2010 cigna medicare rx plan two (pdp) formulary · 2010 cigna medicare rx plan two (pdp) formulary...

2010 CIGNA Medicare Rx Plan Two (PDP) Formulary

(complete drug list effective 01/01/2010)

Cost-Sharing Tier Description Tier 1: Some Generic Drugs. This grouping of prescription drugs represents the lowest cost sharing.

Tier 2: Most Generic Drugs.

Tier 3: Preferred Brand & Generic Drugs that cost more than $100.

Tier 4: Non Preferred Drugs.

Tier 5: Brand Name & Generic High Cost Specialty Drugs. This grouping of prescription drugs represents the highest cost sharing.

Symbol Key - Notes/Requirements/Limits

B vs D - Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only covered under Part D when the member is located in a long term care (LTC) setting.

PA - Prior authorization is required.

QL - Quantity limits apply.

RA - Restricted access. This prescription may be available only at certain pharmacies.

ST - Step therapy is required.

Note: Generally all medications on the formulary are available through mail order except when special circumstances or situations prohibit mailing a particular medication to your home.

Drug Name Drug Tier Notes

Analgesics

Opioid Analgesics

acetaminophen/codeine #2 2



ascomp/codeine 2

buprenorphine hcl 2

butalbital /apap /caffeine /codeine 2

butorphanol tartrate injection 2

butorphanol tartrate nasal solution 2 QL (5 per 30 days)

co-gesic 2

DEMEROL TABLET 4

DEMEROL INJECTION 4 PA

duramorph 2 PA

endocet 2

fentanyl patch 3 QL (20 per 30 days)

fentanyl citrate 2 PA

fentanyl citrate oral transmucosal 5 QL (120 per 30 days) PA

hydrocodone /acetaminophen-hs 2

hydrocodone /acetaminophen tablet 2

hydrocodone /acetaminophen solution 500mg/15ml; 7.5mg/15ml

2

hydrocodone /ibuprofen 2

hydrocodone bitartrate/acetaminophen 2


hydromorphone hcl 2

INFUMORPH 200 4 PA

INFUMORPH 500 4 PA

KADIAN 3 QL (60 per 30 days)

levorphanol tartrate 2

margesic-h 2

maxidone 2

meperidine hcl oral solution, tablet 2

meperidine hcl injection 2 PA

methadone hcl 2

methadose 2

morphine sulfate er tablet extended release 12 hour 100mg, 200mg, 60mg

2 QL (120 per 30 days)

morphine sulfate er tablet extended release 12 hour 15mg, 30mg


morphine sulfate oral solution, tablet 2

morphine sulfate injection 1mg/ml 2

morphine sulfate injection 0.5mg/ml, 5mg/ml 2 PA

nalbuphine hcl 2 PA

oxycodone /acetaminophen 2

oxycodone /apap 2

oxycodone /aspirin 2

oxycodone /ibuprofen 2

oxycodone hcl 2

oxycodone hcl er tablet extended release 12 hour 80mg 3 QL (120 per 30 days)

oxycodone hcl er tablet extended release 12 hour 10mg, 20mg, 40mg


oxycodone-apap 2

OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR 80MG


OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR 10MG, 15MG, 20MG, 30MG, 40MG, 60MG


pentazocine /acetaminophen 2

pentazocine/naloxone hcl 2

propoxyphene /acetaminophen 2

propoxyphene hcl 2

propoxyphene-n /acetaminophen 2

reprexain 2

ROXICET 2

ROXICODONE 4

stagesic 2

SUBOXONE 4

SUBUTEX 4

TALWIN 4 PA

tramadol hcl 2

tramadol hydrochloride/acetaminophen 2

vanacet 2

zerlor 3

Anesthetics

Local Anesthetics


lidocaine 2

lidocaine hcl 2

lidocaine hcl jelly 2

lidocaine viscous 2

lidocaine/prilocaine 2

LIDODERM 3 QL (90 per 30 days)

Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugs

CELEBREX 3 QL (60 per 30 days)

diclofenac potassium 1

diclofenac sodium 1

diclofenac sodium ec 1

diclofenac sodium xr 1

diflunisal 3

etodolac 2

etodolac er 2

fenoprofen calcium 2

flurbiprofen 1

ibu 1

ibuprofen 1

indomethacin 1

indomethacin er 1

ketorolac tromethamine injection 2 PA

ketorolac tromethamine tablet 2 QL (20 per 30 days)

meclofenamate sodium 1

meloxicam 1

nabumetone 2

naproxen 1

naproxen dr 1

naproxen sodium 1

oxaprozin 2

piroxicam 1

sulindac 1

tolmetin sodium 2

Antibacterials

Aminoglycosides

amikacin sulfate 2

gentamicin sulfate 2

gentamicin sulfate/0.9% sodium chloride 2

gentamicin sulfate/sodium chloride 2

ISOTONIC GENTAMICIN 3

kanamycin sulfate 3

neomycin sulfate 2

paromomycin sulfate 3

streptomycin sulfate 3

TOBI 5 B vs D

tobramycin /dexamethasone 2

tobramycin sulfate 2

tobramycin sulfate/sodium chloride 2

tobrasol 2


Antibacterials, Other

ALTABAX 4

baciim 3

bacitracin 3

chloramphenicol sodium succinate 2

CLEOCIN GALAXY 4

CLEOCIN PHOSPHATE 4

clindamycin hcl 2

clindamycin phosphate 2

clindamycin phosphate add-vantage 2

colistimethate sodium 5

COLY-MYCIN M 5

CUBICIN 5

FURADANTIN 3

HELIDAC 4

LINCOCIN 3

MACRODANTIN CAPSULE 25MG 4

methenamine hippurate 2

METROGEL-VAGINAL 4

metronidazole 2

metronidazole in nacl 0.79% 2

metronidazole vaginal 2

mupirocin 2

neomycin /bacitracin /polymyxin 2

neomycin /polymyxin /dexamethasone 2

neomycin/polymyxin b sulfates 3

NEUTREXIN 3 PA

nitrofurantoin macrocrystalline 2

nitrofurantoin monohydrate 2

PHISOHEX 4

polycin b 2

polymyxin b sulfate 3

PRIMSOL 4

SILVADENE 4

silver sulfadiazine 2

ssd 2

SYNERCID 5

thermazene 2

trimethoprim 2

TYGACIL 5

urex 2

VANCOCIN HCL 5

vancomycin hcl 3

VANCOMYCIN HCL ISO-OSMOTIC DEXTROSE 3

VANDAZOLE 4

ZYVOX 5 PA

Beta-lactam, Cephalosporins

CEDAX 4

cefaclor 2

cefaclor er 2


cefadroxil 2

cefazolin sodium 3

cefdinir 3

cefepime 3

CEFIZOX IN DEXTROSE 5% INJECTION 1GM/50ML; 5%

4

CEFIZOX IN DEXTROSE 5% INJECTION 2GM/50ML; 5%

5

cefotaxime sodium 2

cefotetan 3

cefoxitin sodium injection 10gm, 1gm, 2gm 3

cefpodoxime proxetil 2

cefprozil 2

CEFTIN 4

ceftriaxone sodium 3

ceftriaxone/dextrose 3

cefuroxime axetil 3

cefuroxime sodium 3

cefuroxime/dextrose 3

cephalexin 2

CLAFORAN 3

CLAFORAN/D5W 3

FORTAZ 3

MAXIPIME 4

MEFOXIN 5

MEFOXIN ADD-VANTAGE INJECTION 1GM 4

MEFOXIN ADD-VANTAGE INJECTION 2GM 5

MEFOXIN IN DEXTROSE 2.2% 5

MEFOXIN IN DEXTROSE 3.9% 4

RANICLOR 4

SPECTRACEF 4

SUPRAX SUSPENSION RECONSTITUTED 4

TAZICEF 3

Beta-lactam, Other

AZACTAM 5

AZACTAM IN DEXTROSE INJECTION 1GM; 0 4

AZACTAM IN DEXTROSE INJECTION 2GM; 0 5

DORIBAX 5

INVANZ 4

MERREM 4

PRIMAXIN I.M. 5

PRIMAXIN IV INJECTION 250MG; 250MG 3

PRIMAXIN IV INJECTION 500MG; 500MG 5

Beta-lactam, Penicillins

amoclan 2

amoxicillin 2

amoxicillin/clavulanate potassium 2

amoxicillin/potassium clavulanate 2

amoxil 2

ampicillin 2


ampicillin sodium 3

ampicillin-sulbactam 3

bactocill in dextrose 3

BICILLIN C-R 3

BICILLIN L-A 4

dicloxacillin sodium 2

nafcillin sodium 3

NALLPEN/DEXTROSE 3

oxacillin sodium 3

penicillin g potassium 2

penicillin g potassium in iso-osmotic dextrose 2

penicillin g procaine 2

penicillin g sodium 2

penicillin v potassium 2

PFIZERPEN-G 3

piperacillin sodium 3

TIMENTIN 4

trimox 2

veetids 2

ZOSYN 3

Macrolides

AZASITE 3

azithromycin injection, suspension reconstituted 2

azithromycin tablet 500mg, 600mg 2

azithromycin tablet 250mg 2 QL (12 per 30 days)

clarithromycin 2

clarithromycin er 2

e.e.s. 400 2

e.e.s. granules 2

ery 2

ERY-TAB 3

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 2

erythrocin stearate 2

erythromycin 2

erythromycin /sulfisoxazole 2

erythromycin base 2

KETEK 4

PCE 3

ZMAX 4 QL (120 per 30 days)

Quinolones

AVELOX ABC PACK 4 QL (30 per 30 days)

AVELOX INJECTION 4

AVELOX TABLET 4 QL (30 per 30 days)

CIPRO I.V.-IN D5W 4

ciprofloxacin 2

CIPROFLOXACIN ER 3

ciprofloxacin hcl 2

FACTIVE 4 QL (30 per 30 days)


IQUIX 3

LEVAQUIN PREMIX 3

LEVAQUIN INJECTION, ORAL SOLUTION 3

LEVAQUIN TABLET 3 QL (30 per 30 days)

NOROXIN 4

ofloxacin 2

VIGAMOX 3

Sulfonamides

BLEPHAMIDE S.O.P. 4

ocusulf-10 2

sodium sulfacetamide 2

sulf-10 2

sulfadiazine 2

sulfamethoxazole /trimethoprim 2

sulfamethoxazole/trimethoprim ds 2

sulfatrim 2

Tetracyclines

DECLOMYCIN 5

demeclocycline hcl tablet 150mg 3

demeclocycline hcl tablet 300mg 5

DORYX 4

doxy-caps 3

doxycycline hyclate capsule, capsule delayed release particles, tablet

3

doxycycline hyclate injection 100mg 3

doxycycline monohydrate 3

MINOCIN 4

minocycline hcl 2

ORACEA 4

tetracycline hcl 2

Anticonvulsants

Anticonvulsants, Other

BANZEL 4 PA

KEPPRA INJECTION 4

levetiracetam 2

VIMPAT INJECTION 4 PA

VIMPAT TABLET 4 PA

Calcium Channel Modifying Agents

CELONTIN 3

ethosuximide 3

LYRICA 3

Gamma-aminobutyric Acid (GABA) Augmenting Agents

DEPACON 3

divalproex sodium capsule sprinkle, tablet delayed release

2

divalproex sodium tablet extended release 24 hour 3

gabapentin 2

GABITRIL 4

MYSOLINE 4

NEURONTIN SOLUTION 4


primidone 2

valproate sodium 2

valproic acid 2

zonisamide 2

Glutamate Reducing Agents

FELBATOL 4

LAMICTAL 3

LAMICTAL CHEWABLE DISPERSIBLE 3

LAMICTAL ODT 3

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE3

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

3

LAMICTAL STARTER/TAKING VALPROATE 3

LAMICTAL XR 3

lamotrigine 3

TOPAMAX SPRINKLE CAPSULE SPRINKLE 15MG 4 PA

TOPAMAX SPRINKLE CAPSULE SPRINKLE 25MG 4 QL (480 per 30 days) PA

TOPAMAX TABLET 25MG 4 QL (120 per 30 days) PA

TOPAMAX TABLET 100MG, 200MG, 50MG 4 QL (60 per 30 days) PA

topiramate capsule sprinkle 15mg 2 PA

topiramate capsule sprinkle 25mg 2 QL (480 per 30 days) PA

topiramate tablet 25mg 2 QL (120 per 30 days) PA

topiramate tablet 100mg, 200mg, 50mg 2 QL (60 per 30 days) PA

Sodium Channel Inhibitors

carbamazepine 2

carbamazepine er 2

CARBATROL 4

CEREBYX 3

DILANTIN 3

DILANTIN INFATABS 3

epitol 2

fosphenytoin sodium 2

oxcarbazepine 3

PEGANONE 3

PHENYTEK 3

phenytoin 2

phenytoin sodium 2

phenytoin sodium extended 2

TEGRETOL-XR 3

TRILEPTAL 4

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates 2

Cholinesterase Inhibitors

ARICEPT 3 QL (30 per 30 days)

ARICEPT ODT 3 QL (30 per 30 days)

COGNEX 4 QL (120 per 30 days)

EXELON SOLUTION 3 QL (180 per 30 days)

EXELON PATCH 24 HOUR 3 QL (30 per 30 days)

EXELON CAPSULE 3 QL (60 per 30 days)


galantamine hydrobromide capsule extended release 24 hour


galantamine hydrobromide tablet 3 QL (60 per 30 days)

Glutamate Pathway Modifiers

NAMENDA TITRATION PAK 3 QL (49 per 30 days)

NAMENDA SOLUTION 3 QL (300 per 30 days)

NAMENDA TABLET 3 QL (60 per 30 days)

Antidepressants

Antidepressants, Other

budeprion sr 2 QL (60 per 30 days)

budeprion xl 3 QL (30 per 30 days) ST

buproban 2 QL (60 per 30 days)

bupropion hcl 2

bupropion hcl sr 2 QL (60 per 30 days)

EFFEXOR XR CAPSULE EXTENDED RELEASE 24 HOUR 37.5MG, 75MG


EFFEXOR XR CAPSULE EXTENDED RELEASE 24 HOUR 150MG


mirtazapine 2 QL (30 per 30 days)

mirtazapine odt 2 QL (30 per 30 days)

nefazodone hcl 2

trazodone hcl 2

venlafaxine hcl 3

Monoamine Oxidase Inhibitors

EMSAM 4

MARPLAN 4

NARDIL 3

tranylcypromine sulfate 3

Serotonin/ Norepinephrine Reuptake Inhibitors

citalopram hydrobromide solution 3 QL (900 per 30 days)

citalopram hydrobromide tablet 10mg, 40mg 2 QL (30 per 30 days)

citalopram hydrobromide tablet 20mg 2 QL (90 per 30 days)

CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 60MG

4 QL (30 per 30 days) ST

CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 20MG, 30MG


fluoxetine hcl 2

fluvoxamine maleate 2

LEXAPRO TABLET 3 QL (30 per 30 days)

LEXAPRO SOLUTION 3 QL (600 per 30 days)

paroxetine hcl tablet 2 QL (30 per 30 days)

paroxetine hcl suspension 3 QL (900 per 30 days)

PRISTIQ 4 QL (30 per 30 days) PA

selfemra 2

sertraline hcl concentrate 2 QL (300 per 30 days)

sertraline hcl tablet 25mg, 50mg 2 QL (30 per 30 days)

sertraline hcl tablet 100mg 2 QL (60 per 30 days)

Tricyclics

amitriptyline hcl 2

amoxapine 2


chlordiazepoxide /amitriptyline 2

clomipramine hcl 2

desipramine hcl 2

doxepin hcl 2

imipramine hcl 2

imipramine pamoate 3

LIMBITROL 4

maprotiline hcl 2

nortriptyline hcl 2

perphenazine /amitriptyline 2

protriptyline hcl 3

trimipramine maleate 2

Antidotes, Deterrents, and Toxicologic Agents

Antidotes

ANTIZOL 5 PA

CHEMET 4

CUPRIMINE 3

DEPEN TITRATABS 3

EXJADE 5 PA

fomepizole 5 PA

RELISTOR 4 PA

sodium polystyrene sulfonate 2

SYPRINE 3

Deterrents

ANTABUSE 3

CAMPRAL 4 QL (180 per 30 days)

CHANTIX STARTING MONTH PAK 4 QL (106 per 365 days) ST

CHANTIX TABLET 0.5MG, 1MG 4 QL (336 per 365 days) ST

DEPADE 2

NICOTROL INHALER 3

NICOTROL NS 3

REVIA 4

VIVITROL 5 PA

Toxicologic Agents

naloxone hcl 2

naltrexone hcl 2

SUBOXONE 4

Antiemetics

Antiemetics

ANZEMET INJECTION 4 PA

ANZEMET TABLET 4 QL (5 per 30 days) B vs D

compro 2

dronabinol capsule 2.5mg 4 B vs D

dronabinol capsule 10mg, 5mg 5 B vs D

EMEND TRIFOLD PACK 3 QL (12 per 30 days) B vs D

EMEND CAPSULE 40MG 3 QL (2 per 30 days) B vs D



MARINOL CAPSULE 2.5MG 4 B vs D

MARINOL CAPSULE 10MG, 5MG 5 B vs D


meclizine hcl rx 1

metoclopramide hcl 2

MIGRANAL 4 QL (8 per 30 days)

ondansetron hcl injection 2 PA

ondansetron hcl oral solution 2 QL (900 per 30 days) B vs D

ondansetron hcl tablet 24mg 2 QL (5 per 30 days) B vs D



ondansetron odt tablet dispersible 4mg 2 QL (60 per 30 days) B vs D

ondansetron odt tablet dispersible 8mg 2 QL (90 per 30 days) B vs D

phenadoz 2

prochlorperazine edisylate 2

prochlorperazine maleate 2 B vs D

promethazine hcl syrup 2

promethazine hcl injection 2 PA

promethazine hcl tablet 50mg 2

promethazine hcl tablet 12.5mg, 25mg 2 B vs D

promethegan 2

TRANSDERM-SCOP 4

trimethobenzamide hcl capsule 2 B vs D

trimethobenzamide hcl injection 2 PA

Antifungals

Antifungals

ABELCET 5 B vs D

AMBISOME 5 B vs D

AMPHOTEC 4 B vs D

amphotericin b 3 B vs D

ANCOBON 5

CANCIDAS 5 PA

ciclopirox 2

ciclopirox nail lacquer 2 PA

ciclopirox olamine 2

clotrimazole 2

clotrimazole/betamethasone dipropionate 2

DIFLUCAN IN NACL 5

econazole nitrate 2

ERAXIS 3 PA

fluconazole 2

fluconazole in dextrose 5

GRIFULVIN V 3

griseofulvin microsize 2

itraconazole 4 PA

ketoconazole 2

kuric 2

miconazole 3 rx 2

MYCAMINE 5 PA

NAFTIN 3

NOXAFIL 5

nyamyc 2

nystatin 2


nystatin/triamcinolone 2

nystop 2

pedi-dri 3

PENLAC NAIL LACQUER 4 PA

selenium sulfide 2

SPORANOX SOLUTION 4 PA

terbinafine hcl tablet 1 QL (90 per 270 days) PA

terconazole 2

VFEND 5 PA

VFEND IV 5 PA

zazole 2

Antigout Agents

Antigout Agents

allopurinol 2

allopurinol sodium 3

ALOPRIM 3 PA

colchicine 2

probenecid 2

probenecid/colchicine 2

Antimigraine Agents

Abortive

CAFERGOT 4

D.H.E. 45 4

dihydroergotamine mesylate 3

ERGOMAR 3

ergotamine tartrate/caffeine 2

MAXALT-MLT TABLET DISPERSIBLE 10MG 3 QL (18 per 30 days)

MAXALT-MLT TABLET DISPERSIBLE 5MG 3 QL (27 per 30 days)

MAXALT TABLET 10MG 3 QL (18 per 30 days)

MAXALT TABLET 5MG 3 QL (27 per 30 days)

migergot 2

sumatriptan succinate injection 3 QL (4 per 30 days)

sumatriptan succinate tablet 50mg 3 QL (18 per 30 days)



TREXIMET 3 QL (9 per 30 days)

ZOMIG ZMT TABLET DISPERSIBLE 2.5MG 4 QL (12 per 30 days)

ZOMIG ZMT TABLET DISPERSIBLE 5MG 4 QL (6 per 30 days)

ZOMIG SOLUTION 4 QL (6 per 30 days)

ZOMIG TABLET 2.5MG 4 QL (12 per 30 days)

ZOMIG TABLET 5MG 4 QL (6 per 30 days)

Antimyasthenic Agents

Parasympathomimetics

bethanechol chloride 2

guanidine hcl 2

MESTINON 3

MESTINON TIMESPAN 3

MYTELASE 3

pyridostigmine bromide 2

REGONOL 4


Antimycobacterials

Antimycobacterials, Other

dapsone 2

MYCOBUTIN 3

Antituberculars

CAPASTAT SULFATE 3

ethambutol hcl 2

isonarif 2

isoniazid 2

PASER 4

PRIFTIN 4

pyrazinamide 2

RIFAMATE 3

rifampin 2

RIFATER 4

SEROMYCIN 3

TRECATOR 3

Antineoplastics

Alkylating Agents

ALKERAN 5 B vs D

BICNU 3 B vs D

BUSULFEX 3 B vs D

CEENU 3

HEXALEN 5

LEUKERAN 3

MATULANE 5

MUSTARGEN 3 B vs D

thiotepa 2 B vs D

TREANDA 5 B vs D

ZANOSAR 5 B vs D

Antiangiogenic Agents

REVLIMID 5 PA RA

THALOMID 5

Antiestrogens/Modifiers

EMCYT 3

FARESTON 4

FASLODEX 5 B vs D

tamoxifen citrate 2

Antimetabolites

ALIMTA 5 B vs D

cladribine 5 B vs D

DROXIA 3

ELITEK 5 PA

FLUDARA 5 B vs D

fludarabine phosphate 5 B vs D

fluorouracil 3 B vs D

GEMZAR 5 B vs D

HYDREA 4

hydroxyurea 2

LEUSTATIN 3 B vs D


mercaptopurine 3

NIPENT 5 B vs D

PURINETHOL 4

tabloid 2

Antineoplastics, Other

ABRAXANE 5 B vs D

ADRIAMYCIN 4 B vs D

amifostine 5 B vs D

ARRANON 5 B vs D

AVASTIN 5 PA

bleomycin sulfate 5 B vs D

CAMPTOSAR 5 B vs D

carboplatin 3 B vs D

CERUBIDINE 4 B vs D

cisplatin 2 B vs D

CLOLAR 5 B vs D

COSMEGEN 5 B vs D

cyclophosphamide 3 B vs D

cytarabine 2 B vs D

cytarabine aqueous 2 B vs D

dacarbazine 2 B vs D

DACOGEN 5 B vs D

daunorubicin hcl 3 B vs D

DAUNOXOME 5 B vs D

DOXIL 5 B vs D

doxorubicin hcl 3 B vs D

ELLENCE 5 B vs D

ELOXATIN 3 B vs D

ELSPAR 3 B vs D

epirubicin hcl 5 B vs D

ETHYOL 5 B vs D

ETOPOPHOS 5 B vs D

etoposide 3 B vs D

FIRMAGON 4 PA

HYCAMTIN 5 B vs D

IDAMYCIN PFS 5 B vs D

idarubicin hcl 5 B vs D

IFEX 4 B vs D

ifosfamide 2 B vs D

ifosfamide/mesna 5 B vs D

irinotecan 5 B vs D

IXEMPRA KIT 5 B vs D

mesna 3 B vs D

MESNEX TABLET 5

MESNEX INJECTION 5 B vs D

mitomycin 3 B vs D

mitoxantrone hcl 5 B vs D

NAVELBINE 5 B vs D

NOVANTRONE 5 B vs D

ONCASPAR 5 B vs D


ONTAK 5 B vs D

ONXOL 5 B vs D

paclitaxel 2 B vs D

pentostatin 5 B vs D

PHOTOFRIN 5 B vs D

PLATINOL AQ 3 B vs D

PROLEUKIN 5 PA

TAXOTERE 5 B vs D

toposar 3 B vs D

TORISEL 5 PA

TRISENOX 4 B vs D

TYKERB 5 PA

VELCADE 5 PA

VIDAZA 3 PA

vinblastine sulfate 2 B vs D

vincasar pfs 2 B vs D

vincristine sulfate 2 B vs D

vinorelbine tartrate 3 B vs D

ZOLINZA 5 PA

Aromatase Inhibitors, 3rd Generation

ARIMIDEX 3 QL (30 per 30 days)

AROMASIN 4

FEMARA 4

Molecular Target Inhibitors

AFINITOR 5 PA

GLEEVEC 5 PA

IRESSA 5 PA RA

NEXAVAR 5 PA RA

SPRYCEL 5 PA

SUTENT 5 PA

TARCEVA 5 PA

TASIGNA 5

Monoclonal Antibodies

CAMPATH 5 B vs D

ERBITUX 5 B vs D

HERCEPTIN 5 PA

MYLOTARG 5 B vs D

RITUXAN 5 PA

VECTIBIX 5 B vs D

Retinoids

PANRETIN 5 PA

TARGRETIN 5 PA

tretinoin - oral 5 PA

VESANOID 5 PA

Antiparasitics

Anthelmintics

ALBENZA 3

BILTRICIDE 3

mebendazole 2

STROMECTOL 3


Antiprotozoals

ALINIA 4

chloroquine phosphate 2

DARAPRIM 3

FANSIDAR 3

hydroxychloroquine sulfate 2

MALARONE 4

mefloquine hcl 2 QL (6 per 30 days)

MEPRON 5

PENTAM 300 4 PA

primaquine phosphate 2

QUALAQUIN 3 PA

TINDAMAX 4

Pediculicides/ Scabicides

acticin 2

ELIMITE 4

EURAX 4

lindane 2

OVIDE 4

permethrin 2

Antiparkinson Agents

Antiparkinson Agents

amantadine hcl 2

APOKYN 5 PA

atamet 2

AZILECT 3

benztropine mesylate 2

bromocriptine mesylate 3

carbidopa/levodopa 2

carbidopa/levodopa cr 2

carbidopa/levodopa odt 2

carbidopa/levodopa sr 2

COMTAN 4

LODOSYN 4

MIRAPEX 3

PARCOPA 4

REQUIP XL 3

ropinirole hcl 2

selegiline hcl 2

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR 3 PA

trihexyphenidyl hcl 2

ZELAPAR 4

Antipsychotics

Atypicals


ABILIFY DISCMELT 4 QL (60 per 30 days) PA

ABILIFY INJECTION 4 PA

ABILIFY TABLET 4 QL (30 per 30 days) PA

ABILIFY ORAL SOLUTION 4 QL (900 per 30 days) PA

clozapine 3

FAZACLO 4

GEODON INJECTION 4 PA

GEODON CAPSULE 4 QL (60 per 30 days) PA

INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG, 9MG


INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG


RISPERDAL CONSTA INJECTION 12.5MG, 25MG 4 QL (4 per 28 days)

RISPERDAL CONSTA INJECTION 37.5MG, 50MG 5 QL (4 per 28 days)

RISPERDAL M-TAB TABLET DISPERSIBLE 4MG 4 QL (120 per 30 days)

RISPERDAL M-TAB TABLET DISPERSIBLE 0.5MG, 1MG, 2MG, 3MG


risperidone odt tablet dispersible 4mg 3 QL (120 per 30 days)

risperidone odt tablet dispersible 0.25mg, 0.5mg, 2mg, 3mg


risperidone solution 3 QL (240 per 30 days)

risperidone tablet 4mg 3 QL (120 per 30 days)

risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg 3 QL (60 per 30 days)

SEROQUEL XR TABLET EXTENDED RELEASE 24 HOUR 150MG, 200MG


SEROQUEL XR TABLET EXTENDED RELEASE 24 HOUR 300MG, 400MG, 50MG


SEROQUEL TABLET 100MG, 200MG, 25MG, 50MG 3 QL (120 per 30 days)

SEROQUEL TABLET 300MG, 400MG 3 QL (60 per 30 days)

SYMBYAX 4 QL (30 per 30 days) PA

ZYPREXA ZYDIS 3 QL (30 per 30 days)

ZYPREXA INJECTION 3

ZYPREXA TABLET 3 QL (30 per 30 days)

Conventional

chlorpromazine hcl injection 2

chlorpromazine hcl tablet 100mg, 200mg, 50mg 2

chlorpromazine hcl tablet 10mg, 25mg 2 B vs D

fluphenazine decanoate 2

fluphenazine hcl 2

haloperidol 2

haloperidol decanoate 2

haloperidol lactate 2

loxapine succinate 2

MOBAN 4

NAVANE 4

ORAP 4

perphenazine tablet 16mg, 2mg 2

perphenazine tablet 4mg, 8mg 2 B vs D

prochlorperazine 2

thioridazine hcl 2


thiothixene 2

trifluoperazine hcl 2

Antispasticity Agents

Antispasticity Agents

baclofen 2

tizanidine hcl 2

Antivirals

Anti-cytomegalovirus (CMV) Agents

CYTOVENE 4 B vs D

foscarnet sodium 3 B vs D

FOSCAVIR 5 B vs D

ganciclovir 5

VALCYTE 5

VISTIDE 5 PA

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors

RESCRIPTOR 3

SUSTIVA 3

VIRAMUNE 3

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors

ATRIPLA 5

COMBIVIR 5

didanosine 3

EMTRIVA 3

EPIVIR 3

EPIVIR HBV 3

EPZICOM 5

INTELENCE 5

RETROVIR 3

RETROVIR IV INFUSION 3

stavudine 3

TRIZIVIR 5

TRUVADA 5

VIDEX EC 3

VIDEX PEDIATRIC 3

VIREAD 4

ZERIT 3

ZIAGEN 3

zidovudine 3

Anti-HIV Agents, Other

FUZEON 5

ISENTRESS 5

SELZENTRY 5

Anti-HIV Agents, Protease Inhibitors

APTIVUS 5

CRIXIVAN 3

INVIRASE 5

KALETRA 5

LEXIVA SUSPENSION 4


LEXIVA TABLET 5

NORVIR CAPSULE 4

NORVIR SOLUTION 5

PREZISTA 5

REYATAZ 5

VIRACEPT POWDER 4

VIRACEPT TABLET 5

Anti-influenza Agents

FLUMADINE 4

RELENZA DISKHALER 4 QL (120 per 365 days)

rimantadine hcl 2

TAMIFLU SUSPENSION RECONSTITUTED 3

TAMIFLU CAPSULE 45MG 3 QL (20 per 365 days)



Antihepatitis Agents

BARACLUDE SOLUTION 4

BARACLUDE TABLET 5

COPEGUS 5

HEPSERA 5

REBETOL SOLUTION 3

REBETOL CAPSULE 5

RIBAPAK 5

ribasphere capsule 3

ribasphere tablet 200mg 3

ribasphere tablet 400mg, 600mg 5

ribavirin capsule 3

ribavirin tablet 200mg 3

ribavirin tablet 400mg, 600mg 5

TYZEKA 4

VIRAZOLE 5

Antiherpetic Agents

acyclovir sodium 3 B vs D

acyclovir capsule, tablet 2

acyclovir suspension 3

DENAVIR 3

famciclovir 3

FAMVIR 4

VALTREX 4

Anxiolytics

Anxiolytics, Other

buspirone hcl 2

LEXAPRO TABLET 3 QL (30 per 30 days)

LEXAPRO SOLUTION 3 QL (600 per 30 days)

meprobamate 3

Bipolar Agents

Bipolar Agents

EQUETRO 4

lithium carbonate 2

lithium carbonate er 2


lithium citrate 2

LITHOBID 4

SYMBYAX 4 QL (30 per 30 days) PA

Blood Glucose Regulators

Antidiabetic Agents

acarbose 2

ACTOPLUS MET 3 QL (90 per 30 days)

ACTOS 3 QL (30 per 30 days)

AVANDAMET 3 QL (60 per 30 days)

AVANDARYL TABLET 2MG; 8MG, 4MG; 8MG 3 QL (30 per 30 days)

AVANDARYL TABLET 1MG; 4MG, 2MG; 4MG, 4MG; 4MG


AVANDIA TABLET 8MG 3 QL (30 per 30 days)

AVANDIA TABLET 2MG, 4MG 3 QL (60 per 30 days)

BYETTA 3 QL (3 per 30 days)

chlorpropamide 2

DUETACT 3 QL (30 per 30 days)

glimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glipizide/metformin hcl 2

glyburide 1

glyburide micronized 1

glyburide/metformin hcl 2

GLYSET 4

JANUMET 4 QL (60 per 30 days)

JANUVIA 4 QL (30 per 30 days)

metformin hcl 1

metformin hcl er 1

PRECOSE 3

RIOMET 4

STARLIX 4

SYMLIN 4 QL (20 per 30 days) PA

SYMLINPEN 60 4 QL (12 per 30 days) PA

tolazamide 2

tolbutamide 2

Glycemic Agents

GLUCAGEN HYPOKIT 3 QL (2 per 1 days)

GLUCAGON EMERGENCY KIT 3 QL (2 per 1 days)

PROGLYCEM 3

Insulins

APIDRA 3

APIDRA SOLOSTAR 3

HUMULIN R U-500 (CONCENTRATED) 3

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXPEN 3

NOVOLIN 70/30 3


NOVOLIN 70/30 INNOLET 3

NOVOLIN N 3

NOVOLIN N INNOLET 3

NOVOLIN R 3

NOVOLIN R INNOLET 3

NOVOLOG 3

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 3

NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3

Blood Products/Modifiers/ Volume Expanders

Anticoagulants

ARIXTRA INJECTION 5MG/0.4ML 3 QL (12 per 365 days)

ARIXTRA INJECTION 7.5MG/0.6ML 3 QL (18 per 365 days)

ARIXTRA INJECTION 10MG/0.8ML 3 QL (24 per 365 days)

ARIXTRA INJECTION 2.5MG/0.5ML 3 QL (32 per 365 days)

COUMADIN 4

FRAGMIN INJECTION 2500UNIT/0.2ML, 5000UNIT/0.2ML


FRAGMIN INJECTION 25000UNIT/ML 5 QL (133 per 365 days)

FRAGMIN INJECTION 10000UNIT/ML 5 QL (180 per 365 days)

FRAGMIN INJECTION 7500UNIT/0.3ML 5 QL (54 per 365 days)

heparin sodium 2

heparin sodium dcu 2

heparin sodium/d5w 2

heparin sodium/nacl 0.45% 2

heparin sodium/nacl 0.9% 2

heparin sodium/sodium chloride 0.9% premix 2

INNOHEP 4 QL (26 per 365 days)

jantoven 2

LOVENOX INJECTION 30MG/0.3ML 4 QL (18 per 365 days)



LOVENOX INJECTION 120MG/0.8ML, 80MG/0.8ML 5 QL (48 per 365 days)

LOVENOX INJECTION 100MG/ML, 150MG/ML 5 QL (60 per 365 days)

LOVENOX INJECTION 300MG/3ML 5 QL (90 per 365 days)

warfarin sodium 2

Blood Formation Products

ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML, 25MCG/ML

3 PA

ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML

5 PA

EPOGEN INJECTION 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 QL (12 per 28 days) PA

EPOGEN INJECTION 10000UNIT/ML, 20000UNIT/ML, 40000UNIT/ML

5 PA

LEUKINE 5 PA

NEULASTA 5 PA


NEUMEGA 5 PA

NEUPOGEN 5 PA

PROCRIT INJECTION 10000UNIT/ML 3 PA

PROCRIT INJECTION 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 QL (12 per 28 days) PA

PROCRIT INJECTION 20000UNIT/ML, 40000UNIT/ML 5 PA

Blood Products/Modifiers/ Volume Expanders

PROMACTA 5 PA

Coagulants

CYKLOKAPRON 3 PA

Platelet Aggregation Inhibitors

AGGRENOX 4 QL (60 per 30 days)

cilostazol 2

dipyridamole 2

PLAVIX TABLET 75MG 3

ticlopidine hcl 2

Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine hcl 2

guanabenz acetate 2

guanfacine hcl 2

methyldopa 1

methyldopa /hydrochlorothiazide 1

methyldopate hcl 2

midodrine hcl 2

Alpha-adrenergic Blocking Agents

prazosin hcl 2

reserpine 2

Antiarrhythmics

amiodarone hcl 2

disopyramide phosphate 2

flecainide acetate 2

mexiletine hcl 2

MULTAQ 4 QL (60 per 30 days)

pacerone 3

procainamide hcl 2

propafenone hcl 2

quinidine gluconate 2

quinidine gluconate cr 2

quinidine sulfate 2

quinidine sulfate er 2

sorine 2

sotalol hcl 2

TIKOSYN 4

Beta-adrenergic Blocking Agents

acebutolol hcl 1

atenolol 1

atenolol/chlorthalidone 1

bisoprolol fumarate 1

bisoprolol fumarate/hydrochlorothiazide 1


BYSTOLIC TABLET 10MG 3 QL (120 per 30 days)

BYSTOLIC TABLET 20MG 3 QL (60 per 30 days)

BYSTOLIC TABLET 2.5MG, 5MG 3 QL (90 per 30 days)

CARTROL 4

carvedilol 2 QL (60 per 30 days)

COREG CR 3 QL (30 per 30 days)

CORZIDE 4

INNOPRAN XL 4

labetalol hcl 2

metoprolol /hydrochlorothiazide 2

metoprolol succinate er tablet extended release 24 hour 100mg, 25mg, 50mg


metoprolol succinate er tablet extended release 24 hour 200mg


metoprolol tartrate tablet 1

metoprolol tartrate injection 2

nadolol 2

nadolol /bendroflumethiazide 2

pindolol 2

propranolol /hydrochlorothiazide 2

propranolol hcl 2

propranolol hcl er 2

TIMOLIDE 10/25 3

timolol maleate 1

TOPROL XL TABLET EXTENDED RELEASE 24 HOUR 100MG, 25MG, 50MG


TOPROL XL TABLET EXTENDED RELEASE 24 HOUR 200MG


Calcium Channel Blocking Agents

afeditab cr 2

amlodipine besylate 2

cartia xt 2

dilt-cd 2

dilt-xr 2

diltiazem cd 2

diltiazem hcl 2

diltiazem hcl er 2

diltzac 2

DYNACIRC CR 4

EXFORGE 3 QL (30 per 30 days) ST

EXFORGE HCT 3 QL (30 per 30 days) ST

felodipine er 2 QL (30 per 30 days)

isradipine 2

nicardipine hcl capsule 2

nifediac cc 2

nifedical xl 2

nifedipine 2

nifedipine er 2

nimodipine 5

nisoldipine 3 QL (30 per 30 days)


SULAR 3 QL (30 per 30 days)

taztia xt 2

verapamil hcl er capsule extended release 24 hour 120mg, 180mg, 240mg

1

verapamil hcl er capsule extended release 24 hour 100mg, 200mg, 300mg

2

verapamil hcl er tablet extended release 1

verapamil hcl tablet 1

verapamil hcl injection 2

Cardiovascular Agents, Other

digoxin oral solution, tablet 1

digoxin injection 2

LANOXIN 3

RANEXA 4 PA

Diuretics

acetazolamide sodium 2

acetazolamide tablet 2

acetazolamide capsule extended release 12 hour 3

amiloride /hydrochlorothiazide 1

amiloride hcl 2

bumetanide 2

chlorothiazide 2

chlorthalidone 1

DIURIL IV 4 PA

furosemide 1

hydrochlorothiazide 1

indapamide 1

methyclothiazide 1

metolazone 2

torsemide 2

triamterene /hydrochlorothiazide 1

Dyslipidemics

CADUET 3 QL (30 per 30 days)

cholestyramine 2

cholestyramine light 3

colestipol hcl 2

CRESTOR 3 QL (30 per 30 days)

fenofibrate micronized 2 QL (30 per 30 days)

fenofibrate tablet 160mg 2 QL (30 per 30 days)

fenofibrate tablet 54mg 2 QL (60 per 30 days)

gemfibrozil 2

LESCOL XL 3 QL (30 per 30 days)

LESCOL CAPSULE 20MG 3 QL (30 per 30 days)

LESCOL CAPSULE 40MG 3 QL (60 per 30 days)

LIPITOR 3 QL (30 per 30 days)

lovastatin tablet 10mg, 20mg 1 QL (30 per 30 days)

lovastatin tablet 40mg 1 QL (60 per 30 days)

LOVAZA 3

NIASPAN TABLET EXTENDED RELEASE 500MG, 750MG



NIASPAN TABLET EXTENDED RELEASE 1000MG 3 QL (60 per 30 days)

pravastatin sodium 1 QL (30 per 30 days)

SIMCOR TABLET EXTENDED RELEASE 24 HOUR 500MG; 20MG


SIMCOR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 20MG, 750MG; 20MG


simvastatin 1 QL (30 per 30 days)

TRICOR TABLET 145MG 4 QL (30 per 30 days)

TRICOR TABLET 48MG 4 QL (60 per 30 days)

TRILIPIX CAPSULE DELAYED RELEASE 135MG 3 QL (30 per 30 days)

TRILIPIX CAPSULE DELAYED RELEASE 45MG 3 QL (60 per 30 days)

VYTORIN 4 QL (30 per 30 days)

WELCHOL 4 QL (210 per 30 days)

ZETIA 3 QL (30 per 30 days)

Renin-angiotensin-aldosterone System Inhibitors

ACEON 3

amlodipine besylate/benazepril hydrochloride 3

benazepril hcl 1

benazepril hcl/hydrochlorothiazide 1

captopril 1

captopril /hydrochlorothiazide 1

COZAAR 3 QL (30 per 30 days)

DIOVAN 3 QL (30 per 30 days)

DIOVAN HCT 3 QL (30 per 30 days)

enalapril maleate 1

enalapril maleate/hydrochlorothiazide 1

eplerenone 3

fosinopril sodium 1

fosinopril sodium/hydrochlorothiazide 1

HYZAAR 3 QL (30 per 30 days)

INSPRA 4

lisinopril 1

lisinopril /hydrochlorothiazide 1

LOTREL 3 QL (30 per 30 days)

MICARDIS 3 QL (30 per 30 days)

MICARDIS HCT 3 QL (30 per 30 days)

moexipril /hydrochlorothiazide 2

moexipril hcl 2

quinapril /hydrochlorothiazide 2

quinapril hcl 2

quinaretic 2

ramipril 2 QL (60 per 30 days)

spironolactone 2

spironolactone /hydrochlorothiazide 2

TARKA TABLET EXTENDED RELEASE 1MG; 240MG, 2MG; 180MG, 2MG; 240MG


TARKA TABLET EXTENDED RELEASE 4MG; 240MG 4 QL (60 per 30 days)

TEKTURNA 4 QL (30 per 30 days) ST

TEKTURNA HCT 4 QL (30 per 30 days) ST

trandolapril 2


Vasodilators

hydralazine hcl 2

isosorbide dinitrate 2

isosorbide dinitrate er 2

isosorbide mononitrate 2

isosorbide mononitrate er 2

minitran 3

minoxidil 2

MONOKET 4

NITRO-BID 4

nitroglycerin 2

nitroglycerin transdermal 2

NITROLINGUAL PUMPSPRAY 3

NITROSTAT 3

REMODULIN 5 PA

Central Nervous System Agents

Amphetamines, ADHD

ADDERALL XR CAPSULE EXTENDED RELEASE 24 HOUR 5MG, 10MG, 15MG


ADDERALL XR CAPSULE EXTENDED RELEASE 24 HOUR 20MG, 25MG, 30MG


amphetamine salt combo 2

DESOXYN 4 PA

dextroamphetamine sulfate 2

dextroamphetamine sulfate er 2

Non-amphetamines, ADHD

CONCERTA 4 QL (30 per 30 days)

DAYTRANA 4

dexmethylphenidate hcl 2

metadate er 3

methylin er 3

METHYLIN TABLET CHEWABLE, SOLUTION 3

methylin tablet 3

methylphenidate hcl 2

methylphenidate hcl sr 2

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

STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG 3 QL (60 per 30 days)

Non-amphetamines, Other

PROVIGIL TABLET 100MG 4 QL (30 per 30 days) PA

PROVIGIL TABLET 200MG 4 QL (60 per 30 days) PA

RILUTEK 3

XYREM 5 RA

Dental and Oral Agents

Dental and Oral Agents

chlorhexidine gluconate oral rinse 2

KEPIVANCE 5 PA

PERIDEX ORAL RINSE 3

periogard 3

pilocarpine hcl 2

pilocarpine hydrochloride 2


triamcinolone in orabase 2

Dermatological Agents

Dermatological Agents

8-MOP 3

ALDARA 3

AMEVIVE 5 PA

ammonium lactate 2

amnesteem 3

calcipotriene 3

CARAC 4

claravis 3

clindamycin phosphate 2

CONDYLOX 4

DOVONEX 3

EFUDEX 3

ELIDEL 4

erythromycin/benzoyl peroxide 3

fluorouracil 3

laclotion 2

OXSORALEN 4

OXSORALEN ULTRA 3

podofilox 3

PROTOPIC 4

REGRANEX 5 PA

SANTYL 3

SOLARAZE 3

SORIATANE CK 5

sotret 3

TACLONEX 4

tretinoin - topical 3 PA

UVADEX 3 B vs D

ZONALON 3

Enzyme Replacements/ Modifiers

Enzyme Replacements/ Modifiers

ADAGEN 5 PA

ALDURAZYME 5 PA

BUPHENYL 3

CEREDASE 5 PA

CEREZYME 5 PA

CYSTADANE 3

CYSTAGON 3

ELAPRASE 5 PA

FABRAZYME 5 PA

MYOZYME 5 PA

NAGLAZYME 5 PA

ORFADIN 5

PANCRELIPASE 2

PANCRELIPASE MST-16 2

PANCRON 10 2

PANCRON 20 2


SUCRAID 4

ULTRASE 3

ULTRASE MT 12 3

ULTRASE MT 18 3

ULTRASE MT 20 3

VIOKASE 3

VIOKASE 16 3

ZAVESCA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

atropine sulfate 2

dicyclomine hcl capsule, oral solution, tablet 2

dicyclomine hcl injection 2 PA

glycopyrrolate 3

methscopolamine bromide 2

propantheline bromide 2

Gastrointestinal Agents, Other

constulose 2

diphenoxylate/atropine 2

enulose 2

gavilyte-g 2

generlac 2

GOLYTELY 3

HALFLYTELY BOWEL PREP 4

lactulose 2

lonox 2

loperamide hcl 2

metoclopramide hcl 2

NULYTELY 3

peg 3350/electrolytes 2

trilyte 4

ursodiol capsule 2

ursodiol tablet 3

Histamine2 (H2) Blocking Agents

cimetidine 2

cimetidine hcl 2

famotidine 2

famotidine premixed 2

ranitidine hcl 2

Irritable Bowel Syndrome Agents

LOTRONEX 3 PA

Protectants

CARAFATE 4

misoprostol 2

sucralfate 2

Proton Pump Inhibitors

NEXIUM 3 QL (30 per 30 days)

NEXIUM I.V. 3 PA

omeprazole capsule delayed release 10mg, 40mg 1 QL (30 per 30 days)

omeprazole capsule delayed release 20mg 1 QL (60 per 30 days)


pantoprazole sodium 3 QL (30 per 30 days)

PREVACID 4 QL (30 per 30 days)

PREVACID SOLUTAB 4 QL (30 per 30 days)

Genitourinary Agents

Antispasmodics, Urinary

DETROL 3 QL (60 per 30 days)

DETROL LA 3 QL (30 per 30 days)

ENABLEX 4 QL (30 per 30 days)

flavoxate hcl 2

oxybutynin chloride 2

oxybutynin chloride er tablet extended release 24 hour 5mg


oxybutynin chloride er tablet extended release 24 hour 10mg, 15mg


OXYTROL 3

SANCTURA 4 QL (60 per 30 days) ST

TOVIAZ 3 QL (30 per 30 days)

VESICARE 4 QL (30 per 30 days) ST

Benign Prostatic Hypertrophy Agents

AVODART 3 QL (30 per 30 days)

doxazosin mesylate 2

finasteride 2 QL (30 per 30 days)

FLOMAX 3 QL (60 per 30 days) ST

terazosin hcl 2

UROXATRAL 4 QL (30 per 30 days) ST

Genitourinary Agents, Other

ELMIRON 3

LITHOSTAT 4

THIOLA 4

Phosphate Binders

calcium acetate 3

FOSRENOL 3

PHOSLO 3

RENAGEL 3

RENVELA 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Glucocorticoids/ Mineralocorticoids

a-hydrocort 2 B vs D

a-methapred 2 B vs D

ala-cort 2

alclometasone dipropionate 2

amcinonide 2

augmented betamethasone dipropionate 2

beta-val 2

betamethasone dipropionate 2

betamethasone valerate 2

clobetasol propionate e 2

clobetasol propionate gel, ointment, solution 2

clobetasol propionate foam 3


cormax 2

CORTEF TABLET 10MG 3

CORTEF TABLET 20MG, 5MG 3 B vs D

cortisone acetate 2

del-beta 2

DEPO-MEDROL 4 B vs D

desonide 2

desoximetasone 2

dexamethasone 2

dexamethasone intensol 2

dexamethasone sodium phosphate 2 B vs D

dexpak 13 day 2

diflorasone diacetate 2

fludrocortisone acetate 2

fluocinolone acetonide 2

fluocinonide 2

fluocinonide emollient base 2

fluticasone propionate 2

halobetasol propionate 2

hydrocortisone butyrate 2

hydrocortisone in absorbase 2

hydrocortisone valerate 2

hydrocortisone cream, lotion, ointment 2

hydrocortisone tablet 10mg 2

hydrocortisone tablet 20mg, 5mg 2 B vs D

lokara 2

methylprednisolone 2 B vs D

methylprednisolone acetate 2 B vs D

methylprednisolone sodiumsuccinate 2 B vs D

mometasone furoate 2

PANDEL 3

prednicarbate 2

prednisolone sodium phosphate 2

prednisone 2 B vs D

prednisone intensol 2 B vs D

procto-pak 2

proctocort 2

proctocream-hc 2

proctosol hc 2

proctozone-hc 2

SOLU-CORTEF 3 B vs D

SOLU-MEDROL 3 B vs D

triamcinolone acetonide 2

triamcinolone acetonide in absorbase 2

triderm 2

u-cort 2

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)


desmopressin acetate nasal solution, tablet 3

desmopressin acetate injection 3 PA

GENOTROPIN 5 PA

GENOTROPIN MINIQUICK INJECTION 0.2MG 4 PA

GENOTROPIN MINIQUICK INJECTION 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

HUMATROPE 5 PA

HUMATROPE COMBO PACK 5 PA

INCRELEX 5 PA

METHERGINE 4

NORDITROPIN CARTRIDGE 5 PA

NORDITROPIN NORDIFLEX PEN 5 PA

NUTROPIN 5 PA

NUTROPIN AQ 5 PA

OMNITROPE 5 PA

SAIZEN 5 PA

SAIZEN CLICK.EASY 5 PA

SEROSTIM 5 PA

TEV-TROPIN 5 PA

ZORBTIVE 5 PA

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

Anabolic Steroids

ANADROL-50 5

OXANDRIN 5

oxandrolone tablet 2.5mg 3

oxandrolone tablet 10mg 5

Androgens

ANDROGEL 3

methitest 3

TESTIM 3

testosterone cypionate 2 PA

testosterone enanthate 2 PA

Estrogens

ALORA 3 QL (8 per 28 days)

DIVIGEL 4

ENJUVIA 3

estradiol 2

estradiol/norethindrone acetate 2

ESTRASORB 4 QL (97.44 per 28 days)

estropipate 1

ORTHO TRI-CYCLEN LO 3

ortho-est 2

PREMARIN W/APPLICATOR 4

PREMARIN INJECTION 4

PREMARIN TABLET 4 QL (30 per 30 days)

tri-legest fe 3

tri-lo-sprintec 3

VIVELLE-DOT 3 QL (8 per 28 days)

Progestins


ANGELIQ 3

apri 3

aranelle 3

aviane 3

balziva 3

camila 3

cesia 3

cryselle-28 3

CYCLESSA 3

enpresse-28 3

errin 3

jolivette 3

junel 1.5/30 3

junel 1/20 3

junel fe 1.5/30 3

junel fe 1/20 3

kariva 3

kelnor 1/35 3

leena 3

lessina-28 3

levora 0.15/30-28 3

LOESTRIN 24 FE 3

low-ogestrel 3

lutera 3

LYBREL 3

medroxyprogesterone acetate 2

MEGACE ES 3

MEGACE ORAL 4

megestrol acetate 3

microgestin 1.5/30 3

microgestin 1/20 3

microgestin fe 3

microgestin fe 1.5/30 3

mononessa 3

necon 0.5/35-28 3

necon 1/35-28 3

necon 1/50-28 3

necon 10/11-28 3

necon 7/7/7 3

NOR-QD 3

nora-be 3

norethindrone acetate 2

nortrel 0.5/35 (28) 3

nortrel 1/35 (21) 3

nortrel 1/35 (28) 3

nortrel 7/7/7 3

NUVARING 4

ocella 3

ogestrel 3

ORTHO EVRA 4


PLAN B 3

portia-28 3

PREFEST 4

PREMPHASE 4

PREMPRO 4 QL (28 per 28 days)

previfem 3

PROMETRIUM 3

quasense 3

reclipsen 3

SEASONIQUE 3

solia 3

sprintec 28 3

sronyx 3

tri-previfem 3

tri-sprintec 3

trinessa 3

trivora-28 3

velivet 3

YAZ 3

zovia 1/35e 3

zovia 1/50e 3

Selective Estrogen Receptor Modifying Agents

EVISTA 3 QL (30 per 30 days)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

CYTOMEL 4

LEVOTHROID 2

levothyroxine sodium 1

LEVOXYL 1

liothyronine sodium 2

SYNTHROID 4

THYROLAR-1 4

THYROLAR-1/2 4

THYROLAR-1/4 4

THYROLAR-2 4

THYROLAR-3 4

UNITHROID 3

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 5

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR TABLET 30MG 3 QL (60 per 30 days)



Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

cabergoline 3 QL (16 per 28 days)


ELIGARD 4 PA

leuprolide acetate 2 PA

LUPRON DEPOT-PED 5 PA

LUPRON DEPOT INJECTION 11.25MG, 3.75MG 4 PA

LUPRON DEPOT INJECTION 22.5MG, 30MG, 7.5MG 5 PA

octreotide acetate 5 PA

SANDOSTATIN 5 PA

SANDOSTATIN LAR DEPOT 5 PA

SOMATULINE DEPOT 5 PA

SOMAVERT 5 PA

SYNAREL 5 PA

TRELSTAR DEPOT 4 PA

TRELSTAR LA 4 PA

Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)

Antiandrogens

bicalutamide 3

CASODEX 4

flutamide 3

NILANDRON 3

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole 2

propylthiouracil 2

Immunological Agents

Immune Suppressants

AZASAN 3 B vs D

azathioprine 2 B vs D

azathioprine sodium 2 B vs D

CELLCEPT INTRAVENOUS 4 B vs D

CELLCEPT CAPSULE 4 B vs D

CELLCEPT SUSPENSION RECONSTITUTED, TABLET5 B vs D

CIMZIA 5 PA

cyclosporine 3 B vs D

cyclosporine modified 3 B vs D

ENBREL 5 PA

ENBREL SURECLICK 5 PA

gengraf 3 B vs D

HUMIRA 5 PA

HUMIRA PEN 5 PA

IMURAN 4 B vs D

methotrexate 2 B vs D

methotrexate sodium 2 B vs D

mycophenolate mofetil 3 B vs D

MYFORTIC 3 B vs D

NEORAL 4 B vs D

ORENCIA 5 PA

ORTHOCLONE OKT3 5 B vs D

PROGRAF INJECTION 4 B vs D

PROGRAF CAPSULE 0.5MG 4 B vs D

PROGRAF CAPSULE 1MG, 5MG 5 B vs D


RAPAMUNE 4 B vs D

REMICADE 5 PA

RHEUMATREX 3

SANDIMMUNE 3 B vs D

SIMPONI 5 PA

SIMULECT 5 B vs D

TREXALL 4 B vs D

ZENAPAX 5 B vs D

Immunizing Agents, Passive

ATGAM 5 PA

CARIMUNE NANOFILTERED 5 PA

FLEBOGAMMA 5 PA

GAMASTAN S/D 4 PA

GAMMAGARD LIQUID 5 PA

GAMUNEX 5 PA

OCTAGAM 5 PA

POLYGAM S/D 5 PA

THYMOGLOBULIN 5 PA

VIVAGLOBIN 5 PA

Immunomodulators

ACTIMMUNE 5 PA

ALFERON N 5 PA

ARAVA 4 PA

ARCALYST 5 PA RA

AVONEX 5 PA

BETASERON 5 PA

COPAXONE 5 PA

INFERGEN 5 PA

INTRON-A W/DILUENT 5 PA

INTRON-A INJECTION 3MU/0.2ML 3 PA

INTRON-A INJECTION 10MU/0.2ML, 5MU/0.2ML, 6000000UNIT/ML

5 PA

KINERET 5 PA

leflunomide 2 PA

PEG-INTRON 5 PA

PEG-INTRON REDIPEN 5 PA

PEGASYS 5 PA

REBIF 5 PA

REBIF TITRATION PACK 5 PA

RIDAURA 3

SYNAGIS 5 PA

TYSABRI 5 PA RA

Vaccines

ACTHIB 3

ADACEL 3

ATTENUVAX 3

BOOSTRIX 3

COMVAX 3

DAPTACEL 3

DECAVAC 3


diphtheria/tetanus toxoid pediatric 3

ENGERIX-B 3 B vs D

GARDASIL 3

HAVRIX 3

HIBTITER 3

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3

IPOL INACTIVATED IPV 3

JE-VAX 3

M-M-R II W/DILUENT 10 DOSE 3

MENACTRA 3

MENOMUNE-A/C/Y/W-135 3

MERUVAX II W/DILUENT 10 DOSE 3

PEDIARIX 3

PEDVAX HIB 3

PROQUAD 3

RABAVERT 3

RECOMBIVAX HB 3 B vs D

ROTATEQ 3

TETANUS TOXOID ADSORBED 3

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

3

TRIHIBIT 3

TRIPEDIA 3

TWINRIX 3

TYPHIM VI 4

VAQTA 3

VARIVAX 3

VIVOTIF BERNA 3

YF-VAX 3

ZOSTAVAX 3

Inflammatory Bowel Disease Agents

Glucocorticoids

colocort 2

ENTOCORT EC 4

hydrocortisone enema 2

methylprednisolone 2 B vs D

Salicylates

ASACOL 4 ST

ASACOL HD 4 ST

balsalazide disodium 3

CANASA 3

LIALDA 3

mesalamine enema 2

PENTASA 3

Sulfonamides

sulfasalazine 2

sulfazine 2

sulfazine ec 2

Metabolic Bone Disease Agents


Metabolic Bone Disease Agents

ACTONEL WITH CALCIUM 4 QL (28 per 28 days) ST

ACTONEL TABLET 75MG 4 QL (2 per 30 days) ST

ACTONEL TABLET 30MG, 5MG 4 QL (30 per 30 days) ST

ACTONEL TABLET 35MG 4 QL (4 per 28 days) ST

alendronate sodium tablet 10mg, 40mg, 5mg 2 QL (30 per 30 days)

alendronate sodium tablet 35mg, 70mg 2 QL (4 per 28 days)

BONIVA INJECTION 3 QL (3 per 90 days) PA

BONIVA TABLET 150MG 3 QL (1 per 30 days)

BONIVA TABLET 2.5MG 3 QL (30 per 30 days)

CALCIJEX 3 PA

calcitonin-salmon nasal spray 2

calcitriol 2

etidronate disodium 3

FORTEO 5 PA

FORTICAL 3

FOSAMAX PLUS D 4 QL (4 per 28 days) ST

FOSAMAX SOLUTION 4 QL (300 per 28 days)

HECTOROL INJECTION 3 PA

HECTOROL CAPSULE 0.5MCG 3 QL (210 per 30 days)

HECTOROL CAPSULE 1MCG 3 QL (90 per 30 days)

HECTOROL CAPSULE 2.5MCG 3 QL (96 per 28 days)

pamidronate disodium 4 PA

ZEMPLAR INJECTION 3 PA

ZEMPLAR CAPSULE 3 QL (30 per 30 days)

ZOMETA 5 PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

ALCOHOL 5%/DEXTROSE 5% 3 B vs D

ALCOHOL PREP PADS 3

anagrelide hydrochloride 2 PA

dexrazoxane 5 PA

GAUZE PADS 2"X2" 3

INSULIN SYRINGES & PEN NEEDLES 3

INTRALIPID 3 B vs D

KUVAN 5

levocarnitine oral solution, tablet 2

levocarnitine injection 2 PA

pentopak 2

pentoxifylline er 2

pentoxil 2

sterile water irrigation 2

XENAZINE 5 PA RA

ZINECARD 5 PA

Ophthalmic Agents

Ophthalmic Agents, Other

ak-con 2

ak-poly-bac 2

ak-tob 2

bac /poly /neomy /hc 2


bacitracin 2

bacitracin/polymyxin b 2

gentak 2

gentasol 2

LACRISERT 4

mydral 2

naphazoline hcl 2

NATACYN 3

neomycin /polymyxin /gramicidin 2

ofloxacin 2

parcaine 2

proparacaine hcl 2

RESTASIS 3

romycin 2

trifluridine 3

trimethoprim sulfate/polymyxin b sulfate 2

tropicacyl 2

tropicamide 2

Ophthalmic Anti-allergy Agents

ALAMAST 4

ALOCRIL 4

ALOMIDE 4

crolom 2

cromolyn sodium 2

ELESTAT 4

EMADINE 4

OPTIVAR 4

PATADAY 3

PATANOL 3

Ophthalmic Anti-inflammatories

ACULAR 4

ACULAR LS 4

dexamethasone sodium phosphate 2

dexasporin 2

diclofenac sodium 1

FLAREX 4

fluor-op 2

fluorometholone 2

flurbiprofen sodium 2

FML FORTE 4

MAXIDEX 4

neomycin /polymyxin /dexamethasone 2

neomycin /polymyxin /hydrocortisone 2

NEVANAC 3

OCUFEN 4

poly-dex 2

PRED MILD 4

prednisolone acetate 2

prednisolone sodium phosphate 2

sulfacetamide sodium/prednisolone sodium phosphate 2


TOBRADEX OINTMENT 4

VOLTAREN 4

XIBROM 4

Ophthalmic Antiglaucoma Agents

ALPHAGAN P 3

AZOPT 3

betaxolol hcl 2

BETIMOL 3

BETOPTIC-S 3

brimonidine tartrate 2

carteolol hcl 1

COMBIGAN 3

COSOPT 4

dipivefrin hcl 2

dorzolamide hcl 2

dorzolamide hcl/timolol maleate 2

IOPIDINE 3

ISTALOL 4

levobunolol hcl 1

methazolamide 2

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 3

PILOPINE HS 3

timolol maleate 1

TRUSOPT 4

Ophthalmic Prostaglandin and Prostamide Analogs

TRAVATAN 3

TRAVATAN Z 3

XALATAN 3

Otic Agents

Otic Agents

acetasol hc 2

acetic acid 2

acetic acid/aluminum acetate 2

borofair 2

CIPRODEX 3

COLY-MYCIN S 3

cortomycin 2

DERMOTIC 3

neomycin /polymyxin /hc 2

neomycin /polymyxin /hydrocortisone 2

PEDIOTIC 4

Respiratory Tract Agents

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS 3

ADVAIR HFA 3

ASMANEX 3

AZMACORT 4

FLOVENT DISKUS 3


FLOVENT HFA 3

fluticasone propionate 2

NASACORT AQ 3

PULMICORT 4 B vs D

QVAR 3

SYMBICORT 3

VERAMYST 3

Antihistamines

ALLEGRA-D 12 HOUR 4 QL (60 per 30 days)

ALLEGRA-D 24 HOUR 4 QL (30 per 30 days)

ASTELIN 3

ASTEPRO 3

carbinoxamine maleate 2

clemastine fumarate 2

cyproheptadine hcl 2

dexchlorpheniramine maleate 2

diphenhydramine hcl 2

fexofenadine hcl tablet 180mg 3 QL (30 per 30 days)

fexofenadine hcl tablet 30mg, 60mg 3 QL (60 per 30 days)

hydroxyzine hcl 2

hydroxyzine pamoate 2

palgic liquid 2

promethazine hcl 2

promethazine vc 2

XYZAL TABLET 4 QL (30 per 30 days)

XYZAL SOLUTION 4 QL (300 per 30 days)

Antileukotrienes

ACCOLATE 4

SINGULAIR 3

ZYFLO CR 4

Bronchodilators, Anticholinergic

ATROVENT 3

ATROVENT HFA 3

ipratropium bromide/albuterol sulfate inhalant solution 3 B vs D

ipratropium bromide nasal solution 2

ipratropium bromide inhalation solution 2 B vs D

SPIRIVA HANDIHALER 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

aminophylline 2

theochron 2

theophylline cr 2

theophylline er 2

Bronchodilators, Sympathomimetic

albuterol sulfate er 2

albuterol sulfate syrup, tablet 2

albuterol sulfate inhalant solution 2 B vs D

BROVANA 4 B vs D

COMBIVENT 4

epinephrine hcl 2


EPIPEN 3 QL (2 per 1 day)

EPIPEN-JR 3 QL (2 per 1 day)

FORADIL AEROLIZER 3

metaproterenol sulfate 2

PROAIR HFA 3

PROVENTIL HFA 4

SEREVENT DISKUS 3

terbutaline sulfate 2

TWINJECT 3 QL (2 per 1 day)

VENTOLIN HFA 3

VOSPIRE ER 3

XOPENEX 4 B vs D

XOPENEX HFA 3

Mast Cell Stabilizers

cromolyn sodium inhalant solution 2 B vs D

Pulmonary Antihypertensives

ADCIRCA 5 QL (60 per 30 days) PA

LETAIRIS 5

REVATIO 5 PA

TRACLEER 5 RA

VENTAVIS 5 PA

Respiratory Tract Agents, Other

acetylcysteine 2

ARALAST 5 PA

flunisolide 2

ipratropium bromide 2

PROLASTIN 5 PA

PULMOZYME 5 B vs D

TYZINE 3

TYZINE PEDIATRIC NASAL DROPS 3

XOLAIR 5 PA

ZEMAIRA 5 PA

Sedatives/Hypnotics

Sedatives/Hypnotics

AMBIEN CR 4 QL (30 per 30 days) ST

zaleplon 3 QL (30 per 30 days)

zolpidem tartrate 2 QL (30 per 30 days)

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

carisoprodol 2

carisoprodol /aspirin 2

carisoprodol /aspirin /codeine 2

chlorzoxazone 2

cyclobenzaprine hcl 2


methocarbamol 2

orphenadrine /asa /caffeine 2

orphenadrine citrate 2 PA

orphenadrine citrate er 2

orphenadrine compound ds 2

ROBAXIN INJECTION 4 PA

Therapeutic Nutrients/Minerals/ Electrolytes

Electrolytes/Minerals

AMINESS 3 B vs D

AMINOSYN 3 B vs D

AMINOSYN 7%/ELECTROLYTES 3 B vs D

AMINOSYN 8.5%/ELECTROLYTES 3 B vs D

AMINOSYN II 3 B vs D

AMINOSYN II 3.5%/DEXTROSE25% 3 B vs D

AMINOSYN II 3.5/DEXTROSE 25% 3 B vs D

AMINOSYN II 4.25/DEXTROSE10% 3 B vs D



AMINOSYN II 5/DEXTROSE 25 3 B vs D

AMINOSYN II 8.5%/ELECTROLYTES 3 B vs D

AMINOSYN II M 3.5%/DEXTROSE 5% 3 B vs D

AMINOSYN M 3 B vs D

AMINOSYN-HBC 3 B vs D

AMINOSYN-HF 3 B vs D

AMINOSYN-PF 3 B vs D

AMINOSYN-PF 7% 3 B vs D

AMMONIUM CHLORIDE 3 PA

CLINIMIX 2.75%/DEXTROSE 5% 3 B vs D





CLINIMIX 5%/DEXTROSE 15% 3 B vs D



CLINIMIX E 2.75%/DEXTROSE 10% 3 B vs D




CLINIMIX E 5%/DEXTROSE 15% 3 B vs D




CLINISOL SF 15% 3 B vs D

dextrose 10%/nacl 0.45% 2 B vs D

dextrose 5% /electrolyte #48 viaflex 2 B vs D

dextrose 10% flex container 2 B vs D


dextrose 2.5%/sodium chloride 0.45% 2 B vs D

dextrose 5% 2 B vs D







dextrose 5%/potassium chloride 0.075% 2 B vs D

ed k+10 2

eliphos 3

FREAMINE HBC 6.9% 3 B vs D

FREAMINE III 3 B vs D

FREAMINE III 3% 3 B vs D

HEPATAMINE 3 B vs D

HEPATASOL 3 B vs D

IONOSOL-B/DEXTROSE 5% 3 B vs D

IONOSOL-MB/DEXTROSE 5% 3 B vs D

IONOSOL-T/DEXTROSE 5% 3 B vs D

ISOLYTE-H/DEXTROSE 5% 3 B vs D

ISOLYTE-M/DEXTROSE 5% 3 B vs D

ISOLYTE-P/DEXTROSE 5% 3 B vs D

ISOLYTE-S 3 B vs D

ISOLYTE-S/DEXTROSE 5% 3 B vs D

K-TABS 3

kaon-cl-10 2

KCL 0.075%/D5W/NACL 0.45% 3 B vs D

KCL 0.15%/D10W/NACL 0.2% 3 B vs D

KCL 0.15%/D5W/LR 3 B vs D

KCL 0.15%/D5W/NACL 0.2% 3 B vs D

KCL 0.15%/D5W/NACL 0.225% 3 B vs D


KCL 0.224%/D5W/NACL 0.2% 3 B vs D

KCL 0.3%/D5W/LR IV LAC RING 3 B vs D




klor-con 10 2

klor-con 8 2

klor-con m15 2

klor-con m20 2

LACTATED RINGERS IRRIGATION 3

LACTATED RINGERS VIAFLEX 3

leucovorin calcium tablet 2

leucovorin calcium injection 2 B vs D

magnesium sulfate 2 B vs D

magnesium sulfate in d5w 2

NEPHRAMINE 3 B vs D

NORMOSOL-M IN D5W 3 B vs D

NORMOSOL-R 3 B vs D

NORMOSOL-R IN D5W 3 B vs D

NOVAMINE 3 B vs D

PHYSIOLYTE 3 B vs D


PHYSIOSOL IRRIGATION 3 B vs D

PLASMA-LYTE 56 3 B vs D

PLASMA-LYTE A 3 B vs D

PLASMA-LYTE-148 3 B vs D

PLASMA-LYTE-148/D5W 3 B vs D

PLASMA-LYTE-56/D5W 3 B vs D

PLASMA-LYTE-R 3 B vs D

POTASSIUM CHLORIDE 1 B vs D

POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% 1 B vs D

POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX

1 B vs D

POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% 1 B vs D

POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% VIAFLEX

1 B vs D

POTASSIUM CHLORIDE 0.15% NACL 0.9% 1 B vs D

POTASSIUM CHLORIDE 0.15%/D5W 1 B vs D

POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 1 B vs D


POTASSIUM CHLORIDE 0.224%D5W/NACL 0.33% 1 B vs D

POTASSIUM CHLORIDE 0.3%/ NACL 0.9% 1 B vs D


potassium chloride cr 1

potassium chloride er 1

potassium citrate extended-release 1

PREMASOL 3 B vs D

PROCALAMINE 3 B vs D

PROSOL 3 B vs D

RENAMIN 3 B vs D

RINGERS INJECTION 3

RINGERS IRRIGATION 3

sodium bicarbonate 2 B vs D

sodium chloride 2 B vs D

sodium chloride 0.9% 2

sodium chloride 0.45% viaflex 2 B vs D

sodium fluoride 2

SODIUM LACTATE 3 B vs D

TIS-U-SOL 3 B vs D

TPN ELECTROLYTES FTV 3 B vs D

TRAVASOL 4 B vs D

TRAVASOL 2.75%/DEXTROSE 10% 4 B vs D


TRAVASOL 3.5%/ELECTROLYTES 4 B vs D




TRAVASOL 8.5%/ELECTROLYTES 4 B vs D

TROPHAMINE 3 B vs D

UROCIT-K 10 4

UROCIT-K 5 4

Vitamins


PRENATABS OBN 3

Formulary ID: 10480.v10 Last Updated: 01/01/2010

CIGNA Medicare Services, "CIGNA Medicare Rx" (PDP) and the "Tree of Life" logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. CIGNA Medicare Rx (PDP) plans are offered by operating subsidiary Connecticut General Life Insurance Company, and not by CIGNA Corporation. Connecticut General Life Insurance Company is a Medicare approved Part D sponsor.

2010 cigna medicare rx plan two (pdp) formulary · 2010 cigna medicare rx plan two (pdp) formulary...

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