2015 631 3t copper comm eff 11/01/2015 · ultram er) tb24 200mg ql (30 tabs / 30 days) 1 ql...

2015 631 3T Copper Comm eff 11/01/2015

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

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS QL (120 tabs / 30 days)

2 QL

probenecid 1

ULORIC 2 ST

ZYLOPRIM 3

MISCELLANEOUS ARTHROTEC 50 3

ARTHROTEC 75 3

diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 3

VIMOVO 2

NSAIDS ANAPROX 2

ANAPROX DS 2

CELEBREX CAP 50MG 3

CELEBREX CAP 100MG 3



celecoxib (generic of CELEBREX) CAPS

1

DAYPRO 2

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

EC-NAPROSYN 3

etodolac 1

etodolac er 1

FELDENE 3

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

Drug Name Drug Tier

Requirements/Limits

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

meloxicam tabs (generic of MOBIC)

1

MOBIC 2

nabumetone TABS 1

NAPRELAN 3

NAPROSYN 2

naproxen SUSP 1

naproxen (generic of NAPROSYN) TABS

1

naproxen (generic of EC-NAPROSYN) TBEC

1

NAPROXEN SOD TAB 375MG CR

1

NAPROXEN SOD TAB 500MG CR

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 3 NM

sulindac TABS 1

tolmetin sodium 1

VOLTAREN-XR 3

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

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


1 QL

2015 631 3T Copper Comm eff 11/01/2015


2

Drug Name Drug Tier

Requirements/Limits

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


1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE


1 QL

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

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

2 QL

BUTRANS 7.5mcg/hr, 10mcg/hr

QL (8 patches / 28 days)

2 QL

BUTRANS 15mcg/hr, 20mcg/hr


2 QL

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 100mg QL (90 caps / 30 days)

3 QL


3 QL


3 QL

hycet QL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL

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


1 QL

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


1 QL

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


1 QL

Drug Name Drug Tier

Requirements/Limits

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

QL (5400 mL / 30 days)

1 QL

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


1 QL

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


1 QL

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


1 QL

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


1 QL

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


1 QL

ibudone 5-200 mg (generic of REPREXAIN)


1 QL

ibudone tab 10-200mg QL (150 tabs / 30 days)

1 QL

lorcet hd tab 10-325mg (generic of NORCO)


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

lortab elix QL (6000 mL / 30 days)

3 QL

lortab tab 5-325mg (generic of NORCO)


1 QL

lortab tab 7.5-325 (generic of NORCO)


1 QL

lortab tab 10-325mg (generic of NORCO)


1 QL

2015 631 3T Copper Comm eff 11/01/2015


3

Drug Name Drug Tier

Requirements/Limits

norco QL (360 tabs / 30 days)

3 QL

reprexain 2.5/200 QL (150 tabs / 30 days)

3 QL

reprexain 5/200 QL (150 tabs / 30 days)

3 QL

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

1 QL

SYNALGOS-DC QL (360 caps / 30 days)

3 QL

TRAMADOL HCL CP24 100mg


1 QL



1 QL



1 QL

TRAMADOL HCL TB24 QL (30 tabs / 30 days)

1 QL

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


1 QL

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


1 QL

tramadol hcl er (biphasic) 100mg


1 QL



1 QL



1 QL

tramadol hcl tab 50 mg (generic of ULTRAM)


1 QL

tramadol-acetaminophen (generic of ULTRACET)


1 QL

trezix QL (360 caps / 30 days)

3 QL

tylenol with codeine QL (400 tabs / 30 days)

3 QL

ULTRACET QL (240 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

ULTRAM QL (240 tabs / 30 days)

2 QL

ULTRAM ER 100mg QL (90 tabs / 30 days)

3 QL

ULTRAM ER 200mg, 300mg QL (30 tabs / 30 days)

3 QL

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

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

VICOPROFEN QL (150 tabs / 30 days)

3 QL

xodol tab 5-300mg QL (400 tabs / 30 days)

3 QL

xodol tab 7.5-300 QL (400 tabs / 30 days)

3 QL

xodol tab 10-300mg QL (400 tabs / 30 days)

3 QL NM

zamicet QL (5400 mL / 30 days)

1 QL

OPIOID ANALGESICS, CII ABSTRAL

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

ACTIQ QL (120 lozenges / 30 days)

3 QL NM PA

AVINZA QL (60 caps / 30 days)

3 QL

CODEINE SULFATE 15mg QL (720 tabs / 30 days)

1 QL


1 QL


1 QL

DILAUDID INJ 3 B/D

DILAUDID TAB QL (270 tabs / 30 days)

3 QL

DILAUDID-5 ORAL LIQD 3

DILAUDID-HP INJ 3 B/D

DILAUDID-HP INJ 250MG 3 B/D

DOLOPHINE QL (240 tabs / 30 days)

3 QL

2015 631 3T Copper Comm eff 11/01/2015


4

Drug Name Drug Tier

Requirements/Limits

DURAGESIC 12mcg/hr, 25mcg/hr, 50mcg/hr


3 QL

DURAGESIC 75mcg/hr, 100mcg/hr


3 QL NM

DURAMORPH 1 B/D

EMBEDA CAPS 20-0.8MG QL (60 caps / 30 days)

3 QL


3 QL

EMBEDA CAPS 50-2MG QL (60 caps / 30 days)

3 QL


3 QL


3 QL

EMBEDA CAPS 100-4MG QL (30 caps / 30 days)

3 QL

endocet (generic of PERCOCET)


1 QL

ENDODAN TAB QL (360 tabs / 30 days)

1 QL

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

3 QL

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

3 QL NM

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

3 QL NM PA

fentanyl patch (generic of DURAGESIC)


1 QL

FENTORA QL (120 tabs / 30 days)

3 QL NM PA

hydromorphone hcl (generic of DILAUDID) LIQD

1

HYDROMORPHONE HCL SOLN 1mg/ml, 2mg/ml, 4mg/ml

1 B/D

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

1 B/D

Drug Name Drug Tier

Requirements/Limits

hydromorphone hcl (generic of DILAUDID) TABS


1 QL

hydromorphone tab 8mg er (generic of EXALGO)


1 QL



1 QL



1 QL

HYDROMORPHONE TABS 32MG


3 QL NM

HYSINGLA ER 20mg, 30mg, 40mg, 60mg


3 QL

HYSINGLA ER 80mg, 100mg, 120mg


3 QL NM

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 10mg, 20mg, 30mg, 40mg, 50mg


3 QL

KADIAN 60mg, 80mg, 100mg, 200mg


3 QL NM

LAZANDA QL (30 bottles / 30 days)

3 QL NM PA

levorphanol tartrate TABS QL (180 tabs / 30 days)

1 QL

methadone hcl (generic of METHADOSE) CONC

QL (120 mL / 30 days)

1 QL

methadone hcl SOLN QL (600 mL / 30 days)

1 QL

methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 3

METHADOSE CONC QL (120 mL / 30 days)

3 QL

2015 631 3T Copper Comm eff 11/01/2015


5

Drug Name Drug Tier

Requirements/Limits

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg


1 QL

morphine sulfate (generic of KADIAN) CP24 80mg, 100mg


3 QL NM

MORPHINE SULFATE SOLN 1mg/ml, 10mg/ml, 15mg/ml

1 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 8mg/ml

3 B/D

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

1

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

1 B/D

MORPHINE SULFATE TABS


1 QL

morphine sulfate beads QL (60 caps / 30 days)

1 QL

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


1 QL

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


1 QL

MS CONTIN 15mg, 30mg, 60mg


3 QL

MS CONTIN 100mg QL (90 tabs / 30 days)

3 QL NM

MS CONTIN 200mg QL (60 tabs / 30 days)

3 QL NM

NUCYNTA 50mg QL (360 tabs / 30 days)

2 QL


2 QL


2 QL

Drug Name Drug Tier

Requirements/Limits

NUCYNTA ER 50mg, 100mg


2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

OPANA TABS QL (180 tabs / 30 days)

3 QL

OPANA ER (CRUSH RESISTANT


2 QL

OXECTA QL (270 tabs / 30 days)

3 QL

OXYCODONE HCL CAPS QL (180 caps / 30 days)

1 QL

OXYCODONE HCL CONC 1

oxycodone hcl SOLN 1

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


1 QL

oxycodone hcl TABS 10mg, 20mg


1 QL

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


1 QL

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


1 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)


1 QL

oxycodone-aspirin (generic of PERCODAN)


1 QL

oxycodone-ibuprofen QL (28 tabs / 30 days)

1 QL

OXYCONTIN QL (120 tabs / 30 days)

2 QL

2015 631 3T Copper Comm eff 11/01/2015


6

Drug Name Drug Tier

Requirements/Limits

oxymorphone hcl (generic of OPANA) TABS


1 QL

percocet 2.5/325 QL (360 tabs / 30 days)

3 QL

percocet 7.5/325 QL (360 tabs / 30 days)

3 QL

percocet 10/325 QL (360 tabs / 30 days)

3 QL NM

percocet tab 5-325mg QL (360 tabs / 30 days)

3 QL

PERCODAN QL (360 tabs / 30 days)

3 QL

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tabs (generic of PERCOCET)


1 QL

ROXICODONE 5mg, 15mg QL (180 tabs / 30 days)

3 QL

ROXICODONE 30mg QL (180 tabs / 30 days)

3 QL NM

SUBSYS QL (4 boxes / 30 days)

3 QL NM PA

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg


3 QL

ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg


3 QL

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 1%

1 B/D

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

1

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

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 1% (generic of XYLOCAINE)

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

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

1 B/D

XYLOCAINE .5%, 1%, 2% 3 B/D

XYLOCAINE-MPF 4% 3

XYLOCAINE-MPF .5%, 1%, 1.5%, 2%

3 B/D

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

BETHKIS 3 B/D NM

gentamicin in saline inj 0.8 mg/ml

1


3

gentamicin in saline inj 1 mg/ml

1


1


3


1

gentamicin in saline inj 2 mg/ml

1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI NEB 3 B/D NM

TOBI PODHALER 3 NM PA

tobramycin (generic of TOBI) NEBU

3 B/D NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

2015 631 3T Copper Comm eff 11/01/2015


7

Drug Name Drug Tier

Requirements/Limits

atovaquone (generic of MEPRON) SUSP

3 NM

AZACTAM 3

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3 NM

aztreonam (generic of AZACTAM)

1

BACTRIM 2

BACTRIM DS 2

BILTRICIDE 2

CAYSTON 2 NM LA PA

CLEOCIN CAPS 2

cleocin SOLR 2

CLEOCIN CAP 75MG 2

CLEOCIN IN D5W 3

CLEOCIN INJ 3

CLEOCIN PHOSPHATE 3

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

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

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3

CUBICIN 3 NM

DALVANCE 3 NM

dapsone TABS 1

DARAPRIM 3

DORIBAX 3

FLAGYL 3

FURADANTIN 90 day limit if >64 yr

3 NM PA

Drug Name Drug Tier

Requirements/Limits

HIPREX 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

ivermectin (generic of STROMECTOL) TABS

1

linezolid (generic of ZYVOX) SOLN

3 NM

LINEZOLID TABS 3 NM

MACROBID 90 day limit if >64 yr

3 PA

MACRODANTIN 90 day limit if >64 yr

3 PA

MEPRON 3 NM

meropenem (generic of MERREM)

1

MERREM 3

methenamine hippurate (generic of HIPREX)

1

METRO IV 3

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

90 day limit if >64 yr

3 PA

nitrofurantoin macrocrystal (generic of MACRODANTIN)


3 PA

nitrofurantoin monohyd macro (generic of MACROBID)


3 PA

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMAXIN 3

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO 3 NM

STROMECTOL 3

sulfamethoxazole-trimethop SUSP

1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS

1

2015 631 3T Copper Comm eff 11/01/2015


8

Drug Name Drug Tier

Requirements/Limits

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3 NM

trimethoprim TABS 1

TYGACIL 3 NM

VANCOCIN HCL 3 NM

vancomycin hcl (generic of VANCOCIN HCL) CAPS

3 NM

vancomycin hcl SOLR 10gm, 500mg, 1000mg, 5000mg

1

vancomycin hcl SOLR 750mg

3

XIFAXAN TAB 200MG 3 NM

ZYVOX 3 NM

ANTIFUNGALS ABELCET 3 B/D NM

AMBISOME 3 B/D NM

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

ANCOBON 3 NM

CANCIDAS 3 NM

CRESEMBA 3 NM

DIFLUCAN 3

ERAXIS 3 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole inj nacl 100 3



flucytosine (generic of ANCOBON) CAPS

3 NM

GRIS-PEG 2

griseofulvin microsize SUSP 1

griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1 PA

LAMISIL PACK 3

LAMISIL TABS QL (90 tabs / 365 days)

3 QL

MYCAMINE 3 NM

Drug Name Drug Tier

Requirements/Limits

NOXAFIL 3 NM

nystatin TABS 1

ONMEL 3 PA

SPORANOX 3 NM PA

SPORANOX PULSEPAK 3 NM PA

SPORANOX SOL 10MG/ML 3 NM

terbinafine hcl (generic of LAMISIL) TABS


1 QL

VFEND IV 3

VFEND SUS 40MG/ML 3 NM

VFEND TAB 3 NM

voriconazole (generic of VFEND) SUSR; TABS

3 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

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

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

MALARONE 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3 PA

quinine sulfate (generic of QUALAQUIN) CAPS

1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 3 NM

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 3 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

EPIVIR TABS 2

FUZEON 2 NM

2015 631 3T Copper Comm eff 11/01/2015


9

Drug Name Drug Tier

Requirements/Limits

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 3 NM

INVIRASE CAPS 3

INVIRASE TABS 3 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 3 NM

ISENTRESS PACK 2

ISENTRESS TABS 3 NM

lamivudine (generic of EPIVIR)

1

LEXIVA SUSP 3

LEXIVA TABS 3 NM

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA SUSP 3 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

3 NM

RESCRIPTOR 2

RETROVIR CAPS 2

RETROVIR IV INFUSION 3

RETROVIR SYRP 2

REYATAZ 3 NM

SELZENTRY 3 NM

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 2

SUSTIVA TABS 3 NM

TIVICAY 3 NM

TYBOST 3

VIDEX EC 2

VIDEX PEDIATRIC 3

VIRACEPT 3 NM

VIRAMUNE 2

VIRAMUNE XR 2

VIREAD 3 NM

VITEKTA 3 NM

ZERIT 2

ZIAGEN SOLN 3

ZIAGEN TABS 2

Drug Name Drug Tier

Requirements/Limits

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

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

3 NM

ATRIPLA 3 NM

COMBIVIR 3 NM

COMPLERA 3 NM

EPZICOM 3 NM

EVOTAZ 3 NM

KALETRA SOL 3 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 3 NM

lamivudine-zidovudine (generic of COMBIVIR)

3 NM

PREZCOBIX 3 NM

STRIBILD 3 NM

TRIUMEQ 3 NM

TRIZIVIR 3 NM

TRUVADA QL (30 tabs / 30 days)

3 QL NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3 NM

cycloserine CAPS 1

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

MYAMBUTOL 2

MYCOBUTIN 3

paser d/r 3

PRIFTIN 3

pyrazinamide 1

rifabutin (generic of MYCOBUTIN)

1

rifadin CAPS 150mg 2

RIFADIN CAPS 300mg 2

RIFADIN SOLR 3

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

SIRTURO 3 NM LA PA

2015 631 3T Copper Comm eff 11/01/2015


10

Drug Name Drug Tier

Requirements/Limits

TRECATOR 3

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

1

acyclovir sodium 1 B/D

adefovir dipivoxil (generic of HEPSERA)

3 NM

BARACLUDE SOLN 2

BARACLUDE TABS 3 NM

cidofovir (generic of VISTIDE) 1

COPEGUS 3 NM PA

CYTOVENE 3 B/D

entecavir (generic of BARACLUDE)

3 NM

EPIVIR HBV 2

famciclovir (generic of FAMVIR) TABS

1

FAMVIR 3

FLUMADINE 3

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HARVONI 3 NM PA

HEPSERA 3 NM

lamivudine (hbv) (generic of EPIVIR HBV)

1

moderiba pak 3 NM PA

moderiba tab 200mg (generic of COPEGUS)

1 NM PA

OLYSIO 3 NM PA

REBETOL 3 NM PA

RELENZA DISKHALER 2

ribapak mis 600/day 3 NM PA

ribasphere (generic of REBETOL) CAPS

1 NM PA

ribasphere (generic of COPEGUS) TABS 200mg

1 NM PA

ribasphere TABS 400mg 1 NM PA

ribasphere TABS 600mg 3 NM PA

ribasphere ribapak 800 3 NM PA



ribavirin 200mg (generic of REBETOL) CAPS

1 NM PA

ribavirin 200mg (generic of COPEGUS) TABS

1 NM PA

Drug Name Drug Tier

Requirements/Limits

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 3 NM PA

TAMIFLU 2

TYZEKA 3 NM

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 3 NM

valganciclovir hcl (generic of VALCYTE)

3 NM

VALTREX 3

VICTRELIS 3 NM PA

VISTIDE 3

ZOVIRAX CAPS; SUSP 3

CEPHALOSPORINS AVYCAZ 3 NM

CEDAX 3

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 3

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefixime (generic of SUPRAX) 1

cefotaxime sodium (generic of CLAFORAN) 1gm, 2gm, 500mg

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ)

1

CEFTAZIDIME/DEXTROSE 3

ceftibuten 1

CEFTIN 3

2015 631 3T Copper Comm eff 11/01/2015


11

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1

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

1

cefuroxime sodium soln iv 7.5 gm

3

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

CLAFORAN 1gm, 2gm, 10gm, 500mg

3

FORTAZ 3

KEFLEX 3

MAXIPIME 3

rocephin 3

SUPRAX CAPS 2

suprax CHEW 2

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

2

SUPRAX SUSR 500mg/5ml 2

tazicef (generic of FORTAZ) SOLR

1

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZERBAXA 3 NM

ZINACEF SOLR 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR 500mg

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

BIAXIN 3

clarithromycin SUSR 125mg/5ml

1

Drug Name Drug Tier

Requirements/Limits

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

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 3 NM

e.e.s. 400 mg tab 1

E.E.S. GRANULES 3

ery-tab 3

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

FLUOROQUINOLONES AVELOX 3

AVELOX ABC PACK 3

CIPRO 3

CIPRO XR 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin (generic of CIPRO) SUSR

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

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

1

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

1

ciprofloxacn inj 1

LEVAQUIN 3

levofloxacin SOLN 1

2015 631 3T Copper Comm eff 11/01/2015


12

Drug Name Drug Tier

Requirements/Limits

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 1

MOXIFLOXACIN HCL SOLN 3

moxifloxacin hcl (generic of AVELOX) TABS

1

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

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

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN 3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3 NM

BICILLIN C-R 3

Drug Name Drug Tier

Requirements/Limits

BICILLIN L-A 3

dicloxacillin sodium 1

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 3 NM

NALLPEN ISO-OSMOTIC IN DE

3 NM

NALLPEN/DEXTROSE 3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 3 NM

PENICILLIN G POT IN DEXTROSE

3

penicillin g potassium 1

PENICILLIN G POTASSIUM IN

3

penicillin g procaine 3

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

UNASYN 3

UNASYN BULK PACK 3

ZOSYN 3

TETRACYCLINES adoxa CAPS 3

demeclocycline hcl 1

DORYX 150mg, 200mg 3

doxy inj 1

doxycycline (monohydrate) CAPS 50mg

1

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

1

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

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

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

1

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

1

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Drug Name Drug Tier

Requirements/Limits

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate TBEC 1

MINOCIN CAPS 3

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 3 NM

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN CAPS 3

VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN SOLR 3 B/D

BICNU 3 B/D

BUSULFEX 3 B/D

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 1 B/D

dacarbazine 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 3 NM

IFEX 3 B/D

IFEX INJ 3GM 3 B/D

ifosfamide (generic of IFOSFAMIDE) 1gm/20ml, 3gm/60ml

1 B/D

ifosfamide 3gm/60ml 3 B/D

ifosfamide for inj 1 gm (generic of IFEX)

1 B/D

IFOSFAMIDE FOR INJ 3 GM 3 B/D

ifosfamide inj 1gm/20ml 3 B/D

LEUKERAN 2

LOMUSTINE 1

melphalan hcl (generic of ALKERAN)

3 B/D NM

MUSTARGEN 3 B/D

TREANDA 3 B/D NM

ZANOSAR 3 B/D

Drug Name Drug Tier

Requirements/Limits

ANTHRACYCLINES daunorubicin hcl 1 B/D

DOXIL 3 B/D NM

doxorubicin hcl 50mg 1 B/D

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

3 B/D NM

doxorubicin inj 50mg 1 B/D

ELLENCE 3 B/D NM

EPIRUBICIN INJ 50MG 3 B/D

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

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

3 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D NM

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D NM

ARRANON 3 B/D

azacitidine (generic of VIDAZA)

3 B/D NM

cladribine 3 B/D NM

CLOLAR 3 B/D

cytarabine inj 1 B/D

DACOGEN 3 B/D NM

decitabine (generic of DACOGEN)

1 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 3 B/D NM

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

3 B/D NM

gemcitabine hcl 2gm 3 B/D NM

GEMZAR 3 B/D NM

mercaptopurine TABS 1

methotrexate sodium inj 1 B/D

NIPENT 3 B/D NM

2015 631 3T Copper Comm eff 11/01/2015


14

Drug Name Drug Tier

Requirements/Limits

PURIXAN 3 NM

TABLOID 2

VIDAZA 3 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM

DOCETAXEL INJ 20MG/2ML 1 B/D

DOCETAXEL INJ 20MG/ML 3 B/D NM

DOCETAXEL INJ 80MG/4ML 3 B/D NM

DOCETAXEL INJ 80MG/8ML 3 B/D NM

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

DOCETAXEL INJ 160MG/16ML

3 B/D NM

DOCETAXEL INJ 200MG/20ML

3 B/D NM

paclitaxel 1 B/D

TAXOTERE 3 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 B/D NM

AVASTIN 3 B/D NM

ERBITUX 3 B/D NM

ERIVEDGE 3 NM LA PA

FARYDAK 3 NM LA PA

HERCEPTIN 3 B/D NM

IBRANCE 3 NM LA PA

ISTODAX 3 B/D NM

KADCYLA 3 B/D NM

LYNPARZA 3 NM PA

PROLEUKIN 3 B/D NM

RITUXAN 500mg/50ml 2 NM PA

TORISEL 3 B/D NM

VECTIBIX 3 B/D NM

VELCADE 3 B/D NM

ZOLINZA 3 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARIMIDEX 2

AROMASIN 2

bicalutamide (generic of CASODEX)

1

Drug Name Drug Tier

Requirements/Limits

CASODEX 2

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 3 B/D NM

ELIGARD INJ 22.5MG 3 B/D NM

ELIGARD INJ 30MG 3 B/D NM

ELIGARD INJ 45MG 3 B/D NM

exemestane (generic of AROMASIN)

1

FARESTON 3 NM

FASLODEX 3 B/D NM

FEMARA 2

FIRMAGON 3 B/D NM

flutamide 1

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPR DEP-PED INJ 15MG 3 NM PA

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

3 NM PA

LUPRON DEP INJ 11.25MG 3 NM PA

LUPRON DEPOT 3.75mg, 7.5mg

3 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

3 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

3 NM PA

LUPRON DEPOT-PED 3 NM PA

LYSODREN 2

MEGACE ES 3 NM PA

MEGACE ORAL 3 PA

megestrol acetate TABS 3 PA

megestrol acetate sus 40mg/ml (generic of MEGACE ORAL)

3 PA

MEGESTROL ACETATE SUS 625MG/5ML

3 NM PA

NILANDRON 3 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 3 NM PA

XTANDI 3 NM LA PA

ZYTIGA 3 NM PA

KINASE INHIBITORS AFINITOR 3 NM PA

AFINITOR DISPERZ 3 NM PA

BOSULIF 3 NM PA

CAPRELSA 3 NM LA PA

2015 631 3T Copper Comm eff 11/01/2015


15

Drug Name Drug Tier

Requirements/Limits

COMETRIQ 3 NM PA

GILOTRIF TAB 20MG 3 NM LA PA



GLEEVEC 2 NM PA

ICLUSIG 3 NM LA PA

IMBRUVICA CAP 140MG 3 NM LA PA

INLYTA 3 NM LA PA

IRESSA 3 NM LA PA

JAKAFI 3 NM LA PA

LENVIMA 10MG DAILY DOSE

3 NM LA PA


3 NM LA PA


3 NM LA PA


3 NM LA PA

MEKINIST 3 NM PA

NEXAVAR 3 NM LA PA

SPRYCEL 3 NM PA

STIVARGA 3 NM LA PA

SUTENT 3 NM PA

TAFINLAR 3 NM PA

TARCEVA 3 NM PA

TASIGNA 3 NM PA

TYKERB 3 NM LA PA

VOTRIENT 3 NM PA

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

ZYDELIG 3 NM LA PA

ZYKADIA 3 NM LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

3 NM PA

DROXIA 3

HALAVEN 3 B/D NM

HYDREA 2

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 3 B/D NM

MATULANE 3 NM

mitoxantrone hcl 1 B/D NM

POMALYST 3 NM LA PA

SYLATRON KIT 296MCG 3 NM PA



Drug Name Drug Tier

Requirements/Limits

TARGRETIN CAPS 3 NM PA

tretinoin CAPS 2 NM

TRISENOX 3 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

ELOXATIN 3 B/D NM

oxaliplatin 3 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

3 B/D NM

dexrazoxane (generic of ZINECARD) 250mg

3 B/D NM

ELITEK 3 B/D NM

KEPIVANCE 3 B/D NM

leucovor ca inj 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

leucovorin calcium 500 mg 3 B/D

mesna (generic of MESNEX) 1 B/D

MESNEX SOLN 3 B/D

MESNEX TABS 3 NM

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

HYCAMTIN SOLR 3 B/D NM

irinotecan (generic of CAMPTOSAR)

3 B/D NM

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

3 B/D NM

irinotecan hcl 500mg/25ml 3 B/D NM

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

3 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS ACCURETIC 3

amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

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16

Drug Name Drug Tier

Requirements/Limits

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTREL 2

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

trandolapril-verapamil hcl (generic of TARKA)

1

VASERETIC 3

ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3

ALTACE 3

benazepril hcl TABS 5mg 1

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

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

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

1

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

1

LOTENSIN 20mg, 40mg 3

MAVIK 3

moexipril hcl 1

perindopril erbumine 2mg 1

Drug Name Drug Tier

Requirements/Limits

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

1

PRINIVIL 3

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

VASOTEC 3

ZESTRIL 3

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2

eplerenone (generic of INSPRA)

1

INSPRA 2

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS CARDURA 3

doxazosin mesylate (generic of CARDURA)

1

MINIPRESS 3

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)

1

amlodipine besylate-valsartan tab 5-320 mg (generic of EXFORGE)

1


1


1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)

1

2015 631 3T Copper Comm eff 11/01/2015


17

Drug Name Drug Tier

Requirements/Limits

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)

1


1


1

ATACAND HCT 3

AVALIDE 3

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

DIOVAN HCT 3

EDARBYCLOR 3

EXFORGE 3

EXFORGE HCT 3

HYZAAR 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan potassium & hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 3

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TEVETEN HCT 3

TRIBENZOR 2

TWYNSTA 3

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3

AVAPRO 3

BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

COZAAR 3

DIOVAN 3

EDARBI 3

Drug Name Drug Tier

Requirements/Limits

eprosartan mesylate 1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 2

TELMISARTAN 1

TEVETEN 3

valsartan (generic of DIOVAN)

1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg, 400mg

1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

BETAPACE 2

BETAPACE AF 2

disopyramide phosphate (generic of NORPACE)

3 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE 3 PA

NORPACE CR 3 PA

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

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

1

propafenone hcl TABS 300mg

1

quinidine gluconate er 1

quinidine sulfate TABS 1

RYTHMOL 2

RYTHMOL SR 2

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

1

sorine 240mg 1

2015 631 3T Copper Comm eff 11/01/2015


18

Drug Name Drug Tier

Requirements/Limits

sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg

1

sotalol hcl 240mg 1

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

1

TIKOSYN 2 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic of LIPITOR) TABS

1

CRESTOR 2

fluvastatin sodium (generic of LESCOL) 20mg

1

fluvastatin sodium 40mg 1

LESCOL 3

LESCOL XL 3

LIPITOR 3

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

PRAVACHOL 3

pravastatin sodium 10mg 1

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

1

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

1

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ZOCOR 5mg, 10mg, 20mg, 40mg

3

ZOCOR 80mg QL (30 tabs / 30 days)

3 QL

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3

cholestyramine (generic of QUESTRAN)

1

cholestyramine light 1

choline fenofibrate (generic of TRILIPIX)

1

Drug Name Drug Tier

Requirements/Limits

COLESTID 3

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

fenofibrate (generic of TRICOR) TABS 48mg, 145mg

1

fenofibrate (generic of LOFIBRA) TABS 54mg, 160mg

1

FENOFIBRATE TABS 120mg

1

fenofibrate micronized 43mg, 130mg

1

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

1

FENOFIBRIC ACID 1

FENOGLIDE 3

FIBRICOR 3

gemfibrozil (generic of LOPID) TABS

1

LIPOFEN 3

LIPTRUZET 3

lofibra 3

LOPID 3

LOVAZA CAP 1GM 2

niacin (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

NIASPAN 3

omega-3-acid ethyl esters (generic of LOVAZA)

1

prevalite (generic of QUESTRAN LIGHT)

1

questran 3

questran light 3

SIMCOR 2

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

2015 631 3T Copper Comm eff 11/01/2015


19

Drug Name Drug Tier

Requirements/Limits

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

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

CORZIDE 3

DUTOPROL 3

LOPRESSOR HCT 2

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

1

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

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

TENORETIC 50 2

TENORETIC 100 2

ZIAC 2

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG 3

COREG CR 2

CORGARD 3

INDERAL LA 3

labetalol hcl SOLN 1

labetalol hcl (generic of TRANDATE) TABS

1

Drug Name Drug Tier

Requirements/Limits

LOPRESSOR 3

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate SOLN 1

metoprolol tartrate TABS 25mg

1

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

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

SECTRAL 3

SOTYLIZE 3 NM

TENORMIN 3

timolol maleate TABS 1

TOPROL XL 3

TRANDATE 3

ZEBETA 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CADUET 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CALAN 3

CALAN SR 3

CARDIZEM 60mg, 120mg 3

CARDIZEM CD 3

CARDIZEM LA 3

cartia xt (generic of CARDIZEM CD)

1

dilt-cd cap (generic of CARDIZEM CD)

1

dilt-xr cap 1

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20

Drug Name Drug Tier

Requirements/Limits

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

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

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads cp24 120mg (generic of CARDIZEM CD)

1


1


1


1


1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 3

diltiazem inj 125/25ml 1

diltzac (generic of TIAZAC) 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 1

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

1

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

1

NORVASC 3

Drug Name Drug Tier

Requirements/Limits

NYMALIZE 3 NM

PROCARDIA XL 3

SULAR 3

taztia xt (generic of TIAZAC) 1

TIAZAC 3

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

1

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

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

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

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) 1

digoxin (generic of LANOXIN) 1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN INJ 0.25MG/ML 3

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS TEKAMLO TAB 150-5MG 2

TEKAMLO TAB 150-10MG 2

TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

ALDACTAZIDE TAB 50/50 3

2015 631 3T Copper Comm eff 11/01/2015


21

Drug Name Drug Tier

Requirements/Limits

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DEMADEX 3

DIAMOX 2

DIURIL SUS 250/5ML 3

DYAZIDE 3

DYRENIUM 3

EDECRIN 3

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 1

furosemide oral soln 8 mg/ml 2

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

LASIX 3

MAXZIDE 3

MAXZIDE-25 3

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone 1

MICROZIDE 3

neptazane 3

SODIUM DIURIL 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 20mg/2ml 3

torsemide inj 50mg/5ml 3

torsemide tabs (generic of DEMADEX) 5mg, 10mg, 20mg

1

torsemide tabs 100mg 1

triamt/hctz cap 37.5-25 (generic of DYAZIDE)

1

triamt/hctz cap 50-25mg 1

triamt/hctz tab 37.5-25 (generic of MAXZIDE-25)

1

Drug Name Drug Tier

Requirements/Limits

triamt/hctz tab 75-50mg (generic of MAXZIDE)

1

MISCELLANEOUS BIDIL 2

CATAPRES TAB 2

CATAPRES-TTS 2

CATAPRES-TTS-3 2

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

1


1


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

CORLANOR 3

DEMSER 3 NM

DIBENZYLINE 3

hydralazine hcl SOLN; TABS 1

midodrine hcl 1

minoxidil TABS 1

PHENOXYBENZAMINE HCL CAPS

1

RANEXA 2

NITRATES DILATRATE SR 3

imdur 2

ISORDIL TITRADOSE 2

isosorbide dinitrate (generic of ISORDIL TITRADOSE) TABS 5mg

1

isosorbide dinitrate TABS 10mg, 20mg, 30mg

1

isosorbide dinitrate TBCR 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran (generic of NITRO-DUR)

1

nitro-bid 3

NITRO-DUR 2

NITROGLYCERIN .4mg/spray

1

2015 631 3T Copper Comm eff 11/01/2015


22

Drug Name Drug Tier

Requirements/Limits

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 3 NM PA

ADEMPAS 3 NM PA

LETAIRIS 3 NM LA PA

OPSUMIT 3 NM PA

ORENITRAM TAB 0.25MG 3 NM PA


ORENITRAM TAB 1MG 3 NM PA


REMODULIN 3 B/D NM LA

REVATIO SUSR 2 NM PA

REVATIO TABS 3 NM PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO) TABS

2 NM PA

TRACLEER 3 NM LA PA

TYVASO 3 B/D NM

VENTAVIS 3 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of XANAX) TABS 1mg


1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of XANAX) TABS .25mg


1 QL

ATIVAN SOLN 3

ATIVAN TABS QL (150 tabs / 30 days)

2 QL

buspirone hcl TABS 1

Drug Name Drug Tier

Requirements/Limits

fluvoxamine maleate 25mg, 50mg


1 QL

fluvoxamine maleate 100mg 1

fluvoxamine maleate er 100mg


1 QL

fluvoxamine maleate er 150mg


1 QL

lorazepam CONC QL (150 mL / 30 days)

1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

XANAX TAB 0.5MG QL (240 tabs / 30 days)

2 QL

XANAX TAB 0.25MG QL (480 tabs / 30 days)

2 QL

XANAX TAB 1MG QL (120 tabs / 30 days)

2 QL

XANAX TAB 2MG QL (150 tabs / 30 days)

2 QL

ANTICONVULSANTS APTIOM 3

BANZEL SUS 40MG/ML 3 NM PA

BANZEL TAB 200MG 3 PA

BANZEL TAB 400MG 3 NM PA

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CARBATROL 3

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

2015 631 3T Copper Comm eff 11/01/2015


23

Drug Name Drug Tier

Requirements/Limits

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

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

1 QL

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

1 QL

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

1 QL


1 QL


1 QL

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


1 QL PA

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL PA

DEPACON 3

DEPAKENE 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

diazepam CONC QL (240 mL / 30 days)

1 QL PA

diazepam SOLN 1mg/ml QL (1200 mL / 30 days)

1 QL PA

diazepam SOLN 5mg/ml 1

diazepam (generic of VALIUM) TABS


1 QL PA

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

Drug Name Drug Tier

Requirements/Limits

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

3 NM

felbamate (generic of FELBATOL) TABS 400mg

1

felbamate (generic of FELBATOL) TABS 600mg

3 NM

FELBATOL 3 NM

FYCOMPA 3 PA

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

1 QL

gabapentin (generic of NEURONTIN) TABS 600mg


1 QL

gabapentin (generic of NEURONTIN) TABS 800mg


1 QL

GABITRIL 2

KEPPRA SOLN 100mg/ml 3

KEPPRA SOLN 500mg/5ml 3 NM

KEPPRA TABS 250mg, 500mg

3

KEPPRA TABS 750mg, 1000mg

3 NM

KEPPRA XR 500mg 3

KEPPRA XR 750mg 3 NM

KLONOPIN 1mg QL (600 tabs / 30 days)

2 QL

KLONOPIN 2mg QL (300 tabs / 30 days)

2 QL

2015 631 3T Copper Comm eff 11/01/2015


24

Drug Name Drug Tier

Requirements/Limits

KLONOPIN .5mg QL (1200 tabs / 30 days)

2 QL

LAMICTAL TABS 3

LAMICTAL CHEWABLE DISPERS 5mg

3

LAMICTAL CHEWABLE DISPERS 25mg

3 NM

LAMICTAL ODT 2

LAMICTAL STARTER 3

LAMICTAL XR 2

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

lamotrigine (generic of LAMICTAL ODT) TBDP

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LEVETIRACETAM IN NACL 3

levetiracetam inj 500/5ml (generic of KEPPRA)

1

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


2 QL

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

2 QL

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946 mL / 30 days)

2 QL

MYSOLINE 3

NEURONTIN CAPS 100mg QL (1080 caps / 30 days)

3 QL


3 QL


3 QL

NEURONTIN SOLN QL (2160 mL / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

NEURONTIN TABS 600mg QL (180 tabs / 30 days)

3 QL

NEURONTIN TABS 800mg QL (120 tabs / 30 days)

3 QL

ONFI SUS 2.5MG/ML 3 PA

ONFI TAB 10MG 3 PA

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS 3 PA

PHENOBARBITAL SODIUM 65mg/ml

3 PA

phenobarbital sodium 130mg/ml

3 PA

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN-125) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended 200mg, 300mg

1

POTIGA 50mg 3

POTIGA 200mg QL (180 tabs / 30 days)

3 QL

POTIGA 300mg, 400mg QL (90 tabs / 30 days)

3 QL

primidone (generic of MYSOLINE) TABS

1

QUDEXY XR 3

SABRIL PACK QL (180 packets / 30 days)

3 QL NM LA PA

SABRIL TABS QL (180 tabs / 30 days)

3 QL NM LA PA

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 25mg, 50mg 3

TOPAMAX 100mg, 200mg 3 NM

2015 631 3T Copper Comm eff 11/01/2015


25

Drug Name Drug Tier

Requirements/Limits

TOPAMAX SPRINKLE 15mg

3

TOPAMAX SPRINKLE 25mg

3 NM

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1

topiramate (generic of TOPAMAX) TABS

1

TRANXENE T TAB 3.75MG QL (120 tabs / 30 days)

3 QL PA

TRANXENE T TAB 7.5MG QL (120 tabs / 30 days)

3 QL PA

TRANXENE T TAB 15MG QL (180 tabs / 30 days)

3 QL PA

TRILEPTAL 3

TRILEPTAL SUSP 3

TROKENDI XR 3

VALIUM QL (120 tabs / 30 days)

2 QL PA

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT 2

ZARONTIN CAPS 3

zarontin SOLN 3

ZONEGRAN 3

zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA ARICEPT 3

donepezil odt 5mg 1

donepezil odt 10mg 1

donepezil tab hcl 23mg (generic of ARICEPT)

1

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON 3

Drug Name Drug Tier

Requirements/Limits

EXELON PATCHES 2

galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide SOLN

1

galantamine hydrobromide (generic of RAZADYNE) TABS

1

memantine hcl (generic of NAMENDA) 5mg

PA if <30 yr

1 PA

MEMANTINE HCL 10mg PA if <30 yr

1 PA

NAMENDA SOL 10MG/5ML PA if <30 yr

2 PA

NAMENDA TAB PA if <30 yr

2 PA

NAMENDA XR PA if <30 yr

2 PA

NAMENDA XR TITRATION PACK

PA if <30 yr

2 PA

NAMZARIC 3

RAZADYNE ER 3

RAZADYNE TABS 3

RIVASTIGMINE PATCH 1

rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS 3 PA

amoxapine 1

ANAFRANIL 3 PA

APLENZIN 174mg, 348mg 3

APLENZIN 522mg 3 NM

BRINTELLIX 2

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

CELEXA 3

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

2015 631 3T Copper Comm eff 11/01/2015


26

Drug Name Drug Tier

Requirements/Limits

clomipramine hcl (generic of ANAFRANIL) CAPS

3 PA

CYMBALTA 3

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC 3 PA

duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg

1

EFFEXOR XR 3

EMSAM 3 NM PA

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine cap 10mg (generic of PROZAC)

1


1


1

fluoxetine cap 90mg dr (generic of PROZAC WEEKLY)

1

fluoxetine sol 20mg/5ml 1

fluoxetine tab 10mg 1

fluoxetine tab 20mg 1

FLUOXETINE TAB 60MG 2

FORFIVO XL QL (30 tabs / 30 days)

3 QL

imipramine hcl (generic of TOFRANIL) TABS

3 PA

imipramine pamoate (generic of TOFRANIL-PM)

3 PA

LEXAPRO 3

maprotiline hcl 1

MARPLAN 2

mirtazapine TABS 7.5mg 1

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

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

mirtazapine odt (generic of REMERON SOLTAB)

1

NARDIL 2

Drug Name Drug Tier

Requirements/Limits

nefazodone hcl 1

NORPRAMIN 2

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

PAMELOR 3 NM

PARNATE 3 NM

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl (generic of PAXIL)

1

PAXIL 3

PAXIL CR 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl 1

PROZAC 3

PROZAC WEEKLY 3

REMERON 3

REMERON SOLTAB 3

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3 PA

tofranil 3 PA

TOFRANIL-PM 3 PA

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl 1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

VIIBRYD STARTER PACK 2

WELLBUTRIN 3

WELLBUTRIN SR 3

WELLBUTRIN XL 3

2015 631 3T Copper Comm eff 11/01/2015


27

Drug Name Drug Tier

Requirements/Limits

ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 3 NM LA PA

AZILECT 2

benztropine mesylate (generic of COGENTIN) SOLN

1

benztropine mesylate TABS 3 PA

bromocriptine mesylate (generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of LODOSYN) TABS

1

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1


1


1


1


1


1

COGENTIN 3

COMTAN 3

DUOPA 3 B/D NM

ELDEPRYL 3

entacapone (generic of COMTAN)

1

LODOSYN 3

MIRAPEX 3

MIRAPEX ER 2

NEUPRO 2

pramipexole dihydrochloride (generic of MIRAPEX)

1

Drug Name Drug Tier

Requirements/Limits

pramipexole dihydrochloride er tabs (generic of MIRAPEX ER)

1

REQUIP 3

REQUIP XL 3

ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

RYTARY 3

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

SINEMET 3

SINEMET CR 3

STALEVO 3

trihexyphenidyl hcl 3 PA

ZELAPAR 2

ANTIPSYCHOTICS ABILIFY DISCMELT

QL (60 tabs / 30 days) 3 QL NM

ABILIFY INJ 9.75MG QL (4 mL / 1 day)

2 QL

ABILIFY MAIN INJ 300MG QL (1 vial / 28 days)

3 QL NM

ABILIFY MAIN INJ 400MG QL (1 vial / 28 days)

3 QL NM

ABILIFY MAINTENA QL (1 syringe / 28 days)

3 QL NM

ABILIFY SOLN 3 NM

ABILIFY TABS QL (30 tabs / 30 days)

3 QL NM

aripiprazole SOLN 3 NM

aripiprazole (generic of ABILIFY) TABS


3 QL NM

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

clozapine (generic of CLOZARIL) 25mg

1

clozapine 50mg 1

clozapine (generic of CLOZARIL) 100mg


1 QL

clozapine 200mg QL (135 tabs / 30 days)

1 QL

2015 631 3T Copper Comm eff 11/01/2015


28

Drug Name Drug Tier

Requirements/Limits

CLOZAPINE ODT 12.5mg, 25mg

1 PA

CLOZAPINE ODT 100mg QL (270 tabs / 30 days)

1 QL PA

CLOZAPINE ODT 150MG QL (180 tabs / 30 days)

1 QL PA

CLOZAPINE ODT 200MG QL (135 tabs / 30 days)

1 QL PA

CLOZARIL 25mg 3

CLOZARIL 100mg QL (270 tabs / 30 days)

3 QL NM

FANAPT QL (60 tabs / 30 days)

3 QL ST

FANAPT TITRATION PACK 3 ST

FAZACLO 12.5mg, 25mg 3 PA

FAZACLO 100mg QL (270 tabs / 30 days)

3 QL PA


3 QL PA


3 QL PA

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON 20mg, 40mg QL (60 caps / 30 days)

3 QL

GEODON 60mg, 80mg QL (90 caps / 30 days)

3 QL NM

GEODON INJ QL (6 mL / 3 days)

3 QL

HALDOL 3

HALDOL DECANOATE 50 3

HALDOL DECANOATE 100 3

haloperidol TABS 1

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

1

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

1

haloperidol lactate CONC 1

haloperidol lactate (generic of HALDOL) SOLN

1

INVEGA 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)

3 QL NM

Drug Name Drug Tier

Requirements/Limits

INVEGA 6mg QL (60 tabs / 30 days)

3 QL NM

INVEGA SUST INJ 39 MG/0.25 ML

QL (1 injection / 28 days)

3 QL



3 QL NM



3 QL NM

INVEGA SUST INJ 156MG/ML


3 QL NM



3 QL NM

INVEGA TRINZA QL (1 syringe / 90 days)

3 QL NM

LATUDA 20mg QL (240 tabs / 30 days)

3 QL NM

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

3 QL NM

LATUDA 60mg, 80mg QL (60 tabs / 30 days)

3 QL NM

loxapine succinate 1

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

1 QL

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg


1 QL

olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg


1 QL

2015 631 3T Copper Comm eff 11/01/2015


29

Drug Name Drug Tier

Requirements/Limits

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


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 20mg


3 QL NM

ORAP 3

perphenazine TABS 1

quetiapine fumarate (generic of SEROQUEL)


1 QL

REXULTI 1mg QL (90 tabs / 30 days)

3 QL NM ST

REXULTI 2mg QL (60 tabs / 30 days)

3 QL NM ST

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

3 QL NM ST

REXULTI .5mg QL (180 tabs / 30 days)

3 QL NM ST

REXULTI .25mg QL (360 tabs / 30 days)

3 QL NM ST

RISPERDAL SOLN QL (240 mL / 30 days)

3 QL

RISPERDAL TABS 1mg, 2mg, 3mg


3 QL

RISPERDAL TABS 4mg QL (120 tabs / 30 days)

3 QL

RISPERDAL TABS .25mg, .5mg


3 QL

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 25MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

3 QL NM

RISPERDAL INJ 50MG QL (2 injections / 28 days)

3 QL NM

RISPERDAL M-TAB 1mg QL (60 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

RISPERDAL M-TAB 2mg, 3mg


3 QL NM

RISPERDAL M-TAB 4mg QL (120 tabs / 30 days)

3 QL NM

RISPERDAL M-TAB .5mg QL (90 tabs / 30 days)

3 QL

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

1 QL

risperidone (generic of RISPERDAL) TABS 1mg, 2mg, 3mg


1 QL

risperidone (generic of RISPERDAL) TABS 4mg


1 QL

risperidone (generic of RISPERDAL) TABS .25mg, .5mg


1 QL

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


1 QL

risperidone odt (generic of RISPERDAL M-TAB) 4mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) .5mg


1 QL

risperidone odt .25mg QL (90 tabs / 30 days)

1 QL

SAPHRIS 2.5mg QL (240 tabs / 30 days)

3 QL

SAPHRIS 5mg QL (120 tabs / 30 days)

3 QL

SAPHRIS 10mg QL (60 tabs / 30 days)

3 QL

SEROQUEL QL (90 tabs / 30 days)

3 QL

SEROQUEL XR 50mg QL (120 tabs / 30 days)

2 QL

SEROQUEL XR 150mg, 200mg


2 QL

2015 631 3T Copper Comm eff 11/01/2015


30

Drug Name Drug Tier

Requirements/Limits

SEROQUEL XR 300mg, 400mg


2 QL

thioridazine hcl TABS 3 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ QL (600 mL / 30 days)

3 QL NM PA

ziprasidone hcl (generic of GEODON) 20mg, 40mg


1 QL

ziprasidone hcl (generic of GEODON) 60mg, 80mg


1 QL

ZYPREXA SOLR QL (3 vials / 1 day)

3 QL

ZYPREXA TABS 2.5mg, 5mg, 7.5mg


3 QL

ZYPREXA TABS 10mg QL (60 tabs / 30 days)

3 QL

ZYPREXA TABS 15mg, 20mg


3 QL NM

ZYPREXA RELPREVV 3 B/D NM

ZYPREXA ZYDI TAB 10MG QL (60 tabs / 30 days)

3 QL

ZYPREXA ZYDIS 5mg QL (30 tabs / 30 days)

3 QL

ZYPREXA ZYDIS 15mg, 20mg


3 QL NM

ATTENTION DEFICIT HYPERACTIVITY DISORDER adderall tab 5mg

QL (360 tabs / 30 days) 3 QL

adderall tab 7.5mg QL (240 tabs / 30 days)

3 QL

adderall tab 10mg QL (180 tabs / 30 days)

3 QL

adderall tab 12.5mg QL (144 tabs / 30 days)

3 QL


3 QL


3 QL


3 QL

Drug Name Drug Tier

Requirements/Limits

ADDERALL XR CAP 5MG QL (90 caps / 30 days)

3 QL


3 QL


3 QL


3 QL


3 QL


3 QL

amphetamine cap 10mg er (generic of ADDERALL XR)


1 QL



1 QL



1 QL



1 QL



1 QL

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


1 QL



1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL

APTENSIO XR 10mg, 15mg, 20mg, 30mg


3 QL

APTENSIO XR 40mg, 50mg, 60mg


3 QL

CONCERTA 18mg, 27mg, 36mg


3 QL

CONCERTA 54mg QL (30 tabs / 30 days)

3 QL

DAYTRANA QL (30 patches / 30 days)

2 QL

guanfacine hcl (adhd) (generic of INTUNIV)

3

INTUNIV 3

METADATE CD 10mg, 20mg, 30mg


3 QL

METADATE CD 40mg, 50mg, 60mg


3 QL

metadate er 20 mg QL (90 tabs / 30 days)

1 QL

METHYLIN 5mg/5ml QL (1800 mL / 30 days)

3 QL

METHYLIN 10mg/5ml QL (900 mL / 30 days)

3 QL

METHYLIN CHEW TAB QL (180 tabs / 30 days)

2 QL

methylphenidate hcl (generic of METHYLIN) CHEW


1 QL

Drug Name Drug Tier

Requirements/Limits

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


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 40mg


1 QL

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


1 QL

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


1 QL

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

QL (1800 mL / 30 days)

1 QL

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

QL (900 mL / 30 days)

1 QL

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


1 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


1 QL

methylphenidate hcl er TB24 27mg, 36mg


1 QL

methylphenidate hcl er TB24 54mg


1 QL

methylphenidate hcl er tabs 10mg


1 QL



1 QL



1 QL

QUILLIVANT XR QL (360 mL / 30 days)

2 QL

RITALIN 5mg, 10mg QL (180 tabs / 30 days)

3 QL

2015 631 3T Copper Comm eff 11/01/2015


32

Drug Name Drug Tier

Requirements/Limits

RITALIN 20mg QL (90 tabs / 30 days)

3 QL

RITALIN LA 10mg, 20mg, 30mg


3 QL

RITALIN LA 40mg, 60mg QL (30 caps / 30 days)

3 QL

STRATTERA 10mg, 18mg, 25mg


2 QL

STRATTERA 40mg QL (60 caps / 30 days)

2 QL

STRATTERA 60mg, 80mg, 100mg


2 QL

VYVANSE 10mg, 20mg, 30mg


2 QL

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


2 QL

HYPNOTICS AMBIEN

QL (30 tabs / 30 days) 90 day limit if >64 yr

3 QL PA

RESTORIL 7.5mg QL (30 caps / 30 days)


3 QL PA

RESTORIL 15mg QL (60 caps / 30 days)


3 QL PA

ROZEREM QL (30 tabs / 30 days)

3 QL

SILENOR 3mg QL (60 tabs / 30 days)

3 QL

SILENOR 6mg QL (30 tabs / 30 days)

3 QL

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) 90 day limit if >64 yr

1 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) 90 day limit if >64 yr

1 QL PA

Drug Name Drug Tier

Requirements/Limits

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) 90 day limit if >64 yr

3 QL PA

MIGRAINE almotriptan malate (generic of AXERT)


1 QL

ALSUMA QL (6 mL / 30 days)

3 QL

AMERGE QL (9 tabs / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 2

D.H.E. 45 3 NM

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

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

1 QL

ergomar 3

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

3 QL

IMITREX SOLN 5mg/act QL (24 inhalers / 30 days)

3 QL

IMITREX SOLN 20mg/act QL (12 inhalers / 30 days)

3 QL

IMITREX TABS QL (9 tabs / 30 days)

3 QL

IMITREX INJ 6MG/0.5 QL (6 mL / 30 days)

3 QL

IMITREX STATDOSE REFILL 4mg/0.5ml

QL (6 mL / 30 days)

3 QL

IMITREX STATDOSE REFILL 6mg/0.5ml

QL (6 mL / 30 days)

3 QL NM

IMITREX STATDOSE SYSTEM 4mg/0.5ml

QL (6 mL / 30 days)

3 QL

IMITREX STATDOSE SYSTEM 6mg/0.5ml

QL (6 mL / 30 days)

3 QL NM

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

MAXALT QL (18 tabs / 30 days)

3 QL

MAXALT-MLT QL (18 tabs / 30 days)

3 QL

migergot 1

MIGRANAL QL (8 mL / 30 days)

3 QL NM

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

SUMATRIPTAN SUCCINATE SOAJ 4mg/0.5ml

QL (6 mL / 30 days)

1 QL

sumatriptan succinate (generic of IMITREX STATDOSE SYSTEM) SOAJ 6mg/0.5ml

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOCT 4mg/0.5ml

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOCT 6mg/0.5ml

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 20mg/act


1 QL

sumatriptan succinate SOSY QL (6 mL / 30 days)

1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

Drug Name Drug Tier

Requirements/Limits

sumatriptan succinate inj (generic of IMITREX STATDOSE SYSTEM) SOAJ

QL (6 mL / 30 days)

1 QL

sumatriptan succinate inj (generic of IMITREX) SOLN

QL (6 mL / 30 days)

1 QL

SUMAVEL DOSEPRO 4mg/0.5ml

QL (6mL / 30 days)

3 QL NM

SUMAVEL DOSEPRO 6mg/0.5ml

QL (6 mL / 30 days)

3 QL NM

TREXIMET QL (9 tabs / 30 days)

2 QL

zolmitriptan (generic of ZOMIG) TABS


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG QL (12 tabs / 30 days)

3 QL

ZOMIG NASAL SPRAY QL (2 boxes / 30 days)

2 QL

ZOMIG ZMT QL (12 tabs / 30 days)

3 QL

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 300mg QL (180 tabs / 30 days)

2 QL

GRALISE 600mg QL (90 tabs / 30 days)

2 QL

GRALISE STARTER 2

HORIZANT 3

LITHIUM 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHOBID 2

MESTINON 2

MESTINON SYRUP 2

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide (generic of MESTINON) TABS

1

pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR

1

RILUTEK 3 NM

riluzole (generic of RILUTEK) 1

SAVELLA 12.5mg QL (480 tabs / 30 days)

2 QL

SAVELLA 25mg QL (240 tabs / 30 days)

2 QL


2 QL


2 QL

SAVELLA TITRATION PACK 2

TETRABENAZINE 12.5mg QL (240 tabs / 30 days)

3 QL NM PA

TETRABENAZINE 25mg QL (120 tabs / 30 days)

3 QL NM PA

XENAZINE 12.5mg QL (240 tabs / 30 days)

3 QL NM LA PA

XENAZINE 25mg QL (120 tabs / 30 days)

3 QL NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO QL (30 tabs / 30 days)

3 QL NM PA

AVONEX KIT QL (4 boxes / 28 day)

3 QL NM PA

AVONEX PSKT QL (4 boxes / 28 days)

3 QL NM PA

AVONEX PEN QL (4 boxes / 28 days)

3 QL NM PA

BETASERON QL (14 syringes / 28 days)

3 QL NM PA

COPAXONE INJ 40MG/ML QL (12 syringes / 28 days)

3 QL NM PA

COPAXONE KIT 20MG/ML QL (30 syringes / 30 days)

3 QL NM PA

Drug Name Drug Tier

Requirements/Limits

EXTAVIA QL (15 syringes / 30 days)

3 QL NM PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

3 QL NM PA

glatopa (generic of COPAXONE)

QL (30 syringes / 30 days)

3 QL NM PA

LEMTRADA 3 NM LA PA

PLEGRIDY SOPN QL (2 pens / 28 days)

3 QL NM PA

PLEGRIDY SOSY QL (2 syringes / 28 days)

3 QL NM PA

PLEGRIDY STARTER PACK QL (1 box / 28 days)

3 QL NM PA

REBIF QL (6 mL / 28 days)

3 QL NM PA

REBIF REBIDOSE QL (6 mL / 28 days)

3 QL NM PA

REBIF REBIDOSE TITRATION

QL (6 mL / 30 days)

3 QL NM PA

REBIF TITRATION PACK QL (6 mL / 30 days)

3 QL NM PA

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

3 QL NM PA

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

3 QL NM PA

TECFIDERA MIS STARTER 3 NM PA

TYSABRI 3 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

cyclobenzaprine hcl TABS 5mg, 10mg

3 PA

DANTRIUM CAP 25MG 2

DANTRIUM CAP 50MG 2

dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg

1

dantrolene sodium CAPS 100mg

1

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

2015 631 3T Copper Comm eff 11/01/2015


35

Drug Name Drug Tier

Requirements/Limits

ZANAFLEX CAPS 3

ZANAFLEX TABS 2

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg


1 QL PA

modafinil (generic of PROVIGIL) 200mg


3 QL NM PA

NUVIGIL 50mg QL (150 tabs / 30 days)

2 QL PA

NUVIGIL 150mg QL (60 tabs / 30 days)

2 QL PA

NUVIGIL 200mg, 250mg QL (30 tabs / 30 days)

2 QL PA

PROVIGIL 100mg QL (30 tabs / 30 days)

3 QL NM PA

PROVIGIL 200mg QL (60 tabs / 30 days)

3 QL NM PA

XYREM QL (540 mL / 30 days)

3 QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

antabuse 2

BUNAVAIL MIS 2.1-0.3 QL (4 boxes / 30 days)

3 QL PA

BUNAVAIL MIS 4.2-0.7 QL (4 boxes / 30 days)

3 QL PA

BUNAVAIL MIS 6.3-1MG QL (2 boxes / 30 days)

3 QL PA

buprenorphine hcl SUBL 1 PA

buprenorphine hcl-naloxone hcl sl


1 QL PA

buproban (generic of ZYBAN) 1

CHANTIX 2 PA

CHANTIX CONTINUING MONTH

2 PA

CHANTIX STARTER PACK 2 PA

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

Drug Name Drug Tier

Requirements/Limits

SUBOXONE MIS 2-0.5MG QL (4 boxes / 30 days)

3 QL PA

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

3 QL PA


3 QL PA


3 QL PA

VIVITROL 3 NM

ZUBSOLV SUB 1.4-0.36 QL (120 tabs / 30 days)

2 QL PA


2 QL PA


2 QL PA


2 QL PA

ZYBAN 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM


2 QL PA

ANDROGEL 1% QL (300 grams / 30 days)

3 QL PA

ANDROGEL 1.62% QL (150 grams / 30 days)

3 QL PA

ANDROGEL GEL PUMP 1% QL (300 grams / 30 days)

3 QL PA

AXIRON QL (440 mL / 30 days)

2 QL PA

depo-testosterone 3

FORTESTA QL (120 grams / 30 days)

2 QL PA

oxandrolone (generic of OXANDRIN) TABS

1 PA

STRIANT QL (1 kit / 30 days)

3 QL PA

TESTIM QL (300 grams / 30 days)

3 QL PA

testosterone cypionate SOLN 100mg/ml

1

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

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

1

testosterone enanthate SOLN

1

VOGELXO QL (300 grams / 30 days)

3 QL PA

VOGELXO PUMP QL (300 grams / 30 days)

3 QL PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 2

APIDRA SOLOSTAR 2

BYDUREON PEN QL (4 pens / 28 days)

2 QL PA

BYDUREON SUSR QL (4 vials / 28 days)

2 QL PA

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

3 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

Drug Name Drug Tier

Requirements/Limits

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2 PA

SYMLINPEN 120 2 PA

TANZEUM QL (4 pens / 28 days)

3 QL

TOUJEO SOLOSTAR 2

TRULICITY QL (4 pens / 28 days)

3 QL

VICTOZA QL (3 pens / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET TAB 15-500MG


3 QL

ACTOPLUS MET TAB 15-850MG


3 QL

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

ACTOS QL (30 tabs / 30 days)

3 QL

AMARYL 1mg QL (240 tabs / 30 days)

3 QL


3 QL


3 QL

DUETACT QL (30 tabs / 30 days)

3 QL

FARXIGA 5mg QL (60 tabs / 30 days)

3 QL

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

FARXIGA 10mg QL (30 tabs / 30 days)

3 QL

FORTAMET 500mg QL (150 tabs / 30 days)

3 QL

FORTAMET 1000mg QL (75 tabs / 30 days)

3 QL

glimepiride (generic of AMARYL) 1mg


1 QL



1 QL



1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide er (generic of GLUCOTROL XL) 2.5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 10mg


1 QL

glipizide-metformin 2.5-250 mg


1 QL

glipizide-metformin 2.5-500 mg


1 QL

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

1 QL

GLUCOPHAGE 500mg QL (150 tabs / 30 days)

3 QL


3 QL


3 QL

GLUCOPHAGE XR 500mg QL (120 tabs / 30 days)

3 QL

GLUCOPHAGE XR 750mg QL (60 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

GLUCOTROL 5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL 10mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 2.5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL XL 5mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 10mg QL (60 tabs / 30 days)

3 QL

GLUMETZA 500mg QL (120 tabs / 30 days)

3 QL

GLUMETZA 1000mg QL (60 tabs / 30 days)

3 QL

GLYSET 3

GLYXAMBI QL (30 tabs / 30 days)

3 QL

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

2 QL

INVOKAMET TAB 50-1000 QL (60 tabs / 30 days)

2 QL


2 QL


2 QL

INVOKANA TAB 100MG QL (90 tabs / 30 days)

2 QL

INVOKANA TAB 300MG QL (30 tabs / 30 days)

2 QL

JANUMET QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 50-500MG


2 QL

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

2 QL

JANUVIA QL (30 tabs / 30 days)

2 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL

JENTADUETO QL (60 tabs / 30 days)

2 QL

KAZANO QL (60 tabs / 30 days)

3 QL

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

KOMBIGLYZE XR 2.5-1000MG


3 QL

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

3 QL

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

3 QL

metformin er (generic of GLUCOPHAGE XR) 500mg


1 QL

metformin er (generic of GLUCOPHAGE XR) 750mg


1 QL

metformin hcl (generic of GLUCOPHAGE) TABS 500mg


1 QL



1 QL



1 QL

metformin hcl (generic of FORTAMET) TB24 500mg


1 QL

metformin hcl (generic of FORTAMET) TB24 1000mg


1 QL

nateglinide (generic of STARLIX)


1 QL

NESINA 6.25mg QL (120 tabs / 30 days)

3 QL

NESINA 12.5mg QL (60 tabs / 30 days)

3 QL

NESINA 25mg QL (30 tabs / 30 days)

3 QL

ONGLYZA QL (30 tabs / 30 days)

3 QL

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

3 QL


3 QL


3 QL

Drug Name Drug Tier

Requirements/Limits

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

3 QL


3 QL


3 QL

pioglitazone hcl (generic of ACTOS)


1 QL

pioglitazone hcl-glimepiride (generic of DUETACT)


1 QL

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)


1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

PRANDIN 2mg QL (240 tabs / 30 days)

3 QL

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

3 QL

PRECOSE 2

repaglinide (generic of PRANDIN) 2mg


1 QL

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


1 QL

RIOMET QL (946 mL / 30 days)

3 QL

STARLIX QL (90 tabs / 30 days)

3 QL

TRADJENTA QL (30 tabs / 30 days)

2 QL

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL


3 QL

BISPHOSPHONATES ACTONEL 2

alendronate sodium SOLN QL (300 mL / 28 days)

1 QL

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

1

2015 631 3T Copper Comm eff 11/01/2015


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Drug Name Drug Tier

Requirements/Limits

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 2

BINOSTO 3

BONIVA INJ 3MG/3ML QL (1 syringe / 90 days)

3 B/D QL

BONIVA TAB 150MG 3 B/D

FOSAMAX 3

FOSAMAX PLUS D 3

ibandronate sodium (generic of BONIVA) SOLN 3mg/3ml

QL (1 syringe / 90 days)

1 B/D QL

ibandronate sodium (generic of BONIVA) SOLN 3mg/3ml

QL (1 vial / 90 days)

1 B/D QL

ibandronate sodium (generic of BONIVA) TABS

1 B/D

pamidronate inj 6mg/ml 3 B/D

pamidronate inj 30/10ml 1 B/D

pamidronate inj 90/10ml 1 B/D

risedronate sodium (generic of ACTONEL) TABS

1

risedronate sodium (generic of ATELVIA) TBEC

1

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

3 B/D NM

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D NM

ZOMETA 3 B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 2 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 3 NM

EXJADE 3 NM LA PA

FERRIPROX 3 NM PA

JADENU 3 NM PA

KAYEXALATE 3

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate 1

SYPRINE 3 NM

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

Drug Name Drug Tier

Requirements/Limits

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

ashlyna 91 day (generic of SEASONIQUE)

1

aubra 28 day 1

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

BREVICON-28 3

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

cryselle 28 1

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

1

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

1

CYCLESSA 3

cyred tab (generic of DESOGEN)

1

deblitane 28 day (generic of NOR-QD)

1

delyla 28 day 1

DEPO-PROVERA CONTRACEPTIV

2

DEPO-SUBQ PROVERA 104 2

DESOGEN 3

desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)

1

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

drospirenone-ethinyl estradiol (generic of YAZ)

1

ELLA 2

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

2015 631 3T Copper Comm eff 11/01/2015


40

Drug Name Drug Tier

Requirements/Limits

ESTROSTEP FE 3

falmina 28 day 1

FEMCON FE 3

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia (generic of OVCON-35)

1

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

1

gildess 24 fe 28 day 1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

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

1

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

1

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

1

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

1

junel fe 24 1/20 28 day 1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

kimidess 28 day (generic of MIRCETTE)

1

larin 1.5/30 (generic of LOESTRIN 1.5/30-21)

1

larin 1/20 (generic of LOESTRIN 1/20-21)

1

larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

1

larin fe 1/20 (generic of LOESTRIN FE 1/20)

1

LAYOLIS FE CHW 1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1

levonorgestrel & eth estradiol 1

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

1

levonorgestrel (emergency oc) .75mg

1

Drug Name Drug Tier

Requirements/Limits

levonorgestrel-ethinyl estradiol (91-day)

1

levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONIQUE)

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

loestrin 1.5/30 21 day 3

loestrin 1/20 21 day 3

loestrin fe 1.5/30 28 day 3

loestrin fe 1/20 28 day 3

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

LOSEASONIQUE 3

low-ogestrel 28 day 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

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

1

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

1

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

1

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

1

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

1

MINASTRIN 24 FE 2

mircette 3

MODICON 3

MONONESSA 1

my way (generic of PLAN B ONE-STEP)

1

myzilra 1

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Drug Name Drug Tier

Requirements/Limits

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

1

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

1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

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

1

nikki 28 day (generic of YAZ) 1

NOR-QD 2

NORA-BE TAB 1

norethin acet & estrad-fe 1

norethindrone & ethinyl estradiol-fe (generic of GENERESS FE)

1

norethindrone (contraceptive) (generic of NOR-QD)

1

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

1

NORINYL 1+35 3

NORINYL 1+50 3

norlyroc 28 day (generic of NOR-QD)

1

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

1

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

1

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

1

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

1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO MICRONOR 2

ORTHO TRI-CYCLEN LO 2

ORTHO-CEPT 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

ovcon 35 28 day 3

philith (generic of OVCON-35) 1

Drug Name Drug Tier

Requirements/Limits

pimtrea pack (generic of MIRCETTE)

1

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

1

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3

sharobel 28 day (generic of ORTHO MICRONOR)

1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

tarina fe tab 1/20 (generic of LOESTRIN FE 1/20)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

TRI-NORINYL 28 3

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

1

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

1

TRINESSA 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

viorele (generic of MIRCETTE)

1

vyfemia 28 day (generic of OVCON-35)

1

WYMZYA FE 1

xulane dis 150-35 1

YASMIN 28 3

YAZ 3

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

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42

Drug Name Drug Tier

Requirements/Limits

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 NM PA

SYNAREL 3 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA

ALDURAZYME 3 NM LA PA

CARBAGLU 3 NM LA PA

CARNITOR SOLN 1gm/10ml

2 B/D

CARNITOR SOLN 200mg/ml

3 B/D

CARNITOR TABS 2 B/D

CERDELGA 3 NM PA

CEREZYME 3 NM PA

CYSTADANE 3 NM

CYSTAGON 3 NM PA

ELAPRASE 3 NM PA

ELELYSO 3 NM PA

FABRAZYME 3 NM PA

KUVAN 3 NM PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 3 NM PA

MYOZYME 3 NM PA

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM PA

PROCYSBI 3 NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

3 NM

VIMIZIM 3 NM PA

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGENS ALORA 3 PA

CLIMARA 3 PA

COMBIPATCH 3 PA

DELESTROGEN 3

depo-estradiol 3

DUAVEE QL (30 tabs / 30 days)

3 QL PA

Drug Name Drug Tier

Requirements/Limits

estrace CREA 2

estrace TABS 3 PA

estradiol (generic of VIVELLE-DOT) PTTW

3 PA

estradiol (generic of CLIMARA) PTWK

3 PA

estradiol (generic of ESTRACE) TABS

3 PA

ESTRADIOL VALERATE OIL 10mg/ml

1

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

1

ESTRADIOL VALERATE OIL 40mg/ml

1

ESTRING 3

FEMRING 3

MENOSTAR 3 PA

MINIVELLE 3 PA

PREMARIN 1.25mg 3 PA

PREMARIN .3mg, .45mg QL (60 tabs / 30 days)

3 QL PA

PREMARIN .625mg, .9mg QL (30 tabs / 30 days)

3 QL PA

PREMARIN CREAM 2

PREMARIN INJ 3

PREMPHASE QL (28 tabs / 28 days)

3 QL PA

PREMPRO QL (28 tabs / 28 days)

3 QL PA

VAGIFEM 2

VIVELLE-DOT 3 PA

GLUCOCORTICOIDS a-hydrocort 1

CORTEF 3

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D


3 B/D


3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

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43

Drug Name Drug Tier

Requirements/Limits

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL PAK 4MG 3 B/D

MEDROL TAB 2MG 3 B/D





methylpr ace inj 40mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ace inj 80mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ss inj 1gm (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 40mg (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 125mg (generic of SOLU-MEDROL)

1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1 B/D

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

millipred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D



pediapred sol 6.7/5ml 3 B/D

pred sod pho sol 5mg/5ml (generic of PEDIAPRED)

1 B/D

prednisolone sodium phosphate (generic of ORAPRED ODT)

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml 1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

Drug Name Drug Tier

Requirements/Limits

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





RAYOS TAB 1MG 3 B/D NM



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 1GM 3 B/D

SOLU-MEDROL INJ 2GM 3 B/D

SOLU-MEDROL INJ 40MG 3 B/D



veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 3 NM PA

GENOTROPIN MINIQUICK 3 NM PA

HUMATROPE 3 NM PA

HUMATROPE COMBO PACK 3 NM PA

NORDITROPIN FLEXPRO 3 NM PA

NORDITROPIN NORDIFLEX PEN

3 NM PA

NUTROPIN AQ INJ 20MG/2ML

3 NM PA

NUTROPIN AQ NUSPIN 5 3 NM PA

NUTROPIN AQ PEN 3 NM PA

OMNITROPE 5.8MG 3 NM PA

OMNITROPE 5MG 3 NM PA

OMNITROPE 10MG 3 NM PA

SAIZEN 3 NM PA

SAIZEN CLICK.EASY 3 NM PA

SEROSTIM 3 NM PA

TEV-TROPIN 3 NM PA

ZOMACTON 3 NM PA

2015 631 3T Copper Comm eff 11/01/2015


44

Drug Name Drug Tier

Requirements/Limits

ZORBTIVE 3 NM PA

MISCELLANEOUS AFREZZA 3

cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 3 NM PA

EVISTA 3

FORTICAL SPR 200/ACT 3

H.P. ACTHAR 3 NM PA

INCRELEX 3 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 2 B/D

MIACALCIN SPR 200/ACT 3

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml, 200mcg/ml

1 NM PA

octreotide acetate (generic of SANDOSTATIN) 500mcg/ml, 1000mcg/ml

3 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM

raloxifene hcl (generic of EVISTA)

1

SAMSCA 3 NM PA

SANDOSTATIN 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM PA

SIGNIFOR LAR 3 NM LA PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 3 NM LA PA

XGEVA 3 NM PA

PARATHYROID HORMONES FORTEO 3 NM PA

NATPARA 3 NM PA

PHOSPHATE BINDER AGENTS AURYXIA 3 NM

calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

Drug Name Drug Tier

Requirements/Limits

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

1

eliphos 3

FOSRENOL 3 NM

PHOSLO 3

PHOSLYRA 2

RENAGEL 3

RENVELA PAK 3 NM

RENVELA TAB 800MG 2

VELPHORO 3 NM

PROGESTINS aygestin 3

CRINONE 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

PROMETRIUM 3

PROVERA 3

THYROID AGENTS CYTOMEL 2

levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

tapazole 2

TIROSINT 3

TRIOSTAT 3

UNITHROID 1

VASOPRESSINS DDAVP SOLN 4mcg/ml 3 NM

DDAVP SOLN .01% 2

DDAVP TABS 2

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45

Drug Name Drug Tier

Requirements/Limits

DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM

GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D

ALOXI 3 NM

CESAMET QL (60 caps / 30 days)

3 B/D QL NM

compro supp 1

dronabinol (generic of MARINOL) 2.5mg, 5mg


1 B/D QL

dronabinol (generic of MARINOL) 10mg


3 B/D QL NM

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

MARINOL 2.5mg QL (60 caps / 30 days)

3 B/D QL

MARINOL 5mg, 10mg QL (60 caps / 30 days)

3 B/D QL NM

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl (generic of METOZOLV ODT) TBDP

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

ondansetron hcl SOLN 4mg/2ml

1

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

1

Drug Name Drug Tier

Requirements/Limits

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

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz sup 3 PA

phenergan inj 3 PA

phenergan supp 3 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

3 PA

promethazine hcl SUPP; SYRP; TABS

3 PA

promethegan 3 PA

REGLAN 3

SANCUSO QL (4 patches / 30 days)

3 QL NM

TRANSDERM-SCOP QL (10 patches / 30 days)

2 QL PA

ZOFRAN SOLN 4mg/5ml 3 B/D NM

ZOFRAN SOLN 40mg/20ml 3

ZOFRAN TABS 3 B/D NM

ZOFRAN ODT 3 B/D NM

ZUPLENZ 3 B/D NM

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

1

BENTYL CAPS; TABS 2

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1

glycate 3

glycopyrrolate (generic of ROBINUL) SOLN

1

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46

Drug Name Drug Tier

Requirements/Limits

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3

PAMINE FORTE 3

ROBINUL 3

ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine SOLN 20mg/2ml, 40mg/4ml, 200mg/20ml

1

famotidine (generic of PEPCID) SUSR

1

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

1

nizatidine CAPS 150mg 1

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine SOLN 1

PEPCID 3

PEPCID SUSP 3

PEPCID TAB 3

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl SYRP 1

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

1

ZANTAC 3

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium (generic of COLAZAL)

1

Drug Name Drug Tier

Requirements/Limits

budesonide (generic of ENTOCORT EC) CP24

3 NM

CANASA 2

COLAZAL 3

colocort (generic of CORTENEMA)

1

CORTENEMA 3

DELZICOL 3

DIPENTUM 3 NM

ENTOCORT EC 3 NM

ENTYVIO 3 NM PA

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

ROWASA 3

SF-ROWASA 2

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS FOAM 3

UCERIS TB24 3 NM

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-h 1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

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47

Drug Name Drug Tier

Requirements/Limits

OSMOPREP 3

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

1

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

1

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

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2 PA

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS ACTIGALL 2

alosetron hcl (generic of LOTRONEX)

3 NM PA

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1

CARAFATE 2

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

3 NM

CYTOTEC 2

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GASTROCROM 3 NM

GATTEX 3 NM LA PA

LINZESS 2

LOMOTIL 2

loperamide hcl CAPS 1

LOTRONEX 3 NM PA

misoprostol (generic of CYTOTEC) TABS

1

MOVANTIK 2

OMECLAMOX-PAK 3

Drug Name Drug Tier

Requirements/Limits

PREVPAC 2

PYLERA 2

SUCRAID 3 NM

sucralfate (generic of CARAFATE) TABS

1

URSO 250 2

URSO FORTE 2

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 3 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 3 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX

QL (30 tabs / 30 days) 3 QL

ACIPHEX SPR CAP 5MG 3

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

3 QL

DEXILANT 2

esomeprazole magnesium (generic of NEXIUM) 20mg

1

esomeprazole magnesium 40mg

1

esomeprazole sodium inj 20mg

1

esomeprazole sodium inj (generic of NEXIUM I.V.) 40mg

1

lansoprazole (generic of PREVACID) CPDR


1 QL

NEXIUM CAP 20MG 2

NEXIUM CAP 40MG 2

NEXIUM GRA 2.5MG DR 2

NEXIUM GRA 5MG DR 2

NEXIUM GRA 10MG DR 2

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Drug Name Drug Tier

Requirements/Limits



NEXIUM I.V. 3

omeprazole (generic of PRILOSEC) CPDR 10mg, 40mg


1 QL

omeprazole (generic of PRILOSEC) CPDR 20mg

1

OMEPRAZOLE-SODIUM BICARBONATE


1 QL

pantoprazole sodium tbec (generic of PROTONIX)


1 QL

PREVACID QL (30 caps / 30 days)

3 QL

PREVACID SOLUTAB QL (30 tabs / 30 days)

3 QL

PRILOSEC CPDR 10mg, 40mg


3 QL

PRILOSEC CPDR 20mg 3

PRILOSEC PACK 3

PROTONIX PACK QL (30 packets / 30 days)

3 QL

PROTONIX TBEC QL (30 tabs / 30 days)

3 QL

PROTONIX INJ 3

rabeprazole sodium (generic of ACIPHEX)


1 QL

ZEGERID CAPS QL (30 caps / 30 days)

3 QL

ZEGERID PACK QL (30 packets / 30 days)

3 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3

finasteride (generic of PROSCAR) TABS 5mg

1

FLOMAX 3

Drug Name Drug Tier

Requirements/Limits

JALYN 3

PROSCAR 3

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 2

potassium citrate (alkalinizer) (generic of UROCIT-K 15)

1

POTASSIUM CITRATE (ALKALINIZER) TAB 540mg

1

POTASSIUM CITRATE (ALKALINIZER) TAB 1080mg

1

urecholine 2

UROCIT-K 2

UROCIT-K 15 2

URINARY ANTISPASMODICS DETROL 3

DETROL LA 3

DITROPAN XL 3

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

TOLTERODINE TARTRATE ER

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN CREA 2

CLEOCIN VAG SUPP 100MG 2

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49

Drug Name Drug Tier

Requirements/Limits

clindamycin cre 2% vag (generic of CLEOCIN)

1

CLINDESSE 3

METROGEL-VAGINAL 2

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole nitrate vaginal 1

NUVESSA 3 NM

TERAZOL 3 CRE 0.8% 2

TERAZOL 7 CRE 0.4% 2

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

1

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

1

terconazole vaginal SUPP 1

VANDAZOLE 1

zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS ARIXTRA 3 NM

COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

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

1

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

3 NM

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

1

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

3 NM

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

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

3 NM

HEP SOD/NACL INJ 25000 1

Drug Name Drug Tier

Requirements/Limits

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

3 B/D

HEPARIN SOD INJ 2500U/ML

3 B/D

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




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

jantoven (generic of COUMADIN)

1

LOVENOX 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 300mg/3ml

2

LOVENOX 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml

3 NM

PRADAXA 2

SAVAYSA 3

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 NM PA

EPOGEN 2 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MIRCERA 3 NM PA

MOZOBIL 3 NM PA

NEULASTA 3 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 3 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS AGRYLIN 2

anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

cilostazol (generic of PLETAL) 1

CINRYZE 3 NM LA PA

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50

Drug Name Drug Tier

Requirements/Limits

CYKLOKAPRON 3

FIRAZYR 2 NM PA

LYSTEDA 3

pentoxifylline TBCR 1

PLETAL 2

PROMACTA 12.5mg QL (360 tabs / 30 days)

3 QL NM LA PA

PROMACTA 25mg QL (180 tabs / 30 days)

3 QL NM LA PA


3 QL NM LA PA


3 QL NM LA PA

RUCONEST 3 NM PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

ASPIRIN-DIPYRIDAMOLE 1

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

EFFIENT 2

PLAVIX 3

ZONTIVITY 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 NM PA

ARAVA 3 NM

CIMZIA 3 NM PA

ENBREL 3 NM PA

ENBREL SURECLICK 3 NM PA

HUMIRA 3 NM PA

HUMIRA PEN 3 NM PA

HUMIRA PEN-CROHNS STARTER KIT

3 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

3 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 3 NM PA

leflunomide (generic of ARAVA) TABS

1

Drug Name Drug Tier

Requirements/Limits

methotrexate sodium tabs 1

ORENCIA 3 NM PA

OTEZLA 3 NM PA

PLAQUENIL 2

REMICADE 3 NM PA

RHEUMATREX 2

SIMPONI 3 NM PA

SIMPONI ARIA 3 NM PA

trexall 2 B/D

XELJANZ 3 NM PA

IMMUNOGLOBULINS BIVIGAM 3 NM PA

CARIMUNE NANOFILTERED 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAGARD S/D IGA LESS TH

3 NM PA

GAMMAKED 3 NM PA

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

3 NM PA

GAMUNEX-C 3 NM PA

GAMUNEX-C 1GM/10ML 3 NM PA

OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml

3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

GRASTEK 2 PA

INTRON-A INJ 10MU 3 B/D NM




PEG-INTRON 3 NM PA

PEG-INTRON REDIPEN 3 NM PA

PEGASYS 3 NM PA

PEGASYS PROCLICK 3 NM PA

RAGWITEK 2 PA

REVLIMID 3 NM LA PA

THALOMID 2 NM PA

IMMUNOSUPPRESSANTS

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51

Drug Name Drug Tier

Requirements/Limits

ASTAGRAF XL 5mg 3 B/D NM

ASTAGRAF XL .5mg, 1mg 3 B/D

ATGAM 3 B/D

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

CELLCEPT CAP 3 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

CELLCEPT SUSP 3 B/D NM

CELLCEPT TAB 3 B/D NM

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

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

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

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

1 B/D

gengraf (generic of NEORAL) 1 B/D

IMURAN 2 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil SUSR

3 B/D NM

mycophenolate sodium (generic of MYFORTIC) 180mg

1 B/D

mycophenolate sodium (generic of MYFORTIC) 360mg

3 B/D NM

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 3 B/D NM

NEORAL 2 B/D

NULOJIX 3 B/D NM

PROGRAF CAPS 5mg 3 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 3 B/D NM

RAPAMUNE TABS 1mg, 2mg

3 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

Drug Name Drug Tier

Requirements/Limits

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 3 B/D

SIROLIMUS TABS 1mg 1 B/D

SIROLIMUS TABS 2mg 3 B/D NM

sirolimus tab 0.5 mg (generic of RAPAMUNE)

1 B/D

tacrolimus (generic of PROGRAF) CAPS 5mg

3 B/D NM

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

1 B/D

THYMOGLOBULIN 3 B/D NM

ZORTRESS TAB 0.5MG 3 B/D NM

ZORTRESS TAB 0.25MG 3 B/D

ZORTRESS TAB 0.75MG 3 B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 3

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

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

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

KINRIX 3

M-M-R II 3

MENACTRA 3

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

MENVEO 3

PEDVAX HIB 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

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52

Drug Name Drug Tier

Requirements/Limits

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 3 NM

TENIVAC 3 B/D

TETANUS TOXOID ADSORBED

3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

K-TAB 8meq, 20meq 3

K-TAB 10meq 2

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20meq 1

klor-con spr cap (generic of MICRO-K)

1

MAGNESIUM SULFATE SOLN 4gm/50ml, 20gm/500ml

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

1

MICRO-K 2

potassium chloride SOLN 10%, 20%

1

potassium chloride TBCR 8meq

1

POTASSIUM CHLORIDE TBCR 10meq, 20meq

1

potassium chloride caps er (generic of MICRO-K)

1

Drug Name Drug Tier

Requirements/Limits

potassium chloride microencapsulated crystals cr

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D


3 B/D


3 B/D

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53

Drug Name Drug Tier

Requirements/Limits

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

LIPOSYN III INJ 10% 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID EMU 20% 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

travasol 10 3 B/D

TROPHAMINE 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

isolyte s 3

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

KCL0.15%/D5W/NACL0.225%

3

kcl 0.3%/d5w/lr iv lac ri 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

KCL IN NACL INJ .15-0.45 1

KCL/D5W/NACL INJ .15/.33% 1

KCL/D5W/NACL INJ .15/.45% 1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

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54

Drug Name Drug Tier

Requirements/Limits

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

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL)

1 B/D

HECTOROL CAPS 2 B/D

HECTOROL SOLN 3 B/D

paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg

1 B/D

paricalcitol CAPS 4mcg 1 B/D

PARICALCITOL SOLN 1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ROCALTROL 2 B/D

ZEMPLAR CAP 1MCG 2 B/D

ZEMPLAR CAP 2MCG 2 B/D

ZEMPLAR INJ 2MCG/ML 3 B/D

ZEMPLAR INJ 5MCG/ML 3 B/D

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

blephamide OINT 3

BLEPHAMIDE SUSP 3

MAXITROL 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX SUSP 3

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

Drug Name Drug Tier

Requirements/Limits

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

BLEPH-10 3

CILOXAN OIN 0.3% OP 3

CILOXAN SOL 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

garamycin 3

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) OINT

1

gentamicin sulfate (ophth) (generic of GARAMYCIN) SOLN

1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

neosporin solution 3

OCUFLOX 3

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3

sulfacetamide sodium (ophth) OINT

1

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

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

TOBREX SOL 0.3% OP 3

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55

Drug Name Drug Tier

Requirements/Limits

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

VIROPTIC 2

ZIRGAN 3

ZYMAXID 3

ANTI-INFLAMMATORIES ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

FML LIQUIFILM 3

ILEVRO 3

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

1

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

1

LOTEMAX 2

MAXIDEX 3

NEVANAC 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

Drug Name Drug Tier

Requirements/Limits

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine drop 0.05% 1

BEPREVE 3

cromolyn sodium (ophth) 1

ELESTAT 3

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

BETAGAN 3

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT 3

COSOPT PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

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56

Drug Name Drug Tier

Requirements/Limits

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 2

TRUSOPT 3

XALATAN 3

ZIOPTAN 2

MISCELLANEOUS alcaine 3

BOTOX INJ 100UNIT 3 NM PA

BOTOX INJ 200UNIT 3 NM PA

LACRISERT 3

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

XEOMIN 3 NM PA

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

QL (1 inhaler / 30 days) 2 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

2 QL

DUONEB 3 B/D

ipratropium-albuterol 1 B/D

STIOLTO RESPIMAT QL (1 inhaler / 30 days)

3 QL

ANTICHOLINERGICS ATROVENT 2

ATROVENT HFA QL (2 inhalers / 30 days)

3 QL

INCRUSE ELLIPTA QL (1 Inhaler / 30 days)

3 QL

ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

SPIRIVA RESPIMAT 2.5mcg/act

QL (1 inhaler / 30 days)

2 QL

TUDORZA PRESSAIR QL (1 inhaler / 30 days)

3 QL

TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT


3 QL

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 QL (1 bottle / 30 days)

3 QL

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 2

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

3 PA

hydroxyzine hcl inj 3 PA

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

3 PA

hydroxyzine pamoate CAPS 100mg

3 PA

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

1

levocetirizine tab 5 mg (generic of XYZAL)

1

olopatadine hcl (nasal) (generic of PATANASE)

1

PATANASE 3

VISTARIL 3 PA

XYZAL SOLN 3

XYZAL TABS 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

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57

Drug Name Drug Tier

Requirements/Limits

albuterol sulfate SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER QL (30 caps / 30 days)

2 QL

BROVANA 3 B/D

FORADIL AEROLIZER QL (60 caps / 30 days)

2 QL

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

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

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

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA QL (2 inhalers / 30 days)

2 QL

PROAIR RESPICLICK QL (2 inhalers / 30 days)

3 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

2 QL

SEREVENT DISKUS QL (1 inhaler / 30 days)

2 QL

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

3 QL

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

vospire 2

XOPENEX 3 B/D

XOPENEX CONCENTRATE 3 B/D

XOPENEX HFA QL (2 inhalers / 30 days)

3 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3

montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

SINGULAIR 3

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3 NM

Drug Name Drug Tier

Requirements/Limits

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 3 NM LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 3 NM PA

GLASSIA 3 NM LA PA

OFEV 3 NM PA

ORKAMBI 3 NM PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 3 B/D NM

tyzine .05% 3

XOLAIR 3 NM LA PA

ZEMAIRA 3 NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 inhalers / 30 days) 3 QL

budesonide (nasal) (generic of RHINOCORT AQUA)

QL (2 bottles / 30 days)

1 QL

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

1 QL

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL

NASONEX QL (2 bottles / 30 days)

2 QL

OMNARIS QL (1 inhaler / 30 days)

3 QL

QNASL QL (1 inhaler / 30 days)

3 QL

QNASL CHILDRENS QL (1 inhaler / 30 days)

3 QL

RHINOCORT AQUA QL (2 bottles / 30 days)

3 QL

triamcinolone acetonide (nasal)

QL (1 bottle / 30 days)

1 QL

VERAMYST QL (1 bottle / 30 days)

3 QL

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Drug Name Drug Tier

Requirements/Limits

ZETONNA QL (1 inhaler / 30 days)

3 QL

STEROID INHALANTS AEROSPAN

QL (2 inhalers / 30 days) 3 QL

ALVESCO QL (2 inhalers / 30 days)

3 QL

ARNUITY ELLIPTA QL (1 Inhaler / 30 days)

3 QL

ASMANEX HFA 100mcg/act QL (2 Inhalers / 30 days)

2 QL

ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)

2 QL

ASMANEX TWISTHALER QL (2 inhalers / 30 days)

2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 0.5MG/2 ML

3 B/D

PULMICORT INH SUSP 0.25MG/2 ML

3 B/D

PULMICORT INH SUSP 1MG/2ML

3 B/D NM

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

2 QL

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

2 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS

QL (1 inhaler / 30 days) 2 QL

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

BREO ELLIPTA QL (1 inhaler / 30 days)

3 QL

DULERA QL (1 inhaler / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

SYMBICORT QL (1 inhaler / 30 days)

2 QL

XANTHINES aminophylline inj 1

elixophyllin 2

lufyllin 200mg 3

theo-24 2

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NM

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA

1

adapalene (generic of DIFFERIN) GEL .1%

1

ADAPALENE GEL .3% 1

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

BENZACLIN 2

BENZAMYCIN 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLEOCIN-T 3

CLINDAGEL 3

clindamax (generic of CLEOCIN-T)

1

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

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

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

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Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of DUAC)

1

DIFFERIN 2

DUAC 3

EPIDUO 2

EPIDUO FORTE 3

ery pad 2% 1

erygel 3

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

EVOCLIN 3

FABIOR 3

KLARON 3

myorisan 1

neuac gel 1.2-5% (generic of DUAC)

1

ONEXTON 3

RETIN-A 3

RETIN-A MICRO 2

RETIN-A MICRO PUMP 2

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA 3

tretinoin (generic of RETIN-A) CREA

1

tretinoin (generic of RETIN-A) GEL .01%, .025%

1

tretinoin (generic of ATRALIN) GEL .05%

1

TRETINOIN MICROSPHERE 1

VELTIN 3

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN 2

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

Drug Name Drug Tier

Requirements/Limits

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVADENE 2

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON 3

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

EXTINA 3

ketoconazole (topical) CREA 1

ketoconazole (topical) (generic of EXTINA) FOAM

1

ketodan aer 2% (generic of EXTINA)

1

LOPROX SHAMPOO 3

LUZU 2

MENTAX 2

NAFTIFINE HCL 1

NAFTIN 2

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC anusol hc 2

CORTIFOAM 2

procto-pak 1

proctosol hc 2.5 % (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

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Drug Name Drug Tier

Requirements/Limits

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

3 NM PA

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 3 NM PA

COSENTYX SENSOREADY PEN

3 NM PA

DOVONEX CRE 0.005% 3

methoxsalen rapid (generic of OXSORALEN ULTRA)

3 NM

8-MOP 3

OXSORALEN ULTRA 3 NM

SORIATANE 3 NM PA

SORILUX 2

STELARA 3 NM PA

TAZORAC 2 PA

VECTICAL 3 NM

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

NIZORAL 3

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS acyclovir topical (generic of ZOVIRAX)

1

DENAVIR 2

XERESE 3

ZOVIRAX CREA 3

ZOVIRAX OINT 3 NM

DERMATOLOGY, CORTICOSTEROIDS aclovate 2

ala-cort 1

ala-scalp 3

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

Drug Name Drug Tier

Requirements/Limits

apexicon e cre 0.05% 3

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotrien oin betameth (generic of TACLONEX)

1

CAPEX 2

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

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LIQD; LOTN; SHAM

1

clobetasol propionate emollient base (generic of TEMOVATE E)

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX LIQD 3

CLOBEX LOTN; SHAM 2

CLOCORTOLONE PIVALATE 1

clodan (generic of CLOBEX) 1

CLODERM PUMP 2

CORDRAN TAPE 3

cormax (generic of TEMOVATE)

1

CUTIVATE CREA 3

CUTIVATE LOTN 3 NM

DERMATOP 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN; OINT

1

DESOWEN CREA 2

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Drug Name Drug Tier

Requirements/Limits

desowen LOTN 2

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

DIPROLENE LOTN 3

DIPROLENE OINT 2

DIPROLENE AF 3

ELOCON CREA; LOTN 3

ELOCON OINT 2

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

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

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

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

1

fluocinonide (generic of VANOS) CREA .1%

1

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN

1

fluticasone propionate OINT 1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

Drug Name Drug Tier

Requirements/Limits

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOCOID 3

LOCOID LIPOCREAM 3

LOKARA LOTN 0.05% 1

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

1

OLUX 3

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

psorcon 3

SYNALAR CREA; OINT 3

SYNALAR SOLN 2

TACLONEX 3 NM

TEMOVATE CRE 0.05% 2

TEMOVATE E CREAM 2

TEMOVATE GEL 0.05% 2

TEMOVATE OIN 0.05% 2

TEMOVATE SOL 0.05% 3

texacort 2

topicort CREA 3

topicort GEL 2

TOPICORT LIQD 3

TOPICORT OINT .05% 2

topicort OINT .25% 2

triamcinolone acetonide (topical) (generic of KENALOG) AERS

1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

trianex 3

triderm 1

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Drug Name Drug Tier

Requirements/Limits

ULTRAVATE 2

VANOS 3

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 4% 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ALDARA 3

ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CARAC 3

CONDYLOX 2

diclofenac gel 3% (generic of SOLARAZE)

3 NM PA

diclofenac sol 1.5% 1

DOXYCYCLINE (ROSACEA) 1

EFUDEX 3

ELIDEL 2 PA

FINACEA 2

fluorouracil (topical) (generic of EFUDEX) CREA 5%

1

FLUOROURACIL (TOPICAL) CREA .5%

1

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

LAC-HYDRIN 2

laclotion lot 12% (generic of LAC-HYDRIN)

1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (topical) (generic of METROCREAM) CREA

1

Drug Name Drug Tier

Requirements/Limits

metronidazole (topical) (generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 3

ORACEA 2

OXSORALEN 3

PANRETIN 3 NM

PENNSAID SOL 1.5% 2

PENNSAID SOL 2% 2

PICATO 3 NM

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 3 PA

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOLARAZE 3 NM PA

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1 PA

TARGRETIN GEL 3 NM PA

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

ZYCLARA 3 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion (generic of OVIDE) 1

OVIDE 2

permethrin (generic of ELIMITE)

1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

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

1

REGRANEX 3 NM PA

SANTYL 3

SODIUM CHLORIDE 0.9% 1

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Drug Name Drug Tier

Requirements/Limits

STERILE WATER IRRIGATION

1

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

1

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

1

clotrimazole TROC 1

EVOXAC 2

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard soln 0.12% (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

1

SALAGEN 2

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

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

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1

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Index 8 8-MOP .............................. 60 A abacavir sulfate ...................8 abacavir sulfate-lamivudine-zidovudine ..........................................9 ABELCET............................8 ABILIFY

see aripiprazole ............. 27 ABILIFY DISCMELT ......... 27 ABILIFY INJ 9.75MG ........ 27 ABILIFY MAIN INJ 300MG 27 ABILIFY MAIN INJ 400MG 27 ABILIFY MAINTENA ......... 27 ABILIFY SOLN .................. 27 ABILIFY TABS .................. 27 ABRAXANE ...................... 14 ABSORICA ....................... 58 ABSTRAL............................3 acamprosate calcium ........ 35 ACANYA ........................... 58 acarbose ........................... 36 ACCOLATE ....................... 57

see zafirlukast ............... 57 ACCUPRIL ........................ 16

see quinapril hcl ............ 16 ACCURETIC ..................... 15

see quinapril-hydrochlorothiazide .................................. 16

acebutolol hcl .................... 19 ACEON

see perindopril erbumine ...................................... 16

acetaminophen w/ codeine 1, 2 acetaminophen-caff-dihydrocod ........................................2 acetasol hc ........................ 63 acetazolamide ................... 20 acetazolamide sodium ...... 20 acetic acid ......................... 62 acetic acid (otic) ................ 63 acetic acid sol/hc ............... 63 acetic acid-aluminum acetate .......................................... 63

acetylcysteine ................... 57 ACIPHEX .......................... 47

see rabeprazole sodium 48 ACIPHEX SPR CAP 10MG .......................................... 47 ACIPHEX SPR CAP 5MG . 47 acitretin ............................. 60 aclovate ............................ 60 ACLOVATE

see alclometasone dipropionate .................. 60

ACTEMRA ........................ 50 ACTHIB ............................. 51 ACTIGALL ........................ 47

see ursodiol ................... 47 ACTIMMUNE .................... 50 ACTIQ ................................. 3

see fentanyl citrate .......... 4 ACTONEL ......................... 38

see risedronate sodium . 39 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 38

ACTOPLUS MET TAB 15-500MG ......................... 36 ACTOPLUS MET TAB 15-850MG ......................... 36 ACTOPLUS MET XR 15-1000MG ....................... 36 ACTOPLUS MET XR 30-1000MG ....................... 36 ACTOS ............................. 36

see pioglitazone hcl ....... 38 ACULAR ........................... 55

see ketorolac tromethamine (ophth) .... 55

ACULAR LS ...................... 55 see ketorolac tromethamine (ophth) .... 55

ACUVAIL .......................... 55 acyclovir ............................ 10 acyclovir sodium ............... 10 acyclovir topical ................ 60 ACZONE ........................... 58 ADACEL ........................... 51 ADAGEN ........................... 42 ADALAT CC ...................... 19

see afeditab cr............... 19 see nifedipine ................ 20

adapalene ......................... 58 ADAPALENE .................... 58 ADCIRCA ......................... 22 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg ........ 30 see amphetamine-dextroamphetamine tab 12.5 mg ..... 30 see amphetamine-dextroamphetamine tab 15 mg ........ 31 see amphetamine-dextroamphetamine tab 20 mg ........ 31 see amphetamine-dextroamphetamine tab 30 mg ........ 31 see amphetamine-dextroamphetamine tab 5 mg .......... 30 see amphetamine-dextroamphetamine tab 7.5 mg ....... 30

adderall tab 10mg ............. 30 adderall tab 12.5mg .......... 30 adderall tab 15mg ............. 30 adderall tab 20mg ............. 30 adderall tab 30mg ............. 30 adderall tab 5mg ............... 30 adderall tab 7.5mg ............ 30 ADDERALL XR

see amphetamine cap 10mg er ......................... 30 see amphetamine cap 15mg er ......................... 30 see amphetamine cap 20mg er ......................... 30 see amphetamine cap 25mg er ......................... 30 see amphetamine cap 30mg er ......................... 30 see amphetamine-dextroamph

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etamine cap sr 24hr 5 mg ...................................... 30

ADDERALL XR CAP 10MG .......................................... 30 ADDERALL XR CAP 15MG .......................................... 30 ADDERALL XR CAP 20MG .......................................... 30 ADDERALL XR CAP 25MG .......................................... 30 ADDERALL XR CAP 30MG .......................................... 30 ADDERALL XR CAP 5MG 30 adefovir dipivoxil ............... 10 ADEMPAS ........................ 22 adoxa ................................ 12 ADOXA

see doxycycline (monohydrate) ............... 12

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 12

ADRENACLICK ................ 57 adrucil ............................... 13 ADVAIR DISKUS .............. 58 ADVAIR HFA .................... 58 ADVICOR.......................... 18 AEROSPAN ...................... 58 afeditab cr ......................... 19 AFINITOR ......................... 14 AFINITOR DISPERZ ......... 14 AFREZZA.......................... 44 AGGRENOX ..................... 50 AGRYLIN .......................... 49

see anagrelide hcl ......... 49 a-hydrocort ........................ 42 AKYNZEO ......................... 45 ala-cort .............................. 60 ala-scalp............................ 60 ALBENZA............................6 albuterol sulfate ........... 56, 57 albuterol sulfate er ............ 57 alcaine .............................. 56 ALCAINE

see proparacaine hcl ..... 56 alclometasone dipropionate .......................................... 60 ALCOHOL SWABS ........... 36

ALDACTAZIDE ................. 20 see spironolactone & hydrochlorothiazide ....... 21

ALDACTAZIDE TAB 50/50 .......................................... 20 ALDACTONE .................... 16

see spironolactone ........ 16 ALDARA ........................... 62

see imiquimod ............... 62 ALDURAZYME ................. 42 alendronate sodium .... 38, 39 alfuzosin hcl ...................... 48 ALIMTA ............................. 13 ALINIA ................................ 6 ALKERAN ......................... 13

see melphalan hcl ......... 13 allopurinol tab ..................... 1 almotriptan malate ............ 32 ALOCRIL .......................... 55 ALOMIDE .......................... 55 ALOPRIM ............................ 1 ALORA .............................. 42 alosetron hcl ..................... 47 ALOXI ............................... 45 ALPHAGAN P 0.1% .......... 55 ALPHAGAN P 0.15% ........ 55 alprazolam ........................ 22 ALREX .............................. 55 ALSUMA ........................... 32 ALTABAX .......................... 59 ALTACE ............................ 16

see ramipril .................... 16 altavera ............................. 39 ALTOPREV ....................... 18 ALVESCO ......................... 58 amantadine hcl ................. 27 AMARYL ........................... 36

see glimepiride .............. 37 AMBIEN ............................ 32

see zolpidem tartrate ..... 32 AMBISOME ........................ 8 amcinonide ....................... 60 AMERGE .......................... 32

see naratriptan hcl ......... 33 amethia 91 day ................. 39 amethyst 28 day ............... 39 amifostine crystalline......... 15 amikacin sulfate .................. 6

amiloride & hydrochlorothiazide ........... 21 amiloride hcl ..................... 21 aminophylline inj ............... 58 AMINOSYN ...................... 52 AMINOSYN 7%/ELECTROLYTES ....... 52 AMINOSYN II ................... 52 AMINOSYN II 8.5%/ELECTROL.............. 52 AMINOSYN INJ 8.5/LYTE 52 AMINOSYN M .................. 52 AMINOSYN-HBC .............. 52 AMINOSYN-PF ................. 52 AMINOSYN-PF 7% ........... 52 AMINOSYN-RF................. 52 amiodarone hcl ................. 17 amiodarone inj 50mg/ml ... 17 AMITIZA ........................... 47 amitriptyline hcl ................. 25 amlodipine besylate .......... 19 AMLODIPINE BESYLATE/ATORV .......... 19 amlodipine besylate-benazepril hcl ..... 15 amlodipine besylate-valsartan tab 10-160 mg ........................ 16 amlodipine besylate-valsartan tab 10-320 mg ........................ 16 amlodipine besylate-valsartan tab 5-160 mg ..................................... 16 amlodipine besylate-valsartan tab 5-320 mg ..................................... 16 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

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.......................................... 16 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 16 ammonium chloride ........... 52 ammonium lactate ............. 62 amnesteem ....................... 58 amoxapine ........................ 25 amoxicillin ......................... 12 amoxicillin & pot clavulanate .......................................... 12 amoxicillin-clarithromycin w/ lansoprazole ...................... 47 amphetamine cap 10mg er .......................................... 30 amphetamine cap 15mg er .......................................... 30 amphetamine cap 20mg er .......................................... 30 amphetamine cap 25mg er .......................................... 30 amphetamine cap 30mg er .......................................... 30 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 30 amphetamine-dextroamphetamine tab 10 mg ............... 30 amphetamine-dextroamphetamine tab 12.5 mg ............ 30 amphetamine-dextroamphetamine tab 15 mg ............... 31 amphetamine-dextroamphetamine tab 20 mg ............... 31 amphetamine-dextroamphetamine tab 30 mg ............... 31 amphetamine-dextroamphetamine tab 5 mg ................. 30 amphetamine-dextroamphetamine tab 7.5 mg .............. 30 AMPHOTEC ........................8 amphotericin b ....................8 ampicillin & sulbactam sodium .............................. 12 ampicillin cap 250mg ........ 12 ampicillin cap 500 mg ....... 12 ampicillin inj ....................... 12 ampicillin sodium ............... 12 ampicillin susp ................... 12 AMPYRA ........................... 34

ANAFRANIL ...................... 25 see clomipramine hcl ..... 26

anagrelide hcl ................... 49 ANAPROX .......................... 1

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

see naproxen sodium ...... 1 anastrozole ....................... 14 ANCOBON .......................... 8

see flucytosine ................ 8 ANDRODERM .................. 35 ANDROGEL 1% ............... 35 ANDROGEL 1.62% .......... 35 ANDROGEL GEL PUMP 1% .......................................... 35 ANORO ELLIPT AER 62.5-25 .............................. 56 antabuse ........................... 35 ANTABUSE

see disulfiram ................ 35 ANTARA ........................... 18 anusol hc .......................... 59 ANUSOL-HC

see proctosol hc 2.5 % .. 59 see proctozone hc ......... 59

apexicon e cre 0.05% ....... 60 APIDRA ............................ 36 APIDRA SOLOSTAR ........ 36 APLENZIN ........................ 25 APOKYN ........................... 27 apri 28 day ........................ 39 APRISO ............................ 46 APTENSIO XR .................. 31 APTIOM ............................ 22 APTIVUS ............................ 8 ARALAST NP ................... 57 ARALEN

see chloroquine phosphate ....................... 8

aranelle 28 ........................ 39 ARANESP ALBUMIN FREE .......................................... 49 ARAVA .............................. 50

see leflunomide ............. 50 ARCALYST ....................... 50 ARCAPTA NEOHALER .... 57 ARICEPT .......................... 25

see donepezil tab hcl

23mg ............................. 25 see donepezil tabs 10mg ...................................... 25 see donepezil tabs 5mg 25

ARIMIDEX ........................ 14 see anastrozole ............. 14

aripiprazole ....................... 27 ARIXTRA .......................... 49

see fondaparinux sodium ...................................... 49

ARNUITY ELLIPTA ........... 58 AROMASIN ...................... 14

see exemestane ............ 14 ARRANON ........................ 13 ARTHROTEC 50 ................ 1

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

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

ARZERRA ........................ 14 ASACOL HD ..................... 46 ashlyna 91 day ................. 39 ASMANEX HFA ................ 58 ASMANEX TWISTHALER 58 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE............................................ 2 ASPIRIN-DIPYRIDAMOLE.......................................... 50 ASTAGRAF XL ................. 51 ASTEPRO ........................ 56

see azelastine spr 0.15% ...................................... 56

ATACAND ........................ 17 see candesartan cilexetil ...................................... 17

ATACAND HCT ................ 17 see candesartan cilexetil-hydrochlorothiazide .................................... 17

ATELVIA ........................... 39 see risedronate sodium . 39

atenolol ............................. 19 atenolol & chlorthalidone .. 19 ATGAM ............................. 51 ATIVAN ............................. 22

see lorazepam............... 22

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atorvastatin calcium .......... 18 atovaquone .........................7 atovaquone-proguanil hcl tab 250-100 mg .........................8 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ......8 ATRALIN ........................... 58

see tretinoin ................... 59 ATRIPLA .............................9 ATROPINE SULFATE ...... 45 ATROVENT ...................... 56

see ipratropium bromide (nasal) ........................... 56

ATROVENT HFA .............. 56 AUBAGIO.......................... 34 aubra 28 day ..................... 39 AUGMENTIN .................... 12

see amoxicillin & pot clavulanate .................... 12

AUGMENTIN ES-600 ....... 12 see amoxicillin & pot clavulanate .................... 12

AUGMENTIN XR .............. 12 see amoxicillin & pot clavulanate .................... 12

AURYXIA .......................... 44 AUVI-Q ............................. 57 AVALIDE ........................... 17

see irbesartan-hydrochlorothiazide ................................ 17

AVAPRO ........................... 17 see irbesartan ................ 17

AVASTIN........................... 14 AVELOX............................ 11

see moxifloxacin hcl ...... 12 AVELOX ABC PACK ........ 11 aviane 28 .......................... 39 AVINZA ...............................3 AVITA ............................... 58 AVODART ......................... 48 AVONEX ........................... 34 AVONEX PEN ................... 34 AVYCAZ............................ 10 AXERT .............................. 32

see almotriptan malate .. 32 AXID

see nizatidine ................ 46

AXIRON ............................ 35 aygestin ............................ 44 AYGESTIN

see norethindrone acetate ...................................... 44

azacitidine ......................... 13 AZACTAM ........................... 7

see aztreonam ................ 7 AZACTAM/DEX INJ 1GM ... 7 AZACTAM/DEX INJ 2GM ... 7 azasan .............................. 51 AZASITE ........................... 54 azathioprine ...................... 51 azelastine drop 0.05% ...... 55 azelastine spr 0.1% .......... 56 azelastine spr 0.15%......... 56 AZELEX ............................ 58 AZILECT ........................... 27 azithromycin ...................... 11 AZITHROMYCIN .............. 11 AZOPT .............................. 55 AZOR ................................ 17 aztreonam ........................... 7 AZULFIDINE ..................... 46

see sulfasalazine ir ........ 46 AZULFIDINE EN-TABS .... 46

see sulfasalazine dr....... 46 B bacitracin (ophthalmic) ...... 54 bacitracin-polymyxin b (ophth) .............................. 54 bacitracin-poly-neomycin-hc .......................................... 54 baclofen ............................ 34 BACTOCILL INJ DEX 1GM .......................................... 12 BACTOCILL INJ DEX 2GM .......................................... 12 BACTRIM ............................ 7

see sulfamethoxazole-trimethop ...................................... 7

BACTRIM DS ...................... 7 see sulfamethoxazole-trimethop ...................................... 7

BACTROBAN ................... 59 see mupirocin ................ 59

see mupirocin calcium (topical) ......................... 59

BACTROBAN NASAL ....... 59 balsalazide disodium ........ 46 balziva 28 day ................... 39 BANZEL SUS 40MG/ML ... 22 BANZEL TAB 200MG ....... 22 BANZEL TAB 400MG ....... 22 BARACLUDE .................... 10

see entecavir ................. 10 BCG VACCINE ................. 51 BECONASE AQ................ 57 benazepril & hydrochlorothiazide ........... 16 benazepril hcl ................... 16 BENICAR .......................... 17 BENICAR HCT ................. 17 BENTYL ............................ 45

see dicyclomine hcl ....... 45 BENZACLIN ..................... 58

see clindamycin phosphate-benzoyl peroxide ........................ 58

BENZAMYCIN .................. 58 see benzoyl peroxide-erythromycin ... 58

benzoyl peroxide-erythromycin ...... 58 benztropine mesylate ........ 27 BEPREVE ......................... 55 BESIVANCE ..................... 54 BETAGAN ........................ 55

see levobunolol hcl ........ 55 betamethasone dipropionate (topical) ............................. 60 betamethasone dipropionate augmented ........................ 60 betamethasone valerate ... 60 BETAPACE ...................... 17

see sorine ..................... 17 see sotalol hcl ............... 18

BETAPACE AF ................. 17 see sotalol hcl (afib/afl) . 18

BETASERON ................... 34 betaxolol hcl ...................... 19 betaxolol hcl (ophth) ......... 55 bethanechol chloride ......... 48 BETHKIS ............................ 6

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BETIMOL .......................... 55 BETOPTIC-S .................... 55 bexarotene ........................ 15 BEXSERO......................... 51 BEYAZ .............................. 39 BIAXIN .............................. 11

see clarithromycin ......... 11 BIAXIN XL

see clarithromycin ......... 11 bicalutamide ...................... 14 BICILLIN C-R .................... 12 BICILLIN L-A ..................... 12 BICNU ............................... 13 BIDIL ................................. 21 BILTRICIDE ........................7 BINOSTO .......................... 39 bisoprolol & hydrochlorothiazide ........... 19 bisoprolol fumarate ........... 19 BIVIGAM ........................... 50 bleomycin sulfate .............. 13 BLEPH-10 ......................... 54

see sulfacetamide sodium (ophth) ........................... 54

blephamide ....................... 54 BLEPHAMIDE ................... 54 BONIVA

see ibandronate sodium 39 BONIVA INJ 3MG/3ML ..... 39 BONIVA TAB 150MG ........ 39 BOOSTRIX ....................... 51 BOSULIF........................... 14 BOTOX INJ 100UNIT ........ 56 BOTOX INJ 200UNIT ........ 56 BREO ELLIPTA ................ 58 BREVICON-28 .................. 39

see necon 0.5/35 28 day ...................................... 41 see nortrel 0.5/35 28 day ...................................... 41

briellyn 28 day ................... 39 BRILINTA .......................... 50 BRIMONIDINE SOL 0.15% .......................................... 55 brimonidine sol 0.2% ......... 55 BRINTELLIX ..................... 25 BRISDELLE ...................... 33 bromfenac sodium (ophth) 55

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 55 bromocriptine mesylate ..... 27 BROVANA ........................ 57 budesonide ....................... 46 budesonide (inhalation) ..... 58 budesonide (nasal) ........... 57 bumetanide ....................... 21 BUNAVAIL MIS 2.1-0.3..... 35 BUNAVAIL MIS 4.2-0.7..... 35 BUNAVAIL MIS 6.3-1MG .. 35 BUPHENYL

see sodium phenylbutyrate ...................................... 42

buprenorphine hcl ............. 35 buprenorphine hcl-naloxone hcl sl.................................. 35 buproban ........................... 35 bupropion hcl .................... 25 buspirone hcl .................... 22 BUSULFEX ....................... 13 butorphanol nasal spray ...... 2 butorphanol tartrate ............ 2 BUTRANS ........................... 2 BYDUREON ..................... 36 BYETTA ............................ 36 BYSTOLIC ........................ 19 C cabergoline ....................... 44 CADUET ........................... 19 cafergot tab 1-100mg ........ 32 CALAN .............................. 19

see verapamil hcl .......... 20 CALAN SR ........................ 19

see verapamil hcl .......... 20 calcipotrien oin betameth .. 60 calcipotriene ...................... 60 calcitonin (salmon) nasal spray ................................. 44 calcitrene oin 0.005%........ 60 calcitriol ............................. 54 CALCITRIOL ..................... 60 calcium acetate (phosphate binder) ............................... 44 camila 28 day .................... 39 CAMPTOSAR ................... 15

see irinotecan ................ 15 see irinotecan hcl .......... 15

CAMRESE LO TAB .......... 39 CANASA ........................... 46 CANCIDAS ......................... 8 candesartan cilexetil ......... 17 candesartan cilexetil-hydrochlorothiazide.......................................... 17 CANTIL ............................. 45 CAPASTAT SULFATE ........ 9 CAPEX ............................. 60 capital

and codeine .................... 2 CAPRELSA ...................... 14 captopril ............................ 16 captopril & hydrochlorothiazide ........... 16 CARAC ............................. 62 CARAFATE ...................... 47

see sucralfate ................ 47 CARBAGLU ...................... 42 carbamazepine ................. 22 CARBATROL .................... 22

see carbamazepine ....... 22 carbidopa .......................... 27 CARBIDOPA/LEVODOPA/ENTACAPONE ................... 27 carbidopa-levodopa .......... 27 carboplatin ........................ 15 CARDIZEM ....................... 19

see diltiazem hcl ............ 20 CARDIZEM CD ................. 19

see cartia xt ................... 19 see dilt-cd cap ............... 19 see diltiazem hcl coated beads cp24 120mg ........ 20 see diltiazem hcl coated beads cp24 180mg ........ 20 see diltiazem hcl coated beads cp24 240mg ........ 20 see diltiazem hcl coated beads cp24 300mg ........ 20 see diltiazem hcl coated beads cp24 360mg ........ 20

CARDIZEM LA.................. 19 see matzim la ................ 20

CARDURA ........................ 16 see doxazosin mesylate 16

CARDURA XL .................. 48

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CARIMUNE NANOFILTERED .............. 50 CARNITOR ....................... 42

see levocarnitine (metabolic modifiers) ..... 42

carteolol hcl (ophth) .......... 55 cartia xt ............................. 19 carvedilol ........................... 19 CASODEX ........................ 14

see bicalutamide ........... 14 CATAPRES

see clonidine hcl ............ 21 CATAPRES TAB ............... 21 CATAPRES-TTS ............... 21 CATAPRES-TTS-1

see clonidine hcl ............ 21 CATAPRES-TTS-2

see clonidine hcl ............ 21 CATAPRES-TTS-3 ........... 21

see clonidine hcl ............ 21 CAYSTON ...........................7 CEDAX ............................. 10 cefaclor ............................. 10 cefaclor er tab 500mg ....... 10 cefadroxil........................... 10 cefazolin inj ....................... 10 cefazolin sodium ............... 10 cefazolin/dextrose ............. 10 cefdinir .............................. 10 CEFEPIME 1GM SOLN .... 10 CEFEPIME 2GM SOLN .... 10 cefepime inj 1gm ............... 10 cefepime inj 2gm ............... 10 cefixime ............................. 10 cefotaxime sodium ............ 10 cefotetan disodium ............ 10 cefoxitin sodium ................ 10 CEFOXITIN SODIUM IN DEXTROSE ...................... 10 cefpodoxime proxetil ......... 10 cefprozil............................. 10 ceftazidime ........................ 10 CEFTAZIDIME/DEXTROSE .......................................... 10 ceftibuten .......................... 10 CEFTIN ............................. 10

see cefuroxime axetil ..... 11 ceftriaxone sodium ............ 11

cefuroxime axetil ............... 11 cefuroxime sodium ............ 11 cefuroxime sodium soln iv 7.5 gm ............................... 11 CELEBREX

see celecoxib .................. 1 CELEBREX CAP 100MG .... 1 CELEBREX CAP 200MG .... 1 CELEBREX CAP 400MG .... 1 CELEBREX CAP 50MG ...... 1 celecoxib ............................. 1 CELEXA ............................ 25

see citalopram hydrobromide ................ 25

CELLCEPT see mycophenolate mofetil ...................................... 51

CELLCEPT CAP ............... 51 CELLCEPT INTRAVENOUS .......................................... 51 CELLCEPT SUSP ............ 51 CELLCEPT TAB ............... 51 CELONTIN ........................ 22 CENTANY ......................... 59 cephalexin ......................... 11 CERDELGA ...................... 42 CEREZYME ...................... 42 CERVARIX ....................... 51 CESAMET ........................ 45 cetirizine syrup .................. 56 cevimeline hcl ................... 63 CHANTIX .......................... 35 CHANTIX CONTINUING MONTH ............................. 35 CHANTIX STARTER PACK .......................................... 35 CHEMET ........................... 39 chlorhexidine gluconate (mouth-throat) ................... 63 chloroquine phosphate........ 8 chlorothiazide .................... 21 chlorpromaz inj 25mg/ml ... 27 chlorpromazine hcl ............ 27 chlorthalidone ................... 21 cholestyramine .................. 18 cholestyramine light .......... 18 choline fenofibrate ............ 18 CHORIONIC

GONADOTROPIN ............ 44 ciclopirox ........................... 59 ciclopirox cre 0.77% .......... 59 ciclopirox shampoo 1% ..... 59 ciclopirox sus 0.77% ......... 59 cidofovir ............................ 10 cilostazol ........................... 49 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 54

CILOXAN OIN 0.3% OP ... 54 CILOXAN SOL 0.3% OP .. 54 cimetidine ......................... 46 cimetidine sol 300/5ml ...... 46 CIMZIA ............................. 50 CINRYZE .......................... 49 CIPRO .............................. 11

see ciprofloxacin ........... 11 see ciprofloxacin hcl ...... 11

CIPRO HC ........................ 63 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w 11 CIPRO XR ........................ 11

see ciprofloxacin er ....... 11 CIPRODEX ....................... 63 ciprofloxacin ...................... 11 ciprofloxacin er ................. 11 ciprofloxacin hcl ................ 11 ciprofloxacin hcl (ophth) .... 54 ciprofloxacin in d5w .......... 11 ciprofloxacn inj .................. 11 cisplatin ............................. 15 citalopram hydrobromide .. 25 cladribine .......................... 13 claforan ............................. 11 CLAFORAN ...................... 11

see cefotaxime sodium . 10 claravis ............................. 58 CLARINEX ........................ 56

see desloratadine .......... 56 CLARINEX REDITABS

see desloratadine .......... 56 CLARINEX-D TAB 2.5-120.......................................... 56 clarithromycin ................... 11 cleocin ................................ 7 CLEOCIN ...................... 7, 48

see clindamycin cre 2%

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vag ................................ 49 see clindamycin hcl .........7

CLEOCIN CAP 75MG .........7 CLEOCIN IN D5W ..............7

see clindamycin phosphate in d5w ............7

CLEOCIN INJ ......................7 CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ...................7

CLEOCIN PHOSPHATE .....7 see clindamycin phosphate ........................7

CLEOCIN VAG SUPP 100MG .............................. 48 CLEOCIN-T ....................... 58

see clindamax ............... 58 see clindamycin phosphate (topical) ........ 58

CLIMARA .......................... 42 see estradiol .................. 42

CLINDAGEL ...................... 58 clindamax .......................... 58 clindamycin cre 2% vag .... 49 clindamycin hcl ....................7 clindamycin palmitate hydrochloride ......................7 clindamycin phosphate .......7 clindamycin phosphate (topical) ............................. 58 clindamycin phosphate in d5w .....................................7 clindamycin phosphate-benzoyl peroxide .......................................... 58 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 59 CLINDESSE ...................... 49 CLINIMIX 2.75%/DEXTROSE 5% ..... 52 CLINIMIX 4.25%/DEXTROSE 10% ... 52 CLINIMIX 4.25%/DEXTROSE 20% ... 52 CLINIMIX 4.25%/DEXTROSE 25% ... 52

CLINIMIX 4.25%/DEXTROSE 5% ..... 52 CLINIMIX 5%/DEXTROSE 15%................................... 52 CLINIMIX 5%/DEXTROSE 20%................................... 52 CLINIMIX 5%/DEXTROSE 25%................................... 52 CLINIMIX E 2.75%/DEXTROSE 10% ... 52 CLINIMIX E 2.75%/DEXTROSE 5% ..... 52 CLINIMIX E 4.25%/DEXTROSE ........... 52 CLINIMIX E 4.25%/DEXTROSE 25% ... 52 CLINIMIX E 4.25%/DEXTROSE 5% ..... 52 CLINIMIX E 5%/DEXTROSE 15%................................... 53 CLINIMIX E 5%/DEXTROSE 20%................................... 53 CLINIMIX E 5%/DEXTROSE 25%................................... 53 clinisol 15 .......................... 53 clobetasol propionate ........ 60 clobetasol propionate emollient base ................... 60 clobetasol propionate emulsion ........................... 60 CLOBEX ........................... 60

see clobetasol propionate ...................................... 60 see clodan ..................... 60

CLOCORTOLONE PIVALATE ......................... 60 clodan ............................... 60 CLODERM PUMP ............ 60 CLOLAR ........................... 13 clomipramine hcl ............... 26 clonazepam ................ 22, 23 clonidine hcl ...................... 21 clopidogrel bisulfate .......... 50 clorazepate dipotassium ... 23 clorpres ............................. 21 clotrimazole ....................... 63 clotrimazole (topical) ......... 59 clozapine ........................... 27

CLOZAPINE ODT ............. 28 CLOZAPINE ODT 150MG 28 CLOZAPINE ODT 200MG 28 CLOZARIL ........................ 28

see clozapine ................ 27 COARTEM .......................... 8 codeine

and capital ....................... 2 CODEINE SULFATE .......... 3 COGENTIN ....................... 27

see benztropine mesylate ...................................... 27

COLAZAL ......................... 46 see balsalazide disodium ...................................... 46

colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID ........................ 18

see colestipol hcl ........... 18 colestipol hcl ..................... 18 colistimethate sodium ......... 7 colocort ............................. 46 COLY-MYCIN M ................. 7

see colistimethate sodium ........................................ 7

COLY-MYCIN S ................ 63 COLYTE-FLAVOR PACKS.......................................... 46

see gavilyte-c ................ 46 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........................... 47

COMBIGAN ...................... 55 COMBIPATCH .................. 42 COMBIVENT RESPIMAT . 56 COMBIVIR .......................... 9

see lamivudine-zidovudine ........................................ 9

COMETRIQ ...................... 15 COMPAZINE

see prochlorperazine maleate ......................... 45

COMPLERA ....................... 9 compro supp ..................... 45 COMTAN .......................... 27

see entacapone............. 27 COMVAX .......................... 51 CONCERTA ..................... 31

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CONDYLOX ...................... 62 see podofilox ................. 62

constulose ......................... 46 CONZIP ..............................2 COPAXONE

see glatopa .................... 34 COPAXONE INJ 40MG/ML .......................................... 34 COPAXONE KIT 20MG/ML .......................................... 34 COPEGUS ........................ 10

see moderiba tab 200mg ...................................... 10 see ribasphere ............... 10 see ribavirin 200mg ....... 10

CORDARONE see amiodarone hcl ....... 17 see pacerone ................. 17

CORDRAN ........................ 60 COREG ............................. 19

see carvedilol ................ 19 COREG CR ....................... 19 CORGARD ........................ 19

see nadolol .................... 19 CORLANOR ...................... 21 cormax .............................. 60 CORTEF ........................... 42

see hydrocortisone ........ 43 CORTENEMA ................... 46

see colocort ................... 46 CORTIFOAM .................... 59 cortisone acetate ............... 42 CORTISPORIN ................. 59

see neomycin-polymyxin-hc (otic) .............................. 63

CORTISPORIN-TC ........... 63 CORZIDE .......................... 19

see nadolol & bendroflumethiazide ...... 19

COSENTYX ...................... 60 COSENTYX SENSOREADY PEN .................................. 60 COSMEGEN ..................... 13 COSOPT ........................... 55

see dorzolamide hcl-timolol maleate ........ 55

COSOPT PF ..................... 55

COUMADIN ...................... 49 see jantoven .................. 49 see warfarin sodium ...... 49

COZAAR ........................... 17 see losartan potassium . 17

CREON ............................. 47 CRESEMBA ........................ 8 CRESTOR ........................ 18 CRINONE ......................... 44 CRIXIVAN ........................... 8 cromolyn sodium ............... 57 cromolyn sodium (mastocytosis) ................... 47 cromolyn sodium (ophth) .. 55 cryselle 28 ......................... 39 CUBICIN ............................. 7 CUTIVATE ........................ 60

see fluticasone propionate ...................................... 61

CUVPOSA ........................ 45 cyclafem 1/35 28 day ........ 39 cyclafem 7/7/7 28 day ....... 39 CYCLESSA ....................... 39

see velivet 28 day ......... 41 cyclobenzaprine hcl .......... 34 cyclophosphamide ............ 13 CYCLOPHOSPHAMIDE ... 13 cycloserine .......................... 9 cyclosporine ...................... 51 cyclosporine modified (for microemulsion) ................. 51 CYKLOKAPRON .............. 50

see tranexamic acid ...... 50 CYMBALTA ...................... 26

see duloxetine hcl ......... 26 cyred tab ........................... 39 CYSTADANE .................... 42 CYSTAGON ...................... 42 cytarabine inj ..................... 13 CYTOMEL ........................ 44

see liothyronine sodium . 44 CYTOTEC ......................... 47

see misoprostol ............. 47 CYTOVENE ...................... 10

see ganciclovir inj 500mg ...................................... 10

D D.H.E. 45 .......................... 32

see dihydroergotamine mesylate ........................ 32

dacarbazine ...................... 13 DACOGEN ....................... 13

see decitabine ............... 13 DALIRESP ........................ 57 DALVANCE ........................ 7 danazol ............................. 42 DANTRIUM

see dantrolene sodium .. 34 DANTRIUM CAP 25MG .... 34 DANTRIUM CAP 50MG .... 34 dantrolene sodium ............ 34 dapsone .............................. 7 DAPTACEL ....................... 51 DARAPRIM ......................... 7 daunorubicin hcl................ 13 DAYPRO ............................ 1

see oxaprozin .................. 1 DAYTRANA ...................... 31 DDAVP ............................. 44

see desmopressin acetate ...................................... 45 see desmopressin acetate inj .................................. 45 see desmopressin acetate spray ............................. 45

deblitane 28 day ............... 39 decitabine ......................... 13 DELESTROGEN............... 42

see estradiol valerate .... 42 delyla 28 day .................... 39 DELZICOL ........................ 46 DEMADEX ........................ 21

see torsemide tabs ........ 21 demeclocycline hcl ............ 12 DEMSER .......................... 21 DENAVIR .......................... 60 DEPACON ........................ 23

see valproate sodium .... 25 DEPAKENE ...................... 23

see valproate sodium .... 25 see valproic acid ........... 25

DEPAKOTE ...................... 23 see divalproex sodium .. 23

DEPAKOTE ER ................ 23 see divalproex sodium .. 23

DEPAKOTE SPRINKLES . 23

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see divalproex sodium ... 23 DEPEN TITRATABS ......... 39 depo-estradiol ................... 42 DEPO-MEDROL

see methylpr ace inj 40mg/ml ......................... 43 see methylpr ace inj 80mg/ml ......................... 43

DEPO-MEDROL INJ 20MG/ML .......................... 42 DEPO-MEDROL INJ 40MG/ML .......................... 42 DEPO-MEDROL INJ 80MG/ML .......................... 42 DEPO-PROVERA CONTRACEPTIV .............. 39

see medroxyprogesterone acetate (contraceptive) .. 40

DEPO-PROVERA INJ 400/ML .............................. 14 DEPO-SUBQ PROVERA 104 .................................... 39 depo-testosterone ............. 35 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 36

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide body oil .......................... 61

DERMA-SMOOTHE/FS SCALP

see fluocinolone acetonide ...................................... 61

DERMATOP ...................... 60 see prednicarbate .......... 61

DERMOTIC see fluocinolone acetonide (otic) .............................. 63

desipramine hcl ................. 26 desloratadine .................... 56 desmopressin acetate ....... 45 DESMOPRESSIN ACETATE .......................................... 45 desmopressin acetate inj .. 45 desmopressin acetate spray .......................................... 45 desmopressin acetate spray

refrigerated ....................... 45 DESOGEN ........................ 39

see apri 28 day .............. 39 see cyred tab ................. 39 see emoquette .............. 39 see reclipsen 28 day ..... 41

desogestrel-ethinyl estradiol (biphasic) .......................... 39 DESONATE ...................... 60 desonide ........................... 60 DESONIDE ....................... 60 desowen ........................... 61 DESOWEN ....................... 60

see desonide ................. 60 desoximetasone ................ 61 DESOXIMETASONE ........ 61 DETROL ........................... 48

see tolterodine tartrate tab 1 mg .............................. 48 see tolterodine tartrate tab 2 mg .............................. 48

DETROL LA ...................... 48 dexamethasone ................ 42 dexamethasone sodium phosphate ......................... 42 dexamethasone sodium phosphate (ophth) ............. 55 DEXILANT ........................ 47 dexpak taperpak 13 day.... 43 dexrazoxane ..................... 15 dextrose ............................ 53 DEXTROSE ...................... 53 DEXTROSE 10% FLEX CONTAIN .......................... 53 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 53 DEXTROSE 10%/NACL 0.45%................................ 53 DEXTROSE 2.5%/NACL 0.45%................................ 53 DEXTROSE 5% ................ 53 DEXTROSE 5% /ELECTROLYTE ............... 53 DEXTROSE 5%/LACTATED RING ................................. 53 DEXTROSE 5%/NACL 0.2% .......................................... 53

DEXTROSE 5%/NACL 0.225% ............................. 53 DEXTROSE 5%/NACL 0.3%.......................................... 53 DEXTROSE 5%/NACL 0.33% ............................... 53 DEXTROSE 5%/NACL 0.45% ............................... 53 DEXTROSE 5%/NACL 0.9%.......................................... 53 DEXTROSE 5%/POTASSIUM CHL ...... 53 DIAMOX ........................... 21

see acetazolamide ........ 20 DIASTAT ACUDIAL .......... 23 DIASTAT PEDIATRIC ...... 23 diazepam .......................... 23 DIAZEPAM GEL (ANTICONVULSANT) ....... 23 DIBENZYLINE .................. 21 diclofenac gel 3%.............. 62 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 55 diclofenac sol 1.5% ........... 62 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 12 dicyclomine hcl ................. 45 didanosine .......................... 8 DIFFERIN ......................... 59

see adapalene............... 58 DIFICID ............................. 11 diflorasone diacetate ......... 61 DIFLUCAN .......................... 8

see fluconazole ............... 8 diflunisal .............................. 1 digitek ............................... 20 digoxin .............................. 20 digoxin inj .......................... 20 DIGOXIN SOL 50MCG/ML.......................................... 20 dihydroergotamine mesylate.......................................... 32 DIHYDROERGOTAMINE MESYLATE ...................... 32 dilantin .............................. 23 DILANTIN

see phenytoin sodium

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extended........................ 24 DILANTIN INFATABS

see phenytoin ................ 24 DILANTIN-125 .................. 23

see phenytoin ................ 24 DILATRATE SR ................ 21 DILAUDID

see hydromorphone hcl ...4 DILAUDID INJ .....................3 DILAUDID TAB ...................3 DILAUDID-5 ORAL LIQD ....3 DILAUDID-HP

see hydromorphone hcl ...4 DILAUDID-HP INJ ...............3 DILAUDID-HP INJ 250MG ..3 dilt-cd cap.......................... 19 diltiazem cap 120mg/24hr . 20 diltiazem cap er/12hr ......... 20 diltiazem hcl ...................... 20 diltiazem hcl coated beads cp24 120mg ...................... 20 diltiazem hcl coated beads cp24 180mg ...................... 20 diltiazem hcl coated beads cp24 240mg ...................... 20 diltiazem hcl coated beads cp24 300mg ...................... 20 diltiazem hcl coated beads cp24 360mg ...................... 20 diltiazem hcl er .................. 20 diltiazem hcl extended release beads ................... 20 diltiazem inj 100mg ........... 20 diltiazem inj 125/25ml ....... 20 diltiazem inj 25mg/5ml ...... 20 diltiazem inj 50/10ml ......... 20 dilt-xr cap .......................... 19 diltzac ................................ 20 DIOVAN ............................ 17

see valsartan ................. 17 DIOVAN HCT .................... 17

see valsartan-hydrochlorothiazide .................................. 17

DIPENTUM ....................... 46 diphenhydram inj 50mg/ml 56 diphenoxylate w/ atropine . 47 DIPHTHERIA/TETANUS

TOXOID ............................ 51 DIPROLENE ..................... 61

see betamethasone dipropionate augmented 60

DIPROLENE AF ............... 61 see betamethasone dipropionate augmented 60

disopyramide phosphate ... 17 disulfiram .......................... 35 DITROPAN XL .................. 48

see oxybutynin chloride . 48 DIURIL SUS 250/5ML ....... 21 divalproex sodium ............. 23 docetaxel inj 140mg/7ml ... 14 DOCETAXEL INJ 160MG/16ML .................... 14 DOCETAXEL INJ 200MG/20ML .................... 14 DOCETAXEL INJ 20MG/2ML ........................ 14 DOCETAXEL INJ 20MG/ML .......................................... 14 DOCETAXEL INJ 80MG/4ML ........................ 14 DOCETAXEL INJ 80MG/8ML ........................ 14 DOLOPHINE ....................... 3

see methadone hcl .......... 4 DOLOPHINE HCL

see methadone hcl .......... 4 donepezil odt 10mg .......... 25 donepezil odt 5mg ............ 25 donepezil tab hcl 23mg ..... 25 donepezil tabs 10mg ......... 25 donepezil tabs 5mg ........... 25 DORIBAX ............................ 7 DORYX ............................. 12 dorzolamide hcl ................. 55 dorzolamide hcl-timolol maleate ............................. 55 DOVONEX

see calcipotriene ........... 60 DOVONEX CRE 0.005% .. 60 doxazosin mesylate .......... 16 doxepin hcl ........................ 26 doxercalciferol ................... 54 DOXIL ............................... 13

see doxorubicin hcl

liposomal inj (for iv infusion) 2 mg/ml ........... 13

doxorubicin hcl .................. 13 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .... 13 doxorubicin inj 50mg ......... 13 doxy inj ............................. 12 doxycycline (monohydrate).......................................... 12 DOXYCYCLINE (ROSACEA) ...................... 62 doxycycline hyclate ........... 13 dronabinol ......................... 45 drospirenone-ethinyl estradiol ............................ 39 DROXIA ............................ 15 DUAC ............................... 59

see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 59 see neuac gel 1.2-5% ... 59

DUAVEE ........................... 42 DUETACT ......................... 36

see pioglitazone hcl-glimepiride ............... 38

DUEXIS .............................. 1 DULERA ........................... 58 duloxetine hcl .................... 26 DUONEB .......................... 56 DUOPA ............................. 27 DURAGESIC ...................... 4

see fentanyl patch ........... 4 DURAMORPH .................... 4 DUREZOL ........................ 55 DUTOPROL ...................... 19 DYAZIDE .......................... 21

see triamt/hctz cap 37.5-25 .......................... 21

DYMISTA SPR 137-50 ..... 56 DYRENIUM ...................... 21 E e.e.s. 400 mg tab .............. 11 E.E.S. GRANULES ........... 11 EC-NAPROSYN ................. 1

see naproxen .................. 1 econazole nitrate .............. 59 EDARBI ............................ 17 EDARBYCLOR ................. 17

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EDECRIN .......................... 21 EDURANT ...........................8 EFFEXOR XR ................... 26

see venlafaxine cap er .. 26 EFFIENT ........................... 50 EFUDEX ........................... 62

see fluorouracil (topical) 62 EGRIFTA .......................... 44 ELAPRASE ....................... 42 ELDEPRYL ....................... 27

see selegiline hcl ........... 27 ELECTROLYTE-R IN DEXTROSE ...................... 53 ELELYSO.......................... 42 ELESTAT .......................... 55

see epinastine hcl (ophth) ...................................... 55

ELIDEL ............................. 62 ELIGARD INJ 22.5MG ...... 14 ELIGARD INJ 30MG ......... 14 ELIGARD INJ 45MG ......... 14 ELIGARD INJ 7.5MG ........ 14 ELIMITE

see permethrin .............. 62 eliphos .............................. 44 ELIPHOS

see calcium acetate (phosphate binder) ........ 44

ELIQUIS TAB 2.5MG ........ 49 ELIQUIS TAB 5MG ........... 49 ELITEK ............................. 15 elixophyllin ........................ 58 ELLA ................................. 39 ELLENCE.......................... 13

see epirubicin inj 200mg 13 see epirubicin inj 50mg/25ml ..................... 13

ELMIRON.......................... 48 ELOCON ........................... 61

see mometasone furoate ...................................... 61

ELOXATIN ........................ 15 EMADINE.......................... 55 EMBEDA CAPS 100-4MG ..4 EMBEDA CAPS 20-0.8MG .4 EMBEDA CAPS 30-1.2MG .4 EMBEDA CAPS 50-2MG ....4 EMBEDA CAPS 60-2.4MG .4

EMBEDA CAPS 80-3.2MG . 4 EMCYT ............................. 13 EMEND CAP 125MG ........ 45 EMEND CAP 40MG .......... 45 EMEND CAP 80MG .......... 45 EMEND PAK 80 & 125 ..... 45 EMLA ................................ 62

see lidocaine-prilocaine . 62 emoquette ......................... 39 EMSAM ............................. 26 EMTRIVA ............................ 8 ENABLEX ......................... 48 enalapril maleate .............. 16 enalapril maleate & hydrochlorothiazide ........... 16 ENBREL ........................... 50 ENBREL SURECLICK ...... 50 endocet ............................... 4 ENDODAN TAB .................. 4 ENGERIX-B ...................... 51 enoxaparin sodium ........... 49 enpresse 28 day ............... 39 entacapone ....................... 27 entecavir ........................... 10 ENTOCORT EC ................ 46

see budesonide ............. 46 ENTYVIO .......................... 46 enulose ............................. 46 EPIDUO ............................ 59 EPIDUO FORTE ............... 59 epinastine hcl (ophth)........ 55 EPINEPHRINE ................. 57 EPIPEN 2-PAK ................. 57 EPIPEN-JR 2-PAK ............ 57 epirubicin inj 200mg .......... 13 EPIRUBICIN INJ 50MG .... 13 epirubicin inj 50mg/25ml ... 13 epitol ................................. 23 EPIVIR

see lamivudine ................ 9 EPIVIR HBV ...................... 10

see lamivudine (hbv) ..... 10 EPIVIR SOL 10MG/ML ....... 8 EPIVIR TABS ...................... 8 eplerenone ........................ 16 EPOGEN .......................... 49 eprosartan mesylate ......... 17 EPZICOM ........................... 9

EQUETRO ........................ 33 ERAXIS .............................. 8 ERBITUX .......................... 14 ergomar ............................ 32 ERIVEDGE ....................... 14 errin 28 day ....................... 39 ERTACZO ........................ 59 ery pad 2% ....................... 59 erygel ................................ 59 ERYGEL

see erythromycin (acne aid) ................................ 59

ERYPED 200 .................... 11 ERYPED 400 .................... 11 ery-tab .............................. 11 erythrocin lactobionate ...... 11 erythrocin stearate ............ 11 erythromycin (acne aid) .... 59 erythromycin (ophth) ......... 54 erythromycin base ............ 11 erythromycin cap 250mg ec.......................................... 11 erythromycin ethylsuccinate.......................................... 11 ESBRIET .......................... 57 escitalopram oxalate ......... 26 esomeprazole magnesium 47 esomeprazole sodium inj .. 47 estrace .............................. 42 ESTRACE

see estradiol .................. 42 estradiol ............................ 42 estradiol valerate .............. 42 ESTRADIOL VALERATE .. 42 ESTRING .......................... 42 ESTROSTEP FE .............. 40

see tri-legest 28 day ...... 41 ethambutol hcl .................... 9 ethosuximide .................... 23 ETHYOL

see amifostine crystalline ...................................... 15

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 15 etoposide .......................... 15 EURAX ............................. 62 EVISTA ............................. 44

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see raloxifene hcl .......... 44 EVOCLIN .......................... 59

see clindamycin phosphate (topical) ........ 58

EVOTAZ..............................9 EVOXAC ........................... 63

see cevimeline hcl ......... 63 EXALGO .............................4

see hydromorphone tab 12mg er ...........................4 see hydromorphone tab 16mg er ...........................4 see hydromorphone tab 8mg er .............................4

EXELDERM ...................... 59 EXELON ........................... 25

see rivastigmine tartrate 25 EXELON PATCHES ......... 25 exemestane ...................... 14 EXFORGE ........................ 17

see amlodipine besylate-valsartan tab 10-160 mg ..................... 16 see amlodipine besylate-valsartan tab 10-320 mg ..................... 16 see amlodipine besylate-valsartan tab 5-160 mg ....................... 16 see amlodipine besylate-valsartan tab 5-320 mg ....................... 16

EXFORGE HCT ................ 17 see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 17 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide

5-160-12.5mg ................ 16 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 16

EXJADE ............................ 39 EXTAVIA ........................... 34 EXTINA ............................. 59

see ketoconazole (topical) ...................................... 59 see ketodan aer 2% ...... 59

F FABIOR ............................ 59 FABRAZYME .................... 42 falmina 28 day .................. 40 famciclovir ......................... 10 famotidine ......................... 46 FAMVIR ............................ 10

see famciclovir .............. 10 FANAPT ............................ 28 FANAPT TITRATION PACK .......................................... 28 FARESTON ...................... 14 FARXIGA .................... 36, 37 FARYDAK ......................... 14 FASLODEX ....................... 14 FAZACLO ......................... 28 felbamate .......................... 23 FELBATOL ....................... 23

see felbamate ................ 23 FELDENE ........................... 1

see piroxicam .................. 1 felodipine .......................... 20 FEMARA ........................... 14

see letrozole .................. 14 FEMCON FE ..................... 40

see zenchent fe 28 day . 41 FEMRING ......................... 42 fenofibrate ......................... 18 FENOFIBRATE ................. 18 fenofibrate micronized....... 18 FENOFIBRIC ACID........... 18 FENOGLIDE ..................... 18 fenoprofen calcium ............. 1 fentanyl citrate .................... 4 fentanyl patch ..................... 4 FENTORA ........................... 4 FERRIPROX ..................... 39

FETZIMA .......................... 26 FETZIMA TITRATION PACK.......................................... 26 FIBRICOR ........................ 18 FINACEA .......................... 62 finasteride ......................... 48 FIRAZYR .......................... 50 FIRMAGON ...................... 14 FLAGYL .............................. 7

see metronidazole ........... 7 FLAREX ............................ 55 FLEBOGAMMA ................ 50 FLEBOGAMMA DIF .......... 50 flecainide acetate .............. 17 FLOMAX ........................... 48

see tamsulosin hcl ......... 48 FLO-PRED SUS ............... 43 FLOVENT DISKUS ........... 58 FLOVENT HFA ................. 58 fluconazole ......................... 8 fluconazole in dextrose ....... 8 fluconazole inj nacl 100 ...... 8 fluconazole inj nacl 200 ...... 8 fluconazole inj nacl 400 ...... 8 flucytosine ........................... 8 FLUDARA

see fludarabine phosphate ...................................... 13

fludarabine phosphate ...... 13 fludrocortisone acetate ..... 43 FLUMADINE ..................... 10

see rimantadine hydrochloride................. 10

flunisolide (nasal) .............. 57 fluocinolone acetonide ...... 61 fluocinolone acetonide (otic).......................................... 63 fluocinolone acetonide body oil ...................................... 61 fluocinonide ...................... 61 fluocinonide emulsified base.......................................... 61 FLUOROMETHOLONE (OPHTH) ........................... 55 fluorouracil ........................ 13 fluorouracil (topical) .......... 62 FLUOROURACIL (TOPICAL) ........................ 62

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fluoxetine cap 10mg .......... 26 fluoxetine cap 20mg .......... 26 fluoxetine cap 40mg .......... 26 fluoxetine cap 90mg dr ...... 26 fluoxetine sol 20mg/5ml .... 26 fluoxetine tab 10mg ........... 26 fluoxetine tab 20mg ........... 26 FLUOXETINE TAB 60MG . 26 fluphenazine decanoate .... 28 fluphenazine hcl ................ 28 flurbiprofen ..........................1 flurbiprofen sodium ........... 55 flutamide ........................... 14 fluticasone propionate ....... 61 fluticasone propionate (nasal) ............................... 57 fluvastatin sodium ............. 18 fluvoxamine maleate ......... 22 fluvoxamine maleate er ..... 22 FML ................................... 55 FML FORTE ...................... 55 FML LIQUIFILM ................ 55 fondaparinux sodium ......... 49 FORADIL AEROLIZER ..... 57 FORFIVO XL ..................... 26 FORTAMET ...................... 37

see metformin hcl .......... 38 FORTAZ............................ 11

see ceftazidime ............. 10 see tazicef ..................... 11 see tazicef vial ............... 11

FORTEO ........................... 44 FORTESTA ....................... 35 FORTICAL SPR 200/ACT . 44 FOSAMAX ........................ 39

see alendronate sodium 39 FOSAMAX PLUS D .......... 39 fosinopril sodium ............... 16 fosinopril sodium & hydrochlorothiazide ........... 16 FOSRENOL ...................... 44 FRAGMIN ......................... 49 FREAMINE HBC 6.9% ...... 53 FREAMINE III ................... 53 FROVA TAB 2.5MG .......... 32 FURADANTIN .....................7

see nitrofurantoin .............7 furosemide ........................ 21

furosemide inj ................... 21 furosemide oral soln 8 mg/ml .......................................... 21 FUZEON ............................. 8 FYCOMPA ........................ 23 G gabapentin ........................ 23 GABITRIL ......................... 23

see tiagabine hcl ........... 24 galantamine hydrobromide 25 GAMASTAN S/D ............... 50 GAMMAGARD LIQUID ..... 50 GAMMAGARD S/D ........... 50 GAMMAGARD S/D IGA LESS TH ........................... 50 GAMMAKED ..................... 50 GAMMAPLEX ................... 50 GAMUNEX-C .................... 50 GAMUNEX-C 1GM/10ML . 50 ganciclovir inj 500mg ........ 10 garamycin ......................... 54 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 54

GARDASIL ........................ 51 GARDASIL 9 ..................... 51 GASTROCROM ................ 47

see cromolyn sodium (mastocytosis) ............... 47

gatifloxacin (ophth) ........... 54 GATTEX ........................... 47 GAUZE PADS 2X2 ........... 36 gaviltye-g .......................... 46 gavilyte-c ........................... 46 gavilyte-h .......................... 46 gavilyte-n .......................... 46 GELNIQUE ....................... 48 GEMCITABINE ................. 13 gemcitabine hcl ................. 13 gemfibrozil ........................ 18 GEMZAR .......................... 13

see gemcitabine hcl....... 13 GENERESS FE ................ 40

see norethindrone & ethinyl estradiol-fe ......... 41

generlac ............................ 46 gengraf .............................. 51 GENOTROPIN .................. 43

GENOTROPIN MINIQUICK.......................................... 43 gentak ............................... 54 gentamicin in saline inj 0.8 mg/ml .................................. 6 gentamicin in saline inj 0.9 mg/ml .................................. 6 gentamicin in saline inj 1 mg/ml .................................. 6 gentamicin in saline inj 1.2 mg/ml .................................. 6 gentamicin in saline inj 1.4 mg/ml .................................. 6 gentamicin in saline inj 1.6 mg/ml .................................. 6 gentamicin in saline inj 2 mg/ml .................................. 6 gentamicin sulfate ............... 6 gentamicin sulfate (ophth) 54 gentamicin sulfate (topical).......................................... 59 GEODON .......................... 28

see ziprasidone hcl ....... 30 GEODON INJ ................... 28 GIANVI TAB 3-0.02MG ..... 40 GIAZO .............................. 46 gildagia ............................. 40 gildess 1.5/30 21 day ........ 40 gildess 24 fe 28 day .......... 40 GILENYA CAP 0.5MG ...... 34 GILOTRIF TAB 20MG ...... 15 GILOTRIF TAB 30MG ...... 15 GILOTRIF TAB 40MG ...... 15 GLASSIA .......................... 57 glatopa .............................. 34 GLEEVEC ......................... 15 GLEOSTINE ..................... 13 glimepiride ........................ 37 glipizide ............................. 37 glipizide er ........................ 37 glipizide-metformin 2.5-250 mg ..................................... 37 glipizide-metformin 2.5-500 mg ..................................... 37 glipizide-metformin 5-500mg.......................................... 37 GLUCAGEN HYPOKIT ..... 43 GLUCAGON EMERGENCY

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KIT .................................... 43 GLUCOPHAGE ................. 37

see metformin hcl .......... 38 GLUCOPHAGE XR ........... 37

see metformin er ........... 38 GLUCOTROL .................... 37

see glipizide ................... 37 GLUCOTROL XL .............. 37

see glipizide er .............. 37 GLUMETZA ...................... 37 glycate .............................. 45 glycopyrrolate .............. 45, 46 GLYSET ............................ 37 GLYXAMBI ........................ 37 GOLYTELY ....................... 46

see gaviltye-g ................ 46 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 47

GRALISE .......................... 33 GRALISE STARTER ......... 33 granisetron hcl .................. 45 GRANIX ............................ 49 GRASTEK ......................... 50 GRIFULVIN V

see griseofulvin microsize ........................................8

griseofulvin microsize ..........8 griseofulvin ultramicrosize ...8 GRIS-PEG ..........................8

see griseofulvin ultramicrosize ..................8

guanfacine hcl (adhd) ....... 31 H H.P. ACTHAR ................... 44 HALAVEN ......................... 15 HALDOL............................ 28

see haloperidol lactate .. 28 HALDOL DECANOATE 100 .......................................... 28

see haloperidol decanoate ...................................... 28

HALDOL DECANOATE 50 .......................................... 28

see haloperidol decanoate ...................................... 28

halobetasol propionate ...... 61 HALOG ............................. 61

haloperidol ........................ 28 haloperidol decanoate....... 28 haloperidol lactate ............. 28 HARVONI ......................... 10 HAVRIX ............................ 51 heather .............................. 40 HECTOROL ...................... 54

see doxercalciferol ........ 54 HEP SOD/NACL INJ 25000 .......................................... 49 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 49 heparin sod inj 10000u/ml . 49 heparin sod inj 1000u/ml ... 49 heparin sod inj 20000u/ml . 49 HEPARIN SOD INJ 2000U/ML ......................... 49 HEPARIN SOD INJ 2500U/ML ......................... 49 heparin sod inj 5000u/0.5ml .......................................... 49 heparin sod inj 5000u/ml ... 49 HEPARIN SODIUM/D5W .. 49 HEPARIN SODIUM/NACL 0.45%................................ 49 HEPATAMINE .................. 53 HEPSERA ......................... 10

see adefovir dipivoxil ..... 10 HERCEPTIN ..................... 14 HEXALEN ......................... 13 HIBERIX ........................... 51 HIPREX .............................. 7

see methenamine hippurate ......................... 7

HORIZANT ....................... 33 HUMALOG ........................ 36 HUMALOG KWIKPEN ...... 36 HUMALOG MIX 50/50 ...... 36 HUMALOG MIX 50/50 KWIKPEN ......................... 36 HUMALOG MIX 75/25 ...... 36 HUMALOG MIX 75/25 KWIKPEN ......................... 36 HUMATROPE ................... 43 HUMATROPE COMBO PACK ................................ 43 HUMIRA ............................ 50

HUMIRA PEN ................... 50 HUMIRA PEN-CROHNS STARTER KIT .................. 50 HUMIRA PEN-PSORIASIS STARTER KIT .................. 50 HUMULIN 70/30 ............... 36 HUMULIN 70/30 KWIKPEN.......................................... 36 HUMULIN N ...................... 36 HUMULIN N KWIKPEN .... 36 HUMULIN R ...................... 36 HUMULIN R U-500 (CONCENTRATE) ............ 36 HYCAMTIN ....................... 15

see topotecan hcl .......... 15 hycet ................................... 2 HYCET

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

hydralazine hcl .................. 21 HYDREA ........................... 15

see hydroxyurea ............ 15 hydrochlorothiazide ........... 21 hydrocodone-acetaminophen 10-300mg ........................... 2 hydrocodone-acetaminophen 2.5-325mg .......................... 2 hydrocodone-acetaminophen 5-300mg ............................. 2 hydrocodone-acetaminophen 5-325mg ............................. 2 hydrocodone-acetaminophen 7.5-300mg .......................... 2 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg .......................... 2 hydrocodone-acetaminophen tab 10-325mg ..................... 2 hydrocodone-ibuprofen 2.5-200 mg ......................... 2 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 2 hydrocortisone .................. 43 HYDROCORTISONE (INTRARECTAL) .............. 46 hydrocortisone (topical) .... 61

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hydrocortisone butyrate .... 61 hydrocortisone butyrate hydrophilic lipo base ......... 61 hydrocortisone valerate ..... 61 hydromorphone hcl .............4 HYDROMORPHONE HCL ..4 hydromorphone tab 12mg er ............................................4 hydromorphone tab 16mg er ............................................4 hydromorphone tab 8mg er .4 HYDROMORPHONE TABS 32MG ..................................4 hydroxychloroquine sulfate .......................................... 50 hydroxyurea ...................... 15 hydroxyzine hcl ................. 56 hydroxyzine hcl inj ............. 56 hydroxyzine pamoate ........ 56 HYSINGLA ER ....................4 HYZAAR ........................... 17

see losartan potassium & hydrochlorothiazide ....... 17

I ibandronate sodium .......... 39 IBRANCE .......................... 14 ibudone 5-200 mg ...............2 ibudone tab 10-200mg ........2 ibuprofen .............................1 ICLUSIG............................ 15 IDAMYCIN PFS ................ 13

see idarubicin hcl ........... 13 idarubicin hcl ..................... 13 IFEX .................................. 13

see ifosfamide for inj 1 gm ...................................... 13

IFEX INJ 3GM ................... 13 ifosfamide.......................... 13 IFOSFAMIDE

see ifosfamide ............... 13 ifosfamide for inj 1 gm ....... 13 IFOSFAMIDE FOR INJ 3 GM .................................... 13 ifosfamide inj 1gm/20ml .... 13 ILEVRO ............................. 55 ilotycin ............................... 54 IMBRUVICA CAP 140MG . 15 imdur ................................. 21

imipenem-cilastatin ............. 7 imipramine hcl ................... 26 imipramine pamoate ......... 26 imiquimod ......................... 62 IMITREX ........................... 32

see sumatriptan succinate ...................................... 33 see sumatriptan succinate inj................................... 33

IMITREX INJ 6MG/0.5 ...... 32 IMITREX STATDOSE REFILL .............................. 32 IMITREX STATDOSE SYSTEM ........................... 32

see sumatriptan succinate ...................................... 33 see sumatriptan succinate inj................................... 33

IMOVAX RABIES (H.D.C.V.) .......................................... 51 IMURAN ............................ 51

see azathioprine ............ 51 INCRELEX ........................ 44 INCRUSE ELLIPTA .......... 56 indapamide ....................... 21 INDERAL LA ..................... 19

see propranolol hcl er .... 19 INFANRIX ......................... 51 INFUMORPH 200 ............... 4 INFUMORPH 500 ............... 4 INLYTA ............................. 15 INSPRA ............................ 16

see eplerenone ............. 16 INSULIN PEN NEEDLES .. 36 INSULIN SAFETY NEEDLES ......................... 36 INSULIN SYRINGES ........ 36 INTELENCE ........................ 9 INTRALIPID INJ 20%........ 53 INTRALIPID INJ 30%........ 53 INTRON-A INJ 10MU........ 50 INTRON-A INJ 18MU........ 50 INTRON-A INJ 25MU........ 50 INTRON-A INJ 50MU........ 50 introvale 91 day ................ 40 INTUNIV ........................... 31

see guanfacine hcl (adhd) ...................................... 31

INVANZ .............................. 7 INVEGA ............................ 28 INVEGA SUST INJ 117 MG/0.75 ML ...................... 28 INVEGA SUST INJ 156MG/ML ........................ 28 INVEGA SUST INJ 234 MG/1.5 ML ........................ 28 INVEGA SUST INJ 39 MG/0.25 ML ...................... 28 INVEGA SUST INJ 78 MG/0.5 ML ........................ 28 INVEGA TRINZA .............. 28 INVIRASE ........................... 9 INVOKAMET TAB 150-1000.......................................... 37 INVOKAMET TAB 150-500.......................................... 37 INVOKAMET TAB 50-1000.......................................... 37 INVOKAMET TAB 50-500MG ......................... 37 INVOKANA TAB 100MG .. 37 INVOKANA TAB 300MG .. 37 IONOSOL-B/DEXTROSE 5% .................................... 53 IONOSOL-MB/DEXTROSE 5% .................................... 53 IPOL INACTIVATED IPV .. 51 ipratropium bromide (nasal).......................................... 56 ipratropium sol inhal .......... 56 ipratropium-albuterol ......... 56 irbesartan .......................... 17 irbesartan-hydrochlorothiazide........................................ 17 IRESSA ............................ 15 irinotecan .......................... 15 irinotecan hcl .................... 15 ISENTRESS ....................... 9 ISOLYTE P ....................... 53 isolyte s ............................. 53 isoniazid .............................. 9 isoniazid tabs ...................... 9 ISOPTO CARPINE ........... 55 ISORDIL TITRADOSE ...... 21

see isosorbide dinitrate . 21 isosorbide dinitrate ............ 21

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isosorbide mononitrate ...... 21 isosorbide mononitrate er . 21 isradipine........................... 20 ISTALOL ........................... 55 ISTODAX .......................... 14 itraconazole .........................8 ivermectin............................7 IXEMPRA KIT ................... 15 IXIARO .............................. 51 J JADENU............................ 39 JAKAFI .............................. 15 JALYN ............................... 48 jantoven ............................ 49 JANUMET ......................... 37 JANUMET XR TAB 100-1000 ........................... 37 JANUMET XR TAB 50-1000 .......................................... 37 JANUMET XR TAB 50-500MG ......................... 37 JANUVIA ........................... 37 JARDIANCE ...................... 37 JENTADUETO .................. 37 JOLESSA TAB 0.15-0.03 MG .................................... 40 JOLIVETTE ....................... 40 junel 1.5/30 21 day ............ 40 junel 1/20 21 day ............... 40 junel fe 1.5/30 28 day ........ 40 junel fe 1/20 28 day ........... 40 junel fe 24 1/20 28 day ...... 40 K KADCYLA ......................... 14 KADIAN...............................4

see morphine sulfate .......5 KALETRA SOL ...................9 KALETRA TAB 100-25MG ..9 KALETRA TAB 200-50MG ..9 kariva 28 day ..................... 40 KAYEXALATE ................... 39

see kionex ..................... 39 KAZANO ........................... 37 KCL 0.075%/D5W/NACL 0.45% ................................ 53 KCL 0.15%/D5W/LR ......... 53 KCL 0.15%/D5W/NACL 0.9% .................................. 53

kcl 0.3%/d5w/lr iv lac ri ...... 53 KCL 0.3%/D5W/NACL 0.45%................................ 53 KCL 0.3%/D5W/NACL 0.9% .......................................... 53 KCL IN NACL INJ .15-0.45 .......................................... 53 KCL/D5W/NACL INJ .15/.33% ............................ 53 KCL/D5W/NACL INJ .15/.45% ............................ 53 KCL0.15%/D5W/NACL0.2% .......................................... 53 KCL0.15%/D5W/NACL0.225% ...................................... 53 KEFLEX ............................ 11

see cephalexin .............. 11 kelnor 1/35 28 day ............ 40 KENALOG ........................ 61

see triamcinolone acetonide (topical) ......... 61

KEPIVANCE ..................... 15 KEPPRA ........................... 23

see levetiracetam .......... 24 see levetiracetam inj 500/5ml ......................... 24

KEPPRA XR ..................... 23 see levetiracetam .......... 24

KERLONE see betaxolol hcl ........... 19

ketoconazole ....................... 8 ketoconazole (topical) ....... 59 ketoconazole shampoo ..... 60 ketodan aer 2% ................. 59 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 55 kimidess 28 day ................ 40 KINERET .......................... 50 KINRIX .............................. 51 kionex ............................... 39 KLARON ........................... 59

see sulfacetamide sodium (acne) ............................ 59

KLONOPIN ................. 23, 24 see clonazepam ...... 22, 23

KLOR-CON 10 .................. 52 KLOR-CON 8 .................... 52

klor-con m15 ..................... 52 klor-con m20 ..................... 52 klor-con pow 20meq ......... 52 klor-con spr cap ................ 52 KOMBIGLYZE XR 2.5-1000MG ...................... 38 KOMBIGLYZE XR 5-1000MG ......................... 38 KOMBIGLYZE XR 5-500MG.......................................... 38 kristalose .......................... 46 K-TAB ............................... 52 KUVAN ............................. 42 L labetalol hcl ....................... 19 LAC-HYDRIN .................... 62

see ammonium lactate .. 62 see laclotion lot 12% ..... 62

laclotion lot 12%................ 62 LACRISERT ..................... 56 LACTATED RINGERS VIAFLEX ........................... 53 lactulose ........................... 46 lactulose (encephalopathy).......................................... 46 LAMICTAL ........................ 24

see lamotrigine .............. 24 LAMICTAL CHEWABLE DISPERS .......................... 24

see lamotrigine .............. 24 LAMICTAL ODT................ 24

see lamotrigine .............. 24 LAMICTAL STARTER ...... 24 LAMICTAL XR .................. 24

see lamotrigine .............. 24 LAMISIL .............................. 8

see terbinafine hcl ........... 8 lamivudine .......................... 9 lamivudine (hbv) ............... 10 lamivudine-zidovudine ........ 9 lamotrigine ........................ 24 LANOXIN

see digitek ..................... 20 see digoxin .................... 20 see digoxin inj ............... 20

LANOXIN INJ 0.25MG/ML 20 LANOXIN PEDIATRIC ...... 20 LANOXIN TAB .................. 20

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lansoprazole ...................... 47 LANTUS ............................ 36 LANTUS SOLOSTAR ....... 36 larin 1.5/30 ........................ 40 larin 1/20 ........................... 40 larin fe 1.5/30 .................... 40 larin fe 1/20 ....................... 40 LASIX ................................ 21

see furosemide .............. 21 LASTACAFT ..................... 55 latanoprost ........................ 55 LATUDA ............................ 28 LAYOLIS FE CHW ............ 40 LAZANDA ...........................4 LEENA TAB ...................... 40 leflunomide ........................ 50 LEMTRADA ...................... 34 LENVIMA 10MG DAILY DOSE ................................ 15 LENVIMA 14MG DAILY DOSE ................................ 15 LENVIMA 20MG DAILY DOSE ................................ 15 LENVIMA 24MG DAILY DOSE ................................ 15 LESCOL ............................ 18

see fluvastatin sodium ... 18 LESCOL XL ...................... 18 lessina 28 day ................... 40 LETAIRIS .......................... 22 letrozole ............................ 14 leucovor ca inj ................... 15 leucovorin calcium ............ 15 leucovorin calcium 500 mg 15 LEUKERAN ....................... 13 LEUKINE........................... 49 leuprolide acetate .............. 14 levalbuterol conc 1.25mg/0.5ml .................... 57 levalbuterol hcl .................. 57 LEVALBUTEROL HCL ...... 57 LEVAQUIN ........................ 11

see levofloxacin ............. 12 LEVEMIR .......................... 36 LEVEMIR FLEXTOUCH.... 36 levetiracetam ..................... 24 LEVETIRACETAM IN NACL .......................................... 24

levetiracetam inj 500/5ml .. 24 levobunolol hcl .................. 55 LEVOBUNOLOL HCL ....... 55 levocarnitine (metabolic modifiers) .......................... 42 levocetirizine soln 2.5mg/5ml .......................................... 56 levocetirizine tab 5 mg ...... 56 levofloxacin ................. 11, 12 levofloxacin (ophth) ........... 54 levofloxacin in d5w ............ 12 levonest 28 day ................. 40 levonorgestrel & eth estradiol .......................................... 40 levonorgestrel (emergency oc) ..................................... 40 levonorgestrel-ethinyl estradiol (91-day) .............. 40 levonorgestrel-ethinyl estradiol (continuous)........ 40 levora 0.15/30 28 day ....... 40 levorphanol tartrate ............. 4 levothyroxine sodium ........ 44 LEVOXYL ......................... 44 LEXAPRO ......................... 26

see escitalopram oxalate ...................................... 26

LEXIVA ............................... 9 LIALDA ............................. 46 lidocaine ............................ 62 lidocaine hcl ...................... 62 lidocaine hcl (local anesth.) . 6 lidocaine hcl (mouth-throat) .......................................... 63 lidocaine inj 0.5% ................ 6 lidocaine inj 1% ................... 6 lidocaine inj 1.5% ................ 6 lidocaine inj 2% ................... 6 lidocaine-prilocaine ........... 62 LIDODERM ....................... 62

see lidocaine ................. 62 linezolid ............................... 7 LINEZOLID ......................... 7 LINZESS ........................... 47 liothyronine sodium ........... 44 LIPITOR ............................ 18

see atorvastatin calcium 18 LIPOFEN .......................... 18

LIPOSYN II ....................... 53 LIPOSYN III ...................... 53 LIPOSYN III INJ 10% ........ 53 LIPTRUZET ...................... 18 lisinopril ............................. 16 lisinopril & hydrochlorothiazide ........... 16 LITHIUM ........................... 33 lithium carbonate .............. 33 LITHOBID ......................... 33

see lithium carbonate .... 33 LIVALO ............................. 18 LO LOESTRIN FE ............ 40 LOCOID ............................ 61

see hydrocortisone butyrate ......................... 61

LOCOID LIPOCREAM ...... 61 see hydrocortisone butyrate hydrophilic lipo base .............................. 61

LODOSYN ........................ 27 see carbidopa................ 27

loestrin 1.5/30 21 day ....... 40 LOESTRIN 1.5/30-21

see gildess 1.5/30 21 day ...................................... 40 see junel 1.5/30 21 day . 40 see larin 1.5/30.............. 40 see microgestin 1.5/30 21 day ................................ 40

loestrin 1/20 21 day .......... 40 LOESTRIN 1/20-21

see junel 1/20 21 day .... 40 see larin 1/20................. 40 see microgestin 1/20 21 day ................................ 40

LOESTRIN FE 1.5/30 see junel fe 1.5/30 28 day ...................................... 40 see larin fe 1.5/30 .......... 40 see microgestin fe 1.5/30 28 day ........................... 40

loestrin fe 1.5/30 28 day ... 40 LOESTRIN FE 1/20

see junel fe 1/20 28 day 40 see larin fe 1/20............. 40 see microgestin fe 1/20 28 day ................................ 40

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see tarina fe tab 1/20 ..... 41 loestrin fe 1/20 28 day ....... 40 lofibra ................................ 18 LOFIBRA

see fenofibrate ............... 18 see fenofibrate micronized ...................................... 18

LOKARA LOTN 0.05% ...... 61 lomedia 24 fe .................... 40 LOMOTIL .......................... 47

see diphenoxylate w/ atropine ......................... 47

LOMUSTINE ..................... 13 loperamide hcl ................... 47 LOPID ............................... 18

see gemfibrozil .............. 18 LOPRESSOR .................... 19

see metoprolol tartrate .. 19 LOPRESSOR HCT ........... 19

see metoprolol & hctz tab 100-25mg ...................... 19 see metoprolol & hctz tab 50-25mg ........................ 19

LOPROX SHAMPOO ........ 59 see ciclopirox shampoo 1% ................................. 59

lorazepam ......................... 22 lorcet hd tab 10-325mg .......2 lorcet plus tab 7.5-325 ........2 lorcet tab 5-325mg ..............2 lortab elix.............................2 lortab tab 10-325mg ............2 lortab tab 5-325mg ..............2 lortab tab 7.5-325 ................2 loryna 28 day .................... 40 losartan potassium ............ 17 losartan potassium & hydrochlorothiazide ........... 17 LOSEASONIQUE ............. 40 LOTEMAX ......................... 55 LOTENSIN ........................ 16

see benazepril hcl ......... 16 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 16

LOTREL ............................ 16 see amlodipine besylate-benazepril hcl .. 15

LOTRONEX ...................... 47 see alosetron hcl ........... 47

lovastatin ........................... 18 LOVAZA

see omega-3-acid ethyl esters ............................ 18

LOVAZA CAP 1GM .......... 18 LOVENOX ........................ 49

see enoxaparin sodium . 49 low-ogestrel 28 day ........... 40 loxapine succinate ............ 28 lufyllin ................................ 58 LUMIGAN ......................... 55 LUMIZYME ....................... 42 LUPANETA PACK ............ 42 LUPR DEP-PED INJ 15MG .......................................... 14 LUPR DEP-PED INJ 30MG (3-MONTH) ....................... 14 LUPRON DEP INJ 11.25MG .......................................... 14 LUPRON DEPOT ............. 14 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 14 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 14 LUPRON DEPOT-PED ..... 14 lutera 28 day ..................... 40 LUXIQ

see betamethasone valerate ......................... 60

LUZU ................................ 59 LYNPARZA ....................... 14 LYRICA ............................. 24 LYSODREN ...................... 14 LYSTEDA ......................... 50

see tranexamic acid ...... 50 lyza ................................... 40 M MACROBID ........................ 7

see nitrofurantoin monohyd macro .............. 7

MACRODANTIN ................. 7 see nitrofurantoin macrocrystal .................... 7

magnesium sulfate ............ 52 MAGNESIUM SULFATE ... 52 MAGNESIUM SULFATE IN

D5W .................................. 52 MAGNESIUM SULFATE INJ 50% .................................. 52 MALARONE ....................... 8

see atovaquone-proguanil hcl tab 250-100 mg ......... 8

malathion .......................... 62 maprotiline hcl .................. 26 MARINOL ......................... 45

see dronabinol............... 45 marlissa 28 day................. 40 MARPLAN ........................ 26 MATULANE ...................... 15 matzim la .......................... 20 MAVIK .............................. 16

see trandolapril.............. 16 MAXALT ........................... 33

see rizatriptan benzoate 33 MAXALT-MLT ................... 33

see rizatriptan benzoate 33 MAXIDEX ......................... 55 MAXIPIME ........................ 11

see cefepime inj 1gm .... 10 see cefepime inj 2gm .... 10

MAXITROL ....................... 54 see neomycin-polymy-dexameth .................................... 54

MAXZIDE .......................... 21 see triamt/hctz tab 75-50mg ........................ 21

MAXZIDE-25 .................... 21 see triamt/hctz tab 37.5-25 ...................................... 21

meclizine hcl ..................... 45 MEDROL

see methylpred tab 16mg ...................................... 43 see methylpred tab 32mg ...................................... 43 see methylpred tab 4mg 43 see methylpred tab 8mg 43

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 43

MEDROL PAK 4MG ......... 43 MEDROL TAB 16MG ........ 43 MEDROL TAB 2MG .......... 43

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MEDROL TAB 32MG ........ 43 MEDROL TAB 4MG .......... 43 MEDROL TAB 8MG .......... 43 medroxyprogesterone acetate .............................. 44 medroxyprogesterone acetate (contraceptive) ..... 40 mefenamic acid ...................1 mefloquine hcl .....................8 MEGACE ES ..................... 14 MEGACE ORAL ................ 14

see megestrol acetate sus 40mg/ml ......................... 14

megestrol acetate ............. 14 megestrol acetate sus 40mg/ml ............................ 14 MEGESTROL ACETATE SUS 625MG/5ML .............. 14 MEKINIST ......................... 15 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 13 memantine hcl ................... 25 MEMANTINE HCL ............ 25 MENACTRA ...................... 51 MENOMUNE-A/C/Y/W-135 .......................................... 51 MENOSTAR ...................... 42 MENTAX ........................... 59 MENVEO .......................... 51 MEPRON ............................7

see atovaquone ...............7 mercaptopurine ................. 13 meropenem .........................7 MERREM ............................7

see meropenem ..............7 mesalamine enema ........... 46 mesna ............................... 15 MESNEX ........................... 15

see mesna ..................... 15 MESTINON ....................... 33

see pyridostigmine bromide ......................... 34

MESTINON SYRUP .......... 33 MESTINON TIMESPAN .... 34

see pyridostigmine bromide ......................... 34

METADATE CD ................ 31

see methylphenidate hcl 31 metadate er 20 mg ............ 31 metformin er ...................... 38 metformin hcl .................... 38 methadone hcl .................... 4 METHADONE INJ 10MG/ML ............................................ 4 METHADOSE ..................... 4

see methadone hcl .......... 4 methazolamide ................. 21 methenamine hippurate ...... 7 METHERGINE

see methylergonovine maleate ......................... 44

methimazole ..................... 44 methotrexate sodium inj .... 13 methotrexate sodium tabs . 50 methoxsalen rapid ............ 60 methscopolamine bromide 46 methyclothiazide ............... 21 methylergonovine maleate 44 METHYLIN ........................ 31

see methylphenidate hcl 31 METHYLIN CHEW TAB .... 31 methylphenidate hcl .......... 31 methylphenidate hcl er ...... 31 methylphenidate hcl er tabs 10mg ................................. 31 methylphenidate hcl er tabs 18mg ................................. 31 methylphenidate hcl er tabs 20mg ................................. 31 methylpr ace inj 40mg/ml .. 43 methylpr ace inj 80mg/ml .. 43 methylpr ss inj 125mg ....... 43 methylpr ss inj 1gm ........... 43 methylpr ss inj 40mg ......... 43 methylpred pak 4mg ......... 43 methylpred tab 16mg ........ 43 methylpred tab 32mg ........ 43 methylpred tab 4mg .......... 43 methylpred tab 8mg .......... 43 metipranolol ...................... 55 metoclopramide hcl ........... 45 metoclopramide hcl inj 5 mg/ml ................................ 45 metolazone ....................... 21 metoprolol & hctz tab

100-25mg ......................... 19 metoprolol & hctz tab 100-50mg ......................... 19 metoprolol & hctz tab 50-25mg ........................... 19 metoprolol succinate ......... 19 metoprolol tartrate............. 19 METOZOLV ODT ............. 45

see metoclopramide hcl 45 METRO IV .......................... 7 METROCREAM ................ 62

see metronidazole (topical) ......................... 62 see rosadan cre 0.75% . 62

METROGEL ..................... 62 see metronidazole (topical) ......................... 62

METROGEL-VAGINAL ..... 49 see metronidazole vaginal ...................................... 49

METROLOTION ............... 62 see metronidazole (topical) ......................... 62

metronidazole ..................... 7 metronidazole (topical) ..... 62 metronidazole inj................. 7 metronidazole vaginal ....... 49 MEVACOR

see lovastatin ................ 18 mexiletine hcl .................... 17 MIACALCIN

see calcitonin (salmon) nasal spray .................... 44

MIACALCIN INJ 200U/ML 44 MIACALCIN SPR 200/ACT.......................................... 44 MICARDIS ........................ 17 MICARDIS HCT ................ 17

see telmisartan-hydrochlorothiazide ............................. 17

miconazole nitrate vaginal 49 microgestin 1.5/30 21 day . 40 microgestin 1/20 21 day .... 40 microgestin fe 1.5/30 28 day.......................................... 40 microgestin fe 1/20 28 day 40 MICRO-K .......................... 52

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see klor-con spr cap ...... 52 see potassium chloride caps er........................... 52

MICROZIDE ...................... 21 see hydrochlorothiazide 21

midodrine hcl ..................... 21 migergot ............................ 33 MIGRANAL ....................... 33 millipred............................. 43 MINASTRIN 24 FE ............ 40 MINIPRESS ...................... 16

see prazosin hcl ............ 16 minitran ............................. 21 MINIVELLE ....................... 42 MINOCIN .......................... 13

see minocycline hcl ....... 13 minocycline hcl .................. 13 minoxidil ............................ 21 MIRAPEX .......................... 27

see pramipexole dihydrochloride .............. 27

MIRAPEX ER .................... 27 see pramipexole dihydrochloride er tabs .. 27

MIRCERA ......................... 49 mircette ............................. 40 MIRCETTE

see desogestrel-ethinyl estradiol (biphasic) ........ 39 see kariva 28 day .......... 40 see kimidess 28 day ...... 40 see pimtrea pack ........... 41 see viorele ..................... 41

mirtazapine ....................... 26 mirtazapine odt ................. 26 misoprostol ........................ 47 mitomycin .......................... 13 mitoxantrone hcl ................ 15 M-M-R II ............................ 51 MOBIC ................................1

see meloxicam tabs .........1 modafinil............................ 35 moderiba pak .................... 10 moderiba tab 200mg ......... 10 MODICON ......................... 40 moexipril hcl ...................... 16 moexipril-hydrochlorothiazide ........................................ 16

mometasone furoate ......... 61 MONODOX

see doxycycline (monohydrate) ............... 12

MONONESSA .................. 40 montelukast sodium .......... 57 MORPHINE SUL 20MG/ML ORAL SOL .......................... 5 morphine sulfate ................. 5 MORPHINE SULFATE ....... 5 morphine sulfate beads....... 5 morphine sulfate ext-rel tab 5 MOVANTIK ....................... 47 MOVIPREP ....................... 46 MOXEZA ........................... 54 moxifloxacin hcl ................ 12 MOXIFLOXACIN HCL....... 12 MOZOBIL .......................... 49 MS CONTIN ........................ 5

see morphine sulfate ext-rel tab ........................ 5

MULTAQ ........................... 17 mupirocin .......................... 59 mupirocin calcium (topical) 59 MUSTARGEN ................... 13 my way .............................. 40 MYAMBUTOL ..................... 9

see ethambutol hcl .......... 9 MYCAMINE ........................ 8 MYCOBUTIN ...................... 9

see rifabutin ..................... 9 mycophenolate mofetil ...... 51 mycophenolate sodium ..... 51 MYFORTIC ....................... 51

see mycophenolate sodium ........................... 51

myorisan ........................... 59 MYOZYME ........................ 42 MYRBETRIQ .................... 48 MYSOLINE ....................... 24

see primidone ................ 24 myzilra .............................. 40 N nabumetone ........................ 1 nadolol .............................. 19 nadolol & bendroflumethiazide ......... 19 nafcillin sodium ................. 12

NAFTIFINE HCL ............... 59 NAFTIN ............................. 59 NAGLAZYME ................... 42 NALLPEN ISO-OSMOTIC IN DE ..................................... 12 NALLPEN/DEXTROSE ..... 12 naloxone hcl ..................... 35 naltrexone hcl ................... 35 NAMENDA

see memantine hcl ........ 25 NAMENDA SOL 10MG/5ML.......................................... 25 NAMENDA TAB ................ 25 NAMENDA XR .................. 25 NAMENDA XR TITRATION PACK ................................ 25 NAMZARIC ....................... 25 naphazoline 0.1% ............. 56 NAPRELAN ........................ 1 NAPROSYN ....................... 1

see naproxen .................. 1 naproxen ............................. 1 NAPROXEN SOD TAB 375MG CR .......................... 1 NAPROXEN SOD TAB 500MG CR .......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 33 NARDIL ............................ 26

see phenelzine sulfate .. 26 NASONEX ........................ 57 NATACYN ........................ 54 nateglinide ........................ 38 NATPARA ......................... 44 NAVELBINE

see vinorelbine tartrate .. 14 NEBUPENT ........................ 7 necon 0.5/35 28 day ......... 41 necon 1/35 28 day ............ 41 necon 10/11 28 day .......... 41 NECON 7/7/7 .................... 41 NECON TAB 1/50-28 ........ 41 nefazodone hcl ................. 26 neomycin sulfate ................. 6 neomycin/polymyxin b gu . 62 neomycin-bacitracin zn-polymyxin ..................... 54 neomycin-polymy-dexameth

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.......................................... 54 neomycin-polymyxin-gramicidin ..................................... 54 neomycin-polymyxin-hc (ophth) .............................. 54 neomycin-polymyxin-hc (otic) .......................................... 63 NEORAL ........................... 51

see cyclosporine modified (for microemulsion) ........ 51 see gengraf ................... 51

NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 54

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 62

neosporin solution ............. 54 NEPHRAMINE .................. 53 neptazane ......................... 21 NEPTAZANE

see methazolamide ....... 21 NESINA............................. 38 neuac gel 1.2-5% .............. 59 NEULASTA ....................... 49 NEUMEGA ........................ 49 NEUPOGEN ..................... 49 NEUPRO........................... 27 NEURONTIN ..................... 24

see gabapentin .............. 23 NEVANAC ......................... 55 nevirapine ...........................9 NEVIRAPINE ......................9 NEXAVAR ......................... 15 NEXIUM

see esomeprazole magnesium .................... 47

NEXIUM CAP 20MG ......... 47 NEXIUM CAP 40MG ......... 47 NEXIUM GRA 10MG DR .. 47 NEXIUM GRA 2.5MG DR . 47 NEXIUM GRA 20MG DR .. 48 NEXIUM GRA 40MG DR .. 48 NEXIUM GRA 5MG DR .... 47 NEXIUM I.V. ...................... 48

see esomeprazole sodium inj ................................... 47

next choice tab 1.5mg ....... 41 niacin (antihyperlipidemic) 18 niacor ................................ 18 NIASPAN .......................... 18

see niacin (antihyperlipidemic) ....... 18

nicardipine hcl ................... 20 NICOTROL INHALER ....... 35 NICOTROL NS ................. 35 nifedical ............................. 20 nifedipine .......................... 20 nifedipine er ...................... 20 nikki 28 day ....................... 41 NILANDRON ..................... 14 nimodipine ........................ 20 NIPENT ............................. 13 nisoldipine ......................... 20 nitro-bid ............................. 21 NITRO-DUR ...................... 21

see minitran ................... 21 nitrofurantoin ....................... 7 nitrofurantoin macrocrystal .. 7 nitrofurantoin monohyd macro .................................. 7 NITROGLYCERIN ............ 21 NITROGLYCERIN LINGUAL .......................................... 22 nitroglycerin patches ......... 22 NITROLINGUAL SPR PUMPSPRA ...................... 22 NITROMIST ...................... 22 NITROSTAT ..................... 22 nizatidine ........................... 46 NIZORAL .......................... 60

see ketoconazole shampoo ....................... 60

NORA-BE TAB ................. 41 norco ................................... 3 NORCO

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

see lorcet hd tab 10-325mg ........................ 2 see lorcet plus tab 7.5-325 ........................................ 2 see lorcet tab 5-325mg ... 2 see lortab tab 10-325mg . 2 see lortab tab 5-325mg ... 2 see lortab tab 7.5-325 ..... 2

NORDITROPIN FLEXPRO.......................................... 43 NORDITROPIN NORDIFLEX PEN ............. 43 norethin acet & estrad-fe .. 41 norethindrone & ethinyl estradiol-fe ........................ 41 norethindrone (contraceptive) .................. 41 norethindrone acetate ....... 44 norgestimate-ethinyl estradiol (triphasic) ........... 41 NORINYL 1+35 ................. 41

see cyclafem 1/35 28 day ...................................... 39 see necon 1/35 28 day .. 41 see nortrel 1/35 21 day . 41 see nortrel 1/35 28 day . 41 see pirmella 1/35 28 day ...................................... 41

NORINYL 1+50 ................. 41 NORITATE ....................... 62 norlyroc 28 day ................. 41 normosol-m ....................... 53 NORMOSOL-R ................. 53 NORPACE ........................ 17

see disopyramide phosphate ..................... 17

NORPACE CR .................. 17 NORPRAMIN .................... 26

see desipramine hcl ...... 26 NOR-QD ........................... 41

see camila 28 day ......... 39 see deblitane 28 day ..... 39 see heather ................... 40 see norethindrone (contraceptive) .............. 41 see norlyroc 28 day ....... 41

nortrel 0.5/35 28 day ......... 41 nortrel 1/35 21 day ............ 41

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nortrel 1/35 28 day ............ 41 nortrel 7/7/7 28 day ........... 41 nortriptyline hcl .................. 26 NORVASC ........................ 20

see amlodipine besylate 19 NORVIR ..............................9 NOVAREL INJ 10000UNT 44 NOVOLIN 70/30 ................ 36 NOVOLIN 70/30 RELION.. 36 NOVOLIN N ...................... 36 NOVOLIN N RELION ........ 36 NOVOLIN R ...................... 36 NOVOLIN R RELION ........ 36 NOVOLOG ........................ 36 NOVOLOG FLEXPEN ...... 36 NOVOLOG MIX 70/30 ...... 36 NOVOLOG MIX 70/30 PREFILL ........................... 36 NOVOLOG PENFILL ........ 36 NOXAFIL.............................8 NUCYNTA ...........................5 NUCYNTA ER .....................5 NUEDEXTA ...................... 34 NULOJIX ........................... 51 NULYTELY/FLAVOR PACKS .............................. 46

see gavilyte-n ................ 46 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 47 see trilyte ....................... 47

NUTRILIPID EMU 20% ..... 53 NUTROPIN AQ INJ 20MG/2ML ........................ 43 NUTROPIN AQ NUSPIN 5 43 NUTROPIN AQ PEN ......... 43 NUVARING ....................... 41 NUVESSA ......................... 49 NUVIGIL............................ 35 nyamyc ............................. 59 NYMALIZE ........................ 20 nystatin ...............................8 nystatin (mouth-throat) ...... 63 nystatin (topical) ................ 59 nystatin pow 100000 ......... 59 nystop ............................... 59

O OCELLA TAB 3-0.03MG ... 41 OCTAGAM ........................ 50 octreotide acetate ............. 44 OCUFEN ........................... 55

see flurbiprofen sodium . 55 OCUFLOX ........................ 54

see ofloxacin (ophth) ..... 54 OFEV ................................ 57 ofloxacin (ophth) ............... 54 ofloxacin (otic) ................... 63 ogestrel 28 day ................. 41 olanzapine ........................ 28 olanzapine odt ............ 28, 29 olopatadine hcl (nasal) ...... 56 OLUX ................................ 61

see clobetasol propionate ...................................... 60

OLUX-E see clobetasol propionate emulsion ........................ 60

OLYSIO ............................ 10 OMECLAMOX-PAK .......... 47 omega-3-acid ethyl esters . 18 omeprazole ....................... 48 OMEPRAZOLE-SODIUM BICARBONATE ................ 48 OMNARIS ......................... 57 OMNIPRED ...................... 55 OMNITROPE 10MG ......... 43 OMNITROPE 5.8MG ........ 43 OMNITROPE 5MG ........... 43 ondansetron hcl ................ 45 ondansetron hcl inj ............ 45 ondansetron hcl oral soln .. 45 ondansetron odt ................ 45 ONEXTON ........................ 59 ONFI SUS 2.5MG/ML ....... 24 ONFI TAB 10MG .............. 24 ONGLYZA ......................... 38 ONMEL ............................... 8 OPANA ............................... 5

see oxymorphone hcl ...... 6 OPANA ER (CRUSH RESISTANT ........................ 5 OPSUMIT ......................... 22 OPTIPRANOLOL .............. 55 ORACEA ........................... 62

ORAP ............................... 29 ORAPRED ODT

see prednisolone sodium phosphate ..................... 43

ORAPRED ODT TAB 10MG.......................................... 43 ORAPRED ODT TAB 15MG.......................................... 43 ORAPRED ODT TAB 30MG.......................................... 43 ORENCIA ......................... 50 ORENITRAM TAB 0.125MG.......................................... 22 ORENITRAM TAB 0.25MG.......................................... 22 ORENITRAM TAB 1MG ... 22 ORENITRAM TAB 2.5MG 22 ORFADIN ......................... 42 ORKAMBI ......................... 57 orsythia 28 day ................. 41 ORTHO MICRONOR ........ 41

see errin 28 day ............ 39 see lyza ......................... 40 see sharobel 28 day ...... 41

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 41 see tri-previfem 28 day .. 41 see tri-sprintec 28 day ... 41

ORTHO TRI-CYCLEN LO 41 ORTHO-CEPT .................. 41 ORTHO-CYCLEN ............. 41

see previfem 28 day ...... 41 see sprintec 28 day ....... 41

ORTHO-NOVUM 1/35 ...... 41 ORTHO-NOVUM 7/7/7 ..... 41

see cyclafem 7/7/7 28 day ...................................... 39 see nortrel 7/7/7 28 day 41

OSENI TAB 12.5-15MG .... 38 OSENI TAB 12.5-30MG .... 38 OSENI TAB 12.5-45MG .... 38 OSENI TAB 25-15MG ....... 38 OSENI TAB 25-30MG ....... 38 OSENI TAB 25-45MG ....... 38 OSMOPREP ..................... 47 OTEZLA ............................ 50 ovcon 35 28 day ............... 41

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OVCON-35 see balziva 28 day ......... 39 see briellyn 28 day ........ 39 see gildagia ................... 40 see philith ...................... 41 see vyfemia 28 day ....... 41 see zenchent tab ........... 42

OVIDE ............................... 62 see malathion ................ 62

oxacillin sodium ................. 12 oxaliplatin .......................... 15 OXANDRIN

see oxandrolone ............ 35 oxandrolone ...................... 35 oxaprozin ............................1 oxcarbazepine ................... 24 OXECTA .............................5 OXISTAT........................... 59 OXSORALEN .................... 62 OXSORALEN ULTRA ....... 60

see methoxsalen rapid .. 60 OXTELLAR XR ................. 24 oxybutynin chloride ........... 48 oxycodone hcl .....................5 OXYCODONE HCL ............5 oxycodone w/ acetaminophen 10-325mg ..5 oxycodone w/ acetaminophen 2.5-325mg .5 oxycodone w/ acetaminophen 5-325mg ....5 oxycodone w/ acetaminophen 7.5-325mg .5 oxycodone-aspirin ...............5 oxycodone-ibuprofen ..........5 OXYCONTIN .......................5 oxymorphone hcl .................6 OXYTROL ......................... 48 P pacerone ........................... 17 paclitaxel ........................... 14 PAMELOR ........................ 26

see nortriptyline hcl ....... 26 pamidronate inj 30/10ml .... 39 pamidronate inj 6mg/ml ..... 39 pamidronate inj 90/10ml .... 39 PAMINE ............................ 46

see methscopolamine

bromide ......................... 46 PAMINE FORTE ............... 46

see methscopolamine bromide ......................... 46

PANCREAZE .................... 47 PANDEL ........................... 61 PANRETIN ........................ 62 pantoprazole sodium tbec . 48 paricalcitol ......................... 54 PARICALCITOL ................ 54 PARLODEL

see bromocriptine mesylate ........................ 27

PARNATE ......................... 26 see tranylcypromine sulfate ............................ 26

paromomycin sulfate ........... 6 paroxetine er tab ............... 26 paroxetine hcl ................... 26 paser d/r .............................. 9 PATADAY ......................... 55 PATANASE ....................... 56

see olopatadine hcl (nasal) ...................................... 56

PATANOL ......................... 55 PAXIL................................ 26

see paroxetine hcl ......... 26 PAXIL CR ......................... 26

see paroxetine er tab..... 26 PAZEO .............................. 55 PCE .................................. 11 PEDIAPRED

see pred sod pho sol 5mg/5ml ........................ 43

pediapred sol 6.7/5ml........ 43 PEDVAX HIB .................... 51 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 47 PEGANONE ..................... 24 PEGASYS ......................... 50 PEGASYS PROCLICK ..... 50 PEG-INTRON ................... 50 PEG-INTRON REDIPEN .. 50 PENICILLIN G POT IN DEXTROSE ...................... 12

penicillin g potassium ........ 12 PENICILLIN G POTASSIUM IN ...................................... 12 penicillin g procaine .......... 12 penicillin g sodium ............ 12 penicillin v potassium ........ 12 PENNSAID SOL 1.5% ...... 62 PENNSAID SOL 2% ......... 62 PENTAM 300 ...................... 7 PENTASA ......................... 46 pentoxifylline ..................... 50 PEPCID ............................ 46

see famotidine ............... 46 PEPCID SUSP.................. 46 PEPCID TAB .................... 46 PERCOCET

see endocet .................... 4 see oxycodone w/ acetaminophen 10-325mg ........................................ 5 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 5 see oxycodone w/ acetaminophen 5-325mg 5 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 5 see roxicet tabs ............... 6

percocet 10/325 .................. 6 percocet 2.5/325 ................. 6 percocet 7.5/325 ................. 6 percocet tab 5-325mg ......... 6 PERCODAN ....................... 6

see oxycodone-aspirin .... 5 PERFOROMIST ............... 57 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 63 see periogard soln 0.12% ...................................... 63

perindopril erbumine ......... 16 periogard soln 0.12% ........ 63 permethrin ........................ 62 perphenazine .................... 29 PERTZYE ......................... 47 PEXEVA ........................... 26

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pfizerpen ........................... 12 phenadoz sup ................... 45 phenelzine sulfate ............. 26 PHENERGAN

see promethazine hcl .... 45 phenergan inj .................... 45 phenergan supp ................ 45 phenobarbital .................... 24 phenobarbital sodium ........ 24 PHENOBARBITAL SODIUM .......................................... 24 PHENOXYBENZAMINE HCL ................................... 21 phenytek ........................... 24 phenytoin .......................... 24 phenytoin inj 50mg/ml ....... 24 phenytoin sodium extended .......................................... 24 philith ................................ 41 PHOSLO ........................... 44

see calcium acetate (phosphate binder) ........ 44

PHOSLYRA ...................... 44 PHOSPHOLINE IODIDE ... 55 PICATO............................. 62 PILOCARPINE HCL .......... 55 pilocarpine hcl (oral) .......... 63 pimtrea pack ..................... 41 pindolol ............................. 19 pioglitazone hcl ................. 38 pioglitazone hcl-glimepiride .......................................... 38 pioglitazone hcl-metformin hcl ..................................... 38 piperacillin sodium-tazobactam sodium .......................................... 12 pirmella 1/35 28 day .......... 41 piroxicam.............................1 PLAN B ONE-STEP

see levonorgestrel (emergency oc) ............. 40 see my way ................... 40 see next choice tab 1.5mg ...................................... 41

PLAQUENIL ...................... 50 see hydroxychloroquine sulfate ............................ 50

PLASMA-LYTE A .............. 53 PLASMA-LYTE-148 .......... 53 PLASMA-LYTE-56/D5W ... 53 PLAVIX ............................. 50

see clopidogrel bisulfate 50 PLEGRIDY ........................ 34 PLEGRIDY STARTER PACK ................................ 34 PLETAL ............................ 50

see cilostazol ................. 49 podofilox ........................... 62 polyethylene glycol 3350 ... 47 polymyxin b sulfate ............. 7 polymyxin b-trimethoprim .. 54 POLYTRIM ....................... 54

see polymyxin b-trimethoprim ............... 54

POMALYST ...................... 15 PONSTEL ........................... 1

see mefenamic acid ........ 1 portia 28 day ..................... 41 potassium chloride ...... 52, 53 POTASSIUM CHLORIDE . 52 POTASSIUM CHLORIDE 0.15%................................ 53 POTASSIUM CHLORIDE 0.22%................................ 53 POTASSIUM CHLORIDE 0.3%/D .............................. 53 potassium chloride caps er .......................................... 52 potassium chloride in nacl . 53 POTASSIUM CHLORIDE IN NACL ................................ 53 potassium chloride microencapsulated crystals cr ....................................... 52 potassium citrate (alkalinizer) .......................................... 48 POTASSIUM CITRATE (ALKALINIZER) TAB......... 48 POTIGA ............................ 24 PRADAXA ......................... 49 pramipexole dihydrochloride .......................................... 27 pramipexole dihydrochloride er tabs ............................... 27 PRANDIMET ..................... 38

PRANDIN ......................... 38 see repaglinide .............. 38

PRAVACHOL ................... 18 see pravastatin sodium . 18

pravastatin sodium ............ 18 prazosin hcl ...................... 16 PRECOSE ........................ 38

see acarbose................. 36 PRED FORTE .................. 55 PRED MILD ...................... 55 pred sod pho sol 5mg/5ml 43 PRED-G ............................ 54 PRED-G S.O.P. ................ 54 prednicarbate .................... 61 PREDNICARBATE ........... 61 PREDNISOLONE ACETATE (OPHTH) ........................... 55 prednisolone sodium phosphate ......................... 43 prednisolone sodium phosphate (ophth)............. 55 prednisolone sol 15mg/5ml.......................................... 43 prednisolone sol 25mg/5ml.......................................... 43 prednisolone syrup 15 mg/5ml .............................. 43 prednisone con 5mg/ml .... 43 prednisone pak 10mg ....... 43 prednisone pak 5mg ......... 43 prednisone sol 5mg/5ml .... 43 prednisone tab 10mg ........ 43 prednisone tab 1mg .......... 43 prednisone tab 2.5mg ....... 43 prednisone tab 20mg ........ 43 prednisone tab 50mg ........ 43 prednisone tab 5mg .......... 43 PREGNYL W/DILUENT BENZYL ............................ 44 PREMARIN ....................... 42 PREMARIN CREAM ......... 42 PREMARIN INJ ................ 42 premasol 10% ................... 53 premasol 6% ..................... 53 PREMPHASE ................... 42 PREMPRO ....................... 42 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

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.......................................... 54 PREPOPIK ........................ 47 PREVACID ........................ 48

see lansoprazole ........... 47 PREVACID SOLUTAB ...... 48 prevalite ............................ 18 previfem 28 day ................ 41 PREVPAC ......................... 47

see amoxicillin-clarithromycin w/ lansoprazole ............. 47

PREZCOBIX .......................9 PREZISTA ..........................9 PRIFTIN ..............................9 PRILOSEC ........................ 48

see omeprazole ............. 48 PRIMAQUINE PHOSPHATE ............................................8 PRIMAXIN ...........................7 PRIMAXIN IV

see imipenem-cilastatin ...7 primidone .......................... 24 PRIMSOL SOL 50MG/5ML .7 PRINIVIL ........................... 16

see lisinopril ................... 16 PRISTIQ............................ 26 PRIVIGEN ......................... 50 PROAIR HFA .................... 57 PROAIR RESPICLICK ...... 57 probenecid ..........................1 PROCALAMINE ................ 53 PROCARDIA XL ............... 20

see nifedical .................. 20 see nifedipine er ............ 20

prochlorperazine inj 5 mg/ml .......................................... 45 prochlorperazine maleate.. 45 prochlorperazine supp ...... 45 PROCRIT .......................... 49 procto-pak ......................... 59 proctosol hc 2.5 % ............ 59 proctozone hc ................... 59 PROCYSBI ....................... 42 progesterone micronized... 44 PROGLYCEM SUS 50MG/ML .......................... 43 PROGRAF ........................ 51

see tacrolimus ............... 51

PROLASTIN-C .................. 57 PROLENSA ...................... 56 PROLEUKIN ..................... 14 PROLIA ............................. 44 PROMACTA ..................... 50 promethazine hcl .............. 45 promethegan ..................... 45 PROMETRIUM ................. 44

see progesterone micronized ..................... 44

propafenone hcl ................ 17 proparacaine hcl ............... 56 propranolol & hydrochlorothiazide ........... 19 propranolol hcl er .............. 19 propranolol inj 1mg/ml....... 19 propranolol sol .................. 19 propranolol tab .................. 19 propylthiouracil .................. 44 PROQUAD ........................ 51 PROSCAR ........................ 48

see finasteride ............... 48 PROSOL ........................... 53 PROTONIX ....................... 48

see pantoprazole sodium tbec ............................... 48

PROTONIX INJ ................. 48 PROTOPIC ....................... 62

see tacrolimus (topical) . 62 protriptyline hcl .................. 26 PROVENTIL HFA ............. 57 PROVERA ........................ 44

see medroxyprogesterone acetate .......................... 44

PROVIGIL ......................... 35 see modafinil ................. 35

PROZAC ........................... 26 see fluoxetine cap 10mg 26 see fluoxetine cap 20mg 26 see fluoxetine cap 40mg 26

PROZAC WEEKLY ........... 26 see fluoxetine cap 90mg dr ................................... 26

PRUDOXIN CRE 5% ........ 59 psorcon ............................. 61 PULMICORT

see budesonide (inhalation) .................... 58

PULMICORT FLEXHALER.......................................... 58 PULMICORT INH SUSP 0.25MG/2 ML .................... 58 PULMICORT INH SUSP 0.5MG/2 ML ...................... 58 PULMICORT INH SUSP 1MG/2ML .......................... 58 PULMOZYME ................... 57 PURIXAN .......................... 14 PYLERA ........................... 47 pyrazinamide ...................... 9 pyridostigmine bromide ..... 34 Q QNASL ............................. 57 QNASL CHILDRENS ........ 57 QUADRACEL ................... 51 QUALAQUIN ...................... 8

see quinine sulfate .......... 8 QUARTETTE .................... 41 quasense 91 day .............. 41 QUDEXY XR .................... 24 questran ............................ 18 QUESTRAN

see cholestyramine ....... 18 questran light .................... 18 QUESTRAN LIGHT

see prevalite .................. 18 quetiapine fumarate .......... 29 QUILLIVANT XR ............... 31 quinapril hcl ...................... 16 quinapril-hydrochlorothiazide.......................................... 16 quinidine gluconate er ....... 17 quinidine sulfate ................ 17 quinine sulfate .................... 8 QVAR ............................... 58 R RABAVERT ...................... 51 rabeprazole sodium .......... 48 RAGWITEK ...................... 50 raloxifene hcl .................... 44 ramipril .............................. 16 RANEXA ........................... 21 ranitidine hcl ..................... 46 RAPAFLO ......................... 48 RAPAMUNE ..................... 51

see sirolimus tab 0.5 mg 51

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RAYOS TAB 1MG ............. 43 RAYOS TAB 2MG ............. 43 RAYOS TAB 5MG ............. 43 RAZADYNE

see galantamine hydrobromide ................ 25

RAZADYNE ER ................ 25 see galantamine hydrobromide ................ 25

RAZADYNE TABS ............ 25 REBETOL ......................... 10

see ribasphere ............... 10 see ribavirin 200mg ....... 10

REBIF ............................... 34 REBIF REBIDOSE ............ 34 REBIF REBIDOSE TITRATION ....................... 34 REBIF TITRATION PACK . 34 RECLAST

see zoledronic inj 5/100ml ...................................... 39

reclipsen 28 day ................ 41 RECOMBIVAX HB ............ 52 RECTIV ............................. 62 REGLAN ........................... 45

see metoclopramide hcl. 45 REGRANEX ...................... 62 RELENZA DISKHALER .... 10 RELISTOR ........................ 47 RELPAX ............................ 33 REMERON ........................ 26

see mirtazapine ............. 26 REMERON SOLTAB ........ 26

see mirtazapine ............. 26 see mirtazapine odt ....... 26

REMICADE ....................... 50 REMODULIN .................... 22 RENAGEL ......................... 44 RENVELA PAK ................. 44 RENVELA TAB 800MG .... 44 repaglinide ........................ 38 REPREXAIN

see hydrocodone-ibuprofen 2.5-200 mg ......................2 see ibudone 5-200 mg .....2

reprexain 10/200 .................3 reprexain 2.5/200 ................3

reprexain 5/200 ................... 3 REQUIP ............................ 27

see ropinirole hydrochloride ................. 27

REQUIP XL ....................... 27 see ropinirole hydrochloride ................. 27

RESCRIPTOR .................... 9 RESTASIS ........................ 56 RESTORIL ........................ 32

see temazepam ............. 32 RETIN-A ........................... 59

see tretinoin ................... 59 RETIN-A MICRO .............. 59 RETIN-A MICRO PUMP ... 59 RETROVIR

see zidovudine ................ 9 RETROVIR CAPS .............. 9 RETROVIR IV INFUSION ... 9 RETROVIR SYRP .............. 9 REVATIO .......................... 22

see sildenafil citrate (pulmonary hypertension) ...................................... 22

REVIA see naltrexone hcl ......... 35

REVLIMID ......................... 50 REXULTI ........................... 29 REYATAZ ........................... 9 RHEUMATREX ................. 50 RHINOCORT AQUA ......... 57

see budesonide (nasal) . 57 ribapak mis 600/day .......... 10 ribasphere ......................... 10 ribasphere ribapak 1000 ... 10 ribasphere ribapak 1200 ... 10 ribasphere ribapak 800 ..... 10 ribavirin 200mg ................. 10 rifabutin ............................... 9 rifadin .................................. 9 RIFADIN ............................. 9

see rifampin ..................... 9 rifamate ............................... 9 rifampin ............................... 9 RIFATER ............................ 9 RILUTEK ........................... 34

see riluzole .................... 34 riluzole .............................. 34

rimantadine hydrochloride 10 RINGER'S ......................... 53 RIOMET ............................ 38 risedronate sodium ........... 39 RISPERDAL ..................... 29

see risperidone.............. 29 RISPERDAL INJ 12.5MG . 29 RISPERDAL INJ 25MG .... 29 RISPERDAL INJ 37.5MG . 29 RISPERDAL INJ 50MG .... 29 RISPERDAL M-TAB ......... 29

see risperidone odt ........ 29 risperidone ........................ 29 risperidone odt .................. 29 RITALIN ...................... 31, 32

see methylphenidate hcl 31 RITALIN LA ...................... 32

see methylphenidate hcl 31 RITUXAN .......................... 14 RIVASTIGMINE PATCH ... 25 rivastigmine tartrate .......... 25 rizatriptan benzoate .......... 33 ROBINUL .......................... 46

see glycopyrrolate ... 45, 46 ROBINUL FORTE ............. 46

see glycopyrrolate ......... 46 ROCALTROL .................... 54

see calcitriol .................. 54 rocephin ............................ 11 ROCEPHIN

see ceftriaxone sodium . 11 ropinirole hydrochloride .... 27 rosadan cre 0.75% ............ 62 ROTARIX .......................... 52 ROTATEQ ........................ 52 ROWASA .......................... 46

see mesalamine enema 46 roxicet soln ......................... 6 roxicet tabs ......................... 6 ROXICODONE ................... 6

see oxycodone hcl .......... 5 ROZEREM ........................ 32 RUCONEST ..................... 50 RYTARY ........................... 27 RYTHMOL ........................ 17

see propafenone hcl ...... 17 RYTHMOL SR .................. 17

see propafenone hcl ...... 17

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S SABRIL ............................. 24 SAIZEN ............................. 43 SAIZEN CLICK.EASY ....... 43 SALAGEN ......................... 63

see pilocarpine hcl (oral) ...................................... 63

SAMSCA ........................... 44 SANCUSO ........................ 45 SANDIMMUNE

see cyclosporine ............ 51 SANDIMMUNE CAPS ....... 51 SANDIMMUNE INJ ........... 51 SANDIMMUNE SOLN ....... 51 SANDOSTATIN ................ 44

see octreotide acetate ... 44 SANDOSTATIN LAR DEPOT ............................. 44 SANTYL ............................ 62 SAPHRIS .......................... 29 SARAFEM ......................... 35 SAVAYSA ......................... 49 SAVELLA .......................... 34 SAVELLA TITRATION PACK ................................ 34 SEASONIQUE .................. 41

see amethia 91 day ....... 39 see ashlyna 91 day ....... 39 see levonorgestrel-ethinyl estradiol (91-day) .......... 40

SECTRAL ......................... 19 see acebutolol hcl .......... 19

selegiline hcl ..................... 27 selenium sulfide ................ 60 SELZENTRY .......................9 SEMPREX-D ..................... 56 SENSIPAR ........................ 39 SEREVENT DISKUS ........ 57 SEROQUEL ...................... 29

see quetiapine fumarate 29 SEROQUEL XR .......... 29, 30 SEROSTIM ....................... 43 sertraline hcl ...................... 26 SF-ROWASA .................... 46 sharobel 28 day ................ 41 SIGNIFOR ......................... 44 SIGNIFOR LAR ................. 44 sildenafil citrate (pulmonary

hypertension) .................... 22 SILENOR .......................... 32 SILVADENE ...................... 59 SILVER SULFADIAZINE .. 59 SIMBRINZA SUS 1-0.2% .. 56 SIMCOR ........................... 18 SIMPONI ........................... 50 SIMPONI ARIA ................. 50 SIMULECT ........................ 51 simvastatin ........................ 18 SINEMET .......................... 27

see carbidopa-levodopa 27 SINEMET CR .................... 27

see carbidopa-levodopa 27 SINGULAIR ...................... 57

see montelukast sodium 57 SIROLIMUS ...................... 51 sirolimus tab 0.5 mg .......... 51 SIRTURO ............................ 9 SIVEXTRO .......................... 7 SKLICE ............................. 62 SODIUM CHLORIDE .. 52, 54 SODIUM CHLORIDE 0.45% VIA .................................... 54 SODIUM CHLORIDE 0.9% .......................................... 62 SODIUM DIURIL ............... 21 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 52 sodium phenylbutyrate ...... 42 sodium polystyrene sulfonate .......................................... 39 SOLARAZE ....................... 62

see diclofenac gel 3% ... 62 SOLIA ............................... 41 SOLODYN ........................ 13 SOLTAMOX ...................... 14 SOLU-CORTEF 1000MG . 43 SOLU-CORTEF 100MG ... 43 SOLU-CORTEF 250MG ... 43 SOLU-CORTEF 500MG ... 43 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 43 see methylpr ss inj 1gm . 43 see methylpr ss inj 40mg ...................................... 43

SOLU-MEDROL INJ 125MG.......................................... 43 SOLU-MEDROL INJ 1GM 43 SOLU-MEDROL INJ 2GM 43 SOLU-MEDROL INJ 40MG.......................................... 43 SOLU-MEDROL INJ 500MG.......................................... 43 SOMATULINE DEPOT ..... 44 SOMAVERT ..................... 44 SOOLANTRA ................... 62 SORIATANE ..................... 60

see acitretin ................... 60 SORILUX .......................... 60 sorine ................................ 17 sotalol hcl .......................... 18 sotalol hcl (afib/afl) ............ 18 SOTYLIZE ........................ 19 SOVALDI .......................... 10 SPIRIVA HANDIHALER ... 56 SPIRIVA RESPIMAT ........ 56 spironolactone .................. 16 spironolactone & hydrochlorothiazide ........... 21 SPORANOX ....................... 8

see itraconazole .............. 8 SPORANOX PULSEPAK ... 8 SPORANOX SOL 10MG/ML............................................ 8 sprintec 28 day ................. 41 SPRYCEL ......................... 15 sronyx 28 day ................... 41 SSD .................................. 59 STALEVO ......................... 27 STARLIX ........................... 38

see nateglinide .............. 38 stavudine ............................ 9 STELARA ......................... 60 STERILE WATER IRRIGATION ..................... 63 STIMATE .......................... 45 STIOLTO RESPIMAT ....... 56 STIVARGA ....................... 15 STRATTERA .................... 32 streptomycin sulfate ............ 6 STRIANT .......................... 35 STRIBILD ........................... 9 STRIVERDI RESPIMAT ... 57

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STROMECTOL ...................7 see ivermectin .................7

SUBOXONE MIS 12-3MG 35 SUBOXONE MIS 2-0.5MG .......................................... 35 SUBOXONE MIS 4-1MG .. 35 SUBOXONE MIS 8-2MG .. 35 SUBSYS .............................6 SUCLEAR ......................... 47 SUCRAID .......................... 47 sucralfate .......................... 47 SULAR .............................. 20

see nisoldipine ............... 20 sulfacetamide sodium (acne) .......................................... 59 sulfacetamide sodium (ophth) .............................. 54 sulfacetamide sod-prednisolone .............. 54 sulfadiazine .........................6 sulfamethoxazole-trimethop 7 sulfamethoxazole-trimethoprim inj ....................................8 SULFAMYLON .................. 59 sulfasalazine dr ................. 46 sulfasalazine ir .................. 46 sulindac ...............................1 sumatriptan succinate ....... 33 SUMATRIPTAN SUCCINATE ..................... 33 sumatriptan succinate inj .. 33 SUMAVEL DOSEPRO ...... 33 suprax ............................... 11 SUPRAX ........................... 11

see cefixime .................. 10 SUPREP BOWEL PREP... 47 SURMONTIL ..................... 26 SUSTIVA.............................9 SUTENT............................ 15 syeda ................................ 41 SYLATRON KIT 296MCG . 15 SYLATRON KIT 444MCG . 15 SYLATRON KIT 888MCG . 15 SYMBICORT ..................... 58 SYMLINPEN 120 .............. 36 SYMLINPEN 60 ................ 36 SYNAGIS .......................... 52 SYNALAR ......................... 61

see fluocinolone acetonide ...................................... 61

SYNALGOS-DC .................. 3 SYNAREL ......................... 42 SYNERA ........................... 62 SYNERCID ......................... 8 SYNTHROID ..................... 44

see levothyroxine sodium ...................................... 44

SYPRINE .......................... 39 T TABLOID .......................... 14 TACLONEX ...................... 61

see calcipotrien oin betameth ....................... 60

tacrolimus ......................... 51 tacrolimus (topical) ............ 62 TAFINLAR ........................ 15 TAMIFLU .......................... 10 tamoxifen citrate ............... 14 tamsulosin hcl ................... 48 TANZEUM ........................ 36 tapazole ............................ 44 TAPAZOLE

see methimazole ........... 44 TARCEVA ......................... 15 TARGRETIN

see bexarotene ............. 15 TARGRETIN CAPS .......... 15 TARGRETIN GEL ............. 62 tarina fe tab 1/20 ............... 41 TARKA .............................. 16

see trandolapril-verapamil hcl.................................. 16

TASIGNA .......................... 15 TAXOTERE ...................... 14 tazicef ............................... 11 tazicef vial ......................... 11 TAZORAC ......................... 60 taztia xt ............................. 20 TECFIDERA CAP 120MG 34 TECFIDERA CAP 240MG 34 TECFIDERA MIS STARTER .......................................... 34 TEFLARO ......................... 11 TEGRETOL ...................... 24

see carbamazepine ....... 22 see epitol ....................... 23

TEGRETOL-XR ................ 24 see carbamazepine ....... 22

TEKAMLO TAB 150-10MG.......................................... 20 TEKAMLO TAB 150-5MG . 20 TEKTURNA ...................... 20 TEKTURNA HCT .............. 20 TELMISARTAN................. 17 telmisartan-amlodipine ...... 17 telmisartan-hydrochlorothiazide ...................................... 17 temazepam ....................... 32 TEMOVATE

see clobetasol propionate ...................................... 60 see cormax ................... 60

TEMOVATE CRE 0.05% .. 61 TEMOVATE E

see clobetasol propionate emollient base ............... 60

TEMOVATE E CREAM ..... 61 TEMOVATE GEL 0.05% ... 61 TEMOVATE OIN 0.05% ... 61 TEMOVATE SOL 0.05% ... 61 TENIVAC .......................... 52 TENORETIC 100 .............. 19

see atenolol & chlorthalidone ................ 19

TENORETIC 50 ................ 19 see atenolol & chlorthalidone ................ 19

TENORMIN ...................... 19 see atenolol ................... 19

TERAZOL 3 see terconazole vaginal 49

TERAZOL 3 CRE 0.8% .... 49 TERAZOL 7

see terconazole vaginal 49 see zazole ..................... 49

TERAZOL 7 CRE 0.4% .... 49 terazosin hcl ..................... 16 terbinafine hcl ..................... 8 terbutaline sulfate ............. 57 terconazole vaginal ........... 49 TESTIM ............................ 35 testosterone cypionate 35, 36 testosterone enanthate ..... 36 TETANUS TOXOID

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ADSORBED ...................... 52 TETANUS/DIPHTHERIA TOXOID ............................ 52 TETRABENAZINE ............ 34 TETRACYCLINE HCL ...... 13 TEVETEN ......................... 17 TEVETEN HCT ................. 17 TEV-TROPIN .................... 43 texacort ............................. 61 THALOMID ....................... 50 theo-24 .............................. 58 theophylline ....................... 58 thioridazine hcl .................. 30 thiothixene......................... 30 THYMOGLOBULIN ........... 51 tiagabine hcl ...................... 24 TIAZAC ............................. 20

see diltiazem hcl er ........ 20 see diltiazem hcl extended release beads ................ 20 see diltzac ..................... 20 see taztia xt ................... 20

TIKOSYN .......................... 18 timolol maleate .................. 19 timolol maleate (ophth) ..... 56 TIMOLOL MALEATE GEL 56 TIMOPTIC ......................... 56

see timolol maleate (ophth) ........................... 56

TIMOPTIC OCUDOSE ...... 56 TIMOPTIC-XE ................... 56 TIROSINT ......................... 44 TIVICAY ..............................9 tizanidine ........................... 34 TOBI

see tobramycin ................6 TOBI NEB ...........................6 TOBI PODHALER ...............6 TOBRADEX ...................... 54

see tobramycin-dexamethasone .................................... 54

TOBRADEX ST ................. 54 tobramycin ..........................6 tobramycin (ophth) ............ 54 tobramycin sulfate ...............6 tobramycin sulfate in saline .6 tobramycin-dexamethasone

.......................................... 54 TOBREX

see tobramycin (ophth) .. 54 TOBREX OINT 0.3% ........ 54 TOBREX SOL 0.3% OP .... 54 tofranil ............................... 26 TOFRANIL

see imipramine hcl ........ 26 TOFRANIL-PM ................. 26

see imipramine pamoate ...................................... 26

tolmetin sodium ................... 1 TOLTERODINE TARTRATE ER ..................................... 48 tolterodine tartrate tab 1 mg .......................................... 48 tolterodine tartrate tab 2 mg .......................................... 48 TOPAMAX ........................ 24

see topiramate .............. 25 TOPAMAX SPRINKLE ...... 25

see topiramate .............. 25 topicort .............................. 61 TOPICORT ....................... 61

see desoximetasone ..... 61 topiramate ......................... 25 TOPIRAMATE .................. 25 toposar .............................. 15 topotecan hcl .................... 15 TOPROL XL ...................... 19

see metoprolol succinate ...................................... 19

TORISEL .......................... 14 torsemide inj 20mg/2ml ..... 21 torsemide inj 50mg/5ml ..... 21 torsemide tabs .................. 21 TOUJEO SOLOSTAR ....... 36 TOVIAZ ............................. 48 TPN ELECTROLYTES ..... 52 TRACLEER ....................... 22 TRADJENTA ..................... 38 TRAMADOL HCL ................ 3 tramadol hcl er .................... 3 tramadol hcl er (biphasic) 100mg ................................. 3 tramadol hcl er (biphasic) 200mg ................................. 3 tramadol hcl er (biphasic)

300mg ................................. 3 tramadol hcl tab 50 mg ....... 3 tramadol-acetaminophen .... 3 TRANDATE ...................... 19

see labetalol hcl ............ 19 trandolapril ........................ 16 trandolapril-verapamil hcl .. 16 tranexamic acid................. 50 TRANSDERM-SCOP ........ 45 TRANXENE T

see clorazepate dipotassium ................... 23

TRANXENE T TAB 15MG 25 TRANXENE T TAB 3.75MG.......................................... 25 TRANXENE T TAB 7.5MG 25 tranylcypromine sulfate ..... 26 travasol 10 ........................ 53 TRAVATAN Z ................... 56 trazodone hcl .................... 26 TREANDA ........................ 13 TRECATOR ...................... 10 TRELSTAR MIXJECT ....... 14 tretinoin ....................... 15, 59 TRETINOIN MICROSPHERE ............... 59 tretin-x ............................... 59 trexall ................................ 50 TREXIMET ....................... 33 trezix ................................... 3 triamcinolone acetonide (mouth) ............................. 63 triamcinolone acetonide (nasal) ............................... 57 triamcinolone acetonide (topical) ............................. 61 triamt/hctz cap 37.5-25 ..... 21 triamt/hctz cap 50-25mg ... 21 triamt/hctz tab 37.5-25 ...... 21 triamt/hctz tab 75-50mg .... 21 trianex ............................... 61 TRIBENZOR ..................... 17 TRICOR ............................ 18

see fenofibrate .............. 18 triderm .............................. 61 trifluoperazine hcl.............. 30 trifluridine .......................... 55 TRIGLIDE ......................... 18

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trihexyphenidyl hcl ............ 27 tri-legest 28 day ................ 41 TRILEPTAL ....................... 25

see oxcarbazepine ........ 24 TRILEPTAL SUSP ............ 25 TRILIPIX ........................... 18

see choline fenofibrate .. 18 trilyte ................................. 47 trimethoprim ........................8 TRINESSA ........................ 41 TRI-NORINYL 28 .............. 41

see aranelle 28 .............. 39 TRIOSTAT ........................ 44

see liothyronine sodium . 44 tri-previfem 28 day ............ 41 TRISENOX ........................ 15 tri-sprintec 28 day ............. 41 TRIUMEQ ...........................9 trivora 28 day .................... 41 TRIZIVIR .............................9

see abacavir sulfate-lamivudine-zidovudine ...................................9

TROKENDI XR ................. 25 TROPHAMINE .................. 53 TROPHAMINE INJ 10% ... 53 trospium chloride ............... 48 trospium chloride er .......... 48 TRULICITY ....................... 36 TRUMENBA ...................... 52 TRUSOPT ......................... 56

see dorzolamide hcl ...... 55 TRUVADA ...........................9 TUDORZA PRESSAIR ..... 56 TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT ................... 56 TWINRIX INJ .................... 52 TWYNSTA ........................ 17

see telmisartan-amlodipine ...................................... 17

TYBOST..............................9 TYGACIL.............................8 TYKERB............................ 15 tylenol with codeine .............3 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................ 2

TYPHIM VI ........................ 52 TYSABRI .......................... 34 TYVASO ........................... 22 TYZEKA ............................ 10 tyzine ................................ 57 U UCERIS ............................ 46 ULORIC .............................. 1 ULTRACET ......................... 3

see tramadol-acetaminophen . 3

ULTRAM ............................. 3 see tramadol hcl tab 50 mg ................................... 3

ULTRAM ER ....................... 3 see tramadol hcl er .......... 3

ULTRAVATE ..................... 62 see halobetasol propionate ..................... 61

ULTRESA ......................... 47 UNASYN ........................... 12

see ampicillin & sulbactam sodium ........................... 12

UNASYN BULK PACK ...... 12 see ampicillin & sulbactam sodium ........................... 12

UNITHROID ...................... 44 urecholine ......................... 48 URECHOLINE

see bethanechol chloride ...................................... 48

UROCIT-K ........................ 48 UROCIT-K 15 ................... 48

see potassium citrate (alkalinizer) .................... 48

UROXATRAL .................... 48 see alfuzosin hcl ............ 48

URSO 250 ........................ 47 see ursodiol ................... 47

URSO FORTE .................. 47 see ursodiol ................... 47

ursodiol ............................. 47 UVADEX ........................... 15 V VAGIFEM .......................... 42

valacyclovir hcl.................. 10 VALCHLOR ...................... 62 VALCYTE ......................... 10

see valganciclovir hcl .... 10 valganciclovir hcl............... 10 VALIUM ............................ 25

see diazepam ................ 23 valproate sodium .............. 25 valproic acid ...................... 25 valsartan ........................... 17 valsartan-hydrochlorothiazide........................................ 17 VALTREX ......................... 10

see valacyclovir hcl ....... 10 VANCOCIN HCL................. 8

see vancomycin hcl ......... 8 vancomycin hcl ................... 8 VANDAZOLE .................... 49 VANOS ............................. 62

see fluocinonide ............ 61 VAQTA ............................. 52 VARIVAX .......................... 52 VASCEPA ......................... 18 VASERETIC ..................... 16

see enalapril maleate & hydrochlorothiazide ....... 16

VASOTEC ........................ 16 see enalapril maleate .... 16

VECTIBIX ......................... 14 VECTICAL ........................ 60 VELCADE ......................... 14 velivet 28 day .................... 41 VELPHORO ...................... 44 VELTIN ............................. 59 venlafaxine cap er............. 26 venlafaxine hcl .................. 26 VENLAFAXINE HCL ER

see venlafaxine tab er ... 26 VENLAFAXINE HCL ER TAB (VERT) ...................... 26 venlafaxine tab ................. 26 VENLAFAXINE TAB 225MG ER ..................................... 26 venlafaxine tab er ............. 26 VENTAVIS ........................ 22 VENTOLIN HFA................ 57 VERAMYST ...................... 57 verapamil hcl .................... 20

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VERAPAMIL HCL ............. 20 VERELAN ......................... 20

see verapamil hcl .......... 20 VERELAN PM ................... 20

see verapamil hcl .......... 20 veripred ............................. 43 VERSACLOZ .................... 30 VESICARE ........................ 48 vestura .............................. 41 VEXOL .............................. 55 VFEND

see voriconazole .............8 VFEND IV ...........................8

see voriconazole inj 200mg .............................8

VFEND SUS 40MG/ML .......8 VFEND TAB ........................8 VIBRAMYCIN .................... 13

see doxycycline (monohydrate) ............... 12 see doxycycline hyclate . 13

vicodin .................................3 vicodin es ............................3 vicodin hp ............................3 VICOPROFEN ....................3

see hydrocodone-ibuprofen tab 7.5-200 mg ......................2

VICTOZA .......................... 36 VICTRELIS ....................... 10 VIDAZA ............................. 14

see azacitidine ............... 13 VIDEX EC ...........................9

see didanosine ................8 VIDEX PEDIATRIC .............9 VIGAMOX ......................... 55 VIIBRYD............................ 26 VIIBRYD STARTER PACK .......................................... 26 VIMIZIM ............................ 42 VIMOVO..............................1 VIMPAT............................. 25 vinblastine sulfate ............. 14 vincasar............................. 14 vincristine sulfate .............. 14 vinorelbine tartrate ............ 14 VIOKACE 10 ..................... 47 VIOKACE 20 ..................... 47

viorele ............................... 41 VIRACEPT .......................... 9 VIRAMUNE ......................... 9

see nevirapine ................. 9 VIRAMUNE XR ................... 9

see nevirapine ................. 9 VIREAD .............................. 9 VIROPTIC ......................... 55

see trifluridine ................ 55 VISTARIL .......................... 56

see hydroxyzine pamoate ...................................... 56

VISTIDE ............................ 10 see cidofovir .................. 10

VITEKTA ............................. 9 VIVELLE-DOT .................. 42

see estradiol .................. 42 VIVITROL ......................... 35 VOGELXO ........................ 36 VOGELXO PUMP ............. 36 VOLTAREN GEL 1% ........ 62 VOLTAREN-XR .................. 1 voriconazole ........................ 8 voriconazole inj 200mg ....... 8 vospire .............................. 57 VOSPIRE ER

see albuterol sulfate er .. 57 VOTRIENT ........................ 15 VPRIV ............................... 42 vyfemia 28 day .................. 41 VYTORIN .......................... 18 VYVANSE ......................... 32 W warfarin sodium ................ 49 WELCHOL ........................ 18 WELLBUTRIN ................... 26

see bupropion hcl .......... 25 WELLBUTRIN SR ............. 26

see bupropion hcl .......... 25 WELLBUTRIN XL ............. 26

see bupropion hcl .......... 25 WESTCORT

see hydrocortisone valerate ......................... 61

WYMZYA FE .................... 41 X XALATAN ......................... 56

see latanoprost .............. 55

XALKORI .......................... 15 XANAX

see alprazolam .............. 22 XANAX TAB 0.25MG ........ 22 XANAX TAB 0.5MG .......... 22 XANAX TAB 1MG ............. 22 XANAX TAB 2MG ............. 22 XARELTO ......................... 49 XARELTO STARTER PACK.......................................... 49 XARTEMIS XR ................... 6 XELJANZ .......................... 50 XENAZINE ........................ 34 XEOMIN ........................... 56 XERESE ........................... 60 XGEVA ............................. 44 XIFAXAN TAB 200MG ........ 8 XIFAXAN TAB 550MG ...... 47 XIGDUO XR TAB 10-1000MG ....................... 38 XIGDUO XR TAB 10-500MG.......................................... 38 XIGDUO XR TAB 5-1000MG.......................................... 38 XIGDUO XR TAB 5-500MG.......................................... 38 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 2 see hydrocodone-acetaminophen 5-300mg ..................... 2 see hydrocodone-acetaminophen 7.5-300mg .................. 2 see vicodin ...................... 3 see vicodin es ................. 3 see vicodin hp ................. 3

xodol tab 10-300mg ............ 3 xodol tab 5-300mg .............. 3 xodol tab 7.5-300 ................ 3 XOLAIR ............................ 57 XOPENEX ........................ 57

see levalbuterol hcl ....... 57 XOPENEX CONCENTRATE.......................................... 57

see levalbuterol conc

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1.25mg/0.5ml ................. 57 XOPENEX HFA ................ 57 XTANDI ............................. 14 xulane dis 150-35 .............. 41 XYLOCAINE ................. 6, 62

see lidocaine hcl ............ 62 see lidocaine hcl (local anesth.) ...........................6 see lidocaine inj 1% .........6 see lidocaine inj 2% .........6

XYLOCAINE-MPF ...............6 see lidocaine hcl (local anesth.) ...........................6 see lidocaine inj 0.5% ......6 see lidocaine inj 1.5% ......6 see lidocaine inj 2% .........6

XYREM ............................. 35 XYZAL .............................. 56

see levocetirizine soln 2.5mg/5ml ...................... 56 see levocetirizine tab 5 mg ...................................... 56

Y YASMIN 28 ....................... 41

see drospirenone-ethinyl estradiol ......................... 39 see syeda ...................... 41 see zarah ....................... 41

YAZ ................................... 41 see drospirenone-ethinyl estradiol ......................... 39 see loryna 28 day .......... 40 see nikki 28 day ............. 41 see vestura .................... 41

YF-VAX ............................. 52 Z zafirlukast .......................... 57 zamicet ...............................3 ZANAFLEX ....................... 35

see tizanidine ................ 34 ZANOSAR ......................... 13 ZANTAC............................ 46

see ranitidine hcl ........... 46 zarah ................................. 41 zarontin ............................. 25 ZARONTIN ........................ 25

see ethosuximide .......... 23 ZAVESCA ......................... 42

zazole ............................... 49 ZAZOLE ............................ 49 ZEBETA ............................ 19

see bisoprolol fumarate . 19 ZEGERID .......................... 48 ZELAPAR ......................... 27 ZELBORAF ....................... 15 ZEMAIRA .......................... 57 ZEMPLAR

see paricalcitol .............. 54 ZEMPLAR CAP 1MCG ..... 54 ZEMPLAR CAP 2MCG ..... 54 ZEMPLAR INJ 2MCG/ML . 54 ZEMPLAR INJ 5MCG/ML . 54 zenatane ........................... 59 zenchent fe 28 day ........... 41 zenchent tab ..................... 42 ZENPEP ........................... 47 ZERBAXA ......................... 11 ZERIT ................................. 9

see stavudine .................. 9 ZESTORETIC ................... 16

see lisinopril & hydrochlorothiazide ....... 16

ZESTRIL ........................... 16 see lisinopril .................. 16

ZETIA TAB 10MG ............. 18 ZETONNA ......................... 58 ZIAC.................................. 19

see bisoprolol & hydrochlorothiazide ....... 19

ZIAGEN .............................. 9 see abacavir sulfate ........ 8

ZIANA ............................... 59 zidovudine ........................... 9 ZINACEF .......................... 11

see cefuroxime sodium . 11 ZINECARD ....................... 15

see dexrazoxane ........... 15 ZIOPTAN .......................... 56 ziprasidone hcl .................. 30 ZIPSOR .............................. 1 ZIRGAN ............................ 55 ZITHROMAX ..................... 11

see azithromycin ........... 11 ZITHROMAX TRI-PAK ...... 11 ZITHROMAX Z-PAK ......... 11 ZMAX ................................ 11

ZOCOR ............................. 18 see simvastatin ............. 18

ZOFRAN ........................... 45 see ondansetron hcl ...... 45 see ondansetron hcl oral soln ............................... 45

ZOFRAN ODT .................. 45 see ondansetron odt ..... 45

ZOHYDRO ER (ABUSE DETERRENT)..................... 6 zoledronic inj 4mg/5ml ...... 39 zoledronic inj 5/100ml ....... 39 ZOLINZA .......................... 14 zolmitriptan ....................... 33 zolmitriptan odt ................. 33 ZOLOFT ........................... 27

see sertraline hcl ........... 26 zolpidem tartrate ............... 32 ZOMACTON ..................... 43 ZOMETA ........................... 39

see zoledronic inj 4mg/5ml ...................................... 39

ZOMIG .............................. 33 see zolmitriptan ............. 33

ZOMIG NASAL SPRAY .... 33 ZOMIG ZMT ..................... 33

see zolmitriptan odt ....... 33 ZONALON ........................ 60 ZONEGRAN ..................... 25

see zonisamide ............. 25 zonisamide ....................... 25 ZONTIVITY ....................... 50 ZORBTIVE ........................ 44 ZORTRESS TAB 0.25MG 51 ZORTRESS TAB 0.5MG .. 51 ZORTRESS TAB 0.75MG 51 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 52 ZOSYN ............................. 12

see piperacillin sodium-tazobactam sodium .......................... 12

zovia 1/35e 28 day............ 42 zovia 1/50e 28 day............ 42 ZOVIRAX .................... 10, 60

see acyclovir ................. 10 see acyclovir topical ...... 60

ZUBSOLV SUB 1.4-0.36 .. 35

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ZUBSOLV SUB 11.4-2.9 ... 35 ZUBSOLV SUB 5.7-1.4 ..... 35 ZUBSOLV SUB 8.6-2.1 ..... 35 ZUPLENZ.......................... 45 ZYBAN .............................. 35

see buproban ................ 35 ZYCLARA ......................... 62 ZYDELIG........................... 15 ZYFLO CR ........................ 57

ZYKADIA .......................... 15 ZYLET ............................... 54 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1 ZYMAXID .......................... 55

see gatifloxacin (ophth) . 54 ZYPREXA ......................... 30

see olanzapine .............. 28 ZYPREXA RELPREVV ..... 30

ZYPREXA ZYDI TAB 10MG.......................................... 30 ZYPREXA ZYDIS ............. 30

see olanzapine odt .. 28, 29 ZYTIGA ............................. 14 ZYVOX ............................... 8

see linezolid .................... 7

2015 631 3t copper comm eff 11/01/2015 · ultram er) tb24 200mg ql (30 tabs / 30 days) 1 ql...

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