your 2013 prescription drug list quick-reference guide

Your 2013Prescription Drug ListQuick-Reference Guide

Oxford

Your Prescription Drug List:Helping you get the most out of your pharmacy benefit.

This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and divides them into tiers. Your costs may change depending on a medication’s tier placement. To help you better use your pharmacy benefit, this guide answers commonly asked questions about your PDL.

Go to oxfordhealth.com for complete and up-to-date PDL informationSince the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options and how the cost of medications compare.

Table of Contents

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . 6Antifungals . . . . . . . . . . . . . . . . . . . . . . 6Antivirals . . . . . . . . . . . . . . . . . . . . . . . 7

Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . 7High Blood Pressure . . . . . . . . . . . . . . 7High Cholesterol . . . . . . . . . . . . . . . . . 8Other . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . 9Depression . . . . . . . . . . . . . . . . . . . . . . 9Migraine . . . . . . . . . . . . . . . . . . . . . . .10Multiple Sclerosis . . . . . . . . . . . . . . .10Sedatives/Hypnotics . . . . . . . . . . . . .10Seizure Disorders . . . . . . . . . . . . . . .11Other . . . . . . . . . . . . . . . . . . . . . . . . . .11

Dermatology . . . . . . . . . . . . . . . . . .12

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . .13Insulin . . . . . . . . . . . . . . . . . . . . . . . . .13Non-Insulin . . . . . . . . . . . . . . . . . . . . .13

EndocrineGrowth Hormone . . . . . . . . . . . . . . . .14Other . . . . . . . . . . . . . . . . . . . . . . . . . .14

Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . .14Antibiotics . . . . . . . . . . . . . . . . . . . . . .15 Glaucoma . . . . . . . . . . . . . . . . . . . . . .15

GastrointestinalAcid Suppression . . . . . . . . . . . . . . .15Nausea/Vomiting . . . . . . . . . . . . . . . .16Other . . . . . . . . . . . . . . . . . . . . . . . . . .16

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . .16Prostate . . . . . . . . . . . . . . . . . . . . . . .16

MiscellaneousMiscellaneous . . . . . . . . . . . . . . . . . .17Overactive Bladder . . . . . . . . . . . . . .17

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . .17Pain Relief . . . . . . . . . . . . . . . . . . . . .18Rheumatoid Arthritis . . . . . . . . . . . . .18Other . . . . . . . . . . . . . . . . . . . . . . . . . .19

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . .19Nasal Allergies . . . . . . . . . . . . . . . . . .19Oral Allergies . . . . . . . . . . . . . . . . . . .20

Women’s HealthContraceptives . . . . . . . . . . . . . . . . . .20Estrogen/Progesterone . . . . . . . . . . .21Prenatal Vitamins . . . . . . . . . . . . . . . .21

Welcome to Your Prescription Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Information About Tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Prescription Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Additional Tier 3 drugs with a generic equivalent in Tier 1 . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

12013 Prescription Drug List – Oxford Traditional Three-Tier

Welcome to your 2013 Prescription Drug List (PDL)

We want to help you better understand your medication choices. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the PDL.

What is a PDL? A PDL is a list of commonly prescribed medications placed into tiers. The PDL includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). The PDL is reviewed periodically and may change. It is not a complete list of medications and not all medications listed may be covered under your plan. If you have pharmacy benefit coverage through your Oxford plan, please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. Where differences are noted between this PDL quick-reference guide and your benefit plan documents, the benefit plan documents will govern. You may also log on to oxfordhealth.com or call the Pharmacy Customer Service member telephone number on the back of your health plan ID card for more information.

How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. This guide is organized by common medical conditions. Then, within each medical condition section, medications are listed by tier. If your medication is not located in the PDL, please log on to oxfordhealth.com or call the Pharmacy Customer Service member telephone number on the back of your health plan ID card.

2 Visit oxfordhealth.com for updates

What are Tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 alternative. Discuss your options with your doctor.Check your benefit plan documents to find out your pharmacy plan costs.

Tier 1 Tier 2 Tier 3 Your lowest-cost Your midrange-cost Your highest-cost medications medications medications

When do medications change tiers? Medications may go from a lower to a higher tier once per calendar year ( January 1). When a generic medication becomes available, the tier placement of both the brand and generic medication are evaluated. Medications may change tiers with this evaluation. When a medication changes tiers, you may have to pay a different amount for that medication. These changes may occur without prior notice to you. For the most current information on your pharmacy coverage, please call the Pharmacy Customer Service member telephone number on the back of your health plan ID card or visit oxfordhealth.com.


Why are there notations (SL, N, etc.) next to certain medications in the PDL, and what do they mean? As you go through this list, you might notice some medications are noted with symbols next to them. The notations refer to our pharmacy programs. Your benefit plan determines how these medications may be covered for you but the symbols are guidelines to help you check what medications may be impacted. To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com or call the Pharmacy Customer Service member telephone number on the back of your health plan ID card. Here is a quick symbol overview:

Why is the medication that I am currently taking no longer covered? Medications may be excluded from coverage under your pharmacy benefit. For example, a medication may be excluded from coverage when it is therapeutically equivalent to another prescription medication or an over-the-counter (OTC) medication.1 There may be alternatives on the PDL or OTC medications that are right for your treatment.

Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about OTC options. These medications are not covered under your pharmacy benefit, but they may cost less than your out-of-pocket expense for prescription medications.

PDL Symbols

1/2T Eligible for Half Tablet Program

DSN Designated Specialty Network

E May be excluded from coverage

MC Multiple copayment

N Notification or precertification required*

RS May be eligible for the Refill and Save Program

SDP Select Designated Pharmacy

SL Supply limit

ST Step Therapy

*Depending on your benefit, you may have notification or prior authorization requirements for select medications.

1 This is not applicable for Connecticut Public Sector plans and plans written in New Jersey. For Connecticut commercial business and New York plans, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary.


What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients as brand-name medications, but they often cost less. After the patent on a brand-name medication expires, other companies can manufacture an FDA-approved version of the medication. These types of medications are called generic medications. Many times, the same company that makes a brand-name medication also makes the generic version.

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-tier alternative is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Check oxfordhealth.com to make sure.

Are you taking a specialty medication? Specialty medications are managed through our Specialty Pharmacy Program, which offers personalized member support. The program also offers access to on-call pharmacists available 24 hours a day, robust clinical and adherence programs, and support coaching on lower-cost medication options.2 Visit www.uhcspecialtyrx.com or call 1-866-429-8177 to learn more. Please note your specialty medication may not be listed in this guide. Please log on to oxfordhealth.com for more information.

2 Not all plans require use of the specialty network. Please refer to your Prescription Drug List Rider to determine if the Specialty Pharmacy Network is required as part of your plan.


How do I access updated information about my pharmacy benefit? Since the PDL may change, we encourage you to visit oxfordhealth.com or call the Pharmacy Customer Service member telephone number on the back of your health plan ID card for more current information.

What if I still have questions? Please call the Pharmacy Customer Service member telephone number on the back of your health plan ID card. Representatives are available 24 hours a day (except Thanksgiving and Christmas).

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in descriptive terms does not affect your benefit coverage.

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc., and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.


Please refer to page 3 for a definition of notations/symbols.

Anti-Infectives Antibiotics (Oral, inhaled and ear antibiotics are listed)

Amoxicillin Amoxicillin/Potassium

ClavulanateAmoxicillin-Clavulanate

ER NAmpicillinAzithromycin Cefadroxil CefdinirCefprozil Cefuroxime Cephalexin Ciprofloxacin

Sustained-Release 24 Hour Tablet

Ciprofloxacin TabletClarithromycin Suspension

Clarithromycin Sustained-Release Tablet

Clarithromycin TabletClindamycin HClClindamycin PalmitateDicloxacillin Sodium Doxycycline Hyclate

Enteric-Coated Tablet NDoxycycline MonohydrateDoxycycline Monohydrate

Capsule 150 mg NErythromycin Erythromycin Base

Enteric-Coated TabletLevofloxacinMetronidazole

Minocycline Extended-Release 24 Hour Tablet

Minocycline HCl Neomycin/Polymyxin/HC

OticNitrofurantoin Macrocrystal Nitrofurantoin Suspension Nitrofurantoin/Nitrofurantoin

Macrocrystal Ofloxacin Otic Penicillin V PotassiumSolodyn 45, 90, 135 mgSulfamethoxazole/

TrimethoprimTetracyclineVancomycin SL

Augmentin Cayston NCipro Suspension Ciprodex Otic

Cleocin HCl 75 mg Dapsone Ery-Tab 500 mgMacrodantin 25 mg

Tobi DSNZyvox SL

Tier 2

Adoxa NAugmentin XR NAveloxCetraxal

Cipro HCDoryx NOracea

Solodyn 55, 65, 80, 105, 115 mg

Suprax

Tier 3

Tier 1

ClotrimazoleFluconazole Itraconazole Capsule SLKetoconazole

Ketoconazole Foam SLMetronidazole Vaginal Nystatin Terbinafine Tablet SL

Terconazole VaginalVoriconazole SL

Clindesse Vaginal Noxafil Sporanox Oral SolutionTier 2

Gynazole-1 Vaginal Lamisil Granules SL Mycostatin Tier 3

Tier 1

Anti-Infectives Antifungals (Oral and topical antifungals are listed)



Anti-Infectives Antivirals

Cardiovascular/Heart Disease Coagulation Therapy

Cardiovascular/Heart Disease High Blood Pressure

Acyclovir Amantadine

Famciclovir SLRibapak DSN N

Ribavirin DSN NValacyclovir SL

Baraclude DSNEpivir HBV DSN

Hepsera DSN Incivek DSN N SL

Rebetol Solution DSN NValcyte SL

Tier 2

Relenza SL Tamiflu SL Victrelis DSN N SLTier 3

Tier 1

CilostazolClopidogrel

Enoxaparin SL Fondaparinux SL

PentoxifyllineWarfarin Sodium

Coumadin Xarelto SLTier 2

AggrenoxEffient SL

Fragmin SLInnohep SL

Pradaxa SLTier 3

Tier 1

AmlodipineAmlodipine/Benazepril SLAtenolol Atenolol/ChlorthalidoneBenazepril Benazepril/

HydrochlorothiazideBisoprololBisoprolol/

Hydrochlorothiazide Bumetanide Captopril Captopril/

Hydrochlorothiazide Carvedilol Chlorthalidone ClonidineClonidine Transdermal

Weekly Patch SL Diltiazem Diltiazem Controlled-Release

CapsuleDiltiazem Sustained-Action

CapsuleDiltiazem Sustained-Release

12 Hour CapsuleDiltiazem Sustained-Release

24 Hour Capsule

Diltiazem Sustained-Release 24 Hour Tablet

Doxazosin EnalaprilEnalapril/Hydrochlorothiazide Eplerenone Eprosartan SLFelodipine FurosemideGuanfacine Hydralazine Hydrochlorothiazide Irbesartan 1/2T SLIrbesartan/

Hydrochlorothiazide SLLabetalol Lisinopril Lisinopril/

HydrochlorothiazideLosartan 1/2TLosartan/

HydrochlorothiazideMetolazoneMetoprolol Succinate

Sustained-Release TabletMetoprolol Tartrate Metoprolol/

Hydrochlorothiazide

Moexipril 1/2TNadolol Nifedipine Nisoldipine Perindopril Erbumine 1/2TPropranolol Propranolol

Sustained-Action CapsulePropranolol/

HydrochlorothiazideQuinapril/

Hydrochlorothiazide Ramipril Spironolactone Spironolactone/

HydrochlorothiazideTerazosin TorsemideTrandolapril 1/2TTrandolapril/VerapamilTriamterene/

Hydrochlorothiazide Verapamil Verapamil Sustained-Release

24 Hour Pellets

Tier 1



Cardiovascular/Heart Disease High Blood Pressure (cont. from page 7)

Aceon 1/2TAmturnide N SLAtacand 1/2T SDP SLAtacand HCT SDP SLAvalide SLAvapro 1/2T SLAzor SLCardizem LA 180, 240, 300,

360, 420 mg

Coreg CR N SLDiovan 1/2T SLDiovan HCT SLEdarbi SLEdarbyclor SLExforge N SLExforge HCT N SLNexiclon XR NSular

Tekamlo N SLTekturna SDP SLTekturna HCT SDP SLTeveten HCT SLTribenzor N SLTwynsta N SL

Tier 3

Cardiovascular/Heart Disease High Cholesterol

Amlodipine/ Atorvastatin N SL

Atorvastatin 1/2T SLCholestyramine

Colestipol Fenofibrate Fenofibric AcidFluvastatin SL

Gemfibrozil Lovastatin Pravastatin 1/2TSimvastatin 1/2T

Tier 1

Antara Crestor 1/2T SL

Lipofen Welchol

Tier 2

Advicor SL Altoprev N SLCaduet N SLFenoglideLescol XL SL

Lipitor 1/2T N SLLivalo SLLovaza NNiaspan Simcor SL

Tricor N Triglide Trilipix NVytorin SLZetia SL

Tier 3

Aldactazide 50-50 mg Benicar 1/2T SLBenicar HCT SLBiDilBystolic

Cardizem LA 120 mgClorpresDibenzyline Diuril Suspension

250 mg/5 ml

Dutoprol SLMicardis SLMicardis HCT SLThalitone

Tier 2



Central Nervous System Attention Deficit Disorder

Central Nervous System Depression

Cardiovascular/Heart Disease Other

AmiodaroneDigoxinFlecainide AcetateIsosorbide DinitrateIsosorbide Mononitrate

MexiletineNitroglycerinNitroglycerin

Transdermal PatchNitroglycerin Spray N SL

Propafenone Sustained-Release 12 Hour Capsule

Sotalol

Tier 1

LanoxinMultaq

NitrostatRanexa

Tier 2

Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Sustained-Release 24 Hour Capsule SL

Amphetamine Salt Combo

Dextroamphetamine Sulfate Methamphetamine MethylphenidateMethylphenidate

Extended-Release 24 Hour Tablet SL

Methylphenidate Extended-Release Capsule SL

Tier 1

Intuniv SL Vyvanse SLTier 2

Adderall XR SLConcerta SLDaytrana SL

Focalin XR SLKapvay NMetadate CD SL

Methylin TabletRitalin LA SLStrattera SL

Tier 3

Amitriptyline BupropionBupropion XLCitalopram Hydrobromide Doxepin Escitalopram 1/2T SL FluoxetineFluoxetine Delayed-Release

Capsule SL

Fluvoxamine Maleate Mirtazapine Nefazodone Nortriptyline Paroxetine

Sustained-Release 24 Hour Tablet SL

Paroxetine Tablet Phenelzine

Sertraline 1/2TTrazodone Venlafaxine

Extended-Release Tablet N SL

Venlafaxine Sustained-Release Capsule SL

Tier 1

Aplenzin N SLCymbalta SDP SLLexapro 1/2T SL

Luvox CR SLOleptro N SLPexeva 1/2T SL

Pristiq RS SLTier 3

Nitrolingual N SL Nitromist SLTier 3



Central Nervous System Migraine

Central Nervous System Multiple Sclerosis

Acetaminophen/Butalbital/Caffeine SL

Acetaminophen/Dichloralphenazone/Isometheptene Mucate

Aspirin/Butalbital/CaffeineNaratriptan SLRelpax SLSumatriptan Succinate

Injection, Tablet SL

Sumatriptan Succinate Nasal Spray SL

Tier 1

ErgomarTier 2

Alsuma N SLAxert SDP SLCafergot Cambia N SLFrova SDP SL

Maxalt SDP SLMaxalt MLT SDP SLMigranalSumavel DosePro SLTreximet N SL

Zomig SDP SLZomig Nasal Spray SL Zomig ZMT SDP SL

Tier 3

Ampyra DSN N SLAvonex DSN N SL

Copaxone DSN N SLRebif DSN N SL

Tier 2

Betaseron DSN SL ST Extavia DSN SL ST Gilenya DSN SL STTier 3

Central Nervous System Sedatives/Hypnotics

Temazepam Zaleplon SL

Zolpidem Multiphasic-Release Tablet SL ST

Zolpidem Tablet SLTier 1

Ambien SL STAmbien CR SL STEdluar SL ST

Lunesta SL STRozerem SL STSilenor N SL

Sonata SL STZolpimist SL ST

Tier 3



Central Nervous System Other

Central Nervous System Seizure Disorders

Carbamazepine Carbamazepine

Extended-Release 12 Hour Capsule

Carbamazepine Sustained-Release 12 Hour Tablet

Clonazepam Diazepam Rectal Gel SL

Divalproex Sodium Sprinkle Capsule

Divalproex Sodium Sustained-Release Tablet

Divalproex Sodium TabletFelbamateGabapentinLamotrigine Levetiracetam

Levetiracetam Extended-Release 24 Hour Tablet ST

Oxcarbazepine Phenobarbital Phenytoin SodiumPrimidone Topiramate Zonisamide

Tier 1

Celontin DilantinGabitril

Mysoline Peganone Sabril

TegretolTier 2

CarbatrolDepakote ER STKeppra STKeppra XR ST

Lamictal STLamictal Dose Pack SL STLamictal ODT ST Lamictal XR ST

Lyrica SDP SLStavzor STTopamax ST

Tier 3

AlprazolamBenztropine MesylateBuspirone Carbidopa/Levodopa ClozapineDiazepam Donepezil 5, 10 mgGalantamineLithium Carbonate

Lithium Carbonate Controlled-Release Tablet

Lorazepam Modafinil N SLOlanzapine Rapid Dissolve

Tablet SLOlanzapine Tablet SLOlanzapine/Fluoxetine SLPramipexole

Quetiapine SLRisperidoneRivastigmine RopiniroleRopinirole Extended-Release

24 Hour Tablet NZiprasidone SL

Tier 1

Apokyn DSN Comtan

FazaCloNuedexta

Tasmar Xyrem N SL

Tier 2

Abilify 1/2T SLAricept 23 mg NExelon SolutionFanapt SLGeodon SLInvega SL

Mirapex ER NNamendaNuvigil N SLProvigil N SLRequip XL NSeroquel SL

Seroquel XR SLSymbyax SLZyprexa SL Zyprexa Zydis SL

Tier 3



Dermatology

Adapalene N SL Alclometasone DipropionateBetamethasone DipropionateBetamethasone ValerateCalcipotriene Cream,

Ointment SLCiclopirox Cream, Gel,

Lotion Ciclopirox Non-Oral SolutionCiclopirox Shampoo 1% Clindamycin Foam 1% SLClindamycin Gel, Lotion,

Solution, SwabsClindamycin Phosphate/

Benzoyl Peroxide Extended-Release Gel N SL

Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% SL

Clobetasol PropionateClobetasol Propionate

Foam SLClobetasol Propionate

Lotion SLClobetasol Propionate

Shampoo N SLClotrimazole/BetamethasoneDesonide Desoximetasone Econazole Nitrate ErythromycinErythromycin/Benzoyl

PeroxideFluocinolone FluocinonideFluticasone PropionateFluticasone Propionate

LotionHalobetasol Propionate

HydrocortisoneHydrocortisone ValerateImiquimod SLIsotretinoin KetoconazoleLidocaineMetronidazole Gel 0.75%Mometasone FuroateMupirocinNystatin Nystatin/Triamcinolone

Acetonide PermethrinSilver SulfadiazineSulfacetamide Sodium/

Sulfur Tretinoin NTriamcinolone AcetonideUrea

Tier 1

Azelex SLBenzamycin

Oxsoralen-Ultra Protopic N SL

Regranex NStelara DSN N SL

Tier 2

Acanya SLAczone SLAltabax SLAtralin N SLAvita Gel N SL Bactroban SLBenzaclin Gel 1%-5% SLClindagel N SLClobex SLClobex Shampoo N SLCondylox Gel Cutivate LotionDenavirDesonate SLDifferin Cream,

Gel 0.1% N SLDifferin Gel 0.3% N SL

Differin Lotion N SLDovonex SLDuac SLElidel N SL Epiduo N SLEvoclin SLFinaceaFinacea PlusLocoid Lipocream SL Locoid Lotion SLLoprox ShampooMetrogel 1% NMetrolotion NaftinNoritateOlux-E SLOxistat

Retin-A Micro N SLTaclonex SLTaclonex Scalp SLTazorac N SLTretin-X N SLVanos SLVectical SLVeltin N SLVerdeso SLVusionXerese NXolegelZiana N SLZovirax SLZyclara N SL

Tier 3



Diabetes/Endocrine Blood Glucose Monitoring

Accu-Chek Active Test Strips SL

Accu-Chek Aviva PlusAccu-Chek Aviva Plus

Test Strips SLAccu-Chek Comfort Curve

Test Strips SL

Accu-Chek Compact Test Strips SL

Accu-Chek Nano SmartViewAccu-Chek SmartView Test

Strip SL One Touch Test Strips SLOne Touch Ultra 2 System

One Touch Ultra Mini System One Touch Ultra Test

Strips SLOne Touch Verio IQ SystemOne Touch Verio IQ Test

Strips SL

Tier 1

Ascensia Autodisc Test Strips SL

Ascensia Breeze 2 Test Strips SL

Contour Test Strips SLFreestyle Lite Test Strips SLFreestyle Test Strips SLPrecision Xtra Test Strips SL

Tier 3

Diabetes/Endocrine Insulin

Humalog VialsHumalog-Mix Vials

Humulin 70-30 Vials Humulin Vials

Tier 1

Humalog KwikPenHumalog-Mix KwikPen

Humulin KwikPen Lantus Vials

Levemir VialsTier 2

Apidra SolostarApidra Vial

Lantus Solostar Pens/Cartridges

Levemir Flexpen

Novolin VialsNovoLog

Tier 3

Diabetes/Endocrine Non-Insulin

Acarbose Glimepiride Glipizide Glipizide/Metformin Glyburide

Glyburide/Metformin Metformin Metformin Extended-Release

24 Hour TabletNateglinide SL

Pioglitazone 1/2T SLPioglitazone/Metformin SL

Tier 1

Byetta SLDuetact SLGlyset

Jentadueto SL Kombiglyze XR SLOnglyza SL

Prandin SLTradjenta SL

Tier 2

Actoplus Met SLActoplus Met XR SLActos 1/2T SLAvandamet SLAvandaryl SL

Avandia SLFortametGlumetzaJanumet SLJanumet XR SL

Januvia SLJuvisync SL Symlin SLVictoza SL

Tier 3

Note: Diabetic supplies and prescription medications may be subject to different cost share arrangements. Please see your Member Summary of Benefits for specifics.



Eye Conditions Allergies

Azelastine HCl SL Epinastine N SL Ketorolac TromethamineTier 1

Bepreve E SLElestat N SL Emadine N

Lastacaft SLOptivar E SL Pataday N SL

Patanol N SLTier 3

Endocrine Growth Hormone

Nutropin, AQ, NuSpin DSN N SL

Saizen DSN N SLSerostim DSN N SL

Tev-Tropin DSN N SLTier 2

Genotropin DSN N SLHumatrope DSN N SL

Norditropin DSN N SLOmnitrope DSN N SL

Zorbtive DSN N SLTier 3

Endocrine Other

Cabergoline Calcitriol Desmopressin Dexamethasone Fludrocortisone Hydrocortisone Tablet

Levothyroxine Sodium LevoxylLiothyronine Sodium Methimazole Methylprednisolone Dosepak

Tablet 4 mg

Octreotide Acetate DSN N Orapred Oxandrolone Prednisolone Prednisone Testosterone

Tier 1

Androderm SL Android Hectorol Kuvan DSN N SL

Medrol 2, 8, 24, 32 mg Pediapred Synarel Synthroid

Testim SLTirosintZemplar DSN

Tier 2

Androgel N SLArmour Thyroid

Axiron N SLFortesta N SL

Orapred ODTTier 3



Eye Conditions Glaucoma

Gastrointestinal Acid Suppression

Eye Conditions Antibiotics

CiprofloxacinErythromycinGentamicin SulfateLevofloxacin

Neomycin/Polymyxin B Sulfate/Dexamethasone

OfloxacinPolymyxin B Sulfate/

Trimethoprim

Sulfacetamide SodiumTobramycin Sulfate DropsTobramycin/Dexamethasone

Tier 1

Blephamide S.O.P. Tier 2

Azasite SLMoxeza

Tobradex ST N SLVigamox

ZyletZymaxid SL

Tier 3

Acetazolamide ApraclonidineBrimonidine Tartrate SL

Dorzolamide HClDorzolamide HCl/Timolol

Maleate

Latanoprost SLTimolol Maleate

Tier 1

Alphagan P 0.1% SLAzopt SLBetimol SL

Combigan SLLumigan SLPilopine HS

Travatan Z SLTier 2

Iopidine 1%Tier 3

CimetidineLansoprazole N SL MisoprostolNizatidine Oral Solution

Omeprazole Omeprazole/Sodium

Bicarbonate Capsule E SLPantoprazole

Ranitidine SyrupSucralfate Tablet

Tier 1

Helidac Prevpac SL PyleraTier 2

Aciphex SLCarafate Oral SuspensionDexilant SLNexium Capsule N SLNexium Suspension

Prevacid Delayed-Release Enteric-Coated Capsule N SL

Prevacid Solutab N SLPrilosec Rx 10, 20 mg E

Prilosec Rx 40 mg E Protonix Granules SLZegerid Capsule E SL Zegerid Packet SL

Tier 3



Gastrointestinal Other

Gastrointestinal Nausea/Vomiting

Men’s Health Prostate

Men’s Health Erectile Dysfunction

Granisetron Tablet SL Ondansetron Prochlorperazine MaleateTier 1

Emend SLTier 2

Anzemet SLCesamet

Sancuso N SLTransderm-Scop

Zuplenz N SLTier 3

BalsalazideBelladonna/PhenobarbitalBudesonide

Extended-Release 24 Hour Capsule

Chlordiazepoxide/ClidiniumDiphenoxylate/AtropineLactuloseMesalamineMetoclopramide

Polyethylene GlycolSulfasalazineTrilyte with Flavor PacketsUrsodiol

Tier 1

AprisoCanasaCreon

GoLYTELY PacketLialdaLotronex SL

RelistorZenpep

Tier 2

Amitiza N SLAsacol SDPAsacol HD N SDP

DipentumHalflytely-BisacodylMetozolv ODT N

MoviprepPancreaze SDP Pentasa

Tier 3

Caverject N SLCialis N SLEdex N SL

Levitra N SLMuse N SLStaxyn N SL

Viagra N SLTier 3

AlfuzosinDoxazosin

Finasteride Tamsulosin

TerazosinTier 1

Avodart N SDP Jalyn N RapafloTier 3



Miscellaneous Overactive Bladder

Miscellaneous

Musculoskeletal Osteoporosis

Anastrozole Antipyrine/BenzocaineAzathioprineBenzonatateBromfenac SLChlorhexidine Gluconate

ExemestaneHydrocodone/

Chlorpheniramine Suspension SL

LetrozoleMegestrol Acetate

Mycophenolate Capsule, Tablet DSN

PhenazopyridineTacrolimus DSNTamoxifen

Tier 1

Cellcept Suspension DSNEpipen SLEpipen Jr SLFareston

Lidoderm SLLysteda SLMyfortic DSNNeoral DSN

Pegasys DSN N SLRapamune DSNSandimmune DSN

Tier 2

Acuvail N SLAromasinBromday N SL

Infergen DSN N SLIntron A DSN NPeg-Intron DSN SL ST

Restasis N SLTussionex SL

Tier 3

Dicyclomine Tablet Hyoscyamine Sulfate

OxybutyninTolterodine

TrospiumTier 1

GelniqueOxytrol

Sanctura XR Vesicare

Tier 2

Detrol SDPDetrol LA N

Enablex Toviaz SDP

Tier 3

Alendronate SL Calcitonin Salmon Nasal Spray

ForticalIbandronate Tablet SL

Tier 1

Evista Forteo DSN NTier 2

Actonel SL Atelvia N SL Fosamax Plus D SLTier 3



Musculoskeletal Pain Relief

Acetaminophen/Butalbital/Caffeine/Codeine SL

Acetaminophen/Codeine SLAcetaminophen/

Hydrocodone Bit SLAcetaminophen/

Oxycodone SLAspirin/Butalbital/Caffeine/

CodeineAspirin/OxycodoneButorphanol Nasal Spray SLDiclofenac Potassium Diclofenac Sodium Etodolac Fentanyl Citrate

Lollipop N SLFentanyl Transdermal SLHydromorphone

Ibuprofen Ibuprofen/HydrocodoneIbuprofen/OxycodoneIndomethacin Ketorolac Tromethamine Mefenamic Acid Meloxicam Meperidine Methadone Morphine SulfateMorphine Sulfate

Extended-Release Pellets SL

Morphine Sulfate Sustained-Action Tablet SL

NabumetoneNaproxenNaproxen Sodium

Oxaprozin Oxycodone Oxymorphone SLOxymorphone

Extended-Release 12 Hour Tablet SL

Piroxicam Sulindac Tolmetin Sodium Tramadol Tramadol Extended-Release

Multiphase 24 Hour Tablet SL

Tramadol Sustained-Release 24 Hour Tablet SL

Tramadol/Acetaminophen SL

Tier 1

Codeine Phosphate MSIR Capsule

Opana ER SLOxyContin SL

Voltaren GelTier 2

Abstral N SLArthrotecAvinza SLCelebrex SLConzip N SL Duexis N SL Duragesic SLEmbeda SLExalgo SL

Fentora N SLFlector NHycet SLKadian N SLLazanda N SLNaprelan N Nucynta SL Nucynta ER SL Onsolis N SL

Opana SLPennsaid NRybix ODT N SLRyzolt N SLSprix SLVimovo N SLZipsor N

Tier 3

Musculoskeletal Rheumatoid Arthritis

Azathioprine Hydroxychloroquine Sulfate

Leflunomide Methotrexate

SulfasalazineTier 1

Cimzia DSN N SLCuprimine

Enbrel DSN N SL Simponi DSN N SL

TrexallTier 2

Humira DSN SL ST Kineret DSN N SL Orencia DSN N SLTier 3



Musculoskeletal Other

Respiratory Asthma/COPD

Respiratory Nasal Allergies

AllopurinolBaclofenCarisoprodol 250 mg NCarisoprodol 350 mgCyclobenzaprine

Cyclobenzaprine Extended-Release 24 Hour Capsule N

MetaxaloneMethocarbamol

Orphenadrine Orphenadrine/Aspirin/

Caffeine Tizanidine

Tier 1

ColcrysTier 2

Amrix NGralise N SLHorizant N SL

Savella SLSkelaxin NSoma 250 mg N

Uloric SLTier 3

Albuterol Sulfate Albuterol Sulfate/Ipratropium

Non-Oral SolutionAlvesco SLAsmanex SL

Budesonide Inhalation Suspension 0.25 mg/ 2 ml, 0.5 mg/2 ml SL

Ipratropium BromideLevalbuterol Vial,

Nebulizer N SL

Montelukast SLQVAR SLTheophylline Ventolin HFA SLZafirlukast SL

Tier 1

Foradil SL Pulmicort Respules 1 mg/2 ml SL

Spiriva SLTier 2

Advair Diskus RS SLAdvair HFA RS SLAtrovent HFA SLCombivent SLCombivent Respimat SLDaliresp N SLDulera RS SL

Flovent Diskus SDP SLFlovent HFA SDP SLMaxair Autohaler SLPerforomist SLProair HFA SLProventil HFA SLPulmicort Flexhaler SDP SL

Serevent Diskus SLSingulair SLSymbicort SDP SLXopenex HFA SLXopenex Vial,

Nebulizer N SL

Tier 3

Azelastine HCl SLFlunisolide

Fluticasone Propionate SLTriamcinolone Acetonide SL

Tier 1

Nasonex SLTier 2

Astelin N SLAstepro SLBeconase AQ SL

Nasacort AQ SLOmnaris SLPatanase SL

Rhinocort Aqua SLVeramyst N SL

Tier 3



Respiratory Oral Allergies

CyproheptadineDesloratadine N SL

HydroxyzineLevocetirizine SL

PromethazineTier 1

Clarinex N SL Clarinex-D N SLTier 3

Women’s Health Contraceptives

AltaveraAlyacen 7/7/7 Amethia MCAmethia Lo MCAmethystApriAranelle AvianeAzuretteBalzivaBriellyn CamilaCamrese MCCamrese Lo MCCaziant CryselleCyclafem 1/35Cyclafem 7/7/7Ella SLEmoquette EnpresseErrinGianviGildess FEHeatherIntrovale MCJolessa MCJolivetteJunel

Junel FeKarivaKelnorLeenaLessinaLevoraLorynaLow-OgestrelLuteraMarlissa Medroxyprogesterone

150 mg/ml MCMicrogestinMicrogestin FeMononessa Myzilra NataziaNecon 0.5/35Necon 1/35Necon 1/50Necon 7/7/7Necon 10/11Next Choice One Dose Nora-BeNorethindrone Nortrel 0.5/35 Nortrel 1/35Nortrel 7/7/7Ocella

OgestrelOrsythia Philith Plan BPortiaPrevifemQuasense MCReclipsenSprintecSronyx SyedaTilia FeTri-Legest FeTri-PrevifemTri-SprintecTrinessa TrivoraVelivet VesturaViorele Wymzya Fe Zarah ZenchentZenchent FeZeosa Zovia 1/35EZovia 1/50E

Tier 1

Depo-SubQ Provera MC NuvaRingTier 2

Beyaz NFemcon FeGeneress Fe NLo Loestrin FeLoestrin 24 Fe

Ortho EvraOrtho MicronorOrtho Tri-Cyclen Ortho Tri-Cyclen LoOrtho-Cyclen

Ortho-Novum 7/7/7Safyral NYasminYaz

Tier 3



Women’s Health Estrogen/Progesterone

Women’s Health Prenatal Vitamins

EstradiolEstradiol/Norethindrone

AcetateEstradiol Transdermal

Weekly Patch SL

Estropipate Medroxyprogesterone Norethindrone AcetateProgesterone Micronized

Capsule

Tier 1

Cenestin Climara SLCrinone NDivigel

Enjuvia Estrace Cream with

ApplicatorEstring SL

EvamistPrefest VagifemVivelle-Dot SL

Tier 2

ActivellaAlora SLClimara Pro SLCombipatch SLEstrasorb SLEstrogel SL

FemhrtFemring SLFirst-Progesterone NMenostar Transdermal

Weekly Patch SLPremarin

PremphasePrempro

Tier 3

Advanced Care PlusCavan-EC Sod DHAFolcal DHAFolic AcidMulti-Nate 30Multinatal Plus

PR Natal 430PR Natal 430 ECPrenatal 19Prenatal AdvantagePrenatal PlusSetonet

Setonet-ECTaron A PrenatalZatean-PNZatean-PN DHAZatean-PN Plus

Tier 1

Brand Prenatal VitaminsTier 3



Accolate SL (Zafirlukast SL)Accupril (Quinapril)Acular (Ketorolac

Tromethamine)Adderall (Amphetamine/

Dextroamphetamine Salt Combination)

Aldactone (Spironolactone)Altace (Ramipril)Amaryl (Glimepiride)Ambien SL ST

(Zolpidem SL)Amerge SL (Naratriptan SL)Anaprox (Naproxen)Aricept (Donepezil)Arimidex (Anastrozole)Ativan (Lorazepam)Augmentin ES (Amoxicillin/

Potassium Clavulanate)Biaxin Tablet (Clarithromycin

Tablet)Buspar (Buspirone)Calan, Calan SR (Verapamil)Cardizem CD except for

360 mg strength (Diltiazem Capsule, Sustained-Release 24 Hour)

Cardura (Doxazosin)Ceftin (Cefuroxime)Cefzil (Cefprozil)Celexa (Citalopram)Ciloxan Eye Drops

(Ciprofloxacin)Cipro (Ciprofloxacin)Cleocin T (Clindamycin Gel,

Lotion, Solution, Swabs)Clozaril (Clozapine)Colazal (Balsalazide)Colestid (Colestipol)Coreg (Carvedilol)Cozaar 1/2T (Losartan 1/2T)DDAVP (Desmopressin)Depakote (Divalproex Sodium

Tablet)Depakote ER ST (Divalproex

Sodium Sustained-Release 24 Hour Tablet)

Depo-Provera MC (Medroxyprogesterone 150 mg/ml MC)

Derma-Smoothe/FS (Fluocinolone)

DiaBeta, Glynase (Glyburide)

Diastat Acudial SL (Diazepam Rectal Gel SL)

Didronel (Etidronate Disodium)

Diflucan (Fluconazole) Ditropan XL (Oxybutynin

Sustained-Release Tablet)Dyazide (Triamterene/

Hydrochlorothiazide)Effexor (Venlafaxine)Effexor XR SL (Venlafaxine

Sustained-Release Capsule SL)

Felbatol (Felbamate)Femara (Letrozole)Fioricet SL (Acetaminophen/

Butalbital/Caffeine SL)Flomax (Tamsulosin)Flonase SL (Fluticasone

Nasal Spray SL)Fosamax SL

(Alendronate SL)Glucophage, XR (Metformin)Glucotrol, XL (Glipizide)Glucovance (Glyburide/

Metformin)Hyzaar SL (Losartan/

Hydrochlorothiazide SL)Imitrex SL (Sumatriptan

Succinate Injection, Tablet SL)

Keflex (Cephalexin)Keppra ST (Levetiracetam)Klonopin (Clonazepam)Lamictal ST (Lamotrigine)Lamisil SL (Terbinafine

Tablet SL)Lasix (Furosemide)Levaquin (Levofloxacin)Lipitor 1/2T N SL

(Atorvastatin 1/2T SL)Lopid (Gemfibrozil)Lopressor (Metoprolol)Mavik 1/2T (Trandolapril 1/2T)Medrol (Methylprednisolone

Dosepak Tablet 4 mg)Metrogel Vaginal

(Metronidazole)Mevacor (Lovastatin)Mobic (Meloxicam)Monopril (Fosinopril)Naprosyn (Naproxen) -

Prescription strengths only

Nardil (Phenelzine)Neurontin (Gabapentin)Norvasc (Amlodipine)Ocuflox Eye Drops

(Ofloxacin)Paxil (Paroxetine)Penlac (Ciclopirox Solution,

Non-Oral)Percocet 5-325, 7.5-500,

10-650 SL (Acetaminophen/Oxycodone SL)

Plavix (Clopidogrel)Pletal (Cilostazol)Pravachol 1/2T

(Pravastatin 1/2T)Precose (Acarbose)Prilosec (Omeprazole)Prinivil, Zestril (Lisinopril)Prinzide, Zestoretic

(Lisinopril/Hydrochlorothiazide)

Procardia XL (Nifedipine Extended-Release Tablet)

Proscar (Finasteride)Protonix (Pantoprazole)Provera

(Medroxyprogesterone)Prozac (Fluoxetine Capsule)Prozac Weekly SL (Fluoxetine

Delayed-Release Capsule SL)

Remeron (Mirtazapine)Remeron SolTab (Mirtazapine

Dispersible Tablet)Requip (Ropinirole)Restoril (Temazepam)Risperdal (Risperidone)Ritalin (Methylphenidate)Ritalin SR (Methylphenidate

Extended-Release Tablet)Sonata SL ST (Zaleplon SL)Surmontil (Trimipramine

Maleate)Tenoretic (Atenolol/

Chlorthalidone)Tenormin (Atenolol)Teveten SL (Eprosartan SL)Tiazac (Diltiazem)Topamax ST (Topiramate)Toprol XL 25 mg

(Metoprolol Succinate Sustained-Release Tablet)

Additional Tier 3 Drugs with a generic equivalent in Tier 1



Trileptal (Oxcarbazepine)Trusopt (Dorzolamide Eye

Drops)Tylenol #3 SL

(Acetaminophen/ Codeine SL)

Ultracet SL (Tramadol/Acetaminophen SL)

Ultram (Tramadol)Uroxatral (Alfuzosin)Valium (Diazepam)Vaseretic (Enalapril/

Hydrochlorothiazide)Vasotec (Enalapril)Vfend SL (Voriconazole SL)

Vicodin SL, Vicodin ES SL (Acetaminophen/Hydrocodone SL)

Vicoprofen (Ibuprofen/Hydrocodone)

Voltaren Tablet (Diclofenac)Wellbutrin (Bupropion HCl)Wellbutrin SR (Bupropion

HCl Sustained-Action Tablet)

Wellbutrin XL (Bupropion HCl Sustained-Release 24 Hour Tablet)

Xalatan SL (Latanoprost SL)

Xanax, Xanax XR (Alprazolam)

Zantac Syrup (Ranitidine Syrup)

Ziac (Bisoprolol/Hydrochlorothiazide)

Zithromax (Azithromycin)Zocor 1/2T (Simvastatin 1/2T)Zofran (Ondansetron)Zoloft 1/2T (Sertraline 1/2T)Zonegran (Zonisamide)Zovirax (Acyclovir Capsule,

Suspension, Tablet)

Additional Tier 3 Drugs with a generic equivalent in Tier 1 (cont. from page 22)


AAbilify 11Abstral 18Acanya 12Acarbose 13, 22Accolate 22Accu-Chek Active Test Strips 13Accu-Chek Aviva Plus 13Accu-Chek Aviva Plus Test Strips 13Accu-Chek Comfort Curve Test Strips 13Accu-Chek Compact Test Strips 13Accu-Chek Nano SmartView 13Accu-Chek SmartView Test Strip 13Accupril 22Aceon 8Acetaminophen/Butalbital/Caffeine 10, 18, 22Acetaminophen/Butalbital/Caffeine/Codeine 18Acetaminophen/Codeine 18, 23Acetaminophen/Dichloralphenazone/Isometheptene Mucate 10Acetaminophen/Hydrocodone 18, 23Acetaminophen/Hydrocodone Bit 18Acetaminophen/Oxycodone 18, 22Acetazolamide 15Aciphex 15Activella 21Actonel 17Actoplus Met 13Actoplus Met XR 13Actos 13Acular 22Acuvail 17Acyclovir 7, 23Acyclovir Capsule, Suspension, Tablet 23Aczone 12Adapalene 12Adderall 9, 22Adderall XR 9Adoxa 6Advair Diskus 19Advair HFA 19Advanced Care Plus 21Advicor 8Aggrenox 7Albuterol Sulfate 19

Albuterol Sulfate/Ipratropium Non-Oral Solution 19Alclometasone Dipropionate 12Aldactazide 50-50 mg 8Aldactone 22Alendronate 17, 22Alfuzosin 16, 23Allopurinol 19Alora 21Alphagan P 0.1% 15Alprazolam 11, 23Alsuma 10Altabax 12Altace 22Altavera 20Altoprev 8Alvesco 19Alyacen 7/7/7 20Amantadine 7Amaryl 22Ambien 10, 22Ambien CR 10Amerge 22Amethia 20Amethia Lo 20Amethyst 20Amiodarone 9Amitiza 16Amitriptyline 9Amlodipine 7-8, 22Amlodipine/Atorvastatin 8Amlodipine/Benazepril 7Amoxicillin 6, 22Amoxicillin-Clavulanate ER 6Amoxicillin/Potassium Clavulanate 6, 22Amphetamine/Dextroamphetamine Salt Combination 22Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Sustained-Release 24 Hour Capsule 9Amphetamine Salt Combo 9Ampicillin 6Ampyra 10Amrix 19Amturnide 8Anaprox 22Anastrozole 17, 22Androderm 14Androgel 14Android 14Antara 8Antipyrine/Benzocaine 17Anzemet 16Apidra Solostar 13Apidra Vial 13

Aplenzin 9Apokyn 11Apraclonidine 15Apri 20Apriso 16Aranelle 20Aricept 11, 22Aricept 23 mg 11Arimidex 22Armour Thyroid 14Aromasin 17Arthrotec 18Asacol 16Asacol HD 16Ascensia Autodisc Test Strips 13Ascensia Breeze 2 Test Strips 13Asmanex 19Aspirin/Butalbital/Caffeine 10, 18Aspirin/Butalbital/Caffeine/Codeine 18Aspirin/Oxycodone 18Astelin 19Astepro 19Atacand 8Atacand HCT 8Atelvia 17Atenolol 7, 22Atenolol/Chlorthalidone 7, 22Ativan 22Atorvastatin 8, 22Atralin 12Atrovent HFA 19Augmentin 6, 22Augmentin ES 22Augmentin XR 6Avalide 8Avandamet 13Avandaryl 13Avandia 13Avapro 8Avelox 6Aviane 20Avinza 18Avita Gel 12Avodart 16Avonex 10Axert 10Axiron 14Azasite 15Azathioprine 17-18Azelastine HCl 14, 19Azelex 12Azithromycin 6, 23Azopt 15Azor 8Azurette 20

Index


BBaclofen 19Bactroban 12Balsalazide 16, 22Balziva 20Baraclude 7Beconase AQ 19Belladonna/Phenobarbital 16Benazepril 7Benazepril/Hydrochlorothiazide 7Benicar 8Benicar HCT 8Benzaclin Gel 1%-5% 12Benzamycin 12Benzonatate 17Benztropine Mesylate 11Bepreve 14BetamethasoneDipropionate 12Betamethasone Valerate 12Betaseron 10Betimol 15Beyaz 20Biaxin Tablet 22BiDil 8Bisoprolol 7, 23Bisoprolol/Hydrochlorothiazide 7, 23Blephamide S.O.P. 15Brand Prenatal Vitamins 21Briellyn 20Brimonidine Tartrate 15Bromday 17Bromfenac 17Budesonide Extended-Release 24 Hour Capsule 16Budesonide Inhalation Suspension 0.25 mg/2 ml, 0.5 mg/2 ml 19Bumetanide 7Bupropion 9, 23Bupropion HCl 23Bupropion HCl Sustained-Action Tablet 23Bupropion HCl Sustained-Release 24 Hour Tablet 23Bupropion XL 9Buspar 22Buspirone 11, 22Butorphanol Nasal Spray 18Byetta 13Bystolic 8CCabergoline 14Caduet 8Cafergot 10Calan, Calan SR 22

Calcipotriene Cream, Ointment 12Calcitonin Salmon Nasal Spray 17Calcitriol 14Cambia 10Camila 20Camrese 20Camrese Lo 20Canasa 16Captopril 7Captopril/Hydrochlorothiazide 7Carafate Oral Suspension 15Carbamazepine 11Carbamazepine Extended-Release 12 Hour Capsule 11Carbamazepine Sustained-Release 12 Hour Tablet 11Carbatrol 11Carbidopa/Levodopa 11Cardizem CD except for 360 mg strength 22Cardizem LA 120 mg 8Cardizem LA 180, 240, 300, 360, 420 mg 8Cardura 22Carisoprodol 250 mg 19Carisoprodol 350 mg 19Carvedilol 7, 22Cavan-EC Sod DHA 21Caverject 16Cayston 6Caziant 20Cefadroxil 6Cefdinir 6Cefprozil 6, 22Ceftin 22Cefuroxime 6, 22Cefzil 22Celebrex 18Celexa 22Cellcept Suspension 17Celontin 11Cenestin 21Cephalexin 6, 22Cesamet 16Cetraxal 6Chlordiazepoxide/Clidinium 16Chlorhexidine Gluconate 17Chlorthalidone 7, 22Cholestyramine 8Cialis 16Ciclopirox Cream, Gel, Lotion 12Ciclopirox Non-Oral Solution 12Ciclopirox Shampoo 1% 12

Ciclopirox Solution, Non-Oral 22Cilostazol 7, 22Ciloxan Eye Drops 22Cimetidine 15Cimzia 18Cipro 6, 22Cipro HC 6Cipro Suspension 6Ciprodex Otic 6Ciprofloxacin 6, 15, 22Ciprofloxacin Sustained-Release 24 Hour Tablet 6Ciprofloxacin Tablet 6Citalopram 9, 22Citalopram Hydrobromide 9Clarinex 20Clarinex-D 20Clarithromycin Suspension 6Clarithromycin Sustained-Release Tablet 6Clarithromycin Tablet 6, 22Cleocin HCl 75 mg 6Cleocin T 22Climara 21Climara Pro 21Clindagel 12Clindamycin Foam 1% 12Clindamycin Gel, Lotion, Solution, Swabs 12, 22Clindamycin HCl 6Clindamycin Palmitate 6Clindamycin Phosphate/Benzoyl Peroxide Extended-Release Gel 12Clindamycin Phosphate/Benzoyl Peroxide Gel 1%-5% 12Clindesse Vaginal 6Clobetasol Propionate 12Clobetasol Propionate Foam 12Clobetasol Propionate Lotion 12Clobetasol Propionate Shampoo 12Clobex 12Clobex Shampoo 12Clonazepam 11, 22Clonidine 7Clonidine Transdermal Weekly Patch 7Clopidogrel 7, 22Clorpres 8Clotrimazole 6, 12Clotrimazole/Betamethasone 12Clozapine 11, 22Clozaril 22Codeine Phosphate 18Colazal 22


Colcrys 19Colestid 22Colestipol 8, 22Combigan 15Combipatch 21Combivent 19Combivent Respimat 19Comtan 11Concerta 9Condylox Gel 12Contour Test Strips 13Conzip 18Copaxone 10Coreg 8, 22Coreg CR 8Coumadin 7Cozaar 22Creon 16Crestor 8Crinone 21Cryselle 20Cuprimine 18Cutivate Lotion 12Cyclafem 1/35 20Cyclafem 7/7/7 20Cyclobenzaprine 19Cyclobenzaprine Extended-Release 24 Hour Capsule 19Cymbalta 9Cyproheptadine 20DDaliresp 19Dapsone 6Daytrana 9DDAVP 22Denavir 12Depakote 11, 22Depakote ER 11, 22Depo-Provera 22Depo-SubQ Provera 20Derma-Smoothe/FS 22Desloratadine 20Desmopressin 14, 22Desonate 12Desonide 12Desoximetasone 12Detrol 17Detrol LA 17Dexamethasone 14-15Dexilant 15Dextroamphetamine Sulfate 9DiaBeta 22Diastat Acudial 22Diazepam 11, 22-23Diazepam Rectal Gel 11, 22Dibenzyline 8Diclofenac 18, 23Diclofenac Potassium 18Diclofenac Sodium 18Dicloxacillin Sodium 6

Dicyclomine Tablet 17Didronel 22Differin Cream, Gel 0.1% 12Differin Gel 0.3% 12Differin Lotion 12Diflucan 22Digoxin 9Dilantin 11Diltiazem 7, 22Diltiazem Capsule, Sustained-Release 24 Hour 22Diltiazem Controlled-Release Capsule 7Diltiazem Sustained-Action Capsule 7Diltiazem Sustained-Release 12 Hour Capsule 7Diltiazem Sustained-Release 24 Hour Capsule 7Diltiazem Sustained-Release 24 Hour Tablet 7Diovan 8Diovan HCT 8Dipentum 16Diphenoxylate/Atropine 16Ditropan XL 22Diuril Suspension 250 mg/5 ml 8Divalproex Sodium Sprinkle Capsule 11Divalproex Sodium Sustained-Release 24 Hour Tablet 22Divalproex Sodium Sustained-Release Tablet 11Divalproex Sodium Tablet 11, 22Divigel 21Donepezil 11, 22Donepezil 5, 10 mg 11Doryx 6Dorzolamide Eye Drops 23Dorzolamide HCl 15Dorzolamide HCl/Timolol Maleate 15Dovonex 12Doxazosin 7, 16, 22Doxepin 9Doxycycline Hyclate Enteric-Coated Tablet 6Doxycycline Monohydrate 6Doxycycline Monohydrate Capsule 150 mg 6Duac 12Duetact 13Duexis 18Dulera 19Duragesic 18Dutoprol 8Dyazide 22

EEconazole Nitrate 12Edarbi 8Edarbyclor 8Edex 16Edluar 10Effexor 22Effexor XR 22Effient 7Elestat 14Elidel 12Ella 20Emadine 14Embeda 18Emend 16Emoquette 20Enablex 17Enalapril 7, 23Enalapril/Hydrochlorothiazide 7, 23Enbrel 18Enjuvia 21Enoxaparin 7Enpresse 20Epiduo 12Epinastine 14Epipen 17Epipen Jr 17Epivir HBV 7Eplerenone 7Eprosartan 7, 22Ergomar 10Errin 20Ery-Tab 500 mg 6Erythromycin 6, 12, 15Erythromycin/Benzoyl Peroxide 12Erythromycin Base Enteric-Coated Tablet 6Escitalopram 9Estrace Cream with Applicator 21Estradiol 21Estradiol/Norethindrone Acetate 21Estradiol Transdermal Weekly Patch 21Estrasorb 21Estring 21Estrogel 21Estropipate 21Etidronate Disodium 22Etodolac 18Evamist 21Evista 17Evoclin 12Exalgo 18Exelon Solution 11Exemestane 17Exforge 8Exforge HCT 8Extavia 10


FFamciclovir 7Fanapt 11Fareston 17FazaClo 11Felbamate 11, 22Felbatol 22Felodipine 7Femara 22Femcon Fe 20Femhrt 21Femring 21Fenofibrate 8Fenofibric Acid 8Fenoglide 8Fentanyl Citrate Lollipop 18Fentanyl Transdermal 18Fentora 18Finacea 12Finacea Plus 12Finasteride 16, 22Fioricet 22First-Progesterone 21Flecainide Acetate 9Flector 18Flomax 22Flonase 22Flovent Diskus 19Flovent HFA 19Fluconazole 6, 22Fludrocortisone 14Flunisolide 19Fluocinolone 12, 22Fluocinonide 12Fluoxetine 9, 11, 22Fluoxetine Capsule 22Fluoxetine Delayed-Release Capsule 9, 22Fluticasone Nasal Spray 22Fluticasone Propionate 12, 19Fluticasone Propionate Lotion 12Fluvastatin 8Fluvoxamine Maleate 9Focalin XR 9Folcal DHA 21Folic Acid 21Fondaparinux 7Foradil 19Fortamet 13Forteo 17Fortesta 14Fortical 17Fosamax 17, 22Fosamax Plus D 17Fosinopril 22Fragmin 7Freestyle Lite Test Strips 13Freestyle Test Strips 13Frova 10Furosemide 7, 22

GGabapentin 11, 22Gabitril 11Galantamine 11Gelnique 17Gemfibrozil 8, 22Generess Fe 20Genotropin 14Gentamicin Sulfate 15Geodon 11Gianvi 20Gildess FE 20Gilenya 10Glimepiride 13, 22Glipizide 13, 22Glipizide/Metformin 13Glucophage, XR 22Glucotrol, XL 22Glucovance 22Glumetza 13Glyburide 13, 22Glyburide/Metformin 13, 22Glynase 22Glyset 13GoLYTELY Packet 16Gralise 19Granisetron Tablet 16Guanfacine 7Gynazole-1 Vaginal 6HHalflytely-Bisacodyl 16Halobetasol Propionate 12Heather 20Hectorol 14Helidac 15Hepsera 7Horizant 19Humalog-Mix KwikPen 13Humalog-Mix Vials 13Humalog KwikPen 13Humalog Vials 13Humatrope 14Humira 18Humulin 70-30 Vials 13Humulin KwikPen 13Humulin Vials 13Hycet 18Hydralazine 7Hydrochlorothiazide 7, 22-23Hydrocodone/Chlorpheniramine Suspension 17Hydrocortisone 12, 14Hydrocortisone Tablet 14Hydrocortisone Valerate 12Hydromorphone 18Hydroxychloroquine Sulfate 18Hydroxyzine 20Hyoscyamine Sulfate 17Hyzaar 22

IIbandronate Tablet 17Ibuprofen 18, 23Ibuprofen/Hydrocodone 18, 23Ibuprofen/Oxycodone 18Imiquimod 12Imitrex 22Incivek 7Indomethacin 18Infergen 17Innohep 7Intron A 17Introvale 20Intuniv 9Invega 11Iopidine 1% 15Ipratropium Bromide 19Irbesartan 7Irbesartan/Hydrochlorothiazide 7Isosorbide Dinitrate 9Isosorbide Mononitrate 9Isotretinoin 12Itraconazole Capsule 6JJalyn 16Janumet 13Janumet XR 13Januvia 13Jentadueto 13Jolessa 20Jolivette 20Junel 20Junel Fe 20Juvisync 13KKadian 18Kapvay 9Kariva 20Keflex 22Kelnor 20Keppra 11, 22Keppra XR 11Ketoconazole 6, 12Ketoconazole Foam 6Ketorolac Tromethamine 14, 18, 22Kineret 18Klonopin 22Kombiglyze XR 13Kuvan 14LLabetalol 7Lactulose 16Lamictal 11, 22Lamictal Dose Pack 11Lamictal ODT 11Lamictal XR 11Lamisil 6, 22Lamisil Granules 6Lamotrigine 11, 22


Lanoxin 9Lansoprazole 15Lantus Solostar Pens/Cartridges 13Lantus Vials 13Lasix 22Lastacaft 14Latanoprost 15, 23Lazanda 18Leena 20Leflunomide 18Lescol XL 8Lessina 20Letrozole 17, 22Levalbuterol Vial, Nebulizer 19Levaquin 22Levemir Flexpen 13Levemir Vials 13Levetiracetam 11, 22Levetiracetam Extended-Release 24 Hour Tablet 11Levitra 16Levocetirizine 20Levofloxacin 6, 15, 22Levora 20Levothyroxine Sodium 14Levoxyl 14Lexapro 9Lialda 16Lidocaine 12Lidoderm 17Liothyronine Sodium 14Lipitor 8, 22Lipofen 8Lisinopril 7, 22Lisinopril/Hydrochlorothiazide 7, 22Lithium Carbonate 11Lithium Carbonate Controlled-Release Tablet 11Livalo 8Lo Loestrin Fe 20Locoid Lipocream 12Locoid Lotion 12Loestrin 24 Fe 20Lopid 22Lopressor 22Loprox Shampoo 12Lorazepam 11, 22Loryna 20Losartan 7, 22Losartan/Hydrochlorothiazide 7, 22Lotronex 16Lovastatin 8, 22Lovaza 8Low-Ogestrel 20Lumigan 15Lunesta 10Lutera 20

Luvox CR 9Lyrica 11Lysteda 17MMacrodantin 25 mg 6Marlissa 20Mavik 22Maxair Autohaler 19Maxalt 10Maxalt MLT 10Medrol 14, 22Medrol 2, 8, 24, 32 mg 14Medroxyprogesterone 20-22Medroxyprogesterone 150 mg/ml 20, 22Mefenamic Acid 18Megestrol Acetate 17Meloxicam 18, 22Menostar Transdermal Weekly Patch 21Meperidine 18Mesalamine 16Metadate CD 9Metaxalone 19Metformin 13, 22Metformin Extended-Release 24 Hour Tablet 13Methadone 18Methamphetamine 9Methimazole 14Methocarbamol 19Methotrexate 18Methylin Tablet 9Methylphenidate 9, 22Methylphenidate Extended-Release 24 Hour Tablet 9Methylphenidate Extended-Release Capsule 9Methylphenidate Extended-Release Tablet 22Methylprednisolone Dosepak Tablet 4 mg 14, 22Metoclopramide 16Metolazone 7Metoprolol 7, 22Metoprolol/Hydrochlorothiazide 7Metoprolol Succinate Sustained-Release Tablet 7, 22Metoprolol Tartrate 7Metozolv ODT 16Metrogel 1% 12Metrogel Vaginal 22Metrolotion 12Metronidazole 6, 12, 22Metronidazole Gel 0.75% 12Metronidazole Vaginal 6Mevacor 22Mexiletine 9Micardis 8

Micardis HCT 8Microgestin 20Microgestin Fe 20Migranal 10Minocycline Extended-Release 24 Hour Tablet 6Minocycline HCl 6Mirapex ER 11Mirtazapine 9, 22Mirtazapine Dispersible Tablet 22Misoprostol 15Mobic 22Modafinil 11Moexipril 7Mometasone Furoate 12Mononessa 20Monopril 22Montelukast 19Morphine Sulfate 18Morphine Sulfate Extended-Release Pellets 18Morphine Sulfate Sustained-Action Tablet 18Moviprep 16Moxeza 15MSIR Capsule 18Multaq 9Multi-Nate 30 21Multinatal Plus 21Mupirocin 12Muse 16Mycophenolate Capsule, Tablet 17Mycostatin 6Myfortic 17Mysoline 11Myzilra 20NNabumetone 18Nadolol 7Naftin 12Namenda 11Naprelan 18Naprosyn - Prescription strengths only 22Naproxen 18, 22Naproxen - Prescription strengths only 22Naproxen Sodium 18Naratriptan 10, 22Nardil 22Nasacort AQ 19Nasonex 19Natazia 20Nateglinide 13Necon 0.5/35 20Necon 1/35 20Necon 1/50 20Necon 10/11 20Necon 7/7/7 20


Nefazodone 9Neomycin/Polymyxin/HC Otic 6Neomycin/Polymyxin B Sulfate/Dexamethasone 15Neoral 17Neurontin 22Nexiclon XR 8Nexium Capsule 15Nexium Suspension 15Next Choice One Dose 20Niaspan 8Nifedipine 7, 22Nifedipine Extended-Release Tablet 22Nisoldipine 7Nitrofurantoin/Nitrofurantoin Macrocrystal 6Nitrofurantoin Macrocrystal 6Nitrofurantoin Suspension 6Nitroglycerin 9Nitroglycerin Spray 9Nitroglycerin Transdermal Patch 9Nitrolingual 9Nitromist 9Nitrostat 9Nizatidine Oral Solution 15Nora-Be 20Norditropin 14Norethindrone 20-21Norethindrone Acetate 21Noritate 12Nortrel 0.5/35 20Nortrel 1/35 20Nortrel 7/7/7 20Nortriptyline 9Norvasc 22Novolin Vials 13NovoLog 13Noxafil 6Nucynta 18Nucynta ER 18Nuedexta 11Nutropin, AQ, NuSpin 14NuvaRing 20Nuvigil 11Nystatin 6, 12Nystatin/Triamcinolone Acetonide 12OOcella 20Octreotide Acetate 14Ocuflox Eye Drops 22Ofloxacin 6, 15, 22Ofloxacin Otic 6Ogestrel 20Olanzapine/Fluoxetine 11Olanzapine Rapid Dissolve Tablet 11Olanzapine Tablet 11Oleptro 9

Olux-E 12Omeprazole 15, 22Omeprazole/Sodium Bicarbonate Capsule 15Omnaris 19Omnitrope 14Ondansetron 16, 23One Touch Test Strips 13One Touch Ultra 2 System 13One Touch Ultra Mini System 13One Touch Ultra Test Strips 13One Touch Verio IQ System 13One Touch Verio IQ Test Strips 13Onglyza 13Onsolis 18Opana 18Opana ER 18Optivar 14Oracea 6Orapred 14Orapred ODT 14Orencia 18Orphenadrine 19Orphenadrine/Aspirin/Caffeine 19Orsythia 20Ortho-Cyclen 20Ortho-Novum 7/7/7 20Ortho Evra 20Ortho Micronor 20Ortho Tri-Cyclen 20Ortho Tri-Cyclen Lo 20Oxandrolone 14Oxaprozin 18Oxcarbazepine 11, 23Oxistat 12Oxsoralen-Ultra 12Oxybutynin 17, 22Oxybutynin Sustained-Release Tablet 22Oxycodone 18, 22OxyContin 18Oxymorphone 18Oxymorphone Extended-Release 12 Hour Tablet 18Oxytrol 17PPancreaze 16Pantoprazole 15, 22Paroxetine 9, 22Paroxetine Sustained-Release 24 Hour Tablet 9Paroxetine Tablet 9Pataday 14Patanase 19Patanol 14

Paxil 22Pediapred 14Peg-Intron 17Peganone 11Pegasys 17Penicillin V Potassium 6Penlac 22Pennsaid 18Pentasa 16Pentoxifylline 7Percocet 5-325, 7.5-500, 10-650 22Perforomist 19Perindopril Erbumine 7Permethrin 12Pexeva 9Phenazopyridine 17Phenelzine 9, 22Phenobarbital 11, 16Phenytoin Sodium 11Philith 20Pilopine HS 15Pioglitazone 13Pioglitazone/Metformin 13Piroxicam 18Plan B 20Plavix 22Pletal 22Polyethylene Glycol 16Polymyxin B Sulfate/Trimethoprim 15Portia 20PR Natal 430 21PR Natal 430 EC 21Pradaxa 7Pramipexole 11Prandin 13Pravachol 22Pravastatin 8, 22Precision Xtra Test Strips 13Precose 22Prednisolone 14Prednisone 14Prefest 21Premarin 21Premphase 21Prempro 21Prenatal 19 21Prenatal Advantage 21Prenatal Plus 21Prevacid Delayed-Release Enteric-Coated Capsule 15Prevacid Solutab 15Previfem 20Prevpac 15Prilosec 15, 22Prilosec Rx 10, 20 mg 15Prilosec Rx 40 mg 15Primidone 11Prinivil 22Prinzide 22Pristiq 9


Proair HFA 19Procardia XL 22Prochlorperazine Maleate 16Progesterone Micronized Capsule 21Promethazine 20Propafenone Sustained-Release 12 Hour Capsule 9Propranolol 7Propranolol/Hydrochlorothiazide 7Propranolol Sustained-Action Capsule 7Proscar 22Protonix 15, 22Protonix Granules 15Protopic 12Proventil HFA 19Provera 20, 22Provigil 11Prozac 22Prozac Weekly 22Pulmicort Flexhaler 19Pulmicort Respules 1 mg/2 ml 19Pylera 15QQuasense 20Quetiapine 11Quinapril 7, 22Quinapril/Hydrochlorothiazide 7QVAR 19RRamipril 7, 22Ranexa 9Ranitidine Syrup 15, 23Rapaflo 16Rapamune 17Rebetol Solution 7Rebif 10Reclipsen 20Regranex 12Relenza 7Relistor 16Relpax 10Remeron 22Remeron SolTab 22Requip 11, 22Requip XL 11Restasis 17Restoril 22Retin-A Micro 12Rhinocort Aqua 19Ribapak 7Ribavirin 7Risperdal 22Risperidone 11, 22Ritalin 9, 22Ritalin LA 9Ritalin SR 22

Rivastigmine 11Ropinirole 11, 22Ropinirole Extended-Release 24 Hour Tablet 11Rozerem 10Rybix ODT 18Ryzolt 18SSabril 11Safyral 20Saizen 14Sanctura XR 17Sancuso 16Sandimmune 17Savella 19Serevent Diskus 19Seroquel 11Seroquel XR 11Serostim 14Sertraline 9, 23Setonet 21Setonet-EC 21Silenor 10Silver Sulfadiazine 12Simcor 8Simponi 18Simvastatin 8, 23Singulair 19Skelaxin 19Solodyn 45, 90, 135 mg 6Solodyn 55, 65, 80, 105, 115 mg 6Soma 250 mg 19Sonata 10, 22Sotalol 9Spiriva 19Spironolactone 7, 22Spironolactone/Hydrochlorothiazide 7Sporanox Oral Solution 6Sprintec 20Sprix 18Sronyx 20Stavzor 11Staxyn 16Stelara 12Strattera 9Sucralfate Tablet 15Sular 8Sulfacetamide Sodium 12, 15Sulfacetamide Sodium/Sulfur 12Sulfamethoxazole/Trimethoprim 6Sulfasalazine 16, 18Sulindac 18Sumatriptan Succinate Injection, Tablet 10, 22Sumatriptan Succinate Nasal Spray 10Sumavel DosePro 10Suprax 6

Surmontil 22Syeda 20Symbicort 19Symbyax 11Symlin 13Synarel 14Synthroid 14TTaclonex 12Taclonex Scalp 12Tacrolimus 17Tamiflu 7Tamoxifen 17Tamsulosin 16, 22Taron A Prenatal 21Tasmar 11Tazorac 12Tegretol 11Tekamlo 8Tekturna 8Tekturna HCT 8Temazepam 10, 22Tenoretic 22Tenormin 22Terazosin 7, 16Terbinafine Tablet 6, 22Terconazole Vaginal 6Testim 14Testosterone 14Tetracycline 6Tev-Tropin 14Teveten 8, 22Teveten HCT 8Thalitone 8Theophylline 19Tiazac 22Tilia Fe 20Timolol Maleate 15Tirosint 14Tizanidine 19Tobi 6Tobradex ST 15Tobramycin/Dexamethasone 15Tobramycin Sulfate Drops 15Tolmetin Sodium 18Tolterodine 17Topamax 11, 22Topiramate 11, 22Toprol XL 25 mg 22Torsemide 7Toviaz 17Tradjenta 13Tramadol 18, 23Tramadol/Acetaminophen 18, 23Tramadol Extended-Release Multiphase 24 Hour Tablet 18Tramadol Sustained-Release 24 Hour Tablet 18Trandolapril 7, 22Trandolapril/Verapamil 7


Transderm-Scop 16Travatan Z 15Trazodone 9Tretin-X 12Tretinoin 12Trexall 18Treximet 10Tri-Legest Fe 20Tri-Previfem 20Tri-Sprintec 20Triamcinolone Acetonide 12, 19Triamterene/Hydrochlorothiazide 7, 22Tribenzor 8Tricor 8Triglide 8Trileptal 23Trilipix 8Trilyte with Flavor Packets 16Trimipramine Maleate 22Trinessa 20Trivora 20Trospium 17Trusopt 23Tussionex 17Twynsta 8Tylenol #3 23UUloric 19Ultracet 23Ultram 23Urea 12Uroxatral 23Ursodiol 16VVagifem 21Valacyclovir 7Valcyte 7Valium 23Vancomycin 6Vanos 12Vectical 12Vaseretic 23Vasotec 23Velivet 20Veltin 12Venlafaxine 9, 22Venlafaxine Extended-Release Tablet 9Venlafaxine Sustained-Release Capsule 9, 22Ventolin HFA 19Veramyst 19Verapamil 7, 22Verapamil Sustained-Release 24 Hour Pellets 7Verdeso 12Vesicare 17Vestura 20Vfend 23

Viagra 16Vicodin, Vicodin ES 23Vicoprofen 23Victoza 13Victrelis 7Vigamox 15Vimovo 18Viorele 20Vivelle-Dot 21Voltaren Gel 18Voltaren Tablet 23Voriconazole 6, 23Vusion 12Vytorin 8Vyvanse 9WWarfarin Sodium 7Welchol 8Wellbutrin 23Wellbutrin SR 23Wellbutrin XL 23Wymzya Fe 20XXalatan 23Xanax, Xanax XR 23Xarelto 7Xerese 12Xolegel 12Xopenex HFA 19Xopenex Vial, Nebulizer 19Xyrem 11YYasmin 20Yaz 20ZZafirlukast 19, 22Zaleplon 10, 22Zantac Syrup 23Zarah 20Zatean-PN 21Zatean-PN DHA 21Zatean-PN Plus 21Zegerid Capsule 15Zegerid Packet 15Zemplar 14Zenchent 20Zenchent Fe 20Zenpep 16Zeosa 20Zestoretic 22Zestril 22Zetia 8Ziac 23Ziana 12Ziprasidone 11Zipsor 18Zithromax 23Zocor 23Zofran 23Zoloft 23Zolpidem 10, 22

Zolpidem Multiphasic-Release Tablet 10Zolpidem Tablet 10Zolpimist 10Zomig 10Zomig Nasal Spray 10Zomig ZMT 10Zonegran 23Zonisamide 11, 23Zorbtive 14Zovia 1/35E 20Zovia 1/50E 20Zovirax 12, 23Zuplenz 16Zyclara 12Zylet 15Zymaxid 15Zyprexa 11Zyprexa Zydis 11Zyvox 6

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2013 Prescription Drug List – Oxford Traditional Three-Tier 8466 R7 MS-12-992 DL5014B 1/13

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