hmsa essential prescription formulary · introduction hmsa's essential prescription formulary...

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HMSA Essential Prescription Formulary

(Effective 07/01/2017)

INTRODUCTION

HMSA's Essential Prescription Formulary for commercial plan members is a new

product to help keep health care affordable, while maintaining a patient's health and

safety, and providing quality care.

HMSA Essential Prescription Formulary is a managed formulary. Drugs listed on

this formulary are considered covered benefits.

Consistent with the principles of this formulary, new drugs will be reviewed by HMSA's

Pharmacy & Therapeutics Committee (HMSA P&T Committee) to assess safety and

effectiveness before any drug is added to the formulary. The HMSA P&T Committee is

comprised of practicing physicians and pharmacists from our community.

In addition to new drugs, the HMSA P&T Committee reviews the formulary on a

continuous basis with the help of HMSA staff. The formulary approval process is

designed to ensure that clinical evidence and medical value are considered before cost.

If drugs within a treatment class are clinically comparable, the committee will assess

cost-effectiveness and choose agents with the best value.

PREFACE

The document is organized by sections. Each section is divided by therapeutic drug

class primarily defined by mechanism of action. Tier level and coverage criteria (if

applicable) are notated next to each drug.

Tier 1 - mostly Generic Drugs

Tier 2 - mostly Preferred Drugs

Tier 3 - mostly Other Brand Name Drugs

Tier 4 - mostly Preferred Specialty Drugs

Tier 5* - mostly Other Brand Name Specialty Drugs

*If applicable to your plan coverage

Zero ($0) Copay - When obtained from a Participating Provider, HMSA pays 100% of

Eligible Charge. You owe no copayment.

Please refer to your Plan's Prescription Drug Benefits Rider for the specific copayment

or coinsurance amount associated with each tier.

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ABBREVIATIONS USED IN THIS FORMULARY

AGE - Age Limit: age requirements for coverage of drug

OC - Oral Chemotherapy: Refer to plan benefits

PA - Prior Authorization: Requires that you or your physician receive

approval from HMSA before we will cover your prescription

QL - Quantity Limit: A limit on the amount of the drug that HMSA will

cover

SP - Specialty Drug with Network Requirements: Must go to a Specialty

Network Provider, limited to a 30 days supply

ST - Step Therapy: Requires you to first try certain drugs to treat your

medical condition before we will cover another drug for that condition

$0 - Zero ($0) Copay: When obtained from a Participating Provider, HMSA

pays 100% of Eligible Charge. You owe no copayment.

EXCEPTION REQUEST

Drugs listed on this formulary are considered covered benefits. Certain medications on

the list are covered if utilization management criteria are met (i.e. Step Therapy, Prior

Authorization, Quantity Limits, etc.); requests for use of such medications outside of

their listed criteria will be reviewed for medical necessity. If a medication is not listed

on the document, a formulary exception may be requested for coverage. Medical

necessity or formulary exception requests will be reviewed based on drug-specific prior

authorization criteria or standard non-formulary prescription request criteria.

To request a PA or an exception, please call or fax CVS Caremark®, HMSA's Pharmacy

Benefit Manager

Call

Commercial 1 (855) 240-0543 toll-free

FAX Commercial 1 (855) 762-5207 toll-free

This drug list is subject to change and drugs may be added or removed without notice.

Please contact HMSA to confirm your drug plan coverage. This list is effective July 1,

2017.

LEGEND

AGE Age Limit

lowercase Indicates generic drug

OC Oral Chemotherapy: Refer to plan benefits

PA Prior Authorization

QL Quantity Limit

SP Specialty Drug with network requirement

ST Step Therapy

UPPERCASE Indicates brand name drug

$0 Zero ($0) Copay

NOTE

The status of a drug on this list is current as of the date of this publication.

The list serves as a guide to product selection for our providers and members. The list

is subject to change. Participating pharmacies have the most up-to-date formulary

CVS Caremark® is an independent company providing pharmacy benefit management services on behalf of HMSA.

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information at the time prescriptions are filled. New drugs, strengths, forms, and/or

therapeutic categories introduced in the marketplace will be reflected in the formulary,

as applicable, following the completion of HMSA’s review process.

Not all generic drugs may be listed.

Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality

health care system that improves the overall health and well-being of our state.

HMSA CENTERS

Convenient evening and Saturday hours:

HMSA Center @ Honolulu

818 Keeaumoku St.

Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl City

Pearl City Gateway | 1132 Kuala St., Suite 400


HMSA Center @ Hilo

Waiakea Center | 303A E. Makaala St.


OFFICES

Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291

Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295

Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

PHONE

948-6372 on Oahu

If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to

call a local Hawaii telephone number from the Mainland, the area code is 808.

Check hmsa.com/contact for our holiday schedule.

The information contained in this document is proprietary. The information may not be

copied in whole or in part without written permission. ©2017. All rights reserved.

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This document contains references to brand-name prescription drugs that are

trademarks or registered trademarks of pharmaceutical manufacturers.

Drug Name Drug Tier Requirements/Limits

ANALGESICS COX-II INHIBITORS celecoxib 1

GOUT allopurinol 1

colchicine CAPS 1 QL (60 per 30 days); ST (Try allopurinol,

probenecid or colchicine w/ probenecid)

colchicine TABS 1 QL (30 per 30 days)

colchicine w/ probenecid 1

COLCRYS 3 QL (30 per 30 days)

probenecid 1

ULORIC 3 QL (30 per 30 days); ST (Try allopurinol)

NON-OPIOID ANALGESICS butalbital-acetaminophen 1

butalbital-acetaminophen-caffeine 1

butalbital-aspirin-caffeine 1

ESGIC 3

NSAIDS ANAPROX DS 3

diclofenac potassium 1

diclofenac sodium delayed-rel 1

diclofenac sodium ext-rel 1

diflunisal 1

etodolac 1

etodolac ext-rel 1

fenoprofen calcium 1

flurbiprofen 1

ibuprofen 1

INDOCIN SUPP 3

indomethacin 1

indomethacin ext-rel 1

ketoprofen 1

ketoprofen ext-rel 1

ketorolac tromethamine 1

meclofenamate sodium 1

mefenamic acid 1

meloxicam tabs 1

nabumetone 1

naproxen 1

naproxen delayed-rel 1

naproxen sodium 1

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naproxen sodium ext-rel 1

oxaprozin 1

piroxicam 1

sulindac 1

tolmetin sodium 1

NSAIDS, COMBINATIONS diclofenac w/ misoprostol 1

NSAIDS, TOPICAL diclofenac sodium gel 1% 1

diclofenac sodium soln 1.5% 1

FLECTOR 3

KETOROLAC GEL 2% 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN 1 QL (5000 mL per 30

days)

acetaminophen w/ codeine TABS 1 QL (400 tabs per 30 days)

aspirin/caffeine/dihydrocodeine 1 QL (336 caps per 30 days)

butalbital-acetaminophen-caffeine w/ codeine

1

butalbital-aspirin-caffeine w/codeine 1

butorphanol tartrate 1

BUTRANS 3

codeine sulfate 1

EXALGO 3

fentanyl citrate lozenge 1 QL (120 per 30 days),

PA

fentanyl transdermal 12mcg/hr,

25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr

1 QL (20 per 30 days)

FENTANYL TRANSDERMAL 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr


FIORICET/CODEINE 3

hydrocodone-ibuprofen 1

hydrocodone/acetaminophen 2.5-325 mg 1 QL (369 tabs per 30

days)

hydrocodone/acetaminophen 5-300 mg 1 QL (400 tabs per 30

days)

hydrocodone/acetaminophen 5-325 mg 1 QL (369 tabs per 30

days)


days)


days)

hydrocodone/acetaminophen 7.5-325 mg/15 ml

1 QL (5538 mL per 30 days)

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hydrocodone/acetaminophen 10-300 mg 1 QL (400 tabs per 30 days)

hydrocodone/acetaminophen 10-325 mg 1 QL (369 tabs per 30 days)

hydrocodone/acetaminophen 10-325 mg/15 ml


hydrocodone/acetaminophen sol 5-217 mg/10 ml


hydromorphone ext-rel 1

HYDROMORPHONE HCL SUPP 3

hydromorphone hcl TABS 1

HYSINGLA ER 3

LORTAB ELIXIR 3 QL (6000 mL per 30 days)

meperidine hcl 1

methadone hcl 1

METHADOSE CONC 3

morphine sulfate 1

morphine sulfate ext-rel 1

NUCYNTA 3

NUCYNTA ER 3

OPANA ER 3

oxycodone hcl 1

oxycodone hcl ext-rel 1 QL (90 tabs per 30 days)

oxycodone/acetaminophen 1 QL (369 tabs per 30 days)

oxycodone/aspirin 1 QL (369 tabs per 30

days)

OXYCONTIN 3 QL (90 tabs per 30

days)

oxymorphone hcl 1

oxymorphone hcl ext-rel 1

pentazocine/naloxone 1

PRIMLEV 3 QL (400 tabs per 30 days)

SYNALGOS-DC 3 QL (336 caps per 30 days)

tramadol hcl 1

tramadol hcl ext-rel 1

tramadol/acetaminophen 1

XARTEMIS XR 3 QL (369 tabs per 30 days)

ZOHYDRO ER 10mg, 15mg, 20mg 3 QL (120 caps per 30 days)

ZOHYDRO ER 30mg, 40mg, 50mg 3 QL (60 caps per 30 days)

ANTI-INFECTIVES

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ANTIBACTERIALS, AMINOGLYCOSIDES neomycin sulfate 1

ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil 1

cephalexin 1

KEFLEX 3

ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor 1

cefprozil 1

CEFTIN SUSP 3

cefuroxime axetil 1

ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN CEDAX CAPS 3

cefdinir 1

cefditoren pivoxil 1

cefixime susp 1

cefpodoxime proxetil tabs 1

ceftibuten caps 1

SUPRAX 3

ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin 1

BIAXIN 3

clarithromycin 1

clarithromycin ext-rel 1

DIFICID 3 PA

E.E.S. GRANULES 3

ERYPED 3

erythromycin base 1

erythromycin base delayed-rel 1

erythromycin ethylsuccinate 1

erythromycin stearate 1

ZMAX 3

ANTIBACTERIALS, FLUOROQUINOLONES CIPRO 3

ciprofloxacin 1

ciprofloxacin ext-rel 1

FACTIVE 3

levofloxacin 1

moxifloxacin hcl 1

ANTIBACTERIALS, PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate 1

amoxicillin & pot clavulanate ext-rel 1

ampicillin 1

AUGMENTIN 3

AUGMENTIN ES-600 3

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AUGMENTIN XR 3

dicloxacillin sodium 1

penicillin v potassium 1

ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE 3

sulfamethoxazole-trimethoprim 1

ANTIBACTERIALS, TETRACYCLINES ACTICLATE 3

ADOXA CAPS 3

demeclocycline hcl 1

DORYX 3

doxycycline (monohydrate) 1

doxycycline hyclate 1

minocycline hcl 1

minocycline hcl ext-rel 1 AGE: Min age 12 years

MORGIDOX KIT 3

SOLODYN 3 AGE: Min age 12 years;

ST (Try 2 generics, including minocycline)

tetracycline hcl 1

VIBRAMYCIN 3

ANTIFUNGALS clotrimazole troches 1

fluconazole 1

GRIS-PEG 3

griseofulvin microsize 1

griseofulvin ultramicrosize 1

itraconazole 1

ketoconazole 1

LAMISIL TABS 3

NOXAFIL 3

nystatin 1

nystatin (mouth-throat) 1

ONMEL 3

SPORANOX SOLN 3

terbinafine hcl 1

VFEND TABS 3

voriconazole 1

ANTIMALARIALS atovaquone-proguanil hcl 1

chloroquine phosphate 1

COARTEM 3

DARAPRIM 3

MALARONE 3

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

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QUALAQUIN 3

quinine sulfate 1

ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine 1

abacavir sulfate-lamivudine-zidovudine 1

ATRIPLA 2

COMBIVIR 3

COMPLERA 2

DESCOVY 2

EPZICOM 2

GENVOYA 2

lamivudine-zidovudine 1

ODEFSEY 2

STRIBILD 2

TRIUMEQ 3

TRIZIVIR 3

TRUVADA 2

ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY TABS 2

ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS TABS 2

TIVICAY 2

ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAPS 2

INVIRASE 2

KALETRA 2

LEXIVA TABS 2

lopinavir-ritonavir soln 1

NORVIR CAPS 2

NORVIR TABS 2

PREZISTA TABS 2

REYATAZ CAPS 2

VIRACEPT 2

ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

NUCLEOSIDE INTELENCE 2

nevirapine ext-rel 1

nevirapine tabs 1

RESCRIPTOR 2

SUSTIVA 2

ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir sulfate 1

didanosine 1

EMTRIVA CAPS 2

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EPIVIR 3

lamivudine 1

stavudine caps 1

ZIAGEN 3

zidovudine syrup 1

zidovudine tabs 1

ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD TABS 2

ANTITUBERCULAR AGENTS ethambutol hcl 1

isoniazid 1

MYAMBUTOL 3

PRIFTIN 3

pyrazinamide 1

RIFADIN 3

rifampin 1

ANTIVIRALS, CMV AGENTS VALCYTE 3

valganciclovir hcl 1

ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil 1

entecavir tabs 1

VEMLIDY 2

ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C COPEGUS 3 PA

EPCLUSA 4 PA; SP; only for genotypes 2, 3

HARVONI 4 PA; SP; only for genotypes 1, 4, 5 and 6

MODERIBA DOSE PACK 3 PA

RIBASPHERE RIBAPAK 3 PA

ribavirin 1 PA

ANTIVIRALS, HERPES AGENTS acyclovir 1

famciclovir 1

SITAVIG 3

valacyclovir hcl 1

ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate 30mg 1 QL (28 per 180 days)

oseltamivir phosphate 45mg, 75mg 1 QL (14 per 180 days)

RELENZA DISKHALER 2 QL (40 per 180 days)

TAMIFLU CAPS 30mg 2 QL (28 per 180 days)

TAMIFLU CAPS 45mg, 75mg 2 QL (14 per 180 days)

TAMIFLU SUSR 2 QL (180 mL per 180 days)

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MISCELLANEOUS ALBENZA 3

ALINIA 3

atovaquone 1

BILTRICIDE 3

clindamycin hcl 1

clindamycin palmitate hydrochloride 1

dapsone 1

ivermectin 1

linezolid 1

metronidazole tabs 1

MONUROL 3

MYCOBUTIN 3

nitrofurantoin macrocrystal 1

nitrofurantoin monohyd macro 1

nitrofurantoin susp 1

paromomycin sulfate 1

rifabutin 1

STROMECTOL 3

tinidazole 1

trimethoprim 1

vancomycin hcl 1

XIFAXAN 3

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN OC oral chemotherapy -

refer to plan benefits

CYCLOPHOSPHAMIDE OC oral chemotherapy -


GLEOSTINE OC oral chemotherapy -


LEUKERAN OC oral chemotherapy -


MYLERAN OC oral chemotherapy -


TEMODAR OC PA; SP; oral

chemotherapy - refer to plan benefits

temozolomide OC PA; SP; oral chemotherapy - refer to

plan benefits

VALCHLOR 4 PA; SP

ANTIMETABOLITES capecitabine OC PA; SP; oral


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mercaptopurine OC oral chemotherapy - refer to plan benefits

methotrexate sodium OC oral chemotherapy - refer to plan benefits

TABLOID OC oral chemotherapy - refer to plan benefits

XELODA OC PA; SP; oral chemotherapy - refer to

plan benefits

HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide OC oral chemotherapy -


CASODEX OC oral chemotherapy - refer to plan benefits

flutamide OC oral chemotherapy - refer to plan benefits

NILANDRON OC oral chemotherapy - refer to plan benefits

nilutamide OC oral chemotherapy - refer to plan benefits

XTANDI OC PA; SP; oral


ZYTIGA OC PA; SP; oral chemotherapy - refer to plan benefits

HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON OC oral chemotherapy -


tamoxifen citrate OC oral chemotherapy - refer to plan benefits

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole OC PA; (PA for males only);

oral chemotherapy - refer to plan benefits

ARIMIDEX OC PA; (PA for males only); oral chemotherapy -


AROMASIN OC PA; (PA for males only);


exemestane OC PA; (PA for males only); oral chemotherapy -


FEMARA OC PA; (PA for males only);


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letrozole OC PA; (PA for males only); oral chemotherapy - refer to plan benefits

HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate susp 40 mg/ml OC oral chemotherapy -


megestrol acetate tabs OC oral chemotherapy - refer to plan benefits

IMMUNOMODULATORS POMALYST OC PA; SP; oral


REVLIMID OC PA; SP; oral chemotherapy - refer to

plan benefits

THALOMID OC PA; SP; oral


KINASE INHIBITORS AFINITOR TABS OC PA; SP; oral


BOSULIF OC PA; SP; oral chemotherapy - refer to

plan benefits

CABOMETYX OC PA; SP; oral


GILOTRIF OC PA; SP; oral chemotherapy - refer to

plan benefits

GLEEVEC OC PA; SP; oral


ICLUSIG OC PA; SP; oral chemotherapy - refer to plan benefits

imatinib mesylate OC PA; SP; oral


IMBRUVICA OC PA; SP; oral chemotherapy - refer to plan benefits

INLYTA OC PA; SP; oral chemotherapy - refer to

plan benefits

IRESSA OC PA; SP; oral chemotherapy - refer to plan benefits

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JAKAFI OC PA; SP; oral chemotherapy - refer to plan benefits

MEKINIST OC PA; SP; oral chemotherapy - refer to

plan benefits

NEXAVAR OC PA; SP; oral chemotherapy - refer to plan benefits

SPRYCEL OC PA; SP; oral chemotherapy - refer to

plan benefits

STIVARGA OC PA; SP; oral


SUTENT OC PA; SP; oral chemotherapy - refer to

plan benefits

TAFINLAR OC PA; SP; oral


TARCEVA OC PA; SP; oral chemotherapy - refer to

plan benefits

TASIGNA OC PA; SP; oral


TYKERB OC PA; SP; oral chemotherapy - refer to

plan benefits

VOTRIENT OC PA; SP; oral


XALKORI OC PA; SP; oral chemotherapy - refer to

plan benefits

ZELBORAF OC PA; SP; oral


ZYDELIG OC PA; SP; oral chemotherapy - refer to plan benefits

MISCELLANEOUS bexarotene OC PA; SP; oral


DROXIA 3

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ERIVEDGE OC PA; SP; oral chemotherapy - refer to plan benefits

etoposide OC oral chemotherapy - refer to plan benefits

HYDREA OC oral chemotherapy -


hydroxyurea OC oral chemotherapy -


leucovorin calcium 1

LYNPARZA OC PA; SP; oral


LYSODREN OC oral chemotherapy - refer to plan benefits

MESNEX 3

RUBRACA OC PA; SP; oral


TARGRETIN CAPS OC PA; SP; oral chemotherapy - refer to

plan benefits

TARGRETIN GEL 2 PA

tretinoin (chemotherapy) OC oral chemotherapy -


VENCLEXTA OC PA; SP; oral


VISTOGARD 5 SP

TOPOISOMERASE INHIBITORS HYCAMTIN OC PA; SP; oral

chemotherapy - refer to

plan benefits

CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate/benazepril 1

LOTREL 3

trandolapril/verapamil ext-rel 1

ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide 1

captopril/hydrochlorothiazide 1

enalapril maleate/hydrochlorothiazide 1

fosinopril sodium/hydrochlorothiazide 1

lisinopril/hydrochlorothiazide 1

moexipril/hydrochlorothiazide 1

quinapril/hydrochlorothiazide 1

ACE INHIBITORS benazepril 1

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captopril 1

enalapril maleate 1

EPANED 3 AGE (Covered for ages 1 month to 12 years of

age)

fosinopril sodium 1

lisinopril 1

moexipril hcl 1

perindopril erbumine 1

QBRELIS 3 AGE (Covered for ages 6

to 12 years of age)

quinapril hcl 1

ramipril 1

trandolapril 1

ADRENOLYTICS, CENTRAL CATAPRES-TTS 3

clonidine hcl 1

clonidine hcl transdermal 1

guanfacine hcl 1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1

spironolactone 1

ALPHA BLOCKERS prazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil 1

amlodipine besylate-valsartan 1

EXFORGE 3

telmisartan-amlodipine 1

TWYNSTA 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide 1

EXFORGE HCT 3

olmesartan medoxomil-amlodipine-

hydrochlorothiazide

1

ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS ATACAND HCT 3

candesartan cilexetil-hydrochlorothiazide 1

EDARBYCLOR 3

irbesartan-hydrochlorothiazide 1

losartan potassium & hydrochlorothiazide 1

olmesartan medoxomil-hydrochlorothiazide 1

telmisartan-hydrochlorothiazide 1

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valsartan-hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 1

EDARBI 3

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

olmesartan medoxomil 1

telmisartan 1

valsartan 1

ANTIARRHYTHMICS amiodarone hcl 1

BETAPACE 3

BETAPACE AF 2

disopyramide phosphate 1

dofetilide 1 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE CR 2

propafenone hcl 1

propafenone hcl ext-rel 1

RYTHMOL SR 2

sotalol hcl 1

sotalol hcl (afib/afl) 1

ANTILIPEMICS, BILE ACID RESINS cholestyramine 1

cholestyramine light 1

COLESTID GRANULES 3

colestipol hcl 1

WELCHOL 3

ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 1 QL (30 per 30 days)

ZETIA 3 QL (30 per 30 days)

ANTILIPEMICS, FIBRATES ANTARA 3

choline fenofibrate 1

fenofibrate 1

fenofibrate micronized 1

gemfibrozil 1

TRIGLIDE 3

ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS ALTOPREV 3 QL (30 per 30 days); ST

(Try generic statin)

atorvastatin calcium 1 QL (30 per 30 days)

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ezetimibe-simvastatin 1 QL (30 per 30 days)

fluvastatin sodium 1 QL (30 per 30 days)

fluvastatin sodium ext-rel 1 QL (30 per 30 days)

LIVALO 3 QL (30 per 30 days); ST

(Try generic statin)

lovastatin 1 QL (30 per 30 days)

pravastatin sodium 1 QL (30 per 30 days)

rosuvastatin calcium 1 QL (30 per 30 days)

simvastatin 1 QL (30 per 30 days)

VYTORIN 3 QL (30 per 30 days)

ANTILIPEMICS, NIACINS niacin 1

niacin ext-rel 1

ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters 1

VASCEPA 3

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1

bisoprolol & hydrochlorothiazide 1

DUTOPROL 3

metoprolol & hydrochlorothiazide 1

propranolol & hydrochlorothiazide 1

BETA-BLOCKERS acebutolol hcl 1

atenolol 1

betaxolol hcl 1

bisoprolol fumarate 1

BYSTOLIC 3

carvedilol 1

COREG 3

COREG CR 2

CORGARD 3

INDERAL LA 3

labetalol hcl 1

LOPRESSOR 3

metoprolol succinate ext-rel 1

metoprolol tartrate 1

nadolol 1

pindolol 1

propranolol hcl 1

propranolol hcl ext-rel 1

TENORMIN 3

timolol maleate 1

TOPROL XL 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium 1 QL (30 per 30 days)

19


CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC 3

amlodipine besylate 1

felodipine ext-rel 1

isradipine 1

nicardipine hcl 1

nifedipine 1

nifedipine ext-rel 1

nimodipine 1

nisoldipine ext-rel 1

NORVASC 3

PROCARDIA XL 3

SULAR 3

CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN SR 3

CARDIZEM CD 3

CARDIZEM LA 3

diltiazem hcl 1

diltiazem hcl ext-rel 1

TIAZAC 3

verapamil hcl 1

verapamil hcl ext-rel 1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES digoxin 1

LANOXIN 3

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA 3

TEKTURNA HCT 3

DIURETICS ALDACTAZIDE 3

amiloride & hydrochlorothiazide 1

amiloride hcl 1

bumetanide 1

chlorthalidone 1

DIURIL 3

DYRENIUM 3

EDECRIN 3

ethacrynic acid 1

furosemide 1

hydrochlorothiazide 1

indapamide 1

methyclothiazide 1

metolazone 1

spironolactone & hydrochlorothiazide 1

20


torsemide 1

triamterene/hydrochlorothiazide 1

HEART FAILURE BIDIL 3

ENTRESTO 2 QL (60 per 30 days)

MISCELLANEOUS hydralazine hcl 1

methyldopa 1

midodrine hcl 1

minoxidil 1

NORTHERA 4 PA; SP

phenoxybenzamine hcl 1

RANEXA 3

NITRATES, ORAL isosorbide dinitrate 1

isosorbide dinitrate ext-rel 1

isosorbide mononitrate 1

isosorbide mononitrate ext-rel 1

nitroglycerin ext-rel 1

NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual spray 1

nitroglycerin sublingual 1

nitroglycerin sublingual aerosol 1

NITRATES, TRANSDERMAL NITRO-BID 3

NITRO-DUR 2

nitroglycerin transdermal 1

PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST LETAIRIS 4 QL (30 per 30 days),

PA; SP

OPSUMIT 4 QL (30 per 30 days), PA; SP

TRACLEER 4 QL (60 per 30 days), PA; SP

PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITORS ADCIRCA 4 QL (30 per 30 days),

PA; SP

REVATIO SUSP 4 QL (180 mL per 30 days), PA; SP

REVATIO TABS 4 QL (90 per 30 days), PA; SP

sildenafil citrate (pulmonary hypertension) 4 QL (90 per 30 days), PA; SP

21


PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM 4 QL (60 per 30 days),

PA; SP

TYVASO 4 QL (Max 1 ampule per

day), PA; SP

VENTAVIS 4 QL (Max 9 ampules per

day), PA; SP

PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS 4 QL (90 per 30 days),

PA; SP

CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES alprazolam ext-rel 1

alprazolam orally disintegrating tabs 1

alprazolam tabs 1

chlordiazepoxide hcl 1

clonazepam orally disintegrating tabs 1

clonazepam tabs 1

clorazepate dipotassium 1

diazepam 1

KLONOPIN 3

lorazepam 1

oxazepam 1

VALIUM 3

ANTIANXIETY, MISCELLANEOUS buspirone hcl 1

clomipramine hcl 1

fluvoxamine maleate 1

fluvoxamine maleate ext-rel 1

meprobamate 1

ANTICONVULSANTS BANZEL TABS 3

carbamazepine 1

carbamazepine ext-rel 1

CARBATROL 3

CELONTIN 3

DEPAKENE SYRUP 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 2

DIASTAT PEDIATRIC 2

diazepam (anticonvulsant) 1

DILANTIN 3

22


DILANTIN INFATABS 3

DILANTIN-125 3

divalproex sodium 1

divalproex sodium ext-rel 1

ethosuximide 1

felbamate 1

FELBATOL TABS 3

gabapentin 1

GABITRIL 3

KEPPRA 3

KEPPRA XR 3

LAMICTAL 3

LAMICTAL CHEWABLE 3

LAMICTAL ODT 3

LAMICTAL ODT KIT 3

LAMICTAL STARTER KIT 3

LAMICTAL XR 3

LAMICTAL XR KIT 3

lamotrigine 1

lamotrigine ext-rel 1

lamotrigine orally disintegrating tabs 1

levetiracetam 1

levetiracetam ext-rel 1

MYSOLINE 3

NEURONTIN 3

ONFI 3

oxcarbazepine 1

OXTELLAR XR 3

phenobarbital 1

PHENYTEK 3

phenytoin 1

phenytoin sodium extended 1

primidone 1

TEGRETOL 3

TEGRETOL-XR 2

tiagabine hcl 1

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate 1

topiramate ext-rel 1

topiramate sprinkle caps 1

TRILEPTAL 3

TROKENDI XR 3

valproate sodium 1

valproic acid 1

VIMPAT 3

ZARONTIN 3

23


ZONEGRAN 3

zonisamide 1

ANTIDEMENTIA donepezil hydrochloride 1

donepezil orally disintegrating tabs 1

galantamine hydrobromide ext-rel 1

galantamine hydrobromide tabs 1

memantine hcl 1

memantine hcl titration pack 1

NAMENDA XR 2

NAMENDA XR TITRATION PACK 2

rivastigmine tartrate 1

rivastigmine transdermal 1

ANTIDEPRESSANTS, MAOIS EMSAM 3

MARPLAN 3

phenelzine sulfate 1

tranylcypromine sulfate 1

ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN 3

bupropion hcl 1

bupropion hcl ext-rel 100mg, 150mg, 200mg, 300mg

1

chlordiazepoxide-amitriptyline 1

FORFIVO XL 3

maprotiline hcl 1

mirtazapine 1

mirtazapine orally disintegrating tabs 1

nefazodone hcl 1

trazodone hcl 1

ANTIDEPRESSANTS, SNRIS desvenlafaxine ext-rel 50mg 1 QL (240 per 30 days)

desvenlafaxine ext-rel 100mg 1 QL (120 per 30 days)

desvenlafaxine succinate ext-rel 1

duloxetine hcl 1

FETZIMA 20mg 3 QL (180 per 30 days)

FETZIMA 40mg 3 QL (90 per 30 days)

FETZIMA 80mg, 120mg 3 QL (30 per 30 days)

FETZIMA TITRATION PACK 3 QL (90 per 30 days)

PRISTIQ 3

venlafaxine hcl 1

VENLAFAXINE HCL ER 3

venlafaxine hcl ext-rel 1

ANTIDEPRESSANTS, SSRIS citalopram hydrobromide 1

escitalopram oxalate 1

24


fluoxetine hcl CAPS 1

fluoxetine hcl CPDR 1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg 1

FLUOXETINE HCL TABS 60mg 3

fluoxetine hcl (pmdd) 1

paroxetine hcl 1

paroxetine hcl ext-rel 1

PAXIL SUSP 3

PEXEVA 3

SARAFEM 3

sertraline hcl 1

TRINTELLIX 5mg 3 QL (120 per 30 days)



VIIBRYD TABS 3

ANTIDEPRESSANTS, TCAS amitriptyline hcl 1

amoxapine 1

desipramine hcl 1

doxepin hcl 1

imipramine hcl 1

imipramine pamoate 1

nortriptyline hcl 1

protriptyline hcl 1

ANTIPARKINSONIAN AGENTS amantadine hcl 1

AZILECT 2

benztropine mesylate 1

bromocriptine mesylate 1

carbidopa 1

carbidopa-levodopa 1

carbidopa-levodopa ext-rel 1

carbidopa-levodopa orally disintegrating

tabs

1

carbidopa-levodopa-entacapone 1

entacapone 1

NEUPRO 3

pramipexole dihydrochloride 1

pramipexole dihydrochloride ext-rel 1

rasagiline mesylate 1

ropinirole hydrochloride 1

ropinirole hydrochloride ext-rel 1

selegiline hcl 1

trihexyphenidyl hcl 1

ZELAPAR 3

25


ANTIPSYCHOTICS, ATYPICALS ABILIFY TABS 3

aripiprazole 1

clozapine 1

FANAPT 3

FANAPT TITRATION PACK 3

LATUDA 3

loxapine succinate 1

olanzapine 1

olanzapine orally disintegrating tabs 1

olanzapine-fluoxetine hcl 1

paliperidone ext-rel 1

quetiapine fumarate 1

quetiapine fumarate ext-rel 1

risperidone 1

risperidone orally disintegrating tabs 1

SAPHRIS 3

ziprasidone hcl 1

ANTIPSYCHOTICS, MISCELLANEOUS chlorpromazine hcl 1

fluphenazine hcl 1

haloperidol 1

haloperidol lactate 1

NUPLAZID 5 PA; SP

ORAP 3

perphenazine 1

perphenazine-amitriptyline 1

pimozide 1

thioridazine hcl 1

thiothixene 1

trifluoperazine hcl 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine ext-rel

5 mg 1 QL (360 per 30 days)

amphetamine-dextroamphetamine ext-rel

10 mg



15 mg



20 mg



25 mg



30 mg


amphetamine-dextroamphetamine tab 5

mg


26


amphetamine-dextroamphetamine tab 7.5 mg


amphetamine-dextroamphetamine tab 10 mg


amphetamine-dextroamphetamine tab 12.5 mg








APTENSIO XR 10mg 3 QL (180 per 30 days)




APTENSIO XR 40mg, 50mg, 60mg 3 QL (30 per 30 days)

clonidine ext-rel tab 0.1mg 1

DAYTRANA 10mg/9hr 3 QL (90 per 30 days)

DAYTRANA 15mg/9hr 3 QL (60 per 30 days)

DAYTRANA 20mg/9hr, 30mg/9hr 3 QL (30 per 30 days)

dexmethylphenidate hcl ext-rel 5 mg 1 QL (300 per 30 days)








dexmethylphenidate hcl tab 2.5 mg 1 QL (600 per 30 days)

dexmethylphenidate hcl tab 5 mg 1 QL (300 per 30 days)

dexmethylphenidate hcl tab 10 mg 1 QL (150 per 30 days)

dextroamphetamine sulfate 5mg 1 QL (360 per 30 days)

dextroamphetamine sulfate 10mg 1 QL (180 per 30 days)

dextroamphetamine sulfate ext-rel 5mg 1 QL (360 per 30 days)



FOCALIN XR CAP 5MG 3 QL (300 per 30 days)








guanfacine hcl ext-rel 1

INTUNIV 3

27


KAPVAY 3

METADATE CD 10mg 3 QL (300 per 30 days)



METADATE CD 40mg, 50mg 3 QL (60 per 30 days)


methamphetamine hcl tab 5 mg 1 QL (150 per 30 days)

methylphenidate hcl SOLN 5mg/5ml 1 QL (3000 mL per 30

days)

methylphenidate hcl SOLN 10mg/5ml 1 QL (1500 mL per 30

days)

methylphenidate hcl TABS 5mg 1 QL (600 per 30 days)



methylphenidate hcl ext-rel caps 10mg 1 QL (300 per 30 days)






methylphenidate hcl ext-rel tabs 10mg 1 QL (300 per 30 days)






QUILLIVANT XR 3

RITALIN LA 10mg 3 QL (300 per 30 days)




STRATTERA 10mg 3 QL (300 per 30 days)




STRATTERA 60mg, 80mg, 100mg 3 QL (30 per 30 days)

VYVANSE 10mg, 20mg, 30mg 3 QL (60 per 30 days)

VYVANSE 40mg, 50mg, 60mg, 70mg 3 QL (30 per 30 days)

zenzedi tab 2.5mg 1 QL (480 per 30 days)

zenzedi tab 5mg 1 QL (360 per 30 days)

zenzedi tab 7.5mg 1 QL (150 per 30 days)





FIBROMYALGIA

28


LYRICA CAPS 25MG, 50MG, 75MG, 100MG, 150MG


LYRICA CAPS 200MG 2 QL (90 per 30 days)

LYRICA CAPS 225MG, 300MG 2 QL (60 per 30 days)

LYRICA SOLN 2 QL (900 mL per 30

days)

SAVELLA 2

SAVELLA TITRATION PACK 2

HUNTINGTON'S DISEASE AGENTS tetrabenazine 4 PA; SP

HYPNOTICS, TRICYCLICS SILENOR 3

HYPNOTICS: BENZODIAZEPINES estazolam 1

flurazepam hcl 1

temazepam 1

triazolam 1

HYPNOTICS: NON-BENZODIAZEPINES BELSOMRA 3

EDLUAR 3 QL (30 per 30 days)

eszopiclone 1 QL (30 per 30 days)

INTERMEZZO 1.75mg 3 QL (females only - 30

per 30 days)

INTERMEZZO 3.5mg 3 QL (males only - 30 per

30 days)

ROZEREM 3

SECONAL 3

zaleplon 5mg 1 QL (90 per 30 days)

zaleplon 10mg 1 QL (60 per 30 days)

zolpidem tartrate 1 QL (30 per 30 days)

zolpidem tartrate ext-rel 1 QL (30 per 30 days)

zolpidem tartrate sublingual 1.75mg 1 QL (females only - 30 per 30 days)

zolpidem tartrate sublingual 3.5mg 1 QL (males only - 30 per 30 days)

MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate 1

ergotamine w/ caffeine 1

MIGRANAL 3

MIGRAINE, MISCELLANEOUS isometheptene-caffeine-acetaminophen 1

isometheptene-dichloralphenazone-acetaminophen

1

PRODRIN 3

MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID TREXIMET 3 QL (9 tabs per 30 days)

29


MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate 1 QL (12 tabs per 30

days)

frovatriptan succinate 1 QL (9 tabs per 30 days)

naratriptan hcl 1 QL (9 tabs per 30 days)

RELPAX 2 QL (12 tabs per 30

days)

rizatriptan benzoate 1 QL (12 tabs per 30 days)

rizatriptan benzoate orally disintegrating tabs

1 QL (12 tabs per 30 days)

sumatriptan nasal spray 1 QL (12 units per 30 days)

sumatriptan succinate 1 QL (9 tabs per 30 days)

sumatriptan succinate inj 4 mg/0.5 ml 1 QL (4 inj per 30 days)

sumatriptan succinate inj 6 mg/0.5 ml 1 QL (5 inj per 30 days)

SUMAVEL DOSEPRO 2 QL (6 inj per 30 days)

zolmitriptan 1 QL (12 tabs per 30 days)

zolmitriptan orally disintegrating tabs 1 QL (12 tabs per 30 days)

ZOMIG NASAL SPRAY 3 QL (12 units per 30 days)

ZOMIG ZMT 3 QL (12 tabs per 30 days)

MISCELLANEOUS riluzole 1

MOOD STABILIZERS EQUETRO 3

LITHIUM 3

lithium carbonate 1

lithium carbonate ext-rel 1

LITHOBID 2

MULTIPLE SCLEROSIS AMPYRA 4 PA; SP

AUBAGIO 4 PA; SP

GILENYA 4 PA; SP

TECFIDERA 4 PA; SP

TECFIDERA STARTER PACK 4 PA; SP

MUSCULOSKELETAL THERAPY AGENTS AMRIX 3

baclofen 1

carisoprodol 1 QL (1400 mg per day)

chlorzoxazone 1

cyclobenzaprine hcl 1

dantrolene sodium 1

FEXMID 3

30


LORZONE 3

metaxalone 1

methocarbamol 1

orphenadrine citrate ext-rel 1

tizanidine hcl 1

ZANAFLEX TABS 3

MYASTHENIA GRAVIS pyridostigmine bromide 1

pyridostigmine bromide ext-rel 1

NARCOLEPSY/CATAPLEXY armodafinil 1 PA

modafinil 1 PA

XYREM 4 PA; SP

POSTHERPETIC NEURALGIA GRALISE 3

GRALISE STARTER 3

PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium 1

disulfiram 1

PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONISTS naltrexone hcl 1

NARCAN NASAL SPRAY 3

PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID

AGONIST/ANTAGONIST COMBINATIONS buprenorphine hcl-naloxone hcl dihydrate 1

SUBOXONE FILM 2

ZUBSOLV 3

PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl 1

PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA 3

PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl ext-rel 150mg 0 QL (Max 180 days per

year); AGE: Min Age 19 years; $0

CHANTIX 0 QL (Max 180 days per year); AGE: Min Age 19

years; $0

NICODERM CQ 0 QL (Max 180 days per


NICORETTE 0 QL (Max 180 days per year); AGE: Min Age 19

years; $0

31


nicotine polacrilex gum 0 QL (Max 180 days per year); AGE: Min Age 19 years; $0

nicotine polacrilex lozenge 0 QL (Max 180 days per year); AGE: Min Age 19

years; $0

nicotine transdermal 0 QL (Max 180 days per year); AGE: Min Age 19 years; $0

NICOTROL INHALER 3 QL (Max 180 days per year); AGE: Min Age 19

years; $0

NICOTROL NS 3 QL (Max 180 days per


ZYBAN 3 QL (Max 180 days per year); AGE: Min Age 19

years; $0

PSYCHOTHERAPEUTIC-MISC, VASOMOTOR SYMPTOM AGENTS BRISDELLE 3 ST (Try generic or Tier 2

estrogen)

RESTLESS LEGS SYNDROME HORIZANT 3

DIAGNOSTIC PRODUCTS RADIOGRAPHIC CONTRAST MEDIA - BARIUM E-Z-CAT DRY 3

ENTERO VU 3

LIQUID E-Z-PAQUE 3

LIQUID POLIBAR PLUS 3

READI-CAT 2 3

TAGITOL V 3

VARIBAR HONEY 3

VARIBAR NECTAR 3

VARIBAR THIN HONEY 3

VOLUMEN 3

ENDOCRINE AND METABOLIC ANDROGENS METHITEST 3

methyltestosterone 1

NATESTO 3 males only

oxandrolone 1

testosterone gel 1 QL (300 grams per 30 days); males only

TESTRED 3

ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose 1

miglitol 1

32


ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 3

SYMLINPEN 120 3

ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl 1

glyburide-metformin 1

ANTIDIABETICS, BIGUANIDES metformin hcl 1

metformin hcl xr 1 (generic for

GLUCOPHAGE XR)

ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET 2

JANUMET XR 2

JENTADUETO 2

JENTADUETO XR 2

ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS JANUVIA 2

TRADJENTA 2

ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON 2

BYETTA 3

TANZEUM 3

TRULICITY 3

VICTOZA 2

ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE

COMBINATIONS ACTOPLUS MET XR 3

pioglitazone hcl-metformin hcl 1

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO DUETACT 3

pioglitazone hcl-glimepiride 1

ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl 1

ANTIDIABETICS, INSULINS HUMULIN R U-500 (CONCENTR 1

LANTUS 1

LANTUS SOLOSTAR 1

NOVOLIN 70/30 1

NOVOLIN N 1

NOVOLIN R 1

NOVOLOG 1

NOVOLOG FLEXPEN 1

NOVOLOG MIX 70/30 1

NOVOLOG MIX 70/30 PREFILL 1

33


NOVOLOG PENFILL 1

ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl 1

ANTIDIABETICS, MEGLITINIDES nateglinide 1

repaglinide 1

ANTIDIABETICS, MISCELLANEOUS CYCLOSET 3

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2

INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET 2 ST (Try metformin or

metformin combinations)

INVOKAMET XR 2 ST (Try metformin or metformin

combinations)

SYNJARDY 2 ST (Try metformin or


SYNJARDY XR 2 ST (Try metformin or metformin

combinations)

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2

INHIBITORS INVOKANA 2 ST (Try metformin or


JARDIANCE 2 ST (Try metformin or metformin

combinations)

ANTIDIABETICS, SULFONYLUREAS chlorpropamide 1

glimepiride 1

glipizide 1

glipizide ext-rel 1

glyburide 1

glyburide micronized 1

tolbutamide 1

ANTIDIABETICS, SUPPLIES ACCU-CHEK ACTIVE STRIPS 2

ACCU-CHEK AVIVA 2

ACCU-CHEK AVIVA PLUS 2

ACCU-CHEK COMFORT CURVE T 2

ACCU-CHEK COMPACT TEST DR 2

ACCU-CHEK SMARTVIEW STRIP 2

ACCUTREND GLUCOSE 2

34


ACURA BLOOD GLUCOSE TEST 2

ADVANCE INTUITION TEST ST 2

ADVANCE MICRO-DRAW TEST S 2

ADVOCATE TEST STRIPS 2

AGAMATRIX AMP NO CODE TES 2

AGAMATRIX JAZZ TEST STRIP 2

AGAMATRIX KEYNOTE TEST ST 2

AGAMATRIX PRESTO TEST STR 2

ALCOHOL PREP PADS 0 $0

ASCENSIA AUTODISC TEST ST 2

ASSURE 3 TEST STRIPS 2

ASSURE 4 TEST STRIPS 2

ASSURE II TEST STRIPS 2

ASSURE PLATINUM TEST STRI 2

ASSURE PRISM MULTI TEST S 2

ASSURE PRO TEST STRIPS 2

AT LAST TEST STRIPS 2

BAYER BREEZE 2 TEST DISC 2

BAYER CONTOUR BLOOD GLUCO 2

BAYER CONTOUR NEXT BLOOD 2

BG STAR BLOOD GLUCOSE TES 2

BIOSCANNER GLUCOSE TEST S 2

BLOOD GLUCOSE CONTROL TEST SOLUTIONS

2

BLOOD GLUCOSE TEST STRIPS 2

CAREONE BLOOD GLUCOSE TES 2

CARESENS N BLOOD GLUCOSE 2

CHEK-STIX CONTROL 0 $0

CHEMSTRIP UGK 0 $0

CHEMSTRIP-K 0 $0

CLEVER CHEK TEST STRIPS 2

CLEVER CHOICE MICRO TEST 2

CLINISTIX 0 $0

CONTROL AST 2

CONTROL TEST STRIPS 2

DIASTIX 0 $0

DIATRUE PLUS BLOOD GLUCOS 2

DUO-CARE TEST STRIPS 2

EASY PLUS BLOOD GLUCOSE T 2

EASY PLUS II BLOOD GLUCOS 2

EASY STEP TEST STRIPS 2

EASY TALK BLOOD GLUCOSE T 2

EASY TOUCH GLUCOSE TEST S 2

EASY TOUCH HEALTHPRO GLUC 2

EASY TRAK BLOOD GLUCOSE T 2

EASYGLUCO 2

EASYGLUCO PLUS 2

35


EASYMAX 15 TEST STRIPS 2

EASYMAX TEST STRIPS 2

EASYPLUS BLOOD GLUCOSE TE 2

EASYPRO BLOOD GLUCOSE TES 2

EASYPRO PLUS 2

ELEMENT COMPACT TEST STRI 2

ELEMENT TEST STRIPS 2

EMBRACE BLOOD GLUCOSE TEST 2

EMBRACE EVO BLOOD GLUCOSE 2

EMBRACE PRO BLOOD GLUCOSE 2

EVENCARE + BLOOD GLUCOSE 2

EVENCARE BLOOD GLUCOSE TEST STRIPS 2

EVENCARE G2 TEST STRIPS 2

EVOLUTION AUTOCODE 2

EXACTECH R-S-G TEST STRIP 2

EXACTECH TEST STRIPS 2

EZ SMART BLOOD GLUCOSE TEST STRIPS 2

EZ SMART PLUS BLOOD GLUCOSE 2

FIFTY50 GLUCOSE TEST STRIPS 2

FORA BLOOD GLUCOSE TEST S 2

FORA D15G BLOOD GLUCOSE T 2

FORA D20 BLOOD GLUCOSE TE 2

FORA G20 BLOOD GLUCOSE TE 2

FORA G30A BLOOD GLUCOSE T 2

FORA GD20 TEST STRIPS 2

FORA GD50 BLOOD GLUCOSE T 2

FORA V10 BLOOD GLUCOSE TE 2



FORA V30A BLOOD GLUCOSE T 2

FORACARE GD40 2

FORACARE PREMIUM V10 TEST 2

FORACARE TEST N GO TEST S 2

FREESTYLE INSULINX BLOOD 0 $0

FREESTYLE LITE TEST STRIP 0 $0

FREESTYLE TEST STRIPS 0 $0

GE100 BLOOD GLUCOSE TEST 2

GHT TEST STRIPS 2

GLUCO PERFECT 3 TEST STRI 2

GLUCOCARD 01 SENSOR PLUS 2

GLUCOCARD EXPRESSION BLOO 2

GLUCOCARD SHINE TEST STRI 2

GLUCOCARD VITAL TEST STRI 2

GLUCOCARD X-SENSOR 2

GLUCOCOM TEST STRIPS 2

GLUCONAVII BLOOD GLUCOSE 2

GMATE BLOOD GLUCOSE TEST 2

36


INFINITY BLOOD GLUCOSE TE 2

INSULIN SYRINGES, NEEDLES 0 $0

KETO-DIASTIX 0 $0

KETOCARE 0 $0

KETONE TEST STRIPS 0 $0

KETOSTIX 0 $0

LANCETS 0 $0

LANCING DEVICE 0 $0

LIBERTY NEXT GENERATION B 2

LIBERTY TEST STRIPS 2

MAXIMA BLOOD GLUCOSE TEST 2

MICRODOT TEST STRIPS 2

MYGLUCOHEALTH BLOOD GLUCO 2

NEUTEK 2TEK TEST STRIPS 2

NEXGEN TEST STRIPS 2

NOVA MAX GLUCOSE TEST STR 2

NOVA MAX PLUS KETONE TEST 0 $0

ON CALL EXPRESS BLOOD GLU 2

ON CALL PLUS BLOOD GLUCOS 2

ON CALL VIVID BLOOD GLUCO 2

ONETOUCH ULTRA BLUE 0 $0

ONETOUCH VERIO TEST STRIP 0 $0

OPTIUM TEST STRIPS 2

OPTIUMEZ TEST STRIPS 2

OPTUMRX BLOOD GLUCOSE TES 2

PHARMACIST CHOICE AUTOCOD 2

POCKETCHEM EZ BLOOD GLUCO 2

PRECISION GLUCOSE/KETONE 0 $0

PRECISION PCX 0 $0

PRECISION PCX PLUS TEST S 0 $0

PRECISION POINT OF CARE T 0 $0

PRECISION QID TEST STRIPS 0 $0

PRECISION SOF-TACT TEST S 0 $0

PRECISION XTRA 0 $0

PRECISION XTRA BLOOD GLUC 0 $0

PRODIGY NO CODING BLOOD G 2

PTS PANELS GLUCOSE TEST 2

PTS PANELS KETONE TEST 0 $0

QUICKTEK TEST STRIPS 2

QUINTET AC BLOOD GLUCOSE 2

QUINTET BLOOD GLUCOSE TES 2

REFUAH PLUS BLOOD GLUCOSE 2

REVEAL BLOOD GLUCOSE TEST 2

RIGHTEST GS100 BLOOD GLUC 2



SMART SENSE PREMIUM BLOOD 2

37


SMARTEST BLOOD GLUCOSE TE 2

SOLUS V2 AUDIBLE TEST 2

SUPREME TEST STRIPS 2

SURE EDGE BLOOD GLUCOSE T 2

SURE-TEST EASYPLUS MINI B 2

SURECHEK BLOOD GLUCOSE TE 2

SURESTEP PRO TEST STRIPS 0 $0

TELCARE BLOOD GLUCOSE TES 2

TGT BLOOD GLUCOSE TEST ST 2

TRUE METRIX BLOOD GLUCOSE 2

TRUETRACK BLOOD GLUCOSE T 2

TRUETRACK TEST 2

ULTIMA TEST STRIPS 2

ULTRATRAK PRO TEST STRIPS 2

ULTRATRAK ULTIMATE TEST S 2

UNISTRIP1 GENERIC 2

VICTORY AGM-4000 TEST STR 2

VOCAL POINT BLOOD GLUCOSE 2

WAVESENSE PRESTO TEST STR 2

ANTIOBESITY AGENTS BELVIQ 3 PA

XENICAL 3 PA

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 2 PA

CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium 1

FOSAMAX PLUS D 3

ibandronate sodium 1

risedronate sodium 1

risedronate sodium delayed-rel 1

CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) 1

CONTRACEPTIVES, BIPHASIC desogestrel-ethinyl estradiol (biphasic) 0 $0

MIRCETTE 3

CONTRACEPTIVES, CONTINUOUS levonorgestrel/ethinyl estradiol

(continuous)

0 $0

CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA 0 $0

levonorgestrel (emergency) 0 $0

PLAN B ONE-STEP 0 $0

CONTRACEPTIVES, EXTENDED CYCLE levonorgestrel/ethinyl estradiol (91-day) 0 $0

LOSEASONIQUE 3

38


QUARTETTE 3

SEASONIQUE 3

CONTRACEPTIVES, FOUR PHASE NATAZIA 3

CONTRACEPTIVES, MISCELLANEOUS OPTIONS CONCEPTROL VAGINA 0 $0

OPTIONS GYNOL II VAGINAL 0 $0

SHUR-SEAL 0 $0

vcf vaginal gel contraceptive 0 $0

CONTRACEPTIVES, MONOPHASIC BEYAZ 3

BREVICON-28 3

DESOGEN 3

desogestrel/ethinyl estradiol 0 $0

drospirenone-ethinyl estradiol-levomefolate calcium

0 $0

drospirenone/ethinyl estradiol 0 $0

ethynodiol diacetate/ethinyl estradiol 0 $0

FEMCON FE 3

GENERESS FE 3

levonorgestrel/ethinyl estradiol 0 $0

LO LOESTRIN FE 3

LOESTRIN 1.5/30-21 3

LOESTRIN 1/20-21 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

MINASTRIN 24 FE 3

norethindrone & ethinyl estradiol 0 $0

norethindrone & ethinyl estradiol-fe 0 $0

norethindrone & mestranol 0 $0

norethindrone acetate & ethinyl estradiol-

fe

0 $0

norethindrone acetate/ethinyl estradiol 0 $0

norgestimate-ethinyl estradiol 0 $0

norgestrel & ethinyl estradiol 0 $0

NORINYL 1+35 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

OVCON-35 3

SAFYRAL 3

YASMIN 28 3

YAZ 3

CONTRACEPTIVES, PROGESTIN ONLY norethindrone (contraceptive) 0 $0

ORTHO MICRONOR 3

CONTRACEPTIVES, TRANSDERMAL

39


norelgestromin-ethinyl estradiol 0 $0

CONTRACEPTIVES, TRIPHASIC desogestrel/ethinyl estradiol (triphasic) 0 $0

ESTROSTEP FE 3

levonorgestrel/ethinyl estradiol (triphasic) 0 $0

norethindrone acetate-ethinyl estradiol-fe 0 $0

norethindrone/ethinyl estradiol (triphasic) 0 $0

norgestimate/ethinyl estradiol (triphasic) 0 $0

ORTHO TRI-CYCLEN 3

ORTHO-NOVUM 7/7/7 3

TRI-NORINYL 28 3

CONTRACEPTIVES, VAGINAL NUVARING 0 $0

ENDOMETRIOSIS danazol 1

SYNAREL 2

ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate 1

norethindrone acetate-ethinyl estradiol 1

PREFEST 3

PREMPHASE 2

PREMPRO 2

ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO 3

COMBIPATCH 3

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS DUAVEE 2

ESTROGENS, ORAL esterified estrogens & methyltestosterone 1

ESTRACE 3

estradiol TABS 1

estropipate 1

MENEST 3

PREMARIN 2

ESTROGENS, TRANSDERMAL ALORA 3

DIVIGEL 3

ELESTRIN 3

estradiol PTTW; PTWK 1

ESTROGEL 3

EVAMIST 2

MENOSTAR 3

MINIVELLE 3

VIVELLE-DOT 3

40


ESTROGENS, VAGINAL ESTRACE CREAM 2

estradiol vaginal tabs 1

ESTRING 3

FEMRING 3

PREMARIN CREAM 2

FERTILITY REGULATORS, OVULATION STIMULANTS, SYNTHETIC clomiphene citrate 1

GLUCOCORTICOIDS cortisone acetate 1

dexamethasone 1

DEXAMETHASONE INTENSOL 3

DEXPAK 3

fludrocortisone acetate 1

hydrocortisone 1

MEDROL TABS 3

methylprednisolone 1

MILLIPRED 3

prednisolone 1

prednisolone sodium phosphate 1

prednisolone sodium phosphate orally

disintegrating tabs

1

prednisone 1

PREDNISONE INTENSOL 3

RAYOS 3

VERIPRED 20 3

GLUCOSE ELEVATING AGENT GLUCAGEN DIAGNOSTIC 2

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT 2

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol 1

doxercalciferol 1

HECTOROL 3

paricalcitol 1

MISCELLANEOUS cabergoline 1

CARNITOR 3

CARNITOR SF 3

CYSTADANE 2

CYSTAGON 4 PA; SP

levocarnitine (metabolic modifiers) 1

RAVICTI 4 PA; SP

PHENYLKETONURIA TREATMENT AGENTS KUVAN 4 PA; SP

PHOSPHATE BINDER AGENTS

41


calcium acetate (phosphate binder) 1

FOSRENOL CHEW TABS 3

PHOSLYRA 3

RENVELA 2

POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate 1

PROGESTINS, ORAL medroxyprogesterone acetate 1

MEGACE ES 3

megestrol acetate susp 625 mg/5 ml 1

norethindrone acetate 1

progesterone micronized 1

PROGESTINS, VAGINAL CRINONE 3

SELECTIVE ESTROGEN RECEPTOR MODULATOR OSPHENA 3 ST (Try generic or Tier 2

estrogen)

raloxifene hcl 1 AGE (Min age 35 years); generic covered at $0; females only

THYROID AGENTS, ANTITHYROID AGENTS iodine strong (lugol's) 1

methimazole 1

propylthiouracil 1

SSKI 3

THYROID SUPPLEMENTS CYTOMEL 3

levothyroxine sodium 1

liothyronine sodium 1

SYNTHROID 2

TIROSINT 3

VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA 4 PA; SP

VASOPRESSINS desmopressin acetate 1

desmopressin acetate spray 1

desmopressin acetate spray refrigerated 1

STIMATE 2 PA

GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine 1

loperamide hcl 1

ANTIEMETICS aprepitant caps 1

aprepitant pak 80 mg & 125 mg 1 QL (1 pak per 15 days)

42


CESAMET 3

DICLEGIS 3

dronabinol 1

EMEND 40 MG 2

EMEND 80 MG 2

EMEND 125 MG 2

EMEND PAK 2 QL (1 pak per 15 days)

granisetron hcl 1

meclizine hcl 1

metoclopramide hcl 1

ondansetron hcl 1

ondansetron orally disintegrating tabs 1

prochlorperazine 1

prochlorperazine maleate 1

promethazine hcl 1

SANCUSO 3

TRANSDERM-SCOP 3

trimethobenzamide hcl 1

ZUPLENZ 3

ANTISPASMODICS ANASPAZ 3

chlordiazepoxide hcl-clidinium bromide 1

dicyclomine hcl 1

DONNATAL 3

glycopyrrolate 1

hyoscyamine sulfate 1

hyoscyamine sulfate ext-rel 1

hyoscyamine sulfate sublingual 1

propantheline bromide 1

ROBINUL FORTE 3

CHOLELITHOLYTICS URSO 250 3

ursodiol 1

H2-RECEPTOR ANTAGONISTS cimetidine 1

cimetidine hcl 1

famotidine 1

nizatidine 1

ranitidine hcl 1

INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO 2

balsalazide disodium 1

budesonide 1

DELZICOL 2

DIPENTUM 3

LIALDA 3

43


PENTASA 3

sulfasalazine 1

UCERIS 3

INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA 2

CORTIFOAM 3

hydrocortisone (intrarectal) 1

mesalamine 1

mesalamine w/ cleanser 1 QL (28 per 28 days)

SFROWASA 3

IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA 3

LINZESS 3

IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hydrochloride 1

LAXATIVES COLYTE-FLAVOR PACKS 3

GOLYTELY 3

KRISTALOSE 3

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 3

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

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

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350 1

PREPOPIK 3

SUPREP BOWEL PREP KIT 3

MISCELLANEOUS BUPHENYL TABS 4 PA; SP

CARAFATE SUSP 3

cromolyn sodium (mastocytosis) 1

GASTROCROM 3

OCALIVA 5 PA; SP

RECTIV 3

sucralfate 1

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ZENPEP 3

PROSTAGLANDIN misoprostol 1

44


PROTON PUMP INHIBITORS (PPI) esomeprazole magnesium 2

FIRST-LANSOPRAZOLE 3

FIRST-OMEPRAZOLE 3

lansoprazole 1

omeprazole 1

OMEPRAZOLE + SYRSPEND SF 3

omeprazole-sodium bicarbonate 1

pantoprazole sodium 1

PRILOSEC POWDER 3

PROTONIX PAK 3

rabeprazole sodium 1

SALIVA STIMULANTS cevimeline hcl 1

pilocarpine hcl (oral) 1

STEROIDS, RECTAL EPIFOAM 3

hydrocortisone (rectal) 1

hydrocortisone acetate (rectal) 1

hydrocortisone acetate w/ pramoxine 1

lidocaine-hydrocortisone acetate (rectal) 1

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 3

ULCER THERAPY COMBINATION amoxicillin-clarithromycin w/ lansoprazole 1

OMECLAMOX-PAK 3

PYLERA 3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA: 5-ALPHA REDUCTASE

INHIBITORS dutasteride 1

finasteride 1

BENIGN PROSTATIC HYPERPLASIA: ALPHA BLOCKERS alfuzosin hcl ext-rel 1

CARDURA XL 3

doxazosin mesylate 1

RAPAFLO 3

tamsulosin hcl 1

terazosin hcl 1

BENIGN PROSTATIC HYPERPLASIA: COMBINATION AGENTS dutasteride-tamsulosin hcl 1

BENIGN PROSTATIC HYPERPLASIA: PHOSPHODIESTERASE

INHIBITORS

45


CIALIS TAB 5MG 3 AGE (Min age 18 years); ST (Try other BPH drugs); males only

ERECTILE DYSFUNCTION: ALPROSTADIL AGENTS MUSE 3

MISCELLANEOUS acetic acid/oxyquinoline 1

ELMIRON 2

FEM PH 3

HIPREX 3

methenamine hippurate 1

methenamine mandelate 1

phenazopyridine hcl 1

pot & sod citrates w/citric acid 1

potassium citrate (alkalinizer) 1

potassium citrate-citric acid 1

sodium citrate & citric acid 1

UROCIT-K 5 3

UROCIT-K 10 3

UROCIT-K 15 3

URINARY ANTISPASMODICS bethanechol chloride 1

darifenacin hydrobromide ext-rel 1

flavoxate hcl 1

GELNIQUE 10% 3

MYRBETRIQ 3

oxybutynin chloride 1

oxybutynin chloride ext-rel 1

OXYTROL 3

tolterodine tartrate 1

tolterodine tartrate ext-rel 1

TOVIAZ 3

trospium chloride 1

trospium chloride ext-rel 1

VESICARE 3

VAGINAL ANTI-INFECTIVES CLEOCIN SUPP 3

clindamycin phosphate vaginal 1

CLINDESSE 3

metronidazole vaginal 1

miconazole nitrate vaginal 1

NUVESSA 3

terconazole vaginal 1

HEMATOLOGIC ANTICOAGULANTS, ORAL COUMADIN 3

46


ELIQUIS 2

PRADAXA 2

warfarin sodium 1

XARELTO 2

IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA 4 PA; SP

MISCELLANEOUS AMICAR 3

CHEMET 2

cilostazol 1

EXJADE 4 PA; SP

pentoxifylline ext-rel 1

tranexamic acid 1

PLATELET AGGREGATION INHIBITORS aspirin 81 mg 0 $0; QL (100 tabs per

fill); AGE (Min age 12

years)

aspirin 325 mg, 500 mg 0 $0

aspirin enteric coated 0 $0; QL (100 tabs per fill); AGE (Min age 45 years)

BRILINTA 2

clopidogrel bisulfate 1

dipyridamole 1

dipyridamole ext-rel/aspirin 1

EFFIENT 2

PLATELET SYNTHESIS INHIBITOR anagrelide hcl 1

IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS ORALAIR 3 PA

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) CUPRIMINE 2

hydroxychloroquine sulfate 1

leflunomide 1

PLAQUENIL 3

XELJANZ 4 PA; SP

XELJANZ XR 5 PA; SP

IMMUNOMODULATORS, MISCELLANEOUS OTEZLA 4 PA; SP

IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN 3

azathioprine 1

CELLCEPT 2

IMURAN 3

mycophenolate mofetil 1

47


mycophenolate sodium 1

MYFORTIC 2

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL 3

cyclosporine 1

cyclosporine modified (for microemulsion) 1

NEORAL 2

PROGRAF 2

SANDIMMUNE CAPS 2

tacrolimus 1

IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE 3

sirolimus 1

ZORTRESS 3

NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS K-PHOS 3

K-PHOS NO 2 3

potassium phosphate monobasic w/ sodium phosphate dibasic & monobasic

1

ELECTROLYTES, POTASSIUM K-TAB 3

KLOR-CON M15 3

potassium bicarb & chloride 1

potassium bicarbonate 1

potassium chloride 1

potassium chloride ext-rel 1

potassium chloride microencapsulated

crystals cr

1

VITAMINS AND MINERALS, FOLIC ACID AGENTS folic acid 1mg 1

folic acid 400mcg, 800mcg 0 $0; AGE (Covered for ages 55 years and

under); females only

VITAMINS AND MINERALS, MISCELLANEOUS BABY DDROPS 0 $0

cholecalciferol CAPS 1

cholecalciferol CHEW; LIQD; TABS 0 $0

D-VI-SOL 0 $0

DDROPS 0 $0

DECARA 0 $0

ergocalciferol 1

FER-IN-SOL 0 $0

ferrous sulfate elixir, soln 0 $0; AGE (Covered for ages less than 2 years

old)

48


FLUOR-A-DAY 3

MAGNEBIND 400 3

MEPHYTON 2

NASCOBAL 2

NICOMIDE 3

POTABA CAPS 3

SM VITAMIN D3 MAXIMUM STR 0 $0

sodium fluoride 0 $0; AGE (Covered for

ages 5 years and under)

SUPER DAILY D3 0 $0

VITAMIN D3 0 $0

WELLESSE VITAMIN D3 0 $0

RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector 1

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, Long-Acting ANORO ELLIPTA 3

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, Short-Acting COMBIVENT RESPIMAT 2

ipratropium-albuterol 1

ANTICHOLINERGICS ATROVENT HFA 2

ipratropium bromide 1

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine 1

ANTIHISTAMINES, SEDATING carbinoxamine maleate 1

clemastine fumarate 1

cyproheptadine hcl 1

diphenhydramine hcl 1

hydroxyzine hcl 1

hydroxyzine pamoate 1

ANTITUSSIVE COMBINATIONS, NON-OPIOID promethazine-dextromethorphan 1

pseudoephedrine-brompheniramine-

dextromethorphan

1

ANTITUSSIVE COMBINATIONS, OPIOID CAPCOF 3

guaifenesin-codeine 1

hydrocodone polistirex-chlorpheniramine

polistirex

1

hydrocodone w/ homatropine 1

phenylephrine-promethazine w/ codeine 1

PRO-CLEAR AC 3

49


promethazine w/codeine 1

pseudoephedrine w/ codeine-guaifenesin 1

pseudoephedrine/chlorpheniramine/hydrocodone

1

REZIRA 3

TUSSICAPS 3

ANTITUSSIVES benzonatate 1

BETA AGONISTS, ORAL AGENTS albuterol sulfate 1

terbutaline sulfate 1

BETA-AGONISTS, INHALANTS, Long-Acting: Hand-held Active

Inhalation STRIVERDI RESPIMAT 2

BETA-AGONISTS, INHALANTS, Long-Acting: Nebulized Passive

Inhalation BROVANA 3

PERFOROMIST 3

BETA-AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate inhalation soln 1

levalbuterol hcl inhalation soln 1

levalbuterol tartrate 1

PROAIR HFA 2

PROAIR RESPI INH 2

VENTOLIN HFA 2

XOPENEX HFA 3

CYSTIC FIBROSIS BETHKIS 4 PA; SP

CAYSTON 4 PA; SP

KALYDECO 4 PA; SP

KITABIS PAK 4 PA; SP

ORKAMBI 5 PA; SP

PULMOZYME 4 PA; SP

TOBI 5 PA; SP

TOBI PODHALER 5 PA; SP

tobramycin 4 PA; SP

LEUKOTRIENE MODIFIERS montelukast sodium 1

zafirlukast 1

zileuton ext-rel 1

ZYFLO 3

ZYFLO CR 3

MAST CELL STABILIZERS cromolyn sodium 1

MEDICAL SUPPLIES

50


AIRZONE PEAK FLOW METER 0 $0

E-Z SPACER 0 $0

E-Z SPACER THE BODY GUARD 0 $0

MASK VORTEX/BABY WHIRL DU 0 $0

MASK VORTEX/CHILD/FROG 0 $0

MASK VORTEX/SPINNER THE D 0 $0

MASK VORTEX/TODDLER/LADY 0 $0

PEAK AIR PEAK FLOW METER 0 $0

VORTEX HOLDING CHAMBER/MA 0 $0

VORTEX VALVED HOLDING CHA 0 $0

MISCELLANEOUS acetylcysteine 1

HYPERSAL 3

ipratropium bromide (nasal) 1

NEBUSAL 3

sodium chloride (inhalant) 1

NASAL ANTIHISTAMINES azelastine hcl 1

olopatadine hcl (nasal) 1

NASAL STEROIDS/COMBINATIONS DYMISTA 3 ST (Try fluticasone and

flunisolide)

flunisolide (nasal) 1

fluticasone propionate (nasal) 1

mometasone (nasal) 1

QNASL 3 ST (Try fluticasone and

flunisolide)

PHOSPHODIESTERASE-4 INHIBITORS DALIRESP 3

PULMONARY FIBROSIS AGENTS ESBRIET 4 PA; SP

OFEV 4 PA; SP

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ARNUITY ELLIPTA 2

ASMANEX HFA 2

ASMANEX TWISTHALER 2

budesonide (inhalation) 1

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

QVAR 2

STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKUS 2 QL (1 inhaler per 30

days)

51


ADVAIR HFA 2 QL (1 inhaler per 30 days)

BREO ELLIPTA 2

DULERA 2

SYMBICORT 2

XANTHINES ELIXOPHYLLIN 3

THEO-24 2

theophylline 1

TOPICAL DERMATOLOGY, ACNE: ORAL ABSORICA 3

isotretinoin 1

DERMATOLOGY, ACNE: TOPICAL ACANYA 3

ACZONE 3

adapalene 1

avita cre 0.025% 1

AZELEX 3 PA

BENZAC AC WASH 3

BENZEFOAM 3

BENZEFOAMULTRA 3

BENZIQ 3

BENZIQ LS 3

benzoyl peroxide 1

benzoyl peroxide-erythromycin 1

clindamycin phosphate (topical) 1

clindamycin phosphate-benzoyl peroxide 1

clindamycin phosphate-tretinoin 1

DIFFERIN CREAM, LOTION 3

EPIDUO 3

erythromycin (acne aid) 1

FABIOR 3

ONEXTON 3

RETIN-A GEL 3

RETIN-A MICRO 3

RETIN-A MICRO PUMP 3

sulfacetamide lotion, susp 1

sulfacetamide sodium-sulfur-sunscreen 1

SULFACETAMIDE/SULFUR 3

SULFACETAMIDE/SULFUR IN UREA EMUL 3

sulfacetamide/sulfur w/ skin cleanser 1

SUMADAN KIT 3

SUMADAN XLT 3

SUMAXIN CP KIT 3

tazarotene cream 0.1% 1

52


TAZORAC 2

TRETIN-X 3

tretinoin 1

tretinoin microsphere 1

DERMATOLOGY, ACTINIC KERATOSIS diclofenac sodium (actinic keratoses) 1

FLUOROPLEX 3

fluorouracil (topical) 1

LEVULAN KERASTICK 3

PICATO 3

ZYCLARA 3

DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CREAM 2

CORTISPORIN OINT 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN NASAL 3

CENTANY 3

gentamicin sulfate (topical) 1

mupirocin 1

mupirocin calcium (topical) 1

silver sulfadiazine 1

DERMATOLOGY, ANTIFUNGALS ALCORTIN A 3

ciclopirox 1

ciclopirox olamine 1

clotrimazole (topical) 1

clotrimazole w/ betamethasone 1

econazole nitrate 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) 1

LUZU 3 ST (Try generic topical antifungal)

MENTAX 3

naftifine hcl 1

NAFTIN GEL 3

nystatin (topical) 1

nystatin-triamcinolone 1

oxiconazole nitrate crm 1

OXISTAT LOTION 3

VUSION 3

XOLEGEL 3

DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin 1

53


methoxsalen rapid 1

DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene 1

calcipotriene-betamethasone dipropionate 1

calcitriol oint 1

DRITHO-CREME HP 3

SORILUX 3

TACLONEX SUSP 3

ZITHRANOL 3

DERMATOLOGY, ANTISEBORRHEICS LOUTREX 3

PROMISEB 3

PROMISEB COMPLETE 3

selenium sulfide 1

sulfacetamide liqd, shampoo 1

DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream, lotn 1

AMCINONIDE OINT 3

APEXICON E 3

betamethasone dipropionate 1

betamethasone dipropionate augmented

cream, gel, lotn

1

desoximetasone cream, oint 0.25% 1

desoximetasone gel 0.05% 1

diflorasone diacetate cream 1

DIPROLENE AF 3

fluocinonide 1

fluocinonide emulsified base 1

HALOG 3

TOPICORT GEL 0.05% 3

TOPICORT OINT 0.25% 3

triamcinolone acetonide cream, oint 0.5% 1

DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate 1

DERMA-SMOOTHE/FS BODY 3

DERMA-SMOOTHE/FS SCALP 3

DESONATE 3

desonide 1

DESOWEN 3

fluocinolone acetonide body, scalp oil 1

fluocinolone acetonide cream, soln 0.01% 1

hydrocortisone (topical) 1

PRAMOSONE 3

pramoxine/hydrocortisone 1

SYNALAR 3

TOPICORT SPRAY 0.25% 3

54


VERDESO 3

DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate 1

CAPEX 3

clocortolone pivalate 1

CLODERM 3

CLODERM PUMP 3

CORDRAN CREAM 2

CORDRAN LOTION 2

CORDRAN TAPE 2

desoximetasone cream, oint 0.05% 1

ELOCON OINT 3

fluocinolone acetonide 1

flurandrenolide cream, lotion 1

fluticasone propionate 1

hydrocortisone butyrate 1

hydrocortisone butyrate hydrophilic lipo base

1

hydrocortisone valerate 1

LOCOID LOTION 3

mometasone furoate 1

prednicarbate 1

TOPICORT OINT 0.05% 3

triamcinolone acetonide cream, lotion, oint 0.25%, 0.1%

1

TRIANEX 3

WESTCORT 3

DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented

oint

1

clobetasol propionate 1

clobetasol propionate emollient base 1

clobetasol propionate emulsion 1

CLOBEX SHAMPOO, SPRAY 3

diflorasone diacetate oint 1

halobetasol propionate 1

TEMOVATE OINT, SOLN 3

ULTRAVATE CREAM 3

ULTRAVATE X 3

DERMATOLOGY, EMOLLIENTS HPR 3

HPR PLUS FOAM 3

HYLATOPIC 3

HYLATOPIC PLUS FOAM 3

lactic acid (ammonium lactate) 1

NEOSALUS FOAM 3

55


PRESERA 3

URAMAXIN AEROSOL 3

urea in zinc undecylenate-lactic acid vehicle

1

DERMATOLOGY, IMMUNOMODULATORS ELIDEL 2

tacrolimus (topical) 1

DERMATOLOGY, LOCAL ANALGESIC lidocaine PTCH 1

LIDODERM 3

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine hcl 1

lidocaine-prilocaine 1

LIDORX 3

QUTENZA 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical 1

ATOPICLAIR 3

BENSAL HP 3

CONDYLOX GEL 3

DENAVIR 3

doxepin hcl cream 1

DRYSOL 3

ELETONE 3

ELETONE TWINPACK 3

EMULSION SB 3

EPICERAM 3

formaldehyde 1

GEBAUERS SPRAY 3

GENADUR 3

HPR PLUS CREAM 3

HPR PLUS HYDROGEL KIT 3

HYLATOPIC PLUS CREAM 3

imiquimod 1

KERALYT 3

MB HYDROGEL 3

NEOSALUS CP 3

NEOSALUS CREAM 3

NIVATOPIC PLUS 3

NUVAIL 3

PANRETIN 3

podofilox 1

PR CREAM 3

PRUCLAIR 3

PRUMYX 3

56


QUTENZA 3

REGRANEX 3

SALEX CREAM 3

SALEX LOTION 3

salicylic acid 1

salicylic acid w/ cleanser 1 QL (1 per 30 days)

SALVAX 3

SANTYL 3

silver nitrate-potassium nitrate 1

SILVER NITRATE-POTASSIUM NITRATE 3

SULFAMYLON CREAM 3

TRI-CHLOR 3

trypsin w/ castor oil & peruvian balsam

spray

1

VEREGEN 3

XERESE 3

ZOVIRAX CREAM 3

DERMATOLOGY, ROSACEA doxycycline (rosacea) 1 ST (Try 2 generic

tetracyclines)

FINACEA 2

METROCREAM 3

metronidazole (topical) 1

NORITATE 3

ORACEA 3 ST (Try 2 generic tetracyclines)

sulfacetamide/sulfur cream, emul, liqd, lotn, pads, soln, susp

1

sulfacetamide/sulfur in urea gel 1

DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX 3

lindane shampoo 1

malathion 1

permethrin 1

SKLICE 3

spinosad 1

DERMATOLOGY, WOUND CARE PRODUCTS ALEVICYN ANTIPRURITIC GEL 3

ATRAPRO ANTIPRURITIC HYDR 3

ATRAPRO CP 3

ATRAPRO DERMAL SPRAY 3

CARRASYN HYDROGEL WOUND D 3

DIAB 3

DIAB F.D.G. FREEZE-DRIED 3

KENDALL AMORPHOUS HYDROGE 3

PICO SINGLE USE NEGATIVE 3

RADIAGEL 3

57


RADIAPLEXRX 3

SILVASORB 3

SPECTRAGEL 3

THERAHONEY 3

VASCUDERM HYDROGEL WOUND 3

XEROFORM NON-OCCLUSIVE DRESSING 3

XEROFORM OCCLUSIVE DRESSING 3

XEROFORM PETROLATUM DRESSING 3

MOUTH/THROAT/DENTAL AGENTS, Miscellaneous ARESTIN 3

CAPHOSOL 3

chlorhexidine gluconate (mouth-throat) 1

lidocaine hcl (mouth-throat) 1

NEUTRASAL 3

NUMOISYN 3

PREVIDENT 5000 BOOSTER 3

PREVIDENT 5000 BOOSTER PL 3

PREVIDENT 5000 DRY MOUTH 3

PREVIDENT 5000 ENAMEL PRO 3

PREVIDENT 5000 PLUS 3

PREVIDENT 5000 SENSITIVE 3

PREVIDENT FLUORIDE 3

sodium fluoride (dental) 1

THERA-FLUR-N 3

triamcinolone acetonide paste 1

OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS bacitracin-polymyxin-neomycin-

hydrocortisone 1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

neomycin-polymyin-dexamethasone 1

neomycin-polymyxin-hydrocortisone (ophth)

1

sulfacetamide sod-prednisolone 1

TOBRADEX OINT 2

TOBRADEX ST 3

tobramycin-dexamethasone 1

ZYLET 2

OPHTHALMIC, ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 3

CILOXAN 2

ciprofloxacin hcl (ophth) 1

58


erythromycin (ophth) 1

gatifloxacin (ophth) 1

gentamicin sulfate (ophth) 1

levofloxacin (ophth) 1

MOXEZA 3

neomycin-bacitracin zn-polymyxin 1

neomycin-polymyxin-gramicidin 1

ofloxacin (ophth) 1

polymyxin b-trimethoprim 1

sulfacetamide soln 1

tobramycin (ophth) 1

TOBREX OINT 2

VIGAMOX 2

OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL 3

bromfenac sodium (ophth) 1

diclofenac sodium (ophth) 1

flurbiprofen sodium 1

ILEVRO 3

ketorolac tromethamine (ophth) 1

NEVANAC 3

PROLENSA 3

OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX 2

dexamethasone sodium phosphate (ophth) 1

DUREZOL 3

fluorometholone (ophth) 1

FML 3

FML FORTE 3

LOTEMAX 2

MAXIDEX 3

PRED FORTE 2

PRED MILD 2

prednisolone acetate (ophth) 1

PREDNISOLONE SODIUM PHOSP 3

OPHTHALMIC, ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) 1

BEPREVE 3

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) 1

LASTACAFT 3

olopatadine hcl 1

PATADAY 3

59


PAZEO 3

OPHTHALMIC, ANTIFUNGALS NATACYN 3

OPHTHALMIC, ANTIVIRAL trifluridine 1

ZIRGAN 2

OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL 3

carteolol hcl (ophth) 1

ISTALOL 3

levobunolol hcl 1

timolol maleate (ophth) 1

TIMOPTIC OCUDOSE 3

OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl (ophth) 1

BETOPTIC-S 3

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS COSOPT PF 3

dorzolamide hcl-timolol maleate 1

OPHTHALMIC, CARBONIC ANHYDRASE

INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA 3

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide 1

acetazolamide ext-rel 1

methazolamide 1

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT 3

dorzolamide hcl 1

OPHTHALMIC, DECONGESTANTS phenylephrine hcl (ophth) 1

OPHTHALMIC, IMMUNOMODULATOR RESTASIS 2 QL (Max 2 vials per day)

OPHTHALMIC, MISCELLANEOUS LACRISERT 3

proparacaine hcl 1

tetracaine hcl (ophth) 1

OPHTHALMIC, MYDRIATICS atropine sulfate soln 1

CYCLOMYDRIL 3

cyclopentolate hcl 1

homatropine hbr 1

tropicamide 1

60


OPHTHALMIC, PARASYMPATHOMIMETICS pilocarpine hcl 1

OPHTHALMIC, PROSTAGLANDINS latanoprost 1

LUMIGAN 2

TRAVATAN Z 3

ZIOPTAN 3

OPHTHALMIC, SYMPATHOMIMETIC/BETA BLOCKER COMBINATIONS COMBIGAN 3

OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 3

brimonidine tartrate 1

OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC 3

CIPRODEX 3

COLY-MYCIN S 3

hydrocortisone w/acetic acid 1

neomycin-polymyxin-hydrocortisone (otic) 1

pramoxine-hydrocortisone-chloroxylenol 1

OTIC, ANTI-INFECTIVES acetic acid (otic) 1

acetic acid-aluminum acetate 1

ciprofloxacin hcl (otic) 1

ofloxacin (otic) 1

OTIC, MISCELLANEOUS fluocinolone acetonide oil 1

61

Index A abacavir sulfate ................................. 9

abacavir sulfate-lamivudine ................. 9 abacavir sulfate-lamivudine-zidovudine 9

ABILIFY TABS ................................... 24 ABSORICA ....................................... 51

acamprosate calcium ......................... 30

ACANYA ........................................... 51 acarbose .......................................... 31

ACCU-CHEK ACTIVE STRIPS ............... 33 ACCU-CHEK AVIVA ............................ 33

ACCU-CHEK AVIVA PLUS.................... 33 ACCU-CHEK COMFORT CURVE T ......... 33

ACCU-CHEK COMPACT TEST DR .......... 33 ACCU-CHEK SMARTVIEW STRIP .......... 33

ACCUTREND GLUCOSE ...................... 33 acebutolol hcl ................................... 18

acetaminophen w/ codeine .................. 5 acetazolamide .................................. 59

acetazolamide ext-rel ........................ 59 acetic acid (otic) ............................... 60

acetic acid/oxyquinoline ..................... 45

acetic acid-aluminum acetate ............. 60 acetylcysteine .................................. 50

acitretin ........................................... 52 ACTICLATE ........................................ 8

ACTOPLUS MET XR ............................ 32 ACURA BLOOD GLUCOSE TEST ........... 33

ACUVAIL .......................................... 58 acyclovir .......................................... 10

acyclovir topical ................................ 55 ACZONE .......................................... 51

ADALAT CC ...................................... 18 adapalene ........................................ 51

ADCIRCA ......................................... 20 adefovir dipivoxil .............................. 10

ADEMPAS ......................................... 21

ADOXA CAPS ..................................... 8 ADVAIR DISKUS ............................... 50

ADVAIR HFA ..................................... 50 ADVANCE INTUITION TEST ST ............ 33

ADVANCE MICRO-DRAW TEST S ......... 33 ADVOCATE TEST STRIPS ................... 33

AEROSPAN ....................................... 50 AFINITOR TABS ................................ 13

AGAMATRIX AMP NO CODE TES .......... 34 AGAMATRIX JAZZ TEST STRIP ............ 34

AGAMATRIX KEYNOTE TEST ST .......... 34 AGAMATRIX PRESTO TEST STR .......... 34

AIRZONE PEAK FLOW METER ............. 49 ALBENZA......................................... 10

albuterol sulfate ............................... 49 albuterol sulfate inhalation soln .......... 49

alclometasone dipropionate ............... 53

ALCOHOL PREP PADS........................ 34 ALCORTIN A .................................... 52

ALDACTAZIDE.................................. 19 alendronate sodium .......................... 37

ALEVICYN ANTIPRURITIC GEL ............ 56 alfuzosin hcl ext-rel .......................... 44

ALINIA ............................................ 11 ALKERAN ........................................ 11

allopurinol ......................................... 4 almotriptan malate ........................... 28

ALOCRIL ......................................... 58 ALOMIDE ........................................ 58

ALORA ............................................ 39 alosetron hydrochloride ..................... 43

ALPHAGAN P 0.1% ........................... 60

ALPHAGAN P 0.15% ......................... 60 alprazolam ext-rel ............................ 21

alprazolam orally disintegrating tabs... 21 alprazolam tabs ............................... 21

ALREX ............................................ 58 ALTABAX ......................................... 52

ALTOPREV ....................................... 17 ALVESCO ........................................ 50

amantadine hcl ................................ 24 amcinonide cream, lotn ..................... 53

AMCINONIDE OINT ........................... 53 AMICAR .......................................... 46

amiloride & hydrochlorothiazide ......... 19 amiloride hcl .................................... 19

amiodarone hcl ................................ 17

AMITIZA ......................................... 43 amitriptyline hcl ............................... 24

amlodipine besylate .......................... 19 amlodipine besylate/benazepril .......... 15

amlodipine besylate-atorvastatin calcium...................................................... 18

amlodipine besylate-olmesartan medoxomil ...................................... 16

amlodipine besylate-valsartan ........... 16 amlodipine-valsartan-hydrochlorothiazide

62

...................................................... 16

amoxapine ....................................... 24 amoxicillin ........................................ 7

amoxicillin & pot clavulanate ............... 7 amoxicillin & pot clavulanate ext-rel ..... 7

amoxicillin-clarithromycin w/ lansoprazole ..................................... 44

amphetamine-dextroamphetamine ext-rel 10 mg ......................................... 25




amphetamine-dextroamphetamine ext-

rel 30 mg ......................................... 25 amphetamine-dextroamphetamine ext-

rel 5 mg .......................................... 25 amphetamine-dextroamphetamine tab

10 mg ............................................. 26 amphetamine-dextroamphetamine tab

12.5 mg .......................................... 26 amphetamine-dextroamphetamine tab



30 mg ............................................. 26 amphetamine-dextroamphetamine tab 5

mg .................................................. 25

amphetamine-dextroamphetamine tab 7.5 mg ............................................ 25

ampicillin .......................................... 7 AMPYRA ........................................... 29

AMRIX ............................................. 29 anagrelide hcl ................................... 46

ANAPROX DS ..................................... 4 ANASPAZ ......................................... 42

anastrozole ...................................... 12 ANORO ELLIPTA ................................ 48

ANTARA ........................................... 17 APEXICON E ..................................... 53

APLENZIN ........................................ 23 aprepitant caps ................................. 41

aprepitant pak 80 mg & 125 mg ......... 41

APRISO ........................................... 42 APTENSIO XR ................................... 26

APTIVUS CAPS ................................... 9

ARESTIN ......................................... 57 ARIMIDEX ....................................... 12

aripiprazole ..................................... 25 armodafinil ...................................... 30

ARNUITY ELLIPTA ............................. 50 AROMASIN ...................................... 12

ASCENSIA AUTODISC TEST ST .......... 34 ASMANEX HFA ................................. 50

ASMANEX TWISTHALER .................... 50 aspirin 325 mg, 500 mg .................... 46

aspirin 81 mg .................................. 46 aspirin enteric coated ....................... 46

aspirin/caffeine/dihydrocodeine ............ 5 ASSURE 3 TEST STRIPS .................... 34

ASSURE 4 TEST STRIPS .................... 34

ASSURE II TEST STRIPS ................... 34 ASSURE PLATINUM TEST STRI ........... 34

ASSURE PRISM MULTI TEST S ........... 34 ASSURE PRO TEST STRIPS ................ 34

ASTAGRAF XL .................................. 46 AT LAST TEST STRIPS ....................... 34

ATACAND HCT ................................. 16 atenolol .......................................... 18

atenolol & chlorthalidone ................... 18 ATOPICLAIR .................................... 55

atorvastatin calcium ......................... 17 atovaquone ..................................... 11

atovaquone-proguanil hcl .................... 8 ATRAPRO ANTIPRURITIC HYDR .......... 56

ATRAPRO CP .................................... 56

ATRAPRO DERMAL SPRAY .................. 56 ATRIPLA ............................................ 9

atropine sulfate soln ......................... 59 ATROVENT HFA ................................ 48

AUBAGIO ........................................ 29 AUGMENTIN ...................................... 7

AUGMENTIN ES-600 ........................... 7 AUGMENTIN XR ................................. 7

avita cre 0.025% ............................. 51 AZASAN .......................................... 46

AZASITE ......................................... 57 azathioprine .................................... 46

azelastine hcl ................................... 50 azelastine hcl (ophth) ....................... 58

AZELEX ........................................... 51

AZILECT .......................................... 24 azithromycin ...................................... 7

63

AZOPT ............................................. 59

B BABY DDROPS .................................. 47

bacitracin (ophthalmic) ...................... 57 bacitracin-polymyxin b (ophth) ........... 57

bacitracin-polymyxin-neomycin-hydrocortisone ................................. 57

baclofen .......................................... 29 BACTROBAN NASAL .......................... 52

balsalazide disodium ......................... 42 BANZEL TABS ................................... 21

BAYER BREEZE 2 TEST DISC .............. 34 BAYER CONTOUR BLOOD GLUCO ........ 34

BAYER CONTOUR NEXT BLOOD ........... 34 BELSOMRA ....................................... 28

BELVIQ ............................................ 37

benazepril ........................................ 15 benazepril/hydrochlorothiazide ........... 15

BENSAL HP ...................................... 55 BENZAC AC WASH ............................ 51

BENZEFOAM ..................................... 51 BENZEFOAMULTRA ............................ 51

BENZIQ ........................................... 51 BENZIQ LS ....................................... 51

benzonatate ..................................... 49 benzoyl peroxide .............................. 51

benzoyl peroxide-erythromycin ........... 51 benztropine mesylate ........................ 24

BEPREVE.......................................... 58 BESIVANCE ...................................... 57

betamethasone dipropionate .............. 53

betamethasone dipropionate augmented cream, gel, lotn ................................ 53

betamethasone dipropionate augmented oint ................................................. 54

betamethasone valerate .................... 53 BETAPACE ........................................ 17

BETAPACE AF ................................... 17 betaxolol hcl ..................................... 18

betaxolol hcl (ophth) ......................... 59 bethanechol chloride ......................... 45

BETHKIS .......................................... 49 BETIMOL .......................................... 59

BETOPTIC-S ..................................... 59 bexarotene ...................................... 14

BEYAZ ............................................. 38

BG STAR BLOOD GLUCOSE TES .......... 34 BIAXIN ............................................. 7

bicalutamide .................................... 12

BIDIL .............................................. 20 BILTRICIDE ..................................... 11

BIOSCANNER GLUCOSE TEST S ......... 34 bisoprolol & hydrochlorothiazide ......... 18

bisoprolol fumarate .......................... 18 BLEPHAMIDE ................................... 57

BLEPHAMIDE S.O.P. ......................... 57 BLOOD GLUCOSE CONTROL TEST

SOLUTIONS ..................................... 34 BLOOD GLUCOSE TEST STRIPS .......... 34

BOSULIF ......................................... 13 BREO ELLIPTA ................................. 50

BREVICON-28 .................................. 38 BRILINTA ........................................ 46

brimonidine tartrate ......................... 60

BRISDELLE ...................................... 31 bromfenac sodium (ophth) ................ 58

bromocriptine mesylate ..................... 24 BROVANA ........................................ 49

budesonide ...................................... 42 budesonide (inhalation) .................... 50

bumetanide ..................................... 19 BUPHENYL TABS .............................. 43

buprenorphine hcl ............................ 30 buprenorphine hcl-naloxone hcl dihydrate

...................................................... 30 bupropion hcl ................................... 23

bupropion hcl ext-rel 100mg, 150mg, 200mg, 300mg ................................ 23

bupropion hcl ext-rel 150mg .............. 30

buspirone hcl ................................... 21 butalbital-acetaminophen .................... 4

butalbital-acetaminophen-caffeine ........ 4 butalbital-acetaminophen-caffeine w/

codeine ............................................. 5 butalbital-aspirin-caffeine .................... 4

butalbital-aspirin-caffeine w/codeine..... 5 butorphanol tartrate ........................... 5

BUTRANS .......................................... 5 BYDUREON ...................................... 32

BYETTA ........................................... 32 BYSTOLIC ....................................... 18

C cabergoline ..................................... 40

CABOMETYX .................................... 13

CALAN SR ....................................... 19 calcipotriene .................................... 52

64

calcipotriene-betamethasone

dipropionate ..................................... 52 calcitonin (salmon)............................ 37

calcitriol ........................................... 40 calcitriol oint .................................... 52

calcium acetate (phosphate binder) ..... 40 CANASA ........................................... 43

candesartan cilexetil .......................... 17 candesartan cilexetil-hydrochlorothiazide

...................................................... 16 CAPCOF ........................................... 48

capecitabine ..................................... 11 CAPEX ............................................. 53

CAPHOSOL ....................................... 57 captopril .......................................... 15

captopril/hydrochlorothiazide ............. 15

CARAFATE SUSP ............................... 43 carbamazepine ................................. 21

carbamazepine ext-rel ....................... 21 CARBATROL ..................................... 21

carbidopa ......................................... 24 carbidopa-levodopa ........................... 24

carbidopa-levodopa ext-rel................. 24 carbidopa-levodopa orally disintegrating

tabs ................................................ 24 carbidopa-levodopa-entacapone ......... 24

carbinoxamine maleate ...................... 48 CARDIZEM CD .................................. 19

CARDIZEM LA ................................... 19 CARDURA XL .................................... 44

CAREONE BLOOD GLUCOSE TES ......... 34

CARESENS N BLOOD GLUCOSE........... 34 carisoprodol ..................................... 29

CARNITOR ....................................... 40 CARNITOR SF ................................... 40

CARRASYN HYDROGEL WOUND D ....... 56 carteolol hcl (ophth) .......................... 59

carvedilol ......................................... 18 CASODEX ........................................ 12

CATAPRES-TTS ................................. 16 CAYSTON ......................................... 49

CEDAX CAPS ..................................... 7 cefaclor ............................................ 7

cefadroxil .......................................... 7 cefdinir ............................................. 7

cefditoren pivoxil ............................... 7

cefixime susp .................................... 7 cefpodoxime proxetil tabs ................... 7

cefprozil ............................................ 7

ceftibuten caps .................................. 7 CEFTIN SUSP ..................................... 7

cefuroxime axetil ............................... 7 celecoxib ........................................... 4

CELLCEPT ........................................ 46 CELONTIN ....................................... 21

CENTANY ........................................ 52 cephalexin ......................................... 7

CESAMET ........................................ 41 cevimeline hcl .................................. 44

CHANTIX ......................................... 30 CHEK-STIX CONTROL ....................... 34

CHEMET .......................................... 46 CHEMSTRIP UGK .............................. 34

CHEMSTRIP-K .................................. 34

chlordiazepoxide hcl ......................... 21 chlordiazepoxide hcl-clidinium bromide 42

chlordiazepoxide-amitriptyline ........... 23 chlorhexidine gluconate (mouth-throat)

...................................................... 57 chloroquine phosphate ........................ 8

chlorpromazine hcl ........................... 25 chlorpropamide ................................ 33

chlorthalidone .................................. 19 chlorzoxazone .................................. 29

cholecalciferol .................................. 47 cholestyramine ................................ 17

cholestyramine light ......................... 17 choline fenofibrate ............................ 17

CIALIS TAB 5MG .............................. 44

ciclopirox ........................................ 52 ciclopirox olamine ............................ 52

cilostazol ......................................... 46 CILOXAN ......................................... 57

cimetidine ....................................... 42 cimetidine hcl .................................. 42

CIPRO ............................................... 7 CIPRO HC ........................................ 60

CIPRODEX ....................................... 60 ciprofloxacin ...................................... 7

ciprofloxacin ext-rel ............................ 7 ciprofloxacin hcl (ophth) .................... 57

ciprofloxacin hcl (otic) ....................... 60 citalopram hydrobromide .................. 23

clarithromycin .................................... 7

clarithromycin ext-rel ......................... 7 clemastine fumarate ......................... 48

65

CLEOCIN SUPP ................................. 45

CLEVER CHEK TEST STRIPS ............... 34 CLEVER CHOICE MICRO TEST ............. 34

CLIMARA PRO ................................... 39 clindamycin hcl ................................. 11

clindamycin palmitate hydrochloride .... 11 clindamycin phosphate (topical) .......... 51

clindamycin phosphate vaginal ........... 45 clindamycin phosphate-benzoyl peroxide

...................................................... 51 clindamycin phosphate-tretinoin ......... 51

CLINDESSE ...................................... 45 CLINISTIX ........................................ 34

clobetasol propionate ........................ 54 clobetasol propionate emollient base ... 54

clobetasol propionate emulsion ........... 54

CLOBEX SHAMPOO, SPRAY ................ 54 clocortolone pivalate ......................... 53

CLODERM ........................................ 54 CLODERM PUMP ................................ 54

clomiphene citrate ............................ 40 clomipramine hcl .............................. 21

clonazepam orally disintegrating tabs .. 21 clonazepam tabs ............................... 21

clonidine ext-rel tab 0.1mg ................ 26 clonidine hcl ..................................... 16

clonidine hcl transdermal ................... 16 clopidogrel bisulfate .......................... 46

clorazepate dipotassium .................... 21 clotrimazole (topical) ......................... 52

clotrimazole troches ........................... 8

clotrimazole w/ betamethasone .......... 52 clozapine ......................................... 25

COARTEM ......................................... 8 codeine sulfate .................................. 5

colchicine .......................................... 4 colchicine w/ probenecid ..................... 4

COLCRYS .......................................... 4 COLESTID GRANULES ........................ 17

colestipol hcl .................................... 17 COLY-MYCIN S ................................. 60

COLYTE-FLAVOR PACKS ..................... 43 COMBIGAN....................................... 60

COMBIPATCH ................................... 39 COMBIVENT RESPIMAT ...................... 48

COMBIVIR ......................................... 9

COMPLERA ........................................ 9 CONDYLOX GEL ................................ 55

CONTROL AST ................................. 34

CONTROL TEST STRIPS ..................... 34 COPEGUS ........................................ 10

CORDRAN CREAM ............................. 54 CORDRAN LOTION ............................ 54

CORDRAN TAPE ............................... 54 COREG ............................................ 18

COREG CR ....................................... 18 CORGARD ....................................... 18

CORTIFOAM ..................................... 43 cortisone acetate .............................. 40

CORTISPORIN CREAM ....................... 52 CORTISPORIN OINT.......................... 52

COSOPT PF ...................................... 59 COUMADIN ...................................... 45

CREON ............................................ 43

CRINONE ........................................ 41 cromolyn sodium .............................. 49

cromolyn sodium (mastocytosis) ........ 43 cromolyn sodium (ophth) .................. 58

CUPRIMINE ..................................... 46 cyclobenzaprine hcl .......................... 29

CYCLOMYDRIL ................................. 59 cyclopentolate hcl ............................ 59

CYCLOPHOSPHAMIDE ....................... 11 CYCLOSET ....................................... 33

cyclosporine .................................... 46 cyclosporine modified (for

microemulsion) ................................ 47 cyproheptadine hcl ........................... 48

CYSTADANE .................................... 40

CYSTAGON ...................................... 40 CYTOMEL ........................................ 41

D DALIRESP ....................................... 50

danazol ........................................... 39 dantrolene sodium ........................... 29

dapsone .......................................... 11 DARAPRIM......................................... 8

darifenacin hydrobromide ext-rel ....... 45 DAYTRANA ...................................... 26

DDROPS .......................................... 47 DECARA .......................................... 47

DELZICOL ....................................... 42 demeclocycline hcl ............................. 8

DENAVIR ......................................... 55

DEPAKENE SYRUP ............................ 21 DEPAKOTE ...................................... 21

66

DEPAKOTE ER .................................. 21

DEPAKOTE SPRINKLES ...................... 21 DERMA-SMOOTHE/FS BODY ............... 53

DERMA-SMOOTHE/FS SCALP .............. 53 DESCOVY .......................................... 9

desipramine hcl ................................ 24 desmopressin acetate ........................ 41

desmopressin acetate spray ............... 41 desmopressin acetate spray refrigerated

...................................................... 41 DESOGEN ........................................ 38

desogestrel/ethinyl estradiol .............. 38 desogestrel/ethinyl estradiol (triphasic)

...................................................... 38 desogestrel-ethinyl estradiol (biphasic) 37

DESONATE ....................................... 53

desonide .......................................... 53 DESOWEN ........................................ 53

desoximetasone cream, oint 0.05% .... 54 desoximetasone cream, oint 0.25% .... 53

desoximetasone gel 0.05% ................ 53 desvenlafaxine ext-rel ....................... 23

desvenlafaxine succinate ext-rel ......... 23 dexamethasone ................................ 40

DEXAMETHASONE INTENSOL ............. 40 dexamethasone sodium phosphate

(ophth) ............................................ 58 dexmethylphenidate hcl ext-rel 10 mg . 26

dexmethylphenidate hcl ext-rel 15 mg . 26 dexmethylphenidate hcl ext-rel 20 mg . 26

dexmethylphenidate hcl ext-rel 25 mg . 26

dexmethylphenidate hcl ext-rel 30 mg . 26 dexmethylphenidate hcl ext-rel 35 mg . 26

dexmethylphenidate hcl ext-rel 40 mg . 26 dexmethylphenidate hcl ext-rel 5 mg .. 26

dexmethylphenidate hcl tab 10 mg ..... 26 dexmethylphenidate hcl tab 2.5 mg .... 26

dexmethylphenidate hcl tab 5 mg ....... 26 DEXPAK ........................................... 40

dextroamphetamine sulfate ................ 26 dextroamphetamine sulfate ext-rel ..... 26

DIAB ............................................... 56 DIAB F.D.G. FREEZE-DRIED ............... 56

DIASTAT ACUDIAL ............................ 21 DIASTAT PEDIATRIC ......................... 21

DIASTIX .......................................... 34

DIATRUE PLUS BLOOD GLUCOS .......... 34 diazepam ......................................... 21

diazepam (anticonvulsant) ................ 21

DICLEGIS ........................................ 41 diclofenac potassium .......................... 4

diclofenac sodium (actinic keratoses) .. 52 diclofenac sodium (ophth) ................. 58

diclofenac sodium delayed-rel .............. 4 diclofenac sodium ext-rel .................... 4

diclofenac sodium gel 1% .................... 5 diclofenac sodium soln 1.5% ............... 5

diclofenac w/ misoprostol .................... 5 dicloxacillin sodium ............................ 7

dicyclomine hcl ................................ 42 didanosine ......................................... 9

DIFFERIN CREAM, LOTION ................ 51 DIFICID ............................................ 7

diflorasone diacetate cream ............... 53

diflorasone diacetate oint .................. 54 diflunisal ........................................... 4

digoxin ........................................... 19 dihydroergotamine mesylate.............. 28

DILANTIN ........................................ 21 DILANTIN INFATABS ......................... 21

DILANTIN-125 ................................. 21 diltiazem hcl .................................... 19

diltiazem hcl ext-rel .......................... 19 DIPENTUM ....................................... 42

diphenhydramine hcl ........................ 48 diphenoxylate w/ atropine ................. 41

DIPROLENE AF ................................. 53 dipyridamole ................................... 46

dipyridamole ext-rel/aspirin ............... 46

disopyramide phosphate ................... 17 disulfiram ........................................ 30

DIURIL............................................ 19 divalproex sodium ............................ 22

divalproex sodium ext-rel .................. 22 DIVIGEL .......................................... 39

dofetilide ......................................... 17 donepezil hydrochloride .................... 23

donepezil orally disintegrating tabs ..... 23 DONNATAL ...................................... 42

DORYX .............................................. 8 dorzolamide hcl ................................ 59

dorzolamide hcl-timolol maleate ......... 59 doxazosin mesylate .......................... 44

doxepin hcl ...................................... 24

doxepin hcl cream ............................ 55 doxercalciferol ................................. 40

67

doxycycline (monohydrate) ................. 8

doxycycline (rosacea) ........................ 56 doxycycline hyclate ............................ 8

DRITHO-CREME HP ........................... 53 dronabinol ....................................... 41

drospirenone/ethinyl estradiol ............ 38 drospirenone-ethinyl estradiol-

levomefolate calcium ......................... 38 DROXIA ........................................... 14

DRYSOL ........................................... 55 DUAVEE ........................................... 39

DUETACT ......................................... 32 DULERA ........................................... 50

duloxetine hcl ................................... 23 DUO-CARE TEST STRIPS .................... 34

DUREZOL ......................................... 58

dutasteride ...................................... 44 dutasteride-tamsulosin hcl ................. 44

DUTOPROL ....................................... 18 D-VI-SOL ......................................... 47

DYMISTA ......................................... 50 DYRENIUM ....................................... 19

E E.E.S. GRANULES .............................. 7

EASY PLUS BLOOD GLUCOSE T ........... 34 EASY PLUS II BLOOD GLUCOS ............ 34

EASY STEP TEST STRIPS .................... 34 EASY TALK BLOOD GLUCOSE T ........... 34

EASY TOUCH GLUCOSE TEST S ........... 34 EASY TOUCH HEALTHPRO GLUC ......... 34

EASY TRAK BLOOD GLUCOSE T .......... 34

EASYGLUCO ..................................... 34 EASYGLUCO PLUS ............................. 34

EASYMAX 15 TEST STRIPS ................. 34 EASYMAX TEST STRIPS ..................... 34

EASYPLUS BLOOD GLUCOSE TE .......... 34 EASYPRO BLOOD GLUCOSE TES ......... 34

EASYPRO PLUS ................................. 35 econazole nitrate .............................. 52

EDARBI ........................................... 17 EDARBYCLOR ................................... 16

EDECRIN ......................................... 19 EDLUAR ........................................... 28

EFFIENT........................................... 46 ELEMENT COMPACT TEST STRI ........... 35

ELEMENT TEST STRIPS ...................... 35

ELESTRIN ........................................ 39 ELETONE ......................................... 55

ELETONE TWINPACK ......................... 55

ELIDEL ............................................ 54 ELIQUIS .......................................... 45

ELIXOPHYLLIN ................................. 51 ELLA ............................................... 37

ELMIRON......................................... 45 ELOCON OINT .................................. 54

EMADINE ........................................ 58 EMBRACE BLOOD GLUCOSE TEST ...... 35

EMBRACE EVO BLOOD GLUCOSE ........ 35 EMBRACE PRO BLOOD GLUCOSE ........ 35

EMEND 125 MG ................................ 42 EMEND 40 MG ................................. 41

EMEND 80 MG ................................. 42 EMEND PAK ..................................... 42

EMSAM ........................................... 23

EMTRIVA CAPS .................................. 9 EMULSION SB .................................. 55

enalapril maleate ............................. 15 enalapril maleate/hydrochlorothiazide . 15

entacapone ..................................... 24 entecavir tabs .................................. 10

ENTERO VU ..................................... 31 ENTRESTO ...................................... 20

EPANED .......................................... 16 EPCLUSA ......................................... 10

EPICERAM ....................................... 55 EPIDUO ........................................... 51

EPIFOAM ......................................... 44 epinastine hcl (ophth) ....................... 58

epinephrine auto-injector .................. 48

EPIVIR .............................................. 9 eplerenone ...................................... 16

eprosartan mesylate ......................... 17 EPZICOM ........................................... 9

EQUETRO ........................................ 29 ergocalciferol ................................... 47

ergotamine w/ caffeine ..................... 28 ERIVEDGE ....................................... 14

ERTACZO ........................................ 52 ERYPED ............................................. 7

erythromycin (acne aid) .................... 51 erythromycin (ophth) ....................... 57

erythromycin base.............................. 7 erythromycin base delayed-rel ............. 7

erythromycin ethylsuccinate ................ 7

erythromycin stearate ......................... 7 ESBRIET ......................................... 50

68

escitalopram oxalate ......................... 23

ESGIC .............................................. 4 esomeprazole magnesium .................. 43

estazolam ........................................ 28 esterified estrogens &

methyltestosterone ........................... 39 ESTRACE ......................................... 39

ESTRACE CREAM .............................. 39 estradiol .......................................... 39

estradiol & norethindrone acetate ....... 39 estradiol vaginal tabs ........................ 39

ESTRING ......................................... 39 ESTROGEL ....................................... 39

estropipate ...................................... 39 ESTROSTEP FE ................................. 38

eszopiclone ...................................... 28

ethacrynic acid ................................. 19 ethambutol hcl ................................. 10

ethosuximide.................................... 22 ethynodiol diacetate/ethinyl estradiol .. 38

etodolac ........................................... 4 etodolac ext-rel ................................. 4

etoposide ......................................... 14 EURAX ............................................. 56

EVAMIST.......................................... 39 EVENCARE + BLOOD GLUCOSE .......... 35

EVENCARE BLOOD GLUCOSE TEST STRIPS ............................................ 35

EVENCARE G2 TEST STRIPS ............... 35 EVOLUTION AUTOCODE ..................... 35

EXACTECH R-S-G TEST STRIP ............ 35

EXACTECH TEST STRIPS .................... 35 EXALGO ............................................ 5

EXELDERM ....................................... 52 exemestane ..................................... 12

EXFORGE ......................................... 16 EXFORGE HCT .................................. 16

EXJADE ........................................... 46 EZ SMART BLOOD GLUCOSE TEST

STRIPS ............................................ 35 EZ SMART PLUS BLOOD GLUCOSE ...... 35

E-Z SPACER ..................................... 49 E-Z SPACER THE BODY GUARD ........... 49

E-Z-CAT DRY .................................... 31 ezetimibe ......................................... 17

ezetimibe-simvastatin ....................... 17

F FABIOR ........................................... 51

FACTIVE ............................................ 7

famciclovir ...................................... 10 famotidine ....................................... 42

FANAPT ........................................... 25 FANAPT TITRATION PACK .................. 25

FARESTON ...................................... 12 felbamate ........................................ 22

FELBATOL TABS ............................... 22 felodipine ext-rel .............................. 19

FEM PH ........................................... 45 FEMARA .......................................... 12

FEMCON FE ..................................... 38 FEMRING ........................................ 40

fenofibrate ...................................... 17 fenofibrate micronized ...................... 17

fenoprofen calcium ............................. 4

fentanyl citrate lozenge ....................... 5 fentanyl transdermal .......................... 5

FENTANYL TRANSDERMAL ................... 5 FER-IN-SOL ..................................... 47

ferrous sulfate elixir, soln .................. 47 FETZIMA ......................................... 23

FETZIMA TITRATION PACK ................ 23 FEXMID ........................................... 29

FIFTY50 GLUCOSE TEST STRIPS ........ 35 FINACEA ......................................... 56

finasteride ....................................... 44 FIORICET/CODEINE ............................ 5

FIRST-LANSOPRAZOLE ..................... 43 FIRST-OMEPRAZOLE ......................... 43

flavoxate hcl .................................... 45

flecainide acetate ............................. 17 FLECTOR ........................................... 5

FLOVENT DISKUS ............................. 50 FLOVENT HFA .................................. 50

fluconazole ........................................ 8 fludrocortisone acetate ..................... 40

flunisolide (nasal) ............................. 50 fluocinolone acetonide ...................... 54

fluocinolone acetonide body, scalp oil . 53 fluocinolone acetonide cream, soln

0.01% ............................................ 53 fluocinolone acetonide oil .................. 60

fluocinonide ..................................... 53 fluocinonide emulsified base .............. 53

FLUOR-A-DAY .................................. 47

fluorometholone (ophth) ................... 58 FLUOROPLEX ................................... 52

69

fluorouracil (topical) .......................... 52

fluoxetine hcl ............................. 23, 24 FLUOXETINE HCL .............................. 24

fluoxetine hcl (pmdd) ........................ 24 fluphenazine hcl ................................ 25

flurandrenolide cream, lotion .............. 54 flurazepam hcl .................................. 28

flurbiprofen ....................................... 4 flurbiprofen sodium ........................... 58

flutamide ......................................... 12 fluticasone propionate ....................... 54

fluticasone propionate (nasal) ............ 50 fluvastatin sodium ............................ 17

fluvastatin sodium ext-rel .................. 18 fluvoxamine maleate ......................... 21

fluvoxamine maleate ext-rel ............... 21

FML ................................................. 58 FML FORTE ....................................... 58

FOCALIN XR CAP 10MG ..................... 26 FOCALIN XR CAP 15MG ..................... 26



FOCALIN XR CAP 40MG ..................... 26 FOCALIN XR CAP 5MG ....................... 26

folic acid .......................................... 47 FORA BLOOD GLUCOSE TEST S .......... 35

FORA D15G BLOOD GLUCOSE T .......... 35 FORA D20 BLOOD GLUCOSE TE .......... 35

FORA G20 BLOOD GLUCOSE TE .......... 35

FORA G30A BLOOD GLUCOSE T .......... 35 FORA GD20 TEST STRIPS .................. 35

FORA GD50 BLOOD GLUCOSE T .......... 35 FORA V10 BLOOD GLUCOSE TE .......... 35

FORA V12 BLOOD GLUCOSE TE .......... 35 FORA V20 BLOOD GLUCOSE TE .......... 35

FORA V30A BLOOD GLUCOSE T .......... 35 FORACARE GD40 .............................. 35

FORACARE PREMIUM V10 TEST .......... 35 FORACARE TEST N GO TEST S ............ 35

FORFIVO XL ..................................... 23 formaldehyde ................................... 55

FOSAMAX PLUS D ............................. 37 fosinopril sodium .............................. 16

fosinopril sodium/hydrochlorothiazide .. 15

FOSRENOL CHEW TABS ..................... 40 FREESTYLE INSULINX BLOOD ............. 35

FREESTYLE LITE TEST STRIP ............. 35

FREESTYLE TEST STRIPS ................... 35 frovatriptan succinate ....................... 29

furosemide ...................................... 19 G gabapentin ...................................... 22 GABITRIL ........................................ 22

galantamine hydrobromide ext-rel ...... 23 galantamine hydrobromide tabs ......... 23

GASTROCROM ................................. 43 gatifloxacin (ophth) .......................... 57

GE100 BLOOD GLUCOSE TEST ........... 35 GEBAUERS SPRAY ............................ 55

GELNIQUE 10% ............................... 45 gemfibrozil ...................................... 17

GENADUR........................................ 55

GENERESS FE .................................. 38 gentamicin sulfate (ophth) ................ 57

gentamicin sulfate (topical) ............... 52 GENVOYA .......................................... 9

GHT TEST STRIPS ............................ 35 GILENYA ......................................... 29

GILOTRIF ........................................ 13 GLEEVEC ......................................... 13

GLEOSTINE ..................................... 11 glimepiride ...................................... 33

glipizide .......................................... 33 glipizide ext-rel ................................ 33

glipizide-metformin hcl ..................... 32 GLUCAGEN DIAGNOSTIC ................... 40

GLUCAGEN HYPOKIT......................... 40

GLUCAGON EMERGENCY KIT ............. 40 GLUCO PERFECT 3 TEST STRI ............ 35

GLUCOCARD 01 SENSOR PLUS .......... 35 GLUCOCARD EXPRESSION BLOO ........ 35

GLUCOCARD SHINE TEST STRI .......... 35 GLUCOCARD VITAL TEST STRI ........... 35

GLUCOCARD X-SENSOR .................... 35 GLUCOCOM TEST STRIPS .................. 35

GLUCONAVII BLOOD GLUCOSE .......... 35 glyburide ......................................... 33

glyburide micronized ........................ 33 glyburide-metformin ......................... 32

glycopyrrolate .................................. 42 GMATE BLOOD GLUCOSE TEST .......... 35

GOLYTELY ....................................... 43

GRALISE ......................................... 30 GRALISE STARTER ........................... 30

70

granisetron hcl ................................. 42

griseofulvin microsize ......................... 8 griseofulvin ultramicrosize................... 8

GRIS-PEG ......................................... 8 guaifenesin-codeine .......................... 48

guanfacine hcl .................................. 16 guanfacine hcl ext-rel ........................ 26

H halobetasol propionate ...................... 54

HALOG ............................................ 53 haloperidol ....................................... 25

haloperidol lactate ............................ 25 HARVONI ......................................... 10

HECTOROL ....................................... 40 HIPREX ............................................ 45

homatropine hbr ............................... 59

HORIZANT ....................................... 31 HPR ................................................ 54

HPR PLUS CREAM.............................. 55 HPR PLUS FOAM ............................... 54

HPR PLUS HYDROGEL KIT .................. 55 HUMULIN R U-500 (CONCENTR ........... 32

HYCAMTIN ....................................... 15 hydralazine hcl ................................. 20

HYDREA ........................................... 15 hydrochlorothiazide ........................... 19

hydrocodone polistirex-chlorpheniramine polistirex ......................................... 48

hydrocodone w/ homatropine ............. 48 hydrocodone/acetaminophen 10-300 mg

....................................................... 5

hydrocodone/acetaminophen 10-325 mg ....................................................... 6

hydrocodone/acetaminophen 10-325 mg/15 ml.......................................... 6

hydrocodone/acetaminophen 2.5-325 mg ....................................................... 5

hydrocodone/acetaminophen 5-300 mg 5 hydrocodone/acetaminophen 5-325 mg 5



hydrocodone/acetaminophen 7.5-325 mg/15 ml.......................................... 5

hydrocodone/acetaminophen sol 5-217

mg/10 ml.......................................... 6 hydrocodone-ibuprofen ....................... 5

hydrocortisone ................................. 40

hydrocortisone (intrarectal) ............... 43 hydrocortisone (rectal) ..................... 44

hydrocortisone (topical) .................... 53 hydrocortisone acetate (rectal) .......... 44

hydrocortisone acetate w/ pramoxine . 44 hydrocortisone butyrate .................... 54

hydrocortisone butyrate hydrophilic lipo base ............................................... 54

hydrocortisone valerate .................... 54 hydrocortisone w/acetic acid .............. 60

hydromorphone ext-rel ....................... 6 hydromorphone hcl ............................ 6

HYDROMORPHONE HCL ....................... 6 hydroxychloroquine sulfate ................ 46

hydroxyurea .................................... 15

hydroxyzine hcl ................................ 48 hydroxyzine pamoate ....................... 48

HYLATOPIC ...................................... 54 HYLATOPIC PLUS CREAM ................... 55

HYLATOPIC PLUS FOAM .................... 54 hyoscyamine sulfate ......................... 42

hyoscyamine sulfate ext-rel ............... 42 hyoscyamine sulfate sublingual .......... 42

HYPERSAL ....................................... 50 HYSINGLA ER .................................... 6

I ibandronate sodium .......................... 37

ibuprofen .......................................... 4 ICLUSIG .......................................... 13

ILEVRO ........................................... 58

imatinib mesylate ............................. 13 IMBRUVICA ..................................... 13

imipramine hcl ................................. 24 imipramine pamoate ......................... 24

imiquimod ....................................... 55 IMURAN .......................................... 46

indapamide ..................................... 19 INDERAL LA ..................................... 18

INDOCIN SUPP .................................. 4 indomethacin ..................................... 4

indomethacin ext-rel........................... 4 INFINITY BLOOD GLUCOSE TE ........... 35

INLYTA ........................................... 13 INSULIN SYRINGES, NEEDLES .......... 35

INTELENCE ........................................ 9

INTERMEZZO ................................... 28 INTUNIV ......................................... 26

71

INVIRASE ......................................... 9

INVOKAMET ..................................... 33 INVOKAMET XR ................................ 33

INVOKANA ....................................... 33 iodine strong (lugol's) ........................ 41

ipratropium bromide ......................... 48 ipratropium bromide (nasal) ............... 50

ipratropium-albuterol ........................ 48 irbesartan ........................................ 17

irbesartan-hydrochlorothiazide ........... 16 IRESSA ............................................ 13

ISENTRESS TABS ............................... 9 isometheptene-caffeine-acetaminophen

...................................................... 28 isometheptene-dichloralphenazone-

acetaminophen ................................. 28

isoniazid .......................................... 10 isosorbide dinitrate ........................... 20

isosorbide dinitrate ext-rel ................. 20 isosorbide mononitrate ...................... 20

isosorbide mononitrate ext-rel ............ 20 isotretinoin ....................................... 51

isradipine ......................................... 19 ISTALOL .......................................... 59

itraconazole ...................................... 8 ivermectin........................................ 11

J JAKAFI ............................................ 13

JANUMET ......................................... 32 JANUMET XR .................................... 32

JANUVIA .......................................... 32

JARDIANCE ...................................... 33 JENTADUETO .................................... 32

JENTADUETO XR ............................... 32 K KALETRA........................................... 9 KALYDECO ....................................... 49

KAPVAY ........................................... 26 KEFLEX ............................................. 7

KENDALL AMORPHOUS HYDROGE ....... 56 KEPPRA ........................................... 22

KEPPRA XR....................................... 22 KERALYT .......................................... 55

KETOCARE ....................................... 35 ketoconazole ..................................... 8

ketoconazole (topical) ....................... 52

KETO-DIASTIX ................................. 35 KETONE TEST STRIPS ....................... 36

ketoprofen ........................................ 4

ketoprofen ext-rel .............................. 4 KETOROLAC GEL 2% .......................... 5

ketorolac tromethamine ...................... 4 ketorolac tromethamine (ophth) ........ 58

KETOSTIX ....................................... 36 KITABIS PAK ................................... 49

KLONOPIN ....................................... 21 KLOR-CON M15 ................................ 47

K-PHOS .......................................... 47 K-PHOS NO 2 .................................. 47

KRISTALOSE .................................... 43 K-TAB ............................................. 47

KUVAN ............................................ 40 L labetalol hcl ..................................... 18

LACRISERT ...................................... 59 lactic acid (ammonium lactate) .......... 54

lactulose ......................................... 43 lactulose (encephalopathy) ................ 43

LAMICTAL ....................................... 22 LAMICTAL CHEWABLE ....................... 22

LAMICTAL ODT ................................ 22 LAMICTAL ODT KIT ........................... 22

LAMICTAL STARTER KIT .................... 22 LAMICTAL XR ................................... 22

LAMICTAL XR KIT ............................. 22 LAMISIL TABS .................................... 8

lamivudine ........................................ 9 lamivudine-zidovudine ........................ 9

lamotrigine ...................................... 22

lamotrigine ext-rel............................ 22 lamotrigine orally disintegrating tabs .. 22

LANCETS ......................................... 36 LANCING DEVICE ............................. 36

LANOXIN ......................................... 19 lansoprazole .................................... 44

LANTUS .......................................... 32 LANTUS SOLOSTAR .......................... 32

LASTACAFT ..................................... 58 latanoprost ...................................... 59

LATUDA .......................................... 25 leflunomide ..................................... 46

LETAIRIS ........................................ 20 letrozole .......................................... 12

leucovorin calcium ............................ 15

LEUKERAN ....................................... 11 levalbuterol hcl inhalation soln ........... 49

72

levalbuterol tartrate .......................... 49

levetiracetam ................................... 22 levetiracetam ext-rel ......................... 22

levobunolol hcl ................................. 59 levocarnitine (metabolic modifiers) ..... 40

levofloxacin ....................................... 7 levofloxacin (ophth) .......................... 57

levonorgestrel (emergency) ............... 37 levonorgestrel/ethinyl estradiol ........... 38

levonorgestrel/ethinyl estradiol (91-day) ...................................................... 37

levonorgestrel/ethinyl estradiol (continuous)..................................... 37

levonorgestrel/ethinyl estradiol (triphasic) ........................................ 39

levothyroxine sodium ........................ 41

LEVULAN KERASTICK ........................ 52 LEXIVA TABS ..................................... 9

LIALDA ............................................ 42 LIBERTY NEXT GENERATION B ........... 36

LIBERTY TEST STRIPS ....................... 36 lidocaine .......................................... 55

lidocaine hcl ..................................... 55 lidocaine hcl (mouth-throat) ............... 57

lidocaine-hydrocortisone acetate (rectal) ...................................................... 44

lidocaine-prilocaine ........................... 55 LIDODERM ....................................... 55

LIDORX ........................................... 55 lindane shampoo .............................. 56

linezolid ........................................... 11

LINZESS .......................................... 43 liothyronine sodium ........................... 41

LIQUID E-Z-PAQUE ........................... 31 LIQUID POLIBAR PLUS....................... 31

lisinopril ........................................... 16 lisinopril/hydrochlorothiazide .............. 15

LITHIUM .......................................... 29 lithium carbonate .............................. 29

lithium carbonate ext-rel ................... 29 LITHOBID ........................................ 29

LIVALO ............................................ 18 LO LOESTRIN FE ............................... 38

LOCOID LOTION ............................... 54 LOESTRIN 1.5/30-21 ......................... 38

LOESTRIN 1/20-21 ............................ 38

LOESTRIN FE 1.5/30 ......................... 38 LOESTRIN FE 1/20 ............................ 38

loperamide hcl ................................. 41

lopinavir-ritonavir soln ........................ 9 LOPRESSOR..................................... 18

lorazepam ....................................... 21 LORTAB ELIXIR .................................. 6

LORZONE ........................................ 29 losartan potassium ........................... 17

losartan potassium & hydrochlorothiazide...................................................... 16

LOSEASONIQUE ............................... 37 LOTEMAX ........................................ 58

LOTREL ........................................... 15 LOUTREX ........................................ 53

lovastatin ........................................ 18 loxapine succinate ............................ 25

LUMIGAN ........................................ 59

LUZU .............................................. 52 LYNPARZA ....................................... 15

LYRICA CAPS 200MG ........................ 27 LYRICA CAPS 225MG, 300MG ............ 28

LYRICA CAPS 25MG, 50MG, 75MG, 100MG, 150MG ................................ 27

LYRICA SOLN ................................... 28 LYSODREN ...................................... 15

M MAGNEBIND 400 .............................. 47

MALARONE ........................................ 8 malathion ........................................ 56

maprotiline hcl ................................. 23 MARPLAN ........................................ 23

MASK VORTEX/BABY WHIRL DU ......... 49

MASK VORTEX/CHILD/FROG .............. 49 MASK VORTEX/SPINNER THE D .......... 50

MASK VORTEX/TODDLER/LADY .......... 50 MAXIDEX ........................................ 58

MAXIMA BLOOD GLUCOSE TEST ........ 36 MB HYDROGEL ................................. 55

meclizine hcl .................................... 42 meclofenamate sodium ....................... 4

MEDROL TABS ................................. 40 medroxyprogesterone acetate ............ 41

mefenamic acid .................................. 4 mefloquine hcl ................................... 8

MEGACE ES ..................................... 41 megestrol acetate susp 40 mg/ml ...... 13

megestrol acetate susp 625 mg/5 ml .. 41

megestrol acetate tabs ..................... 13 MEKINIST ....................................... 14

73

meloxicam tabs ................................. 4

memantine hcl ................................. 23 memantine hcl titration pack .............. 23

MENEST ........................................... 39 MENOSTAR ...................................... 39

MENTAX .......................................... 52 meperidine hcl ................................... 6

MEPHYTON ....................................... 47 meprobamate ................................... 21

mercaptopurine ................................ 11 mesalamine ..................................... 43

mesalamine w/ cleanser .................... 43 MESNEX .......................................... 15

METADATE CD ............................ 26, 27 metaxalone ...................................... 29

metformin hcl ................................... 32

metformin hcl xr ............................... 32 methadone hcl ................................... 6

METHADOSE CONC ............................ 6 methamphetamine hcl tab 5 mg ......... 27

methazolamide ................................. 59 methenamine hippurate ..................... 45

methenamine mandelate ................... 45 methimazole .................................... 41

METHITEST ...................................... 31 methocarbamol ................................ 29

methotrexate sodium ........................ 12 methoxsalen rapid ............................ 52

methyclothiazide ............................... 19 methyldopa ...................................... 20

methylphenidate hcl .......................... 27

methylphenidate hcl ext-rel caps 10mg ...................................................... 27






methylphenidate hcl ext-rel tabs 10mg 27 methylphenidate hcl ext-rel tabs 18mg 27

methylphenidate hcl ext-rel tabs 20mg 27

methylphenidate hcl ext-rel tabs 27mg 27 methylphenidate hcl ext-rel tabs 36mg 27

methylphenidate hcl ext-rel tabs 54mg 27

methylprednisolone .......................... 40 methyltestosterone .......................... 31

metoclopramide hcl .......................... 42 metolazone ..................................... 19

metoprolol & hydrochlorothiazide ....... 18 metoprolol succinate ext-rel .............. 18

metoprolol tartrate ........................... 18 METROCREAM .................................. 56

metronidazole (topical) ..................... 56 metronidazole tabs ........................... 11

metronidazole vaginal ....................... 45 mexiletine hcl .................................. 17

miconazole nitrate vaginal ................. 45 MICRODOT TEST STRIPS ................... 36

midodrine hcl ................................... 20

miglitol ........................................... 31 MIGRANAL ...................................... 28

MILLIPRED ...................................... 40 MINASTRIN 24 FE ............................ 38

MINIVELLE ...................................... 39 minocycline hcl .................................. 8

minocycline hcl ext-rel ........................ 8 minoxidil ......................................... 20

MIRCETTE ....................................... 37 mirtazapine ..................................... 23

mirtazapine orally disintegrating tabs . 23 misoprostol ..................................... 43

modafinil ......................................... 30 MODERIBA DOSE PACK ..................... 10

moexipril hcl .................................... 16

moexipril/hydrochlorothiazide ............ 15 mometasone (nasal) ......................... 50

mometasone furoate ........................ 54 montelukast sodium ......................... 49

MONUROL ....................................... 11 MORGIDOX KIT .................................. 8

morphine sulfate ................................ 6 morphine sulfate ext-rel ...................... 6

MOVIPREP ....................................... 43 MOXEZA.......................................... 57

moxifloxacin hcl ................................. 7 MULTAQ .......................................... 17

mupirocin ........................................ 52 mupirocin calcium (topical) ................ 52

MUSE ............................................. 44

MYAMBUTOL .................................... 10 MYCOBUTIN .................................... 11

74

mycophenolate mofetil ...................... 46

mycophenolate sodium ...................... 46 MYFORTIC ........................................ 46

MYGLUCOHEALTH BLOOD GLUCO ....... 36 MYLERAN ......................................... 11

MYRBETRIQ ...................................... 45 MYSOLINE ....................................... 22

N nabumetone ...................................... 4

nadolol ............................................ 18 naftifine hcl ...................................... 52

NAFTIN GEL ..................................... 52 naltrexone hcl .................................. 30

NAMENDA XR ................................... 23 NAMENDA XR TITRATION PACK .......... 23

naproxen .......................................... 4

naproxen delayed-rel ......................... 4 naproxen sodium ............................... 4

naproxen sodium ext-rel ..................... 4 naratriptan hcl .................................. 29

NARCAN NASAL SPRAY ...................... 30 NASCOBAL ....................................... 47

NATACYN ......................................... 58 NATAZIA .......................................... 37

nateglinide ....................................... 33 NATESTO ......................................... 31

NEBUSAL ......................................... 50 nefazodone hcl ................................. 23

neomycin sulfate ............................... 6 neomycin-bacitracin zn-polymyxin ...... 57

neomycin-polymyin-dexamethasone ... 57

neomycin-polymyxin-gramicidin ......... 58 neomycin-polymyxin-hydrocortisone

(ophth) ............................................ 57 neomycin-polymyxin-hydrocortisone

(otic) ............................................... 60 NEORAL ........................................... 47

NEOSALUS CP .................................. 55 NEOSALUS CREAM ............................ 55

NEOSALUS FOAM .............................. 54 NEUPRO........................................... 24

NEURONTIN ..................................... 22 NEUTEK 2TEK TEST STRIPS ............... 36

NEUTRASAL ..................................... 57 NEVANAC ......................................... 58

nevirapine ext-rel .............................. 9

nevirapine tabs .................................. 9 NEXAVAR ......................................... 14

NEXGEN TEST STRIPS ...................... 36

niacin ............................................. 18 niacin ext-rel ................................... 18

nicardipine hcl ................................. 19 NICODERM CQ ................................. 30

NICOMIDE ....................................... 47 NICORETTE ..................................... 30

nicotine polacrilex gum ..................... 30 nicotine polacrilex lozenge ................. 31

nicotine transdermal ......................... 31 NICOTROL INHALER ......................... 31

NICOTROL NS .................................. 31 nifedipine ........................................ 19

nifedipine ext-rel .............................. 19 NILANDRON .................................... 12

nilutamide ....................................... 12

nimodipine ...................................... 19 nisoldipine ext-rel ............................ 19

NITRO-BID ...................................... 20 NITRO-DUR ..................................... 20

nitrofurantoin macrocrystal ............... 11 nitrofurantoin monohyd macro ........... 11

nitrofurantoin susp ........................... 11 nitroglycerin ext-rel .......................... 20

nitroglycerin lingual spray ................. 20 nitroglycerin sublingual ..................... 20

nitroglycerin sublingual aerosol .......... 20 nitroglycerin transdermal .................. 20

NIVATOPIC PLUS .............................. 55 nizatidine ........................................ 42

norelgestromin-ethinyl estradiol ......... 38

norethindrone & ethinyl estradiol ....... 38 norethindrone & ethinyl estradiol-fe .... 38

norethindrone & mestranol ................ 38 norethindrone (contraceptive)............ 38

norethindrone acetate ....................... 41 norethindrone acetate & ethinyl

estradiol-fe ...................................... 38 norethindrone acetate/ethinyl estradiol 38

norethindrone acetate-ethinyl estradiol 39 norethindrone acetate-ethinyl estradiol-

fe ................................................... 39 norethindrone/ethinyl estradiol

(triphasic) ....................................... 39 norgestimate/ethinyl estradiol (triphasic)

...................................................... 39

norgestimate-ethinyl estradiol ........... 38 norgestrel & ethinyl estradiol ............. 38

75

NORINYL 1+35 ................................. 38

NORITATE ........................................ 56 NORPACE CR .................................... 17

NORTHERA ....................................... 20 nortriptyline hcl ................................ 24

NORVASC ........................................ 19 NORVIR CAPS .................................... 9

NORVIR TABS .................................... 9 NOVA MAX GLUCOSE TEST STR .......... 36

NOVA MAX PLUS KETONE TEST .......... 36 NOVOLIN 70/30 ................................ 32

NOVOLIN N ...................................... 32 NOVOLIN R ...................................... 32

NOVOLOG ........................................ 32 NOVOLOG FLEXPEN ........................... 32

NOVOLOG MIX 70/30 ........................ 32

NOVOLOG MIX 70/30 PREFILL ............ 32 NOVOLOG PENFILL ............................ 32

NOXAFIL ........................................... 8 NUCYNTA .......................................... 6

NUCYNTA ER ..................................... 6 NUEDEXTA ....................................... 30

NULYTELY/FLAVOR PACKS ................. 43 NUMOISYN ....................................... 57

NUPLAZID ........................................ 25 NUVAIL ............................................ 55

NUVARING ....................................... 39 NUVESSA ......................................... 45

nystatin ............................................ 8 nystatin (mouth-throat) ...................... 8

nystatin (topical) .............................. 52

nystatin-triamcinolone ....................... 52 O OCALIVA .......................................... 43 ODEFSEY .......................................... 9

OFEV ............................................... 50 ofloxacin (ophth) .............................. 58

ofloxacin (otic) ................................. 60 olanzapine ....................................... 25

olanzapine orally disintegrating tabs .... 25 olanzapine-fluoxetine hcl ................... 25

olmesartan medoxomil ...................... 17 olmesartan medoxomil-amlodipine-

hydrochlorothiazide ........................... 16 olmesartan medoxomil-

hydrochlorothiazide ........................... 16

olopatadine hcl ................................. 58 olopatadine hcl (nasal) ...................... 50

OMECLAMOX-PAK ............................. 44

omega-3-acid ethyl esters ................. 18 omeprazole ..................................... 44

OMEPRAZOLE + SYRSPEND SF ........... 44 omeprazole-sodium bicarbonate ......... 44

ON CALL EXPRESS BLOOD GLU .......... 36 ON CALL PLUS BLOOD GLUCOS .......... 36

ON CALL VIVID BLOOD GLUCO .......... 36 ondansetron hcl ............................... 42

ondansetron orally disintegrating tabs 42 ONETOUCH ULTRA BLUE ................... 36

ONETOUCH VERIO TEST STRIP .......... 36 ONEXTON ........................................ 51

ONFI .............................................. 22 ONMEL .............................................. 8

OPANA ER ......................................... 6

OPSUMIT ........................................ 20 OPTIONS CONCEPTROL VAGINA ......... 38

OPTIONS GYNOL II VAGINAL ............. 38 OPTIUM TEST STRIPS ....................... 36

OPTIUMEZ TEST STRIPS ................... 36 OPTUMRX BLOOD GLUCOSE TES ........ 36

ORACEA .......................................... 56 ORALAIR ......................................... 46

ORAP .............................................. 25 ORENITRAM..................................... 21

ORKAMBI ........................................ 49 orphenadrine citrate ext-rel ............... 30

ORTHO MICRONOR ........................... 38 ORTHO TRI-CYCLEN ......................... 39

ORTHO-CYCLEN ............................... 38

ORTHO-NOVUM 1/35 ........................ 38 ORTHO-NOVUM 7/7/7 ....................... 39

oseltamivir phosphate ....................... 10 OSMOPREP ...................................... 43

OSPHENA ........................................ 41 OTEZLA........................................... 46

OVCON-35 ...................................... 38 oxandrolone .................................... 31

oxaprozin .......................................... 4 oxazepam ....................................... 21

oxcarbazepine ................................. 22 oxiconazole nitrate crm ..................... 52

OXISTAT LOTION ............................. 52 OXTELLAR XR .................................. 22

oxybutynin chloride .......................... 45

oxybutynin chloride ext-rel ................ 45 oxycodone hcl .................................... 6

76

oxycodone hcl ext-rel ......................... 6

oxycodone/acetaminophen .................. 6 oxycodone/aspirin .............................. 6

OXYCONTIN ...................................... 6 oxymorphone hcl ............................... 6

oxymorphone hcl ext-rel ..................... 6 OXYTROL ......................................... 45

P paliperidone ext-rel ........................... 25

PANCREAZE ..................................... 43 PANRETIN ........................................ 55

pantoprazole sodium ......................... 44 paricalcitol ....................................... 40

paromomycin sulfate ......................... 11 paroxetine hcl .................................. 24

paroxetine hcl ext-rel ........................ 24

PATADAY ......................................... 58 PAXIL SUSP...................................... 24

PAZEO ............................................. 58 PEAK AIR PEAK FLOW METER ............. 50

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................................. 43

peg 3350-potassium chloride-sod bicarbonate-sod chloride .................... 43

penicillin v potassium ......................... 8 PENTASA ......................................... 42

pentazocine/naloxone ......................... 6 pentoxifylline ext-rel ......................... 46

PERFOROMIST .................................. 49 perindopril erbumine ......................... 16

permethrin ....................................... 56

perphenazine ................................... 25 perphenazine-amitriptyline ................. 25

PERTZYE .......................................... 43 PEXEVA ........................................... 24

PHARMACIST CHOICE AUTOCOD ........ 36 phenazopyridine hcl .......................... 45

phenelzine sulfate ............................. 23 phenobarbital ................................... 22

phenoxybenzamine hcl ...................... 20 phenylephrine hcl (ophth) .................. 59

phenylephrine-promethazine w/ codeine ...................................................... 48

PHENYTEK ....................................... 22 phenytoin ........................................ 22

phenytoin sodium extended ............... 22

PHOSLYRA ....................................... 40 PICATO ............................................ 52

PICO SINGLE USE NEGATIVE ............. 56

pilocarpine hcl ................................. 59 pilocarpine hcl (oral) ......................... 44

pimozide ......................................... 25 pindolol ........................................... 18

pioglitazone hcl ................................ 32 pioglitazone hcl-glimepiride ............... 32

pioglitazone hcl-metformin hcl ........... 32 piroxicam .......................................... 5

PLAN B ONE-STEP ............................ 37 PLAQUENIL ...................................... 46

POCKETCHEM EZ BLOOD GLUCO ........ 36 podofilox ......................................... 55

polyethylene glycol 3350 ................... 43 polymyxin b-trimethoprim ................. 58

POMALYST ....................................... 13

pot & sod citrates w/citric acid ........... 45 POTABA CAPS .................................. 48

potassium bicarb & chloride ............... 47 potassium bicarbonate ...................... 47

potassium chloride ........................... 47 potassium chloride ext-rel ................. 47

potassium chloride microencapsulated crystals cr ....................................... 47

potassium citrate (alkalinizer) ............ 45 potassium citrate-citric acid ............... 45

potassium phosphate monobasic w/ sodium phosphate dibasic & monobasic

...................................................... 47 PR CREAM ....................................... 55

PRADAXA ........................................ 45

pramipexole dihydrochloride .............. 24 pramipexole dihydrochloride ext-rel .... 24

PRAMOSONE .................................... 53 pramoxine/hydrocortisone ................. 53

pramoxine-hydrocortisone-chloroxylenol...................................................... 60

pravastatin sodium ........................... 18 prazosin hcl ..................................... 16

PRECISION GLUCOSE/KETONE ........... 36 PRECISION PCX ............................... 36

PRECISION PCX PLUS TEST S ............ 36 PRECISION POINT OF CARE T ............ 36

PRECISION QID TEST STRIPS ............ 36 PRECISION SOF-TACT TEST S ............ 36

PRECISION XTRA ............................. 36

PRECISION XTRA BLOOD GLUC .......... 36 PRED FORTE .................................... 58

77

PRED MILD....................................... 58

prednicarbate ................................... 54 prednisolone .................................... 40

prednisolone acetate (ophth) .............. 58 PREDNISOLONE SODIUM PHOSP......... 58

prednisolone sodium phosphate .......... 40 prednisolone sodium phosphate orally

disintegrating tabs ............................ 40 prednisone ....................................... 40

PREDNISONE INTENSOL .................... 40 PREFEST .......................................... 39

PREMARIN ....................................... 39 PREMARIN CREAM ............................. 40

PREMPHASE ..................................... 39 PREMPRO ......................................... 39

PREPOPIK ........................................ 43

PRESERA ......................................... 54 PREVIDENT 5000 BOOSTER ............... 57

PREVIDENT 5000 BOOSTER PL ........... 57 PREVIDENT 5000 DRY MOUTH ............ 57

PREVIDENT 5000 ENAMEL PRO ........... 57 PREVIDENT 5000 PLUS ...................... 57

PREVIDENT 5000 SENSITIVE .............. 57 PREVIDENT FLUORIDE ....................... 57

PREZISTA TABS ................................. 9 PRIFTIN ........................................... 10

PRILOSEC POWDER ........................... 44 PRIMAQUINE PHOSPHATE ................... 8

primidone ........................................ 22 PRIMLEV ........................................... 6

PRISTIQ .......................................... 23

PROAIR HFA ..................................... 49 PROAIR RESPI INH ............................ 49

probenecid ........................................ 4 PROCARDIA XL ................................. 19

prochlorperazine ............................... 42 prochlorperazine maleate ................... 42

PRO-CLEAR AC ................................. 48 PROCORT ......................................... 44

PROCTOCORT ................................... 44 PROCTOFOAM HC.............................. 44

PRODIGY NO CODING BLOOD G ......... 36 PRODRIN ......................................... 28

progesterone micronized .................... 41 PROGRAF ......................................... 47

PROLENSA ....................................... 58

PROMACTA ....................................... 46 promethazine & phenylephrine ........... 48

promethazine hcl ............................. 42

promethazine w/codeine ................... 48 promethazine-dextromethorphan ....... 48

PROMISEB ....................................... 53 PROMISEB COMPLETE ....................... 53

propafenone hcl ............................... 17 propafenone hcl ext-rel ..................... 17

propantheline bromide ...................... 42 proparacaine hcl .............................. 59

propranolol & hydrochlorothiazide ...... 18 propranolol hcl ................................. 18

propranolol hcl ext-rel ...................... 18 propylthiouracil ................................ 41

PROTONIX PAK ................................ 44 protriptyline hcl................................ 24

PRUCLAIR ....................................... 55

PRUMYX .......................................... 55 pseudoephedrine w/ codeine-guaifenesin

...................................................... 48 pseudoephedrine/chlorpheniramine/hydr

ocodone .......................................... 48 pseudoephedrine-brompheniramine-

dextromethorphan............................ 48 PTS PANELS GLUCOSE TEST .............. 36

PTS PANELS KETONE TEST ................ 36 PULMICORT FLEXHALER .................... 50

PULMOZYME .................................... 49 PYLERA ........................................... 44

pyrazinamide ................................... 10 pyridostigmine bromide .................... 30

pyridostigmine bromide ext-rel .......... 30

Q QBRELIS ......................................... 16

QNASL ............................................ 50 QUALAQUIN ...................................... 8

QUARTETTE ..................................... 37 quetiapine fumarate ......................... 25

quetiapine fumarate ext-rel ............... 25 QUICKTEK TEST STRIPS .................... 36

QUILLIVANT XR ............................... 27 quinapril hcl .................................... 16

quinapril/hydrochlorothiazide ............. 15 quinine sulfate ................................... 8

QUINTET AC BLOOD GLUCOSE ........... 36 QUINTET BLOOD GLUCOSE TES ......... 36

QUTENZA ........................................ 55

QVAR .............................................. 50

78

R rabeprazole sodium ........................... 44 RADIAGEL ........................................ 56

RADIAPLEXRX .................................. 56 raloxifene hcl ................................... 41

ramipril ........................................... 16 RANEXA ........................................... 20

ranitidine hcl .................................... 42 RAPAFLO ......................................... 44

RAPAMUNE ....................................... 47 rasagiline mesylate ........................... 24

RAVICTI .......................................... 40 RAYOS ............................................. 40

READI-CAT 2 .................................... 31 RECTIV ............................................ 43

REFUAH PLUS BLOOD GLUCOSE ......... 36

REGRANEX ....................................... 55 RELENZA DISKHALER ........................ 10

RELPAX ........................................... 29 RENVELA ......................................... 40

repaglinide ....................................... 33 repaglinide-metformin hcl .................. 32

RESCRIPTOR ..................................... 9 RESTASIS ........................................ 59

RETIN-A GEL .................................... 51 RETIN-A MICRO ................................ 51

RETIN-A MICRO PUMP ....................... 51 REVATIO SUSP ................................. 20

REVATIO TABS ................................. 20 REVEAL BLOOD GLUCOSE TEST .......... 36

REVLIMID ........................................ 13

REYATAZ CAPS .................................. 9 REZIRA ............................................ 48

RIBASPHERE RIBAPAK ....................... 10 ribavirin ........................................... 10

rifabutin .......................................... 11 RIFADIN .......................................... 10

rifampin ........................................... 10 RIGHTEST GS100 BLOOD GLUC .......... 36

RIGHTEST GS300 BLOOD GLUC .......... 36 RIGHTEST GS550 BLOOD GLUC .......... 36

riluzole ............................................ 29 risedronate sodium ........................... 37

risedronate sodium delayed-rel ........... 37 risperidone ....................................... 25

risperidone orally disintegrating tabs ... 25

RITALIN LA ...................................... 27 rivastigmine tartrate ......................... 23

rivastigmine transdermal................... 23

rizatriptan benzoate ......................... 29 rizatriptan benzoate orally disintegrating

tabs ................................................ 29 ROBINUL FORTE............................... 42

ropinirole hydrochloride .................... 24 ropinirole hydrochloride ext-rel .......... 24

rosuvastatin calcium ......................... 18 ROZEREM ........................................ 28

RUBRACA ........................................ 15 RYTHMOL SR ................................... 17

S SAFYRAL ......................................... 38

SALEX CREAM .................................. 55 SALEX LOTION ................................. 55

salicylic acid .................................... 55

salicylic acid w/ cleanser ................... 55 SALVAX .......................................... 56

SAMSCA .......................................... 41 SANCUSO ........................................ 42

SANDIMMUNE CAPS ......................... 47 SANTYL ........................................... 56

SAPHRIS ......................................... 25 SARAFEM ........................................ 24

SAVELLA ......................................... 28 SAVELLA TITRATION PACK ................ 28

SEASONIQUE ................................... 37 SECONAL ........................................ 28

selegiline hcl .................................... 24 selenium sulfide ............................... 53

SELZENTRY TABS ............................... 9

SENSIPAR ....................................... 37 sertraline hcl ................................... 24

SFROWASA ..................................... 43 SHUR-SEAL ..................................... 38

sildenafil citrate (pulmonary hypertension) .................................. 20

SILENOR ......................................... 28 SILVASORB ..................................... 56

silver nitrate-potassium nitrate .......... 56 SILVER NITRATE-POTASSIUM NITRATE56

silver sulfadiazine ............................. 52 SIMBRINZA ..................................... 59

simvastatin ..................................... 18 sirolimus ......................................... 47

SITAVIG .......................................... 10

SKLICE ........................................... 56 SM VITAMIN D3 MAXIMUM STR .......... 48

79

SMART SENSE PREMIUM BLOOD ......... 36

SMARTEST BLOOD GLUCOSE TE ......... 36 sodium chloride (inhalant) ................. 50

sodium citrate & citric acid ................. 45 sodium fluoride ................................. 48

sodium fluoride (dental) .................... 57 sodium polystyrene sulfonate ............. 41

SOLODYN ......................................... 8 SOLUS V2 AUDIBLE TEST .................. 36

SORILUX.......................................... 53 sotalol hcl ........................................ 17

sotalol hcl (afib/afl) ........................... 17 SPECTRAGEL .................................... 56

spinosad .......................................... 56 SPIRIVA HANDIHALER ....................... 48

SPIRIVA RESPIMAT ........................... 48

spironolactone .................................. 16 spironolactone & hydrochlorothiazide .. 19

SPORANOX SOLN ............................... 8 SPRYCEL .......................................... 14

SSKI ............................................... 41 stavudine caps ................................. 10

STIMATE .......................................... 41 STIVARGA ........................................ 14

STRATTERA ...................................... 27 STRIBILD .......................................... 9

STRIVERDI RESPIMAT ....................... 49 STROMECTOL ................................... 11

SUBOXONE FILM ............................... 30 sucralfate......................................... 43

SULAR ............................................. 19

sulfacetamide liqd, shampoo .............. 53 sulfacetamide lotion, susp .................. 51

sulfacetamide sodium-sulfur-sunscreen ...................................................... 51

sulfacetamide sod-prednisolone .......... 57 sulfacetamide soln ............................ 58

SULFACETAMIDE/SULFUR .................. 51 sulfacetamide/sulfur cream, emul, liqd,

lotn, pads, soln, susp ........................ 56 SULFACETAMIDE/SULFUR IN UREA EMUL

...................................................... 51 sulfacetamide/sulfur in urea gel .......... 56

sulfacetamide/sulfur w/ skin cleanser .. 51 SULFADIAZINE .................................. 8

sulfamethoxazole-trimethoprim ........... 8

SULFAMYLON CREAM......................... 56 sulfasalazine .................................... 42

sulindac ............................................ 5

SUMADAN KIT ................................. 51 SUMADAN XLT ................................. 51

sumatriptan nasal spray .................... 29 sumatriptan succinate ....................... 29

sumatriptan succinate inj 4 mg/0.5 ml 29 sumatriptan succinate inj 6 mg/0.5 ml 29

SUMAVEL DOSEPRO ......................... 29 SUMAXIN CP KIT .............................. 51

SUPER DAILY D3 .............................. 48 SUPRAX ............................................ 7

SUPREME TEST STRIPS ..................... 36 SUPREP BOWEL PREP KIT .................. 43

SURE EDGE BLOOD GLUCOSE T ......... 36 SURECHEK BLOOD GLUCOSE TE ........ 37

SURESTEP PRO TEST STRIPS ............. 37

SURE-TEST EASYPLUS MINI B ............ 37 SUSTIVA ........................................... 9

SUTENT .......................................... 14 SYMBICORT ..................................... 50

SYMLINPEN 120 ............................... 31 SYMLINPEN 60 ................................. 31

SYNALAR ......................................... 53 SYNALGOS-DC ................................... 6

SYNAREL ......................................... 39 SYNJARDY ....................................... 33

SYNJARDY XR .................................. 33 SYNTHROID ..................................... 41

T TABLOID ......................................... 12

TACLONEX SUSP .............................. 53

tacrolimus ....................................... 47 tacrolimus (topical) .......................... 55

TAFINLAR ........................................ 14 TAGITOL V ...................................... 31

TAMIFLU ......................................... 10 tamoxifen citrate .............................. 12

tamsulosin hcl ................................. 44 TANZEUM ........................................ 32

TARCEVA ........................................ 14 TARGRETIN CAPS ............................. 15

TARGRETIN GEL ............................... 15 TASIGNA ......................................... 14

tazarotene cream 0.1% .................... 51 TAZORAC ........................................ 51

TECFIDERA ...................................... 29

TECFIDERA STARTER PACK ............... 29 TEGRETOL ....................................... 22

80

TEGRETOL-XR .................................. 22

TEKTURNA ....................................... 19 TEKTURNA HCT ................................ 19

TELCARE BLOOD GLUCOSE TES .......... 37 telmisartan ...................................... 17

telmisartan-amlodipine ...................... 16 telmisartan-hydrochlorothiazide .......... 16

temazepam ...................................... 28 TEMODAR ........................................ 11

TEMOVATE OINT, SOLN .................... 54 temozolomide ................................... 11

TENORMIN ....................................... 18 terazosin hcl..................................... 44

terbinafine hcl ................................... 8 terbutaline sulfate ............................. 49

terconazole vaginal ........................... 45

testosterone gel ................................ 31 TESTRED ......................................... 31

tetrabenazine ................................... 28 tetracaine hcl (ophth) ........................ 59

tetracycline hcl .................................. 8 TGT BLOOD GLUCOSE TEST ST........... 37

THALOMID ....................................... 13 THEO-24 .......................................... 51

theophylline ..................................... 51 THERA-FLUR-N ................................. 57

THERAHONEY ................................... 56 thioridazine hcl ................................. 25

thiothixene ....................................... 25 tiagabine hcl .................................... 22

TIAZAC ............................................ 19

timolol maleate ................................. 18 timolol maleate (ophth) ..................... 59

TIMOPTIC OCUDOSE ......................... 59 tinidazole ......................................... 11

TIROSINT ........................................ 41 TIVICAY ............................................ 9

tizanidine hcl .................................... 30 TOBI ............................................... 49

TOBI PODHALER ............................... 49 TOBRADEX OINT ............................... 57

TOBRADEX ST .................................. 57 tobramycin....................................... 49

tobramycin (ophth) ........................... 58 tobramycin-dexamethasone ............... 57

TOBREX OINT ................................... 58

tolbutamide ...................................... 33 tolmetin sodium ................................. 5

tolterodine tartrate ........................... 45

tolterodine tartrate ext-rel ................. 45 TOPAMAX ........................................ 22

TOPAMAX SPRINKLE ......................... 22 TOPICORT GEL 0.05% ...................... 53

TOPICORT OINT 0.05% ..................... 54 TOPICORT OINT 0.25% ..................... 53

TOPICORT SPRAY 0.25% ................... 53 topiramate ...................................... 22

topiramate ext-rel ............................ 22 topiramate sprinkle caps ................... 22

TOPROL XL ...................................... 18 torsemide ........................................ 19

TOVIAZ ........................................... 45 TRACLEER ....................................... 20

TRADJENTA ..................................... 32

tramadol hcl ...................................... 6 tramadol hcl ext-rel ............................ 6

tramadol/acetaminophen .................... 6 trandolapril...................................... 16

trandolapril/verapamil ext-rel ............ 15 tranexamic acid ............................... 46

TRANSDERM-SCOP ........................... 42 tranylcypromine sulfate .................... 23

TRAVATAN Z .................................... 59 trazodone hcl ................................... 23

tretinoin .......................................... 51 tretinoin (chemotherapy) .................. 15

tretinoin microsphere ........................ 51 TRETIN-X ........................................ 51

TREXIMET ....................................... 28

triamcinolone acetonide cream, lotion, oint 0.25%, 0.1% ............................ 54

triamcinolone acetonide cream, oint 0.5% .............................................. 53

triamcinolone acetonide paste ............ 57 triamterene/hydrochlorothiazide ........ 19

TRIANEX ......................................... 54 triazolam......................................... 28

TRI-CHLOR ...................................... 56 trifluoperazine hcl ............................ 25

trifluridine ....................................... 58 TRIGLIDE ........................................ 17

trihexyphenidyl hcl ........................... 24 TRILEPTAL ....................................... 22

trimethobenzamide hcl...................... 42

trimethoprim ................................... 11 TRI-NORINYL 28 .............................. 39

81

TRINTELLIX ...................................... 24

TRIUMEQ .......................................... 9 TRIZIVIR .......................................... 9

TROKENDI XR .................................. 22 tropicamide ...................................... 59

trospium chloride .............................. 45 trospium chloride ext-rel .................... 45

TRUE METRIX BLOOD GLUCOSE.......... 37 TRUETRACK BLOOD GLUCOSE T ......... 37

TRUETRACK TEST ............................. 37 TRULICITY ....................................... 32

TRUVADA .......................................... 9 trypsin w/ castor oil & peruvian balsam

spray............................................... 56 TUSSICAPS ...................................... 49

TWYNSTA ........................................ 16

TYKERB ........................................... 14 TYVASO ........................................... 21

U UCERIS ........................................... 42

ULORIC ............................................ 4 ULTIMA TEST STRIPS ........................ 37

ULTRATRAK PRO TEST STRIPS............ 37 ULTRATRAK ULTIMATE TEST S............ 37

ULTRAVATE CREAM ........................... 54 ULTRAVATE X ................................... 54

UNISTRIP1 GENERIC ......................... 37 URAMAXIN AEROSOL ......................... 54

urea in zinc undecylenate-lactic acid vehicle ............................................ 54

UROCIT-K 10.................................... 45

UROCIT-K 15.................................... 45 UROCIT-K 5 ..................................... 45

URSO 250 ........................................ 42 ursodiol ........................................... 42

V valacyclovir hcl ................................. 10

VALCHLOR ....................................... 11 VALCYTE .......................................... 10

valganciclovir hcl .............................. 10 VALIUM ........................................... 21

valproate sodium .............................. 22 valproic acid ..................................... 22

valsartan ......................................... 17 valsartan-hydrochlorothiazide ............. 16

vancomycin hcl ................................. 11

VARIBAR HONEY ............................... 31 VARIBAR NECTAR ............................. 31

VARIBAR THIN HONEY ...................... 31

VASCEPA ......................................... 18 VASCUDERM HYDROGEL WOUND ....... 56

vcf vaginal gel contraceptive .............. 38 VEMLIDY ......................................... 10

VENCLEXTA ..................................... 15 venlafaxine hcl ................................. 23

VENLAFAXINE HCL ER ....................... 23 venlafaxine hcl ext-rel ...................... 23

VENTAVIS ....................................... 21 VENTOLIN HFA ................................. 49

verapamil hcl ................................... 19 verapamil hcl ext-rel ......................... 19

VERDESO ........................................ 53 VEREGEN ........................................ 56

VERELAN ......................................... 19

VERELAN PM .................................... 19 VERIPRED 20 ................................... 40

VESICARE ....................................... 45 VFEND TABS ...................................... 8

VIBRAMYCIN ..................................... 8 VICTORY AGM-4000 TEST STR ........... 37

VICTOZA ......................................... 32 VIGAMOX ........................................ 58

VIIBRYD TABS ................................. 24 VIMPAT ........................................... 22

VIRACEPT .......................................... 9 VIREAD TABS .................................. 10

VISTOGARD..................................... 15 VITAMIN D3 .................................... 48

VIVELLE-DOT ................................... 39

VOCAL POINT BLOOD GLUCOSE ......... 37 VOLUMEN ........................................ 31

voriconazole ...................................... 8 VORTEX HOLDING CHAMBER/MA ....... 50

VORTEX VALVED HOLDING CHA ......... 50 VOTRIENT ....................................... 14

VUSION .......................................... 52 VYTORIN ......................................... 18

VYVANSE ........................................ 27 W warfarin sodium ............................... 45 WAVESENSE PRESTO TEST STR ......... 37

WELCHOL ........................................ 17 WELLESSE VITAMIN D3 .................... 48

WESTCORT ...................................... 54

X XALKORI ......................................... 14

82

XARELTO ......................................... 45

XARTEMIS XR .................................... 6 XELJANZ .......................................... 46

XELJANZ XR ..................................... 46 XELODA ........................................... 12

XENICAL .......................................... 37 XERESE ........................................... 56

XEROFORM NON-OCCLUSIVE DRESSING ...................................................... 56

XEROFORM OCCLUSIVE DRESSING ..... 57 XEROFORM PETROLATUM DRESSING ... 57

XIFAXAN .......................................... 11 XOLEGEL ......................................... 52

XOPENEX HFA .................................. 49 XTANDI ........................................... 12

XYREM ............................................. 30

Y YASMIN 28 ....................................... 38

YAZ ................................................. 38 Z zafirlukast ........................................ 49 zaleplon ........................................... 28

ZANAFLEX TABS ............................... 30 ZARONTIN ....................................... 22

ZELAPAR .......................................... 24 ZELBORAF ....................................... 14

ZENPEP ........................................... 43 zenzedi tab 10mg ............................. 27

zenzedi tab 15mg ............................. 27 zenzedi tab 2.5mg ............................ 27

zenzedi tab 20mg ............................. 27

zenzedi tab 30mg ............................. 27 zenzedi tab 5mg ............................... 27

zenzedi tab 7.5mg ............................ 27

ZETIA ............................................. 17 ZIAGEN ........................................... 10

zidovudine syrup .............................. 10 zidovudine tabs ................................ 10

zileuton ext-rel ................................ 49 ZIOPTAN ......................................... 59

ziprasidone hcl ................................. 25 ZIRGAN .......................................... 58

ZITHRANOL ..................................... 53 ZMAX ............................................... 7

ZOHYDRO ER ..................................... 6 zolmitriptan ..................................... 29

zolmitriptan orally disintegrating tabs . 29 zolpidem tartrate ............................. 28

zolpidem tartrate ext-rel ................... 28

zolpidem tartrate sublingual .............. 28 ZOMIG NASAL SPRAY ....................... 29

ZOMIG ZMT ..................................... 29 ZONEGRAN...................................... 22

zonisamide ...................................... 22 ZORTRESS ...................................... 47

ZOVIRAX CREAM .............................. 56 ZUBSOLV ........................................ 30

ZUPLENZ ......................................... 42 ZYBAN ............................................ 31

ZYCLARA ......................................... 52 ZYDELIG ......................................... 14

ZYFLO ............................................. 49 ZYFLO CR ........................................ 49

ZYLET ............................................. 57

ZYTIGA ........................................... 12

Important Information About Your Health Plan

HMSA doesn’t discriminateWe comply with applicable federal civil rights laws. We don’t discriminate, exclude people, or treat people diff erently because of:

• Race.• Color.• Nati onal origin.• Age.• Disability.• Sex.

Services that HMSA providesTo bett er communicate with people who have disabiliti es or whose primary language isn’t English, HMSA provides free services such as:

• Language services and translati ons.• Text Relay Services.• Informati on writt en in other languages.• Informati on in other formats, such as large print, audio, and accessible digital formats.

If you need these services, please call 1 (800) 776-4672 toll-free.

How to fi le a grievance or complaintIf you believe that we’ve failed to provide these services or discriminated in another way, you can fi le a grievance in any of the following ways:

• Phone: 1 (800) 776-4672 toll-free• Email: [email protected]• Fax: (808) 948-6414 on Oahu• Mail: 818 Keeaumoku St., Honolulu, HI 96814

You can also fi le a civil rights complaint with the U.S. Department of Health and Human Services, Offi ce for Civil Rights, in any of the following ways:

• Online: ocrportal.hhs.gov/ocr/portal/lobby.jsf• Phone: 1 (800) 368-1019 toll-free; TDD users, call 1 (800) 537-7697 toll-free• Mail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W.,

Room 509F, HHH Building, Washington, DC 20201For complaint forms, please go to hhs.gov/ocr/offi ce/fi le/index.html.

1000-6317A 9.16 LEH3832_4036_2025_1157_v2 Accepted

C

English: This notice has important information about your HMSA application or plan benefits. It may also in-clude key dates. You may need to take action by certain dates to keep your health plan or to get help with costs. If you or someone you’re helping has questions about HMSA, you have the right to get this notice and other help in your language at no cost. To talk to an interpret-er, please call 1 (800) 776-4672 toll-free.Ilocano: Daytoy a pakaammo ket naglaon iti napateg nga impormasion maipanggep iti aplikasionyo iti HMSA wenno kadagiti benepisioyo iti plano. Mabalin nga adda pay nairaman a petsa. Mabalin a masapulyo ti manga-ramid iti addang agpatingga kadagiti partikular a petsa tapno agtalinaed kayo iti plano wenno makaala kayo iti tulong kadagiti gastos. No addaan kayo wenno addaan ti maysa a tao a tultu-longanyo iti saludsod maipanggep iti HMSA, karbeng-anyo a maala daytoy a pakaammo ken dadduma pay a tulong iti bukodyo a pagsasao nga awan ti bayadna. Tapno makapatang ti maysa a mangipatarus ti pagsa-sao, tumawag kay koma iti 1 (800) 776-4672 toll-free.Tagalog: Ang abiso na ito ay naglalaman ng mahalagang impormasyon tungkol sa inyong aplikasyon sa HMSA o mga benepisyo sa plano. Maaari ding kasama dito ang mga petsa. Maaaring kailangan ninyong gumawa ng hakbang bago sumapit ang mga partikular na petsa upang mapanatili ninyo ang inyong planong pangkalu-sugan o makakuha ng tulong sa mga gastos. Kung kayo o isang taong tinutulungan ninyo ay may mga tanong tungkol sa HMSA, may karapatan kayong makuha ang abiso na ito at iba pang tulong sa inyong wika nang walang bayad. Upang makipag-usap sa isang tagapagsalin ng wika, mangyaring tumawag sa 1 (800) 776-4672 toll-free.Japanese: 本通知書には、HMSAへの申請や医療給付に関する重要な情報や日付が記載されています。医療保険を利用したり、費用についてサポートを受けるには、本通知書に従って特定の日付に手続きしてください。

患者さん、または付き添いの方がHMSAについて質問がある場合は、母国語で無料で通知を受けとったり、他のサポートを受ける権利があります。通訳を希望する場合は、ダイヤルフリー電話 1 (800) 776-4672 をご利用ください。

Chinese: 本通告包含關於您的 HMSA 申請或計劃福利的重要資訊。也可能包含關鍵日期。您可能需要在某確定日期前採取行動，以維持您的健康計劃或者獲取費用幫助。如果您或您正在幫助的某人對 HMSA 存在疑問，您

有權免費獲得以您母語表述的本通告及其他幫助。如需與口譯員通話，請撥打免費電話 1 (800) 776-4672。Korean: 이 통지서에는 HMSA 신청서 또는 보험 혜택에 대한 중요한 정보가 들어 있으며, 중요한 날짜가 포함되었을 수도 있습니다. 해당 건강보험을 그대로 유지하거나 보상비를 수령하려면 해당 기한 내에 조치를 취하셔야 합니다.신청자 본인 또는 본인의 도움을 받는 누군가가 HMSA에 대해 궁금한 사항이 있으면 본 통지서를 받고 아무런 비용 부담 없이 모국어로 다른 도움을 받을 수 있습니다. 통역사를 이용하려면 수신자 부담 전화 1 (800) 776-4672번으로 연락해 주시기 바랍니다.Spanish: Este aviso contiene información importante sobre su solicitud a HMSA o beneficios del plan. Tam-bién puede incluir fechas clave. Pueda que tenga que tomar medidas antes de determinadas fechas a fin de mantener su plan de salud u obtener ayuda con los gastos. Si usted o alguien a quien le preste ayuda tiene pregun-tas respecto a HMSA, usted tiene el derecho de recibir este aviso y otra ayuda en su idioma, sin ningún costo. Para hablar con un intérprete, llame al número gratuito 1 (800) 776-4672.Vietnamese: Thông báo này có thông tin quan trọng về đơn đăng ký HMSA hoặc phúc lợi chương trình của quý vị. Thông báo cũng có thể bao gồm những ngày quan trọng. Quý vị có thể cần hành động trước một số ngày để duy trì chương trình bảo hiểm sức khỏe của mình hoặc được giúp đỡ có tính phí. Nếu quý vị hoặc người quý vị đang giúp đỡ có thắc mắc về HMSA, quý vị có quyền nhận thông báo này và trợ giúp khác bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, vui lòng gọi số miễn cước 1 (800) 776-4672.Samoan - Fa’asamoa: O lenei fa’aliga tāua e fa’atatau i lau tusi talosaga ma fa’amanuiaga ‘e te ono agava’a ai, pe’ā fa’amanuiaina ‘oe i le polokalame o le HMSA. E aofia ai fo’i i lalo o lenei fa’aliga ia aso tāua. E ono ma-na’omia ‘oe e fa’atinoina ni galuega e fa’atonuina ai ‘oe i totonu o le taimi fa’atulagaina, ina ‘ia e agava’a ai pea mo fa’amanuiaga i le polokalame soifua maloloina ‘ua fa’ata’atia po’o se fesoasoani fo’i mo le totogi’ina. Afai e iai ni fesili e fa’atatau i le HMSA, e iai lou aiātatau e te talosaga ai e maua lenei fa’aliga i lau gagana e aunoa ma se totogi. A mana’omia le feasoasoani a se fa’aliliu ‘upu, fa’amolemole fa’afeso’ota’i le numera 1 (800) 776-4672 e leai se totogi o lenei ‘au’aunaga.

Marshallese: Kojella in ej boktok jet melele ko reaurok kin application ak jipan ko jen HMSA bwilan ne am. Emaron bar kwalok jet raan ko reaurok bwe kwon jela. Komaron aikiuj kommane jet bunten ne ko mokta jen detlain ko aer bwe kwon jab tum jen health bwilan en am ak bok jipan kin wonaan takto. Ne ewor kajjitok kin HMSA, jen kwe ak juon eo kwoj jipane, ewor am jimwe im maron nan am ba ren ukot kojjella in kab melele ko kin jipan ko jet nan kajin ne am ilo ejjelok wonaan. Bwe kwon kenono ippan juon ri-ukok, jouj im calle 1 (800) 776-4672 tollfree, enaj ejjelok wonaan.Trukese: Ei esinesin a kawor auchean porausen omw HMSA apilikeison me/ika omw kewe plan benefit. A pwan pachanong porausen ekoch ran mei auchea ngeni omw ei plan Ina epwe pwan auchea omw kopwe fori ekoch fofor me mwen ekei ran (mei pachanong) pwe omw health plan esap kouno, are/ika ren omw kopwe angei aninisin monien omw ei plan. Ika a wor omw kapas eis usun HMSA, ka tongeni tun-goren aninis, iwe ka pwan tongeni tungoren ar repwe ngonuk eche kapin ei taropwe mei translatini non kapasen fonuom, ese kamo. Ika ka mwochen kapas ngeni emon chon chiakku, kosemochen kopwe kori 1 (800) 776-4672, ese kamo.Hawaiian: He ʻike koʻikoʻi ko kēia hoʻolaha pili i kou ʻinikua a i ʻole palapala noi ʻinikua HMSA. Aia paha he mau lā koʻikoʻi ma kēia hoʻolaha. Pono paha ʻoe e hana i kekahi mea ma mua o kekahi lā no ka hoʻomau i kou ʻinikua a i ʻole ka ʻimi kōkua me ka uku. Inā he mau nīnau kou no HMSA, he kuleana ko mākou no ka hāʻawi manuahi i kēia hoʻolaha a me nā kōkua ʻē aʻe ma kou ʻōlelo ponoʻī. No ke kamaʻilio me kekahi mea unuhi, e kelepona manuahi iā 1 (800) 776-4672.Micronesian - Pohnpeian: Kisin likou en pakair wet audaudki ire kesempwal me pid sapwelimwomwi aplika-sin en HMSA de koasoandihn sawas en kapai kan. E pil kak audaudki rahn me pahn kesemwpwal ieng komwi. Komw pahn kakete anahne wia kemwekid ni rahn akan me koasoandi kan pwe komwi en kak kolokol sawas en roson mwahu de pil ale pweinen sawas pwukat. Ma komwi de emen aramas tohrohr me komw sewese ahniki kalelapak me pid duwen HMSA, komw ahniki pwuhng en ale pakair wet oh sawas teikan ni sapwel-imwomwi mahsen ni soh isepe. Ma komw men mahse-nieng souhn kawehwe, menlau eker telepohn 1 (800) 776-4672 ni soh isepe.

Bisayan - Visayan: Kini nga pahibalo adunay importan-teng impormasyon mahitungod sa imong aplikasyon sa HMSA o mga benepisyo sa plano. Mahimo sab nga aduna kini mga importanteng petsa. Mahimong kinah-anglan kang magbuhat og aksyon sa mga partikular nga petsa aron mapabilin ang imong plano sa panglawas o aron mangayo og tabang sa mga gastos. Kung ikaw o ang usa ka tawo nga imong gitabangan adunay mga pangutana mahitungod sa HMSA, aduna kay katungod nga kuhaon kini nga pahibalo ug ang uban pang tabang sa imong lengguwahe nga walay bayad. Aron makig-istorya sa usa ka tighubad, palihug tawag sa 1 (800) 776-4672 nga walay toll.Tongan - Fakatonga: Ko e fakatokanga mahu’inga eni fekau’aki mo ho’o kole ki he HMSA pe palani penefití. ‘E malava ke hā ai ha ngaahi ‘aho ‘oku mahu’inga. ‘E i ai e ngaahi ‘aho pau ‘e fiema’u ke ke fai e ‘ū me’a ‘uhiā ko ho’o palani mo’ui leleí pe ko ho’o ma’u ha tokoni fekau’aki mo e totongí. Kapau ‘oku ‘i ai ha’o fehu’i pe ha fehu’i ha’a taha ‘oku ke tokonia fekau’aki mo e HMSA, ‘oku totonu ke ke ma’u e fakatokanga ko ení pe ha toe tokoni pē ‘i ho’o lea faka-fonuá ta’e totongi. Ke talanoa ki ha taha fakatonulea, kātaki tā ta’etotongi ki he 1 (800) 776-4672.Laotian: ແຈງການສະບບນມຂມນທສາຄນກຽວກບການສະມກ HMSAຂອງທານ ຫແຜນຜນປະໂຫຍດຈາກ HMSA. ອາດມຂມນກຽວກບວນທທສຳຄນ. ທານອາດຕອງໄດດາເນນການໃນວນທໃດໜງເພອຮກສາແຜນສຂະພາບຂອງທານ ຫຮບການຊວຍເຫອຄາຮກສາ. ຖາຫາກທານ ຫຜທທານຊວຍເຫອມຄາຖາມກຽວກບ HMSA, ທານມສດທຈະໄດຮບແຈງການສະບບນ ແລະການຊວຍເຫອອນໆເປນພາສາຂອງທານໂດຍບຕອງເສຍຄາ. ເພອໂທຫານາຍແປພາສາ, ກະລນາໂທໄປ 1 (800) 776-4672 ໂດຍບເສຍຄາ.

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