aetna better health michigan medicaid pdl...tramadol hcl ; qll (240 per 30 days) *opioid...

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health of Michigan

Formulary Guide October 2015

http://www.aetnabetterhealth.com/michigan




What is the Aetna Better Health of Michigan Formulary?

This is a drug list created by Aetna Better Health (“plan”). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy.

Can the Plan’s Drug List change?

The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use the Plan’s Formulary?

Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).

Column #2: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “Ear-Nose-Throat Medications.” If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.

What are generic drugs?

The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).

Are Over-The-Counter (OTC) drugs covered?

The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.

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Are there Medication Copays?

Copays for brand drugs are $0 and copays for generic drugs are $0.

What are some types of coverage rules?

Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.

Step Therapy (ST): This means you may need to try certain drugs first to treat your condition.

After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered.

What if my drug is not on the plan’s Formulary?

First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:

Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval

process.

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Drug Requirements

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Analeptics**-*Analeptics*** Caffeine Anhydrous

Caffeine Citrate

Caffeine Citrated

*Amebicides*

*Amebicides**-*Amebicides*** YODOXIN

*Aminoglycosides*

*Aminoglycosides**-*Aminoglycosides*** Neomycin Sulfate

Paromomycin Sulfate

Tobramycin

*Analgesics - Anti-Inflammatory*

*Antirheumatic Antimetabolites**-*Antirheumatic Antimetabolites*** RHEUMATREX

*Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PA

HUMIRA PEDIATRIC CROHNS START

HUMIRA PEN PA

HUMIRA PEN-CROHNS STARTER

HUMIRA PEN-PSORIASIS STARTER

*Gold Compounds**-*Gold Compounds*** RIDAURA

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** Celecoxib ST

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Diclofenac Potassium

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Drug Requirements Diclofenac Sodium

Diclofenac Sodium ER

Etodolac

Etodolac ER

Fenoprofen Calcium

Flurbiprofen

Ibuprofen

Indomethacin

Indomethacin ER

Ketoprofen

Ketorolac Tromethamine QLL (20 per 30 days)

Meclofenamate Sodium

Meloxicam

Nabumetone

Naproxen

Naproxen DR

Naproxen Kit

Naproxen Sodium

Oxaprozin

Piroxicam

Sulindac

Tolmetin Sodium

*Pyrimidine Synthesis Inhibitors**-*Pyrimidine Synthesis Inhibitors*** Leflunomide

*Soluble Tumor Necrosis Factor Receptor Agents**-*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL PA

ENBREL SURECLICK PA

*Analgesics - Nonnarcotic*

*Analgesic Combinations**-*Analgesics-Sedatives*** Butalbital-APAP-Caffeine ORAL CAPSULE

Butalbital-APAP-Caffeine ORAL TABLET QLL (180 per 30 days)

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Drug Requirements Butalbital-Aspirin-Caffeine QLL (180 per 30 days)

CAPACET (Butalbital-APAP-Caffeine)

ESGIC (Butalbital-APAP-Caffeine)

Margesic QLL (180 per 30 days)

Marten-Tab

TENCON (Butalbital-Acetaminophen)

ZEBUTAL (Butalbital-APAP-Caffeine)

*Salicylates**-*Salicylate Combinations*** Choline & Mag Trisalicylate

Choline-Mag Trisalicylate

*Salicylates**-*Salicylates*** Diflunisal

Salsalate

*Analgesics - Opioid*

*Opioid Agonists**-*Opioid Agonists*** Codeine Sulfate QLL (30 per 30 days)

FentaNYL QLL (10 per 30 days)

FentaNYL Citrate QLL (90 per 30 days)

HYDROmorphone HCl

HYDROmorphone HCl ORAL TABLET 2 MG

HYDROmorphone HCl ORAL TABLET 4 MG QLL (180 per 30 days)

HYDROmorphone HCl ORAL TABLET 8 MG QLL (120 per 30 days)

METHADONE HCL INTENSOL

Methadone HCl ORAL CONCENTRATE

Methadone HCl ORAL SOLUTION

Methadone HCl ORAL TABLET QLL (240 per 30 days)

Methadone HCl ORAL TABLET SOLUBLE QLL (240 per 30 days)

METHADOSE

Morphine Sulfate

Morphine Sulfate (Concentrate)

Morphine Sulfate ER QLL (60 per 30 days)

Morphine Sulfate ORAL SOLUTION

Morphine Sulfate ORAL TABLET QLL (60 per 30 days)

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Drug Requirements OxyCODONE HCl ORAL CAPSULE QLL (240 per 30 days)

OxyCODONE HCl ORAL CONCENTRATE

OxyCODONE HCl ORAL SOLUTION

OxyCODONE HCl ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG QLL (180 per 30 days)

OxyCODONE HCl ORAL TABLET 5 MG QLL (240 per 30 days)

Oxymorphone HCl

Oxymorphone HCl ER ST; QLL (60 per 30 days)

TraMADol HCl QLL (240 per 30 days)

*Opioid Combinations**-*Codeine Combinations*** Acetaminophen-Codeine

Acetaminophen-Codeine #2



ASCOMP-CODEINE

Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-300-40-30 MG

Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-325-40-30 MG QLL (180 per 30 days)

Butalbital-ASA-Caff-Codeine QLL (180 per 30 days)

*Opioid Combinations**-*Hydrocodone Combinations*** Hydrocodone-Ibuprofen QLL (240 per 30 days)

IBUDONE QLL (240 per 30 days)

LORCET (Hydrocodone-Acetaminophen)

LORCET HD (Hydrocodone-Acetaminophen)

LORCET PLUS (Hydrocodone-Acetaminophen)

LORTAB (Hydrocodone-Acetaminophen)

VERDROCET (Hydrocodone-Acetaminophen)

*Opioid Combinations**-*Opioid Combinations*** ENDOCET (Oxycodone-Acetaminophen)

ENDODAN

Oxycodone-Aspirin QLL (240 per 30 days)

ROXICET (Oxycodone-Acetaminophen)

*Opioid Combinations**-*Tramadol Combinations*** Tramadol-Acetaminophen QLL (240 per 30 days)

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Drug Requirements

*Opioid Partial Agonists**-*Opioid Partial Agonists*** Butorphanol Tartrate QLL (1 per 30 days)

Pentazocine-Naloxone HCl

*Androgens-Anabolic*

*Androgens**-*Androgens*** ANDRODERM

ANDROGEL

ANDROGEL PUMP

ANDROID

Danazol

Testosterone

Testosterone Cypionate

*Anorectal Agents*

*Intrarectal Steroids**-*Intrarectal Steroids*** COLOCORT (Hydrocortisone)

CORTIFOAM

*Rectal Combinations**-*Rectal Anesthetic/Steroids*** LIDAZONE HC (Lidocaine-Hydrocortisone Ace)

PROCTOFOAM HC

*Rectal Steroids**-*Rectal Steroids*** Hydrocortisone Acetate

PROCTO-PAK

PROCTOSOL HC

PROCTOZONE-HC

*Antacids*

*Antacids - Bicarbonate**-*Antacids - Bicarbonate*** Sodium Bicarbonate

*Anthelmintics*

*Anthelmintics**-*Anthelmintics*** ALBENZA

Ivermectin

*Antianginal Agents*

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Drug Requirements

*Nitrates**-*Nitrates*** Isosorbide Dinitrate

Isosorbide Dinitrate ER

Isosorbide Mononitrate

Isosorbide Mononitrate ER

MINITRAN (Nitroglycerin)

NITRO-BID

Nitroglycerin

NITROSTAT

NITRO-TIME (Nitroglycerin ER)

*Antianxiety Agents*

*Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** HydrOXYzine HCl

HydrOXYzine Pamoate

*Antiarrhythmics*

*Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** Disopyramide Phosphate

QuiNIDine Gluconate ER

QuiNIDine Sulfate

QuiNIDine Sulfate ER

*Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** Mexiletine HCl

*Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** Flecainide Acetate

Propafenone HCl

*Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** MULTAQ

PACERONE (Amiodarone HCl)

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Drug Requirements

*Antiasthmatic And Bronchodilator Agents*

*Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** Cromolyn Sodium

*Bronchodilators - Anticholinergics**-*Bronchodilators -Anticholinergics*** ATROVENT HFA

Ipratropium Bromide

SPIRIVA HANDIHALER ST; QLL (30 per 30 days)

SPIRIVA RESPIMAT

TUDORZA PRESSAIR

*Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** Montelukast Sodium QLL (30 per 30 days)

Zafirlukast QLL (60 per 30 days)

*Steroid Inhalants**-*Steroid Inhalants*** Budesonide QLL (120 per 30 days)

FLOVENT DISKUS

FLOVENT HFA

PULMICORT

PULMICORT FLEXHALER QLL (1 per 30 days)

QVAR

*Sympathomimetics**-*Adrenergic Combinations*** ADVAIR DISKUS

ADVAIR HFA

COMBIVENT RESPIMAT

DULERA

Ipratropium-Albuterol

SYMBICORT

*Sympathomimetics**-*Beta Adrenergics*** Albuterol Sulfate ER

Albuterol Sulfate INHALATION QLL (13 per 1 day)

Albuterol Sulfate ORAL

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Drug Requirements Levalbuterol HCl

Metaproterenol Sulfate

PROAIR HFA

PROVENTIL HFA

SEREVENT DISKUS

Terbutaline Sulfate

VENTOLIN HFA

*Xanthines**-*Xanthines*** THEOCHRON (Theophylline ER)

Theophylline

*Anticoagulants*

*Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN (Warfarin Sodium)

*Heparins And Heparinoid-Like Agents**-*Heparins And Heparinoid-Like Agents*** Heparin Sodium (Porcine)

Heparin Sodium (Porcine) PF

*Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins*** Enoxaparin Sodium INJECTION

Enoxaparin Sodium SUBCUTANEOUS* QLL (20 per 10 days)

FRAGMIN QLL (10 per 10 days)

*Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents*** Fondaparinux Sodium

*Antidiabetics*

*Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** Acarbose

*Antidiabetic Combinations**-*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ST

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Drug Requirements JANUMET XR ST

*Antidiabetic Combinations**-*Meglitinide-Biguanide Combinations*** PRANDIMET

*Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl

GlyBURIDE-MetFORMIN

*Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedione Combinations*** Pioglitazone HCl-Glimepiride QLL (30 per 30 days)

*Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET QLL (60 per 30 days)

Pioglitazone HCl-Metformin HCl QLL (90 per 30 days)

*Biguanides**-*Biguanides*** MetFORMIN HCl

MetFORMIN HCl ER

*Diabetic Other**-*Diabetic Other*** GLUCAGEN HYPOKIT

GLUCAGON EMERGENCY

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ST

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYETTA 10 MCG PEN ST

BYETTA 5 MCG PEN ST

*Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA QLL (30 per 30 days)

Pioglitazone HCl QLL (30 per 30 days)

*Insulin**-*Human Insulin*** HUMALOG

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Drug Requirements HUMALOG KWIKPEN

HUMALOG MIX 50/50

HUMALOG MIX 75/25

HUMALOG MIX 75/25 KWIKPEN

HUMULIN R U-500 (CONCENTRATED)

LANTUS

LEVEMIR

NOVOLOG

NOVOLOG MIX 70/30

*Meglitinide Analogues**-*Meglitinide Analogues*** Nateglinide

Repaglinide

*Sulfonylureas**-*Sulfonylureas*** ChlorproPAMIDE

Glimepiride

GlipiZIDE

GLIPIZIDE XL (GlipiZIDE ER)

GlyBURIDE

GlyBURIDE Micronized

TOLAZamide

TOLBUTamide

*Antidiarrheals*

*Antiperistaltic Agents**-*Antiperistaltic Agents*** Lofene

LONOX (Diphenoxylate-Atropine)

Loperamide HCl

Opium Tincture (Paregoric)

*Antidotes*

*Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** CHEMET

*Opioid Antagonists**-*Opioid Antagonists*** Naltrexone HCl

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Drug Requirements

*Antiemetics*

*5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** Granisetron HCl

Ondansetron

Ondansetron HCl

*Antiemetics - Anticholinergic**-*Antiemetics -Anticholinergic*** Meclizine HCl

Trimethobenzamide HCl

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists**-*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND

*Antifungals*

*Antifungals**-*Antifungals*** Bio-Statin

Griseofulvin Microsize

Griseofulvin Ultramicrosize

Nystatin

Terbinafine HCl QLL (84 per 1 Year)

*Imidazole-Related Antifungals**-*Imidazoles*** Ketoconazole

*Imidazole-Related Antifungals**-*Triazoles*** Fluconazole

Itraconazole

SPORANOX

*Antihistamines*

*Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** Brompheniramine Tannate

*Antihistamines - Ethanolamines**-*Antihistamines -Ethanolamines***

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Drug Requirements ARBINOXA (Carbinoxamine Maleate)

Clemastine Fumarate

DiphenhydrAMINE HCl

Pharbedryl

*Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** Cetirizine HCl

Fexofenadine HCl

*Antihistamines - Phenothiazines**-*Antihistamines - Phenothiazines*** PHENADOZ (Promethazine HCl)

PHENERGAN (Promethazine HCl)

Promethazine HCl

PROMETHEGAN (Promethazine HCl)

*Antihistamines - Piperidines**-*Antihistamines -Piperidines*** Cyproheptadine HCl

*Antihyperlipidemics*

*Bile Acid Sequestrants**-*Bile Acid Sequestrants*** Cholestyramine

Colestipol HCl

Micronized Colestipol HCl

PREVALITE (Cholestyramine Light)

*Fibric Acid Derivatives**-*Fibric Acid Derivatives*** Fenofibrate

Fenofibrate Micronized

Fenofibric Acid

Gemfibrozil QLL (60 per 30 days)

*Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium QLL (30 per 30 days)

Fluvastatin Sodium QLL (30 per 30 days)

LESCOL XL QLL (30 per 30 days)

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Drug Requirements Lovastatin ORAL TABLET 10 MG, 20 MG QLL (30 per 30 days)

Lovastatin ORAL TABLET 40 MG QLL (60 per 30 days)

Pravastatin Sodium QLL (30 per 30 days)

Simvastatin QLL (30 per 30 days)

*Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ST

*Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** Niacin ER (Antihyperlipidemic)

*Antihypertensives*

*Ace Inhibitors**-*Ace Inhibitors*** Benazepril HCl

Captopril

Enalapril Maleate

Fosinopril Sodium

Lisinopril ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 5 MG QLL (30 per 30 days)

Lisinopril ORAL TABLET 40 MG QLL (60 per 30 days)

Moexipril HCl

Perindopril Erbumine

Quinapril HCl

Ramipril

Trandolapril

*Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** BENICAR ST; QLL (30 per 30 days)

Candesartan Cilexetil

Irbesartan

Losartan Potassium

Valsartan QLL (60 per 30 days)

*Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** CloNIDine HCl

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Drug Requirements GuanFACINE HCl

Methyldopa

*Antiadrenergic Antihypertensives**-*Antiadrenergics - Peripherally Acting*** Doxazosin Mesylate QLL (30 per 30 days)

Prazosin HCl

Terazosin HCl QLL (30 per 30 days)

*Antiadrenergic Antihypertensives**-*Reserpine*** Reserpine

*Antihypertensive Combinations**-*Ace Inhibitor & Calcium Channel Blocker Combinations*** Amlodipine Besy-Benazepril HCl

*Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** Benazepril-Hydrochlorothiazide

Captopril-Hydrochlorothiazide

Enalapril-Hydrochlorothiazide

Fosinopril Sodium-HCTZ

Lisinopril-Hydrochlorothiazide

Moexipril-Hydrochlorothiazide

Quinapril-Hydrochlorothiazide

*Antihypertensive Combinations**-*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** Methyldopa-Hydrochlorothiazide

*Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** BENICAR HCT ST; QLL (30 per 30 days)

Candesartan Cilexetil-HCTZ

Irbesartan-Hydrochlorothiazide

Losartan Potassium-HCTZ

Valsartan-Hydrochlorothiazide QLL (30 per 30 days)

*Antihypertensive Combinations**-*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides***

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Drug Requirements Amlodipine-Valsartan-HCTZ QLL (30 per 30 days)

*Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** Atenolol-Chlorthalidone

Bisoprolol-Hydrochlorothiazide

Metoprolol-Hydrochlorothiazide

Nadolol-Bendroflumethiazide

Propranolol-HCTZ

*Vasodilators**-*Vasodilators*** HydrALAZINE HCl

Minoxidil

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** MetroNIDAZOLE

Trimethoprim

Vancomycin HCl

*Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** Sulfamethoxazole-Trimethoprim

SULFATRIM PEDIATRIC (Sulfamethoxazole-Trimethoprim)

*Leprostatics**-*Leprostatics*** Dapsone

*Lincosamides**-*Lincosamides*** Clindamycin HCl

Clindamycin Palmitate HCl

*Antimalarials*

*Antimalarials**-*Antimalarials*** Chloroquine Phosphate

DARAPRIM

Hydroxychloroquine Sulfate

Mefloquine HCl

*Antimyasthenic/Cholinergic Agents*

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Drug Requirements

*Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** Pyridostigmine Bromide

*Antimycobacterial Agents*

*Anti Tb Combinations**-*Anti Tb Combinations*** RIFAMATE

*Antimycobacterial Agents**-*Antimycobacterial Agents*** Ethambutol HCl

Isoniazid

PRIFTIN

Pyrazinamide

Rifabutin

Rifampin

*Antineoplastics And Adjunctive Therapies*

*Alkylating Agents**-*Alkylating Agents*** HEXALEN

MYLERAN

*Alkylating Agents**-*Imidazotetrazines*** Temozolomide

*Alkylating Agents**-*Nitrogen Mustards*** ALKERAN

LEUKERAN

*Alkylating Agents**-*Nitrosoureas*** GLEOSTINE

*Antimetabolites**-*Antimetabolites*** Capecitabine

Mercaptopurine

Methotrexate

TABLOID

TREXALL

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Drug Requirements

*Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** LYSODREN

*Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** Bicalutamide

Flutamide

NILANDRON

*Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** FARESTON

SOLTAMOX

Tamoxifen Citrate

*Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** Anastrozole

Exemestane

Letrozole

*Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT

*Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** VANTAS PA

ZOLADEX PA

*Antineoplastic - Hormonal And Related Agents**-*Progestins-Antineoplastic*** Megestrol Acetate

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors***

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Drug Requirements AFINITOR PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** IRESSA

TYKERB

VOTRIENT

*Antineoplastics Misc.**-*Antineoplastics Misc.*** Hydroxyurea

MATULANE PA

*Antineoplastics Misc.**-*Retinoids*** Tretinoin PA

*Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** Leucovorin Calcium

*Chemotherapy Rescue/Antidote Agents**-*Urinary Tract Protective Agents*** MESNEX

*Mitotic Inhibitors**-*Mitotic Inhibitors*** Etoposide

*Antiparkinson Agents*

*Antiparkinson Comt Inhibitors**-*Peripheral Comt Inhibitors*** Entacapone QLL (120 per 30 days)

*Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** Amantadine HCl

Bromocriptine Mesylate

*Antiparkinson Dopaminergics**-*Levodopa Combinations*** Carbidopa-Levodopa

Carbidopa-Levodopa ER

Carbidopa-Levodopa-Entacapone QLL (270 per 30 days)

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Drug Requirements

*Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** MIRAPEX (Pramipexole Dihydrochloride)

Pramipexole Dihydrochloride

ROPINIRole HCl QLL (90 per 30 days)

ROPINIRole HCl ER

*Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl

*Antipsychotics/Antimanic Agents*

*Phenothiazines**-*Phenothiazines*** COMPAZINE (Prochlorperazine)

COMPRO (Prochlorperazine)

Prochlorperazine Maleate

*Antiseptics & Disinfectants*

*Chlorine Antiseptics**-*Chlorine Antiseptics*** Chlorhexidine Gluconate

*Antivirals*

*Hepatitis Agents**-*Hepatitis B Agents*** BARACLUDE

Entecavir

TYZEKA

*Hepatitis Agents**-*Hepatitis C Agents*** MODERIBA ORAL ST

MODERIBA ORAL TABLET

PEGASYS PA

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML

PA

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML

PEGINTRON

PEG-INTRON REDIPEN PAK 4

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Drug Requirements PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 50 MCG/0.5ML

PA

PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 150 MCG/0.5ML, 80 MCG/0.5ML

PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 50 MCG/0.5ML

PEG-INTRON SUBCUTANEOUS* KIT 150 MCG/0.5ML, 80 MCG/0.5ML

PA

REBETOL ST

RIBASPHERE ORAL CAPSULE

RIBASPHERE ORAL TABLET 200 MG

RIBASPHERE ORAL TABLET 400 MG, 600 MG ST

RIBASPHERE RIBAPAK

RIBATAB

Ribavirin ST

*Herpes Agents**-*Herpes Agents - Purine Analogues*** Acyclovir ORAL CAPSULE QLL (60 per 30 days)

Acyclovir ORAL SUSPENSION

Acyclovir ORAL TABLET QLL (60 per 30 days)

ValACYclovir HCl ORAL TABLET 1 GM QLL (30 per 30 days)

ValACYclovir HCl ORAL TABLET 500 MG QLL (60 per 30 days)

*Herpes Agents**-*Herpes Agents - Thymidine Analogues*** Famciclovir

*Influenza Agents**-*Influenza Agents*** Rimantadine HCl QLL (14 Max Qty Per Fill Retail)

*Influenza Agents**-*Neuraminidase Inhibitors*** RELENZA DISKHALER QLL (1 Max Qty Per Fill Retail)

TAMIFLU ORAL CAPSULE 30 MG QLL (20 Max Qty Per Fill Retail)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG QLL (10 Max Qty Per Fill Retail)

TAMIFLU ORAL SUSPENSION RECONSTITUTED QLL (3 Max Qty Per Fill Retail)

*Assorted Classes*

*Chelating Agents**-*Chelating Agents***

Updated: 10/01/2015 P a g e | 2 3


Drug Requirements CUPRIMINE

*Immunomodulators**-*Antileprotics*** THALOMID

*Immunomodulators**-*Immunomodulators For Myelodysplastic Syndromes*** REVLIMID

*Immunosuppressive Agents**-*Cyclosporine Analogs*** CycloSPORINE

GENGRAF (CycloSPORINE Modified)

*Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors*** Mycophenolate Mofetil

Mycophenolic Acid

*Immunosuppressive Agents**-*Macrolide Immunosuppressants*** RAPAMUNE

Sirolimus

Tacrolimus

*Immunosuppressive Agents**-*Purine Analogs*** AZASAN

AzaTHIOprine

*Irrigation Solutions**-*Irrigation Solutions*** ARGYLE STERILE WATER (Sterile Water for Irrigation)

*Potassium Removing Resins**-*Potassium Removing Resins*** KIONEX (Sodium Polystyrene Sulfonate)

SPS (Sodium Polystyrene Sulfonate)

*Beta Blockers*

*Alpha-Beta Blockers**-*Alpha-Beta Blockers*** Carvedilol QLL (60 per 30 days)

Labetalol HCl

Updated: 10/01/2015 P a g e | 2 4


Drug Requirements

*Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective*** Acebutolol HCl

Atenolol

Betaxolol HCl

Bisoprolol Fumarate

Metoprolol Succinate ER QLL (60 per 30 days)

Metoprolol Tartrate

*Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** Nadolol

Pindolol

Propranolol HCl

Propranolol HCl ER

SORINE (Sotalol HCl)

Sotalol HCl (AF)

Timolol Maleate

*Calcium Channel Blockers*

*Calcium Channel Blockers**-*Calcium Channel Blockers*** AFEDITAB CR

AmLODIPine Besylate QLL (30 per 30 days)

CARTIA XT (Diltiazem CD)

Diltiazem HCl QLL (120 per 30 days)

Diltiazem HCl ER QLL (60 per 30 days)

Diltiazem HCl ER Beads QLL (60 per 30 days)

Diltiazem HCl ER Coated Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR

QLL (60 per 30 days)

Diltiazem HCl ER Coated Beads ORAL TABLET EXTENDED RELEASE 24 HR*

Dilt-XR

Felodipine ER

Isradipine

MATZIM LA QLL (60 per 30 days)

Updated: 10/01/2015 P a g e | 2 5


Drug Requirements NiCARdipine HCl

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG


NIFEDICAL XL QLL (30 per 30 days)

NIFEdipine

NIFEdipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 90 MG


NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 90 MG


NiMODipine

Nisoldipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 17 MG, 25.5 MG, 34 MG, 8.5 MG

Nisoldipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 20 MG, 30 MG, 40 MG


TAZTIA XT

Verapamil HCl QLL (120 per 30 days)

Verapamil HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR


Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* QLL (60 per 30 days)

*Cardiotonics*

*Cardiac Glycosides**-*Cardiac Glycosides*** DIGITEK (Digoxin)

DIGOX (Digoxin)

LANOXIN

*Cardiovascular Agents - Misc.*

*Cardiovascular Agents Misc. - Combinations**-*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** Amlodipine-Atorvastatin

Updated: 10/01/2015 P a g e | 2 6


Drug Requirements

*Pulmonary Hypertension - Phosphodiesterase Inhibitors**-*Pulmonary Hypertension - Phosphodiesterase Inhibitors*** ADCIRCA PA; QLL (60 per 30 days)

Sildenafil Citrate PA; QLL (90 per 30 days)

*Cephalosporins*

*Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** Cefadroxil

Cephalexin

*Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation*** Cefaclor

Cefprozil

CEFTIN

Cefuroxime Axetil

*Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation*** Cefdinir

Cefpodoxime Proxetil

CefTRIAXone Sodium QLL (2 Max Qty Per Fill Retail)

SUPRAX ORAL SUSPENSION RECONSTITUTED

SUPRAX ORAL TABLET CHEWABLE QLL (1 Max Qty Per Fill Retail)

*Contraceptives*

*Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral*** AZURETTE (Desogestrel-Ethinyl Estradiol)

KARIVA (Desogestrel-Ethinyl Estradiol)

KIMIDESS (Desogestrel-Ethinyl Estradiol)

NECON 10/11 (28)

PIMTREA (Desogestrel-Ethinyl Estradiol)

Viorele

Updated: 10/01/2015 P a g e | 2 7


Drug Requirements

*Combination Contraceptives - Oral**-*Combination Contraceptives - Oral*** ALTAVERA (Levonorgestrel-Ethinyl Estrad)

APRI (Desogestrel-Ethinyl Estradiol)

AUBRA (Levonorgestrel-Ethinyl Estrad)

AVIANE (Levonorgestrel-Ethinyl Estrad)

BALZIVA (Briellyn)

CHATEAL (Levonorgestrel-Ethinyl Estrad)

CRYSELLE-28

CYCLAFEM 1/35 (Alyacen 1/35)

CYRED (Desogestrel-Ethinyl Estradiol)

DASETTA 1/35 (Alyacen 1/35)

DELYLA (Levonorgestrel-Ethinyl Estrad)

ELINEST

EMOQUETTE (Desogestrel-Ethinyl Estradiol)

ENSKYCE (Desogestrel-Ethinyl Estradiol)

ESTARYLLA (Norgestimate-Eth Estradiol)

FALMINA (Levonorgestrel-Ethinyl Estrad)

GIANVI (Drospirenone-Ethinyl Estradiol)

GILDAGIA (Briellyn)

GILDESS 1.5/30

GILDESS 1/20 (Norethindrone Acet-Ethinyl Est)

GILDESS FE 1.5/30

GILDESS FE 1/20 (Norethin Ace-Eth Estrad-FE)

JUNEL 1.5/30

JUNEL 1/20 (Norethindrone Acet-Ethinyl Est)

JUNEL FE 1.5/30

JUNEL FE 1/20 (Norethin Ace-Eth Estrad-FE)

KELNOR 1/35

KURVELO (Levonorgestrel-Ethinyl Estrad)

LARIN 1.5/30

LARIN 1/20 (Norethindrone Acet-Ethinyl Est)

LARIN FE 1.5/30

Updated: 10/01/2015 P a g e | 2 8


Drug Requirements LARIN FE 1/20 (Norethin Ace-Eth Estrad-FE)

LESSINA (Levonorgestrel-Ethinyl Estrad)

LEVORA 0.15/30 (28) (Levonorgestrel-Ethinyl Estrad)

LORYNA (Drospirenone-Ethinyl Estradiol)

LOW-OGESTREL

LUTERA (Levonorgestrel-Ethinyl Estrad)

Marlissa

MICROGESTIN 1.5/30

MICROGESTIN 1/20 (Norethindrone Acet-Ethinyl Est)

MICROGESTIN FE 1.5/30

MICROGESTIN FE 1/20 (Norethin Ace-Eth Estrad-FE)

MONO-LINYAH (Norgestimate-Eth Estradiol)

MONONESSA (Norgestimate-Eth Estradiol)

NECON 0.5/35 (28)

NECON 1/35 (28) (Alyacen 1/35)

NECON 1/50 (28)

NIKKI (Drospirenone-Ethinyl Estradiol)

NORTREL 0.5/35 (28)

NORTREL 1/35 (21) (Alyacen 1/35)

NORTREL 1/35 (28) (Alyacen 1/35)

OCELLA (Drospirenone-Ethinyl Estradiol)

OGESTREL

ORSYTHIA (Levonorgestrel-Ethinyl Estrad)

PHILITH (Briellyn)

PIRMELLA 1/35 (Alyacen 1/35)

PORTIA-28 (Levonorgestrel-Ethinyl Estrad)

PREVIFEM (Norgestimate-Eth Estradiol)

RECLIPSEN (Desogestrel-Ethinyl Estradiol)

SOLIA (Desogestrel-Ethinyl Estradiol)

SPRINTEC 28 (Norgestimate-Eth Estradiol)

SRONYX (Levonorgestrel-Ethinyl Estrad)

SYEDA (Drospirenone-Ethinyl Estradiol)

TARINA FE 1/20 (Norethin Ace-Eth Estrad-FE)

Updated: 10/01/2015 P a g e | 2 9


Drug Requirements VESTURA (Drospirenone-Ethinyl Estradiol)

VYFEMLA (Briellyn)

WERA

ZARAH (Drospirenone-Ethinyl Estradiol)

ZENCHENT (Briellyn)

ZOVIA 1/35E (28)

ZOVIA 1/50E (28)

*Combination Contraceptives - Oral**-*Continuous Contraceptives - Oral*** AMETHYST (Levonorgestrel-Ethinyl Estrad)

*Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral*** AMETHIA (Levonorgest-Eth Estrad 91-Day)

AMETHIA LO (Levonorgest-Eth Estrad 91-Day)

ASHLYNA (Levonorgest-Eth Estrad 91-Day)

CAMRESE (Levonorgest-Eth Estrad 91-Day)

DAYSEE (Levonorgest-Eth Estrad 91-Day)

INTROVALE (Levonorgest-Eth Estrad 91-Day)

JOLESSA (Levonorgest-Eth Estrad 91-Day)

QUASENSE (Levonorgest-Eth Estrad 91-Day)

SETLAKIN (Levonorgest-Eth Estrad 91-Day)

*Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral*** ARANELLE

CAZIANT

CESIA

CYCLAFEM 7/7/7 (Alyacen 7/7/7)

DASETTA 7/7/7 (Alyacen 7/7/7)

ENPRESSE-28

LEENA

LEVONEST

MYZILRA

NECON 7/7/7 (Alyacen 7/7/7)

Updated: 10/01/2015 P a g e | 3 0


Drug Requirements NORTREL 7/7/7 (Alyacen 7/7/7)

PIRMELLA 7/7/7 (Alyacen 7/7/7)

TILIA FE

TRI-ESTARYLLA (Norgestim-Eth Estrad Triphasic)

TRI-LEGEST FE

TRI-LINYAH (Norgestim-Eth Estrad Triphasic)

TRINESSA (28) (Norgestim-Eth Estrad Triphasic)

TRI-PREVIFEM (Norgestim-Eth Estrad Triphasic)

TRI-SPRINTEC (Norgestim-Eth Estrad Triphasic)

TRIVORA (28)

VELIVET

*Combination Contraceptives - Transdermal**-*Combination Contraceptives - Transdermal*** XULANE QLL (3 per 28 days)

*Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal*** NUVARING QLL (1 per 30 days)

*Emergency Contraceptives**-*Emergency Contraceptives*** ELLA

MY WAY QLL (3 per 1 Years)

NEXT CHOICE ONE DOSE (Levonorgestrel)

*Progestin Contraceptives - Implants**-*Progestin Contraceptives - Implants*** NEXPLANON QLL (1 per 3 Yearss)

*Progestin Contraceptives - Injectable**-*Progestin Contraceptives - Injectable*** MedroxyPROGESTERone Acetate QLL (1 per 90 days)

*Progestin Contraceptives - Iud**-*Progestin Contraceptives - Iud*** MIRENA QLL (1 per 5 Yearss)

SKYLA QLL (1 per 3 Yearss)

Updated: 10/01/2015 P a g e | 3 1


Drug Requirements

*Progestin Contraceptives - Oral**-*Progestin Contraceptives - Oral*** CAMILA (Norethindrone)

DEBLITANE (Norethindrone)

ERRIN (Norethindrone)

HEATHER (Norethindrone)

JENCYCLA (Norethindrone)

JOLIVETTE (Norethindrone)

LYZA (Norethindrone)

NORA-BE (Norethindrone)

NORLYROC (Norethindrone)

SHAROBEL (Norethindrone)

*Corticosteroids*

*Glucocorticosteroids**-*Glucocorticosteroids*** Cortisone Acetate

DELTASONE (PredniSONE)

Dexamethasone

Hydrocortisone

MethylPREDNISolone

MethylPREDNISolone (Pak)

PrednisoLONE

PrednisoLONE Sodium Phosphate

PredniSONE

PredniSONE (Pak)

*Mineralocorticoids**-*Mineralocorticoids*** Fludrocortisone Acetate

*Cough/Cold/Allergy*

*Antitussives**-*Antitussive - Nonnarcotic*** Benzonatate

*Antitussives**-*Antitussive - Opioid*** Hydromet

TUSSIGON (Hydrocodone-Homatropine)

Updated: 10/01/2015 P a g e | 3 2


Drug Requirements

*Cough/Cold/Allergy Combinations**-*Antitussive-Expectorants-Decongestant*** Biotuss

*Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** Entre-B

Promethazine VC Plain

Promethazine-Phenylephrine

*Cough/Cold/Allergy Combinations**-*Non-Narc Antitussive-Antihistamine*** Promethazine-DM

*Cough/Cold/Allergy Combinations**-*Non-Narc Antitussive-Decongestant-Antihistamine*** Phenylephrine-Chlorphen-DM

TGQ 50PSE/3BRM/30DM

*Cough/Cold/Allergy Combinations**-*Opioid Antitussive-Antihistamine*** Promethazine-Codeine

*Cough/Cold/Allergy Combinations**-*Opioid Antitussive-Decongestant-Antihistamine*** Phenyleph-Promethazine-Cod

Promethazine VC/Codeine

*Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** HYPERSAL

NEBUSAL (Sodium Chloride)

PULMOSAL (Sodium Chloride)

Sodium Chloride

*Mucolytics**-*Mucolytics*** Acetylcysteine

*Dermatologicals*

*Acne Products**-*Acne Antibiotics*** CLINDACIN ETZ (Clindamycin Phosphate)

Updated: 10/01/2015 P a g e | 3 3


Drug Requirements CLINDACIN-P (Clindamycin Phosphate)

CLINDAMAX (Clindamycin Phosphate)

Clindamycin Phosphate

Ery

Erythromycin

Sulfacetamide Sodium

Sulfacetamide Sodium (Acne)

*Acne Products**-*Acne Combinations*** AVAR CLEANSER (Sulfacetamide Sodium-Sulfur)

Benzoyl Peroxide-Erythromycin

BP Cleansing Wash

CERISA WASH (BP 10-1)

Clindamycin Phos-Benzoyl Perox

NEUAC (Clindamycin Phos-Benzoyl Perox)

PRASCION (Sulfacetamide Sodium-Sulfur)

PRASCION FC (Sulfacetamide Sodium-Sulfur)

ROSANIL CLEANSER (Sulfacetamide Sodium-Sulfur)

ROSULA (Sulfacetamide Sodium-Sulfur)

Sulfacetamide Sodium-Sulfur

*Acne Products**-*Acne Products*** Acne Medication 5

Adapalene

AMNESTEEM

AVITA QLL (20 per 30 days)

BENZEPRO CREAMY WASH (BP Wash)

BENZIQ WASH (BP Wash)

Benzoyl Peroxide

Benzoyl Peroxide Wash

BP Foaming Wash

BP Wash

CLARAVIS

CLEARPLEX X (Benzoyl Peroxide)

MYORISAN

Updated: 10/01/2015 P a g e | 3 4


Drug Requirements OSCION CLEANSER (Benzoyl Peroxide Cleanser)

PR BENZOYL PEROXIDE WASH (BP Wash)

Tretinoin EXTERNAL 0.01 % QLL (20 per 30 days)

Tretinoin EXTERNAL 0.025 %

Tretinoin EXTERNAL CREAM 0.025 %

Tretinoin EXTERNAL CREAM 0.05 %, 0.1 % QLL (20 per 30 days)

ZENATANE

*Antibiotics - Topical**-*Antibiotics - Topical*** Gentamicin Sulfate

Mupirocin

Mupirocin Calcium

*Antifungals - Topical**-*Antifungals - Topical Combinations*** Clotrimazole-Betamethasone

DERMAZENE (Hydrocortisone-Iodoquinol)

Nystatin-Triamcinolone

*Antifungals - Topical**-*Antifungals - Topical*** CICLODAN (Ciclopirox)

Ciclopirox Olamine

Ciclopirox-Vitamin E

NYAMYC (Nystatin)

Nystatin

NYSTOP (Nystatin)

*Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** Clotrimazole

Clotrimazole Anti-Fungal

Econazole Nitrate

Ketoconazole

KP Clotrimazole

*Antineoplastic Or Premalignant Lesion Agents -Topical**-*Antineoplastic Antimetabolites - Topical*** FLUOROPLEX

Updated: 10/01/2015 P a g e | 3 5


Drug Requirements Fluorouracil

*Antineoplastic Or Premalignant Lesion Agents -Topical**-*Topical Selective Retinoid X Receptor Agonists*** TARGRETIN

*Antipsoriatics**-*Antipsoriatics - Systemic*** Methoxsalen Rapid

*Antipsoriatics**-*Antipsoriatics*** Calcipotriene

CALCITRENE (Calcipotriene)

VECTICAL (Calcitriol)

*Antiseborrheic Products**-*Antiseborrheic Combinations*** Selenium Sulfide

Selenium Sulf-Pyrithione-Urea

*Antiseborrheic Products**-*Antiseborrheic Products*** SEB-PREV WASH (Sulfacetamide Sodium)

Selenium Sulfide

*Antivirals - Topical**-*Antivirals - Topical*** Acyclovir

ZOVIRAX

*Burn Products**-*Burn Products*** SSD (Silver Sulfadiazine)

*Cauterizing Agents**-*Cauterizing Agent Combinations*** ARZOL SILVER NIT APPLICATORS (Grafco Silver Nit Applicator)

*Corticosteroids - Topical**-*Corticosteroids -Topical*** Ala Cort

Alclometasone Dipropionate

AlphaTrex

Updated: 10/01/2015 P a g e | 3 6


Drug Requirements Amcinonide

Betamethasone Dipropionate

Betamethasone Dipropionate Aug

Betamethasone Valerate

Clobetasol Propionate E

CLODAN (Clobetasol Propionate)

CORMAX SCALP APPLICATION (Clobetasol Propionate)

Desonide

Desoximetasone

Diflorasone Diacetate

Fluocinolone Acetonide

Fluocinonide

Fluocinonide-E

Fluticasone Propionate

Halobetasol Propionate

Hydrocortisone

Hydrocortisone Acetate

Hydrocortisone Butyr Lipo Base

Hydrocortisone Butyrate

Hydrocortisone Micronized

Hydrocortisone Valerate

LOKARA (Desonide)

Mometasone Furoate

Prednicarbate

PROCTOZONE-HC (Hydrocortisone)

Scalacort

Triamcinolone Acetonide

TRIDERM (Triamcinolone Acetonide)

*Emollients**-*Emollients*** Ammonium Lactate

LACLOTION (Ammonium Lactate)

NEOSALUS

TROPAZONE

Updated: 10/01/2015 P a g e | 3 7


Drug Requirements

*Enzymes - Topical**-*Enzymes - Topical*** SANTYL

*Immunomodulating Agents - Topical**-*Immunomodulators Imidazoquinolinamines -Topical*** Imiquimod

*Immunosuppressive Agents - Topical**-*Macrolide Immunosuppressants - Topical*** ELIDEL ST; QLL (30 per 30 days)

*Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents*** CONDYLOX

Podofilox

SALACYN (Salicylic Acid)

*Local Anesthetics - Topical**-*Local Anesthetics -Topical*** GLYDO (Lidocaine HCl)

Lidocaine EXTERNAL OINTMENT

Lidocaine EXTERNAL PATCH QLL (90 per 30 days)

Lidocaine HCl

Lidopin

Premium Lidocaine

*Local Anesthetics - Topical**-*Topical Anesthetic Combinations*** Lidocaine-Prilocaine

LIVIXIL PAK (Lidocaine-Prilocaine)

RELADOR PAK (Lidocaine-Prilocaine)

RELADOR PAK PLUS (Lidocaine-Prilocaine)

*Misc. Topical**-*Skin Cleansers*** Essentra Wipes 9x9"

*Rosacea Agents**-*Rosacea Agents*** ROSADAN (MetroNIDAZOLE)

Updated: 10/01/2015 P a g e | 3 8


Drug Requirements

*Scabicides & Pediculicides**-*Scabicides & Pediculicides*** ACTICIN (Permethrin)

Lindane

Malathion

ULESFIA

*Digestive Aids*

*Digestive Enzymes**-*Digestive Enzymes*** CREON

PANCREAZE

Pancrelipase (Lip-Prot-Amyl)

ZENPEP

*Diuretics*

*Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** AcetaZOLAMIDE

AcetaZOLAMIDE ER

Methazolamide

*Diuretic Combinations**-*Diuretic Combinations*** Amiloride-Hydrochlorothiazide

Spironolactone-HCTZ

Triamterene-HCTZ

*Loop Diuretics**-*Loop Diuretics*** Bumetanide

Furosemide

Torsemide

*Potassium Sparing Diuretics**-*Potassium Sparing Diuretics*** AMILoride HCl

Spironolactone

*Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics*** Chlorothiazide

Updated: 10/01/2015 P a g e | 3 9


Drug Requirements Chlorthalidone

Hydrochlorothiazide

Indapamide

Methyclothiazide

Metolazone

*Endocrine And Metabolic Agents - Misc.*

*Bone Density Regulators**-*Bisphosphonates*** Alendronate Sodium ORAL SOLUTION

Alendronate Sodium ORAL TABLET 10 MG, 40 MG, 5 MG QLL (30 per 30 days)

Alendronate Sodium ORAL TABLET 35 MG, 70 MG QLL (4 per 30 days)

Etidronate Disodium

Ibandronate Sodium

*Bone Density Regulators**-*Calcitonins*** Calcitonin (Salmon)

*Growth Hormones**-*Growth Hormones*** OMNITROPE PA

*Hormone Receptor Modulators**-*Selective Estrogen Receptor Modulators (Serms)*** Raloxifene HCl QLL (30 per 30 days)

*Metabolic Modifiers**-*Calcimimetic Agents*** SENSIPAR

*Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs*** Calcitriol

Paricalcitol

*Posterior Pituitary Hormones**-*Vasopressin*** Desmopressin Ace Rhinal Tube QLL (1 per 30 days)

Desmopressin Ace Spray Refrig QLL (1 per 30 days)

Desmopressin Acetate QLL (90 per 30 days)

Desmopressin Acetate Spray QLL (1 per 30 days)

*Prolactin Inhibitors**-*Dopamine Receptor Agonists*** Cabergoline

Updated: 10/01/2015 P a g e | 4 0


Drug Requirements

*Somatostatic Agents**-*Somatostatic Agents*** SOMATULINE DEPOT PA

*Estrogens*

*Estrogen Combinations**-*Estrogen & Progestin*** CLIMARA PRO

COMBIPATCH

JINTELI (Norethindrone-Eth Estradiol)

LOPREEZA (Estradiol-Norethindrone Acet)

MIMVEY (Estradiol-Norethindrone Acet)

MIMVEY LO (Estradiol-Norethindrone Acet)

Norethindrone-Eth Estradiol

PREFEST

PREMPHASE

PREMPRO

*Estrogens**-*Estrogens*** Estradiol ORAL

Estradiol TRANSDERMAL PATCH BIWEEKLY

Estradiol TRANSDERMAL PATCH WEEKLY QLL (4 per 30 days)

MENEST

ORTHO-EST 0.625 (Estropipate)

ORTHO-EST 1.25 (Estropipate)

PREMARIN

*Fluoroquinolones*

*Fluoroquinolones**-*Fluoroquinolones*** Ciprofloxacin HCl QLL (28 per 30 days)

Ciprofloxacin-Ciproflox HCl ER QLL (3 Max Qty Per Fill Retail)

Levofloxacin

Ofloxacin

*Gastrointestinal Agents - Misc.*

*Gallstone Solubilizing Agents**-*Gallstone Solubilizing Agents*** Ursodiol

Updated: 10/01/2015 P a g e | 4 1


Drug Requirements

*Gastrointestinal Chloride Channel Activators**-*Gastrointestinal Chloride Channel Activators*** AMITIZA QLL (60 per 30 days)

*Gastrointestinal Stimulants**-*Gastrointestinal Stimulants*** Metoclopramide HCl

*Inflammatory Bowel Agents**-*Inflammatory Bowel Agents*** ASACOL HD

Balsalazide Disodium

CANASA

DELZICOL

DIPENTUM

Mesalamine

PENTASA

SULFAZINE (SulfaSALAzine)

SULFAZINE EC (SulfaSALAzine)

*Inflammatory Bowel Agents**-*Tumor Necrosis Factor Alpha Blockers*** REMICADE PA

*Phosphate Binder Agents**-*Phosphate Binder Agents*** Calcium Acetate

RENVELA

*Genitourinary Agents - Miscellaneous*

*Acidifiers**-*Phosphates*** K-PHOS NO 2

*Alkalinizers**-*Citrates*** Citric Acid-Sodium Citrate

Cytra-2

CYTRA-3

Cytra-K

Pot & Sod Cit-Cit Ac

Updated: 10/01/2015 P a g e | 4 2


Drug Requirements Potassium Citrate ER

Potassium Citrate-Citric Acid

Sod Citrate-Citric Acid

TARON-CRYSTALS (Cytra K Crystals)

Tricitrates

Virtrate-2

Virtrate-3

Virtrate-K

*Genitourinary Irrigants**-*Genitourinary Irrigants*** ARGYLE STERILE SALINE (Sodium Chloride)

CURITY STERILE SALINE (Sodium Chloride)

*Interstitial Cystitis Agents**-*Interstitial Cystitis Agents*** ELMIRON

*Prostatic Hypertrophy Agents**-*5-Alpha Reductase Inhibitors*** Finasteride

*Prostatic Hypertrophy Agents**-*Alpha 1-Adrenoceptor Antagonists*** Alfuzosin HCl ER

Tamsulosin HCl QLL (60 per 30 days)

*Urinary Analgesics**-*Urinary Analgesics*** PHENAZO (Phenazopyridine HCl)

Phenazopyridine HCl

*Gout Agents*

*Gout Agent Combinations**-*Gout Agent Combinations*** Colchicine-Probenecid

*Gout Agents**-*Gout Agents*** Allopurinol

Colchicine

ULORIC ST

*Uricosurics**-*Uricosurics***

Updated: 10/01/2015 P a g e | 4 3


Drug Requirements Probenecid

*Hematological Agents - Misc.*

*Hematorheologic Agents**-*Hematorheologic Agents*** Pentoxifylline ER

*Platelet Aggregation Inhibitors**-*Phosphodiesterase Iii Inhibitors*** Cilostazol

*Platelet Aggregation Inhibitors**-*Platelet Aggregation Inhibitors*** Dipyridamole

*Platelet Aggregation Inhibitors**-*Quinazoline Agents*** Anagrelide HCl

*Platelet Aggregation Inhibitors**-*Thienopyridine Derivatives*** Clopidogrel Bisulfate QLL (30 per 30 days)

*Hematopoietic Agents*

*Agents For Sickle Cell Anemia**-*Cytotoxic Agents*** DROXIA

*Cobalamins**-*Cobalamins*** Cyanocobalamin

*Folic Acid/Folates**-*Folic Acid/Folates*** Folic Acid

*Hematopoietic Growth Factors**-*Erythropoiesis-Stimulating Agents (Esas)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 500 MCG/ML, 60 MCG/ML

PA

EPOGEN PA

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Drug Requirements PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PROCRIT INJECTION SOLUTION 40000 UNIT/ML PA

*Hematopoietic Growth Factors**-*Granulocyte Colony-Stimulating Factors (G-Csf)*** NEULASTA PA

NEULASTA DELIVERY KIT

NEUPOGEN PA

*Hematopoietic Growth Factors**-*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE PA

*Hematopoietic Growth Factors**-*Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA PA

*Hematopoietic Mixtures**-*Folic Acid/Folate Combinations*** FA-Vitamin B-6-Vitamin B-12

Folplex 2.2

*Hematopoietic Mixtures**-*Iron Combinations*** FE C PLUS

ICAR-C PLUS

*Stem Cell Mobilizers**-*Cxcr4 Receptor Antagonist*** MOZOBIL

*Laxatives*

*Laxative Combinations**-*Bowel Evacuant Combinations*** GAVILYTE-C (PEG 3350/Electrolytes)

GAVILYTE-G (PEG-3350/Electrolytes)

GAVILYTE-N WITH FLAVOR PACK (PEG 3350-KCl-Na Bicarb-NaCl)

TRILYTE (PEG 3350-KCl-Na Bicarb-NaCl)

*Laxatives - Miscellaneous**-*Laxatives - Miscellaneous***

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Drug Requirements Constulose

Lactulose

PEGYLAX (Polyethylene Glycol 3350)

*Macrolides*

*Azithromycin**-*Azithromycin*** Azithromycin ORAL PACKET

Azithromycin ORAL SUSPENSION RECONSTITUTED

Azithromycin ORAL TABLET 250 MG QLL (12 per 30 days)

Azithromycin ORAL TABLET 500 MG

Azithromycin ORAL TABLET 600 MG QLL (8 per 30 days)

*Clarithromycin**-*Clarithromycin*** Clarithromycin ER QLL (14 per 30 days)

Clarithromycin ORAL SUSPENSION RECONSTITUTED

Clarithromycin ORAL TABLET QLL (28 per 30 days)

*Erythromycins**-*Erythromycins*** E.E.S. 400 (Erythromycin Ethylsuccinate)

E.E.S. GRANULES

ERYPED 200

ERYPED 400

ERYTHROCIN STEARATE

Erythromycin Base

*Medical Devices*

*Contraceptives**-*Cervical Caps*** FEMCAP

PRENTIF CAVITY-RIM CERV CAP

PRENTIF FITTING SET

*Contraceptives**-*Diaphragms*** OMNIFLEX DIAPHRAGM

ORTHO DIAPHRAGM COIL

ORTHO DIAPHRAGM FLAT

WIDE-SEAL DIAPHRAGM 60



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Drug Requirements WIDE-SEAL DIAPHRAGM 75





*Misc. Devices**-*Applicators,Cotton Balls,Etc*** ALCOH-GLOVE CONTOURED WIPE (Alcohol Wipes)

*Parenteral Therapy Supplies**-*Needles & Syringes*** ASSURE ID INSULIN SAFETY SYR

BD ECLIPSE SYRINGE

BD INSULIN SYRINGE ULTRAFINE

MAGELLAN INSULIN SAFETY SYR

MONOJECT INSULIN SYRINGE

MONOJECT MAGELLAN SYRINGE

MONOJECT SAFETY SYRINGE/SHIELD

MONOJECT SYRINGE

MONOJECT ULTRA COMFORT SYRINGE

ULTICARE INSULIN SAFETY SYR

*Respiratory Therapy Supplies**-*Nebulizers*** Nebulizer

Nebulizer Compressor

Nebulizer Updraft-Style

*Respiratory Therapy Supplies**-*Peak Flow Meters*** TRUZONE PEAK FLOW METER QLL (1 per 1 Year)

*Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MINI CHAMBER (Valved Holding Chamber)

AEROCHAMBER MV (Valved Holding Chamber)

AEROCHAMBER PLUS FLO-VU (Valved Holding Chamber)

AEROCHAMBER PLUS FLO-VU LARGE (Valved Holding Chamber)

AEROCHAMBER PLUS FLO-VU MEDIUM (Valved Holding Chamber)

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Drug Requirements AEROCHAMBER PLUS FLO-VU SMALL (Valved Holding Chamber)

AEROCHAMBER PLUS FLO-VU W/MASK (Valved Holding Chamber)

AEROCHAMBER PLUS FLOW VU (Valved Holding Chamber)

AEROCHAMBER W/FLOWSIGNAL (Valved Holding Chamber)

AEROCHAMBER Z-STAT PLUS (Valved Holding Chamber)

AEROCHAMBER Z-STAT PLUS CHAMBR (Valved Holding Chamber)

AEROCHAMBER Z-STAT PLUS/LARGE (Valved Holding Chamber)

AEROCHAMBER Z-STAT PLUS/MEDIUM (Valved Holding Chamber)

AEROCHAMBER Z-STAT PLUS/SMALL (Valved Holding Chamber)

AEROVENT PLUS (Valved Holding Chamber)

BREATHERITE (Valved Holding Chamber)

BREATHERITE COLL SPACER ADULT (Valved Holding Chamber)

BREATHERITE COLL SPACER CHILD (Valved Holding Chamber)

BREATHERITE COLL SPACER INFANT (Valved Holding Chamber)

BREATHERITE RIGID SPACER/MASK (Valved Holding Chamber)

BREATHERITE SPACER NEONATE (Valved Holding Chamber)

BREATHERITE SPACER SMALL CHILD (Valved Holding Chamber)

BREATHERITE/LARGE MASK (Valved Holding Chamber)

BREATHERITE/MEDIUM MASK (Valved Holding Chamber)

BREATHERITE/SMALL MASK (Valved Holding Chamber)

EASIVENT (Valved Holding Chamber)

EASIVENT MASK LARGE (Valved Holding Chamber)

EASIVENT MASK MEDIUM (Valved Holding Chamber)

EASIVENT MASK SMALL (Valved Holding Chamber)

E-Z SPACER (Valved Holding Chamber)

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Drug Requirements E-Z SPACER THE BODY GUARDS PK (Valved Holding Chamber)

FLEXICHAMBER (Valved Holding Chamber)

INSPIRACHAMBER/MEDIUM (Valved Holding Chamber)

INSPIRACHAMBER/MOUTHPIECE (Valved Holding Chamber)

INSPIRACHAMBER/SMALL (Valved Holding Chamber)

INSPIREASE QLL (1 per 1 Year)

LITEAIRE (Valved Holding Chamber)

MICROCHAMBER (Valved Holding Chamber)

MICROSPACER (Valved Holding Chamber)

OPTICHAMBER ADVANTAGE (Valved Holding Chamber)

OPTICHAMBER ADVANTAGE-LG MASK (Valved Holding Chamber)

OPTICHAMBER ADVANTAGE-MED MASK (Valved Holding Chamber)

OPTICHAMBER ADVANTAGE-SM MASK (Valved Holding Chamber)

OPTICHAMBER DIAMOND (Valved Holding Chamber)

OPTICHAMBER DIAMOND-LG MASK (Valved Holding Chamber)

OPTICHAMBER DIAMOND-MD MASK (Valved Holding Chamber)

OPTICHAMBER DIAMOND-SM MASK (Valved Holding Chamber)

OPTIHALER (Valved Holding Chamber)

POCKET CHAMBER (Valved Holding Chamber)

POCKET SPACER (Valved Holding Chamber)

RITEFLO (Valved Holding Chamber)

VORTEX VALVED HOLDING CHAMBER (Valved Holding Chamber)

WATCHHALER (Valved Holding Chamber)

*Migraine Products*

*Migraine Combinations**-*Ergot Combinations*** CAFERGOT

MIGERGOT

*Migraine Products**-*Migraine Products***

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Drug Requirements Dihydroergotamine Mesylate QLL (8 per 30 days)

ERGOMAR

*Serotonin Agonists**-*Selective Serotonin Agonists 5-Ht(1)*** ALSUMA (SUMAtriptan Succinate) QLL (4 per 30 days)

Naratriptan HCl

RELPAX QLL (6 per 30 days)

Rizatriptan Benzoate ORAL TABLET QLL (12 per 30 days)

Rizatriptan Benzoate ORAL TABLET DISPERSIBLE

SUMAtriptan QLL (6 per 30 days)

SUMAtriptan Succinate ORAL QLL (9 per 30 days)

SUMAtriptan Succinate Refill QLL (4 per 30 days)

SUMAtriptan Succinate SUBCUTANEOUS* QLL (4 per 30 days)

*Minerals & Electrolytes*

*Bicarbonates**-*Bicarbonates*** Sodium Bicarbonate

*Fluoride**-*Fluoride Combinations*** FLUOR-A-DAY

*Fluoride**-*Fluoride*** FLUORABON

FLUOR-A-DAY (Fluoritab)

FLURA-DROPS (Fluoritab)

KARIDIUM (Fluoritab)

LUDENT (Fluoritab)

NAFRINSE (Fluoritab)

NAFRINSE DROPS (Fluoritab)

Sodium Fluoride

*Phosphate**-*Phosphate*** K-PHOS

PHOSPHA 250 NEUTRAL (Virt-Phos 250 Neutral)

*Potassium**-*Potassium Combinations*** Effervescent Pot Chloride

Pot Bicarb-Pot Chloride

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Drug Requirements

*Potassium**-*Potassium*** EFFER-K (K-Effervescent)

KLOR-CON (Potassium Chloride ER)

KLOR-CON 10 (Potassium Chloride ER)

KLOR-CON M10 (Potassium Chloride Crys ER)

KLOR-CON M15

KLOR-CON M20 (Potassium Chloride Crys ER)

KLOR-CON SPRINKLE (Potassium Chloride ER)

KLOR-CON/EF (K-Effervescent)

K-PRIME (K-Effervescent)

K-SOL (Potassium Chloride)

K-Vescent

Potassium Bicarbonate

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral**-*Anesthetics Topical Oral*** Lidocaine HCl

Lidocaine Viscous

*Anti-Infectives - Throat**-*Anti-Infectives - Throat*** Clotrimazole

Nystatin

*Antiseptics - Mouth/Throat**-*Antiseptics - Mouth/Throat*** PAROEX (Chlorhexidine Gluconate)

PERIOGARD (Chlorhexidine Gluconate)

*Dental Products**-*Dental Products - Combinations*** FLUORIDEX SENSITIVITY RELIEF

*Dental Products**-*Fluoride Dental Products*** CAVAREST (SF)

CAVIRINSE (Neutral Sodium Fluoride)

CONTROLRX (SF 5000 Plus)

DENTA 5000 PLUS (SF 5000 Plus)

DENTAGEL (SF)

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Drug Requirements FLUORIDEX DAILY DEFENSE (SF)

FLUORIDEX ENHANCED WHITENING (SF)

KARIGEL (SF)

KARIGEL-N (SF)

NEUTRAGARD ADVANCED (SF)

PHOS-FLUR (SF)

*Steroids - Mouth/Throat**-*Steroids -Mouth/Throat*** ORALONE (Triamcinolone Acetonide)

*Throat Products - Misc.**-*Saliva Stimulants*** Pilocarpine HCl

*Multivitamins*

*Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** Biocel

CORVITE FREE (B-Plex Plus)

LYSIPLEX PLUS (B-Plex Plus)

NUTRIFAC ZX (B-Plex Plus)

VIC-FORTE (V-C Forte)

Vit B3-AzelAc-Turm-FA-B6-Zn-CU

VITA S FORTE (B-Plex Plus)

VITACEL (B-Plex Plus)

Vita-Min

*Ped Multi Vitamins W/Fl & Fe**-*Ped Multi Vitamins W/Fl & Fe*** Multi-Vit/Fluoride/Iron

Multi-Vitamin/Fluoride/Iron

*Ped Multi Vitamins W/Fl & Fe**-*Ped Vitamins Acd Fluoride & Iron*** Tri-Vit/Fluoride/Iron

*Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride*** Multi Vitamin/Fluoride

Multi-Vit/Fluoride

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Drug Requirements Multivitamin/Fluoride

Multi-Vitamins/Fluoride

MVC-FLUORIDE (Multivitamins/Fluoride)

QUFLORA PEDIATRIC (Multi-Vitamin/Fluoride)

*Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/ Fluoride*** Triple-Vitamin/Fluoride

Tri-Vit/Fluoride

Tri-Vitamin/Fluoride

Vitamins ACD-Fluoride

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa*** BP MultiNatal Plus

CompleteNate

CONCEPT DHA (Virt-C DHA)

Dothelle DHA

INATAL ADVANCE (Ultra Tabs)

INATAL GT (Ultra Tabs)

INATAL ULTRA (Ultra Tabs)

M-VIT (Prenatal Plus)

Mynatal Plus

NIVA-PLUS (Prenatal Plus)

O-CAL FA (Prenatal Plus)

PNV Folic Acid + Iron

PNV Prenatal Plus Multivitamin

PNV-Select

Prenatabs FA

PRENATABS RX

Prenatal

Prenatal 19

Prenatal Low Iron

PRENATAL-U (PNV-VP-U)

PrePLUS

SELECT-OB

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Drug Requirements Se-Natal 19

TARON-C DHA (Virt-C DHA)

TriAdvance

TRICARE (Prenatal Plus)

TRINATE

VINATE AZ EXTRA

VINATE CALCIUM

VINATE II

VINATE M

VINATE ONE (Trinatal Rx 1)

VITAFOL-OB (Mynatal-Z)

Vol-Plus

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa-Dha*** Folcal DHA

PNV-DHA

SELECT-OB+DHA

VEMAVITE-PRX 2 (PNV-DHA+Docusate)

*Prenatal Vitamins**-*Prenatal Vitamins*** BP FoliNatal Plus B

*Specialty Vitamins Products**-*Specialty Vitamins Products*** Urosex

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants**-*Central Muscle Relaxants*** Baclofen

Carisoprodol QLL (120 per 30 days)

Chlorzoxazone

Cyclobenzaprine HCl QLL (120 per 30 days)

Metaxalone QLL (120 per 30 days)

Methocarbamol QLL (120 per 30 days)

TiZANidine HCl

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Drug Requirements

*Direct Muscle Relaxants**-*Direct Muscle Relaxants*** Dantrolene Sodium

*Muscle Relaxant Combinations**-*Muscle Relaxant Combinations*** Carisoprodol-Aspirin

Carisoprodol-Aspirin-Codeine

*Nasal Agents - Systemic And Topical*

*Nasal Antiallergy**-*Nasal Antihistamines*** Azelastine HCl NASAL SOLUTION 0.1 % QLL (60 per 30 days)

Azelastine HCl NASAL SOLUTION 0.15 %

*Nasal Anticholinergics**-*Nasal Anticholinergics*** Ipratropium Bromide

*Nasal Steroids**-*Nasal Steroids*** Flunisolide ST

Fluticasone Propionate ST

NASONEX QLL (2 per 30 days)

Triamcinolone Acetonide

*Sympathomimetic Decongestants**-*Systemic Decongestants*** Pseudoephedrine HCl

*Neuromuscular Agents*

*Als Agents**-*Benzathiazoles*** Riluzole

*Ophthalmic Agents*

*Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** Polyvinyl Alcohol

*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic Combinations*** COMBIGAN

Dorzolamide HCl-Timolol Mal

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Drug Requirements

*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic*** Betaxolol HCl

BETOPTIC-S

Carteolol HCl

Levobunolol HCl

Metipranolol

Timolol Maleate

*Cycloplegic Mydriatics**-*Cycloplegic Mydriatics*** Atropine Sulfate

Cyclopentolate HCl

HOMATROPAIRE (Homatropine HBr)

Tropicamide

*Miotics**-*Miotics - Direct Acting*** Pilocarpine HCl

*Ophthalmic Adrenergic Agents**-*Ophthalmic Selective Alpha Adrenergic Agonists*** Brimonidine Tartrate

*Ophthalmic Anti-Infectives**-*Ophthalmic Antibiotics*** Bacitracin

CILOXAN

Ciprofloxacin HCl

Gatifloxacin

GENTAK (Gentamicin Sulfate)

Gentamicin Sulfate

ILOTYCIN (Erythromycin)

Levofloxacin

Ofloxacin

Tobramycin

TOBREX

VIGAMOX

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Drug Requirements

*Ophthalmic Anti-Infectives**-*Ophthalmic Anti-Infective Combinations*** Bacitracin-Polymyxin B

Neomycin-Polymyxin-Gramicidin

NEO-POLYCIN (Neomycin-Bacitracin Zn-Polymyx)

POLYCIN (AK-Poly-Bac)

Polymyxin B-Trimethoprim

*Ophthalmic Anti-Infectives**-*Ophthalmic Antivirals*** Trifluridine

*Ophthalmic Anti-Infectives**-*Ophthalmic Sulfonamides*** Sulfacetamide Sodium

*Ophthalmic Decongestants**-*Ophthalmic Decongestants*** ALTAFRIN (Phenylephrine HCl)

Naphazoline HCl

*Ophthalmic Steroids**-*Ophthalmic Steroid Combinations*** Neomycin-Polymyxin-Dexameth

Neomycin-Polymyxin-HC

NEO-POLYCIN HC (Bacitra-Neomycin-Polymyxin-HC)

Sulfacetamide-Prednisolone

TOBRADEX

Tobramycin-Dexamethasone

*Ophthalmic Steroids**-*Ophthalmic Steroids*** Dexamethasone Sodium Phosphate

Fluorometholone

FML FORTE

PRED MILD

PrednisoLONE Acetate

PrednisoLONE Sodium Phosphate

*Ophthalmics - Misc.**-*Ophthalmic Antiallergic***

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Drug Requirements Azelastine HCl

Cromolyn Sodium

Epinastine HCl

Ketotifen Fumarate

PATANOL

*Ophthalmics - Misc.**-*Ophthalmic Carbonic Anhydrase Inhibitors*** AZOPT

Dorzolamide HCl

*Ophthalmics - Misc.**-*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** Diclofenac Sodium

Flurbiprofen Sodium

Ketorolac Tromethamine

*Prostaglandins - Ophthalmic**-*Prostaglandins - Ophthalmic*** Bimatoprost

Latanoprost

LUMIGAN

Travoprost

*Otic Agents*

*Otic Agents - Miscellaneous**-*Otic Agents -Miscellaneous*** Acetic Acid

Acetic Acid-Aluminum Acetate

*Otic Anti-Infectives**-*Otic Anti-Infectives*** Ofloxacin

*Otic Combinations**-*Otic Analgesic Combinations*** Antipyrine-Benzocaine

CORTIC-ND (Exotic-HC)

CYOTIC (Exotic-HC)

Oto-End 10

Otomax-HC

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Drug Requirements

*Otic Combinations**-*Otic Steroid-Anti-Infective Combinations*** CIPRO HC

CIPRODEX

Neomycin-Polymyxin-HC

*Otic Steroids**-*Otic Steroids*** ACETASOL HC (Hydrocortisone-Acetic Acid)

*Oxytocics*

*Oxytocics**-*Oxytocics*** Methylergonovine Maleate

*Passive Immunizing Agents*

*Immune Serums**-*Immune Serums*** HEPAGAM B

HYPERHEP B S/D

HYPERRHO S/D

MICRHOGAM ULTRA-FILTERED PLUS

NABI-HB

RHOGAM ULTRA-FILTERED PLUS

RHOPHYLAC

*Monoclonal Antibodies**-*Antiviral Monoclonal Antibodies*** SYNAGIS PA

*Penicillins*

*Aminopenicillins**-*Aminopenicillins*** Amoxicillin

Ampicillin

*Natural Penicillins**-*Natural Penicillins*** Penicillin V Potassium

*Penicillin Combinations**-*Penicillin Combinations*** Amoxicillin-Pot Clavulanate ER QLL (28 per 30 days)

Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED

Amoxicillin-Pot Clavulanate ORAL TABLET QLL (28 per 30 days)

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Drug Requirements Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE QLL (28 per 30 days)

*Penicillinase-Resistant Penicillins**-*Penicillinase-Resistant Penicillins*** Dicloxacillin Sodium

*Pharmaceutical Adjuvants*

*Antimicrobial Agents**-*Antimicrobial Agents*** Benzyl Alcohol

*Pharmaceutical Excipients**-*Pharmaceutical Excipients*** Lactose Monohydrate

Xanthan Gum

*Progestins*

*Progestins**-*Progestins*** MedroxyPROGESTERone Acetate

MEGACE ES

Norethindrone Acetate

Progesterone

Progesterone Micronized

*Psychotherapeutic And Neurological Agents - Misc.*

*Antidementia Agents**-*Cholinomimetics - Ache Inhibitors*** Donepezil HCl QLL (30 per 30 days)

EXELON

Galantamine Hydrobromide QLL (60 per 30 days)

Galantamine Hydrobromide ER QLL (30 per 30 days)

Rivastigmine Tartrate QLL (60 per 30 days)

*Antidementia Agents**-*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** NAMENDA

NAMENDA TITRATION PAK

*Fibromyalgia Agents**-*Fibromyalgia Agent - Snris*** SAVELLA ST

SAVELLA TITRATION PACK ST

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Drug Requirements

*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents - Interferons*** AVONEX PA

AVONEX PEN

AVONEX PREFILLED PA

BETASERON

EXTAVIA PA

REBIF PA

REBIF REBIDOSE

REBIF REBIDOSE TITRATION PACK PA

REBIF TITRATION PACK

*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents*** COPAXONE PA

*Smoking Deterrents**-*Smoking Deterrents*** BUPROBAN (BuPROPion HCl ER (Smoking Det))

CHANTIX

CHANTIX CONTINUING MONTH PAK

CHANTIX STARTING MONTH PAK

Nicotine

NICOTROL

NICOTROL NS

*Sulfonamides*

*Sulfonamides**-*Sulfonamides*** SulfADIAZINE

*Tetracyclines*

*Tetracyclines**-*Tetracyclines*** Avidoxy

Demeclocycline HCl

Doxycycline Hyclate

Doxycycline Monohydrate

Minocycline HCl

Minocycline HCl ER

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Drug Requirements MORGIDOX (Doxycycline Hyclate)

Tetracycline HCl

*Thyroid Agents*

*Antithyroid Agents**-*Antithyroid Agents*** Methimazole

Propylthiouracil

*Thyroid Hormones**-*Thyroid Hormones*** ARMOUR THYROID

LEVOXYL (Levothyroxine Sodium)

Liothyronine Sodium

NATURE-THROID

NP Thyroid

UNITHROID (Levothyroxine Sodium)

UNITHROID DIRECT (Levothyroxine Sodium)

WESTHROID

WP THYROID

*Ulcer Drugs*

*Antispasmodics**-*Antispasmodics*** Dicyclomine HCl

*Antispasmodics**-*Belladonna Alkaloids*** Ed-Spaz

HYOMAX-SL (Hyoscyamine Sulfate)

Hyoscyamine Sulfate

Hyosyne

NULEV (Hyoscyamine Sulfate)

Oscimin

Oscimin SR

SYMAX FASTABS (Hyoscyamine Sulfate)

SYMAX-SL (Hyoscyamine Sulfate)

SYMAX-SR (Hyoscyamine Sulfate ER)

*Antispasmodics**-*Quaternary Anticholinergics*** Glycopyrrolate

Propantheline Bromide

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Drug Requirements

*H-2 Antagonists**-*H-2 Antagonists*** Cimetidine

Cimetidine HCl

Famotidine

Nizatidine

Ranitidine HCl

*Misc. Anti-Ulcer**-*Misc. Anti-Ulcer*** Sucralfate

*Proton Pump Inhibitors**-*Proton Pump Inhibitors*** FIRST-LANSOPRAZOLE

FIRST-OMEPRAZOLE

Lansoprazole QLL (30 per 30 days)

Omeprazole ORAL CAPSULE DELAYED RELEASE 10 MG QLL (30 per 30 days)



OMEPRAZOLE+SYRSPEND SF ALKA

Pantoprazole Sodium QLL (30 per 30 days)

PREVACID SOLUTAB

*Ulcer Drugs - Prostaglandins**-*Ulcer Drugs - Prostaglandins*** Misoprostol

*Urinary Anti-Infectives*

*Urinary Anti-Infectives**-*Urinary Anti-Infectives*** MACRODANTIN

Methenamine Hippurate

Methenamine Mandelate

Nitrofurantoin

Nitrofurantoin Macrocrystal

Nitrofurantoin Monohyd Macro

*Urinary Antispasmodics*

*Urinary Antispasmodic - Antimuscarinics (Anticholinergic)**-*Urinary Antispasmodic -Antimuscarinic (Anticholinergic)***

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Drug Requirements Oxybutynin Chloride

Oxybutynin Chloride ER

Tolterodine Tartrate

Trospium Chloride QLL (60 per 30 days)

Trospium Chloride ER QLL (30 per 30 days)

*Urinary Antispasmodics - Cholinergic Agonists**-*Urinary Antispasmodics - Cholinergic Agonists*** Bethanechol Chloride

*Urinary Antispasmodics - Direct Muscle Relaxants**-*Urinary Antispasmodics - Direct Muscle Relaxants*** FlavoxATE HCl

*Vaccines*

*Bacterial Vaccines**-*Bacterial Vaccines*** PNEUMOVAX 23

*Vaginal Products*

*Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** Miconazole 3

ZAZOLE (Terconazole)

*Vaginal Anti-Infectives**-*Vaginal Anti-Infectives*** CLEOCIN

Clindamycin Phosphate

VANDAZOLE (MetroNIDAZOLE)

*Vaginal Estrogens**-*Vaginal Estrogens*** ESTRACE

ESTRING QLL (1 per 30 days)

FEMRING QLL (1 per 30 days)

PREMARIN

VAGIFEM

*Vasopressors*

*Anaphylaxis Therapy Agents**-*Anaphylaxis Therapy Agents*** AUVI-Q (EPINEPHrine)

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Drug Requirements EPIPEN 2-PAK (EPINEPHrine)

EPIPEN JR 2-PAK

*Vasopressors**-*Vasopressors*** Midodrine HCl

*Vitamins*

*Oil Soluble Vitamins**-*Vitamin D*** Ergocalciferol

Vitamin D (Ergocalciferol)

*Oil Soluble Vitamins**-*Vitamin K*** MEPHYTON

*Water Soluble Vitamins**-*Vitamin B-3*** Niacin ER

Updated: 10/01/2015 P a g e | 6 5

aetna better health michigan medicaid pdl...tramadol hcl ; qll (240 per 30 days) *opioid...

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