reader’s digest value rx (pdp) · 2012-10-02 · page 2 of 79 effective: january 1, 2013 what is...

of 79 Effective: January 1, 2013

P.O. Box 4169

Scranton, PA 18505

Reader’s Digest Value Rx (PDP)

2013 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE

COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to

make sure that it still contains the drugs you take.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,

formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,

2014.

Reader's Digest Value Rx (PDP) is a stand-alone prescription drug plan with a Medicare contract.

This information is available for free in other languages. Please contact our Customer Care number at

1-888-630-9137 for additional information. TTY users should call 711. Hours are 8 a.m. - 8 p.m.,

Monday through Friday. Customer Care also has free language interpreter services available for non-

English speakers.

S0128_H095 CMS Accepted 08072012

Formulary ID 13466, Version 9


What is the Reader’s Digest Value Rx Formulary?

A formulary is a list of covered drugs selected by Reader’s Digest Value Rx in consultation with a team

of health care providers, which represents the prescription therapies believed to be a necessary part of a

quality treatment program. Reader’s Digest Value Rx will generally cover the drugs listed in our

formulary as long as the drug is medically necessary, the prescription is filled at a Reader’s Digest Value

Rx network pharmacy, and other plan rules are followed. For more information on how to fill your

prescriptions, please review your Evidence of Coverage.

Can the Formulary change?

Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,

we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a

new, less expensive generic drug becomes available or when new adverse information about the safety

or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from

our formulary, will not affect members who are currently taking the drug. It will remain available at the

same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is

important that you have continued access for the remainder of the coverage year to the formulary drugs

that were available when you chose our plan, except for cases in which you can save additional money

or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy

restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of

the change at least 60 days before the change becomes effective, or at the time the member requests a

refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and

Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes

the drug from the market, we will immediately remove the drug from our formulary and provide notice

to members who take the drug. The enclosed formulary is current as of January 1, 2013. To get updated

information about the drugs covered by Reader’s Digest Value Rx, please visit our Web site at

www.hmic-medicare.com/formulary or call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday

through Friday. TTY users should call 711. If we have a mid-year non-maintenance formulary change

(i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy

restrictions on a drug, or move a drug to a higher cost-sharing tier), we will update our formulary and

post in on our website. You will also be notified in your Explanation of Benefits if you are affected by

the change. The updated formulary may be obtained from our Web site at www.hmic-

medicare.com/formulary or by calling Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday

through Friday. TTY users should call 711. We will notify beneficiaries in writing prior to making this

type of change.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on

the type of medical conditions that they are used to treat. For example, drugs used to treat a heart

condition are listed under the category, cardiovascular drugs. If you know what your drug is used for,

look for the category name in the list that begins on page number 6. Then look under the category name

for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins

on page 63. The Index provides an alphabetical list of all of the drugs included in this document. Both

brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next


to your drug, you will see the page number where you can find coverage information. Turn to the page

listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Reader’s Digest Value Rx covers both brand name drugs and generic drugs. A generic drug is approved

by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost

less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and

limits may include:

Prior Authorization: Reader’s Digest Value Rx requires you [or your physician] to get prior

authorization for certain drugs. This means that you will need to get approval from Reader’s

Digest Value Rx before you fill your prescriptions. If you don’t get approval, Reader’s Digest

Value Rx may not cover the drug.

Quantity Limits: For certain drugs, Reader’s Digest Value Rx limits the amount of the drug that

Reader’s Digest Value Rx will cover. For example, Reader’s Digest Value Rx provides 30

tablets per prescription for Crestor. This may be in addition to a standard one month or three

month supply.

Step Therapy: In some cases, Reader’s Digest Value Rx requires you to first try certain drugs to

treat your medical condition before we will cover another drug for that condition. For example,

if Drug A and Drug B both treat your medical condition, Reader’s Digest Value Rx may not

cover Drug B unless you try Drug A first. If Drug A does not work for you, Reader’s Digest

Value Rx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 6. You can also get more information about the restrictions applied to specific covered

drugs by visiting our Web site at www.hmic-medicare.com/formulary.

You can ask Reader’s Digest Value Rx to make an exception to these restrictions or limits. See the

section, “How do I request an exception to the Reader’s Digest Value Rx formulary?” on page 3 for

information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Customer Care and confirm that

your drug is not covered. If you learn that Reader’s Digest Value Rx does not cover your drug, you

have two options:

You can ask Customer Care for a list of similar drugs that are covered by Reader’s Digest Value Rx.

When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is

covered by Reader’s Digest Value Rx.

You can ask Reader’s Digest Value Rx to make an exception and cover your drug. See below for

information about how to request an exception.

How do I request an exception to the Reader’s Digest Value Rx Formulary? You can ask Reader’s Digest Value Rx to make an exception to our coverage rules. There are several

types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.


You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Reader’s Digest Value Rx limit the amount of the drug that we will cover. If your drug has a quantity

limit, you can ask us to waive the limit and cover more.

You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our

non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the

preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant

your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of

coverage for the drug.

Generally, Reader’s Digest Value Rx will only approve your request for an exception if the alternative

drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would

not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization

restriction exception. When you are requesting a formulary, tiering or utilization restriction

exception you should submit a statement from your physician supporting your request. Generally,

we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s

supporting statement. You can request an expedited (fast) exception if you or your doctor believe that

your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to

expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or

prescribing physician’s supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting

an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,

you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you

may need a prior authorization from us before you can fill your prescription. You should talk to your

doctor to decide if you should switch to an appropriate drug that we cover or request a formulary

exception so that we will cover the drug you take. While you talk to your doctor to determine the right

course of action for you, we may cover your drug in certain cases during the first 90 days you are a

member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will

cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to

a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have

been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we

have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless

you have a prescription written for fewer days). We will cover more than one refill of these drugs for the

first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your

ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will

cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you

pursue a formulary exception.

If you are a current enrollee with a level of care change and you need a drug that is not on our formulary

or if your ability to get your drugs is limited, we will cover a temporary 31-day transition supply (unless

you have a prescription written for fewer days), while you seek to obtain a formulary exception from

Reader’s Digest Value Rx. If you are in the process of seeking an exception, we will consider allowing

continued coverage until a decision is made.

For more information

For more detailed information about your Reader’s Digest Value Rx prescription drug coverage, please

review your Evidence of Coverage and other plan materials. If you have questions about Reader’s

Digest Value Rx, please call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday through Friday.


TTY users should call 711.) Or visit www.hmic-medicare.com/formulary.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-

MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-

2048. Or, visit www.medicare.gov.

Reader’s Digest Value Rx Formulary

The formulary below provides coverage information about some of the drugs covered by Reader’s

Digest Value Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page

63.

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

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

The information in the Requirements/Limits column tells you if Reader’s Digest Value Rx has any

special requirements for coverage of your drug.

B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This

drug may be covered under Medicare Part B or D depending upon the circumstances. Information may

need to be submitted describing the use and setting of the drug to make the determination.

CB: This prescription drug has a capped benefit limit.

ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount

you pay when you fill a prescription for this drug does not count towards your total drug costs (that is,

the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are

receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

FF: Free First Fill. This prescription drug will be provided at reduced cost-sharing the first time you fill

it.

GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.

Please refer to our Evidence of Coverage for more information about this coverage.

HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more

information, call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday through Friday. TTY users

should call 711.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more

information consult your Pharmacy Directory or call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m.,

Monday through Friday. TTY users should call 711.

MO: Mail Order Drug. This prescription drug is available through a mail-order service.

MW: Medicaid Wrap for Dual Demonstration Plan. This prescription drug is covered under the

Medicaid Wrap benefit for Dual Demonstration plan members.

PA: Prior Authorization. Reader’s Digest Value Rx requires you or your physician to get prior

authorization for certain drugs. This means that you will need to get approval from Reader’s Digest

Value Rx before you fill your prescriptions. If you don't get approval, Reader’s Digest Value Rx may

not cover the drug.

QL: Quantity Limit. For certain drugs, Reader’s Digest Value Rx limits the amount of the drug that

Reader’s Digest Value Rx will cover. For example, Reader’s Digest Value Rx provides 30 tablets per

prescription for Crestor. This may be in addition to a standard one month or three month supply.

ST: Step Therapy. In some cases, Reader’s Digest Value Rx requires you to first try certain drugs to

treat your medical condition before we will cover another drug for that condition. For example, if Drug

A and Drug B both treat your medical condition, Reader’s Digest Value Rx may not cover drug B unless

you try Drug A first. If Drug A does not work for you, Reader’s Digest Value Rx will then cover Drug


Drug Name Drug Tier Requirements/Limits

ANTI-INFECTIVE AGENTS

ADAMANTANES

amantadine hcl 2 MO

rimantadine hcl 2 MO

ALLYLAMINES

terbinafine hcl 2 QL (90 EA per 365 days)

MO

AMEBICIDES

METRO IV 4 MO

metronidazole 1 MO

AMINOGLYCOSIDES

amikacin sulfate 3 MO

gentamicin sulfate/0.9% sodium chloride 3 MO

gentamicin sulfate/sodium chloride 3 MO

gentamicin sulfate inj 40mg/ml 2 MO

gentamicin sulfate inj 10mg/ml 3 MO

isotonic gentamicin 3 MO

kanamycin sulfate 1 MO

neomycin sulfate 2 MO

paromomycin sulfate 3 MO

streptomycin sulfate 3 MO

TOBI 4 QL (280 ML per 28 days)

PA MO

tobramycin sulfate 1 MO

tobramycin sulfate/sodium chloride 2 MO

ANTHELMINTICS

ALBENZA 4 MO

BILTRICIDE 4 MO

STROMECTOL 3 MO

ANTIBACTERIALS, MISCELLANEOUS

bacitracin 2 MO

CLEOCIN GALAXY 4 MO

CLEOCIN IN D5W 4 MO

clindamycin hcl 2 MO

clindamycin palmitate hcl 3 MO

clindamycin phosphate 2 MO

clindamycin phosphate add-vantage 2 MO

clindamycin phosphate pharmacy bulk package 2 MO

colistimethate sodium 4 MO

COLY-MYCIN M 4 MO

CUBICIN 4 B/D MO

isonarif 2 MO

MYCOBUTIN 4 MO

polymyxin b sulfate 2 MO

PRIFTIN 4 MO

RIFAMATE 4 MO

rifampin 3 MO

SYNERCID 4 MO

VANCOCIN HCL 4 MO

vancomycin hcl inj 3 B/D MO

vancomycin hcl caps 4 MO



VIBATIV 4 B/D MO

XIFAXAN TABS 550MG 4 QL (60 EA per 30 days)

PA MO

XIFAXAN TABS 200MG 4 QL (9 EA per 30 days) PA

MO

ZYVOX 4 MO

ANTIFUNGALS, MISCELLANEOUS

GRIS-PEG 4 MO

griseofulvin microsize 3 MO

ANTIMALARIALS

atovaquone/proguanil hcl 4 MO

chloroquine phosphate 2 MO

COARTEM 4 QL (24 EA per 30 days)

MO

DARAPRIM 4 MO

hydroxychloroquine sulfate 2 MO

MALARONE 4 MO

mefloquine hcl 2 MO

QUALAQUIN 4 QL (42 EA per 7 days) PA

MO

quinidine gluconate 2 MO

quinidine gluconate cr 3 MO

quinidine gluconate er 3 MO

quinidine sulfate 2 MO

quinidine sulfate er 2 MO

ANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone 2 MO

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA SUSR 4 QL (150 ML per 30 days)

MO

ALINIA TABS 4 QL (40 EA per 30 days)

MO

MEPRON 4 MO

ANTIRETROVIRALS

APTIVUS CAPS 4 QL (120 EA per 30 days)

MO

APTIVUS SOLN 4 QL (285 ML per 28 days)

MO

ATRIPLA 4 QL (30 EA per 30 days)

MO

COMPLERA 4 QL (30 EA per 30 days)

MO

CRIXIVAN CAPS 400MG 4 QL (180 EA per 30 days)

MO

CRIXIVAN CAPS 200MG 4 QL (360 EA per 30 days)

MO

didanosine cpdr 250mg, 400mg 3 QL (30 EA per 30 days)

MO

didanosine cpdr 200mg 3 QL (60 EA per 30 days)

MO

didanosine cpdr 125mg 3 QL (90 EA per 30 days)



MO

EDURANT 4 QL (30 EA per 30 days)

MO

EMTRIVA CAPS 4 QL (30 EA per 30 days)

MO

EMTRIVA SOLN 4 QL (680 ML per 28 days)

MO

EPIVIR HBV SOLN 4 QL (1680 ML per 28 days)

MO

EPIVIR HBV TABS 4 QL (90 EA per 30 days)

MO

EPIVIR SOLN 4 QL (960 ML per 30 days)

MO

EPIVIR TABS 300MG 4 QL (30 EA per 30 days)

MO

EPIVIR TABS 150MG 4 QL (60 EA per 30 days)

MO

EPZICOM 4 QL (30 EA per 30 days)

MO

FUZEON 3 QL (60 EA per 30 days)

MO

INTELENCE TABS 100MG 4 QL (120 EA per 30 days)

MO

INTELENCE TABS 200MG 4 QL (60 EA per 30 days)

MO

INVIRASE TABS 4 QL (120 EA per 30 days)

MO

INVIRASE CAPS 4 QL (300 EA per 30 days)

MO

ISENTRESS 4 QL (120 EA per 30 days)

MO

KALETRA SOLN 4 MO

KALETRA TABS 200MG; 50MG 4 QL (150 EA per 30 days)

MO

KALETRA TABS 100MG; 25MG 4 QL (300 EA per 30 days)

MO

lamivudine/zidovudine 4 QL (60 EA per 30 days)

MO

lamivudine tabs 300mg 4 QL (30 EA per 30 days)

MO

lamivudine tabs 150mg 4 QL (60 EA per 30 days)

MO

LEXIVA SUSP 3 QL (1575 ML per 28 days)

MO

LEXIVA TABS 4 QL (120 EA per 30 days)

MO

nevirapine 3 QL (60 EA per 30 days)

MO

NORVIR CAPS, TABS 4 QL (360 EA per 30 days)

MO

NORVIR SOLN 4 QL (480 ML per 30 days)



MO

PREZISTA TABS 150MG 4 QL (240 EA per 30 days)

MO


MO


MO


MO

RESCRIPTOR TABS 200MG 4 QL (180 EA per 30 days)

MO

RESCRIPTOR TABS 100MG 4 QL (360 EA per 30 days)

MO

RETROVIR IV INFUSION 4 MO

RETROVIR SYRP 4 QL (1680 ML per 28 days)

MO

RETROVIR CAPS 4 QL (180 EA per 30 days)

MO

RETROVIR TABS 4 QL (60 EA per 30 days)

MO

REYATAZ CAPS 100MG 4 QL (120 EA per 30 days)

MO

REYATAZ CAPS 300MG 4 QL (30 EA per 30 days)

MO

REYATAZ CAPS 150MG, 200MG 4 QL (60 EA per 30 days)

MO

SELZENTRY TABS 300MG 4 QL (120 EA per 30 days)

MO

SELZENTRY TABS 150MG 4 QL (240 EA per 30 days)

MO

stavudine caps 15mg, 20mg 2 QL (120 EA per 30 days)

MO

stavudine caps 30mg 2 QL (30 EA per 30 days)

MO

stavudine caps 40mg 2 QL (60 EA per 30 days)

MO

SUSTIVA TABS 4 QL (30 EA per 30 days)

MO

SUSTIVA CAPS 200MG 4 QL (120 EA per 30 days)

MO

SUSTIVA CAPS 50MG 4 QL (480 EA per 30 days)

MO

TRIZIVIR 3 QL (60 EA per 30 days)

MO

TRUVADA 4 QL (30 EA per 30 days)

MO

VIDEX PEDIATRIC SOLR 2GM 4 QL (1200 ML per 30 days)

VIDEX PEDIATRIC SOLR 4GM 4 QL (1200 ML per 30 days)

MO

VIRACEPT TABS 625MG 4 QL (120 EA per 30 days)

MO



VIRACEPT TABS 250MG 4 QL (300 EA per 30 days)

MO

VIRAMUNE XR 4 QL (30 EA per 30 days)

MO

VIRAMUNE SUSP 3 QL (1200 ML per 30 days)

MO

VIRAMUNE TABS 3 QL (60 EA per 30 days)

MO

VIREAD POWD 4 QL (240 GM per 30 days)

MO

VIREAD TABS 4 QL (30 EA per 30 days)

MO

ZERIT SOLR 4 QL (2400 ML per 30 days)

MO

ZERIT CAPS 15MG 4 QL (120 EA per 30 days)

MO

ZERIT CAPS 30MG 4 QL (30 EA per 30 days)

MO

ZIAGEN TABS 4 QL (60 EA per 30 days)

MO

ZIAGEN SOLN 4 QL (960 ML per 30 days)

MO

zidovudine syrp 3 QL (1680 ML per 28 days)

MO

zidovudine caps 3 QL (180 EA per 30 days)

MO

zidovudine tabs 3 QL (60 EA per 30 days)

MO

ANTITUBERCULOSIS AGENTS

CAPASTAT SULFATE 4 MO

ethambutol hcl 3 MO

isoniazid 1 MO

PASER 2 MO

pyrazinamide 3 MO

SEROMYCIN 4 MO

TRECATOR 4 MO

AZOLES

fluconazole in dextrose 1 MO

fluconazole in nacl 2 MO

fluconazole susr 1 MO

fluconazole tabs 100mg, 200mg, 50mg 2 MO

fluconazole tabs 150mg 2 QL (4 EA per 28 days)

MO

itraconazole 3 QL (120 EA per 30 days)

MO

ketoconazole 2 MO

NOXAFIL 4 QL (840 ML per 28 days)

PA MO

VFEND 4 QL (400 ML per 30 days)

PA MO

VFEND IV 4 MO



voriconazole 3 QL (120 EA per 30 days)

PA MO

CEPHALOSPORINS

cefaclor 2 MO

cefaclor er 3 MO

cefadroxil 2 MO

cefazolin sodium 3 MO

cefazolin sodium/dextrose 3 MO

cefdinir 3 MO

cefditoren pivoxil 1 MO

cefepime 3 MO

cefotaxime sodium 1 MO

cefotetan 3 MO

cefoxitin sodium inj 1gm; 4%, 2gm; 2.2% 1 MO

cefoxitin sodium inj 10gm, 1gm, 2gm 3 MO

cefpodoxime proxetil 3 MO

cefprozil 3 MO

ceftazidime 2 MO

ceftazidime/dextrose 2 MO

ceftriaxone sodium 3 MO

cefuroxime axetil 2 MO

cefuroxime sodium 3 MO

cephalexin 2 MO

KEFLEX 4 MO

ROCEPHIN 4 MO

SUPRAX 4 MO

tazicef 3 MO

TEFLARO 4 MO

CHLORAMPHENICOL

chloramphenicol sodium succinate 2 MO

ECHINOCANDINS

CANCIDAS 4 B/D MO

ERAXIS 4 B/D MO

HCV PROTEASE INHIBITORS

INCIVEK 4 QL (168 EA per 28 days)

PA MO

VICTRELIS 4 QL (336 EA per 28 days)

PA MO

INTERFERONS

INFERGEN 4 QL (30 ML per 30 days)

PA MO

INTRON-A 4 PA MO

INTRON-A W/DILUENT 4 PA MO

PEG-INTRON 4 QL (4 EA per 28 days) PA

PEG-INTRON REDIPEN 4 QL (4 EA per 28 days) PA

PEG-INTRON REDIPEN PAK 4 INJ 120MCG/0.5ML,

150MCG/0.5ML, 80MCG/0.5ML

4 QL (4 EA per 28 days) PA

PEG-INTRON REDIPEN PAK 4 INJ 50MCG/0.5ML 4 QL (4 EA per 28 days) PA

MO

PEGASYS INJ 180MCG/0.5ML 4 QL (4 EA per 28 days) PA

MO



PEGASYS INJ 180MCG/ML 4 QL (4 ML per 28 days) PA

MO

SYLATRON 4 QL (4 EA per 28 days) PA

MO

MACROLIDES

azithromycin 2 MO

clarithromycin 2 MO

clarithromycin er 3 MO

DIFICID 4 QL (20 EA per 10 days)

MO

E.E.S. 400 4 MO

E.E.S. GRANULES 4 MO

e.s.p. 2 MO

ERY-TAB 4 MO

ERYPED 200 4 MO

ERYPED 400 4 MO

ERYTHROCIN LACTOBIONATE 1 MO

ERYTHROCIN STEARATE 2 MO

erythromycin base 2 MO

erythromycin ethylsuccinate 2 MO

erythromycin/sulfisoxazole 2 MO

KETEK 4 MO

PCE 4 MO

MISCELLANEOUS B-LACTAM ANTIBIOTICS

aztreonam inj 1gm 2 MO

aztreonam inj 2gm 4 MO

CAYSTON 4 QL (84 ML per 28 days)

PA MO

DORIBAX 4 MO

imipenem/cilastatin 3 MO

meropenem 3 MO

MERREM 4 MO

PRIMAXIN IV 3 MO

PRIMAXIN IV ADD-VANTAGE 3 MO

NEURAMINIDASE INHIBITORS

RELENZA DISKHALER 4 QL (60 EA per 180 days)

MO

TAMIFLU SUSR 4 QL (720 ML per 365 days)

MO

TAMIFLU CAPS 30MG 4 QL (112 EA per 365 days)

MO

TAMIFLU CAPS 45MG, 75MG 4 QL (56 EA per 365 days)

MO

NUCLEOSIDES AND NUCLEOTIDES

acyclovir 2 MO

acyclovir sodium 2 MO

BARACLUDE TABS 4 QL (30 EA per 30 days)

MO

BARACLUDE SOLN 4 QL (630 ML per 30 days)

MO

CYTOVENE 4 MO



famciclovir 3 QL (60 EA per 30 days)

MO

ganciclovir 3 MO

HEPSERA 4 MO

REBETOL 4 QL (1000 ML per 30 days)

PA MO

ribavirin 3 QL (168 EA per 28 days)

PA MO

TYZEKA 4 QL (30 EA per 30 days)

MO

valacyclovir hcl tabs 500mg 3 QL (60 EA per 30 days)

MO

valacyclovir hcl tabs 1000mg 3 QL (90 EA per 30 days)

MO

VALCYTE SOLR 4 QL (1056 ML per 30 days)

MO

VALCYTE TABS 4 QL (120 EA per 30 days)

MO

PENICILLINS

amoxicillin 1 MO

amoxicillin/clavulanate potassium er 3 MO

amoxicillin/clavulanate potassium chew 2 MO

amoxicillin/clavulanate potassium susr 200mg/5ml;

28.5mg/5ml, 250mg/5ml; 62.5mg/5ml, 400mg/5ml;

57mg/5ml

2 MO

amoxicillin/clavulanate potassium susr 600mg/5ml;

42.9mg/5ml

3 MO

amoxicillin/clavulanate potassium tabs 500mg; 125mg,

875mg; 125mg

2 MO

amoxicillin/clavulanate potassium tabs 250mg; 125mg 3 MO

amoxicillin/potassium clavulanate 2 MO

ampicillin 2 MO

ampicillin sodium 3 MO

ampicillin-sulbactam 3 MO

bactocill in dextrose 3 MO

dicloxacillin sodium 2 MO

nafcillin sodium 3 MO

nallpen/dextrose 4 MO

oxacillin sodium 3 MO

penicillin g potassium 2 MO

penicillin g potassium in iso-osmotic dextrose 2 MO

penicillin g procaine 3 MO

penicillin g sodium 2 MO

penicillin v potassium 2 MO

pfizerpen-g 2 MO

piperacillin sodium/tazobactam sodium 2 MO

piperacillin/tazobactam 2 MO

TIMENTIN 4 MO

POLYENES

AMPHOTEC 4 MO

amphotericin b 3 MO



nystatin 2 MO

PYRIMIDINES

ANCOBON 4 MO

flucytosine 3 MO

QUINOLONES

AVELOX 4 MO

ciprofloxacin 2 MO

ciprofloxacin hcl 1 MO

ciprofloxacin i.v.-in d5w 2 MO

FACTIVE 4 MO

levofloxacin in d5w 4 MO

levofloxacin oral soln, tabs 2 MO

levofloxacin inj 4 MO

ofloxacin 2 MO

SULFONAMIDES (SYSTEMIC)

sulfadiazine 3 MO

sulfamethoxazole/trimethoprim 1 MO

sulfamethoxazole/trimethoprim ds 1 MO

sulfasalazine 2 MO

sulfazine 2 MO

TETRACYCLINES

demeclocycline hcl 3 MO

doxycycline 3 QL (30 EA per 30 days)

MO

doxycycline hyclate cpep, inj 1 MO

doxycycline hyclate caps, tabs 2 MO

doxycycline hyclate tbec 3 MO

doxycycline monohydrate tabs 2 MO

doxycycline monohydrate caps 2 QL (60 EA per 30 days)

MO

minocycline hcl 2 MO

morgidox 1x100mg 1 MO

morgidox 2x100mg 1 MO

tetracycline hcl 1 MO

TYGACIL 4 MO

VIBRAMYCIN 4 MO

URINARY ANTI-INFECTIVES

methenamine hippurate 3 MO

nitrofurantoin 4 PA MO

nitrofurantoin macrocrystal 3 PA MO

nitrofurantoin macrocrystalline 3 PA MO

nitrofurantoin monohydrate 3 PA MO

nitrofurantoin monohydrate/macrocrystals 3 PA MO

PRIMSOL 2 MO

trimethoprim 2 MO

UREX 2 MO

ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

arbinoxa 2 MO

carbinoxamine maleate 2 MO

clemastine fumarate syrp 2 MO



clemastine fumarate tabs 2.68mg 2 MO

palgic 2 MO

PHENOTHIAZINE DERIVATIVES

phenadoz 2 PA MO

promethegan supp 50mg 3 MO

promethegan supp 12.5mg, 25mg 3 PA MO

PIPERAZINE DERIVATIVES

hydroxyzine hcl 2 PA MO

meclizine hcl 2 MO

SECOND GENERATION ANTIHISTAMINES

cetirizine hcl syrp 2 QL (300 ML per 30 days)

MO

levocetirizine dihydrochloride tabs 2 QL (30 EA per 30 days)

MO

SEMPREX-D 4 MO

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

ABRAXANE 4 QL (700 EA per 21 days)

PA MO

adriamycin inj 2mg/ml 3 B/D

AFINITOR 4 QL (30 EA per 30 days)

PA MO

ALIMTA INJ 500MG 4 QL (60 EA per 21 days)

PA MO

ALKERAN INJ 4 B/D MO

anastrozole 1 QL (30 EA per 30 days)

MO

ARRANON 4 PA MO

ARZERRA 4 QL (400 ML per 28 days)

PA MO

AVASTIN INJ 100MG/4ML 4 PA

AVASTIN INJ 400MG/16ML 4 PA MO

bicalutamide 2 QL (30 EA per 30 days)

MO

BICNU 4 B/D MO

bleomycin sulfate inj 30unit 3 B/D MO

BUSULFEX 4 B/D MO

CAMPATH 4 QL (12 ML per 28 days)

PA MO

CAPRELSA TABS 300MG 4 QL (30 EA per 30 days)

PA MO

CAPRELSA TABS 100MG 4 QL (60 EA per 30 days)

PA MO

carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,

600mg/60ml

3 B/D MO

CEENU 4 MO

CERUBIDINE 4 B/D MO

cisplatin inj 100mg/100ml 3 B/D

cisplatin inj 200mg/200ml, 50mg/50ml 3 B/D MO

cladribine 1 B/D MO

CLOLAR 4 B/D MO



COSMEGEN 4 B/D MO

cyclophosphamide tabs 3 B/D MO

cytarabine aqueous 1 B/D MO

cytarabine inj 100mg/ml, 500mg 1 B/D MO

dacarbazine inj 200mg 1 B/D MO

DACOGEN 4 PA MO

dactinomycin 3 B/D MO

daunorubicin hcl inj 20mg 1 B/D MO

DOCEFREZ 4 B/D MO

docetaxel inj 80mg/2ml, 80mg/4ml, 80mg/8ml 4 B/D MO

DROXIA 4 MO

ELOXATIN INJ 100MG/20ML 4 PA MO

EMCYT 4 MO

epirubicin hcl inj 50mg/25ml 3 PA MO

epirubicin hcl inj 200mg/100ml 3 PA MO

ERBITUX INJ 100MG/50ML 4 PA MO

ERIVEDGE 4 QL (28 EA per 28 days)

PA MO

ETOPOPHOS 4 B/D MO

etoposide inj 3 MO

exemestane 3 QL (60 EA per 30 days)

MO

FARESTON 4 QL (30 EA per 30 days)

MO

FASLODEX 4 QL (30 ML per 30 days)

B/D MO

FIRMAGON INJ 80MG 4 QL (4 EA per 28 days) PA

MO

FIRMAGON INJ 120MG 4 QL (6 EA per 365 days)

PA MO

fludarabine phosphate inj 50mg 2 B/D MO

fluorouracil inj 500mg/10ml 3 B/D MO

flutamide 3 MO

FOLOTYN INJ 40MG/2ML 4 PA MO

gemcitabine hcl inj 1gm 4 B/D MO

gemcitabine inj 1gm/26.3ml 4 B/D MO

GEMZAR INJ 1GM 4 PA MO

GLEEVEC TABS 100MG 4 QL (180 EA per 30 days)

PA MO

GLEEVEC TABS 400MG 4 QL (60 EA per 30 days)

PA MO

HALAVEN 4 QL (10 ML per 21 days)

PA MO

HERCEPTIN 4 PA MO

HEXALEN 4 MO

HYCAMTIN INJ 4 B/D MO

hydroxyurea 2 MO

IDAMYCIN PFS 4 B/D MO

idarubicin hcl 4 B/D MO



IFEX 4 B/D MO

ifosfamide inj 1gm, 3gm 3 B/D MO

INLYTA TABS 1MG 4 QL (180 EA per 30 days)

PA MO

INLYTA TABS 5MG 4 QL (60 EA per 30 days)

PA MO

IRESSA 3 QL (30 EA per 30 days)

MO

irinotecan inj 100mg/5ml 3 B/D MO

ISTODAX 4 PA MO

IXEMPRA KIT INJ 45MG 4 QL (45 EA per 21 days)

PA MO

JAKAFI 4 QL (60 EA per 30 days)

PA MO

JEVTANA 4 QL (4 ML per 21 days) PA

MO

letrozole 2 QL (30 EA per 30 days)

MO

LEUKERAN 3 MO

leuprolide acetate 3 QL (2.8 EA per 14 days)

PA MO

LUPRON DEPOT-PED INJ 11.25MG, 15MG 4 QL (1 EA per 28 days) PA

MO

LUPRON DEPOT INJ 30MG 4 QL (1 EA per 120 days)

PA MO

LUPRON DEPOT INJ 45MG 4 QL (1 EA per 180 days)

PA MO

LUPRON DEPOT INJ 3.75MG, 7.5MG 4 QL (1 EA per 30 days) PA

MO

LUPRON DEPOT INJ 11.25MG, 22.5MG 4 QL (1 EA per 90 days) PA

MO

LYSODREN 3 MO

MATULANE 4 MO

megestrol acetate susp 3 MO

megestrol acetate tabs 20mg 2 MO

megestrol acetate tabs 40mg 3 MO

melphalan hydrochloride 1 B/D MO

mercaptopurine 3 MO

methotrexate 2 B/D MO

methotrexate sodium 2 MO

mitomycin inj 20mg 4 B/D MO

mitoxantrone hcl inj 2mg/ml 3 B/D

mitoxantrone hcl inj 2mg/ml 3 B/D MO

MUSTARGEN 4 B/D MO

NAVELBINE INJ 50MG/5ML 4 MO

NEXAVAR 4 QL (120 EA per 30 days)

PA MO

NILANDRON 4 QL (60 EA per 30 days)

MO

NIPENT 4 B/D MO

ONTAK 4 QL (108 ML per 21 days)



PA MO

oxaliplatin inj 100mg/20ml 2 PA MO

paclitaxel inj 300mg/50ml 3 B/D

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 30mg/5ml 3 B/D MO

pentostatin 1 B/D MO

PROLEUKIN 4 MO

REVLIMID CAPS 10MG, 15MG, 25MG, 5MG 4 QL (28 EA per 28 days)

PA MO

RHEUMATREX 4 B/D MO

RITUXAN 3 PA MO

SPRYCEL TABS 140MG 4 QL (30 EA per 30 days)

PA MO

SPRYCEL TABS 100MG, 50MG, 70MG, 80MG 4 QL (60 EA per 30 days)

PA MO

SPRYCEL TABS 20MG 4 QL (90 EA per 30 days)

PA MO

SUTENT 4 QL (28 EA per 28 days)

PA MO

TABLOID 4 MO

tamoxifen citrate 2 MO

TARCEVA TABS 100MG, 150MG 4 QL (30 EA per 30 days)

PA MO

TARCEVA TABS 25MG 4 QL (90 EA per 30 days)

PA MO

TARGRETIN 4 QL (300 EA per 30 days)

PA MO

TASIGNA 4 QL (120 EA per 30 days)

PA MO

TAXOTERE INJ 80MG/2ML, 80MG/4ML 4 B/D MO

thiotepa 1 B/D MO

toposar 4 B/D MO

topotecan hcl inj 4mg 4 B/D MO

TORISEL 4 QL (100 ML per 28 days)

PA MO

TREANDA INJ 100MG 4 QL (600 EA per 21 days)

PA MO

TRELSTAR DEPOT MIXJECT 4 PA

TRELSTAR LA MIXJECT 4 PA

TRELSTAR MIXJECT 4 PA

tretinoin 3 MO

TREXALL 4 B/D MO

TRISENOX 4 B/D MO

TYKERB 3 QL (150 EA per 30 days)

PA MO

VANDETANIB TABS 300MG 4 QL (30 EA per 30 days)

PA MO

VANDETANIB TABS 100MG 4 QL (60 EA per 30 days)

PA MO

VECTIBIX INJ 100MG/5ML 4 PA MO

VELCADE 4 PA MO

VIDAZA 4 PA MO



vinblastine sulfate inj 10mg 1 B/D MO

vincasar pfs 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate inj 50mg/5ml 3 MO

VOTRIENT 4 QL (120 EA per 30 days)

PA MO

XALKORI 4 QL (60 EA per 30 days)

PA MO

YERVOY INJ 50MG/10ML 4 QL (70 ML per 21 days)

PA MO

ZANOSAR 4 B/D MO

ZELBORAF 4 QL (240 EA per 30 days)

PA MO

ZOLINZA 4 QL (120 EA per 30 days)

PA MO

ZYTIGA 4 QL (120 EA per 30 days)

PA MO

AUTONOMIC DRUGS

ALPHA- AND BETA-ADRENERGIC AGONISTS

epinephrine 3 MO

epinephrine hcl 1 MO

TWINJECT INJ 0.15MG/0.15ML 4

TWINJECT INJ 0.3MG/0.3ML 4 MO

ALPHA-ADRENERGIC AGONISTS

methyldopa 2 MO

methyldopa/hydrochlorothiazide 2 MO

methyldopate hcl 1 MO

midodrine hcl 3 MO

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

alfuzosin hcl er 3 QL (30 EA per 30 days)

MO

carvedilol 1 MO

dihydroergotamine mesylate 4 MO

doxazosin mesylate 2 MO

ergoloid mesylates 2 PA MO

ergotamine tartrate/caffeine 2 MO

labetalol hcl 2 MO

migergot 4 MO

prazosin hcl 2 MO

tamsulosin hcl 2 QL (60 EA per 30 days)

MO

terazosin hcl 2 MO

ANTIMUSCARINICS/ANTISPASMODICS

atropine sulfate 2 MO

ATROVENT HFA 4 QL (30 GM per 30 days)

MO

dicyclomine hcl 2 PA MO

diphenoxylate/atropine 2 PA MO

DUONEB 4 B/D MO

glycopyrrolate 2 MO

ipratropium bromide 2 B/D MO



ipratropium bromide/albuterol sulfate 3 B/D MO

methscopolamine bromide 3 MO

propantheline bromide 2 PA MO

SPIRIVA HANDIHALER 3 QL (30 EA per 30 days)

MO

ANTIPARKINSONIAN AGENTS

benztropine mesylate inj 1 MO

benztropine mesylate tabs 2 MO

trihexyphenidyl hcl 2 MO

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX 4 QL (56 EA per 28 days)

MO

CHANTIX CONTINUING MONTH PAK 4 QL (56 EA per 28 days)

MO

CHANTIX STARTING MONTH PAK 4 QL (56 EA per 28 days)

MO

NICOTROL NS 4 MO

BETA-ADRENERGIC AGONISTS

albuterol sulfate er 3 MO

albuterol sulfate nebu 2 B/D MO

albuterol sulfate syrp, tabs 2 MO

BROVANA 4 QL (124 ML per 30 days)

PA MO

FORADIL AEROLIZER 4 QL (60 EA per 30 days)

MO

levalbuterol 2 B/D MO

metaproterenol sulfate tabs 2 MO

metaproterenol sulfate syrp 3 MO

PERFOROMIST 4 QL (120 ML per 30 days)

PA MO

PROAIR HFA 3 QL (36 GM per 30 days)

MO

SEREVENT DISKUS 4 QL (60 EA per 30 days)

MO

SYMBICORT 3 QL (11 GM per 30 days)

MO

terbutaline sulfate tabs 3 MO

terbutaline sulfate inj 4

BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)

acebutolol hcl 2 MO

atenolol 1 MO

atenolol/chlorthalidone 2 MO

betaxolol hcl 2 MO

bisoprolol fumarate 2 MO

bisoprolol fumarate/hydrochlorothiazide 2 MO

metoprolol succinate er 2 QL (60 EA per 30 days)

MO

metoprolol tartrate 1 MO

metoprolol/hydrochlorothiazide 3 MO

nadolol 2 MO

nadolol/bendroflumethiazide 3 MO



pindolol 2 MO

propranolol hcl er 3 MO

propranolol hcl inj, oral soln 1 MO

propranolol hcl tabs 2 MO

propranolol/hydrochlorothiazide 2 MO

sorine 1 MO

sotalol hcl 2 MO

sotalol hcl (af) 2 MO

timolol maleate 2 MO

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

carisoprodol 2 PA MO

carisoprodol/aspirin 3 PA MO

carisoprodol/aspirin/codeine 3 QL (360 EA per 30 days)

PA MO

metaxalone 3 QL (120 EA per 30 days)

PA MO

methocarbamol 2 PA MO

tizanidine hcl 2 MO

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

dantrolene sodium 3 MO

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

baclofen 2 MO

ed baclofen 2 MO

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

bethanechol chloride 3 MO

donepezil hcl tbdp 1 QL (30 EA per 30 days)

MO

donepezil hcl tabs 5mg 1 QL (30 EA per 30 days)

MO

donepezil hcl tabs 10mg 1 QL (60 EA per 30 days)

MO

EXELON SOLN 4 QL (240 ML per 30 days)

MO

EXELON PT24 4 QL (30 EA per 30 days)

MO

galantamine 3 QL (60 EA per 30 days)

MO

galantamine hydrobromide soln 2 QL (200 ML per 30 days)

MO

galantamine hydrobromide cp24 2 QL (30 EA per 30 days)

MO

galantamine hydrobromide tabs 3 QL (60 EA per 30 days)

MO

MESTINON TIMESPAN 4 MO

MESTINON SYRP 4 MO

MESTINON TABS 4 PA MO

pilocarpine hcl 3 MO

pilocarpine hydrochloride 3 MO

pyridostigmine bromide 2 MO

rivastigmine tartrate caps 4.5mg, 6mg 2 QL (60 EA per 30 days)

MO



rivastigmine tartrate caps 1.5mg, 3mg 2 QL (90 EA per 30 days)

MO

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

orphenadrine citrate 3 MO

orphenadrine citrate er 3 PA MO

BLOOD FORMATION, COAGULATION, AND

THROMBOSIS

ANTICOAGULANTS

argatroban 1 B/D MO

COUMADIN 4 MO

enoxaparin sodium 3 QL (28 ML per 30 days)

MO

fondaparinux sodium 4 QL (14 ML per 30 days)

MO

FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,

15000UNIT/0.6ML, 18000UNT/0.72ML,

2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML

4 QL (14 ML per 30 days)

MO

FRAGMIN INJ 25000UNIT/ML 4 QL (2 ML per 30 days)

MO

heparin sodium dcu 3 MO

heparin sodium/d5w 1 MO

heparin sodium/nacl 0.45% 1 MO

heparin sodium/sodium chloride 0.9% 1 MO

heparin sodium/sodium chloride 0.9% premix 1 MO

heparin sodium inj 1000unit/ml 3 B/D MO

heparin sodium inj 10000unit/ml, 20000unit/ml,

2000unit/ml, 5000unit/ml

3 MO

jantoven 2 MO

PRADAXA 4 QL (60 EA per 30 days)

MO

warfarin sodium 1 MO

XARELTO TABS 15MG, 20MG 4 QL (30 EA per 30 days)

MO

XARELTO TABS 10MG 4 QL (35 EA per 60 days)

MO

HEMATOPOIETIC AGENTS

EPOGEN INJ 2000UNIT/ML, 3000UNIT/ML,

4000UNIT/ML

3 QL (14 ML per 30 days)

PA

EPOGEN INJ 10000UNIT/ML, 20000UNIT/ML 4 QL (14 ML per 30 days)

PA

LEUKINE 4 PA MO

MOZOBIL 4 QL (8 ML per 30 days) PA

MO

NEULASTA 4 QL (2 ML per 28 days) PA

MO

NEUMEGA 4 QL (42 EA per 30 days)

MO

NEUPOGEN 4 QL (14 ML per 30 days)

PA MO

PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML 4 QL (14 ML per 30 days)

PA



PROCRIT INJ 40000UNIT/ML 4 QL (4 ML per 30 days) PA

procrit inj 2000unit/ml, 3000unit/ml, 4000unit/ml 3 QL (14 ML per 30 days)

PA

PROMACTA 4 QL (30 EA per 30 days)

PA MO

HEMORRHEOLOGIC AGENTS

pentoxifylline er 2 MO

HEMOSTATICS

CYKLOKAPRON 3 QL (400 ML per 30 days)

PA MO

desmopressin acetate 3 MO

STIMATE 4 MO

tranexamic acid 3 MO

PLATELET-AGGREGATION INHIBITORS

AGGRENOX 4 MO

cilostazol 2 MO

clopidogrel tabs 300mg 2 QL (1 EA per 30 days)

MO

clopidogrel tabs 75mg 2 QL (30 EA per 30 days)

MO

EFFIENT 4 QL (30 EA per 30 days)

MO

ticlopidine hcl 3 MO

PLATELET-REDUCING AGENTS

anagrelide hydrochloride 2 MO

CARDIOVASCULAR DRUGS

ANGIOTENSIN II RECEPTOR ANTAGONISTS

irbesartan 3 QL (30 EA per 30 days)

MO

irbesartan/hydrochlorothiazide 3 QL (30 EA per 30 days)

MO

ANTIARRHYTHMIC AGENTS

amiodarone hcl 2 MO

cartia xt cp24 300mg 1 QL (30 EA per 30 days)

MO

cartia xt cp24 120mg, 180mg, 240mg 1 QL (60 EA per 30 days)

MO

COVERA-HS TB24 240MG 4 QL (60 EA per 30 days)

MO

COVERA-HS TB24 180MG 4 QL (90 EA per 30 days)

MO

digoxin 1 MO

DILANTIN 4 MO

dilantin infatabs 4 MO

dilt-cd cp24 300mg 2 QL (30 EA per 30 days)

MO

dilt-cd cp24 180mg, 240mg 2 QL (60 EA per 30 days)

MO

dilt-cd cp24 120mg 3 QL (60 EA per 30 days)

MO

dilt-xr 3 QL (60 EA per 30 days)



MO

diltiazem cd cp24 120mg, 180mg 2 QL (60 EA per 30 days)

MO

diltiazem cd cp24 300mg 3 QL (30 EA per 30 days)

MO

diltiazem cd cp24 240mg 3 QL (60 EA per 30 days)

MO

diltiazem hcl er cp24 300mg, 360mg 2 QL (30 EA per 30 days)

MO

diltiazem hcl er cp24 120mg, 180mg, 240mg 2 QL (60 EA per 30 days)

MO


MO


MO

diltiazem hcl er cp12 3 MO

diltiazem hcl cp24 300mg, 360mg 2 QL (30 EA per 30 days)

MO

diltiazem hcl cp24 120mg, 240mg 2 QL (60 EA per 30 days)

MO

diltiazem hcl cp24 180mg 3 QL (60 EA per 30 days)

MO

diltiazem hcl tabs 2 MO

diltiazem hcl inj 4 MO

diltzac cp24 300mg, 360mg 3 QL (30 EA per 30 days)

MO

diltzac cp24 120mg, 180mg, 240mg 3 QL (60 EA per 30 days)

MO

disopyramide phosphate 2 MO

flecainide acetate 3 MO

LANOXIN 4 MO

magnesium sulfate 2 MO

magnesium sulfate in d5w 2 MO

mexiletine hcl 2 MO

MULTAQ 3 QL (60 EA per 30 days)

MO

NORPACE CR 4 MO

PACERONE TABS 100MG, 400MG 4 MO

pacerone tabs 200mg 4 MO

PHENYTEK 3 MO

phenytoin 2 MO

phenytoin sodium 3 MO

phenytoin sodium extended 2 MO

procainamide hcl 1 MO

propafenone hcl 3 MO

propafenone hcl er 3 MO

sotalol hydrochloride 2 MO

taztia xt cp24 300mg, 360mg 3 QL (30 EA per 30 days)

MO

taztia xt cp24 120mg, 180mg, 240mg 3 QL (60 EA per 30 days)

MO



TIKOSYN CAPS 250MCG 4 QL (120 EA per 30 days)

MO


MO


MO

verapamil hcl 2 MO

verapamil hcl er cp24 100mg, 300mg 2 QL (30 EA per 30 days)

MO

verapamil hcl er cp24 120mg, 180mg, 200mg, 240mg 2 QL (60 EA per 30 days)

MO

verapamil hcl er tbcr 2 MO

verapamil hcl sr tbcr 2 MO

verapamil hcl sr cp24 2 QL (60 EA per 30 days)

MO

ANTILIPEMIC AGENTS, MISCELLANEOUS

lovaza 3 QL (120 EA per 30 days)

MO

niacor 2 MO

NIASPAN 3 MO

BETA-ADRENERGIC BLOCKING AGENTS

carvedilol 1 MO

propranolol/hydrochlorothiazide 2 MO

TENORMIN 4 PA MO

BILE ACID SEQUESTRANTS

cholestyramine 3 MO

cholestyramine light 3 MO

colestipol hcl 3 MO

micronized colestipol hcl 3 MO

prevalite 3 MO

WELCHOL 3 MO

CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)

afeditab cr 3 QL (60 EA per 30 days)

MO

amlodipine besylate 1 MO

amlodipine besylate/benazepril hcl 3 QL (30 EA per 30 days)

MO

amlodipine besylate/benazepril hydrochloride 3 QL (60 EA per 30 days)

MO

felodipine er 3 QL (30 EA per 30 days)

MO

isradipine 3 MO

nicardipine hcl 2 MO

nifediac cc 3 QL (60 EA per 30 days)

MO

nifedical xl 3 QL (60 EA per 30 days)

MO

nifedipine er 3 QL (60 EA per 30 days)

MO

nimodipine 4 MO

nisoldipine er 3 QL (60 EA per 30 days)



MO

nisoldipine tb24 17mg, 20mg, 34mg, 40mg, 8.5mg 3 QL (30 EA per 30 days)

MO

nisoldipine tb24 30mg 3 QL (60 EA per 30 days)

MO

CARDIAC DRUGS, MISCELLANEOUS

RANEXA 3 QL (120 EA per 30 days)

ST MO

CENTRAL ALPHA-AGONISTS

clonidine hcl ptwk 3 QL (4 EA per 28 days)

MO

clonidine hcl tabs 0.1mg, 0.2mg 2 MO

clonidine hcl tabs 0.3mg 3 MO

clorpres 4 MO

guanfacine hcl 2 MO

KAPVAY 4 QL (120 EA per 30 days)

ST MO

CHOLESTEROL ABSORPTION INHIBITORS

ZETIA 3 QL (30 EA per 30 days)

MO

DIHYDROPYRIDINES

amlodipine besylate/atorvastatin calcium 2 QL (30 EA per 30 days)

MO

DIRECT VASODILATORS

BIDIL 3 QL (180 EA per 30 days)

MO

hydralazine hcl inj 3 MO

hydralazine hcl tabs 10mg, 25mg 2 MO

hydralazine hcl tabs 100mg, 50mg 3 MO

minoxidil 2 MO

PROGLYCEM 4 MO

DIURETICS (HYPOTENSIVE AGENTS)

acetazolamide 2 MO

acetazolamide er 2 MO

acetazolamide sodium 2 MO

amiloride hcl 2 MO

amiloride/hydrochlorothiazide 2 MO

benazepril hcl/hydrochlorothiazide 2 MO

bumetanide 2 MO

captopril/hydrochlorothiazide 2 MO

chlorothiazide 2 MO

chlorothiazide sodium 2 MO

chlorthalidone 2 MO

DIURIL 3 MO

DYRENIUM 4 MO

ELIXOPHYLLIN 2 MO

enalapril maleate/hydrochlorothiazide 2 MO

eplerenone 3 MO

fosinopril sodium/hydrochlorothiazide 3 MO

furosemide 1 MO

hydrochlorothiazide 1 MO



indapamide 1 MO

lisinopril/hydrochlorothiazide 1 MO

losartan potassium/hydrochlorothiazide 1 QL (60 EA per 30 days)

MO

methyclothiazide 2 MO

metolazone 2 MO

moexipril/hydrochlorothiazide 2 MO

quinapril/hydrochlorothiazide 3 MO

SODIUM EDECRIN 3 MO

spironolactone 2 MO

spironolactone/hydrochlorothiazide 2 MO

theophylline cr 2 MO

theophylline er 2 MO

torsemide 2 MO

triamterene/hydrochlorothiazide caps 25mg; 50mg 1 MO

triamterene/hydrochlorothiazide caps 25mg; 37.5mg 2 MO

triamterene/hydrochlorothiazide tabs 2 MO

FIBRIC ACID DERIVATIVES

fenofibrate micronized caps 134mg, 200mg 3 QL (30 EA per 30 days)

MO

fenofibrate micronized caps 67mg 3 QL (60 EA per 30 days)

MO

fenofibrate tabs 160mg 3 QL (30 EA per 30 days)

MO

fenofibrate tabs 54mg 3 QL (60 EA per 30 days)

MO

gemfibrozil 2 QL (60 EA per 30 days)

MO

TRICOR TABS 145MG 3 QL (30 EA per 30 days)

MO

TRICOR TABS 48MG 3 QL (60 EA per 30 days)

MO

HMG-COA REDUCTASE INHIBITORS

amlodipine besylate/atorvastatin calcium 2 QL (30 EA per 30 days)

MO

atorvastatin calcium 2 QL (30 EA per 30 days)

MO

CRESTOR 3 QL (30 EA per 30 days)

MO

JUVISYNC 3 QL (30 EA per 30 days)

ST MO

lovastatin 2 QL (60 EA per 30 days)

MO

pravastatin sodium tabs 10mg, 20mg, 80mg 2 QL (30 EA per 30 days)

MO

pravastatin sodium tabs 40mg 2 QL (60 EA per 30 days)

MO

simvastatin 1 QL (30 EA per 30 days)

MO

NITRATES AND NITRITES

DILATRATE SR 4 MO



isoditrate er 3 MO

ISORDIL TITRADOSE 4 MO

isosorbide dinitrate er 3 MO

isosorbide dinitrate tabs 2 MO

isosorbide dinitrate subl 2.5mg 1 MO

isosorbide dinitrate subl 5mg 2 MO

isosorbide mononitrate 2 MO

isosorbide mononitrate er 2 MO

minitran pt24 0.1mg/hr, 0.2mg/hr, 0.6mg/hr 3 QL (30 EA per 30 days)

MO

minitran pt24 0.4mg/hr 3 QL (60 EA per 30 days)

MO

nitroglycerin lingual 3 MO

nitroglycerin transdermal pt24 0.1mg/hr, 0.2mg/hr,

0.6mg/hr

2 QL (30 EA per 30 days)

MO

nitroglycerin transdermal pt24 0.4mg/hr 2 QL (60 EA per 30 days)

MO

nitroglycerin inj 2 MO

nitroglycerin pt24 0.2mg/hr, 0.6mg/hr 2 QL (30 EA per 30 days)

MO

nitroglycerin pt24 0.4mg/hr 2 QL (60 EA per 30 days)

MO

NITROLINGUAL PUMPSPRAY 4 MO

NITROSTAT 3 MO

PERIPHERAL ADRENERGIC INHIBITORS

reserpine 2 MO

PHOSPHODIESTERASE TYPE 5 INHIBITORS

ADCIRCA 4 QL (60 EA per 30 days)

PA MO

REVATIO 3 QL (90 EA per 30 days)

PA MO

RENIN INHIBITORS

TEKTURNA 4 QL (30 EA per 30 days)

MO

RENIN-ANGIOTENSIN-ALDOSTERINHIB(HYPOTN)

benazepril hcl 1 MO

captopril 1 MO

enalapril maleate 1 MO

fosinopril sodium 2 MO

lisinopril 1 MO

losartan potassium 1 QL (60 EA per 30 days)

MO

moexipril hcl 2 MO

perindopril erbumine 3 MO

quinapril hcl 2 MO

ramipril 2 MO

trandolapril 2 MO

VASODILATING AGENTS, MISCELLANEOUS

LETAIRIS 4 QL (30 EA per 30 days)

PA MO

REMODULIN 4 PA MO



TRACLEER 4 QL (60 EA per 30 days)

PA MO

Central Nervous System Agents

"BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)"

DIAZEPAM 4 MO

ANTICONVULSANTS, MISCELLANEOUS

TRILEPTAL 4 MO

ANTIPSYCHOTIC AGENTS

GEODON 4 MO

ZYPREXA 4 QL (60 EA per 30 days)

MO

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

phenobarbital tabs 30mg 3 QL (210 EA per 30 days)

PA MO

phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg 3 QL (90 EA per 30 days)

PA MO

BENZODIAZEPINES (ANTICONVULSANTS)

clonazepam 3 MO

CLONAZEPAM ODT 4 MO

ONFI 4 QL (60 EA per 30 days)

PA MO

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

CLORAZEPATE DIPOTASSIUM 4 MO

DIAZEPAM INTENSOL 4 QL (1200 ML per 30 days)

MO

DIAZEPAM GEL 4 MO

DIAZEPAM SOLN 4 QL (1200 ML per 30 days)

MO

DIAZEPAM TABS 10MG 4 QL (120 EA per 30 days)

MO

DIAZEPAM TABS 2MG, 5MG 4 QL (90 EA per 30 days)

MO

CENTRAL NERVOUS SYSTEMS AGENTS

AMPHETAMINES

dextroamphetamine sulfate 3 PA MO

dextroamphetamine sulfate er 3 PA MO

methamphetamine hcl 3 MO

ANOREX,RESPIR,CEREBRAL STIMULANTS,MISC

dexmethylphenidate hcl 2 PA MO

methylphenidate hcl 2 PA MO

ANTICONVULSANTS, MISCELLANEOUS

BANZEL SUSP 4 QL (2760 ML per 30 days)

PA MO

BANZEL TABS 400MG 4 QL (240 EA per 30 days)

PA MO

BANZEL TABS 200MG 4 QL (480 EA per 30 days)

PA MO

carbamazepine 2 MO

carbamazepine er cp12 300mg 4 QL (150 EA per 30 days)

MO




MO


MO

carbamazepine er tb12 2 MO

CARBATROL CP12 300MG 4 QL (150 EA per 30 days)

MO


MO


MO

divalproex sodium 3 MO

divalproex sodium dr 3 MO

divalproex sodium er 2 MO

epitol 2 MO

EQUETRO 4 MO

felbamate 4 MO

FELBATOL 4 MO

gabapentin tabs 2 QL (180 EA per 30 days)

MO

gabapentin caps 2 QL (270 EA per 30 days)

MO

gabapentin soln 3 MO

GABITRIL TABS 4MG 4 MO

GABITRIL TABS 12MG 4 QL (120 EA per 30 days)

MO

GABITRIL TABS 16MG, 2MG 4 QL (90 EA per 30 days)

MO

LAMICTAL CHEWABLE DISPERSIBLE 4 MO

LAMICTAL ODT TBDP 100MG, 25MG 4 QL (120 EA per 30 days)

MO

LAMICTAL ODT TBDP 200MG, 50MG 4 QL (90 EA per 30 days)

MO

LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE

4 MO

LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE

4 MO

LAMICTAL STARTER/TAKING VALPROATE 4 MO

LAMICTAL XR KIT 4 MO

LAMICTAL XR TB24 100MG 4 QL (120 EA per 30 days)

MO

LAMICTAL XR TB24 250MG 4 QL (60 EA per 30 days)

MO

LAMICTAL XR TB24 200MG, 25MG, 50MG 4 QL (90 EA per 30 days)

MO

LAMICTAL TABS 25MG 4 QL (120 EA per 30 days)

MO

LAMICTAL TABS 100MG 4 QL (150 EA per 30 days)

MO

LAMICTAL TABS 150MG, 200MG 4 QL (90 EA per 30 days)

MO

lamotrigine chew 2 MO



lamotrigine tabs 25mg 2 QL (120 EA per 30 days)

MO

lamotrigine tabs 100mg 2 QL (150 EA per 30 days)

MO

lamotrigine tabs 150mg, 200mg 2 QL (90 EA per 30 days)

MO

levetiracetam er tb24 750mg 2 QL (120 EA per 30 days)

MO

levetiracetam er tb24 500mg 2 QL (180 EA per 30 days)

MO

levetiracetam inj, oral soln 2 MO

levetiracetam tabs 2 QL (120 EA per 30 days)

MO

LYRICA CAPS 225MG, 300MG 4 QL (60 EA per 30 days)

ST MO

LYRICA CAPS 100MG, 150MG, 200MG, 25MG,

50MG, 75MG


ST MO

NEURONTIN 4 MO

oxcarbazepine 3 MO

POTIGA TABS 50MG 4 QL (270 EA per 30 days)

PA MO

POTIGA TABS 200MG, 300MG, 400MG 4 QL (90 EA per 30 days)

PA MO

SABRIL 4 QL (180 EA per 30 days)

PA MO

TEGRETOL-XR 4 MO

topiragen tabs 100mg, 200mg, 50mg 2 QL (120 EA per 30 days)

MO

topiragen tabs 25mg 2 QL (90 EA per 30 days)

MO

topiramate cpsp 2 MO

topiramate tabs 100mg, 200mg, 50mg 2 QL (120 EA per 30 days)

MO

topiramate tabs 25mg 2 QL (90 EA per 30 days)

MO

valproate sodium 2 MO

valproic acid 2 MO

VIMPAT INJ 4 MO

VIMPAT ORAL SOLN 4 QL (1395 ML per 30 days)

MO

VIMPAT TABS 200MG 4 QL (60 EA per 30 days)

MO

VIMPAT TABS 100MG, 150MG, 50MG 4 QL (90 EA per 30 days)

MO

zonisamide 2 MO

ANTIDEPRESSANTS

amitriptyline hcl 1 MO

amoxapine 2 MO

budeprion sr tb12 100mg 3 QL (120 EA per 30 days)

MO

budeprion sr tb12 150mg 3 QL (90 EA per 30 days)



MO

budeprion xl 3 QL (90 EA per 30 days)

MO

buproban 3 QL (90 EA per 30 days)

MO

bupropion hcl er tb12 150mg 2 QL (90 EA per 30 days)

MO


MO


MO

bupropion hcl sr tb12 150mg 2 QL (90 EA per 30 days)

MO


MO


MO

bupropion hcl xl 3 QL (90 EA per 30 days)

MO

bupropion hcl tabs 75mg 3 MO

bupropion hcl tabs 100mg 3 QL (180 EA per 30 days)

MO

citalopram hydrobromide soln 1 MO

citalopram hydrobromide tabs 1 QL (30 EA per 30 days)

MO

clomipramine hcl 2 MO

CYMBALTA 4 QL (60 EA per 30 days)

MO

desipramine hcl 3 MO

doxepin hcl 2 MO

EMSAM 4 QL (30 EA per 30 days)

MO

escitalopram oxalate tabs 3 QL (30 EA per 30 days)

MO

escitalopram oxalate soln 3 QL (600 ML per 30 days)

MO

fluoxetine dr 3 QL (4 EA per 28 days)

MO

fluoxetine hcl caps 20mg 1 QL (120 EA per 30 days)

MO


MO


MO

fluoxetine hcl soln, tabs 2 MO

fluoxetine caps 20mg 1 QL (120 EA per 30 days)

MO

fluoxetine caps 10mg 1 QL (60 EA per 30 days)

MO

fluvoxamine maleate 3 QL (90 EA per 30 days)

MO



imipramine hcl 2 MO

imipramine pamoate 3 MO

LUVOX CR 4 QL (60 EA per 30 days)

MO

maprotiline hcl 2 MO

MARPLAN 4 MO

mirtazapine odt tbdp 15mg 2 QL (30 EA per 30 days)

MO

mirtazapine odt tbdp 30mg, 45mg 3 QL (30 EA per 30 days)

MO

mirtazapine tbdp 2 QL (30 EA per 30 days)

MO

mirtazapine tabs 7.5mg 2 MO

mirtazapine tabs 15mg, 30mg, 45mg 2 QL (30 EA per 30 days)

MO

NARDIL 4 MO

nefazodone hcl 2 MO

nortriptyline hcl 2 MO

paroxetine hcl er tb24 12.5mg, 37.5mg 3 QL (60 EA per 30 days)

MO

paroxetine hcl er tb24 25mg 3 QL (90 EA per 30 days)

MO

paroxetine hcl tabs 10mg, 20mg 2 QL (30 EA per 30 days)

MO

paroxetine hcl tabs 30mg, 40mg 2 QL (60 EA per 30 days)

MO

PAXIL 4 MO

perphenazine/amitriptyline 2 MO

phenelzine sulfate 3 MO

PRISTIQ 4 QL (30 EA per 30 days)

MO

protriptyline hcl 2 MO

selegiline hcl 3 MO

sertraline hcl conc 1 MO

sertraline hcl tabs 1 QL (60 EA per 30 days)

MO

SURMONTIL 4 MO

tranylcypromine sulfate 3 MO

trazodone hcl 2 MO

trimipramine maleate 4 MO

venlafaxine hcl 3 MO

venlafaxine hcl er cp24 37.5mg 2 QL (30 EA per 30 days)

MO

venlafaxine hcl er cp24 150mg 2 QL (60 EA per 30 days)

MO

venlafaxine hcl er cp24 75mg 2 QL (90 EA per 30 days)

MO

VENLAFAXINE HCL ER TB24 225MG 4 QL (30 EA per 30 days)

MO

venlafaxine hcl er tb24 150mg, 37.5mg 4 QL (30 EA per 30 days)

MO



venlafaxine hcl er tb24 75mg 4 QL (60 EA per 30 days)

MO

VIIBRYD 4 QL (30 EA per 30 days)

MO

ZYBAN 3 QL (90 EA per 30 days)

MO

ANTIMANIC AGENTS

lithium carbonate 2 MO

lithium carbonate er 2 MO

lithium citrate 2 MO

ANTIPSYCHOTIC AGENTS

ABILIFY DISCMELT 4 QL (60 EA per 30 days)

MO

ABILIFY INJ 4 QL (120 ML per 30 days)

MO

ABILIFY TABS 4 QL (30 EA per 30 days)

MO

ABILIFY ORAL SOLN 4 QL (750 ML per 30 days)

MO

chlorpromazine hcl inj 2 MO

chlorpromazine hcl tabs 10mg, 25mg 2 B/D MO

chlorpromazine hcl tabs 100mg, 200mg, 50mg 2 MO

clozapine 3 MO

compro 2 MO

FANAPT 4 QL (60 EA per 30 days)

PA MO

FANAPT TITRATION PACK 4 QL (60 EA per 30 days)

PA MO

FAZACLO 4 ST MO

fluphenazine decanoate 2 MO

fluphenazine hcl 2 MO

HALDOL 4 MO

haloperidol 2 MO

haloperidol decanoate 3 MO

haloperidol lactate 2 MO

INVEGA SUSTENNA 4 QL (1 ML per 30 days)

MO

INVEGA TB24 1.5MG, 3MG, 9MG 4 QL (30 EA per 30 days)

ST MO

INVEGA TB24 6MG 4 QL (60 EA per 30 days)

ST MO

LATUDA TABS 20MG, 40MG 4 QL (30 EA per 30 days)

PA MO

LATUDA TABS 80MG 4 QL (60 EA per 30 days)

PA MO

loxapine 3 MO

loxapine succinate 3 MO

olanzapine odt tbdp 10mg, 5mg 3 QL (30 EA per 30 days)

MO

olanzapine odt tbdp 15mg, 20mg 3 QL (60 EA per 30 days)

MO



olanzapine inj 3 QL (60 EA per 30 days)

MO

olanzapine tabs 10mg, 2.5mg, 5mg, 7.5mg 3 QL (30 EA per 30 days)

MO

olanzapine tabs 15mg, 20mg 3 QL (60 EA per 30 days)

MO

ORAP 4 MO

perphenazine 2 MO

prochlorperazine 2 MO

prochlorperazine edisylate 2 MO

prochlorperazine maleate 1 B/D MO

quetiapine fumarate tabs 200mg, 25mg, 50mg 3 QL (120 EA per 30 days)

MO

quetiapine fumarate tabs 100mg, 300mg, 400mg 3 QL (90 EA per 30 days)

MO

RISPERDAL CONSTA INJ 12.5MG, 25MG 4 QL (2 EA per 28 days)

MO

RISPERDAL CONSTA INJ 37.5MG, 50MG 4 QL (4 EA per 28 days)

MO

risperidone m-tab tbdp 0.5mg 3 QL (120 EA per 30 days)

MO

risperidone m-tab tbdp 1mg, 2mg, 3mg, 4mg 3 QL (60 EA per 30 days)

MO

risperidone odt tbdp 0.5mg 3 QL (120 EA per 30 days)

MO

risperidone odt tbdp 0.25mg, 1mg, 2mg, 3mg, 4mg 3 QL (60 EA per 30 days)

MO

risperidone soln 3 MO

risperidone tabs 0.5mg 2 QL (120 EA per 30 days)

MO

risperidone tabs 0.25mg, 1mg, 2mg, 3mg, 4mg 2 QL (60 EA per 30 days)

MO

SAPHRIS 4 QL (60 EA per 30 days)

PA MO

SEROQUEL XR TB24 50MG 3 QL (120 EA per 30 days)

MO


MO

SEROQUEL XR TB24 300MG, 400MG 3 QL (60 EA per 30 days)

MO


MO

thioridazine hcl 2 PA MO

thiothixene 2 MO

trifluoperazine hcl 2 MO

ziprasidone hcl 3 QL (60 EA per 30 days)

MO

ANXIOLYTICS, SEDATIVES - HYPNOTICS,MISC

buspirone hcl 2 MO

zaleplon caps 5mg 2 QL (30 EA per 30 days)

MO



zaleplon caps 10mg 2 QL (60 EA per 30 days)

MO

zolpidem tartrate 1 QL (30 EA per 30 days)

MO

BARBITURATES (ANTICONVULSANTS)

primidone 3 MO

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB

COMTAN 3 QL (300 EA per 30 days)

MO

TASMAR 4 PA MO

CENTRAL NERVOUS SYSTEM AGENTS, MISC

NAMENDA TITRATION PAK 3 QL (98 EA per 30 days)

MO

NAMENDA SOLN 3 QL (360 ML per 30 days)

MO

NAMENDA TABS 3 QL (60 EA per 30 days)

MO

NUEDEXTA 4 QL (60 EA per 30 days)

MO

RILUTEK 3 MO

STRATTERA CAPS 100MG, 80MG 4 QL (30 EA per 30 days)

MO

STRATTERA CAPS 10MG, 18MG, 25MG, 40MG,

60MG


MO

XENAZINE TABS 25MG 4 QL (120 EA per 30 days)

PA MO

XENAZINE TABS 12.5MG 4 QL (240 EA per 30 days)

PA MO

XYREM 4 MO

DOPAMINE PRECURSORS

carbidopa/levodopa 3 MO

carbidopa/levodopa cr 2 MO

carbidopa/levodopa er 2 MO

carbidopa/levodopa odt 3 MO

carbidopa/levodopa sr 2 MO

DOPAMINE RECEPTOR AGONISTS

APOKYN 4 QL (60 ML per 30 days)

MO

bromocriptine mesylate 3 MO

cabergoline 2 QL (16 EA per 28 days)

MO

pramipexole dihydrochloride 2 MO

ropinirole hcl 2 MO

FIBROMYALGIA AGENTS

SAVELLA 3 QL (60 EA per 30 days)

MO

SAVELLA TITRATION PACK 3 QL (60 EA per 30 days)

MO

HYDANTOINS

fosphenytoin sodium 1 MO

PEGANONE 4 MO



MONOAMINE OXIDASE B INHIBITORS

AZILECT 3 QL (30 EA per 30 days)

MO

ELDEPRYL 4 PA MO

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ascomp/codeine 3 QL (360 EA per 30 days)

MO

butalbital/aspirn/caffeine/codeine 3 QL (360 EA per 30 days)

MO

diclofenac potassium 2 MO

diclofenac sodium dr 2 MO

diclofenac sodium er 2 MO

diclofenac sodium xr 2 MO

diflunisal 3 MO

etodolac 2 MO

etodolac er 3 MO

fenoprofen calcium 3 MO

flurbiprofen 2 MO

hydrocodone/ibuprofen 3 QL (150 EA per 30 days)

MO

ibuprofen 1 MO

INDOCIN 4 MO

indomethacin 2 MO

indomethacin er 2 MO

ketoprofen 2 MO

ketoprofen er 3 MO

meclofenamate sodium 2 MO

meloxicam susp 1 QL (300 ML per 30 days)

MO

meloxicam tabs 15mg 1 QL (30 EA per 30 days)

MO

meloxicam tabs 7.5mg 1 QL (60 EA per 30 days)

MO

nabumetone 3 MO

NALFON 4 MO

naproxen 2 MO

naproxen dr 2 MO

naproxen sodium 2 MO

oxaprozin 2 MO

oxycodone/aspirin 3 MO

oxycodone/ibuprofen 3 QL (240 EA per 30 days)

MO

piroxicam 2 MO

sulindac 2 MO

tolmetin sodium 3 MO

voltaren 3 MO

OPIATE AGONISTS

acetaminophen/caffeine/dihydrocodeine bitartrate 4 QL (180 EA per 30 days)

MO

acetaminophen/codeine #2 3 QL (390 EA per 30 days)

MO




MO


MO

acetaminophen/codeine phosphate 3 QL (390 EA per 30 days)

MO

acetaminophen/codeine tabs 3 QL (390 EA per 30 days)

MO

acetaminophen/codeine soln 3 QL (5010 ML per 30 days)

MO

ASTRAMORPH 3 MO

butalbital/acetaminophen/caffeine/codeine 3 QL (360 EA per 30 days)

MO

CAPITAL/CODEINE 3 QL (5010 ML per 30 days)

MO

codeine sulfate tabs 60mg 3 QL (180 EA per 30 days)

MO

codeine sulfate tabs 15mg, 30mg 3 QL (360 EA per 30 days)

MO

DURAMORPH 4 MO

endocet tabs 650mg; 10mg 3 QL (180 EA per 30 days)

MO

endocet tabs 500mg; 7.5mg 3 QL (240 EA per 30 days)

MO

endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 3 QL (360 EA per 30 days)

MO

fentanyl 3 QL (20 EA per 30 days)

MO

fentanyl citrate 3 MO

fentanyl citrate oral transmucosal 4 QL (120 EA per 30 days)

PA MO

hydrocodone bitartrate/acetaminophen soln 3 QL (5520 ML per 30 days)

MO

hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg 3 QL (150 EA per 30 days)

MO

hydrocodone bitartrate/acetaminophen tabs 300mg;

10mg, 300mg; 5mg, 300mg; 7.5mg


MO

hydrocodone/acetaminophen tabs 750mg; 7.5mg 3 QL (150 EA per 30 days)

MO

hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg;

7.5mg, 660mg; 10mg


MO


2.5mg, 500mg; 5mg, 500mg; 7.5mg


MO


5mg, 325mg; 7.5mg


MO

hydromorphone hcl inj 3 MO

hydromorphone hcl tabs 8mg 3 QL (240 EA per 30 days)

MO

hydromorphone hcl tabs 2mg, 4mg 3 QL (360 EA per 30 days)

MO

INFUMORPH 200 4 MO



INFUMORPH 500 4 MO

levorphanol tartrate 3 MO

methadone hcl 3 MO

methadone hcl intensol 3 MO

METHADOSE SUGAR-FREE 3 MO

METHADOSE CONC 3 MO

methadose tabs 3 MO

morphine sulfate 3 MO

morphine sulfate er 3 MO

oxycodone hcl 3 MO

oxycodone/acetaminophen caps 3 QL (240 EA per 30 days)

MO

oxycodone/acetaminophen tabs 650mg; 10mg 3 QL (180 EA per 30 days)

MO

oxycodone/acetaminophen tabs 500mg; 7.5mg 3 QL (240 EA per 30 days)

MO

oxycodone/acetaminophen tabs 325mg; 10mg, 325mg;

2.5mg, 325mg; 5mg, 325mg; 7.5mg


MO

ROXICET TABS 500MG; 5MG 3 QL (240 EA per 30 days)

MO

roxicet tabs 325mg; 5mg 3 QL (360 EA per 30 days)

MO

tramadol hcl 2 QL (240 EA per 30 days)

MO

tramadol hydrochloride/acetaminophen 3 QL (240 EA per 30 days)

MO

OPIATE ANTAGONISTS

naloxone hcl 2 MO

naltrexone hcl 2 MO

OPIATE PARTIAL AGONISTS

buprenorphine hcl subl 3 QL (90 EA per 30 days)

PA MO

buprenorphine hcl inj 4 QL (240 ML per 30 days)

PA MO

butorphanol tartrate nasal soln 3 QL (5 ML per 28 days)

MO

butorphanol tartrate inj 2mg/ml 3 QL (480 ML per 30 days)

MO

butorphanol tartrate inj 1mg/ml 3 QL (960 ML per 30 days)

MO

nalbuphine hcl 3 MO

SELECTIVE SEROTONIN AGONISTS

ALSUMA 4 QL (6 ML per 30 days)

MO

naratriptan hcl 3 QL (9 EA per 30 days)

MO

sumatriptan 3 QL (12 EA per 30 days)

MO

sumatriptan succinate refill 3 QL (6 ML per 30 days)

MO

sumatriptan succinate tabs 2 QL (9 EA per 30 days)



MO

sumatriptan succinate inj 3 QL (6 ML per 30 days)

MO

SUCCINIMIDES

CELONTIN 4 MO

ethosuximide 3 MO

Devices

Devices

bd insulin syringe safetyglide/1ml/29g x 1/2" 1 MO

bd insulin syringe ultrafine/0.3ml/31g x 5/16" 1 MO

bd insulin syringe ultrafine/0.5ml/30g x 1/2" 1 MO

bd insulin syringe ultrafine/1ml/31g x 5/16" 1 MO

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS

ammonium chloride 1 MO

ALKALINIZING AGENTS

potassium citrate 3 MO

sodium bicarbonate inj 7.5%, 8.4% 2 MO

sodium lactate 1 MO

UROCIT-K 10 4 MO

UROCIT-K 5 4 MO

AMMONIA DETOXICANTS

BUPHENYL 4 MO

CARBAGLU 4 PA MO

enulose 2 MO

generlac 2 MO

lactulose 2 MO

CALORIC AGENTS

AMINOSYN 4 B/D MO

AMINOSYN 8.5%/ELECTROLYTES 4 B/D MO

AMINOSYN II 4 B/D MO

AMINOSYN II 8.5%/ELECTROLYTES 4 B/D MO

AMINOSYN M 4 B/D MO

AMINOSYN-HBC 4 B/D MO

AMINOSYN-PF 4 B/D MO

AMINOSYN-PF 7% 4 B/D MO

CLINIMIX 2.75%/DEXTROSE 5% 4 B/D MO





CLINIMIX 5%/DEXTROSE 15% 4 B/D MO



CLINIMIX E 2.75%/DEXTROSE 10% 4 B/D MO




CLINIMIX E 5%/DEXTROSE 15% 4 B/D MO





dextrose 10%/nacl 0.45% 1 MO

dextrose 10% 2 MO

dextrose 10% flex container 2 MO



dextrose 2.5%/nacl 0.45% 2 MO

dextrose 2.5%/sodium chloride 0.45% 2 MO

dextrose 5% 2 MO

dextrose 5% viaflex 2 MO







dextrose 5%/sodium chloride 0.2% 2 MO




dextrose thermoject system 2 MO

FREAMINE III 3% 4 B/D MO

FREAMINE III INJ 72MEQ/L; 600MG/100ML;

810MG/100ML; 3MEQ/L; 14MG/100ML;

1190MG/100ML; 240MG/100ML; 590MG/100ML;

770MG/100ML; 620MG/100ML; 450MG/100ML;

480MG/100ML; 10MMOLE/L; 115MG/100ML;

950MG/100ML; 500MG/100ML; 10MEQ/L;

340MG/100ML; 130MG/100ML; 560MG/100ML

4 B/D MO

HEPATAMINE 4 B/D MO

HEPATASOL 4 B/D MO

INTRALIPID 4 B/D MO

LIPOSYN II 4 B/D MO

LIPOSYN III 4 B/D MO

NEPHRAMINE 4 B/D MO

PREMASOL 1 B/D MO

PROCALAMINE 4 B/D MO

TRAVASOL 4 B/D MO

TROPHAMINE 4 B/D MO

IRRIGATING SOLUTIONS

lactated ringers irrigation 2 MO

PHYSIOLYTE 1 MO

PHYSIOSOL IRRIGATION 1 MO

PHYSIOSOL IRRIGATION PH 7.4 1 MO

ringers irrigation 1 MO

sodium chloride 2 MO

sodium chloride 0.9% 2 MO


sterile water irrigation 2 MO

sterile water irrigation plastic bottle 2 MO

sterile water irrigation w/hanger 2 MO

PHOSPHATE-REMOVING AGENTS



calcium acetate 3 MO

eliphos 2 MO

PHOSLYRA 4 MO

RENVELA TABS 3 QL (540 EA per 30 days)

MO

RENVELA PACK 2.4GM 3 QL (180 EA per 30 days)

MO

RENVELA PACK 0.8GM 3 QL (540 EA per 30 days)

MO

POTASSIUM-REMOVING AGENTS

kalexate 4 MO

kionex 3 MO

sodium polystyrene sulfonate 3 MO

REPLACEMENT PREPARATIONS

dextrose 5% /electrolyte #48 viaflex 2 MO

dextrose 5%/potassium chloride 0.15% 2 MO

IONOSOL-B/DEXTROSE 5% 4 MO

IONOSOL-MB/DEXTROSE 5% 4 MO

ISOLYTE-H/DEXTROSE 5% 4 MO

ISOLYTE-M/DEXTROSE 5% 4 MO

ISOLYTE-P/DEXTROSE 5% 4 MO

ISOLYTE-S 4 MO

ISOLYTE-S/DEXTROSE 5% 4 MO

kcl 0.075%/d5w/nacl 0.2% 2 MO

kcl 0.075%/d5w/nacl 0.45% 2 MO

kcl 0.15%/d5w/ nacl 0.3% 2 MO

kcl 0.15%/d5w/lr 2 MO

kcl 0.15%/d5w/nacl 0.2% 2 MO

kcl 0.15%/d5w/nacl 0.225% 2 MO

kcl 0.15%/d5w/nacl 0.45% 2 MO

kcl 0.15%/d5w/nacl 0.9% 2 MO

kcl 0.3%/d5w/lr 2 MO

kcl 0.3%/d5w/lr iv lac ring 2 MO

kcl 0.3%/d5w/nacl 0.2% 2 MO

kcl 0.3%/d5w/nacl 0.45% 2 MO

kcl 0.3%/d5w/nacl 0.9% 2 MO

KLOR-CON 10 2 MO

KLOR-CON 8 2 MO

klor-con m10 2 MO

klor-con m15 2 MO

klor-con m20 2 MO

lactated ringers 2 MO

lactated ringers viaflex 2 MO

MICRO-K 4 MO

NORMOSOL -R 4 MO

NORMOSOL-M IN D5W 4 MO

NORMOSOL-R 4 MO

NORMOSOL-R IN D5W 4 MO

nutrilyte ii 4 MO

PLASMA-LYTE A 4 MO

PLASMA-LYTE-148 4 MO



PLASMA-LYTE-56/D5W 4 MO

potassium chloride 0.075%/d5w/nacl 0.225% 2 MO

potassium chloride 0.15% /nacl 0.45% viaflex 2 MO

potassium chloride 0.15% d5w/nacl 0.33% 2 MO


potassium chloride 0.15% d5w/nacl 0.45% viaflex 2 MO

potassium chloride 0.15% nacl 0.9% 2 MO

potassium chloride 0.15% w/nacl 0.9% viaflex 2 MO

potassium chloride 0.15%/d5w 2 MO

potassium chloride 0.15%/nacl 0.9% 2 MO



potassium chloride 0.224%/d5w/nacl 0.45% 2 MO

potassium chloride 0.224%/dextrose 5% viaflex 2 MO

potassium chloride 0.224%d5w/nacl 0.45% viaflex 2 MO

potassium chloride 0.3%/ nacl 0.9% 2 MO


potassium chloride 0.3%/d5w/viaflex 2 MO

potassium chloride 0.3%/nacl 0.9%/viaflex 2 MO

potassium chloride cr 2 MO

potassium chloride er 2 MO

potassium chloride sr 2 MO

potassium chloride inj 0.4meq/ml, 10meq/100ml,

10meq/50ml, 2meq/ml, 30meq/100ml

1 MO

ringers injection 1 MO


sodium chloride 0.45% viaflex 2

sodium chloride pab 2 MO

sodium chloride inj 0.9%, 2.5meq/ml 2

sodium chloride inj 3%, 5% 2 MO

TPN ELECTROLYTES 4 MO

URICOSURIC AGENTS

probenecid 2 MO

probenecid/colchicine 2 MO

VASOPRESSIN ANTAGONISTS

SAMSCA 4 QL (60 EA per 30 days)

MO

ENZYMES

ENZYMES

ADAGEN 4 MO

ALDURAZYME 4 QL (480 ML per 28 days)

PA MO

CEREDASE 4 PA MO

CEREZYME INJ 200UNIT 4 PA MO

ELAPRASE 4 PA MO

ELITEK INJ 1.5MG 4 PA MO

FABRAZYME INJ 35MG 4 PA MO

LUMIZYME 4 PA MO

MYOZYME 4 PA MO

NAGLAZYME 4 QL (480 ML per 28 days)

PA MO



PULMOZYME 4 QL (150 ML per 30 days)

B/D MO

SUCRAID 4 MO

VPRIV 4 PA MO

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

ALPHA-ADRENERGIC AGONISTS (EENT)

brimonidine tartrate 3 MO

ANTIALLERGIC AGENTS

azelastine hcl 3 MO

ELESTAT 4 MO

epinastine hcl 3 MO

PATADAY 3 MO

ANTIBACTERIALS (EENT)

ak-poly-bac 2 MO

AZASITE 3 MO

bacitracin 2 MO

bacitracin/polymyxin b 2 MO

BESIVANCE 3 MO

BLEPHAMIDE 4 MO

BLEPHAMIDE S.O.P. 4 MO

ciprofloxacin hcl 1 MO

doxycycline hyclate 2 MO

erythromycin 2 MO

GARAMYCIN 3 MO

gentak 3 MO

gentamicin sulfate 2 MO

ILOTYCIN 3 MO

levofloxacin 2 MO

MAXITROL 3 MO

MOXEZA 4 MO

neo-polycin 2 MO

neomycin/bacitracin/polymyxin 2 MO

neomycin/polymyxin/bacitracin zinc 2 MO

neomycin/polymyxin/bacitracin/hydrocortisone 2 MO

neomycin/polymyxin/dexamethasone 2 MO

neomycin/polymyxin/gramicidin 2 MO

neomycin/polymyxin/hc 2 MO

neomycin/polymyxin/hydrocortisone 2 MO

neosporin 2 MO

ofloxacin 2 MO

poly-dex 1 MO

polymyxin b sulfate/trimethoprim sulfate 2 MO

POLYTRIM 2 MO

PRED-G 4 MO

PRED-G S.O.P. 4 MO

romycin 1 MO

sodium sulfacetamide 2 MO

sulfacetamide sodium/prednisolone sodium phosphate 2 MO

sulfacetamide sodium soln 2 MO

sulfacetamide sodium oint 3 MO

TOBRADEX 4 MO



TOBRADEX ST 4 MO

tobramycin sulfate 2 MO

tobramycin/dexamethasone 3 MO

TOBREX 4 MO

trimethoprim sulfate/polymyxin b sulfate 2 MO

VIGAMOX 4 MO

ZYMAXID 4 QL (2.5 ML per 25 days)

MO

ANTIFUNGALS (EENT)

NATACYN 4 MO

ANTIVIRALS (EENT)

trifluridine 3 MO

ZIRGAN 4 QL (5 GM per 30 days)

MO

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

betaxolol hcl 3 MO

BETIMOL 4 MO

dorzolamide hcl/timolol maleate 3 QL (10 ML per 30 days)

MO

levobunolol hcl 2 MO

metipranolol 2 MO

timolol maleate 2 MO

timolol maleate ophthalmic gel forming 3 MO

TIMOPTIC OCUDOSE 4 MO

CARBONIC ANHYDRASE INHIBITORS (EENT)

AZOPT 3 MO

dorzolamide hcl 3 QL (10 ML per 30 days)

MO

methazolamide 3 MO

CORTICOSTEROIDS (EENT)

dexamethasone sodium phosphate 2 MO

DUREZOL 3 MO

fluorometholone 2 MO

FML 4 MO

FML FORTE 4 MO

PRED MILD 4 MO

prednisolone acetate 2 MO

prednisolone sodium phosphate 2 MO

EENT ANTI-INFECTIVES, MISCELLANEOUS

acetasol hc 3 MO

acetic acid 2 MO

chlorhexadine gluconate oral rinse 1 MO

chlorhexidine gluconate 1 MO

chlorhexidine gluconate oral rinse 1 MO

hydrocortisone/acetic acid 3 MO

PERIDEX 4 MO

periogard 1 MO

EENT ANTI-INFLAMMATORY AGENTS, MISC

RESTASIS 3 QL (60 EA per 30 days)

MO

EENT DRUGS, MISCELLANEOUS



apraclonidine 3 MO

carteolol hcl 2 MO

ipratropium bromide nasal soln 0.03% 2 QL (30 ML per 30 days)

MO

ipratropium bromide nasal soln 0.06% 2 QL (45 ML per 30 days)

MO

LACRISERT 4 MO

EENT NONSTEROIDAL ANTI-INFLAM AGENTS

diclofenac sodium 2 MO

flurbiprofen sodium 2 MO

ketorolac tromethamine 2 MO

LOCAL ANESTHETICS (EENT)

lidocaine hcl 2 MO

lidocaine hcl jelly 1 MO

lidocaine viscous 2 MO

proparacaine hcl 1 MO

MIOTICS

PHOSPHOLINE IODIDE 4 MO

pilocarpine hcl soln 1%, 2% 2 MO

pilocarpine hcl soln 4% 3 MO

PILOPINE HS 4 MO

MYDRIATICS

mydral 1 MO

tropicamide 1 MO

PROSTAGLANDIN ANALOGS

latanoprost 2 QL (3 ML per 25 days)

MO

LUMIGAN 3 QL (3 ML per 25 days)

MO

TRAVATAN Z 3 QL (3 ML per 25 days)

MO

VASOCONSTRICTORS

ak-con 1 MO

TYZINE 3 MO

TYZINE PEDIATRIC NASAL DROPS 3 MO

GASTROINTESTINAL DRUGS

5-HT3 RECEPTOR ANTAGONISTS

granisetron hcl tabs 3 QL (28 EA per 28 days)

B/D MO

granisetron hcl inj 0.1mg/ml 3 MO

granisetron hcl inj 1mg/ml 3 QL (4 ML per 28 days)

ondansetron hcl oral soln 3 QL (450 ML per 30 days)

B/D MO

ondansetron hcl inj 4mg/2ml 3

ondansetron hcl inj 40mg/20ml 3 MO

ondansetron hcl tabs 24mg 3 QL (30 EA per 30 days)

B/D MO

ondansetron hcl tabs 4mg, 8mg 3 QL (90 EA per 30 days)

B/D MO

ondansetron odt 2 QL (90 EA per 30 days)

B/D MO



SANCUSO 4 QL (4 EA per 30 days)

MO

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

APRISO 3 QL (120 EA per 30 days)

MO

balsalazide disodium 3 MO

CANASA 3 QL (30 EA per 30 days)

MO

LIALDA 4 QL (120 EA per 30 days)

MO

LOTRONEX 4 QL (60 EA per 30 days)

MO

mesalamine enem 2 QL (1800 ML per 30 days)

MO

mesalamine kit 3 QL (1800 EA per 30 days)

MO

Antidiarrhea Agents

LOMOTIL 4 PA MO

loperamide hcl caps 2 MO

ANTIEMETICS, MISCELLANEOUS

dronabinol caps 2.5mg, 5mg 3 QL (120 EA per 30 days)

B/D MO

dronabinol caps 10mg 4 QL (120 EA per 30 days)

B/D MO

EMEND CAPS 125MG, 40MG 4 QL (2 EA per 28 days)

B/D MO

EMEND CAPS 80MG 4 QL (4 EA per 28 days)

B/D MO

EMEND CAPS 0 4 QL (6 EA per 28 days)

B/D MO

ANTIHISTAMINES (GI DRUGS)

ANTIVERT 4 PA MO

trimethobenzamide hcl 3 B/D MO

CATHARTICS AND LAXATIVES

AMITIZA 3 MO

gavilyte-c 2 MO

gavilyte-g 2 MO

gavilyte-n/flavor pack 2 MO

GOLYTELY 3 MO

HALFLYTELY BOWEL PREP/FLAVOR PACKS 3 MO

MOVIPREP 4 MO

NULYTELY/FLAVOR PACKS 3 MO

OSMOPREP 4 MO

peg 3350/electrolytes 2 MO

peg-3350/electrolytes 2 MO

peg-3350/nacl/na bicarbonate/kcl 2 MO

polyethylene glycol 3350 powd 2 MO

SUPREP BOWEL PREP 3 MO

trilyte 2 MO

CHOLELITHOLYTIC AGENTS

ursodiol 3 MO



DIGESTANTS

CREON 3 MO

PANCREAZE 4 MO

ZENPEP 3 MO

GI DRUGS, MISCELLANEOUS

CIMZIA INJ 200MG/ML 4 QL (6 EA per 30 days) PA

CIMZIA INJ 200MG 4 QL (6 EA per 30 days) PA

MO

RELISTOR INJ 12MG/0.6ML 4 QL (28 EA per 28 days)

PA MO

HISTAMINE H2-ANTAGONISTS

cimetidine 2 MO

cimetidine hcl 2 MO

famotidine 2 MO

famotidine premixed 2 MO

nizatidine 2 MO

ranitidine hcl caps 300mg 2 MO

ranitidine hcl caps 150mg 3 MO

ranitidine hcl inj 1 MO

ranitidine hcl syrp, tabs 2 MO

PROKINETIC AGENTS

metoclopramide hcl 2 MO

PROSTAGLANDINS

misoprostol 2 MO

PROTECTANTS

sucralfate 2 MO

PROTON-PUMP INHIBITORS

lansoprazole 3 QL (30 EA per 30 days)

MO

omeprazole cpdr 10mg, 40mg 2 QL (30 EA per 30 days)

MO

omeprazole cpdr 20mg 2 QL (60 EA per 30 days)

MO

pantoprazole sodium 1 QL (30 EA per 30 days)

MO

PROTONIX 3 MO

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA 4 MO

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CHEMET 4 MO

CUPRIMINE 4 MO

EXJADE 3 PA MO

SYPRINE 4 MO

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

a-hydrocort 1 MO

a-methapred 2 MO

baycadron 1 MO



BUDESONIDE 4 MO

cortisone acetate 2 MO

dexamethasone intensol 3 MO

dexamethasone sodium phosphate inj 4mg/ml 2 MO

dexamethasone elix 2 MO

dexamethasone tabs 6mg 1 MO

dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg,

4mg

2 MO

ENTOCORT EC 4 MO

fludrocortisone acetate 2 MO

hydrocortisone 2 MO

methylprednisolone 2 MO

methylprednisolone acetate 1 MO

methylprednisolone dose pack 2 MO

methylprednisolone sodiumsuccinate inj 1gm 2 MO

ORAPRED ODT TBDP 15MG, 30MG 4 MO

prednisolone sodium phosphate 2 MO

prednisone 1 MO

prednisone intensol 3 MO

SOLU-CORTEF INJ 100MG, 250MG 4 MO

SOLU-MEDROL 4 MO

VERIPRED 20 4 MO

ALPHA-GLUCOSIDASE INHIBITORS

acarbose 3 MO

GLYSET 4 MO

AMYLINOMIMETICS

SYMLINPEN 120 4 QL (11 ML per 30 days)

PA MO

SYMLINPEN 60 4 QL (11 ML per 30 days)

PA MO

ANDROGENS

ANADROL-50 4 MO

ANDROGEL PUMP GEL 1.62% 3 QL (176 GM per 30 days)

MO

ANDROGEL GEL 50MG/5GM 3 QL (300 GM per 30 days)

MO

androxy 4 MO

danazol 3 MO

oxandrolone tabs 2.5mg 3 QL (120 EA per 30 days)

MO

oxandrolone tabs 10mg 4 QL (60 EA per 30 days)

MO

testosterone cypionate inj 100mg/ml 2 MO

testosterone cypionate inj 200mg/ml 3 MO

testosterone enanthate 3 MO

ANTITHYROID AGENTS

methimazole 2 MO

propylthiouracil 2 MO

BIGUANIDES

glipizide/metformin hcl 3 MO

glyburide/metformin hcl 2 MO



JANUMET 3 QL (60 EA per 30 days)

MO

metformin hcl 1 MO

metformin hcl er tb24 500mg 1 QL (120 EA per 30 days)

MO

metformin hcl er tb24 1000mg, 750mg 1 QL (60 EA per 30 days)

MO

CONTRACEPTIVES

altavera 4 MO

amethia lo 4 QL (91 EA per 90 days)

MO

apri 4 MO

aranelle 4 MO

aviane 4 MO

azurette 4 MO

camila 4 MO

camrese lo 4 QL (91 EA per 90 days)

MO

caziant 4 MO

cryselle-28 4 MO

cyclafem 1/35 4 MO

cyclafem 7/7/7 4 MO

emoquette 4 MO

enpresse-28 4 MO

errin 4 MO

FEMCON FE 4 MO

gianvi 4 MO

gildess fe 1.5/30 4 MO

gildess fe 1/20 4 MO

heather 4 MO

introvale 4 QL (91 EA per 90 days)

MO

junel 1.5/30 4 MO

junel 1/20 4 MO

junel fe 1.5/30 4 MO

junel fe 1/20 4 MO

kariva 4 MO

kelnor 1/35 4 MO

lessina-28 4 MO

levonorgestrel 3 MO

levonorgestrel and ethinyl estradiol 4 QL (91 EA per 90 days)

MO

levora 0.15/30-28 4 MO

loryna 4 MO

LOSEASONIQUE 4 QL (91 EA per 90 days)

MO

low-ogestrel 4 MO

lutera 4 MO

MARLISSA 4 MO

microgestin 1.5/30 4 MO

microgestin 1/20 4 MO



microgestin fe 4 MO

microgestin fe 1.5/30 4 MO

necon 0.5/35-28 4 MO

necon 1/35-28 4 MO

necon 10/11-28 4 MO

next choice 3 MO

norethindrone 4 MO

norgestimate/ethinyl estradiol tabs 0; 0 4 MO

norgestrel/ethinyl estradiol 4 MO

nortrel 0.5/35 (28) 4 MO

nortrel 1/35 (21) 4 MO

nortrel 1/35 (28) 4 MO

nortrel 7/7/7 4 MO

ogestrel 4 MO

orsythia 4 MO

PLAN B 4 MO

portia-28 4 MO

previfem 4 MO

quasense 4 QL (91 EA per 90 days)

MO

reclipsen 4 MO

sprintec 28 2 MO

sronyx 4 MO

syeda 4 MO

tilia fe 4 MO

tri-legest fe 4 MO

tri-previfem 4 MO

tri-sprintec 3 MO

trinessa 4 MO

trivora-28 4 MO

velivet 4 MO

vestura 2 MO

wymzya fe 4 MO

zarah 4 MO

zenchent fe 4 MO

zeosa 4 MO

zovia 1/35e 4 MO

zovia 1/50e 4 MO

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

JANUMET XR TB24 1000MG; 100MG 3 QL (30 EA per 30 days)

ST MO

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG 3 QL (60 EA per 30 days)

ST MO

JANUVIA 3 QL (30 EA per 30 days)

MO

onglyza 3 QL (30 EA per 30 days)

ST MO

ESTROGEN AGONIST-ANTAGONISTS

EVISTA 3 QL (30 EA per 30 days)

MO

ESTROGENS



DEPO-ESTRADIOL 2 MO

estradiol valerate 3 MO

estradiol/norethindrone acetate 3 MO

estradiol tabs 2 MO

estradiol ptwk 2 QL (4 EA per 28 days)

MO

EVAMIST 4 MO

jevantique 3 MO

jinteli 3 MO

mimvey 2 MO

PREMARIN 3 MO

GLYCOGENOLYTIC AGENTS

GLUCAGEN HYPOKIT 3 MO

GLUCAGON EMERGENCY KIT 4 MO

GONADOTROPINS

chorionic gonadotropin 4 MO

SYNAREL 4 MO

INCRETIN MIMETICS

BYETTA 4 QL (3 ML per 30 days) PA

MO

victoza 3 QL (9 ML per 30 days) PA

MO

INSULINS

HUMALOG 3 QL (240 ML per 30 days)

MO

HUMALOG KWIKPEN 3 MO

HUMALOG MIX 50/50 3 MO

HUMALOG MIX 50/50 KWIKPEN 3 MO

HUMALOG MIX 75/25 3 MO

HUMALOG MIX 75/25 KWIKPEN 3 MO

HUMULIN 70/30 3 MO

HUMULIN 70/30 PEN 3 MO

HUMULIN N 3 MO

HUMULIN N U-100 PEN 3 MO

HUMULIN R 3 MO

HUMULIN R U-500 (CONCENTRATED) 3 MO

LANTUS 3 MO

LANTUS SOLOSTAR 3 MO

LEVEMIR 3 MO

LEVEMIR FLEXPEN 3 MO

NOVOLIN 70/30 3 MO

NOVOLIN N 3 MO

NOVOLIN R 3 MO

NOVOLOG 3 MO

NOVOLOG FLEXPEN 3 MO

NOVOLOG MIX 70/30 3 MO

NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3 MO

MEGLITINIDES

nateglinide 3 MO

PRANDIN 4 MO

PARATHYROID



calcitonin-salmon 3 QL (4 ML per 28 days)

B/D MO

FORTEO 4 QL (2.4 ML per 28 days)

ST MO

FORTICAL 4 QL (4 ML per 28 days)

B/D MO

Pituitary

DDAVP 4 PA MO

desmopressin acetate 3 MO

OMNITROPE INJ 10MG/1.5ML, 5MG/1.5ML 4 PA

OMNITROPE INJ 5.8MG 4 PA MO

SAIZEN CLICK.EASY 4 PA

SAIZEN INJ 5MG 4 PA

SAIZEN INJ 8.8MG 4 PA MO

SEROSTIM INJ 5MG 4 PA

SEROSTIM INJ 4MG, 6MG 4 PA MO

PROGESTINS

CRINONE GEL 8% 4 MO

ENDOMETRIN 4 MO

medroxyprogesterone acetate tabs 2 MO

medroxyprogesterone acetate inj 2 QL (1 ML per 90 days)

MO

norethindrone acetate 3 MO

progesterone caps 3 MO

SOMATOTROPIN AGONISTS

EGRIFTA 4 QL (60 EA per 30 days)

PA MO

INCRELEX 4 PA MO

SOMATOTROPIN ANTAGONISTS

SOMAVERT 4 QL (60 EA per 30 days)

PA MO

SULFONYLUREAS

glimepiride 1 MO

glipizide 1 MO

glipizide er 2 MO

glipizide xl 2 MO

glyburide 2 MO

glyburide micronized 2 MO

tolazamide 3 MO

tolbutamide 3 MO

THIAZOLIDINEDIONES

ACTOS 4 QL (30 EA per 30 days)

MO

THYROID AGENTS

CYTOMEL 4 MO

LEVOTHROID 1 MO

levothyroxine sodium 1 MO

LEVOXYL 3 MO

liothyronine sodium tabs 2 MO

liothyronine sodium inj 3 MO

SYNTHROID 3 MO



UNITHROID 2 MO

LOCAL ANESTHETICS

LOCAL ANESTHETICS (PARENTERAL)

lidocaine hcl 1 MO

Miscellaneous Therapeutic Agents

5-alpha-Reductase Inhibitors

avodart 3 QL (30 EA per 30 days)

MO

finasteride 3 QL (30 EA per 30 days)

MO

ANTIDOTES

ANTIZOL 4 MO

fomepizole 1 MO

FUSILEV 4 PA MO

leucovorin calcium tabs 2 MO

leucovorin calcium inj 100mg, 350mg 2 B/D MO

ANTIGOUT AGENTS

allopurinol 1 MO

allopurinol sodium 1 MO

COLCRYS 3 QL (120 EA per 30 days)

MO

BIOLOGIC RESPONSE MODIFIERS

ACTIMMUNE 4 PA MO

AVONEX INJ 30MCG/0.5ML 4 QL (4 EA per 28 days) PA

AVONEX INJ 30MCG/VIAL 4 QL (4 EA per 28 days) PA

MO

BETASERON 4 QL (15 EA per 30 days)

PA

COPAXONE 4 QL (30 EA per 30 days)

PA MO

REBIF 4 QL (12 ML per 30 days)

PA MO

REBIF TITRATION PACK 4 QL (12 ML per 30 days)

PA MO

THALOMID CAPS 100MG, 50MG 3 QL (30 EA per 30 days)

PA MO

THALOMID CAPS 200MG 4 QL (30 EA per 30 days)

PA MO

THALOMID CAPS 150MG 4 QL (60 EA per 30 days)

PA MO

BONE RESORPTION INHIBITORS

ACTONEL TABS 150MG 4 QL (2 EA per 30 days)

MO

ACTONEL TABS 30MG, 5MG 4 QL (30 EA per 30 days)

MO

ACTONEL TABS 35MG 4 QL (4 EA per 28 days)

MO

alendronate sodium tabs 10mg, 40mg, 5mg 1 QL (30 EA per 30 days)

MO

alendronate sodium tabs 35mg, 70mg 1 QL (4 EA per 28 days)

MO



ATELVIA 4 QL (4 EA per 28 days)

MO

etidronate disodium 3 MO

ibandronate sodium 4 QL (1 EA per 28 days)

MO

pamidronate disodium inj 30mg/10ml, 6mg/ml,

90mg/10ml

3 B/D MO

pamidronate disodium inj 90mg 3 B/D MO

pamidronate disodium inj 30mg 3 B/D MO

PROLIA 4 QL (60 ML per 180 days)

PA MO

RECLAST 4 QL (100 ML per 365 days)

PA MO

XGEVA 4 QL (1.7 ML per 28 days)

PA MO

ZOMETA INJ 4MG/5ML 4 QL (15 ML per 21 days)

PA MO

COMPLEMENT INHIBITORS

FIRAZYR 4 QL (9 ML per 30 days) PA

MO

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ENBREL INJ 25MG 4 QL (8 EA per 28 days) PA

MO

ENBREL INJ 50MG/ML 4 QL (8 ML per 28 days) PA

ENBREL INJ 25MG/0.5ML 4 QL (8 ML per 28 days) PA

MO

HUMIRA PEN 4 QL (6 EA per 28 days) PA

MO

HUMIRA PEN-CROHNS DISEASESTARTER 4 QL (6 EA per 28 days) PA

HUMIRA PEN-PSORIASIS STARTER 4 QL (6 EA per 28 days) PA

MO

HUMIRA INJ 40MG/0.8ML 4 QL (6 EA per 28 days) PA

HUMIRA INJ 20MG/0.4ML 4 QL (6 EA per 28 days) PA

MO

leflunomide 2 QL (30 EA per 30 days)

MO

REMICADE 4 PA MO

IMMUNOSUPPRESSIVE AGENTS

azathioprine 2 B/D MO

azathioprine sodium 1 B/D MO

BENLYSTA INJ 120MG 4 QL (30 EA per 28 days)

PA MO

CELLCEPT 4 B/D MO

CELLCEPT INTRAVENOUS 4 B/D MO

cyclosporine 3 B/D MO

cyclosporine modified caps 100mg 2 B/D MO

cyclosporine modified caps 25mg 3 B/D MO

gengraf 3 B/D

mycophenolate mofetil 2 B/D MO

MYFORTIC 3 B/D MO

NULOJIX 4 QL (20 EA per 30 days)



PA MO

PROGRAF INJ 4 B/D MO

RAPAMUNE 4 B/D MO

SIMULECT INJ 20MG 4 B/D MO

tacrolimus 2 B/D MO

THYMOGLOBULIN 3 B/D MO

ZORTRESS 4 QL (60 EA per 30 days)

B/D MO

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

AMPYRA 4 QL (60 EA per 30 days)

PA MO

ARCALYST 4 PA MO

CARNITOR INJ 3 B/D MO

CYSTADANE 4 MO

CYSTAGON 4 MO

DEMSER 4 MO

KUVAN 4 PA MO

levocarnitine 3 B/D MO

octreotide acetate inj 500mcg/ml, 50mcg/ml 3 PA

octreotide acetate inj 100mcg/ml 4 PA

octreotide acetate inj 1000mcg/ml, 200mcg/ml 4 PA MO

ORFADIN 4 MO

SANDOSTATIN LAR DEPOT 4 PA MO

SANDOSTATIN INJ 100MCG/ML, 500MCG/ML,

50MCG/ML

4 PA

SANDOSTATIN INJ 1000MCG/ML, 200MCG/ML 4 PA MO

SENSIPAR TABS 30MG 3 QL (60 EA per 30 days)

MO


MO


MO

SOMATULINE DEPOT 4 QL (1 ML per 28 days) PA

MO

ZAVESCA 4 QL (90 EA per 30 days)

MO

PROTECTIVE AGENTS

amifostine 3 B/D MO

dexrazoxane inj 500mg 3 B/D

dexrazoxane inj 250mg 3 B/D MO

ETHYOL 4 B/D MO

mesna 4 B/D MO

MESNEX INJ 4 B/D MO

MESNEX TABS 4 MO

TOTECT 4 MO

OXYTOCICS

OXYTOCICS

METHERGINE 4 MO

methylergonovine maleate tabs 3 MO

Pharmaceutical Aids

Pharmaceutical Aids



curity gauze pads 2"x2" 1 MO

RESPIRATORY TRACT AGENTS

CORTICOSTEROIDS (RESPIRATORY TRACT)

ASMANEX 120 METERED DOSES 3 QL (0.24 EA per 28 days)

MO


MO

ASMANEX 30 METERED DOSES AEPB

110MCG/INH

3 QL (0.13 EA per 28 days)

MO

ASMANEX 30 METERED DOSES AEPB

220MCG/INH

3 QL (0.24 EA per 28 days)

MO


MO

budesonide susp 0.25mg/2ml 2 B/D MO

budesonide susp 0.5mg/2ml 3 B/D MO

DULERA 3 QL (13 GM per 30 days)

MO

flunisolide 3 QL (50 ML per 30 days)

MO

fluticasone propionate 2 QL (16 GM per 30 days)

MO

NASONEX 3 QL (34 GM per 30 days)

MO

QVAR AERS 80MCG/ACT 3 QL (22 GM per 30 days)

MO

QVAR AERS 40MCG/ACT 3 QL (37 GM per 30 days)

MO

VERAMYST 4 QL (10 GM per 30 days)

MO

LEUKOTRIENE MODIFIERS

SINGULAIR 4 QL (30 EA per 30 days)

MO

zafirlukast 3 QL (60 EA per 30 days)

MO

MAST-CELL STABILIZERS

cromolyn sodium nebu 2 B/D MO

cromolyn sodium conc, soln 2 MO

MUCOLYTIC AGENTS

acetylcysteine 2 B/D MO

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

ARALAST NP INJ 400MG 4 PA

ARALAST NP INJ 1000MG, 500MG, 800MG 4 PA MO

GLASSIA 4 PA MO

KALYDECO 4 QL (60 EA per 30 days)

PA MO

PROLASTIN-C 4 PA

PROLASTIN INJ 500MG 4 PA

PROLASTIN INJ 1000MG 4 PA MO

XOLAIR 4 QL (900 EA per 28 days)

PA MO

ZEMAIRA 4 PA



XANTHINE DERIVATIVES

aminophylline 2 MO

LUFYLLIN 4 MO

SERUMS, TOXOIDS, AND VACCINES

SERUMS

carimune nanofiltered 4 PA MO

flebogamma 4 PA MO

FLEBOGAMMA DIF INJ 10% 4 PA MO

flebogamma dif inj 0.5gm/10ml, 20gm/400ml, 5% 4 PA MO

GAMMAGARD LIQUID INJ 0 4 PA MO

gammagard liquid inj 0 4 PA

gammagard liquid inj 0 4 PA MO

gammaplex inj 10gm/200ml 4 PA

gammaplex inj 2.5gm/50ml, 5gm/100ml 4 PA MO

GAMUNEX INJ 10% 4 PA

GAMUNEX INJ 10% 4 PA MO

HIZENTRA 4 PA MO

privigen inj 20gm/200ml 4 PA

privigen inj 10gm/100ml, 5gm/50ml 4 PA MO

TOXOIDS

ADACEL 4

BOOSTRIX 4

DAPTACEL 4 MO

DECAVAC 4

diphtheria/tetanus toxoid pediatric 4 MO

INFANRIX 4

TENIVAC 4 MO

tetanus/diphtheria toxoids-adsorbed adult 4 MO

TRIPEDIA 4 MO

VACCINES

ACTHIB 4

CERVARIX 4 MO

COMVAX 4 MO

ENGERIX-B 4 B/D

GARDASIL 4 QL (3 ML per 365 days)

HAVRIX 4

HIBERIX 4 MO

IPOL INACTIVATED IPV 4

IXIARO 4 MO

JE-VAX 4 MO

M-M-R II W/DILUENT 10 DOSE 4 MO

MENACTRA 4

MENOMUNE-A/C/Y/W-135 4

MENVEO 4 MO

PEDVAX HIB 4 MO

PROQUAD 4 MO

RABAVERT 3 B/D MO

RECOMBIVAX HB INJ 10MCG/ML 4 B/D

RECOMBIVAX HB INJ 40MCG/ML 4 B/D MO

ROTATEQ 4 MO

TWINRIX 4



TYPHIM VI 4

VAQTA 4 MO

VARIVAX 3 MO

YF-VAX 4 MO

ZOSTAVAX 4 QL (1 EA per 365 days)

MO

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFLAMMATORY AGENTS (SKIN - MUCOUS)

ALA SCALP 3 MO

alclometasone dipropionate 2 MO

amcinonide 2 MO

apexicon 3 MO

augmented betamethasone dipropionate 2 MO

betamethasone dipropionate 3 MO

betamethasone valerate 2 MO

clobetasol propionate 2 MO

clobetasol propionate e 2 MO

clobetasol propionate emollient 2 MO

colocort 3 MO

cormax 4 MO

CORTIFOAM 4 MO

desonide 2 MO

desoximetasone 3 MO

diflorasone diacetate 3 MO

fluocinolone acetonide 2 MO

fluocinonide 2 MO

fluocinonide emollient base 2 MO

fluocinonide-e 2 MO

fluticasone propionate 2 MO

halobetasol propionate 3 MO

HALOG 4 MO

hydrocortisone butyrate 2 MO

hydrocortisone valerate 2 MO

hydrocortisone enem 1 MO

hydrocortisone crea, lotn, oint 2 MO

KENALOG 4 MO

lokara 2 MO

mometasone furoate 2 MO

oralone 1 MO

prednicarbate 2 MO

proctocream hc 2 MO

proctosol hc 2 MO

scalacort 1 MO

triamcinolone acetonide 2 MO

triamcinolone in orabase 2 MO

triderm 1 MO

u-cort 2 MO

ANTIBACTERIALS (SKIN - MUCOUS MEMBRANE)

ALTABAX 4 MO

BACTROBAN 4 MO

clindacin-p 2 MO



clindamax 1 MO

clindamycin phosphate 2 MO

clindamycin/benzoyl peroxide 2 MO

ery 2 MO

erythromycin 2 MO

erythromycin/benzoyl peroxide 3 MO

gentamicin sulfate 2 MO

metronidazole 1 MO

metronidazole vaginal 2 MO

mupirocin 3 MO

neomycin/polymyxin b sulfates 3 MO

vitazol 4 MO

ANTIFUNGALS (SKIN - MUCOUS MEMBRANE)

ciclodan 3 MO

ciclopirox 3 MO

ciclopirox nail lacquer 3 MO

ciclopirox olamine 3 MO

clotrimazole 2 MO

clotrimazole/betamethasone dipropionate 2 MO

econazole nitrate 2 MO

ketoconazole 2 MO

MENTAX 4 MO

miconazole 3 2 MO

nyamyc 2 MO

nystatin 2 MO

nystatin/triamcinolone 2 MO

nystop 2 MO

pedi-dri 2 MO

terconazole 2 MO

ANTIPRURITICS AND LOCAL ANESTHETICS

lidocaine 2 B/D MO

lidocaine/prilocaine 2 B/D MO

LIDODERM 4 QL (90 EA per 30 days)

PA MO

SYNERA 4 B/D MO

ANTIVIRALS (SKIN - MUCOUS MEMBRANE)

DENAVIR 4 MO

ZOVIRAX OINT 4 PA MO

ZOVIRAX CREA 4 ST MO

BASIC LOTIONS AND LINIMENTS

ammonium lactate 2 MO

laclotion 4 MO

BASIC OINTMENTS AND PROTECTANTS

ammonium lactate 2 MO

CELL STIMULANTS AND PROLIFERANTS

KEPIVANCE 4 PA MO

tretinoin 3 PA MO

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCOHOL PREPS 1 MO

selenium sulfide 2 MO

silver sulfadiazine 2 MO



sodium sulfacetamide 2 MO

sulfacetamide sodium 2 MO

thermazene 2 MO

PIGMENTING AGENTS

8-MOP 4 MO

OXSORALEN 4 MO

OXSORALEN ULTRA 4 MO

UVADEX 4 B/D MO

SCABICIDES AND PEDICULICIDES

acticin 2 MO

EURAX 4 MO

lindane 3 MO

malathion 2 MO

permethrin 2 MO

SKIN AND MUCOUS MEMBRANE AGENTS, MISC

ACZONE 4 MO

adapalene 3 MO

calcipotriene oint 3 MO

calcipotriene soln 3 QL (60 ML per 30 days)

MO

calcitrene 3 MO

CARAC 4 MO

ELIDEL 4 MO

EPIDUO 4 MO

FLUOROPLEX 4 MO

fluorouracil 3 MO

imiquimod 3 QL (12 EA per 30 days)

MO

PANRETIN 4 MO

podofilox 3 MO

REGRANEX 4 MO

SANTYL 4 MO

SORIATANE 4 MO

STELARA INJ 45MG/0.5ML 4 QL (3 ML per 84 days) PA

STELARA INJ 90MG/ML 4 QL (3 ML per 84 days) PA

MO

TARGRETIN 4 PA MO

TAZORAC 4 MO

VEREGEN 4 MO

SMOOTH MUSCLE RELAXANTS

GENITOURINARY SMOOTH MUSCLE RELAXANTS

flavoxate hcl 3 MO

oxybutynin chloride 2 MO

oxybutynin chloride er 3 QL (60 EA per 30 days)

MO

trospium chloride 3 MO

VITAMINS

VITAMIN D

calcitriol 3 B/D MO

HECTOROL 3 B/D MO

ZEMPLAR 3 B/D MO


OTC products

Drug Name

Drug

Tier Requirements/Limits

SKIN AND MUCOUS MEMBRANE AGENTS

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCOHOL PREP PADS 1 MO

ALCOHOL SWABS 1 MO

BD SWABS SINGLE USE 1 MO

CURITY ALCOHOL PREPS 1 MO

CURITY ALCOHOL PREPS/MEDIUM/2 PLY 1 MO

FIFTY50 ALCOHOL PREP PADS 1 MO

GLOBAL ALCOHOL PREP EASE PADS 1 MO

IV PREP WIPES 1 MO

PHARMACIST CHOICE ALCOHOLPREP PADS 1 MO

SURE-PREP ALCOHOL PREP PADS 1 MO

ULTILET ALCOHOL SWAB 1 MO

ULTILET ALCOHOL SWABS 1 MO

WEBCOL ALCOHOL PREP LARGE 1 PLY 1 MO

WEBCOL ALCOHOL PREP LARGE 2 PLY 1 MO

WEBCOL ALCOHOL PREP MEDIUM 2 PLY 1 MO

of 79

Index Drug Name Page #

8-MOP 61

ABILIFY 34

ABILIFY DISCMELT 34

ABRAXANE 15

acarbose 49

acebutolol hcl 20

acetaminophen/caffeine/dihydrocodeine

bitartrate

37

acetaminophen/codeine 38

acetaminophen/codeine #2 37



acetaminophen/codeine phosphate 38

acetasol hc 45

acetazolamide 26

acetazolamide er 26

acetazolamide sodium 26

acetic acid 45

acetylcysteine 57

ACTHIB 58

acticin 61

ACTIMMUNE 54

ACTONEL 54

ACTOS 53

acyclovir 12

acyclovir sodium 12

ACZONE 61

ADACEL 58

ADAGEN 43

adapalene 61

ADCIRCA 28

adriamycin 15

afeditab cr 25

AFINITOR 15

AGGRENOX 23

a-hydrocort 48

ak-con 46

ak-poly-bac 44

ALA SCALP 59

ALBENZA 6

albuterol sulfate 20

albuterol sulfate er 20

alclometasone dipropionate 59

ALCOHOL PREP PADS 62

ALCOHOL PREPS 60

ALCOHOL SWABS 62

ALDURAZYME 43

Drug Name Page #

alendronate sodium 54

alfuzosin hcl er 19

ALIMTA 15

ALINIA 7

ALKERAN 15

allopurinol 54

allopurinol sodium 54

ALSUMA 39

ALTABAX 59

altavera 50

amantadine hcl 6

amcinonide 59

a-methapred 48

amethia lo 50

amifostine 56

amikacin sulfate 6

amiloride hcl 26

amiloride/hydrochlorothiazide 26

aminophylline 58

AMINOSYN 40

AMINOSYN 8.5%/ELECTROLYTES 40

AMINOSYN II 40

AMINOSYN II 8.5%/ELECTROLYTES 40

AMINOSYN M 40

AMINOSYN-HBC 40

AMINOSYN-PF 40

AMINOSYN-PF 7% 40

amiodarone hcl 23

AMITIZA 47

amitriptyline hcl 31

amlodipine besylate 25

amlodipine besylate/atorvastatin calcium 26

amlodipine besylate/atorvastatin calcium 27

amlodipine besylate/benazepril hcl 25

amlodipine besylate/benazepril

hydrochloride

25

ammonium chloride 40

ammonium lactate 60

ammonium lactate 60

amoxapine 31

amoxicillin 13

amoxicillin/clavulanate potassium 13

amoxicillin/clavulanate potassium er 13

amoxicillin/potassium clavulanate 13

AMPHOTEC 13

amphotericin b 13

ampicillin 13

ampicillin sodium 13

ampicillin-sulbactam 13

AMPYRA 56

ANADROL-50 49

of 79

Drug Name Page #

anagrelide hydrochloride 23

anastrozole 15

ANCOBON 14

ANDROGEL 49

ANDROGEL PUMP 49

androxy 49

ANTIVERT 47

ANTIZOL 54

apexicon 59

APOKYN 36

apraclonidine 46

apri 50

APRISO 47

APTIVUS 7

ARALAST NP 57

aranelle 50

arbinoxa 14

ARCALYST 56

argatroban 22

ARRANON 15

ARZERRA 15

ascomp/codeine 37

ASMANEX 120 METERED DOSES 57




ASTRAMORPH 38

ATELVIA 55

atenolol 20

atenolol/chlorthalidone 20

atorvastatin calcium 27

atovaquone/proguanil hcl 7

ATRIPLA 7

atropine sulfate 19

ATROVENT HFA 19

augmented betamethasone dipropionate 59

AVASTIN 15

AVELOX 14

aviane 50

avodart 54

AVONEX 54

AZASITE 44

azathioprine 55

azathioprine sodium 55

azelastine hcl 44

AZILECT 37

azithromycin 12

AZOPT 45

aztreonam 12

azurette 50

bacitracin 6

Drug Name Page #

bacitracin 44

bacitracin/polymyxin b 44

baclofen 21

bactocill in dextrose 13

BACTROBAN 59

balsalazide disodium 47

BANZEL 29

BARACLUDE 12

baycadron 48

bd insulin syringe safetyglide/1ml/29g x

1/2"

40

bd insulin syringe ultrafine/0.3ml/31g x

5/16"

40

bd insulin syringe ultrafine/0.5ml/30g x 1/2" 40

bd insulin syringe ultrafine/1ml/31g x 5/16" 40

BD SWABS SINGLE USE 62

benazepril hcl 28

benazepril hcl/hydrochlorothiazide 26

BENLYSTA 55

benztropine mesylate 20

BESIVANCE 44

betamethasone dipropionate 59

betamethasone valerate 59

BETASERON 54

betaxolol hcl 20

betaxolol hcl 45

bethanechol chloride 21

BETIMOL 45

bicalutamide 15

BICNU 15

BIDIL 26

BILTRICIDE 6

bisoprolol fumarate 20

bisoprolol fumarate/hydrochlorothiazide 20

bleomycin sulfate 15

BLEPHAMIDE 44

BLEPHAMIDE S.O.P. 44

BOOSTRIX 58

brimonidine tartrate 44

bromocriptine mesylate 36

BROVANA 20

budeprion sr 31

budeprion xl 32

BUDESONIDE 49

budesonide 57

bumetanide 26

BUPHENYL 40

buprenorphine hcl 39

buproban 32

bupropion hcl 32

bupropion hcl er 32

of 79

Drug Name Page #

bupropion hcl sr 32

bupropion hcl xl 32

buspirone hcl 35

BUSULFEX 15

butalbital/acetaminophen/caffeine/codeine 38

butalbital/aspirn/caffeine/codeine 37

butorphanol tartrate 39

BYETTA 52

cabergoline 36

calcipotriene 61

calcitonin-salmon 53

calcitrene 61

calcitriol 61

calcium acetate 42

camila 50

CAMPATH 15

camrese lo 50

CANASA 47

CANCIDAS 11

CAPASTAT SULFATE 10

CAPITAL/CODEINE 38

CAPRELSA 15

captopril 28

captopril/hydrochlorothiazide 26

CARAC 61

CARBAGLU 40

carbamazepine 29

carbamazepine er 29

CARBATROL 30

carbidopa/levodopa 36

carbidopa/levodopa cr 36

carbidopa/levodopa er 36

carbidopa/levodopa odt 36

carbidopa/levodopa sr 36

carbinoxamine maleate 14

carboplatin 15

carimune nanofiltered 58

carisoprodol 21

carisoprodol/aspirin 21

carisoprodol/aspirin/codeine 21

CARNITOR 56

carteolol hcl 46

cartia xt 23

carvedilol 19

carvedilol 25

CAYSTON 12

caziant 50

CEENU 15

cefaclor 11

cefaclor er 11

cefadroxil 11

Drug Name Page #

cefazolin sodium 11

cefazolin sodium/dextrose 11

cefdinir 11

cefditoren pivoxil 11

cefepime 11

cefotaxime sodium 11

cefotetan 11

cefoxitin sodium 11

cefpodoxime proxetil 11

cefprozil 11

ceftazidime 11

ceftazidime/dextrose 11

ceftriaxone sodium 11

cefuroxime axetil 11

cefuroxime sodium 11

CELLCEPT 55

CELLCEPT INTRAVENOUS 55

CELONTIN 40

cephalexin 11

CEREDASE 43

CEREZYME 43

CERUBIDINE 15

CERVARIX 58

cetirizine hcl 15

CHANTIX 20

CHANTIX CONTINUING MONTH PAK 20

CHANTIX STARTING MONTH PAK 20

CHEMET 48

chloramphenicol sodium succinate 11

chlorhexadine gluconate oral rinse 45

chlorhexidine gluconate 45

chlorhexidine gluconate oral rinse 45

chloroquine phosphate 7

chlorothiazide 26

chlorothiazide sodium 26

chlorpromazine hcl 34

chlorthalidone 26

cholestyramine 25

cholestyramine light 25

chorionic gonadotropin 52

ciclodan 60

ciclopirox 60

ciclopirox nail lacquer 60

ciclopirox olamine 60

cilostazol 23

cimetidine 48

cimetidine hcl 48

CIMZIA 48

ciprofloxacin 14

ciprofloxacin hcl 14

ciprofloxacin hcl 44

of 79

Drug Name Page #

ciprofloxacin i.v.-in d5w 14

cisplatin 15

citalopram hydrobromide 32

cladribine 15

clarithromycin 12

clarithromycin er 12

clemastine fumarate 14

CLEOCIN GALAXY 6

CLEOCIN IN D5W 6

clindacin-p 59

clindamax 60

clindamycin hcl 6

clindamycin palmitate hcl 6

clindamycin phosphate 6

clindamycin phosphate 60

clindamycin phosphate add-vantage 6

clindamycin phosphate pharmacy bulk

package

6

clindamycin/benzoyl peroxide 60

CLINIMIX 2.75%/DEXTROSE 5% 40





CLINIMIX 5%/DEXTROSE 15% 40



CLINIMIX E 2.75%/DEXTROSE 10% 40




CLINIMIX E 5%/DEXTROSE 15% 40



clobetasol propionate 59

clobetasol propionate e 59

clobetasol propionate emollient 59

CLOLAR 15

clomipramine hcl 32

clonazepam 29

CLONAZEPAM ODT 29

clonidine hcl 26

clopidogrel 23

CLORAZEPATE DIPOTASSIUM 29

clorpres 26

clotrimazole 60

clotrimazole/betamethasone dipropionate 60

clozapine 34

COARTEM 7

codeine sulfate 38

COLCRYS 54

Drug Name Page #

colestipol hcl 25

colistimethate sodium 6

colocort 59

COLY-MYCIN M 6

COMPLERA 7

compro 34

COMTAN 36

COMVAX 58

COPAXONE 54

cormax 59

CORTIFOAM 59

cortisone acetate 49

COSMEGEN 16

COUMADIN 22

COVERA-HS 23

CREON 48

CRESTOR 27

CRINONE 53

CRIXIVAN 7

cromolyn sodium 57

cryselle-28 50

CUBICIN 6

CUPRIMINE 48

CURITY ALCOHOL PREPS 62

CURITY ALCOHOL PREPS/MEDIUM/2

PLY

62

curity gauze pads 2"x2" 57

cyclafem 1/35 50

cyclafem 7/7/7 50

cyclophosphamide 16

cyclosporine 55

cyclosporine modified 55

CYKLOKAPRON 23

CYMBALTA 32

CYSTADANE 56

CYSTAGON 56

cytarabine 16

cytarabine aqueous 16

CYTOMEL 53

CYTOVENE 12

dacarbazine 16

DACOGEN 16

dactinomycin 16

danazol 49

dantrolene sodium 21

dapsone 7

DAPTACEL 58

DARAPRIM 7

DAUNORUBICIN HCL DisplayText cannot span more than one line! DDAVP 53

of 79

Drug Name Page #

DECAVAC 58

demeclocycline hcl 14

DEMSER 56

DENAVIR 60

DEPO-ESTRADIOL 52

desipramine hcl 32

desmopressin acetate 23

desmopressin acetate 53

desonide 59

desoximetasone 59

dexamethasone 49

dexamethasone intensol 49

dexamethasone sodium phosphate 45

dexamethasone sodium phosphate 49

dexmethylphenidate hcl 29

dexrazoxane 56

dextroamphetamine sulfate 29

dextroamphetamine sulfate er 29

dextrose 10%/nacl 0.45% 41

dextrose 5% /electrolyte #48 viaflex 42

dextrose 10% 41

dextrose 10% flex container 41



dextrose 2.5%/nacl 0.45% 41

dextrose 2.5%/sodium chloride 0.45% 41

dextrose 5% 41

dextrose 5% viaflex 41







dextrose 5%/potassium chloride 0.15% 42

dextrose 5%/sodium chloride 0.2% 41




dextrose thermoject system 41

DIAZEPAM 29

DIAZEPAM 29

DIAZEPAM INTENSOL 29

diclofenac potassium 37

diclofenac sodium 46

diclofenac sodium dr 37

diclofenac sodium er 37

diclofenac sodium xr 37

dicloxacillin sodium 13

dicyclomine hcl 19

didanosine 7

Drug Name Page #

DIFICID 12

diflorasone diacetate 59

diflunisal 37

digoxin 23

dihydroergotamine mesylate 19

DILANTIN 23

dilantin infatabs 23

DILATRATE SR 27

dilt-cd 23

diltiazem cd 24

diltiazem hcl 24

diltiazem hcl er 24

dilt-xr 23

diltzac 24

diphenoxylate/atropine 19

diphtheria/tetanus toxoid pediatric 58

disopyramide phosphate 24

DIURIL 26

divalproex sodium 30

divalproex sodium dr 30

divalproex sodium er 30

DOCEFREZ 16

docetaxel 16

donepezil hcl 21

DORIBAX 12

dorzolamide hcl 45

dorzolamide hcl/timolol maleate 45

doxazosin mesylate 19

doxepin hcl 32

doxycycline 14

doxycycline hyclate 14

doxycycline hyclate 44

doxycycline monohydrate 14

dronabinol 47

DROXIA 16

DULERA 57

DUONEB 19

DURAMORPH 38

DUREZOL 45

DYRENIUM 26

E.E.S. 400 12

E.E.S. GRANULES 12

e.s.p. 12

econazole nitrate 60

ed baclofen 21

EDURANT 8

EFFIENT 23

EGRIFTA 53

ELAPRASE 43

ELDEPRYL 37

ELESTAT 44

of 79

Drug Name Page #

ELIDEL 61

eliphos 42

ELITEK 43

ELIXOPHYLLIN 26

ELOXATIN 16

EMCYT 16

EMEND 47

emoquette 50

EMSAM 32

EMTRIVA 8

enalapril maleate 28

enalapril maleate/hydrochlorothiazide 26

ENBREL 55

endocet 38

ENDOMETRIN 53

ENGERIX-B 58

enoxaparin sodium 22

enpresse-28 50

ENTOCORT EC 49

enulose 40

EPIDUO 61

epinastine hcl 44

epinephrine 19

epinephrine hcl 19

epirubicin hcl 16

epitol 30

EPIVIR 8

EPIVIR HBV 8

eplerenone 26

EPOGEN 22

EPZICOM 8

EQUETRO 30

ERAXIS 11

ERBITUX 16

ergoloid mesylates 19

ergotamine tartrate/caffeine 19

ERIVEDGE 16

errin 50

ery 60

ERYPED 200 12

ERYPED 400 12

ERY-TAB 12

ERYTHROCIN LACTOBIONATE 12

ERYTHROCIN STEARATE 12

erythromycin 44

erythromycin 60

erythromycin base 12

erythromycin ethylsuccinate 12

erythromycin/benzoyl peroxide 60

erythromycin/sulfisoxazole 12

escitalopram oxalate 32

Drug Name Page #

estradiol 52

estradiol valerate 52

estradiol/norethindrone acetate 52

ethambutol hcl 10

ethosuximide 40

ETHYOL 56

etidronate disodium 55

etodolac 37

etodolac er 37

ETOPOPHOS 16

etoposide 16

EURAX 61

EVAMIST 52

EVISTA 51

EXELON 21

exemestane 16

EXJADE 48

FABRAZYME 43

FACTIVE 14

famciclovir 13

famotidine 48

famotidine premixed 48

FANAPT 34

FANAPT TITRATION PACK 34

FARESTON 16

FASLODEX 16

FAZACLO 34

felbamate 30

FELBATOL 30

felodipine er 25

FEMCON FE 50

fenofibrate 27

fenofibrate micronized 27

fenoprofen calcium 37

fentanyl 38

fentanyl citrate 38

fentanyl citrate oral transmucosal 38

FIFTY50 ALCOHOL PREP PADS 62

finasteride 54

FIRAZYR 55

FIRMAGON 16

flavoxate hcl 61

flebogamma 58

FLEBOGAMMA DIF 58

flecainide acetate 24

fluconazole 10

fluconazole in dextrose 10

fluconazole in nacl 10

flucytosine 14

fludarabine phosphate 16

fludrocortisone acetate 49

of 79

Drug Name Page #

flunisolide 57

fluocinolone acetonide 59

fluocinonide 59

fluocinonide emollient base 59

fluocinonide-e 59

fluorometholone 45

FLUOROPLEX 61

fluorouracil 16

fluorouracil 61

fluoxetine 32

fluoxetine dr 32

fluoxetine hcl 32

fluphenazine decanoate 34

fluphenazine hcl 34

flurbiprofen 37

flurbiprofen sodium 46

flutamide 16

fluticasone propionate 57

fluticasone propionate 59

fluvoxamine maleate 32

FML 45

FML FORTE 45

FOLOTYN 16

fomepizole 54

fondaparinux sodium 22

FORADIL AEROLIZER 20

FORTEO 53

FORTICAL 53

fosinopril sodium 28

fosinopril sodium/hydrochlorothiazide 26

fosphenytoin sodium 36

FRAGMIN 22

FREAMINE III 41

FREAMINE III 3% 41

furosemide 26

FUSILEV 54

FUZEON 8

gabapentin 30

GABITRIL 30

galantamine 21

galantamine hydrobromide 21

GAMMAGARD LIQUID 58

gammaplex 58

GAMUNEX 58

ganciclovir 13

GARAMYCIN 44

GARDASIL 58

gavilyte-c 47

gavilyte-g 47

gavilyte-n/flavor pack 47

gemcitabine 16

Drug Name Page #

gemcitabine hcl 16

gemfibrozil 27

GEMZAR 16

generlac 40

gengraf 55

gentak 44

gentamicin sulfate 6



gentamicin sulfate/0.9% sodium chloride 6

gentamicin sulfate/sodium chloride 6

GEODON 29

gianvi 50

gildess fe 1.5/30 50

gildess fe 1/20 50

GLASSIA 57

GLEEVEC 16

glimepiride 53

glipizide 53

glipizide er 53

glipizide xl 53

glipizide/metformin hcl 49

GLOBAL ALCOHOL PREP EASE PADS 62

GLUCAGEN HYPOKIT 52

GLUCAGON EMERGENCY KIT 52

glyburide 53

glyburide micronized 53

glyburide/metformin hcl 49

glycopyrrolate 19

GLYSET 49

GOLYTELY 47

granisetron hcl 46

griseofulvin microsize 7

GRIS-PEG 7

guanfacine hcl 26

HALAVEN 16

HALDOL 34

HALFLYTELY BOWEL PREP/FLAVOR

PACKS

47

halobetasol propionate 59

HALOG 59

haloperidol 34

haloperidol decanoate 34

haloperidol lactate 34

HAVRIX 58

heather 50

HECTOROL 61

heparin sodium 22

heparin sodium dcu 22

heparin sodium/d5w 22

heparin sodium/nacl 0.45% 22

of 79

Drug Name Page #

heparin sodium/sodium chloride 0.9% 22

heparin sodium/sodium chloride 0.9%

premix

22

HEPATAMINE 41

HEPATASOL 41

HEPSERA 13

HERCEPTIN 16

HEXALEN 16

HIBERIX 58

HIZENTRA 58

HUMALOG 52

HUMALOG KWIKPEN 52

HUMALOG MIX 50/50 52

HUMALOG MIX 50/50 KWIKPEN 52

HUMALOG MIX 75/25 52

HUMALOG MIX 75/25 KWIKPEN 52

HUMIRA 55

HUMIRA PEN 55

HUMIRA PEN-CROHNS

DISEASESTARTER

55

HUMIRA PEN-PSORIASIS STARTER 55

HUMULIN 70/30 52

HUMULIN 70/30 PEN 52

HUMULIN N 52

HUMULIN N U-100 PEN 52

HUMULIN R 52

HUMULIN R U-500 (CONCENTRATED) 52

HYCAMTIN 16

hydralazine hcl 26

hydrochlorothiazide 26

hydrocodone bitartrate/acetaminophen 38

hydrocodone/acetaminophen 38

hydrocodone/ibuprofen 37

hydrocortisone 49

hydrocortisone 59

hydrocortisone butyrate 59

hydrocortisone valerate 59

hydrocortisone/acetic acid 45

hydromorphone hcl 38

hydroxychloroquine sulfate 7

hydroxyurea 16

hydroxyzine hcl 15

ibandronate sodium 55

ibuprofen 37

IDAMYCIN PFS 16

idarubicin hcl 16

IFEX 17

ifosfamide 17

ILOTYCIN 44

imipenem/cilastatin 12

imipramine hcl 33

Drug Name Page #

imipramine pamoate 33

imiquimod 61

INCIVEK 11

INCRELEX 53

indapamide 27

INDOCIN 37

indomethacin 37

indomethacin er 37

INFANRIX 58

INFERGEN 11

INFUMORPH 200 38

INFUMORPH 500 39

INLYTA 17

INTELENCE 8

INTRALIPID 41

INTRON-A 11

INTRON-A W/DILUENT 11

introvale 50

INVEGA 34

INVEGA SUSTENNA 34

INVIRASE 8

IONOSOL-B/DEXTROSE 5% 42

IONOSOL-MB/DEXTROSE 5% 42

IPOL INACTIVATED IPV 58

ipratropium bromide 19

ipratropium bromide 46

ipratropium bromide/albuterol sulfate 20

irbesartan 23

irbesartan/hydrochlorothiazide 23

IRESSA 17

irinotecan 17

ISENTRESS 8

isoditrate er 28

ISOLYTE-H/DEXTROSE 5% 42

ISOLYTE-M/DEXTROSE 5% 42

ISOLYTE-P/DEXTROSE 5% 42

ISOLYTE-S 42

ISOLYTE-S/DEXTROSE 5% 42

isonarif 6

isoniazid 10

ISORDIL TITRADOSE 28

isosorbide dinitrate 28

isosorbide dinitrate er 28

isosorbide mononitrate 28

isosorbide mononitrate er 28

isotonic gentamicin 6

isradipine 25

ISTODAX 17

itraconazole 10

IV PREP WIPES 62

IXEMPRA KIT 17

of 79

Drug Name Page #

IXIARO 58

JAKAFI 17

jantoven 22

JANUMET 50

JANUMET XR 51

JANUVIA 51

jevantique 52

JE-VAX 58

JEVTANA 17

jinteli 52

junel 1.5/30 50

junel 1/20 50

junel fe 1.5/30 50

junel fe 1/20 50

JUVISYNC 27

KALETRA 8

kalexate 42

KALYDECO 57

kanamycin sulfate 6

KAPVAY 26

kariva 50

kcl 0.075%/d5w/nacl 0.2% 42

kcl 0.075%/d5w/nacl 0.45% 42

kcl 0.15%/d5w/ nacl 0.3% 42

kcl 0.15%/d5w/lr 42

kcl 0.15%/d5w/nacl 0.2% 42

kcl 0.15%/d5w/nacl 0.225% 42

kcl 0.15%/d5w/nacl 0.45% 42

kcl 0.15%/d5w/nacl 0.9% 42

kcl 0.3%/d5w/lr 42

kcl 0.3%/d5w/lr iv lac ring 42

kcl 0.3%/d5w/nacl 0.2% 42

kcl 0.3%/d5w/nacl 0.45% 42

kcl 0.3%/d5w/nacl 0.9% 42

KEFLEX 11

kelnor 1/35 50

KENALOG 59

KEPIVANCE 60

KETEK 12

ketoconazole 10

ketoconazole 60

ketoprofen 37

ketoprofen er 37

ketorolac tromethamine 46

kionex 42

KLOR-CON 10 42

KLOR-CON 8 42

klor-con m10 42

klor-con m15 42

klor-con m20 42

KUVAN 56

Drug Name Page #

labetalol hcl 19

laclotion 60

LACRISERT 46

lactated ringers 42

lactated ringers irrigation 41

lactated ringers viaflex 42

lactulose 40

LAMICTAL 30

LAMICTAL CHEWABLE DISPERSIBLE 30

LAMICTAL ODT 30

LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE

30


CARBAMAZEPINE/NOT TAKING

VALPROATE

30


VALPROATE

30

LAMICTAL XR 30

lamivudine 8

lamivudine/zidovudine 8

lamotrigine 30

LANOXIN 24

lansoprazole 48

LANTUS 52

LANTUS SOLOSTAR 52

latanoprost 46

LATUDA 34

leflunomide 55

lessina-28 50

LETAIRIS 28

letrozole 17

leucovorin calcium 54

LEUKERAN 17

LEUKINE 22

leuprolide acetate 17

levalbuterol 20

LEVEMIR 52

LEVEMIR FLEXPEN 52

levetiracetam 31

levetiracetam er 31

levobunolol hcl 45

levocarnitine 56

levocetirizine dihydrochloride 15

levofloxacin 14

levofloxacin 44

levofloxacin in d5w 14

levonorgestrel 50

levonorgestrel and ethinyl estradiol 50

levora 0.15/30-28 50

levorphanol tartrate 39

LEVOTHROID 53

of 79

Drug Name Page #

levothyroxine sodium 53

LEVOXYL 53

LEXIVA 8

LIALDA 47

lidocaine 60

lidocaine hcl 46

lidocaine hcl 54

lidocaine hcl jelly 46

lidocaine viscous 46

lidocaine/prilocaine 60

LIDODERM 60

lindane 61

liothyronine sodium 53

LIPOSYN II 41

LIPOSYN III 41

lisinopril 28

lisinopril/hydrochlorothiazide 27

lithium carbonate 34

lithium carbonate er 34

lithium citrate 34

lokara 59

LOMOTIL 47

loperamide hcl 47

loryna 50

losartan potassium 28

losartan potassium/hydrochlorothiazide 27

LOSEASONIQUE 50

LOTRONEX 47

lovastatin 27

lovaza 25

low-ogestrel 50

loxapine 34

loxapine succinate 34

LUFYLLIN 58

LUMIGAN 46

LUMIZYME 43

LUPRON DEPOT 17

LUPRON DEPOT-PED 17

lutera 50

LUVOX CR 33

LYRICA 31

LYSODREN 17

magnesium sulfate 24

magnesium sulfate in d5w 24

MALARONE 7

malathion 61

maprotiline hcl 33

MARLISSA 50

MARPLAN 33

MATULANE 17

MAXITROL 44

Drug Name Page #

meclizine hcl 15

meclofenamate sodium 37

medroxyprogesterone acetate 53

mefloquine hcl 7

megestrol acetate 17

meloxicam 37

melphalan hydrochloride 17

MENACTRA 58

MENOMUNE-A/C/Y/W-135 58

MENTAX 60

MENVEO 58

MEPRON 7

mercaptopurine 17

meropenem 12

MERREM 12

mesalamine 47

mesna 56

MESNEX 56

MESTINON 21

MESTINON TIMESPAN 21

metaproterenol sulfate 20

metaxalone 21

metformin hcl 50

metformin hcl er 50

methadone hcl 39

methadone hcl intensol 39

METHADOSE 39

METHADOSE SUGAR-FREE 39

methamphetamine hcl 29

methazolamide 45

methenamine hippurate 14

METHERGINE 56

methimazole 49

methocarbamol 21

methotrexate 17

methotrexate sodium 17

methscopolamine bromide 20

methyclothiazide 27

methyldopa 19

methyldopa/hydrochlorothiazide 19

methyldopate hcl 19

methylergonovine maleate 56

methylphenidate hcl 29

methylprednisolone 49

methylprednisolone acetate 49

methylprednisolone dose pack 49

methylprednisolone sodiumsuccinate 49

metipranolol 45

metoclopramide hcl 48

metolazone 27

metoprolol succinate er 20

of 79

Drug Name Page #

metoprolol tartrate 20

metoprolol/hydrochlorothiazide 20

METRO IV 6

metronidazole 6

metronidazole 60

metronidazole vaginal 60

mexiletine hcl 24

miconazole 3 60

microgestin 1.5/30 50

microgestin 1/20 50

microgestin fe 51

microgestin fe 1.5/30 51

MICRO-K 42

micronized colestipol hcl 25

midodrine hcl 19

migergot 19

mimvey 52

minitran 28

minocycline hcl 14

minoxidil 26

mirtazapine 33

mirtazapine odt 33

misoprostol 48

mitomycin 17

mitoxantrone hcl 17

M-M-R II W/DILUENT 10 DOSE 58

moexipril hcl 28

moexipril/hydrochlorothiazide 27

mometasone furoate 59

morgidox 1x100mg 14

morgidox 2x100mg 14

morphine sulfate 39

morphine sulfate er 39

MOVIPREP 47

MOXEZA 44

MOZOBIL 22

MULTAQ 24

mupirocin 60

MUSTARGEN 17

MYCOBUTIN 6

mycophenolate mofetil 55

mydral 46

MYFORTIC 55

MYOZYME 43

nabumetone 37

nadolol 20

nadolol/bendroflumethiazide 20

nafcillin sodium 13

NAGLAZYME 43

nalbuphine hcl 39

NALFON 37

Drug Name Page #

nallpen/dextrose 13

naloxone hcl 39

naltrexone hcl 39

NAMENDA 36

NAMENDA TITRATION PAK 36

naproxen 37

naproxen dr 37

naproxen sodium 37

naratriptan hcl 39

NARDIL 33

NASONEX 57

NATACYN 45

nateglinide 52

NAVELBINE 17

necon 0.5/35-28 51

necon 1/35-28 51

necon 10/11-28 51

nefazodone hcl 33

neomycin sulfate 6

neomycin/bacitracin/polymyxin 44

neomycin/polymyxin b sulfates 60

neomycin/polymyxin/bacitracin zinc 44

neomycin/polymyxin/bacitracin/hydrocortis

one

44

neomycin/polymyxin/dexamethasone 44

neomycin/polymyxin/gramicidin 44

neomycin/polymyxin/hc 44

neomycin/polymyxin/hydrocortisone 44

neo-polycin 44

neosporin 44

NEPHRAMINE 41

NEULASTA 22

NEUMEGA 22

NEUPOGEN 22

NEURONTIN 31

nevirapine 8

NEXAVAR 17

next choice 51

niacor 25

NIASPAN 25

nicardipine hcl 25

NICOTROL NS 20

nifediac cc 25

nifedical xl 25

nifedipine er 25

NILANDRON 17

nimodipine 25

NIPENT 17

nisoldipine 26

nisoldipine er 25

nitrofurantoin 14

of 79

Drug Name Page #

nitrofurantoin macrocrystal 14

nitrofurantoin macrocrystalline 14

nitrofurantoin monohydrate 14

nitrofurantoin monohydrate/macrocrystals 14

nitroglycerin 28

nitroglycerin lingual 28

nitroglycerin transdermal 28

NITROLINGUAL PUMPSPRAY 28

NITROSTAT 28

nizatidine 48

norethindrone 51

norethindrone acetate 53

norgestimate/ethinyl estradiol 51

norgestrel/ethinyl estradiol 51

NORMOSOL -R 42

NORMOSOL-M IN D5W 42

NORMOSOL-R 42

NORMOSOL-R IN D5W 42

NORPACE CR 24

nortrel 0.5/35 (28) 51

nortrel 1/35 (21) 51

nortrel 1/35 (28) 51

nortrel 7/7/7 51

nortriptyline hcl 33

NORVIR 8

NOVOLIN 70/30 52

NOVOLIN N 52

NOVOLIN R 52

NOVOLOG 52

NOVOLOG FLEXPEN 52

NOVOLOG MIX 70/30 52

NOVOLOG MIX 70/30 PREFILLED

FLEXPEN

52

NOXAFIL 10

NUEDEXTA 36

NULOJIX 55

NULYTELY/FLAVOR PACKS 47

nutrilyte ii 42

nyamyc 60

nystatin 14

nystatin 60

nystatin/triamcinolone 60

nystop 60

octreotide acetate 56

ofloxacin 14

ofloxacin 44

ogestrel 51

olanzapine 35

olanzapine odt 34

omeprazole 48

OMNITROPE 53

Drug Name Page #

ondansetron hcl 46

ondansetron odt 46

ONFI 29

onglyza 51

ONTAK 17

oralone 59

ORAP 35

ORAPRED ODT 49

ORFADIN 56

orphenadrine citrate 22

orphenadrine citrate er 22

orsythia 51

OSMOPREP 47

oxacillin sodium 13

oxaliplatin 18

oxandrolone 49

oxaprozin 37

oxcarbazepine 31

OXSORALEN 61

OXSORALEN ULTRA 61

oxybutynin chloride 61

oxybutynin chloride er 61

oxycodone hcl 39

oxycodone/acetaminophen 39

oxycodone/aspirin 37

oxycodone/ibuprofen 37

PACERONE 24

paclitaxel 18

palgic 15

pamidronate disodium 55

PANCREAZE 48

PANRETIN 61

pantoprazole sodium 48

paromomycin sulfate 6

paroxetine hcl 33

paroxetine hcl er 33

PASER 10

PATADAY 44

PAXIL 33

PCE 12

pedi-dri 60

PEDVAX HIB 58

peg 3350/electrolytes 47

peg-3350/electrolytes 47

peg-3350/nacl/na bicarbonate/kcl 47

PEGANONE 36

PEGASYS 11

PEG-INTRON 11

PEG-INTRON REDIPEN 11

PEG-INTRON REDIPEN PAK 4 11

penicillin g potassium 13

of 79

Drug Name Page #

penicillin g potassium in iso-osmotic

dextrose

13

penicillin g procaine 13

penicillin g sodium 13

penicillin v potassium 13

pentostatin 18

pentoxifylline er 23

PERFOROMIST 20

PERIDEX 45

perindopril erbumine 28

periogard 45

permethrin 61

perphenazine 35

perphenazine/amitriptyline 33

pfizerpen-g 13

PHARMACIST CHOICE ALCOHOLPREP

PADS

62

phenadoz 15

phenelzine sulfate 33

phenobarbital 29

PHENYTEK 24

phenytoin 24

phenytoin sodium 24

phenytoin sodium extended 24

PHOSLYRA 42

PHOSPHOLINE IODIDE 46

PHYSIOLYTE 41

PHYSIOSOL IRRIGATION 41

PHYSIOSOL IRRIGATION PH 7.4 41

pilocarpine hcl 21

pilocarpine hcl 46

pilocarpine hydrochloride 21

PILOPINE HS 46

pindolol 21

piperacillin sodium/tazobactam sodium 13

piperacillin/tazobactam 13

piroxicam 37

PLAN B 51

PLASMA-LYTE A 42

PLASMA-LYTE-148 42

PLASMA-LYTE-56/D5W 43

podofilox 61

poly-dex 44

polyethylene glycol 3350 47

polymyxin b sulfate 6

polymyxin b sulfate/trimethoprim sulfate 44

POLYTRIM 44

portia-28 51

potassium chloride 43

potassium chloride 0.075%/d5w/nacl

0.225%

43

Drug Name Page #

potassium chloride 0.15% /nacl 0.45%

viaflex

43

potassium chloride 0.15% d5w/nacl 0.33% 43


potassium chloride 0.15% d5w/nacl 0.45%

viaflex

43

potassium chloride 0.15% nacl 0.9% 43

potassium chloride 0.15% w/nacl 0.9%

viaflex

43

potassium chloride 0.15%/d5w 43

potassium chloride 0.15%/nacl 0.9% 43



potassium chloride 0.224%/d5w/nacl 0.45% 43

potassium chloride 0.224%/dextrose 5%

viaflex

43

potassium chloride 0.224%d5w/nacl 0.45%

viaflex

43

potassium chloride 0.3%/ nacl 0.9% 43


potassium chloride 0.3%/d5w/viaflex 43

potassium chloride 0.3%/nacl 0.9%/viaflex 43

potassium chloride cr 43

potassium chloride er 43

potassium chloride sr 43

potassium citrate 40

POTIGA 31

PRADAXA 22

pramipexole dihydrochloride 36

PRANDIN 52

pravastatin sodium 27

prazosin hcl 19

PRED MILD 45

PRED-G 44

PRED-G S.O.P. 44

prednicarbate 59

prednisolone acetate 45

prednisolone sodium phosphate 45

prednisolone sodium phosphate 49

prednisone 49

prednisone intensol 49

PREMARIN 52

PREMASOL 41

prevalite 25

previfem 51

PREZISTA 9

PRIFTIN 6

PRIMAXIN IV 12

PRIMAXIN IV ADD-VANTAGE 12

primidone 36

PRIMSOL 14

of 79

Drug Name Page #

PRISTIQ 33

privigen 58

PROAIR HFA 20

probenecid 43

probenecid/colchicine 43

procainamide hcl 24

PROCALAMINE 41

prochlorperazine 35

prochlorperazine edisylate 35

prochlorperazine maleate 35

PROCRIT 22

proctocream hc 59

proctosol hc 59

progesterone 53

PROGLYCEM 26

PROGRAF 56

PROLASTIN 57

PROLASTIN-C 57

PROLEUKIN 18

PROLIA 55

PROMACTA 23

promethegan 15

propafenone hcl 24

propafenone hcl er 24

propantheline bromide 20

proparacaine hcl 46

propranolol hcl 21

propranolol hcl er 21

propranolol/hydrochlorothiazide 21

propranolol/hydrochlorothiazide 25

propylthiouracil 49

PROQUAD 58

PROTONIX 48

protriptyline hcl 33

PULMOZYME 44

pyrazinamide 10

pyridostigmine bromide 21

QUALAQUIN 7

quasense 51

quetiapine fumarate 35

quinapril hcl 28

quinapril/hydrochlorothiazide 27

quinidine gluconate 7

quinidine gluconate cr 7

quinidine gluconate er 7

quinidine sulfate 7

quinidine sulfate er 7

QVAR 57

RABAVERT 58

ramipril 28

RANEXA 26

Drug Name Page #

ranitidine hcl 48

RAPAMUNE 56

REBETOL 13

REBIF 54

REBIF TITRATION PACK 54

RECLAST 55

reclipsen 51

RECOMBIVAX HB 58

REGRANEX 61

RELENZA DISKHALER 12

RELISTOR 48

REMICADE 55

REMODULIN 28

RENVELA 42

RESCRIPTOR 9

reserpine 28

RESTASIS 45

RETROVIR 9

RETROVIR IV INFUSION 9

REVATIO 28

REVLIMID 18

REYATAZ 9

RHEUMATREX 18

ribavirin 13

RIDAURA 48

RIFAMATE 6

rifampin 6

RILUTEK 36

rimantadine hcl 6

ringers injection 43

ringers irrigation 41

RISPERDAL CONSTA 35

risperidone 35

risperidone m-tab 35

risperidone odt 35

RITUXAN 18

rivastigmine tartrate 21

ROCEPHIN 11

romycin 44

ropinirole hcl 36

ROTATEQ 58

ROXICET 39

SABRIL 31

SAIZEN 53

SAIZEN CLICK.EASY 53

SAMSCA 43

SANCUSO 47

SANDOSTATIN 56

SANDOSTATIN LAR DEPOT 56

SANTYL 61

SAPHRIS 35

of 79

Drug Name Page #

SAVELLA 36

SAVELLA TITRATION PACK 36

scalacort 59

selegiline hcl 33

selenium sulfide 60

SELZENTRY 9

SEMPREX-D 15

SENSIPAR 56

SEREVENT DISKUS 20

SEROMYCIN 10

SEROQUEL XR 35

SEROSTIM 53

sertraline hcl 33

silver sulfadiazine 60

SIMULECT 56

simvastatin 27

SINGULAIR 57

sodium bicarbonate 40

sodium chloride 41

sodium chloride 43

sodium chloride 0.9% 41


sodium chloride 0.45% viaflex 43


sodium chloride pab 43

SODIUM EDECRIN 27

sodium lactate 40

sodium polystyrene sulfonate 42

sodium sulfacetamide 44

sodium sulfacetamide 61

SOLU-CORTEF 49

SOLU-MEDROL 49

SOMATULINE DEPOT 56

SOMAVERT 53

SORIATANE 61

sorine 21

sotalol hcl 21

sotalol hcl (af) 21

sotalol hydrochloride 24

SPIRIVA HANDIHALER 20

spironolactone 27

spironolactone/hydrochlorothiazide 27

sprintec 28 51

SPRYCEL 18

sronyx 51

stavudine 9

STELARA 61

sterile water irrigation 41

sterile water irrigation plastic bottle 41

sterile water irrigation w/hanger 41

STIMATE 23

Drug Name Page #

STRATTERA 36

streptomycin sulfate 6

STROMECTOL 6

SUCRAID 44

sucralfate 48

sulfacetamide sodium 44

sulfacetamide sodium 61

sulfacetamide sodium/prednisolone sodium

phosphate

44

sulfadiazine 14

sulfamethoxazole/trimethoprim 14

sulfamethoxazole/trimethoprim ds 14

sulfasalazine 14

sulfazine 14

sulindac 37

sumatriptan 39

sumatriptan succinate 39

sumatriptan succinate refill 39

SUPRAX 11

SUPREP BOWEL PREP 47

SURE-PREP ALCOHOL PREP PADS 62

SURMONTIL 33

SUSTIVA 9

SUTENT 18

syeda 51

SYLATRON 12

SYMBICORT 20

SYMLINPEN 120 49

SYMLINPEN 60 49

SYNAREL 52

SYNERA 60

SYNERCID 6

SYNTHROID 53

SYPRINE 48

TABLOID 18

tacrolimus 56

TAMIFLU 12

tamoxifen citrate 18

tamsulosin hcl 19

TARCEVA 18

TARGRETIN 18

TARGRETIN 61

TASIGNA 18

TASMAR 36

TAXOTERE 18

tazicef 11

TAZORAC 61

taztia xt 24

TEFLARO 11

TEGRETOL-XR 31

TEKTURNA 28

of 79

Drug Name Page #

TENIVAC 58

TENORMIN 25

terazosin hcl 19

terbinafine hcl 6

terbutaline sulfate 20

terconazole 60

testosterone cypionate 49

testosterone enanthate 49

tetanus/diphtheria toxoids-adsorbed adult 58

tetracycline hcl 14

THALOMID 54

theophylline cr 27

theophylline er 27

thermazene 61

thioridazine hcl 35

thiotepa 18

thiothixene 35

THYMOGLOBULIN 56

ticlopidine hcl 23

TIKOSYN 25

tilia fe 51

TIMENTIN 13

timolol maleate 21

timolol maleate 45

timolol maleate ophthalmic gel forming 45

TIMOPTIC OCUDOSE 45

tizanidine hcl 21

TOBI 6

TOBRADEX 44

TOBRADEX ST 45

tobramycin sulfate 6

tobramycin sulfate 45

tobramycin sulfate/sodium chloride 6

tobramycin/dexamethasone 45

TOBREX 45

tolazamide 53

tolbutamide 53

tolmetin sodium 37

topiragen 31

topiramate 31

toposar 18

topotecan hcl 18

TORISEL 18

torsemide 27

TOTECT 56

TPN ELECTROLYTES 43

TRACLEER 29

tramadol hcl 39

tramadol hydrochloride/acetaminophen 39

trandolapril 28

tranexamic acid 23

Drug Name Page #

tranylcypromine sulfate 33

TRAVASOL 41

TRAVATAN Z 46

trazodone hcl 33

TREANDA 18

TRECATOR 10

TRELSTAR DEPOT MIXJECT 18

TRELSTAR LA MIXJECT 18

TRELSTAR MIXJECT 18

tretinoin 18

tretinoin 60

TREXALL 18

triamcinolone acetonide 59

triamcinolone in orabase 59

triamterene/hydrochlorothiazide 27

TRICOR 27

triderm 59

trifluoperazine hcl 35

trifluridine 45

trihexyphenidyl hcl 20

tri-legest fe 51

TRILEPTAL 29

trilyte 47

trimethobenzamide hcl 47

trimethoprim 14

trimethoprim sulfate/polymyxin b sulfate 45

trimipramine maleate 33

trinessa 51

TRIPEDIA 58

tri-previfem 51

TRISENOX 18

tri-sprintec 51

trivora-28 51

TRIZIVIR 9

TROPHAMINE 41

tropicamide 46

trospium chloride 61

TRUVADA 9

TWINJECT 19

TWINRIX 58

TYGACIL 14

TYKERB 18

TYPHIM VI 59

TYZEKA 13

TYZINE 46

TYZINE PEDIATRIC NASAL DROPS 46

u-cort 59

ULTILET ALCOHOL SWAB 62

ULTILET ALCOHOL SWABS 62

UNITHROID 54

UREX 14

of 79

Drug Name Page #

UROCIT-K 10 40

UROCIT-K 5 40

ursodiol 47

UVADEX 61

valacyclovir hcl 13

VALCYTE 13

valproate sodium 31

valproic acid 31

VANCOCIN HCL 6

vancomycin hcl 6

VANDETANIB 18

VAQTA 59

VARIVAX 59

VECTIBIX 18

VELCADE 18

velivet 51

venlafaxine hcl 33

venlafaxine hcl er 33

VERAMYST 57

verapamil hcl 25

verapamil hcl er 25

verapamil hcl sr 25

VEREGEN 61

VERIPRED 20 49

vestura 51

VFEND 10

VFEND IV 10

VIBATIV 7

VIBRAMYCIN 14

victoza 52

VICTRELIS 11

VIDAZA 18

VIDEX PEDIATRIC 9

VIGAMOX 45

VIIBRYD 34

VIMPAT 31

vinblastine sulfate 19

vincasar pfs 19

vincristine sulfate 19

vinorelbine tartrate 19

VIRACEPT 9

VIRAMUNE 10

VIRAMUNE XR 10

VIREAD 10

vitazol 60

voltaren 37

voriconazole 11

VOTRIENT 19

VPRIV 44

warfarin sodium 22

WEBCOL ALCOHOL PREP LARGE 1 62

Drug Name Page #

PLY

WEBCOL ALCOHOL PREP LARGE 2

PLY

62

WEBCOL ALCOHOL PREP MEDIUM 2

PLY

62

WELCHOL 25

wymzya fe 51

XALKORI 19

XARELTO 22

XENAZINE 36

XGEVA 55

XIFAXAN 7

XOLAIR 57

XYREM 36

YERVOY 19

YF-VAX 59

zafirlukast 57

zaleplon 35

ZANOSAR 19

zarah 51

ZAVESCA 56

ZELBORAF 19

ZEMAIRA 57

ZEMPLAR 61

zenchent fe 51

ZENPEP 48

zeosa 51

ZERIT 10

ZETIA 26

ZIAGEN 10

zidovudine 10

ziprasidone hcl 35

ZIRGAN 45

ZOLINZA 19

zolpidem tartrate 36

ZOMETA 55

zonisamide 31

ZORTRESS 56

ZOSTAVAX 59

zovia 1/35e 51

zovia 1/50e 51

ZOVIRAX 60

ZYBAN 34

ZYMAXID 45

ZYPREXA 29

ZYTIGA 19

ZYVOX 7

reader’s digest value rx (pdp) · 2012-10-02 · page 2 of 79 effective: january 1, 2013 what is...

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