 MG (UseCyclosporine)

NFMO; B/D

SANDIMMUNE SOLN IV50 MG/ML (UseCyclosporine)

NFB/D

SANDIMMUNE SOLN OR100 MG/ML

$0-$6.60(Tier

2)

MO; B/D

SIMULECT$0-

$6.60(Tier

2)

B/D

sirolimus$0-

$2.65(Tier

1)

MO; B/D

tacrolimus caps or 0.5 mg,1 mg, 5 mg

$0-$2.65(Tier

1)

MO; B/D

THYMOGLOBULIN$0-

$6.60(Tier

2)

B/D

ZORTRESS$0-

$6.60(Tier

2)

MO; B/D

Irrigation Solutions



74

Name of drug

Whatthe


level)


irrigation solutions,physiological

$0-$2.65(Tier

1)

PHYSIOSOL IRRIGATIONPH 7.4

$0-$6.60(Tier

2)

water for irrigation, sterile$0-

$2.65(Tier

1)

MO

Potassium Removing ResinsKAYEXALATE (UseSodium PolystyreneSulfonate)

NFMO

sodium polystyrenesulfonate powd or

$0-$2.65(Tier

1)

MO

sodium polystyrenesulfonate susp or 15gm/60ml

$0-$2.65(Tier

1)

MO

Systemic Lupus Erythematosus Agents

BENLYSTA 120 MG$0-

$6.60(Tier

2)

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol$0-

$2.65(Tier

1)

MO

COREG (Use Carvedilol) NF MO

COREG CR$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


labetalol hcl tabs or 100mg, 200 mg, 300 mg

$0-$2.65(Tier

1)

MO

TRANDATE (Use LabetalolHCl) NF MO

Beta Blockers Cardio-Selective

acebutolol hcl caps or 200mg, 400 mg

$0-$2.65(Tier

1)

MO

atenolol tabs or 100 mg, 25mg, 50 mg

$0-$2.65(Tier

1)

MO

betaxolol hcl$0-

$2.65(Tier

1)

MO

bisoprolol fumarate$0-

$2.65(Tier

1)

MO

KERLONE (Use BetaxololHCl) NF MO

LOPRESSOR TABS OR100 MG, 50 MG (UseMetoprolol Tartrate)

NFMO

metoprolol succinate$0-

$2.65(Tier

1)

MO

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

SECTRAL (Use AcebutololHCl) NF MO

TENORMIN (Use Atenolol) NF MO

TOPROL XL (UseMetoprolol Succinate) NF MO



75

Name of drug

Whatthe


level)


ZEBETA (Use BisoprololFumarate) NF MO

Beta Blockers Non-SelectiveBETAPACE (Use SotalolHCl) NF tabs;MO

BETAPACE AF (UseSotalol HCl (AFIB/AFL)) NF MO

CORGARD (Use Nadolol) NF MO

INDERAL LA (UsePropranolol HCl) NF MO

nadolol tabs or 20 mg, 40mg, 80 mg

$0-$2.65(Tier

1)

MO

pindolol$0-

$2.65(Tier

1)

MO

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg

$0-$2.65(Tier

1)

MO

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

$0-$2.65(Tier

1)

MO

sotalol hcl$0-

$2.65(Tier

1)

tabs;MO

sotalol hcl (afib/afl)$0-

$2.65(Tier

1)

MO

Sotalol Hcl IV Soln NF

SOTYLIZE$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


BIOLOGICALS MISC - Drugs to Treat LowEnzymesBiologicals Misc

ADAGEN$0-

$6.60(Tier

2)

LA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC (UseNifedipine) NF MO

amlodipine besylate tabs or10 mg

$0-$2.65(Tier

1)

QL(1 ea daily);MO

amlodipine besylate tabs or2.5 mg

$0-$2.65(Tier

1)

QL(4 ea daily);MO

amlodipine besylate tabs or5 mg

$0-$2.65(Tier

1)

QL(2 ea daily);MO

CALAN (Use VerapamilHCl) NF MO

CALAN SR (Use VerapamilHCl) NF MO

CARDIZEM (Use DiltiazemHCl) NF MO

CARDIZEM CD (UseDiltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA 180 MG,240 MG, 300 MG, 360 MG,420 MG (Use Diltiazem HClCoated Beads)

NF

MO

diltiazem hcl coated beads$0-

$2.65(Tier

1)

MO



76

Name of drug

Whatthe


level)


diltiazem hcl cp12 or 120mg, 60 mg, 90 mg

$0-$2.65(Tier

1)

MO

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg

$0-$2.65(Tier

1)

MO

diltiazem hcl extendedrelease beads

$0-$2.65(Tier

1)

MO

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg

$0-$2.65(Tier

1)

MO

felodipine$0-

$2.65(Tier

1)

MO

nicardipine hcl caps or 20mg, 30 mg

$0-$2.65(Tier

1)

MO

nifedipine tb24 or 30 mg,60 mg, 90 mg

$0-$2.65(Tier

1)

MO

nimodipine caps or$0-

$2.65(Tier

1)

MO

nisoldipine 17 mg, 34 mg,8.5 mg

$0-$2.65(Tier

1)

MO

NORVASC 10 MG (UseAmlodipine Besylate) NF QL(1 ea daily);

MONORVASC 2.5 MG (UseAmlodipine Besylate) NF QL(4 ea daily);

MONORVASC 5 MG (UseAmlodipine Besylate) NF QL(2 ea daily);

MO

Name of drug

Whatthe


level)


NYMALIZE$0-

$6.60(Tier

2)PROCARDIA XL (UseNifedipine) NF MO

SULAR (Use Nisoldipine) NF MO

TIAZAC (Use Diltiazem HClExtended Release Beads) NF MO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

$0-$2.65(Tier

1)

MO

verapamil hcl tabs or 120mg, 40 mg, 80 mg

$0-$2.65(Tier

1)

MO

verapamil hcl tbcr or 120mg, 180 mg, 240 mg

$0-$2.65(Tier

1)

MO

VERELAN (Use VerapamilHCl) NF MO

VERELAN PM (UseVerapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac Glycosides

DIGOXIN SOLN OR 0.05MG/ML

$0-$6.60(Tier

2)

MO

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250mcg

$0-$2.65(Tier

1)

MO

LANOXIN TABS OR 125MCG, 250 MCG (UseDigoxin)

NFMO



77

Name of drug

Whatthe


level)


LANOXIN TABS OR 187.5MCG, 62.5 MCG

$0-$6.60(Tier

2)

MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinations

ENTRESTO$0-

$6.60(Tier

2)

PA; MO

Prostaglandin Vasodilators

REMODULIN$0-

$6.60(Tier

2)

LA; B/D

TYVASO$0-

$6.60(Tier

2)

LA; B/D

TYVASO REFILL$0-

$6.60(Tier

2)

LA; B/D

TYVASO STARTER$0-

$6.60(Tier

2)

LA; B/D

VENTAVIS$0-

$6.60(Tier

2)

LA; B/D

Pulmonary Hypertension - Endothelin Receptor

LETAIRIS$0-

$6.60(Tier

2)

LA

OPSUMIT$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


TRACLEER$0-

$6.60(Tier

2)

LA

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA$0-

$6.60(Tier

2)

PA

REVATIO SOLN IV 10MG/12.5ML (Use SildenafilCitrate (PulmonaryHypertension))

$0-$6.60(Tier

2)

PA

REVATIO TABS OR 20MG (Use Sildenafil Citrate(Pulmonary Hypertension))

NFPA

sildenafil citrate (pulmonaryhypertension)

$0-$2.65(Tier

1)

PA

Sinus Node Inhibitors

CORLANOR$0-

$6.60(Tier

2)

QL(2 ea daily);MO

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generation

cefadroxil$0-

$2.65(Tier

1)

MO

cefazolin sodium solr ij 1gm, 10 gm, 500 mg

$0-$2.65(Tier

1)

MO

cephalexin caps 250 mg,500 mg, 750 mg

$0-$2.65(Tier

1)

MO



78

Name of drug

Whatthe


level)


cephalexin susr 125mg/5ml, 250 mg/5ml

$0-$2.65(Tier

1)

MO

KEFLEX (Use Cephalexin) NF MO

Cephalosporins - 2nd Generation

cefaclor caps 250 mg, 500mg

$0-$2.65(Tier

1)

MO

cefprozil$0-

$2.65(Tier

1)

MO

CEFTIN SUSR 125MG/5ML

$0-$6.60(Tier

2)

MO

CEFTIN TABS 250 MG,500 MG (Use CefuroximeAxetil)

NFMO

cefuroxime axetil$0-

$2.65(Tier

1)

MO

cefuroxime sodium ij 1.5gm, 7.5 gm

$0-$2.65(Tier

1)

cefuroxime sodium ij 750mg

$0-$2.65(Tier

1)

MO

ZINACEF SOLR IJ 1.5 GM,7.5 GM (Use CefuroximeSodium)

NF

ZINACEF SOLR IJ 750 MG(Use Cefuroxime Sodium) NF MO

Cephalosporins - 3rd Generation

Name of drug

Whatthe


level)


cefdinir$0-

$2.65(Tier

1)

MO

cefixime chew 100 mg$0-

$2.65(Tier

1)

cefixime chew 200 mg$0-

$2.65(Tier

1)

MO

cefixime susr 100 mg/5ml,200 mg/5ml

$0-$2.65(Tier

1)

MO

cefixime tabs 400 mg$0-

$2.65(Tier

1)

cefotaxime sodium 1 gm,10 gm

$0-$2.65(Tier

1)

MO

cefotaxime sodium 2 gm,500 mg

$0-$2.65(Tier

1)

cefpodoxime proxetil$0-

$2.65(Tier

1)

MO

ceftazidime ij 1 gm, 2 gm$0-

$2.65(Tier

1)

MO

ceftazidime ij 6 gm$0-

$2.65(Tier

1)



79

Name of drug

Whatthe


level)


ceftriaxone sodium solr ij 1gm

$0-$2.65(Tier

1)

QL(4 ea daily);MO

ceftriaxone sodium solr ij 2gm

$0-$2.65(Tier

1)

QL(2 ea daily);MO

ceftriaxone sodium solr ij250 mg

$0-$2.65(Tier

1)

QL(16 eadaily); MO

ceftriaxone sodium solr ij500 mg

$0-$2.65(Tier

1)

QL(8 ea daily);MO

ceftriaxone sodium solr iv 1gm

$0-$2.65(Tier

1)

QL(4 ea daily)

ceftriaxone sodium solr iv10 gm

$0-$2.65(Tier

1)

MO

ceftriaxone sodium solr iv 2gm

$0-$2.65(Tier

1)

QL(2 ea daily);MO

CLAFORAN IJ 1 GM, 10GM (Use CefotaximeSodium)

NFMO

CLAFORAN IJ 2 GM, 500MG (Use CefotaximeSodium)

NF

FORTAZ SOLR IJ 1 GM, 2GM (Use Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Use Ceftazidime) NF

SUPRAX CAPS 400 MG$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


SUPRAX SUSR 500MG/5ML

$0-$6.60(Tier

2)

Cephalosporins - 4th Generation

cefepime hcl$0-

$2.65(Tier

1)

MO

CEFEPIME SOLN 1GM/50ML, 2 GM/100ML

$0-$6.60(Tier

2)MAXIPIME IJ 1 GM, 2 GM(Use Cefepime HCl) NF MO

Cephalosporins - 5th Generation

TEFLARO 400 MG$0-

$6.60(Tier

2)

CHEMICALS

Acids, Bases, & Buffers

LACTIC ACID$0

(Tier3)

RX/OTC; MO;NT

LACTIC ACID RACEMIC$0

(Tier3)

RX/OTC; MO;NT

Bulk Chemicals - S's

SODIUM CITRATEDIHYDRATE

$0(Tier

3)

NT

Liquids

GLYCERIN LIQD 99 %,99.5 %

$0(Tier

3)

RX/OTC; MO;NT

GLYCERINE$0

(Tier3)

RX/OTC; MO;NT



80

Name of drug

Whatthe


level)


GLYCEROL FORMAL$0

(Tier3)

RX/OTC; MO;NT

Semi-Solids

COAL TAR SOLN XX$0

(Tier3)

RX/OTC; MO;NT

SolidsSODIUMCHLORIDE/SODIUMBICARBONATE

$0(Tier

3)

NT

THYMOL$0

(Tier3)

RX/OTC; MO;NT

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBREVICON-28 (UseNorethindrone & EthEstradiol)

NFMO

DESOGEN (UseDesogestrel & EthinylEstradiol)

NFMO

desogestrel & ethinylestradiol

$0-$2.65(Tier

1)

MO

desogestrel-ethinylestradiol (biphasic)

$0-$2.65(Tier

1)

MO

drospirenone-ethinylestradiol

$0-$2.65(Tier

1)

MO

ethynodiol diacet & ethestrad

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


FEMCON FE (UseNorethindrone & EthinylEstradiol-Fe)

NFMO

levonorgestrel & ethestradiol

$0-$2.65(Tier

1)

MO

levonorgestrel-eth estradiol(triphasic)

$0-$2.65(Tier

1)

MO

levonorgestrel-ethinylestradiol (91-day)

$0-$2.65(Tier

1)

MO

LOSEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

MODICON (UseNorethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fe75mg-20mcg-1mg, 75mg-30mcg-1.5mg

$0-$2.65(Tier

1)

MO

norethindrone & ethestradiol

$0-$2.65(Tier

1)

MO

norethindrone & ethinylestradiol-fe 0.4mg-35mcg

$0-$2.65(Tier

1)

MO

norethindrone acet & ethestra

$0-$2.65(Tier

1)

MO

norethindrone-eth estradiol(triphasic)

$0-$2.65(Tier

1)

MO



81

Name of drug

Whatthe


level)


norgestimate-ethinylestradiol

$0-$2.65(Tier

1)

MO

norgestimate-ethinylestradiol (triphasic)

$0-$2.65(Tier

1)

MO

norgestrel & ethinylestradiol

$0-$2.65(Tier

1)

MO

NORINYL 1+35 (UseNorethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLEN (UseNorgestimate-EthinylEstradiol (Triphasic))

NFMO

ORTHO-CEPT (UseDesogestrel & EthinylEstradiol)

NFMO

ORTHO-CYCLEN (UseNorgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35(Use Norethindrone & EthEstradiol)

NFMO

ORTHO-NOVUM 7/7/7(Use Norethindrone-EthEstradiol (Triphasic))

NFMO

SEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

YASMIN 28 (UseDrospirenone-EthinylEstradiol)

NFMO

YAZ (Use Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermal

Name of drug

Whatthe


level)


norelgestromin-ethinylestradiol

$0-$2.65(Tier

1)

MO

ORTHO EVRA (UseNorelgestromin-EthinylEstradiol)

$0-$6.60(Tier

2)

MO

Combination Contraceptives - Vaginal

NUVARING$0-

$6.60(Tier

2)

MO

Emergency Contraceptives

ELLA$0-

$6.60(Tier

2)

levonorgestrel (emergencyoc) 0.75 mg

$0-$2.65(Tier

1)

levonorgestrel (emergencyoc) 1.5 mg

$0-$2.65(Tier

1)

RX/OTC

PLAN B ONE-STEP (UseLevonorgestrel (EmergencyOC))

NFRX/OTC

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE (UseMedroxyprogesteroneAcetate (Contraceptive))

NF

MO

medroxyprogesteroneacetate (contraceptive)

$0-$2.65(Tier

1)

MO

Progestin Contraceptives - Oral



82

Name of drug

Whatthe


level)


NOR-QD (UseNorethindrone(Contraceptive))

NFMO

norethindrone(contraceptive)

$0-$2.65(Tier

1)

MO

ORTHO MICRONOR (UseNorethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroids

ARISTOSPAN INTRA-ARTICULAR

$0-$6.60(Tier

2)

MO

betamethasone sodphosphate & acetate

$0-$2.65(Tier

1)

MO

budesonide cp24 or$0-

$2.65(Tier

1)

MO

CELESTONE-SOLUSPAN(Use Betamethasone SodPhosphate & Acetate)

NFMO

CORTEF (UseHydrocortisone) NF MO

cortisone acetate tabs or$0-

$2.65(Tier

1)

MO

DEPO-MEDROL 20MG/ML

$0-$6.60(Tier

2)

MO

DEPO-MEDROL 40MG/ML, 80 MG/ML (UseMethylprednisoloneAcetate)

NF

MO

Name of drug

Whatthe


level)


dexamethasone elix or 0.5mg/5ml

$0-$2.65(Tier

1)

MO

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0-$2.65(Tier

1)

PreservativeFree;MO

dexamethasone sodiumphosphate soln ij 10 mg/ml,120 mg/30ml

$0-$2.65(Tier

1)dexamethasone sodiumphosphate soln ij 100mg/10ml, 20 mg/5ml, 4mg/ml

$0-$2.65(Tier

1)

MO

dexamethasone soln or 0.5mg/5ml

$0-$2.65(Tier

1)

MO

dexamethasone tabs or 0.5mg, 0.75 mg, 1 mg, 1.5 mg,2 mg, 4 mg, 6 mg

$0-$2.65(Tier

1)

MO

ENTOCORT EC (UseBudesonide) NF MO

hydrocortisone sodsuccinate

$0-$2.65(Tier

1)

MO

hydrocortisone tabs or 10mg, 20 mg, 5 mg

$0-$2.65(Tier

1)

MO

KENALOG-10$0-

$6.60(Tier

2)

MO

KENALOG-40$0-

$6.60(Tier

2)

MO



83

Name of drug

Whatthe


level)


MEDROL 16 MG, 32 MG, 4MG, 8 MG (UseMethylprednisolone)

NFMO

MEDROL 2 MG$0-

$6.60(Tier

2)

MO

MEDROL DOSEPAK (UseMethylprednisolone) NF MO

methylprednisolone acetatesusp ij 40 mg/ml, 80 mg/ml

$0-$2.65(Tier

1)

MO

methylprednisolone sodsucc

$0-$2.65(Tier

1)

MO

methylprednisolone tabs or16 mg, 32 mg, 4 mg, 8 mg

$0-$2.65(Tier

1)

MO

ORAPRED ODT 10 MG,15MG,30 MG (UsePrednisolone SodiumPhosphate)

NF

MO

prednisolone$0-

$2.65(Tier

1)

MO

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

$0-$2.65(Tier

1)

MO

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

$0-$2.65(Tier

1)

MO

prednisone conc or 5mg/ml

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


prednisone soln or 5mg/5ml

$0-$2.65(Tier

1)

MO

prednisone tabs or 1 mg,10 mg, 2.5 mg, 20 mg, 5mg, 50 mg

$0-$2.65(Tier

1)

MO

SOLU-CORTEF 100 MG,250 MG, 500 MG

$0-$6.60(Tier

2)

MO

SOLU-CORTEF 1000 MG$0-

$6.60(Tier

2)SOLU-MEDROL 1000 MG,125 MG, 40 MG (UseMethylprednisolone SodSucc)

NF

MO

Mineralocorticoids

fludrocortisone acetate tabsor

$0-$2.65(Tier

1)

MO

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussives

benzonatate 100 mg, 200mg

$0(Tier

3)

MO; NT

hydrocodone w/homatropine

$0(Tier

3)

MO; NT

TESSALON PERLES (UseBenzonatate) NF MO; NT

Cough/Cold/Allergy Combinations

ADVIL ALLERGY &CONGESTION

$0(Tier

3)

AL; NT



84

Name of drug

Whatthe


level)


ALBATUSSIN NN$0

(Tier3)

NT

BENADRYL ALLERGY &COLD (UseDiphenhydramine-Phenylephrine-Acetaminophen)

NF

AL; NT

BENADRYL ALLERGY &SINUSHEADACHE (UseDiphenhydramine-Phenylephrine-Acetaminophen)

NF

AL; NT

BENADRYL-D ALLERGY &SINUS (UseDiphenhydramine-Phenylephrine)

NF

AL; NT

brompheniramine &phenyleph

$0(Tier

3)

AL; NT

brompheniramine &pseudoeph

$0(Tier

3)

AL; NT

BRONCOPECTOL$0

(Tier3)

AL; NT

chlorpheniramine &phenylephrine

$0(Tier

3)

AL; NT

chlorpheniramine &pseudoeph syrp 15mg/5ml-1mg/5ml

$0(Tier

3)

AL; NT

chlorpheniramine w/codeine

$0(Tier

3)

AL; RX/OTC;NT

chlorpheniramine-phenylephrine-acetaminophen susp1mg/5ml-160mg/5ml-2.5mg/5ml

$0(Tier

3)

AL; NT

DECON-A ELIX 2MG/5ML-5MG/5ML

$0(Tier

3)

AL; NT

Name of drug

Whatthe


level)


dexbrompheniramine &pseudoephedrine

$0(Tier

3)

AL; MO; NT

DIMETAPP COLD &ALLERGY ELIX 1MG/5ML-2.5MG/5ML (UseBrompheniramine &Phenyleph)

NF

AL; NT

diphenhydramine-phenylephrine liqd12.5mg/5ml-5mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine soln12.5mg/5ml-5mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine tabs 25mg-10mg

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine-acetaminophen susp12.5mg/5ml-160mg/5ml-2.5mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine-acetaminophen tabs12.5mg-12.5mg-325mg-325mg-5mg-5mg, 12.5mg-325mg-5mg

$0(Tier

3)

AL; NT

diphenhydramine-pseudoephedrine-acetaminophen

$0(Tier

3)

AL; NT

DRIXORALCOLD/ALLERGY (UseDexbrompheniramine &Pseudoephedrine)

NF

AL; MO; NT

ED CHLORPED D$0

(Tier3)

AL; NT

GILTUSS PED-C$0

(Tier3)

NT



85

Name of drug

Whatthe


level)


guaifenesin-codeine liqd100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine soln100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine syrp100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

hydrocodone polistirex-chlorpheniramine polistirex

$0(Tier

3)

AL; MO; NT

LEXUSS 210$0

(Tier3)

AL; RX/OTC;NT

NEXAFED SINUSPRESSURE +PAIN

$0(Tier

3)

NT

PEDIATEX TD (UseTriprolidine &Pseudoephedrine)

NFAL; RX/OTC;NT

phenyleph-promethazinew/ cod

$0(Tier

3)

AL; MO; NT

promethazine w/codeine$0

(Tier3)

AL; MO; NT

promethazine-dm$0

(Tier3)

AL; MO; NT

pseudoephedrine-acetaminophen

$0(Tier

3)

NT

pseudoephedrine-ibuprofensusp 100mg/5ml-15mg/5ml

$0(Tier

3)

NT

RYMED$0

(Tier3)

AL; NT

Name of drug

Whatthe


level)


SUDAFED PE SEVERECOLD MULTI-SYMPTOM(Use Diphenhydramine-Phenylephrine-Acetaminophen)

NF

AL; NT

triprolidine &pseudoephedrine liqd0.938mg/ml-10mg/ml

$0(Tier

3)

AL; RX/OTC;NT

triprolidine &pseudoephedrine tabs2.5mg-2.5mg-60mg-60mg,2.5mg-60mg

$0(Tier

3)

AL; MO; NT

TUSNEL CAPS 2MG-15MG-200MG

$0(Tier

3)

AL; NT

TUSSIONEXPENNKINETICEXTENDED RELEASE(Use HydrocodonePolistirex-ChlorpheniraminePolistirex)

NF

AL; MO; NT

TYLENOL CHILDRENSPLUS COLD & ALLERGY(Use Diphenhydramine-Phenylephrine-Acetaminophen)

NF

AL; NT

TYLENOL CHILDRENSPLUS COLD (UseChlorpheniramine-Phenylephrine-Acetaminophen)

NF

AL; NT

Misc. Respiratory Inhalants

sodium chloride (inhalant)$0

(Tier3)

NT

Mucolytics

acetylcysteine soln in 10 %,20 %

$0-$2.65(Tier

1)

MO; B/D

DERMATOLOGICALS - Drugs to Treat SkinConditions



86

Name of drug

Whatthe


level)


Acne Products

ABSORICA 10 MG,20MG,25 MG,35 MG,40 MG

$0-$6.60(Tier

2)

ABSORICA 30 MG (UseIsotretinoin)

$0-$6.60(Tier

2)

ACNE MEDICATION$0

(Tier3)

MO; NT

ACNE MEDICATION 10$0

(Tier3)

MO; NT

adapalene crea 0.1 %$0-

$2.65(Tier

1)

MO

adapalene gel 0.1 %$0-

$2.65(Tier

1)

MO

ADULT ACNOMEL$0

(Tier3)

NT

BENSULFOID$0

(Tier3)

NT

BENZACLIN (UseClindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMP(Use ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN (UseBenzoyl Peroxide-Erythromycin)

NFMO

benzoyl peroxide gel ex 5%

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


benzoyl peroxide-erythromycin

$0-$2.65(Tier

1)

MO

CLEOCIN-T (UseClindamycin Phosphate(Topical))

NFMO

CLINDAGEL$0-

$6.60(Tier

2)

MO

clindamycin phosphate(topical)

$0-$2.65(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide

$0-$2.65(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide(refrigerate)

$0-$2.65(Tier

1)

MO

DIFFERIN CREA 0.1 %(Use Adapalene) NF MO

DIFFERIN GEL 0.1 % (UseAdapalene) NF MO

DUAC (Use ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NFMO

erythromycin (acne aid)soln

$0-$2.65(Tier

1)

MO

EVOCLIN (UseClindamycin Phosphate(Topical))

NFMO

isotretinoin caps or 10 mg,20 mg, 30 mg, 40 mg

$0-$2.65(Tier

1)



87

Name of drug

Whatthe


level)


KLARON (UseSulfacetamide Sodium(Acne))

NFMO

RETIN-A (Use Tretinoin) NF MO

RETIN-A MICRO (UseTretinoin Microsphere) NF MO

RETIN-A MICRO PUMP0.04 %, 0.1 % (UseTretinoin Microsphere)

NFMO

REZAMID$0

(Tier3)

MO; NT

sulfacetamide sodium(acne)

$0-$2.65(Tier

1)

MO

tretinoin crea ex 0.025 %,0.05 %, 0.1 %

$0-$2.65(Tier

1)

MO

tretinoin gel ex 0.01 %,0.025 %

$0-$2.65(Tier

1)

MO

tretinoin microsphere$0-

$2.65(Tier

1)

MO

Analgesics - Topical

menthol (topical analgesic)pads 5 %

$0(Tier

3)

MO; NT

Anti-inflammatory Agents - Topical

FLECTOR$0-

$6.60(Tier

2)

PA; MO

VOLTAREN$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


Antibiotics - TopicalBACIGUENT (UseBacitracin (Topical)) NF MO; NT

bacitracin (topical)$0

(Tier3)

MO; NT

bacitracin zinc oint ex$0

(Tier3)

MO; NT

bacitracin-polymyxin b$0

(Tier3)

MO; NT

BACTROBAN (UseMupirocin Calcium(Topical))

NFMO

BACTROBAN (UseMupirocin) NF MO

CENTANY$0-

$6.60(Tier

2)

MO

gentamicin sulfate (topical)$0-

$2.65(Tier

1)

MO

mupirocin calcium (topical)$0-

$2.65(Tier

1)

MO

mupirocin oint ex$0-

$2.65(Tier

1)

MO

neomycin-bacitracin-polymyxin w/ lidocaine

$0(Tier

3)

NT

POLYSPORIN OINT (UseBacitracin-Polymyxin B) NF MO; NT

Antifungals - Topical

ALEVAZOL$0

(Tier3)

NT



88

Name of drug

Whatthe


level)


ciclopirox gel 0.77 %$0-

$2.65(Tier

1)

MO

ciclopirox olamine crea ex$0-

$2.65(Tier

1)

MO

ciclopirox olamine susp ex$0-

$2.65(Tier

1)

MO

ciclopirox sham 1 %$0-

$2.65(Tier

1)

MO

ciclopirox soln 8 %$0-

$2.65(Tier

1)

MO

clotrimazole (topical) crea$0-

$2.65(Tier

1)

RX/OTC; MO

clotrimazole (topical) soln$0-

$2.65(Tier

1)

RX/OTC; MO

clotrimazole w/betamethasone

$0-$2.65(Tier

1)

MO

CLOVERINE SALVE$0

(Tier3)

NT

econazole nitrate$0-

$2.65(Tier

1)

MO

EXTINA (UseKetoconazole (Topical)) NF MO

Name of drug

Whatthe


level)


ketoconazole (topical)$0-

$2.65(Tier

1)

MO

LAMISIL AT CREA (UseTerbinafine HCl (Topical)) NF MO; NT

LAMISIL AT JOCK ITCH(Use Terbinafine HCl(Topical))

NFMO; NT

LOPROX (Use Ciclopirox) NF MO

LOPROX SHAMPOO (UseCiclopirox) NF MO

LOTRISONE (UseClotrimazole w/Betamethasone)

NFMO

MICATIN (Use MiconazoleNitrate (Topical)) NF RX/OTC; MO;

NT

miconazole nitrate (topical)crea

$0(Tier

3)

RX/OTC; MO;NT

NAFTIN CREA 2 %$0-

$6.60(Tier

2)

MO

NAFTIN GEL 2 %$0-

$6.60(Tier

2)

MO

NIZORAL (UseKetoconazole (Topical)) NF MO

NIZORAL A-D$0

(Tier3)

MO; NT

nystatin (topical)$0-

$2.65(Tier

1)

MO

nystatin-triamcinolone$0-

$2.65(Tier

1)

MO



89

Name of drug

Whatthe


level)


PENLAC NAIL LACQUER(Use Ciclopirox) NF MO

terbinafine hcl (topical)$0

(Tier3)

MO; NT

TINACTIN CREA (UseTolnaftate) NF MO; NT

TINACTIN JOCK ITCHCREA (Use Tolnaftate) NF MO; NT

tolnaftate crea ex$0

(Tier3)

MO; NT

tolnaftate liqd ex$0

(Tier3)

MO; NT

tolnaftate soln ex$0

(Tier3)

MO; NT

UNDELENIC TINCTURE$0

(Tier3)

NT

Antihistamines-Topical

diphenhydramine hcl(topical) crea

$0(Tier

3)

NT

diphenhydramine-zincacetate crea 0.1%-1%

$0(Tier

3)

NT

Antineoplastic or Premalignant Lesion Agents -

CARAC$0-

$6.60(Tier

2)

MO

diclofenac sodium (actinickeratoses)

$0-$2.65(Tier

1)

MO

EFUDEX (Use Fluorouracil(Topical)) NF MO

Name of drug

Whatthe


level)


fluorouracil (topical)$0-

$2.65(Tier

1)

MO

FLUOROURACIL CREAEX 0.5 %

$0-$6.60(Tier

2)

MO

PANRETIN$0-

$6.60(Tier

2)

MO

PICATO$0-

$6.60(Tier

2)

MO

SOLARAZE (UseDiclofenac Sodium (ActinicKeratoses))

NFMO

TARGRETIN 1 %,75 MG$0-

$6.60(Tier

2)

VALCHLOR$0-

$6.60(Tier

2)

PA

Antipsoriatics

acitretin$0-

$2.65(Tier

1)

MO

calcipotriene$0-

$2.65(Tier

1)

MO

COSENTYX$0-

$6.60(Tier

2)

PA; LA



90

Name of drug

Whatthe


level)


COSENTYXSENSOREADY PEN

$0-$6.60(Tier

2)

PA; LA

DOVONEX (UseCalcipotriene) NF MO

methoxsalen rapid$0-

$2.65(Tier

1)

MO

OXSORALEN ULTRA (UseMethoxsalen Rapid)

$0-$6.60(Tier

2)

MO

SORIATANE (UseAcitretin) NF MO

STELARA$0-

$6.60(Tier

2)

PA;

TAZORAC$0-

$6.60(Tier

2)

MO

Antiseborrheic Products

DERMAZINC BABY$0

(Tier3)

MO; NT

DERMAZINC SCALP$0

(Tier3)

MO; NT

DERMAZINC SPRAY (UsePyrithione Zinc) NF MO; NT

DHS ZINC (Use PyrithioneZinc) NF MO; NT

NOBLE FORMULA BAR 2%

$0(Tier

3)

NT

P & S LIQD$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


pyrithione zinc liqd 0.25 %$0

(Tier3)

MO; NT

pyrithione zinc sham 2 %$0

(Tier3)

MO; NT

selenium sulfide lotn ex 2.5%

$0-$2.65(Tier

1)

MO

Antivirals - Topical

acyclovir topical$0-

$2.65(Tier

1)

MO

DENAVIR$0-

$6.60(Tier

2)

MO

ZOVIRAX CREA EX 5 %$0-

$6.60(Tier

2)

MO

ZOVIRAX OINT EX 5 %(Use Acyclovir Topical) NF MO

Bath Products

AVEENO SKIN RELIEFSHOWER& BATH

$0(Tier

3)

MO; NT

bath products oil 40%-40%-40%-40%, 5%-5%-5%

$0(Tier

3)

MO; NT

BODI WHIRL OIL$0

(Tier3)

MO; NT

GERISILK BATH OIL$0

(Tier3)

MO; NT

ULTRA DERM BATH OIL$0

(Tier3)

MO; NT



91

Name of drug

Whatthe


level)


Burn Products

mafenide acetate pack ex$0-

$2.65(Tier

1)

MO

SILVADENE (Use SilverSulfadiazine) NF MO

silver sulfadiazine crea ex$0-

$2.65(Tier

1)

MO

SULFAMYLON PACK 5 %(Use Mafenide Acetate) NF MO

Corticosteroids - Topical

alclometasone dipropionate$0-

$2.65(Tier

1)

MO

amcinonide crea$0-

$2.65(Tier

1)

MO

betamethasonedipropionate (topical)

$0-$2.65(Tier

1)

MO

betamethasonedipropionate augmented

$0-$2.65(Tier

1)

MO

betamethasone valeratecrea ex 0.1 %

$0-$2.65(Tier

1)

MO

betamethasone valeratefoam ex 0.12 %

$0-$2.65(Tier

1)

MO

betamethasone valeratelotn ex 0.1 %

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


betamethasone valerateoint ex 0.1 %

$0-$2.65(Tier

1)

MO

clobetasol propionate creaex

$0-$2.65(Tier

1)

MO

clobetasol propionateemollient base

$0-$2.65(Tier

1)

MO

clobetasol propionateemulsion

$0-$2.65(Tier

1)

MO

clobetasol propionate foamex

$0-$2.65(Tier

1)

MO

clobetasol propionate gelex

$0-$2.65(Tier

1)

MO

clobetasol propionate lotnex

$0-$2.65(Tier

1)

MO

clobetasol propionate ointex

$0-$2.65(Tier

1)

MO

clobetasol propionate shamex

$0-$2.65(Tier

1)

MO

clobetasol propionate solnex

$0-$2.65(Tier

1)

MO

CLOBEX LOTN (UseClobetasol Propionate) NF MO



92

Name of drug

Whatthe


level)


CLOBEX SHAM (UseClobetasol Propionate) NF MO

CUTIVATE (UseFluticasone Propionate) NF MO

CVS HDYROCORTISONEACETATE

$0(Tier

3)

NT

DERMA-SMOOTHE/FSBODY (Use FluocinoloneAcetonide)

NFMO

DERMA-SMOOTHE/FSSCALP (Use FluocinoloneAcetonide)

NFMO

DERMATOP CREA (UsePrednicarbate) NF MO

desonide crea ex$0-

$2.65(Tier

1)

MO

desonide lotn ex$0-

$2.65(Tier

1)

MO

desonide oint ex$0-

$2.65(Tier

1)

MO

DESOWEN 0.05 % (UseDesonide) NF MO

desoximetasone crea ex0.25 %

$0-$2.65(Tier

1)

MO

desoximetasone gel ex0.05 %

$0-$2.65(Tier

1)

MO

desoximetasone oint ex0.25 %

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


diflorasone diacetate oint$0-

$2.65(Tier

1)

MO

DIPROLENE (UseBetamethasoneDipropionate Augmented)

NFMO

DIPROLENE AF (UseBetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA (UseMometasone Furoate) NF MO

ELOCON OINT (UseMometasone Furoate) NF MO

fluocinolone acetonide creaex 0.01 %, 0.025 %

$0-$2.65(Tier

1)

MO

fluocinolone acetonide oilex 0.01 %

$0-$2.65(Tier

1)

MO

fluocinolone acetonide ointex 0.025 %

$0-$2.65(Tier

1)

MO

fluocinolone acetonide solnex 0.01 %

$0-$2.65(Tier

1)

MO

fluocinonide crea ex 0.05 %$0-

$2.65(Tier

1)

MO

fluocinonide emulsifiedbase

$0-$2.65(Tier

1)

MO

fluocinonide gel ex 0.05 %$0-

$2.65(Tier

1)

MO



93

Name of drug

Whatthe


level)


fluocinonide oint ex 0.05 %$0-

$2.65(Tier

1)

MO

fluocinonide soln ex 0.05 %$0-

$2.65(Tier

1)

MO

fluticasone propionate creaex 0.05 %

$0-$2.65(Tier

1)

MO

fluticasone propionate lotnex 0.05 %

$0-$2.65(Tier

1)

MO

fluticasone propionate ointex 0.005 %

$0-$2.65(Tier

1)

MO

halobetasol propionate$0-

$2.65(Tier

1)

MO

hydrocortisone (topical)crea 0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)crea 1 %

$0-$2.65(Tier

1)

RX/OTC; MO

hydrocortisone (topical)crea 2.5 %

$0-$2.65(Tier

1)

MO

hydrocortisone (topical)lotn 1 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)lotn 2.5 %

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


hydrocortisone (topical) oint0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical) oint1 %

$0-$2.65(Tier

1)

RX/OTC; MO

hydrocortisone (topical) oint2.5 %

$0-$2.65(Tier

1)

MO

hydrocortisone (topical)soln 1 %

$0(Tier

3)

NT

hydrocortisone acetate(topical)

$0(Tier

3)

NT

hydrocortisone butyrate$0-

$2.65(Tier

1)

MO

hydrocortisone butyratehydrophilic lipo base

$0-$2.65(Tier

1)

MO

hydrocortisone valerate$0-

$2.65(Tier

1)

MO

hydrocortisone-aloe vera$0

(Tier3)

NT

LOCOID CREA (UseHydrocortisone Butyrate) NF MO

LOCOID LIPOCREAM(Use HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID OINT (UseHydrocortisone Butyrate) NF MO

LOCOID SOLN (UseHydrocortisone Butyrate) NF MO



94

Name of drug

Whatthe


level)


LUXIQ (UseBetamethasone Valerate)

$0-$6.60(Tier

2)

MO

mometasone furoate creaex

$0-$2.65(Tier

1)

MO

mometasone furoate ointex

$0-$2.65(Tier

1)

MO

mometasone furoate solnex

$0-$2.65(Tier

1)

MO

OLUX (Use ClobetasolPropionate) NF MO

OLUX-E (Use ClobetasolPropionate Emulsion) NF MO

prednicarbate crea$0-

$2.65(Tier

1)

MO

SYNALAR (UseFluocinolone Acetonide) NF MO

TEMOVATE (UseClobetasol Propionate) NF MO

TEMOVATE E (UseClobetasol PropionateEmollient Base)

NFMO

triamcinolone acetonide(topical) crea 0.025 %, 0.1%, 0.5 %

$0-$2.65(Tier

1)

MO

triamcinolone acetonide(topical) lotn 0.025 %, 0.1%

$0-$2.65(Tier

1)

MO

triamcinolone acetonide(topical) oint 0.025 %, 0.1%, 0.5 %

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


TUCKS ANTI-ITCH$0

(Tier3)

NT

ULTRAVATE (UseHalobetasol Propionate) NF MO

WESTCORT (UseHydrocortisone Valerate) NF MO

Emollient/Keratolytic Agents

CARMOL$0

(Tier3)

NT

CARMOL 20 (Use Urea) NF MO; NT

ULTRA MIDE 25 (UseUrea) NF MO; NT

urea crea ex 20 %$0

(Tier3)

MO; NT

urea lotn ex 25 %$0

(Tier3)

MO; NT

EmollientsLAC-HYDRIN (Use LacticAcid (Ammonium Lactate)) NF RX/OTC; MO

lactic acid (ammoniumlactate) crea 12 %

$0-$2.65(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) lotn 12 %

$0-$2.65(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) lotn 5 %

$0(Tier

3)

MO; NT

PANTHODERM$0

(Tier3)

NT

PETROLATUM$0

(Tier3)

NT



95

Name of drug

Whatthe


level)


SUPER E CREA$0

(Tier3)

MO; NT

SUPER E DAY$0

(Tier3)

MO; NT

SUPER E EYE$0

(Tier3)

MO; NT

SUPER E NIGHT$0

(Tier3)

MO; NT

vitamin e (topical) crea1000 unit, 1500 unit/30gm,30000 unit/60gm, 6000 unit

$0(Tier

3)

MO; NT

vitamin e (topical) oil 100unit/5drop, 12000 unit,20000 unit, 28000 unit,28000 unit/29ml, 400unit/ml, 4000 unit, 49000unit/52ml, 933.333 unit/ml

$0(Tier

3)

NT

Enzymes - Topical

SANTYL$0-

$6.60(Tier

2)

MO

Immunomodulating Agents - TopicalALDARA (Use Imiquimod) NF MO

imiquimod crea ex$0-

$2.65(Tier

1)

MO

ZYCLARA$0-

$6.60(Tier

2)

MO

ZYCLARA PUMP$0-

$6.60(Tier

2)

MO

Immunosuppressive Agents - Topical

Name of drug

Whatthe


level)


ELIDEL$0-

$6.60(Tier

2)

MO

PROTOPIC (UseTacrolimus (Topical))

$0-$6.60(Tier

2)

MO

tacrolimus (topical)$0-

$2.65(Tier

1)

MO

Keratolytic/Antimitotic AgentsCONDYLOX SOLN (UsePodofilox) NF MO

MEDIPLAST$0

(Tier3)

NT

MOSCO CALLUS/CORNREMOVER

$0(Tier

3)

NT

P & S SHAM$0

(Tier3)

NT

podofilox soln ex$0-

$2.65(Tier

1)

MO

Liniments

ARTHRICARE DOUBLEICE PAIN RELIEVING RUB

$0(Tier

3)

NT

ARTHRICARE PAINRELIEVINGRUB

$0(Tier

3)

NT

ARTHRICARE TRIPLEMEDICATED PAINRELIEVING RUB

$0(Tier

3)

NT

BIOFLEXOR$0

(Tier3)

NT



96

Name of drug

Whatthe


level)


BLUE-EMU SUPERSTRENGTH

$0(Tier

3)

MO; NT

DEEP BLUE RELIEF$0

(Tier3)

NT

liniments & rubs crea0.01%-5%-10%, 1.2%-2.6%-4.7%, 10%-0.025%-15%

$0(Tier

3)

MO; NT

liniments & rubs oint0.25%, 8%-2%

$0(Tier

3)

NT

SM PAINRELIEF/MENTHOL

$0(Tier

3)

NT

VICKS BABYRUB$0

(Tier3)

MO; NT

Local Anesthetics - Topical

AXSAIN$0

(Tier3)

NT

capsaicin in lidocainevehicle

$0(Tier

3)

NT

DERMOPLAST$0

(Tier3)

NT

DERMOPLAST PAINRELIEVINGSPRAY

$0(Tier

3)

NT

EMLA (Use Lidocaine-Prilocaine) NF MO

ITCH-X GEL$0

(Tier3)

MO; NT

LANACANE$0

(Tier3)

NT

Name of drug

Whatthe


level)


lidocaine hcl gel ex 0.5 %$0

(Tier3)

NT

lidocaine hcl gel ex 2 %$0-

$2.65(Tier

1)

RX/OTC; MO

lidocaine hcl soln ex 4 %$0-

$2.65(Tier

1)

MO

lidocaine oint ex 5 %$0-

$2.65(Tier

1)

MO

lidocaine ptch ex 5 %$0-

$2.65(Tier

1)

PA; MO

lidocaine-prilocaine crea$0-

$2.65(Tier

1)

MO

LIDODERM (UseLidocaine) NF PA; MO

pramoxine-camphor-zincacetate

$0(Tier

3)

NT

REGENECARE HA$0

(Tier3)

NT

SOLARCAINE ALOEEXTRA GEL (UseLidocaine HCl)

NFNT

SOLARCAINE ALOEVERA

$0(Tier

3)

NT

XYLOCAINE EX 4 % (UseLidocaine HCl) NF MO

Misc. Dermatological Products



97

Name of drug

Whatthe


level)


ATOPICLAIR$0

(Tier3)

RX/OTC; MO;NT

AURSTAT ANTI-ITCHHYDROGEL

$0(Tier

3)

RX/OTC; MO;NT

BURN SPRAY$0

(Tier3)

MO; NT

DERMAGRAN AERO$0

(Tier3)

MO; NT

DERMAREST ROSACEA$0

(Tier3)

RX/OTC; MO;NT

dermatological products,misc. crea 0.17%-2.7%,4%-2%-0.5%

$0(Tier

3)

RX/OTC; MO;NT

ELETONE$0

(Tier3)

RX/OTC; MO;NT

ELETONE TWINPACK$0

(Tier3)

RX/OTC; MO;NT

FRESH'N FEMININEDEODORANT

$0(Tier

3)

MO; NT

HPR PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

HYLATOPIC PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

NASALGUARD$0

(Tier3)

RX/OTC; MO;NT

NEOSALUS CP$0

(Tier3)

RX/OTC; MO;NT

NEOSALUS CREA$0

(Tier3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


NEW SKIN$0

(Tier3)

MO; NT

NIVATOPIC PLUS$0

(Tier3)

RX/OTC; MO;NT

NONYX$0

(Tier3)

RX/OTC; MO;NT

OC8$0

(Tier3)

RX/OTC; MO;NT

PRUCLAIR$0

(Tier3)

RX/OTC; MO;NT

PRUMYX$0

(Tier3)

RX/OTC; MO;NT

SUMMERS EVEDEODORANT SPRAY

$0(Tier

3)

MO; NT

SUMMERS EVEDEODORANT SPRAYULTRA

$0(Tier

3)

MO; NT

YODORA DEODORANT$0

(Tier3)

RX/OTC; MO;NT

Misc. TopicalA & D ZINC OXIDE (UseDimethicone-Zinc Oxide-Vitamin A-Vitamin D)

NFNT

A-MANTLE$0

(Tier3)

MO; NT

ACNE-AID$0

(Tier3)

MO; NT

ACUICYN DAILY EYELID& EYELASH CLEANSER

$0(Tier

3)

RX/OTC; NT



98

Name of drug

Whatthe


level)


ALOE VESTA MULTIPURPOSECLEANSING

$0(Tier

3)

NT

ALUMINUM ACETATESOLN EX

$0(Tier

3)

MO; NT

aluminum hydroxide$0

(Tier3)

NT

aluminum sulfate & calciumacetate

$0(Tier

3)

MO; NT

AMBI COCOA BUTTERCLEANSING

$0(Tier

3)

MO; NT

AMBI COMPLEXIONCLEANSING

$0(Tier

3)

MO; NT

ANTI-BACTERIAL HANDLOTION

$0(Tier

3)

MO; NT

AQUANIL SKINCLEANSER

$0(Tier

3)

MO; NT

AVEENO ACTIVENATURALS PURERENEWAL SHAMPOO

$0(Tier

3)

MO; NT

AVEENO MOISTURIZING$0

(Tier3)

MO; NT

AVEENO POSITIVELYAGELESSDAILYEXFOLIATING CLEANSER

$0(Tier

3)

MO; NT

AVEENO POSITIVELYRADIANTCLEANSER

$0(Tier

3)

MO; NT

AVEENO ULTRA-CALMING CLEANSER

$0(Tier

3)

NT

AVENOVA$0

(Tier3)

RX/OTC; NT

Name of drug

Whatthe


level)


BASIS ALL CLEAR$0

(Tier3)

MO; NT

BASIS COMBINATION$0

(Tier3)

MO; NT

BASIS EXTRA DRY$0

(Tier3)

MO; NT

BASIS NORMAL/DRY$0

(Tier3)

MO; NT

BASIS SENSITIVE SKIN$0

(Tier3)

MO; NT

BODY WASH &SHAMPOO

$0(Tier

3)

NT

CALAMINE LOTN EX$0

(Tier3)

NT

CALAMINE LOTN EX$0

(Tier3)

Calamine-ZincOxideLotion;MO; NT

CALAMINE PHENOLATED$0

(Tier3)

NT

CARRAFOAM FOAM$0

(Tier3)

NT

CAVILON NO STINGBARRIERFILM

$0(Tier

3)

MO; NT

CETAPHIL GENTLECLEANSER

$0(Tier

3)

MO; NT

CETAPHIL GENTLECLEANSING

$0(Tier

3)

MO; NT

CONTI CASTILE SOAP$0

(Tier3)

MO; NT



99

Name of drug

Whatthe


level)


CVS SALINE WOUNDWASH

$0(Tier

3)

NT

DARA$0

(Tier3)

MO; NT

DERMAGRAN OINT (UseAluminum Hydroxide) NF NT

DHS$0

(Tier3)

MO; NT

DHS COLOR SAFESHAMPOO

$0(Tier

3)

MO; NT

DHS CONDITIONINGRINSE

$0(Tier

3)

MO; NT

DIABETIDERMCLEANSING

$0(Tier

3)

MO; NT

dimethicone-zinc oxide-vitamin a-vitamin d

$0(Tier

3)

NT

DOMEBORO 1347MG-952MG (Use AluminumSulfate & Calcium Acetate)

NFMO; NT

ELTA CLEANSE FOAM$0

(Tier3)

NT

FORMULA 405 FACIAL &BODYCLEANSING

$0(Tier

3)

MO; NT

FORMULA 405MOISTURIZINGSOAP

$0(Tier

3)

MO; NT

FREE & CLEAR$0

(Tier3)

MO; NT

GENTLE RAIN EXTRAMILD

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


GENTLE RAIN SHAMPOOAND SKIN CLEANSER

$0(Tier

3)

MO; NT

GENTLE SKIN CLEANSER$0

(Tier3)

MO; NT

GERI-SHAMPOO/SHEABUTTER

$0(Tier

3)

MO; NT

GNP CALAMINE$0

(Tier3)


GNP CALAMINEPHENOLATED

$0(Tier

3)

NT

GNP SALINE WOUNDWASH

$0(Tier

3)

NT

GRANDPAS BAKINGSODA SOAP

$0(Tier

3)

MO; NT

GRANDPAS INDIANCORN SOAP

$0(Tier

3)

MO; NT

GRANDPAS LOVE MYLOOFAH SOAP

$0(Tier

3)

MO; NT

GRANDPAS OATMEALSOAP

$0(Tier

3)

MO; NT

GRANDPAS ORANGEESSENCE SOAP

$0(Tier

3)

MO; NT

GRANDPAS PATCHOULISOAP

$0(Tier

3)

MO; NT

GRANDPAS SHEABUTTER SOAP

$0(Tier

3)

MO; NT

GRANDPAS WITCHHAZEL SOAP

$0(Tier

3)

MO; NT



100

Name of drug

Whatthe


level)


HM CALAMINE$0

(Tier3)


HYDROPEL$0

(Tier3)

NT

JOHNSONS BABY BAR$0

(Tier3)

MO; NT

JOHNSONS BUDDIESEASY-GRIP SUDZING

$0(Tier

3)

MO; NT

JOHNSONS KIDS SUPERSUDZER E-Z GRIP SOAP

$0(Tier

3)

MO; NT

lanolin (topical)$0

(Tier3)

NT

LOBOB CONTACT LENSWEARERS SOAP

$0(Tier

3)

MO; NT

LOWILA$0

(Tier3)

MO; NT

MEIJER CALAMINE$0

(Tier3)

NT

NATURE DE FRANCEALGOLI SOAP

$0(Tier

3)

MO; NT

NATURE DE FRANCEARGILE BLANCHE SOAP

$0(Tier

3)

MO; NT

NATURE DE FRANCEARGIMIEL SOAP

$0(Tier

3)

MO; NT

NEUTROGENA ACNECLEANSING SOAP

$0(Tier

3)

MO; NT

NEUTROGENA CLEANREPLENISHING

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


NEUTROGENA FACIALSOAP ORIGINALFORMULA

$0(Tier

3)

MO; NT

NEUTROGENANATURALS FACE& BODY

$0(Tier

3)

MO; NT

NEUTROGENASHAMPOO

$0(Tier

3)

MO; NT

NEUTROGENA TRIPLEMOISTURE UV SHIELD

$0(Tier

3)

MO; NT

NIVEA MOISTURIZINGBODY WASH

$0(Tier

3)

MO; NT

NIVEA MOISTURIZINGBODY WASH 2 IN 1

$0(Tier

3)

MO; NT

NIVEA TOUCH OFSMOOTHNESSMOISTURIZING BODYWASH

$0(Tier

3)

MO; NT

NIVEA VISAGE GENTLECLEANSING

$0(Tier

3)

MO; NT

NO-STING SKIN-PREP$0

(Tier3)

MO; NT

OCUSOFT HAND SOAP$0

(Tier3)

MO; NT

OCUSOFT LID SCRUBFOAMING

$0(Tier

3)

RX/OTC; NT

OCUSOFT LID SCRUBORIGINAL

$0(Tier

3)

RX/OTC; NT

OILATUM$0

(Tier3)

MO; NT



101

Name of drug

Whatthe


level)


PHACID$0

(Tier3)

MO; NT

PROSHIELD FOAM &SPRAY CLEANSER

$0(Tier

3)

NT

PURPOSE BAR$0

(Tier3)

MO; NT

PX CALAMINE$0

(Tier3)


QC CALAMINE$0

(Tier3)

NT

RA BEAUTY BAR$0

(Tier3)

MO; NT

RA CALAMINE LOTN6.971%-6.971%

$0(Tier

3)


RA SALINE WOUNDWASH

$0(Tier

3)

NT

SAFE WASH$0

(Tier3)

NT

SALINE WOUND WASH$0

(Tier3)

NT

SALJET$0

(Tier3)

NT

SALJET RINSE$0

(Tier3)

NT

SAYMAN LANOLIN$0

(Tier3)

MO; NT

SAYMAN WITCH HAZEL$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


skin protectants, misc. liqd$0

(Tier3)

NT

SM CALAMINE$0

(Tier3)

NT

SM CALAMINEPHENOLATED

$0(Tier

3)

NT

STYGIENE STERILEEYELID CLEANSER

$0(Tier

3)

RX/OTC; NT

SUMMERS EVE NIGHT-TIMECLEANSING/SENSITIVESKIN

$0(Tier

3)

MO; NT

TERSASEPTICGLYCERINE CLEANSING

$0(Tier

3)

MO; NT

TOPICLEAR$0

(Tier3)

MO; NT

ULTRASWIM$0

(Tier3)

MO; NT

ULTRASWIM ULTRAREPAIR

$0(Tier

3)

MO; NT

UNIVERSAL REMOVERWIPES

$0(Tier

3)

MO; NT

URO-PREP PROTECTIVESKINWIPES

$0(Tier

3)

MO; NT

VANICREAM BAR$0

(Tier3)

MO; NT

witch hazel-glycerin$0

(Tier3)

NT



102

Name of drug

Whatthe


level)


WOUND WASH SALINE$0

(Tier3)

NT

Rosacea Agents

FINACEA GEL$0-

$6.60(Tier

2)

MO

METROCREAM (UseMetronidazole (Topical)) NF MO

METROGEL (UseMetronidazole (Topical)) NF MO

METROLOTION (UseMetronidazole (Topical)) NF MO

metronidazole (topical)$0-

$2.65(Tier

1)

MO

MIRVASO$0-

$6.60(Tier

2)

PA; MO

Scabicides & Pediculicides

lindane lotn$0-

$2.65(Tier

1)

MO

LYCELLE$0

(Tier3)

RX/OTC; NT

malathion$0-

$2.65(Tier

1)

MO

nit remover$0

(Tier3)

RX/OTC; NT

NIX CREME RINSE (UsePermethrin) NF MO; NT

OVIDE 0.5 % (UseMalathion) NF MO

Name of drug

Whatthe


level)


permethrin aero xx 0.5 %$0

(Tier3)

NT

permethrin crea ex 5 %$0-

$2.65(Tier

1)

MO

permethrin liqd ex 1 %$0

(Tier3)

MO; NT

permethrin lotn ex 1 %$0

(Tier3)

MO; NT

PRONTO SHAM EX0.33%-4% (Use Pyrethrins-Piperonyl Butoxide)

NFNT

PYRETHINS/PIPERONYLBUTOXIDE

$0(Tier

3)

NT

pyrethrins-piperonylbutoxide

$0(Tier

3)

NT

RID (Use Permethrin) NF NT

RID (Use Pyrethrins-Piperonyl Butoxide) NF NT

Sunscreens

BULL FROG QUIK GELSPF 36

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPF 50

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPORTSPF 36

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPORTSPRAY SPF 50

$0(Tier

3)

MO; NT

BULL FROG SPF 36$0

(Tier3)

MO; NT



103

Name of drug

Whatthe


level)


BULL FROG WATERARMOR SPORT QUIKGEL SPF 50

$0(Tier

3)

MO; NT

BULL FROG WATERARMOR SPORT QUIKSPRAY SPF 50

$0(Tier

3)

MO; NT

NIVEA VISAGE EYECONTOUR

$0(Tier

3)

MO; NT

PRESUN ULTRA/PARSOLGEL 3%-5%-7.5%-6%

$0(Tier

3)

MO; NT

SHADE OIL FREE CLEARGELSPF 25

$0(Tier

3)

MO; NT

SOLBAR PF LIQUID/GELSPF30

$0(Tier

3)

MO; NT

Tar Products

BALNETAR LIQUIM$0

(Tier3)

NT

coal tar extract sham 1 %$0

(Tier3)

NT

coal tar extract sham 1 %,15 %

$0(Tier

3)

MO; NT

COAL TAR SOLN EX$0

(Tier3)

NT

CUTAR$0

(Tier3)

MO; NT

ELTA LITE TAR$0

(Tier3)

NT

ELTA TAR$0

(Tier3)

NT

Name of drug

Whatthe


level)


GRANDPAS PINE TARSOAP

$0(Tier

3)

NT

MG217 MEDICATED TAR$0

(Tier3)

NT

POLYTAR BAR$0

(Tier3)

NT

TARSUM$0

(Tier3)

MO; NT

THERAPLEX T (Use CoalTar Extract) NF NT

Wound Care Products

REGRANEX$0-

$6.60(Tier

2)

MO

DIAGNOSTIC PRODUCTS

Diagnostic Drugs

GLUTOL$0

(Tier3)

NT

Diagnostic Tests

ALBUSTIX$0

(Tier3)

MO; NT

CHEK-STIX COMBO PAKURINALYSIS CONTROL

$0(Tier

3)

MO; NT

CHEK-STIX CONTROL$0

(Tier3)

MO; NT

CHEMSTRIP -10 WITH SG$0

(Tier3)

MO; NT

CHEMSTRIP 10 MD$0

(Tier3)

MO; NT



104

Name of drug

Whatthe


level)


CHEMSTRIP 2 GPSTRIPS

$0(Tier

3)

MO; NT

CHEMSTRIP 2 LN STRIPS$0

(Tier3)

MO; NT

CHEMSTRIP 5 OB$0

(Tier3)

MO; NT

CHEMSTRIP 7$0

(Tier3)

MO; NT

CHEMSTRIP 9 STRIPS$0

(Tier3)

MO; NT

CHEMSTRIP UGK$0

(Tier3)

MO; NT

CHEMSTRIP-K$0

(Tier3)

MO; NT

CHEMSTRIP-MICRAL$0

(Tier3)

MO; NT

CLINISTIX$0

(Tier3)

MO; NT

CLINITEST$0

(Tier3)

NT

CLINITEST REAGENT$0

(Tier3)

NT

COMBISTIX$0

(Tier3)

MO; NT

CVS KETONE CARE$0

(Tier3)

MO; NT

DIASTIX$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


HEMA-COMBISTIX$0

(Tier3)

MO; NT

KETO-DIASTIX$0

(Tier3)

MO; NT

KETOCARE$0

(Tier3)

MO; NT

KETONE TEST STRIPS$0

(Tier3)

MO; NT

KETOSTIX$0

(Tier3)

MO; NT

LABSTIX$0

(Tier3)

MO; NT

MULTISTIX$0

(Tier3)

MO; NT

MULTISTIX 10 SG$0

(Tier3)

MO; NT

MULTISTIX 5$0

(Tier3)

MO; NT

MULTISTIX 7$0

(Tier3)

MO; NT

MULTISTIX 8 SG$0

(Tier3)

MO; NT

MULTISTIX 9$0

(Tier3)

MO; NT

MULTISTIX 9 SG$0

(Tier3)

MO; NT

NITRATEST PAPER$0

(Tier3)

MO; NT



105

Name of drug

Whatthe


level)


NOVA MAX PLUSKETONE TESTSTRIPS

$0(Tier

3)

MO; NT

PRECISION XTRA$0

(Tier3)

MO; NT

PTS PANELS KETONETEST

$0(Tier

3)

MO; NT

RELION KETONE$0

(Tier3)

MO; NT

RELION KETONE TESTSTRIPS

$0(Tier

3)

MO; NT

UNIVERSAL PH STRIPS$0

(Tier3)

MO; NT

URISTIX$0

(Tier3)

MO; NT

URISTIX 4$0

(Tier3)

MO; NT

WFHC PH PAPER$0

(Tier3)

MO; NT

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTSDietary Management Products

CEREFOLIN$0

(Tier3)

MO; NT

folic acid-pyridoxine-cyancobalamin

$0(Tier

3)

MO; NT

L-METHYL-MC$0

(Tier3)

MO; NT

METAFOLBIC$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


SULFZIX$0

(Tier3)

RX/OTC; NT

XIZFLUS$0

(Tier3)

RX/OTC; NT

Nutritional SupplementsDEXATRIM MAX PACK1MG-5.5UNIT-34MCG-72MG-75MG-0.35MG-70MG-45MG-0.263MG-10MG-1.8MG-3.5MG-0.3MG-3MCG-70MCG-0.35MG-25MG-30MG

$0(Tier

3)

PA; NT

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes

CREON$0-

$6.60(Tier

2)

MO

PANCREAZE$0-

$6.60(Tier

2)

MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitors

acetazolamide cp12 or 500mg

$0-$2.65(Tier

1)

MO

acetazolamide tabs or 250mg

$0-$2.65(Tier

1)

MO

DIAMOX (UseAcetazolamide) NF MO



106

Name of drug

Whatthe


level)


methazolamide tabs or 25mg, 50 mg

$0-$2.65(Tier

1)

MO

Diuretic CombinationsALDACTAZIDE 25MG-25MG (Use Spironolactone& Hydrochlorothiazide)

NFMO

amiloride &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

DYAZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE-25 (UseTriamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

triamterene &hydrochlorothiazide

$0-$2.65(Tier

1)

MO

Loop Diuretics

bumetanide tabs or 0.5 mg,1 mg, 2 mg

$0-$2.65(Tier

1)

MO

BUMEX (Use Bumetanide) NF MO

DEMADEX (UseTorsemide) NF MO

furosemide soln ij 10 mg/ml$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


furosemide soln or 10mg/ml

$0-$2.65(Tier

1)

MO

furosemide tabs or 20 mg,40 mg, 80 mg

$0-$2.65(Tier

1)

MO

LASIX (Use Furosemide) NF MO

torsemide tabs or 10 mg,100 mg, 20 mg, 5 mg

$0-$2.65(Tier

1)

MO

Potassium Sparing DiureticsALDACTONE (UseSpironolactone) NF MO

amiloride hcl$0-

$2.65(Tier

1)

MO

spironolactone tabs or 100mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

Thiazides and Thiazide-Like Diuretics

chlorothiazide 500 mg$0-

$2.65(Tier

1)

MO

chlorthalidone 25 mg, 50mg

$0-$2.65(Tier

1)

MO

hydrochlorothiazide caps or12.5 mg

$0-$2.65(Tier

1)

MO

hydrochlorothiazide tabs or12.5 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO



107

Name of drug

Whatthe


level)


indapamide$0-

$2.65(Tier

1)

MO

metolazone$0-

$2.65(Tier

1)

MO

MICROZIDE (UseHydrochlorothiazide) NF MO

ZAROXOLYN (UseMetolazone) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

alendronate sodium tabs10 mg, 5 mg

$0-$2.65(Tier

1)

MO

alendronate sodium tabs35 mg, 70 mg

$0-$2.65(Tier

1)


BONIVA SOLN IV 3MG/3ML (Use IbandronateSodium)

NFQL(0.04 mldaily); MO

BONIVA TABS OR 150 MG(Use Ibandronate Sodium) NF QL(0.036 ea

daily); MO

calcitonin (salmon)$0-

$2.65(Tier

1)

MO

FORTEO$0-

$6.60(Tier

2)

QL(0.09 mldaily)

FORTICAL$0-

$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


FOSAMAX (UseAlendronate Sodium) NF QL(0.15 ea

daily); MO

ibandronate sodium soln iv3 mg/3ml

$0-$2.65(Tier

1)

QL(0.04 mldaily); MO

ibandronate sodium tabs or150 mg

$0-$2.65(Tier

1)


MIACALCIN IJ 200UNIT/ML

$0-$6.60(Tier

2)

MO

MIACALCIN NA 200UNIT/ACT (Use Calcitonin(Salmon))

NFMO

NATPARA$0-

$6.60(Tier

2)

PA; LA

PROLIA$0-

$6.60(Tier

2)

QL(0.01 mldaily)

RECLAST (Use ZoledronicAcid) NF QL(0.28 ml

daily)

XGEVA$0-

$6.60(Tier

2)

QL(0.243 mldaily)

zoledronic acid conc 4mg/5ml

$0-$2.65(Tier

1)

zoledronic acid soln 5mg/100ml

$0-$2.65(Tier

1)

QL(0.28 mldaily)

zoledronic acid solr 4 mg$0-

$2.65(Tier

1)



108

Name of drug

Whatthe


level)


ZOMETA CONC 4MG/5ML (Use ZoledronicAcid)

NF

Corticotropin

H.P. ACTHAR$0-

$6.60(Tier

2)

PA; LA

Fertility Regulators

chorionic gonadotropin solrim

$0-$2.65(Tier

1)

Growth Hormone Receptor Antagonists

SOMAVERT$0-

$6.60(Tier

2)

LA

Growth Hormone Releasing Hormones (GHRH)

EGRIFTA 2 MG$0-

$6.60(Tier

2)

Growth Hormones

GENOTROPIN 5 MG$0-

$6.60(Tier

2)

PA

GENOTROPIN MINIQUICK0.4 MG

$0-$6.60(Tier

2)

PA

HUMATROPE$0-

$6.60(Tier

2)

PA

HUMATROPE COMBOPACK

$0-$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


NORDITROPIN FLEXPRO10 MG/1.5ML, 5 MG/1.5ML

$0-$6.60(Tier

2)

PA

NUTROPIN AQ NUSPIN20

$0-$6.60(Tier

2)

PA

NUTROPIN AQ PEN 20MG/2ML

$0-$6.60(Tier

2)

PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML

$0-$6.60(Tier

2)

PA

SEROSTIM 4 MG, 6 MG$0-

$6.60(Tier

2)

PA

TEV-TROPIN$0-

$6.60(Tier

2)

PA

ZOMACTON 5 MG$0-

$6.60(Tier

2)

PA

Hormone Receptor ModulatorsEVISTA (Use RaloxifeneHCl) NF QL(1 ea daily);

MO

raloxifene hcl$0-

$2.65(Tier

1)

QL(1 ea daily);MO

Insulin-Like Growth Factors (Somatomedins)

INCRELEX$0-

$6.60(Tier

2)

LA

LHRH/GnRH Agonist Analog Pituitary



109

Name of drug

Whatthe


level)


LUPRON DEPOT-PED11.25 MG

$0-$6.60(Tier

2)

3 Month Kit;

LUPRON DEPOT-PED11.25 MG, 15 MG, 7.5 MG

$0-$6.60(Tier

2)

LUPRON DEPOT-PED 30MG

$0-$6.60(Tier

2)

SYNAREL$0-

$6.60(Tier

2)

MO

Metabolic Modifiers

calcitriol caps or 0.25 mcg,0.5 mcg

$0-$2.65(Tier

1)

MO

calcitriol soln or 1 mcg/ml$0-

$2.65(Tier

1)

MO

CARNITOR TABS OR 330MG (Use Levocarnitine(Metabolic Modifiers))

NFMO

FABRAZYME 35 MG$0-

$6.60(Tier

2)

LA

KUVAN PACK 100 MG,500 MG

$0-$6.60(Tier

2)

KUVAN TBSO 100 MG$0-

$6.60(Tier

2)

LA

Name of drug

Whatthe


level)


levocarnitine (metabolicmodifiers) tabs or 330 mg

$0-$2.65(Tier

1)

MO

LUMIZYME$0-

$6.60(Tier

2)

LA

MYALEPT$0-

$6.60(Tier

2)

LA

MYOZYME$0-

$6.60(Tier

2)

LA

NAGLAZYME$0-

$6.60(Tier

2)

LA

ORFADIN$0-

$6.60(Tier

2)

LA

paricalcitol caps or 1 mcg,2 mcg, 4 mcg

$0-$2.65(Tier

1)

MO

ROCALTROL (UseCalcitriol) NF MO

SENSIPAR$0-

$6.60(Tier

2)

VIMIZIM$0-

$6.60(Tier

2)ZEMPLAR CAPS OR 1MCG, 2 MCG, 4 MCG (UseParicalcitol)

NFMO

Posterior Pituitary Hormones



110

Name of drug

Whatthe


level)


DDAVP (UseDesmopressin AcetateRefrigerated)

NFMO

DDAVP (UseDesmopressin AcetateSpray)

NFMO

DDAVP (UseDesmopressin Acetate) NF MO

desmopressin acetaterefrigerated

$0-$2.65(Tier

1)

MO

desmopressin acetate solnij 4 mcg/ml

$0-$2.65(Tier

1)

MO

desmopressin acetatespray

$0-$2.65(Tier

1)

MO

desmopressin acetatespray refrigerated

$0-$2.65(Tier

1)

MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg

$0-$2.65(Tier

1)

MO

Prolactin Inhibitors

cabergoline$0-

$2.65(Tier

1)

MO

Somatostatic Agents

octreotide acetate 100mcg/ml, 1000 mcg/5ml,200 mcg/ml, 50 mcg/ml

$0-$2.65(Tier

1)SANDOSTATIN 100MCG/ML, 200 MCG/ML, 50MCG/ML (Use OctreotideAcetate)

NF

Name of drug

Whatthe


level)


SANDOSTATIN LARDEPOT 20 MG, 30 MG

$0-$6.60(Tier

2)

SIGNIFOR$0-

$6.60(Tier

2)

LA

SIGNIFOR LAR 20 MG$0-

$6.60(Tier

2)

QL(0.11 eadaily)

SIGNIFOR LAR 40 MG, 60MG

$0-$6.60(Tier

2)

QL(0.036 eadaily)

SOMATULINE DEPOT$0-

$6.60(Tier

2)

Vasopressin Receptor Antagonists

SAMSCA$0-

$6.60(Tier

2)

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA (Use Estradiol& Norethindrone Acetate) NF AL; MO

estradiol & norethindroneacetate

$0-$2.65(Tier

1)

AL; MO

estradiol-norgestimate$0-

$2.65(Tier

1)

AL; MO

norethindrone acetate-ethinyl estradiol 5mcg-1mg

$0-$2.65(Tier

1)

AL; MO



111

Name of drug

Whatthe


level)


PREMPHASE$0-

$6.60(Tier

2)

MO

PREMPRO$0-

$6.60(Tier

2)

AL; MO

EstrogensCLIMARA (Use Estradiol) NF AL; MO

DELESTROGEN 10MG/ML

$0-$6.60(Tier

2)

MO

DELESTROGEN 20MG/ML, 40 MG/ML (UseEstradiol Valerate)

NFMO

DIVIGEL$0-

$6.60(Tier

2)

MO

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

$0-$2.65(Tier

1)

AL; MO

estradiol tabs or 0.5 mg, 1mg, 2 mg

$0-$2.65(Tier

1)

AL; MO

estradiol valerate oil im 10mg/ml, 20 mg/ml, 40 mg/ml

$0-$2.65(Tier

1)

MO

estropipate 0.75 mg, 1.5mg

$0-$2.65(Tier

1)

AL; MO

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

$0-$6.60(Tier

2)

AL; MO

Name of drug

Whatthe


level)


FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO I.V.-IN D5W200MG/100ML-5% (UseCiprofloxacin in D5W)

NF

CIPRO I.V.-IN D5W400MG/200ML-5% (UseCiprofloxacin in D5W)

NFMO

CIPRO TABS 250 MG, 500MG (Use CiprofloxacinHCl)

NFMO

CIPRO XR (UseCiprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

$0-$2.65(Tier

1)

MO

ciprofloxacin in d5w200mg/100ml-5%

$0-$2.65(Tier

1)

ciprofloxacin in d5w400mg/200ml-5%

$0-$2.65(Tier

1)

MO

ciprofloxacin soln iv 400mg/40ml

$0-$2.65(Tier

1)

MO

ciprofloxacin-ciprofloxacinhcl

$0-$2.65(Tier

1)

MO

LEVAQUIN SOLN IV250MG/50ML-5%,500MG/100ML-5% (UseLevofloxacin in D5W)

NF

LEVAQUIN SOLN IV750MG/150ML-5% (UseLevofloxacin in D5W)

NFMO



112

Name of drug

Whatthe


level)


LEVAQUIN SOLN OR 25MG/ML (Use Levofloxacin) NF MO

LEVAQUIN TABS OR 250MG, 500 MG, 750 MG (UseLevofloxacin)

NFMO

levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5%

$0-$2.65(Tier

1)

levofloxacin in d5w750mg/150ml-5%

$0-$2.65(Tier

1)

MO

levofloxacin soln iv 25mg/ml

$0-$2.65(Tier

1)

levofloxacin soln or 25mg/ml

$0-$2.65(Tier

1)

MO

levofloxacin tabs or 250mg, 500 mg, 750 mg

$0-$2.65(Tier

1)

MO

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulentsGAS-X EXTRASTRENGTH CHEW 125MG (Use Simethicone)

NFMO; NT

MYLANTA GAS (UseSimethicone) NF MO; NT

MYLANTA GAS RELIEFMAXIMUM STRENGTH(Use Simethicone)

NFMO; NT

simethicone caps or 125mg

$0(Tier

3)

MO; NT

simethicone chew or 125mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


Gallstone Solubilizing AgentsACTIGALL (Use Ursodiol) NF MO

chenodiol$0-

$2.65(Tier

1)

LA

URSO 250 (Use Ursodiol) NF MO

URSO FORTE (UseUrsodiol) NF MO

ursodiol caps or 300 mg$0-

$2.65(Tier

1)

MO

ursodiol tabs or 250 mg,500 mg

$0-$2.65(Tier

1)

MO

Gastrointestinal Antiallergy Agents

cromolyn sodium(mastocytosis)

$0-$2.65(Tier

1)

MO

GASTROCROM (UseCromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Stimulants

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml

$0-$2.65(Tier

1)

MO

metoclopramide hcl tabs or10 mg, 5 mg

$0-$2.65(Tier

1)

MO

REGLAN (UseMetoclopramide HCl) NF MO

Inflammatory Bowel Agents



113

Name of drug

Whatthe


level)


APRISO$0-

$6.60(Tier

2)

MO

ASACOL HD$0-

$6.60(Tier

2)

MO

AZULFIDINE (UseSulfasalazine) NF MO

AZULFIDINE EN-TABS(Use Sulfasalazine) NF MO

balsalazide disodium$0-

$2.65(Tier

1)

MO

CIMZIA$0-

$6.60(Tier

2)

PA

CIMZIA STARTER KIT$0-

$6.60(Tier

2)

PA

COLAZAL (UseBalsalazide Disodium) NF MO

DELZICOL$0-

$6.60(Tier

2)

MO

DIPENTUM$0-

$6.60(Tier

2)

MO

ENTYVIO$0-

$6.60(Tier

2)

PA

mesalamine enem re$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


mesalamine w/ cleanser$0-

$2.65(Tier

1)

MO

REMICADE$0-

$6.60(Tier

2)

PA

ROWASA (UseMesalamine w/ Cleanser) NF MO

sulfasalazine tabs or$0-

$2.65(Tier

1)

MO

sulfasalazine tbec or$0-

$2.65(Tier

1)

MO

Intestinal Acidifiers

lactulose (encephalopathy)$0-

$2.65(Tier

1)

MO

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl$0-

$2.65(Tier

1)

MO

LINZESS$0-

$6.60(Tier

2)

MO

LOTRONEX (UseAlosetron HCl)

$0-$6.60(Tier

2)

MO

Peripheral Opioid Receptor Antagonists

RELISTOR KIT 12MG/0.6ML

$0-$6.60(Tier

2)



114

Name of drug

Whatthe


level)


RELISTOR SOLN 12MG/0.6ML, 8 MG/0.4ML

$0-$6.60(Tier

2)

MO

Phosphate Binder Agents

calcium acetate (phosphatebinder) caps

$0-$2.65(Tier

1)

MO

FOSRENOL$0-

$6.60(Tier

2)

MO

PHOSLO (Use CalciumAcetate (PhosphateBinder))

NFMO

RENVELA PACK 2.4 GM$0-

$6.60(Tier

2)

MO

RENVELA TABS 800 MG$0-

$6.60(Tier

2)

MO

SEVELAMERCARBONATE

$0-$6.60(Tier

2)

MO

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizers

potassium citrate(alkalinizer) 1080 mg, 540mg

$0-$2.65(Tier

1)

MO

UROCIT-K 10 (UsePotassium Citrate(Alkalinizer))

$0-$6.60(Tier

2)

MO

Name of drug

Whatthe


level)


UROCIT-K 5 (UsePotassium Citrate(Alkalinizer))

$0-$6.60(Tier

2)

MO

Genitourinary Irrigants

acetic acid ir 0.25 %$0-

$2.65(Tier

1)

MO

neomycin/polymyxin b gu$0-

$2.65(Tier

1)

MO

sodium chloride (guirrigant)

$0-$2.65(Tier

1)

MO

Prostatic Hypertrophy Agents

alfuzosin hcl$0-

$2.65(Tier

1)

MO

AVODART (UseDutasteride)

$0-$6.60(Tier

2)

GL; MO

dutasteride$0-

$2.65(Tier

1)

GL; MO

finasteride tabs or$0-

$2.65(Tier

1)

GL; MO

FLOMAX (Use TamsulosinHCl) NF MO

JALYN$0-

$6.60(Tier

2)

GL; MO

PROSCAR (UseFinasteride) NF GL; MO



115

Name of drug

Whatthe


level)


tamsulosin hcl$0-

$2.65(Tier

1)

MO

UROXATRAL (UseAlfuzosin HCl) NF MO

Urinary Analgesics

phenazopyridine hcl tabs or100 mg, 200 mg

$0(Tier

3)

MO; NT

PYRIDIUM (UsePhenazopyridine HCl) NF MO; NT

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations

colchicine w/ probenecid$0-

$2.65(Tier

1)

MO

Gout Agents

allopurinol tabs or 100 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

allopurinol tabs or 300 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

COLCHICINE TABS OR$0-

$6.60(Tier

2)

MO

COLCRYS$0-

$6.60(Tier

2)

MO

ZYLOPRIM 100 MG (UseAllopurinol) NF QL(8 ea daily);

MOZYLOPRIM 300 MG (UseAllopurinol) NF QL(2 ea daily);

MOUricosurics

Name of drug

Whatthe


level)


probenecid$0-

$2.65(Tier

1)

MO

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor Antagonists

FIRAZYR$0-

$6.60(Tier

2)

Complement Inhibitors

BERINERT$0-

$6.60(Tier

2)

CINRYZE$0-

$6.60(Tier

2)

LA

RUCONEST$0-

$6.60(Tier

2)

Hematorheologic Agents

pentoxifylline tbcr or$0-

$2.65(Tier

1)

MO

Plasma Kallikrein Inhibitors

KALBITOR$0-

$6.60(Tier

2)

Platelet Aggregation Inhibitors

AGGRENOX$0-

$6.60(Tier

2)

MO

AGRYLIN (Use AnagrelideHCl) NF MO



116

Name of drug

Whatthe


level)


anagrelide hcl$0-

$2.65(Tier

1)

MO

ASPIRIN/DIPYRIDAMOLE$0-

$6.60(Tier

2)

MO

BRILINTA$0-

$6.60(Tier

2)

MO

cilostazol$0-

$2.65(Tier

1)

MO

clopidogrel bisulfate 300mg

$0-$2.65(Tier

1)

clopidogrel bisulfate 75 mg$0-

$2.65(Tier

1)

MO

dipyridamole tabs or 25mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

AL; MO

EFFIENT$0-

$6.60(Tier

2)

MO

PERSANTINE (UseDipyridamole) NF AL; MO

PLAVIX 300 MG (UseClopidogrel Bisulfate) NF

PLAVIX 75 MG (UseClopidogrel Bisulfate) NF MO

PLETAL (Use Cilostazol) NF MO

Name of drug

Whatthe


level)


ticlopidine hcl$0-

$2.65(Tier

1)

AL

ZONTIVITY$0-

$6.60(Tier

2)

MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher Disease

CERDELGA$0-

$6.60(Tier

2)

PA

CEREZYME$0-

$6.60(Tier

2)

LA

ELELYSO$0-

$6.60(Tier

2)

VPRIV$0-

$6.60(Tier

2)

ZAVESCA$0-

$6.60(Tier

2)

LA

Agents for Sickle Cell Anemia

DROXIA$0-

$6.60(Tier

2)

MO

Cobalamins

cyanocobalamin subl sl1000 mcg

$0(Tier

3)

MO; NT



117

Name of drug

Whatthe


level)


cyanocobalamin tabs or250 mcg

$0(Tier

3)

MO; NT

Folic Acid/Folates

FA-8$0

(Tier3)

NT

FOLIC ACID CAPS OR 20MG, 5 MG

$0(Tier

3)

NT

folic acid tabs or 1 mg$0

(Tier3)

RX/OTC; MO;NT

folic acid tabs or 400 mcg,800 mcg

$0(Tier

3)

MO; NT

Hematopoietic Growth Factors

ARANESP ALBUMINFREE

$0-$6.60(Tier

2)

PA

EPOGEN$0-

$6.60(Tier

2)

PA

GRANIX$0-

$6.60(Tier

2)

PA

LEUKINE$0-

$6.60(Tier

2)

PA

NEULASTA$0-

$6.60(Tier

2)

PA

NEULASTA DELIVERYKIT

$0-$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


NEUMEGA$0-

$6.60(Tier

2)

PA

NEUPOGEN$0-

$6.60(Tier

2)

PA

PROCRIT$0-

$6.60(Tier

2)

PA

PROMACTA 12.5 MG$0-

$6.60(Tier

2)

QL(12 eadaily); LA

PROMACTA 25 MG$0-

$6.60(Tier

2)

QL(6 ea daily);LA

PROMACTA 50 MG$0-

$6.60(Tier

2)

QL(3 ea daily);LA

PROMACTA 75 MG$0-

$6.60(Tier

2)

QL(2 ea daily);LA

ZARXIO$0-

$6.60(Tier

2)

PA

Hematopoietic Mixtures

B-6 FOLIC ACID$0

(Tier3)

NT

FOLGARD RX (Use FolicAcid-Vitamin B6-VitaminB12)

NFMO; NT

FOLIC + B12$0

(Tier3)

RX/OTC; MO;NT



118

Name of drug

Whatthe


level)


folic acid-vitamin b6-vitamin b12

$0(Tier

3)

MO; NT

FOLTRATE$0

(Tier3)

RX/OTC; MO;NT

HEMOCYTE-F$0

(Tier3)

RX/OTC; NT

I.L.X. B-12$0

(Tier3)

RX/OTC; NT

iron combinations$0

(Tier3)

RX/OTC; MO;NT

MTX SUPPORT$0

(Tier3)

RX/OTC; MO;NT

OPURITY B12/FOLICACID

$0(Tier

3)

RX/OTC; MO;NT

PRE-FOLIC$0

(Tier3)

NT

VITAMIN B12/FOLIC ACID$0

(Tier3)

RX/OTC; MO;NT

IronFER-IN-SOL (Use FerrousSulfate) NF MO; NT

FERGON 240 MG (UseFerrous Gluconate) NF NT

ferrous fumarate tabs or324 mg, 325 mg

$0(Tier

3)

MO; NT

FERROUS FUMARATETABS OR 90 MG

$0(Tier

3)

NT

FERROUS GLUCONATE225 MG

$0(Tier

3)

NT

Name of drug

Whatthe


level)


ferrous gluconate 240 mg,27 mg

$0(Tier

3)

NT

ferrous sulfate dried tbcr160 mg

$0(Tier

3)

NT

ferrous sulfate elix or 220mg/5ml

$0(Tier

3)

MO; NT

FERROUS SULFATE LIQDOR 220 MG/5ML

$0(Tier

3)

NT

ferrous sulfate soln or 15mg/ml

$0(Tier

3)

MO; NT

FERROUS SULFATESYRP OR 300 MG/5ML

$0(Tier

3)

NT

ferrous sulfate tabs or 325mg, 65 mg

$0(Tier

3)

MO; NT

ferrous sulfate tbcr or 50mg

$0(Tier

3)

NT

FERROUS SULFATETBEC OR 324 MG

$0(Tier

3)

MO; NT

ferrous sulfate tbec or 325mg

$0(Tier

3)

NT

HEMOCYTE (Use FerrousFumarate) NF MO; NT

IRON CHEWS PEDIATRIC$0

(Tier3)

MO; NT

IRON TABS 256 MG$0

(Tier3)

MO; NT

IRON TABS 28 MG$0

(Tier3)

NT



119

Name of drug

Whatthe


level)


polysaccharide ironcomplex 150 mg

$0(Tier

3)

MO; NT

PROFERRIN ES$0

(Tier3)

MO; NT

SLOW FE 160 MG (UseFerrous Sulfate Dried) NF NT

SLOW RELEASE IRON$0

(Tier3)

NT

Stem Cell Mobilizers

MOZOBIL$0-

$6.60(Tier

2)

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - Systemic

AMICAR TABS 500 MG$0-

$6.60(Tier

2)

MO

aminocaproic acid tabs or500 mg

$0-$2.65(Tier

1)

MO

CYKLOKAPRON (UseTranexamic Acid) NF

LYSTEDA (UseTranexamic Acid) NF MO

tranexamic acid soln iv 100mg/ml

$0-$2.65(Tier

1)

tranexamic acid tabs or650 mg

$0-$2.65(Tier

1)

MO

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Name of drug

Whatthe


level)


Barbiturate Hypnotics

BUTISOL SODIUM$0-

$6.60(Tier

2)

MO

phenobarbital elix or 20mg/5ml

$0-$2.65(Tier

1)

AL; MO

phenobarbital soln or 20mg/5ml

$0-$2.65(Tier

1)

AL; MO

phenobarbital tabs or 100mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8mg, 97.2 mg

$0-$2.65(Tier

1)

AL; MO

Hypnotics - Tricyclic Agents

SILENOR$0-

$6.60(Tier

2)

MO

Non-Barbiturate HypnoticsAMBIEN 10 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MOAMBIEN 5 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MOAMBIEN CR 12.5 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MOAMBIEN CR 6.25 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MO

HALCION (Use Triazolam) NF MO

RESTORIL (UseTemazepam) NF MO

SONATA (Use Zaleplon) NF AL; MO

temazepam$0-

$2.65(Tier

1)

MO



120

Name of drug

Whatthe


level)


triazolam$0-

$2.65(Tier

1)

MO

zaleplon$0-

$2.65(Tier

1)

AL; MO

zolpidem tartrate tabs 10mg

$0-$2.65(Tier

1)


zolpidem tartrate tabs 5 mg$0-

$2.65(Tier

1)


zolpidem tartrate tbcr 12.5mg

$0-$2.65(Tier

1)


zolpidem tartrate tbcr 6.25mg

$0-$2.65(Tier

1)


Orexin Receptor Antagonists

BELSOMRA 10 MG$0-

$6.60(Tier

2)


BELSOMRA 15 MG, 20MG

$0-$6.60(Tier

2)


BELSOMRA 5 MG$0-

$6.60(Tier

2)


Selective Melatonin Receptor Agonists

HETLIOZ$0-

$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


ROZEREM$0-

$6.60(Tier

2)

MO

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil$0

(Tier3)

MO; NT

CITRUCEL FIBERLAXATIVE (UseMethylcellulose (Laxative))

NFMO; NT

CVS NATURAL FIBERSUPPLEMENT

$0(Tier

3)

NT

EQL NATURAL FIBER$0

(Tier3)

NT

EVAC (Use Psyllium) NF MO; NT

FIBERCON (Use CalciumPolycarbophil) NF MO; NT

HYDROCIL INSTANTPACK

$0(Tier

3)

MO; NT

HYDROCIL INSTANTPOWD (Use Psyllium) NF MO; NT

KONSYL PACK 100 %$0

(Tier3)

MO; NT

KONSYL PACK 28.3 %,60.3 %

$0(Tier

3)

NT

KONSYL POWD 100 %(Use Psyllium) NF MO; NT

KONSYL POWD 60.3 %,71.67 %

$0(Tier

3)

NT

KONSYL-D$0

(Tier3)

MO; NT



121

Name of drug

Whatthe


level)


METAMUCIL CAPS 0.52GM (Use Psyllium) NF MO; NT

METAMUCILMULTIHEALTH FIBER55.46 %

$0(Tier

3)

NT

METAMUCIL ORIGINALTEXTURE 48.57 % (UsePsyllium)

NFMO; NT

METAMUCIL POWD 48.57% (Use Psyllium) NF MO; NT

METAMUCIL SMOOTHTEXTUREFIBER SINGLES

$0(Tier

3)

NT

methylcellulose (laxative)powd 2 gm/10.2gm, 2gm/19gm

$0(Tier

3)

MO; NT

psyllium caps 0.52 gm, 520mg

$0(Tier

3)

MO; NT

psyllium powd 100 %,48.57 %, 58.6 %, 95 %

$0(Tier

3)

MO; NT

psyllium powd 28.3 %, 30%, 30.9 %, 33 %, 49 %, 68%

$0(Tier

3)

NT

UNIFIBER$0

(Tier3)

NT

Laxative Combinations

COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

$0-$6.60(Tier

2)COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM (Use PEG3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

Name of drug

Whatthe


level)


GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

NULYTELY/FLAVORPACKS (Use PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

$0-$2.65(Tier

1)

MO

peg 3350-potassiumchloride-sod bicarbonate-sod chloride

$0-$2.65(Tier

1)

MO

SUPREP BOWEL PREP$0-

$6.60(Tier

2)

MO

Laxatives - Miscellaneous

CEO-TWO$0

(Tier3)

MO; NT

FLEET LIQUID GLYCERINSUPPOSITORIES

$0(Tier

3)

MO; NT

lactulose$0-

$2.65(Tier

1)

MO

polyethylene glycol 3350pack or

$0-$2.65(Tier

1)

RX/OTC; MO

polyethylene glycol 3350powd or

$0-$2.65(Tier

1)

RX/OTC; MO

Saline Laxatives



122

Name of drug

Whatthe


level)


MILK OF MAGNESIACONCENTRATE

$0(Tier

3)

MO; NT

PHILLIPS MILK OFMAGNESIA CHEWABLE

$0(Tier

3)

NT

PHILLIPS MILK OFMAGNESIACONCENTRATED

$0(Tier

3)

NT

Stimulant Laxatives

bisacodyl supp re 10 mg$0

(Tier3)

MO; NT

bisacodyl tbec or 5 mg$0

(Tier3)

MO; NT

DULCOLAX (UseBisacodyl) NF MO; NT

DULCOLAX BOWEL PREPKIT

$0(Tier

3)

NT

EX-LAX TABS (UseSennosides) NF MO; NT

FLEET BISACODYL$0

(Tier3)

MO; NT

sennosides tabs 15 mg, 8.6mg

$0(Tier

3)

MO; NT

SENOKOT (UseSennosides) NF MO; NT

SENOKOT TO GO (UseSennosides) NF MO; NT

Surfactant Laxatives

benzocaine-docusatesodium

$0(Tier

3)

MO; NT

COLACE (Use DocusateSodium) NF MO; NT

COLACE CLEAR (UseDocusate Sodium) NF MO; NT

Name of drug

Whatthe


level)


docusate calcium$0

(Tier3)

MO; NT

docusate sodium caps or100 mg, 250 mg, 50 mg

$0(Tier

3)

MO; NT

docusate sodium enem re283 mg

$0(Tier

3)

MO; NT

docusate sodium liqd or150 mg/15ml, 50 mg/5ml

$0(Tier

3)

MO; NT

docusate sodium syrp or 60mg/15ml

$0(Tier

3)

MO; NT

docusate sodium tabs or100 mg

$0(Tier

3)

NT

DOCUSOL KIDS$0

(Tier3)

NT

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amides

lidocaine hcl (local anesth.)1 %, 2 %

$0-$2.65(Tier

1)

MO

XYLOCAINE IJ 1 %, 2 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

XYLOCAINE-MPF 1 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycin

azithromycin solr iv 500 mg$0-

$2.65(Tier

1)

MO



123

Name of drug

Whatthe


level)


azithromycin susr or 100mg/5ml, 200 mg/5ml

$0-$2.65(Tier

1)

MO

azithromycin tabs or 250mg, 500 mg, 600 mg

$0-$2.65(Tier

1)

MO

ZITHROMAX SOLR IV 500MG (Use Azithromycin) NF MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Use Azithromycin)

NFMO

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Use Azithromycin)

NFMO

ZITHROMAX TRI-PAK(Use Azithromycin) NF MO

ZITHROMAX Z-PAK (UseAzithromycin) NF MO

ClarithromycinBIAXIN (UseClarithromycin) NF MO

BIAXIN XL (UseClarithromycin) NF MO

BIAXIN XL PAC (UseClarithromycin) NF MO

clarithromycin susr or 125mg/5ml, 250 mg/5ml

$0-$2.65(Tier

1)

MO

clarithromycin tabs or 250mg, 500 mg

$0-$2.65(Tier

1)

MO

clarithromycin tb24 or 500mg

$0-$2.65(Tier

1)

MO

Erythromycins

Name of drug

Whatthe


level)


erythromycin base tabs 250mg

$0-$2.65(Tier

1)

QL(16 eadaily); MO

erythromycin base tabs 500mg

$0-$2.65(Tier

1)

QL(8 ea daily);MO

erythromycinethylsuccinate tabs or

$0-$2.65(Tier

1)

QL(10 eadaily); MO

erythromycin lactobionate$0-

$2.65(Tier

1)

500 MG;QL(8ea daily)

erythromycin stearate$0-

$2.65(Tier

1)

QL(16 eadaily); MO

Fidaxomicin

DIFICID$0-

$6.60(Tier

2)

MO

MEDICAL DEVICES

Bandages-Dressings-Tape

gauze pads 2" x 2"$0-

$2.65(Tier

1)

RX/OTC; MO

Contraceptives

CONDOMS$0

(Tier3)

Misc. Devices

ALCOHOL PADS$0-

$6.60(Tier

2)

RX/OTC; MO



124

Name of drug

Whatthe


level)


Parenteral Therapy Supplies

INSULIN SYRINGES ANDPEN NEEDLES

$0-$6.60(Tier

2)

MO

MEDICAL DEVICES AND SUPPLIES

Contraceptives

OMNIFLEX DIAPHRAGM$0

(Tier3)

NT

ORTHO DIAPHRAGMALL-FLEX/65MM

$0(Tier

3)

NT


$0(Tier

3)

NT


$0(Tier

3)

NT


$0(Tier

3)

NT

Respiratory Therapy Supplies

AEROCHAMBER MINIAEROSOLCHAMBER

$0(Tier

3)

QL(1 ea per365 daysretail,1 ea per365 days mail);RX/OTC; MO;NT

AEROCHAMBER MV$0

(Tier3)


AEROCHAMBER PLUSFLOW VU

$0(Tier

3)


Name of drug

Whatthe


level)


AEROCHAMBER PLUSFLOW-VU

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/LARGE MASK

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/MASK

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/MEDIUM MASK

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/SMALL MASK

$0(Tier

3)


AEROCHAMBER Z-STATPLUS VALVED HOLDINGCHAMBER W/FLOW VU

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/FLOWSIGNAL

$0(Tier

3)




125

Name of drug

Whatthe


level)


AEROCHAMBER Z-STATPLUS/LARGE MASK

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/MEDIUM MASK

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/SMALL MASK

$0(Tier

3)


AEROCHAMBER/FLOWSIGNAL

$0(Tier

3)


AEROVENT PLUSHOLDINGCHAMBER/COLLAPSIBLE

$0(Tier

3)


AIRZONE PEAK FLOWMETER

$0(Tier

3)

RX/OTC; MO;NT

ARIAL CHAMBER$0

(Tier3)


ASSESS FULL RANGEPEAK FLOW METER

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


ASSESS LOW RANGEPEAK FLOW METER

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER FULL RANGE

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER LOW RANGE

$0(Tier

3)

RX/OTC; MO;NT

ASTHMA CHECK METER-ZONE SYSTEM

$0(Tier

3)

RX/OTC; MO;NT

ASTHMAMENTOR$0

(Tier3)

RX/OTC; MO;NT

BREATHERITE$0

(Tier3)


BREATHERITECOLLAPSIBLEADULTSPACER W/MASK

$0(Tier

3)


BREATHERITECOLLAPSIBLECHILDSPACER W/MASK

$0(Tier

3)


BREATHERITECOLLAPSIBLEINFANTSPACER W/MASK

$0(Tier

3)




126

Name of drug

Whatthe


level)


BREATHERITECOLLAPSIBLESMALLCHILD SPACER W/MASK

$0(Tier

3)


BREATHERITECOLLAPSIBLESPACERW/ NEONATE MASK

$0(Tier

3)


BREATHERITE RIGIDSPACERW/MASK

$0(Tier

3)


BREATHERITE W/LARGEMASK

$0(Tier

3)


BREATHERITEW/MEDIUM MASK

$0(Tier

3)


BREATHERITE W/SMALLMASK

$0(Tier

3)


E-Z SPACER$0

(Tier3)


Name of drug

Whatthe


level)


E-Z SPACER THE BODYGUARDS PACK

$0(Tier

3)


EASIVENT$0

(Tier3)


EASIVENT/MASK-LARGE$0

(Tier3)


EASIVENT/MASK-MEDIUM

$0(Tier

3)


EASIVENT/MASK-SMALL$0

(Tier3)


FLEXICHAMBER$0

(Tier3)


INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECE

$0(Tier

3)




127

Name of drug

Whatthe


level)


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM

$0(Tier

3)


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL

$0(Tier

3)


INSPIREASE DRUGDELIVERYSYSTEM

$0(Tier

3)


LITEAIRE$0

(Tier3)


MICROCHAMBER$0

(Tier3)


MICROLIFE DIGITALPEAK FLOW METER

$0(Tier

3)

RX/OTC; MO;NT

MICROSPACER$0

(Tier3)


MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


MINI WRIGHT PEAKFLOW METER

$0(Tier

3)

RX/OTC; MO;NT

NESSI SPACER/LARGEMASK

$0(Tier

3)


NESSISPACER/MOUTHPIECE

$0(Tier

3)


NESSISPACER/SMALL/MEDMASK

$0(Tier

3)


OPTICHAMBERADVANTAGE

$0(Tier

3)


OPTICHAMBERADVANTAGE/LARGEMASK

$0(Tier

3)


OPTICHAMBERADVANTAGE/MEDIUMFACE MASK

$0(Tier

3)




128

Name of drug

Whatthe


level)


OPTICHAMBERADVANTAGE/SMALLFACE MASK

$0(Tier

3)


OPTICHAMBERDIAMOND

$0(Tier

3)


OPTICHAMBERDIAMOND/LARGEFACEMASK

$0(Tier

3)


OPTICHAMBERDIAMOND/MEDIUM FACEMASK

$0(Tier

3)


OPTICHAMBERDIAMOND/SMALLFACEMASK

$0(Tier

3)


OPTICHAMBER FACEMASK/LARGE

$0(Tier

3)


OPTICHAMBER FACEMASK/MEDIUM

$0(Tier

3)


Name of drug

Whatthe


level)


OPTICHAMBER FACEMASK/SMALL

$0(Tier

3)


OPTIHALER$0

(Tier3)


OPTIHALER MDI DRUGDELIVERY SYSTEM

$0(Tier

3)


PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC

$0(Tier

3)

RX/OTC; MO;NT

PEAK FLOW METER$0

(Tier3)

RX/OTC; MO;NT

PERSONAL BEST FULLRANGE

$0(Tier

3)

RX/OTC; MO;NT

PERSONAL BEST LOWRANGE

$0(Tier

3)

RX/OTC; MO;NT

PIKO 1 ELECTRONIC$0

(Tier3)

RX/OTC; MO;NT

POCKET CHAMBER$0

(Tier3)


POCKET PEAK FLOWMETER

$0(Tier

3)

RX/OTC; MO;NT



129

Name of drug

Whatthe


level)


POCKET SPACER$0

(Tier3)


POCKETPEAK PEAKFLOW METER LOWRANGE

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE 50-720 LPM

$0(Tier

3)

RX/OTC; MO;NT

RITEFLO$0

(Tier3)


TRUZONE PEAK FLOWMETER

$0(Tier

3)

RX/OTC; MO;NT

VALVED HOLDINGCHAMBER

$0(Tier

3)


VORTEX VALVEDHOLDING CHAMBER

$0(Tier

3)


WATCHHALER$0

(Tier3)


Name of drug

Whatthe


level)


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine ProductsD.H.E. 45 (UseDihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml

$0-$2.65(Tier

1)

MO

ergotamine tartrate subl sl$0-

$2.65(Tier

1)

Serotonin Agonists

ALSUMA$0-

$6.60(Tier

2)


AMERGE (Use NaratriptanHCl) NF QL(0.3 ea

daily); MOIMITREX SOLN SC 6MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSEREFILL 4 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSEREFILL 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 4 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX TABS OR 100MG (Use SumatriptanSuccinate)




130

Name of drug

Whatthe


level)


IMITREX TABS OR 25 MG(Use SumatriptanSuccinate)


IMITREX TABS OR 50 MG(Use SumatriptanSuccinate)


MAXALT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl$0-

$2.65(Tier

1)

QL(0.3 eadaily); MO

rizatriptan benzoate tabs10 mg

$0-$2.65(Tier

1)

QL(0.4 eadaily); MO

rizatriptan benzoate tabs 5mg

$0-$2.65(Tier

1)

QL(0.8 eadaily); MO

rizatriptan benzoate tbdp10 mg

$0-$2.65(Tier

1)

QL(0.4 eadaily); MO

rizatriptan benzoate tbdp 5mg

$0-$2.65(Tier

1)

QL(0.8 eadaily); MO

sumatriptan succinate soajsc 4 mg/0.5ml

$0-$2.65(Tier

1)


sumatriptan succinate soajsc 6 mg/0.5ml

$0-$2.65(Tier

1)


Name of drug

Whatthe


level)


sumatriptan succinate soctsc 4 mg/0.5ml

$0-$2.65(Tier

1)


sumatriptan succinate soctsc 6 mg/0.5ml

$0-$2.65(Tier

1)


sumatriptan succinate solnsc 6 mg/0.5ml

$0-$2.65(Tier

1)


sumatriptan succinate tabsor 100 mg

$0-$2.65(Tier

1)

QL(0.3 eadaily); MO


$0-$2.65(Tier

1)

QL(0.9 eadaily); MO


$0-$2.65(Tier

1)

QL(0.6 eadaily); MO

zolmitriptan tabs 2.5 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

zolmitriptan tabs 5 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

zolmitriptan tbdp 2.5 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

zolmitriptan tbdp 5 mg$0-

$2.65(Tier

1)

QL(2 ea daily);MO

ZOMIG TABS OR 2.5 MG(Use Zolmitriptan) NF QL(4 ea daily);

MO



131

Name of drug

Whatthe


level)


ZOMIG TABS OR 5 MG(Use Zolmitriptan) NF QL(2 ea daily);

MOZOMIG ZMT 2.5 MG (UseZolmitriptan) NF QL(4 ea daily);

MOZOMIG ZMT 5 MG (UseZolmitriptan) NF QL(2 ea daily);

MO

MINERALS & ELECTROLYTES

Calcium

CALCI-CHEW$0

(Tier3)

NT

CALCI-MIX$0

(Tier3)

MO; NT

CALCIONATE$0

(Tier3)

MO; NT

CALCIUM & MAGNESIUM$0

(Tier3)

NT

calcium carbonate chew or1250 mg

$0(Tier

3)

NT

calcium carbonate tabs or1250 mg, 500 mg, 600 mg,600mg

$0(Tier

3)

MO; NT

calcium carbonate tabs or1500 mg

$0(Tier

3)

NT

calcium carbonate-cholecalciferol caps600mg-500unit

$0(Tier

3)

NT

calcium carbonate-cholecalciferol chew500mg-100unit

$0(Tier

3)

MO; NT

calcium carbonate-vitamind tabs 125unit-250mg,125unit-500mg, 250mg-125unit, 500mg-125unit

$0(Tier

3)

NT

Name of drug

Whatthe


level)


calcium carbonate-vitamind tabs 200unit-500mg,500mg-200unit, 500mg-500mg-200unit-200unit

$0(Tier

3)

MO; NT

calcium citrate tabs or 200mg, 950 mg

$0(Tier

3)

MO; NT

CALCIUM CITRATE TABSOR 250 MG

$0(Tier

3)

MO; NT

calcium citrate-vitamin d250mg-200unit, 315mg-200unit

$0(Tier

3)

MO; NT

calcium gluconate soln iv10 %

$0(Tier

3)

MO; NT

CALCIUM GLUCONATETABS OR 500 MG

$0(Tier

3)

NT

CALCIUM LACTATE 648MG

$0(Tier

3)

MO; NT

calcium tabs 600 mg$0

(Tier3)

NT

calcium w/ magnesium500mg-250mg

$0(Tier

3)

NT

CALCIUM/VITAMIN D$0

(Tier3)

MO; NT

CALCIUM/VITAMIN D3$0

(Tier3)

MO; NT

CITRACAL/VITAMIN D(Use Calcium Citrate-Vitamin D)

NFMO; NT

CORAL CALCIUM TABSOR 500 MG

$0(Tier

3)

NT



132

Name of drug

Whatthe


level)


EQL CALCIUM/VITAMIN D$0

(Tier3)

NT

MAGNEBIND 200$0

(Tier3)

NT

oyster shell$0

(Tier3)

MO; NT

Chloride

ammonium chloride soln iv$0-

$2.65(Tier

1)

MO

Electrolyte MixturesCERALYTE 70 SOLN60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L,70MEQ/L-20MEQ/L

$0(Tier

3)

MO; NT

CERASPORT EX1 SOLN$0

(Tier3)

MO; NT

CERASPORT SOLN4MEQ/L-18MEQ/L-20MEQ/L-69MEQ/L,4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L

$0(Tier

3)

MO; NT

dextrose in lactated ringers$0-

$2.65(Tier

1)

dextrose w/ sodiumchloride 0.45%-2.5%,0.45%-5%

$0-$2.65(Tier

1)

dextrose w/ sodiumchloride 0.9%-5%

$0-$2.65(Tier

1)

MO

ENFALYTE$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


ENFAMIL ENFALYTE$0

(Tier3)

MO; NT

lactated ringer's$0-

$2.65(Tier

1)

MEDI-LYTE$0

(Tier3)

NT



133

Name of drug

Whatthe


level)


oral electrolytes soln16meq/473ml-21meq/473ml-9meq/473ml-11gm/473ml, 18.8meq/l-42.4meq/l-33.2meq/l-4.8gm/l-18.8gm/l,20meq/1000ml-45meq/1000ml-35meq/1000ml-25gm/1000ml, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-25gm/l-25gm/l,20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-25gm/l, 20meq/l-45meq/l-35meq/l-5gm/l-20gm/l,20meq/l-45meq/l-35meq/l-7.8mg/l-25gm, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25meq/l,20meq/l-45meq/l-45meq/l-35meq/l-5gm/l-20gm/l,35meq/l-45meq/l-20meq/l-20gm/l, 35meq/l-45meq/l-20meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-30gm/l,35meq/l-45meq/l-20meq/l-30meq/l-5gm/l-20gm/l,35meq/l-45meq/l-20meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-7.5mg/l-25meq/l, 35meq/l-45meq/l-

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


20meq/l-7.8mg/l-25

oral electrolytes tabs287mg-180mg-15mg

$0(Tier

3)

NT

parenteral electrolytes$0-

$2.65(Tier

1)

B/D

PEDIALYTE FREEZERPOPS (Use OralElectrolytes)

NFMO; NT

PEDIALYTE SOLN20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L, 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L (Use OralElectrolytes)

NF

MO; NT

potassium chloride indextrose & sodium chloride0.45%-20meq/l-5%

$0-$2.65(Tier

1)

THERMOTABS$0

(Tier3)

NT

Fluoride

FLORICAL CAPS$0

(Tier3)

MO; NT

MONOCAL$0

(Tier3)

MO; NT

Iodine Products

IODINE STRONG$0

(Tier3)

MO; NT

POTASSIUM IODIDETABS OR

$0(Tier

3)

NT

Magnesium



134

Name of drug

Whatthe


level)


MAG-TAB SR$0

(Tier3)

MO; NT

MAGINEX$0

(Tier3)

NT

MAGINEX DS$0

(Tier3)

NT

MAGNESIUM CHLORIDEHEXAHYDRATE

$0(Tier

3)

NT

magnesium chloride tbcr or535 mg, 64 mg

$0(Tier

3)

MO; NT

MAGNESIUMELEMENTAL TABS 30 MG

$0(Tier

3)

NT

MAGNESIUMGLUCONATE TABS OR250 MG, 500 MG, 550 MG

$0(Tier

3)

NT

magnesium sulfate soln ij50 %

$0-$2.65(Tier

1)

MO

magnesium tabs 250 mg,250mg

$0(Tier

3)

NT

Phosphate

PHOS-NAK POWDERCONCENTRATE

$0(Tier

3)

MO; NT

PotassiumK-TAB 10 MEQ (UsePotassium Chloride) NF MO

K-TAB 8 MEQ$0-

$6.60(Tier

2)

MO

MICRO-K (Use PotassiumChloride) NF MO

Name of drug

Whatthe


level)


potassium chloride cpcr or10 meq, 8 meq

$0-$2.65(Tier

1)

MO

POTASSIUM CHLORIDEER

$0-$2.65(Tier

1)

MO

potassium chloridemicroencapsulated crystalscr

$0-$2.65(Tier

1)

MO

potassium chloride soln iv 2meq/ml

$0-$2.65(Tier

1)

MO

potassium chloride soln or10 %

$0-$2.65(Tier

1)

potassium chloride soln or20 %

$0-$2.65(Tier

1)

MO

potassium chloride tbcr or10 meq, 8 meq

$0-$2.65(Tier

1)

MO

Sodium

sodium chloride soln iv0.45 %

$0-$2.65(Tier

1)

sodium chloride soln iv 0.9%

$0-$2.65(Tier

1)

MO

Trace Minerals

chromium 200 mcg$0

(Tier3)

NT



135

Name of drug

Whatthe


level)


chromium picolinate capsor 200 mcg

$0(Tier

3)

NT

chromium picolinate tabs or200 mcg

$0(Tier

3)

MO; NT

MULTITRACE-4$0

(Tier3)

MO; NT

SELENIUM SOLN IV 40MCG/ML

$0(Tier

3)

MO; NT

selenium tabs or 100 mcg$0

(Tier3)

NT

selenium tabs or 50 mcg$0

(Tier3)

MO; NT

trace minerals (cr-cu-mn-zn)

$0(Tier

3)

NT

Zinc

ORAZINC$0

(Tier3)

MO; NT

ZINC 15$0

(Tier3)

NT

zinc gluconate lozg mt 10mg

$0(Tier

3)

NT

zinc gluconate tabs or 50mg

$0(Tier

3)

MO; NT

ZINC SULFATE SOLN IV 1MG/ML, 5 MG/ML

$0(Tier

3)

MO; NT

zinc tabs or 25 mg$0

(Tier3)

NT

Name of drug

Whatthe


level)


zinc tabs or 50 mg$0

(Tier3)

MO; NT

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical OralBABY ANBESOL (UseBenzocaine (Dental)) NF NT

BABY ORAJEL GEL (UseBenzocaine (Dental)) NF NT

BABY ORAJEL LIQD$0

(Tier3)

NT

benzocaine (dental) gel 7.5%

$0(Tier

3)

NT

benzocaine (dental) pste20 %

$0(Tier

3)

MO; NT

benzocaine (dental) soln 20%

$0(Tier

3)

RX/OTC; MO;NT

HURRICAINE ONE (UseBenzocaine (Dental)) NF RX/OTC; MO;

NTHURRICAINE SOLN (UseBenzocaine (Dental)) NF RX/OTC; MO;

NT

lidocaine hcl (mouth-throat)2 %

$0-$2.65(Tier

1)

MO

ORABASE (UseBenzocaine (Dental)) NF MO; NT

ZILACTIN$0

(Tier3)

MO; NT

Anti-infectives - Throat

carbamide peroxide soln mt$0

(Tier3)

MO; NT



136

Name of drug

Whatthe


level)


clotrimazole lozg mt$0-

$2.65(Tier

1)

MO

clotrimazole troc mt$0-

$2.65(Tier

1)

MO

hydrogen peroxide (mouth-throat)

$0(Tier

3)

NT

hydrogen peroxide-benzylalcohol

$0(Tier

3)

MO; NT

nystatin (mouth-throat)$0-

$2.65(Tier

1)

MO

PEROXYL SOLN EX 1.5%-6% (Use HydrogenPeroxide-Benzyl Alcohol)

NFMO; NT

ULCEREASE$0

(Tier3)

MO; NT

Antiseptics - Mouth/Throat

chlorhexidine gluconate(mouth-throat)

$0-$2.65(Tier

1)

MO

PERIDEX (UseChlorhexidine Gluconate(Mouth-Throat))

NFMO

phenol (antiseptic) aers$0

(Tier3)

NT

Steroids - Mouth/Throat

triamcinolone acetonide(mouth)

$0-$2.65(Tier

1)

MO

Throat Products - Misc.

Name of drug

Whatthe


level)


AQUORAL$0

(Tier3)

MO; NT

cevimeline hcl$0-

$2.65(Tier

1)

MO

EVOXAC (Use CevimelineHCl) NF MO

pilocarpine hcl (oral)$0-

$2.65(Tier

1)

MO

SALAGEN (UsePilocarpine HCl (Oral)) NF MO

MULTIVITAMINS

B-Complex Vitaminsb-complex vitamins caps or3.33mg-0.4mg-0.33mg-0.66mcg-0.11mg, 60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg, 60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg, 70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg

$0(Tier

3)

MO; NT

b-complex vitamins inj ij2mg/ml-100mg/ml-2mg/ml-100mg/ml-2mg/ml, 2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml

$0(Tier

3)

MO; NT

b-complex vitamins soln ij2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml

$0(Tier

3)

MO; NT



137

Name of drug

Whatthe


level)


b-complex vitamins tabs or0.1mg-20mg-2mg-5mcg-3mg-1mg, 100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg,10mg-10mg-2mg-1.5mg-0.2mg, 10mg-14mg-25mcg-7mg-4.5mg, 15mg-2mg-5mg-2mcg-2mg-2mg,30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg,3mg-10mg-20mg-3mg-6mcg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg,3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg

$0(Tier

3)

MO; NT

B-Complex w/ Cb complex w/ c caps10.2mg-10mg-15mg-50mg-5mg-300mg, 10mg-50mg-10.2mg-15mg-5mg-300mg,10mg-50mg-10mg-15mg-5mg-300mg, 15mg-10mg-50mg-10mg-5mg-300mg

$0(Tier

3)

NT

Name of drug

Whatthe


level)


b complex w/ c tabs10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg,100mg-10mg-20mg-10mcg-15mg-5mg-500mg,100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg,10mg-10mg-15mg-50mg-5mg-300mg, 15mg-10.2mg-10mg-50mg-5mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg,15mg-150mg-10mg-50mg-10.2mg-5mg-300mg,15mg-20mg-50mg-10mg-10mcg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg, 50mg-10.2mg-10mg-15mg-5mg-300mg,50mg-10mg-10mg-15mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg

$0(Tier

3)

NT

B-Complex w/ Folic Acid

B-100 COMPLEX$0

(Tier3)

MO; NT

b-complex w/ c & folic acidtabs 10mg-20mg-1.5mg-1mg-1.5mg-5mg-300mcg-50mg-60mg, 20mg-1.5mg-10mg-1mg-1.5mg-5mg-300mcg-50mg-60mg

$0(Tier

3)

MO; NT



138

Name of drug

Whatthe


level)


b-complex w/ folic acid tabs1.5mg-20mg-1.7mg-6mcg-400mcg-2mg, 1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg, 100mg-100mg-100mg-100mcg-400mcg-100mg, 100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg, 10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg, 10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg,15mg-100mg-200mg-17mg-60mcg-400mcg-20mg, 30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg

$0(Tier

3)

MO; NT

b-complex w/ folic acid tbcr100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 125mg-125mg-125mg-125mg-125mcg-125mg-125mg-400mcg-125mcg-125mg,50mg-50mg-50mg-50mg-50mcg-0.4mg-50mcg-50mg, 50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg

$0(Tier

3)

NT

NERVO B-12 SL$0

(Tier3)

NT

Ped MV w/ Fluoride

pediatric vitamins acd w/fluoride

$0(Tier

3)

MO; NT

Ped MV w/ Iron

Name of drug

Whatthe


level)


MULTI-DELYN/IRON$0

(Tier3)

NT

pediatric multiple vitaminsw/ iron soln 0.6mg/ml-10mg/ml-5unit/ml-8mg/ml-1500unit/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 1500unit/ml-10mg/ml-5unit/ml-400unit/ml-8mg/ml-0.6mg/ml-0.5mg/ml-0.4mg/ml-35mg/ml

$0(Tier

3)

MO; NT

Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron

$0(Tier

3)

MO; NT

TRI-VIT/FLUORIDE/IRON$0

(Tier3)

MO; NT

Pediatric Multiple Vitamins

EQL CHILDRENSMULTIVITAMINS

$0(Tier

3)

NT

pediatric multiple vitamin w/c

$0(Tier

3)

MO; NT

pediatric multiple vitamin w/extra c & fa

$0(Tier

3)

NT

Pediatric Vitamins

pediatric vitamins adc$0

(Tier3)

MO; NT

Prenatal Vitamins

ONE A DAY WOMENSPRENATAL/DHA

$0(Tier

3)

NT



139

Name of drug

Whatthe


level)


PRENATAL FORMULACAPS 35MG-30UNIT-4000UNIT-200MG-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

$0(Tier

3)

NT

Specialty Vitamins Products

ULTRA MAN$0

(Tier3)

MO; NT

ULTRA WOMAN$0

(Tier3)

MO; NT

Vitamin Mixturescod liver oil caps 10 minim,110mg-2664unit-1000mg-100mg-200unit, 1250unit-130unit, 1250unit-133.33unit, 1250unit-133unit, 1250unit-135unit,200unit-4000unit, 20mg-35mg-1250unit-45mg-133.333unit, 34mg-1250unit-415mg-32mg-135unit, 50mg-110mg-250unit-110mg-100unit-10unit, 52mg-2500unit-600mg-52mg-270unit,530mg-1250unit-130unit,90mg-37mg-415mg-36mg-1250unit-135unit

$0(Tier

3)

NT

COD LIVER OIL FOR KIDS$0

(Tier3)

RX/OTC; NT

COD LIVER OIL OIL4000UNIT/5ML-400UNIT/5ML,5000UNIT/5ML-500UNIT/5ML

$0(Tier

3)

RX/OTC; NT

CVS COD LIVER OIL$0

(Tier3)

RX/OTC; NT

Name of drug

Whatthe


level)


NORWEGIAN COD LIVEROIL

$0(Tier

3)

RX/OTC; NT

QC COD LIVER OIL$0

(Tier3)

RX/OTC; NT

RA COD LIVER OIL$0

(Tier3)

RX/OTC; NT

vitamins a & d caps10000unit-400unit,10000unit-5000unit,1250unit-133unit, 1250unit-135unit, 5000unit-400unit,700unit-400unit, 8000unit-400unit

$0(Tier

3)

MO; NT

Vitamins w/ Lipotropics



140

Name of drug

Whatthe


level)


vitamins w/ lipotropics tabs10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg,100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg,100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 100mg-12.5mg-100mg-100mg-12.5mg-12.5mg-100mg-100mcg-100mcg-100mcg-100mg,100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 200mg-29mg-0.333mg-1.666mg-3.33mg-111.333mg-111.333mg-1mg-1.666mcg-0.333mg-100mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-1.67mcg-0.33mg-100mg,200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 20mg-50mg-30mg-10mg-10mcg-

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


30mg-8mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg, 266.MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg$0-

$2.65(Tier

1)

QL(8 ea daily);MO

baclofen tabs or 20 mg$0-

$2.65(Tier

1)

QL(4 ea daily);MO

carisoprodol tabs or 350mg

$0-$2.65(Tier

1)

AL; MO

chlorzoxazone$0-

$2.65(Tier

1)

AL; MO

cyclobenzaprine hcl tabs or10 mg, 5 mg

$0-$2.65(Tier

1)

AL; MO

metaxalone$0-

$2.65(Tier

1)

AL; MO

methocarbamol tabs or 500mg, 750 mg

$0-$2.65(Tier

1)

AL; MO

PARAFON FORTE DSC(Use Chlorzoxazone) NF AL; MO

ROBAXIN TABS OR 500MG (Use Methocarbamol) NF AL; MO



141

Name of drug

Whatthe


level)


ROBAXIN-750 (UseMethocarbamol) NF AL; MO

SKELAXIN (UseMetaxalone) NF AL; MO

SOMA 350 MG (UseCarisoprodol) NF AL; MO

tizanidine hcl caps or 2 mg,4 mg, 6 mg

$0-$2.65(Tier

1)

MO

tizanidine hcl tabs or 2 mg,4 mg

$0-$2.65(Tier

1)

MO

ZANAFLEX (UseTizanidine HCl) NF MO

Direct Muscle RelaxantsDANTRIUM (UseDantrolene Sodium) NF MO

dantrolene sodium caps or100 mg, 25 mg, 50 mg

$0-$2.65(Tier

1)

MO

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agents - Misc.AFRIN PURESEAGENTLE MISTNASALRINSE

$0(Tier

3)

MO; NT

AFRIN PURESEAMEDIUM STREAM NASALRINSE

$0(Tier

3)

MO; NT

AFRIN PURESEA ULTRA-GENTLE MIST NASALRINSE

$0(Tier

3)

MO; NT

AYR NASAL DROPS$0

(Tier3)

NT

ENTSOL HYPERTONICNASAL IRRIGATION MIST

$0(Tier

3)

NT

Name of drug

Whatthe


level)


ENTSOL NASAL SPRAY$0

(Tier3)

NT

ENTSOL NASAL WASH$0

(Tier3)

NT

GELONASAL$0

(Tier3)

MO; NT

OCEAN NASAL SPRAY(Use Saline) NF MO; NT

PONARIS$0

(Tier3)

MO; NT

saline gel na$0

(Tier3)

MO; NT

saline soln na 0.65 %,0.65%, 0.65%-0.002%

$0(Tier

3)

MO; NT

SALTAIRE$0

(Tier3)

NT

Nasal Antiallergy

azelastine hcl 0.1 %$0-

$2.65(Tier

1)

MO

olopatadine hcl (nasal)$0-

$2.65(Tier

1)

MO

PATANASE (UseOlopatadine HCl (Nasal))

$0-$6.60(Tier

2)

MO

Nasal AnticholinergicsATROVENT (UseIpratropium Bromide(Nasal))

NFMO



142

Name of drug

Whatthe


level)


ipratropium bromide (nasal)$0-

$2.65(Tier

1)

MO

Nasal Steroids

budesonide (nasal)$0-

$2.65(Tier

1)

MO

FLONASE (UseFluticasone Propionate(Nasal))

NFRX/OTC; MO

flunisolide (nasal)$0-

$2.65(Tier

1)

MO

fluticasone propionate(nasal)

$0-$2.65(Tier

1)

RX/OTC; MO

RHINOCORT AQUA (UseBudesonide (Nasal))

$0-$6.60(Tier

2)

MO

triamcinolone acetonide(nasal)

$0-$2.65(Tier

1)

RX/OTC; MO

Sympathomimetic Decongestants

BENZEDREX INHALER$0

(Tier3)

NT

ELIXSURE CONGESTION$0

(Tier3)

NT

NASAL DECONGESTANTLIQD

$0(Tier

3)

MO; NT

NASAL DECONGESTANTSYRP

$0(Tier

3)

NT

Name of drug

Whatthe


level)


NEO-SYNEPHRINE 0.25% (Use Phenylephrine HCl) NF MO; NT

NEO-SYNEPHRINE 0.5 %$0

(Tier3)

MO; NT

NEO-SYNEPHRINE COLD& SINUS MILD (UsePhenylephrine HCl)

NFMO; NT

NEO-SYNEPHRINE COLD& SINUS REGULAR

$0(Tier

3)

MO; NT

phenylephrine hcl soln na0.25 %

$0(Tier

3)

MO; NT

pseudoephedrine hcl liqd or15 mg/5ml

$0(Tier

3)

MO; NT

pseudoephedrine hcl tabsor 30 mg, 60 mg

$0(Tier

3)

MO; NT

SUDAFED (UsePseudoephedrine HCl) NF MO; NT

SUDAFED CHILDRENS(Use PseudoephedrineHCl)

NFMO; NT

SUDAFED CONGESTION(Use PseudoephedrineHCl)

NFMO; NT

SUDAFED NASALDECONGESTANTMAXIMUM STRENGTH(Use PseudoephedrineHCl)

NF

MO; NT

SUDAFED PECHILDRENS NASALDECONGESTANT

$0(Tier

3)

NT

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK (Use Riluzole) NF MO



143

Name of drug

Whatthe


level)


riluzole$0-

$2.65(Tier

1)

MO

Neuromuscular Blocking Agent - Neurotoxins

BOTOX 200 UNIT$0-

$6.60(Tier

2)

PA

XEOMIN$0-

$6.60(Tier

2)

PA

NUTRIENTS

Carbohydrates

dextrose soln iv 10 %$0-

$2.65(Tier

1)

B/D

dextrose soln iv 5 %$0-

$2.65(Tier

1)

MO; B/D

GLUCOSE NURSETTE(Use Glucose) NF NT

glucose soln 5 %$0

(Tier3)

NT

POLYCOSE$0

(Tier3)

NT

Lipids

fat emulsion 20 gm/100ml$0-

$2.65(Tier

1)

B/D

LIPOSYN III1.2GM/100ML-10GM/100ML-2.5GM/100ML

$0-$6.60(Tier

2)

B/D

Name of drug

Whatthe


level)


MCT OIL$0

(Tier3)

NT

MICROLIPID$0

(Tier3)

MO; NT

Lipotropics

INOSITOL TABS OR 500MG

$0(Tier

3)

MO; NT

lecithin caps or$0

(Tier3)

MO; NT

LECITHINCONCENTRATE

$0(Tier

3)

NT

Misc. Nutritional Substances

docosahexaenoic acid 200mg

$0(Tier

3)

MO; NT

EXPECTA LIPIL (UseDocosahexaenoic Acid) NF MO; NT

omega-3 fatty acids caps180mg-120mg, 300mg,300mg-160mg-1000mg-100mg-5unit, 300mg-772.5mg-90mg-180mg

$0(Tier

3)

NT

omega-3 fatty acids caps180mg-500mg-120mg,27mg-244mg-500mg-89mg, 300mg-1000mg-200mg, 300mg-200mg, 500mg, 500mg, 500mg-270mg-135mg, 500mg-320mg-130mg, 90mg-500mg-60mg

$0(Tier

3)

MO; NT

Proteins

ADD-INS COMPLETE$0

(Tier3)

NT



144

Name of drug

Whatthe


level)


amino acid infusion 15%$0-

$2.65(Tier

1)

B/D

amino acids caps 130mg-10mg-130mg-130mg

$0(Tier

3)

NT

amino acids tabs 100mg-6.15mg-2.1mg-0.85mg-1.95mg-0.55mg-2.3mg-1.95mg-0.75mg-1.15mg-0.6mg-3.65mg-0.65mg-3.25mg-3.8mg-1.95mg-1.7mg-0.7mg-1.05mg,115.333mg-54.667mg-21mg-33.333mg-33.333mg-46.667mg-14.167mg-46.667mg-40mg-53.333mg-18.167mg-41mg-66.667mg-40mg-30.667mg-17.333mg-14mg, 115.3mg-54.7mg-21mg-33.3mg-13.3mg-33.3mg-63.3mg-14.2mg-46.7mg-40mg-53.3mg-18.2mg-41mg-66.7mg-40mg-30.7mg-17.3mg-14mg, 1200mg-100mg,18.33mg-200mg-33.33mg-50mg-23.16mg-58.33mg-18.33mg-75mg-108.33mg,200mg-33.33mg-50mg-23.16mg-18.33mg-58.33mg-18.33mg-75mg-108.33mg, 35mg-29.5mg-24.667mg-4.833mg-17.667mg-24.667mg-12.5mg-24mg-19mg-36mg-17.5mg-4.667mg-75mg-15mg, 74mg-50mg-0.7mg-77mg-1.4mg-72mg-64mg-27mg-54mg-70mg-41mg-17mg-109mg-7mg-27mg-68mg-47mg-41mg-64mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


amino acids-proteinhydrolysate

$0(Tier

3)

MO; NT

AMINOSYN II 15% (Useamino acid infusion) NF B/D

ARGIMENT$0

(Tier3)

NT

ARGIMENT AT$0

(Tier3)

NT

arginine tabs 500 mg$0

(Tier3)

NT

COMPLEX MSUD AMINOACID BAR

$0(Tier

3)

MO; NT

GLUTAMENT$0

(Tier3)

NT

HEPAMENT$0

(Tier3)

NT

L-CARNITINE TABS OR250 MG

$0(Tier

3)

NT

L-CITRULLINE CAPS OR$0

(Tier3)

NT

levocarnitine caps or 250mg

$0(Tier

3)

MO; NT

PHENYLADE AMINO ACID$0

(Tier3)

MO; NT

PHENYLADE AMINO ACIDBLEND

$0(Tier

3)

NT

PHENYLADE MTE AMINOACIDBLEND

$0(Tier

3)

NT



145

Name of drug

Whatthe


level)


PHENYLADE PHEBLOCTABS

$0(Tier

3)

MO; NT

PHENYLADE40 DRINKMIX

$0(Tier

3)

NT

PHLEXY-10 CAPS$0

(Tier3)

NT

PROTEINEX$0

(Tier3)

MO; NT

SOLVIL$0

(Tier3)

NT

SUPER-AMINO 1600$0

(Tier3)

MO; NT

SYMPT-X G.I.$0

(Tier3)

NT

TRIAMINO$0

(Tier3)

MO; NT

tyrosine tabs 500 mg$0

(Tier3)

NT

Name of drug

Whatthe


level)


XPHE MAXAMUM PACK153MG-280MG-41MCG-1114UNIT-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG, 153MG-280MG-41MCG-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-1114UNIT-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG

$0(Tier

3)

NT

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and LubricantsGENTEAL MILD TOMODERATE (UseHypromellose (Ophth))

NFMO; NT

hypromellose (ophth) 0.3%, 3 mg/ml

$0(Tier

3)

MO; NT

ISOPTO TEARS$0

(Tier3)

MO; NT

NUTRATEAR$0

(Tier3)

NT

polyvinyl alcohol soln op$0

(Tier3)

MO; NT

TEARS AGAIN NIGHT &DAY

$0(Tier

3)

NT



146

Name of drug

Whatthe


level)


TGT LUBRICANT EYEDROPS

$0(Tier

3)

NT

Beta-blockers - OphthalmicBETAGAN (UseLevobunolol HCl) NF MO

betaxolol hcl (ophth)$0-

$2.65(Tier

1)

MO

carteolol hcl (ophth)$0-

$2.65(Tier

1)

MO

COSOPT (UseDorzolamide HCl-TimololMaleate)

NFMO

dorzolamide hcl-timololmaleate

$0-$2.65(Tier

1)

MO

levobunolol hcl 0.5 %$0-

$2.65(Tier

1)

MO

timolol maleate (ophth)$0-

$2.65(Tier

1)

MO

TIMOPTIC (Use TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE (UseTimolol Maleate (Ophth)) NF MO

Cycloplegic Mydriatics

cyclopentolate hcl soln op1 %

$0-$2.65(Tier

1)

MO

Miotics

Name of drug

Whatthe


level)


ISOPTO CARPINE (UsePilocarpine HCl)

$0-$6.60(Tier

2)

MO

PHOSPHOLINE IODIDE$0-

$6.60(Tier

2)

pilocarpine hcl soln op 1 %,2 %, 4 %

$0-$2.65(Tier

1)

MO

Ophthalmic Adrenergic Agents

ALPHAGAN P 0.1 %$0-

$6.60(Tier

2)

MO

ALPHAGAN P 0.15 % (UseBrimonidine Tartrate) NF MO

apraclonidine hcl$0-

$2.65(Tier

1)

MO

brimonidine tartrate$0-

$2.65(Tier

1)

MO

IOPIDINE 0.5 % (UseApraclonidine HCl) NF MO

Ophthalmic Anti-infectives

bacitracin-polymyxin b(ophth)

$0-$2.65(Tier

1)

MO

BLEPH-10 (UseSulfacetamide Sodium(Ophth))

NFMO

CILOXAN SOLN (UseCiprofloxacin HCl (Ophth)) NF MO



147

Name of drug

Whatthe


level)


ciprofloxacin hcl (ophth)$0-

$2.65(Tier

1)

MO

erythromycin (ophth)$0-

$2.65(Tier

1)

MO

gatifloxacin (ophth)$0-

$2.65(Tier

1)

MO

gentamicin sulfate (ophth)$0-

$2.65(Tier

1)

MO

levofloxacin (ophth)$0-

$2.65(Tier

1)

MO

neomycin-bacitracin zn-polymyxin

$0-$2.65(Tier

1)

MO

neomycin-polymyxin-gramicidin

$0-$2.65(Tier

1)

MO

OCUFLOX (Use Ofloxacin(Ophth)) NF MO

ofloxacin (ophth)$0-

$2.65(Tier

1)

MO

polymyxin b-trimethoprim$0-

$2.65(Tier

1)

MO

POLYTRIM (UsePolymyxin B-Trimethoprim) NF MO

Name of drug

Whatthe


level)


sulfacetamide sodium(ophth)

$0-$2.65(Tier

1)

MO

tobramycin (ophth)$0-

$2.65(Tier

1)

MO

TOBREX SOLN (UseTobramycin (Ophth)) NF MO

trifluridine soln op$0-

$2.65(Tier

1)

MO

VIGAMOX$0-

$6.60(Tier

2)

MO

VIROPTIC (UseTrifluridine) NF MO

ZYMAXID (UseGatifloxacin (Ophth)) NF MO

Ophthalmic Decongestants

naphazoline w/pheniramine 0.025%-0.3%

$0(Tier

3)

MO; NT

NAPHCON-A (UseNaphazoline w/Pheniramine)

NFMO; NT

VISINE-LR$0

(Tier3)

NT

Ophthalmic Immunomodulators

RESTASIS$0-

$6.60(Tier

2)

MO

Ophthalmic Local Anesthetics



148

Name of drug

Whatthe


level)


proparacaine hcl soln op$0-

$2.65(Tier

1)

MO

Ophthalmic Steroids

bacitracin-poly-neomycin-hc

$0-$2.65(Tier

1)

MO

dexamethasone sodiumphosphate (ophth)

$0-$2.65(Tier

1)

MO

fluorometholone (ophth)$0-

$2.65(Tier

1)

MO

FML LIQUIFILM (UseFluorometholone (Ophth)) NF MO

LOTEMAX OINT$0-

$6.60(Tier

2)

MO

MAXITROL (UseNeomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth

$0-$2.65(Tier

1)

MO

OMNIPRED (UsePrednisolone Acetate(Ophth))

NFMO

PRED FORTE (UsePrednisolone Acetate(Ophth))

NFMO

prednisolone acetate(ophth)

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


sulfacetamide sod-prednisolone

$0-$2.65(Tier

1)

MO

TOBRADEX SUSP (UseTobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone

$0-$2.65(Tier

1)

MO

Ophthalmics - Misc.ACULAR (Use KetorolacTromethamine (Ophth)) NF MO

ACULAR LS (UseKetorolac Tromethamine(Ophth))

NFMO

azelastine hcl (ophth)$0-

$2.65(Tier

1)

MO

AZOPT$0-

$6.60(Tier

2)

MO

bromfenac sodium (ophth)$0-

$2.65(Tier

1)

Once dailydosing;MO

cromolyn sodium (ophth)$0-

$2.65(Tier

1)

MO

CYSTARAN$0-

$6.60(Tier

2)

Limited to 60ml per 28days;QL(2.15ml daily); LA

diclofenac sodium (ophth)$0-

$2.65(Tier

1)

MO



149

Name of drug

Whatthe


level)


dorzolamide hcl$0-

$2.65(Tier

1)

MO

ELESTAT (Use EpinastineHCl (Ophth)) NF MO

ENUCLENE$0

(Tier3)

MO; NT

epinastine hcl (ophth)$0-

$2.65(Tier

1)

MO

EYE STREAM$0

(Tier3)

MO; NT

flurbiprofen sodium$0-

$2.65(Tier

1)

MO

ILEVRO$0-

$6.60(Tier

2)

MO

ketorolac tromethamine(ophth)

$0-$2.65(Tier

1)

MO

ketotifen fumarate (ophth)$0

(Tier3)

MO; NT

MURO 128 OINT 5 % (UseSodium ChlorideHypertonic)

NFMO; NT

MURO 128 SOLN 2 %$0

(Tier3)

MO; NT

MURO 128 SOLN 5 %(Use Sodium ChlorideHypertonic)

NFMO; NT

Name of drug

Whatthe


level)


NEVANAC$0-

$6.60(Tier

2)

MO

OCUFEN (Use FlurbiprofenSodium) NF MO

OPTIVAR (Use AzelastineHCl (Ophth)) NF MO

PATADAY$0-

$6.60(Tier

2)

MO

sodium chloride hypertonic$0

(Tier3)

MO; NT

TRUSOPT (UseDorzolamide HCl) NF MO

ZADITOR (Use KetotifenFumarate (Ophth)) NF MO; NT

Prostaglandins - Ophthalmic

BIMATOPROST$0-

$6.60(Tier

2)

MO

latanoprost$0-

$2.65(Tier

1)

MO

LUMIGAN$0-

$6.60(Tier

2)

MO

TRAVATAN Z$0-

$6.60(Tier

2)

MO

XALATAN (UseLatanoprost) NF MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous



150

Name of drug

Whatthe


level)


acetic acid (otic)$0-

$2.65(Tier

1)

MO

acetic acid-aluminumacetate

$0-$2.65(Tier

1)

MO

carbamide peroxide (otic)$0

(Tier3)

MO; NT

DEBROX (Use CarbamidePeroxide (Otic)) NF MO; NT

Otic Anti-infectives

ofloxacin (otic)$0-

$2.65(Tier

1)

MO

Otic Combinations

boric acid in isopropyl$0

(Tier3)

NT

CIPRODEX$0-

$6.60(Tier

2)

MO

CORTISPORIN SOLN OT10000UNIT/ML-3.5MG/ML-1% (Use Neomycin-Polymyxin-HC (Otic))

NF

MO

neomycin-polymyxin-hc(otic)

$0-$2.65(Tier

1)

MO

Otic SteroidsDERMOTIC (UseFluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic)

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


hydrocortisone w/aceticacid

$0-$2.65(Tier

1)

MO

VOSOL HC (UseHydrocortisone w/AceticAcid)

NFMO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics

methylergonovine maleatetabs or 0.2 mg

$0-$2.65(Tier

1)

MO

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune Serums

BIVIGAM$0-

$6.60(Tier

2)

B/D

FLEBOGAMMA DIF 10 %$0-

$6.60(Tier

2)

B/D

GAMASTAN S/D$0-

$6.60(Tier

2)

B/D

GAMMAGARD LIQUID$0-

$6.60(Tier

2)

B/D

GAMMAKED$0-

$6.60(Tier

2)

B/D

GAMUNEX-C$0-

$6.60(Tier

2)

B/D



151

Name of drug

Whatthe


level)


HIZENTRA$0-

$6.60(Tier

2)

B/D

OCTAGAM 10 GM/100ML,2 GM/20ML, 20GM/200ML, 5 GM/50ML

$0-$6.60(Tier

2)

B/D

PRIVIGEN$0-

$6.60(Tier

2)

B/D

VARIZIG$0-

$6.60(Tier

2)

Monoclonal Antibodies

SYNAGIS 50 MG/0.5ML$0-

$6.60(Tier

2)

Passive Immunizing Agents - Combinations

HYQVIA$0-

$6.60(Tier

2)

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 250 mg,500 mg

$0-$2.65(Tier

1)

MO

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

$0-$2.65(Tier

1)

MO

amoxicillin tabs 500 mg,875 mg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


ampicillin caps 250 mg,500 mg

$0-$2.65(Tier

1)

MO

ampicillin sodium ij 1 gm, 2gm

$0-$2.65(Tier

1)

MO

ampicillin sodium ij 125 mg$0-

$2.65(Tier

1)

ampicillin sodium iv 10 gm$0-

$2.65(Tier

1)

Natural Penicillins

BICILLIN L-A$0-

$6.60(Tier

2)

MO

penicillin g potassium 20mu, 20000000 unit,5000000 unit

$0-$2.65(Tier

1)

MO

penicillin v potassium$0-

$2.65(Tier

1)

MO

Penicillin Combinations

amoxicillin & potclavulanate

$0-$2.65(Tier

1)

MO

ampicillin & sulbactamsodium ij 1gm-2gm

$0-$2.65(Tier

1)

MO

ampicillin & sulbactamsodium iv 5gm-10gm

$0-$2.65(Tier

1)



152

Name of drug

Whatthe


level)


AUGMENTIN ES-600 (UseAmoxicillin & PotClavulanate)

NFMO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Use Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Use Amoxicillin &Pot Clavulanate)

NF

MO

AUGMENTIN XR (UseAmoxicillin & PotClavulanate)

NFMO

BICILLIN C-R300000UNIT/ML-300000UNIT/ML

$0-$6.60(Tier

2)

MO

BICILLIN C-R900000UNIT/2ML-300000UNIT/2ML

$0-$6.60(Tier

2)

piperacillin sodium-tazobactam sodium

$0-$2.65(Tier

1)UNASYN 1GM-2GM (UseAmpicillin & SulbactamSodium)

NFMO

ZOSYN SOLN0.5GM/100ML-4GM/100ML-5%

$0-$6.60(Tier

2)ZOSYN SOLR 0.25GM-2GM, 0.375GM-3GM,0.5GM-4GM, 4.5GM-36GM(Use Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


nafcillin sodium ij 1 gm, 10gm

$0-$2.65(Tier

1)

nafcillin sodium ij 2 gm$0-

$2.65(Tier

1)

MO

oxacillin sodium 10 gm$0-

$2.65(Tier

1)

oxacillin sodium 2 gm$0-

$2.65(Tier

1)

MO

PHARMACEUTICAL ADJUVANTS

Liquid Vehicles

CHERRY CONCENTRATESYRP

$0(Tier

3)

RX/OTC; MO;NT

CHERRY SYRUP$0

(Tier3)

RX/OTC; MO;NT

PROPYLENE GLYCOLSOLN EX

$0(Tier

3)

RX/OTC; MO;NT

RASPBERRY SYRUP$0

(Tier3)

RX/OTC; NT

Pharmaceutical Excipients

KARAYA GUM GUM$0

(Tier3)

RX/OTC; MO;NT

Semi Solid Vehicles

hydrophilic ointment$0

(Tier3)

MO; NT

LANOLIN ANHYDROUS$0

(Tier3)

RX/OTC; NT



153

Name of drug

Whatthe


level)


LANOLIN ANHYDROUS-GRX

$0(Tier

3)

RX/OTC; NT

lanolin oint ex$0

(Tier3)

RX/OTC; NT

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestins

medroxyprogesteroneacetate

$0-$2.65(Tier

1)

MO

MEGACE ES (UseMegestrol Acetate(Appetite))

$0-$6.60(Tier

2)

AL; MO

megestrol acetate(appetite)

$0-$2.65(Tier

1)

AL; MO

norethindrone acetate tabsor

$0-$2.65(Tier

1)

MO

progesterone micronizedcaps or 100 mg, 200 mg

$0-$2.65(Tier

1)

MO

PROMETRIUM (UseProgesterone Micronized) NF MO

PROVERA (UseMedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependency

Name of drug

Whatthe


level)


acamprosate calcium$0-

$2.65(Tier

1)

MO

CAMPRAL (UseAcamprosate Calcium) NF MO

disulfiram tabs or 250 mg,500 mg

$0-$2.65(Tier

1)

MO

Anti-Cataplectic Agents

XYREM$0-

$6.60(Tier

2)

LA

Antidementia AgentsARICEPT (Use DonepezilHydrochloride) NF MO

ARICEPT ODT (UseDonepezil Hydrochloride) NF MO

donepezil hydrochloride$0-

$2.65(Tier

1)

MO

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Use Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR (UseRivastigmine)

$0-$6.60(Tier

2)

MO

galantamine hydrobromide$0-

$2.65(Tier

1)

MO

memantine hcl soln 2mg/ml

$0-$2.65(Tier

1)

AL; MO



154

Name of drug

Whatthe


level)


memantine hcl tabs 10 mg,5 mg

$0-$2.65(Tier

1)

MO

NAMENDA SOLN 10MG/5ML (Use MemantineHCl)

$0-$6.60(Tier

2)

AL; MO

NAMENDA TABS 10 MG, 5MG (Use Memantine HCl)

$0-$6.60(Tier

2)

MO

NAMENDA TITRATIONPAK (Use Memantine HCl)

$0-$6.60(Tier

2)

MO

NAMENDA XR 14 MG$0-

$6.60(Tier

2)

QL(2 ea daily);MO

NAMENDA XR 21 MG, 28MG

$0-$6.60(Tier

2)

QL(1 ea daily);MO

NAMENDA XR 7 MG$0-

$6.60(Tier

2)

QL(4 ea daily);MO

NAMENDA XR TITRATIONPACK

$0-$6.60(Tier

2)

MO

RAZADYNE (UseGalantamineHydrobromide)

NFMO

RAZADYNE ER (UseGalantamineHydrobromide)

NFMO

rivastigmine$0-

$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


rivastigmine tartrate$0-

$2.65(Tier

1)

MO

Combination Psychotherapeutics

chlordiazepoxide-amitriptyline

$0-$2.65(Tier

1)

AL; MO

olanzapine-fluoxetine hcl$0-

$2.65(Tier

1)

MO

perphenazine-amitriptyline$0-

$2.65(Tier

1)

AL; MO

SYMBYAX (UseOlanzapine-Fluoxetine HCl) NF MO

Movement Disorder Drug Therapy

tetrabenazine$0-

$2.65(Tier

1)

XENAZINE (UseTetrabenazine)

$0-$6.60(Tier

2)

LA

Multiple Sclerosis Agents

AMPYRA$0-

$6.60(Tier

2)

AUBAGIO$0-

$6.60(Tier

2)

PA

AVONEX$0-

$6.60(Tier

2)

PA



155

Name of drug

Whatthe


level)


AVONEX PEN$0-

$6.60(Tier

2)

PA

BETASERON$0-

$6.60(Tier

2)

PA

COPAXONE 20 MG/ML(Use Glatiramer Acetate)

$0-$6.60(Tier

2)

PA

COPAXONE 40 MG/ML$0-

$6.60(Tier

2)

PA

EXTAVIA$0-

$6.60(Tier

2)

PA

GILENYA$0-

$6.60(Tier

2)

PA

glatiramer acetate$0-

$2.65(Tier

1)

PA

LEMTRADA$0-

$6.60(Tier

2)

PA; LA

PLEGRIDY$0-

$6.60(Tier

2)

PA

PLEGRIDY STARTERPACK

$0-$6.60(Tier

2)

PA

Name of drug

Whatthe


level)


REBIF$0-

$6.60(Tier

2)

PA

REBIF REBIDOSE$0-

$6.60(Tier

2)

PA

REBIF REBIDOSETITRATIONPACK

$0-$6.60(Tier

2)

PA

REBIF TITRATION PACK$0-

$6.60(Tier

2)

PA

TECFIDERA$0-

$6.60(Tier

2)

PA

TECFIDERA STARTERPACK

$0-$6.60(Tier

2)

PA

TYSABRI$0-

$6.60(Tier

2)

PA

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) Agents

NUEDEXTA$0-

$6.60(Tier

2)

MO

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs or$0-

$2.65(Tier

1)

AL; MO



156

Name of drug

Whatthe


level)


ORAP (Use Pimozide)

$0-$6.60(Tier

2)

MO

pimozide$0-

$2.65(Tier

1)

MO

Smoking Deterrents

bupropion hcl (smokingdeterrent)

$0-$2.65(Tier

1)

QL(2 ea daily);MO

CHANTIX$0-

$6.60(Tier

2)

PA; MO

CHANTIX CONTINUINGMONTHPAK

$0-$6.60(Tier

2)

PA; MO

NICODERM CQ (UseNicotine) NF MO; NT

NICORETTE (Use NicotinePolacrilex) NF PA; MO; NT

NICORETTE MINI (UseNicotine Polacrilex) NF PA; MO; NT

NICORETTE STARTERKIT (Use NicotinePolacrilex)

NFPA; MO; NT

nicotine$0

(Tier3)

MO; NT

nicotine polacrilex gum mt2 mg, 4 mg

$0(Tier

3)

PA; MO; NT

nicotine polacrilex lozg mt2 mg, 4 mg

$0(Tier

3)

PA; MO; NT

NICOTINETRANSDERMAL SYSTEM

$0(Tier

3)

NT

Name of drug

Whatthe


level)


NICOTROL INHALER$0-

$6.60(Tier

2)

QL(17 eadaily); MO

NICOTROL NS$0-

$6.60(Tier

2)

MO

ZYBAN (Use BupropionHCl (Smoking Deterrent)) NF QL(2 ea daily);

MOVasomotor Symptom Agents

BRISDELLE$0-

$6.60(Tier

2)

MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)

ARALAST NP 1000 MG$0-

$6.60(Tier

2)

LA

PROLASTIN-C$0-

$6.60(Tier

2)

LA

ZEMAIRA$0-

$6.60(Tier

2)

LA

Cystic Fibrosis Agents

KALYDECO PACK 50 MG,75 MG

$0-$6.60(Tier

2)

PA

KALYDECO TABS 150 MG$0-

$6.60(Tier

2)

PA; LA



157

Name of drug

Whatthe


level)


ORKAMBI$0-

$6.60(Tier

2)

PA

PULMOZYME$0-

$6.60(Tier

2)

B/D

Pulmonary Fibrosis Agents

ESBRIET$0-

$6.60(Tier

2)

PA; LA

OFEV$0-

$6.60(Tier

2)


SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamides

sulfadiazine tabs or$0-

$2.65(Tier

1)

MO

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA PAK 1/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA PAK 1/150 (UseDoxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA TABS 100 MG, 50MG, 75 MG (UseDoxycycline(Monohydrate))

NF

MO

Name of drug

Whatthe


level)


demeclocycline hcl$0-

$2.65(Tier

1)

MO

DORYX 150 MG (UseDoxycycline Hyclate) NF MO

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

$0-$2.65(Tier

1)

MO

doxycycline (monohydrate)susr 25 mg/5ml

$0-$2.65(Tier

1)

MO

doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

$0-$2.65(Tier

1)

MO

doxycycline hyclate caps or100 mg, 50 mg

$0-$2.65(Tier

1)

MO

doxycycline hyclate solr iv100 mg

$0-$2.65(Tier

1)

MO

doxycycline hyclate tabs or100 mg, 20 mg

$0-$2.65(Tier

1)

MO

doxycycline hyclate tbec or150 mg

$0-$2.65(Tier

1)

MO

MINOCIN CAPS OR 100MG, 50 MG, 75 MG (UseMinocycline HCl)

NFMO

minocycline hcl caps or 100mg, 50 mg, 75 mg

$0-$2.65(Tier

1)

MO



158

Name of drug

Whatthe


level)


minocycline hcl tabs or 100mg, 50 mg

$0-$2.65(Tier

1)

MO

MONODOX (UseDoxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 250mg, 500 mg

$0-$2.65(Tier

1)

MO

VIBRAMYCIN CAPS 100MG (Use DoxycyclineHyclate)

NFMO

VIBRAMYCIN SUSR 25MG/5ML (Use Doxycycline(Monohydrate))

NFMO

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agents

methimazole tabs or 10mg, 5 mg

$0-$2.65(Tier

1)

MO

propylthiouracil tabs or$0-

$2.65(Tier

1)

MO

Thyroid HormonesCYTOMEL (UseLiothyronine Sodium) NF MO

levothyroxine sodium tabsor 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg

$0-$2.65(Tier

1)

MO

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg

$0-$2.65(Tier

1)

MO

Name of drug

Whatthe


level)


SYNTHROID (UseLevothyroxine Sodium) NF MO

TOXOIDS

Toxoid Combinations

ADACEL$0-

$6.60(Tier

2)

BOOSTRIX$0-

$6.60(Tier

2)

DAPTACEL$0-

$6.60(Tier

2)

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC

$0-$6.60(Tier

2)

INFANRIX$0-

$6.60(Tier

2)

TENIVAC$0-

$6.60(Tier

2)

TETANUS/DIPHTHERIATOXOIDS-ADSORBED

$0-$6.60(Tier

2)

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT

$0-$6.60(Tier

2)

Toxoids

TETANUS TOXOIDADSORBED

$0-$6.60(Tier

2)

B/D



159

Name of drug

Whatthe


level)


ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Use Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Use Dicyclomine HCl) NF MO

dicyclomine hcl caps 10 mg$0-

$2.65(Tier

1)

MO

dicyclomine hcl tabs 20 mg$0-

$2.65(Tier

1)

MO

glycopyrrolate soln ij 0.2mg/ml

$0-$2.65(Tier

1)

MO

glycopyrrolate tabs or 1mg, 2 mg

$0-$2.65(Tier

1)

MO

methscopolamine bromidetabs or 2.5 mg, 5 mg

$0-$2.65(Tier

1)

MO

PAMINE (UseMethscopolamine Bromide) NF MO

PAMINE FORTE (UseMethscopolamine Bromide) NF MO

ROBINUL FORTE (UseGlycopyrrolate) NF MO

ROBINUL SOLN IJ 0.2MG/ML (UseGlycopyrrolate)

NFMO

ROBINUL TABS OR 1 MG(Use Glycopyrrolate) NF MO

H-2 AntagonistsAXID CAPS 300 MG (UseNizatidine) NF MO

Name of drug

Whatthe


level)


cimetidine tabs or 200 mg$0-

$2.65(Tier

1)

RX/OTC; MO

cimetidine tabs or 300 mg,400 mg, 800 mg

$0-$2.65(Tier

1)

MO

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

$0-$2.65(Tier

1)

famotidine susr or 40mg/5ml

$0-$2.65(Tier

1)

MO

famotidine tabs or 10 mg$0

(Tier3)

MO; NT

famotidine tabs or 20 mg$0-

$2.65(Tier

1)

RX/OTC; MO

famotidine tabs or 40 mg$0-

$2.65(Tier

1)

MO

nizatidine caps 150 mg,300 mg

$0-$2.65(Tier

1)

MO

PEPCID 40 MG/5ML (UseFamotidine) NF MO

PEPCID AC CHEW$0

(Tier3)

NT

PEPCID AC TABS (UseFamotidine) NF MO; NT

ranitidine hcl caps or 150mg, 300 mg

$0-$2.65(Tier

1)

MO



160

Name of drug

Whatthe


level)


ranitidine hcl syrp or 15mg/ml, 150 mg/10ml, 75mg/5ml

$0-$2.65(Tier

1)

MO

ranitidine hcl tabs or 150mg

$0-$2.65(Tier

1)

RX/OTC; MO

ranitidine hcl tabs or 300mg

$0-$2.65(Tier

1)

MO

ranitidine hcl tabs or 75 mg$0

(Tier3)

MO; NT

ZANTAC 75 (UseRanitidine HCl) NF MO; NT

ZANTAC SYRP OR 15MG/ML (Use RanitidineHCl)

NFMO

ZANTAC TABS OR 150MG (Use Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Use Ranitidine HCl) NF MO

Misc. Anti-UlcerCARAFATE TABS 1 GM(Use Sucralfate) NF MO

sucralfate tabs or$0-

$2.65(Tier

1)

MO

Proton Pump Inhibitors

DEXILANT$0-

$6.60(Tier

2)

ST; MO

esomeprazole magnesium20 mg

$0-$2.65(Tier

1)

ST; RX/OTC;MO

Name of drug

Whatthe


level)


esomeprazole magnesium40 mg

$0-$2.65(Tier

1)

ST; MO

ESOMEPRAZOLESTRONTIUM

$0-$6.60(Tier

2)

ST

lansoprazole cpdr or 15 mg$0-

$2.65(Tier

1)

RX/OTC; MO

lansoprazole cpdr or 30 mg$0-

$2.65(Tier

1)

MO

NEXIUM CPDR 20 MG$0-

$6.60(Tier

2)

ST; RX/OTC;MO

NEXIUM CPDR 20 MG(Use EsomeprazoleMagnesium)

$0-$6.60(Tier

2)

ST; RX/OTC;MO

NEXIUM CPDR 40 MG$0-

$6.60(Tier

2)

ST; MO

NEXIUM CPDR 40 MG(Use EsomeprazoleMagnesium)

$0-$6.60(Tier

2)

ST; MO

NEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG

$0-$6.60(Tier

2)

ST; MO

omeprazole cpdr or 10 mg,20 mg, 40 mg

$0-$2.65(Tier

1)

MO



161

Name of drug

Whatthe


level)


pantoprazole sodium solr iv40 mg

$0-$2.65(Tier

1)

pantoprazole sodium tbecor 20 mg, 40 mg

$0-$2.65(Tier

1)

MO

PREVACID 15 MG (UseLansoprazole) NF RX/OTC; MO

PREVACID 30 MG (UseLansoprazole) NF MO

PRILOSEC CPDR 10 MG,20 MG, 40 MG (UseOmeprazole)

NFMO

PROTONIX SOLR IV 40MG (Use PantoprazoleSodium)

NF

PROTONIX TBEC OR 20MG, 40 MG (UsePantoprazole Sodium)

NFMO

Ulcer Drugs - ProstaglandinsCYTOTEC (UseMisoprostol) NF MO

misoprostol tabs or 100mcg, 200 mcg

$0-$2.65(Tier

1)

MO

Ulcer Therapy Combinations

amoxicillin-clarithromycinw/ lansoprazole

$0-$2.65(Tier

1)

MO

OMECLAMOX-PAK$0-

$6.60(Tier

2)

MO

omeprazole-sodiumbicarbonate 20mg-1100mg

$0-$2.65(Tier

1)

RX/OTC; MO

Name of drug

Whatthe


level)


omeprazole-sodiumbicarbonate 40mg-1100mg

$0-$2.65(Tier

1)

MO

PREVPAC (UseAmoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

ZEGERID CAPS 20MG-1100MG (Use Omeprazole-Sodium Bicarbonate)

NFRX/OTC; MO

ZEGERID CAPS 40MG-1100MG (Use Omeprazole-Sodium Bicarbonate)

NFMO

ZEGERID PACK 20MG-1680MG

$0-$6.60(Tier

2)

ST; MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesHIPREX (UseMethenamine Hippurate) NF MO

MACROBID (UseNitrofurantoin MonohydMacro)

NFMO

MACRODANTIN 100 MG,50 MG (Use NitrofurantoinMacrocrystal)

NFAL; MO

methenamine hippurate$0-

$2.65(Tier

1)

MO

nitrofurantoin macrocrystalcaps or 100 mg, 50 mg

$0-$2.65(Tier

1)

AL; MO

nitrofurantoin monohydmacro

$0-$2.65(Tier

1)

MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms



162

Name of drug

Whatthe


level)


Urinary Antispasmodic - AntimuscarinicsDETROL (Use TolterodineTartrate) NF MO

DETROL LA (UseTolterodine Tartrate) NF MO

DITROPAN XL (UseOxybutynin Chloride) NF MO

oxybutynin chloride$0-

$2.65(Tier

1)

MO

SANCTURA (UseTrospium Chloride) NF MO

SANCTURA XR (UseTrospium Chloride) NF MO

tolterodine tartrate$0-

$2.65(Tier

1)

MO

trospium chloride$0-

$2.65(Tier

1)

MO

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride 10mg, 25 mg, 5 mg, 50 mg

$0-$2.65(Tier

1)

MO

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl$0-

$2.65(Tier

1)

MO

VACCINES

Bacterial Vaccines

ACTHIB$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


MENACTRA$0-

$6.60(Tier

2)

MENOMUNE-A/C/Y/W-135$0-

$6.60(Tier

2)

MENVEO$0-

$6.60(Tier

2)

PEDVAX HIB$0-

$6.60(Tier

2)

TYPHIM VI$0-

$6.60(Tier

2)

Mixed Vaccine Combinations

COMVAX$0-

$6.60(Tier

2)

Viral Vaccines

CERVARIX$0-

$6.60(Tier

2)

ENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML

$0-$6.60(Tier

2)

B/D

GARDASIL$0-

$6.60(Tier

2)

HAVRIX$0-

$6.60(Tier

2)



163

Name of drug

Whatthe


level)


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

$0-$6.60(Tier

2)

B/D

IPOL INACTIVATED IPV$0-

$6.60(Tier

2)

IXIARO$0-

$6.60(Tier

2)

M-M-R II$0-

$6.60(Tier

2)

PROQUAD$0-

$6.60(Tier

2)

RABAVERT$0-

$6.60(Tier

2)

B/D

RECOMBIVAX HB$0-

$6.60(Tier

2)

B/D

ROTARIX$0-

$6.60(Tier

2)

ROTATEQ$0-

$6.60(Tier

2)

TWINRIX$0-

$6.60(Tier

2)

Name of drug

Whatthe


level)


VAQTA$0-

$6.60(Tier

2)

VARIVAX$0-

$6.60(Tier

2)

YF-VAX$0-

$6.60(Tier

2)

ZOSTAVAX$0-

$6.60(Tier

2)

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesMiscellaneous Vaginal Products

benzocaine-resorcinolvaginal 2%-5%

$0(Tier

3)

NT

FEMINEASE$0

(Tier3)

NT

TRIMO-SAN$0

(Tier3)

MO; NT

VAGISIL (Use Benzocaine-Resorcinol Vaginal) NF NT

Spermicides

ENCARE$0

(Tier3)

NT

nonoxynol-9$0

(Tier3)

MO; NT

OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE

$0(Tier

3)

NT



164

Name of drug

Whatthe


level)


OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

$0(Tier

3)

MO; NT

SHUR-SEAL$0

(Tier3)

NT

VCF VAGINALCONTRACEPTIVE FILM

$0(Tier

3)

NT

VCF VAGINALCONTRACEPTIVE FOAM

$0(Tier

3)

NT

Vaginal Anti-infectivesCLEOCIN CREA VA 2 %(Use ClindamycinPhosphate Vaginal)

NFMO

clindamycin phosphatevaginal

$0-$2.65(Tier

1)

MO

clotrimazole vaginal 1 %$0

(Tier3)

MO; NT

GYNE-LOTRIMIN (UseClotrimazole Vaginal) NF MO; NT

METROGEL-VAGINAL(Use MetronidazoleVaginal)

NFMO

metronidazole vaginal$0-

$2.65(Tier

1)

MO

miconazole nitrate vaginalsupp 100 mg

$0(Tier

3)

MO; NT

TERAZOL 3 (UseTerconazole Vaginal) NF MO

TERAZOL 7 (UseTerconazole Vaginal) NF MO

Name of drug

Whatthe


level)


terconazole vaginal$0-

$2.65(Tier

1)

MO

tioconazole vaginal$0

(Tier3)

NT

VAGISTAT-1 (UseTioconazole Vaginal) NF NT

Vaginal Estrogens

estradiol vaginal$0-

$2.65(Tier

1)

MO

PREMARIN CREA VA0.625 MG/GM

$0-$6.60(Tier

2)

MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

ADRENACLICK$0-

$6.60(Tier

2)

MO

AUVI-Q$0-

$6.60(Tier

2)

MO

EPINEPHRINE SOAJ IJ0.15 MG/0.15ML, 0.3MG/0.3ML

$0-$6.60(Tier

2)

MO

EPIPEN 2-PAK$0-

$6.60(Tier

2)

MO

EPIPEN-JR 2-PAK$0-

$6.60(Tier

2)

MO



165

Name of drug

Whatthe


level)


Vasopressors

dobutamine hcl$0-

$2.65(Tier

1)

midodrine hcl$0-

$2.65(Tier

1)

MO

VITAMINS

Oil Soluble Vitamins

A-25$0

(Tier3)

NT

BABY DDROPS (UseCholecalciferol) NF NT

BETA CAROTENE CAPSOR 10000 UNIT

$0(Tier

3)

NT

beta carotene caps or25000 unit

$0(Tier

3)

MO; NT

cholecalciferol caps or1000 unit, 2000 unit, 400unit, 5000 unit

$0(Tier

3)

MO; NT

cholecalciferol liqd or 400unit/ml

$0(Tier

3)

MO; NT

cholecalciferol liqd or 400unt/0.03ml

$0(Tier

3)

NT

cholecalciferol tabs or 1000unit, 2000 unit, 400 unit

$0(Tier

3)

MO; NT

cholecalciferol tabs or 5000unit

$0(Tier

3)

NT

D-VI-SOL (UseCholecalciferol) NF MO; NT

Name of drug

Whatthe


level)


DRISDOL (UseErgocalciferol) NF MO; NT

ergocalciferol caps or50000 unit

$0(Tier

3)

MO; NT

ergocalciferol soln or 8000unit/ml

$0(Tier

3)

MO; NT

MEPHYTON$0

(Tier3)

MO; NT

phytonadione tabs or 100mcg

$0(Tier

3)

MO; NT

vitamin a caps 10000 unit$0

(Tier3)

MO; NT

VITAMIN A CAPS 25000UNIT

$0(Tier

3)

NT

vitamin a caps 8000 unit$0

(Tier3)

NT

VITAMIN A TABS10000UNIT-1000UNIT

$0(Tier

3)

NT

vitamin e caps or 100 unit$0

(Tier3)

NT

vitamin e caps or 1000 unit$0

(Tier3)

MO; NT

vitamin e liqd or 400unit/15ml

$0(Tier

3)

NT

vitamin e soln or 15unit/0.3ml

$0(Tier

3)

MO; NT

WHEAT GERM$0

(Tier3)

RX/OTC; NT

Water Soluble Vitamins



166

Name of drug

Whatthe


level)


AMINOBENZOATEPOTASSIUM

$0(Tier

3)

NT

ascorbic acid chew or 250mg, 250mg

$0(Tier

3)

MO; NT

ascorbic acid cpcr or 500mg

$0(Tier

3)

MO; NT

ascorbic acid soln ij 500mg/ml

$0(Tier

3)

MO; NT

ascorbic acid syrp or 500mg/5ml

$0(Tier

3)

MO; NT

ascorbic acid tabs or 100mg

$0(Tier

3)

NT

ascorbic acid tabs or 250mg

$0(Tier

3)

MO; NT

ascorbic acid tbcr or 1000mg

$0(Tier

3)

NT

ascorbic acid tbcr or 30mg-500mg, 500 mg, 500mg

$0(Tier

3)

MO; NT

biotin tabs or 300 mcg$0

(Tier3)

MO; NT

biotin tabs or 5 mg, 5000mcg, 800 mcg

$0(Tier

3)

NT

calcium ascorbate tabs or$0

(Tier3)

NT

niacin cpcr or 250 mg, 500mg

$0(Tier

3)

MO; NT

niacin tabs or 100 mg, 250mg, 50 mg, 500 mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


niacin tbcr or 250 mg, 500mg, 750 mg

$0(Tier

3)

MO; NT

NIACIN TR$0

(Tier3)

MO; NT

niacinamide tabs or 100 mg$0

(Tier3)

NT

niacinamide tabs or 500 mg$0

(Tier3)

MO; NT

pyridoxine hcl tabs or 100mg, 25 mg, 50 mg

$0(Tier

3)

MO; NT

riboflavin tabs or 100 mg$0

(Tier3)

MO; NT

riboflavin tabs or 25 mg, 50mg

$0(Tier

3)

NT

SLO-NIACIN 500 MG,750MG (Use Niacin) NF MO; NT

thiamine hcl tabs or 100mg, 50 mg

$0(Tier

3)

MO; NT

thiamine mononitrate$0

(Tier3)

NT



167

IndexA & D ZINC OXIDE 98A-25 166A-MANTLE 98abacavir sulfate 68abacavir sulfate-lamivudine-zidovudine 68ABELCET 41ABILIFY 1 MG/ML 67ABILIFY 10 MG 67ABILIFY 15 MG 67ABILIFY 2 MG 67ABILIFY 20 MG, 30 MG 67ABILIFY 5 MG 67ABILIFY 9.75 MG/1.3ML 67ABILIFY DISCMELT 10 MG 66ABILIFY DISCMELT 15 MG 66ABILIFY MAINTENA 66ABRAXANE 61ABSORICA 87acamprosate calcium 154acarbose 33ACCOLATE 21ACCUPRIL 46ACCURETIC 48acebutolol hcl 200 mg, 400mg 75ACEON 4 MG 46ACEON 8 MG 46acetaminophen 100 mg/ml, 160mg/5ml, 80 mg/0.8ml 7acetaminophen 120 mg 8acetaminophen 160 mg 7acetaminophen 160 mg/5ml 7acetaminophen 160 mg/5ml, 80mg/2.5ml 7acetaminophen 80 mg 7acetaminophen 80 mg/0.8ml 8acetaminophen w/ codeine120mg/5ml-12mg/5ml 12acetaminophen w/ codeine300mg-15mg, 300mg-30mg,300mg-60mg 12acetaminophen-caffeine-pyrilamine 7acetazolamide 250 mg 106acetazolamide 500 mg 106acetic acid (otic) 151acetic acid 0.25 % 115acetic acid-aluminumacetate 151

acetylcysteine 10 %, 20 % 86acitretin 90ACNE MEDICATION 87ACNE MEDICATION 10 87ACNE-AID 98ACTEMRA 4ACTHIB 163ACTIGALL 113ACTIMMUNE 59ACTIQ 1200 MCG, 1600 MCG,400 MCG, 600 MCG, 800MCG 8ACTIQ 200 MCG 8ACTIVELLA 111ACTOPLUS MET 33ACTOS 15 MG 36ACTOS 30 MG, 45 MG 36ACUICYN DAILY EYELID &EYELASH CLEANSER 98ACULAR 149ACULAR LS 149acyclovir 200 mg 72acyclovir 200 mg/5ml 72acyclovir 400 mg, 800 mg 72acyclovir sodium 50 mg/ml 72acyclovir sodium 500 mg 72acyclovir topical 91ADACEL 159ADAGEN 76ADALAT CC 76adapalene 0.1 % 87ADCIRCA 78ADD-INS COMPLETE 144ADDERALL XR 1adefovir dipivoxil 71ADIPEX-P 1ADOXA 100 MG, 50 MG, 75MG 158ADOXA PAK 1/100 158ADOXA PAK 1/150 158ADOXA PAK 2/100 158ADRENACLICK 165ADULT ACNOMEL 87ADVAIR DISKUS 22ADVAIR HFA 22ADVIL 4ADVIL ALLERGY &CONGESTION 84

ADVIL MIGRAINE 4AEROCHAMBER MINIAEROSOLCHAMBER 125AEROCHAMBER MV 125AEROCHAMBER PLUS FLOWVU 125AEROCHAMBER PLUS FLOW-VU 125AEROCHAMBER PLUS FLOW-VU/LARGE MASK 125AEROCHAMBER PLUS FLOW-VU/MASK 125AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 125AEROCHAMBER PLUS FLOW-VU/SMALL MASK 125AEROCHAMBER Z-STAT PLUSVALVED HOLDING CHAMBERW/FLOW VU 125AEROCHAMBER Z-STATPLUS/FLOWSIGNAL 125AEROCHAMBER Z-STATPLUS/LARGE MASK 126AEROCHAMBER Z-STATPLUS/MEDIUM MASK 126AEROCHAMBER Z-STATPLUS/SMALL MASK 126AEROCHAMBER/FLOWSIGNAL

126AEROSPAN 22AEROVENT PLUS HOLDINGCHAMBER/COLLAPSIBLE 126AFINITOR 57AFINITOR DISPERZ 57AFRIN PURESEA GENTLEMISTNASAL RINSE 142AFRIN PURESEA MEDIUMSTREAM NASAL RINSE 142AFRIN PURESEA ULTRA-GENTLE MIST NASALRINSE 142AGGRENOX 116AGRYLIN 116AIRZONE PEAK FLOWMETER 126ALBATUSSIN NN 85ALBENZA 15ALBUSTIX 104albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 22albuterol sulfate 2 mg, 4 mg 22albuterol sulfate 2 mg/5ml 22albuterol sulfate 4 mg, 8 mg 22alclometasone dipropionate 92ALCOHOL PADS 124

Index 1

ALDACTAZIDE 25MG-25MG 107ALDACTONE 107ALDARA 96alendronate sodium 10 mg, 5mg 108alendronate sodium 35 mg, 70mg 108ALER-DRYL 43ALEVAZOL 88ALEVE 4alfuzosin hcl 115ALIMTA 100 MG 53ALIMTA 500 MG 53ALINIA 500 MG 16ALKERAN 2 MG 51ALKERAN 50 MG 51ALLI 1allopurinol 100 mg 116allopurinol 300 mg 116ALMACONE 14ALOE VESTA MULTIPURPOSECLEANSING 99alosetron hcl 114ALPHA LIPOIC ACID 50 MG 2ALPHA-LIPOIC ACID 2alpha-lipoic acid (thioctic acid)100 mg 2ALPHAGAN P 0.1 % 147ALPHAGAN P 0.15 % 147alprazolam 0.25 mg, 0.5 mg, 1mg, 2 mg 19alprazolam 0.5 mg, 1 mg, 2 mg, 3mg 19ALSUMA 130ALTACE 46alum & mag hydrox-simethicone200mg-25mg-200mg 14alum & mag hydrox-simethicone200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml, 200mg/5ml-20mg/5ml-200mg/5ml,400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml 15alum & mag hydrox-simethicone200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml 14ALUMINUM ACETATE 99

ALUMINUM HYDROXIDE 15aluminum hydroxide 99aluminum hydroxide-magtrisil 15aluminum sulfate & calciumacetate 99amantadine hcl 100 mg 62amantadine hcl 50 mg/5ml 62AMARYL 1 MG 38AMARYL 2 MG 38AMARYL 4 MG 38AMBI COCOA BUTTERCLEANSING 99AMBI COMPLEXIONCLEANSING 99AMBIEN 10 MG 120AMBIEN 5 MG 120AMBIEN CR 12.5 MG 120AMBIEN CR 6.25 MG 120AMBISOME 41amcinonide 92AMERGE 130AMICAR 500 MG 120amifostine crystalline 60amikacin sulfate 1 gm/4ml, 500mg/2ml 3amiloride &hydrochlorothiazide 107amiloride hcl 107amino acid infusion 15% 145

amino acids 100mg-6.15mg-2.1mg-0.85mg-1.95mg-0.55mg-2.3mg-1.95mg-0.75mg-1.15mg-0.6mg-3.65mg-0.65mg-3.25mg-3.8mg-1.95mg-1.7mg-0.7mg-1.05mg, 115.333mg-54.667mg-21mg-33.333mg-33.333mg-46.667mg-14.167mg-46.667mg-40mg-53.333mg-18.167mg-41mg-66.667mg-40mg-30.667mg-17.333mg-14mg,115.3mg-54.7mg-21mg-33.3mg-13.3mg-33.3mg-63.3mg-14.2mg-46.7mg-40mg-53.3mg-18.2mg-41mg-66.7mg-40mg-30.7mg-17.3mg-14mg, 1200mg-100mg,18.33mg-200mg-33.33mg-50mg-23.16mg-58.33mg-18.33mg-75mg-108.33mg, 200mg-33.33mg-50mg-23.16mg-18.33mg-58.33mg-18.33mg-75mg-108.33mg, 35mg-29.5mg-24.667mg-4.833mg-17.667mg-24.667mg-12.5mg-24mg-19mg-36mg-17.5mg-4.667mg-75mg-15mg, 74mg-50mg-0.7mg-77mg-1.4mg-72mg-64mg-27mg-54mg-70mg-41mg-17mg-109mg-7mg-27mg-68mg-47mg-41mg-64mg

145amino acids 130mg-10mg-130mg-130mg 145amino acids-proteinhydrolysate 145AMINOBENZOATEPOTASSIUM 167aminocaproic acid 500 mg 120aminophylline 23aminosalicylic acid 51AMINOSYN II 15% (Use aminoacid infusion) 145amiodarone hcl 100 mg, 200 mg,400 mg 20amitriptyline hcl 32amlodipine besylate 10 mg 76amlodipine besylate 2.5 mg 76amlodipine besylate 5 mg 76amlodipine besylate-benazeprilhcl 48ammonium chloride 133amoxapine 32amoxicillin & potclavulanate 152amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 152

Index 2

amoxicillin 250 mg, 500 mg 152amoxicillin 500 mg, 875 mg 152amoxicillin-clarithromycin w/lansoprazole 162amphetamine-dextroamphetamine 1amphotericin b 50 mg 41ampicillin & sulbactam sodium1gm-2gm 152ampicillin & sulbactam sodium5gm-10gm 152ampicillin 250 mg, 500 mg 152ampicillin sodium 1 gm, 2gm 152ampicillin sodium 10 gm 152ampicillin sodium 125 mg 152AMPYRA 155ANADROL-50 13ANAFRANIL 32anagrelide hcl 117ANAPROX 5ANAPROX DS 5anastrozole 55ANCOBON 41ANDRODERM 13ANDROGEL 13ANDROGEL PUMP 13ANORO ELLIPTA 22ANTARA 130 MG, 43 MG 44ANTARA 30 MG 45ANTARA 90 MG 45ANTI-BACTERIAL HANDLOTION 99APOKYN 62apraclonidine hcl 147APRISO 114APTIOM 200 MG 25APTIOM 400 MG 25APTIOM 600 MG 25APTIOM 800 MG 25APTIVUS 100 MG/ML 68APTIVUS 250 MG 68AQUANIL SKIN CLEANSER 99AQUORAL 137ARALAST NP 1000 MG 157ARALEN 50ARANESP ALBUMINFREE 118ARAVA 7

ARCALYST 4argatroban 250 mg/2.5ml 24ARGIMENT 145ARGIMENT AT 145arginine 500 mg 145ARIAL CHAMBER 126ARICEPT 154ARICEPT ODT 154ARIMIDEX 55aripiprazole 1 mg/ml 67aripiprazole 10 mg 67aripiprazole 15 mg 67aripiprazole 2 mg 67aripiprazole 20 mg, 30 mg 67aripiprazole 5 mg 67ARIPIPRAZOLE ODT 10MG 67ARIPIPRAZOLE ODT 15MG 67ARISTOSPAN INTRA-ARTICULAR 83ARIXTRA 24ARNUITY ELLIPTA 22AROMASIN 55ARRANON 53ARTHRICARE DOUBLE ICEPAIN RELIEVING RUB 96ARTHRICARE PAINRELIEVINGRUB 96ARTHRICARE TRIPLEMEDICATED PAIN RELIEVINGRUB 96ARTHROTEC 50 5ARTHROTEC 75 5ARZERRA 54ASACOL HD 114ascorbic acid 100 mg 167ascorbic acid 1000 mg 167ascorbic acid 250 mg 167ascorbic acid 250 mg,250mg 167ascorbic acid 30mg-500mg,500 mg, 500mg 167ascorbic acid 500 mg 167ascorbic acid 500 mg/5ml 167ascorbic acid 500 mg/ml 167ASCRIPTIN 8ASPIRIN 120 MG, 200 MG 8aspirin 300 mg, 600 mg 8

aspirin 324 mg, 325 mg, 500 mg,81 mg 8aspirin 325 mg 8aspirin 81 mg 8aspirin buffered (cal carb-magcarb-mag oxide) 8ASPIRIN/DIPYRIDAMOLE 117ASSESS FULL RANGE PEAKFLOW METER 126ASSESS LOW RANGE PEAKFLOW METER 126ASSESS PEAK FLOW METERFULL RANGE 126ASSESS PEAK FLOW METERLOW RANGE 126ASTAGRAF XL 73ASTHMA CHECK METER-ZONESYSTEM 126ASTHMAMENTOR 126ATACAND 47ATACAND HCT 48atenolol & chlorthalidone 48atenolol 100 mg, 25 mg, 50mg 75ATIVAN 0.5 MG, 1 MG, 2MG 19ATIVAN 2 MG/ML 19ATIVAN 4 MG/ML 19ATOPICLAIR 98atorvastatin calcium 45atovaquone 16atovaquone-proguanil hcl 250mg-100mg 50ATRIPLA 68ATROVENT 142ATROVENT HFA 21AUBAGIO 155AUGMENTIN 250MG/5ML-62.5MG/5ML 153AUGMENTIN 500MG-125MG,875MG-125MG 153AUGMENTIN ES-600 153AUGMENTIN XR 153AURSTAT ANTI-ITCHHYDROGEL 98AUVI-Q 165AVALIDE 48AVANDIA 2 MG 36AVANDIA 4 MG 36AVANDIA 8 MG 36AVAPRO 47AVASTIN 54

Index 3

AVEED 13AVEENO ACTIVE NATURALSPURE RENEWALSHAMPOO 99AVEENO MOISTURIZING 99AVEENO POSITIVELYAGELESSDAILY EXFOLIATINGCLEANSER 99AVEENO POSITIVELYRADIANTCLEANSER 99AVEENO SKIN RELIEFSHOWER& BATH 91AVEENO ULTRA-CALMINGCLEANSER 99AVENOVA 99AVODART 115AVONEX 155AVONEX PEN 156AXID 300 MG 160AXSAIN 97AYR NASAL DROPS 142azacitidine 53AZACTAM 15azathioprine 100 mg, 50 mg, 75mg 73azelastine hcl (ophth) 149azelastine hcl 0.1 % 142AZILECT 63azithromycin 100 mg/5ml, 200mg/5ml 124azithromycin 250 mg, 500 mg,600 mg 124azithromycin 500 mg 123AZOPT 149aztreonam 15AZULFIDINE 114AZULFIDINE EN-TABS 114

b complex w/ c 10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg, 100mg-10mg-20mg-10mcg-15mg-5mg-500mg, 100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg, 10mg-10mg-15mg-50mg-5mg-300mg,15mg-10.2mg-10mg-50mg-5mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg,15mg-150mg-10mg-50mg-10.2mg-5mg-300mg, 15mg-20mg-50mg-10mg-10mcg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg, 50mg-10.2mg-10mg-15mg-5mg-300mg, 50mg-10mg-10mg-15mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg 138b complex w/ c 10.2mg-10mg-15mg-50mg-5mg-300mg,10mg-50mg-10.2mg-15mg-5mg-300mg, 10mg-50mg-10mg-15mg-5mg-300mg,15mg-10mg-50mg-10mg-5mg-300mg 138B-100 COMPLEX 138B-6 FOLIC ACID 118b-complex vitamins 0.1mg-20mg-2mg-5mcg-3mg-1mg,100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg, 10mg-10mg-2mg-1.5mg-0.2mg, 10mg-14mg-25mcg-7mg-4.5mg, 15mg-2mg-5mg-2mcg-2mg-2mg, 30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg, 3mg-10mg-20mg-3mg-6mcg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg, 3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg 138

b-complex vitamins 2mg/ml-100mg/ml-2mg/ml-100mg/ml-2mg/ml, 2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml 137b-complex vitamins 2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml 137b-complex vitamins 3.33mg-0.4mg-0.33mg-0.66mcg-0.11mg,60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg, 60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg, 70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg 137b-complex w/ c & folic acid 10mg-20mg-1.5mg-1mg-1.5mg-5mg-300mcg-50mg-60mg, 20mg-1.5mg-10mg-1mg-1.5mg-5mg-300mcg-50mg-60mg 138b-complex w/ folic acid 1.5mg-20mg-1.7mg-6mcg-400mcg-2mg,1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg, 100mg-100mg-100mg-100mcg-400mcg-100mg,100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg,10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg, 10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg, 15mg-100mg-200mg-17mg-60mcg-400mcg-20mg, 30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg 139b-complex w/ folic acid 100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 125mg-125mg-125mg-125mg-125mcg-125mg-125mg-400mcg-125mcg-125mg, 50mg-50mg-50mg-50mg-50mcg-0.4mg-50mcg-50mg,50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg 139BABY ANBESOL 136BABY DDROPS 166BABY ORAJEL 136BACIGUENT 88bacitracin (topical) 88bacitracin zinc 88bacitracin-poly-neomycin-hc

149bacitracin-polymyxin b 88

Index 4

bacitracin-polymyxin b(ophth) 147baclofen 10 mg 141baclofen 20 mg 141BACTRIM 16BACTRIM DS 16BACTROBAN 88BALNETAR LIQUIM 104balsalazide disodium 114BANZEL 25BARACLUDE 71BASIS ALL CLEAR 99BASIS COMBINATION 99BASIS EXTRA DRY 99BASIS NORMAL/DRY 99BASIS SENSITIVE SKIN 99bath products 40%-40%-40%-40%, 5%-5%-5% 91BD GLUCOSE 35BELEODAQ 57BELSOMRA 10 MG 121BELSOMRA 15 MG, 20MG 121BELSOMRA 5 MG 121BELVIQ 1BENADRYL 43BENADRYL ALLERGY 43BENADRYL ALLERGY &COLD 85BENADRYL ALLERGY &SINUSHEADACHE 85BENADRYL ALLERGYCHILDRENS 12.5 MG 43BENADRYL ALLERGYCHILDRENS 12.5 MG/5ML 43BENADRYL DYE-FREEALLERGYLIQUID-GELS 43BENADRYL-D ALLERGY &SINUS 85benazepril &hydrochlorothiazide 48benazepril hcl 10 mg, 20 mg, 40mg, 5 mg 46BENLYSTA 120 MG 75BENSULFOID 87BENTYL 10 MG 160BENTYL 20 MG 160BENZACLIN 87BENZACLIN WITH PUMP 87BENZALKONIUMCHLORIDE 68

BENZAMYCIN 87BENZEDREX INHALER 143benzocaine (dental) 20 % 136benzocaine (dental) 7.5% 136benzocaine-docusatesodium 123benzocaine-resorcinol vaginal2%-5% 164benzonatate 100 mg, 200mg 84benzoyl peroxide 5 % 87benzoyl peroxide-erythromycin 87benztropine mesylate 0.5 mg, 1mg, 2 mg 62benztropine mesylate 1mg/ml 62BERINERT 116BETA CAROTENE 10000UNIT 166beta carotene 25000 unit 166BETAGAN 147betamethasone dipropionate(topical) 92betamethasone dipropionateaugmented 92betamethasone sod phosphate& acetate 83betamethasone valerate 0.1% 92betamethasone valerate 0.12% 92BETAPACE 76BETAPACE AF 76BETASERON 156betaxolol hcl 75betaxolol hcl (ophth) 147bethanechol chloride 10 mg, 25mg, 5 mg, 50 mg 163BETHKIS 3bexarotene 59BIAXIN 124BIAXIN XL 124BIAXIN XL PAC 124bicalutamide 55BICILLIN C-R 300000UNIT/ML-300000UNIT/ML 153BICILLIN C-R900000UNIT/2ML-300000UNIT/2ML 153BICILLIN L-A 152BICNU 51

BIMATOPROST 150BIOFLEXOR 96biotin 300 mcg 167biotin 5 mg, 5000 mcg, 800mcg 167BIPHENOX 7bisacodyl 10 mg 123bisacodyl 5 mg 123bismuth subsalicylate 262mg 39bismuth subsalicylate 262mg/15ml, 525 mg/15ml, 527mg/30ml 39bisoprolol &hydrochlorothiazide 48bisoprolol fumarate 75BIVIGAM 151bleomycin sulfate 15 unit 56bleomycin sulfate 30 unit 56BLEPH-10 147BLINCYTO 54BLUE-EMU SUPERSTRENGTH 97BODI WHIRL OIL 91BODY WASH & SHAMPOO 99BONIVA 150 MG 108BONIVA 3 MG/3ML 108BOOSTRIX 159boric acid in isopropyl 151BOSULIF 57BOTOX 200 UNIT 144BREATHERITE 126BREATHERITECOLLAPSIBLEADULT SPACERW/MASK 126BREATHERITECOLLAPSIBLECHILD SPACERW/MASK 126BREATHERITECOLLAPSIBLEINFANT SPACERW/MASK 126BREATHERITECOLLAPSIBLESMALL CHILDSPACER W/MASK 127BREATHERITECOLLAPSIBLESPACER W/NEONATE MASK 127BREATHERITE RIGIDSPACERW/MASK 127BREATHERITE W/LARGEMASK 127BREATHERITE W/MEDIUMMASK 127

Index 5

BREATHERITE W/SMALLMASK 127BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH 22BREVICON-28 81BRILINTA 117brimonidine tartrate 147BRINTELLIX 10 MG 31BRINTELLIX 20 MG 31BRINTELLIX 5 MG 31BRISDELLE 157bromfenac sodium (ophth) 149bromocriptine mesylate 2.5mg 63bromocriptine mesylate 5 mg63brompheniramine &phenyleph 85brompheniramine &pseudoeph 85BRONCOPECTOL 85budesonide 83budesonide (inhalation) 0.25mg/2ml, 0.5 mg/2ml 22budesonide (nasal) 143BUFFERIN 8BULL FROG QUIK GEL SPF36 103BULL FROG QUIK GEL SPF50 103BULL FROG QUIK GELSPORTSPF 36 103BULL FROG QUIK GELSPORTSPRAY SPF 50 103BULL FROG SPF 36 103BULL FROG WATER ARMORSPORT QUIK GEL SPF 50 104BULL FROG WATER ARMORSPORT QUIK SPRAY SPF50 104bumetanide 0.5 mg, 1 mg, 2mg 107BUMEX 107BUPRENEX 12buprenorphine hcl 0.3 mg/ml 13buprenorphine hcl 2 mg 13buprenorphine hcl 8 mg 13buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 13buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 13bupropion hcl (smokingdeterrent) 157bupropion hcl 100 mg 29

bupropion hcl 150 mg 29bupropion hcl 150 mg, 200mg 29bupropion hcl 300 mg 29bupropion hcl 75 mg 29BURN SPRAY 98buspirone hcl 10 mg, 15 mg, 30mg, 5 mg, 7.5 mg 19BUSULFEX 52butalbital-aspirin-caffeinew/cod 12BUTISOL SODIUM 120butorphanol tartrate 10mg/ml 13butorphanol tartrate 2mg/ml 13BYDUREON 36BYETTA 36cabergoline 111CALAMINE 99CALAMINEPHENOLATED 99CALAN 76CALAN SR 76CALCI-CHEW 132CALCI-MIX 132CALCIONATE 132calcipotriene 90calcitonin (salmon) 108calcitriol 0.25 mcg, 0.5mcg 110calcitriol 1 mcg/ml 110CALCIUM &MAGNESIUM 132calcium 600 mg 132calcium acetate (phosphatebinder) 115calcium ascorbate 167calcium carbonate (antacid)500 mg, 750 mg 15calcium carbonate (antacid)600 mg 15calcium carbonate 1250mg 132calcium carbonate 1250 mg,500 mg, 600 mg, 600mg 132calcium carbonate 1500mg 132CALCIUM CARBONATE 648MG 15calcium carbonate-cholecalciferol 500mg-100unit 132

calcium carbonate-cholecalciferol600mg-500unit 132calcium carbonate-vitamin d125unit-250mg, 125unit-500mg,250mg-125unit, 500mg-125unit 132calcium carbonate-vitamin d200unit-500mg, 500mg-200unit,500mg-500mg-200unit-200unit

132calcium citrate 200 mg, 950mg 132CALCIUM CITRATE 250MG 132calcium citrate-vitamin d 250mg-200unit, 315mg-200unit 132calcium gluconate 10 % 132CALCIUM GLUCONATE 500MG 132CALCIUM LACTATE 648MG 132calcium polycarbophil 121calcium w/ magnesium 500mg-250mg 132CALCIUM/VITAMIN D 132CALCIUM/VITAMIN D3 132CAMPRAL 154CAMPTOSAR 100 MG/5ML, 40MG/2ML 62CAMPTOSAR 300MG/15ML 62CANCIDAS 50 MG 41CANCIDAS 70 MG 41candesartan cilexetil 47candesartan cilexetil-hydrochlorothiazide 49CAPASTAT SULFATE 51CAPRELSA 57capsaicin in lidocaine vehicle97captopril &hydrochlorothiazide 49captopril 100 mg, 12.5 mg, 25mg, 50 mg 46CARAC 90CARAFATE 1 GM 161carbamazepine 100 mg 25carbamazepine 100 mg, 200 mg,300 mg 25carbamazepine 100 mg/5ml 25carbamazepine 200 mg 25carbamazepine 200 mg, 400mg 26carbamide peroxide 136carbamide peroxide (otic) 151

Index 6

CARBATROL 26carbidopa 62carbidopa-levodopa 63carbinoxamine maleate 43carboplatin 150 mg/15ml, 600mg/60ml 52carboplatin 450 mg/45ml, 50mg/5ml 52CARDIZEM 76CARDIZEM CD 76CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 76CARDURA 48carisoprodol 350 mg 141CARMOL 95CARMOL 20 95CARNITOR 330 MG 110CARRAFOAM 99carteolol hcl (ophth) 147carvedilol 75CASODEX 55CATAFLAM 5CATAPRES 48CATAPRES-TTS-1 48CATAPRES-TTS-2 48CATAPRES-TTS-3 48CAVILON NO STINGBARRIERFILM 99CAYSTON 16cefaclor 250 mg, 500 mg 79cefadroxil 78cefazolin sodium 1 gm, 10 gm,500 mg 78cefdinir 79CEFEPIME 1 GM/50ML, 2GM/100ML 80cefepime hcl 80cefixime 100 mg 79cefixime 100 mg/5ml, 200mg/5ml 79cefixime 200 mg 79cefixime 400 mg 79cefotaxime sodium 1 gm, 10gm 79cefotaxime sodium 2 gm, 500mg 79cefpodoxime proxetil 79cefprozil 79ceftazidime 1 gm, 2 gm 79ceftazidime 6 gm 79

CEFTIN 125 MG/5ML 79CEFTIN 250 MG, 500 MG 79ceftriaxone sodium 1 gm 80ceftriaxone sodium 10 gm 80ceftriaxone sodium 2 gm 80ceftriaxone sodium 250 mg80ceftriaxone sodium 500 mg80cefuroxime axetil 79cefuroxime sodium 1.5 gm, 7.5gm 79cefuroxime sodium 750 mg79CELEBREX 5celecoxib 5CELESTONE-SOLUSPAN 83CELEXA 10 MG 30CELEXA 20 MG 30CELEXA 40 MG 30CELLCEPT 200 MG/ML 73CELLCEPT 250 MG 73CELLCEPT 500 MG 74CELLCEPTINTRAVENOUS 73CELONTIN 28CENTANY 88CEO-TWO 122cephalexin 125 mg/5ml, 250mg/5ml 79cephalexin 250 mg, 500 mg,750 mg 78CERALYTE 70 60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L,70MEQ/L-20MEQ/L 133CERASPORT 4MEQ/L-18MEQ/L-20MEQ/L-69MEQ/L,4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L 133CERASPORT EX1 133CERDELGA 117CEREBYX 100 MGPE/2ML 28CEREBYX 500 MGPE/10ML 28CEREFOLIN 106CEREZYME 117CERVARIX 163CESAMET 41CETAPHILANTIBACTERIAL 68CETAPHIL GENTLECLEANSER 99CETAPHIL GENTLECLEANSING 99

cetirizine hcl 1 mg/ml 43cetirizine hcl 1 mg/ml, 5mg/5ml 43cevimeline hcl 137CHANTIX 157CHANTIX CONTINUINGMONTHPAK 157CHEK-STIX COMBO PAKURINALYSIS CONTROL 104CHEK-STIX CONTROL 104CHEMSTRIP -10 WITH SG 104CHEMSTRIP 10 MD 104CHEMSTRIP 2 GP STRIPS105CHEMSTRIP 2 LN STRIPS 105CHEMSTRIP 5 OB 105CHEMSTRIP 7 105CHEMSTRIP 9 STRIPS 105CHEMSTRIP UGK 105CHEMSTRIP-K 105CHEMSTRIP-MICRAL 105chenodiol 113CHERRY CONCENTRATE 153CHERRY SYRUP 153CHEW Q 100 MG 2CHILDRENS MOTRIN 40MG/ML 5CHILDRENS MOTRIN 50 MG 5CHILDRENS MOTRIN JUNIORSTRENGTH 5CHLOR-TRIMETON 42chloramphenicol sodiumsuccinate 17chlordiazepoxide-amitriptyline

155chlorhexidine gluconate (mouth-throat) 137chloroquine phosphate 250 mg,500 mg 50chlorothiazide 500 mg 107chlorpheniramine &phenylephrine 85chlorpheniramine & pseudoeph15mg/5ml-1mg/5ml 85chlorpheniramine maleate 2mg/5ml 42chlorpheniramine maleate 4mg 42chlorpheniramine w/ codeine 85chlorpheniramine-phenylephrine-acetaminophen 1mg/5ml-160mg/5ml-2.5mg/5ml 85chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg 66

Index 7

chlorpromazine hcl 25 mg/ml66chlorpromazine hcl 50mg/2ml 66chlorthalidone 25 mg, 50mg 107chlorzoxazone 141cholecalciferol 1000 unit, 2000unit, 400 unit 166cholecalciferol 1000 unit, 2000unit, 400 unit, 5000 unit 166cholecalciferol 400 unit/ml 166cholecalciferol 400unt/0.03ml 166cholecalciferol 5000 unit 166cholestyramine 4 gm 44cholestyramine 4 gm/dose 44cholestyramine light 44choline fenofibrate 45chorionic gonadotropin 109chromium 200 mcg 135chromium picolinate 200mcg 136ciclopirox 0.77 % 89ciclopirox 1 % 89ciclopirox 8 % 89ciclopirox olamine 89cidofovir 71cilostazol 117CILOXAN 147cimetidine 200 mg 160cimetidine 300 mg, 400 mg, 800mg 160CIMZIA 114CIMZIA STARTER KIT 114CINRYZE 116CIPRO 250 MG, 500 MG 112CIPRO I.V.-IN D5W200MG/100ML-5% 112CIPRO I.V.-IN D5W400MG/200ML-5% 112CIPRO XR 112CIPRODEX 151ciprofloxacin 400 mg/40ml 112ciprofloxacin hcl (ophth) 148ciprofloxacin hcl 100 mg, 250 mg,500 mg, 750 mg 112ciprofloxacin in d5w200mg/100ml-5% 112ciprofloxacin in d5w400mg/200ml-5% 112ciprofloxacin-ciprofloxacinhcl 112

cisplatin 52citalopram hydrobromide 10mg 30citalopram hydrobromide 10mg/5ml 30citalopram hydrobromide 20mg 30citalopram hydrobromide 40mg 30CITRACAL/VITAMIN D 132CITRUCEL FIBERLAXATIVE 121cladribine 53CLAFORAN 1 GM, 10 GM 80CLAFORAN 2 GM, 500MG 80CLARINEX 5 MG 43CLARINEX REDITABS 5MG 43clarithromycin 125 mg/5ml, 250mg/5ml 124clarithromycin 250 mg, 500mg 124clarithromycin 500 mg 124clemastine fumarate 2.68mg 43CLEOCIN 150 MG, 300 MG, 75MG 17CLEOCIN 2 % 165CLEOCIN IN D5W 17CLEOCIN PHOSPHATE300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% 17CLEOCIN PHOSPHATE 600MG/4ML, 900 MG/6ML 17CLEOCIN-T 87CLIMARA 112CLINDAGEL 87clindamycin hcl 150 mg, 300mg, 75 mg 17clindamycin palmitatehydrochloride 17clindamycin phosphate(topical) 87clindamycin phosphate 150mg/ml, 600 mg/4ml 17clindamycin phosphate 150mg/ml, 9000 mg/60ml 17clindamycin phosphate 600mg/4ml, 900 mg/6ml 17clindamycin phosphate ind5w 17clindamycin phosphatevaginal 165

clindamycin phosphate-benzoylperoxide 87clindamycin phosphate-benzoylperoxide (refrigerate) 87CLINISTIX 105CLINITEST 105CLINITEST REAGENT 105clobetasol propionate 92clobetasol propionate emollientbase 92clobetasol propionateemulsion 92CLOBEX 92CLOLAR 53clomipramine hcl 25 mg, 50 mg,75 mg 32clonazepam 0.125 mg, 0.25 mg,0.5 mg, 1 mg, 2 mg 25clonazepam 0.5 mg 25clonazepam 1 mg 25clonazepam 2 mg 25clonidine hcl (adhd) 1clonidine hcl 0.1 mg, 0.2 mg, 0.3mg 48clonidine hcl 0.1 mg/24hr, 0.2mg/24hr, 0.3 mg/24hr 48clopidogrel bisulfate 300mg 117clopidogrel bisulfate 75 mg 117clorazepate dipotassium 19clotrimazole 137clotrimazole (topical) 89clotrimazole vaginal 1 % 165clotrimazole w/betamethasone 89CLOVERINE SALVE 89clozapine 65CLOZAPINE ODT 65CLOZARIL 65COAL TAR 81coal tar extract 1 % 104coal tar extract 1 %, 15 % 104COARTEM 50

Index 8

cod liver oil 10 minim, 110mg-2664unit-1000mg-100mg-200unit, 1250unit-130unit,1250unit-133.33unit, 1250unit-133unit, 1250unit-135unit,200unit-4000unit, 20mg-35mg-1250unit-45mg-133.333unit,34mg-1250unit-415mg-32mg-135unit, 50mg-110mg-250unit-110mg-100unit-10unit, 52mg-2500unit-600mg-52mg-270unit,530mg-1250unit-130unit, 90mg-37mg-415mg-36mg-1250unit-135unit 140COD LIVER OIL 4000UNIT/5ML-400UNIT/5ML, 5000UNIT/5ML-500UNIT/5ML 140COD LIVER OIL FOR KIDS140coenzyme q10 (ubidecarenone)10 mg, 60 mg 2coenzyme q10 (ubidecarenone)150 mg, 30 mg 2COENZYME Q10 25 MG 3COENZYME Q10 60 MG 2COGENTIN 62COLACE 123COLACE CLEAR 123COLAZAL 114COLCHICINE 116colchicine w/ probenecid 116COLCRYS 116COLESTID 44COLESTID FLAVORED 5GM 44colestipol hcl 44colistimethate sodium 16COLY-MYCIN M 16COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 122COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 122COMBISTIX 105COMBIVENT RESPIMAT 22COMBIVIR 68COMETRIQ 57COMPLERA 68COMPLEX MSUD AMINO ACIDBAR 145COMTAN 62COMVAX 163CONCERTA 27 MG, 36 MG 2

CONDOMS 124CONDYLOX 96CONTI CASTILE SOAP 99CONTRAVE 1COPAXONE 156COPEGUS 71CORAL CALCIUM 500MG 132CORDARONE 20COREG 75COREG CR 75CORGARD 76CORLANOR 78CORTEF 83CORTENEMA 14cortisone acetate 83CORTISPORIN10000UNIT/ML-3.5MG/ML-1%

151CORZIDE 49COSENTYX 90COSENTYX SENSOREADYPEN 91COSMEGEN 56COSOPT 147COUMADIN 1 MG, 10 MG, 2MG, 2.5 MG, 3 MG, 4 MG, 5MG, 6 MG, 7.5 MG 24COZAAR 47CREON 106CRESEMBA 186 MG 42CRESEMBA 372 MG 42CRESTOR 45CRIXIVAN 68cromolyn sodium 21cromolyn sodium(mastocytosis) 113cromolyn sodium (ophth) 149CUBICIN 17CUPRIMINE 73CUTAR 104CUTIVATE 93CVS COD LIVER OIL 140CVS GLUCOSE 4 GM 35CVS HDYROCORTISONEACETATE 93CVS KETONE CARE 105CVS NATURAL FIBERSUPPLEMENT 121

CVS SALINE WOUNDWASH 100cyanocobalamin 1000 mcg 117cyanocobalamin 250 mcg 118cyclobenzaprine hcl 10 mg, 5mg 141cyclopentolate hcl 1 % 147cyclophosphamide 25 mg, 50mg 52CYCLOSET 36cyclosporine 100 mg, 25 mg 74cyclosporine 50 mg/ml 74cyclosporine modified (formicroemulsion) 100 mg, 25 mg,50 mg 74CYKLOKAPRON 120CYMBALTA 31cyproheptadine hcl 2 mg/5ml44cyproheptadine hcl 4 mg 44CYRAMZA 54CYSTARAN 149cytarabine 100 mg/ml 53cytarabine 20 mg/ml 53CYTOMEL 159CYTOTEC 162CYTOVENE 71D-VI-SOL 166D.H.E. 45 130dacarbazine 100 mg 59dacarbazine 200 mg 59DACOGEN 53dakin's solution 0.25 %, 0.5% 68DALIRESP 21danazol 100 mg, 200 mg, 50mg 13DANTRIUM 142dantrolene sodium 100 mg, 25mg, 50 mg 142dapsone 100 mg, 25 mg 17DAPTACEL 159DARA 100DARAPRIM 50daunorubicin hcl 56DAUNOXOME 56DAYPRO 5DDAVP 111DEBROX 151decitabine 53

Index 9

DECON-A 2MG/5ML-5MG/5ML 85DEEP BLUE RELIEF 97DELESTROGEN 10MG/ML 112DELESTROGEN 20 MG/ML, 40MG/ML 112DELZICOL 114DEMADEX 107demeclocycline hcl 158DEMEROL 100 MG/ML, 50MG/ML 8DEMEROL 25 MG/ML 9DEMSER 47DENAVIR 91DEPACON 28DEPAKENE 29DEPAKOTE 29DEPAKOTE ER 29DEPAKOTE SPRINKLES 29DEPEN TITRATABS 73DEPO-MEDROL 20 MG/ML 83DEPO-MEDROL 40 MG/ML, 80MG/ML 83DEPO-PROVERA 55DEPO-PROVERACONTRACEPTIVE 82DERMA-SMOOTHE/FSBODY 93DERMA-SMOOTHE/FSSCALP 93DERMAGRAN 98DERMAREST ROSACEA 98dermatological products, misc.0.17%-2.7%, 4%-2%-0.5% 98DERMATOP 93DERMAZINC BABY 91DERMAZINC SCALP 91DERMAZINC SPRAY 91DERMOPLAST 97DERMOPLAST PAINRELIEVINGSPRAY 97DERMOTIC 151desipramine hcl 10 mg, 100 mg,150 mg, 25 mg, 50 mg, 75mg 32desloratadine 5 mg 43desmopressin acetate 0.1 mg,0.2 mg 111desmopressin acetate 4mcg/ml 111

desmopressin acetaterefrigerated 111desmopressin acetatespray 111desmopressin acetate sprayrefrigerated 111DESOGEN 81desogestrel & ethinylestradiol 81desogestrel-ethinyl estradiol(biphasic) 81desonide 93DESOWEN 93desoximetasone 0.05 % 93desoximetasone 0.25 % 93DESOXYN 1DESVENLAFAXINE ER 100MG, 50 MG 31DETROL 163DETROL LA 163DEX4 QUICK DISSOLVEGLUCOSE 35dexamethasone 0.5 mg, 0.75mg, 1 mg, 1.5 mg, 2 mg, 4 mg,6 mg 83dexamethasone 0.5mg/5ml 83dexamethasone sodiumphosphate (ophth) 149dexamethasone sodiumphosphate 10 mg/ml 83dexamethasone sodiumphosphate 10 mg/ml, 120mg/30ml 83dexamethasone sodiumphosphate 100 mg/10ml, 20mg/5ml, 4 mg/ml 83DEXATRIM MAX 1MG-5.5UNIT-34MCG-72MG-75MG-0.35MG-70MG-45MG-0.263MG-10MG-1.8MG-3.5MG-0.3MG-3MCG-70MCG-0.35MG-25MG-30MG 106dexbrompheniramine &pseudoephedrine 85DEXEDRINE 1DEXILANT 161dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 2dexmethylphenidate hcl 15mg 2dexrazoxane 60dextroamphetamine sulfate 10mg, 15 mg, 5 mg 1dextroamphetamine sulfate 10mg, 5 mg 1

dextrose (diabetic use) 15gm/38gm, 40 % 35dextrose 10 % 144dextrose 5 % 144dextrose in lactated ringers 133dextrose w/ sodium chloride0.45%-2.5%, 0.45%-5% 133dextrose w/ sodium chloride0.9%-5% 133DHS 100DHS COLOR SAFESHAMPOO 100DHS CONDITIONINGRINSE 100DHS ZINC 91DIABETA 1.25 MG 38DIABETA 2.5 MG 38DIABETA 5 MG 38DIABETIDERMCLEANSING 100DIAMOX 106DIASTAT ACUDIAL 25DIASTAT PEDIATRIC 25DIASTIX 105diazepam 1 mg/ml 19diazepam 10 mg, 2 mg, 5mg 19DIAZEPAM 10 MG, 2.5 MG, 20MG 25diazepam 5 mg/ml 19DIBENZYLINE 47diclofenac potassium 5diclofenac sodium (actinickeratoses) 90diclofenac sodium (ophth) 149diclofenac sodium 100 mg 5diclofenac sodium 25 mg, 50 mg,75 mg 5diclofenac w/ misoprostol 5dicloxacillin sodium 153dicyclomine hcl 10 mg 160dicyclomine hcl 20 mg 160didanosine 68diethylpropion hcl 25 mg 1DIETHYLPROPION HCL 25MG 1diethylpropion hcl 75 mg 1DIFFERIN 0.1 % 87DIFICID 124diflorasone diacetate 93DIFLUCAN 42

Index 10

diflunisal 8DIGOXIN 0.05 MG/ML 77digoxin 0.125 mg, 0.25 mg, 125mcg, 250 mcg 77dihydroergotamine mesylate 1mg/ml 130DILANTIN-125 28DILAUDID 1 MG/ML 9DILAUDID 2 MG 9DILAUDID 2 MG/ML 9DILAUDID 4 MG 9DILAUDID 8 MG 9DILAUDID-HP 10 MG/ML 9diltiazem hcl 120 mg, 180 mg,240 mg 77diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 77diltiazem hcl 120 mg, 60 mg, 90mg 77diltiazem hcl coated beads 76diltiazem hcl extended releasebeads 77DIMETAPP COLD & ALLERGY1MG/5ML-2.5MG/5ML 85dimethicone-zinc oxide-vitamin a-vitamin d 100DIOVAN 47DIOVAN HCT 49DIPENTUM 114diphenhydramine hcl(topical) 90diphenhydramine hcl 12.5mg 43diphenhydramine hcl 12.5mg/5ml 43diphenhydramine hcl 12.5mg/5ml, 25 mg/10ml, 50mg/20ml 43diphenhydramine hcl 25 mg 43diphenhydramine hcl 50mg/ml 43diphenhydramine-phenylephrine12.5mg/5ml-5mg/5ml 85diphenhydramine-phenylephrine25mg-10mg 85diphenhydramine-phenylephrine-acetaminophen 12.5mg-12.5mg-325mg-325mg-5mg-5mg,12.5mg-325mg-5mg 85diphenhydramine-phenylephrine-acetaminophen 12.5mg/5ml-160mg/5ml-2.5mg/5ml 85diphenhydramine-pseudoephedrine-acetaminophen

85

diphenhydramine-zinc acetate0.1%-1% 90diphenoxylate w/ atropine 39DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 159DIPROLENE 93DIPROLENE AF 93dipyridamole 25 mg, 50 mg, 75mg 117disopyramide phosphate 20disulfiram 250 mg, 500mg 154DITROPAN XL 163divalproex sodium 29DIVIGEL 112dobutamine hcl 166DOCEFREZ 61docetaxel 140 mg/7ml, 20mg/ml, 80 mg/4ml 61DOCETAXEL 160 MG/16ML,20 MG/2ML, 200 MG/20ML, 80MG/8ML 61DOCETAXEL 20 MG/ML, 80MG/4ML 61docosahexaenoic acid 200mg 144docusate calcium 123docusate sodium 100 mg 123docusate sodium 100 mg, 250mg, 50 mg 123docusate sodium 150 mg/15ml,50 mg/5ml 123docusate sodium 283 mg 123docusate sodium 60mg/15ml 123DOCUSOL KIDS 123DOLOPHINE 10 MG 9DOLOPHINE 5 MG 9DOMEBORO 1347MG-952MG 100donepezil hydrochloride 154DORYX 150 MG 158dorzolamide hcl 150dorzolamide hcl-timololmaleate 147DOVONEX 91doxazosin mesylate 48doxepin hcl 10 mg, 100 mg,150 mg, 25 mg, 50 mg, 75mg 33doxepin hcl 10 mg/ml 33DOXIL 56

doxorubicin hcl 10 mg 57doxorubicin hcl 2 mg/ml 57doxorubicin hcl 50 mg 57doxorubicin hcl liposomal 56doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 158doxycycline (monohydrate) 100mg, 50 mg, 75 mg 158doxycycline (monohydrate) 25mg/5ml 158doxycycline hyclate 100 mg158doxycycline hyclate 100 mg, 20mg 158doxycycline hyclate 100 mg, 50mg 158doxycycline hyclate 150 mg158DRISDOL 166DRIXORALCOLD/ALLERGY 85dronabinol 41drospirenone-ethinylestradiol 81DROXIA 117DUAC 87DUETACT 33DULCOLAX 123DULCOLAX BOWEL PREPKIT 123DULERA 23duloxetine hcl 20 mg, 30 mg, 60mg 31DUONEB 23DUOPA 63DURAGESIC 100 MCG/HR 9DURAGESIC 12 MCG/HR 9DURAGESIC 25 MCG/HR 9DURAGESIC 50 MCG/HR 9DURAGESIC 75 MCG/HR 9dutasteride 115DYAZIDE 107dyphylline-guaifenesin 21E-Z SPACER 127E-Z SPACER THE BODYGUARDS PACK 127EASIVENT 127EASIVENT/MASK-LARGE 127EASIVENT/MASK-MEDIUM

127EASIVENT/MASK-SMALL 127EC-NAPROSYN 5econazole nitrate 89

Index 11

ECOTRIN MAXIMUMSTRENGTH 8ECOTRIN REGULARSTRENGTH 8ED CHLORPED 42ED CHLORPED D 85EDURANT 68EFFEXOR XR 150 MG 31EFFEXOR XR 37.5 MG 31EFFEXOR XR 75 MG 31EFFIENT 117EFUDEX 90EGRIFTA 2 MG 109ELDEPRYL 63ELELYSO 117ELESTAT 150ELETONE 98ELETONE TWINPACK 98ELIDEL 96ELIGARD 55ELIQUIS 24ELITEK 60ELIXSURE CONGESTION 143ELIXSURE FEVER/PAIN 8ELLA 82ELLENCE 57ELOCON 93ELOXATIN 52ELTA CLEANSE FOAM 100ELTA LITE TAR 104ELTA TAR 104EMCYT 55EMEND 125 MG, 80 MG 41EMEND 40 MG 41EMLA 97EMSAM 30EMTRIVA 68enalapril maleate &hydrochlorothiazide 49enalapril maleate 10 mg, 2.5 mg,20 mg, 5 mg 46ENBREL 7ENBREL SURECLICK 7ENCARE 164ENFALYTE 133ENFAMIL ENFALYTE 133ENGERIX-B 10 MCG/0.5ML, 20MCG/ML 163

enoxaparin sodium 24entacapone 62entecavir 71ENTOCORT EC 83ENTRESTO 78ENTSOL HYPERTONICNASAL IRRIGATIONMIST 142ENTSOL NASAL SPRAY 142ENTSOL NASAL WASH 142ENTYVIO 114ENUCLENE 150EPHEDRINE HCL 23EPHEDRINE SULFATE 23epinastine hcl (ophth) 150EPINEPHRINE 0.15MG/0.15ML, 0.3MG/0.3ML 165epinephrine hcl 0.1 mg/ml 23EPIPEN 2-PAK 165EPIPEN-JR 2-PAK 165epirubicin hcl 200 mg/100ml, 50mg/25ml 57EPIVIR 10 MG/ML 68EPIVIR 150 MG, 300 MG 68EPIVIR HBV 100 MG 71EPIVIR HBV 5 MG/ML 71eplerenone 50EPOGEN 118eprosartan mesylate 47EPZICOM 68EQL CALCIUM/VITAMIND 133EQL CHILDRENSMULTIVITAMINS 139EQL NATURAL FIBER 121EQUETRO 64ERAXIS 100 MG 41ERBITUX 54ergocalciferol 50000 unit 166ergocalciferol 8000unit/ml 166ergoloid mesylates 156ergotamine tartrate 130ERIVEDGE 55ERWINAZE 59erythromycin (acne aid) 87erythromycin (ophth) 148erythromycin base 250mg 124

erythromycin base 500 mg 124erythromycinethylsuccinate 124erythromycin lactobionate 124erythromycin stearate 124ESBRIET 158escitalopram oxalate 30esomeprazole magnesium 20mg 161esomeprazole magnesium 40mg 161ESOMEPRAZOLESTRONTIUM 161estradiol & norethindroneacetate 111estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 112estradiol 0.5 mg, 1 mg, 2mg 112estradiol vaginal 165estradiol valerate 10 mg/ml, 20mg/ml, 40 mg/ml 112estradiol-norgestimate 111estropipate 0.75 mg, 1.5mg 112ethambutol hcl 100 mg, 400mg 51ethosuximide 250 mg 28ethosuximide 250 mg/5ml 28ethynodiol diacet & ethestrad 81ETHYOL 60etodolac 200 mg, 300 mg 5etodolac 400 mg, 500 mg 5etodolac 400 mg, 500 mg, 600mg 5ETOPOPHOS 61etoposide 1 gm/50ml, 100mg/5ml 61etoposide 500 mg/25ml 61EVAC 121EVISTA 109EVOCLIN 87EVOTAZ 68EVOXAC 137EX-LAX 123EXELON 1.5 MG, 3 MG, 4.5 MG,6 MG 154EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 154exemestane 55

Index 12

EXJADE 40EXPECTA LIPIL 144EXTAVIA 156EXTINA 89EYE STREAM 150FA-8 118FABRAZYME 35 MG 110famciclovir 72famotidine 10 mg 160famotidine 20 mg 160famotidine 20 mg/2ml, 200mg/20ml, 40 mg/4ml 160famotidine 40 mg 160famotidine 40 mg/5ml 160FAMVIR 72FANAPT 64FARESTON 55FARXIGA 38FARYDAK 57FASLODEX 55fat emulsion 20 gm/100ml 144FAZACLO 65felbamate 28FELBATOL 28FELDENE 5felodipine 77FEMARA 55FEMCON FE 81FEMINEASE 164fenofibrate 145 mg, 160 mg, 48mg, 54 mg 45fenofibrate micronized 45fentanyl 100 mcg/hr 9fentanyl 12 mcg/hr 9fentanyl 25 mcg/hr 9fentanyl 50 mcg/hr 9fentanyl 75 mcg/hr 9fentanyl citrate 1200 mcg, 1600mcg, 400 mcg, 600 mcg, 800mcg 9fentanyl citrate 200 mcg 9FER-IN-SOL 119FERGON 119FERRIPROX 40ferrous fumarate 324 mg, 325mg 119FERROUS FUMARATE 90MG 119

FERROUS GLUCONATE 225MG 119ferrous gluconate 240 mg, 27mg 119ferrous sulfate 15 mg/ml 119ferrous sulfate 220mg/5ml 119FERROUS SULFATE 220MG/5ML 119FERROUS SULFATE 300MG/5ML 119FERROUS SULFATE 324MG 119ferrous sulfate 325 mg 119ferrous sulfate 325 mg, 65mg 119ferrous sulfate 50 mg 119ferrous sulfate dried 160mg 119FETZIMA 120 MG, 40 MG, 80MG 31FETZIMA 20 MG 32FETZIMA TITRATIONPACK 32FEVERALL INFANTS 8FIBERCON 121FINACEA 103finasteride 115FIORINAL/CODEINE #3 12FIRAZYR 116FIRMAGON 55FLAGYL 16flavoxate hcl 163FLEBOGAMMA DIF 10 %151flecainide acetate 100 mg 20flecainide acetate 150 mg 20flecainide acetate 50 mg 20FLECTOR 88FLEET BISACODYL 123FLEET LIQUID GLYCERINSUPPOSITORIES 122FLEXICHAMBER 127FLOMAX 115FLONASE 143FLORICAL 134FLOVENT DISKUS 100MCG/BLIST 22FLOVENT DISKUS 250MCG/BLIST 22FLOVENT DISKUS 50MCG/BLIST 22FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 22

FLOVENT HFA 44MCG/ACT 22fluconazole 10 mg/ml, 40mg/ml 42fluconazole 100 mg, 150 mg, 200mg, 50 mg 42fluconazole in dextrose 42fluconazole in nacl 200mg/100ml-0.9%, 400mg/200ml-0.9% 42flucytosine 41FLUDARA 53fludarabine phosphate 50mg 53fludrocortisone acetate 84FLUMADINE 73flunisolide (nasal) 143fluocinolone acetonide(otic) 151fluocinolone acetonide 0.01% 93fluocinolone acetonide 0.01 %,0.025 % 93fluocinolone acetonide 0.025% 93fluocinonide 0.05 % 93fluocinonide emulsified base 93fluorometholone (ophth) 149fluorouracil (topical) 90FLUOROURACIL 0.5 % 90fluorouracil 1 gm/20ml 53fluorouracil 2.5 gm/50ml, 5gm/100ml, 500 mg/10ml 53fluoxetine hcl (PMDD) cap 10 mg,20 mg 156fluoxetine hcl 10 mg, 20 mg 30fluoxetine hcl 10 mg, 20 mg, 40mg 30fluoxetine hcl 20 mg/5ml 30fluoxetine hcl 90 mg 30fluoxymesterone 13fluphenazine decanoate 66fluphenazine hcl 1 mg, 10 mg, 2.5mg, 5 mg 66fluphenazine hcl 2.5 mg/ml 66fluphenazine hcl 5 mg/ml 66flurbiprofen 100 mg, 50 mg 5flurbiprofen sodium 150flutamide 55fluticasone propionate(nasal) 143fluticasone propionate 0.005% 94

Index 13

fluticasone propionate 0.05% 94fluvastatin sodium 20 mg, 40mg 45fluvoxamine maleate 30FML LIQUIFILM 149FOCALIN 2FOCALIN XR 15 MG 2FOLGARD RX 118FOLIC + B12 118folic acid 1 mg 118FOLIC ACID 20 MG, 5 MG 118folic acid 400 mcg, 800mcg 118folic acid-pyridoxine-cyancobalamin 106folic acid-vitamin b6-vitaminb12 119FOLOTYN 53FOLTRATE 119fondaparinux sodium 24FORADIL AEROLIZER 23FORFIVO XL 29FORMULA 405 FACIAL &BODYCLEANSING 100FORMULA 405MOISTURIZINGSOAP 100FORTAMET 1000 MG 34FORTAMET 500 MG 34FORTAZ 1 GM, 2 GM 80FORTAZ 6 GM 80FORTEO 108FORTICAL 108FOSAMAX 108fosinopril sodium 47fosinopril sodium &hydrochlorothiazide 49fosphenytoin sodium 100 mgpe/2ml 28fosphenytoin sodium 500 mgpe/10ml 28FOSRENOL 115FRAGMIN 10000 UNIT/ML,12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000 UNT/0.72ML,2500 UNIT/0.2ML, 25000UNIT/ML, 5000 UNIT/0.2ML,7500 UNIT/0.3ML 24FRAGMIN 95000UNIT/3.8ML 24FREE & CLEAR 100FRESH'N FEMININEDEODORANT 98

furosemide 10 mg/ml 107furosemide 20 mg, 40 mg, 80mg 107FUSILEV 60FUZEON 68FYCOMPA 10 MG 24FYCOMPA 12 MG 24FYCOMPA 2 MG 24FYCOMPA 4 MG 24FYCOMPA 6 MG 24FYCOMPA 8 MG 25gabapentin 100 mg, 300 mg,400 mg 26gabapentin 250 mg/5ml 26gabapentin 600 mg, 800mg 26GABITRIL 12 MG, 16 MG 28GABITRIL 2 MG, 4 MG 28galantaminehydrobromide 154GAMASTAN S/D 151GAMMAGARD LIQUID 151GAMMAKED 151GAMUNEX-C 151ganciclovir sodium 71GARDASIL 163GAS-X EXTRA STRENGTH125 MG 113GASTROCROM 113gatifloxacin (ophth) 148gauze pads 2" X 2" 124GAZYVA 54gelatin 650 mg 73GELONASAL 142GELUSIL 200MG-25MG-200MG 15GEMCITABINE 53gemcitabine hcl 1 gm, 200mg 53gemcitabine hcl 2 gm 54gemfibrozil 45GEMZAR 54GENOTROPIN 5 MG 109GENOTROPIN MINIQUICK 0.4MG 109gentamicin in saline 0.9%-0.8mg/ml 3gentamicin in saline 0.9%-1.2mg/ml, 0.9%-1.6mg/ml,0.9%-1mg/ml 3

gentamicin sulfate (ophth) 148gentamicin sulfate (topical) 88gentamicin sulfate 10 mg/ml 3gentamicin sulfate 40 mg/ml 3GENTEAL MILD TOMODERATE 146GENTLE RAIN EXTRAMILD 100GENTLE RAIN SHAMPOO ANDSKIN CLEANSER 100GENTLE SKIN CLEANSER100GEODON 20 MG 64GEODON 20 MG, 40 MG, 60MG, 80 MG 64GERI-SHAMPOO/SHEABUTTER 100GERISILK BATH OIL 91GILENYA 156GILOTRIF 57GILTUSS PED-C 85glatiramer acetate 156GLEEVEC 57GLEOSTINE 52glimepiride 1 mg 38glimepiride 2 mg 38glimepiride 4 mg 38glipizide 10 mg 38glipizide 2.5 mg 38glipizide 5 mg 38glipizide-metformin hcl 2.5mg-250mg 33glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg 33GLUCAGEN HYPOKIT 35glucagon (rdna) 35GLUCOPHAGE 1000 MG 34GLUCOPHAGE 500 MG 34GLUCOPHAGE 850 MG 34GLUCOPHAGE XR 500 MG 34GLUCOPHAGE XR 750 MG 34glucosamine sulfate 500 mg 3glucosamine-chondroitin 200mg-250mg 3GLUCOSE 4 GM 35glucose 5 % 144GLUCOSE NURSETTE 144GLUCOTROL 10 MG 38GLUCOTROL 5 MG 38GLUCOTROL XL 10 MG 38GLUCOTROL XL 2.5 MG 38

Index 14

GLUCOTROL XL 5 MG 38GLUCOVANCE 1.25MG-250MG 33GLUCOVANCE 2.5MG-500MG,5MG-500MG 34GLUMETZA 1000 MG 35GLUMETZA 500 MG 35GLUTAMENT 145GLUTOL 104glyburide 1.25 mg 39glyburide 2.5 mg 39glyburide 5 mg 39glyburide micronized 1.5 mg 39glyburide micronized 3 mg 39glyburide micronized 6 mg 39glyburide-metformin 1.25mg-250mg 34glyburide-metformin 2.5mg-500mg, 5mg-500mg 34GLYCERIN 99 %, 99.5 % 80GLYCERINE 80GLYCEROL FORMAL 81glycopyrrolate 0.2 mg/ml 160glycopyrrolate 1 mg, 2 mg 160GLYNASE 1.5 MG 39GLYNASE 3 MG 39GLYNASE 6 MG 39GLYSET 33GNP CALAMINE 100GNP CALAMINEPHENOLATED 100GNP GLUCOSE 4 GM 35GNP QUICK DISSOLVEGLUCOSE 35GNP SALINE WOUNDWASH 100GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM 122GRANDPAS BAKING SODASOAP 100GRANDPAS INDIAN CORNSOAP 100GRANDPAS LOVE MY LOOFAHSOAP 100GRANDPAS OATMEALSOAP 100GRANDPAS ORANGEESSENCE SOAP 100GRANDPAS PATCHOULISOAP 100GRANDPAS PINE TARSOAP 104

GRANDPAS SHEA BUTTERSOAP 100GRANDPAS WITCH HAZELSOAP 100granisetron hcl 1 mg 40GRANIX 118GRIS-PEG 41griseofulvin microsize 41griseofulvin ultramicrosize 41guaifenesin-codeine100mg/5ml-10mg/5ml 86guanfacine hcl 48guanfacine hcl (adhd) 1guanidine hcl 50GYNE-LOTRIMIN 165H.P. ACTHAR 109HALAVEN 61HALCION 120HALDOL 65HALDOL DECANOATE100 65HALDOL DECANOATE 50 65halobetasol propionate 94haloperidol 65haloperidol decanoate 100mg/ml, 50 mg/ml 65haloperidol lactate 65HARVONI 71HAVRIX 163HEMA-COMBISTIX 105HEMOCYTE 119HEMOCYTE-F 119HEPAMENT 145heparin sodium (porcine) 24HEPSERA 71HERCEPTIN 54HETLIOZ 121HEXALEN 52HIPREX 162HIZENTRA 152HM CALAMINE 101HPR PLUS 98HUMALOG 36HUMALOG KWIKPEN 36HUMALOG MIX 50/50 36HUMALOG MIX 50/50KWIKPEN 36HUMALOG MIX 75/25 36

HUMALOG MIX 75/25KWIKPEN 37HUMATROPE 109HUMATROPE COMBOPACK 109HUMIRA 4HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 4HUMIRA PEN 4HUMIRA PEN-CROHNSDISEASESTARTER 4HUMIRA PEN-PSORIASISSTARTER 4HUMULIN 70/30 37HUMULIN 70/30 KWIKPEN 37HUMULIN 70/30 PEN 37HUMULIN N 37HUMULIN N KWIKPEN 37HUMULIN N U-100 PEN 37HUMULIN R 37HUMULIN R U-500(CONCENTRATED) 37HURRICAINE 136HURRICAINE ONE 136HYCAMTIN 62hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 50HYDREA 59hydrochlorothiazide 12.5mg 107hydrochlorothiazide 12.5 mg, 25mg, 50 mg 107HYDROCIL INSTANT 121hydrocodone polistirex-chlorpheniramine polistirex 86hydrocodone w/homatropine 84hydrocodone-acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 12hydrocodone-acetaminophen10mg-325mg, 5mg-325mg,7.5mg-325mg 12hydrocodone-acetaminophen2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml 12hydrocodone-ibuprofen 12hydrocortisone (intrarectal) 14hydrocortisone (rectal) 14hydrocortisone (topical) 0.5% 94hydrocortisone (topical) 1 % 94

Index 15

hydrocortisone (topical) 2.5% 94hydrocortisone 10 mg, 20 mg, 5mg 83hydrocortisone acetate(topical) 94hydrocortisone butyrate 94hydrocortisone butyratehydrophilic lipo base 94hydrocortisone sodsuccinate 83hydrocortisone valerate 94hydrocortisone w/aceticacid 151hydrocortisone-aloe vera 94hydrogen peroxide (mouth-throat) 137hydrogen peroxide-benzylalcohol 137hydromorphone hcl 1 mg/ml 9hydromorphone hcl 10 mg/ml, 2mg/ml, 50 mg/5ml, 500mg/50ml 9hydromorphone hcl 2 mg 9hydromorphone hcl 4 mg 9hydromorphone hcl 8 mg 9HYDROPEL 101hydrophilic ointment 153hydroxychloroquine sulfate 50hydroxyurea 59hydroxyzine hcl 10 mg, 25 mg, 50mg 19hydroxyzine hcl 10 mg/5ml 19hydroxyzine hcl 25 mg/ml, 50mg/ml 19hydroxyzine pamoate 25 mg, 50mg 19HYLATOPIC PLUS 98hypromellose (ophth) 0.3 %, 3mg/ml 146HYQVIA 152HYSINGLA ER 100 MG, 120MG 10HYSINGLA ER 20 MG, 30 MG,40 MG, 60 MG, 80 MG 10HYVEE ADVANCED ANTACIDMAXIMUM STRENGTH 15HYZAAR 49I.L.X. B-12 119ibandronate sodium 150mg 108ibandronate sodium 3mg/3ml 108IBRANCE 57

ibuprofen 100 mg 5ibuprofen 100 mg/5ml 5ibuprofen 200 mg 5ibuprofen 40 mg/ml, 50mg/1.25ml 5ibuprofen 400 mg 6ibuprofen 600 mg 6ibuprofen 800 mg 6ICLUSIG 58IDAMYCIN PFS 57idarubicin hcl 57IFEX 1 GM 52IFEX 3 GM 52ifosfamide 1 gm 52ifosfamide 1 gm/20ml, 3gm/60ml 52IFOSFAMIDE 3 GM 52ILARIS 4ILEVRO 150IMBRUVICA 58imipenem-cilastatin 17imipramine hcl 10 mg, 25 mg,50 mg 33imipramine pamoate 33imiquimod 96IMITREX 100 MG 130IMITREX 25 MG 131IMITREX 50 MG 131IMITREX 6 MG/0.5ML 130IMITREX STATDOSE REFILL4 MG/0.5ML 130IMITREX STATDOSE REFILL6 MG/0.5ML 130IMITREX STATDOSE SYSTEM4 MG/0.5ML 130IMITREX STATDOSE SYSTEM6 MG/0.5ML 130IMOVAX RABIES(H.D.C.V.) 164IMURAN 74INCIVEK 71INCRELEX 109INCRUSE ELLIPTA 21indapamide 108INDERAL LA 76indomethacin 25 mg, 50 mg 6indomethacin 75 mg 6INFANRIX 159INFANTS ADVIL 6INLYTA 58

INOSITOL 500 MG 144INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECE 127INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM

128INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL

128INSPIREASE DRUGDELIVERYSYSTEM 128INSPRA 50INSULIN SYRINGES AND PENNEEDLES 125INTELENCE 100 MG, 200MG 69INTELENCE 25 MG 69INTRON A 59INTRON A W/DILUENT 59INTUNIV 1INVANZ 17INVEGA 1.5 MG 64INVEGA 3 MG 64INVEGA 6 MG 64INVEGA 9 MG 64INVEGA SUSTENNA 64INVEGA TRINZA 64INVIRASE 69INVOKAMET 150MG-1000MG,150MG-500MG, 50MG-1000MG 34INVOKAMET 50MG-500MG 34INVOKANA 38IODINE STRONG 134IOPIDINE 0.5 % 147IPECAC 40IPOL INACTIVATED IPV 164ipratropium bromide 21ipratropium bromide (nasal)143ipratropium-albuterol 23irbesartan 47irbesartan-hydrochlorothiazide

49IRESSA 58irinotecan hcl 100 mg/5ml, 40mg/2ml 62irinotecan hcl 500 mg/25ml 62IRON 256 MG 119IRON 28 MG 119IRON CHEWS PEDIATRIC 119

Index 16

iron combinations 119irrigation solutions,physiological 75ISENTRESS 100 MG 69ISENTRESS 25 MG 69ISENTRESS 400 MG 69isoniazid & rifampin 51isoniazid 100 mg, 300 mg 51ISOPTO CARPINE 147ISOPTO TEARS 146ISORDIL TITRADOSE 5 MG 18isosorbide dinitrate 10 mg, 20mg, 30 mg, 5 mg 18isosorbide dinitrate 40 mg 18isosorbide mononitrate 10 mg, 20mg 18isosorbide mononitrate 120 mg,30 mg, 60 mg 18isotretinoin 10 mg, 20 mg, 30 mg,40 mg 87ISTODAX 58ITCH-X 97itraconazole 42ivermectin 15IXEMPRA KIT 61IXIARO 164JADENU 40JAKAFI 58JALYN 115JANUMET 34JANUMET XR 100MG-1000MG 34JANUMET XR 50MG-1000MG,50MG-500MG 34JANUVIA 36JARDIANCE 10 MG 38JARDIANCE 25 MG 38JENTADUETO 34JEVTANA 61JOHNSONS BABY BAR 101JOHNSONS BUDDIES EASY-GRIP SUDZING 101JOHNSONS KIDS SUPERSUDZER E-Z GRIP SOAP 101JUXTAPID 10 MG 46JUXTAPID 20 MG 46JUXTAPID 30 MG 46JUXTAPID 40 MG, 60 MG 46JUXTAPID 5 MG 46K-TAB 10 MEQ 135

K-TAB 8 MEQ 135KADCYLA 54KADIAN 100 MG 10KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG 10KALBITOR 116KALETRA 69KALYDECO 150 MG 157KALYDECO 50 MG, 75MG 157KAPVAY 1KARAYA GUM 153KAYEXALATE 75KAZANO 34KEFLEX 79KENALOG-10 83KENALOG-40 83KEPIVANCE 60KEPPRA 26KEPPRA XR 26KERLONE 75KETO-DIASTIX 105KETOCARE 105ketoconazole 42ketoconazole (topical) 89KETONE TEST STRIPS 105ketoprofen 50 mg, 75 mg 6ketorolac tromethamine(ophth) 150ketorolac tromethamine 15mg/ml, 30 mg/ml 6ketorolac tromethamine 30mg/ml, 60 mg/2ml 6KETOSTIX 105ketotifen fumarate (ophth)150KEYTRUDA 54KHEDEZLA 32KINERET 4KLARON 88KLONOPIN 0.5 MG 25KLONOPIN 1 MG 25KLONOPIN 2 MG 25KOMBIGLYZE XR 2.5MG-1000MG 34KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 34KONSYL 100 % 121KONSYL 28.3 %, 60.3 % 121KONSYL 60.3 %, 71.67% 121

KONSYL-D 121KUVAN 100 MG 110KUVAN 100 MG, 500 MG 110KYNAMRO 44L-CARNITINE 250 MG 145L-CITRULLINE 145L-METHYL-MC 106labetalol hcl 100 mg, 200 mg, 300mg 75LABSTIX 105LAC-HYDRIN 95lactated ringer's 133LACTIC ACID 80lactic acid (ammonium lactate) 12% 95lactic acid (ammonium lactate) 5% 95LACTIC ACID RACEMIC 80lactulose 122lactulose (encephalopathy) 114LAMICTAL 100 MG, 150 MG,200 MG, 25 MG 26LAMICTAL CHEWABLEDISPERSIBLE 26LAMICTAL XR 26LAMICTAL XR 100 MG, 200 MG,25 MG, 250 MG, 300 MG, 50MG 26LAMISIL 250 MG 41LAMISIL AT 89LAMISIL AT JOCK ITCH 89lamivudine 69lamivudine (hbv) 71lamivudine-zidovudine 69lamotrigine 100 mg, 150 mg, 200mg, 25 mg 26lamotrigine 100 mg, 200 mg, 25mg, 250 mg, 300 mg, 50 mg 26lamotrigine 25 mg, 5 mg 26LANACANE 97lanolin 154lanolin (topical) 101LANOLIN ANHYDROUS 153LANOLIN ANHYDROUS-GRX 154LANOXIN 125 MCG, 250MCG 77LANOXIN 187.5 MCG, 62.5MCG 78lansoprazole 15 mg 161lansoprazole 30 mg 161

Index 17

LANTUS 37LANTUS SOLOSTAR 37LASIX 107latanoprost 150LATUDA 120 MG 64LATUDA 20 MG 64LATUDA 40 MG 64LATUDA 60 MG 64LATUDA 80 MG 64LAZANDA 100 MCG/ACT 10LAZANDA 400 MCG/ACT 10LEADER QUICK DISSOLVEGLUCOSE 35lecithin 144LECITHINCONCENTRATE 144leflunomide 10 mg, 20 mg 7LEMTRADA 156LENVIMA 10MG DAILYDOSE 58LENVIMA 14MG DAILYDOSE 58LENVIMA 20MG DAILYDOSE 58LENVIMA 24MG DAILYDOSE 58LESCOL 45LETAIRIS 78letrozole 55leucovorin calcium 10 mg, 15 mg,25 mg, 5 mg 60leucovorin calcium 100 mg, 200mg, 350 mg 60leucovorin calcium 50 mg, 500mg 60LEUKERAN 52LEUKINE 118leuprolide acetate 55levalbuterol hcl 0.31 mg/3ml, 0.63mg/3ml, 1.25 mg/0.5ml, 1.25mg/3ml 23LEVAQUIN 25 MG/ML 113LEVAQUIN 250 MG, 500 MG,750 MG 113LEVAQUIN 250MG/50ML-5%,500MG/100ML-5% 112LEVAQUIN 750MG/150ML-5% 112LEVEMIR 37LEVEMIR FLEXPEN 37LEVEMIR FLEXTOUCH 37

levetiracetam 100 mg/ml, 500mg/5ml 26levetiracetam 1000 mg, 250mg, 500 mg, 750 mg 26LEVETIRACETAM1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML, 500MG/100ML-820MG/100ML 26levetiracetam 500 mg, 750mg 26levetiracetam 500 mg/5ml 26levobunolol hcl 0.5 % 147levocarnitine (metabolicmodifiers) 330 mg 110levocarnitine 250 mg 145levocetirizinedihydrochloride 43levofloxacin (ophth) 148levofloxacin 25 mg/ml 113levofloxacin 250 mg, 500 mg,750 mg 113levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5% 113levofloxacin in d5w750mg/150ml-5% 113LEVOLEUCOVORIN 60levoleucovorin calcium 60levonorgestrel & ethestradiol 81levonorgestrel (emergency oc)0.75 mg 82levonorgestrel (emergency oc)1.5 mg 82levonorgestrel-eth estradiol(triphasic) 81levonorgestrel-ethinyl estradiol(91-day) 81levothyroxine sodium 100 mcg,112 mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200 mcg,25 mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg 159LEXAPRO 30LEXIVA 69LEXUSS 210 86lidocaine 5 % 97lidocaine hcl (local anesth.) 1%, 2 % 123lidocaine hcl (mouth-throat) 2% 136lidocaine hcl 0.5 % 97lidocaine hcl 2 % 97

lidocaine hcl 4 % 97lidocaine-prilocaine 97LIDODERM 97LINCOCIN 18lindane 103linezolid 2 mg/ml 18linezolid 600 mg 18liniments & rubs 0.01%-5%-10%,1.2%-2.6%-4.7%, 10%-0.025%-15% 97liniments & rubs 0.25%, 8%-2% 97LINZESS 114liothyronine sodium 25 mcg, 5mcg, 50 mcg 159LIPITOR 45LIPOSYN III 1.2GM/100ML-10GM/100ML-2.5GM/100ML

144LIPTRUZET 44LIQ-10 50MG/5ML-15UNIT/5ML 3lisinopril &hydrochlorothiazide 49lisinopril 10 mg, 2.5 mg, 20 mg,30 mg, 40 mg, 5 mg 47LITEAIRE 128lithium 63lithium carbonate 150 mg, 300mg, 600 mg 63lithium carbonate 300 mg 63lithium carbonate 300 mg, 450mg 63LITHIUM CARBONATE 600MG 63LITHOBID 63LOBOB CONTACT LENSWEARERS SOAP 101LOCOID 94LOCOID LIPOCREAM 94LODOSYN 62LOMOTIL 39lomustine 10 mg 52LOMUSTINE 100 MG, 40MG 52loperamide hcl 2 mg 39LOPID 45LOPRESSOR 100 MG, 50MG 75LOPRESSOR HCT 49LOPROX 89LOPROX SHAMPOO 89

Index 18

lorazepam 0.5 mg, 1 mg, 2mg 20lorazepam 2 mg/ml 20lorazepam 2 mg/ml, 20mg/10ml 20lorazepam 4 mg/ml 20losartan potassium 48losartan potassium &hydrochlorothiazide 49LOSEASONIQUE 81LOTEMAX 149LOTENSIN 47LOTENSIN HCT 49LOTREL 49LOTRISONE 89LOTRONEX 114lovastatin 45LOVAZA 44LOVENOX 24LOWILA 101loxapine succinate 10 mg, 25 mg,5 mg, 50 mg 65LUMIGAN 150LUMIZYME 110LUPRON DEPOT 55LUPRON DEPOT-PED 11.25MG 110LUPRON DEPOT-PED 11.25MG, 15 MG, 7.5 MG 110LUPRON DEPOT-PED 30MG 110lutein 6 mg 3LUVOX CR 30LUXIQ 95LYCELLE 103LYNPARZA 58LYRICA 100 MG 26LYRICA 150 MG 26LYRICA 20 MG/ML 27LYRICA 200 MG 26LYRICA 225 MG, 300 MG 27LYRICA 25 MG 27LYRICA 50 MG 27LYRICA 75 MG 27LYSODREN 56LYSTEDA 120M-M-R II 164MAALOX 15MACROBID 162

MACRODANTIN 100 MG, 50MG 162mafenide acetate 92MAG-TAB SR 135MAGINEX 135MAGINEX DS 135MAGNEBIND 200 133magnesium 250 mg,250mg 135magnesium chloride 535 mg,64 mg 135MAGNESIUM CHLORIDEHEXAHYDRATE 135MAGNESIUM ELEMENTAL 30MG 135MAGNESIUM GLUCONATE250 MG, 500 MG, 550MG 135magnesium sulfate 50 % 135MALARONE 250MG-100MG 50malathion 103maprotiline hcl 29MARINOL 41MARPLAN 30MATULANE 59MAVIK 47MAXALT 10 MG 131MAXALT 5 MG 131MAXALT-MLT 10 MG 131MAXALT-MLT 5 MG 131MAXIPIME 1 GM, 2 GM 80MAXITROL 149MAXZIDE 107MAXZIDE-25 107MCT OIL 144meclizine hcl 12.5 mg, 25mg 40meclizine hcl 25 mg 40MEDI-LYTE 133MEDIPLAST 96MEDROL 16 MG, 32 MG, 4MG, 8 MG 84MEDROL 2 MG 84MEDROL DOSEPAK 84medroxyprogesteroneacetate 154medroxyprogesterone acetate(contraceptive) 82mefenamic acid 6mefloquine hcl 50

MEGACE ES 154MEGACE ORAL 56megestrol acetate(appetite) 154megestrol acetate 20 mg, 40mg 56megestrol acetate 40 mg/ml, 400mg/10ml 56MEIJER CALAMINE 101MEKINIST 58meloxicam 15 mg, 7.5 mg 6melphalan hcl 52memantine hcl 10 mg, 5 mg155memantine hcl 2 mg/ml 154MENACTRA 163MENOMUNE-A/C/Y/W-135

163menthol (topical analgesic) 5% 88MENVEO 163meperidine hcl 100 mg/ml, 50mg/ml 10meperidine hcl 25 mg/ml 10meperidine hcl 50 mg/5ml 10MEPHYTON 166MEPRON 17mercaptopurine 54meropenem 17MERREM 17mesalamine 114mesalamine w/ cleanser 114mesna 60MESNEX 100 MG/ML 60MESNEX 400 MG 61MESTINON 60 MG 50MESTINON TIMESPAN 50METADATE CD 2METAFOLBIC 106METAMUCIL 0.52 GM 122METAMUCIL 48.57 % 122METAMUCIL MULTIHEALTHFIBER 55.46 % 122METAMUCIL ORIGINALTEXTURE 122METAMUCIL SMOOTHTEXTUREFIBER SINGLES122metaxalone 141metformin hcl 1000 mg 35metformin hcl 1000 mg, 750mg 35

Index 19

metformin hcl 500 mg 35metformin hcl 850 mg 35methadone hcl 10 mg 10methadone hcl 10 mg/5ml 10methadone hcl 10 mg/ml 10methadone hcl 5 mg 10methadone hcl 5 mg/5ml 10METHADOSE 10METHADOSE SUGAR-FREE 10methamphetamine hcl 1methazolamide 25 mg, 50mg 107methenamine hippurate 162methimazole 10 mg, 5 mg 159methocarbamol 500 mg, 750mg 141methotrexate sodium 1 gm 54methotrexate sodium 1 gm/40ml,100 mg/4ml, 200 mg/8ml, 25mg/ml, 250 mg/10ml, 50mg/2ml 54methotrexate sodium 10 mg, 15mg, 2.5 mg, 5 mg, 7.5 mg 54methoxsalen rapid 91methscopolamine bromide 2.5mg, 5 mg 160methylcellulose (laxative) 2gm/10.2gm, 2 gm/19gm 122methyldopa &hydrochlorothiazide 49methylergonovine maleate 0.2mg 151methylphenidate hcl 10 mg, 20mg, 30 mg, 40 mg, 50 mg, 60mg 2methylphenidate hcl 10 mg, 20mg, 5 mg 2methylphenidate hcl 20 mg, 27mg, 36 mg 2methylphenidate hcl 20 mg, 30mg, 40 mg 2methylphenidate hcl 27 mg, 36mg 2methylprednisolone 16 mg, 32mg, 4 mg, 8 mg 84methylprednisolone acetate 40mg/ml, 80 mg/ml 84methylprednisolone sodsucc 84metoclopramide hcl 10 mg, 5mg 113metoclopramide hcl 10 mg/10ml,5 mg/5ml 113metolazone 108

metoprolol &hydrochlorothiazide 49metoprolol succinate 75metoprolol tartrate 100 mg, 25mg, 50 mg 75METROCREAM 103METROGEL 103METROGEL-VAGINAL 165METROLOTION 103metronidazole (topical) 103metronidazole 250 mg, 500mg 16metronidazole 375 mg 16metronidazole in nacl 16metronidazole vaginal 165MEVACOR 45mexiletine hcl 20MG217 MEDICATEDTAR 104MIACALCIN 200UNIT/ACT 108MIACALCIN 200UNIT/ML 108MICATIN 89miconazole nitrate (topical)89miconazole nitrate vaginal 100mg 165MICRO-K 135MICROCHAMBER 128MICROLIFE DIGITAL PEAKFLOW METER 128MICROLIPID 144MICROSPACER 128MICROZIDE 108midodrine hcl 166MIDOL COMPLETE 500MG-15MG-60MG 7MIDOL MAXIMUM STRENGTHMENSTRUAL 7MIDOL MAXIMUM STRENGTHMENSTRUAL FORMULA 7MILK OF MAGNESIACONCENTRATE 123MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE 128MINI WRIGHT PEAK FLOWMETER 128MINIPRESS 48MINOCIN 100 MG, 50 MG, 75MG 158minocycline hcl 100 mg, 50mg 159

minocycline hcl 100 mg, 50 mg,75 mg 158minoxidil 10 mg, 2.5 mg 50MIRAPEX 63mirtazapine 29MIRVASO 103misoprostol 100 mcg, 200mcg 162mitomycin 20 mg, 40 mg, 5mg 57mitoxantrone hcl 57MOBIC 15 MG, 7.5 MG 6modafinil 2MODICON 81moexipril hcl 47moexipril-hydrochlorothiazide

49mometasone furoate 95MONOCAL 134MONODOX 159montelukast sodium 10 mg 21montelukast sodium 4 mg, 5mg 21morphine sulfate 0.5 mg/ml 10morphine sulfate 1 mg/ml 10morphine sulfate 10 mg/5ml 10morphine sulfate 100 mg 10morphine sulfate 100 mg, 200mg, 30 mg, 60 mg 11morphine sulfate 100 mg/5ml, 20mg/ml 10MORPHINE SULFATE 15MG 11morphine sulfate 15 mg 11morphine sulfate 20 mg, 30 mg,50 mg, 60 mg, 80 mg 10morphine sulfate 20 mg/5ml 11MORPHINE SULFATE 30MG 11MOSCO CALLUS/CORNREMOVER 96MOTRIN INFANTS 6MOTRIN INFANTS DROPS 6MOTRIN JUNIORSTRENGTH 6MOZOBIL 120MS CONTIN 100 MG, 200 MG,30 MG, 60 MG 11MS CONTIN 15 MG 11MS QUICK DISSOLVEGLUCOSE 35MTX SUPPORT 119

Index 20

MULTAQ 21MULTI-DELYN/IRON 139MULTISTIX 105MULTISTIX 10 SG 105MULTISTIX 5 105MULTISTIX 7 105MULTISTIX 8 SG 105MULTISTIX 9 105MULTISTIX 9 SG 105MULTITRACE-4 136mupirocin 88mupirocin calcium (topical) 88MURO 128 2 % 150MURO 128 5 % 150MUSTARGEN 52MYALEPT 110MYAMBUTOL 51MYCAMINE 41MYCOBUTIN 51mycophenolate mofetil 74mycophenolate sodium 74MYFORTIC 74MYLANTA 200MG/5ML-20MG/5ML-200MG/5ML 15MYLANTA DOUBLE-STRENGTH 15MYLANTA GAS 113MYLANTA GAS RELIEFMAXIMUM STRENGTH 113MYOZYME 110MYSOLINE 27nabumetone 6nadolol &bendroflumethiazide 49nadolol 20 mg, 40 mg, 80mg 76nafcillin sodium 1 gm, 10gm 153nafcillin sodium 2 gm 153NAFTIN 2 % 89NAGLAZYME 110nalbuphine hcl 10 mg/ml, 20mg/ml 13naloxone hcl 1 mg/ml 40naltrexone hcl 40NAMENDA 10 MG, 5 MG 155NAMENDA 10 MG/5ML 155NAMENDA TITRATIONPAK 155NAMENDA XR 14 MG 155

NAMENDA XR 21 MG, 28MG 155NAMENDA XR 7 MG 155NAMENDA XR TITRATIONPACK 155naphazoline w/ pheniramine0.025%-0.3% 148NAPHCON-A 148NAPROSYN 6naproxen 250 mg, 375 mg, 500mg 6naproxen 375 mg, 500 mg 6naproxen sodium 220 mg 6naproxen sodium 275 mg, 550mg 6naratriptan hcl 131NARDIL 30NASALDECONGESTANT 143NASALGUARD 98nateglinide 37NATPARA 108NATURE DE FRANCE ALGOLISOAP 101NATURE DE FRANCE ARGILEBLANCHE SOAP 101NATURE DE FRANCEARGIMIEL SOAP 101NAVELBINE 61NEBUPENT 16nefazodone hcl 31NEO-SYNEPHRINE 0.25% 143NEO-SYNEPHRINE 0.5% 143NEO-SYNEPHRINE COLD &SINUS MILD 143NEO-SYNEPHRINE COLD &SINUS REGULAR 143neomycin sulfate 3neomycin-bacitracin zn-polymyxin 148neomycin-bacitracin-polymyxinw/ lidocaine 88neomycin-polymy-dexameth 149neomycin-polymyxin-gramicidin

148neomycin-polymyxin-hc(otic) 151neomycin/polymyxin b gu 115NEORAL 100 MG, 25 MG 74NEOSALUS 98NEOSALUS CP 98

NERVO B-12 SL 139NESINA 36NESSI SPACER/LARGEMASK 128NESSISPACER/MOUTHPIECE 128NESSI SPACER/SMALL/MEDMASK 128NEULASTA 118NEULASTA DELIVERY KIT118NEUMEGA 118NEUPOGEN 118NEUPRO 63NEURONTIN 27NEUTROGENA ACNECLEANSING SOAP 101NEUTROGENA CLEANREPLENISHING 101NEUTROGENA FACIAL SOAPORIGINAL FORMULA 101NEUTROGENA NATURALSFACE& BODY 101NEUTROGENASHAMPOO 101NEUTROGENA TRIPLEMOISTURE UV SHIELD 101NEVANAC 150nevirapine 100 mg 69nevirapine 200 mg 69nevirapine 400 mg 69NEVIRAPINE 50 MG/5ML 69NEW SKIN 98NEXAFED SINUS PRESSURE+PAIN 86NEXAVAR 58NEXIUM 10 MG, 2.5 MG, 20 MG,40 MG, 5 MG 161NEXIUM 20 MG 161NEXIUM 40 MG 161niacin (antihyperlipidemic) 46niacin 100 mg, 250 mg, 50 mg,500 mg 167niacin 250 mg, 500 mg 167niacin 250 mg, 500 mg, 750mg 167NIACIN TR 167niacinamide 100 mg 167niacinamide 500 mg 167NIASPAN 46nicardipine hcl 20 mg, 30 mg77NICODERM CQ 157NICORETTE 157

Index 21

NICORETTE MINI 157NICORETTE STARTERKIT 157nicotine 157nicotine polacrilex 2 mg, 4mg 157NICOTINE TRANSDERMALSYSTEM 157NICOTROL INHALER 157NICOTROL NS 157nifedipine 30 mg, 60 mg, 90mg 77NILANDRON 56nimodipine 77NIRAVAM 20nisoldipine 17 mg, 34 mg, 8.5mg 77nit remover 103NITRATEST PAPER 105NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 18nitrofurantoin macrocrystal 100mg, 50 mg 162nitrofurantoin monohydmacro 162nitroglycerin 0.1 mg/hr, 0.2 mg/hr,0.4 mg/hr, 0.6 mg/hr 19nitroglycerin 0.4 mg/spray 19NITROGLYCERIN LINGUAL18NITROLINGUALPUMPSPRAY 19NITROMIST 19NITROSTAT 19NIVATOPIC PLUS 98NIVEA MOISTURIZING BODYWASH 101NIVEA MOISTURIZING BODYWASH 2 IN 1 101NIVEA TOUCH OFSMOOTHNESS MOISTURIZINGBODY WASH 101NIVEA VISAGE EYECONTOUR 104NIVEA VISAGE GENTLECLEANSING 101NIX CREME RINSE 103nizatidine 150 mg, 300 mg 160NIZORAL 89NIZORAL A-D 89NO-STING SKIN-PREP 101NOBLE FORMULA 2 % 91nonoxynol-9 164

NONYX 98NOR-QD 83NORDITROPIN FLEXPRO 10MG/1.5ML, 5 MG/1.5ML 109norelgestromin-ethinylestradiol 82norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 81norethindrone & ethestradiol 81norethindrone & ethinylestradiol-fe 0.4mg-35mcg 81norethindrone(contraceptive) 83norethindrone acet & ethestra 81norethindrone acetate 154norethindrone acetate-ethinylestradiol 5mcg-1mg 111norethindrone-eth estradiol(triphasic) 81norgestimate-ethinylestradiol 82norgestimate-ethinyl estradiol(triphasic) 82norgestrel & ethinylestradiol 82NORINYL 1+35 82NORPACE 20NORPRAMIN 33nortriptyline hcl 10 mg, 25 mg,50 mg, 75 mg 33nortriptyline hcl 10 mg/5ml 33NORVASC 10 MG 77NORVASC 2.5 MG 77NORVASC 5 MG 77NORVIR 69NORWEGIAN COD LIVEROIL 140NOVA MAX PLUS KETONETESTSTRIPS 106NOXAFIL 100 MG 42NOXAFIL 300 MG/16.7ML 42NOXAFIL 40 MG/ML 42NUEDEXTA 156NULLO 73NULOJIX 74NULYTELY/FLAVORPACKS 122NUTRATEAR 146NUTROPIN AQ NUSPIN20 109

NUTROPIN AQ PEN 20MG/2ML 109NUVARING 82NYMALIZE 77nystatin 41nystatin (mouth-throat) 137nystatin (topical) 89nystatin-triamcinolone 89OC8 98OCEAN NASAL SPRAY 142OCTAGAM 10 GM/100ML, 2GM/20ML, 20 GM/200ML, 5GM/50ML 152octreotide acetate 100 mcg/ml,1000 mcg/5ml, 200 mcg/ml, 50mcg/ml 111OCUFEN 150OCUFLOX 148OCUSOFT HAND SOAP 101OCUSOFT LID SCRUBFOAMING 101OCUSOFT LID SCRUBORIGINAL 101ODOMZO 55OFEV 158ofloxacin (ophth) 148ofloxacin (otic) 151OILATUM 101olanzapine 65olanzapine-fluoxetine hcl 155olopatadine hcl (nasal) 142OLUX 95OLUX-E 95OLYSIO 71OMECLAMOX-PAK 162omega-3 fatty acids 180mg-120mg, 300mg, 300mg-160mg-1000mg-100mg-5unit, 300mg-772.5mg-90mg-180mg 144omega-3 fatty acids 180mg-500mg-120mg, 27mg-244mg-500mg-89mg, 300mg-1000mg-200mg, 300mg-200mg, 500 mg,500mg, 500mg-270mg-135mg,500mg-320mg-130mg, 90mg-500mg-60mg 144omega-3-acid ethyl esters 44omeprazole 10 mg, 20 mg, 40mg 161omeprazole-sodium bicarbonate20mg-1100mg 162

Index 22

omeprazole-sodium bicarbonate40mg-1100mg 162OMNIFLEX DIAPHRAGM 125OMNIPRED 149OMNITROPE 10 MG/1.5ML, 5MG/1.5ML 109ONCASPAR 59ondansetron 40ondansetron hcl 24 mg, 4 mg, 8mg 40ondansetron hcl 4 mg/2ml, 40mg/20ml 40ondansetron hcl 4 mg/5ml 40ONE A DAY WOMENSPRENATAL/DHA 139ONFI 25ONGLYZA 36OPANA 10 MG 11OPANA 5 MG 11OPDIVO 54OPSUMIT 78OPTICHAMBERADVANTAGE 128OPTICHAMBERADVANTAGE/LARGEMASK 128OPTICHAMBERADVANTAGE/MEDIUM FACEMASK 128OPTICHAMBERADVANTAGE/SMALL FACEMASK 129OPTICHAMBER DIAMOND129OPTICHAMBERDIAMOND/LARGEFACEMASK 129OPTICHAMBERDIAMOND/MEDIUM FACEMASK 129OPTICHAMBERDIAMOND/SMALLFACEMASK 129OPTICHAMBER FACEMASK/LARGE 129OPTICHAMBER FACEMASK/MEDIUM 129OPTICHAMBER FACEMASK/SMALL 129OPTIHALER 129OPTIHALER MDI DRUGDELIVERY SYSTEM 129OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE 164

OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

165OPTIVAR 150OPURITY B12/FOLICACID 119ORABASE 136oral electrolytes 16meq/473ml-21meq/473ml-9meq/473ml-11gm/473ml, 18.8meq/l-42.4meq/l-33.2meq/l-4.8gm/l-18.8gm/l, 20meq/1000ml-45meq/1000ml-35meq/1000ml-25gm/1000ml, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-25gm/l-25gm/l,20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-5gm/l-20gm/l,20meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-25gm/l,20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-25gm/l, 20meq/l-45meq/l-35meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm,20meq/l-45meq/l-35meq/l-7.8mg/l-25gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25meq/l, 20meq/l-45meq/l-45meq/l-35meq/l-5gm/l-20gm/l,35meq/l-45meq/l-20meq/l-20gm/l, 35meq/l-45meq/l-20meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-30gm/l,35meq/l-45meq/l-20meq/l-30meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-5gm/l-20gm/l,35meq/l-45meq/l-20meq/l-7.5mg/l-25meq/l, 35meq/l-45meq/l-20meq/l-7.8mg/l-25

134oral electrolytes 287mg-180mg-15mg 134ORAP 157ORAPRED ODT 84ORAZINC 136ORENCIA 7ORFADIN 110

ORKAMBI 158ORTHO DIAPHRAGM ALL-FLEX/65MM 125ORTHO DIAPHRAGM ALL-FLEX/70MM 125ORTHO DIAPHRAGM ALL-FLEX/75MM 125ORTHO DIAPHRAGM ALL-FLEX/80MM 125ORTHO EVRA 82ORTHO MICRONOR 83ORTHO TRI-CYCLEN 82ORTHO-CEPT 82ORTHO-CYCLEN 82ORTHO-NOVUM 1/35 82ORTHO-NOVUM 7/7/7 82OSENI 12.5MG-15MG 34OSENI 12.5MG-30MG, 12.5MG-45MG, 25MG-15MG, 25MG-30MG, 25MG-45MG 34OTEZLA 7OTREXUP 4OVIDE 103oxacillin sodium 10 gm 153oxacillin sodium 2 gm 153oxaliplatin 100 mg, 50 mg 52oxaliplatin 100 mg/20ml, 50mg/10ml 52OXANDRIN 13oxandrolone 10 mg, 2.5 mg 13oxaprozin 6oxazepam 20oxcarbazepine 27OXSORALEN ULTRA 91oxybutynin chloride 163oxycodone hcl 100 mg/5ml, 20mg/ml 11oxycodone hcl 15 mg 11oxycodone hcl 30 mg 11oxycodone hcl 5 mg 11oxycodone w/ acetaminophen10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg 12oxycodone w/ acetaminophen5mg/5ml-325mg/5ml 12oxycodone-aspirin 12oxymorphone hcl 10 mg 11oxymorphone hcl 15 mg 11oxymorphone hcl 5 mg 11oxymorphone hcl 7.5 mg 11

Index 23

oyster shell 133P & S 91paclitaxel 100 mg/16.7ml, 30mg/5ml, 300 mg/50ml 61paclitaxel 150 mg/25ml 61paliperidone 1.5 mg 64paliperidone 3 mg 64paliperidone 6 mg 64paliperidone 9 mg 64PAMELOR 33PAMINE 160PAMINE FORTE 160PANCREAZE 106PANRETIN 90PANTHODERM 95pantoprazole sodium 20 mg, 40mg 162pantoprazole sodium 40mg 162papaya 5mg-5mg-3mg-2mg-20mg 73PARAFON FORTE DSC 141parenteral electrolytes 134paricalcitol 1 mcg, 2 mcg, 4mcg 110PARLODEL 63PARNATE 30paromomycin sulfate 3paroxetine hcl 31PATADAY 150PATANASE 142PAXIL 10 MG, 20 MG, 30 MG, 40MG 31PAXIL 10 MG/5ML 31PAXIL CR 31PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC

129PEAK FLOW METER 129ped multivitamins w/fl &iron 139PEDI-WHIRLCONCENTRATE 68PEDIALYTE 20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L,20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L 134PEDIALYTE FREEZERPOPS 134PEDIATEX TD 86pediatric multiple vitamin w/c 139

pediatric multiple vitamin w/extra c & fa 139pediatric multiple vitamins w/iron 0.6mg/ml-10mg/ml-5unit/ml-8mg/ml-1500unit/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 1500unit/ml-10mg/ml-5unit/ml-400unit/ml-8mg/ml-0.6mg/ml-0.5mg/ml-0.4mg/ml-35mg/ml 139pediatric vitamins acd w/fluoride 139pediatric vitamins adc 139PEDVAX HIB 163peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 122peg 3350-potassium chloride-sod bicarbonate-sodchloride 122PEG-INTRON 72PEG-INTRON REDIPEN 72PEG-INTRON REDIPEN PAK4 72PEGANONE 28PEGASYS 72PEGASYS PROCLICK 72PEGINTRON 72penicillin g potassium 20 mu,20000000 unit, 5000000unit 152penicillin v potassium 152PENLAC NAIL LACQUER 90PENTAM 300 16pentoxifylline 116PEPCID 160PEPCID AC 160PEPTO BISMOL 39PEPTO-BISMOL 39PEPTO-BISMOLINSTACOOL 39PEPTO-BISMOL MAXSTRENGTH 39PEPTO-BISMOL TO-GO 39PERCODAN 12PERIDEX 137perindopril erbumine 2 mg 47perindopril erbumine 4 mg 47perindopril erbumine 8 mg 47PERJETA 54permethrin 0.5 % 103permethrin 1 % 103permethrin 5 % 103

PEROXYL 1.5%-6% 137perphenazine 16 mg, 2 mg, 4 mg,8 mg 66perphenazine-amitriptyline 155PERSANTINE 117PERSONAL BEST FULLRANGE 129PERSONAL BEST LOWRANGE 129PETROLATUM 95PHACID 102phenazopyridine hcl 100 mg, 200mg 116phenelzine sulfate 30phenobarbital 100 mg, 15 mg,16.2 mg, 30 mg, 32.4 mg, 60 mg,64.8 mg, 97.2 mg 120phenobarbital 20 mg/5ml 120phenol (antiseptic) 137phenoxybenzamine hcl 47phentermine hcl 1PHENYLADE AMINO ACID145PHENYLADE AMINO ACIDBLEND 145PHENYLADE MTE AMINOACIDBLEND 145PHENYLADE PHEBLOC 146PHENYLADE40 DRINKMIX 146phenyleph-promethazine w/cod 86phenylephrine hcl 0.25 % 143phenylephrine-shark liver oil-glycerin-petrolatum 14phenytoin 125 mg/5ml 28phenytoin 50 mg 28phenytoin sodium 28phenytoin sodium extended 28PHILLIPS MILK OF MAGNESIACHEWABLE 123PHILLIPS MILK OF MAGNESIACONCENTRATED 123PHLEXY-10 146PHOS-NAK POWDERCONCENTRATE 135PHOSLO 115PHOSPHOLINE IODIDE 147PHYSIOSOL IRRIGATION PH7.4 75phytonadione 100 mcg 166PICATO 90PIKO 1 ELECTRONIC 129

Index 24

pilocarpine hcl (oral) 137pilocarpine hcl 1 %, 2 %, 4% 147pimozide 157pindolol 76pioglitazone hcl 15 mg 36pioglitazone hcl 30 mg, 45mg 36pioglitazone hcl-glimepiride 34pioglitazone hcl-metforminhcl 34piperacillin sodium-tazobactamsodium 153piroxicam 10 mg, 20 mg 6PLAN B ONE-STEP 82PLAQUENIL 50PLAVIX 300 MG 117PLAVIX 75 MG 117PLEGRIDY 156PLEGRIDY STARTERPACK 156PLETAL 117POCKET CHAMBER 129POCKET PEAK FLOWMETER 129POCKET SPACER 130POCKETPEAK PEAK FLOWMETER LOW RANGE 130POCKETPEAK PEAK FLOWMETER/UNIVERSALRANGE 130POCKETPEAK PEAK FLOWMETER/UNIVERSAL RANGE 50-720 LPM 130podofilox 96POLYCOSE 144polyethylene glycol 3350 122polymyxin b sulfate 18polymyxin b-trimethoprim 148polysaccharide iron complex 150mg 120POLYSPORIN 88POLYTAR 104POLYTRIM 148polyvinyl alcohol 146POMALYST 56PONARIS 142PONSTEL 7potassium chloride 10 % 135potassium chloride 10 meq, 8meq 135

potassium chloride 2meq/ml 135potassium chloride 20 % 135POTASSIUM CHLORIDEER 135potassium chloride in dextrose& sodium chloride 0.45%-20meq/l-5% 134potassium chloridemicroencapsulated crystalscr 135potassium citrate (alkalinizer)1080 mg, 540 mg 115POTASSIUM IODIDE 134POTIGA 200 MG 27POTIGA 300 MG 27POTIGA 400 MG 27POTIGA 50 MG 27PRADAXA 24PRALUENT 150 MG/ML 46PRALUENT 75 MG/ML 46pramipexole dihydrochloride0.125 mg, 0.25 mg, 0.5 mg,0.75 mg, 1 mg, 1.5 mg 63pramoxine-camphor-zincacetate 97PRANDIMET 34PRANDIN 0.5 MG 37PRANDIN 1 MG 37PRANDIN 2 MG 37PRAVACHOL 45pravastatin sodium 45prazosin hcl 48PRE-FOLIC 119PRECISION XTRA 106PRECOSE 33PRED FORTE 149prednicarbate 95prednisolone 84prednisolone acetate(ophth) 149prednisolone sodiumphosphate 10 mg, 15 mg, 30mg 84prednisolone sodiumphosphate 15 mg/5ml, 5mg/5ml, 6.7 mg/5ml 84prednisone 1 mg, 10 mg, 2.5mg, 20 mg, 5 mg, 50 mg 84prednisone 5 mg/5ml 84prednisone 5 mg/ml 84

PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25MG 112PREMARIN 0.625 MG/GM 165PREMPHASE 112PREMPRO 112PRENATAL FORMULA 35MG-30UNIT-4000UNIT-200MG-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG 140PRESUN ULTRA/PARSOL 3%-5%-7.5%-6% 104PREVACID 15 MG 162PREVACID 30 MG 162PREVPAC 162PREZCOBIX 69PREZISTA 100 MG/ML 69PREZISTA 150 MG, 600 MG,800 MG 69PREZISTA 400 MG, 75 MG 69PRIFTIN 51PRILOSEC 10 MG, 20 MG, 40MG 162PRIMAQUINE PHOSPHATE50PRIMAXIN IV 17primidone 250 mg, 50 mg 27PRINIVIL 47PRISTIQ 32PRIVIGEN 152PROAIR HFA 23PROAIR RESPICLICK 23probenecid 116PROCARDIA XL 77prochlorperazine 66prochlorperazine edisylate 66prochlorperazine maleate 10 mg,5 mg 66PROCRIT 118PROCTOCORT 1 % 14PROFERRIN ES 120progesterone micronized 100 mg,200 mg 154PROGLYCEM 35PROGRAF 0.5 MG, 1 MG, 5MG 74PROGRAF 5 MG/ML 74PROLASTIN-C 157PROLEUKIN 59PROLIA 108

Index 25

PROMACTA 12.5 MG 118PROMACTA 25 MG 118PROMACTA 50 MG 118PROMACTA 75 MG 118promethazine hcl 12.5 mg, 25mg 44promethazine hcl 12.5 mg, 25mg, 50 mg 44promethazine hcl 25 mg/ml, 50mg/ml 44promethazine hcl 6.25mg/5ml 44promethazine w/codeine 86promethazine-dm 86PROMETRIUM 154PRONTO 0.33%-4% 103propafenone hcl 20proparacaine hcl 149propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 76propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 76PROPYLENE GLYCOL 153propylthiouracil 159PROQUAD 164PROSCAR 115PROSHIELD FOAM & SPRAYCLEANSER 102PROTEINEX 146PROTONIX 20 MG, 40 MG 162PROTONIX 40 MG 162PROTOPIC 96protriptyline hcl 33PROVENTIL HFA 23PROVERA 154PROVIGIL 2PROZAC 31PROZAC WEEKLY 31PRUCLAIR 98PRUMYX 98pseudoephedrine hcl 15mg/5ml 143pseudoephedrine hcl 30 mg, 60mg 143pseudoephedrine-acetaminophen

86pseudoephedrine-ibuprofen100mg/5ml-15mg/5ml 86psyllium 0.52 gm, 520 mg 122psyllium 100 %, 48.57 %, 58.6 %,95 % 122

psyllium 28.3 %, 30 %, 30.9 %,33 %, 49 %, 68 % 122PTS PANELS KETONETEST 106PULMICORT 0.25 MG/2ML, 0.5MG/2ML 22PULMOZYME 158PURINETHOL 54PURIXAN 54PURPOSE 102PX CALAMINE 102pyrazinamide 51PYRETHINS/PIPERONYLBUTOXIDE 103pyrethrins-piperonylbutoxide 103PYRIDIUM 116pyridostigmine bromide 180mg 51pyridostigmine bromide 60mg 51pyridoxine hcl 100 mg, 25 mg,50 mg 167pyrithione zinc 0.25 % 91pyrithione zinc 2 % 91QC CALAMINE 102QC COD LIVER OIL 140QSYMIA 1QUALAQUIN 50quetiapine fumarate 65quinapril hcl 47quinapril-hydrochlorothiazide

49quinidine gluconate 324mg 20quinidine sulfate 20quinine sulfate 50QVAR 22RA BEAUTY BAR 102RA CALAMINE 6.971%-6.971% 102RA COD LIVER OIL 140RA SALINE WOUNDWASH 102RABAVERT 164raloxifene hcl 109ramipril 47RANEXA 18ranitidine hcl 15 mg/ml, 150mg/10ml, 75 mg/5ml 161ranitidine hcl 150 mg 161

ranitidine hcl 150 mg, 300mg 160ranitidine hcl 300 mg 161ranitidine hcl 75 mg 161RAPAMUNE 0.5 MG 74RAPAMUNE 1 MG, 2 MG 74RAPAMUNE 1 MG/ML 74RASPBERRY SYRUP 153RASUVO 4RAZADYNE 155RAZADYNE ER 155REBETOL 200 MG 72REBIF 156REBIF REBIDOSE 156REBIF REBIDOSETITRATIONPACK 156REBIF TITRATION PACK 156RECLAST 108RECOMBIVAX HB 164RECTIV 14REGENECARE HA 97REGIMEX 1REGLAN 113REGRANEX 104RELENZA DISKHALER 73RELION KETONE 106RELION KETONE TESTSTRIPS 106RELISTOR 12 MG/0.6ML 114RELISTOR 12 MG/0.6ML, 8MG/0.4ML 115REMERON 29REMERON SOLTAB 29REMICADE 114REMODULIN 78RENVELA 2.4 GM 115RENVELA 800 MG 115repaglinide 0.5 mg 37repaglinide 1 mg 37repaglinide 2 mg 38REQUIP 63REQUIP XL 63RESCRIPTOR 70RESERPINE 0.1 MG, 0.25MG 48RESTASIS 148RESTORIL 120RETIN-A 88

Index 26

RETIN-A MICRO 88RETIN-A MICRO PUMP 0.04 %,0.1 % 88RETROVIR 70RETROVIR IV INFUSION 70REVATIO 10 MG/12.5ML 78REVATIO 20 MG 78REVLIMID 73REXULTI 0.25 MG 67REXULTI 0.5 MG 67REXULTI 1 MG 67REXULTI 2 MG 67REXULTI 3 MG, 4 MG 67REYATAZ 150 MG, 200 MG, 300MG 70REYATAZ 50 MG 70REZAMID 88RHINOCORT AQUA 143ribavirin (hepatitis c) 72riboflavin 100 mg 167riboflavin 25 mg, 50 mg 167RID 103RIDAURA 4rifabutin 51RIFADIN 51rifampin 150 mg, 300 mg 51rifampin 600 mg 51RIFATER 51RILUTEK 143riluzole 144rimantadine hydrochloride 73RISPERDAL 64RISPERDAL CONSTA 12.5MG 65RISPERDAL CONSTA 25MG 65RISPERDAL CONSTA 37.5 MG,50 MG 65RISPERDAL M-TAB 65risperidone 65RITALIN 2RITALIN LA 20 MG, 30 MG, 40MG 2RITALIN LA 60 MG 2RITALIN SR 2RITEFLO 130RITUXAN 55rivastigmine 155rivastigmine tartrate 155

rizatriptan benzoate 10mg 131rizatriptan benzoate 5 mg 131ROBAXIN 500 MG 141ROBAXIN-750 142ROBINUL 0.2 MG/ML 160ROBINUL 1 MG 160ROBINUL FORTE 160ROCALTROL 110ropinirole hydrochloride 63ROTARIX 164ROTATEQ 164ROWASA 114ROXICODONE 15 MG 11ROXICODONE 30 MG 11ROXICODONE 5 MG 11ROZEREM 121RUCONEST 116RYMED 86RYTARY 63RYTHMOL 20RYTHMOL SR 20SABRIL 28SAFE WASH 102SALAGEN 137saline 142saline 0.65 %, 0.65%, 0.65%-0.002% 142SALINE WOUND WASH 102SALJET 102SALJET RINSE 102SALTAIRE 142SAMSCA 111SANCTURA 163SANCTURA XR 163SANDIMMUNE 100 MG, 25MG 74SANDIMMUNE 100MG/ML 74SANDIMMUNE 50 MG/ML 74SANDOSTATIN 100 MCG/ML,200 MCG/ML, 50MCG/ML 111SANDOSTATIN LAR DEPOT20 MG, 30 MG 111SANTYL 96SAPHRIS 10 MG 65SAPHRIS 2.5 MG 65SAPHRIS 5 MG 65

SAXENDA 1SAYMAN LANOLIN 102SAYMAN WITCH HAZEL 102SEASONIQUE 82SECTRAL 75selegiline hcl 63selenium 100 mcg 136SELENIUM 40 MCG/ML 136selenium 50 mcg 136selenium sulfide 2.5 % 91SELZENTRY 70sennosides 15 mg, 8.6 mg 123SENOKOT 123SENOKOT TO GO 123SENSIPAR 110SEREVENT DISKUS 23SEROQUEL 66SEROSTIM 4 MG, 6 MG 109sertraline hcl 100 mg, 25 mg, 50mg 31sertraline hcl 20 mg/ml 31SEVELAMERCARBONATE 115SHADE OIL FREE CLEARGELSPF 25 104SHUR-SEAL 165SIGNIFOR 111SIGNIFOR LAR 20 MG 111SIGNIFOR LAR 40 MG, 60MG 111sildenafil citrate (pulmonaryhypertension) 78SILENOR 120SILVADENE 92silver sulfadiazine 92simethicone 125 mg 113SIMPONI 4SIMPONI ARIA 4SIMULECT 74simvastatin 10 mg 45simvastatin 20 mg 45simvastatin 40 mg 45simvastatin 5 mg 45simvastatin 80 mg 45SINEMET 63SINEMET CR 63SINGULAIR 10 MG 21SINGULAIR 4 MG, 5 MG 21

Index 27

sirolimus 74SIVEXTRO 18SKELAXIN 142skin protectants, misc. 102SLO-NIACIN 167SLOW FE 160 MG 120SLOW RELEASE IRON 120SM CALAMINE 102SM CALAMINEPHENOLATED 102SM GLUCOSE 4 GM 35SM IPECAC SYRUP 40SM PAINRELIEF/MENTHOL 97sodium chloride (guirrigant) 115sodium chloride (inhalant) 86sodium chloride 0.45 % 135sodium chloride 0.9 % 135sodium chloride hypertonic 150SODIUM CHLORIDE/SODIUMBICARBONATE 81SODIUM CITRATEDIHYDRATE 80sodium polystyrenesulfonate 75sodium polystyrene sulfonate 15gm/60ml 75SOLARAZE 90SOLARCAINE ALOE EXTRAGEL 97SOLARCAINE ALOE VERA 97SOLBAR PF LIQUID/GELSPF30 104SOLTAMOX 56SOLU-CORTEF 100 MG, 250MG, 500 MG 84SOLU-CORTEF 1000 MG 84SOLU-MEDROL 1000 MG, 125MG, 40 MG 84SOLVIL 146SOMA 350 MG 142SOMATULINE DEPOT 111SOMAVERT 109SONATA 120SORIATANE 91sotalol hcl 76sotalol hcl (afib/afl) 76Sotalol Hcl IV Soln 76SOTYLIZE 76SOVALDI 72

SPIRIVA HANDIHALER 21SPIRIVA RESPIMAT 1.25MCG/ACT 21SPIRIVA RESPIMAT 2.5MCG/ACT 21spironolactone &hydrochlorothiazide 107spironolactone 100 mg, 25 mg,50 mg 107SPORANOX 100 MG 42SPORANOX PULSEPAK 42SPRYCEL 58starch (topical) 14STARLIX 38stavudine 70STAVZOR 29STELARA 91STIOLTO RESPIMAT 23STIVARGA 58STRATTERA 2STRIBILD 70STRIVERDI RESPIMAT 23STROMECTOL 15STYGIENE STERILE EYELIDCLEANSER 102SUBSYS 100 MCG, 200MCG 11SUBSYS 1200 MCG, 1600MCG 11SUBSYS 400 MCG, 600 MCG,800 MCG 11sucralfate 161SUDAFED 143SUDAFED CHILDRENS 143SUDAFEDCONGESTION 143SUDAFED NASALDECONGESTANT MAXIMUMSTRENGTH 143SUDAFED PE CHILDRENSNASALDECONGESTANT 143SUDAFED PE SEVERE COLDMULTI-SYMPTOM 86SULAR 77sulfacetamide sod-prednisolone 149sulfacetamide sodium(acne) 88sulfacetamide sodium(ophth) 148sulfadiazine 158sulfamethoxazole-trimethoprim

16

SULFAMYLON 5 % 92sulfasalazine 114SULFZIX 106sulindac 150 mg, 200 mg 7sumatriptan succinate 100mg 131sumatriptan succinate 25mg 131sumatriptan succinate 4mg/0.5ml 131sumatriptan succinate 50mg 131sumatriptan succinate 6mg/0.5ml 131SUMMERS EVE DEODORANTSPRAY 98SUMMERS EVE DEODORANTSPRAY ULTRA 98SUMMERS EVE NIGHT-TIMECLEANSING/SENSITIVESKIN 102SUPER E 96SUPER E DAY 96SUPER E EYE 96SUPER E NIGHT 96SUPER-AMINO 1600 146SUPRAX 400 MG 80SUPRAX 500 MG/5ML 80SUPRENZA 1SUPREP BOWEL PREP 122SURMONTIL 33SUSTIVA 70SUTENT 58SYLATRON 59SYMBYAX 155SYMLINPEN 120 33SYMLINPEN 60 33SYMPT-X G.I. 146SYNAGIS 50 MG/0.5ML 152SYNALAR 95SYNAREL 110SYNERCID 18SYNRIBO 60SYNTHROID 159SYPRINE 73TABLOID 54tacrolimus (topical) 96tacrolimus 0.5 mg, 1 mg, 5mg 74TAFINLAR 58

Index 28

TAMIFLU 73tamoxifen citrate 10 mg, 20mg 56tamsulosin hcl 116TARCEVA 58TARGRETIN 60TARSUM 104TASIGNA 58TASMAR 62TAXOL 61TAXOTERE 61TAZORAC 91TEARS AGAIN NIGHT &DAY 146TECFIDERA 156TECFIDERA STARTERPACK 156TEFLARO 400 MG 80TEGRETOL 27TEGRETOL-XR 100 MG 27TEGRETOL-XR 200 MG, 400MG 27TEKTURNA 50TEKTURNA HCT 49temazepam 120TEMODAR 52TEMOVATE 95TEMOVATE E 95TENEX 48TENIVAC 159TENORETIC 100 49TENORETIC 50 49TENORMIN 75TERAZOL 3 165TERAZOL 7 165terazosin hcl 48terbinafine hcl 42terbinafine hcl (topical) 90terbutaline sulfate 2.5 mg, 5mg 23terconazole vaginal 165TERSASEPTIC GLYCERINECLEANSING 102TESSALON PERLES 84TESTIM 13TESTOSTERONE 1 %, 25MG/2.5GM, 50 MG/5GM 14testosterone 25 mg/2.5gm, 50mg/5gm 14testosterone cypionate 13

testosterone enanthate 14TESTOSTERONE PUMP 14TETANUS TOXOIDADSORBED 159TETANUS/DIPHTHERIATOXOIDS-ADSORBED 159TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 159tetrabenazine 155tetracycline hcl 250 mg, 500mg 159TEV-TROPIN 109TEVETEN 48TGT LUBRICANT EYEDROPS 147THALOMID 73theophylline 100 mg, 200 mg,300 mg, 450 mg 23theophylline 400 mg, 600mg 23THERACYS 60THERAPLEX T 104THERMOTABS 134thiamine hcl 100 mg, 50mg 167thiamine mononitrate 167thioridazine hcl 10 mg, 100 mg,25 mg, 50 mg 66THIOTEPA 53thiothixene 68THYMOGLOBULIN 74THYMOL 81tiagabine hcl 28TIAZAC 77TICE BCG 60ticlopidine hcl 117TIGAN 100 MG/ML 40TIKOSYN 21timolol maleate (ophth) 147TIMOPTIC 147TIMOPTIC-XE 147TINACTIN 90TINACTIN JOCK ITCH 90TINDAMAX 16tinidazole 250 mg, 500 mg 16tioconazole vaginal 165TIVICAY 70tizanidine hcl 2 mg, 4 mg 142tizanidine hcl 2 mg, 4 mg, 6mg 142

TOBI 3TOBI PODHALER 3TOBRADEX 149tobramycin 3tobramycin (ophth) 148tobramycin sulfate 1.2 gm 4tobramycin sulfate 1.2 gm/30ml,40 mg/ml, 80 mg/2ml 3tobramycin sulfate 10 mg/ml 3tobramycin-dexamethasone 149TOBREX 148TOFRANIL-PM 33tolazamide 250 mg 39tolazamide 500 mg 39tolbutamide 39tolcapone 62tolmetin sodium 200 mg 7tolmetin sodium 400 mg 7tolnaftate 90tolterodine tartrate 163TOPAMAX 27TOPAMAX SPRINKLE 27TOPICLEAR 102topiramate 100 mg, 200 mg, 25mg, 50 mg 27topiramate 15 mg, 25 mg 27topotecan hcl 4 mg 62TOPOTECAN HCL 4MG/4ML 62TOPROL XL 75TORISEL 58torsemide 10 mg, 100 mg, 20 mg,5 mg 107TOTECT 61TOUJEO SOLOSTAR 37trace minerals (cr-cu-mn-zn) 136TRACLEER 78TRADJENTA 36tramadol hcl 100 mg 12tramadol hcl 200 mg, 300mg 12tramadol hcl 50 mg 12tramadol-acetaminophen 12TRANDATE 75trandolapril 47tranexamic acid 100 mg/ml 120tranexamic acid 650 mg 120

Index 29

TRANSDERM-SCOP 40TRANXENE T 20tranylcypromine sulfate 30TRAVATAN Z 150trazodone hcl 100 mg, 150 mg,300 mg, 50 mg 31TREANDA 53TRECATOR 51TRELSTAR 56TRELSTAR MIXJECT 56tretinoin (chemotherapy) 60tretinoin 0.01 %, 0.025 % 88tretinoin 0.025 %, 0.05 %, 0.1% 88tretinoin microsphere 88TRI-VIT/FLUORIDE/IRON 139triamcinolone acetonide(mouth) 137triamcinolone acetonide(nasal) 143triamcinolone acetonide (topical)0.025 %, 0.1 % 95triamcinolone acetonide (topical)0.025 %, 0.1 %, 0.5 % 95TRIAMINIC COUGH & RUNNYNOSE 43TRIAMINO 146triamterene &hydrochlorothiazide 107triazolam 121TRICOR 45trifluoperazine hcl 66trifluridine 148TRIGLIDE 45trihexyphenidyl hcl 62TRILEPTAL 27TRILIPIX 45trimethobenzamide hcl 100mg/ml 41trimethoprim 16trimipramine maleate 100 mg, 25mg, 50 mg 33TRIMO-SAN 164triprolidine & pseudoephedrine0.938mg/ml-10mg/ml 86triprolidine & pseudoephedrine2.5mg-2.5mg-60mg-60mg,2.5mg-60mg 86TRISENOX 60TRIUMEQ 70TRIZIVIR 70trospium chloride 163

TRUSOPT 150TRUVADA 70TRUZONE PEAK FLOWMETER 130TUCKS 14TUCKS ANTI-ITCH 95TUDORZA PRESSAIR 21TUMS 15TUMS E-X 750 15TUMS KIDS 15TUMS LASTINGEFFECTS 15TUMS SMOOTHIES 15TUSNEL 2MG-15MG-200MG 86TUSSIONEX PENNKINETICEXTENDED RELEASE 86TWINRIX 164TYBOST 70TYGACIL 17TYKERB 59TYLENOL CHILDRENS 8TYLENOL CHILDRENS PLUSCOLD 86TYLENOL CHILDRENS PLUSCOLD & ALLERGY 86TYLENOLCHILDRENS/FLAVORCREATOR 8TYLENOL INFANTS 160MG/5ML 8TYLENOL INFANTS 80MG/0.8ML 8TYLENOL JR MELTAWAYS8TYPHIM VI 163tyrosine 500 mg 146TYSABRI 156TYVASO 78TYVASO REFILL 78TYVASO STARTER 78TYZEKA 72UCERIS 2 MG/ACT 14ULCEREASE 137ULTILET GLUCOSE 35ULTRA DERM BATH OIL 91ULTRA MAN 140ULTRA MIDE 25 95ULTRA WOMAN 140ULTRACET 12ULTRAM 12

ULTRAM ER 100 MG 12ULTRAM ER 200 MG, 300MG 12ULTRASWIM 102ULTRASWIM ULTRAREPAIR 102ULTRAVATE 95UNASYN 1GM-2GM 153UNDELENIC TINCTURE 90UNIFIBER 122UNIRETIC 49UNIVASC 47UNIVERSAL PH STRIPS 106UNIVERSAL REMOVERWIPES 102urea 20 % 95urea 25 % 95URISTIX 106URISTIX 4 106URO-PREP PROTECTIVESKINWIPES 102UROCIT-K 10 115UROCIT-K 5 115UROXATRAL 116URSO 250 113URSO FORTE 113ursodiol 250 mg, 500 mg 113ursodiol 300 mg 113UVADEX 60VAGISIL 164VAGISTAT-1 165valacyclovir hcl 1 gm, 1000 mg,500 mg 72VALCHLOR 90VALCYTE 450 MG 71valganciclovir hcl 71VALIUM 20valproate sodium 100 mg/ml, 500mg/5ml 29valproate sodium 250mg/5ml 29valproic acid 29valsartan 48valsartan-hydrochlorothiazide

49VALSTAR 57VALTREX 72VALVED HOLDINGCHAMBER 130VANCOCIN HCL 16

Index 30

vancomycin hcl 10 gm, 1000 mg,5000 mg 16vancomycin hcl 125 mg, 250mg 16vancomycin hcl 500 mg 16VANCOMYCIN HCL INDEXTROSE 16VANICREAM 102VANTAS 56VAQTA 164VARIVAX 164VARIZIG 152VASCEPA 44VASERETIC 49VASOTEC 47VCF VAGINALCONTRACEPTIVE FILM 165VCF VAGINALCONTRACEPTIVE FOAM 165VECTIBIX 55VELCADE 59venlafaxine hcl 100 mg 32venlafaxine hcl 150 mg 32venlafaxine hcl 25 mg 32venlafaxine hcl 37.5 mg 32venlafaxine hcl 50 mg 32venlafaxine hcl 75 mg 32VENLAFAXINE HCL ER 32VENTAVIS 78verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 77verapamil hcl 120 mg, 180 mg,240 mg 77verapamil hcl 120 mg, 40 mg, 80mg 77VERELAN 77VERELAN PM 77VERSACLOZ 66VFEND 200 MG, 50 MG 42VFEND IV 42VIBRAMYCIN 100 MG 159VIBRAMYCIN 25 MG/5ML 159VICKS BABYRUB 97VICOPROFEN 12VICTOZA 36VICTRELIS 72VIDAZA 54VIDEX EC 70VIDEXPEDIATRIC 70

VIEKIRA PAK 72VIGAMOX 148VIIBRYD 31VIIBRYD STARTER PACK31VIMIZIM 110VIMPAT 10 MG/ML 27VIMPAT 100 MG, 150 MG, 200MG, 50 MG 27VIMPAT 200 MG/20ML 27vinblastine sulfate 61vincristine sulfate 61vinorelbine tartrate 61VIRACEPT 70VIRAMUNE 200 MG 70VIRAMUNE 50 MG/5ML 70VIRAMUNE XR 100 MG 70VIRAMUNE XR 400 MG 70VIRAZOLE 73VIREAD 150 MG, 200 MG, 300MG 70VIREAD 250 MG 71VIREAD 40 MG/GM 70VIROPTIC 148VISINE-LR 148VISTARIL 19VISTIDE 71VITALINE COQ10/VITAMIN E100MG-300UNIT 3vitamin a 10000 unit 166VITAMIN A 10000UNIT-1000UNIT 166VITAMIN A 25000 UNIT 166vitamin a 8000 unit 166VITAMIN B12/FOLICACID 119vitamin e (topical) 100unit/5drop, 12000 unit, 20000unit, 28000 unit, 28000unit/29ml, 400 unit/ml, 4000unit, 49000 unit/52ml, 933.333unit/ml 96vitamin e (topical) 1000 unit,1500 unit/30gm, 30000unit/60gm, 6000 unit 96vitamin e 100 unit 166vitamin e 1000 unit 166vitamin e 15 unit/0.3ml 166vitamin e 400 unit/15ml 166

vitamins a & d 10000unit-400unit,10000unit-5000unit, 1250unit-133unit, 1250unit-135unit,5000unit-400unit, 700unit-400unit, 8000unit-400unit 140vitamins w/ lipotropics 10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg, 100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg, 100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 100mg-12.5mg-100mg-100mg-12.5mg-12.5mg-100mg-100mcg-100mcg-100mcg-100mg, 100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 200mg-29mg-0.333mg-1.666mg-3.33mg-111.333mg-111.333mg-1mg-1.666mcg-0.333mg-100mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-1.67mcg-0.33mg-100mg, 200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 20mg-50mg-30mg-10mg-10mcg-30mg-8mg,25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg,266. 141VITEKTA 71VOGELXO 14VOGELXO PUMP 14VOLTAREN 88VOLTAREN-XR 7voriconazole 200 mg 42voriconazole 200 mg, 50 mg 42

Index 31

VORTEX VALVED HOLDINGCHAMBER 130VOSOL HC 151VOTRIENT 59VPRIV 117WALGREENS GLUCOSE 4GM 35warfarin sodium 24WATCHHALER 130water for irrigation, sterile 75WELCHOL 44WELLBUTRIN 100 MG 29WELLBUTRIN 75 MG 29WELLBUTRIN SR 100 MG 30WELLBUTRIN SR 150 MG, 200MG 30WELLBUTRIN XL 150 MG 30WELLBUTRIN XL 300 MG 30WESTCORT 95WFHC PH PAPER 106WHEAT GERM 166witch hazel-glycerin 102WOUND WASH SALINE 103XALATAN 150XALKORI 59XANAX 20XANAX XR 20XARELTO 24XARELTO STARTER PACK 24XELJANZ 4XENAZINE 155XEOMIN 144XGEVA 108XIFAXAN 16XIZFLUS 106XOLAIR 21XOPENEX 23XOPENEX CONCENTRATE 23

XPHE MAXAMUM 153MG-280MG-41MCG-1114UNIT-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG,153MG-280MG-41MCG-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-1114UNIT-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG 146XTANDI 56XYLOCAINE 1 %, 2 % 123XYLOCAINE 4 % 97XYLOCAINE-MPF 1 % 123XYREM 154XYZAL 43YASMIN 28 82YAZ 82YERVOY 55YF-VAX 164YODORA DEODORANT 98YONDELIS 53ZADITOR 150zafirlukast 21zaleplon 121ZALTRAP 54ZANAFLEX 142ZANOSAR 53ZANTAC 15 MG/ML 161ZANTAC 150 MG 161ZANTAC 300 MG 161ZANTAC 75 161ZARONTIN 28ZAROXOLYN 108ZARXIO 118ZAVESCA 117ZEBETA 76ZEGERID 20MG-1100MG 162ZEGERID 20MG-1680MG 162

ZEGERID 40MG-1100MG 162ZELBORAF 59ZEMAIRA 157ZEMPLAR 1 MCG, 2 MCG, 4MCG 110ZERIT 71ZESTORETIC 49ZESTRIL 47ZETIA 46ZIAC 50ZIAGEN 20 MG/ML 71ZIAGEN 300 MG 71zidovudine 71ZILACTIN 136ZINACEF 1.5 GM, 7.5 GM 79ZINACEF 750 MG 79ZINC 15 136zinc 25 mg 136zinc 50 mg 136zinc gluconate 10 mg 136zinc gluconate 50 mg 136ZINC SULFATE 1 MG/ML, 5MG/ML 136ZINECARD 61ziprasidone hcl 64ZITHROMAX 100 MG/5ML, 200MG/5ML 124ZITHROMAX 250 MG, 500 MG,600 MG 124ZITHROMAX 500 MG 124ZITHROMAX TRI-PAK 124ZITHROMAX Z-PAK 124ZOCOR 10 MG 45ZOCOR 20 MG 46ZOCOR 40 MG 46ZOCOR 5 MG 46ZOCOR 80 MG 46ZOFRAN 4 MG, 8 MG 40ZOFRAN 4 MG/5ML 40ZOFRAN 40 MG/20ML 40ZOFRAN ODT 40ZOHYDRO ER 10 MG, 15 MG,20 MG, 30 MG, 40 MG, 50MG 12ZOLADEX 56zoledronic acid 4 mg 108zoledronic acid 4 mg/5ml 108zoledronic acid 5 mg/100ml 108

Index 32

ZOLINZA 59zolmitriptan 2.5 mg 131zolmitriptan 5 mg 131ZOLOFT 31zolpidem tartrate 10 mg 121zolpidem tartrate 12.5 mg 121zolpidem tartrate 5 mg 121zolpidem tartrate 6.25 mg 121ZOMACTON 5 MG 109ZOMETA 4 MG/5ML 109ZOMIG 2.5 MG 131ZOMIG 5 MG 132ZOMIG ZMT 2.5 MG 132ZOMIG ZMT 5 MG 132ZONEGRAN 28zonisamide 28ZONTIVITY 117ZORTRESS 74ZOSTAVAX 164ZOSYN 0.25GM-2GM, 0.375GM-3GM, 0.5GM-4GM, 4.5GM-36GM 153ZOSYN 0.5GM/100ML-4GM/100ML-5% 153ZOVIRAX 200 MG 72ZOVIRAX 200 MG/5ML 72ZOVIRAX 400 MG, 800 MG 73ZOVIRAX 5 % 91ZYBAN 157ZYCLARA 96ZYCLARA PUMP 96ZYDELIG 59ZYKADIA 59ZYLOPRIM 100 MG 116ZYLOPRIM 300 MG 116ZYMAXID 148ZYPREXA 66ZYPREXA RELPREVV 210MG 66ZYPREXA ZYDIS 66ZYTIGA 56ZYVOX 100 MG/5ML 18ZYVOX 2 MG/ML 18ZYVOX 600 MG 18

Index 33

This drug list was updated on If you have questions, please call Health Net Cal MediConnect at 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711, 24 hours a day, 7 days a week. The call is free. For more information, visit www.healthnet.com/calmediconnect.

Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Health Net Community Solutions, Inc is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All right reserved.

12/1/2015.

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