pebtf 2014 (effective april 1)

PEBTF 2014 (Effective April 1)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol inj 500mg (generic of ALOPRIM)

1

allopurinol tab (generic of ZYLOPRIM)

1

colchicine w/ probenecid 1

COLCRYS QL (120 tabs / 30 days)

2 QL

probenecid 1

ULORIC 2 ST

MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 3

VIMOVO 2

NSAIDS CELEBREX 2

diclofenac potassium (generic of CATAFLAM)

1

diclofenac sodium (generic of VOLTAREN-XR) TB24

1

diclofenac sodium TBEC 1

diflunisal 1

etodolac CAPS; TABS 1

etodolac er 1

fenoprofen calcium 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 7.5 MG/5ML

1

meloxicam tabs (generic of MOBIC)

1

nabumetone TABS 1

NALFON 3

NAPRELAN 3

naproxen (generic of NAPROSYN) SUSP; TABS

1

Drug Name Drug Tier

Requirements/Limits

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

sulindac TABS 1

tolmetin sodium 1

ZIPSOR 3

ZORVOLEX 3 NM

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS


1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS


1 QL

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 5mcg/hr QL (16 ea / 28 days)

3 QL


3 QL


3 QL NM


3 QL

capital and codeine QL (5000mL / 30 days)

3 QL

co-gesic 5-500mg QL (240 tabs / 30 days)

1 QL



2

Drug Name Drug Tier

Requirements/Limits

CONZIP 100mg QL (90 caps / 30 days)

3 QL


3 QL


3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 5-500mg


1 QL

hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of HYCET)

QL (5400mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL



1 QL

hydrocodone-acetaminophen 7.5-500mg/15ml

QL (3600 mL / 30 days)

1 QL



1 QL



1 QL

hydrocodone-acetaminophen 10-300mg (generic of XODOL)


1 QL



1 QL

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)


1 QL

hydrocodone-ibuprofen 2.5-200mg (generic of REPREXAIN)


1 QL

hydrocodone-ibuprofen 7.5-200mg (generic of VICOPROFEN)


1 QL

ibudone tab 5-200mg (generic of REPREXAIN)


1 QL

lortab elx 10-300mg QL (6000 mL / 30 days)

3 QL NM

reprexain 10/200 QL (150 tabs / 30 days)

1 QL

stagesic 500-5mg QL (240 caps / 30 days)

1 QL

SYNALGOS-DC QL (360 caps / 30 days)

3 QL

tramadol hcl er (generic of ULTRAM ER) TB24 100mg


1 QL

tramadol hcl er (generic of ULTRAM ER) TB24 200mg


1 QL

TRAMADOL HCL ER TB24 300mg


1 QL

tramadol hcl er (biphasic) 100mg


1 QL



1 QL



3

Drug Name Drug Tier

Requirements/Limits



1 QL

tramadol hcl tab 50 mg (generic of ULTRAM)


1 QL

tramadol-acetaminophen (generic of ULTRACET)


1 QL

vicodin (generic of XODOL) QL (400 tabs / 30 days)

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

zamicet QL (5400mL / 30 days)

3 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 ea / 30 days) 3 QL NM PA

AVINZA QL (60 ea / 30 days)

2 QL

CODEINE SULFATE TABS 1

DILAUDID-HP INJ 3 B/D

DURAMORPH 1 B/D

endocet 5/325 (generic of PERCOCET)


1 QL

endocet 7.5/325 (generic of PERCOCET)


1 QL

endocet 10/325 (generic of PERCOCET)


1 QL

ENDODAN QL (360 tabs / 30 days)

1 QL

EXALGO 8mg, 12mg QL (60 tabs / 30 days)

2 QL

EXALGO 16mg, 32mg QL (60 tabs / 30 days)

2 QL NM

fentanyl citrate LPOP 200mcg

QL (120 lpop / 30 days)

1 QL NM PA

Drug Name Drug Tier

Requirements/Limits

fentanyl citrate (generic of ACTIQ) LPOP 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg

QL (120 lpop / 30 days)

1 QL NM PA

fentanyl patch (generic of DURAGESIC)

QL (10 ptch / 30 days)

1 QL

FENTORA QL (120 tabs / 30 days)

2 QL NM PA

hydromorphone hcl (generic of DILAUDID) LIQD

1

hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS

1

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN QL (60 caps / 30 days)

2 QL

LAZANDA QL (30 bottles / 30 days)

2 QL NM PA

levorphanol tartrate TABS 1

methadone hcl (generic of METHADOSE) CONC

1

methadone hcl SOLN 1

methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg

QL (60 ea / 30 days)

1 QL NM

morphine sulfate CP24 30mg, 50mg, 60mg, 80mg, 100mg


1 QL NM

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

1



4

Drug Name Drug Tier

Requirements/Limits

MORPHINE SULFATE TABS


1 QL

morphine sulfate beads cap sr (generic of AVINZA)


1 QL

morphine sulfate ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg


1 QL

morphine sulfate ext-rel tab (generic of MS CONTIN) 200mg


1 QL

MORPHINE SULFATE INJ 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 15mg/ml

1 B/D

morphine sulfate inj .5mg/ml, 1mg/ml

1 B/D

NUCYNTA 2

NUCYNTA ER 50mg, 100mg

QL (120 ea / 30 days)

2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

OPANA ER (CRUSH RESISTANT


2 QL

OXECTA 3

OXYCODONE HCL CAPS QL (180 caps / 30 days)

1 QL

OXYCODONE HCL CONC 1

OXYCODONE HCL SOLN 1

oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg


1 QL

oxycodone hcl TABS 10mg, 20mg


1 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


1 QL

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 5-500mg

QL (240 caps / 30 days)

1 QL



1 QL



1 QL



1 QL



1 QL

oxycodone-aspirin (generic of PERCODAN)


1 QL

oxycodone-ibuprofen QL (28 tabs / 30 days)

1 QL

OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS

1

roxicet soln QL (1800mL / 30 days)

2 QL

roxicet tab 5-325mg (generic of PERCOCET)


1 QL NM

SUBSYS QL (120 ea / 30 days)

3 QL NM PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%

1

lidocaine hcl (local anesth.) (generic of XYLOCAINE) .5%

1 B/D



5

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE) 1%

1 B/D

lidocaine inj 1% (generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of XYLOCAINE-MPF) 2%

1 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 3 B/D NM

gentamicin in saline 0.9mg/ml 1

gentamicin in saline 1.4mg/ml 1

gentamicin in saline 60mg 1



gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI NEB 2 B/D NM

TOBI PODHALER 3 NM PA

tobramycin (generic of TOBI) NEBU

1 B/D NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 2

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 3

ALINIA SUSR QL (9 bottles / 30 days)

2 QL

ALINIA TABS QL (20 tabs / 30 days)

2 QL

AZACTAM 2gm 3

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3 NM

aztreonam (generic of AZACTAM)

1

BILTRICIDE 2

Drug Name Drug Tier

Requirements/Limits

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

CUBICIN 3 B/D NM

dapsone TABS 1

DARAPRIM 3

DORIBAX 3

erythromycin-sulfisoxazole 1

FLAGYL CAPS 3

FLAGYL ER 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

MACRODANTIN 25mg 2

MEPRON 3 NM

meropenem (generic of MERREM)

1

methenamine hippurate (generic of HIPREX)

1

METRO IV 2

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

1

nitrofurantoin macrocrystal (generic of MACRODANTIN)

1

nitrofurantoin monohyd macro (generic of MACROBID)

1



6

Drug Name Drug Tier

Requirements/Limits

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMSOL SOL 50MG/5ML 3

STROMECTOL 3

sulfamethoxazole-trimethoprim SUSP

1

sulfamethoxazole-trimethoprim (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethoprim (generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3 NM

trimethoprim TABS 1

TYGACIL 3 NM

vancomycin hcl (generic of VANCOCIN HCL) CAPS

1 NM

vancomycin hcl SOLR 1 B/D

VIBATIV 3

XIFAXAN TAB 200MG 3 NM

ZYVOX SOLN 3 NM

ZYVOX SUSR; TABS 2 NM

ANTIFUNGALS ABELCET 3 B/D NM

AMBISOME 3 B/D NM

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

CANCIDAS 3 NM

ERAXIS 3 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole in nacl 100mg 1



flucytosine (generic of ANCOBON) CAPS

1 NM

griseofulvin microsize SUSP 1

griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

Drug Name Drug Tier

Requirements/Limits

ketoconazole TABS 1

LAMISIL PACK 3

MYCAMINE 50mg 3

MYCAMINE 100mg 3 NM

NOXAFIL SUSP; TBEC 3 NM

nystatin TABS 1

ONMEL 3 PA

SPORANOX SOL 10MG/ML 3 NM

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

1 QL

VFEND SUS 40MG/ML 2 NM

voriconazole (generic of VFEND) SUSR; TABS

1 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 2

quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 3 NM

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 2 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

FUZEON 2 NM

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 2 NM

INVIRASE CAPS 3



7

Drug Name Drug Tier

Requirements/Limits

INVIRASE TABS 3 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 2 NM

ISENTRESS TABS 2 NM

lamivudine (generic of EPIVIR) 150mg, 300mg

1

LEXIVA SUSP 3

LEXIVA TABS 3 NM

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

NORVIR 2

PREZISTA SUSP 2 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

2 NM

RESCRIPTOR 2

RETROVIR IV INFUSION 2

REYATAZ 100mg 2

REYATAZ 150mg, 200mg, 300mg

2 NM

SELZENTRY 3 NM

stavudine (generic of ZERIT) 1

SUSTIVA 2

TIVICAY 3 NM

VIDEX PEDIATRIC 3

VIRACEPT 3 NM

VIRAMUNE SUSP 2

VIRAMUNE XR 2

VIREAD 2 NM

ZIAGEN SOLN 3

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

1 NM

ATRIPLA 2 NM

COMPLERA 3 NM

EPZICOM 3 NM

KALETRA SOL 2 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 2 NM

Drug Name Drug Tier

Requirements/Limits

lamivudine-zidovudine (generic of COMBIVIR)

1 NM

STRIBILD 3 NM

TRIZIVIR 3 NM

TRUVADA 2 NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3 NM

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

MYCOBUTIN 3

paser d/r 2

PRIFTIN 3

pyrazinamide 1

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

seromycin 3

SIRTURO 3 NM LA PA

TRECATOR 3

ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium 1 B/D

adefovir dipivoxil (generic of HEPSERA)

1 NM ST

BARACLUDE SOLN 2

BARACLUDE TABS 2 NM

cidofovir (generic of VISTIDE) 1

EPIVIR HBV 2

famciclovir (generic of FAMVIR)

1

foscarnet sodium 1

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HEPSERA 3 NM ST

INCIVEK TAB 375MG 2 NM PA

lamivudine (generic of EPIVIR HBV) 100mg

1 NM

moderiba pak 3 NM PA

moderiba tab 200mg (generic of COPEGUS)

1 NM PA

REBETOL SOL 40MG/ML 2 NM PA



8

Drug Name Drug Tier

Requirements/Limits

RELENZA DISKHALER 2

ribapak mis 600/day 3 NM PA

ribasphere (generic of REBETOL) CAPS

1 NM PA

ribasphere (generic of COPEGUS) TABS 200mg

1 NM PA

ribasphere TABS 400mg, 600mg

1 NM PA

ribasphere ribapak 800 3 NM PA



ribavirin cap 200mg (generic of REBETOL)

1 NM PA

ribavirin tab 200mg (generic of COPEGUS)

1 NM PA

rimantadine hydrochloride (generic of FLUMADINE)

1

TAMIFLU 2

TYZEKA 3 NM

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 2 NM

VICTRELIS CAP 200MG 2 NM PA

CEPHALOSPORINS CEDAX 3

cefaclor 1

cefaclor monohydrate 2

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 2

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefotaxime sodium (generic of CLAFORAN)

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

Drug Name Drug Tier

Requirements/Limits

ceftazidime (generic of FORTAZ) 1gm, 2gm, 6gm

1

CEFTAZIDIME/DEXTROSE 2

ceftibuten 1 NM

CEFTIN SUSR 3

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg

1

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm, 500mg

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1

cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium 7.5mg soln

1

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

FORTAZ SOLN 3

FORTAZ SOLR 2gm, 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2

suprax TABS 2

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZINACEF SOLR 750mg 3 NM

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR 500mg

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

clarithromycin SUSR 125mg/5ml

1



9

Drug Name Drug Tier

Requirements/Limits

clarithromycin (generic of BIAXIN) SUSR 250mg/5ml

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 2 NM ST

e.e.s. 1

E.E.S. GRANULES 3

ery-tab 2

ERYPED 200 3

ERYPED 400 2

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin ethylsuccinate 1

PCE 3

ZMAX 2

FLUOROQUINOLONES AVELOX SOLN 3

AVELOX TABS 2

AVELOX ABC PACK 2

CIPRO SUSR 2

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg

1

ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)

1

ciprofloxacn inj 1

FACTIVE 3

levofloxacin SOLN 25mg/ml 1

levofloxacin (generic of LEVAQUIN) SOLN 25mg/ml

1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w (generic of LEVAQUIN)

1

NOROXIN 3

PENICILLINS

Drug Name Drug Tier

Requirements/Limits

amoxicillin 1

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin 1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin inj 1

ampicillin sodium 1

AUGMENTIN SUSR 3

BACTOCILL IN DEXTROSE 3

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

MOXATAG 3

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 1 NM

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 1 NM

PENICILLIN G POT IN DEXTROSE

3



10

Drug Name Drug Tier

Requirements/Limits

PENICILLIN G POTASSIUM SOLN

3

penicillin g potassium SOLR 1

penicillin g procaine 2

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

TIMENTIN 3

TIMENTIN INJ 3.1GM 3

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

DORYX 3

doxycycline (monohydrate) CAPS 50mg

1

doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA PAK 1/150) TABS 150mg

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate TBEC 75mg, 100mg

1

doxycycline hyclate (generic of DORYX) TBEC 150mg

1

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

Drug Name Drug Tier

Requirements/Limits

SOLODYN 3 NM

TETRACYCLINE HCL CAPS

1 NM

VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D

BUSULFEX 3 B/D

CEENU 2

cyclophosphamide SOLR; TABS

1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2

HEXALEN 2 NM

IFEX INJ 3GM 3 B/D

ifosfamide (generic of IFOSFAMIDE) SOLN

1 B/D

ifosfamide (generic of IFEX) SOLR

1 B/D

IFOSFAMIDE FOR INJ 3 GM 3 B/D NM

LEUKERAN 2

LOMUSTINE 1 NM

melphalan hcl (generic of ALKERAN)

1 B/D NM

MUSTARGEN 3 B/D

thiotepa SOLR 3 B/D

TREANDA 3 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES adriamycin 20mg 1 B/D

adriamycin inj 2mg/ml 1 B/D

daunorubicin hcl INJ 1 B/D

daunorubicin hcl (generic of CERUBIDINE) SOLR

1 B/D

DOXIL 3 B/D NM

doxorubicin hcl SOLN 1 B/D

doxorubicin hcl SOLR 50mg 1 B/D

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml (generic of DOXIL)

1 B/D NM

EPIRUBICIN INJ 50MG 3 B/D

epirubicin inj 50mg/25ml (generic of ELLENCE)

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

1 B/D NM



11

Drug Name Drug Tier

Requirements/Limits

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D NM

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D NM

ARRANON 3 B/D

azacitidine (generic of VIDAZA)

1 B/D NM

cladribine 1 B/D NM

CLOLAR 3 B/D

cytarabine inj 1 B/D

DACOGEN 3 B/D NM

decitabine (generic of DACOGEN)

1 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 3 B/D NM

gemcitabine hcl (generic of GEMZAR) 1gm, 200mg

1 B/D NM

gemcitabine hcl 2gm 1 B/D NM

mercaptopurine (generic of PURINETHOL) TABS

1

methotrexate sodium inj 1 B/D

pentostatin (generic of NIPENT)

1 B/D NM

TABLOID 2

VIDAZA 3 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM

DOCETAXEL CONC 20mg/0.5ml

3 B/D NM

DOCETAXEL CONC 20mg/ml, 80mg/4ml

1 B/D NM

docetaxel CONC 140mg/7ml 3 B/D NM

DOCETAXEL SOLN 80mg/8ml

3 B/D NM

paclitaxel 1 B/D

TAXOTERE 3 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLR 2 B/D

vincasar 1 B/D

Drug Name Drug Tier

Requirements/Limits

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 3 B/D NM

ERBITUX 3 B/D NM

ERIVEDGE 3 NM LA PA

HERCEPTIN 3 B/D NM

ISTODAX 3 B/D NM

KADCYLA 3 B/D NM

PROLEUKIN 3 B/D NM

RITUXAN 3 NM PA

TORISEL 3 B/D NM

VECTIBIX 3 B/D NM

VELCADE 3 B/D NM

ZOLINZA 2 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARZERRA 3 B/D NM

bicalutamide (generic of CASODEX)

1

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD 3 B/D NM

exemestane (generic of AROMASIN)

1 ST

FARESTON 2 NM

FASLODEX 2 B/D NM

FIRMAGON 3 B/D NM

flutamide 1

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPR DEP-PED INJ 11.25MG (3-MONTH)

2 NM PA

LUPR DEP-PED INJ 30MG (3-MONTH)

2 NM PA

LUPRON DEPOT 3.75mg, 7.5mg, 11.25mg

2 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

2 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

2 NM PA

LUPRON DEPOT-PED 2 NM PA

LYSODREN 2

MEGACE ES 2



12

Drug Name Drug Tier

Requirements/Limits

megestrol acetate (generic of MEGACE ORAL) SUSP

1

megestrol acetate TABS 1

NILANDRON 2 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR DEPOT MIXJECT

2 NM PA

TRELSTAR LA MIXJECT 2 NM PA

TRELSTAR MIXJECT 2 NM PA

XTANDI 3 NM LA PA

ZYTIGA 3 NM PA

KINASE INHIBITORS AFINITOR 2 NM PA

AFINITOR DISPERZ 2 NM PA

BOSULIF 3 NM PA

CAPRELSA 3 NM LA PA

COMETRIQ 3 NM PA

GILOTRIF 3 NM PA

GLEEVEC 2 NM PA

ICLUSIG 3 NM LA PA

IMBRUVICA 3 NM PA

INLYTA 3 NM LA PA

IRESSA 3 NM

JAKAFI 3 NM LA PA

MEKINIST 3 NM PA

NEXAVAR 2 NM LA PA

SPRYCEL 2 NM PA

STIVARGA 3 NM LA PA

SUTENT 2 NM PA

TAFINLAR 3 NM PA

TARCEVA 2 NM PA

TASIGNA 2 NM PA

TYKERB 2 NM LA PA

VOTRIENT 2 NM PA

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

MISCELLANEOUS DROXIA 2

HALAVEN 3 B/D NM

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 3 B/D NM

MATULANE 2 NM

mitoxantrone hcl 1 B/D NM

POMALYST CAP 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

SYLATRON 2 NM PA

TARGRETIN CAPS 2 NM PA

tretinoin CAPS 1 NM

TRISENOX 3 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin SOLN 1 B/D

cisplatin 1 B/D

ELOXATIN 3 B/D NM

oxaliplatin 1 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

1 B/D NM

dexrazoxane (generic of ZINECARD)

1 B/D NM

ELITEK 3 B/D NM

KEPIVANCE 3 B/D NM

leucovor ca inj 1 B/D

leucovorin calcium SOLN; SOLR

1 B/D

leucovorin calcium TABS 1

mesna (generic of MESNEX) 1 B/D

MESNEX TABS 3 NM

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml

1 B/D NM

irinotecan hcl 500mg/25ml 1 B/D NM

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

1 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1



13

Drug Name Drug Tier

Requirements/Limits

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

moexipril-hydrochlorothiazide 1

moexipril-hydrochlorothiazide (generic of UNIRETIC)

1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

ACE INHIBITORS benazepril hcl TABS 5mg 1

benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

1

moexipril hcl (generic of UNIVASC)

1

perindopril erbumine 2mg 1

perindopril erbumine (generic of ACEON) 4mg, 8mg

1

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA)

1 PA

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS

Drug Name Drug Tier

Requirements/Limits

doxazosin mesylate (generic of CARDURA)

1

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

EXFORGE 2

EXFORGE HCT 2

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan potassium & hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 2

telmisartan-amlodipine (generic of TWYNSTA)

1 NM

TEVETEN HCT 3

TRIBENZOR 2

TWYNSTA 3

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3

BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

DIOVAN 2

EDARBI 3

eprosartan mesylate (generic of TEVETEN)

1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 2

TELMISARTAN 1 NM

TEVETEN 400mg 3

ANTIARRHYTHMICS



14

Drug Name Drug Tier

Requirements/Limits

amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg

1 NM

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone hcl TABS 400mg

1

amiodarone inj 50mg/ml 1

disopyramide phosphate (generic of NORPACE)

1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE CR 2

pacerone 100mg, 400mg 1 NM

pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl (generic of RYTHMOL) TABS 150mg, 225mg

1

propafenone hcl TABS 300mg

1

quinidine gluconate er 1

quinidine sulfate 1

sorine (generic of BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of BETAPACE) 80mg, 160mg

1

sotalol hcl (generic of BETAPACE) 120mg

1 NM

sotalol hcl 240mg 1

sotalol hcl (afib/afl) (generic of BETAPACE AF)

1

TIKOSYN CAP 125MCG 2 NM PA



ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic of LIPITOR)

1

Drug Name Drug Tier

Requirements/Limits

CRESTOR 2

fluvastatin sodium (generic of LESCOL)

1

LESCOL XL 2

LIVALO 3

lovastatin 10mg 1

lovastatin (generic of MEVACOR) 20mg, 40mg

1

pravastatin sodium 10mg 1

pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg

1

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 30mg, 90mg 2 NM

cholestyramine (generic of QUESTRAN)

1

cholestyramine light 1

choline fenofibrate (generic of TRILIPIX)

1

colestipol hcl (generic of COLESTID)

1

fenofibrate (generic of TRICOR) 48mg, 145mg

1

fenofibrate (generic of LOFIBRA) 54mg, 160mg

1

FENOFIBRATE MICRONIZED 43mg, 130mg

1

fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1

FENOGLIDE 3

gemfibrozil (generic of LOPID) TABS

1

LIPOFEN 2

LIPTRUZET 3 NM

LOVAZA 2

niacin (antihyperlipidemic) (generic of NIASPAN)

1 NM

niacor 1



15

Drug Name Drug Tier

Requirements/Limits

NIASPAN 2

prevalite (generic of QUESTRAN LIGHT)

1

SIMCOR 2

TRIGLIDE 3

TRILIPIX 2

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

DUTOPROL 3 NM

metoprolol & hctz tab 50-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG CR 2

labetalol hcl SOLN 1

Drug Name Drug Tier

Requirements/Limits

labetalol hcl (generic of TRANDATE) TABS 100mg, 200mg

1

labetalol hcl TABS 300mg 1

LEVATOL 3

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate (generic of LOPRESSOR) SOLN

1

metoprolol tartrate TABS 25mg

1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CARDIZEM LA 120mg 3

cartia xt (generic of CARDIZEM CD)

1

dilt-cd (generic of CARDIZEM CD)

1

dilt-xr 120mg, 180mg 1

dilt-xr (generic of DILACOR XR) 240mg

1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl SOLN 1

diltiazem hcl SOLR 3



16

Drug Name Drug Tier

Requirements/Limits

diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltzac (generic of TIAZAC) 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifediac (generic of ADALAT CC)

1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 1

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NYMALIZE 3 NM

taztia xt (generic of TIAZAC) 1

verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg, 300mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

verapamil hcl (generic of CALAN) TABS 80mg, 120mg

1

verapamil hcl (generic of CALAN SR) TBCR

1

DIGITALIS GLYCOSIDES

Drug Name Drug Tier

Requirements/Limits

digoxin (generic of LANOXIN) 1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN TABS 2

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE 2

TEKAMLO 2

TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DIURIL SUS 250/5ML 2

DYRENIUM 3

EDECRIN 3

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 1

furosemide oral soln 8 mg/ml 1

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone (generic of ZAROXOLYN) 2.5mg, 5mg

1

metolazone 10mg 1



17

Drug Name Drug Tier

Requirements/Limits

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 1

torsemide tabs (generic of DEMADEX)

1

triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)

1

triamterene & hydrochlorothiazide cap 50-25 mg

1

triamterene & hydrochlorothiazide tab 37.5-25 mg (generic of MAXZIDE-25)

1

triamterene & hydrochlorothiazide tab 75-50 mg (generic of MAXZIDE)

1

MISCELLANEOUS BIDIL 2

clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr

1


1


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 0.1/15 1

clorpres 0.2/15 1

clorpres 0.3/15 1

DEMSER 3 NM

DIBENZYLINE 3

guanfacine hcl (generic of TENEX)

1 NM PA

hydralazine hcl 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 2

Drug Name Drug Tier

Requirements/Limits

isosorbide dinitrate (generic of ISORDIL TITRADOSE) TABS 5mg

1

isosorbide dinitrate TABS 10mg, 20mg, 30mg

1

isosorbide dinitrate TBCR 1

isosorbide dinitrate sl tab 2.5 mg

1

isosorbide mononitrate TABS

1

isosorbide mononitrate (generic of IMDUR) TB24

1

minitran (generic of NITRO-DUR)

1

nitro-bid 2

NITRO-DUR .3mg/hr, .8mg/hr

2

NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 2

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 2 NM PA

ADEMPAS 3 NM PA

LETAIRIS 2 NM LA PA

OPSUMIT 3 NM PA

REMODULIN 2 B/D NM LA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO)

1 NM PA

TRACLEER 2 NM LA PA

VENTAVIS 2 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 ml / 30 days) 1 QL

alprazolam (generic of XANAX) TABS 1mg


1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL



18

Drug Name Drug Tier

Requirements/Limits

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of XANAX) TABS .25mg


1 QL

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er (generic of LUVOX CR)

1

fluvoxamine tabs 1

lorazepam CONC QL (150 mls / 30 days)

1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

ANTICONVULSANTS BANZEL SUSP 3 NM

BANZEL TABS 200mg 3

BANZEL TABS 400mg 3 NM

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg QL (600 tabs / 30 days)

1 QL

clonazepam TBDP 2mg QL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mg QL (1200 tabs / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits


1 QL


1 QL

clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg


1 QL PA

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL PA

diazepam CONC QL (240 ml / 30 days)

1 QL PA

diazepam SOLN QL (1200mL / 30 days)

1 QL PA

diazepam (generic of VALIUM) TABS


1 QL PA

DIAZEPAM GEL 1

diazepam inj 1

dilantin CAPS; CHEW 2

DILANTIN SUSP 2

divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

1 NM

felbamate (generic of FELBATOL) TABS 400mg

1

felbamate (generic of FELBATOL) TABS 600mg

1 NM

FYCOMPA 3 PA

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



19

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160mL / 30 days)

1 QL

gabapentin (generic of NEURONTIN) TABS 600mg


1 QL

gabapentin (generic of NEURONTIN) TABS 800mg


1 QL

GABITRIL 12mg, 16mg 2

LAMICTAL ODT 2

LAMICTAL STARTER 2

LAMICTAL XR KIT 2

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

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


2 QL

LYRICA CAPS 200mg QL (90 caps / 30 days)

2 QL

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946mL / 30 days)

2 QL

ONFI 3 PA

ONFI SUS 2.5MG/ML 3 NM PA

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 3 NM

PEGANONE 3

phenobarbital ELIX; TABS 1

Drug Name Drug Tier

Requirements/Limits

PHENOBARBITAL SODIUM 65mg/ml

1

phenobarbital sodium 130mg/ml

1

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

1

POTIGA 3

primidone (generic of MYSOLINE) TABS

1

SABRIL 2 NM LA PA

STAVZOR 3

TEGRETOL 2

TEGRETOL-XR 2

tiagabine hcl (generic of GABITRIL)

1

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

topiramate (generic of TOPAMAX) TABS

1

TRILEPTAL SUSP 2

TROKENDI XR 3 NM

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT 2

zonisamide (generic of ZONEGRAN) 25mg, 100mg

1

zonisamide 50mg 1

ANTIDEMENTIA ARICEPT 23mg 2

donepezil odt 5mg (generic of ARICEPT ODT)

1



20

Drug Name Drug Tier

Requirements/Limits

donepezil odt 10mg (generic of ARICEPT ODT)

1

donepezil tab hcl 23mg (generic of ARICEPT)

1 NM

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON SOLN 3

EXELON PATCHES 2

galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide (generic of RAZADYNE) SOLN; TABS

1

NAMENDA 2

NAMENDA TITRATION PAK 2

NAMENDA XR 2

NAMENDA XR TITRATION PACK

2

rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS 1

amoxapine 1

APLENZIN 3

BRINTELLIX 5mg QL (120 tabs / 30 days)

3 QL NM


3 QL NM


3 QL NM

budeprion (generic of WELLBUTRIN SR)

1

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

1

Drug Name Drug Tier

Requirements/Limits

CYMBALTA 2

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC 1

duloxetine hcl (generic of CYMBALTA)

1 NM

EMSAM 3 PA

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 20mg QL (180 ea / 30 days)

3 QL NM

FETZIMA 40mg QL (90 ea / 30 days)

3 QL NM

FETZIMA 80mg, 120mg QL (30 ea / 30 days)

3 QL NM

FETZIMA TITRATION PACK 3 NM

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl (generic of TOFRANIL) TABS

1

imipramine pamoate (generic of TOFRANIL-PM)

1

maprotiline hcl 1

MARPLAN 2

mirtazapine TABS 7.5mg 1

mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

nefazodone hcl 1

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

OLEPTRO 3

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl (generic of PAXIL)

1



21

Drug Name Drug Tier

Requirements/Limits

PAXIL SUSP 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl (generic of VIVACTIL)

1

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3 NM

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

trimipramine maleate 1

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1 NM

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 2 NM LA PA

AZILECT 2

benztropine mesylate (generic of COGENTIN) SOLN

1

benztropine mesylate TABS 1

bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

1

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACA

1


1


1


1

Drug Name Drug Tier

Requirements/Limits


1


1

entacapone (generic of COMTAN)

1

LODOSYN 3

MIRAPEX .75mg 3

MIRAPEX ER 3

NEUPRO 2

PARLODEL CAPS 2

pramipexole dihydrochloride .75mg

1

pramipexole dihydrochloride (generic of MIRAPEX) .125mg, .25mg, .5mg, 1mg, 1.5mg

1

ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

trihexyphenidyl hcl 1 NM PA

ZELAPAR 3

ANTIPSYCHOTICS ABILIFY SOLN 2 NM

ABILIFY TABS 2mg, 5mg, 10mg, 15mg

2

ABILIFY TABS 20mg, 30mg 2 NM

ABILIFY DISCMELT 2 NM

ABILIFY INJ 2

ABILIFY MAINTENA 3 NM

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

CLOZAPINE ODT 1 PA

clozapine tab (generic of CLOZARIL) 25mg, 100mg

1

clozapine tab 50mg, 200mg 1

FANAPT 3 ST

FANAPT TITRATION PACK 3 ST

FAZACLO 3 PA

fluphenazine decanoate SOLN

1



22

Drug Name Drug Tier

Requirements/Limits

fluphenazine hcl 1

GEODON INJ 3

haloperidol TABS 1

haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml

1

haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml

1

haloperidol lactate CONC 1

haloperidol lactate (generic of HALDOL) SOLN

1

INVEGA 3

INVEGA SUSTENNA 39mg/0.25ml, 78mg/0.5ml

3

INVEGA SUSTENNA 117mg/0.75ml, 156mg/ml, 234mg/1.5ml

3 NM

LATUDA 20mg, 40mg, 80mg, 120mg

2

LATUDA 60mg 2 NM

loxapine succinate (generic of LOXITANE) 5mg

1

loxapine succinate 10mg, 25mg, 50mg

1

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

1 QL

olanzapine (generic of ZYPREXA) TABS

1

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg, 10mg, 15mg

1

olanzapine odt (generic of ZYPREXA ZYDIS) 20mg

1 NM

ORAP 3

perphenazine TABS 1

quetiapine fumarate (generic of SEROQUEL)

1

RISPERDAL CONSTA 12.5mg, 25mg

2

RISPERDAL CONSTA 37.5mg, 50mg

2 NM

risperidone (generic of RISPERDAL)

1

Drug Name Drug Tier

Requirements/Limits

risperidone odt (generic of RISPERDAL M-TAB) .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone odt .25mg 1

SAPHRIS 3

SEROQUEL XR 2

thioridazine hcl TABS 1 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3 NM

ziprasidone hcl (generic of GEODON)

1

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


1 QL

amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)


1 QL



1 QL



1 QL



1 QL



1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


1 QL



23

Drug Name Drug Tier

Requirements/Limits



1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL



1 QL



1 QL



1 QL

DAYTRANA QL (30 ptch / 30 days)

2 QL

INTUNIV 2

metadate tab 20mg er (generic of RITALIN SR)


1 QL

METHYLIN CHEW TAB QL (180 tabs / 30 days)

2 QL

methylphenidate hcl (generic of RITALIN LA) CP24 20mg, 30mg


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 40mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 30mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 40mg, 50mg, 60mg


1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml

QL (1800 ml / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml

QL (900 ml / 30 days)

1 QL

methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg


1 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


1 QL

METHYLPHENIDATE HCL ER 18mg


1 QL

methylphenidate hcl er (generic of CONCERTA) 27mg, 36mg


1 QL

methylphenidate hcl er (generic of CONCERTA) 54mg


1 QL

methylphenidate tab 10mg er QL (90 ea / 30 days)

1 QL

methylphenidate tab 20mg er (generic of RITALIN SR)


1 QL

QUILLIVANT XR QL (360 ml / 30 days)

2 QL

RITALIN LA 10mg QL (60 caps / 30 days)

2 QL

STRATTERA 10mg, 18mg, 25mg


2 QL

STRATTERA 40mg QL (60 caps / 30 days)

2 QL

STRATTERA 60mg, 80mg, 100mg


2 QL

VYVANSE 20mg, 30mg QL (60 caps / 30 days)

2 QL

VYVANSE 40mg, 50mg, 60mg, 70mg


2 QL

HYPNOTICS EDLUAR

QL (30 ea / 30 days) 3 QL



24

Drug Name Drug Tier

Requirements/Limits

INTERMEZZO QL (30 ea / 30 days)

3 QL

LUNESTA QL (30 tabs / 30 days)

2 QL

ROZEREM QL (30 tabs / 30 days)

3 QL

SILENOR 3mg QL (60 tabs / 30 days)

2 QL

SILENOR 6mg QL (30 tabs / 30 days)

2 QL

zaleplon (generic of SONATA) QL (30 caps / 30 days)

1 QL

zolpidem tartrate (generic of AMBIEN) TABS


1 QL

zolpidem tartrate (generic of AMBIEN CR) TBCR


1 QL

ZOLPIMIST QL (1 bottle / 30 days)

3 QL

MIGRAINE ALSUMA

QL (4 mL / 30 days) 3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 2

dihydroergotamine mesylate (generic of D.H.E. 45) 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

1 QL

ergomar 3

FROVA TAB 2.5MG QL (18 tabs / 30 days)

3 QL

migergot 1

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

Drug Name Drug Tier

Requirements/Limits

SUMATRIPTAN SUCCINATE SOLN

QL (12 inhalers / 30 days)

1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

SUMATRIPTAN SUCCINATE INJ 4mg/0.5ml

QL (4 mL / 30 days)

1 QL

sumatriptan succinate inj (generic of IMITREX) 6mg/0.5ml

QL (8 syringes/vials / 30 days)

1 QL

SUMAVEL DOSEPRO QL (6 mL / 30 days)

2 QL

TREXIMET QL (9 tabs / 30 days)

2 QL

zolmitriptan (generic of ZOMIG)


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG QL (12 tabs / 30 days)

2 QL

ZOMIG NASAL SPRAY 2.5mg

QL (2 boxes / 30 days)

2 QL NM

ZOMIG NASAL SPRAY 5mg QL (2 bottles / 30 days)

2 QL

ZOMIG ZMT QL (12 ea / 30 days)

2 QL

MISCELLANEOUS BRISDELLE 3 NM

EQUETRO 3

GRALISE 300mg QL (180 tabs / 30 days)

2 QL

GRALISE 600mg QL (90 tabs / 30 days)

2 QL

GRALISE STARTER 2

HORIZANT 300mg 3 NM

HORIZANT 600mg 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1



25

Drug Name Drug Tier

Requirements/Limits

lithium carbonate TBCR 450mg

1

LITHIUM CITRATE 2

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA QL (60 caps / 30 days)

2 QL PA

pyridostigmine bromide (generic of MESTINON) TABS

1

REGONOL 2

RILUTEK 3 NM

riluzole (generic of RILUTEK) 1

SAVELLA 12.5mg QL (480 tabs / 30 days)

2 QL

SAVELLA 25mg QL (240 tabs / 30 days)

2 QL


2 QL


2 QL

SAVELLA TITRATION PACK 2

XENAZINE 2 NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO QL (30 tabs / 30 days)

3 QL NM PA

AVONEX QL (4 syringes / 28 days)

2 QL NM PA

AVONEX PEN QL (4 boxes / 28 days)

2 QL NM PA

BETASERON QL (14 vials / 28 days)

2 QL NM PA

COPAXONE KIT QL (1 box / 30 days)

2 QL NM PA

EXTAVIA QL (15 syringes / 30 days)

2 QL NM PA

GILENYA QL (30 caps / 30 days)

2 QL NM PA

REBIF QL (6 syringes / 28 days)

3 QL NM PA

REBIF TITRATION PACK QL (6 syringes / 30 days)

3 QL NM PA

Drug Name Drug Tier

Requirements/Limits

TECFIDERA CAP 120MG QL (14 ea / 7 days)

2 QL NM PA

TECFIDERA CAP 240MG QL (60 ea / 30 days)

2 QL NM PA

TECFIDERA MIS STARTER 2 NM PA

TYSABRI 3 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS AMRIX 15mg

QL (60 ea / 30 days) 3 QL PA

AMRIX 30mg QL (30 ea / 30 days)

3 QL PA

baclofen TABS 1

carisoprodol (generic of SOMA) TABS 350mg


1 QL NM PA

chlorzoxazone (generic of PARAFON FORTE DSC)

1 PA

cyclobenzaprine hcl TABS 5mg, 10mg


1 QL PA

cyclobenzaprine hcl (generic of FEXMID) TABS 7.5mg


1 QL PA

dantrolene sodium (generic of DANTRIUM) CAPS

1

methocarbamol (generic of ROBAXIN) TABS 500mg

1 PA

methocarbamol (generic of ROBAXIN-750) TABS 750mg

1 PA

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg

1 PA

modafinil (generic of PROVIGIL) 200mg

1 NM PA

NUVIGIL 50mg, 150mg, 250mg

2 PA

XYREM 2 NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium (generic of CAMPRAL)

1 NM

buprenorphine hcl SUBL 1 PA



26

Drug Name Drug Tier

Requirements/Limits

buprenorphine hcl-naloxone hcl sl

QL (120 ea / 30 days)

1 QL PA

buproban (generic of ZYBAN) 1

CAMPRAL 2

CHANTIX PAK 0.5& 1MG QL (106 tabs / year)

2 QL NM PA

CHANTIX TAB 0.5MG QL (336 tabs / year)

2 QL NM PA

CHANTIX TAB 1MG QL (336 tabs / year)

2 QL NM PA

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER QL (16 inhalers / year)

3 QL

NICOTROL NS QL (36 bottles / year)

3 QL

SARAFEM 3

SUBOXONE MIS 2-0.5MG QL (120 ea / 30 days)

3 QL PA

SUBOXONE MIS 4-1MG QL (120 ea / 30 days)

3 QL PA


3 QL PA


3 QL PA

VIVITROL 3 NM

ZUBSOLV QL (120 ea / 30 days)

2 QL NM PA

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM

QL (30 ea / 30 days) 2 QL PA

ANDROGEL 1% QL (300 gm / 30 days)

3 QL PA

ANDROGEL 1.62% QL (150 gm / 30 days)

3 QL PA

androxy 3 PA

AXIRON QL (440 mL / 30 days)

2 QL PA

FORTESTA QL (120 gm / 30 days)

2 QL PA

oxandrolone (generic of OXANDRIN) TABS

1 PA

Drug Name Drug Tier

Requirements/Limits

STRIANT QL (60 tabs / 30 days)

3 QL PA

TESTIM QL (300 gm / 30 days)

2 QL PA

testosterone cypionate OIL 100mg/ml

1

testosterone cypionate (generic of DEPO-TESTOSTERONE) OIL 200mg/ml

1

testosterone enanthate OIL 1

ANTIDIABETICS, INJECTABLE ALCOHOL PREPS PADS 2

APIDRA 2

APIDRA SOLOSTAR 2

BYDUREON QL (4 vials / 30 days)

2 QL PA

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 PEN 3

HUMULIN N 3

HUMULIN N U-100 PEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

2 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXPEN 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3



27

Drug Name Drug Tier

Requirements/Limits

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

SYMLINPEN 60 2 PA

SYMLINPEN 120 2 PA

VICTOZA QL (9 mL / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

FARXIGA 5mg QL (60 tabs / 30 days)

3 QL

FARXIGA 10mg QL (30 tabs / 30 days)

3 QL

glimepiride (generic of AMARYL) 1mg


1 QL



1 QL



1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide er (generic of GLUCOTROL XL) 2.5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 10mg


1 QL

Drug Name Drug Tier

Requirements/Limits

glipizide-metformin 2.5-250mg QL (240 tabs / 30 days)

1 QL

glipizide-metformin 2.5-500mg QL (120 tabs / 30 days)

1 QL

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL

GLUMETZA 500mg QL (120 ea / 30 days)

3 QL

GLUMETZA 1000mg QL (60 ea / 30 days)

3 QL

glyburide 1.25mg QL (480 tabs / 30 days)

1 QL PA

glyburide 2.5mg QL (240 tabs / 30 days)

1 QL PA

glyburide 5mg QL (120 tabs / 30 days)

1 QL PA

glyburide micronized (generic of GLYNASE) 1.5mg


1 QL PA

glyburide micronized (generic of GLYNASE) 3mg


1 QL PA

glyburide micronized (generic of GLYNASE) 6mg


1 QL PA

glyburide-metformin 1.25-250mg (generic of GLUCOVANCE)


1 QL PA

glyburide-metformin 2.5-500mg (generic of GLUCOVANCE)


1 QL PA

glyburide-metformin 5-500mg (generic of GLUCOVANCE)


1 QL PA

GLYSET 3

INVOKANA 100mg QL (90 tabs / 30 days)

2 QL

INVOKANA 300mg QL (30 tabs / 30 days)

2 QL

JANUMET 2

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2



28

Drug Name Drug Tier

Requirements/Limits

JENTADUETO QL (60 tabs / 30 days)

2 QL

JUVISYNC QL (30 tabs / 30 days)

2 QL

KAZANO QL (60 tabs / 30 days)

3 QL

KOMBIGLYZE XR 2.5-1000MG


3 QL

KOMBIGLYZE XR 5-500MG QL (30 ea / 30 days)

3 QL

KOMBIGLYZE XR 5-1000MG QL (30 ea / 30 days)

3 QL

metformin er (generic of GLUCOPHAGE XR) 500mg


1 QL

metformin er (generic of GLUCOPHAGE XR) 750mg


1 QL

metformin hcl (generic of GLUCOPHAGE) TABS 500mg


1 QL



1 QL



1 QL

metformin hcl (generic of FORTAMET) TB24 500mg

QL (150 ea / 30 days)

1 QL

metformin hcl (generic of FORTAMET) TB24 1000mg


1 QL

nateglinide (generic of STARLIX)


1 QL

NESINA 6.25mg QL (120 tabs / 30 days)

3 QL

NESINA 12.5mg QL (60 tabs / 30 days)

3 QL

NESINA 25mg QL (30 tabs / 30 days)

3 QL

ONGLYZA QL (30 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

OSENI TAB 12.5-15MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

OSENI TAB 25-15MG QL (30 tabs / 30 days)

3 QL


3 QL


3 QL

pioglitazone hcl (generic of ACTOS)


1 QL

pioglitazone hcl-glimepiride (generic of DUETACT)


1 QL

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)


1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

PRANDIN 2mg QL (240 tabs / 30 days)

2 QL

PRANDIN .5mg, 1mg QL (120 tabs / 30 days)

2 QL

repaglinide (generic of PRANDIN) 2mg


1 QL NM

repaglinide (generic of PRANDIN) .5mg, 1mg


1 QL NM

RIOMET QL (946mL / 30 days)

3 QL

TRADJENTA 2

BISPHOSPHONATES ACTONEL 2

alendronate sodium SOLN QL (4 / 28 days)

1 QL

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 2

BINOSTO 3

BONIVA SOLN QL (1 syringe / 90 days)

3 B/D QL



29

Drug Name Drug Tier

Requirements/Limits

FOSAMAX PLUS D 3

ibandronate sodium (generic of BONIVA) TABS

1 B/D

pamidronate disodium SOLN 1 B/D

zoledronic inj 4mg/5ml (generic of ZOMETA)

1 B/D NM

ZOMETA 3 B/D NM

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 2 NM

CHELATING AGENTS CHEMET 3

EXJADE 3 NM LA PA

FERRIPROX 3 NM PA

kionex (generic of KAYEXALATE) POWD

1

kionex SUSP 1

sodium polystyrene sulfonate 1

sps sus 15gm/60ml 1

SYPRINE 3 NM

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

cryselle 28 1

cyclafem 1/35 28 day (generic of NORINYL 1+35)

1

cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

DEPO-SUBQ PROVERA 104 2

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

Drug Name Drug Tier

Requirements/Limits

ELLA 2

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

GENERESS FE 3

GIANVI 1

gildagia (generic of OVCON-35)

1

heather tab 0.35mg (generic of NOR-QD)

1

introvale 91 day 1

JOLIVETTE 1

junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

junel 1/20 21 day (generic of LOESTRIN 1/20-21)

1

junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

junel fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

LEENA 1

lessina 28 day 1

levonest 28 day 1

levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg

1 NM

levonorgestrel (emergency oc) (generic of PLAN B) .75mg

1 NM

levonorgestrel-ethinyl estradiol (91-day)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

LO MINASTRIN FE 3 NM

LOESTRIN 24 FE 2

lomedia 24 fe 1 NM

loryna 28 day (generic of YAZ)

1

low-ogestrel 28 day 1

lutera 28 day 1



30

Drug Name Drug Tier

Requirements/Limits

lyza (generic of ORTHO MICRONOR)

1 NM

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

1

microgestin 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

microgestin 1/20 21 day (generic of LOESTRIN 1/20-21)

1

microgestin fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

microgestin fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

MINASTRIN 24 FE 2

MONONESSA 1

my way (generic of PLAN B ONE-STEP)

1 NM

myzilra 1

necon 0.5/35 28 day (generic of BREVICON-28)

1

necon 1/35 28 day (generic of NORINYL 1+35)

1

NECON 1/50-28 1

NECON 7/7/7 1

necon 10/11 28 day 2

next choice tab 1.5mg (generic of PLAN B ONE-STEP)

1

NORA-BE 1

norethindrone (contraceptive) (generic of NOR-QD)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

1

NORINYL 1+50 2

nortrel 0.5/35 28 day (generic of BREVICON-28)

1

nortrel 1/35 21 day (generic of NORINYL 1+35)

1

nortrel 1/35 28 day (generic of NORINYL 1+35)

1

Drug Name Drug Tier

Requirements/Limits

nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

NUVARING 2

OCELLA 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO EVRA 2

ORTHO TRI-CYCLEN LO 2

philith (generic of OVCON-35) 1

pimtrea pack (generic of MIRCETTE)

1

pirmella 1/35 28 day (generic of NORINYL 1+35)

1 NM

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

tri-previfem 28 day (generic of ORTHO TRI-CYCLEN)

1

tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN)

1

TRINESSA 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

viorele (generic of MIRCETTE)

1

vyfemla (generic of OVCON-35)

1

zarah (generic of YASMIN 28) 1

zenchent 28 day (generic of OVCON-35)

1

zenchent fe 28 day (generic of FEMCON FE)

1



31

Drug Name Drug Tier

Requirements/Limits

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

SYNAREL 2 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA

ALDURAZYME 3 NM LA PA

BUPHENYL TAB 500MG 3 NM

CARBAGLU 3 NM LA PA

CEREZYME 3 NM PA

CYSTADANE 3 NM

CYSTAGON 3 NM PA

ELAPRASE 3 NM PA

ELELYSO 3 NM PA

FABRAZYME 3 NM PA

KUVAN TBSO 2 NM PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 3 NM PA

MYOZYME 3 NM PA

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM LA PA

PROCYSBI 3 NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

1 NM

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGEN/PROGESTINS estradiol & norethindrone acetate (generic of ACTIVELLA)

1

jinteli 1 PA

ESTROGENS ALORA 3 PA

COMBIPATCH 2 PA

DELESTROGEN 10mg/ml 3

depo-estradiol 3

estrace CREA 2

estradiol (generic of CLIMARA) PTWK

1 PA

estradiol (generic of ESTRACE) TABS

1 PA

ESTRADIOL VALERATE OIL 10mg/ml

1

Drug Name Drug Tier

Requirements/Limits

estradiol valerate (generic of DELESTROGEN) OIL 20mg/ml, 40mg/ml

1

ESTRING 3

estropipate 1 PA

FEMRING 3

menest 2 PA

MENOSTAR 3 PA

MINIVELLE 2 PA

PREMARIN 2 PA

PREMARIN CREAM 2

PREMARIN INJ 3

PREMPHASE 2 PA

PREMPRO 2 PA

VAGIFEM 2

VIVELLE-DOT 2 PA

GLUCOCORTICOIDS a-hydrocort inj 100mg (generic of SOLU-CORTEF)

1

cortisone acetate TABS 1

DEPO-MEDROL 20mg/ml 3

dexamethasone CONC; ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

FLO-PRED 3

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL 2mg 2

methylprednisolone (generic of MEDROL DOSEPAK) TABS 4mg

1

methylprednisolone (generic of MEDROL) TABS 4mg, 8mg, 16mg, 32mg

1

methylprednisolone acetate (generic of DEPO-MEDROL)

1

methylprednisolone sod succ (generic of SOLU-MEDROL)

1

millipred 3

ORAPRED ODT 2

prednisolone (generic of PRELONE)

1



32

Drug Name Drug Tier

Requirements/Limits

prednisolone sodium phosphate (generic of PEDIAPRED) 5mg/5ml

1

prednisolone sodium phosphate (generic of ORAPRED) 15mg/5ml

1

prednisolone sodium phosphate 25mg/5ml

1

prednisone CONC 2

prednisone SOLN; TABS 1

RAYOS 3

SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 2

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL 2gm 3

veripred 3

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM 3 NM

HUMAN GROWTH HORMONES GENOTROPIN 3 NM PA

GENOTROPIN MINIQUICK 3 NM PA

HUMATROPE 2 NM PA

HUMATROPE COMBO PACK 2 NM PA

NORDITROPIN FLEXPRO 2 NM PA

NORDITROPIN NORDIFLEX PEN

2 NM PA

NUTROPIN 3 NM PA

NUTROPIN AQ NUSPIN 5 3 NM PA

NUTROPIN AQ PEN 3 NM PA

OMNITROPE 5.8MG 3 NM PA

OMNITROPE 5MG 3 NM PA

OMNITROPE 10MG 3 NM PA

SAIZEN 3 NM PA

SAIZEN CLICK.EASY 3 NM PA

SEROSTIM 3 NM PA

TEV-TROPIN 3 NM PA

ZORBTIVE 3 NM PA

MISCELLANEOUS ACTHAR HP 3 NM PA

cabergoline 1

Drug Name Drug Tier

Requirements/Limits

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 3 NM PA

FORTICAL SPR 200/ACT 2

INCRELEX 3 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 2 B/D

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of SANDOSTATIN)

1 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM

SAMSCA 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 3 NM LA PA

XGEVA 3 NM PA

PARATHYROID HORMONES FORTEO 2 NM PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS) TABS

1

FOSRENOL 2

PHOSLYRA 2

RENAGEL 3

RENVELA 2

PROGESTINS CRINONE 2

ENDOMETRIN 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1



33

Drug Name Drug Tier

Requirements/Limits

progesterone micronized (generic of PROMETRIUM) CAPS

1

SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA 2

THYROID AGENTS levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

UNITHROID 1

VASOPRESSINS DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM

GASTROINTESTINAL ANTIEMETICS ALOXI 3 NM

ANTIVERT 3

CESAMET QL (60 caps / 30 days)

3 B/D QL NM

compro supp 1

dronabinol (generic of MARINOL) 2.5mg, 5mg


1 B/D QL

dronabinol (generic of MARINOL) 10mg


1 B/D QL NM

EMEND CAPS 40mg QL (3 caps / 180 days)

2 QL

Drug Name Drug Tier

Requirements/Limits


2 B/D QL


2 B/D QL

EMEND PAK 80 & 125 QL (12 caps / 30 days)

2 B/D QL

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

granisol 2 B/D NM

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1

ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml

1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz 1 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

1 PA

promethazine hcl SUPP; SYRP; TABS

1 PA

promethegan 1 PA

SANCUSO QL (4 ptch / 30 days)

2 QL NM

TRANSDERM-SCOP QL (10 ptch / 30 days)

2 QL PA

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3



34

Drug Name Drug Tier

Requirements/Limits

dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1

glycate 3 NM

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine SOLN 1

famotidine (generic of PEPCID) SUSR

1

famotidine (generic of PEPCID) TABS 20mg, 40mg

1

nizatidine CAPS 150mg 1

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine (generic of AXID) SOLN

1

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl SYRP 1

ranitidine hcl (generic of ZANTAC) TABS 150mg, 300mg

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 2

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CP24

1 NM

CANASA 2

colocort (generic of CORTENEMA)

1

Drug Name Drug Tier

Requirements/Limits

DELZICOL 3

DIPENTUM 2 NM

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema 1

mesalamine enema kit (generic of ROWASA)

1

PENTASA 2

SF-ROWASA 2

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS 3

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 2

HALFLYTELY BOWEL PREP/FLA

3

kristalose 2

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 2

OSMOPREP 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of COLYTE-FLAVOR PACKS)

1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

1



35

Drug Name Drug Tier

Requirements/Limits

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2 PA

SUCLEAR 3

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

VISICOL 3

MISCELLANEOUS AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1 NM

CARAFATE SUSP 2

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

1 NM

diphenoxylate w/ atropine LIQD

1 PA

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1 PA

GATTEX 3 NM LA PA

HELIDAC 3 NM

LINZESS CAP 145MCG 2

LINZESS CAP 290MCG 2

loperamide hcl CAPS 1

LOTRONEX 2 NM PA

misoprostol (generic of CYTOTEC) TABS

1

OMECLAMOX-PAK 3

PREVPAC 2

PYLERA 2

SUCRAID 3 NM

sucralfate (generic of CARAFATE) TABS

1

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 2 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

Drug Name Drug Tier

Requirements/Limits

PERTZYE 3

ULTRESA 2

VIOKACE 10440 UNIT 2

VIOKACE 20880 UNIT 2 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX

QL (30 ea / 30 days) 3 QL

ACIPHEX SPR CAP 5MG 3 NM

ACIPHEX SPR CAP 10MG QL (60 ea / 30 days)

3 QL NM

DEXILANT 2

esomeprazole sodium inj (generic of NEXIUM I.V.)

1

lansoprazole (generic of PREVACID) CPDR


1 QL

NEXIUM 2

NEXIUM GRANULES 2.5MG DR

2

NEXIUM GRANULES 5MG DR

2


2


2


2

NEXIUM I.V. 3

omeprazole (generic of PRILOSEC) CPDR 10mg


1 QL

omeprazole (generic of PRILOSEC) CPDR 40mg


1 QL

omeprazole cap 20mg (generic of PRILOSEC)

1 NM

pantoprazole sodium (generic of PROTONIX) SOLR

1

pantoprazole sodium (generic of PROTONIX) TBEC


1 QL

PREVACID SOLUTAB QL (30 ea / 30 days)

3 QL

PROTONIX PACK QL (30 ea / 30 days)

3 QL



36

Drug Name Drug Tier

Requirements/Limits

rabeprazole sodium (generic of ACIPHEX)


1 QL NM

ZEGERID PACK QL (30 packets / 30 days)

3 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3

finasteride (generic of PROSCAR) TABS 5mg

1

JALYN 2

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 2

POTASSIUM CITRATE (ALKALINIZER) 540mg

1

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

UROCIT-K 2

URINARY ANTISPASMODICS DETROL LA 2

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 3

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

tolterodine tartrate (generic of DETROL)

1

TOLTERODINE TARTRATE ER

1 NM

TOVIAZ 2

trospium chloride (generic of SANCTURA XR) CP24

1

trospium chloride (generic of SANCTURA) TABS

1

Drug Name Drug Tier

Requirements/Limits

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN VAG SUPP 100MG 2

clindamycin cre 2% vag (generic of CLEOCIN)

1

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole nitrate vaginal 1

terconazole vaginal (generic of TERAZOL 7) CREA .4%

1

terconazole vaginal (generic of TERAZOL 3) CREA .8%

1

terconazole vaginal (generic of TERAZOL 3) SUPP

1

VANDAZOLE 1

zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

COUMADIN INJ 3

ELIQUIS 2

enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml

1 NM

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

1

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

1 NM

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 25000unit/ml

2 NM

HEP SOD/NACL INJ 25000 2



37

Drug Name Drug Tier

Requirements/Limits

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

2

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

2 B/D

HEPARIN SOD INJ 2500U/ML

2 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/SODIUM CHL

1

jantoven (generic of COUMADIN)

1

PRADAXA 2

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg/0.42ml, 25mcg/ml, 40mcg/0.4ml, 40mcg/ml, 60mcg/0.3ml, 60mcg/ml, 100mcg/0.5ml, 100mcg/ml, 150mcg/0.3ml, 200mcg/0.4ml, 200mcg/ml, 300mcg/0.6ml, 300mcg/ml, 500mcg/ml

2 NM PA

ARANESP ALBUMIN FREE 150mcg/0.75ml

3 NM PA

EPOGEN 2 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MOZOBIL 2 NM PA

NEULASTA 2 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 2 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS anagrelide hcl 1mg 1 PA

anagrelide hcl (generic of AGRYLIN) .5mg

1 PA

cilostazol (generic of PLETAL) 1

pentoxifylline TBCR 1

PROMACTA 2 NM LA PA

Drug Name Drug Tier

Requirements/Limits

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

dipyridamole (generic of PERSANTINE) TABS

1 PA

EFFIENT 2

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA INJ 80MG/4ML 3 NM PA

ACTEMRA INJ 162/0.9 3 NM PA

ACTEMRA INJ 200/10ML 3 NM PA

ACTEMRA INJ 400/20ML 3 NM PA

CIMZIA KIT 3 NM PA

CIMZIA KIT STARTER 3 NM PA

CIMZIA PREFL KIT 200MG/ML

3 NM PA

ENBREL INJ 25/0.5ML 2 NM PA

ENBREL INJ 25MG 2 NM PA

ENBREL INJ 50MG/ML 2 NM PA

ENBREL SURECLICK 2 NM PA

HUMIRA KIT 20MG/0.4 2 NM PA

HUMIRA KIT 40MG/0.8 2 NM PA

HUMIRA PEN KIT 40MG/0.8 2 NM PA

HUMIRA PEN KIT CROHNS 2 NM PA

HUMIRA PEN KIT PSORIASI 2 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET INJ 3 NM PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

ORENCIA INJ 125MG/ML 3 NM PA

ORENCIA INJ 250MG 3 NM PA

REMICADE INJ 100MG 3 NM PA

RHEUMATREX 2

SIMPONI 3 NM PA

SIMPONI ARIA 3 NM PA

SIMPONI INJ 50MG 3 NM PA

trexall 2 B/D



38

Drug Name Drug Tier

Requirements/Limits

XELJANZ 3 NM PA

IMMUNOGLOBULINS CARIMUNE NANOFILTERED 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAKED 3 NM PA

GAMMAPLEX 3 NM PA

GAMUNEX 3 NM PA

GAMUNEX-C 3 NM PA

GAMUNEX-C 1GM/10ML 3 NM PA

OCTAGAM 3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

INFERGEN 2 NM PA

INFERGEN INJ 9MCG 2 NM PA

INFERGEN INJ 15MCG 2 NM PA

INTRON-A 2 B/D NM

INTRON-A W/DILUENT 2 B/D NM

PEG-INTRON KIT 50MCG 2 NM PA

PEG-INTRON KIT 50MCG RP

2 NM PA

PEG-INTRON KIT 80MCG RP

2 NM PA

PEG-INTRON KIT 120 RP 2 NM PA

PEG-INTRON KIT 150 RP 2 NM PA

PEGASYS INJ 2 NM PA

PEGASYS INJ 180MCG/M 2 NM PA

PEGASYS INJ PROCLICK 2 NM PA

PEGASYS KIT 2 NM PA

REVLIMID 2 NM LA PA

THALOMID 2 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 3 B/D NM

ATGAM 3 B/D

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

azathioprine inj 100mg 1 B/D

CELLCEPT SUSR 2 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

Drug Name Drug Tier

Requirements/Limits

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

1 B/D

gengraf (generic of NEORAL) 1 B/D

mycophenolate mofetil (generic of CELLCEPT)

1 B/D

mycophenolate sodium (generic of MYFORTIC)

1 B/D NM

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 2 B/D NM

NEORAL 2 B/D

NULOJIX 3 B/D NM

PROGRAF CAPS 5mg 2 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 2 B/D NM

RAPAMUNE TABS 1mg, 2mg

2 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 3 B/D

sirolimus tab 0.5 mg (generic of RAPAMUNE)

1 B/D

tacrolimus (generic of PROGRAF) CAPS 5mg

1 B/D NM

tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg

1 B/D

THYMOGLOBULIN 3 B/D NM

ZORTRESS 3 B/D NM

VACCINES ACTHIB 2

ADACEL 2

BOOSTRIX 2

CERVARIX 2

COMVAX 2



39

Drug Name Drug Tier

Requirements/Limits

DAPTACEL 2

DECAVAC 2 B/D

DIPHTHERIA/TETANUS TOXOID

2 B/D

ENGERIX-B SUSP 2 B/D

GARDASIL 2

HAVRIX 2

HIBERIX 2

IMOVAX RABIES (H.D.C.V.) 2

INFANRIX 2

IPOL INACTIVATED IPV 2

IXIARO 2

M-M-R II W/DILUENT 10 DOS

2

MENACTRA 2

MENHIBRIX 2

MENOMUNE-A/C/Y/W-135 2

MENVEO 2

PEDVAX HIB 2

PROQUAD 2

RABAVERT 2

RECOMBIVAX HB 2 B/D

ROTATEQ 2

SYNAGIS 3 NM

TENIVAC 2 B/D NM

TETANUS TOXOID ADSORBED

2 B/D

TETANUS/DIPHTHERIA TOXOID

2 B/D

TWINRIX 2 B/D

TYPHIM VI 2

VAQTA 2

VARIVAX 2

YF-VAX 2

ZOSTAVAX 2

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 1

klor-con m20 1

klor-con pow 20meq 1 NM

MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

2

Drug Name Drug Tier

Requirements/Limits

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W 1%

2

MAGNESIUM SULFATE IN D5W 2%

2

potassium chloride LIQD 1 NM

POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

SOD FLUORIDE 2.2MG TAB 1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D



40

Drug Name Drug Tier

Requirements/Limits


3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

hepatasol 8 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 2 B/D

NEPHRAMINE 3 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

travasol 10 3 B/D

TROPHAMINE 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

2

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

2

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-M IN DEXTROSE

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

isolyte s 3

KCL0.15%/D5W/NACL0.2% 1

KCL0.15%/D5W/NACL0.225%

2

kcl 0.3%/d5w/lr iv lac ri 3

KCL 0.3%/D5W/NACL 0.9% 1

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.2% INJ

1

kcl 20 meq/l (0.15%) in nacl 0.45% inj

1

KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ

1


1


1

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3



41

Drug Name Drug Tier

Requirements/Limits

potassium chloride SOLN 1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

RINGER'S 1

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL) SOLN

1 B/D

HECTOROL CAPS 2 B/D

HECTOROL SOLN 3 B/D

paricalcitol (generic of ZEMPLAR) 1mcg, 2mcg

1 B/D NM

paricalcitol (generic of ZEMPLAR) 4mcg

1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ZEMPLAR CAPS 1mcg, 2mcg

2 B/D

ZEMPLAR CAPS 4mcg 2 B/D NM

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

blephamide OINT 2

BLEPHAMIDE SUSP 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

Drug Name Drug Tier

Requirements/Limits

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 2

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OIN 0.3% OP 2

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

gatifloxacin (ophth) (generic of ZYMAXID)

1 NM

gentak 1

gentamicin sulfate (ophth) OINT

1

gentamicin sulfate (ophth) (generic of GARAMYCIN) SOLN

1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymy-gramicid (generic of NEOSPORIN)

1

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

sulfacetamide sodium (ophth) OINT

1

sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN

1

tobramycin sulfate (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 2

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

ZIRGAN 3

ZYMAXID 3

ANTI-INFLAMMATORIES



42

Drug Name Drug Tier

Requirements/Limits

ACUVAIL 3

ALREX 2

BROMDAY 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1 NM

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE 1

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 2

FML FORTE 2

ILEVRO 3

ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

1

LOTEMAX 2

MAXIDEX 2

NEVANAC 3

PRED MILD 2

PREDNISOLONE ACETATE SUSP

1

prednisolone sodium phosphate (ophth)

2

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) (generic of OPTIVAR)

1

BEPREVE 2

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 2

Drug Name Drug Tier

Requirements/Limits

PATADAY 2

PATANOL 2

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

AZOPT 2

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 2

latanoprost (generic of XALATAN)

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 2

metipranolol (generic of OPTIPRANOLOL)

1

PHOSPHOLINE IODIDE 2

PILOCARPINE HCL SOLN 1

PILOPINE HS 2

SIMBRINZA 2 NM

timolol maleate (ophth) (generic of TIMOPTIC) .5%

1

timolol maleate (ophth) .25% 1

TIMOLOL MALEATE GEL 1

TIMOPTIC OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS BOTOX 100unit 3 NM PA

LACRISERT 3

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of ALCAINE) SOLN

1



43

Drug Name Drug Tier

Requirements/Limits

RESTASIS 2

XEOMIN 3 NM PA

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS COMBIVENT RESPIMAT

QL (2 inhalers / 30 days) 2 QL

ipratropium-albuterol (generic of DUONEB)

1 B/D

ANTICHOLINERGICS ATROVENT HFA


ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

TUDORZA PRESSAIR QL (1 kit / 30 days)

2 QL

ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D 3

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 2

azelastine hcl SOLN 1

cetirizine syrup 1

CLARINEX SYRP 3

cyproheptadine hcl SYRP; TABS

1 PA

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

1 PA

hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg

1 PA

hydroxyzine pamoate CAPS 100mg

1 PA

levocetirizine soln 2.5mg/5ml (generic of XYZAL)

1

Drug Name Drug Tier

Requirements/Limits

levocetirizine tab 5 mg (generic of XYZAL)

1

PATANASE 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER QL (30 caps / 30 days)

2 QL

BROVANA 3 B/D

FORADIL AEROLIZER QL (60 caps / 30 days)

2 QL

levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)

1 B/D

LEVALBUTEROL HCL 1.25mg/3ml

1 B/D

levalbuterol hcl (generic of XOPENEX) .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA QL (2 inhalers / 30 days)

2 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

2 QL

SEREVENT DISKUS QL (1 inhaler / 30 days)

2 QL

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

XOPENEX HFA QL (2 inhalers / 30 days)

2 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS



44

Drug Name Drug Tier

Requirements/Limits

acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 3 NM LA PA

AUVI-Q 2

CAYSTON 3 NM LA PA

DALIRESP 2

DYMISTA QL (1 bottle / 30 days)

3 QL

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

GLASSIA 3 NM LA PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 2 B/D NM

tyzine .05% 3

XOLAIR 2 NM LA PA

ZEMAIRA 3 NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 bottles / 30 days) 3 QL

flunisolide (nasal) QL (2 bottles / 30 days)

1 QL

flunisolide nasal soln 29 mcg/act (0.025%)

QL (2 bottles / 30 days)

1 QL

fluticasone propionate (nasal) (generic of FLONASE)

QL (1 bottle / 30 days)

1 QL

NASONEX QL (2 bottles / 30 days)

2 QL

OMNARIS QL (1 bottle / 30 days)

3 QL

QNASL QL (1 bottle / 30 days)

3 QL

RHINOCORT AQUA QL (2 bottles / 30 days)

3 QL

triamcinolone acetonide (nasal)

QL (1 bottle / 30 days)

1 QL

VERAMYST QL (1 bottle / 30 days)

3 QL

ZETONNA QL (1 bottle / 30 days)

3 QL

STEROID INHALANTS ALVESCO


Drug Name Drug Tier

Requirements/Limits

ASMANEX QL (2 inhalers / 30 days)

2 QL

ASMANEX 14 METERED DOSES


2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 3 B/D NM

QVAR 40mcg/act QL (1 inhaler / 30 days)

2 QL

QVAR 80mcg/act QL (2 inhalers / 30 days)

2 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS

QL (1 inhaler / 30 days) 2 QL

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

BREO ELLIPTA QL (1 inhaler / 30 days)

3 QL NM

DULERA QL (1 inhaler / 30 days)

2 QL

SYMBICORT QL (1 inhaler / 30 days)

2 QL

XANTHINES aminophylline inj 1

elixophyllin 2

LUFYLLIN 3

theo-24 2

theophylline TB12; TB24 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NM

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN)

1



45

Drug Name Drug Tier

Requirements/Limits

AKNE-MYCIN 3

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLINDAGEL 3

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN; SOLN; SWAB

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

DIFFERIN GEL .3% 2

DIFFERIN LOTN 2

EPIDUO 2

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) PADS; SOLN

1

FABIOR 3 NM

myorisan 1

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA .038% 3

tretin-x CREA .075% 3 NM

tretin-x KIT 3

tretinoin (generic of RETIN-A) CREA; GEL

1

TRETINOIN MICROSPHERE 1

VELTIN 2

zenatane 1

ZIANA 3

DERMATOLOGY, ACTINIC KERATOSIS CARAC 2

diclofenac sodium (actinic keratoses) (generic of SOLARAZE)

1 NM PA

Drug Name Drug Tier

Requirements/Limits

fluorouracil (topical) (generic of EFUDEX) CREA

1

fluorouracil (topical) SOLN 1

PICATO 2

SOLARAZE 2 PA

DERMATOLOGY, ANTIBIOTICS ALTABAX 2

BACTROBAN NASAL 3

CENTANY 3 NM

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

mafenide acetate (generic of SULFAMYLON) PACK

1

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

PHISOHEX 3

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 2

THERMAZENE 1

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) GEL

1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) CREA 1

ketoconazole (topical) (generic of EXTINA) FOAM

1

MENTAX 2

NAFTIN CREA 3

NAFTIN GEL 1% 3

NAFTIN GEL 2% 3 NM

nyamyc 1

nystatin (topical) 1



46

Drug Name Drug Tier

Requirements/Limits

nystatin pow 100000 1

nystop 1

OXISTAT 2

pedi-dri 1

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

procto-pak 1

proctocream (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

1 NM PA

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

CALCITRIOL OINT 1

8-MOP 3

OXSORALEN ULTRA 2 NM

SORIATANE 2 NM PA

SORILUX 2

STELARA INJ 45MG/0.5 3 NM PA

STELARA INJ 90MG/ML 3 NM PA

TAZORAC 2 PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS acyclovir topical (generic of ZOVIRAX)

1

DENAVIR 3

XERESE 3

ZOVIRAX CREA 3

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

Drug Name Drug Tier

Requirements/Limits

amcinonide OINT 3

apexicon e 3 NM

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

CAPEX 2

clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LOTN; SHAM

1

clobetasol propionate emollient base (generic of TEMOVATE E)

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX LIQD 2

CLODERM PUMP 2

CORDRAN TAPE 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN; OINT

1

desowen oint kit 0.05% 2

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1



47

Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of VANOS) CREA .1%

1

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN; OINT

1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOCOID LOTN 2

LOCOID LIPOCREAM 2

LOKARA LOTN 0.05% 1

mometasone furoate (generic of ELOCON) CREA; OINT; SOLN

1

PANDEL 3

PREDNICARBATE CREA 1

Drug Name Drug Tier

Requirements/Limits

prednicarbate (generic of DERMATOP) OINT

1

TACLONEX 3

texacort 2

TOPICORT LIQD 3

triamcinolone acetonide (topical)

1

triderm 1

u-cort (generic of CARMOL-HC)

1

VANOS 3

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 NM

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

LIDODERM 2

SYNERA 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CONDYLOX GEL 2

ELIDEL CRE 1% 2 NM PA

FINACEA 2

imiquimod (generic of ALDARA) CREA

1

laclotion lotn 12% (generic of LAC-HYDRIN)

1

METROGEL 2

metronidazole (topical) (generic of METROCREAM) CREA

1

metronidazole (topical) (generic of METROGEL) GEL

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

metronidazole gel 0.75% 1

NORITATE 3 NM

ORACEA 2



48

Drug Name Drug Tier

Requirements/Limits

OXSORALEN 3

PANRETIN 3 NM

PENNSAID 2

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC OIN 0.1% 2 NM PA

PROTOPIC OIN 0.03% 2 NM PA

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

TARGRETIN GEL 3 NM PA

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

ZYCLARA 2 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion (generic of OVIDE) 1

permethrin (generic of ELIMITE) CREA

1

SKLICE 3

ULESFIA 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 3 NM PA

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

1

chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1

clotrimazole TROC 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard sol 0.12% (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

1

Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (mouth)

1

OTIC acetasol hc (generic of VOSOL HC)

1

acetic acid (otic) 1

acetic acid sol/hc (generic of VOSOL HC)

1

acetic acid-aluminum acetate 1

CIPRO HC 2

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1


49

Index 8 8-MOP .............................. 46 A abacavir sulfate ...................6 abacavir sulfate-lamivudine-zidovudine ..........................................7 ABELCET............................6 ABILIFY............................. 21 ABILIFY DISCMELT ......... 21 ABILIFY INJ ...................... 21 ABILIFY MAINTENA ......... 21 ABRAXANE ...................... 11 ABSORICA ....................... 44 ABSTRAL............................3 acamprosate calcium ........ 25 ACANYA ........................... 44 acarbose ........................... 27 ACCOLATE

see zafirlukast ............... 43 ACCUPRIL

see quinapril hcl ............ 13 ACCURETIC

see quinapril-hydrochlorothiazide .................................. 13

acebutolol hcl .................... 15 ACEON

see perindopril erbumine ...................................... 13

acetaminophen w/ codeine .1 acetasol hc ........................ 48 acetazolamide ................... 16 acetazolamide sodium ...... 16 acetic acid ......................... 48 acetic acid (otic) ................ 48 acetic acid sol/hc ............... 48 acetic acid-aluminum acetate .......................................... 48 acetylcysteine ................... 44 ACIPHEX .......................... 35

see rabeprazole sodium 36 ACIPHEX SPR CAP 10MG .......................................... 35 ACIPHEX SPR CAP 5MG . 35 acitretin ............................. 46 ACLOVATE

see alclometasone dipropionate .................. 46

ACTEMRA INJ 162/0.9 ..... 37 ACTEMRA INJ 200/10ML . 37 ACTEMRA INJ 400/20ML . 37 ACTEMRA INJ 80MG/4ML .......................................... 37 ACTHAR HP ..................... 32 ACTHIB ............................. 38 ACTIGALL

see ursodiol ................... 35 ACTIMMUNE .................... 38 ACTIQ

see fentanyl citrate .......... 3 ACTIVELLA

see estradiol & norethindrone acetate ... 31

ACTONEL ......................... 28 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 28

ACTOPLUS MET XR 15-1000MG ....................... 27 ACTOPLUS MET XR 30-1000MG ....................... 27 ACTOS

see pioglitazone hcl ....... 28 ACULAR

see ketorolac tromethamine (ophth) .... 42

ACULAR LS see ketorolac tromethamine (ophth) .... 42

ACUVAIL .......................... 42 acyclovir .............................. 7 acyclovir sodium ................. 7 acyclovir topical ................ 46 ACZONE ........................... 44 ADACEL ........................... 38 ADAGEN ........................... 31 ADALAT CC

see afeditab cr ............... 15 see nifediac ................... 16 see nifedipine ................ 16

adapalene ......................... 44 ADCIRCA .......................... 17 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg ........ 23 see amphetamine-dextroamphetamine tab 12.5 mg ..... 23 see amphetamine-dextroamphetamine tab 15 mg ........ 23 see amphetamine-dextroamphetamine tab 20 mg ........ 23 see amphetamine-dextroamphetamine tab 30 mg ........ 23 see amphetamine-dextroamphetamine tab 5 mg .......... 22 see amphetamine-dextroamphetamine tab 7.5 mg ....... 22

ADDERALL XR see amphetamine-dextroamphetamine cap sr 24hr 10 mg ...................................... 22 see amphetamine-dextroamphetamine cap sr 24hr 15 mg ...................................... 22 see amphetamine-dextroamphetamine cap sr 24hr 20 mg ...................................... 22 see amphetamine-dextroamphetamine cap sr 24hr 25 mg ...................................... 22 see amphetamine-dextroamphetamine cap sr 24hr 30 mg ...................................... 22 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 22

adefovir dipivoxil ................. 7


50

ADEMPAS ........................ 17 ADOXA

see doxycycline (monohydrate) ............... 10

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 10

ADRENACLICK ................ 44 adriamycin......................... 10 adriamycin inj 2mg/ml ....... 10 adrucil ............................... 11 ADVAIR DISKUS .............. 44 ADVAIR HFA .................... 44 ADVICOR.......................... 14 afeditab cr ......................... 15 AFINITOR ......................... 12 AFINITOR DISPERZ ......... 12 AGGRENOX ..................... 37 AGRYLIN

see anagrelide hcl ......... 37 a-hydrocort inj 100mg ....... 31 AKNE-MYCIN ................... 45 ala-cort .............................. 46 ALBENZA............................5 albuterol sulfate ................. 43 albuterol sulfate er ............ 43 ALCAINE

see proparacaine hcl ..... 42 alclometasone dipropionate .......................................... 46 ALCOHOL PREPS ............ 26 ALDACTAZIDE ................. 16

see spironolactone & hydrochlorothiazide ....... 17

ALDACTONE see spironolactone ........ 13

ALDARA see imiquimod ............... 47

ALDURAZYME ................. 31 alendronate sodium .......... 28 alfuzosin hcl ...................... 36 ALIMTA ............................. 11 ALINIA ................................5 ALKERAN

see melphalan hcl ......... 10 allopurinol inj 500mg ...........1 allopurinol tab ......................1 ALOCRIL........................... 42

ALOMIDE .......................... 42 ALOPRIM

see allopurinol inj 500mg . 1 ALORA .............................. 31 ALOXI ............................... 33 ALPHAGAN P 0.1% .......... 42 alprazolam .................. 17, 18 ALREX .............................. 42 ALSUMA ........................... 24 ALTABAX .......................... 45 ALTACE

see ramipril .................... 13 altavera ............................. 29 ALTOPREV ....................... 14 ALVESCO ......................... 44 amantadine hcl ................. 21 AMARYL

see glimepiride .............. 27 AMBIEN

see zolpidem tartrate ..... 24 AMBIEN CR

see zolpidem tartrate ..... 24 AMBISOME ........................ 6 amcinonide ....................... 46 AMERGE

see naratriptan hcl ......... 24 amethia 91 day ................. 29 amethyst 28 day ............... 29 amifostine crystalline......... 12 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 16 amiloride hcl ...................... 16 aminophylline inj ............... 44 AMINOSYN ....................... 39 AMINOSYN 7%/ELECTROLYTES ....... 39 AMINOSYN II .................... 39 AMINOSYN II 8.5%/ELECTROL .............. 39 AMINOSYN INJ 8.5/LYTE 39 AMINOSYN M ................... 39 AMINOSYN-HBC .............. 39 AMINOSYN-PF ................. 39 AMINOSYN-PF 7% ........... 39 AMINOSYN-RF ................. 39 amiodarone hcl ................. 14 amiodarone inj 50mg/ml.... 14

AMITIZA ........................... 35 amitriptyline hcl ................. 20 amlodipine besylate .......... 15 AMLODIPINE BESYLATE/ATORV .......... 15 amlodipine besylate-benazepril hcl ..... 12 ammonium chloride .......... 39 ammonium lactate ............ 47 amnesteem ....................... 45 amoxapine ........................ 20 amoxicillin ........................... 9 amoxicillin & pot clavulanate............................................ 9 amoxicillin-clarithromycin w/ lansoprazole ..................... 35 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 22 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 22 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 22 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 22 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 22 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 22 amphetamine-dextroamphetamine tab 10 mg ............... 23 amphetamine-dextroamphetamine tab 12.5 mg ............ 23 amphetamine-dextroamphetamine tab 15 mg ............... 23 amphetamine-dextroamphetamine tab 20 mg ............... 23 amphetamine-dextroamphetamine tab 30 mg ............... 23 amphetamine-dextroamphetamine tab 5 mg ................. 22 amphetamine-dextroamphetamine tab 7.5 mg .............. 22 AMPHOTEC ....................... 6 amphotericin b .................... 6 ampicillin ............................. 9 ampicillin & sulbactam sodium ................................ 9 ampicillin inj ........................ 9


51

ampicillin sodium .................9 AMPYRA ........................... 25 AMRIX .............................. 25 AMTURNIDE ..................... 16 ANAFRANIL

see clomipramine hcl ..... 20 anagrelide hcl .................... 37 ANAPROX

see naproxen sodium ......1 ANAPROX DS

see naproxen sodium ......1 anastrozole ....................... 11 ANCOBON

see flucytosine .................6 ANDRODERM .................. 26 ANDROGEL 1% ................ 26 ANDROGEL 1.62% ........... 26 androxy ............................. 26 ANTABUSE

see disulfiram ................ 26 ANTARA ........................... 14 ANTIVERT ........................ 33 ANUSOL-HC

see proctocream ............ 46 see proctozone hc ......... 46

apexicon e......................... 46 APIDRA............................. 26 APIDRA SOLOSTAR ........ 26 APLENZIN ........................ 20 APOKYN ........................... 21 apri 28 day ........................ 29 APRISO ............................ 34 APTIVUS.............................6 ARALAST NP .................... 44 ARALEN

see chloroquine phosphate ........................6

aranelle 28 ........................ 29 ARANESP ALBUMIN FREE .......................................... 37 ARAVA

see leflunomide ............. 37 ARCALYST ....................... 38 ARCAPTA NEOHALER .... 43 ARICEPT .......................... 19

see donepezil tab hcl 23mg ............................. 20 see donepezil tabs 10mg

...................................... 20 see donepezil tabs 5mg 20

ARICEPT ODT see donepezil odt 10mg 20 see donepezil odt 5mg .. 19

ARIMIDEX see anastrozole ............. 11

ARIXTRA see fondaparinux sodium ...................................... 36

AROMASIN see exemestane ............ 11

ARRANON ........................ 11 ARTHROTEC 50

see diclofenac w/ misoprostol ...................... 1

ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1

ARZERRA ......................... 11 ASACOL HD ..................... 34 ASMANEX ........................ 44 ASMANEX 14 METERED DOSES ............................. 44 ASTAGRAF XL ................. 38 ASTEPRO ......................... 43 ATACAND ......................... 13

see candesartan cilexetil ...................................... 13

ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 13

ATELVIA ........................... 28 atenolol ............................. 15 atenolol & chlorthalidone ... 15 ATGAM ............................. 38 ATIVAN

see lorazepam ............... 18 atorvastatin calcium .......... 14 atovaquone-proguanil hcl tab 250-100 mg ......................... 6 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 6 ATRALIN ........................... 45 ATRIPLA ............................. 7 ATROPINE SULFATE ...... 33 ATROVENT

see ipratropium bromide (nasal) ........................... 43

ATROVENT HFA .............. 43 AUBAGIO ......................... 25 AUGMENTIN ...................... 9

see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN ES-600 see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN XR see amoxicillin & pot clavulanate ...................... 9

AUVI-Q ............................. 44 AVALIDE

see irbesartan-hydrochlorothiazide ............................... 13

AVAPRO see irbesartan ............... 13

AVASTIN .......................... 11 AVELOX ............................. 9 AVELOX ABC PACK .......... 9 aviane 28 .......................... 29 AVINZA ............................... 3

see morphine sulfate beads cap sr ................... 4

AVITA ............................... 45 AVODART ........................ 36 AVONEX ........................... 25 AVONEX PEN .................. 25 AXERT .............................. 24 AXID

see nizatidine ................ 34 AXIRON ............................ 26 AYGESTIN

see norethindrone acetate ...................................... 32

azacitidine ......................... 11 AZACTAM .......................... 5

see aztreonam ................ 5 AZACTAM/DEX INJ 1GM ... 5 AZACTAM/DEX INJ 2GM ... 5 azasan .............................. 38 AZASITE ........................... 41 azathioprine ...................... 38 azathioprine inj 100mg ...... 38 azelastine hcl .................... 43


52

azelastine hcl (ophth) ........ 42 AZELEX ............................ 45 AZILECT ........................... 21 azithromycin ........................8 AZITHROMYCIN .................8 AZOPT .............................. 42 AZOR ................................ 13 aztreonam ...........................5 AZULFIDINE

see sulfasalazine ir ........ 34 AZULFIDINE EN-TABS

see sulfasalazine dr ....... 34 B bacitracin (ophthalmic) ...... 41 bacitracin-polymyxin b (ophth) .............................. 41 bacitracin-poly-neomycin-hc .......................................... 41 baclofen ............................ 25 BACTOCILL IN DEXTROSE ............................................9 BACTRIM

see sulfamethoxazole-trimethoprim .................................6

BACTRIM DS see sulfamethoxazole-trimethoprim .................................6

BACTROBAN see mupirocin ................ 45 see mupirocin calcium (topical).......................... 45

BACTROBAN NASAL ....... 45 balsalazide disodium ......... 34 balziva 28 day ................... 29 BANZEL ............................ 18 BARACLUDE ......................7 BECONASE AQ ................ 44 benazepril & hydrochlorothiazide ........... 12 benazepril hcl .................... 13 BENICAR .......................... 13 BENICAR HCT .................. 13 BENTYL ............................ 33

see dicyclomine hcl ....... 34 BENZACLIN

see clindamycin

phosphate-benzoyl peroxide ........................ 45

BENZAMYCIN see benzoyl peroxide-erythromycin ... 45

benzoyl peroxide-erythromycin ...... 45 benztropine mesylate ........ 21 BEPREVE ......................... 42 BESIVANCE ..................... 41 BETAGAN

see levobunolol hcl ........ 42 betamethasone dipropionate (topical) ............................. 46 betamethasone dipropionate augmented ........................ 46 betamethasone valerate ... 46 BETAPACE

see sorine ...................... 14 see sotalol hcl ............... 14

BETAPACE AF see sotalol hcl (afib/afl) .. 14

BETASERON .................... 25 betaxolol hcl ...................... 15 betaxolol hcl (ophth) ......... 42 bethanechol chloride ......... 36 BETHKIS ............................ 5 BETIMOL .......................... 42 BETOPTIC-S .................... 42 BEYAZ .............................. 29 BIAXIN

see clarithromycin ........... 9 BIAXIN XL

see clarithromycin ........... 9 bicalutamide ...................... 11 BICILLIN C-R ...................... 9 BICILLIN L-A ....................... 9 BICNU ............................... 10 BIDIL ................................. 17 BILTRICIDE ........................ 5 BINOSTO .......................... 28 bisoprolol & hydrochlorothiazide ........... 15 bisoprolol fumarate ........... 15 bleomycin sulfate .............. 11 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 41

blephamide ....................... 41 BLEPHAMIDE .................. 41 BONIVA ............................ 28

see ibandronate sodium 29 BOOSTRIX ....................... 38 BOSULIF .......................... 12 BOTOX ............................. 42 BREO ELLIPTA ................ 44 BREVICON-28

see necon 0.5/35 28 day ...................................... 30 see nortrel 0.5/35 28 day ...................................... 30

briellyn 28 day .................. 29 BRILINTA ......................... 37 BRIMONIDINE SOL 0.15%.......................................... 42 brimonidine sol 0.2% ........ 42 BRINTELLIX ..................... 20 BRISDELLE ...................... 24 BROMDAY ....................... 42 bromfenac sodium (ophth) 42 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) .. 42 bromocriptine mesylate ..... 21 BROVANA ........................ 43 budeprion .......................... 20 budesonide ....................... 34 budesonide (inhalation) .... 44 bumetanide ....................... 16 BUPHENYL

see sodium phenylbutyrate ...................................... 31

BUPHENYL TAB 500MG .. 31 buprenorphine hcl ............. 25 buprenorphine hcl-naloxone hcl sl ................................. 26 buproban .......................... 26 bupropion hcl .................... 20 buspirone hcl .................... 18 BUSULFEX ....................... 10 butorphanol nasal spray ..... 1 butorphanol tartrate ............ 1 BUTRANS .......................... 1 BYDUREON ..................... 26 BYETTA ............................ 26 BYSTOLIC ........................ 15


53

C cabergoline ....................... 32 cafergot tab 1-100mg ........ 24 CALAN

see verapamil hcl .......... 16 CALAN SR

see verapamil hcl .......... 16 calcipotriene ...................... 46 calcitonin (salmon) nasal spray ................................. 32 calcitriol ............................. 41 CALCITRIOL ..................... 46 calcium acetate (phosphate binder) ............................... 32 camila 28 day .................... 29 CAMPRAL ......................... 26

see acamprosate calcium ...................................... 25

CAMPTOSAR ................... 12 see irinotecan hcl .......... 12

CAMRESE LO TAB .......... 29 CANASA ........................... 34 CANCIDAS .........................6 candesartan cilexetil ......... 13 candesartan cilexetil-hydrochlorothiazide .......................................... 13 CANTIL ............................. 33 CAPASTAT SULFATE ........7 CAPEX .............................. 46 capital

and codeine .....................1 CAPRELSA ....................... 12 captopril ............................ 13 captopril & hydrochlorothiazide ........... 12 CARAC ............................. 45 CARAFATE ....................... 35

see sucralfate ................ 35 CARBAGLU ...................... 31 carbamazepine ................. 18 CARBATROL

see carbamazepine ....... 18 CARBIDOPA/LEVODOPA/ENTACA .............................. 21 carbidopa-levodopa .......... 21 carboplatin ........................ 12 CARDIZEM

see diltiazem hcl ............ 16 CARDIZEM CD

see cartia xt ................... 15 see dilt-cd ...................... 15 see diltiazem hcl coated beads ............................ 16

CARDIZEM LA .................. 15 see matzim la ................ 16

CARDURA see doxazosin mesylate 13

CARDURA XL ................... 36 CARIMUNE NANOFILTERED .............. 38 carisoprodol ...................... 25 CARMOL-HC

see u-cort ...................... 47 CARNITOR

see levocarnitine (metabolic modifiers) ..... 31

carteolol hcl (ophth) .......... 42 cartia xt ............................. 15 carvedilol ........................... 15 CASODEX

see bicalutamide ........... 11 CATAFLAM

see diclofenac potassium 1 CATAPRES

see clonidine hcl ............ 17 CATAPRES-TTS-1



see clonidine hcl ............ 17 CAYSTON ........................ 44 CEDAX ............................... 8 CEENU ............................. 10 cefaclor ............................... 8 cefaclor monohydrate ......... 8 cefadroxil ............................ 8 cefazolin inj ......................... 8 cefazolin sodium ................. 8 cefazolin/dextrose ............... 8 cefdinir ................................ 8 CEFEPIME 1GM SOLN ...... 8 CEFEPIME 2GM SOLN ...... 8 cefepime inj 1gm ................. 8 cefepime inj 2gm ................. 8

cefotaxime sodium .............. 8 cefotetan disodium .............. 8 cefoxitin sodium .................. 8 CEFOXITIN SODIUM IN DEXTROSE ........................ 8 cefpodoxime proxetil ........... 8 cefprozil .............................. 8 ceftazidime ......................... 8 CEFTAZIDIME/DEXTROSE............................................ 8 ceftibuten ............................ 8 CEFTIN ............................... 8

see cefuroxime axetil ...... 8 ceftriaxone sodium .............. 8 cefuroxime axetil ................. 8 cefuroxime sodium .............. 8 cefuroxime sodium 7.5mg soln ..................................... 8 CELEBREX ........................ 1 CELEXA

see citalopram hydrobromide ................ 20

CELLCEPT ....................... 38 see mycophenolate mofetil ...................................... 38

CELLCEPT INTRAVENOUS.......................................... 38 CELONTIN ....................... 18 CENTANY ........................ 45 cephalexin .......................... 8 CEREZYME ...................... 31 CERUBIDINE

see daunorubicin hcl ..... 10 CERVARIX ....................... 38 CESAMET ........................ 33 cetirizine syrup .................. 43 cevimeline hcl ................... 48 CHANTIX PAK 0.5& 1MG . 26 CHANTIX TAB 0.5MG ...... 26 CHANTIX TAB 1MG ......... 26 CHEMET .......................... 29 chlorhexidine gluconate (mouth-throat) ................... 48 chloroquine phosphate ....... 6 chlorothiazide ................... 16 chlorpromaz inj 25mg/ml ... 21 chlorpromazine hcl ............ 21 chlorthalidone ................... 16


54

chlorzoxazone ................... 25 cholestyramine .................. 14 cholestyramine light .......... 14 choline fenofibrate ............. 14 CHORIONIC GONADOTROPIN ............ 32 ciclopirox ........................... 45 ciclopirox cre 0.77% .......... 45 ciclopirox shampoo 1% ..... 45 ciclopirox sus 0.77% ......... 45 cidofovir...............................7 cilostazol ........................... 37 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 41

CILOXAN OIN 0.3% OP ... 41 cimetidine .......................... 34 cimetidine sol 300/5ml ...... 34 CIMZIA KIT ....................... 37 CIMZIA KIT STARTER ..... 37 CIMZIA PREFL KIT 200MG/ML ........................ 37 CIPRO ................................9

see ciprofloxacin hcl ........9 CIPRO HC ........................ 48 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w ..9 CIPRO XR

see ciprofloxacin er .........9 CIPRODEX ....................... 48 ciprofloxacin ........................9 ciprofloxacin er ....................9 ciprofloxacin hcl ..................9 ciprofloxacin hcl (ophth) .... 41 ciprofloxacin in d5w .............9 ciprofloxacn inj ....................9 cisplatin ............................. 12 citalopram hydrobromide... 20 cladribine........................... 11 claforan ...............................8 CLAFORAN

see cefotaxime sodium ....8 claravis .............................. 45 CLARINEX ........................ 43

see desloratadine .......... 43 CLARINEX REDITABS

see desloratadine .......... 43 CLARINEX-D .................... 43

clarithromycin .................. 8, 9 CLEOCIN

see clindamycin cre 2% vag ................................ 36 see clindamycin hcl ......... 5

CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 5

CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ................... 5

CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 5

CLEOCIN VAG SUPP 100MG .............................. 36 CLEOCIN-T

see clindamycin phosphate (topical) ........ 45

CLIMARA see estradiol .................. 31

CLINDAGEL ..................... 45 clindamycin cre 2% vag .... 36 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 5 clindamycin phosphate (topical) ............................. 45 clindamycin phosphate in d5w ..................................... 5 clindamycin phosphate-benzoyl peroxide .......................................... 45 CLINIMIX 2.75%/DEXTROSE 5% ..... 39 CLINIMIX 4.25%/DEXTROSE 10% ... 39 CLINIMIX 4.25%/DEXTROSE 20% ... 39 CLINIMIX 4.25%/DEXTROSE 25% ... 39 CLINIMIX 4.25%/DEXTROSE 5% ..... 39 CLINIMIX 5%/DEXTROSE 15%................................... 39 CLINIMIX 5%/DEXTROSE

20% .................................. 39 CLINIMIX 5%/DEXTROSE 25% .................................. 39 CLINIMIX E 2.75%/DEXTROSE 10% ... 40 CLINIMIX E 2.75%/DEXTROSE 5% ..... 39 CLINIMIX E 4.25%/DEXTROSE ........... 40 CLINIMIX E 4.25%/DEXTROSE 25% ... 40 CLINIMIX E 4.25%/DEXTROSE 5% ..... 40 CLINIMIX E 5%/DEXTROSE 15% .................................. 40 CLINIMIX E 5%/DEXTROSE 20% .................................. 40 CLINIMIX E 5%/DEXTROSE 25% .................................. 40 clinisol 15 .......................... 40 clobetasol propionate ........ 46 clobetasol propionate emollient base .................. 46 clobetasol propionate emulsion ........................... 46 CLOBEX ........................... 46

see clobetasol propionate ...................................... 46

CLODERM PUMP ............ 46 CLOLAR ........................... 11 clomipramine hcl ............... 20 clonazepam ...................... 18 clonidine hcl ...................... 17 clopidogrel bisulfate .......... 37 clorazepate dipotassium ... 18 clorpres 0.1/15 .................. 17 clorpres 0.2/15 .................. 17 clorpres 0.3/15 .................. 17 clotrimazole ...................... 48 clotrimazole (topical) ......... 45 CLOZAPINE ODT ............. 21 clozapine tab .................... 21 CLOZARIL

see clozapine tab .......... 21 COARTEM .......................... 6 codeine

and capital ....................... 1 CODEINE SULFATE .......... 3


55

COGENTIN see benztropine mesylate ...................................... 21

co-gesic 5-500mg ...............1 COLAZAL

see balsalazide disodium ...................................... 34

colchicine w/ probenecid .....1 COLCRYS ...........................1 COLESTID

see colestipol hcl ........... 14 colestipol hcl ..................... 14 colistimethate sodium .........5 colocort ............................. 34 COLY-MYCIN M

see colistimethate sodium ........................................5

COLY-MYCIN S ................ 48 COLYTE-FLAVOR PACKS .......................................... 34

see gavilyte-c ................ 34 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 34

COMBIGAN ...................... 42 COMBIPATCH .................. 31 COMBIVENT RESPIMAT . 43 COMBIVIR

see lamivudine-zidovudine ........................................7

COMETRIQ ....................... 12 COMPAZINE

see prochlorperazine maleate.......................... 33

COMPLERA ........................7 compro supp ..................... 33 COMTAN

see entacapone ............. 21 COMVAX .......................... 38 CONCERTA

see methylphenidate hcl er ...................................... 23

CONDYLOX ...................... 47 see podofilox ................. 48

constulose ......................... 34 CONZIP ..............................2 COPAXONE ...................... 25 COPEGUS

see moderiba tab 200mg . 7 see ribasphere ................ 8 see ribavirin tab 200mg ... 8

CORDARONE see amiodarone hcl ....... 14 see pacerone ................ 14

CORDRAN ........................ 46 COREG

see carvedilol ................ 15 COREG CR ...................... 15 CORGARD

see nadolol .................... 15 CORTEF

see hydrocortisone ........ 31 CORTENEMA

see colocort ................... 34 CORTIFOAM .................... 46 cortisone acetate .............. 31 CORTISPORIN ................. 45

see neomycin-polymyxin-hc (otic) .............................. 48

CORTISPORIN-TC ........... 48 CORZIDE

see nadolol & bendroflumethiazide ...... 15

COSMEGEN ..................... 11 COSOPT

see dorzolamide hcl-timolol maleate ........ 42

COSOPT PF ..................... 42 COUMADIN ...................... 36

see jantoven .................. 37 see warfarin sodium ...... 37

COUMADIN INJ ................ 36 COZAAR

see losartan potassium . 13 CREON ............................. 35 CRESTOR ........................ 14 CRINONE ......................... 32 CRIXIVAN ........................... 6 cromolyn sodium ............... 43 cromolyn sodium (mastocytosis) ................... 35 cromolyn sodium (ophth) .. 42 cryselle 28 ......................... 29 CUBICIN ............................. 5 CUTIVATE

see fluticasone propionate ...................................... 47

CUVPOSA ........................ 33 cyclafem 1/35 28 day ........ 29 cyclafem 7/7/7 28 day ....... 29 CYCLESSA

see velivet 28 day ......... 30 cyclobenzaprine hcl .......... 25 cyclophosphamide ............ 10 cyclosporine ...................... 38 cyclosporine modified (for microemulsion) ................. 38 CYKLOKAPRON

see tranexamic acid ...... 37 CYMBALTA ...................... 20

see duloxetine hcl ......... 20 cyproheptadine hcl............ 43 CYSTADANE .................... 31 CYSTAGON ..................... 31 cytarabine inj .................... 11 CYTOMEL

see liothyronine sodium 33 CYTOTEC

see misoprostol ............. 35 CYTOVENE

see ganciclovir inj 500mg 7 D D.H.E. 45

see dihydroergotamine mesylate ........................ 24

dacarbazine ...................... 10 DACOGEN ....................... 11

see decitabine ............... 11 DALIRESP ........................ 44 danazol ............................. 31 DANTRIUM

see dantrolene sodium .. 25 dantrolene sodium ............ 25 dapsone .............................. 5 DAPTACEL ....................... 39 DARAPRIM ......................... 5 daunorubicin hcl................ 10 DAYPRO

see oxaprozin .................. 1 DAYTRANA ...................... 23 DDAVP

see desmopressin acetate ...................................... 33


56

see desmopressin acetate inj ................................... 33 see desmopressin acetate spray ............................. 33

DECAVAC ......................... 39 decitabine.......................... 11 DELESTROGEN ............... 31

see estradiol valerate .... 31 DELZICOL ........................ 34 DEMADEX

see torsemide tabs ........ 17 demeclocycline hcl ............ 10 DEMSER........................... 17 DENAVIR .......................... 46 DEPACON

see valproate sodium .... 19 DEPAKENE

see valproate sodium .... 19 see valproic acid ............ 19

DEPAKOTE see divalproex sodium ... 18

DEPAKOTE ER see divalproex sodium ... 18

DEPAKOTE SPRINKLES see divalproex sodium ... 18

depo-estradiol ................... 31 DEPO-MEDROL ............... 31

see methylprednisolone acetate........................... 31

DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 30

DEPO-PROVERA INJ 400/ML .............................. 11 DEPO-SUBQ PROVERA 104 .................................... 29 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 26

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 47

DERMATOP see prednicarbate .......... 47

DERMOTIC see fluocinolone acetonide

(otic) .............................. 48 desipramine hcl ................. 20 desloratadine .................... 43 desmopressin acetate ....... 33 DESMOPRESSIN ACETATE .......................................... 33 desmopressin acetate inj .. 33 desmopressin acetate spray .......................................... 33 desmopressin acetate spray refrigerated ....................... 33 DESOGEN

see apri 28 day .............. 29 see emoquette .............. 29 see reclipsen 28 day ..... 30

DESONATE ...................... 46 desonide ........................... 46 DESONIDE ....................... 46 DESOWEN

see desonide ................. 46 desowen oint kit 0.05% ..... 46 desoximetasone ................ 46 DESOXIMETASONE ........ 46 DETROL

see tolterodine tartrate .. 36 DETROL LA ...................... 36 dexamethasone ................ 31 dexamethasone sodium phosphate ......................... 31 dexamethasone sodium phosphate (ophth) ............. 42 DEXILANT ........................ 35 dexpak taperpak 13 day.... 31 dexrazoxane ..................... 12 dextrose ............................ 40 DEXTROSE ...................... 40 DEXTROSE 10% FLEX CONTAIN .......................... 40 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 40 DEXTROSE 10%/NACL 0.45%................................ 40 DEXTROSE 2.5%/NACL 0.45%................................ 40 DEXTROSE 5% ................ 40 DEXTROSE 5% /ELECTROLYTE ............... 40

DEXTROSE 5%/LACTATED RING ................................. 40 DEXTROSE 5%/NACL 0.2%.......................................... 40 DEXTROSE 5%/NACL 0.225% ............................. 40 DEXTROSE 5%/NACL 0.3%.......................................... 40 DEXTROSE 5%/NACL 0.33% ............................... 40 DEXTROSE 5%/NACL 0.45% ............................... 40 DEXTROSE 5%/NACL 0.9%.......................................... 40 DEXTROSE 5%/POTASSIUM CHL ...... 40 DIAMOX

see acetazolamide ........ 16 diazepam .......................... 18 DIAZEPAM GEL ............... 18 diazepam inj ..................... 18 DIBENZYLINE .................. 17 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 45 diclofenac sodium (ophth) . 42 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ............. 9 dicyclomine hcl ................. 34 didanosine .......................... 6 DIFFERIN ......................... 45

see adapalene............... 44 DIFICID ............................... 9 diflorasone diacetate ......... 46 DIFLUCAN

see fluconazole ............... 6 diflunisal .............................. 1 digoxin .............................. 16 digoxin inj .......................... 16 DIGOXIN SOL 50MCG/ML.......................................... 16 dihydroergotamine mesylate.......................................... 24 DIHYDROERGOTAMINE MESYLATE ...................... 24 DILACOR XR

see dilt-xr ...................... 15


57

dilantin .............................. 18 DILANTIN.......................... 18

see phenytoin ................ 19 see phenytoin sodium extended........................ 19

DILANTIN INFATABS see phenytoin ................ 19

DILATRATE SR ................ 17 DILAUDID

see hydromorphone hcl ...3 DILAUDID-HP

see hydromorphone hcl ...3 DILAUDID-HP INJ ...............3 dilt-cd ................................ 15 diltiazem cap 120mg/24hr . 15 diltiazem cap er/12hr ......... 15 diltiazem hcl ................ 15, 16 diltiazem hcl coated beads 16 diltiazem hcl er .................. 16 diltiazem hcl extended release beads ................... 16 dilt-xr ................................. 15 diltzac ................................ 16 DIOVAN ............................ 13 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 13

DIPENTUM ....................... 34 diphenhydram inj 50mg/ml 43 diphenoxylate w/ atropine . 35 DIPHTHERIA/TETANUS TOXOID ............................ 39 DIPROLENE

see betamethasone dipropionate augmented 46

DIPROLENE AF see betamethasone dipropionate augmented 46

dipyridamole ...................... 37 disopyramide phosphate ... 14 disulfiram........................... 26 DITROPAN XL

see oxybutynin chloride . 36 DIURIL SUS 250/5ML ....... 16 divalproex sodium ............. 18 docetaxel........................... 11 DOCETAXEL .................... 11

DOLOPHINE see methadone hcl .......... 3

DOLOPHINE HCL see methadone hcl .......... 3

donepezil odt 10mg .......... 20 donepezil odt 5mg ............ 19 donepezil tab hcl 23mg ..... 20 donepezil tabs 10mg ......... 20 donepezil tabs 5mg ........... 20 DORIBAX ............................ 5 DORYX ............................. 10

see doxycycline hyclate . 10 dorzolamide hcl ................. 42 dorzolamide hcl-timolol maleate ............................. 42 DOVONEX

see calcipotriene ........... 46 doxazosin mesylate .......... 13 doxepin hcl ........................ 20 doxercalciferol ................... 41 DOXIL ............................... 10

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 10

doxorubicin hcl .................. 10 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ..... 10 doxycycline (monohydrate) .......................................... 10 doxycycline hyclate ........... 10 dronabinol ......................... 33 drospirenone-ethinyl estradiol ............................ 29 DROXIA ............................ 12 DUETACT

see pioglitazone hcl-glimepiride ............... 28

DUEXIS .............................. 1 DULERA ........................... 44 duloxetine hcl .................... 20 DUONEB

see ipratropium-albuterol ...................................... 43

DURAGESIC see fentanyl patch ........... 3

DURAMORPH .................... 3 DUREZOL ......................... 42 DUTOPROL ...................... 15

DYAZIDE see triamterene & hydrochlorothiazide cap 37.5-25 mg .................... 17

DYMISTA .......................... 44 DYRENIUM ...................... 16 E e.e.s. ................................... 9 E.E.S. GRANULES ............. 9 EC-NAPROSYN

see naproxen .................. 1 econazole nitrate .............. 45 EDARBI ............................ 13 EDARBYCLOR ................. 13 EDECRIN ......................... 16 EDLUAR ........................... 23 EDURANT .......................... 6 EFFEXOR XR

see venlafaxine cap er .. 21 EFFIENT ........................... 37 EFUDEX

see fluorouracil (topical) 45 EGRIFTA .......................... 32 ELAPRASE ....................... 31 ELDEPRYL

see selegiline hcl ........... 21 ELECTROLYTE-M IN DEXTROSE ...................... 40 ELECTROLYTE-R IN DEXTROSE ...................... 40 ELELYSO ......................... 31 ELESTAT

see epinastine hcl (ophth) ...................................... 42

ELIDEL CRE 1%............... 47 ELIGARD .......................... 11 ELIMITE

see permethrin .............. 48 ELIPHOS

see calcium acetate (phosphate binder) ........ 32

ELIQUIS ........................... 36 ELITEK ............................. 12 elixophyllin ........................ 44 ELLA ................................. 29 ELLENCE

see epirubicin inj 200mg 10 see epirubicin inj


58

50mg/25ml ..................... 10 ELMIRON.......................... 36 ELOCON

see mometasone furoate ...................................... 47

ELOXATIN ........................ 12 EMADINE.......................... 42 EMCYT ............................. 10 EMEND ............................. 33 EMEND PAK 80 & 125 ..... 33 EMLA

see lidocaine-prilocaine . 47 emoquette ......................... 29 EMSAM ............................. 20 EMTRIVA ............................6 ENABLEX ......................... 36 enalapril maleate ............... 13 enalapril maleate & hydrochlorothiazide ........... 13 ENBREL INJ 25/0.5ML ..... 37 ENBREL INJ 25MG .......... 37 ENBREL INJ 50MG/ML .... 37 ENBREL SURECLICK ...... 37 endocet 10/325 ...................3 endocet 5/325 .....................3 endocet 7.5/325 ..................3 ENDODAN ..........................3 ENDOMETRIN .................. 32 ENGERIX-B ...................... 39 enoxaparin sodium ............ 36 enpresse 28 day ............... 29 entacapone ....................... 21 ENTOCORT EC

see budesonide ............. 34 enulose ............................. 34 EPIDUO ............................ 45 epinastine hcl (ophth) ........ 42 EPIPEN 2-PAK ................. 44 EPIPEN-JR 2-PAK ............ 44 epirubicin inj 200mg .......... 10 EPIRUBICIN INJ 50MG .... 10 epirubicin inj 50mg/25ml ... 10 epitol ................................. 18 EPIVIR

see lamivudine ................7 EPIVIR HBV ........................7

see lamivudine ................7 EPIVIR SOL 10MG/ML .......6

eplerenone ........................ 13 EPOGEN .......................... 37 eprosartan mesylate ......... 13 EPZICOM ........................... 7 EQUETRO ........................ 24 ERAXIS ............................... 6 ERBITUX .......................... 11 ergomar ............................ 24 ERIVEDGE ....................... 11 errin 28 day ....................... 29 ERTACZO ......................... 45 ERYGEL

see erythromycin (acne aid) ................................ 45

ERYPED 200 ...................... 9 ERYPED 400 ...................... 9 ery-tab ................................. 9 erythrocin lactobionate ........ 9 erythrocin stearate .............. 9 erythromycin (acne aid) .... 45 erythromycin (ophth) ......... 41 erythromycin base .............. 9 erythromycin ethylsuccinate 9 erythromycin-sulfisoxazole .. 5 escitalopram oxalate ......... 20 esomeprazole sodium inj .. 35 estrace .............................. 31 ESTRACE

see estradiol .................. 31 estradiol ............................ 31 estradiol & norethindrone acetate .............................. 31 estradiol valerate .............. 31 ESTRADIOL VALERATE .. 31 ESTRING .......................... 31 estropipate ........................ 31 ESTROSTEP FE

see tri-legest 28 day ...... 30 ethambutol hcl .................... 7 ethosuximide ..................... 18 ETHYOL

see amifostine crystalline ...................................... 12

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 12 etoposide .......................... 12 EURAX ............................. 48

EVISTA ............................. 33 EVOCLIN

see clindamycin phosphate (topical) ........ 45

EVOXAC see cevimeline hcl ......... 48

EXALGO ............................. 3 EXELDERM ...................... 45 EXELON ........................... 20

see rivastigmine tartrate 20 EXELON PATCHES ......... 20 exemestane ...................... 11 EXFORGE ........................ 13 EXFORGE HCT ................ 13 EXJADE ............................ 29 EXTAVIA .......................... 25 EXTINA

see ketoconazole (topical) ...................................... 45

F FABIOR ............................ 45 FABRAZYME .................... 31 FACTIVE ............................ 9 famciclovir ........................... 7 famotidine ......................... 34 FAMVIR

see famciclovir ................ 7 FANAPT ........................... 21 FANAPT TITRATION PACK.......................................... 21 FARESTON ...................... 11 FARXIGA .......................... 27 FASLODEX ...................... 11 FAZACLO ......................... 21 felbamate .......................... 18 FELBATOL

see felbamate................ 18 FELDENE

see piroxicam .................. 1 felodipine .......................... 16 FEMARA

see letrozole .................. 11 FEMCON FE

see zenchent fe 28 day . 30 FEMRING ......................... 31 fenofibrate ......................... 14 fenofibrate micronized ...... 14 FENOFIBRATE


59

MICRONIZED ................... 14 FENOFIBRIC ACID ........... 14 FENOGLIDE ..................... 14 fenoprofen calcium ..............1 fentanyl citrate .....................3 fentanyl patch ......................3 FENTORA ...........................3 FERRIPROX ..................... 29 FETZIMA........................... 20 FETZIMA TITRATION PACK .......................................... 20 FEXMID

see cyclobenzaprine hcl 25 FINACEA .......................... 47 finasteride ......................... 36 FIRMAGON ....................... 11 FLAGYL ..............................5

see metronidazole ...........5 FLAGYL ER ........................5 FLAREX ............................ 42 FLEBOGAMMA ................. 38 FLEBOGAMMA DIF .......... 38 flecainide acetate .............. 14 FLOMAX

see tamsulosin hcl ......... 36 FLONASE

see fluticasone propionate (nasal) ........................... 44

FLO-PRED ........................ 31 FLOVENT DISKUS ........... 44 FLOVENT HFA ................. 44 fluconazole ..........................6 fluconazole in dextrose .......6 fluconazole in nacl 100mg...6 fluconazole in nacl 200mg...6 fluconazole in nacl 400mg...6 flucytosine ...........................6 FLUDARA

see fludarabine phosphate ...................................... 11

fludarabine phosphate ...... 11 fludrocortisone acetate ...... 31 FLUMADINE

see rimantadine hydrochloride ...................8

flunisolide (nasal) .............. 44 flunisolide nasal soln 29 mcg/act (0.025%) .............. 44

fluocinolone acetonide ...... 47 fluocinolone acetonide (otic) .......................................... 48 fluocinonide ....................... 47 fluocinonide emulsified base .......................................... 47 FLUOROMETHOLONE .... 42 FLUOROMETHOLONE (OPHTH) ........................... 42 fluorouracil ........................ 11 fluorouracil (topical) .......... 45 fluoxetine hcl ..................... 20 FLUOXETINE HCL ........... 20 fluphenazine decanoate .... 21 fluphenazine hcl ................ 22 flurbiprofen .......................... 1 flurbiprofen sodium ........... 42 flutamide ........................... 11 fluticasone propionate ....... 47 fluticasone propionate (nasal) ............................... 44 fluvastatin sodium ............. 14 fluvoxamine maleate ......... 18 fluvoxamine maleate er ..... 18 fluvoxamine tabs ............... 18 FML................................... 42 FML FORTE ..................... 42 fondaparinux sodium......... 36 FORADIL AEROLIZER ..... 43 FORFIVO XL .................... 20 FORTAMET

see metformin hcl .......... 28 FORTAZ ............................. 8

see ceftazidime ............... 8 see tazicef vial ................. 8

FORTEO ........................... 32 FORTESTA ....................... 26 FORTICAL SPR 200/ACT . 32 FOSAMAX

see alendronate sodium 28 FOSAMAX PLUS D .......... 29 foscarnet sodium ................ 7 fosinopril sodium ............... 13 fosinopril sodium & hydrochlorothiazide ........... 13 FOSRENOL ...................... 32 FRAGMIN ......................... 36 FREAMINE HBC 6.9% ...... 40

FREAMINE III ................... 40 FROVA TAB 2.5MG .......... 24 FURADANTIN

see nitrofurantoin ............ 5 furosemide ........................ 16 furosemide inj ................... 16 furosemide oral soln 8 mg/ml.......................................... 16 FUZEON ............................. 6 FYCOMPA ........................ 18 G gabapentin .................. 18, 19 GABITRIL ......................... 19

see tiagabine hcl ........... 19 galantamine hydrobromide 20 GAMASTAN S/D............... 38 GAMMAGARD LIQUID ..... 38 GAMMAGARD S/D ........... 38 GAMMAKED ..................... 38 GAMMAPLEX ................... 38 GAMUNEX ....................... 38 GAMUNEX-C .................... 38 GAMUNEX-C 1GM/10ML . 38 ganciclovir inj 500mg .......... 7 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 41

GARDASIL ....................... 39 GASTROCROM

see cromolyn sodium (mastocytosis) ............... 35

gatifloxacin (ophth) ........... 41 GATTEX ........................... 35 GAUZE PADS 2X2 ........... 26 gaviltye-g .......................... 34 gavilyte-c .......................... 34 gavilyte-n .......................... 34 GELNIQUE ....................... 36 GEMCITABINE ................. 11 gemcitabine hcl ................. 11 gemfibrozil ........................ 14 GEMZAR

see gemcitabine hcl ...... 11 GENERESS FE ................ 29 generlac ............................ 34 gengraf ............................. 38 GENOTROPIN.................. 32 GENOTROPIN MINIQUICK


60

.......................................... 32 gentak ............................... 41 gentamicin in saline 0.9mg/ml .............................5 gentamicin in saline 1.4mg/ml .............................5 gentamicin in saline 100mg.5 gentamicin in saline 60mg...5 gentamicin in saline 80mg...5 gentamicin sulfate ...............5 gentamicin sulfate (ophth) . 41 gentamicin sulfate (topical) .......................................... 45 GEODON

see ziprasidone hcl ........ 22 GEODON INJ .................... 22 GIANVI .............................. 29 GIAZO ............................... 34 gildagia ............................. 29 GILENYA .......................... 25 GILOTRIF ......................... 12 GLASSIA........................... 44 GLEEVEC ......................... 12 glimepiride......................... 27 glipizide ............................. 27 glipizide er ......................... 27 glipizide-metformin 2.5-250mg ......................... 27 glipizide-metformin 2.5-500mg ......................... 27 glipizide-metformin 5-500mg .......................................... 27 GLUCAGEN HYPOKIT ..... 32 GLUCAGON EMERGENCY KIT .................................... 32 GLUCOPHAGE

see metformin hcl .......... 28 GLUCOPHAGE XR

see metformin er ........... 28 GLUCOTROL

see glipizide ................... 27 GLUCOTROL XL

see glipizide er .............. 27 GLUCOVANCE

see glyburide-metformin 1.25-250mg ................... 27 see glyburide-metformin 2.5-500mg ..................... 27

see glyburide-metformin 5-500mg ........................ 27

GLUMETZA ...................... 27 glyburide ........................... 27 glyburide micronized ......... 27 glyburide-metformin 1.25-250mg ....................... 27 glyburide-metformin 2.5-500mg ......................... 27 glyburide-metformin 5-500mg ............................ 27 glycate .............................. 34 glycopyrrolate ................... 34 GLYNASE

see glyburide micronized ...................................... 27

GLYSET ............................ 27 GOLYTELY ....................... 34

see gaviltye-g ................ 34 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 34

GRALISE .......................... 24 GRALISE STARTER......... 24 granisetron hcl .................. 33 granisol ............................. 33 GRANIX ............................ 37 GRIFULVIN V

see griseofulvin microsize ........................................ 6

griseofulvin microsize.......... 6 griseofulvin ultramicrosize ... 6 GRIS-PEG

see griseofulvin ultramicrosize .................. 6

guanfacine hcl ................... 17 H HALAVEN ......................... 12 HALDOL

see haloperidol lactate .. 22 HALDOL DECANOATE 100

see haloperidol decanoate ...................................... 22

HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 22

HALFLYTELY BOWEL PREP/FLA ........................ 34

halobetasol propionate ..... 47 HALOG ............................. 47 haloperidol ........................ 22 haloperidol decanoate ...... 22 haloperidol lactate............. 22 HAVRIX ............................ 39 heather tab 0.35mg ........... 29 HECTOROL ...................... 41

see doxercalciferol ........ 41 HELIDAC .......................... 35 HEP SOD/NACL INJ 25000.......................................... 36 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 37 heparin sod inj 10000u/ml . 37 heparin sod inj 1000u/ml ... 37 heparin sod inj 20000u/ml . 37 HEPARIN SOD INJ 2000U/ML ......................... 37 HEPARIN SOD INJ 2500U/ML ......................... 37 heparin sod inj 5000u/0.5ml.......................................... 37 heparin sod inj 5000u/ml ... 37 HEPARIN SODIUM/D5W . 37 HEPARIN SODIUM/SODIUM CHL .... 37 HEPATAMINE .................. 40 hepatasol 8 ....................... 40 HEPSERA .......................... 7

see adefovir dipivoxil ....... 7 HERCEPTIN ..................... 11 HEXALEN ......................... 10 HIBERIX ........................... 39 HIPREX

see methenamine hippurate ......................... 5

HORIZANT ....................... 24 HUMALOG ....................... 26 HUMALOG KWIKPEN ...... 26 HUMALOG MIX 50/50 ...... 26 HUMALOG MIX 50/50 KWIKPEN ......................... 26 HUMALOG MIX 75/25 ...... 26 HUMALOG MIX 75/25 KWIKPEN ......................... 26 HUMATROPE ................... 32


61

HUMATROPE COMBO PACK ................................ 32 HUMIRA KIT 20MG/0.4 .... 37 HUMIRA KIT 40MG/0.8 .... 37 HUMIRA PEN KIT 40MG/0.8 .......................................... 37 HUMIRA PEN KIT CROHNS .......................................... 37 HUMIRA PEN KIT PSORIASI ......................... 37 HUMULIN 70/30 ................ 26 HUMULIN 70/30 PEN ....... 26 HUMULIN N ...................... 26 HUMULIN N U-100 PEN ... 26 HUMULIN R ...................... 26 HUMULIN R U-500 (CONCENTRATE) ............ 26 HYCAMTIN

see topotecan hcl .......... 12 HYCET

see hydrocodone-acetaminophen 7.5-325 mg/15ml ........2

hydralazine hcl .................. 17 HYDREA

see hydroxyurea ............ 12 hydrochlorothiazide ........... 16 hydrocodone-acetaminophen 10-300mg ............................2 hydrocodone-acetaminophen 10-500mg ............................2 hydrocodone-acetaminophen 10-650mg ............................2 hydrocodone-acetaminophen 10-660mg ............................2 hydrocodone-acetaminophen 10-750mg ............................2 hydrocodone-acetaminophen 2.5-325mg ...........................2 hydrocodone-acetaminophen 5-300mg ..............................2 hydrocodone-acetaminophen 5-325mg ..............................2 hydrocodone-acetaminophen 5-500mg ..............................2 hydrocodone-acetaminophen 7.5-300mg ...........................2 hydrocodone-acetaminophen

7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg ........................... 2 hydrocodone-acetaminophen 7.5-500mg ........................... 2 hydrocodone-acetaminophen 7.5-500mg/15ml .................. 2 hydrocodone-acetaminophen 7.5-650mg ........................... 2 hydrocodone-acetaminophen 7.5-750mg ........................... 2 hydrocodone-acetaminophen tab 10-325mg ...................... 2 hydrocodone-ibuprofen 2.5-200mg ........................... 2 hydrocodone-ibuprofen 7.5-200mg ........................... 2 hydrocortisone .................. 31 HYDROCORTISONE (INTRARECTAL) .............. 34 hydrocortisone (topical) ..... 47 hydrocortisone butyrate .... 47 hydrocortisone butyrate hydrophilic lipo base ......... 47 hydrocortisone valerate..... 47 hydromorphone hcl ............. 3 hydroxychloroquine sulfate .......................................... 37 hydroxyurea ...................... 12 hydroxyzine hcl ................. 43 hydroxyzine pamoate ........ 43 HYZAAR

see losartan potassium & hydrochlorothiazide ....... 13

I ibandronate sodium .......... 29 ibudone tab 5-200mg .......... 2 ibuprofen ............................. 1 ICLUSIG ........................... 12 IDAMYCIN PFS

see idarubicin hcl .......... 10 idarubicin hcl ..................... 10 IFEX

see ifosfamide ............... 10 IFEX INJ 3GM ................... 10 ifosfamide ......................... 10 IFOSFAMIDE

see ifosfamide ............... 10

IFOSFAMIDE FOR INJ 3 GM .................................... 10 ILEVRO ............................ 42 IMBRUVICA ...................... 12 IMDUR

see isosorbide mononitrate ................... 17

imipenem-cilastatin ............. 5 imipramine hcl .................. 20 imipramine pamoate ......... 20 imiquimod ......................... 47 IMITREX

see sumatriptan succinate ...................................... 24 see sumatriptan succinate inj .................................. 24

IMOVAX RABIES (H.D.C.V.).......................................... 39 IMURAN

see azathioprine ............ 38 INCIVEK TAB 375MG ......... 7 INCRELEX ........................ 32 indapamide ....................... 16 INDERAL LA

see propranolol hcl er .... 15 INFANRIX ......................... 39 INFERGEN ....................... 38 INFERGEN INJ 15MCG ... 38 INFERGEN INJ 9MCG ..... 38 INFUMORPH 200 ............... 3 INFUMORPH 500 ............... 3 INLYTA ............................. 12 INSPRA

see eplerenone ............. 13 INSULIN PEN NEEDLES . 26 INSULIN SAFETY NEEDLES ......................... 26 INSULIN SYRINGES ........ 26 INTELENCE ....................... 6 INTERMEZZO .................. 24 INTRALIPID INJ 20% ....... 40 INTRALIPID INJ 30% ....... 40 INTRON-A ........................ 38 INTRON-A W/DILUENT .... 38 introvale 91 day ................ 29 INTUNIV ........................... 23 INVANZ .............................. 5 INVEGA ............................ 22


62

INVEGA SUSTENNA ........ 22 INVIRASE ....................... 6, 7 INVOKANA ....................... 27 IONOSOL-B/DEXTROSE 5% ..................................... 40 IONOSOL-MB/DEXTROSE 5% ..................................... 40 IPOL INACTIVATED IPV .. 39 ipratropium bromide (nasal) .......................................... 43 ipratropium sol inhal .......... 43 ipratropium-albuterol ......... 43 irbesartan .......................... 13 irbesartan-hydrochlorothiazide ........................................ 13 IRESSA ............................. 12 irinotecan hcl ..................... 12 ISENTRESS ........................7 ISOLYTE P ....................... 40 isolyte s ............................. 40 isoniazid ..............................7 isoniazid tabs ......................7 ISOPTO CARPINE ........... 42 ISORDIL TITRADOSE ...... 17

see isosorbide dinitrate . 17 isosorbide dinitrate ............ 17 isosorbide dinitrate sl tab 2.5 mg ..................................... 17 isosorbide mononitrate ...... 17 isradipine........................... 16 ISTALOL ........................... 42 ISTODAX .......................... 11 itraconazole .........................6 IXEMPRA KIT ................... 12 IXIARO .............................. 39 J JAKAFI .............................. 12 JALYN ............................... 36 jantoven ............................ 37 JANUMET ......................... 27 JANUMET XR TAB 100-1000 ........................... 27 JANUMET XR TAB 50-1000 .......................................... 27 JANUMET XR TAB 50-500MG ......................... 27 JANUVIA ........................... 27 JENTADUETO .................. 28

jinteli.................................. 31 JOLIVETTE ....................... 29 junel 1.5/30 21 day ........... 29 junel 1/20 21 day .............. 29 junel fe 1.5/30 28 day........ 29 junel fe 1/20 28 day .......... 29 JUVISYNC ........................ 28 K KADCYLA ......................... 11 KADIAN .............................. 3

see morphine sulfate ....... 3 KALETRA SOL ................... 7 KALETRA TAB 100-25MG .. 7 KALETRA TAB 200-50MG .. 7 kariva 28 day .................... 29 KAYEXALATE

see kionex ..................... 29 KAZANO ........................... 28 KCL 0.075%/D5W/NACL 0.45%................................ 40 KCL 0.15%/D5W/LR ......... 40 KCL 0.15%/D5W/NACL 0.9%.................................. 40 kcl 0.3%/d5w/lr iv lac ri ...... 40 KCL 0.3%/D5W/NACL 0.45%................................ 40 KCL 0.3%/D5W/NACL 0.9% .......................................... 40 KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 40 kcl 20 meq/l (0.15%) in nacl 0.45% inj ........................... 40 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ ............... 40 KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 40 KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 40 KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ ................. 40 KCL0.15%/D5W/NACL0.2% .......................................... 40 KCL0.15%/D5W/NACL0.225% ...................................... 40 KEFLEX

see cephalexin ................ 8 kelnor 1/35 28 day ............ 29 KENALOG ........................ 47 KEPIVANCE ..................... 12 KEPPRA

see levetiracetam .......... 19 KEPPRA XR

see levetiracetam .......... 19 KERLONE

see betaxolol hcl ........... 15 ketoconazole ...................... 6 ketoconazole (topical) ....... 45 ketoconazole shampoo ..... 46 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 42 KINERET INJ .................... 37 kionex ............................... 29 KLARON

see sulfacetamide sodium (acne) ............................ 45

KLONOPIN see clonazepam ............ 18

KLOR-CON 10 .................. 39 KLOR-CON 8 .................... 39 klor-con m15 ..................... 39 klor-con m20 ..................... 39 klor-con pow 20meq ......... 39 KOMBIGLYZE XR 2.5-1000MG ...................... 28 KOMBIGLYZE XR 5-1000MG ......................... 28 KOMBIGLYZE XR 5-500MG.......................................... 28 kristalose .......................... 34 KUVAN ............................. 31 L labetalol hcl ....................... 15 LAC-HYDRIN

see ammonium lactate .. 47 see laclotion lotn 12% ... 47

laclotion lotn 12%.............. 47 LACRISERT ..................... 42 LACTATED RINGERS VIAFLEX ........................... 40 lactulose ........................... 34 lactulose (encephalopathy).......................................... 34


63

LAMICTAL see lamotrigine .............. 19

LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 19 LAMICTAL ODT ................ 19 LAMICTAL STARTER ....... 19 LAMICTAL XR .................. 19

see lamotrigine .............. 19 LAMISIL ..............................6

see terbinafine hcl ...........6 lamivudine ...........................7 lamivudine-zidovudine ........7 lamotrigine ........................ 19 LANOXIN .......................... 16

see digoxin .................... 16 see digoxin inj ................ 16

LANOXIN PEDIATRIC ...... 16 LANOXIN TAB .................. 16 lansoprazole ...................... 35 LANTUS ............................ 26 LANTUS SOLOSTAR ....... 26 LASIX

see furosemide .............. 16 LASTACAFT ..................... 42 latanoprost ........................ 42 LATUDA ............................ 22 LAZANDA ...........................3 LEENA .............................. 29 leflunomide ........................ 37 LESCOL

see fluvastatin sodium ... 14 LESCOL XL ...................... 14 lessina 28 day ................... 29 LETAIRIS .......................... 17 letrozole ............................ 11 leucovor ca inj ................... 12 leucovorin calcium ............ 12 LEUKERAN ....................... 10 LEUKINE........................... 37 leuprolide acetate .............. 11 levalbuterol conc 1.25mg/0.5ml .................... 43 levalbuterol hcl .................. 43 LEVALBUTEROL HCL ...... 43 LEVAQUIN

see levofloxacin ...............9 see levofloxacin in d5w....9

LEVATOL .......................... 15 LEVEMIR .......................... 26 LEVEMIR FLEXPEN ......... 26 levetiracetam .................... 19 levobunolol hcl .................. 42 LEVOBUNOLOL HCL ....... 42 levocarnitine (metabolic modifiers) .......................... 31 levocetirizine soln 2.5mg/5ml .......................................... 43 levocetirizine tab 5 mg ...... 43 levofloxacin ......................... 9 levofloxacin (ophth) ........... 41 levofloxacin in d5w .............. 9 levonest 28 day ................. 29 levonorgestrel (emergency oc) ..................................... 29 levonorgestrel-ethinyl estradiol (91-day) .............. 29 levora 0.15/30 28 day ....... 29 levorphanol tartrate ............. 3 levothyroxine sodium ........ 33 LEVOXYL ......................... 33 LEXAPRO

see escitalopram oxalate ...................................... 20

LEXIVA ............................... 7 LIALDA ............................. 34 lidocaine ............................ 47 lidocaine hcl ...................... 47 lidocaine hcl (local anesth.) . 4 lidocaine hcl (mouth-throat) .......................................... 48 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5% ................ 5 lidocaine inj 2% ................... 5 lidocaine-prilocaine ........... 47 LIDODERM ....................... 47

see lidocaine ................. 47 LINZESS CAP 145MCG ... 35 LINZESS CAP 290MCG ... 35 liothyronine sodium ........... 33 LIPITOR

see atorvastatin calcium 14 LIPOFEN .......................... 14 LIPTRUZET ...................... 14 lisinopril ............................. 13

lisinopril & hydrochlorothiazide ........... 13 lithium carbonate ........ 24, 25 LITHIUM CITRATE ........... 25 LITHOBID

see lithium carbonate .... 24 LIVALO ............................. 14 LO LOESTRIN FE ............ 29 LO MINASTRIN FE ........... 29 LOCOID ............................ 47

see hydrocortisone butyrate ......................... 47

LOCOID LIPOCREAM ...... 47 see hydrocortisone butyrate hydrophilic lipo base .............................. 47

LODOSYN ........................ 21 LOESTRIN 1.5/30-21

see junel 1.5/30 21 day . 29 see microgestin 1.5/30 21 day ................................ 30

LOESTRIN 1/20-21 see junel 1/20 21 day .... 29 see microgestin 1/20 21 day ................................ 30

LOESTRIN 24 FE ............. 29 LOESTRIN FE 1.5/30

see junel fe 1.5/30 28 day ...................................... 29 see microgestin fe 1.5/30 28 day ........................... 30

LOESTRIN FE 1/20 see junel fe 1/20 28 day 29 see microgestin fe 1/20 28 day ................................ 30

LOFIBRA see fenofibrate .............. 14 see fenofibrate micronized ...................................... 14

LOKARA LOTN 0.05% ..... 47 lomedia 24 fe .................... 29 LOMOTIL

see diphenoxylate w/ atropine ......................... 35

LOMUSTINE ..................... 10 loperamide hcl .................. 35 LOPID

see gemfibrozil .............. 14


64

LOPRESSOR see metoprolol tartrate .. 15

LOPRESSOR HCT see metoprolol & hctz tab 100-25mg ...................... 15 see metoprolol & hctz tab 50-25mg ........................ 15

LOPROX see ciclopirox ................. 45

LOPROX SHAMPOO see ciclopirox shampoo 1% ................................. 45

lorazepam ......................... 18 lortab elx 10-300mg ............2 loryna 28 day .................... 29 losartan potassium ............ 13 losartan potassium & hydrochlorothiazide ........... 13 LOTEMAX ......................... 42 LOTENSIN

see benazepril hcl ......... 13 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 12

LOTREL see amlodipine besylate-benazepril hcl .. 12

LOTRONEX ...................... 35 lovastatin ........................... 14 LOVAZA ............................ 14 LOVENOX

see enoxaparin sodium . 36 low-ogestrel 28 day ........... 29 loxapine succinate ............ 22 LOXITANE

see loxapine succinate .. 22 LUFYLLIN ......................... 44 LUMIGAN.......................... 42 LUMIZYME ....................... 31 LUNESTA ......................... 24 LUPR DEP-PED INJ 11.25MG (3-MONTH) ....... 11 LUPR DEP-PED INJ 30MG (3-MONTH) ....................... 11 LUPRON DEPOT .............. 11 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 11 LUPRON DEPOT INJ 30MG

(3-MONTH) ....................... 11 LUPRON DEPOT-PED ..... 11 lutera 28 day ..................... 29 LUVOX CR

see fluvoxamine maleate er ................................... 18

LUXIQ see betamethasone valerate ......................... 46

LYRICA ............................. 19 LYSODREN ...................... 11 LYSTEDA

see tranexamic acid ...... 37 lyza ................................... 30 M MACROBID

see nitrofurantoin monohyd macro .............. 5

MACRODANTIN ................. 5 see nitrofurantoin macrocrystal .................... 5

mafenide acetate .............. 45 magnesium sulfate ............ 39 MAGNESIUM SULFATE ... 39 MAGNESIUM SULFATE IN D5W 1% ............................ 39 MAGNESIUM SULFATE IN D5W 2% ............................ 39 MALARONE

see atovaquone-proguanil hcl tab 250-100 mg.......... 6

malathion .......................... 48 maprotiline hcl ................... 20 MARINOL

see dronabinol ............... 33 marlissa 28 day ................. 30 MARPLAN ........................ 20 MATULANE ...................... 12 matzim la .......................... 16 MAVIK

see trandolapril .............. 13 MAXALT

see rizatriptan benzoate 24 MAXALT-MLT

see rizatriptan benzoate 24 MAXIDEX .......................... 42 MAXIPIME .......................... 8

see cefepime inj 1gm ...... 8

see cefepime inj 2gm ...... 8 MAXITROL

see neomycin-polymy-dexameth .................................... 41

MAXZIDE see triamterene & hydrochlorothiazide tab 75-50 mg ....................... 17

MAXZIDE-25 see triamterene & hydrochlorothiazide tab 37.5-25 mg .................... 17

meclizine hcl ..................... 33 MEDROL .......................... 31

see methylprednisolone 31 MEDROL DOSEPAK

see methylprednisolone 31 medroxyprogesterone acetate .............................. 32 medroxyprogesterone acetate (contraceptive) ..... 30 mefenamic acid................... 1 mefloquine hcl .................... 6 MEGACE ES .................... 11 MEGACE ORAL

see megestrol acetate ... 12 megestrol acetate ............. 12 MEKINIST ......................... 12 MELOXICAM SUSP 7.5 MG/5ML .............................. 1 meloxicam tabs ................... 1 melphalan hcl ................... 10 MENACTRA ..................... 39 menest .............................. 31 MENHIBRIX ...................... 39 MENOMUNE-A/C/Y/W-135.......................................... 39 MENOSTAR ..................... 31 MENTAX ........................... 45 MENVEO .......................... 39 MEPRON ............................ 5 mercaptopurine ................. 11 meropenem ........................ 5 MERREM

see meropenem .............. 5 mesalamine enema .......... 34 mesalamine enema kit ...... 34


65

mesna ............................... 12 MESNEX ........................... 12

see mesna ..................... 12 MESTINON

see pyridostigmine bromide ......................... 25

MESTINON SYRUP .......... 25 MESTINON TIMESPAN .... 25 METADATE CD

see methylphenidate hcl 23 metadate tab 20mg er ....... 23 metformin er ...................... 28 metformin hcl .................... 28 methadone hcl ....................3 METHADONE INJ 10MG/ML ............................................3 METHADOSE

see methadone hcl ..........3 methazolamide .................. 16 methenamine hippurate ......5 METHERGINE

see methylergonovine maleate.......................... 32

methimazole ...................... 33 methocarbamol ................. 25 methotrexate sodium inj .... 11 methotrexate sodium tabs . 37 methscopolamine bromide 34 methyclothiazide ............... 16 methylergonovine maleate 32 METHYLIN

see methylphenidate hcl 23 METHYLIN CHEW TAB .... 23 methylphenidate hcl .......... 23 methylphenidate hcl er ...... 23 METHYLPHENIDATE HCL ER ..................................... 23 methylphenidate tab 10mg er .......................................... 23 methylphenidate tab 20mg er .......................................... 23 methylprednisolone ........... 31 methylprednisolone acetate .......................................... 31 methylprednisolone sod succ .......................................... 31 metipranolol ...................... 42 metoclopramide hcl ........... 33

metoclopramide hcl inj 5 mg/ml ................................ 33 metolazone ....................... 16 metoprolol & hctz tab 100-25mg .......................... 15 metoprolol & hctz tab 100-50mg .......................... 15 metoprolol & hctz tab 50-25mg ............................ 15 metoprolol succinate ......... 15 metoprolol tartrate ............. 15 METOZOLV ODT ............. 33 METRO IV .......................... 5 METROCREAM

see metronidazole (topical) ......................... 47 see rosadan cre 0.75% . 48

METROGEL ...................... 47 see metronidazole (topical) ......................... 47

METROGEL-VAGINAL see metronidazole vaginal ...................................... 36

METROLOTION see metronidazole (topical) ......................... 47

metronidazole ..................... 5 metronidazole (topical)...... 47 metronidazole gel 0.75% .. 47 metronidazole inj ................. 5 metronidazole vaginal ....... 36 MEVACOR

see lovastatin ................ 14 mexiletine hcl .................... 14 MIACALCIN

see calcitonin (salmon) nasal spray .................... 32

MIACALCIN INJ 200U/ML 32 MICARDIS ........................ 13 MICARDIS HCT ................ 13 miconazole nitrate vaginal 36 microgestin 1.5/30 21 day . 30 microgestin 1/20 21 day .... 30 microgestin fe 1.5/30 28 day .......................................... 30 microgestin fe 1/20 28 day 30 MICRO-K

see potassium chloride

caps er .......................... 39 MICROZIDE

see hydrochlorothiazide 16 midodrine hcl .................... 17 migergot ............................ 24 millipred ............................ 31 MINASTRIN 24 FE ........... 30 MINIPRESS

see prazosin hcl ............ 13 minitran ............................. 17 MINIVELLE ....................... 31 MINOCIN

see minocycline hcl ....... 10 minocycline hcl ................. 10 minoxidil ............................ 17 MIRAPEX ......................... 21

see pramipexole dihydrochloride .............. 21

MIRAPEX ER ................... 21 MIRCETTE

see kariva 28 day .......... 29 see pimtrea pack ........... 30 see viorele ..................... 30

mirtazapine ....................... 20 misoprostol ....................... 35 mitomycin ......................... 11 mitoxantrone hcl ............... 12 M-M-R II W/DILUENT 10 DOS .................................. 39 MOBIC

see meloxicam tabs ........ 1 modafinil ........................... 25 moderiba pak ...................... 7 moderiba tab 200mg ........... 7 moexipril hcl ...................... 13 moexipril-hydrochlorothiazide........................................ 13 mometasone furoate ......... 47 MONODOX

see doxycycline (monohydrate) ............... 10

MONONESSA .................. 30 montelukast sodium .......... 43 MORPHINE SUL 20MG/ML ORAL SOL .......................... 3 morphine sulfate ................. 3 MORPHINE SULFATE ... 3, 4 morphine sulfate beads cap


66

sr .........................................4 morphine sulfate ext-rel tab.4 morphine sulfate inj .............4 MORPHINE SULFATE INJ .4 MOVIPREP ....................... 34 MOXATAG ..........................9 MOXEZA ........................... 41 MOZOBIL .......................... 37 MS CONTIN

see morphine sulfate ext-rel tab ........................4

MULTAQ ........................... 14 mupirocin .......................... 45 mupirocin calcium (topical) 45 MUSTARGEN ................... 10 my way .............................. 30 MYAMBUTOL

see ethambutol hcl ..........7 MYCAMINE .........................6 MYCOBUTIN ......................7 mycophenolate mofetil ...... 38 mycophenolate sodium ..... 38 MYFORTIC ....................... 38

see mycophenolate sodium ........................... 38

myorisan ........................... 45 MYOZYME ........................ 31 MYRBETRIQ ..................... 36 MYSOLINE

see primidone ................ 19 myzilra .............................. 30 N nabumetone ........................1 nadolol .............................. 15 nadolol & bendroflumethiazide .......... 15 nafcillin sodium ...................9 NAFTIN ............................. 45 NAGLAZYME .................... 31 NALFON .............................1 NALLPEN ISO-OSMOTIC IN DE .......................................9 NALLPEN/DEXTROSE .......9 naloxone hcl ...................... 26 naltrexone hcl .................... 26 NAMENDA ........................ 20 NAMENDA TITRATION PAK .......................................... 20

NAMENDA XR .................. 20 NAMENDA XR TITRATION PACK ................................ 20 naphazoline 0.1% ............. 42 NAPRELAN ........................ 1 NAPROSYN

see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 naratriptan hcl ................... 24 NARDIL

see phenelzine sulfate ... 21 NASONEX ........................ 44 NATACYN ......................... 41 nateglinide ........................ 28 NAVELBINE

see vinorelbine tartrate .. 11 NEBUPENT ........................ 5 necon 0.5/35 28 day ......... 30 necon 1/35 28 day ............ 30 NECON 1/50-28 ................ 30 necon 10/11 28 day .......... 30 NECON 7/7/7 .................... 30 nefazodone hcl ................. 20 neomycin sulfate ................. 5 neomycin/polymyxin b gu .. 48 neomycin-bacitracin zn-polymyxin ..................... 41 neomycin-polymy-dexameth .......................................... 41 neomycin-polymy-gramicid .......................................... 41 neomycin-polymyxin-hc (ophth) .............................. 41 neomycin-polymyxin-hc (otic) .......................................... 48 NEORAL ........................... 38

see cyclosporine modified (for microemulsion)........ 38 see gengraf ................... 38

NEOSPORIN see neomycin-polymy-gramicid ...................................... 41

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 48

NEPHRAMINE .................. 40

NEPTAZANE see methazolamide ....... 16

NESINA ............................ 28 NEULASTA ....................... 37 NEUMEGA ....................... 37 NEUPOGEN ..................... 37 NEUPRO .......................... 21 NEURONTIN

see gabapentin........ 18, 19 NEVANAC ........................ 42 nevirapine ........................... 7 NEVIRAPINE ...................... 7 NEXAVAR ........................ 12 NEXIUM ............................ 35 NEXIUM GRANULES 10MG DR .................................... 35 NEXIUM GRANULES 2.5MG DR .................................... 35 NEXIUM GRANULES 20MG DR .................................... 35 NEXIUM GRANULES 40MG DR .................................... 35 NEXIUM GRANULES 5MG DR .................................... 35 NEXIUM I.V. ..................... 35

see esomeprazole sodium inj .................................. 35

next choice tab 1.5mg ....... 30 niacin (antihyperlipidemic) 14 niacor ................................ 14 NIASPAN .......................... 15

see niacin (antihyperlipidemic) ....... 14

nicardipine hcl ................... 16 NICOTROL INHALER ....... 26 NICOTROL NS ................. 26 nifediac ............................. 16 nifedical ............................ 16 nifedipine .......................... 16 nifedipine er ...................... 16 NILANDRON .................... 12 nimodipine ........................ 16 NIPENT

see pentostatin .............. 11 nisoldipine ......................... 16 nitro-bid ............................. 17 NITRO-DUR ..................... 17

see minitran .................. 17


67

nitrofurantoin .......................5 nitrofurantoin macrocrystal ..5 nitrofurantoin monohyd macro ..................................5 NITROGLYCERIN ............ 17 NITROGLYCERIN LINGUAL .......................................... 17 nitroglycerin patches ......... 17 NITROLINGUAL SPR PUMPSPRA ...................... 17 NITROMIST ...................... 17 NITROSTAT ...................... 17 nizatidine ........................... 34 NIZORAL

see ketoconazole shampoo ........................ 46

NORA-BE.......................... 30 NORCO

see hydrocodone-acetaminophen 5-325mg .....................2 see hydrocodone-acetaminophen 7.5-325mg ..................2 see hydrocodone-acetaminophen tab 10-325mg .............2

NORDITROPIN FLEXPRO .......................................... 32 NORDITROPIN NORDIFLEX PEN ............. 32 norethindrone (contraceptive) .................. 30 norethindrone acetate ....... 32 norgestimate-ethinyl estradiol (triphasic) ............ 30 NORINYL 1+35

see cyclafem 1/35 28 day ...................................... 29 see necon 1/35 28 day .. 30 see nortrel 1/35 21 day .. 30 see nortrel 1/35 28 day .. 30 see pirmella 1/35 28 day ...................................... 30

NORINYL 1+50 ................. 30 NORITATE ........................ 47 normosol-m ....................... 40 NORMOSOL-R ................. 40

NOROXIN ........................... 9 NORPACE

see disopyramide phosphate ..................... 14

NORPACE CR .................. 14 NORPRAMIN

see desipramine hcl ...... 20 NOR-QD

see camila 28 day ......... 29 see heather tab 0.35mg 29 see norethindrone (contraceptive) .............. 30

nortrel 0.5/35 28 day ......... 30 nortrel 1/35 21 day ............ 30 nortrel 1/35 28 day ............ 30 nortrel 7/7/7 28 day ........... 30 nortriptyline hcl .................. 20 NORVASC

see amlodipine besylate 15 NORVIR .............................. 7 NOVAREL INJ 10000UNT 32 NOVOLIN 70/30 ................ 26 NOVOLIN 70/30 RELION . 26 NOVOLIN N ...................... 26 NOVOLIN N RELION ........ 26 NOVOLIN R ...................... 27 NOVOLIN R RELION ........ 27 NOVOLOG ........................ 27 NOVOLOG FLEXPEN ...... 27 NOVOLOG MIX 70/30 ...... 27 NOVOLOG MIX 70/30 PREFILL ........................... 27 NOXAFIL ............................ 6 NUCYNTA .......................... 4 NUCYNTA ER .................... 4 NUEDEXTA ...................... 25 NULOJIX ........................... 38 NULYTELY/FLAVOR PACKS .............................. 34

see gavilyte-n ................ 34 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 34 see trilyte ....................... 35

NUTROPIN ....................... 32 NUTROPIN AQ NUSPIN 5 32 NUTROPIN AQ PEN......... 32

NUVARING ....................... 30 NUVIGIL ........................... 25 nyamyc ............................. 45 NYMALIZE ........................ 16 nystatin ............................... 6 nystatin (mouth-throat) ...... 48 nystatin (topical)................ 45 nystatin pow 100000 ......... 46 nystop ............................... 46 O OCELLA ........................... 30 OCTAGAM ....................... 38 octreotide acetate ............. 32 OCUFEN

see flurbiprofen sodium . 42 OCUFLOX

see ofloxacin (ophth) ..... 41 ofloxacin (ophth) ............... 41 ofloxacin (otic) .................. 48 ogestrel 28 day ................. 30 olanzapine ........................ 22 olanzapine odt .................. 22 OLEPTRO ........................ 20 OLUX


OLUX-E see clobetasol propionate emulsion ........................ 46

OMECLAMOX-PAK .......... 35 omeprazole ....................... 35 omeprazole cap 20mg ...... 35 OMNARIS ......................... 44 OMNITROPE 10MG ......... 32 OMNITROPE 5.8MG ........ 32 OMNITROPE 5MG ........... 32 ondansetron hcl ................ 33 ondansetron hcl inj............ 33 ondansetron hcl oral soln .. 33 ondansetron odt ................ 33 ONFI ................................. 19 ONFI SUS 2.5MG/ML ....... 19 ONGLYZA ........................ 28 ONMEL ............................... 6 OPANA

see oxymorphone hcl ...... 4 OPANA ER (CRUSH RESISTANT ....................... 4


68

OPSUMIT.......................... 17 OPTIPRANOLOL

see metipranolol ............ 42 OPTIVAR

see azelastine hcl (ophth) ...................................... 42

ORACEA ........................... 47 ORAP ................................ 22 ORAPRED

see prednisolone sodium phosphate ...................... 32

ORAPRED ODT ................ 31 ORENCIA INJ 125MG/ML. 37 ORENCIA INJ 250MG ...... 37 ORFADIN .......................... 31 orsythia 28 day .................. 30 ORTHO EVRA .................. 30 ORTHO MICRONOR

see errin 28 day ............. 29 see lyza ......................... 30

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 30 see tri-previfem 28 day .. 30 see tri-sprintec 28 day ... 30

ORTHO TRI-CYCLEN LO . 30 ORTHO-CYCLEN

see previfem 28 day ...... 30 see sprintec 28 day ....... 30

ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ...................................... 29 see nortrel 7/7/7 28 day . 30

OSENI TAB 12.5-15MG .... 28 OSENI TAB 12.5-30MG .... 28 OSENI TAB 12.5-45MG .... 28 OSENI TAB 25-15MG ....... 28 OSENI TAB 25-30MG ....... 28 OSENI TAB 25-45MG ....... 28 OSMOPREP ..................... 34 OVCON-35

see balziva 28 day ......... 29 see briellyn 28 day ........ 29 see gildagia ................... 29 see philith ...................... 30 see vyfemla ................... 30 see zenchent 28 day ..... 30

OVIDE

see malathion ................ 48 oxacillin sodium .................. 9 oxaliplatin .......................... 12 OXANDRIN

see oxandrolone ............ 26 oxandrolone ...................... 26 oxaprozin ............................ 1 oxcarbazepine .................. 19 OXECTA ............................. 4 OXISTAT .......................... 46 OXSORALEN ................... 48 OXSORALEN ULTRA ....... 46 OXTELLAR XR ................. 19 oxybutynin chloride ........... 36 oxycodone hcl ..................... 4 OXYCODONE HCL ............ 4 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 10-650mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 4 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 5-500mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone w/ acetaminophen 7.5-500mg . 4 oxycodone-aspirin ............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone hcl ................ 4 OXYTROL ......................... 36 P pacerone ........................... 14 paclitaxel ........................... 11 PAMELOR

see nortriptyline hcl ....... 20 pamidronate disodium....... 29 PAMINE

see methscopolamine bromide ......................... 34

PAMINE FORTE see methscopolamine bromide ......................... 34

PANCREAZE .................... 35

PANDEL ........................... 47 PANRETIN ....................... 48 pantoprazole sodium ........ 35 PARAFON FORTE DSC

see chlorzoxazone ........ 25 paricalcitol ......................... 41 PARLODEL ...................... 21

see bromocriptine mesylate ........................ 21

PARNATE see tranylcypromine sulfate ........................... 21

paromomycin sulfate ........... 5 paroxetine er tab ............... 20 paroxetine hcl ................... 20 paser d/r ............................. 7 PATADAY ......................... 42 PATANASE ...................... 43 PATANOL ......................... 42 PAXIL ............................... 21

see paroxetine hcl ......... 20 PAXIL CR

see paroxetine er tab .... 20 PCE .................................... 9 PEDIAPRED

see prednisolone sodium phosphate ..................... 32

pedi-dri .............................. 46 PEDVAX HIB .................... 39 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 34 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 34 PEGANONE ..................... 19 PEGASYS INJ .................. 38 PEGASYS INJ 180MCG/M.......................................... 38 PEGASYS INJ PROCLICK.......................................... 38 PEGASYS KIT .................. 38 PEG-INTRON KIT 120 RP 38 PEG-INTRON KIT 150 RP 38 PEG-INTRON KIT 50MCG 38 PEG-INTRON KIT 50MCG RP ..................................... 38 PEG-INTRON KIT 80MCG RP ..................................... 38


69

PENICILLIN G POT IN DEXTROSE ........................9 penicillin g potassium ........ 10 PENICILLIN G POTASSIUM .......................................... 10 penicillin g procaine .......... 10 penicillin g sodium ............. 10 penicillin v potassium ........ 10 PENNSAID ........................ 48 PENTAM 300 ......................6 PENTASA ......................... 34 pentostatin ........................ 11 pentoxifylline ..................... 37 PEPCID

see famotidine ............... 34 PERCOCET

see endocet 10/325 .........3 see endocet 5/325 ...........3 see endocet 7.5/325 ........3 see oxycodone w/ acetaminophen 10-325mg ........................................4 see oxycodone w/ acetaminophen 10-650mg ........................................4 see oxycodone w/ acetaminophen 2.5-325mg ........................................4 see oxycodone w/ acetaminophen 5-325mg .4 see oxycodone w/ acetaminophen 7.5-325mg ........................................4 see oxycodone w/ acetaminophen 7.5-500mg ........................................4 see roxicet tab 5-325mg ..4

PERCODAN see oxycodone-aspirin ....4

PERFOROMIST ................ 43 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 48 see periogard sol 0.12% 48

perindopril erbumine ......... 13 periogard sol 0.12% .......... 48 permethrin ......................... 48

perphenazine .................... 22 PERSANTINE

see dipyridamole ........... 37 PERTZYE ......................... 35 PEXEVA ........................... 21 pfizerpen ........................... 10 phenadoz .......................... 33 phenelzine sulfate ............. 21 PHENERGAN

see promethazine hcl .... 33 phenobarbital .................... 19 phenobarbital sodium........ 19 PHENOBARBITAL SODIUM .......................................... 19 phenytek ........................... 19 PHENYTEK

see phenytoin sodium extended ....................... 19

phenytoin .......................... 19 phenytoin inj 50mg/ml ....... 19 phenytoin sodium extended .......................................... 19 philith ................................ 30 PHISOHEX ....................... 45 PHOSLO

see calcium acetate (phosphate binder) ........ 32

PHOSLYRA ...................... 32 PHOSPHOLINE IODIDE ... 42 PICATO ............................ 45 PILOCARPINE HCL.......... 42 pilocarpine hcl (oral).......... 48 PILOPINE HS ................... 42 pimtrea pack ..................... 30 pindolol ............................. 15 pioglitazone hcl ................. 28 pioglitazone hcl-glimepiride .......................................... 28 pioglitazone hcl-metformin hcl ..................................... 28 piperacillin sodium-tazobactam sodium .......................................... 10 pirmella 1/35 28 day ......... 30 piroxicam ............................ 1 PLAN B

see levonorgestrel (emergency oc) ............. 29

PLAN B ONE-STEP see levonorgestrel (emergency oc) ............. 29 see my way ................... 30 see next choice tab 1.5mg ...................................... 30

PLAQUENIL see hydroxychloroquine sulfate ........................... 37

PLASMA-LYTE A.............. 40 PLASMA-LYTE-148 .......... 40 PLASMA-LYTE-56/D5W ... 40 PLAVIX

see clopidogrel bisulfate 37 PLETAL

see cilostazol................. 37 podofilox ........................... 48 polyethylene glycol 3350 .. 35 polymyxin b sulfate ............. 6 polymyxin b-trimethoprim .. 41 POLYTRIM

see polymyxin b-trimethoprim ............... 41

POMALYST CAP .............. 12 PONSTEL

see mefenamic acid ........ 1 portia 28 day ..................... 30 potassium chloride ...... 39, 41 POTASSIUM CHLORIDE . 39 POTASSIUM CHLORIDE 0.15% ............................... 41 POTASSIUM CHLORIDE 0.22% ............................... 41 POTASSIUM CHLORIDE 0.3%/D .............................. 41 potassium chloride caps er.......................................... 39 potassium chloride microencapsulated crystals cr ....................................... 39 POTASSIUM CITRATE (ALKALINIZER) ................ 36 POTIGA ............................ 19 PRADAXA ........................ 37 pramipexole dihydrochloride.......................................... 21 PRANDIMET .................... 28 PRANDIN ......................... 28


70

see repaglinide .............. 28 PRAVACHOL

see pravastatin sodium.. 14 pravastatin sodium ............ 14 prazosin hcl ....................... 13 PRECOSE

see acarbose ................. 27 PRED MILD ...................... 42 PRED-G ............................ 41 PRED-G S.O.P. ................ 41 prednicarbate .................... 47 PREDNICARBATE ........... 47 prednisolone ..................... 31 PREDNISOLONE ACETATE .......................................... 42 prednisolone sodium phosphate ......................... 32 prednisolone sodium phosphate (ophth) ............. 42 prednisone ........................ 32 PREGNYL W/DILUENT BENZYL ............................ 32 PRELONE

see prednisolone ........... 31 PREMARIN ....................... 31 PREMARIN CREAM ......... 31 PREMARIN INJ ................. 31 premasol 10% ................... 40 premasol 6% ..................... 40 PREMPHASE ................... 31 PREMPRO ........................ 31 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 41 PREPOPIK ........................ 35 PREVACID

see lansoprazole ........... 35 PREVACID SOLUTAB ...... 35 prevalite ............................ 15 previfem 28 day ................ 30 PREVPAC ......................... 35

see amoxicillin-clarithromycin w/ lansoprazole ............. 35

PREZISTA ..........................7 PRIFTIN ..............................7 PRILOSEC

see omeprazole ............. 35

see omeprazole cap 20mg ...................................... 35

PRIMAQUINE PHOSPHATE ............................................ 6 PRIMAXIN IV

see imipenem-cilastatin ... 5 primidone .......................... 19 PRIMSOL SOL 50MG/5ML . 6 PRINIVIL

see lisinopril .................. 13 PRISTIQ ........................... 21 PRIVIGEN ......................... 38 PROAIR HFA .................... 43 probenecid .......................... 1 PROCALAMINE ................ 40 PROCARDIA XL

see nifedical .................. 16 see nifedipine er ............ 16

prochlorperazine inj 5 mg/ml .......................................... 33 prochlorperazine maleate . 33 prochlorperazine supp ...... 33 PROCRIT .......................... 37 proctocream ...................... 46 procto-pak ......................... 46 proctozone hc ................... 46 PROCYSBI ....................... 31 progesterone micronized .. 33 PROGLYCEM ................... 32 PROGRAF ........................ 38

see tacrolimus ............... 38 PROLASTIN-C .................. 44 PROLENSA ...................... 42 PROLEUKIN ..................... 11 PROLIA ............................. 32 PROMACTA ..................... 37 promethazine hcl .............. 33 promethegan ..................... 33 PROMETRIUM

see progesterone micronized ..................... 33

propafenone hcl ................ 14 proparacaine hcl ............... 42 propranolol & hydrochlorothiazide ........... 15 propranolol hcl er .............. 15 propranolol inj 1mg/ml....... 15 propranolol sol .................. 15

propranolol tab .................. 15 propylthiouracil ................. 33 PROQUAD ....................... 39 PROSCAR

see finasteride ............... 36 PROSOL ........................... 40 PROTONIX ....................... 35

see pantoprazole sodium ...................................... 35

PROTOPIC OIN 0.03% .... 48 PROTOPIC OIN 0.1% ...... 48 protriptyline hcl ................. 21 PROVENTIL HFA ............. 43 PROVERA

see medroxyprogesterone acetate .......................... 32

PROVIGIL see modafinil ................. 25

PROZAC see fluoxetine hcl .......... 20

PROZAC WEEKLY see fluoxetine hcl .......... 20

PRUDOXIN CRE 5% ........ 46 PULMICORT

see budesonide (inhalation) .................... 44

PULMICORT FLEXHALER.......................................... 44 PULMICORT INH SUSP ... 44 PULMOZYME ................... 44 PURINETHOL

see mercaptopurine ...... 11 PYLERA ........................... 35 pyrazinamide ...................... 7 pyridostigmine bromide ..... 25 Q QNASL ............................. 44 QUALAQUIN

see quinine sulfate .......... 6 QUARTETTE .................... 30 quasense 91 day .............. 30 QUESTRAN

see cholestyramine ....... 14 QUESTRAN LIGHT

see prevalite .................. 15 quetiapine fumarate .......... 22 QUILLIVANT XR ............... 23 quinapril hcl ...................... 13


71

quinapril-hydrochlorothiazide .......................................... 13 quinidine gluconate er ....... 14 quinidine sulfate ................ 14 quinine sulfate .....................6 QVAR ................................ 44 R RABAVERT ....................... 39 rabeprazole sodium .......... 36 ramipril .............................. 13 RANEXA ........................... 17 ranitidine hcl ...................... 34 RAPAFLO ......................... 36 RAPAMUNE ...................... 38

see sirolimus tab 0.5 mg 38 RAYOS ............................. 32 RAZADYNE

see galantamine hydrobromide ................ 20

RAZADYNE ER see galantamine hydrobromide ................ 20

REBETOL see ribasphere .................8 see ribavirin cap 200mg ..8

REBETOL SOL 40MG/ML ..7 REBIF ............................... 25 REBIF TITRATION PACK . 25 reclipsen 28 day ................ 30 RECOMBIVAX HB ............ 39 RECTIV ............................. 48 REGLAN

see metoclopramide hcl. 33 REGONOL ........................ 25 REGRANEX ...................... 48 RELENZA DISKHALER ......8 RELISTOR ........................ 35 RELPAX ............................ 24 REMERON

see mirtazapine ............. 20 REMERON SOLTAB

see mirtazapine ............. 20 REMICADE INJ 100MG .... 37 REMODULIN .................... 17 RENAGEL ......................... 32 RENVELA ......................... 32 repaglinide ........................ 28 REPREXAIN

see hydrocodone-ibuprofen 2.5-200mg ....................... 2 see ibudone tab 5-200mg 2

reprexain 10/200 ................. 2 REQUIP

see ropinirole hydrochloride ................. 21

REQUIP XL see ropinirole hydrochloride ................. 21

RESCRIPTOR .................... 7 RESTASIS ........................ 43 RETIN-A

see tretinoin ................... 45 RETROVIR

see zidovudine ................ 7 RETROVIR IV INFUSION ... 7 REVATIO

see sildenafil citrate (pulmonary hypertension) ...................................... 17

REVIA see naltrexone hcl ......... 26

REVLIMID ......................... 38 REYATAZ ........................... 7 RHEUMATREX ................. 37 RHINOCORT AQUA ......... 44 ribapak mis 600/day ............ 8 ribasphere ........................... 8 ribasphere ribapak 1000 ..... 8 ribasphere ribapak 1200 ..... 8 ribasphere ribapak 800 ....... 8 ribavirin cap 200mg ............ 8 ribavirin tab 200mg ............. 8 RIFADIN

see rifampin ..................... 7 rifamate ............................... 7 rifampin ............................... 7 RIFATER ............................ 7 RILUTEK ........................... 25

see riluzole .................... 25 riluzole .............................. 25 rimantadine hydrochloride ... 8 RINGER'S ......................... 41 RIOMET ............................ 28 RISPERDAL

see risperidone .............. 22

RISPERDAL CONSTA ..... 22 RISPERDAL M-TAB

see risperidone odt ........ 22 risperidone ........................ 22 risperidone odt .................. 22 RITALIN

see methylphenidate hcl 23 RITALIN LA ...................... 23

see methylphenidate hcl 23 RITALIN SR

see metadate tab 20mg er ...................................... 23 see methylphenidate tab 20mg er ......................... 23

RITUXAN .......................... 11 rivastigmine tartrate .......... 20 rizatriptan benzoate .......... 24 ROBAXIN

see methocarbamol ....... 25 ROBAXIN-750

see methocarbamol ....... 25 ROBINUL

see glycopyrrolate ......... 34 ROBINUL FORTE

see glycopyrrolate ......... 34 ROCALTROL

see calcitriol .................. 41 ROCEPHIN

see ceftriaxone sodium ... 8 ropinirole hydrochloride .... 21 rosadan cre 0.75% ............ 48 ROTATEQ ........................ 39 ROWASA

see mesalamine enema kit ...................................... 34

roxicet soln ......................... 4 roxicet tab 5-325mg ............ 4 ROXICODONE

see oxycodone hcl .......... 4 ROZEREM ........................ 24 RYTHMOL

see propafenone hcl ...... 14 RYTHMOL SR

see propafenone hcl ...... 14 S SABRIL ............................. 19 SAIZEN ............................. 32 SAIZEN CLICK.EASY ....... 32


72

SALAGEN see pilocarpine hcl (oral) ...................................... 48

SAMSCA ........................... 32 SANCTURA

see trospium chloride .... 36 SANCTURA XR

see trospium chloride .... 36 SANCUSO ........................ 33 SANDIMMUNE

see cyclosporine ............ 38 SANDIMMUNE CAPS ....... 38 SANDIMMUNE SOLN ....... 38 SANDOSTATIN

see octreotide acetate ... 32 SANDOSTATIN LAR DEPOT ............................. 32 SANTYL ............................ 48 SAPHRIS .......................... 22 SARAFEM ......................... 26 SAVELLA .......................... 25 SAVELLA TITRATION PACK ................................ 25 SEASONIQUE

see amethia 91 day ....... 29 SECTRAL

see acebutolol hcl .......... 15 selegiline hcl ..................... 21 selenium sulfide ................ 46 SELZENTRY .......................7 SEMPREX-D ..................... 43 SENSIPAR ........................ 29 SEREVENT DISKUS ........ 43 seromycin............................7 SEROQUEL

see quetiapine fumarate 22 SEROQUEL XR ................ 22 SEROSTIM ....................... 32 sertraline hcl ...................... 21 SF-ROWASA .................... 34 SIGNIFOR ......................... 32 sildenafil citrate (pulmonary hypertension) .................... 17 SILENOR .......................... 24 SILVER SULFADIAZINE... 45 SIMBRINZA ...................... 42 SIMCOR............................ 15 SIMPONI ........................... 37

SIMPONI ARIA ................. 37 SIMPONI INJ 50MG.......... 37 SIMULECT ........................ 38 simvastatin ........................ 14 SINEMET

see carbidopa-levodopa 21 SINEMET CR

see carbidopa-levodopa 21 SINGULAIR

see montelukast sodium 43 sirolimus tab 0.5 mg .......... 38 SIRTURO ............................ 7 SKLICE ............................. 48 SOD FLUORIDE 2.2MG TAB ................................... 39 SODIUM CHLORIDE .. 39, 41 SODIUM CHLORIDE 0.45% VIA .................................... 41 SODIUM CHLORIDE 0.9% .......................................... 48 sodium phenylbutyrate ...... 31 sodium polystyrene sulfonate .......................................... 29 SOLARAZE ....................... 45

see diclofenac sodium (actinic keratoses) ......... 45

SOLIA ............................... 30 SOLODYN ........................ 10 SOLTAMOX ...................... 12 SOLU-CORTEF

see a-hydrocort inj 100mg ...................................... 31

SOLU-CORTEF 1000MG . 32 SOLU-CORTEF 100MG ... 32 SOLU-CORTEF 250MG ... 32 SOLU-CORTEF 500MG ... 32 SOLU-MEDROL ............... 32

see methylprednisolone sod succ ........................ 31

SOMA see carisoprodol ............ 25

SOMATULINE DEPOT ..... 32 SOMAVERT ...................... 32 SONATA

see zaleplon .................. 24 SORIATANE ..................... 46

see acitretin ................... 46 SORILUX .......................... 46

sorine ................................ 14 sotalol hcl .......................... 14 sotalol hcl (afib/afl) ............ 14 SPIRIVA HANDIHALER ... 43 spironolactone .................. 13 spironolactone & hydrochlorothiazide ........... 17 SPORANOX

see itraconazole .............. 6 SPORANOX SOL 10MG/ML............................................ 6 sprintec 28 day ................. 30 SPRYCEL ......................... 12 sps sus 15gm/60ml ........... 29 sronyx 28 day ................... 30 SSD .................................. 45 stagesic 500-5mg ............... 2 STARLIX

see nateglinide .............. 28 stavudine ............................ 7 STAVZOR ......................... 19 STELARA INJ 45MG/0.5 .. 46 STELARA INJ 90MG/ML .. 46 STERILE WATER IRRIGATION ..................... 48 STIMATE .......................... 33 STIVARGA ....................... 12 STRATTERA .................... 23 streptomycin sulfate ............ 5 STRIANT .......................... 26 STRIBILD ........................... 7 STROMECTOL ................... 6 SUBOXONE MIS 12-3MG 26 SUBOXONE MIS 2-0.5MG.......................................... 26 SUBOXONE MIS 4-1MG .. 26 SUBOXONE MIS 8-2MG .. 26 SUBSYS ............................. 4 SUCLEAR ......................... 35 SUCRAID ......................... 35 sucralfate .......................... 35 SULAR

see nisoldipine .............. 16 sulfacetamide sodium (acne).......................................... 45 sulfacetamide sodium (ophth) .............................. 41 sulfacetamide


73

sod-prednisolone .............. 41 sulfadiazine .........................5 sulfamethoxazole-trimethoprim .........................................6 sulfamethoxazole-trimethoprim inj ....................................6 SULFAMYLON .................. 45

see mafenide acetate .... 45 sulfasalazine dr ................. 34 sulfasalazine ir .................. 34 sulindac ...............................1 sumatriptan succinate ....... 24 SUMATRIPTAN SUCCINATE ..................... 24 sumatriptan succinate inj .. 24 SUMATRIPTAN SUCCINATE INJ ............... 24 SUMAVEL DOSEPRO ...... 24 suprax .................................8 SUPRAX .............................8 SUPREP BOWEL PREP... 35 SURMONTIL ..................... 21 SUSTIVA.............................7 SUTENT............................ 12 syeda ................................ 30 SYLATRON ....................... 12 SYMBICORT ..................... 44 SYMLINPEN 120 .............. 27 SYMLINPEN 60 ................ 27 SYNAGIS .......................... 39 SYNALAR

see fluocinolone acetonide ...................................... 47

SYNALGOS-DC ..................2 SYNAREL ......................... 31 SYNERA ........................... 47 SYNERCID .........................6 SYNTHROID ..................... 33

see levothyroxine sodium ...................................... 33

SYPRINE .......................... 29 T TABLOID........................... 11 TACLONEX ....................... 47 tacrolimus.......................... 38 TAFINLAR ......................... 12 TAMIFLU.............................8 tamoxifen citrate ................ 12

tamsulosin hcl ................... 36 TAPAZOLE

see methimazole ........... 33 TARCEVA ......................... 12 TARGRETIN ............... 12, 48 TARKA .............................. 13 TASIGNA .......................... 12 TAXOTERE ...................... 11 tazicef vial ........................... 8 TAZORAC ......................... 46 taztia xt ............................. 16 TECFIDERA CAP 120MG 25 TECFIDERA CAP 240MG 25 TECFIDERA MIS STARTER .......................................... 25 TEFLARO ........................... 8 TEGRETOL ...................... 19

see carbamazepine ....... 18 see epitol ....................... 18

TEGRETOL-XR ................ 19 see carbamazepine ....... 18

TEKAMLO ......................... 16 TEKTURNA ...................... 16 TEKTURNA HCT .............. 16 TELMISARTAN ................. 13 telmisartan-amlodipine ...... 13 TEMOVATE


TEMOVATE E see clobetasol propionate emollient base ............... 46

TENEX see guanfacine hcl ........ 17

TENIVAC .......................... 39 TENORETIC 100

see atenolol & chlorthalidone ................ 15

TENORETIC 50 see atenolol & chlorthalidone ................ 15

TENORMIN see atenolol ................... 15

TERAZOL 3 see terconazole vaginal . 36

TERAZOL 7 see terconazole vaginal . 36 see zazole ..................... 36

terazosin hcl ..................... 13 terbinafine hcl ..................... 6 terbutaline sulfate ............. 43 terconazole vaginal ........... 36 TESTIM ............................ 26 testosterone cypionate ...... 26 testosterone enanthate ..... 26 TETANUS TOXOID ADSORBED ..................... 39 TETANUS/DIPHTHERIA TOXOID ............................ 39 TETRACYCLINE HCL ...... 10 TEVETEN ......................... 13

see eprosartan mesylate ...................................... 13

TEVETEN HCT ................. 13 TEV-TROPIN .................... 32 texacort ............................. 47 THALOMID ....................... 38 theo-24 ............................. 44 theophylline ...................... 44 THERMAZENE ................. 45 thioridazine hcl .................. 22 thiotepa ............................. 10 thiothixene ........................ 22 THYMOGLOBULIN ........... 38 tiagabine hcl ..................... 19 TIAZAC

see diltiazem hcl er ....... 16 see diltiazem hcl extended release beads................ 16 see diltzac ..................... 16 see taztia xt ................... 16

TIKOSYN CAP 125MCG .. 14 TIKOSYN CAP 250MCG .. 14 TIKOSYN CAP 500MCG .. 14 TIMENTIN ......................... 10 TIMENTIN INJ 3.1GM ....... 10 timolol maleate ................. 15 timolol maleate (ophth) ..... 42 TIMOLOL MALEATE GEL 42 TIMOPTIC

see timolol maleate (ophth) ........................... 42

TIMOPTIC OCUDOSE ..... 42 TIROSINT ......................... 33 TIVICAY .............................. 7 tizanidine .......................... 25


74

TOBI see tobramycin ................5

TOBI NEB ...........................5 TOBI PODHALER ...............5 TOBRADEX ...................... 41

see tobramycin-dexamethasone .................................... 41

TOBRADEX ST ................. 41 tobramycin ..........................5 tobramycin sulfate ...............5 tobramycin sulfate (ophth). 41 tobramycin sulfate in saline .5 tobramycin-dexamethasone .......................................... 41 TOBREX

see tobramycin sulfate (ophth) ........................... 41

TOBREX OINT 0.3% ........ 41 TOFRANIL

see imipramine hcl ........ 20 TOFRANIL-PM

see imipramine pamoate ...................................... 20

tolmetin sodium ...................1 tolterodine tartrate ............. 36 TOLTERODINE TARTRATE ER ..................................... 36 TOPAMAX

see topiramate ............... 19 TOPAMAX SPRINKLE

see topiramate ............... 19 TOPICORT ....................... 47

see desoximetasone ..... 46 topiramate ......................... 19 toposar .............................. 12 topotecan hcl ..................... 12 TOPROL XL

see metoprolol succinate ...................................... 15

TORISEL........................... 11 torsemide inj ...................... 17 torsemide tabs .................. 17 TOVIAZ ............................. 36 TPN ELECTROLYTES ..... 39 TRACLEER ....................... 17 TRADJENTA ..................... 28 tramadol hcl er ....................2

TRAMADOL HCL ER .......... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 3 tramadol hcl tab 50 mg ....... 3 tramadol-acetaminophen .... 3 TRANDATE

see labetalol hcl ............ 15 trandolapril ........................ 13 tranexamic acid ................. 37 TRANSDERM-SCOP ........ 33 TRANXENE T

see clorazepate dipotassium ................... 18

tranylcypromine sulfate ..... 21 travasol 10 ........................ 40 TRAVATAN Z ................... 42 trazodone hcl .................... 21 TREANDA ......................... 10 TRECATOR ........................ 7 TRELSTAR DEPOT MIXJECT .......................... 12 TRELSTAR LA MIXJECT . 12 TRELSTAR MIXJECT ....... 12 tretinoin ....................... 12, 45 TRETINOIN MICROSPHERE ............... 45 tretin-x ............................... 45 trexall ................................ 37 TREXIMET ........................ 24 triamcinolone acetonide (mouth) ............................. 48 triamcinolone acetonide (nasal) ............................... 44 triamcinolone acetonide (topical) ............................. 47 triamterene & hydrochlorothiazide cap 37.5-25 mg ........................ 17 triamterene & hydrochlorothiazide cap 50-25 mg ........................... 17 triamterene & hydrochlorothiazide tab 37.5-25 mg ........................ 17

triamterene & hydrochlorothiazide tab 75-50 mg .......................... 17 TRIBENZOR ..................... 13 TRICOR

see fenofibrate .............. 14 triderm .............................. 47 trifluoperazine hcl.............. 22 trifluridine .......................... 41 TRIGLIDE ......................... 15 trihexyphenidyl hcl ............ 21 tri-legest 28 day ................ 30 TRILEPTAL ...................... 19

see oxcarbazepine ........ 19 TRILIPIX ........................... 15

see choline fenofibrate .. 14 trilyte ................................. 35 trimethoprim ........................ 6 trimipramine maleate ........ 21 TRINESSA ........................ 30 TRI-NORINYL 28

see aranelle 28.............. 29 TRIOSTAT

see liothyronine sodium 33 tri-previfem 28 day ............ 30 TRISENOX ....................... 12 tri-sprintec 28 day ............. 30 trivora 28 day .................... 30 TRIZIVIR ............................. 7

see abacavir sulfate-lamivudine-zidovudine ................................... 7

TROKENDI XR ................. 19 TROPHAMINE .................. 40 trospium chloride .............. 36 TRUSOPT

see dorzolamide hcl ...... 42 TRUVADA .......................... 7 TUDORZA PRESSAIR ..... 43 TWINRIX .......................... 39 TWYNSTA ........................ 13

see telmisartan-amlodipine ...................................... 13

TYGACIL ............................ 6 TYKERB ........................... 12 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ........................... 1


75

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................1

TYPHIM VI ........................ 39 TYSABRI........................... 25 TYZEKA ..............................8 tyzine ................................ 44 U UCERIS ............................ 34 u-cort ................................. 47 ULESFIA ........................... 48 ULORIC ..............................1 ULTRACET

see tramadol-acetaminophen .3

ULTRAM see tramadol hcl tab 50 mg ...................................3

ULTRAM ER see tramadol hcl er ..........2

ULTRAVATE see halobetasol propionate ..................... 47

ULTRESA ......................... 35 UNASYN

see ampicillin & sulbactam sodium .............................9

UNASYN BULK PACK see ampicillin & sulbactam sodium .............................9

UNIRETIC see moexipril-hydrochlorothiazide .................................. 13

UNITHROID ...................... 33 UNIVASC

see moexipril hcl ............ 13 URECHOLINE

see bethanechol chloride ...................................... 36

UROCIT-K ......................... 36 UROXATRAL

see alfuzosin hcl ............ 36 URSO 250

see ursodiol ................... 35 URSO FORTE

see ursodiol ................... 35 ursodiol ............................. 35

UVADEX ........................... 12 V VAGIFEM .......................... 31 valacyclovir hcl .................... 8 VALCHLOR ...................... 48 VALCYTE ........................... 8 VALIUM

see diazepam ................ 18 valproate sodium .............. 19 valproic acid ...................... 19 valsartan-hydrochlorothiazide ........................................ 13 VALTREX

see valacyclovir hcl ......... 8 VANCOCIN HCL

see vancomycin hcl ......... 6 vancomycin hcl ................... 6 VANDAZOLE .................... 36 VANOS ............................. 47

see fluocinonide ............ 47 VAQTA .............................. 39 VARIVAX .......................... 39 VASCEPA ......................... 15 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 13

VASOTEC see enalapril maleate .... 13

VECTIBIX ......................... 11 VELCADE ......................... 11 velivet 28 day .................... 30 VELTIN ............................. 45 venlafaxine cap er ............. 21 VENLAFAXINE HCL ER

see venlafaxine tab er ... 21 venlafaxine tab .................. 21 VENLAFAXINE TAB 225MG ER ..................................... 21 venlafaxine tab er ............. 21 VENTAVIS ........................ 17 VENTOLIN HFA ................ 43 VERAMYST ...................... 44 verapamil hcl ..................... 16 VERAPAMIL HCL ............. 16 VERELAN

see verapamil hcl .......... 16 VERELAN PM

see verapamil hcl .......... 16

veripred ............................. 32 VERSACLOZ .................... 22 VESICARE ....................... 36 vestura .............................. 30 VEXOL .............................. 42 VFEND

see voriconazole ............. 6 VFEND IV

see voriconazole inj 200mg ............................. 6

VFEND SUS 40MG/ML ...... 6 VIBATIV .............................. 6 VIBRAMYCIN ................... 10

see doxycycline (monohydrate) ............... 10 see doxycycline hyclate 10

vicodin ................................ 3 vicodin es ............................ 3 vicodin hp ........................... 3 VICOPROFEN

see hydrocodone-ibuprofen 7.5-200mg ....................... 2

VICTOZA .......................... 27 VICTRELIS CAP 200MG .... 8 VIDAZA ............................. 11

see azacitidine .............. 11 VIDEX EC

see didanosine ................ 6 VIDEX PEDIATRIC ............. 7 VIGAMOX ......................... 41 VIIBRYD ........................... 21 VIMOVO ............................. 1 VIMPAT ............................ 19 vinblastine sulfate ............. 11 vincasar ............................ 11 vincristine sulfate .............. 11 vinorelbine tartrate ............ 11 VIOKACE 10440 UNIT ..... 35 VIOKACE 20880 UNIT ..... 35 viorele ............................... 30 VIRACEPT .......................... 7 VIRAMUNE ......................... 7

see nevirapine ................. 7 VIRAMUNE XR ................... 7 VIREAD .............................. 7 VIROPTIC

see trifluridine ................ 41


76

VISICOL ............................ 35 VISTARIL

see hydroxyzine pamoate ...................................... 43

VISTIDE see cidofovir ....................7

VIVACTIL see protriptyline hcl ....... 21

VIVELLE-DOT ................... 31 VIVITROL.......................... 26 VOLTAREN GEL 1% ........ 48 VOLTAREN-XR

see diclofenac sodium .....1 voriconazole ........................6 voriconazole inj 200mg .......6 VOSOL HC

see acetasol hc ............. 48 see acetic acid sol/hc .... 48

VOSPIRE ER see albuterol sulfate er .. 43

VOTRIENT ........................ 12 VPRIV ............................... 31 vyfemla ............................. 30 VYTORIN .......................... 15 VYVANSE ......................... 23 W warfarin sodium ................. 37 WELCHOL ........................ 15 WELLBUTRIN

see bupropion hcl .......... 20 WELLBUTRIN SR

see budeprion ................ 20 see bupropion hcl .......... 20

WELLBUTRIN XL see bupropion hcl .......... 20

WESTCORT see hydrocortisone valerate.......................... 47

X XALATAN

see latanoprost .............. 42 XALKORI .......................... 12 XANAX

see alprazolam ........ 17, 18 XARELTO ......................... 37 XELJANZ .......................... 38 XENAZINE ........................ 25 XEOMIN ............................ 43

XERESE ........................... 46 XGEVA ............................. 32 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 35 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 2 see hydrocodone-acetaminophen 5-300mg ..................... 2 see hydrocodone-acetaminophen 7.5-300mg .................. 2 see vicodin ...................... 3 see vicodin es ................. 3 see vicodin hp ................. 3

XOLAIR ............................. 44 XOPENEX

see levalbuterol hcl........ 43 XOPENEX CONCENTRATE

see levalbuterol conc 1.25mg/0.5ml ................ 43

XOPENEX HFA ................ 43 XTANDI ............................. 12 XYLOCAINE

see lidocaine hcl ............ 47 see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 1%......... 5 see lidocaine inj 2%......... 5

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 0.5% ...... 5 see lidocaine inj 1%......... 5 see lidocaine inj 1.5% ...... 5 see lidocaine inj 2%......... 5

XYREM ............................. 25 XYZAL

see levocetirizine soln 2.5mg/5ml ..................... 43 see levocetirizine tab 5 mg ...................................... 43

Y YASMIN 28

see drospirenone-ethinyl estradiol ......................... 29

see syeda ...................... 30 see zarah ...................... 30

YAZ see loryna 28 day .......... 29 see vestura ................... 30

YF-VAX ............................. 39 Z zafirlukast ......................... 43 zaleplon ............................ 24 zamicet ............................... 3 ZANAFLEX

see tizanidine ................ 25 ZANOSAR ........................ 10 ZANTAC

see ranitidine hcl ........... 34 zarah ................................. 30 ZARONTIN

see ethosuximide .......... 18 ZAROXOLYN

see metolazone ............. 16 ZAVESCA ......................... 31 zazole ............................... 36 ZAZOLE ............................ 36 ZEBETA

see bisoprolol fumarate . 15 ZEGERID .......................... 36 ZELAPAR ......................... 21 ZELBORAF ....................... 12 ZEMAIRA .......................... 44 ZEMPLAR ......................... 41

see paricalcitol .............. 41 zenatane ........................... 45 zenchent 28 day ............... 30 zenchent fe 28 day ........... 30 ZENPEP ........................... 35 ZERIT

see stavudine .................. 7 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 13

ZESTRIL see lisinopril .................. 13

ZETIA ............................... 15 ZETONNA ........................ 44 ZIAC

see bisoprolol & hydrochlorothiazide ....... 15

ZIAGEN .............................. 7


77

see abacavir sulfate ........6 ZIANA ............................... 45 zidovudine ...........................7 ZINACEF.............................8

see cefuroxime sodium....8 ZINECARD

see dexrazoxane ........... 12 ZIOPTAN .......................... 42 ziprasidone hcl .................. 22 ZIPSOR...............................1 ZIRGAN ............................ 41 ZITHROMAX

see azithromycin .............8 ZMAX ..................................9 ZOCOR

see simvastatin .............. 14 ZOFRAN

see ondansetron hcl ...... 33 see ondansetron hcl inj.. 33 see ondansetron hcl oral soln ................................ 33

ZOFRAN ODT see ondansetron odt ...... 33

zoledronic inj 4mg/5ml ...... 29

ZOLINZA ........................... 11 zolmitriptan ....................... 24 zolmitriptan odt ................. 24 ZOLOFT

see sertraline hcl ........... 21 zolpidem tartrate ............... 24 ZOLPIMIST ....................... 24 ZOMETA ........................... 29

see zoledronic inj 4mg/5ml ...................................... 29

ZOMIG .............................. 24 see zolmitriptan ............. 24

ZOMIG NASAL SPRAY .... 24 ZOMIG ZMT ...................... 24

see zolmitriptan odt ....... 24 ZONALON ........................ 46 ZONEGRAN

see zonisamide ............. 19 zonisamide ........................ 19 ZORBTIVE ........................ 32 ZORTRESS ...................... 38 ZORVOLEX ........................ 1 ZOSTAVAX ....................... 39 ZOSYN ............................. 10

see piperacillin sodium-tazobactam sodium .......................... 10

zovia 1/35e 28 day............ 31 zovia 1/50e 28 day............ 31 ZOVIRAX .......................... 46

see acyclovir ................... 7 see acyclovir topical ...... 46

ZUBSOLV ......................... 26 ZYBAN

see buproban ................ 26 ZYCLARA ......................... 48 ZYFLO CR ........................ 43 ZYLET .............................. 41 ZYLOPRIM

see allopurinol tab ........... 1 ZYMAXID .......................... 41

see gatifloxacin (ophth) . 41 ZYPREXA

see olanzapine .............. 22 ZYPREXA ZYDIS

see olanzapine odt ........ 22 ZYTIGA ............................. 12 ZYVOX ............................... 6

pebtf 2014 (effective april 1)

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