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Providence Health & Services Prescription Drug Formulary

List of Covered Prescription Drugs

www.ProvidenceHealthPlan.com

Effective January 1, 2015

Providence Health & Services Prescription Drug Plan | i

Providence prescription drug coverage

Providence Health Plan wants to help you to make the most of your prescription drug coverage. That’s why we strive to provide you with the information you need to make smart decisions about medications. Know more, save more

We encourage you to be knowledgeable about your prescription drug benefits. Information is available on your benefit summary, in your member handbook and on the Providence Health Plan website.

When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a generic when possible can help manage your costs. Retail pharmacies

You have access to more than 25,000 participating pharmacies nationwide at discounted rates. Search the provider directory to locate participating pharmacies near you. Preventive drugs

Preventive drugs are those prescribed for the purpose of avoiding a condition or disease in individuals with risk factors. They may also be prescribed for the prevention of a reoccurrence of a disease or condition. Preventive medications are labeled as such in the “status” column of the formulary. Maintenance drugs Maintenance medications are those typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance medication is available through participating mail-order pharmacies, as well as through preferred retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply.

Learn more about mail-order pharmacies and preferred retail pharmacies. Specialty drugs

Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of “Specialty,” and are available through Providence Specialty Pharmacy Services.

Learn more about specialty drugs. Generic drugs

Making the switch from brand to generic medication can save you money. Generic drugs, which are available only after the brand-name patent expires:

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• Have the same active ingredient formula as the brand-name drug and • Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the

brand-name drug.

There are two types of generic drugs:

• Generic equivalent - A generic equivalent is a generic drug that has the same active ingredient, dosage form and strength as its brand-name counterpart. The FDA assures sameness between brand-name and generic equivalent products. Generic equivalents are an important option to brand-name prescription drugs because they cost less. Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now available in generic form under the name simvastatin. Zocor® and simvastatin are identical drugs – the only difference is that one costs more than the other.

• Generic alternative - A generic alternative is a generic drug used to treat the same

condition as a brand-name drug. It is not, however, the exact same medication as the brand-name drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name option. Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in the treatment of high cholesterol. Generic alternatives are an important option for prescription drugs for which there is no generic available.

Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective drug treatment options. The Providence formulary

Your prescription drug plan provides coverage for medications listed on the Providence formulary. Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary includes FDA-approved prescription generic, brand-name and specialty medications. The formulary can help you and your physician choose effective, quality medications that minimize your out-of-pocket expense. Search the formulary

There are two ways to search the formulary. They include:

1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents); and

2. By index (provides an alphabetical listing of drugs included in the formulary). Formulary updates

The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we

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serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence Health Plan prescription drug coverage will not change during the year unless:

• The medication becomes available in generic form; • There are safety or effectiveness concerns raised about the prescription drug; or • The Pharmacy and Therapeutics committee determines that changes to the formulary would

be in the best overall interest of Providence Health Plan members.

If a change to the formulary results in a reduction of benefits or an increase in member copay, affected individuals are notified in writing. Formulary brand-name drugs

The Providence formulary includes prescription drugs that are proven safe, effective and that offer value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount. Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may be available to treat most common conditions. Using these options can provide cost savings. Non-approved drugs

Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for medications to be on the market without FDA approval. The FDA is taking action to ensure these drugs become approved or are removed from the market. In the meantime, many remain on pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely approved prescription drugs available to treat your condition. We encourage you to discuss alternative medications with your doctor. Should you and your doctor determine that there is no covered alternative and you choose to continue to take a medication that is not FDA approved, your health plan will not cover that expense. More information regarding medications that are not FDA approved can be found on our website, in the related article and in the FAQ document, which includes links to the FDA website. You may also call the Providence Health Plan pharmacy team for more information and to discuss potential alternatives. Prior authorization

Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The prior authorization process is initiated by the prescribing medical provider. Many factors – including the potential for serious health risks, FDA-approved indications and cost-effectiveness – are considered before making the decision to require prior authorization of a prescription medication. A limited number of medications require prior authorization review; any medications requiring prior authorization are indicated as such in the Providence formulary.

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Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise, your doctor may submit a prior authorization request on your behalf. Formulary exceptions

There may be times that you require a medication that is not on the Providence formulary. If you currently take a prescription drug that is not on the formulary, contact customer service to confirm that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary exception. Step therapy

Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence already have been tried. If they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the individual’s prescription medication history is not part of Providence Health Plan claims history, prior authorization is required. Quantity limit

For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a drug. Answers to frequently asked questions Learn more about your prescription drug coverage by reviewing answers to frequently asked questions.



2015 Providence Health Plan Formulary(with designated preventive drugs)

[To help find a drug see the back of the document for an alphabetical listing]

Drug Name Status* Requirements/Limits

Analgesics

alagesic lq Generic

butalbital/acetaminophen Generic

butalbital/acetaminophen/caffeine (50-325-40 capsule, 50-325-40 tablet, 50-500-40 tablet)

Generic

butalbital/aspirin/caffeine Generic

capacet Generic

fioricet 50-325-40 mg tablet Generic

tencon 50-325 mg tablet Generic

tramadol hcl/acetaminophen Generic QL (240 PER 30 DAYS)

Nonsteroidal Anti-inflammatory DrugsCELEBREX (50 MG, 100 MG, 200 MG) Brand PA, QL (60 PER 30 DAYS)

CELEBREX 400 MG CAPSULE Brand PA, QL (30 PER 30 DAYS)

diclofenac potassium Generic

diclofenac sodium (25 mg tablet dr, 50mg tablet dr, 75 mg tablet dr, 100 mgtab er 24h)

Generic

diflunisal Generic

etodolac (200 mg capsule, 300 mgcapsule, 400 mg tab er 24h, 400 mgtablet, 500 mg tab er 24h, 500 mgtablet, 600 mg tab er 24h)

Generic

fenoprofen calcium 600 mg tablet Generic

flurbiprofen (50 mg, 100 mg) Generic

ibuprofen (400 mg, 600 mg, 800 mg) Generic

ibuprofen/oxycodone hcl Generic

indomethacin (25 mg, 50 mg, 75 mg er) Generic

ketoprofen (50 mg capsule, 75 mgcapsule, 200 mg cap24h pel)

Generic

*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.

PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access1



Drug Name Status* Requirements/Limitsketorolac tromethamine 10 mg tablet Generic

meclofenamate sodium (50 mg, 100mg)

Generic

meloxicam (7.5 mg tablet, 7.5 mg/5mloral susp, 15 mg tablet)

Generic

nabumetone (500 mg, 750 mg) Generic

NAPRELAN CR 500 MG TABLET Brand

naproxen (125 mg/5ml oral susp, 250mg tablet, 375 mg tablet, 375 mg tabletdr, 500 mg tablet, 500 mg tablet dr)

Generic

naproxen sodium (275 mg, 550 mg) Generic

oxaprozin Generic

piroxicam (10 mg, 20 mg) Generic

sulindac (150 mg, 200 mg) Generic

tolmetin sodium Generic

Opioid Analgesics, Long-actingfentanyl (12 mcg/hr, 25mcg/hr,50mcg/hr, 75mcg/hr, 100 mcg/hr)

Generic QL (15 PER 30 DAYS)

levorphanol tartrate 2 mg tablet Generic

methadone hcl (5 mg tablet, 5 mg/5 mlsolution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mgtablet sol)

Generic

methadone intensol Generic

methadose 40 mg tablet dispr Generic

morphine sulfate (5 mg supp.rect, 10mg supp.rect, 15 mg tablet er, 20 mgsupp.rect, 30 mg supp.rect, 30 mgtablet er, 60 mg tablet er, 100 mgtablet er, 200 mg tablet er)

Generic

oxycodone hcl (10 mg er, 20 mg er, 40mg er, 80 mg er)

Generic PA, QL (90 PER 30 DAYS)





Drug Name Status* Requirements/LimitsOXYCONTIN (15 MG, 30 MG, 60 MG) Brand PA, QL (90 PER 30 DAYS)

tramadol hcl (100 mg tab er 24h, 100mg tbmp 24hr, 200 mg tab er 24h, 200mg tbmp 24hr, 300 mg tab er 24h, 300mg tbmp 24hr)

Generic

Opioid Analgesics, Short-actingacetaminophen with codeine phosphate(120-12mg/5 solution, 240-24/10solution, 300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet,300mg/12.5 solution, 360-36/15solution)

Generic

ascomp with codeine Generic

butalbit/acetamin/caff/codeine 50-325-30 capsule

Generic

butorphanol tartrate 10 mg/ml spray Generic

co-gesic Generic

codeinephosphate/butalbital/aspirin/caffeine

Generic

codeine phosphate/carisoprodol/aspirin Generic

codeine sulfate (15 mg, 30 mg, 60 mg) Generic

dihydrocodeinebitartrate/acetaminophen/caffeine

Generic

endocet (5-325, 7.5-325 mg, 7.5-500mg, 10-325 mg, 10-650 mg)

Generic

endodan Generic

hydrocodone bit/acetaminophen Generic





Drug Name Status* Requirements/Limitshydrocodone bitartrate/acetaminophen(2.5-167/5 solution, 2.5-500 mg tablet,5 mg-500mg tablet, 5-334mg/10solution, 5mg-325mg tablet, 7.5-325/15solution, 7.5-325mg tablet, 7.5-500/15solution, 7.5-500mg tablet, 7.5-650 mgtablet, 7.5-750mg tablet, 10-660mgtablet, 10-750mg tablet, 10mg-325mgtablet, 10mg-500mg tablet, 10mg-650mg tablet)

Generic

hydrocodone/ibuprofen Generic

hydromorphone hcl (1 mg/ml liquid, 2mg tablet, 3 mg supp.rect, 4 mg tablet,8 mg tablet)

Generic

ibudone 5-200 mg tablet Generic

lorcet Generic

lorcet hd Generic

lorcet plus 7.5-325 mg tablet Generic

lortab (5-325 mg, 5-500, 7.5-325 mg,10-325 mg)

Generic

meperidine hcl (50 mg, 100 mg) Generic

meperitab Generic

morphine sulfate (10 mg/5 ml solution,15 mg tablet, 20 mg/5 ml solution, 30mg tablet, 100 mg/5ml solution)

Generic

oxycodone hcl (5 mg capsule, 5 mgtablet, 5 mg/5 ml solution, 10 mgtablet, 15 mg tablet, 20 mg tablet, 20mg/ml oral conc, 30 mg tablet)

Generic

oxycodone hcl/acetaminophen (5 mg-500mg capsule, 5mg-325mg tablet, 7.5-325mg tablet, 7.5-500mg tablet, 10mg-325mg tablet, 10mg-650mg tablet)

Generic

oxycodone hcl/aspirin Generic

oxymorphone hcl (5 mg, 10 mg) Generic PA





Drug Name Status* Requirements/Limitsreprexain 10-200 mg tablet Generic

ROXICET 5-325 ORAL SOLUTION Brand

roxicet 5-325 tablet Generic

stagesic Generic

tramadol hcl 50 mg tablet Generic

xylon 10 Generic

Anesthetics

Local Anestheticsglydo Generic

lidocaine 5 % oint. (g) Generic

lidocaine 5%(700mg) adh. patch Generic PA, QL (90 PER 30 DAYS)

lidocaine hcl (2 % jel (ml), 2 % jel/pfapp, 2 % solution, 4 % solution, 40mg/ml solution)

Generic

lidocaine/prilocaine (2.5 %-2.5% cream(g), 2.5 %-2.5% kit)

Generic

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium Generic

disulfiram (250 mg, 500 mg) Generic

buprenorphine hcl/naloxone hcl Generic

SUBOXONE (2 MG-0.5 MG, 8 MG-2 MG) Brand

Opioid Antagonistsbuprenorphine hcl (2 mg, 8 mg) Generic QL (90 PER 30 DAYS)

depade Generic

naltrexone hcl 50 mg tablet Generic





Drug Name Status* Requirements/Limitsrevia Generic

Smoking Cessation Agentsbuproban Generic

CHANTIX Brand

Anti-inflammatory Agents

Glucocorticoidsalclometasone dipropionate Generic

amcinonide 0.1 % cream (g) Generic

apexicon e Generic

betamethasone dipropionate (0.05 %cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))

Generic

betamethasone dipropionate/propyleneglycol (0.05 % cream (g), 0.05 % lotion,0.05 % oint. (g))

Generic

betamethasone valerate (0.1 % cream(g), 0.1 % lotion, 0.1 % oint. (g))

Generic

clobetasol propionate (0.05 % cream(g), 0.05 % foam, 0.05 % gel (gram),0.05 % oint. (g), 0.05 % shampoo, 0.05% solution)

Generic

clobetasol propionate/emoll 0.05 %cream (g)

Generic

clobetasol propionate/emoll 0.05 %foam

Generic PA

clodan 0.05% shampoo Generic

cormax Generic

cortisone acetate 25 mg tablet Generic

desonide (0.05 % cream (g), 0.05 %lotion, 0.05 % oint. (g))

Generic





Drug Name Status* Requirements/Limitsdesoximetasone Generic

diflorasone diacetate Generic

fludrocortisone acetate 0.1 mg tablet Generic

fluocinolone acetonide (0.01 % cream(g), 0.01 % solution, 0.025 % cream (g),0.025 % oint. (g))

Generic

fluocinonide (0.05 % cream (g), 0.05 %gel (gram), 0.05 % oint. (g), 0.05 %solution)

Generic

fluocinonide/emollient base Generic

fluticasone propionate (0.005 % oint.(g), 0.05 % cream (g), 0.05 % lotion)

Generic

halobetasol propionate Generic

hydrocortisone (2.5 % cream (g), 2.5 %lotion, 2.5 % oint. (g))

Generic

hydrocortisone butyrate 0.1 % cream(g)

Generic

millipred 5 mg tablet Generic

millipred dp Generic

nystatin/triamcinolone acetonide Generic

oralone Generic

ORAPRED ODT Brand

prednisolone 15 mg/5 ml solution Generic

prednisolone sod phosphate (5 ml, 15ml)

Generic

prednisone (1 mg tablet, 2.5 mg tablet,5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet,20 mg tablet, 50 mg tablet)

Generic

prednisone intensol Generic





Drug Name Status* Requirements/Limitstriamcinolone acetonide (0.025 %cream (g), 0.025 % lotion, 0.025 % oint.(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %oint. (g), 0.1 % paste (g), 0.5 % cream(g), 0.5 % oint. (g))

Generic

triderm Generic

Antibacterials

Aminoglycosidesgaramycin 0.3% eye drops Generic

gentak (0.3 % ointment, 3 mg/ml drops) Generic

gentamicin sulfate (0.1 % cream (g), 0.1% oint. (g), 0.3 % drops, 0.3 % oint. (g))

Generic

neomycin sulfate 500 mg tablet Generic

TOBI PODHALER Specialty

tobramycin 0.3 % drops Generic

tobramycin in 0.225 % sodium chloride Generic LA

TOBREX 0.3% EYE OINTMENT Brand

Antibacterials, Otheracetasol hc Generic

acetic acid/aluminum acetate Generic

acetic acid/hydrocortisone Generic

bacitracin 500 unit/g oint. (g) Generic

chlorhexidine gluconate 0.12 %mouthwash

Generic

clinda-derm Generic

clindacin etz 1% pledget Generic

clindacin p Generic

clindamycin hcl (75 mg, 150 mg, 300mg)

Generic





Drug Name Status* Requirements/Limitsclindamycin palmitate hcl Generic

clindamycin phosphate (1 % foam, 1 %gel (gram), 1 % lotion, 1 % med. swab, 1% solution, 2 % cream/appl)

Generic

cycloserine 250 mg capsule Generic

methenamine hippurate Generic

metronidazole (0.75 % cream (g), 0.75% gel (gram))

Generic PA

metronidazole (0.75 % gel w/appl, 0.75% lotion, 250 mg tablet, 375 mgcapsule, 500 mg tablet)

Generic

MONUROL Brand

mupirocin 2 % oint. (g) Generic

nitrofurantoin (25 mg/5 ml oral susp, 50mg capsule)

Generic

nitrofurantoin macrocrystal (50 mg, 100mg)

Generic

nitrofurantoinmonohydrate/macrocrystals

Generic

paroex Generic

periogard Generic

rosadan (0.75% cream, 0.75% gel) Generic PA

trimethoprim 100 mg tablet Generic

vancomycin hcl (125 mg, 250 mg) Generic

vandazole Generic

vitazol Generic PA

XIFAXAN 200 MG TABLET Brand PA, QL (90 PER 30 DAYS)

XIFAXAN 550 MG TABLET Brand PA, QL (60 PER 30 DAYS)

ZYVOX (100 MG/5 ML SUSPENSION,600 MG TABLET)

Brand PA






Beta-lactam, Cephalosporinscefaclor (125 mg/5ml susp recon, 250mg capsule, 250 mg/5ml susp recon,375 mg/5ml susp recon, 500 mgcapsule)

Generic

cefadroxil (1 g tablet, 250 mg/5ml susprecon, 500 mg capsule, 500 mg/5mlsusp recon)

Generic

cefdinir (125 mg/5ml susp recon, 250mg/5ml susp recon, 300 mg capsule)

Generic

cefpodoxime proxetil (50 mg/5 ml susprecon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)

Generic

cefprozil (125 mg/5ml susp recon, 250mg tablet, 250 mg/5ml susp recon, 500mg tablet)

Generic

ceftibuten dihydrate (180 mg/5ml susprecon, 400 mg capsule)

Generic

CEFTIN (125 ML, 250 ML) Brand

cefuroxime axetil Generic

cephalexin (125 mg/5ml susp recon,250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule,500 mg tablet)

Generic

Beta-lactam, Penicillinsamoxicillin (125 mg tab chew, 125mg/5ml susp recon, 200 mg/5ml susprecon, 250 mg capsule, 250 mg tabchew, 250 mg/5ml susp recon, 400 mgtab chew, 400 mg/5ml susp recon, 500mg capsule, 500 mg tablet, 875 mgtablet)

Generic





Drug Name Status* Requirements/Limitsamoxicillin/potassium clavulanate (200-28.5/5 susp recon, 200-28.5mg tabchew, 250-125 mg tablet, 250-62.5/5susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet,600-42.9/5 susp recon, 875-125 mgtablet, 1000-62.5 tab er 12h)

Generic

ampicillin trihydrate (250 mg, 500 mg) Generic

dicloxacillin sodium Generic

penicillin v potassium (125 mg/5ml solnrecon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)

Generic

MacrolidesAZASITE Brand

azithromycin (1 g packet, 100 mg/5mlsusp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mgtablet)

Generic

clarithromycin (125 mg/5ml susp recon,250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)

Generic

E.E.S. 200 Brand

ERY-TAB Brand

erygel Generic

ERYPED 200 Brand

erythromycin base (5 mg/g oint. (g),5mg/g oint. (g), 250 mg capsule dr, 250mg tablet, 500 mg tablet)

Generic

erythromycin base/ethyl alcohol (2 %gel (gram), 2 % solution)

Generic

erythromycin ethylsuccinate 400 mgtablet

Generic

erythromycinethylsuccinate/sulfisoxazole acetyl

Generic






Quinolonesciprofloxacin hcl (0.3 % drops, 100 mgtablet, 250 mg tablet, 500 mg tablet,750 mg tablet)

Generic

ciprofloxacin/ciprofloxa hcl 500 mgtbmp 24hr

Generic

levofloxacin (0.5 % drops, 250 mgtablet, 250mg/10ml solution, 500 mgtablet, 750 mg tablet)

Generic

moxifloxacin hcl 400 mg tablet Generic

ofloxacin (0.3 % drops, 200 mg tablet,300 mg tablet, 400 mg tablet)

Generic

Sulfonamidesbleph-10 Generic

silver sulfadiazine 1 % cream (g) Generic

sulfacetamide sodium (10 % drops, 10 %suspension)

Generic

sulfadiazine 500 mg tablet Generic

sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet,800-160 mg tablet, 800-160/20 oralsusp)

Generic

sulfamide Generic

Tetracyclinesavidoxy Generic

demeclocycline hcl (150 mg, 300 mg) Generic

doxycycline hyclate (20 mg tablet, 50mg capsule, 100 mg capsule, 100 mgtablet)

Generic

doxycycline monohydrate (50 mgcapsule, 50 mg tablet, 75 mg tablet,100 mg capsule, 100 mg tablet, 150 mgtablet)

Generic





Drug Name Status* Requirements/Limitsdynacin 100 mg tablet Generic

minocycline hcl (50 mg capsule, 75 mgcapsule, 100 mg capsule, 100 mgtablet)

Generic

morgidox 100 mg capsule Generic

OCUDOX Brand

tetracycline hcl (250 mg, 500 mg) Generic

Anticonvulsants

Anticonvulsants, Otheracetazolamide (125 mg, 250 mg) Generic

levetiracetam (100 mg/ml solution, 250mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mgtablet)

Generic

primidone (50 mg, 250 mg) Generic

Calcium Channel Modifying AgentsCELONTIN Brand

ethosuximide (250 mg capsule, 250mg/5ml solution)

Generic

LYRICA (20 MG/ML ORAL SOLUTION, 25MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MGCAPSULE, 200 MG CAPSULE, 225 MGCAPSULE, 300 MG CAPSULE)

Brand PA

zonisamide Generic

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam (0.125 mg tab rapdis, 0.25mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet,2 mg tab rapdis, 2 mg tablet)

Generic

clorazepate dipotassium Generic





Drug Name Status* Requirements/LimitsDIASTAT Brand

diazepam (2 mg tablet, 5 mg tablet, 5mg/5 ml solution, 5-7.5-10mg kit, 10mg tablet, 12.5-15-20 kit)

Generic

diazepam 2.5 mg kit Brand

divalproex sodium Generic

gabapentin (100 mg capsule, 250mg/5ml solution, 300 mg capsule, 400mg capsule, 600 mg tablet, 800 mgtablet)

Generic

GABITRIL (12 MG, 16 MG) Brand

lorazepam (0.5 mg tablet, 1 mg tablet,2 mg tablet, 2 mg/ml oral conc)

Generic

lorazepam intensol Generic

ONFI (5 MG, 10 MG, 20 MG) Brand PA, QL (60 PER 30 DAYS)

ONFI 2.5 MG/ML SUSPENSION Brand PA

phenobarbital (15 mg tablet, 16.2 mgtablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mgtablet, 97.2mg tablet, 100 mg tablet)

Generic

SABRIL Brand LA

tiagabine hcl Generic

valproic acid (as sodium salt) (valproatesodium) (250 mg/5ml solution, 500mg/5ml vial, 500mg/10ml solution)

Generic

valproic acid 250 mg capsule Generic

Glutamate Reducing Agentsfelbamate (400 mg tablet, 600 mgtablet, 600 mg/5ml oral susp)

Generic

lamotrigine (5 mg tb chw dsp, 25 mgtablet, 25 mg tb chw dsp, 25mg (35) tabds pk, 100 mg tablet, 150 mg tablet,200 mg tablet)

Generic





Drug Name Status* Requirements/LimitsQUDEXY XR 200 MG CAPSULE Brand PA

topiragen Generic

topiramate (15 mg cap sprink, 25 mgcap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)

Generic

topiramate (25 mg 24, 50 mg 24, 100mg 24, 150 mg 24)

Generic PA

topiramate 200 mg cap spr 24 Brand PA

Sodium Channel AgentsAPTIOM Brand PA

BANZEL (40 MG/ML SUSPENSION, 200MG TABLET, 400 MG TABLET)

Brand PA

carbamazepine (100 mg cpmp 12hr,100 mg tab chew, 100 mg/5ml oralsusp, 200 mg cpmp 12hr, 200 mg tab er12h, 200 mg tablet, 300 mg cpmp 12hr,400 mg tab er 12h)

Generic

DILANTIN 30 MG CAPSULE Brand

epitol Generic

EQUETRO Brand

oxcarbazepine (150 mg tablet, 300 mgtablet, 300 mg/5ml oral susp, 600 mgtablet)

Generic

phenytoin (50 mg tab chew, 100mg/4ml oral susp, 125 mg/5ml oralsusp)

Generic

phenytoin sodium extended (100 mg,200 mg)

Generic

VIMPAT (10 MG/ML SOLUTION, 50 MGTABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

Brand PA

ziprasidone hcl 20 mg capsule Generic






Antidementia Agents

Cholinesterase Inhibitorsdonepezil hcl (5 mg tab rapdis, 5 mgtablet, 10 mg tab rapdis, 10 mg tablet)

Generic

EXELON (2 MG/ML ORAL SOLUTION, 4.6MG/24HR PATCH, 9.5 MG/24HR PATCH,13.3 MG/24HR PATCH)

Brand

rivastigmine tartrate Generic

N-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA (5 MG TABLET, 5-10 MGTITRATION PK, 10 MG TABLET)

Brand PA, QL (60 PER 30 DAYS)

NAMENDA 10 MG/5 ML SOLUTION Brand PA, QL (360 ML PER 30 DAYS)

Antidepressants

Antidepressants, OtherABILIFY (1 MG/ML SOLUTION, 2 MGTABLET, 5 MG TABLET, 10 MG TABLET,15 MG TABLET, 20 MG TABLET, 30 MGTABLET)

Brand

ABILIFY DISCMELT Brand

budeprion sr Generic

budeprion xl Generic

bupropion hcl (75 mg tablet, 100 mgtablet, 100 mg tablet er, 150 mg tab er24h, 150 mg tablet er, 200 mg tablet er,300 mg tab er 24h)

Generic

maprotiline hcl 75 mg tablet Generic

mirtazapine (7.5 mg tablet, 15 mg tabrapdis, 15 mg tablet, 30 mg tab rapdis,30 mg tablet, 45 mg tab rapdis, 45 mgtablet)

Generic





Drug Name Status* Requirements/Limitsnefazodone hcl Generic

trazodone hcl (50 mg, 100 mg, 150 mg,300 mg)

Generic

Monoamine Oxidase InhibitorsMARPLAN Brand

phenelzine sulfate 15 mg tablet Generic

tranylcypromine sulfate Generic

Serotonin/Norepinephrine Reuptake Inhibitorscitalopram hydrobromide (10 mg tablet,10 mg/5 ml solution, 20 mg tablet, 40mg tablet)

Generic

duloxetine hcl (20 mg, 30 mg) Generic QL (60 PER 30 DAYS)

duloxetine hcl 60 mg capsule dr Generic QL (30 PER 30 DAYS)

escitalopram oxalate (5 mg tablet, 5mg/5 ml solution, 10 mg tablet, 20 mgtablet)

Generic

fluoxetine hcl (10 mg capsule, 10 mgtablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mgtablet, 90 mg capsule dr)

Generic

fluvoxamine maleate (25 mg, 50 mg,100 mg)

Generic

olanzapine/fluoxetine hcl Generic

paroxetine hcl (10 mg, 20 mg, 30 mg,40 mg)

Generic

PAXIL 10 MG/5 ML SUSPENSION Brand

sertraline hcl (20 mg/ml oral conc, 25mg tablet, 50 mg tablet, 100 mg tablet)

Generic





Drug Name Status* Requirements/Limitsvenlafaxine hcl (25 mg tablet, 37.5 mgcap er 24h, 37.5 mg tab er 24, 37.5 mgtablet, 50 mg tablet, 75 mg cap er 24h,75 mg tab er 24, 75 mg tablet, 100 mgtablet, 150 mg cap er 24h, 150 mg taber 24)

Generic

venlafaxine hcl 225 mg tab er 24 Brand

Tricyclicsamitriptyline hcl (10 mg, 25 mg, 50 mg,75 mg, 100 mg, 150 mg)

Generic

amoxapine Generic

clomipramine hcl (25 mg, 50 mg, 75mg)

Generic

desipramine hcl (10 mg, 25 mg, 50 mg,75 mg, 100 mg, 150 mg)

Generic

doxepin hcl (10 mg capsule, 10 mg/mloral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mgcapsule, 150 mg capsule)

Generic

imipramine hcl (10 mg, 25 mg, 50 mg) Generic

imipramine pamoate Generic

nortriptyline hcl (10 mg capsule, 10mg/5 ml solution, 25 mg capsule, 50 mgcapsule, 75 mg capsule)

Generic

protriptyline hcl Generic

trimipramine maleate (25 mg, 50 mg) Generic

Antiemetics

Antiemetics, Otherchlorpromazine hcl (10 mg, 25 mg, 50mg, 100 mg, 200 mg)

Generic

COMPRO Preventive





Drug Name Status* Requirements/LimitsDICLEGIS Preventive QL (60 PER 30 DAYS)

hydroxyzine hcl (10 mg tablet, 10 mg/5ml syrup, 25 mg tablet, 50 mg tablet)

Generic

hydroxyzine pamoate (25 mg, 50 mg,100 mg)

Generic

metoclopramide hcl (5 mg tablet, 5mg/5 ml solution, 10 mg tablet, 10mg/10ml solution)

Generic

perphenazine (2 mg, 4 mg, 8 mg, 16mg)

Generic

PHENADOZ Preventive

prochlorperazine maleate (5 mg tablet,10 mg tablet, 25 mg supp.rect)

Preventive

promethazine hcl (12.5 mg, 25 mg, 50mg)

Preventive

promethazine hcl (6.25mg/5ml syrup,12.5 mg tablet, 25 mg tablet, 50 mgtablet)

Generic

PROMETHEGAN Preventive

TRANSDERM-SCOP Preventive

trimethobenzamide hcl 300 mg capsule Preventive

Emetogenic Therapy AdjunctsEMEND (80 MG CAPSULE, 125 MGCAPSULE, TRIFOLD PACK)

Preventive QL (4 PER 30 DAYS)

granisetron hcl 1 mg tablet Preventive PA, QL (8 PER 30 DAYS)

ondansetron Preventive

ondansetron hcl (4 mg tablet, 4 mg/5ml solution, 8 mg tablet)

Preventive

Antifungals

ciclodan 0.77% cream Generic





Drug Name Status* Requirements/Limitsciclopirox (0.77 % gel (gram), 1 %shampoo)

Generic

ciclopirox olamine (0.77 % cream (g),0.77 % suspension)

Generic

clotrimazole 10 mg troche Generic

clotrimazole/betamethasonedipropionate (1 %-0.05 % cream (g), 1%-0.05 % lotion)

Generic

econazole nitrate 1 % cream (g) Generic

fluconazole (10 mg/ml susp recon, 40mg/ml susp recon, 50 mg tablet, 100mg tablet, 150 mg tablet, 200 mgtablet)

Generic

griseofulvin ultramicrosize 250 mgtablet

Generic

griseofulvin, microsize (125 mg/5ml oralsusp, 500 mg tablet)

Generic

itraconazole 100 mg capsule Generic PA

ketoconazole (2 % cream (g), 2 %shampoo)

Generic

LAMISIL 187.5 MG GRANULES PACK Brand PA

NATACYN Brand

NOXAFIL 40 MG/ML SUSPENSION Brand PA

nyamyc Generic

nystatin (50mm unit powder(ea), 100kunit tablet, 150mm unit powder(ea),500k unit tablet, 500mm unitpowder(ea), 100000/g cream (g),100000/g oint. (g), 100000/g powder,100000/ml oral susp)

Generic

nystop Generic

pedi-dri Generic

SPORANOX 10 MG/ML SOLUTION Brand PA





Drug Name Status* Requirements/Limitsterbinafine hcl 250 mg tablet Generic

terconazole (0.4 % cream/appl, 0.8 %cream/appl, 80 mg supp.vag)

Generic

voriconazole 200 mg/5ml susp recon Generic

Antigout Agents

allopurinol (100 mg, 300 mg) Generic

colchicine/probenecid Generic

COLCRYS Brand QL (60 PER 30 DAYS)

probenecid Generic

Antimigraine Agents

Ergot Alkaloidscafergot Generic

dihydroergotamine mesylate0.5mg/spry spray/pump

Brand QL (3.5 ML PER 30 DAYS)

ergotamine tartrate/caffeine Generic

migergot Generic

MIGRANAL Brand QL (3.5 ML PER 30 DAYS)

Prophylactictimolol maleate (5 mg, 10 mg, 20 mg) Preventive

Serotonin (5-HT) 1b/1d Receptor Agonistsrizatriptan benzoate Generic QL (24 PER 30 DAYS)

sumatriptan (5 mg, 20 mg) Generic QL (6 PER 30 DAYS)

sumatriptan succinate (25 mg, 50 mg,100 mg)


sumatriptan succinate (4 cartridge, 4pen injctr, 6 cartridge, 6 pen injctr, 6syringe, 6 vial)

Generic QL (2 ML PER 30 DAYS)





Drug Name Status* Requirements/Limitszolmitriptan (2.5 mg tab rapdis, 2.5 mgtablet, 5 mg tab rapdis, 5 mg tablet)


ZOMIG (2.5 MG, 5 MG) Brand QL (12 PER 30 DAYS)

Antimyasthenic Agents

Parasympathomimeticsguanidine hcl Generic

MESTINON (60 MG/5 ML SYRUP, 180MG TIMESPAN)

Brand

pyridostigmine bromide 60 mg tablet Generic

Antimycobacterials

Antimycobacterials, Otherdapsone (25 mg, 100 mg) Generic

rifabutin Generic

Antitubercularsethambutol hcl Generic

isonarif Generic

isoniazid (50 mg/5 ml solution, 100 mgtablet, 300 mg tablet)

Generic

PRIFTIN Brand

rifampin (150 mg, 300 mg) Generic

RIFATER Brand

SIRTURO Specialty LA

TRECATOR Brand






Antineoplastics

Alkylating AgentsALKERAN 2 MG TABLET Brand

CEENU Brand

cyclophosphamide capsules Generic

cyclophosphamide tablets Generic

LEUKERAN Brand

lomustine Brand

MATULANE Specialty

Antiangiogenic AgentsREVLIMID Specialty PA, LA

THALOMID Specialty

Antiestrogens/ModifiersEMCYT Specialty

FARESTON Brand

SOLTAMOX Brand

tamoxifen citrate (10 mg, 20 mg) Generic

Antimetabolitescapecitabine Generic

decitabine Generic

DROXIA Brand

hydroxyurea 500 mg capsule Generic

mercaptopurine 50 mg tablet Generic

methotrexate sodium (2.5 mg tablet, 25mg/ml vial)

Generic

methotrexate sodium/pf (1 g, 25mg/ml)

Generic





Drug Name Status* Requirements/LimitsPURIXAN Brand

RHEUMATREX Brand

Antineoplastics, OtherHEXALEN Specialty

imiquimod 5 % cream pack Generic

leucovorin calcium (5 mg, 10 mg, 15mg, 25 mg)

Generic

MESNEX 400 MG TABLET Brand

temozolomide Specialty PA

VALCHLOR Specialty PA, LA

Aromatase Inhibitors, 3rd Generationanastrozole 1 mg tablet Generic

exemestane Generic

letrozole 2.5 mg tablet Generic

Enzyme InhibitorsGILOTRIF Specialty PA, LA

HYCAMTIN 0.25 MG CAPSULE Brand PA

HYCAMTIN 1 MG CAPSULE Specialty PA

IRESSA Specialty PA

JAKAFI Specialty PA, LA

MEKINIST Specialty PA

TAFINLAR Specialty PA

VOTRIENT Specialty PA

ZYDELIG Specialty PA, QL (60 PER 30 DAYS)

ZYTIGA Specialty PA






Molecular Target InhibitorsAFINITOR (2.5 MG, 5 MG, 10 MG) Specialty PA, QL (30 PER 30 DAYS)

AFINITOR 7.5 MG TABLET Brand PA, QL (30 PER 30 DAYS)

AFINITOR DISPERZ Specialty PA, QL (30 PER 30 DAYS)

BOSULIF Specialty PA

CAPRELSA 100 MG TABLET Specialty PA

CAPRELSA 300 MG TABLET Brand PA

COMETRIQ Specialty PA, LA

ERIVEDGE Specialty PA, LA

GLEEVEC Specialty PA

ICLUSIG Specialty PA, LA

IMBRUVICA Specialty PA, LA

INLYTA Specialty PA, LA

NEXAVAR Specialty PA

SPRYCEL Specialty PA

STIVARGA Specialty PA

SUTENT Specialty PA

TARCEVA Specialty PA

TASIGNA Specialty PA

TYKERB Specialty PA

vandetanib Specialty PA

ZELBORAF Specialty PA

ZOLINZA Specialty PA

ZYKADIA Specialty PA

RetinoidsPANRETIN Brand

TARGRETIN (1% GEL, 75 MG CAPSULE,75 MG SOFTGEL)

Specialty PA





Drug Name Status* Requirements/Limitstretinoin 10 mg capsule Specialty PA

Antiparasitics

AnthelminticsALBENZA Brand

ivermectin 3 mg tablet Generic

AntiprotozoalsALINIA (100 MG/5 ML SUSPENSION,500 MG TABLET)

Brand

atovaquone Generic PA

chloroquine phosphate (250 mg, 500mg)

Generic PA

DARAPRIM Brand PA

hydroxychloroquine sulfate 200 mgtablet

Generic

mefloquine hcl Generic PA

tinidazole (250 mg, 500 mg) Generic PA

Pediculicides/Scabicideselimite Generic

lindane Generic

permethrin 5 % cream (g) Generic

ULESFIA Brand

Antiparkinson Agents

Anticholinergicsbenztropine mesylate (0.5 mg, 1 mg, 2mg)

Generic

trihexyphenidyl hcl (2 mg, 5 mg) Generic






Antiparkinson Agents, Otheramantadine hcl (50 mg/5 ml syrup, 100mg capsule, 100 mg tablet)

Preventive

carbidopa/levodopa/entacapone Preventive

entacapone Preventive

Dopamine Agonistsbromocriptine mesylate (2.5 mg tablet,5 mg capsule)

Preventive

pramipexole di-hcl Preventive

ropinirole hcl (0.25 mg, 0.5 mg, 1 mg, 2mg, 3 mg, 4 mg, 5 mg)

Preventive

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitorscarbidopa 25 mg tablet Generic

carbidopa/levodopa (10mg-100mg,25mg-100mg, 25mg-100mg er, 25mg-250mg, 50mg-200mg er)

Preventive

Monoamine Oxidase B (MAO-B) InhibitorsAZILECT Preventive

selegiline hcl (5 mg capsule, 5 mgtablet)

Preventive

Antipsychotics

1st Generation/Typicalfluphenazine hcl (1 mg, 2.5 mg, 5 mg,10 mg)

Generic

haloperidol (0.5 mg, 1 mg, 2 mg, 5 mg,10 mg, 20 mg)

Generic

haloperidol lactate 2 mg/ml oral conc Generic

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

Generic





Drug Name Status* Requirements/LimitsORAP Brand

perphenazine/amitriptyline hcl Generic

thioridazine hcl (10 mg, 25 mg, 50 mg,100 mg)

Generic

thiothixene Generic

trifluoperazine hcl Generic

2nd Generation/AtypicalINVEGA Brand

LATUDA Brand PA, QL (30 PER 30 DAYS)

olanzapine (2.5 mg tablet, 5 mg tabrapdis, 5 mg tablet, 7.5 mg tablet, 10mg tab rapdis, 10 mg tablet, 15 mg tabrapdis, 15 mg tablet, 20 mg tab rapdis,20 mg tablet)

Generic

quetiapine fumarate Generic

RISPERDAL CONSTA 12.5 MG SYR Brand

risperidone (0.25 mg tablet, 0.5 mgtablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet, 3 mg tab rapdis, 3 mg tablet,4 mg tablet)

Generic

SAPHRIS Brand PA

ziprasidone hcl (40 mg, 60 mg, 80 mg) Generic

Treatment-Resistantclozapine Generic

FAZACLO (150 MG, 200 MG) Brand

VERSACLOZ Brand

Antispasticity Agents

baclofen (10 mg, 20 mg) Generic

dantrolene sodium (25 mg, 50 mg) Generic





Drug Name Status* Requirements/LimitsMYRBETRIQ Brand PA

tizanidine hcl (2 mg, 4 mg) Generic

Antivirals

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase InhibitorsEDURANT Brand

INTELENCE Brand

nevirapine (200 mg tablet, 400 mg taber 24h)

Generic

SUSTIVA Brand

VIRAMUNE XR 100 MG TABLET Brand

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitorsabacavir sulfate Generic

abacavir sulfate/lamivudine/zidovudine Generic

didanosine Generic

EMTRIVA (10 MG/ML SOLUTION, 200MG CAPSULE)

Brand

EPZICOM Brand

lamivudine (150 mg, 300 mg) Generic

lamivudine/zidovudine Generic

stavudine (20 mg, 30 mg, 40 mg) Generic

TRUVADA Brand

VIREAD (150 MG TABLET, 200 MGTABLET, 250 MG TABLET, 300 MGTABLET, POWDER)

Brand

zidovudine (100 mg capsule, 300 mgtablet)

Generic






Anti-HIV Agents, OtherATRIPLA Brand

COMPLERA Brand

FUZEON Brand

ISENTRESS (100 MG POWDER PACKET,400 MG TABLET)

Brand

SELZENTRY Brand

STRIBILD Brand

TIVICAY Brand

Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/ML SOLUTION, 250MG CAPSULE)

Brand

CRIXIVAN 400 MG CAPSULE Brand

INVIRASE Brand

KALETRA (100-25 MG, 200-50 MG) Brand

LEXIVA (50 MG/ML SUSPENSION, 700MG TABLET)

Brand

NORVIR (100 MG SOFTGEL CAP, 100MG TABLET)

Brand

PREZISTA (75 MG TABLET, 100 MG/MLSUSPENSION, 150 MG TABLET, 400 MGTABLET, 600 MG TABLET, 800 MGTABLET)

Brand

REYATAZ Brand

VIRACEPT Brand

Anti-cytomegalovirus (CMV) AgentsVALCYTE 450 MG TABLET Brand QL (60 PER 30 DAYS)

VALCYTE 50 MG/ML SOLUTION Brand

ZIRGAN Brand






Anti-influenza Agentsrimantadine hcl Generic

TAMIFLU (6 MG/ML SUSPENSION, 30MG CAPSULE, 45 MG CAPSULE, 75 MGCAPSULE)

Preventive

Antihepatitis Agentsadefovir dipivoxil Specialty

BARACLUDE 0.05 MG/ML SOLUTION Specialty PA

entecavir Specialty PA

EPIVIR HBV 25 MG/5 ML SOLN Brand

INCIVEK Specialty PA

INFERGEN Specialty

INTRON A (6 MILLION UNIT/ML VL, 10MILLION UNIT/ML, 10 MILLION UNITSVIL, 18 MILLION UNITS VIL, 50 MILLIONUNITS VIL)

Specialty PA

lamivudine 100 mg tablet Generic

MODERIBA Specialty PA

OLYSIO Specialty PA

PEGASYS (180 MCG/0.5 ML SYRINGE,180 MCG/ML VIAL)

Specialty PA

PEGASYS PROCLICK Specialty PA

PEGINTRON Specialty PA

PEGINTRON REDIPEN Specialty PA

REBETOL 40 MG/ML SOLUTION Specialty PA

RIBAPAK Specialty PA

RIBASPHERE Specialty PA

RIBATAB Specialty PA

ribavirin (200 mg capsule, 200 mgtablet, 400 mg tablet, 600 mg tablet)

Specialty PA





Drug Name Status* Requirements/LimitsSOVALDI Specialty PA

SYLATRON (296 MCG, 444 MCG, 888MCG)

Specialty PA, QL (1 PER 28 DAYS)

SYLATRON 4-PACK Specialty PA, QL (1 PER 28 DAYS)

TYZEKA Brand PA

VICTRELIS Specialty PA

Antiherpetic Agentsacyclovir (200 mg capsule, 200 mg/5mloral susp, 400 mg tablet, 800 mg tablet)

Generic

DENAVIR Brand PA

famciclovir Generic

trifluridine 1 % drops Generic

valacyclovir hcl (500 mg, 1000 mg) Generic

Anxiolytics

Anxiolytics, Otheralprazolam (0.25 mg tablet, 0.5 mg taber 24h, 0.5 mg tablet, 1 mg tab er 24h,1 mg tablet, 2 mg tab er 24h, 2 mgtablet, 3 mg tab er 24h)

Generic

buspirone hcl (5 mg, 7.5 mg, 10 mg, 15mg, 30 mg)

Generic

chlordiazepoxide hcl Generic

meprobamate 400 mg tablet Generic

oxazepam Generic






Bipolar Agents

Mood Stabilizerslithium carbonate (150 mg capsule, 300mg capsule, 300 mg tablet, 300 mgtablet er, 450 mg tablet er, 600 mgcapsule)

Generic

lithium citrate Generic

Blood Glucose Regulators

Antidiabetic Agentsacarbose Preventive

ACTOPLUS MET XR Preventive

BYDUREON Preventive PA

BYDUREON PEN Brand PA

BYETTA Preventive PA

chlorpropamide Preventive

FARXIGA Brand PA

glimepiride Preventive

glipizide (2.5 mg tab er 24, 5 mg tab er24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)

Preventive

glipizide/metformin hcl Preventive

glyburide Preventive

glyburide,micronized Preventive

glyburide/metformin hcl Preventive

INVOKANA Brand PA

JANUMET Preventive PA

JANUMET XR Preventive PA





Drug Name Status* Requirements/LimitsJANUVIA Preventive PA

JENTADUETO Preventive PA

JUVISYNC (50-10 MG, 50-20 MG, 50-40MG)

Preventive

KAZANO Preventive PA

KOMBIGLYZE XR Preventive PA

metformin hcl (500 mg tab er 24h, 500mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)

Preventive

nateglinide Preventive

NESINA Preventive PA

ONGLYZA Preventive PA

OSENI Preventive PA

pioglitazone hcl Preventive

pioglitazone hcl/glimepiride Preventive

pioglitazone hcl/metformin hcl Preventive

RIOMET Preventive

SYMLINPEN 120 Preventive PA

SYMLINPEN 60 Preventive PA

TRADJENTA Preventive PA

VICTOZA 2-PAK Preventive PA

VICTOZA 3-PAK Preventive PA

Glycemic AgentsGLUCAGEN Brand

GLUCAGON EMERGENCY KIT Brand

PROGLYCEM Brand

InsulinsAPIDRA Preventive





Drug Name Status* Requirements/LimitsAPIDRA SOLOSTAR Preventive

HUMALOG Preventive

HUMALOG MIX 50-50 Preventive

HUMALOG MIX 75-25 Preventive

HUMULIN R Preventive

LANTUS Preventive

LANTUS SOLOSTAR Preventive

LEVEMIR Preventive

LEVEMIR FLEXPEN Preventive

LEVEMIR FLEXTOUCH Preventive

NOVOLOG Preventive

NOVOLOG FLEXPEN Preventive

NOVOLOG MIX 70-30 Preventive

NOVOLOG MIX 70-30 FLEXPEN Preventive

Blood Products/Modifiers/ Volume Expanders

AnticoagulantsELIQUIS Preventive

enoxaparin sodium (30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,100 mg/ml, 120mg/.8ml, 150 mg/ml)

Preventive

fondaparinux sodium Preventive

FRAGMIN Preventive

JANTOVEN Preventive

PRADAXA Preventive

warfarin sodium (1 mg, 2 mg, 2.5 mg, 3mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg)

Preventive

XARELTO Preventive






Blood Formation Modifiersanagrelide hcl Generic

ARANESP Specialty PA

EPOGEN Specialty PA

GRANIX Brand

LEUKINE (250 MCG, 500 MCG/ML) Specialty

NEULASTA Specialty

NEUMEGA Specialty

NEUPOGEN Specialty

PROCRIT Specialty PA

PROMACTA Specialty PA

Coagulantstranexamic acid 650 mg tablet Generic

Platelet Modifying AgentsAGGRENOX Preventive

BRILINTA Preventive

cilostazol Preventive

clopidogrel bisulfate 75 mg tablet Preventive

dipyridamole (25 mg, 50 mg, 75 mg) Preventive

EFFIENT Preventive

ticlopidine hcl Preventive

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine Preventive

clonidine hcl (0.1 mg, 0.2 mg, 0.3 mg) Preventive





Drug Name Status* Requirements/Limitsguanfacine hcl Preventive

methyldopa Preventive

methyldopa/hydrochlorothiazide Preventive

midodrine hcl Generic

Alpha-adrenergic Blocking Agentsdoxazosin mesylate Preventive

prazosin hcl (1 mg, 2 mg, 5 mg) Preventive

terazosin hcl Preventive

Angiotensin II Receptor Antagonistscandesartan cilexetil Preventive

irbesartan Preventive

irbesartan/hydrochlorothiazide Preventive

losartan potassium Preventive

losartan potassium/hydrochlorothiazide Preventive

valsartan Preventive

valsartan/hydrochlorothiazide Preventive

Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (5 mg, 10 mg, 20 mg, 40mg)

Preventive

benazepril hcl/hydrochlorothiazide Preventive

captopril (12.5 mg, 25 mg, 50 mg, 100mg)

Preventive

captopril/hydrochlorothiazide Preventive

enalapril maleate (2.5 mg, 5 mg, 10 mg,20 mg)

Preventive

enalapril maleate/hydrochlorothiazide Preventive

EPANED Preventive

fosinopril sodium Preventive





Drug Name Status* Requirements/Limitsfosinopril sodium/hydrochlorothiazide Preventive

lisinopril (2.5 mg, 5 mg, 10 mg, 20 mg,30 mg, 40 mg)

Preventive

lisinopril/hydrochlorothiazide Preventive

moexipril hcl Preventive

moexipril hcl/hydrochlorothiazide Preventive

perindopril erbumine Preventive

quinapril hcl Preventive

quinapril hcl/hydrochlorothiazide Preventive

ramipril Preventive

trandolapril Preventive

Antiarrhythmicsamiodarone hcl (100 mg, 200 mg, 400mg)

Generic

disopyramide phosphate Generic

flecainide acetate Generic

mexiletine hcl (150 mg, 200 mg, 250mg)

Generic

MULTAQ Brand

NORPACE CR Brand

pacerone 200 mg tablet Generic

propafenone hcl Generic

quinidine gluconate 324 mg tablet er Generic

quinidine sulfate (200 mg, 300 mg, 300mg er)

Generic

SORINE Preventive

sotalol hcl (80 mg, 120 mg, 160 mg, 240mg)

Preventive

TIKOSYN Brand





Drug Name Status* Requirements/Limitsverapamil hcl (40 mg, 80 mg, 120 mg) Preventive

Beta-adrenergic Blocking Agentsacebutolol hcl (200 mg, 400 mg) Preventive

atenolol (25 mg, 50 mg, 100 mg) Preventive

atenolol/chlorthalidone Preventive

betaxolol hcl (10 mg, 20 mg) Preventive

bisoprolol fumarate Preventive

bisoprololfumarate/hydrochlorothiazide

Preventive

carvedilol Preventive

COREG CR Preventive

labetalol hcl (100 mg, 200 mg, 300 mg) Preventive

LEVATOL Preventive

metoprolol succinate Preventive

metoprolol tartrate (25 mg, 50 mg, 100mg)

Preventive

metoprololtartrate/hydrochlorothiazide

Preventive

nadolol (20 mg, 40 mg, 80 mg) Preventive

nadolol/bendroflumethiazide Preventive

pindolol Preventive

propranolol hcl (10 mg tablet, 20 mgtablet, 40 mg tablet, 40mg/5mlsolution, 60 mg cap sa 24h, 60 mgtablet, 80 mg cap sa 24h, 80 mg tablet,120 mg cap sa 24h, 160 mg cap sa 24h)

Preventive

propranolol hcl/hydrochlorothiazide Preventive

Calcium Channel Blocking AgentsAFEDITAB CR Preventive





Drug Name Status* Requirements/Limitsamlodipine besylate (2.5 mg, 5 mg, 10mg)

Preventive

amlodipine besylate/benazepril hcl Preventive

CARTIA XT Preventive

DILT-CD Preventive

DILT-XR Preventive

DILTIA XT Preventive

diltiazem hcl (30 mg tablet, 60 mg caper 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120mg cap er 24h, 120 mg cap er deg, 120mg capsule er, 120 mg tablet, 180 mgcap er 24h, 180 mg cap er deg, 180 mgcapsule er, 180 mg tab er 24h, 240 mgcap er 24h, 240 mg cap er deg, 240 mgcapsule er, 240 mg tab er 24h, 300 mgcap er 24h, 300 mg capsule er, 300 mgtab er 24h, 360 mg cap er 24h, 360 mgcapsule er, 360 mg tab er 24h, 420mgcapsule er, 420mg tab er 24h)

Preventive

DILTZAC ER Preventive

felodipine Preventive

isradipine Preventive

MATZIM LA Preventive

nicardipine hcl (20 mg, 30 mg) Preventive

NIFEDIAC CC Preventive

NIFEDICAL XL Preventive

nifedipine (30 mg tab er 24, 30 mgtablet er, 60 mg tab er 24, 60 mg tableter, 90 mg tab er 24, 90 mg tablet er)

Preventive

nimodipine 30 mg capsule Preventive

nisoldipine Preventive

TAZTIA XT Preventive





Drug Name Status* Requirements/Limitsverapamil hcl (100 mg cap24h pct, 120mg cap24h pel, 120 mg tablet er, 180mg cap24h pel, 180 mg tablet er, 200mg cap24h pct, 240 mg cap24h pel, 240mg tablet er, 300 mg cap24h pct, 360mg cap24h pel)

Preventive

Cardiovascular Agents, Otheramlodipine besylate/atorvastatincalcium

Preventive

digox Generic

digoxin (50 mcg/ml solution, 125 mcgtablet, 250 mcg tablet)

Generic

LANOXIN (62.5 MCG, 187.5 MCG) Brand

pentoxifylline 400 mg tablet er Preventive

RANEXA Brand

Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 500 mg capsule er Generic

methazolamide (25 mg, 50 mg) Generic

Diuretics, Loopbumetanide (0.5 mg, 1 mg, 2 mg) Preventive

EDECRIN Preventive

furosemide (10 mg/ml solution, 20 mgtablet, 40 mg tablet, 80 mg tablet)

Preventive

torsemide (5 mg, 10 mg, 20 mg, 100mg)

Preventive

Diuretics, Potassium-sparingamiloride hcl 5 mg tablet Preventive

amiloride hcl/hydrochlorothiazide Preventive

DYRENIUM Preventive

eplerenone Preventive





Drug Name Status* Requirements/Limitsspironolactone (25 mg, 50 mg, 100 mg) Preventive

spironolactone/hydrochlorothiazide Preventive

triamterene/hydrochlorothiazide Preventive

Diuretics, Thiazidechlorothiazide Preventive

chlorthalidone Preventive

hydrochlorothiazide (12.5 mg capsule,12.5 mg tablet, 25 mg tablet, 50 mgtablet)

Preventive

indapamide Preventive

methyclothiazide Preventive

metolazone Preventive

Dyslipidemics, Fibric Acid Derivativesfenofibrate (54 mg, 160 mg) Preventive

fenofibrate nanocrystallized Preventive

fenofibrate,micronized (67 mg, 134mg,200 mg)

Preventive

fenofibric acid Preventive

fenofibric acid (choline) Preventive

gemfibrozil 600 mg tablet Preventive

LOFIBRA Preventive

TRIGLIDE 160 MG TABLET Preventive

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium Preventive

fluvastatin sodium Preventive

lovastatin Preventive

pravastatin sodium Preventive

simvastatin (5 mg, 10 mg, 20 mg, 40mg)

Preventive






Dyslipidemics, Othercholestyramine (with sugar) (suar) 4powd pack, suar) 4 powder)

Preventive

cholestyramine/aspartame (4 powdpack, 4 powder)

Preventive

COLESTID (, FLAVORED) Preventive

colestipol hcl (1 tablet, 5 packet, 5ranules)

Preventive

JUXTAPID Specialty PA, LA

KYNAMRO Specialty PA, LA

PREVALITE (PACKET, POWDER) Preventive

Vasodilators, Direct-acting Arterialhydralazine hcl (10 mg, 25 mg, 50 mg,100 mg)

Generic

minoxidil (2.5 mg, 10 mg) Generic

RECTIV Brand

Vasodilators, Direct-acting Arterial/VenousDILATRATE-SR Brand

isochron Generic

isosorbide dinitrate Generic

isosorbide mononitrate Generic

minitran Generic

NITRO-BID Brand

NITRO-DUR (0.3, 0.8) Brand

nitro-time Generic

nitroglycerin (0.1mg/hr patch td24,0.2mg/hr patch td24, 0.4mg/hr patchtd24, 0.6mg/hr patch td24, 2.5 mgcapsule er, 6.5 mg capsule er, 9 mgcapsule er, 400mcg/spr spray)

Generic





Drug Name Status* Requirements/LimitsNITROSTAT Brand

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine sulf-saccharate/amphetamine sulf-aspartate

Generic

dextroamphetamine sulfate (5 mg er,10 mg er, 15 mg er)

Generic

dextroamphetamine sulfate (5 mg, 10mg)

Generic PA

VYVANSE Brand

zenzedi (5 mg, 10 mg) Generic PA

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesDAYTRANA Brand PA, QL (30 PER 30 DAYS)

dexmethylphenidate hcl (2.5 mg, 5 mg,10 mg)

Generic

dexmethylphenidate hcl (5 mg, 15 mg,30 mg, 40 mg)

Generic PA

FOCALIN XR (10 MG, 20 MG, 25 MG, 35MG)

Brand PA

metadate er Generic





Drug Name Status* Requirements/Limitsmethylphenidate hcl (5 mg tablet, 5mg/5 ml solution, 10 mg cpbp 30-70, 10mg tablet, 10 mg tablet er, 10 mg/5 mlsolution, 18 mg tab er 24, 20 mg cpbp30-70, 20 mg cpbp 50-50, 20 mg tablet,20 mg tablet er, 27 mg tab er 24, 30 mgcpbp 30-70, 30 mg cpbp 50-50, 36 mgtab er 24, 40 mg cpbp 30-70, 40 mgcpbp 50-50, 50 mg cpbp 30-70, 54 mgtab er 24, 60 mg cpbp 30-70)

Generic

RITALIN LA 10 MG CAPSULE Brand

STRATTERA Brand PA, QL (30 PER 30 DAYS)

Central Nervous System Agents, OtherNUEDEXTA Brand PA

riluzole Generic

XENAZINE Specialty PA

Fibromyalgia AgentsSAVELLA (12.5 MG, 25 MG, 50 MG, 100MG)

Brand PA, QL (60 PER 30 DAYS)

SAVELLA TITRATION PACK Brand PA, QL (55 PER 30 DAYS)

Multiple Sclerosis AgentsAMPYRA Specialty PA, LA, QL (60 PER 30 DAYS)

AUBAGIO Specialty PA, LA, QL (30 PER 30 DAYS)

AVONEX (30 MCG, 30 MCG KT) Specialty

AVONEX ADMINISTRATION PACK Specialty

AVONEX PEN Specialty

BETASERON 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS)

BETASERON 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS)

COPAXONE 20 MG/ML SYRINGE Specialty QL (30 ML PER 30 DAYS)

COPAXONE 40 MG/ML SYRINGE Specialty QL (12 ML PER 28 DAYS)





Drug Name Status* Requirements/LimitsEXTAVIA 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS)

EXTAVIA 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS)

FIRAZYR Specialty PA, QL (9 ML PER 30 DAYS)

GILENYA Specialty PA, QL (30 PER 30 DAYS)

PLEGRIDY Specialty QL (1 ML PER 28 DAYS)

PLEGRIDY PEN Specialty QL (1 ML PER 28 DAYS)

REBIF (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS)

REBIF REBIDOSE (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS)

REBIF REBIDOSE TITRATION PACK Specialty QL (4.2 ML PER 30 DAYS)

REBIF TITRATION PACK Specialty QL (4.2 ML PER 30 DAYS)

TECFIDERA Specialty QL (60 PER 30 DAYS)

Dental and Oral Agents

pilocarpine hcl (5 mg, 7.5 mg) Generic

Dermatological Agents

acitretin Generic

adapalene (0.1 % cream (g), 0.1 % gel(gram), 0.3 % gel (gram))

Generic

adapalene 0.3 % gel w/pump Brand

ammonium lactate 12 % cream (g) Generic

amnesteem Generic

avita 0.025% cream Generic

calcipotriene (0.005 % cream (g), 0.005% solution)

Generic

claravis Generic

clindamycin phos/benzoyl perox 1 %-5% gel (gram)

Generic

DIFFERIN 0.3% GEL PUMP Brand





Drug Name Status* Requirements/LimitsELIDEL Brand PA

EPIFOAM Brand

erythromycin base/benzoyl peroxide Generic

FINACEA Brand PA

FLUOROPLEX Brand

fluorouracil (0.5 % cream (g), 2 %solution, 5 % cream (g), 5 % solution)

Generic

gengraf 100 mg capsule Generic

hypercare Generic

methoxsalen, rapid Specialty

mometasone furoate (0.1 % cream (g),0.1 % oint. (g), 0.1 % solution)

Generic

myorisan Generic

OTEZLA Specialty PA

OXSORALEN Brand

PICATO Brand PA

podofilox 0.5 % solution Generic

PROTOPIC Brand PA

refissa Generic

REGRANEX Brand PA

SANTYL Brand QL (30 GM PER 30 DAYS)

STELARA 45 MG/0.5 ML SYRINGE Specialty PA, QL (0.5 ML PER 30 DAYS)

STELARA 90 MG/ML SYRINGE Specialty PA, QL (1 ML PER 30 DAYS)

TAZORAC Brand

tretinoin (0.01 % gel (gram), 0.025 %cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.1 % cream (g))

Generic

tretinoin/emollient base Generic

trianex Generic





Drug Name Status* Requirements/LimitsVOLTAREN Brand

zenatane Generic

Enzyme Replacement/ Modifiers

ADAGEN Specialty

BUPHENYL 500 MG TABLET Specialty

CARBAGLU Brand

CEREZYME 400 UNITS VIAL Brand

CREON Brand

ELELYSO Specialty

KUVAN Specialty PA, LA

ORFADIN Specialty

pancrelipase 5,000 Generic

RAVICTI Specialty LA

sodium phenylbutyrate 0.94 g/g powder Specialty

SUCRAID Specialty

ZAVESCA Specialty

ZENPEP (3,000, 10,000, 15,000, 20,000,25,000)

Brand

Gastrointestinal Agents

Antispasmodics, GastrointestinalCUVPOSA Brand PA

dicyclomine hcl (10 mg capsule, 10mg/5 ml solution, 20 mg tablet)

Generic

glycopyrrolate (1 mg, 2 mg) Generic

Gastrointestinal Agents, OtherAPRISO Brand





Drug Name Status* Requirements/LimitsASACOL Brand

ASACOL HD Brand

CANASA Brand

DELZICOL Brand

diphenoxylate hcl/atropine sulfate (2.5-.025/5 liquid, 2.5-.025mg tablet)

Generic

FULYZAQ Brand PA

GATTEX Specialty PA, LA

gavilyte-c Generic

gavilyte-g Generic

gavilyte-n Generic

GOLYTELY PACKET Brand

LIALDA Brand

mesalamine 4 g/60 ml enema Generic

mesalamine with cleansing wipes Generic

nulytely with flavor packs Generic

peg 3350/sod sulf/sod bicarbonate/sodchloride/potassium chl

Generic

PENTASA Brand

propantheline bromide 15 mg tablet Generic

PYLERA Brand

sodium chloride/sodiumbicarbonate/potassium chloride/peg

Generic

sulfasalazine (500 mg, 500 mg dr) Generic

sulfazine Generic

sulfazine ec Generic

trilyte with flavor packets Generic

ursodiol (250 mg tablet, 300 mgcapsule, 500 mg tablet)

Generic






Histamine2 (H2) Receptor Antagonistscimetidine (300 mg, 400 mg, 800 mg) Generic

cimetidine hcl Generic

famotidine 40 mg tablet Generic

nizatidine (150 mg, 300 mg) Generic

ranitidine hcl (15 mg/ml syrup, 300 mgtablet)

Generic

Irritable Bowel Syndrome AgentsLOTRONEX Brand PA

Laxativesconstulose Generic

enulose Generic

generlac Generic

lactulose Generic

MOVIPREP Brand

SUPREP Brand

Protectantsmisoprostol (100 mcg, 200 mcg) Generic

sucralfate (1 g tablet, 1 g/10 ml oralsusp)

Generic

Proton Pump InhibitorsFIRST-LANSOPRAZOLE Brand

FIRST-OMEPRAZOLE Brand

lansoprazole 30 mg capsule dr Generic

lansoprazole/amoxicillintrihydrate/clarithromycin

Generic

omeprazole (10 mg, 20 mg, 40 mg) Generic





Drug Name Status* Requirements/LimitsOMEPRAZOLE+SYRSPEND SF ALKA Brand

pantoprazole sodium (20 mg, 40 mg) Generic

PROTONIX 40 MG SUSPENSION Brand

rabeprazole sodium Generic

Genitourinary Agents

Antispasmodics, Urinaryflavoxate hcl Generic

oxybutynin chloride (5 mg tab er 24, 5mg tablet, 5 mg/5 ml syrup, 10 mg taber 24, 15 mg tab er 24)

Generic

OXYTROL Brand

tolterodine tartrate Generic

trospium chloride 20 mg tablet Generic

Benign Prostatic Hypertrophy Agentsalfuzosin hcl Generic

finasteride 5 mg tablet Generic

tamsulosin hcl Generic

Genitourinary Agents, Otherbethanechol chloride (5 mg, 10 mg, 25mg, 50 mg)

Generic

CUPRIMINE Brand

CYSTAGON Specialty PA

DEPEN Brand

ELMIRON Brand

PROCYSBI Brand PA, LA

THIOLA Brand






Phosphate Binderscalcium acetate 667 mg capsule Generic

RENAGEL Brand PA

RENVELA Brand PA

sevelamer carbonate Brand PA

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Glucocorticoids/Mineralocorticoidsbetamethasoneacetate/betamethasone sodiumphosphate

Generic

budesonide 3 mg capdr - er Generic

CELESTONE 0.6 MG/5 ML SOLUTION Brand

dexamethasone (0.5 mg tablet, 0.5mg/5ml elixir, 0.5 mg/5ml solution, 0.75mg tablet, 1 mg tablet, 1.5 mg tablet, 2mg tablet, 4 mg tablet, 6 mg tablet)

Generic

FLAREX Brand

FLOVENT DISKUS Preventive

FLOVENT HFA Preventive

fluocinolone acetonide oil Generic

fluorometholone 0.1 % drops susp Generic

fluticasone propionate 50 mcg spraysusp

Generic

FML FORTE Brand

FML S.O.P. Brand

hydrocortisone (5 mg, 10 mg, 20 mg) Generic

hydrocortisone butyrate (0.1 % oint. (g),0.1 % solution)

Generic

hydrocortisone valerate Generic





Drug Name Status* Requirements/Limitsmethylprednisolone Generic

triamcinolone acetonide 55 mcg spray Generic

UCERIS 9 MG ER TABLET Brand PA

Hormonal Agents, Stimulant/Replacement/Modifying (Other)

MYALEPT Brand PA, LA

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate (0.1 mg tablet,0.2 mg tablet, 10/spray spray/pump)

Generic PA

desmopressin acetate (0.1 mg/mlsolution, 4mcg/ml ampul, 4mcg/ml vial)

Generic

desmopressin acetate (non-refrigerated)

Generic PA

EGRIFTA Specialty PA

GENOTROPIN Specialty PA

HUMATROPE Specialty PA

INCRELEX Specialty PA, LA

NORDITROPIN Specialty PA

NORDITROPIN FLEXPRO Specialty PA

NORDITROPIN NORDIFLEX (NORDIFLEX5, NORDIFLX 10, NORDIFLX 15)

Specialty PA

NUTROPIN Specialty PA

NUTROPIN AQ Specialty PA

NUTROPIN AQ NUSPIN Specialty PA

OMNITROPE 5 MG/1.5 ML CRTG Specialty PA

SAIZEN Specialty PA

SEROSTIM Specialty PA

STIMATE Brand





Drug Name Status* Requirements/LimitsTEV-TROPIN Specialty PA

ZORBTIVE Specialty PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 Specialty

oxandrolone 10 mg tablet Generic

AndrogensANDROGEL Brand

danazol (50 mg, 100 mg, 200 mg) Generic

testosterone (1.25g gel md pmp, 50 mggel packet)

Brand

testosterone 50 mg (1%) gel (gram) Generic

testosterone cypionate (100 mg/ml, 200mg/ml)

Generic

testosterone enanthate 200 mg/ml vial Generic

VOGELXO (12.5 MG/1.25 PUMP, 50MG/5 GEL PACKT)

Brand

EstrogensALORA Brand

ALTAVERA Preventive

ALYACEN Preventive

AMETHIA Preventive

AMETHIA LO Preventive

AMETHYST Preventive

APRI Preventive

ARANELLE Preventive

AUBRA Preventive





Drug Name Status* Requirements/LimitsAVIANE Preventive

AZURETTE Preventive

BALZIVA Preventive

BRIELLYN Preventive

CAMRESE Preventive

CAMRESE LO Preventive

CAZIANT Preventive

CHATEAL Preventive

COMBIPATCH Brand

CRYSELLE Preventive

CYCLAFEM Preventive

DASETTA Preventive

DAYSEE Preventive

DELYLA Preventive

desogestrel-ethinyl estradiol Preventive

desogestrel-ethinyl estradiol/ethinylestradiol

Preventive

DUAVEE Brand

ELINEST Preventive

EMOQUETTE Preventive

ENPRESSE Preventive

ENSKYCE Preventive

ESTARYLLA Preventive

ESTRACE 0.01% CREAM Brand

estradiol (.025mg/24h patch tdwk,.0375mg/24 patch tdwk, 0.05mg/24hpatch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk, 0.1mg/24hrpatch tdwk, 0.5 mg tablet, 1 mg tablet,2 mg tablet)

Generic





Drug Name Status* Requirements/Limitsestradiol/norethindrone acet 1 mg-0.5mg tablet

Generic

ESTRING Brand

estropipate (0.75 mg, 1.5 mg, 3 mg) Generic

ethinyl estradiol/drospirenone Preventive

FALMINA Preventive

GIANVI Preventive

GILDAGIA Preventive

GILDESS Preventive

GILDESS FE Preventive

INTROVALE Preventive

JOLESSA Preventive

JUNEL Preventive

JUNEL FE Preventive

KARIVA Preventive

KELNOR 1-35 Preventive

KURVELO Preventive

LARIN Preventive

LARIN FE Preventive

LEENA Preventive

LESSINA Preventive

LEVONEST Preventive

levonorgestrel-eth estra/ethinylestradiol

Preventive

levonorgestrel-ethinyl estradiol Preventive

LEVORA-28 Preventive

LOMEDIA 24 FE Preventive

LORYNA Preventive





Drug Name Status* Requirements/LimitsLOW-OGESTREL Preventive

LUTERA Preventive

MARLISSA Preventive

MICROGESTIN Preventive

MICROGESTIN FE Preventive

mimvey Generic

MINIVELLE Brand

MONO-LINYAH Preventive

MONONESSA Preventive

MYZILRA Preventive

NECON Preventive

NIKKI Preventive

norethindrone acetate-ethinyl estradiol Preventive

norethindrone acetate-ethinylestradiol/ferrous fumarate

Preventive

norgestimate-ethinyl estradiol Preventive

NORTREL Preventive

NUVARING Preventive

OCELLA Preventive

OGESTREL Preventive

ORSYTHIA Preventive

ORTHO TRI-CYCLEN LO Preventive

PHILITH Preventive

PIMTREA Preventive

PIRMELLA Preventive

PORTIA Preventive

PREMARIN (0.3 MG TABLET, 0.45 MGTABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINALCREAM-APPL)

Brand





Drug Name Status* Requirements/LimitsPREMPHASE Brand

PREMPRO Brand

PREVIFEM Preventive

QUASENSE Preventive

RECLIPSEN Preventive

SPRINTEC Preventive

SRONYX Preventive

SYEDA Preventive

TARINA FE Preventive

TILIA FE Preventive

TRI-ESTARYLLA Preventive

TRI-LEGEST FE Preventive

TRI-LINYAH Preventive

TRI-PREVIFEM Preventive

TRI-SPRINTEC Preventive

TRINESSA Preventive

TRIVORA-28 Preventive

VAGIFEM Brand

VELIVET Preventive

VESTURA Preventive

VIORELE Preventive

VIVELLE-DOT Brand

VYFEMLA Preventive

WERA Preventive

XULANE Preventive

ZARAH Preventive

ZENCHENT Preventive





Drug Name Status* Requirements/LimitsZOVIA 1-35E Preventive

ZOVIA 1-50E Preventive

ProgestinsCAMILA Preventive

DEBLITANE Preventive

DEPO-SUBQ PROVERA 104 Brand

ERRIN Preventive

HEATHER Preventive

JENCYCLA Preventive

JOLIVETTE Preventive

LYZA Preventive

medroxyprogesterone acetate (2.5 mgtablet, 5 mg tablet, 10 mg tablet, 150mg/ml syringe, 150 mg/ml vial)

Generic

megestrol acetate (20 mg tablet, 40 mgtablet, 400mg/10ml oral susp)

Generic

NORA-BE Preventive

norethindrone 0.35 mg tablet Preventive

norethindrone acetate 5 mg tablet Generic

NORLYROC Preventive

progesterone,micronized (100 mg, 200mg)

Generic

SHAROBEL Preventive

Selective Estrogen Receptor Modifying Agentsraloxifene hcl Preventive

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothroid Generic





Drug Name Status* Requirements/Limitslevothyroxine sodium (25 mcg, 50 mcg,75 mcg, 88 mcg, 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg, 175mcg, 200mcg, 300 mcg)

Generic

levoxyl Generic

liothyronine sodium (5 mcg, 25 mcg, 50mcg)

Generic

unithroid (25 mcg, 50 mcg, 75 mcg, 88mcg, 100 mcg, 112 mcg, 125 mcg, 150mcg, 175 mcg, 200 mcg, 300 mcg)

Generic

Hormonal Agents, Suppressant (Adrenal)

LYSODREN Brand

SIGNIFOR Specialty PA, LA

Hormonal Agents, Suppressant (Parathyroid)

calcitriol (0.25 mcg capsule, 0.5 mcgcapsule, 1 mcg/ml solution)

Generic

paricalcitol (1 mcg, 2 mcg, 4mcg) Generic

SENSIPAR (30 MG, 60 MG) Specialty QL (60 PER 30 DAYS)

SENSIPAR 90 MG TABLET Specialty

ZEMPLAR (5 MCG/ML, 10 MCG/2 ML) Brand

Hormonal Agents, Suppressant (Pituitary)

cabergoline Generic

ELIGARD Brand PA

leuprolide acetate 1 mg/0.2ml kit Generic PA

octreotide acetate (50 mcg/ml ampul,50 mcg/ml vial, 100 mcg/ml ampul, 100mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml vial,1000mcg/ml vial)

Specialty PA





Drug Name Status* Requirements/LimitsSOMAVERT Specialty PA, LA

Hormonal Agents, Suppressant (Sex Hormones/Modifiers)

Antiandrogensbicalutamide Generic

NILANDRON Brand

XTANDI Specialty PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole (5 mg, 10 mg) Generic

propylthiouracil 50 mg tablet Generic

Immunological Agents

Angioedema (HAE) AgentsBERINERT 500 UNIT KIT Specialty PA, QL (3 PER 30 DAYS)

Immune SuppressantsASTAGRAF XL Brand

azathioprine 50 mg tablet Generic

CELLCEPT 200 MG/ML ORAL SUSP Brand

cyclosporine (25 mg, 100 mg) Generic

cyclosporine, modified (25 mg capsule,50 mg capsule, 100 mg capsule, 100mg/ml solution)

Generic

ENBREL (25 MG/0.5 ML SYRINGE, 50MG/ML SURECLICK SYR, 50 MG/MLSYRINGE)

Specialty QL (4 ML PER 28 DAYS)

ENBREL 25 MG KIT Specialty QL (8 PER 28 DAYS)





Drug Name Status* Requirements/Limitsgengraf (25 mg capsule, 100 mg/mlsolution)

Generic

GRASTEK Brand PA

hecoria Generic

HUMIRA Specialty

HUMIRA PEDIATRIC Specialty

mycophenolate mofetil (250 mgcapsule, 500 mg tablet)

Generic

mycophenolate sodium Generic

ORALAIR Specialty PA, LA

PROGRAF 5 MG/ML AMPULE Brand

RAGWITEK Brand PA

RAPAMUNE 1 MG/ML ORAL SOLN Brand

RESTASIS Brand QL (60 PER 30 DAYS)

SANDIMMUNE 100 MG/ML SOLN Brand

sirolimus (0.5 mg, 1 mg, 2 mg) Generic

tacrolimus (0.5 mg, 1 mg, 5 mg) Generic

ZORTRESS Specialty

Immunizing Agents, PassiveGAMMAGARD S-D Brand PA

GAMMAKED Specialty PA

GAMUNEX-C Specialty PA

ImmunomodulatorsACTIMMUNE Specialty PA

ALFERON N Specialty

leflunomide Generic






Inflammatory Bowel Disease Agents

Aminosalicylatesbalsalazide disodium Generic

DIPENTUM Brand

Glucocorticoidsanusol-hc 2.5% cream Generic

procto-pak Generic

proctocream-hc Generic

PROCTOFOAM-HC Brand

proctosol-hc Generic

proctozone-hc Generic

Metabolic Bone Disease Agents

ACTONEL (5 MG, 30 MG, 35 MG) Preventive PA

alendronate sodium (5 mg tablet, 10mg tablet, 35 mg tablet, 40 mg tablet,70 mg tablet, 70 mg/75ml solution)

Preventive

calcitonin,salmon,synthetic Preventive

doxercalciferol (0.5 mcg capsule, 1 mcgcapsule, 2.5 mcg capsule, 4mcg/2mlvial)

Generic

etidronate disodium Preventive

FORTEO Preventive PA

ibandronate sodium 150 mg tablet Preventive

Miscellaneous

Glucose TestingACCU-CHECK (METERS & TEST STRIPS) DME Benefit QL





Drug Name Status* Requirements/LimitsLIFESCAN (METERS & TEST STRIPS) DME Benefit QL

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogslatanoprost Generic

LUMIGAN Brand Step Therapy

TRAVATAN Z Brand

travoprost (benzalkonium) Generic

Ophthalmic Agents, Otherak-poly-bac Generic

bacitracin/polymyxin b sulfate Generic

BLEPHAMIDE Brand

BLEPHAMIDE S.O.P. Brand

CYSTARAN Brand PA, LA, QL (60 ML PER 30 DAYS)

gatifloxacin Generic

LACRISERT Brand

MOXEZA Brand

naphazoline hcl 0.1 % drops Generic

neo-polycin Generic

neo-polycin hc Generic

neomycin sulfate/bacitracinzinc/polymyxin b/hydrocortisone

Generic

neomycin sulfate/bacitracin/polymyxinb

Generic

neomycin sulfate/polymyxin bsulfate/gramicidin d

Generic

neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp

Generic





Drug Name Status* Requirements/Limitsneomycin/polymyxin bsulfate/dexamethasone (0.1 % dropssusp, 3.5-10k-.1 oint. (g))

Generic

neosporin Generic

polycin Generic

polymyxin b sulfate/trimethoprim Generic

sulfacetamide sodium/prednisolonesodium phosphate

Generic

TOBRADEX EYE OINTMENT Brand

TOBRADEX ST Brand

tobramycin/dexamethasone Generic

tropicamide (0.5 %, 1 %) Generic

VIGAMOX Brand

ZYLET Brand

Ophthalmic Anti-allergy AgentsALOMIDE Brand

azelastine hcl 0.05 % drops Generic

cromolyn sodium 4 % drops Generic

PATANOL Brand PA

Ophthalmic Anti-inflammatoriesALREX Brand

bromfenac sodium Generic

dexamethasone sod phosphate 0.1 %drops

Generic

diclofenac sodium 0.1 % drops Generic

flurbiprofen sodium Generic

ketorolac tromethamine (0.4 %, 0.5 %) Generic

LOTEMAX (0.5% EYE DROPS, 0.5% EYEOINTMENT, 0.5% OPHTHALMIC GEL)

Brand





Drug Name Status* Requirements/Limitsprednisolone acetate 1 % drops susp Generic

prednisolone sod phosphate 1 % drops Generic

VEXOL Brand

Ophthalmic Antiglaucoma AgentsALPHAGAN P 0.1% DROPS Brand

AZOPT Brand

betaxolol hcl 0.5 % drops Generic

BETIMOL Brand

BETOPTIC S Brand

brimonidine tartrate (0.15 %, 0.2 %) Generic

carteolol hcl Generic

dorzolamide hcl Generic

dorzolamide hcl/timolol maleate Generic

ISTALOL Brand

levobunolol hcl Generic

metipranolol Generic

pilocarpine hcl (1 %, 2 %, 4 %) Generic

PILOPINE HS Brand

timolol maleate (0.25 % drops, 0.25 %sol-gel, 0.5 % drops, 0.5 % sol-gel)

Generic

Otic Agents

antipyrine/benzocaine 5.4 %-1.4% drops Generic

aurodex Generic

auroguard Generic

CIPRO HC Brand

CIPRODEX Brand





Drug Name Status* Requirements/Limitsciprofloxacin hcl 0.2 % droperette Generic

neomycin sulfate/polymyxin bsulfate/hydrocortisone (drops susp,solution)

Generic

otic care Generic

Respiratory Tract Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS Preventive

ADVAIR HFA Preventive

AEROSPAN Preventive

ALVESCO Preventive

ASMANEX Preventive

BREO ELLIPTA Preventive

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

budesonide 32mcg spray/pump Generic

flunisolide (25 mcg, 29mcg) Generic

NASONEX Brand QL (17 GM PER 30 DAYS)

PULMICORT 1 MG/2 ML RESPULE Preventive

PULMICORT FLEXHALER Preventive

QVAR Preventive

Antihistaminesazelastine hcl 137 mcg spray/pump Generic

clemastine fumarate (0.67mg/5mlsyrup, 2.68 mg tablet)

Generic

cyproheptadine hcl (2 mg/5 ml syrup, 4mg tablet)

Generic

levocetirizine dihydrochloride (2.5mg/5ml solution, 5 mg tablet)

Generic





Drug Name Status* Requirements/Limitspromethazine hcl/codeine Generic

promethazine/phenylephrinehcl/codeine

Generic

Antileukotrienesmontelukast sodium (4 mg gran pack, 4mg tab chew, 5 mg tab chew, 10 mgtablet)

Preventive

zafirlukast Preventive QL (60 PER 30 DAYS)

ZYFLO CR Preventive

Bronchodilators, AnticholinergicATROVENT HFA Brand

COMBIVENT Brand QL (14.7 GM PER 30 DAYS)

COMBIVENT RESPIMAT Brand QL (4 GM PER 30 DAYS)

hydrocodone bit/homatrop me-br 5-1.5mg/5 syrup

Generic

hydromet Generic

ipratropium bromide (0.2 mg/mlsolution, 21 mcg spray, 42mcg spray)

Generic

ipratropium bromide/albuterol sulfate Generic

SPIRIVA Brand

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)THEOCHRON Preventive

theophylline anhydrous (100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er12h, 400 mg tablet er, 450 mg tab er12h, 600 mg tablet er)

Preventive






Bronchodilators, Sympathomimeticalbuterol sulfate (0.63mg/3ml vial-neb,1.25mg/3ml vial-neb, 2 mg tablet, 2mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er12h)

Preventive

EPIPEN 2-PAK Brand

EPIPEN JR 2-PAK Brand

levalbuterol hcl (0.31mg/3ml,0.63mg/3ml, 1.25mg/0.5, 1.25mg/3ml)

Preventive

PROAIR HFA Preventive QL (17 GM PER 30 DAYS)

SEREVENT DISKUS Preventive

terbutaline sulfate (2.5 mg, 5 mg) Preventive

VENTOLIN HFA Preventive QL (36 GM PER 30 DAYS)

XOPENEX HFA Preventive

Mast Cell Stabilizerscromolyn sodium (20 mg/2 ml ampul-neb, 20 mg/ml solution)

Generic

Pulmonary AntihypertensivesADCIRCA Specialty PA

ADEMPAS Specialty PA

LETAIRIS Specialty PA

OPSUMIT Specialty PA, LA

ORENITRAM ER Specialty PA, LA

sildenafil citrate 20 mg tablet Specialty PA, QL (90 PER 30 DAYS)

TRACLEER Specialty PA, LA

VELETRI 0.5 MG VIAL Specialty

VENTAVIS Specialty PA






Respiratory Tract Agents, OtherANORO ELLIPTA Brand

benzonatate Generic

dextromethorphan hbr/promethazinehcl

Generic

HYPER-SAL 3.5% VIAL Brand

KALYDECO Specialty PA, LA, QL (60 PER 30 DAYS)

phenylephrine hcl/promethazine hcl Generic

pulmosal Generic

PULMOZYME Specialty

sodium chloride for inhalation 7 % vial-neb

Generic

sski Generic

SYMBICORT Preventive

TYZINE Brand

Skeletal Muscle Relaxants

carisoprodol (250 mg, 350 mg) Generic

carisoprodol/aspirin Generic

chlorzoxazone Generic

cyclobenzaprine hcl (5 mg, 7.5 mg, 10mg)

Generic

metaxalone Generic

methocarbamol (500 mg, 750 mg) Generic

orphenadrine citrate 100 mg tablet er Generic

orphenadrine/aspirin/caffeine 50-770-60 tablet

Generic






Sleep Disorder Agents

GABA Receptor Modulatorsestazolam Generic

eszopiclone Generic QL (30 PER 30 DAYS)

flurazepam hcl Generic

temazepam Generic

triazolam Generic

zaleplon Generic QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg, 10 mg) Generic QL (30 PER 30 DAYS)

Sleep Disorders, Othermodafinil Generic PA, QL (30 PER 30 DAYS)

ROZEREM Brand PA, QL (30 PER 30 DAYS)

XYREM Specialty PA, LA, QL (540 ML PER 30 DAYS)

Therapeutic Nutrients/ Minerals/ Electrolytes

Electrolyte/Mineral ModifiersEXJADE Specialty

kionex 15 gm/60 ml suspension Generic

sodium polystyrene sulfonate(15g/60ml oral susp, 30g/120ml enema,50g/200ml enema)

Generic

sps 15 gm/60 ml suspension Generic

SYPRINE Brand

Electrolyte/Mineral Replacementcyanocobalamin (vitamin b-12)1000mcg/ml vial

Generic

ergocalciferol (vitamin d2) 50000 unitcapsule

Generic





Drug Name Status* Requirements/LimitsFLUOR-A-DAY (0.25 MG TAB, 0.5 MGTAB, 1 MG TABLET)

Preventive

fluoride/iron/vitamins a,c,and d Preventive

FLUORITAB 0.5 MG TABLET CHEW Preventive

FLURA-DROPS Preventive

folic acid 1 mg tablet Preventive

klor-con 10 Generic

klor-con 8 Generic

klor-con m10 Generic

klor-con m20 Generic

levocarnitine 330 mg tablet Generic

LUDENT FLUORIDE Preventive

MATERNITY Preventive

multivitamins with fluoride Preventive

pediatric multivitamin combinationno.2/sodium fluoride

Preventive

pediatric multivitamins a,c,& d3 no.21with sodium fluoride

Preventive

pediatric multivitamins no.16 withsodium fluoride

Preventive


Preventive


Preventive

potassium chloride (8 meq capsule er, 8meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20meq tab er prt, 20 meq tablet er,20meq/15ml liquid, 40meq/15ml liquid)

Generic

potassium citrate (5 er, 10 er) Generic

PRENAPLUS Preventive





Drug Name Status* Requirements/Limitsprenatal vitamins comb no.115/ironfumarate/folic acid

Preventive

prenatal vitamins comb no.115/ironfumarate/folic acid/dss

Preventive

prenatal vitamins combo no.60/ferrousfumarate/folic acid

Preventive

prenatal vits with calcium #72/ferrousfumarate/folic acid

Preventive

prenatal vits with calcium#72/iron,carbonyl/folic acid

Preventive

PREPLUS Preventive

QUFLORA (0.25 MG/ML, 0.5 MG/ML) Brand

SE-NATAL 19 Preventive

sodium fluoride (0.25(0.55) tab chew,0.5 mg/ml drops, 0.5(1.1)mg tab chew,1mg(2.2mg) tab chew, 1mg(2.2mg)tablet)

Preventive

TL-FLUORIVITE Preventive

TRICARE Preventive

TRINATAL RX 1 Preventive

VINATE ONE Preventive

VINATE-M Preventive

VOL-PLUS Preventive



Non-Formulary Drugs That Require Prior Authorization

ABSTRALACANYAACIPHEX SPRINKLEACTIQACTONEL 150 MG TABLETACYCLOVIR 5% OINTMENTACZONEADOXAALTABAXAMBIEN CRAMITIZAAMRIXANZEMET 100 MG TABLETANZEMET 50 MG TABLETAPLENZINAPOKYNARICEPT 23 MG TABLETARTHROTEC 50ARTHROTEC 75ASTEPROATELVIAATOVAQUONE-PROGUANIL HCLATRALINAVINZAAZACITIDINEAZELASTINE 0.15% NASAL SPRAYBENZACLIN GEL 35G PUMPBENZACLIN GEL 50G PUMPBEPREVEBIDILBINOSTOBRINTELLIXBRISDELLEBUTALB-ACETAMIN-CAFF 50-300-40BUTRANS 15 MCG/HR PATCHBUTRANS 10 MCG/HR PATCHBUTRANS 20 MCG/HR PATCHBUTRANS 5 MCG/HR PATCHBYSTOLICCALCIPOTRIENE-BETAMETHASONE DPCALCITRIOL 3 MCG/G OINTMENT

CAMBIACARDIZEM LA 120 MG TABLETCARDURA XLCENTANY ATCESAMETCIALIS 5 MG TABLETCIMZIACLARINEXCLARINEX-D 12 HOURCLARINEX-D 24 HOURCLOBEX 0.05% SPRAYCLONIDINE HCL ERCOARTEMCOMBIGANCONZIPCRESTORCRINONECYCLOSETDALIRESPDERMASORB HCDERMASORB TADESLORATADINEDESONATEDESVENLAFAXINE FUMARATE ERDEXILANTDICLOFENAC SODIUM 1.5% SOLNDICLOFENAC SODIUM 3% GELDICLOFENAC SODIUM-MISOPROSTOLDIFFERIN 0.1% LOTIONDIFICIDDONEPEZIL HCL 23 MG TABLETDORYXDOXYCYCLINE HYC DR 100 MG TABDOXYCYCLINE HYC DR 150 MG TABDOXYCYCLINE HYC DR 75 MG TABDOXYCYCLINE IR-DRDOXYCYCLINE MONO 75 MG CAPSULEDOXYCYCLINE MONO 150 MG CAPDRONABINOLDUEXISECOZA

74

EDARBIEDARBYCLOREDLUARENABLEXENDOMETRINEPIDUOEPROSARTAN MESYLATEESOMEPRAZOLE STRONTIUMEXALGOFENOFIBRATE 50 MG CAPSULEFENOFIBRATE 150 MG CAPSULEFENTANYL CITRATE OTFC 800 MCGFENTANYL CITRATE OTFC 600 MCGFENTANYL CITRATE OTFC 200 MCGFENTANYL CITRATE OTFC 400 MCGFENTANYL CIT OTFC 1600 MCGFENTANYL CIT OTFC 1200 MCGFENTORAFETZIMAFIORICET 50-300-40 MG CAPSULEFLECTORFLO-PREDFLUOCINONIDE 0.1% CREAMFLUVOXAMINE MALEATE ERFORFIVO XLFORTAMETFOSAMAX PLUS DFOSRENOLFYCOMPAGELNIQUEGLUMETZAGRALISEHETLIOZHORIZANTHYDROMORPHONE ERINTERMEZZOINTUNIVJALYNKAPVAY

KETEKKORLYMLAMICTAL ODTLAMICTAL ODT (BLUE)LAMICTAL ODT (GREEN)LAMICTAL ODT (ORANGE)LASTACAFTLAZANDALIPOFENLIPTRUZETLIVALOLOVAZALUPRON DEPOTLUPRON DEPOT-PEDLUVOX CRMALARONEMARINOLMETFORMIN ER 1000 MG OSM-TABMETFORMIN HCL ER 500 MG OSM-TBMETOZOLV ODTMETROGELMETRONIDAZOLE TOPICAL 1% GELMICARDISMICARDIS HCTMIRAPEX ERMONODOX 75 MG CAPSULEMORGIDOX 1X100 MG KITMORGIDOX 2X100 MG KITMORPHINE SULFATE ER 75 MG CAPMORPHINE SULFATE ER 120 MG CAPMORPHINE SULFATE ER 60 MG CAPMORPHINE SULFATE ER 90 MG CAPMORPHINE SULFATE ER 45 MG CAPMORPHINE SULFATE ER 30 MG CAPMOZOBILNAMENDA XRNATROBANEXIUMNIACIN ERNIASPAN

75

NORDITROPIN NORDIFLEX 30 MG/3NOXAFIL DR 100 MG TABLETNUCYNTANUCYNTA ERNUVIGILOCTREOTIDE ACET 500 MCG/ML SYROCTREOTIDE ACET 100 MCG/ML SYROCTREOTIDE ACET 50 MCG/ML SYROLEPTRO EROLOPATADINE HCLOMEGA-3 ACID ETHYL ESTERSOMNARISOMNITROPE 10 MG/1.5 ML CRTGOMNITROPE 5.8 MG VIALONSOLISOPANA ERORACEAORBIVANOXECTAOXTELLAR XROXYMORPHONE HCL ERPAROXETINE ER 37.5 MG TABLETPAROXETINE CR 37.5 MG TABLETPAROXETINE CR 12.5 MG TABLETPAROXETINE CR 25 MG TABLETPATADAYPATANASEPAXIL CRPENNSAIDPEXEVAPOMALYSTPOTIGAPRIMAQUINEPRISTIQ ERQUALAQUINQUININE SULFATE 324 MG CAPSULEQUTENZARAPAFLORELISTORRENOVARENOVA PUMP

REQUIP XLRETIN-A MICRORETIN-A MICRO PUMPRISEDRONATE SODIUMROPINIROLE HCL ER 2 MG TABLETROPINIROLE HCL ER 4 MG TABLETROPINIROLE HCL ER 12 MG TABLETROPINIROLE HCL ER 8 MG TABLETROPINIROLE HCL ER 6 MG TABLETROSADAN 0.75% CREAM KITROSADAN 0.75% GEL KITSAMSCASANCTURA XRSANCUSOSEROQUEL XRSILENORSIMPONISIMPONI ARIASIMVASTATIN 80 MG TABLETSOLARAZESOLODYN ER 115 MG TABLETSOLODYN ER 80 MG TABLETSOLODYN ER 105 MG TABLETSOLODYN ER 55 MG TABLETSOLODYN ER 65 MG TABLETSORILUXSPINOSADSTAVZORSUBSYSSUMAVEL DOSEPRO 6 MG/0.5 MLSYNALAR 0.025% OINTMENT KITSYNALAR 0.025% CREAM KITSYNALAR TSTACLONEXTELMISARTANTELMISARTAN-AMLODIPINETELMISARTAN-HYDROCHLOROTHIAZIDTEVETENTEVETEN HCT

76

TIZANIDINE HCL 4 MG CAPSULETIZANIDINE HCL 2 MG CAPSULETIZANIDINE HCL 6 MG CAPSULETOPICORT 0.25% SPRAYTOVIAZTRAMADOL HCL ER 150 MG CAPSULETRETIN-XTRETINOIN MICROSPHERETREXIMETTRIBENZORTROSPIUM CHLORIDE ERTWYNSTATYVASO INHALATION REFILL KITTYVASO 1.74 MG/2.9 ML SOLUTIONTYVASO INHALATION STARTER KITULORICULTRAVATE X CREAM COMBO PACKVANOSVASCEPAVECTICALVELPHOROVELTINVERAMYSTVERDESOVESICAREVIDAZAVIIBRYDVIMOVOVYTORINWELCHOLXALKORIXARTEMIS XRXERESEXOLEGELZANAFLEX 4 MG CAPSULEZANAFLEX 2 MG CAPSULEZANAFLEX 6 MG CAPSULEZELAPAR

ZENZEDI 2.5 MG TABLETZENZEDI 15 MG TABLETZENZEDI 7.5 MG TABLETZENZEDI 20 MG TABLETZENZEDI 30 MG TABLETZETIAZETONNAZIANAZIPSORZMAXZOCOR 80 MG TABLETZOHYDRO ERZOLPIDEM TARTRATE ERZOLPIMISTZORVOLEXZOVIRAX 5% CREAMZOVIRAX 5% OINTMENTZUPLENZZYCLARA 3.75% CREAMZYCLARA 3.75% CREAM PUMP

77

Alphabetical Listing

Aabacavir sulfate 29

abacavir sulfate/lamivudine/zidovudine 29

ABILIFY 16

ABILIFY DISCMELT 16

acamprosate calcium 5

acarbose 33

acebutolol hcl 39

acetaminophen with codeine phosphate 3

acetasol hc 8

acetazolamide 13,41

acetic acid/aluminum acetate 8

acetic acid/hydrocortisone 8

acitretin 46

ACTIMMUNE 62

ACTONEL 63

ACTOPLUS MET XR 33

acyclovir 32

ADAGEN 48

adapalene 46

ADCIRCA 69

adefovir dipivoxil 31

ADEMPAS 69

ADVAIR DISKUS 67

ADVAIR HFA 67

AEROSPAN 67

AFEDITAB CR 39

AFINITOR 25

AFINITOR DISPERZ 25

AGGRENOX 36

ak-poly-bac 64

alagesic lq 1

ALBENZA 26

albuterol sulfate 69

alclometasone dipropionate 6

alendronate sodium 63

ALFERON N 62

alfuzosin hcl 51

ALINIA 26

ALKERAN 23

allopurinol 21

ALOMIDE 65

ALORA 54

ALPHAGAN P 66

alprazolam 32

ALREX 65

ALTAVERA 54

ALVESCO 67

ALYACEN 54

amantadine hcl 27

amcinonide 6

AMETHIA 54

AMETHIA LO 54

AMETHYST 54

amiloride hcl 41

amiloride hcl/hydrochlorothiazide 41

amiodarone hcl 38

amitriptyline hcl 18

amlodipine besylate 40

amlodipine besylate/atorvastatin calcium 41

amlodipine besylate/benazepril hcl 40

ammonium lactate 46

amnesteem 46

amoxapine 18

amoxicillin 10

amoxicillin/potassium clavulanate 11

ampicillin trihydrate 11

AMPYRA 45

ANADROL-50 54

anagrelide hcl 36

anastrozole 24

ANDROGEL 54

ANORO ELLIPTA 70

antipyrine/benzocaine 66

anusol-hc 63

apexicon e 6

APIDRA 34

APIDRA SOLOSTAR 35

APRI 54

APRISO 48

APTIOM 15

78

APTIVUS 30

ARANELLE 54

ARANESP 36

ASACOL 49

ASACOL HD 49

ascomp with codeine 3

ASMANEX 67

ASTAGRAF XL 61

atenolol 39

atenolol/chlorthalidone 39

atorvastatin calcium 42

atovaquone 26

ATRIPLA 30

ATROVENT HFA 68

AUBAGIO 45

AUBRA 54

aurodex 66

auroguard 66

AVIANE 55

avidoxy 12

avita 46

AVONEX 45

AVONEX ADMINISTRATION PACK 45

AVONEX PEN 45

AZASITE 11

azathioprine 61

azelastine hcl 65,67

AZILECT 27

azithromycin 11

AZOPT 66

AZURETTE 55

Bbacitracin 8

bacitracin/polymyxin b sulfate 64

baclofen 28

balsalazide disodium 63

BALZIVA 55

BANZEL 15

BARACLUDE 31

benazepril hcl 37

benazepril hcl/hydrochlorothiazide 37

benzonatate 70

benztropine mesylate 26

BERINERT 61

betamethasone acetate/betamethasone sodium

phosphate 52

betamethasone dipropionate 6

betamethasone dipropionate/propylene glycol 6

betamethasone valerate 6

BETASERON 45

betaxolol hcl 39,66

bethanechol chloride 51

BETIMOL 66

BETOPTIC S 66

bicalutamide 61

bisoprolol fumarate 39

bisoprolol fumarate/hydrochlorothiazide 39

bleph-10 12

BLEPHAMIDE 64

BLEPHAMIDE S.O.P. 64

blood sugar diagnostic 63,64

BOSULIF 25

BREO ELLIPTA 67

BRIELLYN 55

BRILINTA 36

brimonidine tartrate 66

bromfenac sodium 65

bromocriptine mesylate 27

budeprion sr 16

budeprion xl 16

budesonide 52,67

bumetanide 41

BUPHENYL 48

buprenorphine hcl 5

buprenorphine hcl/naloxone hcl 5

buproban 6

bupropion hcl 16

buspirone hcl 32

butalbital/acetaminophen 1

butalbital/acetaminophen/caffeine 1

butalbital/acetaminophen/caffeine/codeine phosphate 3

79

butalbital/aspirin/caffeine 1

butorphanol tartrate 3

BYDUREON 33

BYDUREON PEN 33

BYETTA 33

Ccabergoline 60

cafergot 21

calcipotriene 46

calcitonin,salmon,synthetic 63

calcitriol 60

calcium acetate 52

CAMILA 59

CAMRESE 55

CAMRESE LO 55

CANASA 49

candesartan cilexetil 37

capacet 1

capecitabine 23

CAPRELSA 25

captopril 37

captopril/hydrochlorothiazide 37

CARBAGLU 48

carbamazepine 15

carbidopa 27

carbidopa/levodopa 27

carbidopa/levodopa/entacapone 27

carisoprodol 70

carisoprodol/aspirin 70

carteolol hcl 66

CARTIA XT 40

carvedilol 39

CAZIANT 55

CEENU 23

cefaclor 10

cefadroxil 10

cefdinir 10

cefpodoxime proxetil 10

cefprozil 10

ceftibuten dihydrate 10

CEFTIN 10

cefuroxime axetil 10

CELEBREX 1

CELESTONE 52

CELLCEPT 61

CELONTIN 13

cephalexin 10

CEREZYME 48

CHANTIX 6

CHATEAL 55

chlordiazepoxide hcl 32

chlorhexidine gluconate 8

chloroquine phosphate 26

chlorothiazide 42

chlorpromazine hcl 18

chlorpropamide 33

chlorthalidone 42

chlorzoxazone 70

cholestyramine (with sugar) 43

cholestyramine/aspartame 43

ciclodan 19

ciclopirox 20

ciclopirox olamine 20

cilostazol 36

cimetidine 50

cimetidine hcl 50

CIPRO HC 66

CIPRODEX 66

ciprofloxacin hcl 12,67

ciprofloxacin/ciprofloxacin hcl 12

citalopram hydrobromide 17

claravis 46

clarithromycin 11

clemastine fumarate 67

clinda-derm 8

clindacin etz 8

clindacin p 8

clindamycin hcl 8

clindamycin palmitate hcl 9

clindamycin phosphate 9

clindamycin phosphate/benzoyl peroxide 46

80

clobetasol propionate 6

clobetasol propionate/emollient base 6

clodan 6

clomipramine hcl 18

clonazepam 13

clonidine 36

clonidine hcl 36

clopidogrel bisulfate 36

clorazepate dipotassium 13

clotrimazole 20

clotrimazole/betamethasone dipropionate 20

clozapine 28

co-gesic 3

codeine phosphate/butalbital/aspirin/caffeine 3

codeine phosphate/carisoprodol/aspirin 3

codeine sulfate 3

colchicine/probenecid 21

COLCRYS 21

COLESTID 43

colestipol hcl 43

COMBIPATCH 55

COMBIVENT 68

COMBIVENT RESPIMAT 68

COMETRIQ 25

COMPLERA 30

COMPRO 18

constulose 50

COPAXONE 45

COREG CR 39

cormax 6

cortisone acetate 6

CREON 48

CRIXIVAN 30

cromolyn sodium 65,69

CRYSELLE 55

CUPRIMINE 51

CUVPOSA 48

cyanocobalamin (vitamin b-12) 71

CYCLAFEM 55

cyclobenzaprine hcl 70

cyclophosphamide capsules 23

cyclophosphamide tablets 23

cycloserine 9

cyclosporine 61

cyclosporine, modified 61

cyproheptadine hcl 67

CYSTAGON 51

CYSTARAN 64

Ddanazol 54

dantrolene sodium 28

dapsone 22

DARAPRIM 26

DASETTA 55

DAYSEE 55

DAYTRANA 44

DEBLITANE 59

decitabine 23

DELYLA 55

DELZICOL 49

demeclocycline hcl 12

DENAVIR 32

depade 5

DEPEN 51

DEPO-SUBQ PROVERA 104 59

desipramine hcl 18

desmopressin acetate 53

desmopressin acetate (non-refrigerated) 53

desogestrel-ethinyl estradiol 55

desogestrel-ethinyl estradiol/ethinyl estradiol 55

desonide 6

desoximetasone 7

dexamethasone 52

dexamethasone sod phosphate 65

dexmethylphenidate hcl 44

dextroamphetamine sulf-saccharate/amphetamine sulf-

aspartate 44

dextroamphetamine sulfate 44

dextromethorphan hbr/promethazine hcl 70

DIASTAT 14

diazepam 14

81

DICLEGIS 19

diclofenac potassium 1

diclofenac sodium 1,65

dicloxacillin sodium 11

dicyclomine hcl 48

didanosine 29

DIFFERIN 46

diflorasone diacetate 7

diflunisal 1

digox 41

digoxin 41

dihydrocodeine bitartrate/acetaminophen/caffeine 3

dihydroergotamine mesylate 21

DILANTIN 15

DILATRATE-SR 43

DILT-CD 40

DILT-XR 40

DILTIA XT 40

diltiazem hcl 40

DILTZAC ER 40

DIPENTUM 63

diphenoxylate hcl/atropine sulfate 49

dipyridamole 36

disopyramide phosphate 38

disulfiram 5

divalproex sodium 14

donepezil hcl 16

dorzolamide hcl 66

dorzolamide hcl/timolol maleate 66

doxazosin mesylate 37

doxepin hcl 18

doxercalciferol 63

doxycycline hyclate 12

doxycycline monohydrate 12

DROXIA 23

DUAVEE 55

duloxetine hcl 17

dynacin 13

DYRENIUM 41

EE.E.S. 200 11

econazole nitrate 20

EDECRIN 41

EDURANT 29

EFFIENT 36

EGRIFTA 53

ELELYSO 48

ELIDEL 47

ELIGARD 60

elimite 26

ELINEST 55

ELIQUIS 35

ELMIRON 51

EMCYT 23

EMEND 19

EMOQUETTE 55

EMTRIVA 29

enalapril maleate 37

enalapril maleate/hydrochlorothiazide 37

ENBREL 61

endocet 3

endodan 3

enoxaparin sodium 35

ENPRESSE 55

ENSKYCE 55

entacapone 27

entecavir 31

enulose 50

EPANED 37

EPIFOAM 47

EPIPEN 2-PAK 69

EPIPEN JR 2-PAK 69

epitol 15

EPIVIR HBV 31

eplerenone 41

EPOGEN 36

EPZICOM 29

EQUETRO 15

ergocalciferol (vitamin d2) 71

82

ergotamine tartrate/caffeine 21

ERIVEDGE 25

ERRIN 59

ERY-TAB 11

erygel 11

ERYPED 200 11

erythromycin base 11

erythromycin base/benzoyl peroxide 47

erythromycin base/ethyl alcohol 11

erythromycin ethylsuccinate 11

erythromycin ethylsuccinate/sulfisoxazole acetyl 11

escitalopram oxalate 17

ESTARYLLA 55

estazolam 71

ESTRACE 55

estradiol 55

estradiol/norethindrone acetate 56

ESTRING 56

estropipate 56

eszopiclone 71

ethambutol hcl 22

ethinyl estradiol/drospirenone 56

ethosuximide 13

etidronate disodium 63

etodolac 1

EXELON 16

exemestane 24

EXJADE 71

EXTAVIA 46

FFALMINA 56

famciclovir 32

famotidine 50

FARESTON 23

FARXIGA 33

FAZACLO 28

felbamate 14

felodipine 40

fenofibrate 42

fenofibrate nanocrystallized 42

fenofibrate,micronized 42

fenofibric acid 42

fenofibric acid (choline) 42

fenoprofen calcium 1

fentanyl 2

FINACEA 47

finasteride 51

fioricet 1

FIRAZYR 46

FIRST-LANSOPRAZOLE 50

FIRST-OMEPRAZOLE 50

FLAREX 52

flavoxate hcl 51

flecainide acetate 38

FLOVENT DISKUS 52

FLOVENT HFA 52

fluconazole 20

fludrocortisone acetate 7

flunisolide 67

fluocinolone acetonide 7

fluocinolone acetonide oil 52

fluocinonide 7

fluocinonide/emollient base 7

FLUOR-A-DAY 72

fluoride/iron/vitamins a,c,and d 72

FLUORITAB 72

fluorometholone 52

FLUOROPLEX 47

fluorouracil 47

fluoxetine hcl 17

fluphenazine hcl 27

FLURA-DROPS 72

flurazepam hcl 71

flurbiprofen 1

flurbiprofen sodium 65

fluticasone propionate 7,52

fluvastatin sodium 42

fluvoxamine maleate 17

FML FORTE 52

FML S.O.P. 52

FOCALIN XR 44

83

folic acid 72

fondaparinux sodium 35

FORTEO 63

fosinopril sodium 37

fosinopril sodium/hydrochlorothiazide 38

FRAGMIN 35

FULYZAQ 49

furosemide 41

FUZEON 30

Ggabapentin 14

GABITRIL 14

GAMMAGARD S-D 62

GAMMAKED 62

GAMUNEX-C 62

garamycin 8

gatifloxacin 64

GATTEX 49

gavilyte-c 49

gavilyte-g 49

gavilyte-n 49

gemfibrozil 42

generlac 50

gengraf 47,62

GENOTROPIN 53

gentak 8

gentamicin sulfate 8

GIANVI 56

GILDAGIA 56

GILDESS 56

GILDESS FE 56

GILENYA 46

GILOTRIF 24

GLEEVEC 25

glimepiride 33

glipizide 33

glipizide/metformin hcl 33

GLUCAGEN 34

GLUCAGON EMERGENCY KIT 34

glyburide 33

glyburide,micronized 33

glyburide/metformin hcl 33

glycopyrrolate 48

glydo 5

GOLYTELY 49

granisetron hcl 19

GRANIX 36

GRASTEK 62

griseofulvin ultramicrosize 20

griseofulvin, microsize 20

guanfacine hcl 37

guanidine hcl 22

Hhalobetasol propionate 7

haloperidol 27

haloperidol lactate 27

HEATHER 59

hecoria 62

HEXALEN 24

HUMALOG 35

HUMALOG MIX 50-50 35

HUMALOG MIX 75-25 35

HUMATROPE 53

HUMIRA 62

HUMIRA PEDIATRIC 62

HUMULIN R 35

HYCAMTIN 24

hydralazine hcl 43

hydrochlorothiazide 42

hydrocodone bit/acetaminophen 3

hydrocodone bitartrate/acetaminophen 4

hydrocodone bitartrate/homatropine methylbromide 68

hydrocodone/ibuprofen 4

hydrocortisone 7,52

hydrocortisone butyrate 7,52

hydrocortisone valerate 52

hydromet 68

hydromorphone hcl 4

hydroxychloroquine sulfate 26

hydroxyurea 23

84

hydroxyzine hcl 19

hydroxyzine pamoate 19

HYPER-SAL 70

hypercare 47

Iibandronate sodium 63

ibudone 4

ibuprofen 1

ibuprofen/oxycodone hcl 1

ICLUSIG 25

IMBRUVICA 25

imipramine hcl 18

imipramine pamoate 18

imiquimod 24

INCIVEK 31

INCRELEX 53

indapamide 42

indomethacin 1

INFERGEN 31

INLYTA 25

INTELENCE 29

INTRON A 31

INTROVALE 56

INVEGA 28

INVIRASE 30

INVOKANA 33

ipratropium bromide 68

ipratropium bromide/albuterol sulfate 68

irbesartan 37

irbesartan/hydrochlorothiazide 37

IRESSA 24

ISENTRESS 30

isochron 43

isonarif 22

isoniazid 22

isosorbide dinitrate 43

isosorbide mononitrate 43

isradipine 40

ISTALOL 66

itraconazole 20

ivermectin 26

JJAKAFI 24

JANTOVEN 35

JANUMET 33

JANUMET XR 33

JANUVIA 34

JENCYCLA 59

JENTADUETO 34

JOLESSA 56

JOLIVETTE 59

JUNEL 56

JUNEL FE 56

JUVISYNC 34

JUXTAPID 43

KKALETRA 30

KALYDECO 70

KARIVA 56

KAZANO 34

KELNOR 1-35 56

ketoconazole 20

ketoprofen 1

ketorolac tromethamine 2,65

kionex 71

klor-con 10 72

klor-con 8 72

klor-con m10 72

klor-con m20 72

KOMBIGLYZE XR 34

KURVELO 56

KUVAN 48

KYNAMRO 43

Llabetalol hcl 39

LACRISERT 64

lactulose 50

LAMISIL 20

85

lamivudine 29,31

lamivudine/zidovudine 29

lamotrigine 14

LANOXIN 41

lansoprazole 50

lansoprazole/amoxicillin trihydrate/clarithromycin 50

LANTUS 35

LANTUS SOLOSTAR 35

LARIN 56

LARIN FE 56

latanoprost 64

LATUDA 28

LEENA 56

leflunomide 62

LESSINA 56

LETAIRIS 69

letrozole 24

leucovorin calcium 24

LEUKERAN 23

LEUKINE 36

leuprolide acetate 60

levalbuterol hcl 69

LEVATOL 39

LEVEMIR 35

LEVEMIR FLEXPEN 35

LEVEMIR FLEXTOUCH 35

levetiracetam 13

levobunolol hcl 66

levocarnitine 72

levocetirizine dihydrochloride 67

levofloxacin 12

LEVONEST 56

levonorgestrel-eth estra/ethinyl estradiol 56

levonorgestrel-ethinyl estradiol 56

LEVORA-28 56

levorphanol tartrate 2

levothroid 59

levothyroxine sodium 60

levoxyl 60

LEXIVA 30

LIALDA 49

lidocaine 5

lidocaine hcl 5

lidocaine/prilocaine 5

lindane 26

liothyronine sodium 60

lisinopril 38

lisinopril/hydrochlorothiazide 38

lithium carbonate 33

lithium citrate 33

LOFIBRA 42

LOMEDIA 24 FE 56

lomustine 23

lorazepam 14

lorazepam intensol 14

lorcet 4

lorcet hd 4

lorcet plus 4

lortab 4

LORYNA 56

losartan potassium 37

losartan potassium/hydrochlorothiazide 37

LOTEMAX 65

LOTRONEX 50

lovastatin 42

LOW-OGESTREL 57

loxapine succinate 27

LUDENT FLUORIDE 72

LUMIGAN 64

LUTERA 57

LYRICA 13

LYSODREN 60

LYZA 59

Mmaprotiline hcl 16

MARLISSA 57

MARPLAN 17

MATERNITY 72

MATULANE 23

MATZIM LA 40

meclofenamate sodium 2

86

medroxyprogesterone acetate 59

mefloquine hcl 26

megestrol acetate 59

MEKINIST 24

meloxicam 2

meperidine hcl 4

meperitab 4

meprobamate 32

mercaptopurine 23

mesalamine 49

mesalamine with cleansing wipes 49

MESNEX 24

MESTINON 22

metadate er 44

metaxalone 70

metformin hcl 34

methadone hcl 2

methadone intensol 2

methadose 2

methazolamide 41

methenamine hippurate 9

methimazole 61

methocarbamol 70

methotrexate sodium 23

methotrexate sodium/pf 23

methoxsalen, rapid 47

methyclothiazide 42

methyldopa 37

methyldopa/hydrochlorothiazide 37

methylphenidate hcl 45

methylprednisolone 53

metipranolol 66

metoclopramide hcl 19

metolazone 42

metoprolol succinate 39

metoprolol tartrate 39

metoprolol tartrate/hydrochlorothiazide 39

metronidazole 9

mexiletine hcl 38

MICROGESTIN 57

MICROGESTIN FE 57

midodrine hcl 37

migergot 21

MIGRANAL 21

millipred 7

millipred dp 7

mimvey 57

minitran 43

MINIVELLE 57

minocycline hcl 13

minoxidil 43

mirtazapine 16

misoprostol 50

modafinil 71

MODERIBA 31

moexipril hcl 38

moexipril hcl/hydrochlorothiazide 38

mometasone furoate 47

MONO-LINYAH 57

MONONESSA 57

montelukast sodium 68

MONUROL 9

morgidox 13

morphine sulfate 2,4

MOVIPREP 50

MOXEZA 64

moxifloxacin hcl 12

MULTAQ 38

multivitamins with fluoride 72

mupirocin 9

MYALEPT 53

mycophenolate mofetil 62

mycophenolate sodium 62

myorisan 47

MYRBETRIQ 29

MYZILRA 57

Nnabumetone 2

nadolol 39

nadolol/bendroflumethiazide 39

naltrexone hcl 5

87

NAMENDA 16

naphazoline hcl 64

NAPRELAN 2

naproxen 2

naproxen sodium 2

NASONEX 67

NATACYN 20

nateglinide 34

NECON 57

nefazodone hcl 17

neo-polycin 64

neo-polycin hc 64

neomycin sulfate 8

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 64

neomycin sulfate/bacitracin/polymyxin b 64

neomycin sulfate/polymyxin b sulfate/gramicidin d 64

neomycin sulfate/polymyxin b

sulfate/hydrocortisone 64,67

neomycin/polymyxin b sulfate/dexamethasone 65

neosporin 65

NESINA 34

NEULASTA 36

NEUMEGA 36

NEUPOGEN 36

nevirapine 29

NEXAVAR 25

nicardipine hcl 40

NIFEDIAC CC 40

NIFEDICAL XL 40

nifedipine 40

NIKKI 57

NILANDRON 61

nimodipine 40

nisoldipine 40

NITRO-BID 43

NITRO-DUR 43

nitro-time 43

nitrofurantoin 9

nitrofurantoin macrocrystal 9

nitrofurantoin monohydrate/macrocrystals 9

nitroglycerin 43

NITROSTAT 44

nizatidine 50

NORA-BE 59

NORDITROPIN 53

NORDITROPIN FLEXPRO 53

NORDITROPIN NORDIFLEX 53

norethindrone 59

norethindrone acetate 59

norethindrone acetate-ethinyl estradiol 57

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 57

norgestimate-ethinyl estradiol 57

NORLYROC 59

NORPACE CR 38

NORTREL 57

nortriptyline hcl 18

NORVIR 30

NOVOLOG 35

NOVOLOG FLEXPEN 35

NOVOLOG MIX 70-30 35

NOVOLOG MIX 70-30 FLEXPEN 35

NOXAFIL 20

NUEDEXTA 45

nulytely with flavor packs 49

NUTROPIN 53

NUTROPIN AQ 53

NUTROPIN AQ NUSPIN 53

NUVARING 57

nyamyc 20

nystatin 20

nystatin/triamcinolone acetonide 7

nystop 20

OOCELLA 57

octreotide acetate 60

OCUDOX 13

ofloxacin 12

OGESTREL 57

olanzapine 28

88

olanzapine/fluoxetine hcl 17

OLYSIO 31

omeprazole 50

OMEPRAZOLE+SYRSPEND SF ALKA 51

OMNITROPE 53

ondansetron 19

ondansetron hcl 19

ONFI 14

ONGLYZA 34

OPSUMIT 69

ORALAIR 62

oralone 7

ORAP 28

ORAPRED ODT 7

ORENITRAM ER 69

ORFADIN 48

orphenadrine citrate 70

orphenadrine citrate/aspirin/caffeine 70

ORSYTHIA 57

ORTHO TRI-CYCLEN LO 57

OSENI 34

OTEZLA 47

otic care 67

oxandrolone 54

oxaprozin 2

oxazepam 32

oxcarbazepine 15

OXSORALEN 47

oxybutynin chloride 51

oxycodone hcl 2,4

oxycodone hcl/acetaminophen 4

oxycodone hcl/aspirin 4

OXYCONTIN 3

oxymorphone hcl 4

OXYTROL 51

Ppacerone 38

pancrelipase 5,000 48

PANRETIN 25

pantoprazole sodium 51

paricalcitol 60

paroex 9

paroxetine hcl 17

PATANOL 65

PAXIL 17

pedi-dri 20

pediatric multivitamin combination no.2/sodium

fluoride 72

pediatric multivitamins a,c,& d3 no.21 with sodium

fluoride 72

pediatric multivitamins no.16 with sodium fluoride 72



peg 3350/sod sulf/sod bicarbonate/sod

chloride/potassium chl 49

PEGASYS 31

PEGASYS PROCLICK 31

PEGINTRON 31

PEGINTRON REDIPEN 31

penicillin v potassium 11

PENTASA 49

pentoxifylline 41

perindopril erbumine 38

periogard 9

permethrin 26

perphenazine 19

perphenazine/amitriptyline hcl 28

PHENADOZ 19

phenelzine sulfate 17

phenobarbital 14

phenylephrine hcl/promethazine hcl 70

phenytoin 15

phenytoin sodium extended 15

PHILITH 57

PICATO 47

pilocarpine hcl 46,66

PILOPINE HS 66

PIMTREA 57

pindolol 39

pioglitazone hcl 34

pioglitazone hcl/glimepiride 34

89

pioglitazone hcl/metformin hcl 34

PIRMELLA 57

piroxicam 2

PLEGRIDY 46

PLEGRIDY PEN 46

podofilox 47

polycin 65

polymyxin b sulfate/trimethoprim 65

PORTIA 57

potassium chloride 72

potassium citrate 72

PRADAXA 35

pramipexole di-hcl 27

pravastatin sodium 42

prazosin hcl 37

prednisolone 7

prednisolone acetate 66

prednisolone sod phosphate 7,66

prednisone 7

prednisone intensol 7

PREMARIN 57

PREMPHASE 58

PREMPRO 58

PRENAPLUS 72

prenatal vitamins comb no.115/iron fumarate/folic

acid 73

prenatal vitamins comb no.115/iron fumarate/folic

acid/dss 73

prenatal vitamins combo no.60/ferrous fumarate/folic

acid 73

prenatal vits with calcium #72/ferrous fumarate/folic

acid 73

prenatal vits with calcium #72/iron,carbonyl/folic acid 73

PREPLUS 73

PREVALITE 43

PREVIFEM 58

PREZISTA 30

PRIFTIN 22

primidone 13

PROAIR HFA 69

probenecid 21

prochlorperazine maleate 19

PROCRIT 36

procto-pak 63

proctocream-hc 63

PROCTOFOAM-HC 63

proctosol-hc 63

proctozone-hc 63

PROCYSBI 51

progesterone,micronized 59

PROGLYCEM 34

PROGRAF 62

PROMACTA 36

promethazine hcl 19

promethazine hcl/codeine 68

promethazine/phenylephrine hcl/codeine 68

PROMETHEGAN 19

propafenone hcl 38

propantheline bromide 49

propranolol hcl 39

propranolol hcl/hydrochlorothiazide 39

propylthiouracil 61

PROTONIX 51

PROTOPIC 47

protriptyline hcl 18

PULMICORT 67

PULMICORT FLEXHALER 67

pulmosal 70

PULMOZYME 70

PURIXAN 24

PYLERA 49

pyridostigmine bromide 22

QQUASENSE 58

QUDEXY XR 15

quetiapine fumarate 28

QUFLORA 73

quinapril hcl 38

quinapril hcl/hydrochlorothiazide 38

quinidine gluconate 38

quinidine sulfate 38

90

QVAR 67

Rrabeprazole sodium 51

RAGWITEK 62

raloxifene hcl 59

ramipril 38

RANEXA 41

ranitidine hcl 50

RAPAMUNE 62

RAVICTI 48

REBETOL 31

REBIF 46

REBIF REBIDOSE 46

RECLIPSEN 58

RECTIV 43

refissa 47

REGRANEX 47

RENAGEL 52

RENVELA 52

reprexain 5

RESTASIS 62

revia 6

REVLIMID 23

REYATAZ 30

RHEUMATREX 24

RIBAPAK 31

RIBASPHERE 31

RIBATAB 31

ribavirin 31

rifabutin 22

rifampin 22

RIFATER 22

riluzole 45

rimantadine hcl 31

RIOMET 34

RISPERDAL CONSTA 28

risperidone 28

RITALIN LA 45

rivastigmine tartrate 16

rizatriptan benzoate 21

ropinirole hcl 27

rosadan 9

ROXICET 5

roxicet 5

ROZEREM 71

SSABRIL 14

SAIZEN 53

SANDIMMUNE 62

SANTYL 47

SAPHRIS 28

SAVELLA 45

SE-NATAL 19 73

selegiline hcl 27

SELZENTRY 30

SENSIPAR 60

SEREVENT DISKUS 69

SEROSTIM 53

sertraline hcl 17

sevelamer carbonate 52

SHAROBEL 59

SIGNIFOR 60

sildenafil citrate 69

silver sulfadiazine 12

simvastatin 42

sirolimus 62

SIRTURO 22

sodium chloride for inhalation 70

sodium chloride/sodium bicarbonate/potassium

chloride/peg 49

sodium fluoride 73

sodium phenylbutyrate 48

sodium polystyrene sulfonate 71

SOLTAMOX 23

SOMAVERT 61

SORINE 38

sotalol hcl 38

SOVALDI 32

SPIRIVA 68

spironolactone 42

91

spironolactone/hydrochlorothiazide 42

SPORANOX 20

SPRINTEC 58

SPRYCEL 25

sps 71

SRONYX 58

sski 70

stagesic 5

stavudine 29

STELARA 47

STIMATE 53

STIVARGA 25

STRATTERA 45

STRIBILD 30

SUBOXONE 5

SUCRAID 48

sucralfate 50

sulfacetamide sodium 12

sulfacetamide sodium/prednisolone sodium

phosphate 65

sulfadiazine 12

sulfamethoxazole/trimethoprim 12

sulfamide 12

sulfasalazine 49

sulfazine 49

sulfazine ec 49

sulindac 2

sumatriptan 21

sumatriptan succinate 21

SUPREP 50

SUSTIVA 29

SUTENT 25

SYEDA 58

SYLATRON 32

SYLATRON 4-PACK 32

SYMBICORT 70

SYMLINPEN 120 34

SYMLINPEN 60 34

SYPRINE 71

Ttacrolimus 62

TAFINLAR 24

TAMIFLU 31

tamoxifen citrate 23

tamsulosin hcl 51

TARCEVA 25

TARGRETIN 25

TARINA FE 58

TASIGNA 25

TAZORAC 47

TAZTIA XT 40

TECFIDERA 46

temazepam 71

temozolomide 24

tencon 1

terazosin hcl 37

terbinafine hcl 21

terbutaline sulfate 69

terconazole 21

testosterone 54

testosterone cypionate 54

testosterone enanthate 54

tetracycline hcl 13

TEV-TROPIN 54

THALOMID 23

THEOCHRON 68

theophylline anhydrous 68

THIOLA 51

thioridazine hcl 28

thiothixene 28

tiagabine hcl 14

ticlopidine hcl 36

TIKOSYN 38

TILIA FE 58

timolol maleate 21,66

tinidazole 26

TIVICAY 30

tizanidine hcl 29

TL-FLUORIVITE 73

92

TOBI PODHALER 8

TOBRADEX 65

TOBRADEX ST 65

tobramycin 8

tobramycin in 0.225 % sodium chloride 8

tobramycin/dexamethasone 65

TOBREX 8

tolmetin sodium 2

tolterodine tartrate 51

topiragen 15

topiramate 15

torsemide 41

TRACLEER 69

TRADJENTA 34

tramadol hcl 3,5

tramadol hcl/acetaminophen 1

trandolapril 38

tranexamic acid 36

TRANSDERM-SCOP 19

tranylcypromine sulfate 17

TRAVATAN Z 64

travoprost (benzalkonium) 64

trazodone hcl 17

TRECATOR 22

tretinoin 26,47

tretinoin/emollient base 47

TRI-ESTARYLLA 58

TRI-LEGEST FE 58

TRI-LINYAH 58

TRI-PREVIFEM 58

TRI-SPRINTEC 58

triamcinolone acetonide 8,53

triamterene/hydrochlorothiazide 42

trianex 47

triazolam 71

TRICARE 73

triderm 8

trifluoperazine hcl 28

trifluridine 32

TRIGLIDE 42

trihexyphenidyl hcl 26

trilyte with flavor packets 49

trimethobenzamide hcl 19

trimethoprim 9

trimipramine maleate 18

TRINATAL RX 1 73

TRINESSA 58

TRIVORA-28 58

tropicamide 65

trospium chloride 51

TRUVADA 29

TYKERB 25

TYZEKA 32

TYZINE 70

UUCERIS 53

ULESFIA 26

unithroid 60

ursodiol 49

VVAGIFEM 58

valacyclovir hcl 32

VALCHLOR 24

VALCYTE 30

valproic acid 14

valproic acid (as sodium salt) (valproate sodium) 14

valsartan 37

valsartan/hydrochlorothiazide 37

vancomycin hcl 9

vandazole 9

vandetanib 25

VELETRI 69

VELIVET 58

venlafaxine hcl 18

VENTAVIS 69

VENTOLIN HFA 69

verapamil hcl 39,41

VERSACLOZ 28

VESTURA 58

VEXOL 66

93

VICTOZA 2-PAK 34

VICTOZA 3-PAK 34

VICTRELIS 32

VIGAMOX 65

VIMPAT 15

VINATE ONE 73

VINATE-M 73

VIORELE 58

VIRACEPT 30

VIRAMUNE XR 29

VIREAD 29

vitazol 9

VIVELLE-DOT 58

VOGELXO 54

VOL-PLUS 73

VOLTAREN 48

voriconazole 21

VOTRIENT 24

VYFEMLA 58

VYVANSE 44

Wwarfarin sodium 35

WERA 58

XXARELTO 35

XENAZINE 45

XIFAXAN 9

XOPENEX HFA 69

XTANDI 61

XULANE 58

xylon 10 5

XYREM 71

Zzafirlukast 68

zaleplon 71

ZARAH 58

ZAVESCA 48

ZELBORAF 25

ZEMPLAR 60

zenatane 48

ZENCHENT 58

ZENPEP 48

zenzedi 44

zidovudine 29

ziprasidone hcl 15,28

ZIRGAN 30

ZOLINZA 25

zolmitriptan 22

zolpidem tartrate 71

ZOMIG 22

zonisamide 13

ZORBTIVE 54

ZORTRESS 62

ZOVIA 1-35E 59

ZOVIA 1-50E 59

ZYDELIG 24

ZYFLO CR 68

ZYKADIA 25

ZYLET 65

ZYTIGA 24

ZYVOX 9

94

Category ListingAnalgesics 1

Anesthetics 5

Anti-Addiction/Substance Abuse Treatment Agents 5

Anti-inflammatory Agents 6

Antibacterials 8

Anticonvulsants 13

Antidementia Agents 16

Antidepressants 16

Antiemetics 18

Antifungals 19

Antigout Agents 21

Antimigraine Agents 21

Antimyasthenic Agents 22

Antimycobacterials 22

Antineoplastics 23

Antiparasitics 26

Antiparkinson Agents 26

Antipsychotics 27

Antispasticity Agents 28

Antivirals 29

Anxiolytics 32

Bipolar Agents 33

Blood Glucose Regulators 33

Blood Products/Modifiers/ Volume Expanders 35

Cardiovascular Agents 36

Central Nervous System Agents 44

Dental and Oral Agents 46

Dermatological Agents 46

Enzyme Replacement/ Modifiers 48

Gastrointestinal Agents 48

Genitourinary Agents 51

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) 52

Hormonal Agents, Stimulant/Replacement/Modifying (Other) 53

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 53

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 54

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 59

Hormonal Agents, Suppressant (Adrenal) 60

Hormonal Agents, Suppressant (Parathyroid) 60

Hormonal Agents, Suppressant (Pituitary) 60

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) 61

Hormonal Agents, Suppressant (Thyroid) 61

Immunological Agents 61

95

Inflammatory Bowel Disease Agents 63

Metabolic Bone Disease Agents 63

Miscellaneous 63

Ophthalmic Agents 64

Otic Agents 66

Respiratory Tract Agents 67

Skeletal Muscle Relaxants 70

Sleep Disorder Agents 71

Therapeutic Nutrients/ Minerals/ Electrolytes 71

96

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