drug requirements/ drug name drug requirements/ …...2017 602 4t platinum comm bvd plus eff...

2017 602 4T Platinum Comm BvD Plus eff 01/01/2017

PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS 2

KRYSTEXXA 4 NDS NM LA

probenecid 1

ULORIC 2

MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 4 NDS

VIMOVO 4 NDS

NSAIDS celecoxib (generic of CELEBREX) CAPS

1

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

etodolac 1

etodolac er 1

FENOPROFEN CALCIUM CAPS 400mg

1

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

meloxicam tabs (generic of MOBIC)

1

nabumetone TABS 1

NAPRELAN 750mg 3

naproxen (generic of NAPROSYN) SUSP

1

Drug Name Drug Tier

Requirements/Limits

naproxen (generic of NAPROSYN) TABS 250mg, 500mg

1

naproxen TABS 375mg 1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

NAPROXEN SODIUM TB24 4 NDS

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

sulindac TABS 1

tolmetin sodium 1

VIVLODEX 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

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


1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG

1

BELBUCA 3

butorphanol nasal spray 1



2

Drug Name Drug Tier

Requirements/Limits

butorphanol tartrate SOLN 1

BUTRANS 2

capital and codeine QL (5000 mL / 30 days)

3 QL

nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml

1

nalbuphine hcl SOLN 20mg/ml

1

TRAMADOL HCL CP24 1

tramadol hcl er TB24 100mg, 200mg

1

TRAMADOL HCL ER TB24 300mg

1

tramadol hcl er (biphasic) 100mg

1


1


1

tramadol hcl tab 50 mg (generic of ULTRAM)

1

tramadol-acetaminophen (generic of ULTRACET)


1 QL

OPIOID ANALGESICS, CII ABSTRAL 4 NDS PA

CODEINE SULFATE 1

DURAMORPH 1 B/D

EMBEDA 3

endocet (generic of PERCOCET)


1 QL

fentanyl citrate (generic of ACTIQ) LPOP

4 NDS PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)

1


1


1


1


1

FENTORA 4 NDS PA

Drug Name Drug Tier

Requirements/Limits

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

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 tab 5-200mg (generic of REPREXAIN)

1

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

1

hydrocodone-ibuprofen tab 10-200mg

1

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 10mg/ml, 50mg/5ml, 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS

1



3

Drug Name Drug Tier

Requirements/Limits

hydromorphone tab 8mg er (generic of EXALGO)

1


1


4 NDS

HYDROMORPHONE TABS 32MG

4 NDS

HYSINGLA ER 2

ibudone tab 5-200mg (generic of REPREXAIN)

1

ibudone tab 10-200mg 1

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 40mg 3

KADIAN 200mg 4 NDS

LAZANDA 4 NDS PA

levorphanol tartrate TABS 4 NDS

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 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

methadone hcl (generic of METHADOSE) CONC

1

methadone hcl SOLN 1

methadone hcl 5mg (generic of DOLOPHINE)

1

methadone hcl 10mg (generic of DOLOPHINE)

1

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

MORPHINE SUL INJ 1MG/ML

1 B/D

Drug Name Drug Tier

Requirements/Limits


3 B/D


1 B/D


1 B/D

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg, 80mg

1

morphine sulfate (generic of KADIAN) CP24 100mg

4 NDS

MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml, 150mg/30ml

3 B/D

morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml

1 B/D

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

1

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

1 B/D

MORPHINE SULFATE TABS

1

morphine sulfate beads 1

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

1

NUCYNTA 2

NUCYNTA ER 50mg, 100mg, 150mg

2

NUCYNTA ER 200mg, 250mg

4 NDS

OPANA ER (CRUSH RESISTANT)

2

oxycodone hcl CAPS 1

oxycodone hcl CONC 1

OXYCODONE HCL SOLN 1

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

1

oxycodone hcl TABS 10mg, 20mg

1

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


1 QL



4

Drug Name Drug Tier

Requirements/Limits

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 w/ acetaminophen soln

QL (1800 mL / 30 days)

1 QL

oxycodone-aspirin 1

oxycodone-ibuprofen 1

OXYCONTIN 2

oxymorphone hcl (generic of OPANA) TABS

1

reprexain tab 10-200mg 1

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tab 5-325mg (generic of PERCOCET)


1 QL

SUBSYS 4 NDS PA

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

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

XTAMPZA ER 3

xylon tab 10-200mg 1

zamicet QL (5400 mL / 30 days)

1 QL

ZOHYDRO ER (ABUSE DETERRENT)

3

ANESTHETICS LOCAL ANESTHETICS

Drug Name Drug Tier

Requirements/Limits

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

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

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

BETHKIS 4 NDS B/D NM

gentamicin in saline 1

gentamicin sulfate SOLN 1

gentamicin sulfate/0.9% s 3

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI PODHALER 4 NDS NM LA

tobramycin (generic of TOBI) NEBU

4 NDS B/D NM

tobramycin inj 1.2 gm/30ml 1

tobramycin inj 1.2gm 4 NDS

tobramycin inj 10mg/ml 1

tobramycin inj 40mg/ml 1

tobramycin inj 80mg/2ml 1

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 4 NDS

ALINIA 2

atovaquone (generic of MEPRON) SUSP

4 NDS

AZACTAM IN ISO-OSMOTIC DE

3



5

Drug Name Drug Tier

Requirements/Limits

AZACTAM/DEX INJ 2GM 3

aztreonam (generic of AZACTAM)

1

BILTRICIDE 2

CAYSTON 4 NDS NM LA

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

CUBICIN 4 NDS

DALVANCE 4 NDS

dapsone TABS 1

DARAPRIM 4 NDS

DORIBAX 3

emverm 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

ivermectin (generic of STROMECTOL) TABS

1

linezolid (generic of ZYVOX) SOLN

4 NDS

LINEZOLID SUSR; TABS 4 NDS

LINEZOLID IN SODIUM CHLORIDE

4 NDS

meropenem (generic of MERREM)

1

MEROPENEM/SODIUM CHLORIDE

3

methenamine hippurate (generic of HIPREX)

1

METRO IV 3

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

Drug Name Drug Tier

Requirements/Limits

NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

1

nitrofurantoin macrocrystal (generic of MACRODANTIN)

3

nitrofurantoin monohyd macro (generic of MACROBID)

3

ORBACTIV 4 NDS

PENTAM 300 3

polymyxin b sulfate SOLR 1

SIVEXTRO 4 NDS

sulfamethoxazole-trimethop SUSP

1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop ds (generic of BACTRIM DS)

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 4 NDS

trimethoprim TABS 1

TYGACIL 4 NDS

vancomycin hcl (generic of VANCOCIN HCL) CAPS

4 NDS

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

1

vancomycin hcl SOLR 750mg

3

VANCOMYCIN IN NACL 3

XIFAXAN TAB 200MG 4 NDS

ANTIFUNGALS ABELCET 4 NDS B/D

AMBISOME 3 B/D

amphotericin b SOLR 1 B/D

CANCIDAS 4 NDS

CRESEMBA 4 NDS

ERAXIS 4 NDS

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole inj nacl 100 3



flucytosine (generic of ANCOBON) CAPS

4 NDS



6

Drug Name Drug Tier

Requirements/Limits

griseofulvin microsize 1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1

ketoconazole TABS 1

LAMISIL PACK 3

MYCAMINE 4 NDS

NOXAFIL 4 NDS

nystatin TABS 1

ONMEL 4 NDS

SPORANOX SOL 10MG/ML 4 NDS

terbinafine hcl (generic of LAMISIL) TABS

1

voriconazole (generic of VFEND) SUSR; TABS

4 NDS

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)

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

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 4 NDS

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 4 NDS

EMTRIVA 2

FUZEON 4 NDS NM

INTELENCE 25mg 2

Drug Name Drug Tier

Requirements/Limits

INTELENCE 100mg, 200mg 4 NDS

INVIRASE 4 NDS

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 4 NDS

ISENTRESS PACK 4 NDS

ISENTRESS TABS 4 NDS

lamivudine (generic of EPIVIR)

1

LEXIVA SUSP 3

LEXIVA TABS 4 NDS

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA SUSP 4 NDS

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

4 NDS

RESCRIPTOR 3

RETROVIR IV INFUSION 3

REYATAZ 4 NDS

SELZENTRY 4 NDS

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 50mg 2

SUSTIVA CAPS 200mg 4 NDS

SUSTIVA TABS 4 NDS

TIVICAY 10mg 2

TIVICAY 25mg, 50mg 4 NDS

TYBOST 2

VIDEX PEDIATRIC 3

VIRACEPT 4 NDS

VIREAD 4 NDS

VITEKTA 4 NDS

ZIAGEN SOLN 2

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

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

4 NDS



7

Drug Name Drug Tier

Requirements/Limits

ATRIPLA 4 NDS

COMPLERA 4 NDS

DESCOVY 4 NDS

EPZICOM 4 NDS

EVOTAZ 4 NDS

GENVOYA 4 NDS

KALETRA SOL 4 NDS

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 4 NDS

lamivudine-zidovudine (generic of COMBIVIR)

1

ODEFSEY 4 NDS

PREZCOBIX 4 NDS

STRIBILD 4 NDS

TRIUMEQ 4 NDS

TRUVADA TAB 100-150 4 NDS




ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

cycloserine CAPS 4 NDS

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

paser d/r 3

PRIFTIN 3

pyrazinamide TABS 1

rifabutin (generic of MYCOBUTIN)

1

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

SIRTURO 4 NDS LA

TRECATOR 3

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

1

acyclovir sodium SOLN 1 B/D

acyclovir sodium SOLR 500mg

1 B/D

Drug Name Drug Tier

Requirements/Limits

adefovir dipivoxil (generic of HEPSERA)

4 NDS

BARACLUDE SOLN 4 NDS

cidofovir (generic of VISTIDE) 4 NDS

DAKLINZA 4 NDS NM

entecavir (generic of BARACLUDE)

4 NDS

EPIVIR HBV SOLN 2

famciclovir (generic of FAMVIR) TABS

1

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

lamivudine (hbv) (generic of EPIVIR HBV)

1

moderiba pak 4 NDS NM

moderiba tab 200mg (generic of COPEGUS)

1 NM

PEGASYS 4 NDS NM

PEGASYS PROCLICK 4 NDS NM

RAPIVAB 3

REBETOL SOLN 4 NDS NM

RELENZA DISKHALER 2

ribapak mis 600/day 4 NDS NM

ribasphere (generic of REBETOL) CAPS

1 NM

ribasphere (generic of COPEGUS) TABS 200mg

1 NM

ribasphere TABS 400mg, 600mg

4 NDS NM

ribasphere ribapak 800 4 NDS NM



ribavirin 200mg (generic of REBETOL) CAPS

1 NM

ribavirin 200mg (generic of COPEGUS) TABS

1 NM

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 4 NDS NM

TAMIFLU 2

TYZEKA 4 NDS

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE SOLR 4 NDS

valganciclovir hcl (generic of VALCYTE)

4 NDS



8

Drug Name Drug Tier

Requirements/Limits

CEPHALOSPORINS AVYCAZ 4 NDS

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin sodium 1 gm/50ml 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

CEFEPIME/DEXTROSE 3

cefixime (generic of SUPRAX) 1

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

1

cefotetan disodium (generic of CEFOTAN) 1gm, 2gm

1

cefotetan disodium 10gm 1

CEFOXITIN SODIUM 3

cefoxitin sodium 1gm, 2gm, 10gm

1

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ)

1

CEFTAZIDIME/DEXTROSE 3

CEFTIBUTEN 1

CEFTIN SUSP 3

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm

1

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1

cefuroxime axetil (generic of CEFTIN)

1

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

1

Drug Name Drug Tier

Requirements/Limits

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

CLAFORAN/D5W 3

FORTAZ SOLN 3

FORTAZ SOLR 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

SUPRAX SUSR 500mg/5ml 2

tazicef (generic of FORTAZ) SOLR

1

tazicef vial (generic of FORTAZ)

1

TEFLARO 4 NDS

ZERBAXA 4 NDS

ZINACEF SOLR 750mg 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR; SUSR; TABS

1

clarithromycin SUSR 125mg/5ml

1

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

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 4 NDS

e.e.s 400 1

E.E.S. GRANULES 3

ery-tab 1

ERYPED 200 3

ERYPED 400 3

erythrocin 3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZMAX 3



9

Drug Name Drug Tier

Requirements/Limits

FLUOROQUINOLONES AVELOX SOLN 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 1

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

1

ciprofloxacn inj 400mg/40ml 1

levofloxacin SOLN 1

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 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

Drug Name Drug Tier

Requirements/Limits

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 SUSR 3

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 4 NDS

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

MOXATAG 3

NAFCILLIN IN DEXTROSE 3

nafcillin sodium 1

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 4 NDS

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM IN

3

penicillin g procaine 3

penicillin g sodium 1

penicillin v potassium 1

penicilln gk inj 5mu 1

penicilln gk inj 20mu 1

pfizerpen g inj 5mu 1

pfizerpen-g inj 20mu 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

doxy 1

doxycycline (monohydrate) CAPS 50mg

1

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

1



10

Drug Name Drug Tier

Requirements/Limits

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

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate (generic of DORYX) TBEC

1

doxycycline hyclate tab 75 mg dr

1


1


1

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 4 NDS

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 4 NDS B/D NM

BICNU 4 NDS B/D

BUSULFEX 4 NDS B/D

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 4 NDS B/D

dacarbazine 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 4 NDS

Drug Name Drug Tier

Requirements/Limits

IFEX INJ 3GM 3 B/D

ifosfamide inj 1gm (generic of IFEX)

1 B/D

ifosfamide inj 1gm/20ml 1 B/D

IFOSFAMIDE INJ 3GM 3 B/D

ifosfamide inj 3gm/60ml 1 B/D

LEUKERAN 2

melphalan hcl (generic of ALKERAN)

4 NDS B/D

MUSTARGEN 4 NDS B/D

thiotepa SOLR 4 NDS B/D

TREANDA 4 NDS B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES daunorubicin hcl 1 B/D

doxorubicin hcl 50mg 1 B/D

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

4 NDS B/D

doxorubicin inj 50mg 1 B/D

epirubicin hcl (generic of ELLENCE)

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

4 NDS B/D

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 4 NDS B/D

mitomycin SOLR 4 NDS B/D

VALSTAR 4 NDS NM

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 4 NDS B/D

ARRANON 4 NDS B/D

azacitidine (generic of VIDAZA)

4 NDS B/D NM

cladribine 4 NDS B/D

CLOLAR 4 NDS B/D

cytarabine inj 1 B/D

decitabine (generic of DACOGEN)

4 NDS B/D NM

fludarabine phosphate SOLN

1 B/D



11

Drug Name Drug Tier

Requirements/Limits

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 4 NDS NM

GEMCITABINE HCL SOLN 4 NDS B/D

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

4 NDS B/D

gemcitabine hcl SOLR 2gm 4 NDS B/D

mercaptopurine TABS 1

METHOTREXATE SODIUM 50mg/2ml

1 B/D

methotrexate sodium 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml

1 B/D

methotrexate sodium inj 1 B/D

NIPENT 4 NDS B/D

PURIXAN 4 NDS NM

TABLOID 2

ANTIMITOTIC, TAXOIDS ABRAXANE 4 NDS B/D

DOCEFREZ 20mg 4 NDS B/D

DOCETAXEL CONC 20mg/ml

4 NDS B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml

4 NDS B/D

docetaxel CONC 140mg/7ml 4 NDS B/D

DOCETAXEL SOLN 4 NDS B/D

DOCETAXEL SOLN 80MG/8ML

4 NDS B/D

JEVTANA 4 NDS NM

paclitaxel 1 B/D

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 4 NDS B/D NM

AVASTIN 4 NDS B/D NM LA

BELEODAQ 4 NDS NM

CYRAMZA 4 NDS NM LA

DARZALEX 4 NDS NM LA

Drug Name Drug Tier

Requirements/Limits

EMPLICITI 4 NDS NM LA

ERBITUX 4 NDS B/D NM

ERIVEDGE 4 NDS NM LA

FARYDAK 4 NDS NM LA

GAZYVA 4 NDS NM LA

HERCEPTIN 4 NDS B/D NM

IBRANCE 4 NDS NM LA

ISTODAX 4 NDS B/D NM

KADCYLA 4 NDS B/D NM

KEYTRUDA 4 NDS NM

LYNPARZA 4 NDS NM LA

NINLARO 4 NDS NM

OPDIVO 4 NDS NM LA

PERJETA 4 NDS NM

PORTRAZZA 4 NDS NM LA

PROLEUKIN 4 NDS B/D NM

RITUXAN 4 NDS NM LA

TECENTRIQ 4 NDS NM LA

TORISEL 4 NDS B/D NM

VECTIBIX 4 NDS B/D NM

VELCADE 4 NDS B/D NM

VENCLEXTA 10mg, 50mg 3 NM LA

VENCLEXTA 100mg 4 NDS NM LA

VENCLEXTA STARTING PACK

4 NDS NM LA

YERVOY 4 NDS NM

ZALTRAP 4 NDS NM LA

ZOLINZA 4 NDS NM

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

bicalutamide (generic of CASODEX)

1

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 4 NDS

FASLODEX 4 NDS B/D

FIRMAGON 80mg 3 B/D NM

FIRMAGON 120mg 4 NDS B/D NM

flutamide 1



12

Drug Name Drug Tier

Requirements/Limits

hydroxyprogesterone caproate (antineoplastic)

3 B/D

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM

LUPRON DEPOT INJ 3.75MG

4 NDS NM

LUPRON DEPOT INJ 7.5MG 4 NDS NM

LUPRON DEPOT INJ 11.25MG (3-MONTH)

4 NDS NM

LUPRON DEPOT INJ 22.5MG (3-MONTH)

4 NDS NM

LUPRON DEPOT INJ 30MG (4-MONTH)

4 NDS NM

LUPRON DEPOT INJ 45MG (6-MONTH)

4 NDS NM

LYSODREN 2

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

3

megestrol ac tab 20mg 3

megestrol ac tab 40mg 3

MEGESTROL SUS 625MG/5ML

3

NILANDRON 4 NDS

nilutamide 4 NDS

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 4 NDS NM

VANTAS 3 NM

XTANDI 4 NDS NM LA

ZOLADEX 2 NM

ZYTIGA 4 NDS NM LA

KINASE INHIBITORS AFINITOR 4 NDS NM

AFINITOR DISPERZ 4 NDS NM

ALECENSA 4 NDS NM LA

BOSULIF 4 NDS NM

CABOMETYX 4 NDS NM LA

CAPRELSA 4 NDS NM LA

COMETRIQ 4 NDS NM LA

COTELLIC 4 NDS NM LA

GILOTRIF TAB 20MG 4 NDS NM LA



ICLUSIG 4 NDS NM LA

Drug Name Drug Tier

Requirements/Limits

imatinib mesylate (generic of GLEEVEC)

4 NDS NM

IMBRUVICA CAP 140MG 4 NDS NM LA

INLYTA 4 NDS NM LA

IRESSA 4 NDS NM LA

JAKAFI 4 NDS NM LA

LENVIMA 8 MG DAILY DOSE 4 NDS NM LA

LENVIMA 10 MG DAILY DOSE

4 NDS NM LA


4 NDS NM LA


4 NDS NM LA


4 NDS NM LA


4 NDS NM LA

MEKINIST 4 NDS NM LA

NEXAVAR 4 NDS NM LA

SPRYCEL 4 NDS NM

STIVARGA 4 NDS NM LA

SUTENT 4 NDS NM

TAFINLAR 4 NDS NM LA

TAGRISSO 4 NDS NM LA

TARCEVA 4 NDS NM LA

TASIGNA 4 NDS NM

TYKERB 4 NDS NM LA

VOTRIENT 4 NDS NM LA

XALKORI 4 NDS NM LA

ZELBORAF 4 NDS NM LA

ZYDELIG 4 NDS NM LA

ZYKADIA 4 NDS NM LA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

4 NDS NM

DROXIA 3

ERWINAZE 4 NDS NM LA

HALAVEN 4 NDS B/D NM

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 4 NDS B/D NM

LONSURF 4 NDS NM

MATULANE 4 NDS LA

mitoxantrone hcl 1 B/D NM

ODOMZO 4 NDS NM LA

SYLATRON KIT 200MCG 4 NDS NM



13

Drug Name Drug Tier

Requirements/Limits



SYLVANT 4 NDS NM LA

SYNRIBO 4 NDS NM

tretinoin CAPS 4 NDS

TRISENOX 4 NDS B/D

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

oxaliplatin 1 B/D

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

4 NDS B/D

dexrazoxane (generic of ZINECARD)

4 NDS B/D

ELITEK 4 NDS B/D

FUSILEV 4 NDS B/D NM

KEPIVANCE 4 NDS B/D

leucovor ca inj 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

leucovorin calcium 500 mg 1 B/D

levoleucovorin calcium 4 NDS B/D NM

mesna (generic of MESNEX) 1 B/D

MESNEX TABS 4 NDS

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 1 B/D

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

1 B/D

irinotecan inj 100/5ml (generic of CAMPTOSAR)

1 B/D

irinotecan inj 500mg/25ml 1 B/D

toposar 1 B/D

TOPOTECAN HCL SOLN 4 NDS B/D

topotecan hcl (generic of HYCAMTIN) SOLR

4 NDS B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

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

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

trandolapril-verapamil hcl (generic of TARKA)

1

ACE INHIBITORS 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

moexipril hcl 1

perindopril erbumine 2mg 1

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

1

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

ALDOSTERONE RECEPTOR ANTAGONISTS



14

Drug Name Drug Tier

Requirements/Limits

eplerenone (generic of INSPRA)

1

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA)

1

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

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

1


1


1

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

ENTRESTO 2

Drug Name Drug Tier

Requirements/Limits

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide (generic of HYZAAR)

1

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TRIBENZOR 2

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

EDARBI 3

eprosartan mesylate 1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

telmisartan (generic of MICARDIS)

1

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

disopyramide phosphate (generic of NORPACE)

3

DOFETILIDE 1 NM

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE CR 3

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1



15

Drug Name Drug Tier

Requirements/Limits

propafenone hcl 150mg, 300mg

1

propafenone hcl (generic of RYTHMOL) 225mg

1

propafenone hcl 12hr (generic of RYTHMOL SR)

1

quinidine gluconate TBCR 1

quinidine sulfate TABS 1

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

1

sorine 240mg 1

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

1

sotalol hcl 240mg 1

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

1

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 20mg, 40mg 3

atorvastatin calcium (generic of LIPITOR) TABS

1

fluvastatin sodium cap 20 mg (generic of LESCOL)

1

fluvastatin sodium cap 40 mg 1

FLUVASTATIN SODIUM TAB SR 24 HR 80 MG

1

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

pravastatin sodium 10mg 1

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

1

rosuvastatin calcium (generic of CRESTOR)

1

simvastatin (generic of ZOCOR) TABS

1

ANTILIPEMICS, MISCELLANEOUS ANTARA 3

cholestyramine (generic of QUESTRAN)

1

cholestyramine light 1

Drug Name Drug Tier

Requirements/Limits

choline fenofibrate (generic of TRILIPIX)

1

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

FENOFIBRATE TABS 40mg, 120mg

1

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

1

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

1

fenofibrate micronized 43mg, 130mg

1

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

1

FENOFIBRIC ACID 1

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 4 NDS NM LA PA

KYNAMRO 4 NDS NM

niacin er (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

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

1

PRALUENT 4 NDS NM

prevalite (generic of QUESTRAN LIGHT)

1

TRIGLIDE 3

VASCEPA 2

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

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

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1



16

Drug Name Drug Tier

Requirements/Limits

DUTOPROL 3

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

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 CR 2

labetalol hcl SOLN; TABS 1

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 60mg, 80mg

1

propranolol hcl er (generic of INDERAL LA) 120mg, 160mg

1

propranolol inj 1mg/ml 1

propranolol oral sol 1

propranolol tab 1

Drug Name Drug Tier

Requirements/Limits

SOTYLIZE 3

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv (generic of CADUET)

1

CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CARDIZEM LA 120mg 3

cartia xt (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap 240mg/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 (generic of CARDIZEM CD)

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

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 4 NDS



17

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

NYMALIZE 4 NDS

taztia xt (generic of TIAZAC) 1

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

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) 1

digox (generic of LANOXIN) 1

digoxin (generic of LANOXIN) TABS

1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN TABS 62.5mcg, 187.5mcg

2

LANOXIN PEDIATRIC 3

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE TAB 50/50 3

amiloride & hydrochlorothiazide

1

amiloride hcl TABS 1

Drug Name Drug Tier

Requirements/Limits

bumetanide SOLN 1

bumetanide (generic of BUMEX) TABS

1

chlorothiazide tabs 1

chlorthalidone 25mg, 50mg 1

DIURIL SUS 250/5ML 3

DYRENIUM 3

EDECRIN 4 NDS

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 10mg/ml 1

FUROSEMIDE INJ 10mg/ml 1

furosemide oral soln 8 mg/ml 1

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone 1

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

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

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

1

MISCELLANEOUS BIDIL 2

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

1


1



18

Drug Name Drug Tier

Requirements/Limits


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

CORLANOR 3

DEMSER 4 NDS

hydralazine hcl SOLN; TABS 1

KEVEYIS 4 NDS NM

midodrine hcl 1

minoxidil TABS 1

NORTHERA 4 NDS NM LA

PHENOXYBENZAMINE HCL CAPS

4 NDS

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 4 NDS

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

1

isosorbide dinitrate 10mg, 20mg, 30mg

1

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran (generic of NITRO-DUR)

1

nitro-bid 3

NITRO-DUR .3mg/hr, .8mg/hr

2

nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin td patch 1

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 4 NDS NM PA

ADEMPAS 4 NDS NM LA

epoprostenol sodium (generic of FLOLAN)

4 NDS B/D NM LA

FLOLAN 4 NDS B/D NM LA

Drug Name Drug Tier

Requirements/Limits

LETAIRIS 4 NDS NM LA

OPSUMIT 4 NDS NM LA

ORENITRAM TAB 0.25MG 4 NDS NM LA

ORENITRAM TAB 0.125MG 2 NM LA

ORENITRAM TAB 1MG 4 NDS NM LA

ORENITRAM TAB 2.5MG 4 NDS NM LA

REMODULIN 4 NDS B/D NM LA

REVATIO SUSR 4 NDS NM PA

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

4 NDS NM

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

1 NM PA

TRACLEER 4 NDS NM LA

TYVASO 4 NDS B/D NM

UPTRAVI 4 NDS NM LA

VELETRI 4 NDS B/D NM LA

VENTAVIS 4 NDS B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC 3

alprazolam (generic of XANAX) TABS

1

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

lorazepam CONC 1

lorazepam (generic of ATIVAN) SOLN; TABS

1

ANTICONVULSANTS APTIOM 3

BANZEL SUS 40MG/ML 4 NDS

BANZEL TAB 200MG 4 NDS

BANZEL TAB 400MG 4 NDS

BRIVIACT SOLN 10mg/ml 4 NDS

BRIVIACT SOLN 50mg/5ml 3

BRIVIACT TABS 4 NDS

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1



19

Drug Name Drug Tier

Requirements/Limits

carbamazepine (generic of TEGRETOL-XR) TB12

1

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS

1

clonazepam TBDP 1

clorazepate dipotassium 3.75mg, 15mg

1

clorazepate dipotassium (generic of TRANXENE T) 7.5mg

1

diazepam CONC; SOLN 1

diazepam (generic of VALIUM) TABS

1

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

1

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

4 NDS

felbamate (generic of FELBATOL) TABS

1

FYCOMPA 2

gabapentin (generic of NEURONTIN) CAPS; SOLN; TABS

1

GABITRIL 12mg, 16mg 2

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine KIT 1

lamotrigine (generic of LAMICTAL) TABS

1

Drug Name Drug Tier

Requirements/Limits

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 IV 3

levetiracetam oral soln 100 mg/ml (generic of KEPPRA)

1

LYRICA 2

ONFI SUSP 4 NDS

ONFI TABS 10mg 3

ONFI TABS 20mg 4 NDS

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 2

PEGANONE 3

phenobarbital ELIX; TABS 3

PHENOBARBITAL SODIUM SOLN 65mg/ml

3

phenobarbital sodium SOLN 130mg/ml

3

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 (generic of PHENYTEK) 200mg, 300mg

1

POTIGA 3

primidone (generic of MYSOLINE) TABS

1

roweepra (generic of KEPPRA)

1

SABRIL 4 NDS NM LA

SPRITAM 3

TEGRETOL 3

TEGRETOL-XR 3



20

Drug Name Drug Tier

Requirements/Limits

tiagabine hcl (generic of GABITRIL)

1

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1

topiramate (generic of TOPAMAX) TABS

1

TROKENDI XR 25mg, 50mg, 100mg

2

TROKENDI XR 200mg 4 NDS

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE)

1

VIMPAT 2

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

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA 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

galantamine hydrobromide SOLN

1

galantamine hydrobromide (generic of RAZADYNE) TABS

1

galantamine hydrobromide er (generic of RAZADYNE ER)

1

memantine hcl (generic of NAMENDA) SOLN

PA if < 30 yrs

1 PA

memantine hcl (generic of NAMENDA) TABS 5mg

PA if < 30 yrs

1 PA

Drug Name Drug Tier

Requirements/Limits

MEMANTINE HCL TABS 10mg

PA if < 30 yrs

1 PA

NAMENDA XR PA if < 30 yrs

2 PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

2 PA

NAMZARIC 3

rivastigmine cap (generic of EXELON)

1

rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)

1


1


1

ANTIDEPRESSANTS amitriptyline hcl TABS 10mg, 50mg, 75mg, 100mg, 150mg

3

amitriptyline hcl (generic of ELAVIL) TABS 25mg

3

amoxapine 1

APLENZIN 4 NDS

bupropion hcl TABS 1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

3

desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg

1

desipramine hcl TABS 50mg, 75mg, 100mg, 150mg

1

doxepin hcl CAPS; CONC 3

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

1

EMSAM 4 NDS



21

Drug Name Drug Tier

Requirements/Limits

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine cap 10mg (generic of PROZAC)

1


1


1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl (generic of TOFRANIL) TABS

3

imipramine pamoate 3

maprotiline hcl 1

MARPLAN 3

mirtazapine TABS 7.5mg 1

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

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

nefazodone hcl 1

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl tabs (generic of PAXIL)

1

PAXIL SUSP 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl 1

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

Drug Name Drug Tier

Requirements/Limits

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

trimipramine maleate CAPS 25mg, 50mg

3

trimipramine maleate (generic of SURMONTIL) CAPS 100mg

3

TRINTELLIX 2

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl TABS 1

venlafaxine hcl (generic of VENLAFAXINE HCL ER) TB24 37.5mg, 75mg, 150mg

1

VENLAFAXINE HCL TB24 225mg

1

venlafaxine tab 1

VIIBRYD STARTER PACK 2

VIIBRYD TAB 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 4 NDS NM LA

AZILECT 2

BENZTROPINE MESYLATE SOLN

1

benztropine mesylate TABS 3

bromocriptine mesylate (generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of LODOSYN) TABS

4 NDS

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



22

Drug Name Drug Tier

Requirements/Limits


1


1


1

DUOPA 3 B/D NM

ENTACAPONE 1

MIRAPEX ER 3.75mg 2

NEUPRO 2

pramipexole dihydrochloride (generic of MIRAPEX ER)

1

pramipexole tab 0.5mg (generic of MIRAPEX)

1


1

pramipexole tab 0.75 er (generic of MIRAPEX ER)

1


1


1

pramipexole tab 0.375mg (generic of MIRAPEX ER)

1


1

pramipexole tab 1.5mg er (generic of MIRAPEX ER)

1

pramipexole tab 1mg (generic of MIRAPEX)

1


1

pramipexole tab 3mg (generic of MIRAPEX ER)

1


1

ropinirole tab 0.5mg (generic of REQUIP)

1

ropinirole tab 0.25mg (generic of REQUIP)

1

ropinirole tab 1mg (generic of REQUIP)

1


1

ropinirole tab 2mg er (generic of REQUIP XL)

1

Drug Name Drug Tier

Requirements/Limits


1


1


1


1


1


1


1

RYTARY 3

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

ZELAPAR 4 NDS

ANTIPSYCHOTICS ABILIFY MAINTENA 4 NDS

aripiprazole odt 4 NDS

aripiprazole oral solution 1 mg/ml

4 NDS

aripiprazole tabs (generic of ABILIFY) 2mg, 5mg, 10mg, 15mg

1

aripiprazole tabs (generic of ABILIFY) 20mg, 30mg

4 NDS

ARISTADA 4 NDS

chlorpromazine hcl TABS 1

chlorpromazine inj 3

CLOZAPINE ODT 12.5mg 1

CLOZAPINE ODT 25mg, 100mg, 150mg

1

CLOZAPINE ODT 200mg 4 NDS

clozapine tab 25mg (generic of CLOZARIL)

1

clozapine tab 50mg 1

clozapine tab 100mg (generic of CLOZARIL)

1

clozapine tab 200mg 1

FANAPT 3

FANAPT TITRATION PACK 3

fluphenazine decanoate SOLN

1



23

Drug Name Drug Tier

Requirements/Limits

fluphenazine hcl 1

GEODON INJ 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 1

haloperidol lactate inj 5 mg/ml (generic of HALDOL)

1

INVEGA SUST INJ 39 MG/0.25 ML

3


4 NDS


4 NDS

INVEGA SUST INJ 156MG/ML

4 NDS


4 NDS

INVEGA TRINZA 4 NDS

LATUDA 2

loxapine succinate 1

molindone hcl 1

NUPLAZID 4 NDS NM LA

olanzapine odt (generic of ZYPREXA ZYDIS)

1

olanzapine solr (generic of ZYPREXA)

1

olanzapine tabs (generic of ZYPREXA)

1

paliperidone (generic of INVEGA)

4 NDS

perphenazine TABS 1

pimozide (generic of ORAP) 1

quetiapine fumarate (generic of SEROQUEL)

1

REXULTI 3

RISPERDAL INJ 12.5MG 2

RISPERDAL INJ 25MG 2

RISPERDAL INJ 37.5MG 4 NDS

RISPERDAL INJ 50MG 4 NDS

Drug Name Drug Tier

Requirements/Limits

risperidone odt (generic of RISPERDAL M-TAB) .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone odt .25mg 1

risperidone soln (generic of RISPERDAL)

1

risperidone tabs (generic of RISPERDAL)

1

SAPHRIS 3

SEROQUEL XR 2

thioridazine hcl TABS 3

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 4 NDS

VRAYLAR 4 NDS

VRAYLAR THERAPY PACK 3

ziprasidone hcl (generic of GEODON)

1

ZYPREXA RELPREVV INJ 210MG

3


4 NDS


4 NDS

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 10mg er (generic of ADDERALL XR)

1

amphetamine cap 15mg er (generic of ADDERALL XR)

1


1


1


1

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

1

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)

1

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)

1



24

Drug Name Drug Tier

Requirements/Limits


1

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)

1


1


1


1

APTENSIO XR 2

DAYTRANA 3

guanfacine er (adhd) (generic of INTUNIV)

3

metadate er tab 20mg 1

methylphenidate hcl (generic of METHYLIN) CHEW

1

methylphenidate hcl (generic of RITALIN LA) CP24 20mg

1

METHYLPHENIDATE HCL CP24 30mg, 40mg

1

methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 40mg, 50mg, 60mg

1

METHYLPHENIDATE HCL CPCR 30mg

1

methylphenidate hcl (generic of METHYLIN) SOLN

1

methylphenidate hcl (generic of RITALIN) TABS

1

methylphenidate hcl TB24 1

methylphenidate hcl TBCR 10mg, 20mg

1

METHYLPHENIDATE HCL TBCR 18mg, 27mg, 36mg, 54mg

1

methylphenidate hcl er 1

QUILLICHEW ER 3

QUILLIVANT XR 2

RITALIN LA 10mg, 60mg 3

Drug Name Drug Tier

Requirements/Limits

STRATTERA 2

VYVANSE 2

HYPNOTICS HETLIOZ 4 NDS NM LA

ROZEREM 3

SILENOR 2

temazepam (generic of RESTORIL) 7.5mg, 15mg

1

zolpidem tartrate (generic of AMBIEN) TABS

3

MIGRAINE almotriptan malate (generic of AXERT)

1

cafergot tab 1-100mg 3

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

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

4 NDS

ergomar 3

frovatriptan succinate (generic of FROVA)

1

migergot 4 NDS

naratriptan hcl (generic of AMERGE)

1

ONZETRA XSAIL 3

RELPAX 2

rizatriptan benzoate (generic of MAXALT) TABS

1

rizatriptan benzoate (generic of MAXALT-MLT) TBDP

1

SUMATRIPTAN INJ 4MG/0.5ML

1

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

1

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT

1

sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN

1

sumatriptan inj 6mg/0.5ml SOSY

1

SUMATRIPTAN NASAL SOLN

1



25

Drug Name Drug Tier

Requirements/Limits

sumatriptan succinate (generic of IMITREX) TABS

1

SUMAVEL DOSEPRO 4 NDS

TREXIMET 4 NDS

ZEMBRACE SYMTOUCH 3

zolmitriptan (generic of ZOMIG) TABS

1

zolmitriptan odt (generic of ZOMIG ZMT)

1

ZOMIG NASAL SPRAY 2

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 2

GRALISE STARTER 2

HORIZANT 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM SOLN 8MEQ/5ML 3

MESTINON SYRUP 4 NDS

NUEDEXTA 3

pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR

1

pyridostigmine tab 60mg (generic of MESTINON)

1

riluzole (generic of RILUTEK) 1

SAVELLA 2

SAVELLA TITRATION PACK 2

TETRABENAZINE 4 NDS NM

MULTIPLE SCLEROSIS AGENTS AMPYRA 4 NDS NM LA

AUBAGIO 4 NDS NM LA

AVONEX 4 NDS NM

AVONEX PEN 4 NDS NM

BETASERON 4 NDS NM

COPAXONE INJ 40MG/ML 4 NDS NM

COPAXONE KIT 20MG/ML 4 NDS NM

EXTAVIA 4 NDS NM

GILENYA CAP 0.5MG 4 NDS NM

Drug Name Drug Tier

Requirements/Limits

glatopa (generic of COPAXONE)

4 NDS NM

LEMTRADA 4 NDS NM LA

PLEGRIDY 4 NDS NM

PLEGRIDY STARTER PACK 4 NDS NM

REBIF 4 NDS NM

REBIF REBIDOSE 4 NDS NM

REBIF REBIDOSE TITRATION

4 NDS NM

REBIF TITRATION PACK 4 NDS NM

TECFIDERA 4 NDS NM LA

TECFIDERA STARTER PACK

4 NDS NM LA

TYSABRI 4 NDS NM LA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX INJ 100UNIT 4 NDS NM PA

BOTOX INJ 200UNIT 4 NDS NM PA

cyclobenzaprine hcl TABS 5mg, 10mg

3

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

1

dantrolene sodium CAPS 100mg

1

DYSPORT 3 NM PA

MYOBLOC 3 NM PA

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

XEOMIN 50unit 3 NM PA

XEOMIN 100unit, 200unit 4 NDS NM PA

NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg, 150mg, 250mg

1

ARMODAFINIL 200mg 1

modafinil (generic of PROVIGIL)

1

XYREM 4 NDS LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

BUNAVAIL MIS 2.1-0.3MG 3

BUNAVAIL MIS 4.2-0.7MG 3



26

Drug Name Drug Tier

Requirements/Limits

BUNAVAIL MIS 6.3-1MG 3

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban (generic of ZYBAN) 1

bupropion hcl (smoking deterrent) (generic of ZYBAN)

1

CHANTIX 2

CHANTIX CONTINUING MONTH

2

CHANTIX STARTER PACK 2

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl TABS 1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG 2

SUBOXONE MIS 4-1MG 2



VIVITROL 4 NDS NM

ZUBSOLV SUB 1.4-0.36MG 3





ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 4 NDS PA

ANDRODERM 2 PA

ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm

3 PA

ANDROGEL 1% 3 PA

ANDROGEL 1.62% 3 PA

AVEED 3 NM LA PA

AXIRON 2 PA

depo-testosterone 100mg/ml 3 PA

oxandrolone (generic of OXANDRIN) TABS

1 PA

STRIANT 3 PA

testosterone GEL 1% 1 PA

Drug Name Drug Tier

Requirements/Limits

TESTOSTERONE GEL 1% 1 PA

testosterone (generic of FORTESTA) GEL 10mg/act

1 PA

TESTOSTERONE GEL 25mg/2.5gm

1 PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

1 PA

testosterone enanthate SOLN

1 PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 3

APIDRA SOLOSTAR 3

BYDUREON INJ 3

BYDUREON PEN 3

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)

4 NDS B/D

HUMULIN R U-500 KWIKPEN 4 NDS

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

NOVOLIN 70/30 RELION 3



27

Drug Name Drug Tier

Requirements/Limits

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 4 NDS

SYMLINPEN 120 4 NDS

TANZEUM 3

TOUJEO SOLOSTAR 3

TRESIBA FLEXTOUCH 2

TRULICITY 2

VICTOZA 2

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

FARXIGA 2

glimepiride (generic of AMARYL)

1

glipizide (generic of GLUCOTROL) TABS

1

glipizide er (generic of GLUCOTROL XL)

1

GLIPIZIDE XL TB24 2.5MG 1

GLIPIZIDE XL TB24 5MG 1

glipizide-metformin 2.5-250 mg

1

glipizide-metformin 2.5-500 mg

1

glipizide-metformin 5-500mg 1

GLYXAMBI 3

INVOKAMET TAB 50-500MG 3

INVOKAMET TAB 50-1000MG

3


3

Drug Name Drug Tier

Requirements/Limits


3

INVOKANA TAB 100MG 3

INVOKANA TAB 300MG 3

JANUMET 2

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2.5-1000MG

2

JENTADUETO XR 5-1000MG 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er (generic of GLUCOPHAGE XR)

1

metformin hcl (generic of GLUCOPHAGE) TABS

1

metformin hcl (generic of FORTAMET) TB24

1

miglitol (generic of GLYSET) 1

nateglinide (generic of STARLIX)

1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl (generic of ACTOS)

1

pioglitazone hcl-glimepiride (generic of DUETACT)

1

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)

1

repaglinide (generic of PRANDIN)

1



28

Drug Name Drug Tier

Requirements/Limits

repaglinide-metformin hcl 1

RIOMET 3

SYNJARDY TAB 5-500MG 3

SYNJARDY TAB 5-1000MG 3

SYNJARDY TAB 12.5-500 3

SYNJARDY TAB 12.5-1000 3

TRADJENTA 2

XIGDUO XR TAB 5-500MG 2




BISPHOSPHONATES alendronate sodium SOLN 1

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

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

BINOSTO 3

FOSAMAX PLUS D 3

ibandronate sodium (generic of BONIVA)

1 B/D

ibandronate tab 150mg (generic of BONIVA)

1 B/D

pamidronate disodium SOLN 6mg/ml

3 B/D

pamidronate disodium SOLN 30mg/10ml, 90mg/10ml

1 B/D

pamidronate disodium SOLR 1 B/D

risedronate sodium (generic of ACTONEL) TABS

1

risedronate sodium (generic of ATELVIA) TBEC

1

zoledronic acid SOLR 3 B/D NM

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

1 B/D NM

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D NM

ZOMETA SOLN 4 NDS B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 2 NM

SENSIPAR 60mg, 90mg 4 NDS NM

CHELATING AGENTS CHEMET 3

deferoxamine mesylate 2gm 1 B/D NM

Drug Name Drug Tier

Requirements/Limits

deferoxamine mesylate (generic of DESFERAL) 500mg

1 B/D NM

DEPEN TITRATABS 4 NDS

EXJADE 4 NDS NM LA

FERRIPROX 4 NDS NM LA

JADENU 4 NDS NM

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate (generic of KAYEXALATE) POWD

1

sodium polystyrene sulfonate SUSP

1

sps susp 15gm/60ml 1

SYPRINE 4 NDS

VELTASSA 3 NM LA

CONTRACEPTIVES altavera tab 1

amethia 91 day (generic of SEASONIQUE)

1

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

bekyree 28 day (generic of MIRCETTE)

1

BEYAZ 2

blisovi 21 fe 1.5/30 28 day pack (generic of LOESTRIN FE 1.5/30)

1

blisovi 21 fe 1/20 28 day pack (generic of LOESTRIN FE 1/20)

1

blisovi 24 fe 1/20 28 day 1

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1



29

Drug Name Drug Tier

Requirements/Limits

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

cyred tab (generic of DESOGEN)

1

deblitane 28 day (generic of NOR-QD)

1

delyla 28 day 1

DEPO-SUBQ PROVERA 104 2

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

1

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

drospirenone-ethinyl estradiol (generic of YAZ)

1

ELLA 3

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

estarylla tab 0.25-35 (generic of ORTHO-CYCLEN)

1

falmina 28 day 1

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

juleber 28 day (generic of DESOGEN)

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

Drug Name Drug Tier

Requirements/Limits

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

kaitlib fe 28 day (generic of GENERESS FE)

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 (generic of GENERESS FE)

1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1

levonor/ethi tab 1

levonorgestrel & eth estradiol 1

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

1

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

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

low-ogestrel 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1



30

Drug Name Drug Tier

Requirements/Limits

marlissa 28 day 1

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

1

MICROGESTIN 1.5/30 1

MICROGESTIN 1/20 1

MICROGESTIN FE 1.5/30 1

MICROGESTIN FE 1/20 1

MINASTRIN 24 FE 2

mono-linyah tab 0.25-35 (generic of ORTHO-CYCLEN)

1

MONONESSA 1

myzilra 1

NATAZIA 2

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

nikki 28 day (generic of YAZ) 1

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

norgest/ethi tab 0.25/35 (generic of ORTHO-CYCLEN)

1

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

1

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

1

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

Drug Name Drug Tier

Requirements/Limits

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

philith (generic of OVCON-35) 1

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

SAFYRAL 2

setlakin tab 1

sharobel 28 day (generic of ORTHO MICRONOR)

1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

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

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

tri-linyah (generic of ORTHO TRI-CYCLEN)

1

tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)

1

tri-lo-marzia (generic of ORTHO TRI-CYCLEN LO)

1

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

1

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

1

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

1

TRINESSA 1



31

Drug Name Drug Tier

Requirements/Limits

TRINESSA LO TAB 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

vienva 28 day 1

viorele (generic of MIRCETTE)

1

vyfemla 28 day (generic of OVCON-35)

1

wymzya fe (generic of FEMCON FE)

1

xulane dis 150-35 1

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

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 4 NDS NM

SYNAREL 4 NDS

ENZYME REPLACEMENTS ADAGEN 4 NDS NM LA

ALDURAZYME 4 NDS NM LA

BUPHENYL TABS 4 NDS NM LA

CARBAGLU 4 NDS NM LA

CERDELGA 4 NDS NM

CEREZYME 4 NDS NM LA

CYSTADANE 4 NDS NM LA

CYSTAGON 3 NM LA

ELAPRASE 4 NDS NM LA

ELELYSO 4 NDS NM

FABRAZYME 4 NDS NM LA

KANUMA 4 NDS NM LA

KUVAN 4 NDS NM LA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 4 NDS NM LA

NAGLAZYME 4 NDS NM LA

ORFADIN CAPS 2mg, 5mg, 10mg

4 NDS NM LA

Drug Name Drug Tier

Requirements/Limits

ORFADIN SUSP 4 NDS NM LA

PROCYSBI 4 NDS NM LA

RAVICTI 4 NDS NM

sodium phenylbutyrate (generic of BUPHENYL)

4 NDS NM

STRENSIQ 4 NDS NM LA

VIMIZIM 4 NDS NM

VPRIV 4 NDS NM

ZAVESCA 4 NDS NM LA

ESTROGENS ALORA 3

DELESTROGEN 10mg/ml 3

depo-estradiol 3

estrace CREA 2

estradiol (generic of VIVELLE-DOT) PTTW

3

estradiol (generic of CLIMARA) PTWK

3

estradiol (generic of ESTRACE) TABS

3

estradiol valerate (generic of DELESTROGEN) OIL

1

ESTRING 3

FEMRING 3

fyavolv tab 1-5mg 3

jinteli 3

MENOSTAR 3

MINIVELLE 3

norethindrone acetate-ethinyl estradiol

3

PREMARIN CREAM 2

PREMARIN INJ 3

VAGIFEM 2

GLUCOCORTICOIDS a-hydrocort 1

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak 6 day 3

dexpak 10 day 3



32

Drug Name Drug Tier

Requirements/Limits

dexpak taperpak 13 day 3

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

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

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

methylprednisolone sod succ (generic of SOLU-MEDROL)

1 B/D

millipred 3 B/D

millipred dp 3

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

prednisone pak 10mg 1

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





Drug Name Drug Tier

Requirements/Limits

RAYOS TAB 1MG 4 NDS B/D



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 2GM 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 4 NDS NM PA

GENOTROPIN MINIQUICK .2mg

3 NM PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

4 NDS NM PA

HUMATROPE 4 NDS NM PA

HUMATROPE COMBO PACK 4 NDS NM PA

NORDITROPIN FLEXPRO 4 NDS NM PA

NUTROPIN AQ INJ 20MG/2ML

4 NDS NM LA PA

NUTROPIN AQ NUSPIN 5 4 NDS NM LA PA



NUTROPIN AQ PEN 4 NDS NM LA PA

OMNITROPE 5.8MG 4 NDS NM LA PA

OMNITROPE 5MG 4 NDS NM LA PA

OMNITROPE 10MG 4 NDS NM LA PA

SAIZEN 4 NDS NM LA PA

SAIZEN CLICK.EASY 4 NDS NM LA PA

SEROSTIM 4 NDS NM LA



33

Drug Name Drug Tier

Requirements/Limits

ZOMACTON 5mg 3 NM PA

ZOMACTON 10mg 4 NDS NM PA

ZORBTIVE 4 NDS NM

MISCELLANEOUS AFREZZA 3

cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1 B/D

CHORIONIC GONADOTROPIN SOLR

1 NM

EGRIFTA 1mg 4 NDS NM LA

FORTICAL SPR 200/ACT 3 B/D

H.P. ACTHAR 4 NDS NM LA

INCRELEX 4 NDS NM LA

KORLYM 4 NDS NM LA

LUPRON DEP-PED INJ 7.5MG

4 NDS NM

LUPRON DEP-PED INJ 11.25MG

4 NDS NM

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

4 NDS NM

LUPRON DEP-PED INJ 15MG

4 NDS NM

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

4 NDS NM

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 4 NDS B/D

MYALEPT 4 NDS NM LA

NOVAREL INJ 10000UNT 1 NM

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

1 NM

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

4 NDS NM

PREGNYL W/DILUENT BENZYL

1 NM

PROLIA 3 NM

raloxifene hcl (generic of EVISTA)

1

SAMSCA 4 NDS NM

SANDOSTATIN LAR DEPOT 4 NDS NM

SIGNIFOR 4 NDS NM LA

Drug Name Drug Tier

Requirements/Limits

SIGNIFOR LAR 4 NDS NM LA

SOMATULINE DEPOT 4 NDS NM

SOMAVERT 4 NDS NM LA

XGEVA 4 NDS B/D NM

PARATHYROID HORMONES FORTEO 4 NDS NM

NATPARA 4 NDS NM

PHOSPHATE BINDER AGENTS AURYXIA 4 NDS

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

1

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

1

FOSRENOL 4 NDS

PHOSLYRA 2

RENAGEL 400mg 3

RENAGEL 800mg 4 NDS

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 4 NDS

PROGESTINS CRINONE 2 PA

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

THYROID AGENTS levothyroxine sodium (generic of SYNTHROID) TABS 25mcg, 50mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg

1

LEVOTHYROXINE SODIUM TABS 75mcg, 300mcg

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1



34

Drug Name Drug Tier

Requirements/Limits

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

UNITHROID 1

VASOPRESSINS 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 4 NDS

CESAMET 4 NDS B/D

compro supp 1

dronabinol (generic of MARINOL)

1 B/D

EMEND SOLR 3

EMEND SUSR 3 B/D

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

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

metoclopramide odt 3

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

1 B/D

Drug Name Drug Tier

Requirements/Limits

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1

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

1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz 3

phenergan SUPP 3

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

3

promethazine hcl SUPP; SYRP; TABS

3

promethegan 3

SANCUSO 4 NDS

TRANSDERM-SCOP 3

VARUBI 2 B/D

ZUPLENZ 3 B/D

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

1

BENTYL SOLN 3

CUVPOSA 3

dicyclomine hcl (generic of BENTYL) CAPS

1

dicyclomine hcl SOLN 10mg/5ml

1

dicyclomine hcl (generic of BENTYL) SOLN 10mg/ml

1

dicyclomine hcl (generic of BENTYL) TABS

1

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1



35

Drug Name Drug Tier

Requirements/Limits

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

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

1

famotidine (generic of PEPCID) SUSR

1

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

1

famotidine inj 1

nizatidine 1

ranitidine hcl CAPS 1

ranitidine hcl SOLN 1

ranitidine hcl SYRP 1

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

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CPEP

4 NDS

CANASA 4 NDS

colocort (generic of CORTENEMA)

1

DELZICOL 3

DIPENTUM 4 NDS

ENTYVIO 4 NDS NM

GIAZO 4 NDS

HYDROCORTISONE (ENEMA)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

SF-ROWASA 4 NDS

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

Drug Name Drug Tier

Requirements/Limits

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS FOAM 3

UCERIS TAB 4 NDS

LAXATIVES constulose 1

enulose 1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-g (generic of GOLYTELY)

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

OSMOPREP 3

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

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

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS alosetron hcl (generic of LOTRONEX)

4 NDS

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1



36

Drug Name Drug Tier

Requirements/Limits

CARAFATE SUSP 2

CHOLBAM 4 NDS NM LA

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

4 NDS

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GATTEX 4 NDS NM LA

LINZESS 2

loperamide hcl CAPS 1

misoprostol (generic of CYTOTEC) TABS

1

MOVANTIK 2

OCALIVA 4 NDS NM LA

OMECLAMOX-PAK 3

PYLERA 4 NDS

RELISTOR 4 NDS

SUCRAID 4 NDS LA

sucralfate (generic of CARAFATE) TABS

1

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

VIBERZI 4 NDS

XIFAXAN TAB 550MG 4 NDS

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

VIOKACE 10 2

VIOKACE 20 4 NDS

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG 3

DEXILANT 2

esomeprazole magnesium (generic of NEXIUM)

1

esomeprazole sodium inj 20mg

1

Drug Name Drug Tier

Requirements/Limits

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

1

lansoprazole (generic of PREVACID) CPDR

1

NEXIUM GRA 2.5MG DR 3

NEXIUM GRA 5MG DR 3

NEXIUM GRA 10MG DR 3



omeprazole cap 10mg (generic of PRILOSEC)

1


1


1

pantoprazole sodium (generic of PROTONIX)

1

PREVACID SOLUTAB 3

PRILOSEC PACK 3

PROTONIX PACK 3

rabeprazole sodium (generic of ACIPHEX)

1

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

CARDURA XL 2

dutasteride (generic of AVODART)

1

dutasteride-tamsulosin hcl (generic of JALYN)

1

finasteride (generic of PROSCAR) TABS 5mg

1

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 3

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

1

POTASSIUM CITRATE (ALKALINIZER) 540mg

1



37

Drug Name Drug Tier

Requirements/Limits

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

URINARY ANTISPASMODICS darifenacin hydrobromide (generic of ENABLEX)

1

GELNIQUE 3

MYRBETRIQ 2

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

tolterodine tartrate er (generic of DETROL LA)

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

TOVIAZ 2

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES AVC 3

CLEOCIN VAG SUPP 100MG 3

clindamycin cre 2% vag (generic of CLEOCIN)

1

CLINDESSE 3

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole 3 sup 200mg 1

NUVESSA 3

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 CREAM 0.8% 1

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

Drug Name Drug Tier

Requirements/Limits

enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml

1

ENOXAPARIN SODIUM 300mg/3ml

1

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

4 NDS

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

4 NDS

HEP SOD/NACL INJ 25000 1

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

PRADAXA 3

SAVAYSA 3

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS



38

Drug Name Drug Tier

Requirements/Limits

ARANESP ALBUMIN FREE SOLN 10mcg/0.4ml, 25mcg/ml, 40mcg/ml, 60mcg/ml

2 B/D NM

ARANESP ALBUMIN FREE SOLN 100mcg/ml, 200mcg/ml, 300mcg/ml

4 NDS B/D NM

ARANESP ALBUMIN FREE SOSY 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml

2 B/D NM

ARANESP ALBUMIN FREE SOSY 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

4 NDS B/D NM

EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 B/D NM

EPOGEN 20000unit/ml 4 NDS B/D NM

GRANIX 4 NDS NM

LEUKINE 4 NDS NM

MIRCERA 3 B/D NM

MOZOBIL 4 NDS NM

NEULASTA 4 NDS NM

NEULASTA ONPRO KIT 4 NDS NM

NEUPOGEN 4 NDS NM

NPLATE 4 NDS NM

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

2 B/D NM

PROCRIT 20000unit/ml, 40000unit/ml

4 NDS B/D NM

ZARXIO 4 NDS NM

MISCELLANEOUS anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 4 NDS NM LA

cilostazol 1

CINRYZE 4 NDS NM LA

FIRAZYR 4 NDS NM

KALBITOR 4 NDS NM LA

pentoxifylline TBCR 1

PROMACTA 4 NDS NM LA

RUCONEST 4 NDS NM

SOLIRIS 4 NDS NM LA

Drug Name Drug Tier

Requirements/Limits

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS ASPIRIN-DIPYRIDAMOLE 1

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

DURLAZA 3

EFFIENT 2

ZONTIVITY 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 4 NDS NM

CIMZIA 4 NDS NM

CIMZIA STARTER KIT 4 NDS NM

COSENTYX 4 NDS NM LA

COSENTYX SENSOREADY PEN

4 NDS NM LA

ENBREL 4 NDS NM

ENBREL SURECLICK 4 NDS NM

HUMIRA INJ 10MG/0.2ML 4 NDS NM

HUMIRA KIT 20MG/0.4ML 4 NDS NM

HUMIRA KIT 40MG/0.8ML 4 NDS NM

HUMIRA PEDIATRIC CROHNS DISEASE

4 NDS NM

HUMIRA PEN 4 NDS NM

HUMIRA PEN-CROHNS STARTER KIT

4 NDS NM

HUMIRA PEN-PSORIASIS STARTER KIT

4 NDS NM

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 4 NDS NM

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

ORENCIA 4 NDS NM

ORENCIA CLICKJECT 4 NDS NM

OTEZLA 4 NDS NM

OTREXUP 7.5mg/0.4ml, 10mg/0.4ml, 15mg/0.4ml, 17.5mg/0.4ml, 20mg/0.4ml, 22.5mg/0.4ml, 25mg/0.4ml

3 NM



39

Drug Name Drug Tier

Requirements/Limits

RASUVO 2 NM

REMICADE 4 NDS NM

RHEUMATREX 2

SIMPONI 4 NDS NM

SIMPONI ARIA 4 NDS NM

STELARA 4 NDS NM

trexall 2 B/D

XELJANZ 4 NDS NM

XELJANZ XR 4 NDS NM

IMMUNOGLOBULINS BIVIGAM 4 NDS B/D NM

CARIMUNE NANOFILTERED 4 NDS B/D NM

CYTOGAM 4 NDS B/D NM

FLEBOGAMMA DIF 4 NDS B/D NM

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 4 NDS B/D NM

GAMMAGARD S/D 4 NDS B/D NM

GAMMAKED 4 NDS B/D NM

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

4 NDS B/D NM

GAMUNEX-C 4 NDS B/D NM

HIZENTRA 4 NDS B/D NM LA

HYQVIA 4 NDS B/D NM

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

4 NDS B/D NM

PRIVIGEN 4 NDS B/D NM

IMMUNOMODULATORS ACTIMMUNE 4 NDS B/D NM

LA

ARCALYST 4 NDS NM

GRASTEK 2

ILARIS 4 NDS NM LA

INTRON-A INJ 10MU 4 NDS B/D NM




ORALAIR 2 NM

POMALYST 4 NDS NM LA

RAGWITEK 2

REVLIMID 4 NDS NM LA

THALOMID 4 NDS NM

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 4 NDS B/D

Drug Name Drug Tier

Requirements/Limits

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

ATGAM 4 NDS B/D

azasan 2 B/D

azathioprine SOLR 3 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

BENLYSTA 4 NDS NM

CELLCEPT INTRAVENOUS 3 B/D

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

ENVARSUS XR 3 B/D

gengraf (generic of NEORAL) 1 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil (generic of CELLCEPT) SUSR

4 NDS B/D

mycophenolate sodium (generic of MYFORTIC)

1 B/D

NEORAL 2 B/D

NULOJIX 4 NDS B/D

PROGRAF CAPS 5mg 4 NDS B/D

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 4 NDS B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 10mg 3 B/D

SIMULECT 20mg 4 NDS B/D

sirolimus (generic of RAPAMUNE) TABS 2mg

4 NDS B/D

sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg

1 B/D

tacrolimus (generic of PROGRAF) CAPS

1 B/D



40

Drug Name Drug Tier

Requirements/Limits

THYMOGLOBULIN 4 NDS B/D

ZORTRESS TAB 0.5MG 4 NDS B/D

ZORTRESS TAB 0.25MG 2 B/D

ZORTRESS TAB 0.75MG 4 NDS B/D

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

CERVARIX 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

MENHIBRIX 3

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

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 4 NDS NM

TENIVAC 3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

Drug Name Drug Tier

Requirements/Limits

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20 meq 1

klor-con spr cap 8meq (generic of MICRO-K)

1

klor-con spr cap 10meq (generic of MICRO-K)

1

magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml

1

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

1

POTASSIUM CHLORIDE SOLN 10%, 20%

1

potassium chloride TBCR 8meq

1

POTASSIUM CHLORIDE TBCR 20meq

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

POTASSIUM CHLORIDE TAB CR 10 MEQ

1



41

Drug Name Drug Tier

Requirements/Limits

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 7% 3 B/D

AMINOSYN-PF INJ 10% 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%/D10 3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D

Drug Name Drug Tier

Requirements/Limits


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

NEPHRAMINE 3 B/D

nutrilipid inj 20% 1 B/D

plenamine 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

TRAVASOL 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 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

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



42

Drug Name Drug Tier

Requirements/Limits

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 0.22%/0.45%

1

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

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

KCL/NACL INJ 0.15%-0.9% 1

LACTATED RINGERS VIAFLEX

1

NORMOSOL-M IN D5W 3

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

pot chloride inj 2meq/ml 1

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

1

POTASSIUM CHLORIDE 0.3%/D

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

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

Drug Name Drug Tier

Requirements/Limits

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL) CAPS 1mcg, 2.5mcg

4 NDS B/D

doxercalciferol (generic of HECTOROL) CAPS .5mcg

1 B/D

doxercalciferol (generic of HECTOROL) SOLN

1 B/D

HECTOROL SOLN 2mcg/ml 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

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

blephamide OINT 3

BLEPHAMIDE SUSP 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 ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OIN 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1



43

Drug Name Drug Tier

Requirements/Limits

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) 1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 3

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

sulfacet sod oin 10% op 1

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

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 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

ILEVRO 3

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

1

Drug Name Drug Tier

Requirements/Limits

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

1

LOTEMAX 2

MAXIDEX 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine drop 0.05% 1

BEPREVE 3

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

olopatadine hcl (generic of PATANOL)

1

PATADAY 2

PAZEO 2

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

AZOPT 2

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 PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1



44

Drug Name Drug Tier

Requirements/Limits

levobunolol hcl (generic of BETAGAN)

1

LUMIGAN 3

metipranolol 1

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) soln (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS CYSTARAN 4 NDS NM LA

EYLEA 4 NDS NM LA

LACRISERT 3

LUCENTIS 4 NDS NM LA

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25 2

COMBIVENT RESPIMAT 2

ipratropium-albuterol 1 B/D

STIOLTO RESPIMAT 3

ANTICHOLINERGICS ATROVENT HFA 3

INCRUSE ELLIPTA 3

ipratropium bromide (nasal) 1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3

TUDORZA PRESSAIR (INSTITUTIONAL PACK)

3

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 2

Drug Name Drug Tier

Requirements/Limits

SEMPREX-D 3

ANTIHISTAMINES azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX SYRP 3

cyproheptadine hcl SYRP; TABS

3

desloratadine (generic of CLARINEX) TABS

1

desloratadine TBDP 1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; SYRP; TABS

3

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

3

hydroxyzine pamoate CAPS 100mg

3

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

1

levocetirizine tab 5 mg (generic of XYZAL)

1

olopatadine hcl (nasal) (generic of PATANASE)

1

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER 2

BROVANA 3 B/D

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 2

PROAIR RESPICLICK 2

PROVENTIL HFA 3



45

Drug Name Drug Tier

Requirements/Limits

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 3

terbutaline sulfate SOLN 4 NDS

terbutaline sulfate TABS 1

VENTOLIN HFA 3

XOPENEX HFA 3

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

1

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 4 NDS

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ARALAST NP 4 NDS NM LA

CINQAIR 4 NDS NM LA

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 4 NDS NM

GLASSIA 4 NDS NM LA

KALYDECO 4 NDS NM

NUCALA 4 NDS NM LA

OFEV 4 NDS NM

ORKAMBI 4 NDS NM

PROLASTIN-C 4 NDS NM LA

PULMOZYME 4 NDS B/D NM

XOLAIR 4 NDS NM LA

ZEMAIRA 4 NDS NM LA

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) (generic of RHINOCORT AQUA)

1

flunisolide (nasal) 1

fluticasone propionate (nasal) 1

mometasone furoate (nasal) (generic of NASONEX)

1

OMNARIS 3

QNASL 3

Drug Name Drug Tier

Requirements/Limits

QNASL CHILDRENS 3

VERAMYST 3

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ARNUITY ELLIPTA 3

ASMANEX 2

ASMANEX HFA 2

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

QVAR 2

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 2

DULERA 2

SYMBICORT 3

XANTHINES aminophylline inj 1

elixophyllin 3

theo-24 3

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 4 NDS

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA; GEL

1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLINDAGEL 4 NDS



46

Drug Name Drug Tier

Requirements/Limits

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

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

1

clindamycin phosphate-tretinoin (generic of ZIANA)

1

DIFFERIN LOTN 2

EPIDUO 2

EPIDUO FORTE 2

ery pad 2% 1

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

FABIOR 3

myorisan 1

neuac gel 1.2-5% (generic of DUAC)

1

ONEXTON 3

RETIN-A MICRO PUMP .08%

2

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA 3

tretinoin (generic of RETIN-A) CREA

1

TRETINOIN GEL .01% 1

TRETINOIN GEL .05% 1

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

1

tretinoin microsphere (generic of RETIN-A MICRO) .1%

1

Drug Name Drug Tier

Requirements/Limits

TRETINOIN MICROSPHERE .04%

1

VELTIN 3

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN 3

gentamicin sulfate (topical) 1

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

SULFAMYLON PACK 4 NDS

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% (generic of LOPROX)

1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 4 NDS

EXELDERM 3

ketoconazole (topical) CREA 1

ketoconazole (topical) (generic of EXTINA) FOAM

1

ketodan aer 2% (generic of EXTINA)

1

LUZU 2

MENTAX 3

NAFTIFINE HCL 1% 1

NAFTIFINE HCL 2% 1

NAFTIN GEL 2

nyamyc 1

nystatin (topical) 1



47

Drug Name Drug Tier

Requirements/Limits

nystatin pow 100000 1

nystop 1

OXICONAZOLE NITRATE 1

OXISTAT LOTN 3

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

DOXEPIN HCL (ANTIPRURITIC)

1

procto-med (generic of ANUSOL-HC)

1

procto-pak 1

proctosol hc 2.5 % (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

4 NDS

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

CALCITRIOL OINT 1

methoxsalen rapid (generic of OXSORALEN ULTRA)

4 NDS

8-MOP 3

SORILUX 3

TALTZ 4 NDS NM LA

TAZORAC 2

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon 3

betamethasone dipropionate (topical)

1

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN

1

BETAMETHASONE DIPROPIONATE AUGMENTED OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotriene/betamethasone (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

CLOCORTOLONE PIVALATE 1

clodan (generic of CLOBEX) 1

CORDRAN TAPE 3

cormax (generic of TEMOVATE)

1

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN

1

desonide OINT 1

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1



48

Drug Name Drug Tier

Requirements/Limits

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

ENSTILAR 4 NDS

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL .01%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS SCALP) OIL .01%

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

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

flurandrenolide (generic of CORDRAN)

1

fluticasone propionate (generic of CUTIVATE) CREA

1

fluticasone propionate (generic of CUTIVATE) LOTN

1

fluticasone propionate OINT 1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

Drug Name Drug Tier

Requirements/Limits

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

LOCOID LOTN 2

lokara (generic of DESOWEN)

1

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

1

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

psorcon 3

SERNIVO 4 NDS

TACLONEX SUSP 4 NDS

texacort 2

TOPICORT SPRAY 0.25% 3

triamcinolone acetonide (topical) (generic of KENALOG) AERS

1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

trianex 3

triderm 1

ULTRAVATE LOTN 3

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine 1 B/D

SYNERA 3 B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of ZOVIRAX)

1



49

Drug Name Drug Tier

Requirements/Limits

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

1

CONDYLOX GEL 2

DENAVIR 4 NDS

diclofenac sodium (actinic keratoses) (generic of SOLARAZE)

4 NDS

diclofenac sodium (topical) 1% gel (generic of VOLTAREN)

1

diclofenac sodium (topical) 1.5% gel

1

DOXYCYCLINE (ROSACEA) 1

ELIDEL 2

FINACEA AER 15% 2

FINACEA GEL 15% 2

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

1

FLUOROURACIL (TOPICAL) CREA .5%

4 NDS

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

metronidazole (topical) (generic of METROCREAM) CREA

1

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

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 4 NDS

PANRETIN 4 NDS

PENNSAID 4 NDS

PICATO 4 NDS

podofilox (generic of CONDYLOX) SOLN

1

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1

Drug Name Drug Tier

Requirements/Limits

TARGRETIN GEL 4 NDS NM

TOLAK 3

VALCHLOR 4 NDS NM LA

XERESE 4 NDS

ZOVIRAX CREA 4 NDS

ZYCLARA 4 NDS

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion (generic of OVIDE) 1

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 4 NDS

SANTYL 3

SODIUM CHLORIDE 0.9% 1

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

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

ORAVIG 4 NDS

paroex sol 0.12% (generic of PERIDEX)

1

periogard soln 0.12% (generic of PERIDEX)

1

PILOCARPINE HCL (ORAL) 5mg

1

pilocarpine hcl (oral) (generic of SALAGEN) 7.5mg

1

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1



50

Drug Name Drug Tier

Requirements/Limits

ACETIC ACID (OTIC) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 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) (generic of FLOXIN OTIC)

1


51

Index 8 8-MOP .............................. 47 A abacavir sulfate ...................6 abacavir sulfate-lamivudine-zidovudine ..........................................6 ABELCET............................5 ABILIFY

see aripiprazole tabs ..... 22 ABILIFY MAINTENA ......... 22 ABRAXANE ...................... 11 ABSORICA ....................... 45 ABSTRAL............................2 acamprosate calcium ........ 25 ACANYA ........................... 45 acarbose ........................... 27 ACCOLATE

see zafirlukast ............... 45 ACCUPRIL

see quinapril hcl ............ 13 ACCURETIC

see quinapril-hydrochlorothiazide .................................. 13

acebutolol hcl .................... 16 ACEON

see perindopril erbumine ...................................... 13

acetaminophen w/ codeine .1 acetaminophen-caff-dihydrocod ........................................1 acetasol hc ........................ 49 acetazolamide ................... 17 acetazolamide sodium ...... 17 ACETIC ACID ................... 49 ACETIC ACID (OTIC) ....... 50 acetic acid sol/hc ............... 50 acetic acid-aluminum acetate .......................................... 50 acetylcysteine ................... 45 ACIPHEX

see rabeprazole sodium 36 ACIPHEX SPR CAP 10MG .......................................... 36 ACIPHEX SPR CAP 5MG . 36 acitretin ............................. 47

ACLOVATE see alclometasone dipropionate .................. 47

ACTEMRA ........................ 38 ACTHIB ............................. 40 ACTIGALL

see ursodiol ................... 36 ACTIMMUNE .................... 39 ACTIQ

see fentanyl citrate .......... 2 ACTONEL

see risedronate sodium . 28 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 27

ACTOPLUS MET XR 15-1000MG ....................... 27 ACTOPLUS MET XR 30-1000MG ....................... 27 ACTOS

see pioglitazone hcl ....... 27 ACULAR

see ketorolac tromethamine (ophth) .... 43

ACULAR LS see ketorolac tromethamine (ophth) .... 43

ACUVAIL .......................... 43 acyclovir .............................. 7 acyclovir sodium ................. 7 acyclovir topical ................ 48 ACZONE ........................... 45 ADACEL ........................... 40 ADAGEN ........................... 31 ADALAT CC

see afeditab cr ............... 16 see nifedipine ................ 16

adapalene ......................... 45 ADCIRCA .......................... 18 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg......... 24 see amphetamine-dextroamphetamine tab 12.5 mg...... 24 see

amphetamine-dextroamphetamine tab 15 mg ........ 24 see amphetamine-dextroamphetamine tab 20 mg ........ 24 see amphetamine-dextroamphetamine tab 30 mg ........ 24 see amphetamine-dextroamphetamine tab 5 mg .......... 23 see amphetamine-dextroamphetamine tab 7.5 mg ....... 23

ADDERALL XR see amphetamine cap 10mg er ......................... 23 see amphetamine cap 15mg er ......................... 23 see amphetamine cap 20mg er ......................... 23 see amphetamine cap 25mg er ......................... 23 see amphetamine cap 30mg er ......................... 23 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 23

adefovir dipivoxil ................. 7 ADEMPAS ........................ 18 ADOXA

see doxycycline (monohydrate) ............... 10

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 10

adrucil ............................... 10 ADVAIR DISKUS .............. 45 ADVAIR HFA .................... 45 AEROSPAN ...................... 45 afeditab cr ......................... 16 AFINITOR ......................... 12 AFINITOR DISPERZ ........ 12 AFREZZA ......................... 33 AGRYLIN

see anagrelide hcl ......... 38


52

a-hydrocort ........................ 31 AKYNZEO ......................... 34 ala-cort .............................. 47 ALBENZA............................4 albuterol sulfate ................. 44 albuterol sulfate er ............ 44 ALCAINE

see proparacaine hcl ..... 44 alclometasone dipropionate .......................................... 47 ALCOHOL SWABS ........... 26 ALDACTAZIDE

see spironolactone & hydrochlorothiazide ....... 17

ALDACTAZIDE TAB 50/50 .......................................... 17 ALDACTONE

see spironolactone ........ 14 ALDARA

see imiquimod ............... 49 ALDURAZYME ................. 31 ALECENSA ....................... 12 alendronate sodium .......... 28 alfuzosin hcl ...................... 36 ALIMTA ............................. 10 ALINIA ................................4 ALKERAN

see melphalan hcl ......... 10 allopurinol tab ......................1 almotriptan malate ............ 24 ALOCRIL........................... 43 ALOMIDE .......................... 43 ALOPRIM ............................1 ALORA .............................. 31 alosetron hcl ...................... 35 ALOXI ............................... 34 ALPHAGAN P 0.1% .......... 43 alprazolam ........................ 18 ALREX .............................. 43 ALTABAX .......................... 46 ALTACE

see ramipril .................... 13 altavera tab ....................... 28 ALTOPREV ....................... 15 ALVESCO ......................... 45 amantadine hcl .................. 21 AMARYL

see glimepiride .............. 27

AMBIEN see zolpidem tartrate ..... 24

AMBISOME ........................ 5 amcinonide ....................... 47 AMERGE

see naratriptan hcl ......... 24 amethia 91 day ................. 28 amethyst 28 day ............... 28 amifostine crystalline......... 13 amikacin sulfate .................. 4 amiloride & hydrochlorothiazide ........... 17 amiloride hcl ...................... 17 aminophylline inj ............... 45 AMINOSYN ....................... 41 AMINOSYN 7%/ELECTROLYTES ....... 41 AMINOSYN II .................... 41 AMINOSYN II 8.5%/ELECTROL .............. 41 AMINOSYN INJ 8.5/LYTE 41 AMINOSYN M ................... 41 AMINOSYN-HBC .............. 41 AMINOSYN-PF 7% ........... 41 AMINOSYN-PF INJ 10% .. 41 AMINOSYN-RF ................. 41 amiodarone hcl ................. 14 amiodarone inj 50mg/ml.... 14 AMITIZA ............................ 35 amitriptyline hcl ................. 20 amlodipine besylate .......... 16 amlodipine besylate/atorv . 16 amlodipine besylate-benazepril hcl ..... 13 amlodipine besylate-valsartan tab 10-160 mg ......................... 14 amlodipine besylate-valsartan tab 10-320 mg ......................... 14 amlodipine besylate-valsartan tab 5-160 mg ..................................... 14 amlodipine besylate-valsartan tab 5-320 mg ..................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 14 ammonium chloride .......... 40 ammonium lactate ............ 49 amoxapine ........................ 20 amoxicillin ........................... 9 amoxicillin & pot clavulanate............................................ 9 amoxicillin-clarithromycin w/ lansoprazole ..................... 35 amphetamine cap 10mg er.......................................... 23 amphetamine cap 15mg er.......................................... 23 amphetamine cap 20mg er.......................................... 23 amphetamine cap 25mg er.......................................... 23 amphetamine cap 30mg er.......................................... 23 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 23 amphetamine-dextroamphetamine tab 10 mg ............... 24 amphetamine-dextroamphetamine tab 12.5 mg ............ 24 amphetamine-dextroamphetamine tab 15 mg ............... 24 amphetamine-dextroamphetamine tab 20 mg ............... 24 amphetamine-dextroamphetamine tab 30 mg ............... 24 amphetamine-dextroamphetamine tab 5 mg ................. 23 amphetamine-dextroamphetamine tab 7.5 mg .............. 23 amphotericin b .................... 5 ampicillin & sulbactam


53

sodium ................................9 ampicillin cap 250mg ..........9 ampicillin cap 500 mg .........9 ampicillin inj .........................9 ampicillin sodium .................9 ampicillin susp .....................9 AMPYRA ........................... 25 ANADROL-50 ................... 26 ANAFRANIL

see clomipramine hcl ..... 20 anagrelide hcl .................... 38 ANAPROX DS

see naproxen sodium ......1 anastrozole ....................... 11 ANCOBON

see flucytosine .................5 ANDRODERM .................. 26 ANDROGEL ...................... 26 ANDROGEL 1% ................ 26 ANDROGEL 1.62% ........... 26 ANORO ELLIPT AER 62.5-25 .............................. 44 ANTABUSE

see disulfiram ................ 26 ANTARA ........................... 15 ANUSOL-HC

see procto-med ............. 47 see proctosol hc 2.5 % .. 47 see proctozone hc ......... 47

apexicon............................ 47 APIDRA............................. 26 APIDRA SOLOSTAR ........ 26 APLENZIN ........................ 20 APOKYN ........................... 21 apri 28 day ........................ 28 APRISO ............................ 35 APTENSIO XR .................. 24 APTIOM ............................ 18 APTIVUS.............................6 ARALAST NP .................... 45 ARALEN

see chloroquine phosphate ........................6

aranelle 28 ........................ 28 ARANESP ALBUMIN FREE .......................................... 38 ARAVA

see leflunomide ............. 38

ARCALYST ....................... 39 ARCAPTA NEOHALER .... 44 ARICEPT

see donepezil tab hcl 23mg ............................. 20 see donepezil tabs 10mg ...................................... 20 see donepezil tabs 5mg 20

ARIMIDEX see anastrozole ............. 11

aripiprazole odt ................. 22 aripiprazole oral solution 1 mg/ml ................................ 22 aripiprazole tabs ............... 22 ARISTADA ........................ 22 ARIXTRA

see fondaparinux sodium ...................................... 37

armodafinil ........................ 25 ARMODAFINIL ................. 25 ARNUITY ELLIPTA ........... 45 AROMASIN

see exemestane ............ 11 ARRANON ........................ 10 ARTHROTEC 50

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

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

ARZERRA ......................... 11 ASACOL HD ..................... 35 ashlyna 91 day .................. 28 ASMANEX ........................ 45 ASMANEX HFA ................ 45 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG .................. 1 ASPIRIN-DIPYRIDAMOLE .......................................... 38 ASTAGRAF XL ................. 39 ASTEPRO

see azelastine spr 0.15% ...................................... 44

ATACAND see candesartan cilexetil ...................................... 14

ATACAND HCT

see candesartan cilexetil-hydrochlorothiazide .................................... 14

ATELVIA see risedronate sodium . 28

atenolol ............................. 16 atenolol & chlorthalidone .. 15 ATGAM ............................. 39 ATIVAN

see lorazepam............... 18 atorvastatin calcium .......... 15 atovaquone ......................... 4 atovaquone-proguanil hcl tab 250-100 mg ........................ 6 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 6 ATRALIN .......................... 45 ATRIPLA ............................. 7 ATROPINE SULFATE ...... 34 ATROVENT HFA .............. 44 AUBAGIO ......................... 25 aubra 28 day ..................... 28 AUGMENTIN ...................... 9

see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN ES-600 see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN XR see amoxicillin & pot clavulanate ...................... 9

AURYXIA .......................... 33 AVALIDE

see irbesartan-hydrochlorothiazide ............................... 14

AVAPRO see irbesartan ............... 14

AVASTIN .......................... 11 AVC .................................. 37 AVEED ............................. 26 AVELOX ............................. 9

see moxifloxacin hcl ........ 9 aviane 28 .......................... 28 AVITA ............................... 45 AVODART

see dutasteride.............. 36 AVONEX ........................... 25


54

AVONEX PEN ................... 25 AVYCAZ..............................8 AXERT

see almotriptan malate .. 24 AXIRON ............................ 26 AYGESTIN

see norethindrone acetate ...................................... 33

azacitidine ......................... 10 AZACTAM

see aztreonam .................5 AZACTAM IN ISO-OSMOTIC DE ..............4 AZACTAM/DEX INJ 2GM ...5 azasan .............................. 39 AZASITE ........................... 42 azathioprine ...................... 39 azelastine drop 0.05% ...... 43 azelastine spr 0.1% ........... 44 azelastine spr 0.15% ......... 44 AZELEX ............................ 45 AZILECT ........................... 21 azithromycin ........................8 AZITHROMYCIN .................8 AZOPT .............................. 43 AZOR ................................ 14 aztreonam ...........................5 AZULFIDINE

see sulfasalazine ir ........ 35 AZULFIDINE EN-TABS

see sulfasalazine dr ....... 35 B bacitracin (ophthalmic) ...... 42 bacitracin-polymyxin b (ophth) .............................. 42 bacitracin-poly-neomycin-hc .......................................... 42 baclofen ............................ 25 BACTOCILL INJ DEX 1GM.9 BACTOCILL INJ DEX 2GM.9 BACTRIM

see sulfamethoxazole-trimethop ......................................5

BACTRIM DS see sulfamethoxazole-trimethop ds .................................5

BACTROBAN see mupirocin ................ 46 see mupirocin calcium (topical) ......................... 46

BACTROBAN NASAL ....... 46 balsalazide disodium......... 35 balziva 28 day ................... 28 BANZEL SUS 40MG/ML ... 18 BANZEL TAB 200MG ....... 18 BANZEL TAB 400MG ....... 18 BARACLUDE ...................... 7

see entecavir ................... 7 BCG VACCINE ................. 40 BECONASE AQ ................ 45 bekyree 28 day ................. 28 BELBUCA ........................... 1 BELEODAQ ...................... 11 benazepril & hydrochlorothiazide ........... 13 benazepril hcl .................... 13 BENDEKA ......................... 10 BENICAR .......................... 14 BENICAR HCT ................. 14 BENLYSTA ....................... 39 BENTYL ............................ 34

see dicyclomine hcl ....... 34 BENZACLIN

see clindamycin phosphate-benzoyl peroxide ........................ 46

BENZAMYCIN see benzoyl peroxide-erythromycin ... 45

benzoyl peroxide-erythromycin ...... 45 benztropine mesylate ........ 21 BENZTROPINE MESYLATE .......................................... 21 BEPREVE ......................... 43 BERINERT ........................ 38 BESIVANCE ..................... 42 BETAGAN

see levobunolol hcl ........ 44 betamethasone dipropionate (topical) ............................. 47 betamethasone dipropionate augmented ........................ 47 BETAMETHASONE

DIPROPIONATE AUGMENTED ................... 47 betamethasone valerate ... 47 BETAPACE

see sorine ..................... 15 see sotalol hcl ............... 15

BETAPACE AF see sotalol hcl (afib/afl) . 15

BETASERON ................... 25 betaxolol hcl ...................... 16 betaxolol hcl (ophth) ......... 43 bethanechol chloride ......... 36 BETHKIS ............................ 4 BETIMOL .......................... 43 BETOPTIC-S .................... 43 bexarotene ........................ 12 BEXSERO ........................ 40 BEYAZ .............................. 28 BIAXIN

see clarithromycin ........... 8 BIAXIN XL

see clarithromycin ........... 8 bicalutamide ..................... 11 BICILLIN C-R ...................... 9 BICILLIN L-A ...................... 9 BICNU .............................. 10 BIDIL ................................. 17 BILTRICIDE ........................ 5 BINOSTO ......................... 28 bisoprolol & hydrochlorothiazide ........... 15 bisoprolol fumarate ........... 16 BIVIGAM ........................... 39 bleomycin sulfate .............. 10 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 43

blephamide ....................... 42 BLEPHAMIDE .................. 42 blisovi 21 fe 1.5/30 28 day pack .................................. 28 blisovi 21 fe 1/20 28 day pack .................................. 28 blisovi 24 fe 1/20 28 day ... 28 BONIVA

see ibandronate sodium 28 see ibandronate tab 150mg ........................... 28


55

BOOSTRIX ....................... 40 BOSULIF........................... 12 BOTOX INJ 100UNIT ........ 25 BOTOX INJ 200UNIT ........ 25 BREO ELLIPTA ................ 45 BREVICON-28

see necon 0.5/35 28 day ...................................... 30 see nortrel 0.5/35 28 day ...................................... 30

briellyn 28 day ................... 28 BRILINTA .......................... 38 BRIMONIDINE SOL 0.15% .......................................... 43 brimonidine sol 0.2% ......... 43 BRISDELLE ...................... 25 BRIVIACT ......................... 18 bromfenac sodium (ophth) 43 bromocriptine mesylate ..... 21 BROVANA ........................ 44 budesonide ....................... 35 budesonide (inhalation) ..... 45 budesonide (nasal) ........... 45 bumetanide ....................... 17 BUMEX

see bumetanide ............. 17 BUNAVAIL MIS 2.1-0.3MG .......................................... 25 BUNAVAIL MIS 4.2-0.7MG .......................................... 25 BUNAVAIL MIS 6.3-1MG .. 26 BUPHENYL ....................... 31

see sodium phenylbutyrate ...................................... 31

buprenorphine hcl ............. 26 buprenorphine hcl-naloxone hcl sl .................................. 26 buproban ........................... 26 bupropion hcl .................... 20 bupropion hcl (smoking deterrent) .......................... 26 buspirone hcl ..................... 18 BUSULFEX ....................... 10 butorphanol nasal spray ......1 butorphanol tartrate .............2 BUTRANS ...........................2 BYDUREON INJ ............... 26 BYDUREON PEN ............. 26

BYETTA ............................ 26 BYSTOLIC ........................ 16 C cabergoline ....................... 33 CABOMETYX ................... 12 CADUET

see amlodipine besylate/atorv ................ 16

cafergot tab 1-100mg ........ 24 CALAN

see verapamil hcl .......... 17 CALAN SR

see verapamil hcl .......... 17 calcipotriene ...................... 47 calcipotriene/betamethasone .......................................... 47 calcitonin (salmon) nasal spray ................................. 33 calcitriol ............................. 42 CALCITRIOL ..................... 47 calcium acetate (phosphate binder) ............................... 33 camila 28 day .................... 28 CAMPTOSAR ................... 13

see irinotecan inj 100/5ml ...................................... 13 see irinotecan inj 40mg/2ml ...................... 13

CAMRESE LO TAB .......... 29 CANASA ........................... 35 CANCIDAS ......................... 5 candesartan cilexetil ......... 14 candesartan cilexetil-hydrochlorothiazide .......................................... 14 CAPASTAT SULFATE ........ 7 CAPEX .............................. 47 capital

and codeine ..................... 2 CAPRELSA ....................... 12 captopril ............................ 13 captopril & hydrochlorothiazide ........... 13 CARAFATE ....................... 36

see sucralfate ................ 36 CARBAGLU ...................... 31 carbamazepine ........... 18, 19 CARBATROL

see carbamazepine ....... 18 carbidopa .......................... 21 CARBIDOPA/LEVODOPA/ENTACAPONE ............. 21, 22 carbidopa-levodopa .......... 21 carboplatin ........................ 13 CARDIZEM

see diltiazem hcl ............ 16 CARDIZEM CD

see cartia xt ................... 16 see diltiazem hcl coated beads ............................ 16

CARDIZEM LA.................. 16 see matzim la ................ 16

CARDURA see doxazosin mesylate 14

CARDURA XL .................. 36 CARIMUNE NANOFILTERED .............. 39 CARNITOR

see levocarnitine (metabolic modifiers) ..... 31

carteolol hcl (ophth) .......... 43 cartia xt ............................. 16 carvedilol .......................... 16 CASODEX

see bicalutamide ........... 11 CATAPRES

see clonidine hcl ............ 18 CATAPRES-TTS-1



see clonidine hcl ............ 18 CAYSTON .......................... 5 cefaclor ............................... 8 cefaclor er tab 500mg ......... 8 cefadroxil ............................ 8 CEFAZOLIN IN DEXTROSE 2GM/100ML-4%.................. 8 cefazolin inj ......................... 8 cefazolin sodium ................. 8 cefazolin sodium 1 gm/50ml8 cefdinir ................................ 8 CEFEPIME 1GM SOLN ...... 8 CEFEPIME 2GM SOLN ...... 8 cefepime inj 1gm................. 8


56

cefepime inj 2gm .................8 CEFEPIME/DEXTROSE .....8 cefixime ...............................8 CEFOTAN

see cefotetan disodium....8 cefotaxime sodium ..............8 cefotetan disodium ..............8 cefoxitin sodium ..................8 CEFOXITIN SODIUM .........8 cefpodoxime proxetil ...........8 cefprozil...............................8 ceftazidime ..........................8 CEFTAZIDIME/DEXTROSE ............................................8 CEFTIBUTEN .....................8 CEFTIN

see cefuroxime axetil .......8 CEFTIN SUSP ....................8 ceftriaxone sodium ..............8 cefuroxime axetil .................8 cefuroxime sodium ..............8 CELEBREX

see celecoxib ...................1 celecoxib .............................1 CELEXA

see citalopram hydrobromide ................ 20

CELLCEPT see mycophenolate mofetil ...................................... 39

CELLCEPT INTRAVENOUS .......................................... 39 CELONTIN ........................ 19 CENTANY ......................... 46 cephalexin ...........................8 CERDELGA ...................... 31 CEREZYME ...................... 31 CERVARIX ........................ 40 CESAMET ......................... 34 cetirizine syrup .................. 44 cevimeline hcl ................... 49 CHANTIX .......................... 26 CHANTIX CONTINUING MONTH ............................. 26 CHANTIX STARTER PACK .......................................... 26 CHEMET ........................... 28 chlorhexidine gluconate

(mouth-throat) ................... 49 chloroquine phosphate........ 6 chlorothiazide tabs ............ 17 chlorpromazine hcl ............ 22 chlorpromazine inj ............. 22 chlorthalidone ................... 17 CHOLBAM ........................ 36 cholestyramine .................. 15 cholestyramine light .......... 15 choline fenofibrate ............ 15 CHORIONIC GONADOTROPIN ............ 33 ciclopirox ........................... 46 ciclopirox cre 0.77% .......... 46 ciclopirox shampoo 1% ..... 46 ciclopirox sus 0.77% ......... 46 cidofovir .............................. 7 cilostazol ........................... 38 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 42

CILOXAN OIN 0.3% OP ... 42 cimetidine .......................... 35 cimetidine sol 300/5ml ...... 35 CIMZIA .............................. 38 CIMZIA STARTER KIT ..... 38 CINQAIR ........................... 45 CINRYZE .......................... 38 CIPRO

see ciprofloxacin ............. 9 see ciprofloxacin hcl ........ 9

CIPRO HC ........................ 50 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w .. 9 CIPRO XR

see ciprofloxacin er ......... 9 CIPRODEX ....................... 50 ciprofloxacin ........................ 9 ciprofloxacin er .................... 9 ciprofloxacin hcl .................. 9 ciprofloxacin hcl (ophth) .... 42 ciprofloxacin in d5w ............ 9 ciprofloxacn inj 400mg/40ml9 cisplatin ............................. 13 citalopram hydrobromide .. 20 cladribine .......................... 10 claforan ............................... 8 CLAFORAN

see cefotaxime sodium ... 8 CLAFORAN/D5W ............... 8 claravis ............................. 45 CLARINEX ........................ 44

see desloratadine .......... 44 CLARINEX-D TAB 2.5-120.......................................... 44 clarithromycin ..................... 8 CLEOCIN

see clindamycin cre 2% vag ................................ 37 see clindamycin hcl ......... 5

CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 5

CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride................... 5

CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 5

CLEOCIN VAG SUPP 100MG .............................. 37 CLEOCIN-T

see clindamax ............... 46 see clindamycin phosphate (topical) ........ 46

CLIMARA see estradiol .................. 31

CLINDAGEL ..................... 45 clindamax ......................... 46 clindamycin cre 2% vag .... 37 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 5 clindamycin phosphate (topical) ............................. 46 clindamycin phosphate in d5w ..................................... 5 clindamycin phosphate-benzoyl peroxide.......................................... 46 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 46 clindamycin


57

phosphate-tretinoin ........... 46 CLINDESSE ...................... 37 CLINIMIX 2.75%/DEXTROSE 5% ..... 41 CLINIMIX 4.25%/DEXTROSE 10% ... 41 CLINIMIX 4.25%/DEXTROSE 20% ... 41 CLINIMIX 4.25%/DEXTROSE 25% ... 41 CLINIMIX 4.25%/DEXTROSE 5% ..... 41 CLINIMIX 5%/DEXTROSE 15% ................................... 41 CLINIMIX 5%/DEXTROSE 20% ................................... 41 CLINIMIX 5%/DEXTROSE 25% ................................... 41 CLINIMIX E 2.75%/DEXTROSE 10% ... 41 CLINIMIX E 2.75%/DEXTROSE 5% ..... 41 CLINIMIX E 4.25%/D10 .... 41 CLINIMIX E 4.25%/DEXTROSE 25% ... 41 CLINIMIX E 4.25%/DEXTROSE 5% ..... 41 CLINIMIX E 5%/DEXTROSE 15% ................................... 41 CLINIMIX E 5%/DEXTROSE 20% ................................... 41 CLINIMIX E 5%/DEXTROSE 25% ................................... 41 clinisol 15 .......................... 41 clobetasol propionate ........ 47 clobetasol propionate emollient base ................... 47 clobetasol propionate emulsion............................ 47 CLOBEX

see clobetasol propionate ...................................... 47 see clodan ..................... 47

CLOCORTOLONE PIVALATE ......................... 47 clodan ............................... 47 CLOLAR............................ 10 clomipramine hcl ............... 20

clonazepam ...................... 19 clonidine hcl ................ 17, 18 clopidogrel bisulfate .......... 38 clorazepate dipotassium ... 19 clorpres ............................. 18 clotrimazole ....................... 49 clotrimazole (topical) ......... 46 CLOZAPINE ODT ............. 22 clozapine tab 100mg ......... 22 clozapine tab 200mg ......... 22 clozapine tab 25mg ........... 22 clozapine tab 50mg ........... 22 CLOZARIL

see clozapine tab 100mg ...................................... 22 see clozapine tab 25mg 22

COARTEM .......................... 6 codeine

and capital ....................... 2 CODEINE SULFATE .......... 2 COLAZAL

see balsalazide disodium ...................................... 35

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

see colestipol hcl ........... 15 colestipol hcl ..................... 15 colistimethate sodium ......... 5 colocort ............................. 35 COLY-MYCIN M

see colistimethate sodium ........................................ 5

COLY-MYCIN S ................ 50 COLYTE-FLAVOR PACKS

see gavilyte-c ................ 35 COMBIGAN ...................... 43 COMBIVENT RESPIMAT . 44 COMBIVIR

see lamivudine-zidovudine ........................................ 7

COMETRIQ ...................... 12 COMPLERA ........................ 7 compro supp ..................... 34 CONDYLOX ...................... 49

see podofilox ................. 49 constulose ......................... 35 COPAXONE

see glatopa ................... 25 COPAXONE INJ 40MG/ML.......................................... 25 COPAXONE KIT 20MG/ML.......................................... 25 COPEGUS

see moderiba tab 200mg 7 see ribasphere ................ 7 see ribavirin 200mg ......... 7

CORDARONE see amiodarone hcl ....... 14 see pacerone ................ 14

CORDRAN ....................... 47 see flurandrenolide ........ 48

COREG see carvedilol ................ 16

COREG CR ...................... 16 CORGARD

see nadolol .................... 16 CORLANOR ..................... 18 cormax .............................. 47 CORTEF

see hydrocortisone ........ 32 CORTENEMA

see colocort ................... 35 CORTIFOAM .................... 47 cortisone acetate .............. 31 CORTISPORIN ................. 46

see neomycin-polymyxin-hc (otic) .............................. 50

CORZIDE see nadolol & bendroflumethiazide ...... 16

COSENTYX ...................... 38 COSENTYX SENSOREADY PEN .................................. 38 COSMEGEN ..................... 10 COSOPT

see dorzolamide hcl-timolol maleate ........ 43

COSOPT PF ..................... 43 COTELLIC ........................ 12 COUMADIN ...................... 37

see jantoven .................. 37 see warfarin sodium ...... 37

COZAAR see losartan potassium . 14


58

CREON ............................. 36 CRESEMBA ........................5 CRESTOR

see rosuvastatin calcium ...................................... 15

CRINONE ......................... 33 CRIXIVAN ...........................6 cromolyn sodium ............... 45 cromolyn sodium (mastocytosis) ................... 36 cromolyn sodium (ophth) .. 43 cryselle 28 ......................... 29 CUBICIN .............................5 CUTIVATE

see fluticasone propionate ...................................... 48

CUVPOSA ........................ 34 cyclafem 1/35 28 day ........ 29 cyclafem 7/7/7 28 day ....... 29 CYCLESSA

see velivet 28 day .......... 31 cyclobenzaprine hcl .......... 25 cyclophosphamide ............ 10 CYCLOPHOSPHAMIDE ... 10 cycloserine ..........................7 cyclosporine ...................... 39 cyclosporine modified (for microemulsion) .................. 39 CYKLOKAPRON

see tranexamic acid ...... 38 CYMBALTA

see duloxetine hcl .......... 20 cyproheptadine hcl ............ 44 CYRAMZA ........................ 11 cyred tab ........................... 29 CYSTADANE .................... 31 CYSTAGON ...................... 31 CYSTARAN ...................... 44 cytarabine inj ..................... 10 CYTOGAM ........................ 39 CYTOMEL

see liothyronine sodium . 33 CYTOTEC

see misoprostol ............. 36 CYTOVENE

see ganciclovir inj 500mg 7 D D.H.E. 45

see dihydroergotamine mesylate ........................ 24

dacarbazine ...................... 10 DACOGEN

see decitabine ............... 10 DAKLINZA .......................... 7 DALIRESP ........................ 45 DALVANCE ........................ 5 danazol ............................. 31 DANTRIUM

see dantrolene sodium .. 25 dantrolene sodium ............ 25 dapsone .............................. 5 DAPTACEL ....................... 40 DARAPRIM ......................... 5 darifenacin hydrobromide . 37 DARZALEX ....................... 11 daunorubicin hcl ................ 10 DAYPRO

see oxaprozin .................. 1 DAYTRANA ...................... 24 DDAVP

see desmopressin acetate ...................................... 34 see desmopressin acetate inj................................... 34 see desmopressin acetate spray ............................. 34

deblitane 28 day ............... 29 decitabine ......................... 10 deferoxamine mesylate ..... 28 DELESTROGEN ............... 31

see estradiol valerate .... 31 delyla 28 day ..................... 29 DELZICOL ........................ 35 DEMADEX

see torsemide tabs ........ 17 demeclocycline hcl .............. 9 DEMSER .......................... 18 DENAVIR .......................... 49 DEPACON

see valproate sodium .... 20 DEPAKENE

see valproate sodium .... 20 see valproic acid ........... 20

DEPAKOTE see divalproex sodium ... 19

DEPAKOTE ER

see divalproex sodium .. 19 DEPAKOTE SPRINKLES

see divalproex sodium .. 19 DEPEN TITRATABS ......... 28 depo-estradiol ................... 31 DEPO-MEDROL

see methylpr ace inj 40mg/ml ........................ 32 see methylpr ace inj 80mg/ml ........................ 32

DEPO-MEDROL INJ 20MG/ML .......................... 31 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 30

DEPO-PROVERA INJ 400/ML .............................. 11 DEPO-SUBQ PROVERA 104 .................................... 29 depo-testosterone ............. 26 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 26

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 48

DERMA-SMOOTHE/FS SCALP


DERMATOP see prednicarbate ......... 48

DERMOTIC see fluocinolone acetonide (otic) .............................. 50

DESCOVY .......................... 7 DESFERAL

see deferoxamine mesylate ........................ 28

desipramine hcl................. 20 desloratadine .................... 44 desmopressin acetate ....... 34 DESMOPRESSIN ACETATE.......................................... 34 desmopressin acetate inj .. 34 desmopressin acetate spray


59

.......................................... 34 desmopressin acetate spray refrigerated ........................ 34 DESOGEN

see apri 28 day .............. 28 see cyred tab ................. 29 see emoquette ............... 29 see juleber 28 day ......... 29 see reclipsen 28 day ..... 30

desogestrel-ethinyl estradiol (biphasic) .......................... 29 DESONATE ...................... 47 desonide ........................... 47 DESONIDE ....................... 47 DESOWEN

see desonide ................. 47 see lokara ...................... 48

desoximetasone .......... 47, 48 DESOXIMETASONE ........ 48 DETROL

see tolterodine tartrate tab 1 mg .............................. 37 see tolterodine tartrate tab 2 mg .............................. 37

DETROL LA see tolterodine tartrate er ...................................... 37

dexamethasone ................ 31 dexamethasone sodium phosphate ......................... 31 dexamethasone sodium phosphate (ophth) ............. 43 DEXILANT ........................ 36 dexpak 10 day ................... 31 dexpak 6 day ..................... 31 dexpak taperpak 13 day .... 32 dexrazoxane ..................... 13 DEXTROSE ...................... 41 DEXTROSE 10% FLEX CONTAIN .......................... 41 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 41 DEXTROSE 10%/NACL 0.45% ................................ 41 DEXTROSE 2.5%/NACL 0.45% ................................ 41 DEXTROSE 5% ................ 41

DEXTROSE 5% /ELECTROLYTE ............... 41 DEXTROSE 5%/LACTATED RING ................................. 41 DEXTROSE 5%/NACL 0.2% .......................................... 41 DEXTROSE 5%/NACL 0.225% .............................. 41 DEXTROSE 5%/NACL 0.3% .......................................... 41 DEXTROSE 5%/NACL 0.33%................................ 41 DEXTROSE 5%/NACL 0.45%................................ 41 DEXTROSE 5%/NACL 0.9% .......................................... 41 DEXTROSE 5%/POTASSIUM CHL ...... 41 DIAMOX

see acetazolamide ........ 17 diazepam .......................... 19 DIAZEPAM GEL (ANTICONVULSANT) ....... 19 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 49 diclofenac sodium (ophth) . 43 diclofenac sodium (topical) 1% gel ............................... 49 diclofenac sodium (topical) 1.5% gel ............................ 49 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ............. 9 dicyclomine hcl ................. 34 didanosine .......................... 6 DIFFERIN ......................... 46

see adapalene ............... 45 DIFICID ............................... 8 diflorasone diacetate ......... 48 DIFLUCAN

see fluconazole ............... 5 diflunisal .............................. 1 digitek ............................... 17 digox ................................. 17 digoxin .............................. 17 digoxin inj .......................... 17 DIGOXIN SOL 50MCG/ML

.......................................... 17 dihydroergotamine mesylate.......................................... 24 DIHYDROERGOTAMINE MESYLATE ...................... 24 dilantin .............................. 19 DILANTIN

see phenytoin sodium extended ....................... 19

DILANTIN INFATABS see phenytoin ................ 19

DILANTIN-125 .................. 19 see phenytoin ................ 19

DILATRATE SR ................ 18 DILAUDID

see hydromorphone hcl ... 2 DILAUDID-HP

see hydromorphone hcl ... 2 diltiazem cap 120mg/24hr . 16 diltiazem cap 240mg/24hr . 16 diltiazem cap er/12hr ........ 16 diltiazem hcl ...................... 16 diltiazem hcl coated beads 16 diltiazem hcl er .................. 16 diltiazem hcl extended release beads ................... 16 diltiazem inj 100mg ........... 16 diltiazem inj 125/25ml ....... 16 diltiazem inj 25mg/5ml ...... 16 diltiazem inj 50/10ml ......... 16 dilt-xr cap .......................... 16 DIOVAN

see valsartan ................. 14 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 14

DIPENTUM ....................... 35 diphenhydram inj 50mg/ml 44 diphenoxylate w/ atropine . 36 DIPHTHERIA/TETANUS TOXOID ............................ 40 DIPROLENE

see betamethasone dipropionate augmented 47

DIPROLENE AF see betamethasone dipropionate augmented 47


60

disopyramide phosphate ... 14 disulfiram........................... 26 DITROPAN XL

see oxybutynin chloride . 37 DIURIL SUS 250/5ML ....... 17 divalproex sodium ............. 19 DOCEFREZ ...................... 11 docetaxel........................... 11 DOCETAXEL .................... 11 DOCETAXEL SOLN 80MG/8ML ........................ 11 DOFETILIDE ..................... 14 DOLOPHINE

see methadone hcl 10mg 3 see methadone hcl 5mg ..3

donepezil odt 10mg ........... 20 donepezil odt 5mg ............. 20 donepezil tab hcl 23mg ..... 20 donepezil tabs 10mg ......... 20 donepezil tabs 5mg ........... 20 DORIBAX ............................5 DORYX

see doxycycline hyclate . 10 dorzolamide hcl ................. 43 dorzolamide hcl-timolol maleate ............................. 43 DOVONEX

see calcipotriene ........... 47 doxazosin mesylate .......... 14 doxepin hcl ........................ 20 DOXEPIN HCL (ANTIPRURITIC) .............. 47 doxercalciferol ................... 42 DOXIL

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 10

doxorubicin hcl .................. 10 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ..... 10 doxorubicin inj 50mg ......... 10 doxy ....................................9 doxycycline (monohydrate) 9, 10 DOXYCYCLINE (ROSACEA) ...................... 49 doxycycline hyclate ........... 10 doxycycline hyclate tab 100

mg dr................................. 10 doxycycline hyclate tab 150 mg dr................................. 10 doxycycline hyclate tab 75 mg dr................................. 10 dronabinol ......................... 34 drospirenone-ethinyl estradiol ............................ 29 DROXIA ............................ 12 DUAC

see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 46 see neuac gel 1.2-5% .... 46

DUETACT see pioglitazone hcl-glimepiride ............... 27

DUEXIS .............................. 1 DULERA ........................... 45 duloxetine hcl .................... 20 DUOPA ............................. 22 DURAGESIC

see fentanyl patch 100 mcg/hr ............................. 2 see fentanyl patch 12 mcg/hr ............................. 2 see fentanyl patch 25 mcg/hr ............................. 2 see fentanyl patch 50 mcg/hr ............................. 2 see fentanyl patch 75 mcg/hr ............................. 2

DURAMORPH .................... 2 DUREZOL ......................... 43 DURLAZA ......................... 38 dutasteride ........................ 36 dutasteride-tamsulosin hcl 36 DUTOPROL ...................... 16 DYAZIDE

see triamt/hctz cap 37.5-25 .......................... 17

DYMISTA SPR 137-50 ..... 44 DYRENIUM ....................... 17 DYSPORT ........................ 25 E e.e.s 400 ............................. 8 E.E.S. GRANULES ............. 8 EC-NAPROSYN

see naproxen .................. 1 econazole nitrate .............. 46 EDARBI ............................ 14 EDARBYCLOR ................. 14 EDECRIN ......................... 17 EDURANT .......................... 6 EFFEXOR XR

see venlafaxine cap er .. 21 EFFIENT ........................... 38 EFUDEX

see fluorouracil (topical) 49 EGRIFTA .......................... 33 ELAPRASE ....................... 31 ELAVIL

see amitriptyline hcl ....... 20 ELDEPRYL

see selegiline hcl ........... 22 ELECTROLYTE-R IN DEXTROSE ...................... 41 ELELYSO ......................... 31 ELESTAT

see epinastine hcl (ophth) ...................................... 43

ELIDEL ............................. 49 ELIGARD INJ 22.5MG ...... 11 ELIGARD INJ 30MG ......... 11 ELIGARD INJ 45MG ......... 11 ELIGARD INJ 7.5MG ........ 11 ELIMITE

see permethrin .............. 49 ELIPHOS

see calcium acetate (phosphate binder) ........ 33

ELIQUIS TAB 2.5MG ........ 37 ELIQUIS TAB 5MG ........... 37 ELITEK ............................. 13 elixophyllin ........................ 45 ELLA ................................. 29 ELLENCE

see epirubicin hcl .......... 10 see epirubicin inj 200mg 10

ELMIRON ......................... 36 ELOCON

see mometasone furoate ...................................... 48

EMADINE ......................... 43 EMBEDA ............................ 2 EMCYT ............................. 10


61

EMEND ............................. 34 EMEND CAP 125MG ........ 34 EMEND CAP 40MG .......... 34 EMEND CAP 80MG .......... 34 EMEND PAK 80 & 125 ..... 34 emoquette ......................... 29 EMPLICITI ........................ 11 EMSAM ............................. 20 EMTRIVA ............................6 emverm ...............................5 ENABLEX

see darifenacin hydrobromide ................ 37

enalapril maleate ............... 13 enalapril maleate & hydrochlorothiazide ........... 13 ENBREL............................ 38 ENBREL SURECLICK ...... 38 endocet ...............................2 ENGERIX-B ...................... 40 enoxaparin sodium ............ 37 ENOXAPARIN SODIUM ... 37 enpresse 28 day ............... 29 ENSTILAR ........................ 48 ENTACAPONE ................. 22 entecavir .............................7 ENTOCORT EC

see budesonide ............. 35 ENTRESTO ...................... 14 ENTYVIO .......................... 35 enulose ............................. 35 ENVARSUS XR ................ 39 EPIDUO ............................ 46 EPIDUO FORTE ............... 46 epinastine hcl (ophth) ........ 43 EPINEPHRINE .................. 45 EPIPEN 2-PAK ................. 45 EPIPEN-JR 2-PAK ............ 45 epirubicin hcl ..................... 10 epirubicin inj 200mg .......... 10 epitol ................................. 19 EPIVIR

see lamivudine ................6 EPIVIR HBV ........................7

see lamivudine (hbv) .......7 eplerenone ........................ 14 EPOGEN........................... 38 epoprostenol sodium ......... 18

eprosartan mesylate ......... 14 EPZICOM ........................... 7 EQUETRO ........................ 25 ERAXIS ............................... 5 ERBITUX .......................... 11 ergomar ............................ 24 ERIVEDGE ....................... 11 errin 28 day ....................... 29 ERTACZO ......................... 46 ERWINAZE ....................... 12 ery pad 2% ........................ 46 ERYGEL

see erythromycin (acne aid) ................................ 46

ERYPED 200 ...................... 8 ERYPED 400 ...................... 8 ery-tab ................................. 8 erythrocin ............................ 8 erythrocin stearate .............. 8 erythromycin (acne aid) .... 46 erythromycin (ophth) ......... 42 erythromycin base .............. 8 erythromycin cap 250mg ec 8 erythromycin ethylsuccinate 8 ESBRIET .......................... 45 escitalopram oxalate ......... 21 esomeprazole magnesium 36 esomeprazole sodium inj .. 36 estarylla tab 0.25-35 ......... 29 estrace .............................. 31 ESTRACE

see estradiol .................. 31 estradiol ............................ 31 estradiol valerate .............. 31 ESTRING .......................... 31 ESTROSTEP FE

see tri-legest 28 day ...... 30 ethambutol hcl .................... 7 ethosuximide ..................... 19 ETHYOL

see amifostine crystalline ...................................... 13

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 13 etoposide .......................... 13 EURAX ............................. 49 EVISTA

see raloxifene hcl .......... 33 EVOCLIN

see clindamycin phosphate (topical) ........ 46

EVOTAZ ............................. 7 EVOXAC

see cevimeline hcl ......... 49 EXALGO

see hydromorphone tab 12mg er ........................... 3 see hydromorphone tab 16mg er ........................... 3 see hydromorphone tab 8mg er ............................. 3

EXELDERM ...................... 46 EXELON

see rivastigmine cap ..... 20 see rivastigmine td patch 24hr 13.3 mg/24hr ......... 20 see rivastigmine td patch 24hr 4.6 mg/24hr ........... 20 see rivastigmine td patch 24hr 9.5 mg/24hr ........... 20

exemestane ...................... 11 EXFORGE

see amlodipine besylate-valsartan tab 10-160 mg ..................... 14 see amlodipine besylate-valsartan tab 10-320 mg ..................... 14 see amlodipine besylate-valsartan tab 5-160 mg ....................... 14 see amlodipine besylate-valsartan tab 5-320 mg ....................... 14

EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 14 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 14 see amlodipine-valsartan-hydr


62

ochlorothiazide 10-320-25mg ................. 14 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 14 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 14

EXJADE ............................ 28 EXTAVIA ........................... 25 EXTINA

see ketoconazole (topical) ...................................... 46 see ketodan aer 2% ...... 46

EYLEA .............................. 44 F FABIOR............................. 46 FABRAZYME .................... 31 falmina 28 day ................... 29 famciclovir ...........................7 famotidine ......................... 35 famotidine inj ..................... 35 FAMVIR

see famciclovir .................7 FANAPT ............................ 22 FANAPT TITRATION PACK .......................................... 22 FARESTON ...................... 11 FARXIGA .......................... 27 FARYDAK ......................... 11 FASLODEX ....................... 11 felbamate .......................... 19 FELBATOL

see felbamate ................ 19 FELDENE

see piroxicam ..................1 felodipine........................... 16 FEMARA

see letrozole .................. 12 FEMCON FE

see wymzya fe ............... 31 see zenchent fe 28 day . 31

FEMRING ......................... 31 fenofibrate ......................... 15 FENOFIBRATE ................. 15 fenofibrate micronized ....... 15

FENOFIBRIC ACID........... 15 fenoprofen calcium ............. 1 FENOPROFEN CALCIUM .. 1 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr ... 2 fentanyl patch 12 mcg/hr ..... 2 fentanyl patch 25 mcg/hr ..... 2 fentanyl patch 50 mcg/hr ..... 2 fentanyl patch 75 mcg/hr ..... 2 FENTORA ........................... 2 FERRIPROX ..................... 28 FETZIMA .......................... 21 FETZIMA TITRATION PACK .......................................... 21 FINACEA AER 15% .......... 49 FINACEA GEL 15% .......... 49 finasteride ......................... 36 FIRAZYR .......................... 38 FIRMAGON ...................... 11 FLAGYL

see metronidazole ........... 5 FLAREX ............................ 43 FLEBOGAMMA DIF .......... 39 flecainide acetate .............. 14 FLOLAN ............................ 18

see epoprostenol sodium ...................................... 18

FLOMAX see tamsulosin hcl ......... 36

FLOVENT DISKUS ........... 45 FLOVENT HFA ................. 45 FLOXIN OTIC

see ofloxacin (otic) ........ 50 fluconazole .......................... 5 fluconazole in dextrose ....... 5 fluconazole inj nacl 100....... 5 fluconazole inj nacl 200....... 5 fluconazole inj nacl 400....... 5 flucytosine ........................... 5 FLUDARA

see fludarabine phosphate ...................................... 11

fludarabine phosphate 10, 11 fludrocortisone acetate...... 32 FLUMADINE

see rimantadine hydrochloride ................... 7

flunisolide (nasal) .............. 45

fluocinolone acetonide ...... 48 fluocinolone acetonide (otic).......................................... 50 fluocinonide ...................... 48 fluocinonide emulsified base.......................................... 48 FLUOROMETHOLONE (OPHTH) ........................... 43 fluorouracil ........................ 11 fluorouracil (topical) .......... 49 FLUOROURACIL (TOPICAL) ........................ 49 fluoxetine cap 10mg .......... 21 fluoxetine cap 20mg .......... 21 fluoxetine cap 40mg .......... 21 fluoxetine hcl ..................... 21 FLUOXETINE HCL ........... 21 fluphenazine decanoate .... 22 fluphenazine hcl ................ 23 flurandrenolide .................. 48 flurbiprofen .......................... 1 flurbiprofen sodium ........... 43 flutamide ........................... 11 fluticasone propionate ....... 48 fluticasone propionate (nasal) ............................... 45 fluvastatin sodium cap 20 mg.......................................... 15 fluvastatin sodium cap 40 mg.......................................... 15 FLUVASTATIN SODIUM TAB SR 24 HR 80 MG ...... 15 fluvoxamine maleate ......... 18 fluvoxamine maleate er ..... 18 FML .................................. 43 FML FORTE ..................... 43 FOLOTYN ......................... 11 fondaparinux sodium ........ 37 FORFIVO XL .................... 21 FORTAMET

see metformin hcl .......... 27 FORTAZ ............................. 8

see ceftazidime ............... 8 see tazicef ....................... 8 see tazicef vial................. 8

FORTEO ........................... 33 FORTESTA

see testosterone ............ 26


63

FORTICAL SPR 200/ACT . 33 FOSAMAX

see alendronate sodium 28 FOSAMAX PLUS D .......... 28 fosinopril sodium ............... 13 fosinopril sodium & hydrochlorothiazide ........... 13 FOSRENOL ...................... 33 FRAGMIN ......................... 37 FREAMINE HBC 6.9% ...... 41 FREAMINE III ................... 41 FROVA

see frovatriptan succinate ...................................... 24

frovatriptan succinate ........ 24 FURADANTIN

see nitrofurantoin .............5 furosemide ........................ 17 furosemide inj .................... 17 FUROSEMIDE INJ ............ 17 furosemide oral soln 8 mg/ml .......................................... 17 FUSILEV ........................... 13 FUZEON .............................6 fyavolv tab 1-5mg .............. 31 FYCOMPA ........................ 19 G gabapentin ........................ 19 GABITRIL.......................... 19

see tiagabine hcl ........... 20 galantamine hydrobromide 20 galantamine hydrobromide er ....................................... 20 GAMASTAN S/D ............... 39 GAMMAGARD LIQUID ..... 39 GAMMAGARD S/D ........... 39 GAMMAKED ..................... 39 GAMMAPLEX ................... 39 GAMUNEX-C .................... 39 ganciclovir inj 500mg ..........7 GARDASIL ........................ 40 GARDASIL 9 ..................... 40 GASTROCROM

see cromolyn sodium (mastocytosis) ............... 36

gatifloxacin (ophth) ............ 43 GATTEX............................ 36 GAUZE PADS 2X2 ........... 26

gavilyte-c ........................... 35 gavilyte-g .......................... 35 gavilyte-h .......................... 35 gavilyte-n .......................... 35 GAZYVA ........................... 11 GELNIQUE ....................... 37 gemcitabine hcl ................. 11 GEMCITABINE HCL ......... 11 gemfibrozil ........................ 15 GEMZAR

see gemcitabine hcl....... 11 GENERESS FE

see kaitlib fe 28 day....... 29 see layolis fe chw .......... 29 see norethindrone & ethinyl estradiol-fe ......... 30

generlac ............................ 35 gengraf .............................. 39 GENOTROPIN .................. 32 GENOTROPIN MINIQUICK .......................................... 32 gentak ............................... 43 gentamicin in saline ............ 4 gentamicin sulfate ............... 4 gentamicin sulfate (ophth) . 43 gentamicin sulfate (topical) .......................................... 46 gentamicin sulfate/0.9% s ... 4 GENVOYA .......................... 7 GEODON

see ziprasidone hcl........ 23 GEODON INJ ................... 23 GIANVI TAB 3-0.02MG ..... 29 GIAZO ............................... 35 gildagia ............................. 29 gildess 1.5/30 21 day ........ 29 gildess 24 fe 28 day .......... 29 GILENYA CAP 0.5MG ...... 25 GILOTRIF TAB 20MG....... 12 GILOTRIF TAB 30MG....... 12 GILOTRIF TAB 40MG....... 12 GLASSIA .......................... 45 glatopa .............................. 25 GLEEVEC

see imatinib mesylate .... 12 GLEOSTINE ..................... 10 glimepiride ........................ 27 glipizide ............................. 27

glipizide er ........................ 27 GLIPIZIDE XL TB24 2.5MG.......................................... 27 GLIPIZIDE XL TB24 5MG . 27 glipizide-metformin 2.5-250 mg ..................................... 27 glipizide-metformin 2.5-500 mg ..................................... 27 glipizide-metformin 5-500mg.......................................... 27 GLUCAGEN HYPOKIT ..... 32 GLUCAGON EMERGENCY KIT .................................... 32 GLUCOPHAGE

see metformin hcl .......... 27 GLUCOPHAGE XR

see metformin er ........... 27 GLUCOTROL

see glipizide .................. 27 GLUCOTROL XL

see glipizide er .............. 27 glycopyrrolate ................... 34 GLYSET

see miglitol .................... 27 GLYXAMBI ....................... 27 GOLYTELY ....................... 35

see gavilyte-g ................ 35 GRALISE .......................... 25 GRALISE STARTER ........ 25 granisetron hcl .................. 34 GRANIX ............................ 38 GRASTEK ........................ 39 griseofulvin microsize ......... 6 griseofulvin ultramicrosize .. 6 GRIS-PEG

see griseofulvin ultramicrosize .................. 6

guanfacine er (adhd) ......... 24 H H.P. ACTHAR ................... 33 HALAVEN ......................... 12 HALDOL

see haloperidol lactate inj 5 mg/ml ......................... 23

HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 23

HALDOL DECANOATE 50


64

see haloperidol decanoate ...................................... 23

halobetasol propionate ...... 48 HALOG ............................. 48 haloperidol ........................ 23 haloperidol decanoate ....... 23 haloperidol lactate ............. 23 haloperidol lactate inj 5 mg/ml ................................ 23 HAVRIX............................. 40 heather .............................. 29 HECTOROL ...................... 42

see doxercalciferol ........ 42 HEP SOD/NACL INJ 25000 .......................................... 37 heparin (porcine) in sodium chloride 100u/ml ................ 37 heparin sod inj 10000u/ml . 37 heparin sod inj 1000u/ml ... 37 heparin sod inj 20000u/ml . 37 HEPARIN SOD INJ 2000U/ML ......................... 37 HEPARIN SOD INJ 2500U/ML ......................... 37 heparin sod inj 5000u/0.5ml .......................................... 37 heparin sod inj 5000u/ml ... 37 HEPARIN SODIUM/D5W .. 37 HEPARIN SODIUM/NACL 0.45% ................................ 37 HEPATAMINE ................... 41 HEPSERA

see adefovir dipivoxil .......7 HERCEPTIN ..................... 11 HETLIOZ ........................... 24 HEXALEN ......................... 10 HIBERIX............................ 40 HIPREX

see methenamine hippurate .........................5

HIZENTRA ........................ 39 HORIZANT ........................ 25 HUMALOG ........................ 26 HUMALOG KWIKPEN ...... 26 HUMALOG MIX 50/50 ...... 26 HUMALOG MIX 50/50 KWIKPEN ......................... 26 HUMALOG MIX 75/25 ...... 26

HUMALOG MIX 75/25 KWIKPEN ......................... 26 HUMATROPE ................... 32 HUMATROPE COMBO PACK ................................ 32 HUMIRA INJ 10MG/0.2ML 38 HUMIRA KIT 20MG/0.4ML 38 HUMIRA KIT 40MG/0.8ML 38 HUMIRA PEDIATRIC CROHNS DISEASE .......... 38 HUMIRA PEN ................... 38 HUMIRA PEN-CROHNS STARTER KIT .................. 38 HUMIRA PEN-PSORIASIS STARTER KIT .................. 38 HUMULIN 70/30 ............... 26 HUMULIN 70/30 KWIKPEN .......................................... 26 HUMULIN N ...................... 26 HUMULIN N KWIKPEN .... 26 HUMULIN R ...................... 26 HUMULIN R U-500 (CONCENTRATE) ............ 26 HUMULIN R U-500 KWIKPEN ......................... 26 HYCAMTIN

see topotecan hcl .......... 13 HYCET

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

hydralazine hcl .................. 18 HYDREA

see hydroxyurea ............ 12 hydrochlorothiazide ........... 17 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 tab 10-200mg ........................... 2 hydrocodone-ibuprofen tab 5-200mg ............................. 2 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 2 hydrocortisone .................. 32 HYDROCORTISONE (ENEMA) .......................... 35 hydrocortisone (topical) .... 48 hydrocortisone butyrate .... 48 hydrocortisone butyrate hydrophilic lipo base ......... 48 hydrocortisone valerate .... 48 hydromorphone hcl ............. 2 HYDROMORPHONE HCL . 2 hydromorphone tab 12mg er............................................ 3 hydromorphone tab 16mg er............................................ 3 hydromorphone tab 8mg er 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate.......................................... 38 hydroxyprogesterone caproate (antineoplastic) .. 12 hydroxyurea ...................... 12 hydroxyzine hcl ................. 44 hydroxyzine pamoate ........ 44 HYQVIA ............................ 39 HYSINGLA ER.................... 3 HYZAAR

see losartan-hydrochlorothiazide .................................. 14

I ibandronate sodium .......... 28 ibandronate tab 150mg ..... 28 IBRANCE .......................... 11 ibudone tab 10-200mg ........ 3 ibudone tab 5-200mg .......... 3 ibuprofen ............................. 1 ICLUSIG ........................... 12 IDAMYCIN PFS


65

see idarubicin hcl ........... 10 idarubicin hcl ..................... 10 IFEX

see ifosfamide inj 1gm ... 10 IFEX INJ 3GM ................... 10 ifosfamide inj 1gm ............. 10 ifosfamide inj 1gm/20ml .... 10 IFOSFAMIDE INJ 3GM ..... 10 ifosfamide inj 3gm/60ml .... 10 ILARIS .............................. 39 ILEVRO ............................. 43 ilotycin ............................... 43 imatinib mesylate .............. 12 IMBRUVICA CAP 140MG . 12 imipenem-cilastatin .............5 imipramine hcl ................... 21 imipramine pamoate ......... 21 imiquimod.......................... 49 IMITREX

see sumatriptan inj 6mg/0.5ml ...................... 24 see sumatriptan succinate ...................................... 25

IMITREX STATDOSE REFILL

see sumatriptan inj 6mg/0.5ml ...................... 24

IMITREX STATDOSE SYSTEM

see sumatriptan inj 6mg/0.5ml ...................... 24

IMOVAX RABIES (H.D.C.V.) .......................................... 40 IMURAN

see azathioprine ............ 39 INCRELEX ........................ 33 INCRUSE ELLIPTA .......... 44 indapamide ....................... 17 INDERAL LA

see propranolol hcl er .... 16 INFANRIX ......................... 40 INFUMORPH 200 ...............3 INFUMORPH 500 ...............3 INLYTA ............................. 12 INSPRA

see eplerenone .............. 14 INSULIN PEN NEEDLES .. 26 INSULIN SAFETY

NEEDLES ......................... 26 INSULIN SYRINGES ........ 26 INTELENCE ........................ 6 INTRALIPID INJ 20%........ 41 INTRALIPID INJ 30%........ 41 INTRON-A INJ 10MU........ 39 INTRON-A INJ 18MU........ 39 INTRON-A INJ 25MU........ 39 INTRON-A INJ 50MU........ 39 introvale 91 day ................ 29 INTUNIV

see guanfacine er (adhd) ...................................... 24

INVANZ ............................... 5 INVEGA

see paliperidone ............ 23 INVEGA SUST INJ 117 MG/0.75 ML ...................... 23 INVEGA SUST INJ 156MG/ML ........................ 23 INVEGA SUST INJ 234 MG/1.5 ML ........................ 23 INVEGA SUST INJ 39 MG/0.25 ML ...................... 23 INVEGA SUST INJ 78 MG/0.5 ML ........................ 23 INVEGA TRINZA .............. 23 INVIRASE ........................... 6 INVOKAMET TAB 150-1000MG ..................... 27 INVOKAMET TAB 150-500MG ....................... 27 INVOKAMET TAB 50-1000MG ....................... 27 INVOKAMET TAB 50-500MG ......................... 27 INVOKANA TAB 100MG ... 27 INVOKANA TAB 300MG ... 27 IONOSOL-B/DEXTROSE 5% .................................... 41 IONOSOL-MB/DEXTROSE 5% .................................... 41 IPOL INACTIVATED IPV .. 40 ipratropium bromide (nasal) .......................................... 44 ipratropium sol inhal .......... 44 ipratropium-albuterol ......... 44 irbesartan .......................... 14

irbesartan-hydrochlorothiazide........................................ 14 IRESSA ............................ 12 irinotecan inj 100/5ml ........ 13 irinotecan inj 40mg/2ml ..... 13 irinotecan inj 500mg/25ml . 13 ISENTRESS ....................... 6 ISOLYTE P ....................... 42 ISOLYTE S ....................... 42 isoniazid .............................. 7 isoniazid tabs ...................... 7 ISORDIL TITRADOSE ...... 18

see isosorbide dinitrate . 18 isosorbide dinitrate ............ 18 isosorbide dinitrate er ....... 18 isosorbide mononitrate ..... 18 isosorbide mononitrate er . 18 isradipine .......................... 16 ISTALOL ........................... 43 ISTODAX .......................... 11 itraconazole ........................ 6 ivermectin ........................... 5 IXEMPRA KIT ................... 12 IXIARO ............................. 40 J JADENU ........................... 28 JAKAFI ............................. 12 JALYN

see dutasteride-tamsulosin hcl ................................. 36

jantoven ............................ 37 JANUMET ......................... 27 JANUMET XR TAB 100-1000 .......................... 27 JANUMET XR TAB 50-1000.......................................... 27 JANUMET XR TAB 50-500MG ......................... 27 JANUVIA .......................... 27 JARDIANCE ..................... 27 JENTADUETO .................. 27 JENTADUETO XR 2.5-1000MG ...................... 27 JENTADUETO XR 5-1000MG ......................... 27 JEVTANA ......................... 11 jinteli ................................. 31 JOLESSA TAB 0.15-0.03


66

MG .................................... 29 JOLIVETTE ....................... 29 juleber 28 day ................... 29 junel 1.5/30 21 day ............ 29 junel 1/20 21 day ............... 29 junel fe 1.5/30 28 day ........ 29 junel fe 1/20 28 day ........... 29 junel fe 24 1/20 28 day ...... 29 JUXTAPID ......................... 15 K KADCYLA ......................... 11 KADIAN...............................3

see morphine sulfate .......3 kaitlib fe 28 day ................. 29 KALBITOR ........................ 38 KALETRA SOL ...................7 KALETRA TAB 100-25MG ..7 KALETRA TAB 200-50MG ..7 KALYDECO ...................... 45 KANUMA........................... 31 kariva 28 day ..................... 29 KAYEXALATE

see kionex ..................... 28 see sodium polystyrene sulfonate ........................ 28

KAZANO ........................... 27 KCL 0.075%/D5W/NACL 0.45% ................................ 42 KCL 0.15%/D5W/LR ......... 42 KCL 0.15%/D5W/NACL 0.9% .................................. 42 KCL 0.3%/D5W/LR IV LAC RI ...................................... 42 KCL 0.3%/D5W/NACL 0.45% ................................ 42 KCL 0.3%/D5W/NACL 0.9% .......................................... 42 KCL IN NACL INJ .15-0.45 .......................................... 42 KCL/D5W/NACL INJ .15/.33% ............................ 42 KCL/D5W/NACL INJ .15/.45% ............................ 42 KCL/D5W/NACL INJ 0.22%/0.45% ..................... 42 KCL/NACL INJ 0.15%-0.9% .......................................... 42 KCL0.15%/D5W/NACL0.2%

.......................................... 42 KCL0.15%/D5W/NACL0.225% ...................................... 42 KEFLEX

see cephalexin ................ 8 kelnor 1/35 28 day ............ 29 KENALOG

see triamcinolone acetonide (topical) ......... 48

KEPIVANCE ..................... 13 KEPPRA

see levetiracetam .......... 19 see levetiracetam oral soln 100 mg/ml ..................... 19 see roweepra ................ 19

KEPPRA XR see levetiracetam .......... 19

KERLONE see betaxolol hcl ........... 16

ketoconazole ....................... 6 ketoconazole (topical) ....... 46 ketoconazole shampoo ..... 47 ketodan aer 2% ................. 46 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 43 KEVEYIS .......................... 18 KEYTRUDA ...................... 11 kimidess 28 day ................ 29 KINERET .......................... 38 KINRIX .............................. 40 kionex ............................... 28 KLARON

see sulfacetamide sodium (acne) ............................ 46

KLONOPIN see clonazepam ............ 19

KLOR-CON 10 .................. 40 KLOR-CON 8 .................... 40 klor-con m10 ..................... 40 klor-con m15 ..................... 40 klor-con m20 ..................... 40 klor-con pow 20 meq......... 40 klor-con spr cap 10meq .... 40 klor-con spr cap 8meq ...... 40 KOMBIGLYZE XR 2.5-1000MG ...................... 27 KOMBIGLYZE XR

5-1000MG ......................... 27 KOMBIGLYZE XR 5-500MG.......................................... 27 KORLYM .......................... 33 kristalose .......................... 35 KRYSTEXXA ...................... 1 KUVAN ............................. 31 KYNAMRO ....................... 15 L labetalol hcl ....................... 16 LAC-HYDRIN

see ammonium lactate .. 49 LACRISERT ..................... 44 LACTATED RINGERS VIAFLEX ........................... 42 lactulose ........................... 35 lactulose (encephalopathy).......................................... 35 LAMICTAL

see lamotrigine .............. 19 LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 19 LAMICTAL ODT

see lamotrigine .............. 19 LAMICTAL STARTER ...... 19 LAMICTAL XR .................. 19

see lamotrigine .............. 19 LAMISIL .............................. 6

see terbinafine hcl ........... 6 lamivudine .......................... 6 lamivudine (hbv) ................. 7 lamivudine-zidovudine ........ 7 lamotrigine ........................ 19 LANOXIN .......................... 17

see digitek ..................... 17 see digox ....................... 17 see digoxin .................... 17 see digoxin inj ............... 17

LANOXIN PEDIATRIC ...... 17 lansoprazole ..................... 36 LANTUS ........................... 26 LANTUS SOLOSTAR ....... 26 larin 1.5/30 ........................ 29 larin 1/20 ........................... 29 larin fe 1.5/30 .................... 29 larin fe 1/20 ....................... 29 LASIX


67

see furosemide .............. 17 LASTACAFT ..................... 43 latanoprost ........................ 43 LATUDA ............................ 23 layolis fe chw ..................... 29 LAZANDA ...........................3 LEENA TAB ...................... 29 leflunomide ........................ 38 LEMTRADA ...................... 25 LENVIMA 10 MG DAILY DOSE ................................ 12 LENVIMA 14 MG DAILY DOSE ................................ 12 LENVIMA 18 MG DAILY DOSE ................................ 12 LENVIMA 20 MG DAILY DOSE ................................ 12 LENVIMA 24 MG DAILY DOSE ................................ 12 LENVIMA 8 MG DAILY DOSE ................................ 12 LESCOL

see fluvastatin sodium cap 20 mg ............................ 15

lessina 28 day ................... 29 LETAIRIS .......................... 18 letrozole ............................ 12 leucovor ca inj ................... 13 leucovorin calcium ............ 13 leucovorin calcium 500 mg 13 LEUKERAN ....................... 10 LEUKINE........................... 38 leuprolide acetate .............. 12 levalbuterol conc 1.25mg/0.5ml .................... 44 levalbuterol hcl .................. 44 LEVALBUTEROL HCL ...... 44 LEVAQUIN

see levofloxacin ...............9 LEVEMIR .......................... 26 LEVEMIR FLEXTOUCH.... 26 levetiracetam ..................... 19 LEVETIRACETAM IV ........ 19 levetiracetam oral soln 100 mg/ml ................................ 19 levobunolol hcl .................. 44 levocarnitine (metabolic modifiers) .......................... 31

levocetirizine soln 2.5mg/5ml .......................................... 44 levocetirizine tab 5 mg ...... 44 levofloxacin ......................... 9 levofloxacin (ophth) ........... 43 levofloxacin in d5w .............. 9 levoleucovorin calcium ...... 13 levonest 28 day ................. 29 levonor/ethi tab ................. 29 levonorgestrel & eth estradiol .......................................... 29 levonorgestrel (emergency oc) ..................................... 29 levonorgestrel-ethinyl estradiol (91-day) .............. 29 levonorgestrel-ethinyl estradiol (continuous)........ 29 levora 0.15/30 28 day ....... 29 levorphanol tartrate ............. 3 levothyroxine sodium ........ 33 LEVOTHYROXINE SODIUM .......................................... 33 LEVOXYL ......................... 33 LEXAPRO

see escitalopram oxalate ...................................... 21

LEXIVA ............................... 6 LIALDA ............................. 35 lidocaine ............................ 48 lidocaine hcl ...................... 48 lidocaine hcl (local anesth.) . 4 lidocaine hcl (mouth-throat) .......................................... 49 lidocaine inj 0.5% ................ 4 lidocaine inj 1% ................... 4 lidocaine inj 1.5% ................ 4 lidocaine inj 2% ................... 4 lidocaine-prilocaine ........... 48 LIDODERM

see lidocaine ................. 48 linezolid ............................... 5 LINEZOLID ......................... 5 LINEZOLID IN SODIUM CHLORIDE ......................... 5 LINZESS ........................... 36 liothyronine sodium ........... 33 LIPITOR

see atorvastatin calcium 15

lisinopril ............................. 13 lisinopril & hydrochlorothiazide ........... 13 lithium carbonate .............. 25 LITHIUM SOLN 8MEQ/5ML.......................................... 25 LITHOBID

see lithium carbonate .... 25 LIVALO ............................. 15 LO LOESTRIN FE ............ 29 LOCOID ............................ 48

see hydrocortisone butyrate ......................... 48

LOCOID LIPOCREAM see hydrocortisone butyrate hydrophilic lipo base .............................. 48

LODOSYN see carbidopa................ 21

LOESTRIN 1.5/30-21 see gildess 1.5/30 21 day ...................................... 29 see junel 1.5/30 21 day . 29 see larin 1.5/30.............. 29

LOESTRIN 1/20-21 see junel 1/20 21 day .... 29 see larin 1/20................. 29

LOESTRIN FE 1.5/30 see blisovi 21 fe 1.5/30 28 day pack ........................ 28 see junel fe 1.5/30 28 day ...................................... 29 see larin fe 1.5/30 .......... 29

LOESTRIN FE 1/20 see blisovi 21 fe 1/20 28 day pack ........................ 28 see junel fe 1/20 28 day 29 see larin fe 1/20............. 29 see tarina fe 1/20 28 day ...................................... 30

LOFIBRA see fenofibrate .............. 15 see fenofibrate micronized ...................................... 15

lokara ................................ 48 lomedia 24 fe .................... 29 LOMOTIL

see diphenoxylate w/


68

atropine ......................... 36 LONSURF ......................... 12 loperamide hcl ................... 36 LOPID

see gemfibrozil .............. 15 LOPRESSOR

see metoprolol tartrate .. 16 LOPRESSOR HCT

see metoprolol & hctz tab 100-25mg ...................... 16 see metoprolol & hctz tab 50-25mg ........................ 16

LOPROX see ciclopirox cre 0.77% 46

LOPROX SHAMPOO see ciclopirox shampoo 1% ................................. 46

lorazepam ......................... 18 lorcet plus tab 7.5-325 ........3 lorcet tab 5-325mg ..............3 lortab tab 10-325mg ............3 lortab tab 5-325mg ..............3 lortab tab 7.5-325 ................3 loryna 28 day .................... 29 losartan potassium ............ 14 losartan-hydrochlorothiazide .......................................... 14 LOTEMAX ......................... 43 LOTENSIN

see benazepril hcl ......... 13 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 13

LOTREL see amlodipine besylate-benazepril hcl .. 13

LOTRONEX see alosetron hcl ........... 35

lovastatin ........................... 15 LOVAZA

see omega-3-acid ethyl esters............................. 15

LOVENOX see enoxaparin sodium . 37

low-ogestrel ....................... 29 loxapine succinate ............ 23 LUCENTIS ........................ 44 LUMIGAN.......................... 44

LUMIZYME ....................... 31 LUPANETA PACK ............ 31 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 12 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 12 LUPRON DEPOT INJ 3.75MG ............................. 12 LUPRON DEPOT INJ 30MG (4-MONTH) ....................... 12 LUPRON DEPOT INJ 45MG (6-MONTH) ....................... 12 LUPRON DEPOT INJ 7.5MG .......................................... 12 LUPRON DEP-PED INJ 11.25MG ........................... 33 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 33 LUPRON DEP-PED INJ 15MG ................................ 33 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 33 LUPRON DEP-PED INJ 7.5MG ............................... 33 lutera 28 day ..................... 29 LUXIQ

see betamethasone valerate ......................... 47

LUZU ................................ 46 LYNPARZA ....................... 11 LYRICA ............................. 19 LYSODREN ...................... 12 LYSTEDA

see tranexamic acid ...... 38 lyza ................................... 29 M MACROBID

see nitrofurantoin monohyd macro .............. 5

MACRODANTIN see nitrofurantoin macrocrystal .................... 5

magnesium sulfate ............ 40 MAGNESIUM SULFATE ... 40

see magnesium sulfate . 40 MAGNESIUM SULFATE IN D5W .................................. 40 MAGNESIUM SULFATE INJ

50% .................................. 40 MALARONE

see atovaquone-proguanil hcl tab 250-100 mg ......... 6 see atovaquone-proguanil hcl tab 62.5-25 mg .......... 6

malathion .......................... 49 maprotiline hcl .................. 21 MARINOL

see dronabinol............... 34 marlissa 28 day................. 30 MARPLAN ........................ 21 MATULANE ...................... 12 matzim la .......................... 16 MAVIK

see trandolapril.............. 13 MAXALT

see rizatriptan benzoate 24 MAXALT-MLT

see rizatriptan benzoate 24 MAXIDEX ......................... 43 MAXIPIME .......................... 8

see cefepime inj 1gm ...... 8 see cefepime inj 2gm ...... 8

MAXITROL see neomycin-polymy-dexameth .................................... 42

MAXZIDE see triamt/hctz tab 75-50mg ........................ 17

MAXZIDE-25 see triamt/hctz tab 37.5-25 ...................................... 17

meclizine hcl ..................... 34 MEDROL

see methylpred tab 16mg ...................................... 32 see methylpred tab 32mg ...................................... 32 see methylpred tab 4mg 32 see methylpred tab 8mg 32

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 32

MEDROL TAB 2MG .......... 32 medroxyprogesterone acetate .............................. 33


69

medroxyprogesterone acetate (contraceptive) ..... 30 mefenamic acid ...................1 mefloquine hcl .....................6 MEGACE ORAL

see megestrol ac sus 40mg/ml ......................... 12

megestrol ac sus 40mg/ml 12 megestrol ac tab 20mg ..... 12 megestrol ac tab 40mg ..... 12 MEGESTROL SUS 625MG/5ML ...................... 12 MEKINIST ......................... 12 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 10 memantine hcl ................... 20 MEMANTINE HCL ............ 20 MENACTRA ...................... 40 MENHIBRIX ...................... 40 MENOMUNE-A/C/Y/W-135 .......................................... 40 MENOSTAR ...................... 31 MENTAX ........................... 46 MENVEO .......................... 40 MEPRON

see atovaquone ...............4 mercaptopurine ................. 11 meropenem .........................5 MEROPENEM/SODIUM CHLORIDE .........................5 MERREM

see meropenem ..............5 mesalamine enema ........... 35 mesna ............................... 13 MESNEX ........................... 13

see mesna ..................... 13 MESTINON

see pyridostigmine tab 60mg ............................. 25

MESTINON SYRUP .......... 25 MESTINON TIMESPAN

see pyridostigmine bromide ......................... 25

METADATE CD see methylphenidate hcl 24

metadate er tab 20mg ....... 24 metformin er ...................... 27

metformin hcl .................... 27 methadone hcl .................... 3 methadone hcl 10mg .......... 3 methadone hcl 5mg ............ 3 METHADONE INJ 10MG/ML ............................................ 3 METHADOSE

see methadone hcl .......... 3 methazolamide ................. 17 methenamine hippurate ...... 5 METHERGINE

see methylergonovine maleate ......................... 33

methimazole ..................... 34 methotrexate sodium ........ 11 METHOTREXATE SODIUM .......................................... 11 methotrexate sodium inj .... 11 methotrexate sodium tabs . 38 methoxsalen rapid ............ 47 methscopolamine bromide .................................... 34, 35 methyclothiazide ............... 17 methylergonovine maleate 33 METHYLIN

see methylphenidate hcl 24 methylphenidate hcl .......... 24 METHYLPHENIDATE HCL .......................................... 24 methylphenidate hcl er ...... 24 methylpr ace inj 40mg/ml .. 32 methylpr ace inj 80mg/ml .. 32 methylpr ss inj 1gm ........... 32 methylpr ss inj 40mg ......... 32 methylpred pak 4mg ......... 32 methylpred tab 16mg ........ 32 methylpred tab 32mg ........ 32 methylpred tab 4mg .......... 32 methylpred tab 8mg .......... 32 methylprednisolone sod succ .......................................... 32 metipranolol ...................... 44 metoclopramide hcl ........... 34 metoclopramide hcl inj 5 mg/ml ................................ 34 metoclopramide odt .......... 34 metolazone ....................... 17 metoprolol & hctz tab

100-25mg ......................... 16 metoprolol & hctz tab 100-50mg ......................... 16 metoprolol & hctz tab 50-25mg ........................... 16 metoprolol succinate ......... 16 metoprolol tartrate............. 16 METOZOLV ODT

see metoclopramide hcl 34 METRO IV .......................... 5 METROCREAM

see metronidazole (topical) ......................... 49 see rosadan cre 0.75% . 49

METROGEL see metronidazole (topical) ......................... 49

METROGEL-VAGINAL see metronidazole vaginal ...................................... 37

METROLOTION see metronidazole (topical) ......................... 49

metronidazole ..................... 5 metronidazole (topical) ..... 49 metronidazole inj................. 5 metronidazole vaginal ....... 37 MEVACOR

see lovastatin ................ 15 mexiletine hcl .................... 14 MIACALCIN

see calcitonin (salmon) nasal spray .................... 33

MIACALCIN INJ 200U/ML 33 MICARDIS

see telmisartan .............. 14 MICARDIS HCT

see telmisartan-hydrochlorothiazide ............................. 14

miconazole 3 sup 200mg .. 37 MICROGESTIN 1.5/30 ..... 30 MICROGESTIN 1/20 ........ 30 MICROGESTIN FE 1.5/30 30 MICROGESTIN FE 1/20 ... 30 MICRO-K

see klor-con spr cap 10meq ........................... 40


70

see klor-con spr cap 8meq ...................................... 40 see potassium chloride caps er........................... 40

MICROZIDE see hydrochlorothiazide 17

midodrine hcl ..................... 18 migergot ............................ 24 miglitol ............................... 27 millipred............................. 32 millipred dp ........................ 32 MINASTRIN 24 FE ............ 30 MINIPRESS

see prazosin hcl ............ 14 minitran ............................. 18 MINIVELLE ....................... 31 MINOCIN

see minocycline hcl ....... 10 minocycline hcl .................. 10 minoxidil ............................ 18 MIRAPEX

see pramipexole tab 0.125mg ........................ 22 see pramipexole tab 0.25mg .......................... 22 see pramipexole tab 0.5mg ............................ 22 see pramipexole tab 0.75mg .......................... 22 see pramipexole tab 1.5mg ............................ 22 see pramipexole tab 1mg ...................................... 22

MIRAPEX ER .................... 22 see pramipexole dihydrochloride .............. 22 see pramipexole tab 0.375mg ........................ 22 see pramipexole tab 0.75 er ................................... 22 see pramipexole tab 1.5mg er ........................ 22 see pramipexole tab 2.25mg .......................... 22 see pramipexole tab 3mg ...................................... 22 see pramipexole tab 4.5mg ............................ 22

MIRCERA ......................... 38 MIRCETTE

see bekyree 28 day ....... 28 see desogestrel-ethinyl estradiol (biphasic) ........ 29 see kariva 28 day .......... 29 see kimidess 28 day ...... 29 see pimtrea pack ........... 30 see viorele ..................... 31

mirtazapine ....................... 21 misoprostol ....................... 36 mitomycin .......................... 10 mitoxantrone hcl ............... 12 M-M-R II ............................ 40 MOBIC

see meloxicam tabs......... 1 modafinil ........................... 25 moderiba pak ...................... 7 moderiba tab 200mg ........... 7 moexipril hcl ...................... 13 moexipril-hydrochlorothiazide ........................................ 13 molindone hcl .................... 23 mometasone furoate ......... 48 mometasone furoate (nasal) .......................................... 45 MONODOX

see doxycycline (monohydrate) ................. 9

mono-linyah tab 0.25-35 ... 30 MONONESSA .................. 30 montelukast sodium .......... 45 MORPHINE SUL 20MG/ML ORAL SOL .......................... 3 MORPHINE SUL INJ 10MG/ML ............................ 3 MORPHINE SUL INJ 15MG/ML ............................ 3 MORPHINE SUL INJ 1MG/ML .............................. 3 MORPHINE SUL INJ 4MG/ML .............................. 3 morphine sulfate ................. 3 MORPHINE SULFATE ....... 3

see morphine sulfate ....... 3 morphine sulfate beads....... 3 morphine sulfate ext-rel tab 3 MOVANTIK ....................... 36

MOVIPREP ....................... 35 MOXATAG .......................... 9 MOXEZA .......................... 43 moxifloxacin hcl .................. 9 MOXIFLOXACIN HCL ........ 9 MOZOBIL ......................... 38 MS CONTIN

see morphine sulfate ext-rel tab ........................ 3

MULTAQ ........................... 14 mupirocin .......................... 46 mupirocin calcium (topical) 46 MUSTARGEN ................... 10 MYALEPT ......................... 33 MYAMBUTOL

see ethambutol hcl .......... 7 MYCAMINE ........................ 6 MYCOBUTIN

see rifabutin .................... 7 mycophenolate mofetil ...... 39 mycophenolate sodium ..... 39 MYFORTIC

see mycophenolate sodium .......................... 39

MYOBLOC ........................ 25 myorisan ........................... 46 MYRBETRIQ .................... 37 MYSOLINE

see primidone................ 19 myzilra .............................. 30 N nabumetone ........................ 1 nadolol .............................. 16 nadolol & bendroflumethiazide ......... 16 NAFCILLIN IN DEXTROSE 9 nafcillin sodium ................... 9 NAFTIFINE HCL ............... 46 NAFTIN ............................. 46 NAGLAZYME ................... 31 nalbuphine hcl .................... 2 naloxone hcl ..................... 26 naltrexone hcl ................... 26 NAMENDA

see memantine hcl ........ 20 NAMENDA XR .................. 20 NAMENDA XR TITRATION PACK ................................ 20


71

NAMZARIC ....................... 20 naphazoline 0.1% ............. 44 NAPRELAN .........................1 NAPROSYN

see naproxen ...................1 naproxen .............................1 naproxen sodium ................1 NAPROXEN SODIUM ........1 naratriptan hcl ................... 24 NARDIL

see phenelzine sulfate ... 21 NASONEX

see mometasone furoate (nasal) ........................... 45

NATACYN ......................... 43 NATAZIA ........................... 30 nateglinide......................... 27 NATPARA ......................... 33 NAVELBINE

see vinorelbine tartrate .. 11 NEBUPENT ........................5 necon 0.5/35 28 day ......... 30 necon 1/35 28 day ............ 30 necon 10/11 28 day .......... 30 NECON 7/7/7 .................... 30 NECON TAB 1/50-28 ........ 30 nefazodone hcl .................. 21 neomycin sulfate .................4 neomycin/polymyxin b gu .. 49 neomycin-bacitracin zn-polymyxin ..................... 43 neomycin-polymy-dexameth .......................................... 42 neomycin-polymyxin-gramicidin ..................................... 43 neomycin-polymyxin-hc (ophth) .............................. 42 neomycin-polymyxin-hc (otic) .......................................... 50 NEORAL ........................... 39

see cyclosporine modified (for microemulsion) ........ 39 see gengraf ................... 39

NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 43

NEOSPORIN GU IRRIGANT

see neomycin/polymyxin b gu .................................. 49

NEPHRAMINE .................. 41 NEPTAZANE

see methazolamide ....... 17 NESINA ............................ 27 neuac gel 1.2-5% .............. 46 NEULASTA ....................... 38 NEULASTA ONPRO KIT .. 38 NEUPOGEN ..................... 38 NEUPRO .......................... 22 NEURONTIN

see gabapentin .............. 19 nevirapine ........................... 6 NEVIRAPINE ...................... 6 NEXAVAR ......................... 12 NEXIUM

see esomeprazole magnesium .................... 36

NEXIUM GRA 10MG DR .. 36 NEXIUM GRA 2.5MG DR . 36 NEXIUM GRA 20MG DR .. 36 NEXIUM GRA 40MG DR .. 36 NEXIUM GRA 5MG DR .... 36 NEXIUM I.V.

see esomeprazole sodium inj................................... 36

niacin er (antihyperlipidemic) .......................................... 15 niacor ................................ 15 NIASPAN

see niacin er (antihyperlipidemic) ....... 15

nicardipine hcl ................... 16 NICOTROL INHALER ....... 26 NICOTROL NS ................. 26 nifedical ............................. 16 nifedipine .......................... 16 nifedipine er ...................... 16 nikki 28 day ....................... 30 NILANDRON ..................... 12 nilutamide ......................... 12 nimodipine ........................ 16 NINLARO .......................... 11 NIPENT ............................. 11 nisoldipine ......................... 17 nitro-bid ............................. 18 NITRO-DUR ...................... 18

see minitran .................. 18 nitrofurantoin ....................... 5 nitrofurantoin macrocrystal . 5 nitrofurantoin monohyd macro .................................. 5 nitroglycerin ...................... 18 NITROGLYCERIN LINGUAL.......................................... 18 nitroglycerin td patch ......... 18 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............ 18 NITROSTAT ..................... 18 nizatidine .......................... 35 NIZORAL

see ketoconazole shampoo ....................... 47

NORA-BE TAB ................. 30 NORCO

see hydrocodone-acetaminophen 5-325mg ..................... 2 see hydrocodone-acetaminophen 7.5-325mg .................. 2 see hydrocodone-acetaminophen tab 10-325mg ............. 2 see lorcet plus tab 7.5-325 ........................................ 3 see lorcet tab 5-325mg ... 3 see lortab tab 10-325mg . 3 see lortab tab 5-325mg ... 3 see lortab tab 7.5-325 ..... 3

NORDITROPIN FLEXPRO.......................................... 32 norethin acet & estrad-fe .. 30 norethindrone & ethinyl estradiol-fe ........................ 30 norethindrone (contraceptive) .................. 30 norethindrone acetate ....... 33 norethindrone acetate-ethinyl estradiol ............................ 31 norgest/ethi tab 0.25/35 .... 30 norgestimate-ethinyl estradiol (triphasic) ........... 30 NORINYL 1+35


72

see cyclafem 1/35 28 day ...................................... 29 see necon 1/35 28 day .. 30 see nortrel 1/35 21 day .. 30 see nortrel 1/35 28 day .. 30 see pirmella 1/35 28 day ...................................... 30

NORITATE ........................ 49 norlyroc 28 day ................. 30 NORMOSOL-M IN D5W ... 42 NORMOSOL-R ................. 42 NORPACE

see disopyramide phosphate ...................... 14

NORPACE CR .................. 14 NORPRAMIN

see desipramine hcl ...... 20 NOR-QD

see camila 28 day ......... 28 see deblitane 28 day ..... 29 see heather ................... 29 see norethindrone (contraceptive) ............... 30 see norlyroc 28 day ....... 30

NORTHERA ...................... 18 nortrel 0.5/35 28 day ......... 30 nortrel 1/35 21 day ............ 30 nortrel 1/35 28 day ............ 30 nortrel 7/7/7 28 day ........... 30 nortriptyline hcl .................. 21 NORVASC

see amlodipine besylate 16 NORVIR ..............................6 NOVAREL INJ 10000UNT 33 NOVOLIN 70/30 ................ 26 NOVOLIN 70/30 RELION.. 26 NOVOLIN N ...................... 27 NOVOLIN N RELION ........ 27 NOVOLIN R ...................... 27 NOVOLIN R RELION ........ 27 NOVOLOG ........................ 27 NOVOLOG FLEXPEN ...... 27 NOVOLOG MIX 70/30 ...... 27 NOVOLOG MIX 70/30 PREFILL ........................... 27 NOVOLOG PENFILL ........ 27 NOXAFIL.............................6 NPLATE ............................ 38

NUBAIN see nalbuphine hcl .......... 2

NUCALA ........................... 45 NUCYNTA .......................... 3 NUCYNTA ER .................... 3 NUEDEXTA ...................... 25 NULOJIX ........................... 39 NULYTELY/FLAVOR PACKS .............................. 35

see gavilyte-n ................ 35 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 35 see trilyte ....................... 35

NUPLAZID ........................ 23 nutrilipid inj 20% ................ 41 NUTROPIN AQ INJ 20MG/2ML ........................ 32 NUTROPIN AQ NUSPIN 10 .......................................... 32 NUTROPIN AQ NUSPIN 20 .......................................... 32 NUTROPIN AQ NUSPIN 5 32 NUTROPIN AQ PEN......... 32 NUVARING ....................... 30 NUVESSA ......................... 37 NUVIGIL

see armodafinil .............. 25 nyamyc ............................. 46 NYMALIZE ........................ 17 nystatin ............................... 6 nystatin (mouth-throat) ...... 49 nystatin (topical) ................ 46 nystatin pow 100000 ......... 47 nystop ............................... 47 O OCALIVA .......................... 36 OCELLA TAB 3-0.03MG ... 30 OCTAGAM ........................ 39 octreotide acetate ............. 33 OCUFEN

see flurbiprofen sodium . 43 OCUFLOX

see ofloxacin (ophth) ..... 43 ODEFSEY ........................... 7 ODOMZO .......................... 12 OFEV ................................ 45

ofloxacin (ophth) ............... 43 ofloxacin (otic) .................. 50 ogestrel 28 day ................. 30 olanzapine odt .................. 23 olanzapine solr ................. 23 olanzapine tabs ................ 23 olopatadine hcl ................. 43 olopatadine hcl (nasal) ...... 44 OLUX

see clobetasol propionate ...................................... 47

OLUX-E see clobetasol propionate emulsion ........................ 47

OMECLAMOX-PAK .......... 36 omega-3-acid ethyl esters 15 omeprazole cap 10mg ...... 36 omeprazole cap 20mg ...... 36 omeprazole cap 40mg ...... 36 OMNARIS ......................... 45 OMNITROPE 10MG ......... 32 OMNITROPE 5.8MG ........ 32 OMNITROPE 5MG ........... 32 ondansetron hcl ................ 34 ondansetron hcl inj............ 34 ondansetron hcl oral soln .. 34 ondansetron odt ................ 34 ONEXTON ........................ 46 ONFI ................................. 19 ONGLYZA ........................ 27 ONMEL ............................... 6 ONZETRA XSAIL ............. 24 OPANA

see oxymorphone hcl ...... 4 OPANA ER (CRUSH RESISTANT) ...................... 3 OPDIVO ............................ 11 OPSUMIT ......................... 18 ORALAIR .......................... 39 ORAP

see pimozide ................. 23 ORAPRED ODT

see prednisolone sodium phosphate ..................... 32

ORAVIG ............................ 49 ORBACTIV ......................... 5 ORENCIA ......................... 38 ORENCIA CLICKJECT ..... 38


73

ORENITRAM TAB 0.125MG .......................................... 18 ORENITRAM TAB 0.25MG .......................................... 18 ORENITRAM TAB 1MG .... 18 ORENITRAM TAB 2.5MG . 18 ORFADIN .......................... 31 ORKAMBI ......................... 45 orsythia 28 day .................. 30 ORTHO MICRONOR

see errin 28 day ............. 29 see lyza ......................... 29 see sharobel 28 day ...... 30

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 30 see tri-linyah .................. 30 see tri-previfem 28 day .. 30 see tri-sprintec 28 day ... 30

ORTHO TRI-CYCLEN LO see norgestimate-ethinyl estradiol (triphasic) ........ 30 see tri-lo-estarylla .......... 30 see tri-lo-marzia ............. 30 see tri-lo-sprintec 28 day ...................................... 30

ORTHO-CYCLEN see estarylla tab 0.25-35 ...................................... 29 see mono-linyah tab 0.25-35 .......................... 30 see norgest/ethi tab 0.25/35 .......................... 30 see previfem 28 day ...... 30 see sprintec 28 day ....... 30

ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ...................................... 29 see nortrel 7/7/7 28 day . 30

OSENI TAB 12.5-15MG .... 27 OSENI TAB 12.5-30MG .... 27 OSENI TAB 12.5-45MG .... 27 OSENI TAB 25-15MG ....... 27 OSENI TAB 25-30MG ....... 27 OSENI TAB 25-45MG ....... 27 OSMOPREP ..................... 35 OTEZLA ............................ 38 OTREXUP ......................... 38

OVCON-35 see balziva 28 day......... 28 see briellyn 28 day ........ 28 see gildagia ................... 29 see philith ...................... 30 see vyfemla 28 day ....... 31 see zenchent tab ........... 31

OVIDE see malathion ................ 49

oxacillin sodium .................. 9 oxaliplatin .......................... 13 OXANDRIN

see oxandrolone ............ 26 oxandrolone ...................... 26 oxaprozin ............................ 1 oxcarbazepine .................. 19 OXICONAZOLE NITRATE 47 OXISTAT .......................... 47 OXSORALEN ULTRA

see methoxsalen rapid .. 47 OXTELLAR XR ................. 19 oxybutynin chloride ........... 37 oxycodone hcl ..................... 3 OXYCODONE HCL ............ 3 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 3 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone w/ acetaminophen soln ............ 4 oxycodone-aspirin ............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone hcl ................ 4 OXYTROL ......................... 37 P pacerone ........................... 14 paclitaxel ........................... 11 paliperidone ...................... 23 PAMELOR

see nortriptyline hcl ....... 21 pamidronate disodium....... 28 PAMINE

see methscopolamine

bromide ......................... 34 PAMINE FORTE

see methscopolamine bromide ......................... 35

PANCREAZE .................... 36 PANDEL ........................... 48 PANRETIN ....................... 49 pantoprazole sodium ........ 36 paricalcitol ......................... 42 PARICALCITOL ................ 42 PARLODEL

see bromocriptine mesylate ........................ 21

PARNATE see tranylcypromine sulfate ........................... 21

paroex sol 0.12% .............. 49 paromomycin sulfate ........... 4 paroxetine er tab ............... 21 paroxetine hcl tabs ............ 21 paser d/r ............................. 7 PATADAY ......................... 43 PATANASE

see olopatadine hcl (nasal) ...................................... 44

PATANOL see olopatadine hcl ....... 43

PAXIL ............................... 21 see paroxetine hcl tabs . 21

PAXIL CR see paroxetine er tab .... 21

PAZEO ............................. 43 PCE .................................... 8 PEDIAPRED

see pred sod pho sol 5mg/5ml ........................ 32

PEDIARIX ......................... 40 PEDVAX HIB .................... 40 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE.......................................... 35 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 35 PEGANONE ..................... 19 PEGASYS .......................... 7 PEGASYS PROCLICK ....... 7


74

PENICILLIN G POT IN DEXTROSE ........................9 PENICILLIN G POTASSIUM IN ........................................9 penicillin g procaine ............9 penicillin g sodium ...............9 penicillin v potassium ..........9 penicilln gk inj 20mu ............9 penicilln gk inj 5mu ..............9 PENNSAID ........................ 49 PENTACEL ....................... 40 PENTAM 300 ......................5 PENTASA ......................... 35 pentoxifylline ..................... 38 PEPCID

see famotidine ............... 35 PERCOCET

see endocet .....................2 see oxycodone w/ acetaminophen 10-325mg ........................................4 see oxycodone w/ acetaminophen 2.5-325mg ........................................3 see oxycodone w/ acetaminophen 5-325mg .4 see oxycodone w/ acetaminophen 7.5-325mg ........................................4 see roxicet tab 5-325mg ..4

PERFOROMIST ................ 44 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 49 see paroex sol 0.12% .... 49 see periogard soln 0.12% ...................................... 49

perindopril erbumine ......... 13 periogard soln 0.12% ........ 49 PERJETA .......................... 11 permethrin ......................... 49 perphenazine .................... 23 PERTZYE ......................... 36 PEXEVA............................ 21 pfizerpen g inj 5mu ..............9 pfizerpen-g inj 20mu ...........9 phenadoz .......................... 34

phenelzine sulfate ............. 21 phenergan ......................... 34 PHENERGAN

see promethazine hcl .... 34 phenobarbital .................... 19 phenobarbital sodium........ 19 PHENOBARBITAL SODIUM .......................................... 19 PHENOXYBENZAMINE HCL................................... 18 phenytek ........................... 19 PHENYTEK

see phenytoin sodium extended ....................... 19

phenytoin .......................... 19 phenytoin inj 50mg/ml ....... 19 phenytoin sodium extended .......................................... 19 philith ................................ 30 PHOSLO

see calcium acetate (phosphate binder) ........ 33

PHOSLYRA ...................... 33 PHOSPHOLINE IODIDE ... 44 PICATO ............................ 49 PILOCARPINE HCL.......... 44 pilocarpine hcl (oral).......... 49 PILOCARPINE HCL (ORAL) .......................................... 49 pimozide ........................... 23 pimtrea pack ..................... 30 pindolol ............................. 16 pioglitazone hcl ................. 27 pioglitazone hcl-glimepiride .......................................... 27 pioglitazone hcl-metformin hcl ..................................... 27 piperacillin sodium-tazobactam sodium 9 pirmella 1/35 28 day ......... 30 piroxicam ............................ 1 PLAN B ONE-STEP

see levonorgestrel (emergency oc) ............. 29

PLAQUENIL see hydroxychloroquine sulfate ............................ 38

PLASMA-LYTE A .............. 42

PLASMA-LYTE-148 .......... 42 PLASMA-LYTE-56/D5W ... 42 PLAVIX

see clopidogrel bisulfate 38 PLEGRIDY ....................... 25 PLEGRIDY STARTER PACK ................................ 25 plenamine ......................... 41 podofilox ........................... 49 polyethylene glycol 3350 .. 35 polymyxin b sulfate ............. 5 polymyxin b-trimethoprim .. 43 POLYTRIM

see polymyxin b-trimethoprim ............... 43

POMALYST ...................... 39 PONSTEL

see mefenamic acid ........ 1 portia 28 day ..................... 30 PORTRAZZA .................... 11 pot chloride inj 2meq/ml .... 42 potassium chloride ............ 40 POTASSIUM CHLORIDE 40, 42 POTASSIUM CHLORIDE 0.3%/D .............................. 42 potassium chloride caps er.......................................... 40 potassium chloride in nacl 42 POTASSIUM CHLORIDE IN NACL ................................ 42 potassium chloride microencapsulated crystals cr ....................................... 40 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 40 potassium citrate (alkalinizer).......................................... 36 POTASSIUM CITRATE (ALKALINIZER) .......... 36, 37 POTIGA ............................ 19 PRADAXA ........................ 37 PRALUENT ...................... 15 pramipexole dihydrochloride.......................................... 22 pramipexole tab 0.125mg . 22 pramipexole tab 0.25mg ... 22 pramipexole tab 0.375mg . 22


75

pramipexole tab 0.5mg ..... 22 pramipexole tab 0.75 er .... 22 pramipexole tab 0.75mg ... 22 pramipexole tab 1.5mg ..... 22 pramipexole tab 1.5mg er . 22 pramipexole tab 1mg ........ 22 pramipexole tab 2.25mg ... 22 pramipexole tab 3mg ........ 22 pramipexole tab 4.5mg ..... 22 PRANDIN

see repaglinide .............. 27 PRAVACHOL

see pravastatin sodium.. 15 pravastatin sodium ............ 15 prazosin hcl ....................... 14 PRECOSE

see acarbose ................. 27 PRED MILD ...................... 43 pred sod pho sol 5mg/5ml . 32 PRED-G ............................ 42 PRED-G S.O.P. ................ 42 prednicarbate .................... 48 PREDNICARBATE ........... 48 PREDNISOLONE ACETATE (OPHTH) ........................... 43 prednisolone sodium phosphate ......................... 32 prednisolone sodium phosphate (ophth) ............. 43 prednisolone sol 15mg/5ml .......................................... 32 prednisolone sol 25mg/5ml .......................................... 32 prednisolone syrup 15 mg/5ml .............................. 32 prednisone con 5mg/ml ..... 32 prednisone pak 10mg ....... 32 prednisone pak 5mg ......... 32 prednisone sol 5mg/5ml .... 32 prednisone tab 10mg ........ 32 prednisone tab 1mg .......... 32 prednisone tab 2.5mg ....... 32 prednisone tab 20mg ........ 32 prednisone tab 50mg ........ 32 prednisone tab 5mg .......... 32 PREGNYL W/DILUENT BENZYL ............................ 33 PREMARIN CREAM ......... 31

PREMARIN INJ ................ 31 premasol 10% ................... 41 premasol 6% ..................... 41 prenatal vitamin/folic acid > 0.8 mg (generic) ................ 42 PREPOPIK ....................... 35 PREVACID

see lansoprazole ........... 36 PREVACID SOLUTAB ...... 36 prevalite ............................ 15 previfem 28 day ................ 30 PREVPAC

see amoxicillin-clarithromycin w/ lansoprazole ............. 35

PREZCOBIX ....................... 7 PREZISTA .......................... 6 PRIFTIN .............................. 7 PRILOSEC ........................ 36

see omeprazole cap 10mg ...................................... 36 see omeprazole cap 20mg ...................................... 36 see omeprazole cap 40mg ...................................... 36

PRIMAQUINE PHOSPHATE ............................................ 6 PRIMAXIN IV

see imipenem-cilastatin ... 5 primidone .......................... 19 PRINIVIL

see lisinopril .................. 13 PRISTIQ ........................... 21 PRIVIGEN ......................... 39 PROAIR HFA .................... 44 PROAIR RESPICLICK ...... 44 probenecid .......................... 1 PROCALAMINE ................ 41 PROCARDIA XL

see nifedical .................. 16 see nifedipine er ............ 16

prochlorperazine inj 5 mg/ml .......................................... 34 prochlorperazine maleate . 34 prochlorperazine supp ...... 34 PROCRIT .......................... 38 procto-med ........................ 47 procto-pak ......................... 47

proctosol hc 2.5 % ............ 47 proctozone hc ................... 47 PROCYSBI ....................... 31 progesterone micronized .. 33 PROGLYCEM SUS 50MG/ML .......................... 32 PROGRAF ........................ 39

see tacrolimus ............... 39 PROLASTIN-C.................. 45 PROLENSA ...................... 44 PROLEUKIN ..................... 11 PROLIA ............................ 33 PROMACTA ..................... 38 promethazine hcl .............. 34 promethegan .................... 34 PROMETRIUM

see progesterone micronized ..................... 33

propafenone hcl ................ 15 propafenone hcl 12hr ........ 15 proparacaine hcl ............... 44 propranolol & hydrochlorothiazide ........... 16 propranolol hcl er .............. 16 propranolol inj 1mg/ml ...... 16 propranolol oral sol ........... 16 propranolol tab .................. 16 propylthiouracil ................. 34 PROQUAD ....................... 40 PROSCAR

see finasteride ............... 36 PROSOL ........................... 41 PROTONIX ....................... 36

see pantoprazole sodium ...................................... 36

PROTOPIC see tacrolimus (topical) . 49

protriptyline hcl ................. 21 PROVENTIL HFA ............. 44 PROVERA

see medroxyprogesterone acetate .......................... 33

PROVIGIL see modafinil ................. 25

PROZAC see fluoxetine cap 10mg 21 see fluoxetine cap 20mg 21 see fluoxetine cap 40mg 21


76

PROZAC WEEKLY see fluoxetine hcl ........... 21

psorcon ............................. 48 PULMICORT

see budesonide (inhalation) ..................... 45

PULMICORT FLEXHALER .......................................... 45 PULMOZYME ................... 45 PURIXAN .......................... 11 PYLERA ............................ 36 pyrazinamide .......................7 pyridostigmine bromide ..... 25 pyridostigmine tab 60mg ... 25 Q QNASL .............................. 45 QNASL CHILDRENS ........ 45 QUADRACEL .................... 40 QUALAQUIN

see quinine sulfate ..........6 QUARTETTE .................... 30 quasense 91 day ............... 30 QUESTRAN

see cholestyramine ....... 15 QUESTRAN LIGHT

see prevalite .................. 15 quetiapine fumarate .......... 23 QUILLICHEW ER .............. 24 QUILLIVANT XR ............... 24 quinapril hcl ....................... 13 quinapril-hydrochlorothiazide .......................................... 13 quinidine gluconate ........... 15 quinidine sulfate ................ 15 quinine sulfate .....................6 QVAR ................................ 45 R RABAVERT ....................... 40 rabeprazole sodium .......... 36 RAGWITEK ....................... 39 raloxifene hcl ..................... 33 ramipril .............................. 13 RANEXA ........................... 18 ranitidine hcl ...................... 35 RAPAFLO ......................... 36 RAPAMUNE ...................... 39

see sirolimus ................. 39 RAPIVAB ............................7

RASUVO ........................... 39 RAVICTI ............................ 31 RAYOS TAB 1MG ............ 32 RAYOS TAB 2MG ............ 32 RAYOS TAB 5MG ............ 32 RAZADYNE

see galantamine hydrobromide ................ 20

RAZADYNE ER see galantamine hydrobromide er ............ 20

REBETOL ........................... 7 see ribasphere ................ 7 see ribavirin 200mg ......... 7

REBIF ............................... 25 REBIF REBIDOSE ............ 25 REBIF REBIDOSE TITRATION ....................... 25 REBIF TITRATION PACK . 25 RECLAST

see zoledronic inj 5/100ml ...................................... 28

reclipsen 28 day ................ 30 RECOMBIVAX HB ............ 40 RECTIV ............................. 49 REGLAN

see metoclopramide hcl 34 REGRANEX ...................... 49 RELENZA DISKHALER ...... 7 RELISTOR ........................ 36 RELPAX ............................ 24 REMERON

see mirtazapine ............. 21 REMERON SOLTAB

see mirtazapine ............. 21 REMICADE ....................... 39 REMODULIN .................... 18 RENAGEL ......................... 33 RENVELA PAK ................. 33 RENVELA TAB 800MG .... 33 repaglinide ........................ 27 repaglinide-metformin hcl .. 28 REPREXAIN

see hydrocodone-ibuprofen tab 5-200mg .......................... 2 see ibudone tab 5-200mg 3

reprexain tab 10-200mg ...... 4

REQUIP see ropinirole tab 0.25mg ...................................... 22 see ropinirole tab 0.5mg 22 see ropinirole tab 1mg ... 22 see ropinirole tab 2mg ... 22 see ropinirole tab 3mg ... 22 see ropinirole tab 4mg ... 22 see ropinirole tab 5mg ... 22

REQUIP XL see ropinirole tab 12mg er ...................................... 22 see ropinirole tab 2mg er ...................................... 22 see ropinirole tab 4mg er ...................................... 22 see ropinirole tab 6mg er ...................................... 22 see ropinirole tab 8mg er ...................................... 22

RESCRIPTOR .................... 6 RESTASIS ........................ 44 RESTORIL

see temazepam............. 24 RETIN-A

see tretinoin .................. 46 RETIN-A MICRO

see tretinoin microsphere ...................................... 46

RETIN-A MICRO PUMP ... 46 RETROVIR

see zidovudine ................ 6 RETROVIR IV INFUSION ... 6 REVATIO .......................... 18

see sildenafil citrate (pulmonary hypertension) ...................................... 18

REVLIMID ......................... 39 REXULTI .......................... 23 REYATAZ ........................... 6 RHEUMATREX................. 39 RHINOCORT AQUA

see budesonide (nasal) . 45 ribapak mis 600/day ............ 7 ribasphere ........................... 7 ribasphere ribapak 1000 ..... 7 ribasphere ribapak 1200 ..... 7 ribasphere ribapak 800 ....... 7


77

ribavirin 200mg ...................7 rifabutin ...............................7 RIFADIN

see rifampin .....................7 rifamate ...............................7 rifampin ...............................7 RIFATER.............................7 RILUTEK

see riluzole .................... 25 riluzole .............................. 25 rimantadine hydrochloride ...7 RINGER'S ......................... 42 RIOMET ............................ 28 risedronate sodium ........... 28 RISPERDAL

see risperidone soln ...... 23 see risperidone tabs ...... 23

RISPERDAL INJ 12.5MG.. 23 RISPERDAL INJ 25MG .... 23 RISPERDAL INJ 37.5MG.. 23 RISPERDAL INJ 50MG .... 23 RISPERDAL M-TAB

see risperidone odt ........ 23 risperidone odt .................. 23 risperidone soln ................. 23 risperidone tabs ................ 23 RITALIN

see methylphenidate hcl 24 RITALIN LA ....................... 24

see methylphenidate hcl 24 RITUXAN .......................... 11 rivastigmine cap ................ 20 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 20 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 20 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 20 rizatriptan benzoate .......... 24 ROBINUL

see glycopyrrolate ......... 34 ROBINUL FORTE

see glycopyrrolate ......... 34 ROCALTROL

see calcitriol ................... 42 ROCEPHIN

see ceftriaxone sodium....8 ropinirole tab 0.25mg ........ 22

ropinirole tab 0.5mg .......... 22 ropinirole tab 12mg er ....... 22 ropinirole tab 1mg ............. 22 ropinirole tab 2mg ............. 22 ropinirole tab 2mg er ......... 22 ropinirole tab 3mg ............. 22 ropinirole tab 4mg ............. 22 ropinirole tab 4mg er ......... 22 ropinirole tab 5mg ............. 22 ropinirole tab 6mg er ......... 22 ropinirole tab 8mg er ......... 22 rosadan cre 0.75% ............ 49 rosuvastatin calcium ......... 15 ROTARIX .......................... 40 ROTATEQ ........................ 40 ROWASA

see mesalamine enema 35 roweepra ........................... 19 roxicet soln .......................... 4 roxicet tab 5-325mg ............ 4 ROXICODONE

see oxycodone hcl........... 3 ROZEREM ........................ 24 RUCONEST ...................... 38 RYTARY ........................... 22 RYTHMOL

see propafenone hcl ...... 15 RYTHMOL SR

see propafenone hcl 12hr ...................................... 15

S SABRIL ............................. 19 SAFYRAL ......................... 30 SAIZEN ............................. 32 SAIZEN CLICK.EASY ....... 32 SALAGEN

see pilocarpine hcl (oral) ...................................... 49

SAMSCA ........................... 33 SANCUSO ........................ 34 SANDIMMUNE

see cyclosporine ........... 39 SANDIMMUNE SOLN....... 39 SANDOSTATIN

see octreotide acetate ... 33 SANDOSTATIN LAR DEPOT ............................. 33 SANTYL ............................ 49

SAPHRIS .......................... 23 SARAFEM ........................ 26 SAVAYSA ......................... 37 SAVELLA .......................... 25 SAVELLA TITRATION PACK ................................ 25 SEASONIQUE

see amethia 91 day ....... 28 see ashlyna 91 day ....... 28 see levonorgestrel-ethinyl estradiol (91-day) .......... 29

SECTRAL see acebutolol hcl ......... 16

selegiline hcl ..................... 22 selenium sulfide ................ 47 SELZENTRY ...................... 6 SEMPREX-D .................... 44 SENSIPAR ....................... 28 SEREVENT DISKUS ........ 45 SERNIVO ......................... 48 SEROQUEL

see quetiapine fumarate 23 SEROQUEL XR ................ 23 SEROSTIM ....................... 32 sertraline hcl ..................... 21 setlakin tab ....................... 30 SF-ROWASA .................... 35 sharobel 28 day ................ 30 SIGNIFOR ........................ 33 SIGNIFOR LAR ................ 33 sildenafil citrate (pulmonary hypertension) .................... 18 SILENOR .......................... 24 SILVER SULFADIAZINE .. 46 SIMBRINZA SUS 1-0.2% . 44 SIMPONI .......................... 39 SIMPONI ARIA ................. 39 SIMULECT ....................... 39 simvastatin ........................ 15 SINEMET

see carbidopa-levodopa 21 SINEMET CR

see carbidopa-levodopa 21 SINGULAIR

see montelukast sodium 45 sirolimus ........................... 39 SIRTURO ........................... 7 SIVEXTRO ......................... 5


78

SKLICE ............................. 49 SODIUM CHLORIDE .. 41, 42 SODIUM CHLORIDE 0.45% VIA .................................... 42 SODIUM CHLORIDE 0.9% .......................................... 49 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 41 sodium phenylbutyrate ...... 31 sodium polystyrene sulfonate .......................................... 28 SOLARAZE

see diclofenac sodium (actinic keratoses) ......... 49

SOLIRIS ............................ 38 SOLODYN ........................ 10 SOLTAMOX ...................... 12 SOLU-CORTEF 1000MG.. 32 SOLU-CORTEF 100MG ... 32 SOLU-CORTEF 250MG ... 32 SOLU-CORTEF 500MG ... 32 SOLU-MEDROL

see methylpr ss inj 1gm . 32 see methylpr ss inj 40mg ...................................... 32 see methylprednisolone sod succ ........................ 32

SOLU-MEDROL INJ 2GM. 32 SOMATULINE DEPOT ..... 33 SOMAVERT ...................... 33 SOOLANTRA .................... 49 SORIATANE

see acitretin ................... 47 SORILUX .......................... 47 sorine ................................ 15 sotalol hcl .......................... 15 sotalol hcl (afib/afl) ............ 15 SOTYLIZE ......................... 16 SOVALDI ............................7 SPIRIVA HANDIHALER .... 44 SPIRIVA RESPIMAT ........ 44 spironolactone ................... 14 spironolactone & hydrochlorothiazide ........... 17 SPORANOX

see itraconazole ..............6 SPORANOX SOL 10MG/ML ............................................6

sprintec 28 day ................. 30 SPRITAM .......................... 19 SPRYCEL ......................... 12 sps susp 15gm/60ml ......... 28 sronyx 28 day ................... 30 SSD .................................. 46 STARLIX

see nateglinide .............. 27 stavudine ............................ 6 STELARA ......................... 39 STERILE WATER IRRIGATION ..................... 49 STIMATE .......................... 34 STIOLTO RESPIMAT ....... 44 STIVARGA ........................ 12 STRATTERA .................... 24 STRENSIQ ....................... 31 streptomycin sulfate ............ 4 STRIANT .......................... 26 STRIBILD ............................ 7 STRIVERDI RESPIMAT ... 45 STROMECTOL

see ivermectin ................. 5 SUBOXONE MIS 12-3MG 26 SUBOXONE MIS 2-0.5MG .......................................... 26 SUBOXONE MIS 4-1MG .. 26 SUBOXONE MIS 8-2MG .. 26 SUBSYS ............................. 4 SUCRAID .......................... 36 sucralfate .......................... 36 SULAR

see nisoldipine .............. 17 sulfacet sod oin 10% op .... 43 sulfacetamide sodium (acne) .......................................... 46 sulfacetamide sodium (ophth) .............................. 43 sulfacetamide sod-prednisolone .............. 42 sulfadiazine ......................... 4 sulfamethoxazole-trimethop 5 sulfamethoxazole-trimethop ds ........................................ 5 sulfamethoxazole-trimethoprim inj .................................... 5 SULFAMYLON ................. 46 sulfasalazine dr ................. 35

sulfasalazine ir .................. 35 sulindac .............................. 1 SUMATRIPTAN INJ 4MG/0.5ML ....................... 24 sumatriptan inj 6mg/0.5ml . 24 SUMATRIPTAN NASAL SOLN ................................ 24 sumatriptan succinate ....... 25 SUMAVEL DOSEPRO ...... 25 suprax ................................. 8 SUPRAX ............................. 8

see cefixime .................... 8 SUPREP BOWEL PREP .. 35 SURMONTIL

see trimipramine maleate ...................................... 21

SUSTIVA ............................ 6 SUTENT ........................... 12 syeda ................................ 30 SYLATRON KIT 200MCG 12 SYLATRON KIT 300MCG 13 SYLATRON KIT 600MCG 13 SYLVANT ......................... 13 SYMBICORT .................... 45 SYMLINPEN 120 .............. 27 SYMLINPEN 60 ................ 27 SYNAGIS .......................... 40 SYNALAR


SYNAREL ......................... 31 SYNERA ........................... 48 SYNERCID ......................... 5 SYNJARDY TAB 12.5-1000.......................................... 28 SYNJARDY TAB 12.5-500 28 SYNJARDY TAB 5-1000MG.......................................... 28 SYNJARDY TAB 5-500MG.......................................... 28 SYNRIBO ......................... 13 SYNTHROID .................... 34

see levothyroxine sodium ...................................... 33

SYPRINE .......................... 28 T TABLOID .......................... 11 TACLONEX ...................... 48


79

see calcipotriene/betamethasone .................................. 47

tacrolimus.......................... 39 tacrolimus (topical) ............ 49 TAFINLAR ......................... 12 TAGRISSO ....................... 12 TALTZ ............................... 47 TAMIFLU.............................7 tamoxifen citrate ................ 12 tamsulosin hcl ................... 36 TANZEUM ......................... 27 TAPAZOLE

see methimazole ........... 34 TARCEVA ......................... 12 TARGRETIN ..................... 49

see bexarotene .............. 12 tarina fe 1/20 28 day ......... 30 TARKA

see trandolapril-verapamil hcl .................................. 13

TASIGNA .......................... 12 tazicef .................................8 tazicef vial ...........................8 TAZORAC ......................... 47 taztia xt ............................. 17 TECENTRIQ ..................... 11 TECFIDERA ...................... 25 TECFIDERA STARTER PACK ................................ 25 TEFLARO ...........................8 TEGRETOL ....................... 19

see carbamazepine ....... 18 see epitol ....................... 19

TEGRETOL-XR ................ 19 see carbamazepine ....... 19

TEKTURNA ....................... 17 TEKTURNA HCT .............. 17 telmisartan ........................ 14 telmisartan-amlodipine ...... 14 telmisartan-hydrochlorothiazide ...................................... 14 temazepam ....................... 24 TEMOVATE

see clobetasol propionate ...................................... 47 see cormax .................... 47

TEMOVATE E

see clobetasol propionate emollient base ............... 47

TENIVAC .......................... 40 TENORETIC 100

see atenolol & chlorthalidone ................ 15

TENORETIC 50 see atenolol & chlorthalidone ................ 15

TENORMIN see atenolol ................... 16

TERAZOL 3 see terconazole vaginal . 37

TERAZOL 7 see terconazole vaginal . 37

terazosin hcl ...................... 14 terbinafine hcl ..................... 6 terbutaline sulfate ............. 45 terconazole vaginal ........... 37 testosterone ...................... 26 TESTOSTERONE ............ 26 testosterone cypionate ...... 26 testosterone enanthate ..... 26 TETANUS/DIPHTHERIA TOXOID ............................ 40 TETRABENAZINE ............ 25 TETRACYCLINE HCL ...... 10 texacort ............................. 48 THALOMID ....................... 39 theo-24 .............................. 45 theophylline ....................... 45 thioridazine hcl .................. 23 thiotepa ............................. 10 thiothixene ........................ 23 THYMOGLOBULIN ........... 40 tiagabine hcl ...................... 20 TIAZAC

see diltiazem hcl er........ 16 see diltiazem hcl extended release beads ................ 16 see taztia xt ................... 17

timolol maleate .................. 16 timolol maleate (ophth) soln .......................................... 44 TIMOLOL MALEATE GEL 44 TIMOPTIC

see timolol maleate (ophth) soln ................... 44

TIMOPTIC OCUDOSE ..... 44 TIROSINT ......................... 34 TIVICAY .............................. 6 tizanidine .......................... 25 TOBI

see tobramycin ................ 4 TOBI PODHALER ............... 4 TOBRADEX ...................... 42

see tobramycin-dexamethasone .................................... 42

TOBRADEX ST ................ 42 tobramycin .......................... 4 tobramycin (ophth) ............ 43 tobramycin inj 1.2 gm/30ml . 4 tobramycin inj 1.2gm ........... 4 tobramycin inj 10mg/ml ....... 4 tobramycin inj 40mg/ml ....... 4 tobramycin inj 80mg/2ml ..... 4 tobramycin-dexamethasone.......................................... 42 TOBREX

see tobramycin (ophth) . 43 TOBREX OINT 0.3% ........ 43 TOFRANIL

see imipramine hcl ........ 21 TOLAK .............................. 49 tolmetin sodium................... 1 tolterodine tartrate er ........ 37 tolterodine tartrate tab 1 mg.......................................... 37 tolterodine tartrate tab 2 mg.......................................... 37 TOPAMAX

see topiramate .............. 20 TOPAMAX SPRINKLE

see topiramate .............. 20 TOPICORT

see desoximetasone 47, 48 TOPICORT SPRAY 0.25%.......................................... 48 topiramate ......................... 20 TOPIRAMATE .................. 20 toposar .............................. 13 topotecan hcl .................... 13 TOPOTECAN HCL ........... 13 TOPROL XL

see metoprolol succinate


80

...................................... 16 TORISEL........................... 11 torsemide tabs .................. 17 TOUJEO SOLOSTAR ....... 27 TOVIAZ ............................. 37 TPN ELECTROLYTES ..... 41 TRACLEER ....................... 18 TRADJENTA ..................... 28 TRAMADOL HCL ................2 tramadol hcl er ....................2 TRAMADOL HCL ER ..........2 tramadol hcl er (biphasic) 100mg .................................2 tramadol hcl er (biphasic) 200mg .................................2 tramadol hcl er (biphasic) 300mg .................................2 tramadol hcl tab 50 mg .......2 tramadol-acetaminophen ....2 trandolapril ........................ 13 trandolapril-verapamil hcl .. 13 tranexamic acid ................. 38 TRANSDERM-SCOP ........ 34 TRANXENE T

see clorazepate dipotassium ................... 19

tranylcypromine sulfate ..... 21 TRAVASOL ....................... 41 TRAVATAN Z .................... 44 trazodone hcl .................... 21 TREANDA ......................... 10 TRECATOR ........................7 TRELSTAR MIXJECT ....... 12 TRESIBA FLEXTOUCH .... 27 tretinoin ....................... 13, 46 TRETINOIN ....................... 46 tretinoin microsphere ........ 46 TRETINOIN MICROSPHERE ............... 46 tretin-x ............................... 46 trexall ................................ 39 TREXIMET ........................ 25 triamcinolone acetonide (mouth) ............................. 49 triamcinolone acetonide (topical) ............................. 48 triamt/hctz cap 37.5-25 ..... 17 triamt/hctz cap 50-25mg ... 17

triamt/hctz tab 37.5-25 ...... 17 triamt/hctz tab 75-50mg .... 17 trianex ............................... 48 TRIBENZOR ..................... 14 TRICOR

see fenofibrate .............. 15 triderm ............................... 48 trifluoperazine hcl .............. 23 trifluridine .......................... 43 TRIGLIDE ......................... 15 tri-legest 28 day ................ 30 TRILEPTAL

see oxcarbazepine ........ 19 tri-linyah ............................ 30 TRILIPIX

see choline fenofibrate .. 15 tri-lo-estarylla .................... 30 tri-lo-marzia ....................... 30 tri-lo-sprintec 28 day ......... 30 trilyte ................................. 35 trimethoprim ........................ 5 trimipramine maleate ........ 21 TRINESSA ........................ 30 TRINESSA LO TAB .......... 31 TRI-NORINYL 28

see aranelle 28 .............. 28 TRINTELLIX ..................... 21 TRIOSTAT

see liothyronine sodium . 33 tri-previfem 28 day ............ 30 TRISENOX ....................... 13 tri-sprintec 28 day ............. 30 TRIUMEQ ........................... 7 trivora 28 day .................... 31 TRIZIVIR

see abacavir sulfate-lamivudine-zidovudine ................................... 6

TROKENDI XR ................. 20 TROPHAMINE INJ 10% ... 41 trospium chloride .............. 37 trospium chloride er .......... 37 TRULICITY ....................... 27 TRUMENBA ...................... 40 TRUSOPT

see dorzolamide hcl ...... 43 TRUVADA TAB 100-150 ..... 7 TRUVADA TAB 133-200 ..... 7

TRUVADA TAB 167-250 .... 7 TRUVADA TAB 200-300 .... 7 TUDORZA PRESSAIR ..... 44 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 44 TWINRIX INJ .................... 40 TWYNSTA

see telmisartan-amlodipine ...................................... 14

TYBOST ............................. 6 TYGACIL ............................ 5 TYKERB ........................... 12 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ........................... 1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ........................... 1

TYPHIM VI ........................ 40 TYSABRI .......................... 25 TYVASO ........................... 18 TYZEKA .............................. 7 U UCERIS FOAM ................. 35 UCERIS TAB .................... 35 ULORIC .............................. 1 ULTRACET

see tramadol-acetaminophen 2

ULTRAM see tramadol hcl tab 50 mg ................................... 2

ULTRAVATE .................... 48 see halobetasol propionate ..................... 48

UNASYN see ampicillin & sulbactam sodium ............................ 9

UNASYN BULK PACK see ampicillin & sulbactam sodium ............................ 9

UNITHROID ...................... 34 UPTRAVI .......................... 18 URECHOLINE

see bethanechol chloride ...................................... 36

UROCIT-K 15 see potassium citrate


81

(alkalinizer) .................... 36 UROXATRAL

see alfuzosin hcl ............ 36 URSO 250

see ursodiol ................... 36 URSO FORTE

see ursodiol ................... 36 ursodiol ............................. 36 UVADEX ........................... 13 V VAGIFEM .......................... 31 valacyclovir hcl ....................7 VALCHLOR ....................... 49 VALCYTE............................7

see valganciclovir hcl ......7 valganciclovir hcl .................7 VALIUM

see diazepam ................ 19 valproate sodium ............... 20 valproic acid ...................... 20 valsartan ........................... 14 valsartan-hydrochlorothiazide ........................................ 14 VALSTAR.......................... 10 VALTREX

see valacyclovir hcl .........7 VANCOCIN HCL

see vancomycin hcl .........5 vancomycin hcl ...................5 VANCOMYCIN IN NACL.....5 VANDAZOLE .................... 37 VANOS

see fluocinonide ............ 48 VANTAS............................ 12 VAQTA .............................. 40 VARIVAX .......................... 40 VARUBI............................. 34 VASCEPA ......................... 15 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 13

VASOTEC see enalapril maleate .... 13

VECTIBIX.......................... 11 VELCADE ......................... 11 VELETRI ........................... 18 velivet 28 day .................... 31 VELPHORO ...................... 33

VELTASSA ....................... 28 VELTIN ............................. 46 VENCLEXTA .................... 11 VENCLEXTA STARTING PACK ................................ 11 venlafaxine cap er ............. 21 venlafaxine hcl .................. 21 VENLAFAXINE HCL ......... 21 VENLAFAXINE HCL ER

see venlafaxine hcl ........ 21 venlafaxine tab .................. 21 VENTAVIS ........................ 18 VENTOLIN HFA ................ 45 VERAMYST ...................... 45 verapamil hcl ..................... 17 VERAPAMIL HCL ............. 17 VERELAN

see verapamil hcl .......... 17 VERELAN PM

see verapamil hcl .......... 17 veripred ............................. 32 VERSACLOZ .................... 23 VESICARE ........................ 37 vestura .............................. 31 VEXOL .............................. 43 VFEND

see voriconazole ............. 6 VFEND IV

see voriconazole inj 200mg ............................. 6

VIBERZI ............................ 36 VIBRAMYCIN ................... 10

see doxycycline (monohydrate) ............... 10 see doxycycline hyclate . 10

vicodin ................................. 4 vicodin es ............................ 4 vicodin hp ............................ 4 VICOPROFEN

see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 2

VICTOZA .......................... 27 VIDAZA

see azacitidine .............. 10 VIDEX EC

see didanosine ................ 6 VIDEX PEDIATRIC ............. 6

vienva 28 day ................... 31 VIGAMOX ......................... 43 VIIBRYD STARTER PACK.......................................... 21 VIIBRYD TAB ................... 21 VIMIZIM ............................ 31 VIMOVO ............................. 1 VIMPAT ............................ 20 vinblastine sulfate ............. 11 vincasar ............................ 11 vincristine sulfate .............. 11 vinorelbine tartrate ............ 11 VIOKACE 10 ..................... 36 VIOKACE 20 ..................... 36 viorele ............................... 31 VIRACEPT .......................... 6 VIRAMUNE

see nevirapine ................. 6 VIRAMUNE XR

see nevirapine ................. 6 VIREAD .............................. 6 VIROPTIC

see trifluridine ................ 43 VISTARIL

see hydroxyzine pamoate ...................................... 44

VISTIDE see cidofovir .................... 7

VITEKTA ............................. 6 VIVELLE-DOT

see estradiol .................. 31 VIVITROL ......................... 26 VIVLODEX .......................... 1 VOLTAREN

see diclofenac sodium (topical) 1% gel ............. 49

voriconazole ....................... 6 voriconazole inj 200mg ....... 6 VOSPIRE ER

see albuterol sulfate er .. 44 VOTRIENT ....................... 12 VPRIV ............................... 31 VRAYLAR ......................... 23 VRAYLAR THERAPY PACK.......................................... 23 vyfemla 28 day ................. 31 VYTORIN .......................... 15 VYVANSE ......................... 24


82

W warfarin sodium ................. 37 WELCHOL ........................ 15 WELLBUTRIN SR

see bupropion hcl .......... 20 WELLBUTRIN XL

see bupropion hcl .......... 20 WESTCORT

see hydrocortisone valerate.......................... 48

wymzya fe ......................... 31 X XALATAN

see latanoprost .............. 43 XALKORI .......................... 12 XANAX

see alprazolam .............. 18 XARELTO ......................... 37 XARELTO STARTER PACK .......................................... 37 XARTEMIS XR ....................4 XELJANZ .......................... 39 XELJANZ XR .................... 39 XEOMIN ............................ 25 XERESE ........................... 49 XGEVA ............................. 33 XIFAXAN TAB 200MG ........5 XIFAXAN TAB 550MG ...... 36 XIGDUO XR TAB 10-1000MG ....................... 28 XIGDUO XR TAB 10-500MG .......................................... 28 XIGDUO XR TAB 5-1000MG .......................................... 28 XIGDUO XR TAB 5-500MG .......................................... 28 XODOL

see hydrocodone-acetaminophen 10-300mg ...................2 see hydrocodone-acetaminophen 5-300mg .....................2 see hydrocodone-acetaminophen 7.5-300mg ..................2 see vicodin ......................4 see vicodin es ..................4

see vicodin hp ................. 4 XOLAIR ............................. 45 XOPENEX

see levalbuterol hcl........ 44 XOPENEX CONCENTRATE

see levalbuterol conc 1.25mg/0.5ml ................ 44

XOPENEX HFA ................ 45 XTAMPZA ER ..................... 4 XTANDI ............................. 12 xulane dis 150-35 ............. 31 XYLOCAINE

see lidocaine hcl ............ 48 see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 1%......... 4 see lidocaine inj 2%......... 4

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 0.5% ...... 4 see lidocaine inj 1.5% ...... 4 see lidocaine inj 2%......... 4

xylon tab 10-200mg ............ 4 XYREM ............................. 25 XYZAL

see levocetirizine soln 2.5mg/5ml ..................... 44 see levocetirizine tab 5 mg ...................................... 44

Y YASMIN 28

see drospirenone-ethinyl estradiol ......................... 29 see syeda ...................... 30 see zarah ...................... 31

YAZ see drospirenone-ethinyl estradiol ......................... 29 see loryna 28 day .......... 29 see nikki 28 day ............ 30 see vestura .................... 31

YERVOY ........................... 11 YF-VAX ............................. 40 Z zafirlukast .......................... 45 ZALTRAP .......................... 11 zamicet ............................... 4

ZANAFLEX see tizanidine ................ 25

ZANOSAR ........................ 10 ZANTAC

see ranitidine hcl ........... 35 zarah ................................. 31 ZARONTIN

see ethosuximide .......... 19 ZARXIO ............................ 38 ZAVESCA ......................... 31 ZAZOLE CREAM 0.8% ..... 37 ZEBETA

see bisoprolol fumarate . 16 ZELAPAR ......................... 22 ZELBORAF ....................... 12 ZEMAIRA .......................... 45 ZEMBRACE SYMTOUCH 25 ZEMPLAR

see paricalcitol .............. 42 zenatane ........................... 46 zenchent fe 28 day ........... 31 zenchent tab ..................... 31 ZENPEP ........................... 36 ZERBAXA ........................... 8 ZERIT

see stavudine .................. 6 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 13

ZESTRIL see lisinopril .................. 13

ZETIA TAB 10MG ............. 15 ZETONNA ........................ 45 ZIAC

see bisoprolol & hydrochlorothiazide ....... 15

ZIAGEN .............................. 6 see abacavir sulfate ........ 6

ZIANA ............................... 46 see clindamycin phosphate-tretinoin ....... 46

zidovudine .......................... 6 ZINACEF ............................ 8

see cefuroxime sodium ... 8 ZINECARD

see dexrazoxane ........... 13 ZIOPTAN .......................... 44 ziprasidone hcl .................. 23


83

ZIPSOR...............................1 ZIRGAN ............................ 43 ZITHROMAX

see azithromycin .............8 ZMAX ..................................8 ZOCOR

see simvastatin .............. 15 ZOFRAN

see ondansetron hcl ...... 34 see ondansetron hcl inj.. 34 see ondansetron hcl oral soln ................................ 34

ZOFRAN ODT see ondansetron odt ...... 34

ZOHYDRO ER (ABUSE DETERRENT) .....................4 ZOLADEX ......................... 12 zoledronic acid .................. 28 zoledronic inj 4mg/5ml ...... 28 zoledronic inj 5/100ml ....... 28 ZOLINZA ........................... 11 zolmitriptan ........................ 25 zolmitriptan odt .................. 25 ZOLOFT

see sertraline hcl ........... 21 zolpidem tartrate ............... 24 ZOMACTON ..................... 33 ZOMETA ........................... 28

see zoledronic inj 4mg/5ml ...................................... 28

ZOMIG

see zolmitriptan ............. 25 ZOMIG NASAL SPRAY .... 25 ZOMIG ZMT

see zolmitriptan odt ....... 25 ZONEGRAN

see zonisamide ............. 20 zonisamide ........................ 20 ZONTIVITY ....................... 38 ZORBTIVE ........................ 33 ZORTRESS TAB 0.25MG . 40 ZORTRESS TAB 0.5MG ... 40 ZORTRESS TAB 0.75MG . 40 ZORVOLEX ........................ 1 ZOSTAVAX ....................... 40 ZOSYN ............................... 9

see piperacillin sodium-tazobactam sodium ............................. 9

zovia 1/35e 28 day ............ 31 zovia 1/50e 28 day ............ 31 ZOVIRAX .......................... 49

see acyclovir ................... 7 see acyclovir topical ...... 48

ZUBSOLV SUB 1.4-0.36MG .......................................... 26 ZUBSOLV SUB 11.4-2.9MG .......................................... 26 ZUBSOLV SUB 2.9-0.71MG .......................................... 26 ZUBSOLV SUB 5.7-1.4MG .......................................... 26

ZUBSOLV SUB 8.6-2.1MG.......................................... 26 ZUPLENZ ......................... 34 ZYBAN

see buproban ................ 26 see bupropion hcl (smoking deterrent) ....... 26

ZYCLARA ......................... 49 ZYDELIG .......................... 12 ZYFLO CR ........................ 45 ZYKADIA .......................... 12 ZYLET .............................. 42 ZYLOPRIM

see allopurinol tab ........... 1 ZYMAXID

see gatifloxacin (ophth) . 43 ZYPREXA

see olanzapine solr ....... 23 see olanzapine tabs ...... 23

ZYPREXA RELPREVV INJ 210MG .............................. 23 ZYPREXA RELPREVV INJ 300MG .............................. 23 ZYPREXA RELPREVV INJ 405MG .............................. 23 ZYPREXA ZYDIS

see olanzapine odt ........ 23 ZYTIGA ............................. 12 ZYVOX

see linezolid .................... 5

drug requirements/ drug name drug requirements/ …...2017 602 4t platinum comm bvd plus eff...

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