exchanges molina wa - caremarkpa - prior authorization ql - special quantity limit may apply st -...

1PA - Prior Authorization QL - Special Quantity Limit may apply ST - Step TherapyAge - Special Age Limit may apply

Tier 0 = Preventative Services at $0 copayDME = Coinsurance may apply

EXCHANGES_MOLINA_WA

Drug Name Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAmphetamines

amphetamine cap 5mg er Tier 1 AGEamphetamine cap 10mg er Tier 1 AGEamphetamine cap 15mg er Tier 1 AGEamphetamine cap 20mg er Tier 1 AGEamphetamine cap 25mg er Tier 1 AGEamphetamine cap 30mg er Tier 1 AGEamphetamine tab 5mg Tier 1 AGEamphetamine tab 7.5mg Tier 1 AGEamphetamine tab 10mg Tier 1 AGEamphetamine tab 12.5mg Tier 1 AGEamphetamine tab 15mg Tier 1 AGEamphetamine tab 20mg Tier 1 AGEamphetamine tab 30mg Tier 1 AGEdextroamphet cap 5mg er Tier 1 AGEdextroamphet cap 10mg er Tier 1 AGEdextroamphet cap 15mg er Tier 1 AGEdextroamphet tab 5mg Tier 1 AGEdextroamphet tab 10mg Tier 1 AGEmethamphetam tab 5mg Tier 1 AGEVYVANSE CAP 20MG Tier 3 AGEVYVANSE CAP 30MG Tier 3 AGEVYVANSE CAP 40MG Tier 3 AGEVYVANSE CAP 50MG Tier 3 AGEVYVANSE CAP 60MG Tier 3 AGEVYVANSE CAP 70MG Tier 3 AGEzenzedi tab 5mg Tier 1 AGEzenzedi tab 10mg Tier 1 AGE

Analepticscaffeine cit sol 20mg/ml Tier 1caffeine cit sol 60mg/3ml Tier 1

Attention-Deficit/Hyperactivity Disorder (ADHD) AgentsINTUNIV TAB 1MG Tier 3 PAINTUNIV TAB 2MG Tier 3 PAINTUNIV TAB 3MG Tier 3 PAINTUNIV TAB 4MG Tier 3 PASTRATTERA CAP 10MG Tier 2 AGESTRATTERA CAP 18MG Tier 2 AGESTRATTERA CAP 25MG Tier 2 AGE



Drug Name Drug Tier Requirements/LimitsSTRATTERA CAP 40MG Tier 2 AGESTRATTERA CAP 60MG Tier 2 AGESTRATTERA CAP 80MG Tier 2 AGESTRATTERA CAP 100MG Tier 2 AGE

Stimulants - Misc.DAYTRANA DIS 10MG/9HR Tier 3 PA; AGEDAYTRANA DIS 15MG/9HR Tier 3 PA; AGEDAYTRANA DIS 20MG/9HR Tier 3 PA; AGEDAYTRANA DIS 30MG/9HR Tier 3 PA; AGEdexmethylph tab 2.5mg Tier 1 AGEdexmethylph tab 5mg Tier 1 AGEdexmethylph tab 10mg Tier 1 AGEFOCALIN XR CAP 5MG Tier 3 PA; AGEFOCALIN XR CAP 10MG Tier 3 PA; AGEFOCALIN XR CAP 15MG Tier 3 PA; AGEFOCALIN XR CAP 20MG Tier 3 PA; AGEFOCALIN XR CAP 25MG Tier 3 PA; AGEFOCALIN XR CAP 30MG Tier 3 PA; AGEFOCALIN XR CAP 35MG Tier 3 PA; AGEFOCALIN XR CAP 40MG Tier 3 PA; AGEmetadate tab 20mg er Tier 1 AGEMETHYLIN CHW 2.5MG Tier 2 AGEMETHYLIN CHW 5MG Tier 2 AGEMETHYLIN CHW 10MG Tier 2 AGEmethylin tab 5mg Tier 1 AGEmethylin tab 10mg Tier 1 AGEmethylin tab 10mg er Tier 1 AGEmethylin tab 20mg Tier 1 AGEmethylin tab 20mg er Tier 1 AGEmethylphenid cap 10mg Tier 1 AGEmethylphenid cap 20mg Tier 1 AGEmethylphenid cap 20mg er Tier 1 AGEmethylphenid cap 30mg Tier 1 AGEmethylphenid cap 30mg er Tier 1 AGEmethylphenid cap 40mg Tier 1 AGEmethylphenid cap 40mg er Tier 1 AGEmethylphenid cap 50mg Tier 1 AGEmethylphenid cap 60mg Tier 1 AGEmethylphenid sol 5mg/5ml Tier 1 AGEmethylphenid sol 10mg/5ml Tier 1 AGEmethylphenid tab 5mg Tier 1 AGEmethylphenid tab 10mg Tier 1 AGEmethylphenid tab 10mg er Tier 1 AGE



Drug Name Drug Tier Requirements/Limitsmethylphenid tab 18mg er Tier 1 AGEmethylphenid tab 20mg Tier 1 AGEmethylphenid tab 20mg er Tier 1 AGEmethylphenid tab 20mg sr Tier 1 AGEmethylphenid tab 27mg er Tier 1 AGEmethylphenid tab 36mg er Tier 1 AGEmethylphenid tab 54mg er Tier 1 AGEmodafinil tab 100mg Tier 1 PAmodafinil tab 200mg Tier 1 PANUVIGIL TAB 50MG Tier 3 PANUVIGIL TAB 150MG Tier 3 PANUVIGIL TAB 250MG Tier 3 PAQUILLIVANT SUS XR Tier 3 PARITALIN LA CAP 10MG Tier 3 PA; AGE

AMEBICIDESAmebicides

YODOXIN TAB 210MG Tier 2YODOXIN TAB 650MG Tier 2

AMINOGLYCOSIDESAminoglycosides

NEO-FRADIN SOL 125/5ML Tier 2neomycin tab 500mg Tier 1paromomycin cap 250mg Tier 1TOBI NEB 300/5ML Tier 4 PA

ANALGESICS - ANTI-INFLAMMATORYAnti-TNF-alpha - Monoclonoal Antibodies

HUMIRA KIT 20MG/0.4 Tier 4 PAHUMIRA KIT 40MG/0.8 Tier 4 PAHUMIRA PEN KIT 40MG/0.8 Tier 4 PAHUMIRA PEN KIT CROHNS Tier 4 PAHUMIRA PEN KIT PSORIASI Tier 4 PA

Antirheumatic AntimetabolitesRHEUMATREX TAB 2.5MG Tier 2

Gold CompoundsRIDAURA CAP 3MG Tier 2

Interleukin-1 BlockersARCALYST INJ 220MG Tier 4 PA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET INJ Tier 4 PA

Interleukin-6 Receptor InhibitorsACTEMRA INJ 80MG/4ML Tier 4 PA



Drug Name Drug Tier Requirements/LimitsACTEMRA INJ 200/10ML Tier 4 PAACTEMRA INJ 400/20ML Tier 4 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)all day pain tab 220mg Tier 1all day relf tab 220mg Tier 1CELEBREX CAP 50MG Tier 2 PACELEBREX CAP 100MG Tier 2 PACELEBREX CAP 200MG Tier 2 PACELEBREX CAP 400MG Tier 2 PAdiclofen pot tab 50mg Tier 1diclofenac tab 25mg dr Tier 1diclofenac tab 50mg dr Tier 1diclofenac tab 75mg dr Tier 1diclofenac tab 100mg er Tier 1diclofenac tab 100mg xr Tier 1etodolac cap 200mg Tier 1etodolac cap 300mg Tier 1etodolac er tab 400mg Tier 1etodolac er tab 500mg Tier 1etodolac er tab 600mg Tier 1etodolac tab 400mg Tier 1etodolac tab 500mg Tier 1fenoprofen tab 600mg Tier 1flanax pain tab 220mg Tier 1flurbiprofen tab 50mg Tier 1flurbiprofen tab 100mg Tier 1ibuprofen tab 400mg Tier 1ibuprofen tab 600mg Tier 1ibuprofen tab 800mg Tier 1INDOCIN SUP 50MG Tier 2INDOCIN SUS 25MG/5ML Tier 2indomethacin cap 25mg Tier 1indomethacin cap 50mg Tier 1indomethacin cap 75mg er Tier 1ketoprofen cap 50mg Tier 1ketoprofen cap 75mg Tier 1ketoprofen cap 200mg er Tier 1ketorolac tab 10mg Tier 1kls naproxen tab 220mg Tier 1meclofen sod cap 50mg Tier 1meclofen sod cap 100mg Tier 1mediproxen tab 220mg Tier 1mefenam acid cap 250mg Tier 1



Drug Name Drug Tier Requirements/Limitsmeloxicam sus 7.5/5ml Tier 1meloxicam tab 7.5mg Tier 1meloxicam tab 15mg Tier 1midol extend tab 220mg Tier 1nabumetone tab 500mg Tier 1nabumetone tab 750mg Tier 1naproxen dr tab 375mg Tier 1naproxen dr tab 500mg Tier 1naproxen sod tab 220mg Tier 1naproxen sod tab 275mg Tier 1naproxen sod tab 550mg Tier 1naproxen sus 125/5ml Tier 1naproxen tab 250mg Tier 1naproxen tab 375mg Tier 1naproxen tab 500mg Tier 1oxaprozin tab 600mg Tier 1pamprin tab 220mg Tier 1piroxicam cap 10mg Tier 1piroxicam cap 20mg Tier 1SPRIX SPR 15.75MG Tier 3 PAsulindac tab 150mg Tier 1sulindac tab 200mg Tier 1th naproxen tab 220mg Tier 1tolmetin sod cap 400mg Tier 1tolmetin sod tab 200mg Tier 1tolmetin sod tab 600mg Tier 1wal-proxen tab 220mg Tier 1

Pyrimidine Synthesis Inhibitorsleflunomide tab 10mg Tier 1leflunomide tab 20mg Tier 1

Soluble Tumor Necrosis Factor Receptor AgentsENBREL INJ 25/0.5ML Tier 4 PAENBREL INJ 25MG Tier 4 PAENBREL INJ 50MG/ML Tier 4 PAENBREL SRCLK INJ 50MG/ML Tier 4 PA

ANALGESICS - NonNarcoticAnalgesic Combinations

alagesic cap Tier 1anolor 300 cap Tier 1bupap tab 50-650mg Tier 1but/apap/caf cap Tier 1but/apap/caf tab Tier 1



Drug Name Drug Tier Requirements/Limitsbut/asa/caff cap Tier 1but/asa/caff tab Tier 1butal/apap tab 50-325mg Tier 1butalbital tab cpd Tier 1capacet cap Tier 1cephadyn tab 50-650mg Tier 1margesic cap Tier 1marten-tab tab 50-325mg Tier 1PHRENILIN CAP FORTE Tier 2promacet tab 50-650mg Tier 1repan tab Tier 1

Salicylatesanacin tab 81mg ec Tier 0aspir-81 tab 81mg ec Tier 0aspir-low tab 81mg ec Tier 0aspirin adlt tab 81mg Tier 0aspirin chil chw 81mg Tier 0aspirin chld chw 81mg Tier 0aspirin chw 81mg Tier 0aspirin low chw 81mg Tier 0aspirin tab 5gr ec Tier 0aspirin tab 81mg Tier 0aspirin tab 81mg ec Tier 0aspirin tab 325mg Tier 0aspirin tab 325mg ec Tier 0aspirtab tab 324mg ec Tier 0bayer adv tab 325mg Tier 0bayer asa tab 325mg Tier 0bayer low chw 81mg Tier 0bayer low tab 81mg ec Tier 0child asa chw 81mg Tier 0child asa ls chw 81mg Tier 0cho mag tris liq 500/5ml Tier 1cho mag tris tab 500mg Tier 1cho mag tris tab 750mg Tier 1cho mag tris tab 1000mg Tier 1cvs aspirin tab 81mg ec Tier 0cvs aspirin tab 325mg Tier 0cvs aspirin tab 325mg ec Tier 0cvs chld asa chw 81mg Tier 0diflunisal tab 500mg Tier 1ecotrin low tab 81mg ec Tier 0ecpirin tab 325mg ec Tier 0



Drug Name Drug Tier Requirements/Limitseq aspirin tab 325mg Tier 0eq aspirin tab 325mg ec Tier 0eq child asa chw 81mg Tier 0eql aspirin tab 81mg ec Tier 0eql aspirin tab 325mg Tier 0eql aspirin tab 325mg ec Tier 0eql chld asa chw 81mg Tier 0gnp aspirin chw 81mg Tier 0gnp aspirin tab 81mg ec Tier 0gnp aspirin tab 325mg Tier 0gnp aspirin tab 325mg ec Tier 0halfprin tab 81mg ec Tier 0hm aspirin chw 81mg Tier 0hm aspirin tab 325mg Tier 0kls aspirin tab 81mg ec Tier 0kls aspirin tab 325mg ec Tier 0kp aspirin tab 81mg ec Tier 0miniprin low tab 81mg ec Tier 0mm aspirin tab 325mg Tier 0norwich asa tab 325mg Tier 0px aspirin chw 81mg Tier 0px aspirin tab 81mg ec Tier 0px aspirin tab 325mg Tier 0px aspirin tab 325mg ec Tier 0qc aspirin tab 325mg Tier 0qc aspirin tab 325mg ec Tier 0qc child asa chw 81mg Tier 0ra aspirin chw 81mg Tier 0ra aspirin tab 81mg ec Tier 0ra aspirin tab 325mg Tier 0ra aspirin tab 325mg ec Tier 0ra child asa chw 81mg Tier 0salsalate tab 500mg Tier 1salsalate tab 750mg Tier 1sb aspirin tab 325mg Tier 0sb aspirin tab 325mg ec Tier 0sb child asa chw 81mg Tier 0sm aspirin chw 81mg Tier 0sm aspirin tab 81mg ec Tier 0sm aspirin tab 325mg Tier 0sm aspirin tab 325mg ec Tier 0sm child asa chw 81mg Tier 0st joseph as chw 81mg Tier 0



Drug Name Drug Tier Requirements/Limitstgt aspirin chw 81mg Tier 0tgt aspirin chw child Tier 0tgt aspirin tab 81mg ec Tier 0tgt aspirin tab 325mg Tier 0th aspirin tab 81mg ec Tier 0th aspirin tab 325mg Tier 0th aspirin tab 325mg ec Tier 0

ANALGESICS - OPIOIDOpioid Agonists

ABSTRAL SUB 100MCG Tier 3 PAABSTRAL SUB 200MCG Tier 3 PAABSTRAL SUB 300MCG Tier 3 PAABSTRAL SUB 400MCG Tier 3 PAABSTRAL SUB 600MCG Tier 3 PAABSTRAL SUB 800MCG Tier 3 PAcodeine sulf tab 15mg Tier 1codeine sulf tab 30mg Tier 1codeine sulf tab 60mg Tier 1fentanyl dis 12mcg/hr Tier 1fentanyl dis 25mcg/hr Tier 1fentanyl dis 50mcg/hr Tier 1fentanyl dis 75mcg/hr Tier 1fentanyl dis 100mcg/h Tier 1fentanyl ot loz 200mcg Tier 1 PAfentanyl ot loz 400mcg Tier 1 PAfentanyl ot loz 600mcg Tier 1 PAfentanyl ot loz 800mcg Tier 1 PAfentanyl ot loz 1200mcg Tier 1 PAfentanyl ot loz 1600mcg Tier 1 PAFENTORA TAB 100MCG Tier 3 PAFENTORA TAB 200MCG Tier 3 PAFENTORA TAB 400MCG Tier 3 PAFENTORA TAB 600MCG Tier 3 PAFENTORA TAB 800MCG Tier 3 PAhydromorphon liq 1mg/ml Tier 1hydromorphon tab 2mg Tier 1hydromorphon tab 4mg Tier 1hydromorphon tab 8mg Tier 1KADIAN CAP 10MG CR Tier 3 PAKADIAN CAP 200MG CR Tier 3 PALAZANDA SPR 100MCG Tier 3 PALAZANDA SPR 400MCG Tier 3 PA



Drug Name Drug Tier Requirements/Limitslevorphanol tab 2mg Tier 1meperidine tab 50mg Tier 1meperidine tab 100mg Tier 1meperitab tab 50mg Tier 1meperitab tab 100mg Tier 1methadone con 10mg/ml Tier 1methadone sol 5mg/5ml Tier 1methadone sol 10mg/5ml Tier 1methadone tab 5mg Tier 1methadone tab 10mg Tier 1methadone tab 40mg Tier 1methadose con 10mg/ml Tier 1methadose sf con 10mg/ml Tier 1methadose tab 5mg Tier 1methadose tab 10mg Tier 1methadose tab 40mg Tier 1morphine sul cap 20mg er Tier 1morphine sul cap 30mg er Tier 1morphine sul cap 50mg er Tier 1morphine sul cap 60mg er Tier 1morphine sul cap 80mg er Tier 1morphine sul cap 100mg er Tier 1morphine sul tab 15mg Tier 1morphine sul tab 15mg er Tier 1morphine sul tab 30mg Tier 1morphine sul tab 30mg er Tier 1morphine sul tab 100mg er Tier 1morphine sul tab 200mg er Tier 1NUCYNTA ER TAB 50MG Tier 3 PANUCYNTA ER TAB 100MG Tier 3 PANUCYNTA ER TAB 150MG Tier 3 PANUCYNTA ER TAB 200MG Tier 3 PANUCYNTA ER TAB 250MG Tier 3 PANUCYNTA TAB 50MG Tier 3 PANUCYNTA TAB 75MG Tier 3 PANUCYNTA TAB 100MG Tier 3 PAONSOLIS MIS 200MCG Tier 3 PAONSOLIS MIS 400MCG Tier 3 PAONSOLIS MIS 600MCG Tier 3 PAONSOLIS MIS 800MCG Tier 3 PAONSOLIS MIS 1200MCG Tier 3 PAOXECTA TAB 5MG Tier 3OXECTA TAB 7.5MG Tier 3



Drug Name Drug Tier Requirements/Limitsoxycodone cap 5mg Tier 1oxycodone con 20mg/ml Tier 1oxycodone con 100/5ml Tier 1oxycodone sol 5mg/5ml Tier 1oxycodone tab 5mg Tier 1oxycodone tab 10mg Tier 1oxycodone tab 15mg Tier 1oxycodone tab 20mg Tier 1oxycodone tab 30mg Tier 1OXYCONTIN TAB 10MG CR Tier 3 PAOXYCONTIN TAB 15MG CR Tier 3 PAOXYCONTIN TAB 20MG CR Tier 3 PAOXYCONTIN TAB 30MG CR Tier 3 PAOXYCONTIN TAB 40MG CR Tier 3 PAOXYCONTIN TAB 60MG CR Tier 3 PAOXYCONTIN TAB 80MG CR Tier 3 PAoxymorphone tab 5mg er Tier 1 PAoxymorphone tab 7.5mg er Tier 1 PAoxymorphone tab 10mg er Tier 1 PAoxymorphone tab 15mg er Tier 1 PAoxymorphone tab 20mg er Tier 1 PAoxymorphone tab 30mg er Tier 1 PAoxymorphone tab 40mg er Tier 1 PAoxymorphone tab hcl 5mg Tier 1 PAoxymorphone tab hcl 10mg Tier 1 PASUBSYS SPR 100MCG Tier 3 PASUBSYS SPR 200MCG Tier 3 PASUBSYS SPR 400MCG Tier 3 PASUBSYS SPR 800MCG Tier 3 PASUBSYS SPR 1200MCG Tier 3 PAtramadol hcl tab 50mg Tier 1tramadol hcl tab 100mg er Tier 1 PAtramadol hcl tab 200mg er Tier 1 PAtramadol hcl tab 300mg er Tier 1 PA

Opioid Combinationsapap/codeine sol 120-12/5 Tier 1apap/codeine tab 300-15mg Tier 1apap/codeine tab 300-30mg Tier 1apap/codeine tab 300-60mg Tier 1ascomp/cod cap 30mg Tier 1but/apap/caf cap codeine Tier 1but/asa/caf/ cap cod 30mg Tier 1co-gesic tab 5-500mg Tier 1



Drug Name Drug Tier Requirements/Limitsendodan tab Tier 1hydroco/apap sol 7.5-500 Tier 1hydroco/apap tab 2.5-500 Tier 1hydroco/apap tab 5-325mg Tier 1hydroco/apap tab 5-500mg Tier 1hydroco/apap tab 7.5-325 Tier 1hydroco/apap tab 7.5-500 Tier 1hydroco/apap tab 7.5-650 Tier 1hydroco/apap tab 7.5-750 Tier 1hydroco/apap tab 10-500mg Tier 1hydroco/apap tab 10-650mg Tier 1hydrocod/ibu tab 7.5-200 Tier 1hydrocodone-acetaminophen SOLN Tier 1 AGEhydrocodone-acetaminophen TABS Tier 1oxycod/apap cap 5-500mg Tier 1oxycod/asa tab Tier 1oxycod/ibu tab 5-400mg Tier 1ROXICET SOL 5-325/5 Tier 2

Opioid Partial Agonistsbupren/nalox sub 2-0.5mg Tier 1 PAbupren/nalox sub 8-2mg Tier 1 PAbuprenorphin sub 2mg Tier 1 PAbuprenorphin sub 8mg Tier 1 PAbutorphanol sol 10mg/ml Tier 1BUTRANS DIS 5MCG/HR Tier 3 PABUTRANS DIS 10MCG/HR Tier 3 PABUTRANS DIS 20MCG/HR Tier 3 PApentaz/nalox tab 50-0.5mg Tier 1

ANDROGENS-ANABOLICAnabolic Steroids

ANADROL-50 TAB 50MG Tier 3 PAoxandrolone tab 2.5mg Tier 1 PAoxandrolone tab 10mg Tier 1 PA

AndrogensANDRODERM DIS 2.5MG/24 Tier 2 PAANDRODERM DIS 5MG/24HR Tier 2 PAANDROGEL GEL 1%(25MG) Tier 2 PAANDROGEL GEL 1%(50MG) Tier 2 PAANDROGEL GEL PUMP 1% Tier 2 PAandroid cap 10mg Tier 1ANDROXY TAB 10MG Tier 2danazol cap 50mg Tier 1



Drug Name Drug Tier Requirements/Limitsdanazol cap 100mg Tier 1danazol cap 200mg Tier 1METHITEST TAB 10MG Tier 2TESTIM GEL 1%(50MG) Tier 2 PAtestost cyp inj 100mg/ml Tier 1testost cyp inj 200mg/ml Tier 1testost enan inj 200mg/ml Tier 1

ANORECTAL AGENTSIntrarectal Steroids

CORTIFOAM AER 90MG Tier 2Rectal Combinations

hc pramoxine cre 1-1% Tier 1hc pramoxine cre 2.5-1% Tier 1PROCORT CRE Tier 2PROCTOFOAM AER HC 1% Tier 2

Rectal Steroidsanucort-hc sup 25mg Tier 1hemril-30 sup 30mg Tier 1hydrocort ac sup 25mg Tier 1hydrocort ac sup 30mg Tier 1procto-pak cre 1% Tier 1proctocream cre hc 2.5% Tier 1proctosol hc cre 2.5% Tier 1proctozone cre -hc 2.5% Tier 1rectacort-hc sup 25mg Tier 1

ANTHELMINTICSAnthelmintics

ALBENZA TAB 200MG Tier 2BILTRICIDE TAB 600MG Tier 2mebendazole chw 100mg Tier 1STROMECTOL TAB 3MG Tier 2

ANTI-INFECTIVE AGENTS - MISC.Anti-infective Agents - Misc.

baciim inj 50000unt Tier 1 PAbacitracin inj 50000unt Tier 1 PAFLAGYL ER TAB 750MG Tier 3metronidazol cap 375mg Tier 1metronidazol tab 250mg Tier 1metronidazol tab 500mg Tier 1NEBUPENT INH 300MG Tier 3 PAPENTAM 300 INJ 300MG Tier 4 PA



Drug Name Drug Tier Requirements/Limitstrimethoprim tab 100mg Tier 1vancomycin cap 125mg Tier 1 PAvancomycin cap 250mg Tier 1 PAXIFAXAN TAB 200MG Tier 3XIFAXAN TAB 550MG Tier 3

Anti-infective Misc. - Combinationse.s.p. sus 200-600 Tier 1ees/sulfisox sus 200-600 Tier 1smz-tmp sus Tier 1smz-tmp sus 200-40/5 Tier 1smz-tmp tab 400-80mg Tier 1smz/tmp ds tab 800-160 Tier 1

Antiprotozoal AgentsALINIA SUS 100MG/5M Tier 3ALINIA TAB 500MG Tier 3MEPRON SUS Tier 2

Carbapenemsimipenem/cil inj 250mg Tier 4 PAimipenem/cil inj 500mg Tier 4 PA

Chloramphenicolschloramphen inj 1gm Tier 1 PA

KetolidesKETEK TAB 300MG Tier 3 PAKETEK TAB 400MG Tier 3 PA

Leprostaticsdapsone tab 25mg Tier 1dapsone tab 100mg Tier 1

Lincosamidesclindamycin cap 75mg Tier 1clindamycin cap 150mg Tier 1clindamycin cap 300mg Tier 1 PA

OxazolidinonesZYVOX SUS 100MG/5M Tier 3 PAZYVOX TAB 600MG Tier 3 PA

Polymyxinspolymyxin b inj 500000 Tier 1 PA

ANTIANGINAL AGENTSAntianginals-Other

RANEXA TAB 500MG Tier 3 PARANEXA TAB 1000MG Tier 3 PA

NitratesDILATRATE SR CAP 40MG Tier 2



Drug Name Drug Tier Requirements/Limitsisochron tab 40mg cr Tier 1isoditrate tab 40mg er Tier 1ISORDIL TAB 40MG Tier 2isosorb din tab 5mg Tier 1isosorb din tab 10mg Tier 1isosorb din tab 20mg Tier 1isosorb din tab 30mg Tier 1isosorb din tab 40mg er Tier 1isosorb mono tab 30mg er Tier 1isosorb mono tab 60mg er Tier 1isosorb mono tab 120mg er Tier 1minitran dis 0.1mg/hr Tier 1minitran dis 0.2mg/hr Tier 1minitran dis 0.4mg/hr Tier 1minitran dis 0.6mg/hr Tier 1NITRO-BID OIN 2% Tier 2nitro-time cap 2.5mg cr Tier 1nitro-time cap 6.5mg cr Tier 1nitro-time cap 9mg cr Tier 1nitroglycer aer 400mcg Tier 1nitroglycer cap 2.5mg er Tier 1nitroglycer cap 2.5mg sr Tier 1nitroglycer cap 6.5mg cr Tier 1nitroglycer cap 6.5mg er Tier 1nitroglycer cap 9mg cr Tier 1nitroglycer cap 9mg er Tier 1nitroglycer dis 0.1mg/hr Tier 1nitroglycer dis 0.2mg/hr Tier 1nitroglycer dis 0.4mg/hr Tier 1nitroglycer dis 0.6mg/hr Tier 1nitroglyceri dis 0.6mg/hr Tier 1nitroglycrn spr lingual Tier 1NITROSTAT SUB 0.3MG Tier 2NITROSTAT SUB 0.4MG Tier 2NITROSTAT SUB 0.6MG Tier 2

ANTIANXIETY AGENTSAntianxiety Agents - Misc.

buspirone tab 5mg Tier 1buspirone tab 7.5mg Tier 1buspirone tab 10mg Tier 1buspirone tab 15mg Tier 1buspirone tab 30mg Tier 1



Drug Name Drug Tier Requirements/Limitshydroxyz hcl inj 25mg/ml Tier 1 PAhydroxyz hcl inj 50mg/ml Tier 1 PAhydroxyz hcl sol 10mg/5ml Tier 1hydroxyz hcl syp 10mg/5ml Tier 1hydroxyz hcl tab 10mg Tier 1hydroxyz hcl tab 25mg Tier 1hydroxyz hcl tab 50mg Tier 1hydroxyz pam cap 25mg Tier 1hydroxyz pam cap 50mg Tier 1hydroxyz pam cap 100mg Tier 1meprobamate tab 200mg Tier 1meprobamate tab 400mg Tier 1

Benzodiazepinesalprazolam tab 0.5mg Tier 1alprazolam tab 0.25mg Tier 1alprazolam tab 1mg Tier 1alprazolam tab 2mg Tier 1chlordiazep cap 5mg Tier 1chlordiazep cap 10mg Tier 1chlordiazep cap 25mg Tier 1cloraz dipot tab 3.75mg Tier 1cloraz dipot tab 7.5mg Tier 1cloraz dipot tab 15mg Tier 1diazepam sol 1mg/ml Tier 1diazepam tab 2mg Tier 1diazepam tab 5mg Tier 1diazepam tab 10mg Tier 1lorazepam tab 0.5mg Tier 1lorazepam tab 1mg Tier 1lorazepam tab 2mg Tier 1oxazepam cap 10mg Tier 1oxazepam cap 15mg Tier 1oxazepam cap 30mg Tier 1

ANTIARRHYTHMICSAntiarrhythmics Type I-A

disopyramide cap 100mg Tier 1disopyramide cap 150mg Tier 1NORPACE CAP 100MG CR Tier 2NORPACE CAP 150MG CR Tier 2procainamide inj 100mg/ml Tier 4 PAquinidine gl tab 324mg cr Tier 1quinidine gl tab 324mg er Tier 1



Drug Name Drug Tier Requirements/Limitsquinidine su tab 200mg Tier 1quinidine su tab 300mg Tier 1quinidine su tab 300mg er Tier 1

Antiarrhythmics Type I-Bmexiletine cap 150mg Tier 1mexiletine cap 200mg Tier 1mexiletine cap 250mg Tier 1

Antiarrhythmics Type I-Cflecainide tab 50mg Tier 1flecainide tab 100mg Tier 1flecainide tab 150mg Tier 1propafenone cap 225mg er Tier 1propafenone cap 325mg er Tier 1propafenone cap 425mg sr Tier 1propafenone tab 150mg Tier 1propafenone tab 225mg Tier 1propafenone tab 300mg Tier 1

Antiarrhythmics Type IIIamiodarone inj 50mg/ml Tier 4 PAamiodarone inj 150mg/3m Tier 4 PAamiodarone tab 200mg Tier 1amiodarone tab 400mg Tier 1MULTAQ TAB 400MG Tier 3PACERONE TAB 100MG Tier 2pacerone tab 200mg Tier 1

ANTIASTHMATIC AND BRONCHODILATOR AGENTSAnti-Inflammatory Agents

cromolyn sod neb 20mg/2ml Tier 1Bronchodilators - Anticholinergics

ATROVENT HFA AER 17MCG Tier 2ipratropium sol 0.02%inh Tier 1SPIRIVA CAP HANDIHLR Tier 2TUDORZA PRES AER 400/ACT Tier 2

Leukotriene Modulatorsmontelukast chw 4mg Tier 1montelukast chw 5mg Tier 1montelukast gra 4mg Tier 1montelukast tab 10mg Tier 1zafirlukast tab 10mg Tier 1zafirlukast tab 20mg Tier 1ZYFLO CR TAB 600MG Tier 3 PAZYFLO TAB 600MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsSTEROID INHALANTS

ASMANEX 7 AER 110MCG Tier 2ASMANEX 30 AER 110MCG Tier 2

Steroid InhalantsALVESCO AER 80MCG Tier 3ALVESCO AER 160MCG Tier 3ASMANEX 14 AER 220MCG Tier 2ASMANEX 30 AER 220MCG Tier 2ASMANEX 60 AER 220MCG Tier 2ASMANEX 120 AER 220MCG Tier 2budesonide sus 0.5mg/2 Tier 1budesonide sus 0.25mg/2 Tier 1FLOVENT DISK AER 50MCG Tier 2FLOVENT DISK AER 100MCG Tier 2FLOVENT DISK AER 250MCG Tier 2FLOVENT HFA AER 44MCG Tier 2FLOVENT HFA AER 110MCG Tier 2FLOVENT HFA AER 220MCG Tier 2PULMICORT INH 90MCG Tier 3PULMICORT INH 180MCG Tier 3PULMICORT SUS 1MG/2ML Tier 3QVAR AER 40MCG Tier 2QVAR AER 80MCG Tier 2

SympathomimeticsADVAIR DISKU AER 100/50 Tier 2 STADVAIR DISKU AER 250/50 Tier 2 STADVAIR DISKU AER 500/50 Tier 2 STADVAIR HFA AER 45/21 Tier 2 STADVAIR HFA AER 115/21 Tier 2 STADVAIR HFA AER 230/21 Tier 2 STalbuterol neb 0.5% Tier 1albuterol neb 0.63mg/3 Tier 1albuterol neb 0.083% Tier 1albuterol neb 1.25mg/3 Tier 1albuterol syp 2mg/5ml Tier 1albuterol tab 2mg Tier 1albuterol tab 4mg Tier 1albuterol tab 4mg er Tier 1albuterol tab 8mg er Tier 1ARCAPTA CAP 75MCG Tier 3COMBIVENT AER Tier 2DULERA AER 100-5MCG Tier 2 STDULERA AER 200-5MCG Tier 2 ST



Drug Name Drug Tier Requirements/Limitsepinephrine inj 0.1mg/ml Tier 1epinephrine inj 1mg/ml Tier 1FORADIL CAP AEROLIZE Tier 2 STlevalbuterol neb 0.31mg Tier 1 PAlevalbuterol neb 0.63mg Tier 1 PAlevalbuterol neb 1.25/0.5 Tier 1 PAlevalbuterol neb 1.25mg Tier 1 PAMAXAIR AUTOH AER 200MCG Tier 2metaproteren syp 10mg/5ml Tier 1metaproteren tab 10mg Tier 1metaproteren tab 20mg Tier 1PERFOROMIST NEB 20MCG Tier 3PROAIR HFA AER Tier 2SEREVENT DIS AER 50MCG Tier 2 STSYMBICORT AER 80-4.5 Tier 2 STSYMBICORT AER 160-4.5 Tier 2 STterbutaline inj 1mg/ml Tier 1terbutaline tab 2.5mg Tier 1terbutaline tab 5mg Tier 1VENTOLIN HFA AER Tier 2XOPENEX HFA AER Tier 3 PA

Xanthinesaminophyllin tab 100mg Tier 1aminophyllin tab 200mg Tier 1ELIXOPHYLLIN ELX 80/15ML Tier 2LUFYLLIN TAB 200MG Tier 2LUFYLLIN TAB 400MG Tier 2THEO-24 CAP 100MG CR Tier 2THEO-24 CAP 200MG CR Tier 2THEO-24 CAP 300MG CR Tier 2THEO-24 CAP 400MG ER Tier 2theochron tab 100mg cr Tier 1theochron tab 200mg cr Tier 1theochron tab 300mg cr Tier 1theophylline sol 80/15ml Tier 1theophylline tab 100mg cr Tier 1theophylline tab 100mg er Tier 1theophylline tab 200mg cr Tier 1theophylline tab 200mg er Tier 1theophylline tab 300mg er Tier 1theophylline tab 400mg er Tier 1theophylline tab 450mg er Tier 1theophylline tab 600mg er Tier 1




ANTICOAGULANTSCoumarin Anticoagulants

jantoven tab 1mg Tier 1jantoven tab 2.5mg Tier 1jantoven tab 2mg Tier 1jantoven tab 3mg Tier 1jantoven tab 4mg Tier 1jantoven tab 5mg Tier 1jantoven tab 6mg Tier 1jantoven tab 7.5mg Tier 1jantoven tab 10mg Tier 1warfarin tab 1mg Tier 1warfarin tab 2.5mg Tier 1warfarin tab 2mg Tier 1warfarin tab 3mg Tier 1warfarin tab 4mg Tier 1warfarin tab 5mg Tier 1warfarin tab 6mg Tier 1warfarin tab 7.5mg Tier 1warfarin tab 10mg Tier 1

Direct Factor Xa InhibitorsXARELTO TAB 10MG Tier 3 PAXARELTO TAB 15MG Tier 3 PAXARELTO TAB 20MG Tier 3 PA

Heparins And Heparinoid-Like Agentsenoxaparin inj 30/0.3ml Tier 4 QLenoxaparin inj 40/0.4ml Tier 4 QLenoxaparin inj 60/0.6ml Tier 4 QLenoxaparin inj 80/0.8ml Tier 4 QLenoxaparin inj 100mg/ml Tier 4 QLenoxaparin inj 120/0.8 Tier 4 QLenoxaparin inj 150mg/ml Tier 4 QLenoxaparin inj 300/3ml Tier 4 QLfondaparinux sol 2.5/0.5 Tier 4 PAfondaparinux sol 5.0/0.4 Tier 4 PAfondaparinux sol 7.5/0.6 Tier 4 PAfondaparinux sol 10/0.8 Tier 4 PAFRAGMIN INJ 2500/0.2 Tier 4 PAFRAGMIN INJ 5000/0.2 Tier 4 PAFRAGMIN INJ 7500/0.3 Tier 4 PAFRAGMIN INJ 10000/ML Tier 4 PAFRAGMIN INJ 12500UNT Tier 4 PA



Drug Name Drug Tier Requirements/LimitsFRAGMIN INJ 15000UNT Tier 4 PAFRAGMIN INJ 18000UNT Tier 4 PAFRAGMIN INJ 25000/ML Tier 4 PAheparin sod inj 1000/ml Tier 1heparin sod inj 10000/ml 10000unit/ml Tier 1heparin sod inj 20000/ml Tier 1INNOHEP INJ 20000/ML Tier 4 PA

ANTICONVULSANTSAnticonvulsants - Benzodiazepines

clonazepam tab 0.5mg Tier 1clonazepam tab 1mg Tier 1clonazepam tab 2mg Tier 1

Anticonvulsants - Misc.BANZEL SUS 40MG/ML Tier 3 PABANZEL TAB 200MG Tier 3 PABANZEL TAB 400MG Tier 3 PAcarbamazepin cap 100mg er Tier 1carbamazepin cap 200mg er Tier 1carbamazepin cap 300mg er Tier 1carbamazepin chw 100mg Tier 1carbamazepin sus 100/5ml Tier 1carbamazepin tab 200mg Tier 1carbamazepin tab 200mg er Tier 1carbamazepin tab 400mg er Tier 1epitol tab 200mg Tier 1gabapentin cap 100mg Tier 1gabapentin cap 300mg Tier 1gabapentin cap 400mg Tier 1gabapentin tab 600mg Tier 1gabapentin tab 800mg Tier 1LAMICTAL CHW 2MG Tier 2LAMICTAL KIT START 35 Tier 2 PALAMICTAL KIT START 49 Tier 2 PALAMICTAL KIT START 98 Tier 2 PALAMICTAL ODT KIT Tier 2 PALAMICTAL ODT TAB 25MG Tier 2 PALAMICTAL ODT TAB 50MG Tier 2 PALAMICTAL ODT TAB 100MG Tier 2 PALAMICTAL ODT TAB 200MG Tier 2 PALAMICTAL XR KIT Tier 2 PAlamotrigine chw 5mg Tier 1lamotrigine chw 25mg Tier 1



Drug Name Drug Tier Requirements/Limitslamotrigine tab 25mg Tier 1lamotrigine tab 25mg er Tier 1 PAlamotrigine tab 50mg er Tier 1 PAlamotrigine tab 100mg Tier 1lamotrigine tab 100mg er Tier 1 PAlamotrigine tab 150mg Tier 1lamotrigine tab 200mg Tier 1lamotrigine tab 200mg er Tier 1 PAlamotrigine tab 250mg er Tier 1 PAlamotrigine tab 300mg er Tier 1 PAlevetiraceta sol 100mg/ml Tier 1levetiraceta sol 500/5ml Tier 1levetiraceta tab 250mg Tier 1levetiraceta tab 500mg Tier 1levetiraceta tab 750mg Tier 1levetiraceta tab 1000mg Tier 1LYRICA CAP 25MG Tier 3LYRICA CAP 50MG Tier 3LYRICA CAP 75MG Tier 3LYRICA CAP 100MG Tier 3LYRICA CAP 150MG Tier 3LYRICA CAP 200MG Tier 3LYRICA CAP 225MG Tier 3LYRICA CAP 300MG Tier 3oxcarbazepin sus 300mg/5m Tier 1oxcarbazepin tab 150mg Tier 1oxcarbazepin tab 300mg Tier 1oxcarbazepin tab 600mg Tier 1OXTELLAR XR TAB 150MG Tier 3OXTELLAR XR TAB 300MG Tier 3OXTELLAR XR TAB 600MG Tier 3primidone tab 50mg Tier 1primidone tab 250mg Tier 1TEGRETOL XR TAB 100MG Tier 2topiragen tab 25mg Tier 1topiragen tab 50mg Tier 1topiragen tab 100mg Tier 1topiragen tab 200mg Tier 1topiramate cap 15mg Tier 1topiramate cap 25mg Tier 1topiramate tab 25mg Tier 1topiramate tab 50mg Tier 1topiramate tab 100mg Tier 1



Drug Name Drug Tier Requirements/Limitstopiramate tab 200mg Tier 1VIMPAT SOL 10MG/ML Tier 3 PAVIMPAT TAB 50MG Tier 3 PAVIMPAT TAB 100MG Tier 3 PAVIMPAT TAB 150MG Tier 3 PAVIMPAT TAB 200MG Tier 3 PAzonisamide cap 25mg Tier 1zonisamide cap 50mg Tier 1zonisamide cap 100mg Tier 1

Carbamatesfelbamate sus 600/5ml Tier 1felbamate tab 400mg Tier 1felbamate tab 600mg Tier 1

GABA ModulatorsGABITRIL TAB 12MG Tier 2GABITRIL TAB 16MG Tier 2SABRIL TAB 500MG Tier 3 PAtiagabine tab 2mg Tier 1tiagabine tab 4mg Tier 1

HydantoinsDILANTIN CAP 30MG Tier 2PEGANONE TAB 250MG Tier 2phenytoin chw 50mg Tier 1phenytoin ex cap 100mg Tier 1phenytoin ex cap 200mg Tier 1phenytoin ex cap 300mg Tier 1phenytoin sus 125/5ml Tier 1

SuccinimidesCELONTIN CAP 300MG Tier 2ethosuximide cap 250mg Tier 1ethosuximide sol 250/5ml Tier 1

Valproic Aciddivalproex cap 125mg Tier 1divalproex tab 125mg dr Tier 1divalproex tab 250mg dr Tier 1divalproex tab 250mg er Tier 1divalproex tab 500mg dr Tier 1divalproex tab 500mg er Tier 1valproic acd cap 250mg Tier 1valproic acd sol 250/5ml Tier 1valproic acd syp 250/5ml Tier 1

ANTIDEPRESSANTS



Drug Name Drug Tier Requirements/LimitsAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tab 7.5mg Tier 1mirtazapine tab 15mg Tier 1mirtazapine tab 15mg odt Tier 1 PAmirtazapine tab 30mg Tier 1mirtazapine tab 30mg odt Tier 1 PAmirtazapine tab 45mg Tier 1mirtazapine tab 45mg odt Tier 1 PA

Antidepressants - Misc.APLENZIN TAB 174MG Tier 3 PAAPLENZIN TAB 348MG Tier 3 PAAPLENZIN TAB 522MG Tier 3 PAbudeprion tab 100mg sr Tier 1budeprion tab 150mg sr Tier 1budeprion xl tab 150mg Tier 1budeprion xl tab 300mg Tier 1bupropion tab 75mg Tier 1bupropion tab 100mg Tier 1bupropion tab 100mg er Tier 1bupropion tab 100mg sr Tier 1bupropion tab 150mg er Tier 1bupropion tab 150mg sr Tier 1bupropion tab 200mg er Tier 1bupropion tab 200mg sr Tier 1bupropn hcl tab 150mg xl Tier 1bupropn hcl tab 300mg xl Tier 1maprotiline tab 25mg Tier 1maprotiline tab 50mg Tier 1maprotiline tab 75mg Tier 1

Modified Cyclicsnefazodone tab 50mg Tier 1nefazodone tab 100mg Tier 1nefazodone tab 150mg Tier 1nefazodone tab 200mg Tier 1nefazodone tab 250mg Tier 1OLEPTRO TAB 24HR150 Tier 3 PAOLEPTRO TAB 24HR300 Tier 3 PAtrazodone tab 50mg Tier 1trazodone tab 100mg Tier 1trazodone tab 150mg Tier 1trazodone tab 300mg Tier 1VIIBRYD KIT Tier 3 PAVIIBRYD TAB 10MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsVIIBRYD TAB 20MG Tier 3 PAVIIBRYD TAB 40MG Tier 3 PA

Monoamine Oxidase Inhibitors (MAOIs)EMSAM DIS 6MG/24HR Tier 3 PAEMSAM DIS 9MG/24HR Tier 3 PAEMSAM DIS 12MG/24H Tier 3 PAMARPLAN TAB 10MG Tier 2phenelzine tab 15mg Tier 1tranylcyprom tab 10mg Tier 1

Selective Serotonin Reuptake Inhibitors (SSRIs)citalopram sol 10mg/5ml Tier 1citalopram tab 10mg Tier 1citalopram tab 20mg Tier 1citalopram tab 40mg Tier 1escitalopram sol 5mg/5ml Tier 1 PAescitalopram tab 5mg Tier 1escitalopram tab 10mg Tier 1escitalopram tab 20mg Tier 1fluoxetine cap 10mg 10mg Tier 1fluoxetine cap 20mg 20mg Tier 1fluoxetine cap 40mg Tier 1fluoxetine cap 90mg dr Tier 1 PAfluoxetine sol 20mg/5ml Tier 1fluoxetine tab 10mg Tier 1fluoxetine tab 20mg Tier 1fluoxetine tab 60mg Tier 1fluvoxamine tab 25mg Tier 1fluvoxamine tab 50mg Tier 1fluvoxamine tab 100mg Tier 1paroxetin er tab 12.5mg Tier 1 PAparoxetin er tab 37.5mg Tier 1 PAparoxetine sus 10mg/5ml Tier 1paroxetine tab 10mg Tier 1paroxetine tab 20mg Tier 1paroxetine tab 25mg er Tier 1 PAparoxetine tab 30mg Tier 1paroxetine tab 40mg Tier 1sertraline con 20mg/ml Tier 1sertraline tab 25mg Tier 1sertraline tab 50mg Tier 1sertraline tab 100mg Tier 1

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)CYMBALTA CAP 20MG Tier 2 PA



Drug Name Drug Tier Requirements/LimitsCYMBALTA CAP 30MG Tier 2 PACYMBALTA CAP 60MG Tier 2 PAPRISTIQ TAB 50MG Tier 3 PAPRISTIQ TAB 100MG Tier 3 PAvenlafaxine cap 37.5mg Tier 1venlafaxine cap 75mg er Tier 1venlafaxine cap 150mg er Tier 1venlafaxine tab 25mg Tier 1venlafaxine tab 37.5 er Tier 1 PAvenlafaxine tab 37.5mg Tier 1venlafaxine tab 50mg Tier 1venlafaxine tab 75mg Tier 1venlafaxine tab 75mg er Tier 1 PAvenlafaxine tab 100mg Tier 1venlafaxine tab 150mg er Tier 1 PAvenlafaxine tab 225mg er Tier 1 PA

Tricyclic Agentsamitriptylin tab 10mg Tier 1amitriptylin tab 25mg Tier 1amitriptylin tab 50mg Tier 1amitriptylin tab 75mg Tier 1amitriptylin tab 100mg Tier 1amitriptylin tab 150mg Tier 1amoxapine tab 25mg Tier 1amoxapine tab 50mg Tier 1amoxapine tab 100mg Tier 1amoxapine tab 150mg Tier 1clomipramine cap 25mg Tier 1clomipramine cap 50mg Tier 1clomipramine cap 75mg Tier 1desipramine tab 10mg Tier 1desipramine tab 25mg Tier 1desipramine tab 50mg Tier 1desipramine tab 75mg Tier 1desipramine tab 100mg Tier 1desipramine tab 150mg Tier 1doxepin hcl cap 10mg Tier 1doxepin hcl cap 25mg Tier 1doxepin hcl cap 50mg Tier 1doxepin hcl cap 75mg Tier 1doxepin hcl cap 100mg Tier 1doxepin hcl cap 150mg Tier 1doxepin hcl con 10mg/ml Tier 1



Drug Name Drug Tier Requirements/Limitsimipram hcl tab 10mg Tier 1imipram hcl tab 25mg Tier 1imipram hcl tab 50mg Tier 1imipram pam cap 75mg Tier 1imipram pam cap 100mg Tier 1imipram pam cap 125mg Tier 1imipram pam cap 150mg Tier 1nortriptylin cap 10mg Tier 1nortriptylin cap 25mg Tier 1nortriptylin cap 50mg Tier 1nortriptylin cap 75mg Tier 1nortriptylin sol 10mg/5ml Tier 1protriptylin tab 5mg Tier 1protriptylin tab 10mg Tier 1trimipramine cap 25mg Tier 1trimipramine cap 50mg Tier 1trimipramine cap 100mg Tier 1

ANTIDIABETICSAlpha-Glucosidase Inhibitors

acarbose tab 25mg Tier 1acarbose tab 50mg Tier 1acarbose tab 100mg Tier 1GLYSET TAB 25MG Tier 2GLYSET TAB 50MG Tier 2GLYSET TAB 100MG Tier 2

Antidiabetic - Amylin AnalogsSYMLIN INJ 600MCG Tier 3 PASYMLINPEN 60 INJ 1000MCG Tier 3 PASYMLNPEN 120 INJ 1000MCG Tier 3 PA

Antidiabetic CombinationsACTOPLUS MET TAB XR Tier 2AVANDAMET TAB 2-500MG Tier 2 PAAVANDAMET TAB 2-1000MG Tier 2 PAAVANDAMET TAB 4-500MG Tier 2 PAAVANDAMET TAB 4-1000MG Tier 2 PA

BiguanidesGLUMETZA TAB 500MG Tier 3GLUMETZA TAB 1000MG Tier 3metformin er tab 1000mg Tier 1metformin tab 500mg Tier 1metformin tab 500mg er Tier 1metformin tab 750mg er Tier 1



Drug Name Drug Tier Requirements/Limitsmetformin tab 850mg Tier 1metformin tab 1000mg Tier 1RIOMET SOL Tier 3

Diabetic OtherGLUCAGEN INJ 1MG Tier 2GLUCAGEN INJ HYPOKIT Tier 2GLUCAGON KIT 1MG Tier 2

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA TAB 25MG Tier 2 STJANUVIA TAB 50MG Tier 2 STJANUVIA TAB 100MG Tier 2 STONGLYZA TAB 2.5MG Tier 3 STONGLYZA TAB 5MG Tier 3 STTRADJENTA TAB 5MG Tier 2 ST

Dopamine Receptor Agonists - AntidiabeticCYCLOSET TAB 0.8MG Tier 2

Incretin Mimetic Agents (GLP-1 Receptor Agonists)BYETTA INJ 5MCG Tier 3 PABYETTA INJ 10MCG Tier 3 PAVICTOZA INJ 18MG/3ML Tier 3 PA

InsulinAPIDRA INJ SOLOSTAR Tier 2APIDRA INJ U-100 Tier 2HUMALOG INJ 100/ML Tier 2HUMALOG KWIK INJ 100/ML Tier 2HUMALOG MIX INJ 50/50 Tier 2HUMALOG MIX INJ 50/50KWP Tier 2HUMALOG MIX INJ 75/25KWP Tier 2HUMALOG MIX SUS 75/25 Tier 2HUMULIN INJ 70/30 Tier 2HUMULIN N INJ U-100 Tier 2HUMULIN N PN INJ U-100 Tier 2HUMULIN PEN INJ 70/30 Tier 2HUMULIN R INJ U-100 Tier 2HUMULIN R INJ U-500 Tier 2LANTUS INJ 100/ML Tier 2LANTUS INJ SOLOSTAR Tier 2LEVEMIR INJ Tier 2LEVEMIR INJ FLEXPEN Tier 2NOVOLIN70/30 INJ RELION Tier 1NOVOLIN INJ 70/30 Tier 1NOVOLIN N INJ RELION Tier 1NOVOLIN N INJ U-100 Tier 1



Drug Name Drug Tier Requirements/LimitsNOVOLIN R INJ RELION Tier 1NOVOLIN R INJ U-100 Tier 1NOVOLOG INJ 100/ML Tier 1NOVOLOG INJ FLEXPEN Tier 2NOVOLOG INJ PENFILL Tier 2NOVOLOG MIX INJ 70/30 Tier 1NOVOLOG MIX INJ FLEXPEN Tier 2

Insulin Sensitizing AgentsAVANDIA TAB 2MG Tier 2 PAAVANDIA TAB 4MG Tier 2 PAAVANDIA TAB 8MG Tier 2 PApioglitazone tab 15mg Tier 1pioglitazone tab 30mg Tier 1pioglitazone tab 45mg Tier 1

Meglitinide Analoguesnateglinide tab 60mg Tier 1nateglinide tab 120mg Tier 1PRANDIN TAB 0.5MG Tier 2PRANDIN TAB 1MG Tier 2PRANDIN TAB 2MG Tier 2

Sulfonylureaschlorpropam tab 100mg Tier 1chlorpropam tab 250mg Tier 1glimepiride tab 1mg Tier 1glimepiride tab 2mg Tier 1glimepiride tab 4mg Tier 1glipizide er tab 2.5mg Tier 1glipizide er tab 5mg Tier 1glipizide er tab 10mg Tier 1glipizide tab 5mg Tier 1glipizide tab 10mg Tier 1glipizide xl tab 2.5mg Tier 1glipizide xl tab 5mg Tier 1glipizide xl tab 10mg Tier 1glyburid mcr tab 1.5mg Tier 1glyburid mcr tab 3mg Tier 1glyburid mcr tab 6mg Tier 1glyburide tab 1.25mg Tier 1glyburide tab 2.5mg Tier 1glyburide tab 5mg Tier 1tolazamide tab 250mg Tier 1tolazamide tab 500mg Tier 1tolbutamide tab 500mg Tier 1




ANTIDIARRHEALSAntiperistaltic Agents

anti-diarrhe cap 2mg Tier 1anti-diarrhe tab 2mg Tier 1diamode tab 2mg Tier 1diphen/atrop liq 2.5/5 Tier 1diphen/atrop tab 2.5mg Tier 1imperim tab 2mg Tier 1kls anti-dia tab 2mg Tier 1lofene tab 2.5mg Tier 1lonox tab 2.5mg Tier 1loperamide cap 2mg Tier 1loperamide tab 2mg Tier 1MOTOFEN TAB Tier 2sm anti-diar tab 2mg Tier 1

ANTIDOTESAntidotes

IPECAC SYP Tier 2SM IPECAC SYP Tier 2

Antidotes - Chelating AgentsCHEMET CAP 100MG Tier 2EXJADE TAB 125MG Tier 4 PAEXJADE TAB 250MG Tier 4 PAEXJADE TAB 500MG Tier 4 PAFERRIPROX TAB 500MG Tier 4 PA

Opioid Antagonistsdepade tab 50mg Tier 1naltrexone tab 50mg Tier 1

ANTIEMETICS5-HT3 Receptor Antagonists

ANZEMET TAB 50MG Tier 3 PAANZEMET TAB 100MG Tier 3 PAgranisetron tab 1mg Tier 1 PAGRANISOL SOL 2MG/10ML Tier 2 PAondansetron inj 32/50ml Tier 1 PAondansetron sol 4mg/5ml Tier 1 PAondansetron tab 4mg Tier 1ondansetron tab 4mg odt Tier 1ondansetron tab 8mg Tier 1ondansetron tab 8mg odt Tier 1ondansetron tab 24mg Tier 1



Drug Name Drug Tier Requirements/LimitsZUPLENZ MIS 4MG Tier 2 PAZUPLENZ MIS 8MG Tier 2 PA

Antiemetics - AnticholinergicANTIVERT TAB 50MG Tier 2dimenhydrin tab 50mg Tier 1dramamine tab 25mg Tier 1driminate tab 50mg Tier 1meclizine tab 12.5mg Tier 1meclizine tab 25mg Tier 1medi-meclizi tab 25mg Tier 1motion relf tab 25mg Tier 1motion sick tab 25mg Tier 1motion sick tab 50mg Tier 1SCOPACE TAB 0.4MG Tier 2TRANSDERM-SC DIS 1.5MG Tier 2trav-tabs tab 50mg Tier 1travel sick tab 50mg Tier 1trimethobenz cap 300mg Tier 1triptone tab 50mg Tier 1wal-dram ii tab 25mg Tier 1wal-dram tab 50mg Tier 1

Antiemetics - MiscellaneousCESAMET CAP 1MG Tier 3 PAdronabinol cap 2.5mg Tier 1 PAdronabinol cap 5mg Tier 1 PAdronabinol cap 10mg Tier 1 PA

Substance P/Neurokinin 1 (NK1) Receptor AntagonistsEMEND CAP 40MG Tier 3 PAEMEND CAP 80MG Tier 3 PAEMEND CAP 125MG Tier 3 PA

ANTIFUNGALSAntifungals

bio-statin pow Tier 1flucytosine cap 250mg Tier 1flucytosine cap 500mg Tier 1griseofulvin sus 125/5ml Tier 1griseofulvin tab micr 500 Tier 1griseofulvin tab ultr 125 Tier 1griseofulvin tab ultr 250 Tier 1nystatin pow Tier 1nystatin tab 500000 Tier 1terbinafine tab 250mg Tier 1



Drug Name Drug Tier Requirements/LimitsImidazole-Related Antifungals

fluconazole sus 10mg/ml Tier 1fluconazole sus 40mg/ml Tier 1fluconazole tab 50mg Tier 1fluconazole tab 100mg Tier 1fluconazole tab 150mg Tier 1fluconazole tab 200mg Tier 1itraconazole cap 100mg Tier 1 PAketoconazole tab 200mg Tier 1SPORANOX SOL 10MG/ML Tier 2 PAvoriconazole tab 50mg Tier 1 PAvoriconazole tab 200mg Tier 1 PA

ANTIHISTAMINESAntihistamines - Alkylamines

dexchlorphen syp 2mg/5ml Tier 1dexchlorphen tab 4mg cr Tier 1

Antihistamines - Ethanolaminesaf-diphedryl elx 12.5/5ml Tier 1aler-cap cap 25mg Tier 1allergy cap 25mg Tier 1allergy med cap 25mg Tier 1allergy rel elx 12.5/5ml Tier 1allergy relf cap 25mg Tier 1altaryl elx 12.5/5ml Tier 1altaryl syp 12.5/5ml Tier 1anti-hist cap 25mg Tier 1antihistamin cap 25mg Tier 1arbinoxa liq 4mg/5ml Tier 1arbinoxa tab 4mg Tier 1banophen cap 25mg Tier 1banophen cap 50mg Tier 1carbinoxamin liq 4mg/5ml Tier 1carbinoxamin tab 4mg Tier 1clemastine syp 0.5/5ml Tier 1clemastine tab 2.68mg Tier 1comp allergy cap 25mg Tier 1cvs allergy cap 25mg Tier 1diphenhist cap 25mg Tier 1diphenhydram cap 25mg Tier 1diphenhydram cap 50mg Tier 1diphenhydram elx 12.5/5ml Tier 1diphenhydram inj 50mg/ml Tier 1 PA



Drug Name Drug Tier Requirements/Limitsdormin cap 25mg Tier 1dytuss syp 12.5/5ml Tier 1eq allergy cap 25mg Tier 1eql allergy cap 25mg Tier 1genahist cap 25mg Tier 1geri-dryl cap 25mg Tier 1gnp allergy cap 25mg Tier 1medi-phedryl cap 25mg Tier 1medi-phedryl elx 12.5/5ml Tier 1mp aller med cap 25mg Tier 1pharbedryl cap 25mg Tier 1pharbedryl cap 50mg Tier 1px allergy cap 25mg Tier 1q-dryl cap 25mg Tier 1quenalin syp 12.5/5ml Tier 1silphen coug syp 12.5/5ml Tier 1wal-dryl cap 25mg Tier 1

Antihistamines - Non-Sedatingall day allg sol 1mg/ml Tier 1all day allg sol 5mg/5ml Tier 1all day allg syp 1mg/ml Tier 1all day allg syp 5mg/5ml Tier 1aller-ease tab 60mg Tier 1aller-ease tab 180mg Tier 1aller-fex tab 180mg Tier 1aller-tec sol 1mg/ml Tier 1allergy chld sol 1mg/ml Tier 1allergy comp sol 1mg/ml Tier 1allergy rel sol 1mg/ml Tier 1allergy relf sol 5mg/5ml Tier 1allergy relf tab 60mg Tier 1allergy relf tab 180mg Tier 1cetirizine sol 1mg/ml Tier 1cetirizine sol 5mg/5ml Tier 1cetirizine syp 1mg/ml Tier 1cetirizine syp 5mg/5ml Tier 1cvs allergy tab 180mg Tier 1desloratadin tab 2.5 odt Tier 1 PAdesloratadin tab 5mg Tier 1 PAdesloratadin tab 5mg odt Tier 1 PAfexofenadine tab 30mg Tier 1fexofenadine tab 60mg Tier 1fexofenadine tab 180mg Tier 1



Drug Name Drug Tier Requirements/Limitsgnp allergy tab 180mg Tier 1levocetirizi sol 2.5/5ml Tier 1 PAlevocetirizi tab 5mg Tier 1 PAwal-fex allr tab 180mg Tier 1wal-fex alrg tab 60mg Tier 1wal-zyr sol 1mg/ml Tier 1wal-zyr sol 5mg/5ml Tier 1

Antihistamines - Phenothiazinesphenadoz sup 12.5mg Tier 1phenadoz sup 25mg Tier 1promethazine sol 6.25/5ml Tier 1promethazine sup 12.5mg Tier 1promethazine sup 25mg Tier 1promethazine syp 6.25/5ml Tier 1promethazine tab 12.5mg Tier 1promethazine tab 25mg Tier 1promethazine tab 50mg Tier 1promethegan sup 12.5mg Tier 1promethegan sup 25mg Tier 1promethegan sup 50mg Tier 1

Antihistamines - Piperidinescyproheptad syp 2mg/5ml Tier 1cyproheptad tab 4mg Tier 1

ANTIHYPERLIPIDEMICSAntihyperlipidemics - Combinations

VYTORIN TAB 10-10MG Tier 3 PAVYTORIN TAB 10-20MG Tier 3 PAVYTORIN TAB 10-40MG Tier 3 PAVYTORIN TAB 10-80MG Tier 3 PA

Antihyperlipidemics - Misc.LOVAZA CAP 1GM Tier 3 PA

Bile Acid Sequestrantscholestyram pow 4gm Tier 1cholestyram pow 4gm lite Tier 1colestipol gra 5gm Tier 1colestipol tab 1gm Tier 1prevalite pow 4gm Tier 1prevalite pow 4gm pk Tier 1WELCHOL PAK 3.75GM Tier 3 STWELCHOL TAB 625MG Tier 3 ST

Fibric Acid Derivativesfenofibrate cap 67mg Tier 1



Drug Name Drug Tier Requirements/Limitsfenofibrate cap 134mg Tier 1fenofibrate cap 200mg Tier 1fenofibrate tab 48mg Tier 1fenofibrate tab 54mg Tier 1fenofibrate tab 145mg Tier 1fenofibrate tab 160mg Tier 1gemfibrozil tab 600mg Tier 1

HMG CoA Reductase Inhibitorsatorvastatin tab 10mg Tier 1 STatorvastatin tab 20mg Tier 1 STatorvastatin tab 40mg Tier 1 STatorvastatin tab 80mg Tier 1 STCRESTOR TAB 5MG Tier 3 PACRESTOR TAB 10MG Tier 3 PACRESTOR TAB 20MG Tier 3 PACRESTOR TAB 40MG Tier 3 PAfluvastatin cap 20mg Tier 1 PAfluvastatin cap 40mg Tier 1 PAFLUVASTATIN TAB 80MG ER Tier 3 PALESCOL XL TAB 80MG Tier 3 PALIVALO TAB 1MG Tier 3 PALIVALO TAB 2MG Tier 3 PALIVALO TAB 4MG Tier 3 PAlovastatin tab 10mg Tier 1lovastatin tab 20mg Tier 1lovastatin tab 40mg Tier 1pravastatin tab 10mg Tier 1pravastatin tab 20mg Tier 1pravastatin tab 40mg Tier 1pravastatin tab 80mg Tier 1simvastatin tab 5mg Tier 1simvastatin tab 10mg Tier 1simvastatin tab 20mg Tier 1simvastatin tab 40mg Tier 1simvastatin tab 80mg Tier 1

Intestinal Cholesterol Absorption InhibitorsZETIA TAB 10MG Tier 2 PA

Nicotinic Acid Derivativesniacor tab 500mg Tier 1NIASPAN TAB 500MG ER Tier 2NIASPAN TAB 750MG ER Tier 2NIASPAN TAB 1000 ER Tier 2




ANTIHYPERTENSIVESACE Inhibitors

benazepril tab 5mg Tier 1benazepril tab 10mg Tier 1benazepril tab 20mg Tier 1benazepril tab 40mg Tier 1captopril tab 12.5mg Tier 1captopril tab 25mg Tier 1captopril tab 50mg Tier 1captopril tab 100mg Tier 1enalapril tab 2.5mg Tier 1enalapril tab 5mg Tier 1enalapril tab 10mg Tier 1enalapril tab 20mg Tier 1fosinopril tab 10mg Tier 1fosinopril tab 20mg Tier 1fosinopril tab 40mg Tier 1lisinopril tab 2.5mg Tier 1lisinopril tab 5mg Tier 1lisinopril tab 10mg Tier 1lisinopril tab 20mg Tier 1lisinopril tab 30mg Tier 1lisinopril tab 40mg Tier 1moexipril tab 7.5mg Tier 1moexipril tab 15mg Tier 1perindopril tab 2mg Tier 1perindopril tab 4mg Tier 1perindopril tab 8mg Tier 1quinapril tab 5mg Tier 1quinapril tab 10mg Tier 1quinapril tab 20mg Tier 1quinapril tab 40mg Tier 1ramipril cap 1.25mg Tier 1ramipril cap 2.5mg Tier 1ramipril cap 5mg Tier 1ramipril cap 10mg Tier 1trandolapril tab 1mg Tier 1trandolapril tab 2mg Tier 1trandolapril tab 4mg Tier 1

Agents for PheochromocytomaDIBENZYLINE CAP 10MG Tier 2

Angiotensin II Receptor Antagonists



Drug Name Drug Tier Requirements/LimitsBENICAR TAB 5MG Tier 3 PABENICAR TAB 20MG Tier 3 PABENICAR TAB 40MG Tier 3 PAcandesartan tab 4mg Tier 3 STcandesartan tab 8mg Tier 3 STcandesartan tab 16mg Tier 3 STcandesartan tab 32mg Tier 3 STDIOVAN TAB 40MG Tier 2 PADIOVAN TAB 80MG Tier 2 PADIOVAN TAB 160MG Tier 2 PADIOVAN TAB 320MG Tier 2 PAEDARBI TAB 40MG Tier 3 PAEDARBI TAB 80MG Tier 3 PAeprosart mes tab 600mg Tier 1 PAirbesartan tab 75mg Tier 1 STirbesartan tab 150mg Tier 1 STirbesartan tab 300mg Tier 1 STlosartan pot tab 25mg Tier 1 STlosartan pot tab 50mg Tier 1 STlosartan pot tab 100mg Tier 1 STMICARDIS TAB 20MG Tier 3 PAMICARDIS TAB 40MG Tier 3 PAMICARDIS TAB 80MG Tier 3 PATEVETEN TAB 400MG Tier 3 PA

Antiadrenergic Antihypertensivesclonidine dis 0.1/24hr Tier 1 PAclonidine dis 0.2/24hr Tier 1 PAclonidine dis 0.3/24hr Tier 1 PAclonidine tab 0.1mg Tier 1clonidine tab 0.2mg Tier 1clonidine tab 0.3mg Tier 1doxazosin tab 1mg Tier 1doxazosin tab 2mg Tier 1doxazosin tab 4mg Tier 1doxazosin tab 8mg Tier 1guanfacine tab 1mg Tier 1guanfacine tab 2mg Tier 1methyldopa tab 250mg Tier 1methyldopa tab 500mg Tier 1prazosin hcl cap 1mg Tier 1prazosin hcl cap 2mg Tier 1prazosin hcl cap 5mg Tier 1reserpine tab 0.1mg Tier 1



Drug Name Drug Tier Requirements/Limitsreserpine tab 0.25mg Tier 1terazosin cap 1mg Tier 1terazosin cap 2mg Tier 1terazosin cap 5mg Tier 1terazosin cap 10mg Tier 1

Antihypertensive Combinationsamlod/benazp cap 2.5-10mg Tier 1amlod/benazp cap 5-10mg Tier 1amlod/benazp cap 5-20mg Tier 1amlod/benazp cap 5-40mg Tier 1amlod/benazp cap 10-20mg Tier 1amlod/benazp cap 10-40mg Tier 1atenol/chlor tab 50-25mg Tier 1atenol/chlor tab 100-25mg Tier 1AVALIDE TAB 300-25MG Tier 3 STbenazep/hctz tab 5-6.25 Tier 1benazep/hctz tab 10-12.5 Tier 1benazep/hctz tab 20-12.5 Tier 1benazep/hctz tab 20-25mg Tier 1BENICAR HCT TAB 20-12.5 Tier 3 PABENICAR HCT TAB 40-12.5 Tier 3 PABENICAR HCT TAB 40-25MG Tier 3 PAbisoprl/hctz tab 2.5/6.25 Tier 1bisoprl/hctz tab 5-6.25mg Tier 1bisoprl/hctz tab 10/6.25 Tier 1captopr/hctz tab 25-15mg Tier 1captopr/hctz tab 25-25mg Tier 1captopr/hctz tab 50-15mg Tier 1captopr/hctz tab 50-25mg Tier 1irbesar/hctz tab 150-12.5 Tier 1 STirbesar/hctz tab 300-12.5 Tier 1 STlisinop/hctz tab 10-12.5 Tier 1lisinop/hctz tab 20-12.5 Tier 1lisinop/hctz tab 20-25mg Tier 1losartan/hct tab 50-12.5 Tier 1 STlosartan/hct tab 100-12.5 Tier 1 STlosartan/hct tab 100-25 Tier 1 STpropran/hctz tab 40/25 Tier 1propran/hctz tab 80/25 Tier 1TARKA TAB 1-240 CR Tier 2 PATARKA TAB 2-180 CR Tier 2 PATARKA TAB 2-240 CR Tier 2 PATARKA TAB 4-240 CR Tier 2 PA



Drug Name Drug Tier Requirements/Limitsvalsart/hctz tab 80-12.5 Tier 1 STvalsart/hctz tab 160-12.5 Tier 1 STvalsart/hctz tab 160-25mg Tier 1 STvalsart/hctz tab 320-12.5 Tier 1 STvalsart/hctz tab 320-25mg Tier 1 ST

Direct Renin InhibitorsTEKTURNA TAB 150MG Tier 3 PATEKTURNA TAB 300MG Tier 3 PA

Selective Aldosterone Receptor Antagonists (SARAs)eplerenone tab 25mg Tier 1 PAeplerenone tab 50mg Tier 1 PA

Vasodilatorshydralazine tab 10mg Tier 1hydralazine tab 25mg Tier 1hydralazine tab 50mg Tier 1hydralazine tab 100mg Tier 1minoxidil tab 2.5mg Tier 1minoxidil tab 10mg Tier 1

ANTIMALARIALSAntimalarial Combinations

atovaq/progu tab 62.5-25 Tier 1atovaq/progu tab 250-100 Tier 1COARTEM TAB 20-120MG Tier 3

Antimalarialschloroquine tab 250mg Tier 1chloroquine tab 500mg Tier 1DARAPRIM TAB 25MG Tier 2hydroxychlor tab 200mg Tier 1mefloquine tab 250mg Tier 1PRIMAQUINE TAB 26.3MG Tier 2quinine sulf cap 324mg Tier 1

ANTIMYASTHENIC AGENTSAntimyasthenic Agents

GUANIDINE TAB 125MG Tier 3MESTINON SYP 60MG/5ML Tier 2MYTELASE TAB 10MG Tier 3PROSTIGMIN TAB 15MG Tier 2pyridostigm tab 60mg Tier 1

ANTIMYCOBACTERIAL AGENTSAnti TB Combinations

isonarif cap Tier 1



Drug Name Drug Tier Requirements/LimitsRIFATER TAB Tier 2

Antimycobacterial Agentsethambutol tab 100mg Tier 1ethambutol tab 400mg Tier 1isoniazid syp 50mg/5ml Tier 1isoniazid tab 100mg Tier 1isoniazid tab 300mg Tier 1MYCOBUTIN CAP 150MG Tier 2PASER GRA 4GM Tier 3PRIFTIN TAB 150MG Tier 3pyrazinamide tab 500mg Tier 1rifampin cap 150mg Tier 1rifampin cap 300mg Tier 1TRECATOR TAB 250MG Tier 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAlkylating Agents

ALKERAN TAB 2MG Tier 2CEENU CAP 10MG Tier 2CEENU CAP 40MG Tier 2CEENU CAP 100MG Tier 2cyclophosph tab 25mg Tier 1cyclophosph tab 50mg Tier 1GLIADEL WAF 7.7MG Tier 4 PAHEXALEN CAP 50MG Tier 2LEUKERAN TAB 2MG Tier 2melphalan inj 50mg Tier 4 PAMYLERAN TAB 2MG Tier 2TEMODAR CAP 5MG Tier 4 PATEMODAR CAP 20MG Tier 4 PATEMODAR CAP 100MG Tier 4 PATEMODAR CAP 140MG Tier 4 PATEMODAR CAP 180MG Tier 4 PATEMODAR CAP 250MG Tier 4 PA

Antimetabolitesadrucil inj 2.5g/50m Tier 4 PAadrucil inj 5gm/100m Tier 4 PAadrucil inj 500/10ml Tier 4 PAfluorouracil inj 1gm/20ml Tier 4 PAfluorouracil inj 2.5g/50m Tier 4 PAfluorouracil inj 5gm/100m Tier 4 PAfluorouracil inj 500/10ml Tier 4 PAmercaptopur tab 50mg Tier 1



Drug Name Drug Tier Requirements/Limitsmethotrexate tab 2.5mg Tier 1OFORTA TAB 10MG Tier 4 PATABLOID TAB 40MG Tier 2TREXALL TAB 5MG Tier 2TREXALL TAB 7.5MG Tier 2TREXALL TAB 10MG Tier 2TREXALL TAB 15MG Tier 2XELODA TAB 150MG Tier 4 PAXELODA TAB 500MG Tier 4 PA

Antineoplastic - AntibodiesRITUXAN INJ 100MG Tier 4 PARITUXAN INJ 500MG Tier 4 PA

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE CAP 150MG Tier 4 PA

Antineoplastic - Hormonal and Related Agentsanastrozole tab 1mg Tier 1bicalutamide tab 50mg Tier 1DEPO-PROVERA INJ 400/ML Tier 2ELIGARD INJ 7.5MG Tier 4 PAELIGARD INJ 22.5MG Tier 4 PAELIGARD INJ 30MG Tier 4 PAELIGARD INJ 45MG Tier 4 PAEMCYT CAP 140MG Tier 2exemestane tab 25mg Tier 1FARESTON TAB 60MG Tier 2flutamide cap 125mg Tier 1letrozole tab 2.5mg Tier 1leuprolide inj 1mg/0.2 Tier 4 PALUPRON DEPOT INJ 3.75MG Tier 4 PALUPRON DEPOT INJ 7.5MG Tier 4 PALUPRON DEPOT INJ 11.25MG Tier 4 PALUPRON DEPOT INJ 22.5MG Tier 4 PALUPRON DEPOT INJ 30MG Tier 4 PALYSODREN TAB 500MG Tier 2megestrol ac sus 40mg/ml Tier 1megestrol ac sus 400mg/10 Tier 1megestrol ac tab 20mg Tier 1megestrol ac tab 40mg Tier 1NILANDRON TAB 150MG Tier 2SOLTAMOX SOL 10MG/5ML Tier 2tamoxifen tab 10mg Tier 1tamoxifen tab 20mg Tier 1XTANDI CAP 40MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsZYTIGA TAB 250MG Tier 4 PA

Antineoplastic AntibioticsVALSTAR SOL 40MG/ML Tier 4 PA

Antineoplastic Enzyme InhibitorsAFINITOR TAB 2.5MG Tier 4 PAAFINITOR TAB 5MG Tier 4 PAAFINITOR TAB 7.5MG Tier 4 PAAFINITOR TAB 10MG Tier 4 PABOSULIF TAB 100MG Tier 4 PABOSULIF TAB 500MG Tier 4 PACAPRELSA TAB 100MG Tier 4 PACAPRELSA TAB 300MG Tier 4 PACOMETRIQ KIT 60MG Tier 4 PACOMETRIQ KIT 100MG Tier 4 PACOMETRIQ KIT 140MG Tier 4 PAGLEEVEC TAB 100MG Tier 4 PAGLEEVEC TAB 400MG Tier 4 PAICLUSIG TAB 15MG Tier 4 PAICLUSIG TAB 45MG Tier 4 PAINLYTA TAB 1MG Tier 4 PAINLYTA TAB 5MG Tier 4 PAIRESSA TAB 250MG Tier 4 PAJAKAFI TAB 5MG Tier 4 PAJAKAFI TAB 10MG Tier 4 PAJAKAFI TAB 15MG Tier 4 PAJAKAFI TAB 20MG Tier 4 PAJAKAFI TAB 25MG Tier 4 PANEXAVAR TAB 200MG Tier 4 PASPRYCEL TAB 20MG Tier 4 PASPRYCEL TAB 50MG Tier 4 PASPRYCEL TAB 70MG Tier 4 PASPRYCEL TAB 80MG Tier 4 PASPRYCEL TAB 100MG Tier 4 PASPRYCEL TAB 140MG Tier 4 PASTIVARGA TAB 40MG Tier 4 PASUTENT CAP 12.5MG Tier 4 PASUTENT CAP 25MG Tier 4 PASUTENT CAP 50MG Tier 4 PATARCEVA TAB 25MG Tier 4 PATARCEVA TAB 100MG Tier 4 PATARCEVA TAB 150MG Tier 4 PATASIGNA CAP 150MG Tier 4 PATASIGNA CAP 200MG Tier 4 PA



Drug Name Drug Tier Requirements/LimitsTORISEL SOL 25MG/ML Tier 4 PATYKERB TAB 250MG Tier 4 PAVANDETANIB TAB 100MG Tier 4 PAVANDETANIB TAB 300MG Tier 4 PAVOTRIENT TAB 200MG Tier 4 PAXALKORI CAP 200MG Tier 4 PAXALKORI CAP 250MG Tier 4 PAZELBORAF TAB 240MG Tier 4 PAZOLINZA CAP 100MG Tier 4 PA

Antineoplastic EnzymesELSPAR INJ 10000UNT Tier 4 PA

Antineoplastics Misc.ACTIMMUNE INJ 2MU/0.5 Tier 4 PAALFERON N INJ 5MU/ML Tier 4 PAhydroxyurea cap 500mg Tier 1INTRON-A INJ 3MU PEN Tier 4 PAINTRON-A INJ 5MU PEN Tier 4 PAINTRON-A INJ 10MU Tier 4 PAINTRON-A INJ 10MU PEN Tier 4 PAINTRON-A INJ 18MU Tier 4 PAINTRON-A INJ 25MU Tier 4 PAINTRON-A INJ 50MU Tier 4 PAMATULANE CAP 50MG Tier 2 PATARGRETIN CAP 75MG Tier 4 PAtretinoin cap 10mg Tier 1

Chemotherapy AdjunctsKEPIVANCE INJ 6.25MG Tier 4 PA

Chemotherapy Rescue/Antidote Agentsleucovor ca tab 5mg Tier 1leucovor ca tab 10mg Tier 1leucovor ca tab 15mg Tier 1leucovor ca tab 25mg Tier 1MESNEX TAB 400MG Tier 3 PA

Mitotic Inhibitorsetoposide cap 50mg Tier 1 PAetoposide inj 20mg/ml Tier 4 PAtoposar inj 1gm/50ml Tier 4 PAtoposar inj 20mg/ml Tier 4 PAtoposar inj 100/5ml Tier 4 PAtoposar inj 500/25ml Tier 4 PA

Topoisomerase I InhibitorsHYCAMTIN CAP 0.25MG Tier 4 PAHYCAMTIN CAP 1MG Tier 4 PA




ANTIPARKINSON AGENTSAntiparkinson Adjuvants

LODOSYN TAB 25MG Tier 2Antiparkinson Anticholinergics

benztropine tab 0.5mg Tier 1benztropine tab 1mg Tier 1benztropine tab 2mg Tier 1trihexyphen elx 0.4mg/ml Tier 1trihexyphen tab 2mg Tier 1trihexyphen tab 5mg Tier 1

Antiparkinson COMT Inhibitorsentacapone tab 200mg Tier 1TASMAR TAB 100MG Tier 2

Antiparkinson Dopaminergicsamantadine cap 100mg Tier 1amantadine syp 50mg/5ml Tier 1amantadine tab 100mg Tier 1APOKYN INJ Tier 4 PAAPOKYN INJ 10MG/ML Tier 4 PAbromocriptin cap 5mg Tier 1bromocriptin tab 2.5mg Tier 1carb/levo er tab 25-100mg Tier 1carb/levo er tab 50-200mg Tier 1carb/levo sr tab 25-100mg Tier 1carb/levo sr tab 50-200mg Tier 1carb/levo tab 10-100mg Tier 1carb/levo tab 25-100mg Tier 1carb/levo tab 25-250mg Tier 1pramipexole tab 0.5mg Tier 1pramipexole tab 0.25mg Tier 1pramipexole tab 0.75mg Tier 1pramipexole tab 0.125mg Tier 1pramipexole tab 1.5mg Tier 1pramipexole tab 1mg Tier 1ropinirole tab 0.5mg Tier 1ropinirole tab 0.25mg Tier 1ropinirole tab 1mg Tier 1ropinirole tab 2mg Tier 1ropinirole tab 2mg er Tier 1 PAropinirole tab 3mg Tier 1ropinirole tab 4mg Tier 1ropinirole tab 4mg er Tier 1 PA



Drug Name Drug Tier Requirements/Limitsropinirole tab 5mg Tier 1ropinirole tab 6mg er Tier 1 PAropinirole tab 8mg er Tier 1 PAropinirole tab 12mg er Tier 1 PA

Antiparkinson Monoamine Oxidase InhibitorsAZILECT TAB 0.5MG Tier 3AZILECT TAB 1MG Tier 3selegiline cap 5mg Tier 1selegiline tab 5mg Tier 1

ANTIPSYCHOTICS/ANTIMANIC AGENTSAntimanic Agents

lithium carb cap 150mg Tier 1lithium carb cap 300mg Tier 1lithium carb cap 600mg Tier 1lithium carb tab 300mg Tier 1lithium carb tab 300mg er Tier 1lithium carb tab 450mg er Tier 1LITHIUM CITR SOL 8MEQ/5ML Tier 2

Antipsychotics - Misc.EQUETRO CAP 100MG Tier 3EQUETRO CAP 200MG Tier 3EQUETRO CAP 300MG Tier 3LATUDA TAB 20MG Tier 2 STLATUDA TAB 40MG Tier 2 STLATUDA TAB 80MG Tier 2 STziprasidone cap 20mg Tier 1 STziprasidone cap 40mg Tier 1 STziprasidone cap 60mg Tier 1 STziprasidone cap 80mg Tier 1 ST

BenzisoxazolesFANAPT PAK Tier 3 PAFANAPT TAB 1MG Tier 3 PAFANAPT TAB 2MG Tier 3 PAFANAPT TAB 4MG Tier 3 PAFANAPT TAB 6MG Tier 3 PAFANAPT TAB 8MG Tier 3 PAFANAPT TAB 10MG Tier 3 PAFANAPT TAB 12MG Tier 3 PAINVEGA SUST INJ 39/0.25 Tier 3 PAINVEGA SUST INJ 78/0.5ML Tier 3 PAINVEGA SUST INJ 117/0.75 Tier 3 PAINVEGA SUST INJ 156MG/ML Tier 3 PA



Drug Name Drug Tier Requirements/LimitsINVEGA SUST INJ 234/1.5 Tier 3 PAINVEGA TAB 1.5MG Tier 3 PAINVEGA TAB 3MG Tier 3 PAINVEGA TAB 6MG Tier 3 PAINVEGA TAB 9MG Tier 3 PARISPERDAL INJ 12.5MG Tier 3 PARISPERDAL INJ 25MG Tier 3 PARISPERDAL INJ 37.5MG Tier 3 PARISPERDAL INJ 50MG Tier 3 PArisperidone sol 1mg/ml Tier 1risperidone tab 0.5mg Tier 1risperidone tab 0.5mg od Tier 1risperidone tab 0.25 odt Tier 1risperidone tab 0.25mg Tier 1risperidone tab 1mg Tier 1risperidone tab 1mg odt Tier 1risperidone tab 2mg Tier 1risperidone tab 2mg odt Tier 1risperidone tab 3mg Tier 1risperidone tab 3mg odt Tier 1risperidone tab 4mg Tier 1risperidone tab 4mg odt Tier 1

Butyrophenoneshaloperidol con 2mg/ml Tier 1haloperidol tab 0.5mg Tier 1haloperidol tab 1mg Tier 1haloperidol tab 2mg Tier 1haloperidol tab 5mg Tier 1haloperidol tab 10mg Tier 1haloperidol tab 20mg Tier 1

Dibenzapinesclozapine tab 12.5/odt Tier 1 STclozapine tab 25mg Tier 1 STclozapine tab 25mg odt Tier 1 STclozapine tab 50mg Tier 1 STclozapine tab 100/odt Tier 1 STclozapine tab 100mg Tier 1 STclozapine tab 200mg Tier 1 STFAZACLO TAB 150MG Tier 3 PAFAZACLO TAB 200MG Tier 3 PAloxapine cap 5mg Tier 1loxapine cap 10mg Tier 1loxapine cap 25mg Tier 1



Drug Name Drug Tier Requirements/Limitsloxapine cap 50mg Tier 1olanzapine tab 2.5mg Tier 1 STolanzapine tab 5mg Tier 1 STolanzapine tab 5mg odt Tier 1 STolanzapine tab 7.5mg Tier 1 STolanzapine tab 10mg Tier 1 STolanzapine tab 10mg odt Tier 1 STolanzapine tab 15mg Tier 1 STolanzapine tab 15mg odt Tier 1 STolanzapine tab 20mg Tier 1 STolanzapine tab 20mg odt Tier 1 STquetiapine tab 25mg Tier 1 STquetiapine tab 50mg Tier 1 STquetiapine tab 100mg Tier 1 STquetiapine tab 200mg Tier 1 STquetiapine tab 300mg Tier 1 STquetiapine tab 400mg Tier 1 STSAPHRIS SUB 5MG Tier 3 PASAPHRIS SUB 10MG Tier 3 PASEROQUEL XR TAB 50MG Tier 2 STSEROQUEL XR TAB 150MG Tier 2 STSEROQUEL XR TAB 200MG Tier 2 STSEROQUEL XR TAB 300MG Tier 2 STSEROQUEL XR TAB 400MG Tier 2 STZYPREXA RELP INJ 210MG Tier 3 PAZYPREXA RELP INJ 300MG Tier 3 PAZYPREXA RELP INJ 405MG Tier 3 PA

Phenothiazineschlorpromaz tab 10mg Tier 1chlorpromaz tab 25mg Tier 1chlorpromaz tab 50mg Tier 1chlorpromaz tab 100mg Tier 1chlorpromaz tab 200mg Tier 1compro sup 25mg Tier 1fluphenaz de inj 25mg/ml Tier 1 PAfluphenazine con 5mg/ml Tier 1fluphenazine elx 2.5/5ml Tier 1fluphenazine tab 1mg Tier 1fluphenazine tab 2.5mg Tier 1fluphenazine tab 5mg Tier 1fluphenazine tab 10mg Tier 1perphenazine tab 2mg Tier 1perphenazine tab 4mg Tier 1



Drug Name Drug Tier Requirements/Limitsperphenazine tab 8mg Tier 1perphenazine tab 16mg Tier 1prochlorper sup 25mg Tier 1prochlorper tab 5mg Tier 1prochlorper tab 10mg Tier 1thioridazine tab 10mg Tier 1thioridazine tab 25mg Tier 1thioridazine tab 50mg Tier 1thioridazine tab 100mg Tier 1trifluoperaz tab 1mg Tier 1trifluoperaz tab 2mg Tier 1trifluoperaz tab 5mg Tier 1trifluoperaz tab 10mg Tier 1

Quinolinone DerivativesABILIFY DISC TAB 10MG Tier 2 STABILIFY DISC TAB 15MG Tier 2 STABILIFY MAIN INJ 300MG Tier 3 PAABILIFY MAIN INJ 400MG Tier 3 PAABILIFY SOL 1MG/ML Tier 2 STABILIFY TAB 2MG Tier 2 STABILIFY TAB 5MG Tier 2 STABILIFY TAB 10MG Tier 2 STABILIFY TAB 15MG Tier 2 STABILIFY TAB 20MG Tier 2 STABILIFY TAB 30MG Tier 2 ST

ThioxanthenesNAVANE CAP 20MG Tier 2thiothixene cap 1mg Tier 1thiothixene cap 2mg Tier 1thiothixene cap 5mg Tier 1thiothixene cap 10mg Tier 1

ANTISEPTICS DISINFECTANTSChlorine Antiseptics

CHLORHEX DIG SOL 20% Tier 2CHLORHEX GLU SOL 20% Tier 2PHISOHEX LIQ 3% Tier 2

ANTIVIRALSAntiretrovirals

abacavir tab 300mg Tier 1APTIVUS CAP 250MG Tier 2APTIVUS SOL Tier 2ATRIPLA TAB Tier 2



Drug Name Drug Tier Requirements/LimitsCOMPLERA TAB Tier 2CRIXIVAN CAP 100MG Tier 2CRIXIVAN CAP 200MG Tier 2CRIXIVAN CAP 400MG Tier 2didanosine cap 125mg Tier 1didanosine cap 200mg Tier 1didanosine cap 250mg Tier 1didanosine cap 400mg Tier 1EDURANT TAB 25MG Tier 2EMTRIVA CAP 200MG Tier 2EMTRIVA SOL 10MG/ML Tier 2EPIVIR HBV SOL 5MG/ML Tier 2EPIVIR HBV TAB 100MG Tier 2EPIVIR SOL 10MG/ML Tier 2EPZICOM TAB 600-300 Tier 2FUZEON INJ 90MG Tier 4 PAFUZEON KIT Tier 4 PAINTELENCE TAB 25MG Tier 4INTELENCE TAB 100MG Tier 4INTELENCE TAB 200MG Tier 4INVIRASE CAP 200MG Tier 2INVIRASE TAB 500MG Tier 2ISENTRESS CHW 25MG Tier 2ISENTRESS CHW 100MG Tier 2ISENTRESS TAB 400MG Tier 2KALETRA SOL Tier 2KALETRA TAB 100-25MG Tier 2KALETRA TAB 200-50MG Tier 2lamivud/zido tab 150-300 Tier 1lamivudine tab 150mg Tier 1lamivudine tab 300mg Tier 1LEXIVA SUS 50MG/ML Tier 2LEXIVA TAB 700MG Tier 2nevirapine sus 50mg/5ml Tier 1nevirapine tab 200mg Tier 1NORVIR CAP 100MG Tier 2NORVIR SOL 80MG/ML Tier 2NORVIR TAB 100MG Tier 2PREZISTA TAB 75MG Tier 2PREZISTA TAB 150MG Tier 2PREZISTA TAB 400MG Tier 2PREZISTA TAB 600MG Tier 2PREZISTA TAB 800MG Tier 2



Drug Name Drug Tier Requirements/LimitsRESCRIPTOR TAB 100 MG Tier 2RESCRIPTOR TAB 200MG Tier 2REYATAZ CAP 100MG Tier 2REYATAZ CAP 150MG Tier 2REYATAZ CAP 200MG Tier 2REYATAZ CAP 300MG Tier 2SELZENTRY TAB 150MG Tier 2SELZENTRY TAB 300MG Tier 2stavudine cap 15mg Tier 1stavudine cap 20mg Tier 1stavudine cap 30mg Tier 1stavudine cap 40mg Tier 1stavudine sol 1mg/ml Tier 1STRIBILD TAB Tier 2 PASUSTIVA CAP 50MG Tier 2SUSTIVA CAP 200MG Tier 2SUSTIVA TAB 600MG Tier 2TRIZIVIR TAB Tier 2TRUVADA TAB 200-300 Tier 2VIDEX SOL 2GM Tier 2VIDEX SOL 4GM Tier 2VIRACEPT POW 50MG/GM Tier 2VIRACEPT TAB 250MG Tier 2VIRACEPT TAB 625MG Tier 2VIRAMUNE XR TAB 400MG Tier 2VIREAD POW 40MG/GM Tier 2VIREAD TAB 150MG Tier 2VIREAD TAB 200MG Tier 2VIREAD TAB 250MG Tier 2VIREAD TAB 300MG Tier 2ZIAGEN SOL 20MG/ML Tier 2zidovudine cap 100mg Tier 1zidovudine syp 50mg/5ml Tier 1zidovudine tab 300mg Tier 1

CMV Agentsganciclovir cap 250mg Tier 1 PAganciclovir cap 500mg Tier 1 PAVALCYTE TAB 450MG Tier 2 PA

Hepatitis AgentsBARACLUDE SOL .05MG/ML Tier 3BARACLUDE TAB 0.5MG Tier 3BARACLUDE TAB 1MG Tier 3HEPSERA TAB 10MG Tier 3



Drug Name Drug Tier Requirements/LimitsINCIVEK TAB 375MG Tier 4 PAINFERGEN INJ 9MCG Tier 4 PAINFERGEN INJ 15MCG Tier 4 PAPEG-INTRON KIT 50MCG Tier 4 PAPEG-INTRON KIT 50MCG RP Tier 4 PAPEG-INTRON KIT 80MCG Tier 4 PAPEG-INTRON KIT 80MCG RP Tier 4 PAPEG-INTRON KIT 120 RP Tier 4 PAPEG-INTRON KIT 120MCG Tier 4 PAPEG-INTRON KIT 150 RP Tier 4 PAPEG-INTRON KIT 150MCG Tier 4 PAPEGASYS INJ Tier 4 PAPEGASYS INJ PROCLICK 180mcg/0.5ml Tier 4 PAPEGASYS KIT Tier 4 PARIBAPAK PAK 800/DAY Tier 4 PARIBAPAK PAK 1200/DAY Tier 4 PAribasphere cap 200mg Tier 4 PAribasphere tab 200mg Tier 4 PAribasphere tab 400mg Tier 4 PAribasphere tab 600mg Tier 4 PARIBATAB TAB 800/DAY Tier 4 PARIBATAB TAB 1200/DAY Tier 4 PAribavirin cap 200mg Tier 4 PAribavirin tab 200mg Tier 4 PATYZEKA TAB 600MG Tier 3VICTRELIS CAP 200MG Tier 4 PA

Herpes Agentsacyclovir cap 200mg Tier 1acyclovir sus 200/5ml Tier 1acyclovir tab 400mg Tier 1acyclovir tab 800mg Tier 1famciclovir tab 125mg Tier 1famciclovir tab 250mg Tier 1famciclovir tab 500mg Tier 1valacyclovir tab 1gm Tier 1valacyclovir tab 500mg Tier 1

Influenza AgentsRELENZA MIS DISKHALE Tier 3rimantadine tab 100mg Tier 1TAMIFLU CAP 30MG Tier 2TAMIFLU CAP 45MG Tier 2TAMIFLU CAP 75MG Tier 2TAMIFLU SUS 6MG/ML Tier 2



Drug Name Drug Tier Requirements/LimitsTAMIFLU SUS 12MG/ML Tier 2

ASSORTED CLASSESChelating Agents

CUPRIMINE CAP 250MG Tier 2DEPEN TITRA TAB 250MG Tier 3 PASYPRINE CAP 250MG Tier 3 PA

ImmunomodulatorsREVLIMID CAP 5MG Tier 4 PAREVLIMID CAP 10MG Tier 4 PAREVLIMID CAP 15MG Tier 4 PAREVLIMID CAP 25MG Tier 4 PATHALOMID CAP 50MG Tier 4 PATHALOMID CAP 100MG Tier 4 PATHALOMID CAP 150MG Tier 4 PATHALOMID CAP 200MG Tier 4 PA

Immunosuppressive AgentsAZASAN TAB 75 MG Tier 2AZASAN TAB 100MG Tier 2azathioprine inj 100mg Tier 1 PAazathioprine tab 50mg Tier 1CELLCEPT SUS 200MG/ML Tier 2cyclosporine cap 25mg Tier 1cyclosporine cap 25mg mod Tier 1cyclosporine cap 50mg mod Tier 1cyclosporine cap 100mg Tier 1cyclosporine cap 100mg md Tier 1cyclosporine sol modified Tier 1gengraf cap 25mg Tier 1gengraf cap 100mg Tier 1gengraf sol 100mg/ml Tier 1hecoria cap 0.5mg Tier 1hecoria cap 1mg Tier 1hecoria cap 5mg Tier 1mycophenolat cap 250mg Tier 1mycophenolat tab 500mg Tier 1MYFORTIC TAB 180MG Tier 3MYFORTIC TAB 360MG Tier 3RAPAMUNE SOL 1MG/ML Tier 3RAPAMUNE TAB 1MG Tier 3RAPAMUNE TAB 2MG Tier 3SANDIMMUNE SOL 100MG/ML Tier 2tacrolimus cap 0.5mg Tier 1



Drug Name Drug Tier Requirements/Limitstacrolimus cap 1mg Tier 1tacrolimus cap 5mg Tier 1

Irrigation Solutionsringers irr sol Tier 1 PAtis-u-sol sol Tier 1 PA

Potassium Removing Resinskalexate pow Tier 1kionex pow usp Tier 1kionex sus 15gm/60 Tier 1sod poly sul pow Tier 1sod poly sul sus 15gm/60 Tier 1sps sus 15gm/60 Tier 1

BETA BLOCKERSAlpha-Beta Blockers

carvedilol tab 3.125mg Tier 1carvedilol tab 6.25mg Tier 1carvedilol tab 12.5mg Tier 1carvedilol tab 25mg Tier 1labetalol tab 100mg Tier 1labetalol tab 200mg Tier 1labetalol tab 300mg Tier 1

Beta Blockers Cardio-Selectiveacebutolol cap 200mg Tier 1acebutolol cap 400mg Tier 1atenolol tab 25mg Tier 1atenolol tab 50mg Tier 1atenolol tab 100mg Tier 1betaxolol tab 10mg Tier 1betaxolol tab 20mg Tier 1bisoprol fum tab 5mg Tier 1bisoprol fum tab 10mg Tier 1BYSTOLIC TAB 2.5MG Tier 3BYSTOLIC TAB 5MG Tier 3BYSTOLIC TAB 10MG Tier 3BYSTOLIC TAB 20MG Tier 3metoprol tar tab 25mg Tier 1metoprol tar tab 50mg Tier 1metoprol tar tab 100mg Tier 1metoprolol tab 25mg er Tier 1metoprolol tab 50mg er Tier 1metoprolol tab 100mg er Tier 1metoprolol tab 200mg er Tier 1



Drug Name Drug Tier Requirements/LimitsBeta Blockers Non-Selective

INNOPRAN XL CAP 80MG Tier 3INNOPRAN XL CAP 120MG Tier 3LEVATOL TAB 20MG Tier 2nadolol tab 20mg Tier 1nadolol tab 40mg Tier 1nadolol tab 80mg Tier 1pindolol tab 5mg Tier 1pindolol tab 10mg Tier 1propranolol cap 60mg er Tier 1propranolol cap 80mg er Tier 1propranolol cap 120mg er Tier 1propranolol cap 160mg er Tier 1propranolol sol 20mg/5ml Tier 1propranolol sol 40mg/5ml Tier 1propranolol tab 10mg Tier 1propranolol tab 20mg Tier 1propranolol tab 40mg Tier 1propranolol tab 60mg Tier 1propranolol tab 80mg Tier 1sorine tab 80mg Tier 1sorine tab 120mg Tier 1sorine tab 160mg Tier 1sorine tab 240mg Tier 1sotalol af tab 80mg Tier 1sotalol af tab 120mg Tier 1sotalol af tab 160mg Tier 1sotalol hcl tab 80mg Tier 1sotalol hcl tab 120mg Tier 1sotalol hcl tab 160mg Tier 1sotalol hcl tab 240mg Tier 1timolol mal tab 5mg Tier 1timolol mal tab 10mg Tier 1timolol mal tab 20mg Tier 1

CALCIUM CHANNEL BLOCKERSCalcium Channel Blockers

afeditab tab 30mg cr Tier 1afeditab tab 60mg cr Tier 1amlodipine tab 2.5mg Tier 1amlodipine tab 5mg Tier 1amlodipine tab 10mg Tier 1CARDENE SR CAP 30MG Tier 2



Drug Name Drug Tier Requirements/LimitsCARDENE SR CAP 45MG Tier 2CARDENE SR CAP 60MG Tier 2cartia xt cap 120/24hr Tier 1cartia xt cap 180/24hr Tier 1cartia xt cap 240/24hr Tier 1cartia xt cap 300/24hr Tier 1COVERA-HS TAB 180MG Tier 3COVERA-HS TAB 240MG Tier 3dilt-cd cap 120mg Tier 1dilt-cd cap 180mg Tier 1dilt-cd cap 240mg Tier 1dilt-cd cap 300mg Tier 1dilt-xr cap 120mg Tier 1dilt-xr cap 180mg Tier 1dilt-xr cap 240mg Tier 1diltiazem cap 60mg er Tier 1diltiazem cap 90mg er Tier 1diltiazem cap 120mg cd Tier 1diltiazem cap 120mg er Tier 1diltiazem cap 120mg/24 Tier 1diltiazem cap 180mg cd Tier 1diltiazem cap 180mg er Tier 1diltiazem cap 180mg/24 Tier 1diltiazem cap 240mg cd Tier 1diltiazem cap 240mg er Tier 1diltiazem cap 240mg/24 Tier 1diltiazem cap 300mg cd Tier 1diltiazem cap 300mg er Tier 1diltiazem cap 300mg/24 Tier 1diltiazem cap 360mg cd Tier 1diltiazem cap 360mg er Tier 1diltiazem cap 360mg/24 Tier 1diltiazem cap 420mg/24 Tier 1diltiazem tab 30mg Tier 1diltiazem tab 60mg Tier 1diltiazem tab 90mg Tier 1diltiazem tab 120mg Tier 1diltzac cap 120mg/24 Tier 1diltzac cap 180mg/24 Tier 1diltzac cap 240mg/24 Tier 1diltzac cap 300mg/24 Tier 1diltzac cap 360mg/24 Tier 1DYNACIRC CR TAB 5MG Tier 2



Drug Name Drug Tier Requirements/LimitsDYNACIRC CR TAB 10MG Tier 2felodipine tab 2.5mg er Tier 1felodipine tab 5mg er Tier 1felodipine tab 10mg er Tier 1isradipine cap 2.5mg Tier 1isradipine cap 5mg Tier 1nicardipine cap 20mg Tier 1nicardipine cap 30mg Tier 1nifediac cc tab 30mg er Tier 1nifediac cc tab 60mg er Tier 1nifediac cc tab 90mg er Tier 1nifedical xl tab 30mg Tier 1nifedical xl tab 60mg Tier 1nifedipine cap 10mg Tier 1nifedipine cap 20mg Tier 1nifedipine tab 30mg er Tier 1nifedipine tab 60mg er Tier 1nifedipine tab 90mg er Tier 1nimodipine cap 30mg Tier 1 PAnisoldipine tab 8.5mg er Tier 1nisoldipine tab 17mg er Tier 1nisoldipine tab 20mg Tier 1nisoldipine tab 25.5mg Tier 1nisoldipine tab 30mg Tier 1nisoldipine tab 34mg er Tier 1nisoldipine tab 40mg Tier 1taztia xt cap 120mg/24 Tier 1taztia xt cap 180mg/24 Tier 1taztia xt cap 240mg/24 Tier 1taztia xt cap 300mg/24 Tier 1taztia xt cap 360mg/24 Tier 1verapamil cap 120mg er Tier 1verapamil cap 120mg sr Tier 1verapamil cap 180mg er Tier 1verapamil cap 180mg sr Tier 1verapamil cap 240mg er Tier 1verapamil cap 240mg sr Tier 1verapamil cap 360mg sr Tier 1verapamil tab 40mg Tier 1verapamil tab 80mg Tier 1verapamil tab 120mg Tier 1verapamil tab 120mg er Tier 1verapamil tab 120mg sr Tier 1



Drug Name Drug Tier Requirements/Limitsverapamil tab 180mg er Tier 1verapamil tab 180mg sr Tier 1verapamil tab 240mg er Tier 1verapamil tab 240mg sr Tier 1

CARDIOTONICSCardiac Glycosides

digoxin sol 50mcg/ml Tier 1digoxin tab 0.25mg Tier 1digoxin tab 0.125mg Tier 1

CARDIOVASCULAR AGENTS - MISC.Impotence Agents

CAVERJECT INJ 20MCG Tier 3 PA; QLCAVERJECT INJ 40MCG Tier 3 PA; QLCAVERJECT KIT 10MCG Tier 3 PA; QLCAVERJECT KIT 20MCG Tier 3 PA; QLCIALIS TAB 2.5MG Tier 3 PA; QLCIALIS TAB 5MG Tier 3 PA; QLCIALIS TAB 10MG Tier 3 PA; QLCIALIS TAB 20MG Tier 3 PA; QLEDEX KIT 10MCG Tier 3 PA; QLEDEX KIT 20MCG Tier 3 PA; QLEDEX KIT 40MCG Tier 3 PA; QLLEVITRA TAB 2.5MG Tier 3 PA; QLLEVITRA TAB 5MG Tier 3 PA; QLLEVITRA TAB 10MG Tier 3 PA; QLLEVITRA TAB 20MG Tier 3 PA; QLMUSE SUP 125MCG Tier 3 PA; QLMUSE SUP 250MCG Tier 3 PA; QLMUSE SUP 500MCG Tier 3 PA; QLMUSE SUP 1000MCG Tier 3 PA; QLSTAXYN TAB 10MG Tier 3 PA; QLVIAGRA TAB 25MG Tier 3 PA; QLVIAGRA TAB 50MG Tier 3 PA; QLVIAGRA TAB 100MG Tier 3 PA; QLyohimbine tab 5.4mg Tier 1 QL

Prostaglandin VasodilatorsREMODULIN INJ 1MG/ML Tier 4 PAREMODULIN INJ 2.5MG/ML Tier 4 PAREMODULIN INJ 5MG/ML Tier 4 PAREMODULIN INJ 10MG/ML Tier 4 PAVENTAVIS SOL 10MCG/ML Tier 4 PA

Pulmonary Hypertension - Endothelin Receptor Antagonists



Drug Name Drug Tier Requirements/LimitsLETAIRIS TAB 5MG Tier 4 PALETAIRIS TAB 10MG Tier 4 PATRACLEER TAB 62.5MG Tier 4 PATRACLEER TAB 125MG Tier 4 PA

Pulmonary Hypertension - Phosphodiesterase InhibitorsADCIRCA TAB 20MG Tier 4 PAsildenafil tab 20mg Tier 4 PA

CEPHALOSPORINSCephalosporins - 1st Generation

cefadroxil cap 500mg Tier 1cefadroxil sus 250/5ml Tier 1cefadroxil sus 500/5ml Tier 1cefadroxil tab 1gm Tier 1cephalexin cap 250mg Tier 1cephalexin cap 500mg Tier 1cephalexin cap 750mg Tier 1cephalexin sus 125/5ml Tier 1cephalexin sus 250/5ml Tier 1cephalexin tab 250mg Tier 1cephalexin tab 500mg Tier 1KEFLEX CAP 750MG Tier 1

Cephalosporins - 2nd Generationcefaclor cap 250mg Tier 1cefaclor cap 500mg Tier 1cefaclor sus 125/5ml Tier 1cefaclor sus 250/5ml Tier 1cefaclor sus 375/5ml Tier 1cefprozil sus 125/5ml Tier 1cefprozil sus 250/5ml Tier 1cefprozil tab 250mg Tier 1cefprozil tab 500mg Tier 1CEFTIN SUS 250/5ML Tier 2cefuroxime sus 125/5ml Tier 1cefuroxime tab 250mg Tier 1cefuroxime tab 500mg Tier 1

Cephalosporins - 3rd GenerationCEDAX CAP 400MG Tier 2cefdinir cap 300mg Tier 1cefdinir sus 125/5ml Tier 1cefdinir sus 250/5ml Tier 1cefditoren tab 200mg Tier 1cefditoren tab 400mg Tier 1



Drug Name Drug Tier Requirements/Limitscefpodo prox sus 50mg/5ml Tier 1cefpodo prox sus 100/5ml Tier 1cefpodoxime tab 100mg Tier 1cefpodoxime tab 200mg Tier 1SUPRAX SUS 100/5ML Tier 2SUPRAX SUS 200/5ML Tier 2SUPRAX TAB 400MG Tier 2

CONTRACEPTIVESCombination Contraceptives - Oral

altavera tab Tier 0alyacen tab 1/35 Tier 0alyacen tab 7/7/7 Tier 0amethyst tab 90-20mcg Tier 0apri tab Tier 0aranelle tab Tier 0aviane tab Tier 0azurette tab 28 day Tier 0balziva tab Tier 0briellyn tab Tier 0caziant pak Tier 0cesia pak Tier 0chateal tab 0.15/30 Tier 0cryselle-28 tab 28 tabs Tier 0cyclafem tab 1/35 Tier 0cyclafem tab 7/7/7 Tier 0dasetta tab 1/35 Tier 0dasetta tab 7/7/7 Tier 0drospir/ethi tab 3-0.03mg Tier 0elinest tab Tier 0emoquette tab Tier 0enpresse-28 tab Tier 0enskyce tab Tier 0estarylla tab 0.25-35 Tier 0falmina tab Tier 0gianvi tab 3-0.02mg Tier 0gildagia tab 0.4-35 Tier 0gildess fe tab 1.5/30 Tier 0gildess fe tab 1/20 Tier 0gildess tab 1.5/30 Tier 0gildess tab 1/20 Tier 0junel 1.5/30 tab Tier 0junel 1/20 tab Tier 0



Drug Name Drug Tier Requirements/Limitsjunel fe tab 1.5/30 Tier 0junel fe tab 1/20 Tier 0kariva tab 28 day Tier 0kelnor tab 1/35 Tier 0kurvelo tab 0.15/30 Tier 0leena tab Tier 0lessina tab Tier 0levonest tab Tier 0levonor/ethi tab 0.1-0.02 Tier 0levonor/ethi tab estradio Tier 0levora-28 tab 0.15/30 Tier 0loryna tab 3-0.02mg Tier 0low-ogestrel tab Tier 0lutera tab Tier 0marlissa tab 0.15/30 Tier 0microgestin tab 1.5/30 Tier 0microgestin tab 1/20 Tier 0microgestin tab fe1.5/30 Tier 0microgestin tab fe 1/20 Tier 0mono-linyah tab 0.25-35 Tier 0mononessa tab Tier 0myzilra tab Tier 0necon tab 0.5/35 Tier 0necon tab 1/35 Tier 0necon tab 1/50-28 Tier 0necon tab 7/7/7 Tier 0norgest/eth tab estrad Tier 0norgest/ethi tab 0.25/35 Tier 0norgest/ethi tab estradio Tier 0nortrel tab 0.5/35 Tier 0nortrel tab 1/35 Tier 0nortrel tab 7/7/7 Tier 0ocella tab 3-0.03mg Tier 0ogestrel tab Tier 0orsythia tab Tier 0philith tab 0.4-35 Tier 0portia-28 tab Tier 0previfem tab Tier 0reclipsen tab Tier 0solia tab Tier 0sprintec 28 tab 28 day Tier 0sronyx tab Tier 0syeda tab 3-0.03mg Tier 0



Drug Name Drug Tier Requirements/Limitstilia fe tab Tier 0tri-estaryll tab Tier 0tri-legest tab fe Tier 0tri-linyah tab Tier 0tri-previfem tab Tier 0tri-sprintec tab Tier 0trinessa tab Tier 0trivora-28 tab Tier 0velivet pak Tier 0vestura tab 3-0.02mg Tier 0viorele tab Tier 0wera tab 0.5/35 Tier 0wymzya fe chw 0.4mg-35 Tier 0zarah tab 3-0.03mg Tier 0zenchent fe chw Tier 0zenchent fe chw 0.4mg-35 Tier 0zenchent tab Tier 0zeosa chw Tier 0zovia 1/35e tab Tier 0zovia 1/50e tab Tier 0

Combination Contraceptives - TransdermalORTHO EVRA DIS WEEK Tier 0

Combination Contraceptives - VaginalNUVARING MIS Tier 0

Emergency ContraceptivesELLA TAB 30MG Tier 0levonorgestr tab 0.75mg Tier 0my way tab 1.5mg Tier 0next choice tab 0.75mg Tier 0next choice tab 1.5mg Tier 0

Progestin Contraceptives - IUDMIRENA IUD SYSTEM Tier 0 PASKYLA IUD 13.5MG Tier 0 PA

Progestin Contraceptives - ImplantsIMPLANON IMP 68MG Tier 0 PANEXPLANON IMP 68MG Tier 0 PA

Progestin Contraceptives - InjectableDEPO-SQ PROV INJ 104 Tier 2medroxypr ac inj 150mg/ml Tier 0

Progestin Contraceptives - Oralcamila tab 0.35mg Tier 0errin tab 0.35mg Tier 0heather tab 0.35mg Tier 0



Drug Name Drug Tier Requirements/Limitsjencycla tab 0.35mg Tier 0jolivette tab 0.35mg Tier 0nora-be tab 0.35mg Tier 0norethindron tab 0.35mg Tier 0

CORTICOSTEROIDSGlucocorticosteroids

asmalpred sol 15mg/5ml Tier 1asmalpred sol plus Tier 1baycadron elx 0.5/5ml Tier 1budesonide cap 3mg/24hr Tier 1 PAcortisone ac tab 25mg Tier 1dexamethason con 1mg/ml Tier 1dexamethason elx 0.5/5ml Tier 1dexamethason sol 0.5/5ml Tier 1dexamethason tab 0.5mg Tier 1dexamethason tab 0.75mg Tier 1dexamethason tab 1.5mg Tier 1dexamethason tab 1mg Tier 1dexamethason tab 2mg Tier 1dexamethason tab 4mg Tier 1dexamethason tab 6mg Tier 1hydrocort tab 5mg Tier 1hydrocort tab 10mg Tier 1hydrocort tab 20mg Tier 1methylpred pak 4mg Tier 1methylpred tab 4mg Tier 1methylpred tab 8mg Tier 1methylpred tab 16mg Tier 1methylpred tab 32mg Tier 1MILLIPRED SOL 10MG/5ML Tier 2MILLIPRED TAB 5MG Tier 2pred sod pho sol 5mg/5ml Tier 1pred sod pho sol 6.7/5ml Tier 1prednisolone sol 15mg/5ml Tier 1prednisolone sol 25mg/5ml Tier 1prednisone pak 5mg Tier 1prednisone pak 10mg Tier 1prednisone sol 5mg/5ml Tier 1prednisone tab 1mg Tier 1prednisone tab 2.5mg Tier 1prednisone tab 5mg Tier 1prednisone tab 10mg Tier 1



Drug Name Drug Tier Requirements/Limitsprednisone tab 20mg Tier 1prednisone tab 50mg Tier 1VERIPRED 20 SOL 20MG/5ML Tier 2

Mineralocorticoidsfludrocort tab 0.1mg Tier 1

COUGH/COLD/ALLERGYAntitussives

benzonatate cap 100mg Tier 1benzonatate cap 200mg Tier 1hydrocod/hom syp 5-1.5/5 Tier 1hydromet syp 5-1.5/5 Tier 1

Cough/Cold/Allergy Combinationsbiocotron liq 100-10/5 Tier 1broncotron liq 10-100/5 Tier 1c-phen dm syp Tier 1ceron-dm syp Tier 1cheratussin sol dac Tier 1cheratussin syp ac Tier 1diabetic tus liq children Tier 1diabetic tus liq dm Tier 1dm/gg sol Tier 1dm/gg sol 10-100/5 Tier 1g-tron liq 10-100/5 Tier 1gani-tuss dm liq 100-10/5 Tier 1gani-tuss nr liq 100-10/5 Tier 1gg/codeine sol 100-10/5 Tier 1gnp tussin liq dm Tier 1gnp tussin liq dm cough Tier 1guaiasorb dm liq 100-10/5 Tier 1guaiatussin syp ac Tier 1guaifenesin sol dac Tier 1guaifenesin syp ac Tier 1hm tussin liq adlt dm Tier 1iophen c-nr liq 100-10/5 Tier 1iophen dm-nr liq 100-10/5 Tier 1medi-tuss dm liq diabetic Tier 1myci-gc sol 100-10/5 Tier 1mytussin ac syp 100-10/5 Tier 1mytussin dac sol Tier 1novagest/cod sol expect Tier 1ped formula liq 100-10/5 Tier 1prometh vc syp 6.25-5/5 Tier 1



Drug Name Drug Tier Requirements/Limitsprometh vc syp plain Tier 1prometh vc/ syp codeine Tier 1prometh/cod syp 6.25-10 Tier 1promethazine syp dm Tier 1px tussin dm liq 100-10/5 Tier 1ra tussin dm liq 100-10/5 Tier 1robafen ac syp 100-10/5 Tier 1robitussin liq cgh/cong Tier 1robitussin liq to go dm Tier 1romilar ac sol 100-10/5 Tier 1safe tussin liq 10-100/5 Tier 1sb cgh contr liq dm Tier 1sildec pe-dm syp Tier 1siltussin dm liq das Tier 1siltussin-dm liq diabetic Tier 1tgt cough liq form dm Tier 1tolu-sed dm liq 100-10/5 Tier 1tusnel diabt liq 10-100/5 Tier 1tussin adult liq cgh/cong Tier 1tussin cough liq 10-100/5 Tier 1tussin cough liq congesti Tier 1tussin dm liq Tier 1tussin dm liq 100-10/5 Tier 1tussin dm liq clear Tier 1wal-tussin liq dm Tier 1

Expectorantsbuckleys liq chest Tier 1chest conges liq child Tier 1chest conges liq childrns Tier 1coughtab tab 200mg Tier 1diabetic tus liq 100/5ml Tier 1eq tussin liq 100/5ml Tier 1ganidin-nr liq 100/5ml Tier 1guaifenesin liq nr Tier 1guaifenesin sol 100/5ml Tier 1guaifenesin sol 200/10ml Tier 1guaifenesin sol 300/15ml Tier 1guaifenesin tab 200mg Tier 1iophen-nr liq 100/5ml Tier 1mucinex chld liq 100/5ml Tier 1mucinex/kids liq 100/5ml Tier 1mucus relief liq 100/5ml Tier 1mucus relief liq 400/20ml Tier 1



Drug Name Drug Tier Requirements/Limitsmucus+chst liq 100/5ml Tier 1organ-i nr tab 200mg Tier 1px tussin sol 100/5ml Tier 1qc medifin liq mucus rl Tier 1qc medifin tab 200mg Tier 1ra tussin liq 100/5ml Tier 1refenesen tab 200mg Tier 1sb coughtab tab 200mg Tier 1scot-tussin liq expct sf Tier 1siltuss das liq 100/5ml Tier 1th tussin liq 100/5ml Tier 1tussin adult liq 100/5ml Tier 1

Misc. Respiratory Inhalantssod chloride neb 0.9% Tier 1sodium chlor neb 7% Tier 1

Mucolyticsacetylcyst sol 10% Tier 1acetylcyst sol 20% Tier 1

DERMATOLOGICALSAcne Products

acne medicat gel 10% Tier 1acne treatmn gel 10% Tier 1acne-clear gel 10% Tier 1adapalene cre 0.1% Tier 1 PAadapalene gel 0.1% Tier 1 PAamnesteem cap 10mg Tier 1 PAamnesteem cap 20mg Tier 1 PAamnesteem cap 40mg Tier 1 PAATRALIN GEL 0.05% Tier 2 PA; AGEavita cre 0.025% Tier 1 AGEavita gel 0.025% Tier 1 AGEAZELEX CRE 20% Tier 3benzoyl per gel 5% Tier 1benzoyl per gel 10% Tier 1benzoyl per liq 5% wash Tier 1benzoyl per liq 10% wash Tier 1bp gel gel 5% Tier 1bp gel gel 10% Tier 1bp wash liq 5% Tier 1bp wash liq 10% Tier 1bpo-5 wash liq 5% Tier 1bpo-10 wash liq 10% Tier 1



Drug Name Drug Tier Requirements/Limitsclaravis cap 10mg Tier 1 PAclaravis cap 20mg Tier 1 PAclaravis cap 30mg Tier 1 PAclaravis cap 40mg Tier 1 PAclearplex v gel 5% Tier 1clearplex x gel 10% Tier 1clindacin-p pad 1% Tier 1clindamax gel 1% Tier 1clindamax lot 10mg/ml Tier 1clindamy/ben gel 1-5% Tier 1clindamy/ben gel 1.2-5% Tier 1clindamycin aer 1% Tier 1 PAclindamycin gel 1% Tier 1clindamycin lot 1% Tier 1clindamycin lot 10mg/ml Tier 1clindamycin pad 1% Tier 1clindamycin sol 1% Tier 1DIFFERIN GEL 0.3% Tier 2 PAEPIDUO GEL 0.1-2.5% Tier 3 PAery pad 2% Tier 1 PAerythromycin gel 2% Tier 1erythromycin gel /benzoyl Tier 1erythromycin pad 2% Tier 1 PAerythromycin sol 2% Tier 1foaming face liq wsh 10% Tier 1myorisan cap 10mg Tier 1 PAmyorisan cap 20mg Tier 1 PAmyorisan cap 40mg Tier 1 PApanoxyl wash liq 10% Tier 1persa-gel gel 10% Tier 1persa-gel xs gel 5% Tier 1ra renewal gel 10% Tier 1sotret cap 10mg Tier 1 PAsotret cap 20mg Tier 1 PAsotret cap 30mg Tier 1 PATRETIN-X CRE 0.0375% Tier 2 AGEtretinoin cre 0.1% Tier 1 AGEtretinoin cre 0.05% Tier 1 AGEtretinoin cre 0.025% Tier 1 AGEtretinoin gel 0.01% Tier 1 AGEtretinoin gel 0.025% Tier 1 AGEVELTIN GEL Tier 3zenatane cap 10mg Tier 1 PA



Drug Name Drug Tier Requirements/Limitszenatane cap 20mg Tier 1 PAzenatane cap 40mg Tier 1 PAZIANA GEL Tier 3

Agents for External Genital and Perianal WartsVEREGEN OIN 15% Tier 3

Agents for Facial Wrinklesrefissa cre 0.05% Tier 1tretinoin em cre 0.05% Tier 1

Anti-inflammatory Agents - TopicalVOLTAREN GEL 1% Tier 2

Antibiotics - TopicalALTABAX OIN 1% Tier 3centany oin 2% Tier 1CORTISPORIN CRE 0.5% Tier 2CORTISPORIN OIN 1% Tier 2gentamicin cre 0.1% Tier 1gentamicin oin 0.1% Tier 1mupirocin ca cre 2% Tier 1mupirocin cre 2% Tier 1mupirocin oin 2% Tier 1

Antifungals - Topicalantifungal cre 1% Tier 1antifungal cre 2% Tier 1athlete foot cre 1% Tier 1baza antifun cre 2% Tier 1ciclodan cre 0.77% Tier 1ciclopirox cre 0.77% Tier 1ciclopirox gel 0.77% Tier 1ciclopirox sus 0.77% Tier 1clotrim/beta cre 1-0.05% Tier 1clotrim/beta cre diprop Tier 1clotrim/beta lot diprop Tier 1clotrimazole cre 1% Tier 1clotrimazole sol 1% Tier 1desenex cre 1% Tier 1econazole cre 1% Tier 1ERTACZO CRE 2% Tier 3EXELDERM CRE 1% Tier 2EXELDERM SOL 1% Tier 2fungicure spr intens Tier 1jock itch cre 1% Tier 1ketoconazole aer 2% Tier 1ketoconazole cre 2% Tier 1



Drug Name Drug Tier Requirements/Limitsketoconazole sha 2% Tier 1ketodan aer 2% Tier 1LAMISIL AT SPR 1% Tier 2LAMISIL SPR 1% Tier 2LOTRIMIN ULT CRE 1% Tier 2MENTAX CRE 1% Tier 2micaderm cre 2% Tier 1miconazole cre 2% Tier 1MICONAZOLE POW NITRATE Tier 2micro guard cre 2% Tier 1mp clotrimaz cre 1% Tier 1NAFTIN CRE 1% Tier 2NAFTIN CRE 2% Tier 2NAFTIN GEL 1% Tier 2neosporin af cre 2% jock Tier 1nuzole cre 2% Tier 1nyamyc pow 100000 Tier 1nystat/triam cre Tier 1nystat/triam oin Tier 1nystatin cre 100000 Tier 1nystatin oin 100000 Tier 1nystatin pow 100000 Tier 1nystop pow 100000 Tier 1OXISTAT CRE 1% Tier 3 PAOXISTAT LOT 1% Tier 3 PApedi-dri pow 100000 Tier 1podactin cre 2% Tier 1remedy cre antifung Tier 1ringworm cre 1% Tier 1sm antifungl cre 2% Tier 1soothe&cool cre inzo 2% Tier 1

Antineoplastic or Premalignant Lesion Agents - Topicalfluorouracil cre 5% Tier 1fluorouracil dro 2% Tier 1fluorouracil dro 5% Tier 1fluorouracil sol 2% Tier 1fluorouracil sol 5% Tier 1PANRETIN GEL 0.1% Tier 4PICATO GEL 0.05% Tier 3PICATO GEL 0.015% Tier 3

Antipruritics - Topicalprudoxin cre 5% Tier 1

Antipsoriatics



Drug Name Drug Tier Requirements/Limitscalcipotrien cre 0.005% Tier 1calcipotrien oin 0.005% Tier 1calcipotrien sol 0.005% Tier 1calcitrene oin 0.005% Tier 1calcitriol oin 3mcg/gm Tier 1OXSORALEN-UL CAP 10MG Tier 3 PASORIATANE CAP 10MG Tier 3SORIATANE CAP 17.5MG Tier 3SORIATANE CAP 25MG Tier 3STELARA INJ 45MG/0.5 Tier 4 PASTELARA INJ 90MG/ML Tier 4 PATAZORAC CRE 0.1% Tier 2TAZORAC CRE 0.05% Tier 2TAZORAC GEL 0.1% Tier 2TAZORAC GEL 0.05% Tier 2

Antiseborrheic Productsselenium sul lot 2.5% Tier 1selenium sul sha 2.5% Tier 1

Antivirals - TopicalDENAVIR CRE 1% Tier 2

Burn Productssilver sulfa cre 1% Tier 1ssd af cre 1% Tier 1ssd cre 1% Tier 1SULFAMYLON CRE 85MG/GM Tier 2thermazene cre 1% Tier 1

Corticosteroids - Topicalala cort cre 1% Tier 1ala-cort lot 1% Tier 1alclometason cre 0.05% Tier 1alclometason oin 0.05% Tier 1amcinonide cre 0.1% Tier 1amcinonide lot 0.1% Tier 1AMCINONIDE OIN 0.1% Tier 2anti-itch cre 1% Tier 1anti-itch cre 1%pls 10 Tier 1anti-itch cre /aloe/e Tier 1anti-itch cre /oatmeal Tier 1anti-itch lot 1% Tier 1anti-itch oin 1% Tier 1anti-itch oin max st Tier 1apexicon oin 0.05% Tier 1aquanil hc lot 1% Tier 1



Drug Name Drug Tier Requirements/Limitsaug betamet cre 0.05% Tier 1aug betamet oin 0.05% Tier 1aveeno cre 1% Tier 1beta hc lot 1% Tier 1betameth dip cre 0.05% Tier 1betameth dip oin 0.05% Tier 1betameth val cre 0.1% Tier 1betameth val lot 0.1% Tier 1betameth val oin 0.1% Tier 1caldecort cre 1% Tier 1clobetasol cre 0.05% Tier 1clobetasol gel 0.05% Tier 1clobetasol oin 0.05% Tier 1clobetasol sol 0.05% Tier 1CLODERM CRE 0.1% Tier 3CLODERM CRE 0.1% PMP Tier 3CORDRAN LOT 0.05% Tier 2CORDRAN SP CRE 0.05% Tier 2cormax oin 0.05% Tier 1cormax scalp sol 0.05% Tier 1cormax sol 0.05% Tier 1cort intense cre heal 1% Tier 1cortaid adv cre 1% 12 hr Tier 1cortaid cre 1% Tier 1cortisone + cre 1% Tier 1cortisone cre 1% Tier 1cortisone lot 1% Tier 1cortisone oin 1%max st Tier 1cortizone-10 lot eczema Tier 1cortizone-10 lot hydraten Tier 1cortizone-10 oin 1% Tier 1cvs cort int cre heal 1% Tier 1desonide cre 0.05% Tier 1desonide lot 0.05% Tier 1desonide oin 0.05% Tier 1desoximetas cre 0.05% Tier 1desoximetas cre 0.25% Tier 1desoximetas gel 0.05% Tier 1desoximetas oin 0.05% Tier 1desoximetas oin 0.25% Tier 1diflorasone cre 0.05% Tier 1diflorasone oin 0.05% Tier 1eq hydrocort cre 1% Tier 1



Drug Name Drug Tier Requirements/Limitsfluocin acet cre 0.01% Tier 1fluocin acet cre 0.025% Tier 1fluocin acet oin 0.025% Tier 1fluocin acet sol 0.01% Tier 1fluocinonide cre 0.05% Tier 1fluocinonide gel 0.05% Tier 1fluocinonide oin 0.05% Tier 1fluocinonide sol 0.05% Tier 1fluticasone cre 0.05% Tier 1fluticasone oin 0.005% Tier 1gnp hydrocor cre 1% plus Tier 1halobetasol cre 0.05% Tier 1halobetasol oin 0.05% Tier 1HALOG CRE 0.1% Tier 2HALOG OIN 0.1% Tier 2hc pramoxine cre 1-2.5% Tier 1hc valerate cre 0.2% Tier 1hc valerate oin 0.2% Tier 1hydro-lotion lot 1% Tier 1hydrocort cre 1% Tier 1hydrocort cre 1% plus Tier 1hydrocort cre 1%pls 10 Tier 1hydrocort cre 1%pls 12 Tier 1hydrocort cre 2.5% Tier 1hydrocort lot 1% Tier 1hydrocort lot 2.5% Tier 1hydrocort oin 1% Tier 1hydrocort oin 2.5% Tier 1hydrocort/ab oin 1% Tier 1hydrocream cre 1% Tier 1hydroskin cre 1% Tier 1itch-x lot 1% Tier 1kericort 10 cre 1% Tier 1lokara lot 0.05% Tier 1med-derm hc cre 1% Tier 1mometasone cre 0.1% Tier 1mometasone oin 0.1% Tier 1mometasone sol 0.1% Tier 1mp hydrocort cre 1% Tier 1mp hydrocort oin 1% Tier 1neosporin cre eczema Tier 1noble formul cre hc 1% Tier 1pramcort cre 1-1% Tier 1



Drug Name Drug Tier Requirements/Limitsprednicarbat cre 0.1% Tier 1prednicarbat oin 0.1% Tier 1prep h hc cre 1% Tier 1qc hydrocort cre 1% Tier 1ra anti-itch cre 1% Tier 1ra anti-itch oin 1% Tier 1ra hydrocort cre 1% Tier 1ra hydrocort cre 1%pls 12 Tier 1recort plus cre 1% Tier 1rederm lot 1% Tier 1sarnol-hc lot 1% Tier 1sb hydrocort cre 1% Tier 1sb hydrocort oin 1% Tier 1scalacort lot 2% Tier 1sm hydrocort cre 1% Tier 1sm hydrocort oin 1% Tier 1TACLONEX OIN Tier 3TACLONEX SUS Tier 3th hydrocort cre 1% Tier 1theracort lot 1% Tier 1triamcinolon cre 0.1% Tier 1triamcinolon cre 0.5% Tier 1triamcinolon cre 0.025% Tier 1triamcinolon lot 0.1% Tier 1triamcinolon oin 0.1% Tier 1triamcinolon oin 0.5% Tier 1triamcinolon oin 0.05% Tier 1triamcinolon oin 0.025% Tier 1triderm cre 0.1% Tier 1VANOS CRE 0.1% Tier 2

Emollientsal12 lot 12% Tier 1amlactin cre 12% Tier 1amlactin lot 12% Tier 1ammonium lac cre 12% Tier 1ammonium lac lot 12% Tier 1geri-hydrola cre 12% Tier 1geri-hydrola lot 12% Tier 1laclotion lot 12% Tier 1moist skin cre 12% Tier 1moist skin lot 12% Tier 1skin trtment lot 12% Tier 1

Enzymes - Topical



Drug Name Drug Tier Requirements/LimitsSANTYL OIN 250/GM Tier 2

Hair Growth Agentsfinasteride tab 1mg Tier 1

Immunomodulating Agents - Topicalimiquimod cre 5% Tier 1ZYCLARA CRE 3.75% Tier 2ZYCLARA PUMP CRE 2.5% Tier 2ZYCLARA PUMP CRE 3.75% Tier 2

Immunosuppressive Agents - TopicalELIDEL CRE 1% Tier 2PROTOPIC OIN 0.1% Tier 2PROTOPIC OIN 0.03% Tier 2

Keratolytic/Antimitotic AgentsCONDYLOX GEL 0.5% Tier 2podofilox sol 0.5% Tier 1

Local Anesthetics - Topicallido/prilocn cre 2.5-2.5% Tier 1lidocaine gel 2% Tier 1lidocaine gel 2% jelly Tier 1lidocaine oin 5% Tier 1lidocaine sol 4% Tier 1LIDODERM DIS 5% Tier 2regenecare gel ha 2% Tier 1SYNERA DIS 70-70MG Tier 3

Misc. Topicalhypercare sol 20% Tier 1

Pigmenting-Depigmenting AgentsOXSORALEN LOT 1% Tier 3

Rosacea AgentsFINACEA GEL 15% Tier 3METROGEL GEL 1% Tier 2metronidazol cre 0.75% Tier 1metronidazol gel 0.75% Tier 1metronidazol lot 0.75% Tier 1NORITATE CRE 1% Tier 2rosadan cre 0.75% Tier 1rosadan gel 0.75% Tier 1vitazol cre 0.75% Tier 1

Scabicides PediculicidesA-200 GEL 0.33-4% Tier 2acticin cre 5% Tier 1BARC LIQ Tier 2



Drug Name Drug Tier Requirements/LimitsEURAX CRE 10% Tier 2EURAX LOT 10% Tier 2gnp lice egg gel remover Tier 2lice egg gel remover Tier 2lice md gel Tier 2LICE TRTMNT KIT MAX-STR Tier 2liceout gel Tier 2liceout gel /comb Tier 2LICIDE TREAT KIT Tier 2lindane lot 1% Tier 1lindane sha 1% Tier 1LYCELLE GEL Tier 2malathion lot 0.5% Tier 1 STmed-lice gel combing Tier 2nix combing gel Tier 2NIX LICE SPR CONTROL Tier 2permethrin cre 5% Tier 1PRONTO AER 0.4% Tier 2PYRE/PIPERON LIQ Tier 2ra lice egg gel remover Tier 2RID LICE KIL AER MOUSSE Tier 2spinosad sus 0.9% Tier 3 PAstop lice gel step 2 Tier 2SULF LIME SOL USP Tier 2TEGRIN-LT KIT Tier 2ULESFIA LOT 5% Tier 3 PA

Wound Care ProductsREGRANEX GEL 0.01% Tier 3 PA

DIAGNOSTIC PRODUCTSDiagnostic Tests

ASCENSIA MIS AUTODISC Tier 2BAYER BREEZE MIS 2 TEST Tier 2CLINISTIX TES STRIPS Tier 2DIASTIX TES STRIPS Tier 2TRUETEST TES Tier 2

DIGESTIVE AIDSDigestive Enzymes

CREON CAP 6000UNIT Tier 2CREON CAP 12000UNT Tier 2CREON CAP 24000UNT Tier 2PANCREAZE CAP 4200UNIT Tier 2PANCREAZE CAP 10500UNT Tier 2



Drug Name Drug Tier Requirements/LimitsPANCREAZE CAP 16800UNT Tier 2PANCREAZE CAP 21000UNT Tier 2pancrelipase cap 5000unit Tier 2ZENPEP CAP 10000UNT Tier 2ZENPEP CAP 15000UNT Tier 2ZENPEP CAP 20000UNT Tier 2

DIURETICSCarbonic Anhydrase Inhibitors

acetazolamid cap 500mg er Tier 1acetazolamid tab 125mg Tier 1acetazolamid tab 250mg Tier 1methazolamid tab 25mg Tier 1methazolamid tab 50mg Tier 1

Diuretic CombinationsALDACTAZIDE TAB 50/50 Tier 2amilor/hctz tab 5-50 Tier 1spirono/hctz tab 25/25 Tier 1triamt/hctz cap 37.5-25 Tier 1triamt/hctz tab 37.5-25 Tier 1triamt/hctz tab 75-50mg Tier 1

Loop Diureticsbumetanide tab 0.5mg Tier 1bumetanide tab 1mg Tier 1bumetanide tab 2mg Tier 1EDECRIN TAB 25MG Tier 2furosemide sol 10mg/ml Tier 1furosemide tab 20mg Tier 1furosemide tab 40mg Tier 1furosemide tab 80mg Tier 1torsemide tab 5mg Tier 1torsemide tab 10mg Tier 1torsemide tab 20mg Tier 1torsemide tab 100mg Tier 1

Potassium Sparing Diureticsamiloride tab 5mg Tier 1DYRENIUM CAP 50MG Tier 2DYRENIUM CAP 100MG Tier 2spironolact tab 25mg Tier 1spironolact tab 50mg Tier 1spironolact tab 100mg Tier 1

Thiazides and Thiazide-Like Diureticschlorothiaz tab 250mg Tier 1



Drug Name Drug Tier Requirements/Limitschlorothiaz tab 500mg Tier 1chlorthalid tab 25mg Tier 1chlorthalid tab 50mg Tier 1chlorthalid tab 100mg Tier 1hydrochlorot cap 12.5mg Tier 1hydrochlorot tab 12.5mg Tier 1hydrochlorot tab 25mg Tier 1hydrochlorot tab 50mg Tier 1indapamide tab 1.25mg Tier 1indapamide tab 2.5mg Tier 1methyclothia tab 5mg Tier 1metolazone tab 2.5mg Tier 1metolazone tab 5mg Tier 1metolazone tab 10mg Tier 1THALITONE TAB 15MG Tier 3

ENDOCRINE AND METABOLIC AGENTS - MISC.Bone Density Regulators

ACTONEL TAB 5MG Tier 2 STACTONEL TAB 30MG Tier 2 STACTONEL TAB 35MG Tier 2 STACTONEL TAB 150MG Tier 2 STalendronate tab 5mg Tier 1alendronate tab 10mg Tier 1alendronate tab 35mg Tier 1alendronate tab 40mg Tier 1alendronate tab 70mg Tier 1calcitonin spr 200/act Tier 1etidron disd tab 200mg Tier 1etidron disd tab 400mg Tier 1FORTEO SOL 600/2.4 Tier 4 PAFOSAMAX + D TAB 70-2800 Tier 3FOSAMAX + D TAB 70-5600 Tier 3ibandronate tab 150mg Tier 1 PApamidronate inj 30/10ml Tier 4 PApamidronate inj 30mg Tier 4 PApamidronate inj 90/10ml Tier 4 PApamidronate inj 90mg Tier 4 PASKELID TAB 200MG Tier 2 PA

Fertility Regulatorschor gonadot inj 10000unt Tier 4 PAnovarel inj 10000unt Tier 4 PApregnyl inj 10000unt Tier 4 PA



Drug Name Drug Tier Requirements/LimitsGrowth Hormone Receptor Antagonists

SOMAVERT INJ 10MG Tier 4 PASOMAVERT INJ 15MG Tier 4 PASOMAVERT INJ 20MG Tier 4 PA

Growth HormonesTEV-TROPIN INJ 5MG Tier 4 PA

Hormone Receptor ModulatorsEVISTA TAB 60MG Tier 2

LHRH/GnRH Agonist Analog Pituitary SuppressantsLUPR DEP-PED INJ 7.5MG Tier 4 PALUPR DEP-PED INJ 11.25MG Tier 4 PALUPR DEP-PED INJ 15MG Tier 4 PALUPR DEP-PED INJ 30MG Tier 4 PASYNAREL SOL 2MG/ML Tier 4 PA

Metabolic ModifiersBUPHENYL TAB 500MG Tier 4 PAcalcitriol cap 0.5mcg Tier 1calcitriol cap 0.25mcg Tier 1calcitriol sol 1mcg/ml Tier 1FABRAZYME INJ 5MG Tier 4 PAHECTOROL CAP 0.5MCG Tier 2HECTOROL CAP 1MCG Tier 2HECTOROL CAP 2.5MCG Tier 2levocarnitin sol 1gm/10ml Tier 1levocarnitin tab 330mg Tier 1LUMIZYME INJ 50MG Tier 4 PAMYOZYME INJ 50MG Tier 4 PAORFADIN CAP 2MG Tier 4 PAORFADIN CAP 5MG Tier 4 PAORFADIN CAP 10MG Tier 4 PASENSIPAR TAB 30MG Tier 4 PASENSIPAR TAB 60MG Tier 4 PASENSIPAR TAB 90MG Tier 4 PA

Posterior Pituitary Hormonesdesmopressin inj 4mcg/ml Tier 4 PAdesmopressin sol 0.01% Tier 1 PAdesmopressin tab 0.1mg Tier 1desmopressin tab 0.2mg Tier 1STIMATE SOL 1.5MG/ML Tier 4 PA

Prolactin Inhibitorscabergoline tab 0.5mg Tier 1

Somatostatic Agents



Drug Name Drug Tier Requirements/Limitsoctreotide inj 50mcg/ml Tier 4 PAoctreotide inj 100mcg Tier 4 PAoctreotide inj 200mcg Tier 4 PAoctreotide inj 500mcg Tier 4 PAoctreotide inj 1000mcg Tier 4 PASANDOSTATIN KIT LAR 10MG Tier 4 PASANDOSTATIN KIT LAR 20MG Tier 4 PASANDOSTATIN KIT LAR 30MG Tier 4 PASOMATULINE INJ 60/0.2ML Tier 4 PASOMATULINE INJ 90/0.3ML Tier 4 PASOMATULINE INJ 120/.5ML Tier 4 PA

Vasopressin Receptor AntagonistsSAMSCA TAB 15MG Tier 4 PASAMSCA TAB 30MG Tier 4 PA

ESTROGENSEstrogen Combinations

covaryx hs tab Tier 1covaryx tab Tier 1eemt hs tab Tier 1eemt tab Tier 1essian h.s. tab Tier 1essian tab Tier 1est estrogen tab mtest Tier 1est estrogen tab mtest ds Tier 1est estrogen tab mtest hs Tier 1mtest hs/est tab estrogen Tier 1mtest/est tab estrogen Tier 1PREMPHASE TAB Tier 2PREMPRO TAB 0.3-1.5 Tier 2PREMPRO TAB 0.45-1.5 Tier 2PREMPRO TAB 0.625-5 Tier 2PREMPRO TAB .625-2.5 Tier 2

EstrogensALORA DIS 0.1MG Tier 2ALORA DIS 0.05MG Tier 2ALORA DIS 0.025MG Tier 2ALORA DIS 0.075MG Tier 2CENESTIN TAB 0.3MG Tier 3CENESTIN TAB 0.9MG Tier 3CENESTIN TAB 0.45MG Tier 3CENESTIN TAB 0.625MG Tier 3CENESTIN TAB 1.25MG Tier 3



Drug Name Drug Tier Requirements/LimitsDEPO-ESTRADI INJ 5MG/ML Tier 2 PADIVIGEL GEL 0.5MG Tier 2 PADIVIGEL GEL 0.25MG Tier 2 PADIVIGEL GEL 1MG/GM Tier 2 PAELESTRIN GEL 0.06% Tier 2 PAENJUVIA TAB 0.3MG Tier 2ENJUVIA TAB 0.9MG Tier 2ENJUVIA TAB 0.45MG Tier 2ENJUVIA TAB 0.625MG Tier 2ENJUVIA TAB 1.25MG Tier 2estrad val inj 10mg/ml Tier 1 PAestrad val inj 20mg/ml Tier 1 PAestrad val inj 40mg/ml Tier 1 PAestrad val inj 200mg/5 Tier 1 PAESTRADERM DIS 0.1MG Tier 2ESTRADERM DIS 0.05MG Tier 2estradiol dis 0.1mg Tier 1estradiol dis 0.05mg Tier 1estradiol dis 0.06mg Tier 1estradiol dis 0.025mg Tier 1estradiol dis 0.075mg Tier 1estradiol dis 0.0375mg Tier 1estradiol tab 0.5mg Tier 1estradiol tab 1mg Tier 1estradiol tab 2mg Tier 1ESTRASORB EMU Tier 2 PAESTROGEL GEL Tier 2 PAestropipate tab 0.75mg Tier 1estropipate tab 1.5mg Tier 1estropipate tab 3mg Tier 1EVAMIST SPR 1.53MG Tier 2 PAFEMTRACE TAB 0.9MG Tier 2FEMTRACE TAB 0.45MG Tier 2FEMTRACE TAB 1.8MG Tier 2MENEST TAB 0.3MG Tier 2MENEST TAB 0.625MG Tier 2MENEST TAB 1.25MG Tier 2MENEST TAB 2.5MG Tier 2MENOSTAR DIS 14MCG Tier 2MINIVELLE DIS 0.1MG Tier 2MINIVELLE DIS 0.05MG Tier 2MINIVELLE DIS 0.075MG Tier 2MINIVELLE DIS 0.0375MG Tier 2



Drug Name Drug Tier Requirements/Limitsortho-est tab 0.625 Tier 1ortho-est tab 1.25 Tier 1PREMARIN TAB 0.3MG Tier 2PREMARIN TAB 0.9MG Tier 2PREMARIN TAB 0.45MG Tier 2PREMARIN TAB 0.625MG Tier 2PREMARIN TAB 1.25MG Tier 2VIVELLE-DOT DIS 0.1MG Tier 2VIVELLE-DOT DIS 0.05MG Tier 2VIVELLE-DOT DIS 0.025MG Tier 2VIVELLE-DOT DIS 0.075MG Tier 2VIVELLE-DOT DIS 0.0375MG Tier 2

FLUOROQUINOLONESFluoroquinolones

AVELOX ABC TAB 400MG Tier 3AVELOX TAB 400MG Tier 3CIPRO (5%) SUS 250MG/5 Tier 2CIPRO (10%) SUS 500MG/5 Tier 2ciprofloxacn tab 100mg Tier 1ciprofloxacn tab 250mg Tier 1ciprofloxacn tab 500mg Tier 1ciprofloxacn tab 750mg Tier 1FACTIVE TAB 320MG Tier 3 PAlevofloxacin sol 25mg/ml Tier 1levofloxacin tab 250mg Tier 1levofloxacin tab 500mg Tier 1levofloxacin tab 750mg Tier 1NOROXIN TAB 400MG Tier 2ofloxacin tab 200mg Tier 1ofloxacin tab 300mg Tier 1ofloxacin tab 400mg Tier 1

GASTROINTESTINAL AGENTS - MISC.Gallstone Solubilizing Agents

ursodiol cap 300mg Tier 1ursodiol tab 250mg Tier 1ursodiol tab 500mg Tier 1

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAP 8MCG Tier 3 PAAMITIZA CAP 24MCG Tier 3 PA

Gastrointestinal Stimulantsmetoclopram sol 5mg/5ml Tier 1metoclopram sol 10/10ml Tier 1



Drug Name Drug Tier Requirements/Limitsmetoclopram tab 5mg Tier 1metoclopram tab 10mg Tier 1

Inflammatory Bowel AgentsAPRISO CAP 0.375GM Tier 2ASACOL HD TAB 800MG Tier 2ASACOL TAB 400MG DR Tier 2balsalazide cap 750mg Tier 1CANASA SUP 1000MG Tier 2CIMZIA KIT Tier 4 PADIPENTUM CAP 250MG Tier 2LIALDA TAB 1.2GM Tier 2mesalamine ene 4gm Tier 1mesalamine kit 4gm Tier 1PENTASA CAP 250MG CR Tier 2PENTASA CAP 500MG CR Tier 2REMICADE INJ 100MG Tier 4 PASFROWASA ENE 4GM Tier 3sulfasalazin tab 500mg Tier 1sulfasalazin tab 500mg dr Tier 1sulfazine ec tab 500mg Tier 1sulfazine tab 500mg Tier 1

Intestinal Acidifiersenulose sol 10gm/15 Tier 1generlac sol 10gm/15 Tier 1lactulose sol 10gm/15 10gm/15ml Tier 1

Irritable Bowel Syndrome (IBS) AgentsLOTRONEX TAB 0.5MG Tier 3 PALOTRONEX TAB 1MG Tier 3 PA

Peripheral Opioid Receptor AntagonistsRELISTOR KIT 12/0.6ML Tier 4 PA

Phosphate Binder Agentscalc acetate cap 667mg Tier 1calc acetate tab 667mg Tier 1FOSRENOL CHW 500MG Tier 3 PAFOSRENOL CHW 750MG Tier 3 PAFOSRENOL CHW 1000MG Tier 3 PARENAGEL TAB 400MG Tier 2 STRENAGEL TAB 800MG Tier 2 STRENVELA PAK 0.8GM Tier 2 STRENVELA PAK 2.4GM Tier 2 STRENVELA TAB 800MG Tier 2 ST

GENITOURINARY AGENTS - MISCELLANEOUS



Drug Name Drug Tier Requirements/LimitsAlkalinizers

cytra-k sol Tier 1k citrate sol citr acd Tier 1pot citrate tab 540mg Tier 1pot citrate tab 1080mg Tier 1UROCIT-K 15 TAB Tier 2

Cystinosis AgentsCYSTAGON CAP 50MG Tier 3 PACYSTAGON CAP 150MG Tier 3 PA

Genitourinary Irrigantsargyl saline sol 0.9% Tier 1 PAcurity salin sol 0.9% irr Tier 1 PAsodium chlor sol 0.9% irr Tier 1 PA

Interstitial Cystitis AgentsELMIRON CAP 100MG Tier 3

Prostatic Hypertrophy Agentsalfuzosin tab 10mg Tier 1AVODART CAP 0.5MG Tier 2finasteride tab 5mg Tier 1RAPAFLO CAP 4MG Tier 3RAPAFLO CAP 8MG Tier 3tamsulosin cap 0.4mg Tier 1

Urinary Analgesicsphenazo tab 200mg Tier 1phenazopyrid tab 100mg Tier 1phenazopyrid tab 200mg Tier 1

GOUT AGENTSGout Agent Combinations

proben/colch tab 500-0.5 Tier 1Gout Agents

allopurinol tab 100mg Tier 1allopurinol tab 300mg Tier 1COLCRYS TAB 0.6MG Tier 3ULORIC TAB 40MG Tier 3 PAULORIC TAB 80MG Tier 3 PA

Uricosuricsprobenecid tab 500mg Tier 1

HEMATOLOGICAL AGENTS - MISC.Hematorheologic Agents

pentoxifylli tab 400mg er Tier 1Platelet Aggregation Inhibitors



Drug Name Drug Tier Requirements/LimitsAGGRENOX CAP 25-200MG Tier 2anagrelide cap 0.5mg Tier 1anagrelide cap 1mg Tier 1cilostazol tab 50mg Tier 1cilostazol tab 100mg Tier 1clopidogrel tab 75mg Tier 1clopidogrel tab 300mg Tier 1dipyridamole tab 25mg Tier 1dipyridamole tab 50mg Tier 1dipyridamole tab 75mg Tier 1EFFIENT TAB 5MG Tier 3 PAEFFIENT TAB 10MG Tier 3 PAticlopidine tab 250mg Tier 1

HEMATOPOIETIC AGENTSAgents for Gaucher Disease

ELELYSO INJ 200UNIT Tier 4 PAVPRIV INJ 400UNIT Tier 4 PAZAVESCA CAP 100MG Tier 4 PA

Folic Acid/Folatesfa-8 tab 0.8mg Tier 0folic acid tab 1mg Tier 1folic acid tab 400mcg Tier 0folic acid tab 800mcg Tier 0folic acid tab 1000mcg Tier 1sm folic acd tab 400mcg Tier 0yl folic aci tab 400mcg Tier 0

Hematopoietic Growth FactorsEPOGEN INJ 2000/ML Tier 4 PAEPOGEN INJ 3000/ML Tier 4 PAEPOGEN INJ 4000/ML Tier 4 PAEPOGEN INJ 10000/ML Tier 4 PAEPOGEN INJ 20000/ML Tier 4 PALEUKINE INJ 250MCG Tier 4 PANEUPOGEN INJ 300/0.5 Tier 4 PANEUPOGEN INJ 300MCG Tier 4 PANEUPOGEN INJ 480/0.8 Tier 4 PANEUPOGEN INJ 480MCG Tier 4 PAPROCRIT INJ 2000/ML Tier 4 PAPROCRIT INJ 3000/ML Tier 4 PAPROCRIT INJ 4000/ML Tier 4 PAPROCRIT INJ 10000/ML Tier 4 PAPROCRIT INJ 20000/ML Tier 4 PA



Drug Name Drug Tier Requirements/LimitsPROCRIT INJ 40000/ML Tier 4 PA

Hematopoietic Mixturesferrocite tab plus Tier 1hematinic pl tab vit/min Tier 1hematinic/fa tab Tier 1hemocyte tab -plus Tier 1hemocyte-f tab Tier 1

Ironfer-iron dro 15mg/ml Tier 0ferrous dro 15mg/ml Tier 0ferrous sulf dro 15mg/ml Tier 0ferrous sulf elx 220/5ml Tier 0iron supplmt dro 15mg/ml Tier 0wee care sus 15/1.25 Tier 0

HEMOSTATICSHemostatics - Systemic

aminocapr ac syp 25% Tier 1aminocapr ac tab 500mg Tier 1aminocapr ac tab 1000mg Tier 1tranexamic inj acid Tier 4 PA

HYPNOTICSBarbiturate Hypnotics

phenobarb elx 20mg/5ml Tier 1phenobarb sol 20mg/5ml Tier 1phenobarb tab 15mg Tier 1phenobarb tab 16.2mg Tier 1phenobarb tab 30mg Tier 1phenobarb tab 32.4mg Tier 1phenobarb tab 60mg Tier 1phenobarb tab 64.8mg Tier 1phenobarb tab 97.2mg Tier 1phenobarb tab 100mg Tier 1

Non-Barbiturate Hypnoticschloral hydr syp 500/5ml Tier 1DORAL TAB 15MG Tier 2estazolam tab 1mg Tier 1estazolam tab 2mg Tier 1flurazepam cap 15mg Tier 1flurazepam cap 30mg Tier 1LUNESTA TAB 1MG Tier 3 PALUNESTA TAB 2MG Tier 3 PALUNESTA TAB 3MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsSOMNOTE CAP 500MG Tier 2temazepam cap 7.5mg Tier 1 PAtemazepam cap 15mg Tier 1temazepam cap 30mg Tier 1triazolam tab 0.25mg Tier 1triazolam tab 0.125mg Tier 1zaleplon cap 5mg Tier 1zaleplon cap 10mg Tier 1zolpidem tab 5mg Tier 1zolpidem tab 10mg Tier 1

Selective Melatonin Receptor AgonistsROZEREM TAB 8MG Tier 3 PA

LAXATIVESLaxative Combinations

COLYTE/FLAVR SOL PACKS Tier 2gavilyte-c sol Tier 1gavilyte-g sol Tier 1gavilyte-n sol flav pk Tier 1MOVIPREP SOL Tier 2peg 3350 sol electrol Tier 1peg-3350 sol electrol Tier 1peg-3350/kcl sol /sodium Tier 1PREPOPIK PAK Tier 2trilyte sol Tier 1

Laxatives - Miscellaneousclearlax pow Tier 1constulose sol 10gm/15 Tier 1cvs purelax pow Tier 1cvs purelax pow 3350 nf Tier 1dulcolax pow balance Tier 1eql clearlax pow Tier 1gavilax pow Tier 1gentlelax pow Tier 1glycolax pow 3350 nf Tier 1gnp clearlax pow Tier 1healthylax pow Tier 1hm clearlax pow Tier 1lactulose sol 10gm/15 10gm/15ml Tier 1lactulose sol 20gm/30 Tier 1laxaclear pow Tier 1natura-lax pow 3350 nf Tier 1peg 3350 pow Tier 1



Drug Name Drug Tier Requirements/Limitspolyeth glyc pow 3350 nf Tier 1polyeth glyc pow 3350-grx Tier 1ra laxative pow Tier 1sm clearlax pow Tier 1smooth lax pow Tier 1smooth lax pow 3350 nf Tier 1sw clearlax pow Tier 1

Saline LaxativesOSMOPREP TAB 1.5GM Tier 2VISICOL TAB 1.5GM Tier 2

MACROLIDESAzithromycin

azithromycin pow 1gm pak Tier 1azithromycin sus 100/5ml Tier 1azithromycin sus 200/5ml Tier 1azithromycin tab 250mg Tier 1azithromycin tab 500mg Tier 1azithromycin tab 600mg Tier 1ZMAX SUS 2GM Tier 2 PA

Clarithromycinclarithromyc sus 125/5ml Tier 1clarithromyc sus 250/5ml Tier 1clarithromyc tab 250mg Tier 1clarithromyc tab 500mg Tier 1

Erythromycinse.e.s. 400 tab 400mg Tier 1E.E.S. GRAN SUS 200/5ML Tier 2ERY-TAB TAB 250MG EC Tier 2ERY-TAB TAB 333MG EC Tier 2ERY-TAB TAB 500MG EC Tier 2ERYPED SUS 200/5ML Tier 2ERYPED SUS 400/5ML Tier 2erythrocin tab 250mg Tier 1erythrom eth tab 400mg Tier 1erythromycin cap 250mg ec Tier 1erythromycin tab 250mg bs Tier 1erythromycin tab 500mg bs Tier 1PCE TAB 333MG EC Tier 2PCE TAB 500MG EC Tier 2

FidaxomicinDIFICID TAB 200MG Tier 3 PA

MEDICAL DEVICES



Drug Name Drug Tier Requirements/LimitsContraceptives

CONDOMS MIS Tier 2FC2 FEMALE MIS CONDOM Tier 0FC FEMALE MIS CONDOM Tier 0FEMCAP MIS 22MM Tier 0FEMCAP MIS 26MM Tier 0FEMCAP MIS 30MM Tier 0LIFESTYLES MIS COLORS Tier 2LIFESTYLES MIS EXT STR Tier 2LIFESTYLES MIS FORM FIT Tier 2LIFESTYLES MIS LUBRICAT Tier 2LIFESTYLES MIS RIBBED Tier 2LIFESTYLES MIS SPERM/LU Tier 2LIFESTYLES MIS STUDDED Tier 2LIFESTYLES MIS ULT/SENS Tier 2LIFESTYLES MIS VIBRA-RI Tier 2LIFESTYLES MIS XPLEASUR Tier 2OMNIFLEX DPR Tier 0ORTHO COIL DPR KIT 50 Tier 0ORTHO COIL DPR KIT 100 Tier 0ORTHO COIL DPR KIT 105 Tier 0ORTHO FLAT DPR KIT 55 Tier 0ORTHO FLAT DPR KIT 60 Tier 0ORTHO FLAT DPR KIT 65 Tier 0ORTHO FLAT DPR KIT 70 Tier 0ORTHO FLAT DPR KIT 75 Tier 0ORTHO FLAT DPR KIT 80 Tier 0ORTHO FLAT DPR KIT 85 Tier 0ORTHO FLAT DPR KIT 90 Tier 0ORTHO FLAT DPR KIT 95 Tier 0ORTHO FLEX DPR 65MM Tier 0ORTHO FLEX DPR 70MM Tier 0ORTHO FLEX DPR 75MM Tier 0ORTHO FLEX DPR 80MM Tier 0PARAGARD IUD T380A Tier 0PRENTIF MIS 22MM Tier 0PRENTIF MIS 25MM Tier 0PRENTIF MIS 28MM Tier 0PRENTIF MIS 31MM Tier 0PRENTIF MIS FITTING Tier 0TODAY SPONGE MIS Tier 0TROJAN MIS NAT LAMB Tier 2WIDE-SEAL DPR KIT 60 Tier 0



Drug Name Drug Tier Requirements/LimitsWIDE-SEAL DPR KIT 65 Tier 0WIDE-SEAL DPR KIT 70 Tier 0WIDE-SEAL DPR KIT 75 Tier 0WIDE-SEAL DPR KIT 80 Tier 0WIDE-SEAL DPR KIT 85 Tier 0WIDE-SEAL DPR KIT 90 Tier 0WIDE-SEAL DPR KIT 95 Tier 0

Diabetic SuppliesLANCETS Tier 5TRUERESULT KIT Tier 5

Misc. DevicesALCOHOL SWABS Tier 2

Parenteral Therapy SuppliesBD NEEDLE MIS 27GX1.25 Tier 5BD NEEDLES MIS 27GX1/2" Tier 5HYPO NEEDLE MIS 27GX1.5" Tier 5HYPO NEEDLE MIS 27GX1.25 Tier 5HYPO NEEDLE MIS 27GX1/2" Tier 5INSULIN PEN NEEDLES Tier 5INSULIN SYRINGES Tier 5POLY HUB MIS 27GX1.25 Tier 5POLY HUB MIS 27GX1/2" Tier 5PRECISIONGLI MIS 27GX1.5" Tier 5SAFETYGLIDE MIS 27GX5/8" Tier 5SURGUARD2 MIS 27GX1/2" Tier 5

Respiratory Therapy SuppliesAEROCHAMBER KIT ACTION Tier 2INSPIREASE MIS BAGS Tier 2INSPIREASE MIS MOUTHPCE Tier 2 QLINSPIREASE MIS REP MOUT Tier 2 QLINSPIREASE MIS RES BAG Tier 2SPACERS DEVI Tier 2SPACERS DEVI Tier 2 QLSPACERS MISC Tier 2SPACERS MISC Tier 2 QL

MIGRAINE PRODUCTSMigraine Combinations

epidrin cap Tier 1isometh/apap cap dichlor Tier 1MIGERGOT SUP 2/100 Tier 2migragesic cap ida Tier 1nodolor cap Tier 1



Drug Name Drug Tier Requirements/LimitsMigraine Products

dihydroergot inj 1mg/ml Tier 1 PAERGOMAR SUB 2MG Tier 2

Serotonin AgonistsAXERT TAB 6.25MG Tier 3 PAAXERT TAB 12.5MG Tier 3 PAFROVA TAB 2.5MG Tier 3 PAnaratriptan tab 1mg Tier 1 ST; QLnaratriptan tab 2.5mg Tier 1 ST; QLRELPAX TAB 20MG Tier 2 ST; QLRELPAX TAB 40MG Tier 2 ST; QLrizatriptan tab 5mg Tier 1 ST; QLrizatriptan tab 10mg Tier 1 ST; QLsumatriptan inj 4mg/0.5 Tier 1 PAsumatriptan inj 6mg/0.5 Tier 1 PA; QLsumatriptan spr 5mg/act Tier 1 QLsumatriptan spr 20mg/act Tier 1 QLsumatriptan tab 25mg Tier 1 QLsumatriptan tab 50mg Tier 1 QLsumatriptan tab 100mg Tier 1 QLzolmitriptan tab 2.5 mg Tier 2 ST; QLzolmitriptan tab 2.5mg Tier 2 ST; QLzolmitriptan tab 5mg Tier 2 ST; QLZOMIG SPR 5MG Tier 2 ST

MINERALS ELECTROLYTESElectrolyte Mixtures

baby darlng sol ped elec Tier 1cvs electrol sol Tier 1gnp pediatri sol electrol Tier 1naturalyte sol bubblegm Tier 1naturalyte sol fruit Tier 1naturalyte sol grape Tier 1naturalyte sol unflavor Tier 1oralyte sol Tier 1oralyte sol freeze Tier 1pc ped elect sol fruit Tier 1pc ped elect sol grape Tier 1pc pediatric sol electrol Tier 1ped elctrlyt sol Tier 1ped elctrlyt sol /zinc Tier 1ped elctrlyt sol apple Tier 1ped elctrlyt sol bubblegm Tier 1



Drug Name Drug Tier Requirements/Limitsped elctrlyt sol bubblgum Tier 1ped elctrlyt sol freeze Tier 1ped elctrlyt sol freezer Tier 1ped elctrlyt sol freezpop Tier 1ped elctrlyt sol fruit Tier 1ped elctrlyt sol grape Tier 1ped elctrlyt sol mango Tier 1ped elctrlyt sol strawbry Tier 1ped elctrlyt sol unflavor Tier 1ped elctrlyt sol unflavrd Tier 1pedia vance sol apple Tier 1pedia vance sol grape Tier 1ra pediatric sol electrol Tier 1rehydralyte sol Tier 1revital frzr sol pops Tier 1revital jell sol cups Tier 1revital lqd sol squeezer Tier 1

Fluorideepiflur chw 0.5mg f Tier 0epiflur chw 0.25mg f Tier 0epiflur chw 1mg f Tier 1fluor-a-day dro 0.125mg Tier 0fluoride chw 0.5mg f Tier 0fluoride chw 0.25mg f Tier 0fluoride chw 1mg f Tier 1fluoritab chw 0.5mg f Tier 0fluoritab chw 0.25mg f Tier 0fluoritab chw 1mg f Tier 1fluoritab chw 2.2mg Tier 1fluoritab dro 0.125mg Tier 0flura-drops dro 0.25mg f Tier 0flura-drops dro 0.125mg Tier 0karidium dro 0.125mg Tier 0ludent chw 0.5mg f Tier 0ludent chw 0.25mg f Tier 0ludent chw 1mg f Tier 1nafrinse chw 1mg f Tier 1nafrinse dro 0.125mg Tier 0sod fluoride chw 0.5mg f Tier 0sod fluoride chw 0.25mg f Tier 0sod fluoride chw 1.1mg Tier 0sod fluoride chw 1mg f Tier 1sod fluoride chw 2.2mg Tier 1



Drug Name Drug Tier Requirements/Limitssod fluoride dro 0.5mg/ml Tier 0sod fluoride tab 0.5mg f Tier 0sod fluoride tab 1mg f Tier 1

Iodine ProductsSSKI SOL 1GM/ML Tier 2

Magnesiummagnesium su inj 50% Tier 1 PA

Phosphatephospha 250 tab neutral Tier 1

Potassiumeffer-k tab 25meq ef Tier 1epiklor pow 20meq Tier 1epiklor/25 pow 25meq Tier 1k-effervesce tab 25meq ef Tier 1k-prime tab 25meq ef Tier 1k-vescent pow 20meq Tier 1k-vescent tab 25meq ef Tier 1klor-con 8 tab 8meq er Tier 1klor-con 10 tab 10meq er Tier 1klor-con m10 tab 10meq er Tier 1KLOR-CON M15 TAB Tier 2klor-con m20 tab 20meq er Tier 1klor-con pow 20meq Tier 1klor-con/ef tab 25meq fr Tier 1pot bicarbon tab 25meq ef Tier 1pot chloride cap 8meq er Tier 1pot chloride cap 10meq er Tier 1pot chloride liq 10% Tier 1pot chloride liq 20% Tier 1pot chloride liq 20% sf Tier 1pot chloride sol 10% sf Tier 1pot chloride tab 8meq er Tier 1pot chloride tab 8meq sr Tier 1pot chloride tab 10meq cr Tier 1pot chloride tab 10meq er Tier 1pot cl micro tab 10meq cr Tier 1pot cl micro tab 10meq er Tier 1pot cl micro tab 20meq er Tier 1potassium tab 25meq ef Tier 1

Sodiumflush syring inj 0.9% Tier 1 PAsod chloride inj 0.9% Tier 1 PAsod chloride inj 0.45% Tier 1 PA



Drug Name Drug Tier Requirements/Limitssod chloride inj 2.5/ml Tier 1 PAsod chloride inj 3% Tier 1 PAsod chloride inj 5% Tier 1 PA

Zincorazinc cap 220mg Tier 1zinc sulfate cap 220mg Tier 1zinc-220 cap Tier 1zincate cap 220mg Tier 1

MOUTH/THROAT/DENTAL AGENTSAnesthetics Topical Oral

lidocaine sol 2% visc Tier 1Anti-infectives - Throat

clotrimazole loz 10mg Tier 1clotrimazole tro 10mg Tier 1nystatin sus 100000 Tier 1ORAVIG TAB 50MG Tier 3

Antiallergy Agents - Mouth/ThroatAPHTHASOL PST 5% Tier 2

Antiseptics - Mouth/Throatchlorhex glu sol 0.12% Tier 1periogard sol 0.12% Tier 1

Steroids - Mouth/Throatoralone pst 0.1% Tier 1triamcin/ora pst 0.1% Tier 1triamcinolon pst 0.1% Tier 1

Throat Products - Misc.cevimeline cap 30mg Tier 1pilocarpine tab 5mg Tier 1pilocarpine tab 7.5mg Tier 1

MULTIVITAMINSB-Complex w/ Folic Acid

BIOTIN FORTE TAB Tier 1dialyvite tab Tier 1dialyvite tab 800 Tier 1folbee plus tab Tier 1FULL SPECT TAB B/ VIT C Tier 1nephronex tab 1mg Tier 1rena-vite rx tab Tier 1rena-vite tab Tier 1renal tab multivit Tier 1virt-vite tab plus Tier 1vol-care rx tab Tier 1



Drug Name Drug Tier Requirements/LimitsMultivitamins

anti-oxidant tab Tier 1cvs daily tab multiple Tier 1daily multi tab vitamin Tier 1daily multi tab vitamins Tier 1daily tab vitamin Tier 1daily value tab multivit Tier 1daily vit tab Tier 1daily vite tab Tier 1daily-vitamn tab Tier 1e/c/beta car tab Tier 1eql one dail tab essentia Tier 1essentl one tab daily Tier 1mult vitamin tab daily Tier 1mult vitamin tab essent Tier 1mult vitamin tab mens Tier 1multi-day tab Tier 1multi-vit tab Tier 1multi-vitamn tab Tier 1multiple vit tab Tier 1multiple vit tab folic Tier 1once daily tab Tier 1one daily tab Tier 1one daily tab essent Tier 1one daily tab essentl Tier 1one-daily tab mult vit Tier 1qc essential tab Tier 1ra one daily tab essentia Tier 1ra one daily tab multivit Tier 1renal/zinc tab multivit Tier 1sigtab tab Tier 1sm multiple tab vitamins Tier 1stress form tab Tier 1stress form tab 500/biot Tier 1stress formu tab Tier 1tab-a-vite tab Tier 1tab-a-vite tab beta car Tier 1thera tab Tier 1thera-mill tab Tier 1thera-tabs tab Tier 1therapeutic tab Tier 1therems tab Tier 1vigomar tab Tier 1



Drug Name Drug Tier Requirements/Limitsvimar hp tab Tier 1vitalee tab Tier 1

Ped MV w/ Fluorideacd/fluoride dro 0.25mg Tier 1mult-vit/fl chw 0.5mg Tier 1multi-vit/fl chw 0.5mg Tier 1multi-vit/fl chw 0.25mg Tier 1multi-vit/fl chw 1mg Tier 1multi-vit/fl dro 0.5mg/ml Tier 1multi-vit/fl dro 0.25mg Tier 1multivit/fl chw 0.5mg Tier 1multivit/fl chw 0.25mg Tier 1multivit/fl chw 1mg Tier 1mvc-fluoride chw 0.5mg Tier 1mvc-fluoride chw 0.25mg Tier 1mvc-fluoride chw 1mg Tier 1poly-vi-flor chw 0.5mg Tier 1poly-vi-flor chw 0.25mg Tier 1poly-vi-flor chw 1mg Tier 1poly-vit/fl dro 0.25mg Tier 1polyvit/fl dro 0.5mg/ml Tier 1tri-vit/fl dro 0.5mg Tier 1tri-vit/fl dro 0.25mg Tier 1tri-vit/fluo dro 0.5mg Tier 1tri-vit/fluo dro 0.25mg Tier 1tri-vita/fl dro 0.25mg Tier 1

Ped Multi Vitamins w/Fl FEmulti-vit/fe dro /fl 0.25 Tier 1multi-vit/fl dro /fe 0.25 Tier 1POLY-VI-FLOR CHW W/IRON Tier 2poly-vit/fe dro /fl 0.5 Tier 1poly-vit/fe dro /fl 0.25 Tier 1tri-vit/fe dro /fl 0.25 Tier 1

Prenatal VitaminsCL PRENATAL TAB 28-0.8MG Tier 2COMPLETE-RF TAB PRENATAL Tier 2COMPLETENATE CHW Tier 2CONCEPT DHA CAP Tier 2CONCEPT OB CAP Tier 2CVS PRENATAL TAB Tier 2CVS PRENATAL TAB 28-0.8MG Tier 2EQL PRENATAL TAB FORMULA Tier 2FOLIVANE-OB CAP Tier 2



Drug Name Drug Tier Requirements/LimitsGNP PRENATAL TAB 28-0.8MG Tier 2HM PRENATAL TAB Tier 2KP PRENATAL TAB MULTIVIT Tier 2M-VIT TAB 27-1MG Tier 2MULTI PRENAT TAB Tier 2NATAL-V RX TAB 29-1MG Tier 2O-CAL FA TAB Tier 2PNV FOLIC AC TAB + IRON Tier 2PNV PRENATAL TAB PLUS Tier 2prenaplus tab Tier 1prenatabs rx tab Tier 1PRENATAL 19 CHW 29-1MG Tier 2prenatal 19 chw tab Tier 1prenatal 19 tab Tier 1PRENATAL 19 TAB 29-1MG Tier 2PRENATAL ONE TAB DAILY Tier 2PRENATAL TAB Tier 2PRENATAL TAB 27-0.8MG Tier 2PRENATAL TAB 27-1MG Tier 2PRENATAL TAB 28-0.8MG Tier 2PRENATAL TAB COMPLETE Tier 2PRENATAL TAB FORMULA Tier 2PRENATAL TAB LOW IRON Tier 2PRENATAL TAB PLUS Tier 2prenatal tab plus fe Tier 1PRENATAL VIT TAB PLUS Tier 2PRENATAL+DHA MIS Tier 2PRENATAL+DHA MIS WOMENS Tier 2PRENATAL+FE TAB 29-1MG Tier 2PRENATAL-U CAP Tier 2PX PRENATAL TAB MULTIVIT Tier 2QC PRENATAL TAB 28-0.8MG Tier 2RA PRENATAL TAB 28-0.8MG Tier 2RA PRENATAL TAB FORMULA Tier 2RIGHT STEP TAB PRENATAL Tier 2SE-NATAL 19 CHW Tier 2SE-NATAL 19 TAB Tier 2SE-NATAL ONE TAB Tier 2SM PRENATAL TAB VITAMINS Tier 2STUART PREN TAB Tier 2TARON-C DHA CAP Tier 2TH PRENATAL TAB VITAMINS Tier 2THERANATAL TAB 27-1 Tier 2



Drug Name Drug Tier Requirements/LimitsTRICARE TAB PRENATAL Tier 2TRINATAL RX TAB 1 Tier 2TRIVEEN-U CAP Tier 2VINATE AZ EX TAB Tier 2VINATE II TAB Tier 2VINATE ONE TAB Tier 2VOL-PLUS TAB Tier 2VOL-TAB RX TAB Tier 2

MUSCULOSKELETAL THERAPY AGENTSCentral Muscle Relaxants

baclofen tab 10mg Tier 1baclofen tab 20mg Tier 1carisoprodol tab 350mg Tier 1chlorzoxazon tab 500mg Tier 1cyclobenzapr tab 5mg Tier 1cyclobenzapr tab 10mg Tier 1ed baclofen tab 10mg Tier 1LORZONE TAB 375MG Tier 2LORZONE TAB 750MG Tier 2metaxalone tab 800mg Tier 1methocarbam tab 500mg Tier 1methocarbam tab 750mg Tier 1orphenadrine tab 100mg er Tier 1ROBAXIN INJ 100MG/ML Tier 4 PAtizanidine cap 2mg Tier 1tizanidine cap 4mg Tier 1tizanidine cap 6mg Tier 1tizanidine tab 2mg Tier 1tizanidine tab 4mg Tier 1

Direct Muscle Relaxantsdantrolene cap 25mg Tier 1dantrolene cap 50mg Tier 1dantrolene cap 100mg Tier 1

Muscle Relaxant Combinationscarisopr/asa tab 200-325 Tier 1carisoprodol tab asa/cod Tier 1orph/asa/caf tab Tier 1orphen cpd tab ds Tier 1

NASAL AGENTS - SYSTEMIC AND TOPICALNasal Anti-infectives

BACTROBAN OIN NASAL 2% Tier 2Nasal Antiallergy



Drug Name Drug Tier Requirements/LimitsASTEPRO SPR 0.15% Tier 2azelastine spr 0.1% Tier 1

Nasal Steroidsflunisolide spr 0.025% Tier 1flunisolide spr 29mcg Tier 1fluticasone spr 50mcg Tier 1NASONEX SPR 50MCG/AC Tier 2 STtriamcinolon spr 55mcg/ac Tier 1

Sympathomimetic Decongestantscongest aid tab 30mg Tier 1congestion tab 30mg Tier 1decongestant tab 30mg Tier 1decongestant tab 60mg Tier 1eq suphedrin tab 30mg Tier 1genaphed tab 30mg Tier 1medi-phedrin tab 30mg Tier 1nasal decon syp 30mg/5ml Tier 1nasal decong tab 30mg Tier 1NEO-SYNEPHRI SPR 0.5% Tier 2pseudoephedr syp 30mg/5ml Tier 1pseudoephedr tab 30mg Tier 1pseudoephedr tab 60mg Tier 1psudatabs tab 30mg Tier 1ra suphedrin tab 30mg Tier 1sb pseudophe tab 30mg Tier 1simply stuff tab 30mg Tier 1sm nasal dec tab 30mg Tier 1sudanyl tab 30mg Tier 1sudogest tab 30mg Tier 1sudogest tab 60mg Tier 1sudophed tab 30mg Tier 1suphedrine tab 30mg Tier 1sw nasal dec tab 30mg Tier 1TYZINE PED DRO 0.05% Tier 2TYZINE SOL 0.1% Tier 2wal-phed tab 30mg Tier 1

NEUROMUSCULAR AGENTSALS Agents

RILUTEK TAB 50MG Tier 2riluzole tab 50mg Tier 2

OPHTHALMIC AGENTSArtificial Tears and Lubricants



Drug Name Drug Tier Requirements/LimitsLACRISERT MIS 5MG OP Tier 3 PA

Beta-blockers - Ophthalmicbetaxolol sol 0.5% op Tier 1BETIMOL SOL 0.5% Tier 2BETIMOL SOL 0.25% Tier 2BETOPTIC-S SUS 0.25% OP Tier 2carteolol sol 1% op Tier 1COMBIGAN SOL 0.2/0.5% Tier 2COSOPT PF SOL Tier 2dorzol/timol sol 2-0.5%op Tier 1ISTALOL SOL 0.5% OP Tier 2levobunolol sol 0.5% op Tier 1levobunolol sol 0.25% op Tier 1metipranolol sol 0.3% Tier 1metipranolol sol 0.3% oph Tier 1timolol gel sol 0.5% op Tier 1timolol gel sol 0.25% op Tier 1timolol mal sol 0.5% op Tier 1timolol mal sol 0.25% op Tier 1TIMOPTIC OCU SOL 0.5% OP Tier 2TIMOPTIC OCU SOL 0.25% OP Tier 2

Cycloplegic Mydriaticsak-pentolate sol 1% op Tier 1atropin-care sol 1% op Tier 1ATROPINE SUL OIN 1% OP Tier 2atropine sul sol 1% op Tier 1CYCLOGYL SOL 0.5% OP Tier 2cyclopentol sol 1% op Tier 1cyclopentol sol 2% op Tier 1cylate sol 1% op Tier 1homatropaire sol 5% op Tier 1homatropine sol 5% op Tier 1ISO HOMATROP SOL 2% OP Tier 2ISO HYOSCINE SOL 0.25% OP Tier 2mydral sol 0.5% op Tier 1mydral sol 1% op Tier 1tropicamide sol 0.5% op Tier 1tropicamide sol 1% op Tier 1

MioticsISO CARBACHO SOL 1.5% OP Tier 2ISO CARBACHO SOL 3% OP Tier 2PHOSPHOLINE SOL 0.125%OP Tier 2pilocarpine sol 1% op Tier 1



Drug Name Drug Tier Requirements/Limitspilocarpine sol 2% op Tier 1pilocarpine sol 4% op Tier 1PILOPINE HS GEL 4% OP Tier 2

Ophthalmic Adrenergic AgentsALPHAGAN P SOL 0.1% Tier 2apraclonidin sol 0.5% op Tier 1brimonidine sol 0.2% op Tier 1brimonidine sol 0.15% Tier 1IOPIDINE SOL 1% OP Tier 2

Ophthalmic Anti-infectivesak-poly-bac oin op Tier 1bacit/polymy oin op Tier 1bacitracin oin op Tier 1BESIVANCE SUS 0.6% Tier 3 PABETADINE SOL 5% OP Tier 2ciprofloxacn sol 0.3% op Tier 1erythromycin oin 5mg/gm Tier 1erythromycin oin op Tier 1garamycin oin 0.3% op Tier 1gentak oin 0.3% op Tier 1gentak sol 0.3% op Tier 1gentamicin oin 0.3% op Tier 1gentamicin sol 0.3% op Tier 1gentasol sol 0.3% op Tier 1ilotycin oin op Tier 1levofloxacin sol 0.5% Tier 1NATACYN SUS 5% OP Tier 2neo-polycin oin op Tier 1neo/bac/poly oin op Tier 1neo/poly/gra sol op Tier 1ofloxacin dro 0.3% op Tier 1polycin b oin op Tier 1polycin oin op Tier 1polymyxin b/ sol trimethp Tier 1romycin oin op Tier 1sod sulfacet sol 10% op Tier 1sulfacet sod oin 10% op Tier 1sulfacet sod sol 10% op Tier 1tobramycin sol 0.3% op Tier 1tobrasol sol 0.3% op Tier 1TOBREX OIN 0.3% OP Tier 2trifluridine sol 1% op Tier 1trimethoprim sol polymyxn Tier 1



Drug Name Drug Tier Requirements/LimitsZIRGAN GEL 0.15% Tier 3 PAZYMAXID SOL 0.5% Tier 3 PA

Ophthalmic Decongestantsnaphazoline sol 0.1% op Tier 1

Ophthalmic ImmunomodulatorsRESTASIS EMU 0.05% Tier 3 PA

Ophthalmic Local Anestheticsparcaine sol 0.5% op Tier 1proparacaine sol 0.5% op Tier 1

Ophthalmic SteroidsALREX SUS 0.2% Tier 3BLEPHAMIDE OIN S.O.P. Tier 2BLEPHAMIDE SUS OP Tier 2dexameth pho sol 0.1% op Tier 1DUREZOL EMU 0.05% Tier 2FLAREX SUS 0.1% OP Tier 2fluor-op sus 0.1% op Tier 1fluoromethol sus 0.1% op Tier 1FML FORTE SUS 0.25% OP Tier 2FML OIN 0.1% OP Tier 2LOTEMAX SUS 0.5% Tier 3MAXIDEX SUS 0.1% OP Tier 2neo-polycin oin hc 1%op Tier 1neo/poly/bac oin /hc 1%op Tier 1neo/poly/dex oin 0.1% op Tier 1neo/poly/dex sus 0.1% op Tier 1neo/poly/hc sus op Tier 1poly-dex oin 0.1% op Tier 1PRED MILD SUS 0.12% OP Tier 2PRED SOD PHO SOL 1% OP Tier 2prednisolone sus 1% op Tier 1sulf/pred na sol op Tier 1tobra/dexame sus 0.3-0.1% Tier 1TOBRADEX OIN 0.3-0.1% Tier 2TOBRADEX ST SUS 0.3-0.05 Tier 2VEXOL SUS 1% OP Tier 2

Ophthalmics - Misc.ACUVAIL SOL 0.45% Tier 2ALAMAST DRO 0.1% Tier 3alaway child dro 0.025%op Tier 1alaway dro 0.025%op Tier 1allergy eye dro 0.025%op Tier 1ALOCRIL SOL 2% Tier 3



Drug Name Drug Tier Requirements/LimitsALOMIDE SOL 0.1% OP Tier 2antihistamin dro 0.025%op Tier 1azelastine dro 0.05% Tier 1AZOPT SUS 1% OP Tier 2BEPREVE DRO 1.5% Tier 3bromfenac sol 0.09% Tier 1claritin eye dro 0.025%op Tier 1cromolyn sod sol 4% op Tier 1cvs allergy dro 0.025%op Tier 1diclofenac sol 0.1% op Tier 1dorzolamide sol 2% op Tier 1EMADINE SOL 0.05% OP Tier 2epinastine dro 0.05% Tier 1eq itchy eye dro 0.025%op Tier 1eye itch rel dro 0.025%op Tier 1flurbiprofen sol 0.03% op Tier 1itchy eye dro 0.025%op Tier 1ketorolac sol 0.4% Tier 1ketorolac sol 0.5% Tier 1ketotif fum dro 0.025%op Tier 1NEVANAC SUS 0.1% Tier 2PATADAY SOL 0.2% Tier 3 PAPATANOL SOL 0.1% OP Tier 2 STwal-zyr dro 0.025%op Tier 1zyrtec itchy dro 0.025%op Tier 1

Prostaglandins - Ophthalmiclatanoprost sol 0.005% Tier 1LUMIGAN SOL 0.03% Tier 2TRAVATAN Z DRO 0.004% Tier 2travoprost dro 0.004% Tier 2

OTIC AGENTSOtic Agents - Miscellaneous

ace acd/alum sol 2% otic Tier 1acetic acid sol 2% otic Tier 1

Otic Anti-infectivesofloxacin dro 0.3%otic Tier 1

Otic Combinationsantipy/benzo sol otic Tier 1aurax sol 5.5-1.4% Tier 1aurodex sol otic Tier 1CIPRO HC SUS OTIC Tier 2CIPRODEX SUS 0.3-0.1% Tier 2



Drug Name Drug Tier Requirements/LimitsCOLY-MYCIN S SUS OTIC Tier 2CORTISPORIN SUS -TC OTIC Tier 2neo/poly/hc sol 1% otic Tier 1neo/poly/hc sus 1% otic Tier 1

Otic Steroidsacetasol hc sol otic Tier 1fluocin acet oil 0.01% Tier 1hc/acet acid sol otic Tier 1

OXYTOCICSOxytocics

methylergon tab 0.2mg Tier 1

PASSIVE IMMUNIZING AGENTSImmune Serums

BIVIGAM INJ 10% Tier 4 PACARIMUNE NF INJ 3GM Tier 4 PACARIMUNE NF INJ 6GM Tier 4 PACARIMUNE NF INJ 12GM Tier 4 PAFLEBOGAMMA INJ 5% Tier 4 PAFLEBOGAMMA INJ 10% Tier 4 PAFLEBOGAMMA INJ DIF 5% Tier 4 PAGAMASTAN S/D INJ Tier 4 PAGAMMAGARD INJ 1GM/10ML Tier 4 PAGAMMAGARD INJ 2.5GM/25 Tier 4 PAGAMMAGARD INJ 5GM/50ML Tier 4 PAGAMMAGARD INJ 10GM/100 Tier 4 PAGAMMAGARD INJ 20GM/200 Tier 4 PAGAMMAGARD INJ 30GM/300 Tier 4 PAGAMMAGARD SD INJ 2.5GM HU Tier 4 PAGAMMAGARD SD INJ 5GM HU Tier 4 PAGAMMAGARD SD INJ 10GM HU Tier 4 PAGAMMAKED INJ 1GM/10ML Tier 4 PAGAMMAKED INJ 2.5GM/25 Tier 4 PAGAMMAKED INJ 5GM/50ML Tier 4 PAGAMMAKED INJ 10GM/100 Tier 4 PAGAMMAKED INJ 20GM/200 Tier 4 PAGAMMAPLEX INJ 2.5GM Tier 4 PAGAMMAPLEX INJ 5GM Tier 4 PAGAMMAPLEX INJ 10GM Tier 4 PAGAMUNEX INJ 10% Tier 4 PAGAMUNEX-C INJ 1GM/10ML Tier 4 PAGAMUNEX-C INJ 2.5GM/25 Tier 4 PAGAMUNEX-C INJ 5GM/50ML Tier 4 PA



Drug Name Drug Tier Requirements/LimitsGAMUNEX-C INJ 10GM/100 Tier 4 PAGAMUNEX-C INJ 20GM/200 Tier 4 PAOCTAGAM INJ 1GM Tier 4 PAOCTAGAM INJ 2.5GM Tier 4 PAOCTAGAM INJ 5GM Tier 4 PAOCTAGAM INJ 10GM Tier 4 PAOCTAGAM INJ 25GM Tier 4 PAPRIVIGEN INJ 5 GRAMS Tier 4 PAPRIVIGEN INJ 10GRAMS Tier 4 PAPRIVIGEN INJ 20GRAMS Tier 4 PAVIVAGLOBIN SOL 160MG/ML Tier 4 PA

PENICILLINSAminopenicillins

amoxicillin cap 250mg Tier 1amoxicillin cap 500mg Tier 1amoxicillin chw 125mg Tier 1amoxicillin chw 250mg Tier 1amoxicillin sus 125/5ml Tier 1amoxicillin sus 200/5ml Tier 1amoxicillin sus 250/5ml Tier 1amoxicillin sus 400/5ml Tier 1amoxicillin tab 500mg Tier 1amoxicillin tab 875mg Tier 1ampicillin cap 250mg Tier 1ampicillin cap 500mg Tier 1ampicillin sus 125/5ml Tier 1ampicillin sus 250/5ml Tier 1MOXATAG TAB 775MG Tier 2

Natural Penicillinspenicilln vk sol 125/5ml Tier 1penicilln vk sol 250/5ml Tier 1penicilln vk tab 250mg Tier 1penicilln vk tab 500mg Tier 1

Penicillin Combinationsamox/k clav chw 200mg Tier 1amox/k clav chw 400mg Tier 1amox/k clav sus 200/5ml Tier 1amox/k clav sus 250/5ml Tier 1amox/k clav sus 400/5ml Tier 1amox/k clav sus 600/5ml Tier 1amox/k clav tab 250mg Tier 1amox/k clav tab 500mg Tier 1



Drug Name Drug Tier Requirements/Limitsamox/k clav tab 875mg Tier 1AUGMENTIN SUS 125/5ML Tier 2

Penicillinase-Resistant PenicillinsBACTOCILL INJ DEX 1GM Tier 4 PABACTOCILL INJ DEX 2GM Tier 4 PAdicloxacill cap 250mg Tier 1dicloxacill cap 500mg Tier 1oxacillin inj 1gm Tier 4 PAoxacillin inj 2gm Tier 4 PAoxacillin inj 10gm Tier 4 PA

PROGESTINSProgestins

medroxypr ac tab 2.5mg Tier 1medroxypr ac tab 5mg Tier 1medroxypr ac tab 10mg Tier 1norethin ace tab 5mg Tier 1progesterone cap 100mg Tier 1progesterone cap 200mg Tier 1

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.Agents for Chemical Dependency

CAMPRAL TAB 333MG Tier 3 PAdisulfiram tab 250mg Tier 1disulfiram tab 500mg Tier 1

Anti-Cataplectic AgentsXYREM SOL 500MG/ML Tier 4

Antidementia AgentsARICEPT TAB 23MG Tier 2 PAdonepezil tab 5mg Tier 1donepezil tab 5mg odt Tier 1donepezil tab 10mg Tier 1donepezil tab 10mg odt Tier 1galantamine cap 8mg er Tier 1galantamine cap 16mg er Tier 1galantamine cap 24mg er Tier 1galantamine tab 4mg Tier 1galantamine tab 8mg Tier 1galantamine tab 12mg Tier 1NAMENDA SOL 10MG/5ML Tier 3 PANAMENDA TAB 5MG Tier 3 PANAMENDA TAB 10MG Tier 3 PArivastigmine cap 1.5mg Tier 1rivastigmine cap 3mg Tier 1



Drug Name Drug Tier Requirements/Limitsrivastigmine cap 4.5mg Tier 1rivastigmine cap 6mg Tier 1

Combination Psychotherapeuticsperphen/amit tab 2-10mg Tier 1perphen/amit tab 2-25mg Tier 1perphen/amit tab 4-10mg Tier 1perphen/amit tab 4-25mg Tier 1perphen/amit tab 4-50mg Tier 1

Fibromyalgia AgentsSAVELLA TAB 12.5MG Tier 3 PASAVELLA TAB 25MG Tier 3 PASAVELLA TAB 50MG Tier 3 PASAVELLA TAB 100MG Tier 3 PA

Movement Disorder Drug TherapyXENAZINE TAB 12.5MG Tier 3 PAXENAZINE TAB 25MG Tier 3 PA

Multiple Sclerosis AgentsAMPYRA TAB 10MG Tier 4 PAAVONEX KIT 30MCG Tier 4 PAAVONEX PEN KIT 30MCG Tier 4 PAAVONEX PREFL KIT 30MCG Tier 4 PABETASERON INJ 0.3MG Tier 4 PACOPAXONE KIT 20MG/ML Tier 4 PAEXTAVIA INJ 0.3MG Tier 4 PAREBIF INJ 22/0.5 Tier 4 PAREBIF INJ 44/0.5 Tier 4 PAREBIF REBIDO INJ 22/0.5 Tier 4 PAREBIF REBIDO INJ 44/0.5 Tier 4 PAREBIF REBIDO SOL TITRATN Tier 4 PAREBIF TITRTN SOL PACK Tier 4 PATYSABRI INJ Tier 4 PA

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine cap 10mg 10mg Tier 1fluoxetine cap 20mg 20mg Tier 1

Pseudobulbar Affect (PBA) AgentsNUEDEXTA CAP 20-10MG Tier 3 PA

Psychotherapeutic and Neurological Agents - Misc.ergoloid mes tab 1mg oral Tier 1ORAP TAB 1MG Tier 2ORAP TAB 2MG Tier 2

Restless Leg Syndrome (RLS) AgentsHORIZANT TAB 600MG Tier 3 PA



Drug Name Drug Tier Requirements/LimitsSmoking Deterrents

buproban tab 150mg Tier 0bupropion tab 150mg Tier 0CHANTIX PAK 0.5& 1MG Tier 0CHANTIX PAK 1MG Tier 0CHANTIX TAB 0.5MG Tier 0CHANTIX TAB 1MG Tier 0cvs nicotine dis 7mg/24hr Tier 0cvs nicotine dis 14mg/24h Tier 0cvs nicotine dis 21mg/24h Tier 0cvs nicotine gum 2mg cinn Tier 0cvs nicotine gum 2mg mint Tier 0cvs nicotine gum 2mg orig Tier 0cvs nicotine gum 2mgfruit Tier 0cvs nicotine gum 4mg cinn Tier 0cvs nicotine gum 4mg mint Tier 0cvs nicotine gum 4mg orig Tier 0cvs nicotine gum 4mgfruit Tier 0cvs nicotine loz 2mg mint Tier 0cvs nicotine loz 4mg mint Tier 0cvs nts dis step 1 Tier 0eq nicotine dis 7mg/24hr Tier 0eq nicotine dis 14mg/24h Tier 0eq nicotine dis 21mg/24h Tier 0eq nicotine gum 2mg cinn Tier 0eq nicotine gum 2mg mint Tier 0eq nicotine gum 2mg orig Tier 0eq nicotine gum 2mgfruit Tier 0eq nicotine gum 4mg cinn Tier 0eq nicotine gum 4mg mint Tier 0eq nicotine gum 4mg orig Tier 0eq nicotine gum 4mg ref Tier 0eq nicotine gum 4mg strt Tier 0eq nicotine gum 4mgfruit Tier 0eq nicotine loz 2mg cher Tier 0eq nicotine loz 2mg mint Tier 0eq nicotine loz 4mg chry Tier 0eq nicotine loz 4mg mint Tier 0eql nicotine dis 7mg/24hr Tier 0eql nicotine dis 14mg/24h Tier 0eql nicotine dis 21mg/24h Tier 0eql nicotine gum 2mg Tier 0eql nicotine gum 2mg ref Tier 0



Drug Name Drug Tier Requirements/Limitseql nicotine gum 2mg strt Tier 0eql nicotine gum 4mg Tier 0eql nicotine gum 4mg ref Tier 0eql nicotine gum 4mg strt Tier 0eql nicotine loz 2mg mint Tier 0eql nicotine loz 4mg mint Tier 0gnp nicotine gum 2mg mint Tier 0gnp nicotine gum 2mg orig Tier 0gnp nicotine gum 4mg mint Tier 0gnp nicotine gum 4mg orig Tier 0gnp nicotine loz 2mg mint Tier 0gnp nicotine loz 4mg mint Tier 0hm nicotine dis 14mg/24h Tier 0hm nicotine dis 21mg/24h Tier 0hm nicotine gum 2mg mint Tier 0hm nicotine gum 4mg mint Tier 0hm nicotine loz 2mg mint Tier 0hm nicotine loz 4mg mint Tier 0kls quit2 gum 2mg Tier 0kls quit4 gum 4mg Tier 0nicorelief gum 2mg mint Tier 0nicorelief gum 2mg orig Tier 0nicorelief gum 4mg mint Tier 0nicorelief gum 4mg orig Tier 0nicorelief loz 2mg mint Tier 0nicorelief loz 4mg mint Tier 0nicotine dis 7mg/24hr Tier 0nicotine dis 14mg/24h Tier 0nicotine dis 21mg/24h Tier 0nicotine dis step 1 Tier 0nicotine dis step 2 Tier 0nicotine dis step 3 Tier 0nicotine gum 2mg Tier 0nicotine gum 2mgfruit Tier 0nicotine gum 4mg Tier 0nicotine loz 2mg chry Tier 0nicotine loz 2mg mint Tier 0nicotine loz 4mg chry Tier 0nicotine loz 4mg cinn Tier 0nicotine loz 4mg mint Tier 0nicotine pol gum 2mg Tier 0nicotine pol gum 2mg cinn Tier 0nicotine pol gum 2mg mint Tier 0



Drug Name Drug Tier Requirements/Limitsnicotine pol gum 2mg orig Tier 0nicotine pol gum 2mg ref Tier 0nicotine pol gum 2mg strt Tier 0nicotine pol gum 2mgfruit Tier 0nicotine pol gum 4mg Tier 0nicotine pol gum 4mg mint Tier 0nicotine pol gum 4mg orig Tier 0nicotine pol gum 4mg ref Tier 0nicotine pol gum 4mg strt Tier 0nicotine pol gum 4mgfruit Tier 0nicotine pol loz 2mg cinn Tier 0nicotine pol loz 2mg mint Tier 0nicotine pol loz 4mg chry Tier 0nicotine pol loz 4mg mint Tier 0NICOTINE SYS KIT TRANSDER Tier 0 PAnicotine td dis 7mg/24hr Tier 0nicotine td dis 14mg/24h Tier 0nicotine td dis 21mg/24h Tier 0NICOTROL INH Tier 0 PANICOTROL NS SPR 10MG/ML Tier 0 PAra nicotine dis 7mg/24hr Tier 0ra nicotine dis 14mg/24h Tier 0ra nicotine dis 21mg/24h Tier 0ra nicotine gum 2mg Tier 0ra nicotine gum 2mg cinn Tier 0ra nicotine gum 2mg mint Tier 0ra nicotine gum 2mgfruit Tier 0ra nicotine gum 4mg Tier 0ra nicotine gum 4mg frut Tier 0ra nicotine gum 4mg mint Tier 0ra nicotine loz 2mg mint Tier 0ra nicotine loz 4mg mint Tier 0sm nicotine dis 7mg/24hr Tier 0sm nicotine dis 14mg/24h Tier 0sm nicotine dis 21mg Tier 0sm nicotine gum 2mg Tier 0sm nicotine gum 2mg mint Tier 0sm nicotine gum 4mg Tier 0sm nicotine gum 4mg mint Tier 0sm nicotine loz 2mg mint Tier 0sm nicotine loz 4mg mint Tier 0stop smoking gum 2mg mint Tier 0stop smoking gum 2mg orig Tier 0



Drug Name Drug Tier Requirements/Limitsstop smoking gum 4mg Tier 0stop smoking loz 2mg mint Tier 0stop smoking loz 4mg mint Tier 0sw nicotine gum 2mg mint Tier 0sw nicotine gum 4mg Tier 0sw nicotine loz 2mg mint Tier 0sw nicotine loz 4mg mint Tier 0tgt nicotine dis 7mg/24hr Tier 0tgt nicotine dis 14mg/24h Tier 0tgt nicotine dis 21mg/24h Tier 0tgt nicotine gum 2mg mint Tier 0tgt nicotine gum 2mg orig Tier 0tgt nicotine gum 2mgfruit Tier 0tgt nicotine gum 4mg Tier 0tgt nicotine gum 4mg mint Tier 0tgt nicotine gum 4mg orig Tier 0tgt nicotine loz 2mg chry Tier 0tgt nicotine loz 2mg mint Tier 0tgt nicotine loz 4mg chry Tier 0tgt nicotine loz 4mg mint Tier 0thrive gum 2mg mint Tier 0thrive gum 4mg mint Tier 0

RESPIRATORY AGENTS - MISC.Alpha-Proteinase Inhibitor (Human)

ARALAST NP INJ 400MG Tier 4 PAARALAST NP INJ 500MG Tier 4 PAARALAST NP INJ 800MG Tier 4 PAARALAST NP INJ 1000MG Tier 4 PAGLASSIA INJ Tier 4 PAPROLASTIN INJ 500MG Tier 4 PAPROLASTIN INJ 1000MG Tier 4 PAPROLASTIN-C INJ 1000MG Tier 4 PAZEMAIRA INJ 1000MG Tier 4 PA

Cystic Fibrosis AgentsPULMOZYME SOL 1MG/ML Tier 4 PA

SULFONAMIDESSulfonamides

SULFADIAZINE TAB 500MG Tier 2

TETRACYCLINESTetracyclines

demeclocycl tab 150mg Tier 1



Drug Name Drug Tier Requirements/Limitsdemeclocycl tab 300mg Tier 1doxycyc mono cap 50mg Tier 1doxycyc mono cap 100mg Tier 1doxycycl hyc cap 50mg Tier 1DOXYCYCL HYC CAP 75MG Tier 2doxycycl hyc cap 100mg CAPS Tier 1DOXYCYCL HYC CAP 100MG CPEP Tier 2doxycycl hyc tab 100mg Tier 1doxycycline cap 75mg Tier 1doxycycline cap 150mg Tier 1doxycycline sus 25mg/5ml Tier 2doxycycline tab 20mg Tier 1minocycline cap 50mg Tier 1minocycline cap 75mg Tier 1minocycline cap 100mg Tier 1morgidox cap 1x100mg Tier 1morgidox cap 2x100mg Tier 1ORAXYL CAP 20MG Tier 3tetracycline cap 250mg Tier 1tetracycline cap 500mg Tier 1VIBRAMYCIN SYP 50MG/5ML Tier 2

THYROID AGENTSAntithyroid Agents

methimazole tab 5mg Tier 1methimazole tab 10mg Tier 1propylthiour tab 50mg Tier 1

Thyroid HormonesARMOUR THYRO TAB 15MG Tier 2ARMOUR THYRO TAB 120MG Tier 2ARMOUR THYRO TAB 180MG Tier 2ARMOUR THYRO TAB 240MG Tier 2ARMOUR THYRO TAB 300MG Tier 2levothroid tab 25mcg Tier 1levothroid tab 50mcg Tier 1levothroid tab 75mcg Tier 1levothroid tab 88mcg Tier 1levothroid tab 100mcg Tier 1levothroid tab 112mcg Tier 1levothroid tab 125mcg Tier 1levothroid tab 137mcg Tier 1levothroid tab 150mcg Tier 1levothroid tab 175mcg Tier 1



Drug Name Drug Tier Requirements/Limitslevothroid tab 200mcg Tier 1levothroid tab 300mcg Tier 1levothyroxin tab 25mcg Tier 1levothyroxin tab 50mcg Tier 1levothyroxin tab 75mcg Tier 1levothyroxin tab 88mcg Tier 1levothyroxin tab 100mcg Tier 1levothyroxin tab 112mcg Tier 1levothyroxin tab 125mcg Tier 1levothyroxin tab 137mcg Tier 1levothyroxin tab 150mcg Tier 1levothyroxin tab 175mcg Tier 1levothyroxin tab 200mcg Tier 1levothyroxin tab 300mcg Tier 1levoxyl tab 25mcg Tier 1levoxyl tab 50mcg Tier 1levoxyl tab 75mcg Tier 1levoxyl tab 88mcg Tier 1levoxyl tab 100mcg Tier 1levoxyl tab 112mcg Tier 1levoxyl tab 125mcg Tier 1levoxyl tab 137mcg Tier 1levoxyl tab 150mcg Tier 1levoxyl tab 175mcg Tier 1levoxyl tab 200mcg Tier 1liothyronine tab 5mcg Tier 1liothyronine tab 25mcg Tier 1liothyronine tab 50mcg Tier 1np thyroid tab 30mg Tier 1np thyroid tab 60mg Tier 1np thyroid tab 90mg Tier 1THYROLAR-1 TAB 60MG Tier 2THYROLAR-1/2 TAB 30MG Tier 2THYROLAR-1/4 TAB 15MG Tier 2THYROLAR-2 TAB 120MG Tier 2THYROLAR-3 TAB 180MG Tier 2unith direct tab 25mcg Tier 1unith direct tab 50mcg Tier 1unith direct tab 75mcg Tier 1unith direct tab 88mcg Tier 1unith direct tab 100mcg Tier 1unith direct tab 112mcg Tier 1unith direct tab 125mcg Tier 1



Drug Name Drug Tier Requirements/Limitsunith direct tab 150mcg Tier 1unith direct tab 175mcg Tier 1unith direct tab 200mcg Tier 1unith direct tab 300mcg Tier 1unithroid tab 25mcg Tier 1unithroid tab 50mcg Tier 1unithroid tab 75mcg Tier 1unithroid tab 88mcg Tier 1unithroid tab 100mcg Tier 1unithroid tab 112mcg Tier 1unithroid tab 125mcg Tier 1unithroid tab 137mcg Tier 1unithroid tab 150mcg Tier 1unithroid tab 175mcg Tier 1unithroid tab 200mcg Tier 1unithroid tab 300mcg Tier 1

ULCER DRUGSAntispasmodics

ATROPEN INJ 0.5MG Tier 1 PAATROPEN INJ 0.25MG Tier 1 PAATROPEN INJ 1MG Tier 1 PAATROPEN INJ 2MG Tier 1 PAatropine sul inj 0.1mg/ml Tier 1 PAatropine sul inj 0.4/0.5 Tier 1 PAatropine sul inj 0.4mg/ml Tier 1 PAatropine sul inj 0.05mg/1 Tier 1 PAatropine sul inj 1mg/ml Tier 1 PAbella alk/pb tab 16.2mg Tier 1belladonna tin 30/100ml Tier 1chlord/clidi cap 5-2.5mg Tier 1colidrops dro 0.125/ml Tier 1dicyclomine cap 10mg Tier 1dicyclomine sol 10mg/5ml Tier 1dicyclomine tab 20mg Tier 1ed-spaz tab 0.125mg Tier 1glycopyrrol tab 1mg Tier 1glycopyrrol tab 2mg Tier 1hyomax tab 0.125mg Tier 1hyomax-ft tab 0.125mg Tier 1hyomax-sl sub 0.125mg Tier 1hyomax-sr tab 0.375mg Tier 1hyoscyamine dro 0.125/ml Tier 1



Drug Name Drug Tier Requirements/Limitshyoscyamine elx 0.125/5 Tier 1hyoscyamine sub 0.125mg Tier 1hyoscyamine tab 0.125mg Tier 1hyoscyamine tab 0.375 er Tier 1hyoscyamine tab 0.375 sr Tier 1hyosyne dro 0.125/ml Tier 1hyosyne elx 0.125/5 Tier 1methscopolam tab 2.5mg Tier 1nulev tab 0.125mg Tier 1oscimin sr tab 0.375mg Tier 1oscimin sub 0.125mg Tier 1oscimin tab 0.125mg Tier 1propanthelin tab 15mg Tier 1quadrapax elx Tier 1SAL-TROPINE TAB 0.4MG Tier 2se-donna elx pb hyos Tier 1symax fastab tab 0.125mg Tier 1symax-sl sub 0.125mg Tier 1symax-sr tab 0.375mg Tier 1

H-2 Antagonistsacid control tab 20mg Tier 1acid control tab 150mg Tier 1acid reducer tab 20mg Tier 1acid reducer tab 150mg Tier 1acid reducer tab 200mg Tier 1acid relief tab 200mg Tier 1cimetidine sol 300/5ml Tier 1cimetidine tab 200mg Tier 1cimetidine tab 300mg Tier 1cimetidine tab 400mg Tier 1cimetidine tab 800mg Tier 1eq heartburn tab relief Tier 1famotidine sus 40mg/5ml Tier 1famotidine tab 20mg Tier 1famotidine tab 40mg Tier 1heartbrn rel tab 200mg Tier 1heartburn tab 20mg Tier 1heartburn tab 150mg Tier 1heartburn tab 200mg Tier 1heartburn tab relief 200mg Tier 1nizatidine cap 150mg Tier 1nizatidine cap 300mg Tier 1qc heartburn tab 200mg Tier 1



Drug Name Drug Tier Requirements/Limitsranitidine cap 150mg Tier 1ranitidine cap 300mg Tier 1ranitidine syp 15mg/ml Tier 1ranitidine syp 75mg/5ml Tier 1ranitidine syp 150/10ml Tier 1ranitidine tab 150mg Tier 1ranitidine tab 300mg Tier 1sm acid redu tab 200mg Tier 1wal-zan tab 150mg Tier 1

Misc. Anti-Ulcersucralfate tab 1gm Tier 1

Proton Pump InhibitorsACIPHEX TAB 20MG Tier 3 PADEXILANT CAP 30MG DR Tier 3 PADEXILANT CAP 60MG DR Tier 3 PAhrtbrn rel cap 15mg dr Tier 1lansoprazole cap 15mg dr Tier 1lansoprazole cap 30mg dr Tier 1LANSOPRAZOLE SUS 3MG/ML Tier 3 PAlansoprazole tab 15mg odt Tier 1lansoprazole tab 30mg odt Tier 1NEXIUM CAP 20MG Tier 3 PANEXIUM CAP 40MG Tier 3 PAomeprazole cap 10mg Tier 1omeprazole cap 20mg Tier 1omeprazole cap 40mg Tier 1 PApantoprazole tab 20mg Tier 1pantoprazole tab 40mg Tier 1

Ulcer Drugs - Prostaglandinsmisoprostol tab 100mcg Tier 1misoprostol tab 200mcg Tier 1

Ulcer Therapy CombinationsHELIDAC MIS Tier 3PREVPAC MIS Tier 3

URINARY ANTI-INFECTIVESUrinary Anti-infectives

MACRODANTIN CAP 25MG Tier 2methenam hip tab 1gm Tier 1nitrofur mac cap 50mg Tier 1nitrofur mac cap 100mg Tier 1nitrofurantn cap 100mg Tier 1nitrofurantn sus 25mg/5ml Tier 1




URINARY ANTISPASMODICSUrinary Antispasmodics

bethanechol tab 5mg Tier 1bethanechol tab 10mg Tier 1bethanechol tab 25mg Tier 1bethanechol tab 50mg Tier 1DETROL LA CAP 2MG Tier 3 STENABLEX TAB 7.5MG Tier 3 PAflavoxate tab 100mg Tier 1oxybutynin syp 5mg/5ml Tier 1oxybutynin tab 5mg Tier 1oxybutynin tab 5mg er Tier 1oxybutynin tab 10mg er Tier 1oxybutynin tab 15mg er Tier 1tolterodine tab 1mg Tier 1 STtolterodine tab 2mg Tier 1 STTOVIAZ TAB 4MG Tier 2 STTOVIAZ TAB 8MG Tier 2 STtrospium chl cap 60mg er Tier 1 STVESICARE TAB 5MG Tier 3 PA

VACCINESViral Vaccines

AFLURIA INJ 2011-12 Tier 0AFLURIA INJ 2012-13 Tier 0AFLURIA INJ PF 10-11 Tier 0AFLURIA INJ PF 11-12 Tier 0AFLURIA INJ PF 12-13 Tier 0AGRIFLU INJ PF 10-11 Tier 0EZ USE FLU KIT 2012-13 Tier 0FLUARIX INJ PF 10-11 Tier 0FLUARIX INJ PF 11-12 Tier 0FLUARIX INJ PF 12-13 Tier 0FLULAVAL INJ 2010-11 Tier 0FLULAVAL INJ 2011-12 Tier 0FLULAVAL INJ 2012-13 Tier 0FLUVIRIN INJ 2011-12 Tier 0FLUVIRIN INJ 2012-13 Tier 0FLUVIRIN INJ PF 11-12 Tier 0FLUVIRIN INJ PF 12-13 Tier 0FLUZONE INJ INTRADRM Tier 0FLUZONE INJ PF 11-12 Tier 0FLUZONE INJ PF 12-13 Tier 0



Drug Name Drug Tier Requirements/LimitsFLUZONE PED/ INJ PF 11-12 Tier 0FLUZONE PED/ INJ PF 12-13 Tier 0FLUZONE QUAD INJ 13-14 Tier 0FLUZONE SPLT INJ 2011-12 Tier 0FLUZONE SPLT INJ 2012-13 Tier 0INFLUENZA A INJ PF09H1N1 Tier 0

VAGINAL PRODUCTSSpermicides

encare gel 4% Tier 0Vaginal Anti-infectives

clindamycin cre 2% vag Tier 1metronidazol gel 0.75%vag Tier 1miconazole 1 kit Tier 2miconazole 1 kit 1200-2% Tier 2miconazole 1 kit 1200mg2% Tier 2miconazole 3 kit combo pk Tier 1miconazole 3 sup 200mg Tier 1NYSTATIN VAG TAB 100000 Tier 2terconazole cre 0.4% Tier 1terconazole cre 0.8% Tier 1terconazole sup 80mg Tier 1vagistat-3 kit combo pk Tier 1vandazole gel 0.75% Tier 1zazole cre 0.4% Tier 1zazole cre 0.8% Tier 1zazole sup 80mg Tier 1

Vaginal EstrogensESTRACE VAG CRE 0.1MG/GM Tier 2ESTRING MIS 2MG Tier 3PREMARIN VAG CRE 0.625MG Tier 2

VASOPRESSORSAnaphylaxis Therapy Agents

ADRENACLICK INJ 0.3MG Tier 2ADRENACLICK INJ 0.15MG Tier 2AUVI-Q INJ 0.3MG Tier 2AUVI-Q INJ 0.15MG Tier 2epinephrine inj 0.3mg Tier 1epinephrine inj 0.15mg Tier 1EPIPEN 2-PAK INJ 0.3MG Tier 2EPIPEN INJ 0.3MG Tier 2EPIPEN-JR INJ 0.15MG Tier 2EPIPEN-JR INJ 2-PAK Tier 2



Drug Name Drug Tier Requirements/LimitsTWINJECT INJ 0.3MG Tier 2TWINJECT INJ 0.15MG Tier 2

VITAMINSOil Soluble Vitamins

A-25 CAP 25000UNT Tier 2bio-d-mulsio liq 400unit Tier 0child vit d chw 400unit Tier 0d3 kids chw 400unit Tier 0d-3 gummy chw 400unit Tier 0d-400 tab 400unit Tier 0d-vita liq 400unit Tier 0DECARA CAP 25000UNT Tier 2delta d3 tab 400unit Tier 0ergocalcifer cap 50000unt Tier 1gnp vit d tab 400unit Tier 0just d liq 400unit Tier 0MEPHYTON TAB 5MG Tier 2sm vitamin d tab 400unit Tier 0vit d gummie chw 400unit Tier 0VITAMIN A CAP 25000UNT Tier 2vitamin d3 chw 400unit Tier 0vitamin d3 dro 400unit Tier 0vitamin d3 tab 400unit Tier 0vitamin d cap 50000unt Tier 1vitamin d chw 400unit Tier 0vitamin d dro 400unit Tier 0vitamin d tab 400unit Tier 0

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Index

AA-200 GEL 0.33-4% 72A-25 CAP 25000UNT 116abacavir tab 300mg 47ABILIFY DISC TAB 10MG 47ABILIFY DISC TAB 15MG 47ABILIFY MAIN INJ 300MG 47ABILIFY MAIN INJ 400MG 47ABILIFY SOL 1MG/ML 47ABILIFY TAB 10MG 47ABILIFY TAB 15MG 47ABILIFY TAB 20MG 47ABILIFY TAB 2MG 47ABILIFY TAB 30MG 47ABILIFY TAB 5MG 47ABSTRAL SUB 100MCG 8ABSTRAL SUB 200MCG 8ABSTRAL SUB 300MCG 8ABSTRAL SUB 400MCG 8ABSTRAL SUB 600MCG 8ABSTRAL SUB 800MCG 8acarbose tab 100mg 26acarbose tab 25mg 26acarbose tab 50mg 26acd/fluoride dro 0.25mg 93ace acd/alum sol 2% otic 100acebutolol cap 200mg 52acebutolol cap 400mg 52acetasol hc sol otic 101acetazolamid cap 500mg er 74acetazolamid tab 125mg 74acetazolamid tab 250mg 74acetic acid sol 2% otic 100acetylcyst sol 10% 64acetylcyst sol 20% 64acid control tab 150mg 112acid control tab 20mg 112acid reducer tab 150mg 112acid reducer tab 200mg 112acid reducer tab 20mg 112acid relief tab 200mg 112ACIPHEX TAB 20MG 113acne medicat gel 10% 64acne treatmn gel 10% 64acne-clear gel 10% 64ACTEMRA INJ 200/10ML 4ACTEMRA INJ 400/20ML 4ACTEMRA INJ 80MG/4ML 3acticin cre 5% 72ACTIMMUNE INJ 2MU/0.5 42ACTONEL TAB 150MG 75ACTONEL TAB 30MG 75ACTONEL TAB 35MG 75ACTONEL TAB 5MG 75ACTOPLUS MET TAB XR 26ACUVAIL SOL 0.45% 99acyclovir cap 200mg 50

acyclovir sus 200/5ml 50acyclovir tab 400mg 50acyclovir tab 800mg 50adapalene cre 0.1% 64adapalene gel 0.1% 64ADCIRCA TAB 20MG 57ADRENACLICK INJ 0.15MG 115ADRENACLICK INJ 0.3MG 115adrucil inj 2.5g/50m 39adrucil inj 500/10ml 39adrucil inj 5gm/100m 39ADVAIR DISKU AER 100/50 17ADVAIR DISKU AER 250/50 17ADVAIR DISKU AER 500/50 17ADVAIR HFA AER 115/21 17ADVAIR HFA AER 230/21 17ADVAIR HFA AER 45/21 17AEROCHAMBER KIT ACTION 87af-diphedryl elx 12.5/5ml 31afeditab tab 30mg cr 53afeditab tab 60mg cr 53AFINITOR TAB 10MG 41AFINITOR TAB 2.5MG 41AFINITOR TAB 5MG 41AFINITOR TAB 7.5MG 41AFLURIA INJ 2011-12 114AFLURIA INJ 2012-13 114AFLURIA INJ PF 10-11 114AFLURIA INJ PF 11-12 114AFLURIA INJ PF 12-13 114AGGRENOX CAP 25-200MG 82AGRIFLU INJ PF 10-11 114ak-pentolate sol 1% op 97ak-poly-bac oin op 98al12 lot 12% 71ala cort cre 1% 68ala-cort lot 1% 68alagesic cap 5ALAMAST DRO 0.1% 99alaway child dro 0.025%op 99alaway dro 0.025%op 99ALBENZA TAB 200MG 12albuterol neb 0.083% 17albuterol neb 0.5% 17albuterol neb 0.63mg/3 17albuterol neb 1.25mg/3 17albuterol syp 2mg/5ml 17albuterol tab 2mg 17albuterol tab 4mg 17albuterol tab 4mg er 17albuterol tab 8mg er 17alclometason cre 0.05% 68alclometason oin 0.05% 68ALCOHOL SWABS 87ALDACTAZIDE TAB 50/50 74alendronate tab 10mg 75alendronate tab 35mg 75alendronate tab 40mg 75alendronate tab 5mg 75alendronate tab 70mg 75

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aler-cap cap 25mg 31ALFERON N INJ 5MU/ML 42alfuzosin tab 10mg 81ALINIA SUS 100MG/5M 13ALINIA TAB 500MG 13ALKERAN TAB 2MG 39all day allg sol 1mg/ml 32all day allg sol 5mg/5ml 32all day allg syp 1mg/ml 32all day allg syp 5mg/5ml 32all day pain tab 220mg 4all day relf tab 220mg 4aller-ease tab 180mg 32aller-ease tab 60mg 32aller-fex tab 180mg 32aller-tec sol 1mg/ml 32allergy cap 25mg 31allergy chld sol 1mg/ml 32allergy comp sol 1mg/ml 32allergy eye dro 0.025%op 99allergy med cap 25mg 31allergy rel elx 12.5/5ml 31allergy rel sol 1mg/ml 32allergy relf cap 25mg 31allergy relf sol 5mg/5ml 32allergy relf tab 180mg 32allergy relf tab 60mg 32allopurinol tab 100mg 81allopurinol tab 300mg 81ALOCRIL SOL 2% 99ALOMIDE SOL 0.1% OP 100ALORA DIS 0.025MG 77ALORA DIS 0.05MG 77ALORA DIS 0.075MG 77ALORA DIS 0.1MG 77ALPHAGAN P SOL 0.1% 98alprazolam tab 0.25mg 15alprazolam tab 0.5mg 15alprazolam tab 1mg 15alprazolam tab 2mg 15ALREX SUS 0.2% 99ALTABAX OIN 1% 66altaryl elx 12.5/5ml 31altaryl syp 12.5/5ml 31altavera tab 58ALVESCO AER 160MCG 17ALVESCO AER 80MCG 17alyacen tab 1/35 58alyacen tab 7/7/7 58amantadine cap 100mg 43amantadine syp 50mg/5ml 43amantadine tab 100mg 43amcinonide cre 0.1% 68amcinonide lot 0.1% 68AMCINONIDE OIN 0.1% 68amethyst tab 90-20mcg 58amilor/hctz tab 5-50 74amiloride tab 5mg 74aminocapr ac syp 25% 83aminocapr ac tab 1000mg 83

aminocapr ac tab 500mg 83aminophyllin tab 100mg 18aminophyllin tab 200mg 18amiodarone inj 150mg/3m 16amiodarone inj 50mg/ml 16amiodarone tab 200mg 16amiodarone tab 400mg 16AMITIZA CAP 24MCG 79AMITIZA CAP 8MCG 79amitriptylin tab 100mg 25amitriptylin tab 10mg 25amitriptylin tab 150mg 25amitriptylin tab 25mg 25amitriptylin tab 50mg 25amitriptylin tab 75mg 25amlactin cre 12% 71amlactin lot 12% 71amlod/benazp cap 10-20mg 37amlod/benazp cap 10-40mg 37amlod/benazp cap 2.5-10mg 37amlod/benazp cap 5-10mg 37amlod/benazp cap 5-20mg 37amlod/benazp cap 5-40mg 37amlodipine tab 10mg 53amlodipine tab 2.5mg 53amlodipine tab 5mg 53ammonium lac cre 12% 71ammonium lac lot 12% 71amnesteem cap 10mg 64amnesteem cap 20mg 64amnesteem cap 40mg 64amox/k clav chw 200mg 102amox/k clav chw 400mg 102amox/k clav sus 200/5ml 102amox/k clav sus 250/5ml 102amox/k clav sus 400/5ml 102amox/k clav sus 600/5ml 102amox/k clav tab 250mg 102amox/k clav tab 500mg 102amox/k clav tab 875mg 103amoxapine tab 100mg 25amoxapine tab 150mg 25amoxapine tab 25mg 25amoxapine tab 50mg 25amoxicillin cap 250mg 102amoxicillin cap 500mg 102amoxicillin chw 125mg 102amoxicillin chw 250mg 102amoxicillin sus 125/5ml 102amoxicillin sus 200/5ml 102amoxicillin sus 250/5ml 102amoxicillin sus 400/5ml 102amoxicillin tab 500mg 102amoxicillin tab 875mg 102amphetamine cap 10mg er 1amphetamine cap 15mg er 1amphetamine cap 20mg er 1amphetamine cap 25mg er 1amphetamine cap 30mg er 1amphetamine cap 5mg er 1

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amphetamine tab 10mg 1amphetamine tab 12.5mg 1amphetamine tab 15mg 1amphetamine tab 20mg 1amphetamine tab 30mg 1amphetamine tab 5mg 1amphetamine tab 7.5mg 1ampicillin cap 250mg 102ampicillin cap 500mg 102ampicillin sus 125/5ml 102ampicillin sus 250/5ml 102AMPYRA TAB 10MG 104anacin tab 81mg ec 6ANADROL-50 TAB 50MG 11anagrelide cap 0.5mg 82anagrelide cap 1mg 82anastrozole tab 1mg 40ANDRODERM DIS 2.5MG/24 11ANDRODERM DIS 5MG/24HR 11ANDROGEL GEL 1%(25MG) 11ANDROGEL GEL 1%(50MG) 11ANDROGEL GEL PUMP 1% 11android cap 10mg 11ANDROXY TAB 10MG 11anolor 300 cap 5anti-diarrhe cap 2mg 29anti-diarrhe tab 2mg 29anti-hist cap 25mg 31anti-itch cre /aloe/e 68anti-itch cre /oatmeal 68anti-itch cre 1% 68anti-itch cre 1%pls 10 68anti-itch lot 1% 68anti-itch oin 1% 68anti-itch oin max st 68anti-oxidant tab 92antifungal cre 1% 66antifungal cre 2% 66antihistamin cap 25mg 31antihistamin dro 0.025%op 100antipy/benzo sol otic 100ANTIVERT TAB 50MG 30anucort-hc sup 25mg 12ANZEMET TAB 100MG 29ANZEMET TAB 50MG 29apap/codeine sol 120-12/5 10apap/codeine tab 300-15mg 10apap/codeine tab 300-30mg 10apap/codeine tab 300-60mg 10apexicon oin 0.05% 68APHTHASOL PST 5% 91APIDRA INJ SOLOSTAR 27APIDRA INJ U-100 27APLENZIN TAB 174MG 23APLENZIN TAB 348MG 23APLENZIN TAB 522MG 23APOKYN INJ 43APOKYN INJ 10MG/ML 43apraclonidin sol 0.5% op 98apri tab 58

APRISO CAP 0.375GM 80APTIVUS CAP 250MG 47APTIVUS SOL 47aquanil hc lot 1% 68ARALAST NP INJ 1000MG 108ARALAST NP INJ 400MG 108ARALAST NP INJ 500MG 108ARALAST NP INJ 800MG 108aranelle tab 58arbinoxa liq 4mg/5ml 31arbinoxa tab 4mg 31ARCALYST INJ 220MG 3ARCAPTA CAP 75MCG 17argyl saline sol 0.9% 81ARICEPT TAB 23MG 103ARMOUR THYRO TAB 120MG 109ARMOUR THYRO TAB 15MG 109ARMOUR THYRO TAB 180MG 109ARMOUR THYRO TAB 240MG 109ARMOUR THYRO TAB 300MG 109ASACOL HD TAB 800MG 80ASACOL TAB 400MG DR 80ASCENSIA MIS AUTODISC 73ascomp/cod cap 30mg 10asmalpred sol 15mg/5ml 61asmalpred sol plus 61ASMANEX 120 AER 220MCG 17ASMANEX 14 AER 220MCG 17ASMANEX 30 AER 110MCG 17ASMANEX 30 AER 220MCG 17ASMANEX 60 AER 220MCG 17ASMANEX 7 AER 110MCG 17aspir-81 tab 81mg ec 6aspir-low tab 81mg ec 6aspirin adlt tab 81mg 6aspirin chil chw 81mg 6aspirin chld chw 81mg 6aspirin chw 81mg 6aspirin low chw 81mg 6aspirin tab 325mg 6aspirin tab 325mg ec 6aspirin tab 5gr ec 6aspirin tab 81mg 6aspirin tab 81mg ec 6aspirtab tab 324mg ec 6ASTEPRO SPR 0.15% 96atenol/chlor tab 100-25mg 37atenol/chlor tab 50-25mg 37atenolol tab 100mg 52atenolol tab 25mg 52atenolol tab 50mg 52athlete foot cre 1% 66atorvastatin tab 10mg 34atorvastatin tab 20mg 34atorvastatin tab 40mg 34atorvastatin tab 80mg 34atovaq/progu tab 250-100 38atovaq/progu tab 62.5-25 38ATRALIN GEL 0.05% 64ATRIPLA TAB 47

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ATROPEN INJ 0.25MG 111ATROPEN INJ 0.5MG 111ATROPEN INJ 1MG 111ATROPEN INJ 2MG 111atropin-care sol 1% op 97atropine sul inj 0.05mg/1 111atropine sul inj 0.1mg/ml 111atropine sul inj 0.4/0.5 111atropine sul inj 0.4mg/ml 111atropine sul inj 1mg/ml 111ATROPINE SUL OIN 1% OP 97atropine sul sol 1% op 97ATROVENT HFA AER 17MCG 16aug betamet cre 0.05% 69aug betamet oin 0.05% 69AUGMENTIN SUS 125/5ML 103aurax sol 5.5-1.4% 100aurodex sol otic 100AUVI-Q INJ 0.15MG 115AUVI-Q INJ 0.3MG 115AVALIDE TAB 300-25MG 37AVANDAMET TAB 2-1000MG 26AVANDAMET TAB 2-500MG 26AVANDAMET TAB 4-1000MG 26AVANDAMET TAB 4-500MG 26AVANDIA TAB 2MG 28AVANDIA TAB 4MG 28AVANDIA TAB 8MG 28aveeno cre 1% 69AVELOX ABC TAB 400MG 79AVELOX TAB 400MG 79aviane tab 58avita cre 0.025% 64avita gel 0.025% 64AVODART CAP 0.5MG 81AVONEX KIT 30MCG 104AVONEX PEN KIT 30MCG 104AVONEX PREFL KIT 30MCG 104AXERT TAB 12.5MG 88AXERT TAB 6.25MG 88AZASAN TAB 100MG 51AZASAN TAB 75 MG 51azathioprine inj 100mg 51azathioprine tab 50mg 51azelastine dro 0.05% 100azelastine spr 0.1% 96AZELEX CRE 20% 64AZILECT TAB 0.5MG 44AZILECT TAB 1MG 44azithromycin pow 1gm pak 85azithromycin sus 100/5ml 85azithromycin sus 200/5ml 85azithromycin tab 250mg 85azithromycin tab 500mg 85azithromycin tab 600mg 85AZOPT SUS 1% OP 100azurette tab 28 day 58

B

baby darlng sol ped elec 88baciim inj 50000unt 12bacit/polymy oin op 98bacitracin inj 50000unt 12bacitracin oin op 98baclofen tab 10mg 95baclofen tab 20mg 95BACTOCILL INJ DEX 1GM 103BACTOCILL INJ DEX 2GM 103BACTROBAN OIN NASAL 2% 95balsalazide cap 750mg 80balziva tab 58banophen cap 25mg 31banophen cap 50mg 31BANZEL SUS 40MG/ML 20BANZEL TAB 200MG 20BANZEL TAB 400MG 20BARACLUDE SOL .05MG/ML 49BARACLUDE TAB 0.5MG 49BARACLUDE TAB 1MG 49BARC LIQ 72baycadron elx 0.5/5ml 61bayer adv tab 325mg 6bayer asa tab 325mg 6BAYER BREEZE MIS 2 TEST 73bayer low chw 81mg 6bayer low tab 81mg ec 6baza antifun cre 2% 66BD NEEDLE MIS 27GX1.25 87BD NEEDLES MIS 27GX1/2" 87bella alk/pb tab 16.2mg 111belladonna tin 30/100ml 111benazep/hctz tab 10-12.5 37benazep/hctz tab 20-12.5 37benazep/hctz tab 20-25mg 37benazep/hctz tab 5-6.25 37benazepril tab 10mg 35benazepril tab 20mg 35benazepril tab 40mg 35benazepril tab 5mg 35BENICAR HCT TAB 20-12.5 37BENICAR HCT TAB 40-12.5 37BENICAR HCT TAB 40-25MG 37BENICAR TAB 20MG 36BENICAR TAB 40MG 36BENICAR TAB 5MG 36benzonatate cap 100mg 62benzonatate cap 200mg 62benzoyl per gel 10% 64benzoyl per gel 5% 64benzoyl per liq 10% wash 64benzoyl per liq 5% wash 64benztropine tab 0.5mg 43benztropine tab 1mg 43benztropine tab 2mg 43BEPREVE DRO 1.5% 100BESIVANCE SUS 0.6% 98beta hc lot 1% 69BETADINE SOL 5% OP 98betameth dip cre 0.05% 69

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betameth dip oin 0.05% 69betameth val cre 0.1% 69betameth val lot 0.1% 69betameth val oin 0.1% 69BETASERON INJ 0.3MG 104betaxolol sol 0.5% op 97betaxolol tab 10mg 52betaxolol tab 20mg 52bethanechol tab 10mg 114bethanechol tab 25mg 114bethanechol tab 50mg 114bethanechol tab 5mg 114BETIMOL SOL 0.25% 97BETIMOL SOL 0.5% 97BETOPTIC-S SUS 0.25% OP 97bicalutamide tab 50mg 40BILTRICIDE TAB 600MG 12bio-d-mulsio liq 400unit 116bio-statin pow 30biocotron liq 100-10/5 62BIOTIN FORTE TAB 91bisoprl/hctz tab 10/6.25 37bisoprl/hctz tab 2.5/6.25 37bisoprl/hctz tab 5-6.25mg 37bisoprol fum tab 10mg 52bisoprol fum tab 5mg 52BIVIGAM INJ 10% 101BLEPHAMIDE OIN S.O.P. 99BLEPHAMIDE SUS OP 99BOSULIF TAB 100MG 41BOSULIF TAB 500MG 41bp gel gel 10% 64bp gel gel 5% 64bp wash liq 10% 64bp wash liq 5% 64bpo-10 wash liq 10% 64bpo-5 wash liq 5% 64briellyn tab 58brimonidine sol 0.15% 98brimonidine sol 0.2% op 98bromfenac sol 0.09% 100bromocriptin cap 5mg 43bromocriptin tab 2.5mg 43broncotron liq 10-100/5 62buckleys liq chest 63budeprion tab 100mg sr 23budeprion tab 150mg sr 23budeprion xl tab 150mg 23budeprion xl tab 300mg 23budesonide cap 3mg/24hr 61budesonide sus 0.25mg/2 17budesonide sus 0.5mg/2 17bumetanide tab 0.5mg 74bumetanide tab 1mg 74bumetanide tab 2mg 74bupap tab 50-650mg 5BUPHENYL TAB 500MG 76bupren/nalox sub 2-0.5mg 11bupren/nalox sub 8-2mg 11buprenorphin sub 2mg 11

buprenorphin sub 8mg 11buproban tab 150mg 105bupropion tab 100mg 23bupropion tab 100mg er 23bupropion tab 100mg sr 23bupropion tab 150mg 105bupropion tab 150mg er 23bupropion tab 150mg sr 23bupropion tab 200mg er 23bupropion tab 200mg sr 23bupropion tab 75mg 23bupropn hcl tab 150mg xl 23bupropn hcl tab 300mg xl 23buspirone tab 10mg 14buspirone tab 15mg 14buspirone tab 30mg 14buspirone tab 5mg 14buspirone tab 7.5mg 14but/apap/caf cap 5but/apap/caf cap codeine 10but/apap/caf tab 5but/asa/caf/ cap cod 30mg 10but/asa/caff cap 6but/asa/caff tab 6butal/apap tab 50-325mg 6butalbital tab cpd 6butorphanol sol 10mg/ml 11BUTRANS DIS 10MCG/HR 11BUTRANS DIS 20MCG/HR 11BUTRANS DIS 5MCG/HR 11BYETTA INJ 10MCG 27BYETTA INJ 5MCG 27BYSTOLIC TAB 10MG 52BYSTOLIC TAB 2.5MG 52BYSTOLIC TAB 20MG 52BYSTOLIC TAB 5MG 52

Cc-phen dm syp 62cabergoline tab 0.5mg 76caffeine cit sol 20mg/ml 1caffeine cit sol 60mg/3ml 1calc acetate cap 667mg 80calc acetate tab 667mg 80calcipotrien cre 0.005% 68calcipotrien oin 0.005% 68calcipotrien sol 0.005% 68calcitonin spr 200/act 75calcitrene oin 0.005% 68calcitriol cap 0.25mcg 76calcitriol cap 0.5mcg 76calcitriol oin 3mcg/gm 68calcitriol sol 1mcg/ml 76caldecort cre 1% 69camila tab 0.35mg 60CAMPRAL TAB 333MG 103CANASA SUP 1000MG 80candesartan tab 16mg 36candesartan tab 32mg 36

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candesartan tab 4mg 36candesartan tab 8mg 36capacet cap 6CAPRELSA TAB 100MG 41CAPRELSA TAB 300MG 41captopr/hctz tab 25-15mg 37captopr/hctz tab 25-25mg 37captopr/hctz tab 50-15mg 37captopr/hctz tab 50-25mg 37captopril tab 100mg 35captopril tab 12.5mg 35captopril tab 25mg 35captopril tab 50mg 35carb/levo er tab 25-100mg 43carb/levo er tab 50-200mg 43carb/levo sr tab 25-100mg 43carb/levo sr tab 50-200mg 43carb/levo tab 10-100mg 43carb/levo tab 25-100mg 43carb/levo tab 25-250mg 43carbamazepin cap 100mg er 20carbamazepin cap 200mg er 20carbamazepin cap 300mg er 20carbamazepin chw 100mg 20carbamazepin sus 100/5ml 20carbamazepin tab 200mg 20carbamazepin tab 200mg er 20carbamazepin tab 400mg er 20carbinoxamin liq 4mg/5ml 31carbinoxamin tab 4mg 31CARDENE SR CAP 30MG 53CARDENE SR CAP 45MG 54CARDENE SR CAP 60MG 54CARIMUNE NF INJ 12GM 101CARIMUNE NF INJ 3GM 101CARIMUNE NF INJ 6GM 101carisopr/asa tab 200-325 95carisoprodol tab 350mg 95carisoprodol tab asa/cod 95carteolol sol 1% op 97cartia xt cap 120/24hr 54cartia xt cap 180/24hr 54cartia xt cap 240/24hr 54cartia xt cap 300/24hr 54carvedilol tab 12.5mg 52carvedilol tab 25mg 52carvedilol tab 3.125mg 52carvedilol tab 6.25mg 52CAVERJECT INJ 20MCG 56CAVERJECT INJ 40MCG 56CAVERJECT KIT 10MCG 56CAVERJECT KIT 20MCG 56caziant pak 58CEDAX CAP 400MG 57CEENU CAP 100MG 39CEENU CAP 10MG 39CEENU CAP 40MG 39cefaclor cap 250mg 57cefaclor cap 500mg 57cefaclor sus 125/5ml 57

cefaclor sus 250/5ml 57cefaclor sus 375/5ml 57cefadroxil cap 500mg 57cefadroxil sus 250/5ml 57cefadroxil sus 500/5ml 57cefadroxil tab 1gm 57cefdinir cap 300mg 57cefdinir sus 125/5ml 57cefdinir sus 250/5ml 57cefditoren tab 200mg 57cefditoren tab 400mg 57cefpodo prox sus 100/5ml 58cefpodo prox sus 50mg/5ml 58cefpodoxime tab 100mg 58cefpodoxime tab 200mg 58cefprozil sus 125/5ml 57cefprozil sus 250/5ml 57cefprozil tab 250mg 57cefprozil tab 500mg 57CEFTIN SUS 250/5ML 57cefuroxime sus 125/5ml 57cefuroxime tab 250mg 57cefuroxime tab 500mg 57CELEBREX CAP 100MG 4CELEBREX CAP 200MG 4CELEBREX CAP 400MG 4CELEBREX CAP 50MG 4CELLCEPT SUS 200MG/ML 51CELONTIN CAP 300MG 22CENESTIN TAB 0.3MG 77CENESTIN TAB 0.45MG 77CENESTIN TAB 0.625MG 77CENESTIN TAB 0.9MG 77CENESTIN TAB 1.25MG 77centany oin 2% 66cephadyn tab 50-650mg 6cephalexin cap 250mg 57cephalexin cap 500mg 57cephalexin cap 750mg 57cephalexin sus 125/5ml 57cephalexin sus 250/5ml 57cephalexin tab 250mg 57cephalexin tab 500mg 57ceron-dm syp 62CESAMET CAP 1MG 30cesia pak 58cetirizine sol 1mg/ml 32cetirizine sol 5mg/5ml 32cetirizine syp 1mg/ml 32cetirizine syp 5mg/5ml 32cevimeline cap 30mg 91CHANTIX PAK 0.5& 1MG 105CHANTIX PAK 1MG 105CHANTIX TAB 0.5MG 105CHANTIX TAB 1MG 105chateal tab 0.15/30 58CHEMET CAP 100MG 29cheratussin sol dac 62cheratussin syp ac 62chest conges liq child 63

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chest conges liq childrns 63child asa chw 81mg 6child asa ls chw 81mg 6child vit d chw 400unit 116chloral hydr syp 500/5ml 83chloramphen inj 1gm 13chlord/clidi cap 5-2.5mg 111chlordiazep cap 10mg 15chlordiazep cap 25mg 15chlordiazep cap 5mg 15CHLORHEX DIG SOL 20% 47chlorhex glu sol 0.12% 91CHLORHEX GLU SOL 20% 47chloroquine tab 250mg 38chloroquine tab 500mg 38chlorothiaz tab 250mg 74chlorothiaz tab 500mg 75chlorpromaz tab 100mg 46chlorpromaz tab 10mg 46chlorpromaz tab 200mg 46chlorpromaz tab 25mg 46chlorpromaz tab 50mg 46chlorpropam tab 100mg 28chlorpropam tab 250mg 28chlorthalid tab 100mg 75chlorthalid tab 25mg 75chlorthalid tab 50mg 75chlorzoxazon tab 500mg 95cho mag tris liq 500/5ml 6cho mag tris tab 1000mg 6cho mag tris tab 500mg 6cho mag tris tab 750mg 6cholestyram pow 4gm 33cholestyram pow 4gm lite 33chor gonadot inj 10000unt 75CIALIS TAB 10MG 56CIALIS TAB 2.5MG 56CIALIS TAB 20MG 56CIALIS TAB 5MG 56ciclodan cre 0.77% 66ciclopirox cre 0.77% 66ciclopirox gel 0.77% 66ciclopirox sus 0.77% 66cilostazol tab 100mg 82cilostazol tab 50mg 82cimetidine sol 300/5ml 112cimetidine tab 200mg 112cimetidine tab 300mg 112cimetidine tab 400mg 112cimetidine tab 800mg 112CIMZIA KIT 80CIPRO (10%) SUS 500MG/5 79CIPRO (5%) SUS 250MG/5 79CIPRO HC SUS OTIC 100CIPRODEX SUS 0.3-0.1% 100ciprofloxacn sol 0.3% op 98ciprofloxacn tab 100mg 79ciprofloxacn tab 250mg 79ciprofloxacn tab 500mg 79ciprofloxacn tab 750mg 79

citalopram sol 10mg/5ml 24citalopram tab 10mg 24citalopram tab 20mg 24citalopram tab 40mg 24CL PRENATAL TAB 28-0.8MG 93claravis cap 10mg 65claravis cap 20mg 65claravis cap 30mg 65claravis cap 40mg 65clarithromyc sus 125/5ml 85clarithromyc sus 250/5ml 85clarithromyc tab 250mg 85clarithromyc tab 500mg 85claritin eye dro 0.025%op 100clearlax pow 84clearplex v gel 5% 65clearplex x gel 10% 65clemastine syp 0.5/5ml 31clemastine tab 2.68mg 31clindacin-p pad 1% 65clindamax gel 1% 65clindamax lot 10mg/ml 65clindamy/ben gel 1-5% 65clindamy/ben gel 1.2-5% 65clindamycin aer 1% 65clindamycin cap 150mg 13clindamycin cap 300mg 13clindamycin cap 75mg 13clindamycin cre 2% vag 115clindamycin gel 1% 65clindamycin lot 1% 65clindamycin lot 10mg/ml 65clindamycin pad 1% 65clindamycin sol 1% 65CLINISTIX TES STRIPS 73clobetasol cre 0.05% 69clobetasol gel 0.05% 69clobetasol oin 0.05% 69clobetasol sol 0.05% 69CLODERM CRE 0.1% 69CLODERM CRE 0.1% PMP 69clomipramine cap 25mg 25clomipramine cap 50mg 25clomipramine cap 75mg 25clonazepam tab 0.5mg 20clonazepam tab 1mg 20clonazepam tab 2mg 20clonidine dis 0.1/24hr 36clonidine dis 0.2/24hr 36clonidine dis 0.3/24hr 36clonidine tab 0.1mg 36clonidine tab 0.2mg 36clonidine tab 0.3mg 36clopidogrel tab 300mg 82clopidogrel tab 75mg 82cloraz dipot tab 15mg 15cloraz dipot tab 3.75mg 15cloraz dipot tab 7.5mg 15clotrim/beta cre 1-0.05% 66clotrim/beta cre diprop 66

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clotrim/beta lot diprop 66clotrimazole cre 1% 66clotrimazole loz 10mg 91clotrimazole sol 1% 66clotrimazole tro 10mg 91clozapine tab 100/odt 45clozapine tab 100mg 45clozapine tab 12.5/odt 45clozapine tab 200mg 45clozapine tab 25mg 45clozapine tab 25mg odt 45clozapine tab 50mg 45co-gesic tab 5-500mg 10COARTEM TAB 20-120MG 38codeine sulf tab 15mg 8codeine sulf tab 30mg 8codeine sulf tab 60mg 8COLCRYS TAB 0.6MG 81colestipol gra 5gm 33colestipol tab 1gm 33colidrops dro 0.125/ml 111COLY-MYCIN S SUS OTIC 101COLYTE/FLAVR SOL PACKS 84COMBIGAN SOL 0.2/0.5% 97COMBIVENT AER 17COMETRIQ KIT 100MG 41COMETRIQ KIT 140MG 41COMETRIQ KIT 60MG 41comp allergy cap 25mg 31COMPLERA TAB 48COMPLETE-RF TAB PRENATAL 93COMPLETENATE CHW 93compro sup 25mg 46CONCEPT DHA CAP 93CONCEPT OB CAP 93CONDOMS MIS 86CONDYLOX GEL 0.5% 72congest aid tab 30mg 96congestion tab 30mg 96constulose sol 10gm/15 84COPAXONE KIT 20MG/ML 104CORDRAN LOT 0.05% 69CORDRAN SP CRE 0.05% 69cormax oin 0.05% 69cormax scalp sol 0.05% 69cormax sol 0.05% 69cort intense cre heal 1% 69cortaid adv cre 1% 12 hr 69cortaid cre 1% 69CORTIFOAM AER 90MG 12cortisone + cre 1% 69cortisone ac tab 25mg 61cortisone cre 1% 69cortisone lot 1% 69cortisone oin 1%max st 69CORTISPORIN CRE 0.5% 66CORTISPORIN OIN 1% 66CORTISPORIN SUS -TC OTIC 101cortizone-10 lot eczema 69cortizone-10 lot hydraten 69

cortizone-10 oin 1% 69COSOPT PF SOL 97coughtab tab 200mg 63covaryx hs tab 77covaryx tab 77COVERA-HS TAB 180MG 54COVERA-HS TAB 240MG 54CREON CAP 12000UNT 73CREON CAP 24000UNT 73CREON CAP 6000UNIT 73CRESTOR TAB 10MG 34CRESTOR TAB 20MG 34CRESTOR TAB 40MG 34CRESTOR TAB 5MG 34CRIXIVAN CAP 100MG 48CRIXIVAN CAP 200MG 48CRIXIVAN CAP 400MG 48cromolyn sod neb 20mg/2ml 16cromolyn sod sol 4% op 100cryselle-28 tab 28 tabs 58CUPRIMINE CAP 250MG 51curity salin sol 0.9% irr 81cvs allergy cap 25mg 31cvs allergy dro 0.025%op 100cvs allergy tab 180mg 32cvs aspirin tab 325mg 6cvs aspirin tab 325mg ec 6cvs aspirin tab 81mg ec 6cvs chld asa chw 81mg 6cvs cort int cre heal 1% 69cvs daily tab multiple 92cvs electrol sol 88cvs nicotine dis 14mg/24h 105cvs nicotine dis 21mg/24h 105cvs nicotine dis 7mg/24hr 105cvs nicotine gum 2mg cinn 105cvs nicotine gum 2mg mint 105cvs nicotine gum 2mg orig 105cvs nicotine gum 2mgfruit 105cvs nicotine gum 4mg cinn 105cvs nicotine gum 4mg mint 105cvs nicotine gum 4mg orig 105cvs nicotine gum 4mgfruit 105cvs nicotine loz 2mg mint 105cvs nicotine loz 4mg mint 105cvs nts dis step 1 105CVS PRENATAL TAB 93CVS PRENATAL TAB 28-0.8MG 93cvs purelax pow 84cvs purelax pow 3350 nf 84cyclafem tab 1/35 58cyclafem tab 7/7/7 58cyclobenzapr tab 10mg 95cyclobenzapr tab 5mg 95CYCLOGYL SOL 0.5% OP 97cyclopentol sol 1% op 97cyclopentol sol 2% op 97cyclophosph tab 25mg 39cyclophosph tab 50mg 39CYCLOSET TAB 0.8MG 27

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cyclosporine cap 100mg 51cyclosporine cap 100mg md 51cyclosporine cap 25mg 51cyclosporine cap 25mg mod 51cyclosporine cap 50mg mod 51cyclosporine sol modified 51cylate sol 1% op 97CYMBALTA CAP 20MG 24CYMBALTA CAP 30MG 25CYMBALTA CAP 60MG 25cyproheptad syp 2mg/5ml 33cyproheptad tab 4mg 33CYSTAGON CAP 150MG 81CYSTAGON CAP 50MG 81cytra-k sol 81

Dd-3 gummy chw 400unit 116d-400 tab 400unit 116d-vita liq 400unit 116d3 kids chw 400unit 116daily multi tab vitamin 92daily multi tab vitamins 92daily tab vitamin 92daily value tab multivit 92daily vit tab 92daily vite tab 92daily-vitamn tab 92danazol cap 100mg 12danazol cap 200mg 12danazol cap 50mg 11dantrolene cap 100mg 95dantrolene cap 25mg 95dantrolene cap 50mg 95dapsone tab 100mg 13dapsone tab 25mg 13DARAPRIM TAB 25MG 38dasetta tab 1/35 58dasetta tab 7/7/7 58DAYTRANA DIS 10MG/9HR 2DAYTRANA DIS 15MG/9HR 2DAYTRANA DIS 20MG/9HR 2DAYTRANA DIS 30MG/9HR 2DECARA CAP 25000UNT 116decongestant tab 30mg 96decongestant tab 60mg 96delta d3 tab 400unit 116demeclocycl tab 150mg 108demeclocycl tab 300mg 109DENAVIR CRE 1% 68depade tab 50mg 29DEPEN TITRA TAB 250MG 51DEPO-ESTRADI INJ 5MG/ML 78DEPO-PROVERA INJ 400/ML 40DEPO-SQ PROV INJ 104 60desenex cre 1% 66desipramine tab 100mg 25desipramine tab 10mg 25desipramine tab 150mg 25

desipramine tab 25mg 25desipramine tab 50mg 25desipramine tab 75mg 25desloratadin tab 2.5 odt 32desloratadin tab 5mg 32desloratadin tab 5mg odt 32desmopressin inj 4mcg/ml 76desmopressin sol 0.01% 76desmopressin tab 0.1mg 76desmopressin tab 0.2mg 76desonide cre 0.05% 69desonide lot 0.05% 69desonide oin 0.05% 69desoximetas cre 0.05% 69desoximetas cre 0.25% 69desoximetas gel 0.05% 69desoximetas oin 0.05% 69desoximetas oin 0.25% 69DETROL LA CAP 2MG 114dexameth pho sol 0.1% op 99dexamethason con 1mg/ml 61dexamethason elx 0.5/5ml 61dexamethason sol 0.5/5ml 61dexamethason tab 0.5mg 61dexamethason tab 0.75mg 61dexamethason tab 1.5mg 61dexamethason tab 1mg 61dexamethason tab 2mg 61dexamethason tab 4mg 61dexamethason tab 6mg 61dexchlorphen syp 2mg/5ml 31dexchlorphen tab 4mg cr 31DEXILANT CAP 30MG DR 113DEXILANT CAP 60MG DR 113dexmethylph tab 10mg 2dexmethylph tab 2.5mg 2dexmethylph tab 5mg 2dextroamphet cap 10mg er 1dextroamphet cap 15mg er 1dextroamphet cap 5mg er 1dextroamphet tab 10mg 1dextroamphet tab 5mg 1diabetic tus liq 100/5ml 63diabetic tus liq children 62diabetic tus liq dm 62dialyvite tab 91dialyvite tab 800 91diamode tab 2mg 29DIASTIX TES STRIPS 73diazepam sol 1mg/ml 15diazepam tab 10mg 15diazepam tab 2mg 15diazepam tab 5mg 15DIBENZYLINE CAP 10MG 35diclofen pot tab 50mg 4diclofenac sol 0.1% op 100diclofenac tab 100mg er 4diclofenac tab 100mg xr 4diclofenac tab 25mg dr 4diclofenac tab 50mg dr 4

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diclofenac tab 75mg dr 4dicloxacill cap 250mg 103dicloxacill cap 500mg 103dicyclomine cap 10mg 111dicyclomine sol 10mg/5ml 111dicyclomine tab 20mg 111didanosine cap 125mg 48didanosine cap 200mg 48didanosine cap 250mg 48didanosine cap 400mg 48DIFFERIN GEL 0.3% 65DIFICID TAB 200MG 85diflorasone cre 0.05% 69diflorasone oin 0.05% 69diflunisal tab 500mg 6digoxin sol 50mcg/ml 56digoxin tab 0.125mg 56digoxin tab 0.25mg 56dihydroergot inj 1mg/ml 88DILANTIN CAP 30MG 22DILATRATE SR CAP 40MG 13dilt-cd cap 120mg 54dilt-cd cap 180mg 54dilt-cd cap 240mg 54dilt-cd cap 300mg 54dilt-xr cap 120mg 54dilt-xr cap 180mg 54dilt-xr cap 240mg 54diltiazem cap 120mg cd 54diltiazem cap 120mg er 54diltiazem cap 120mg/24 54diltiazem cap 180mg cd 54diltiazem cap 180mg er 54diltiazem cap 180mg/24 54diltiazem cap 240mg cd 54diltiazem cap 240mg er 54diltiazem cap 240mg/24 54diltiazem cap 300mg cd 54diltiazem cap 300mg er 54diltiazem cap 300mg/24 54diltiazem cap 360mg cd 54diltiazem cap 360mg er 54diltiazem cap 360mg/24 54diltiazem cap 420mg/24 54diltiazem cap 60mg er 54diltiazem cap 90mg er 54diltiazem tab 120mg 54diltiazem tab 30mg 54diltiazem tab 60mg 54diltiazem tab 90mg 54diltzac cap 120mg/24 54diltzac cap 180mg/24 54diltzac cap 240mg/24 54diltzac cap 300mg/24 54diltzac cap 360mg/24 54dimenhydrin tab 50mg 30DIOVAN TAB 160MG 36DIOVAN TAB 320MG 36DIOVAN TAB 40MG 36DIOVAN TAB 80MG 36

DIPENTUM CAP 250MG 80diphen/atrop liq 2.5/5 29diphen/atrop tab 2.5mg 29diphenhist cap 25mg 31diphenhydram cap 25mg 31diphenhydram cap 50mg 31diphenhydram elx 12.5/5ml 31diphenhydram inj 50mg/ml 31dipyridamole tab 25mg 82dipyridamole tab 50mg 82dipyridamole tab 75mg 82disopyramide cap 100mg 15disopyramide cap 150mg 15disulfiram tab 250mg 103disulfiram tab 500mg 103divalproex cap 125mg 22divalproex tab 125mg dr 22divalproex tab 250mg dr 22divalproex tab 250mg er 22divalproex tab 500mg dr 22divalproex tab 500mg er 22DIVIGEL GEL 0.25MG 78DIVIGEL GEL 0.5MG 78DIVIGEL GEL 1MG/GM 78dm/gg sol 62dm/gg sol 10-100/5 62donepezil tab 10mg 103donepezil tab 10mg odt 103donepezil tab 5mg 103donepezil tab 5mg odt 103DORAL TAB 15MG 83dormin cap 25mg 32dorzol/timol sol 2-0.5%op 97dorzolamide sol 2% op 100doxazosin tab 1mg 36doxazosin tab 2mg 36doxazosin tab 4mg 36doxazosin tab 8mg 36doxepin hcl cap 100mg 25doxepin hcl cap 10mg 25doxepin hcl cap 150mg 25doxepin hcl cap 25mg 25doxepin hcl cap 50mg 25doxepin hcl cap 75mg 25doxepin hcl con 10mg/ml 25doxycyc mono cap 100mg 109doxycyc mono cap 50mg 109DOXYCYCL HYC CAP 100MG 109doxycycl hyc cap 100mg 109doxycycl hyc cap 50mg 109DOXYCYCL HYC CAP 75MG 109doxycycl hyc tab 100mg 109doxycycline cap 150mg 109doxycycline cap 75mg 109doxycycline sus 25mg/5ml 109doxycycline tab 20mg 109dramamine tab 25mg 30driminate tab 50mg 30dronabinol cap 10mg 30dronabinol cap 2.5mg 30

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dronabinol cap 5mg 30drospir/ethi tab 3-0.03mg 58dulcolax pow balance 84DULERA AER 100-5MCG 17DULERA AER 200-5MCG 17DUREZOL EMU 0.05% 99DYNACIRC CR TAB 10MG 55DYNACIRC CR TAB 5MG 54DYRENIUM CAP 100MG 74DYRENIUM CAP 50MG 74dytuss syp 12.5/5ml 32

Ee.e.s. 400 tab 400mg 85E.E.S. GRAN SUS 200/5ML 85e.s.p. sus 200-600 13e/c/beta car tab 92econazole cre 1% 66ecotrin low tab 81mg ec 6ecpirin tab 325mg ec 6ed baclofen tab 10mg 95ed-spaz tab 0.125mg 111EDARBI TAB 40MG 36EDARBI TAB 80MG 36EDECRIN TAB 25MG 74EDEX KIT 10MCG 56EDEX KIT 20MCG 56EDEX KIT 40MCG 56EDURANT TAB 25MG 48eemt hs tab 77eemt tab 77ees/sulfisox sus 200-600 13effer-k tab 25meq ef 90EFFIENT TAB 10MG 82EFFIENT TAB 5MG 82ELELYSO INJ 200UNIT 82ELESTRIN GEL 0.06% 78ELIDEL CRE 1% 72ELIGARD INJ 22.5MG 40ELIGARD INJ 30MG 40ELIGARD INJ 45MG 40ELIGARD INJ 7.5MG 40elinest tab 58ELIXOPHYLLIN ELX 80/15ML 18ELLA TAB 30MG 60ELMIRON CAP 100MG 81ELSPAR INJ 10000UNT 42EMADINE SOL 0.05% OP 100EMCYT CAP 140MG 40EMEND CAP 125MG 30EMEND CAP 40MG 30EMEND CAP 80MG 30emoquette tab 58EMSAM DIS 12MG/24H 24EMSAM DIS 6MG/24HR 24EMSAM DIS 9MG/24HR 24EMTRIVA CAP 200MG 48EMTRIVA SOL 10MG/ML 48ENABLEX TAB 7.5MG 114

enalapril tab 10mg 35enalapril tab 2.5mg 35enalapril tab 20mg 35enalapril tab 5mg 35ENBREL INJ 25/0.5ML 5ENBREL INJ 25MG 5ENBREL INJ 50MG/ML 5ENBREL SRCLK INJ 50MG/ML 5encare gel 4% 115endodan tab 11ENJUVIA TAB 0.3MG 78ENJUVIA TAB 0.45MG 78ENJUVIA TAB 0.625MG 78ENJUVIA TAB 0.9MG 78ENJUVIA TAB 1.25MG 78enoxaparin inj 100mg/ml 19enoxaparin inj 120/0.8 19enoxaparin inj 150mg/ml 19enoxaparin inj 30/0.3ml 19enoxaparin inj 300/3ml 19enoxaparin inj 40/0.4ml 19enoxaparin inj 60/0.6ml 19enoxaparin inj 80/0.8ml 19enpresse-28 tab 58enskyce tab 58entacapone tab 200mg 43enulose sol 10gm/15 80epidrin cap 87EPIDUO GEL 0.1-2.5% 65epiflur chw 0.25mg f 89epiflur chw 0.5mg f 89epiflur chw 1mg f 89epiklor pow 20meq 90epiklor/25 pow 25meq 90epinastine dro 0.05% 100epinephrine inj 0.15mg 115epinephrine inj 0.1mg/ml 18epinephrine inj 0.3mg 115epinephrine inj 1mg/ml 18EPIPEN 2-PAK INJ 0.3MG 115EPIPEN INJ 0.3MG 115EPIPEN-JR INJ 0.15MG 115EPIPEN-JR INJ 2-PAK 115epitol tab 200mg 20EPIVIR HBV SOL 5MG/ML 48EPIVIR HBV TAB 100MG 48EPIVIR SOL 10MG/ML 48eplerenone tab 25mg 38eplerenone tab 50mg 38EPOGEN INJ 10000/ML 82EPOGEN INJ 2000/ML 82EPOGEN INJ 20000/ML 82EPOGEN INJ 3000/ML 82EPOGEN INJ 4000/ML 82eprosart mes tab 600mg 36EPZICOM TAB 600-300 48eq allergy cap 25mg 32eq aspirin tab 325mg 7eq aspirin tab 325mg ec 7eq child asa chw 81mg 7

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eq heartburn tab relief 112eq hydrocort cre 1% 69eq itchy eye dro 0.025%op 100eq nicotine dis 14mg/24h 105eq nicotine dis 21mg/24h 105eq nicotine dis 7mg/24hr 105eq nicotine gum 2mg cinn 105eq nicotine gum 2mg mint 105eq nicotine gum 2mg orig 105eq nicotine gum 2mgfruit 105eq nicotine gum 4mg cinn 105eq nicotine gum 4mg mint 105eq nicotine gum 4mg orig 105eq nicotine gum 4mg ref 105eq nicotine gum 4mg strt 105eq nicotine gum 4mgfruit 105eq nicotine loz 2mg cher 105eq nicotine loz 2mg mint 105eq nicotine loz 4mg chry 105eq nicotine loz 4mg mint 105eq suphedrin tab 30mg 96eq tussin liq 100/5ml 63eql allergy cap 25mg 32eql aspirin tab 325mg 7eql aspirin tab 325mg ec 7eql aspirin tab 81mg ec 7eql chld asa chw 81mg 7eql clearlax pow 84eql nicotine dis 14mg/24h 105eql nicotine dis 21mg/24h 105eql nicotine dis 7mg/24hr 105eql nicotine gum 2mg 105eql nicotine gum 2mg ref 105eql nicotine gum 2mg strt 106eql nicotine gum 4mg 106eql nicotine gum 4mg ref 106eql nicotine gum 4mg strt 106eql nicotine loz 2mg mint 106eql nicotine loz 4mg mint 106eql one dail tab essentia 92EQL PRENATAL TAB FORMULA 93EQUETRO CAP 100MG 44EQUETRO CAP 200MG 44EQUETRO CAP 300MG 44ergocalcifer cap 50000unt 116ergoloid mes tab 1mg oral 104ERGOMAR SUB 2MG 88ERIVEDGE CAP 150MG 40errin tab 0.35mg 60ERTACZO CRE 2% 66ery pad 2% 65ERY-TAB TAB 250MG EC 85ERY-TAB TAB 333MG EC 85ERY-TAB TAB 500MG EC 85ERYPED SUS 200/5ML 85ERYPED SUS 400/5ML 85erythrocin tab 250mg 85erythrom eth tab 400mg 85erythromycin cap 250mg ec 85erythromycin gel /benzoyl 65

erythromycin gel 2% 65erythromycin oin 5mg/gm 98erythromycin oin op 98erythromycin pad 2% 65erythromycin sol 2% 65erythromycin tab 250mg bs 85erythromycin tab 500mg bs 85escitalopram sol 5mg/5ml 24escitalopram tab 10mg 24escitalopram tab 20mg 24escitalopram tab 5mg 24essentl one tab daily 92essian h.s. tab 77essian tab 77est estrogen tab mtest 77est estrogen tab mtest ds 77est estrogen tab mtest hs 77estarylla tab 0.25-35 58estazolam tab 1mg 83estazolam tab 2mg 83ESTRACE VAG CRE 0.1MG/GM 115estrad val inj 10mg/ml 78estrad val inj 200mg/5 78estrad val inj 20mg/ml 78estrad val inj 40mg/ml 78ESTRADERM DIS 0.05MG 78ESTRADERM DIS 0.1MG 78estradiol dis 0.025mg 78estradiol dis 0.0375mg 78estradiol dis 0.05mg 78estradiol dis 0.06mg 78estradiol dis 0.075mg 78estradiol dis 0.1mg 78estradiol tab 0.5mg 78estradiol tab 1mg 78estradiol tab 2mg 78ESTRASORB EMU 78ESTRING MIS 2MG 115ESTROGEL GEL 78estropipate tab 0.75mg 78estropipate tab 1.5mg 78estropipate tab 3mg 78ethambutol tab 100mg 39ethambutol tab 400mg 39ethosuximide cap 250mg 22ethosuximide sol 250/5ml 22etidron disd tab 200mg 75etidron disd tab 400mg 75etodolac cap 200mg 4etodolac cap 300mg 4etodolac er tab 400mg 4etodolac er tab 500mg 4etodolac er tab 600mg 4etodolac tab 400mg 4etodolac tab 500mg 4etoposide cap 50mg 42etoposide inj 20mg/ml 42EURAX CRE 10% 73EURAX LOT 10% 73EVAMIST SPR 1.53MG 78

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EVISTA TAB 60MG 76EXELDERM CRE 1% 66EXELDERM SOL 1% 66exemestane tab 25mg 40EXJADE TAB 125MG 29EXJADE TAB 250MG 29EXJADE TAB 500MG 29EXTAVIA INJ 0.3MG 104eye itch rel dro 0.025%op 100EZ USE FLU KIT 2012-13 114

Ffa-8 tab 0.8mg 82FABRAZYME INJ 5MG 76FACTIVE TAB 320MG 79falmina tab 58famciclovir tab 125mg 50famciclovir tab 250mg 50famciclovir tab 500mg 50famotidine sus 40mg/5ml 112famotidine tab 20mg 112famotidine tab 40mg 112FANAPT PAK 44FANAPT TAB 10MG 44FANAPT TAB 12MG 44FANAPT TAB 1MG 44FANAPT TAB 2MG 44FANAPT TAB 4MG 44FANAPT TAB 6MG 44FANAPT TAB 8MG 44FARESTON TAB 60MG 40FAZACLO TAB 150MG 45FAZACLO TAB 200MG 45FC FEMALE MIS CONDOM 86FC2 FEMALE MIS CONDOM 86felbamate sus 600/5ml 22felbamate tab 400mg 22felbamate tab 600mg 22felodipine tab 10mg er 55felodipine tab 2.5mg er 55felodipine tab 5mg er 55FEMCAP MIS 22MM 86FEMCAP MIS 26MM 86FEMCAP MIS 30MM 86FEMTRACE TAB 0.45MG 78FEMTRACE TAB 0.9MG 78FEMTRACE TAB 1.8MG 78fenofibrate cap 134mg 34fenofibrate cap 200mg 34fenofibrate cap 67mg 33fenofibrate tab 145mg 34fenofibrate tab 160mg 34fenofibrate tab 48mg 34fenofibrate tab 54mg 34fenoprofen tab 600mg 4fentanyl dis 100mcg/h 8fentanyl dis 12mcg/hr 8fentanyl dis 25mcg/hr 8fentanyl dis 50mcg/hr 8

fentanyl dis 75mcg/hr 8fentanyl ot loz 1200mcg 8fentanyl ot loz 1600mcg 8fentanyl ot loz 200mcg 8fentanyl ot loz 400mcg 8fentanyl ot loz 600mcg 8fentanyl ot loz 800mcg 8FENTORA TAB 100MCG 8FENTORA TAB 200MCG 8FENTORA TAB 400MCG 8FENTORA TAB 600MCG 8FENTORA TAB 800MCG 8fer-iron dro 15mg/ml 83FERRIPROX TAB 500MG 29ferrocite tab plus 83ferrous dro 15mg/ml 83ferrous sulf dro 15mg/ml 83ferrous sulf elx 220/5ml 83fexofenadine tab 180mg 32fexofenadine tab 30mg 32fexofenadine tab 60mg 32FINACEA GEL 15% 72finasteride tab 1mg 72finasteride tab 5mg 81FLAGYL ER TAB 750MG 12flanax pain tab 220mg 4FLAREX SUS 0.1% OP 99flavoxate tab 100mg 114FLEBOGAMMA INJ 10% 101FLEBOGAMMA INJ 5% 101FLEBOGAMMA INJ DIF 5% 101flecainide tab 100mg 16flecainide tab 150mg 16flecainide tab 50mg 16FLOVENT DISK AER 100MCG 17FLOVENT DISK AER 250MCG 17FLOVENT DISK AER 50MCG 17FLOVENT HFA AER 110MCG 17FLOVENT HFA AER 220MCG 17FLOVENT HFA AER 44MCG 17FLUARIX INJ PF 10-11 114FLUARIX INJ PF 11-12 114FLUARIX INJ PF 12-13 114fluconazole sus 10mg/ml 31fluconazole sus 40mg/ml 31fluconazole tab 100mg 31fluconazole tab 150mg 31fluconazole tab 200mg 31fluconazole tab 50mg 31flucytosine cap 250mg 30flucytosine cap 500mg 30fludrocort tab 0.1mg 62FLULAVAL INJ 2010-11 114FLULAVAL INJ 2011-12 114FLULAVAL INJ 2012-13 114flunisolide spr 0.025% 96flunisolide spr 29mcg 96fluocin acet cre 0.01% 70fluocin acet cre 0.025% 70fluocin acet oil 0.01% 101

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fluocin acet oin 0.025% 70fluocin acet sol 0.01% 70fluocinonide cre 0.05% 70fluocinonide gel 0.05% 70fluocinonide oin 0.05% 70fluocinonide sol 0.05% 70fluor-a-day dro 0.125mg 89fluor-op sus 0.1% op 99fluoride chw 0.25mg f 89fluoride chw 0.5mg f 89fluoride chw 1mg f 89fluoritab chw 0.25mg f 89fluoritab chw 0.5mg f 89fluoritab chw 1mg f 89fluoritab chw 2.2mg 89fluoritab dro 0.125mg 89fluoromethol sus 0.1% op 99fluorouracil cre 5% 67fluorouracil dro 2% 67fluorouracil dro 5% 67fluorouracil inj 1gm/20ml 39fluorouracil inj 2.5g/50m 39fluorouracil inj 500/10ml 39fluorouracil inj 5gm/100m 39fluorouracil sol 2% 67fluorouracil sol 5% 67fluoxetine cap 10mg 24, 104fluoxetine cap 20mg 24, 104fluoxetine cap 40mg 24fluoxetine cap 90mg dr 24fluoxetine sol 20mg/5ml 24fluoxetine tab 10mg 24fluoxetine tab 20mg 24fluoxetine tab 60mg 24fluphenaz de inj 25mg/ml 46fluphenazine con 5mg/ml 46fluphenazine elx 2.5/5ml 46fluphenazine tab 10mg 46fluphenazine tab 1mg 46fluphenazine tab 2.5mg 46fluphenazine tab 5mg 46flura-drops dro 0.125mg 89flura-drops dro 0.25mg f 89flurazepam cap 15mg 83flurazepam cap 30mg 83flurbiprofen sol 0.03% op 100flurbiprofen tab 100mg 4flurbiprofen tab 50mg 4flush syring inj 0.9% 90flutamide cap 125mg 40fluticasone cre 0.05% 70fluticasone oin 0.005% 70fluticasone spr 50mcg 96fluvastatin cap 20mg 34fluvastatin cap 40mg 34FLUVASTATIN TAB 80MG ER 34FLUVIRIN INJ 2011-12 114FLUVIRIN INJ 2012-13 114FLUVIRIN INJ PF 11-12 114FLUVIRIN INJ PF 12-13 114

fluvoxamine tab 100mg 24fluvoxamine tab 25mg 24fluvoxamine tab 50mg 24FLUZONE INJ INTRADRM 114FLUZONE INJ PF 11-12 114FLUZONE INJ PF 12-13 114FLUZONE PED/ INJ PF 11-12 115FLUZONE PED/ INJ PF 12-13 115FLUZONE QUAD INJ 13-14 115FLUZONE SPLT INJ 2011-12 115FLUZONE SPLT INJ 2012-13 115FML FORTE SUS 0.25% OP 99FML OIN 0.1% OP 99foaming face liq wsh 10% 65FOCALIN XR CAP 10MG 2FOCALIN XR CAP 15MG 2FOCALIN XR CAP 20MG 2FOCALIN XR CAP 25MG 2FOCALIN XR CAP 30MG 2FOCALIN XR CAP 35MG 2FOCALIN XR CAP 40MG 2FOCALIN XR CAP 5MG 2folbee plus tab 91folic acid tab 1000mcg 82folic acid tab 1mg 82folic acid tab 400mcg 82folic acid tab 800mcg 82FOLIVANE-OB CAP 93fondaparinux sol 10/0.8 19fondaparinux sol 2.5/0.5 19fondaparinux sol 5.0/0.4 19fondaparinux sol 7.5/0.6 19FORADIL CAP AEROLIZE 18FORTEO SOL 600/2.4 75FOSAMAX + D TAB 70-2800 75FOSAMAX + D TAB 70-5600 75fosinopril tab 10mg 35fosinopril tab 20mg 35fosinopril tab 40mg 35FOSRENOL CHW 1000MG 80FOSRENOL CHW 500MG 80FOSRENOL CHW 750MG 80FRAGMIN INJ 10000/ML 19FRAGMIN INJ 12500UNT 19FRAGMIN INJ 15000UNT 20FRAGMIN INJ 18000UNT 20FRAGMIN INJ 2500/0.2 19FRAGMIN INJ 25000/ML 20FRAGMIN INJ 5000/0.2 19FRAGMIN INJ 7500/0.3 19FROVA TAB 2.5MG 88FULL SPECT TAB B/ VIT C 91fungicure spr intens 66furosemide sol 10mg/ml 74furosemide tab 20mg 74furosemide tab 40mg 74furosemide tab 80mg 74FUZEON INJ 90MG 48FUZEON KIT 48

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Gg-tron liq 10-100/5 62gabapentin cap 100mg 20gabapentin cap 300mg 20gabapentin cap 400mg 20gabapentin tab 600mg 20gabapentin tab 800mg 20GABITRIL TAB 12MG 22GABITRIL TAB 16MG 22galantamine cap 16mg er 103galantamine cap 24mg er 103galantamine cap 8mg er 103galantamine tab 12mg 103galantamine tab 4mg 103galantamine tab 8mg 103GAMASTAN S/D INJ 101GAMMAGARD INJ 10GM/100 101GAMMAGARD INJ 1GM/10ML 101GAMMAGARD INJ 2.5GM/25 101GAMMAGARD INJ 20GM/200 101GAMMAGARD INJ 30GM/300 101GAMMAGARD INJ 5GM/50ML 101GAMMAGARD SD INJ 10GM HU 101GAMMAGARD SD INJ 2.5GM HU 101GAMMAGARD SD INJ 5GM HU 101GAMMAKED INJ 10GM/100 101GAMMAKED INJ 1GM/10ML 101GAMMAKED INJ 2.5GM/25 101GAMMAKED INJ 20GM/200 101GAMMAKED INJ 5GM/50ML 101GAMMAPLEX INJ 10GM 101GAMMAPLEX INJ 2.5GM 101GAMMAPLEX INJ 5GM 101GAMUNEX INJ 10% 101GAMUNEX-C INJ 10GM/100 102GAMUNEX-C INJ 1GM/10ML 101GAMUNEX-C INJ 2.5GM/25 101GAMUNEX-C INJ 20GM/200 102GAMUNEX-C INJ 5GM/50ML 101ganciclovir cap 250mg 49ganciclovir cap 500mg 49gani-tuss dm liq 100-10/5 62gani-tuss nr liq 100-10/5 62ganidin-nr liq 100/5ml 63garamycin oin 0.3% op 98gavilax pow 84gavilyte-c sol 84gavilyte-g sol 84gavilyte-n sol flav pk 84gemfibrozil tab 600mg 34genahist cap 25mg 32genaphed tab 30mg 96generlac sol 10gm/15 80gengraf cap 100mg 51gengraf cap 25mg 51gengraf sol 100mg/ml 51gentak oin 0.3% op 98gentak sol 0.3% op 98gentamicin cre 0.1% 66

gentamicin oin 0.1% 66gentamicin oin 0.3% op 98gentamicin sol 0.3% op 98gentasol sol 0.3% op 98gentlelax pow 84geri-dryl cap 25mg 32geri-hydrola cre 12% 71geri-hydrola lot 12% 71gg/codeine sol 100-10/5 62gianvi tab 3-0.02mg 58gildagia tab 0.4-35 58gildess fe tab 1.5/30 58gildess fe tab 1/20 58gildess tab 1.5/30 58gildess tab 1/20 58GLASSIA INJ 108GLEEVEC TAB 100MG 41GLEEVEC TAB 400MG 41GLIADEL WAF 7.7MG 39glimepiride tab 1mg 28glimepiride tab 2mg 28glimepiride tab 4mg 28glipizide er tab 10mg 28glipizide er tab 2.5mg 28glipizide er tab 5mg 28glipizide tab 10mg 28glipizide tab 5mg 28glipizide xl tab 10mg 28glipizide xl tab 2.5mg 28glipizide xl tab 5mg 28GLUCAGEN INJ 1MG 27GLUCAGEN INJ HYPOKIT 27GLUCAGON KIT 1MG 27GLUMETZA TAB 1000MG 26GLUMETZA TAB 500MG 26glyburid mcr tab 1.5mg 28glyburid mcr tab 3mg 28glyburid mcr tab 6mg 28glyburide tab 1.25mg 28glyburide tab 2.5mg 28glyburide tab 5mg 28glycolax pow 3350 nf 84glycopyrrol tab 1mg 111glycopyrrol tab 2mg 111GLYSET TAB 100MG 26GLYSET TAB 25MG 26GLYSET TAB 50MG 26gnp allergy cap 25mg 32gnp allergy tab 180mg 33gnp aspirin chw 81mg 7gnp aspirin tab 325mg 7gnp aspirin tab 325mg ec 7gnp aspirin tab 81mg ec 7gnp clearlax pow 84gnp hydrocor cre 1% plus 70gnp lice egg gel remover 73gnp nicotine gum 2mg mint 106gnp nicotine gum 2mg orig 106gnp nicotine gum 4mg mint 106gnp nicotine gum 4mg orig 106

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gnp nicotine loz 2mg mint 106gnp nicotine loz 4mg mint 106gnp pediatri sol electrol 88GNP PRENATAL TAB 28-0.8MG 94gnp tussin liq dm 62gnp tussin liq dm cough 62gnp vit d tab 400unit 116granisetron tab 1mg 29GRANISOL SOL 2MG/10ML 29griseofulvin sus 125/5ml 30griseofulvin tab micr 500 30griseofulvin tab ultr 125 30griseofulvin tab ultr 250 30guaiasorb dm liq 100-10/5 62guaiatussin syp ac 62guaifenesin liq nr 63guaifenesin sol 100/5ml 63guaifenesin sol 200/10ml 63guaifenesin sol 300/15ml 63guaifenesin sol dac 62guaifenesin syp ac 62guaifenesin tab 200mg 63guanfacine tab 1mg 36guanfacine tab 2mg 36GUANIDINE TAB 125MG 38

Hhalfprin tab 81mg ec 7halobetasol cre 0.05% 70halobetasol oin 0.05% 70HALOG CRE 0.1% 70HALOG OIN 0.1% 70haloperidol con 2mg/ml 45haloperidol tab 0.5mg 45haloperidol tab 10mg 45haloperidol tab 1mg 45haloperidol tab 20mg 45haloperidol tab 2mg 45haloperidol tab 5mg 45hc pramoxine cre 1-1% 12hc pramoxine cre 1-2.5% 70hc pramoxine cre 2.5-1% 12hc valerate cre 0.2% 70hc valerate oin 0.2% 70hc/acet acid sol otic 101healthylax pow 84heartbrn rel tab 200mg 112heartburn tab 150mg 112heartburn tab 200mg 112heartburn tab 20mg 112heartburn tab relief 112heather tab 0.35mg 60hecoria cap 0.5mg 51hecoria cap 1mg 51hecoria cap 5mg 51HECTOROL CAP 0.5MCG 76HECTOROL CAP 1MCG 76HECTOROL CAP 2.5MCG 76HELIDAC MIS 113

hematinic pl tab vit/min 83hematinic/fa tab 83hemocyte tab -plus 83hemocyte-f tab 83hemril-30 sup 30mg 12heparin sod inj 1000/ml 20heparin sod inj 10000/ml 20heparin sod inj 20000/ml 20HEPSERA TAB 10MG 49HEXALEN CAP 50MG 39hm aspirin chw 81mg 7hm aspirin tab 325mg 7hm clearlax pow 84hm nicotine dis 14mg/24h 106hm nicotine dis 21mg/24h 106hm nicotine gum 2mg mint 106hm nicotine gum 4mg mint 106hm nicotine loz 2mg mint 106hm nicotine loz 4mg mint 106HM PRENATAL TAB 94hm tussin liq adlt dm 62homatropaire sol 5% op 97homatropine sol 5% op 97HORIZANT TAB 600MG 104hrtbrn rel cap 15mg dr 113HUMALOG INJ 100/ML 27HUMALOG KWIK INJ 100/ML 27HUMALOG MIX INJ 50/50 27HUMALOG MIX INJ 50/50KWP 27HUMALOG MIX INJ 75/25KWP 27HUMALOG MIX SUS 75/25 27HUMIRA KIT 20MG/0.4 3HUMIRA KIT 40MG/0.8 3HUMIRA PEN KIT 40MG/0.8 3HUMIRA PEN KIT CROHNS 3HUMIRA PEN KIT PSORIASI 3HUMULIN INJ 70/30 27HUMULIN N INJ U-100 27HUMULIN N PN INJ U-100 27HUMULIN PEN INJ 70/30 27HUMULIN R INJ U-100 27HUMULIN R INJ U-500 27HYCAMTIN CAP 0.25MG 42HYCAMTIN CAP 1MG 42hydralazine tab 100mg 38hydralazine tab 10mg 38hydralazine tab 25mg 38hydralazine tab 50mg 38hydro-lotion lot 1% 70hydrochlorot cap 12.5mg 75hydrochlorot tab 12.5mg 75hydrochlorot tab 25mg 75hydrochlorot tab 50mg 75hydroco/apap sol 7.5-500 11hydroco/apap tab 10-500mg 11hydroco/apap tab 10-650mg 11hydroco/apap tab 2.5-500 11hydroco/apap tab 5-325mg 11hydroco/apap tab 5-500mg 11hydroco/apap tab 7.5-325 11

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hydroco/apap tab 7.5-500 11hydroco/apap tab 7.5-650 11hydroco/apap tab 7.5-750 11hydrocod/hom syp 5-1.5/5 62hydrocod/ibu tab 7.5-200 11hydrocodone-acetaminophen 11hydrocort ac sup 25mg 12hydrocort ac sup 30mg 12hydrocort cre 1% 70hydrocort cre 1% plus 70hydrocort cre 1%pls 10 70hydrocort cre 1%pls 12 70hydrocort cre 2.5% 70hydrocort lot 1% 70hydrocort lot 2.5% 70hydrocort oin 1% 70hydrocort oin 2.5% 70hydrocort tab 10mg 61hydrocort tab 20mg 61hydrocort tab 5mg 61hydrocort/ab oin 1% 70hydrocream cre 1% 70hydromet syp 5-1.5/5 62hydromorphon liq 1mg/ml 8hydromorphon tab 2mg 8hydromorphon tab 4mg 8hydromorphon tab 8mg 8hydroskin cre 1% 70hydroxychlor tab 200mg 38hydroxyurea cap 500mg 42hydroxyz hcl inj 25mg/ml 15hydroxyz hcl inj 50mg/ml 15hydroxyz hcl sol 10mg/5ml 15hydroxyz hcl syp 10mg/5ml 15hydroxyz hcl tab 10mg 15hydroxyz hcl tab 25mg 15hydroxyz hcl tab 50mg 15hydroxyz pam cap 100mg 15hydroxyz pam cap 25mg 15hydroxyz pam cap 50mg 15hyomax tab 0.125mg 111hyomax-ft tab 0.125mg 111hyomax-sl sub 0.125mg 111hyomax-sr tab 0.375mg 111hyoscyamine dro 0.125/ml 111hyoscyamine elx 0.125/5 112hyoscyamine sub 0.125mg 112hyoscyamine tab 0.125mg 112hyoscyamine tab 0.375 er 112hyoscyamine tab 0.375 sr 112hyosyne dro 0.125/ml 112hyosyne elx 0.125/5 112hypercare sol 20% 72HYPO NEEDLE MIS 27GX1.25 87HYPO NEEDLE MIS 27GX1.5" 87HYPO NEEDLE MIS 27GX1/2" 87

Iibandronate tab 150mg 75

ibuprofen tab 400mg 4ibuprofen tab 600mg 4ibuprofen tab 800mg 4ICLUSIG TAB 15MG 41ICLUSIG TAB 45MG 41ilotycin oin op 98imipenem/cil inj 250mg 13imipenem/cil inj 500mg 13imipram hcl tab 10mg 26imipram hcl tab 25mg 26imipram hcl tab 50mg 26imipram pam cap 100mg 26imipram pam cap 125mg 26imipram pam cap 150mg 26imipram pam cap 75mg 26imiquimod cre 5% 72imperim tab 2mg 29IMPLANON IMP 68MG 60INCIVEK TAB 375MG 50indapamide tab 1.25mg 75indapamide tab 2.5mg 75INDOCIN SUP 50MG 4INDOCIN SUS 25MG/5ML 4indomethacin cap 25mg 4indomethacin cap 50mg 4indomethacin cap 75mg er 4INFERGEN INJ 15MCG 50INFERGEN INJ 9MCG 50INFLUENZA A INJ PF09H1N1 115INLYTA TAB 1MG 41INLYTA TAB 5MG 41INNOHEP INJ 20000/ML 20INNOPRAN XL CAP 120MG 53INNOPRAN XL CAP 80MG 53INSPIREASE MIS BAGS 87INSPIREASE MIS MOUTHPCE 87INSPIREASE MIS REP MOUT 87INSPIREASE MIS RES BAG 87INSULIN PEN NEEDLES 87INSULIN SYRINGES 87INTELENCE TAB 100MG 48INTELENCE TAB 200MG 48INTELENCE TAB 25MG 48INTRON-A INJ 10MU 42INTRON-A INJ 10MU PEN 42INTRON-A INJ 18MU 42INTRON-A INJ 25MU 42INTRON-A INJ 3MU PEN 42INTRON-A INJ 50MU 42INTRON-A INJ 5MU PEN 42INTUNIV TAB 1MG 1INTUNIV TAB 2MG 1INTUNIV TAB 3MG 1INTUNIV TAB 4MG 1INVEGA SUST INJ 117/0.75 44INVEGA SUST INJ 156MG/ML 44INVEGA SUST INJ 234/1.5 45INVEGA SUST INJ 39/0.25 44INVEGA SUST INJ 78/0.5ML 44INVEGA TAB 1.5MG 45

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INVEGA TAB 3MG 45INVEGA TAB 6MG 45INVEGA TAB 9MG 45INVIRASE CAP 200MG 48INVIRASE TAB 500MG 48iophen c-nr liq 100-10/5 62iophen dm-nr liq 100-10/5 62iophen-nr liq 100/5ml 63IOPIDINE SOL 1% OP 98IPECAC SYP 29ipratropium sol 0.02%inh 16irbesar/hctz tab 150-12.5 37irbesar/hctz tab 300-12.5 37irbesartan tab 150mg 36irbesartan tab 300mg 36irbesartan tab 75mg 36IRESSA TAB 250MG 41iron supplmt dro 15mg/ml 83ISENTRESS CHW 100MG 48ISENTRESS CHW 25MG 48ISENTRESS TAB 400MG 48ISO CARBACHO SOL 1.5% OP 97ISO CARBACHO SOL 3% OP 97ISO HOMATROP SOL 2% OP 97ISO HYOSCINE SOL 0.25% OP 97isochron tab 40mg cr 14isoditrate tab 40mg er 14isometh/apap cap dichlor 87isonarif cap 38isoniazid syp 50mg/5ml 39isoniazid tab 100mg 39isoniazid tab 300mg 39ISORDIL TAB 40MG 14isosorb din tab 10mg 14isosorb din tab 20mg 14isosorb din tab 30mg 14isosorb din tab 40mg er 14isosorb din tab 5mg 14isosorb mono tab 120mg er 14isosorb mono tab 30mg er 14isosorb mono tab 60mg er 14isradipine cap 2.5mg 55isradipine cap 5mg 55ISTALOL SOL 0.5% OP 97itch-x lot 1% 70itchy eye dro 0.025%op 100itraconazole cap 100mg 31

JJAKAFI TAB 10MG 41JAKAFI TAB 15MG 41JAKAFI TAB 20MG 41JAKAFI TAB 25MG 41JAKAFI TAB 5MG 41jantoven tab 10mg 19jantoven tab 1mg 19jantoven tab 2.5mg 19jantoven tab 2mg 19jantoven tab 3mg 19

jantoven tab 4mg 19jantoven tab 5mg 19jantoven tab 6mg 19jantoven tab 7.5mg 19JANUVIA TAB 100MG 27JANUVIA TAB 25MG 27JANUVIA TAB 50MG 27jencycla tab 0.35mg 61jock itch cre 1% 66jolivette tab 0.35mg 61junel 1.5/30 tab 58junel 1/20 tab 58junel fe tab 1.5/30 59junel fe tab 1/20 59just d liq 400unit 116

Kk citrate sol citr acd 81k-effervesce tab 25meq ef 90k-prime tab 25meq ef 90k-vescent pow 20meq 90k-vescent tab 25meq ef 90KADIAN CAP 10MG CR 8KADIAN CAP 200MG CR 8KALETRA SOL 48KALETRA TAB 100-25MG 48KALETRA TAB 200-50MG 48kalexate pow 52karidium dro 0.125mg 89kariva tab 28 day 59KEFLEX CAP 750MG 57kelnor tab 1/35 59KEPIVANCE INJ 6.25MG 42kericort 10 cre 1% 70KETEK TAB 300MG 13KETEK TAB 400MG 13ketoconazole aer 2% 66ketoconazole cre 2% 66ketoconazole sha 2% 67ketoconazole tab 200mg 31ketodan aer 2% 67ketoprofen cap 200mg er 4ketoprofen cap 50mg 4ketoprofen cap 75mg 4ketorolac sol 0.4% 100ketorolac sol 0.5% 100ketorolac tab 10mg 4ketotif fum dro 0.025%op 100KINERET INJ 3kionex pow usp 52kionex sus 15gm/60 52klor-con 10 tab 10meq er 90klor-con 8 tab 8meq er 90klor-con m10 tab 10meq er 90KLOR-CON M15 TAB 90klor-con m20 tab 20meq er 90klor-con pow 20meq 90klor-con/ef tab 25meq fr 90kls anti-dia tab 2mg 29

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kls aspirin tab 325mg ec 7kls aspirin tab 81mg ec 7kls naproxen tab 220mg 4kls quit2 gum 2mg 106kls quit4 gum 4mg 106kp aspirin tab 81mg ec 7KP PRENATAL TAB MULTIVIT 94kurvelo tab 0.15/30 59

Llabetalol tab 100mg 52labetalol tab 200mg 52labetalol tab 300mg 52laclotion lot 12% 71LACRISERT MIS 5MG OP 97lactulose sol 10gm/15 80, 84lactulose sol 20gm/30 84LAMICTAL CHW 2MG 20LAMICTAL KIT START 35 20LAMICTAL KIT START 49 20LAMICTAL KIT START 98 20LAMICTAL ODT KIT 20LAMICTAL ODT TAB 100MG 20LAMICTAL ODT TAB 200MG 20LAMICTAL ODT TAB 25MG 20LAMICTAL ODT TAB 50MG 20LAMICTAL XR KIT 20LAMISIL AT SPR 1% 67LAMISIL SPR 1% 67lamivud/zido tab 150-300 48lamivudine tab 150mg 48lamivudine tab 300mg 48lamotrigine chw 25mg 20lamotrigine chw 5mg 20lamotrigine tab 100mg 21lamotrigine tab 100mg er 21lamotrigine tab 150mg 21lamotrigine tab 200mg 21lamotrigine tab 200mg er 21lamotrigine tab 250mg er 21lamotrigine tab 25mg 21lamotrigine tab 25mg er 21lamotrigine tab 300mg er 21lamotrigine tab 50mg er 21LANCETS 87lansoprazole cap 15mg dr 113lansoprazole cap 30mg dr 113LANSOPRAZOLE SUS 3MG/ML 113lansoprazole tab 15mg odt 113lansoprazole tab 30mg odt 113LANTUS INJ 100/ML 27LANTUS INJ SOLOSTAR 27latanoprost sol 0.005% 100LATUDA TAB 20MG 44LATUDA TAB 40MG 44LATUDA TAB 80MG 44laxaclear pow 84LAZANDA SPR 100MCG 8LAZANDA SPR 400MCG 8

leena tab 59leflunomide tab 10mg 5leflunomide tab 20mg 5LESCOL XL TAB 80MG 34lessina tab 59LETAIRIS TAB 10MG 57LETAIRIS TAB 5MG 57letrozole tab 2.5mg 40leucovor ca tab 10mg 42leucovor ca tab 15mg 42leucovor ca tab 25mg 42leucovor ca tab 5mg 42LEUKERAN TAB 2MG 39LEUKINE INJ 250MCG 82leuprolide inj 1mg/0.2 40levalbuterol neb 0.31mg 18levalbuterol neb 0.63mg 18levalbuterol neb 1.25/0.5 18levalbuterol neb 1.25mg 18LEVATOL TAB 20MG 53LEVEMIR INJ 27LEVEMIR INJ FLEXPEN 27levetiraceta sol 100mg/ml 21levetiraceta sol 500/5ml 21levetiraceta tab 1000mg 21levetiraceta tab 250mg 21levetiraceta tab 500mg 21levetiraceta tab 750mg 21LEVITRA TAB 10MG 56LEVITRA TAB 2.5MG 56LEVITRA TAB 20MG 56LEVITRA TAB 5MG 56levobunolol sol 0.25% op 97levobunolol sol 0.5% op 97levocarnitin sol 1gm/10ml 76levocarnitin tab 330mg 76levocetirizi sol 2.5/5ml 33levocetirizi tab 5mg 33levofloxacin sol 0.5% 98levofloxacin sol 25mg/ml 79levofloxacin tab 250mg 79levofloxacin tab 500mg 79levofloxacin tab 750mg 79levonest tab 59levonor/ethi tab 0.1-0.02 59levonor/ethi tab estradio 59levonorgestr tab 0.75mg 60levora-28 tab 0.15/30 59levorphanol tab 2mg 9levothroid tab 100mcg 109levothroid tab 112mcg 109levothroid tab 125mcg 109levothroid tab 137mcg 109levothroid tab 150mcg 109levothroid tab 175mcg 109levothroid tab 200mcg 110levothroid tab 25mcg 109levothroid tab 300mcg 110levothroid tab 50mcg 109levothroid tab 75mcg 109

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levothroid tab 88mcg 109levothyroxin tab 100mcg 110levothyroxin tab 112mcg 110levothyroxin tab 125mcg 110levothyroxin tab 137mcg 110levothyroxin tab 150mcg 110levothyroxin tab 175mcg 110levothyroxin tab 200mcg 110levothyroxin tab 25mcg 110levothyroxin tab 300mcg 110levothyroxin tab 50mcg 110levothyroxin tab 75mcg 110levothyroxin tab 88mcg 110levoxyl tab 100mcg 110levoxyl tab 112mcg 110levoxyl tab 125mcg 110levoxyl tab 137mcg 110levoxyl tab 150mcg 110levoxyl tab 175mcg 110levoxyl tab 200mcg 110levoxyl tab 25mcg 110levoxyl tab 50mcg 110levoxyl tab 75mcg 110levoxyl tab 88mcg 110LEXIVA SUS 50MG/ML 48LEXIVA TAB 700MG 48LIALDA TAB 1.2GM 80lice egg gel remover 73lice md gel 73LICE TRTMNT KIT MAX-STR 73liceout gel 73liceout gel /comb 73LICIDE TREAT KIT 73lido/prilocn cre 2.5-2.5% 72lidocaine gel 2% 72lidocaine gel 2% jelly 72lidocaine oin 5% 72lidocaine sol 2% visc 91lidocaine sol 4% 72LIDODERM DIS 5% 72LIFESTYLES MIS COLORS 86LIFESTYLES MIS EXT STR 86LIFESTYLES MIS FORM FIT 86LIFESTYLES MIS LUBRICAT 86LIFESTYLES MIS RIBBED 86LIFESTYLES MIS SPERM/LU 86LIFESTYLES MIS STUDDED 86LIFESTYLES MIS ULT/SENS 86LIFESTYLES MIS VIBRA-RI 86LIFESTYLES MIS XPLEASUR 86lindane lot 1% 73lindane sha 1% 73liothyronine tab 25mcg 110liothyronine tab 50mcg 110liothyronine tab 5mcg 110lisinop/hctz tab 10-12.5 37lisinop/hctz tab 20-12.5 37lisinop/hctz tab 20-25mg 37lisinopril tab 10mg 35lisinopril tab 2.5mg 35

lisinopril tab 20mg 35lisinopril tab 30mg 35lisinopril tab 40mg 35lisinopril tab 5mg 35lithium carb cap 150mg 44lithium carb cap 300mg 44lithium carb cap 600mg 44lithium carb tab 300mg 44lithium carb tab 300mg er 44lithium carb tab 450mg er 44LITHIUM CITR SOL 8MEQ/5ML 44LIVALO TAB 1MG 34LIVALO TAB 2MG 34LIVALO TAB 4MG 34LODOSYN TAB 25MG 43lofene tab 2.5mg 29lokara lot 0.05% 70lonox tab 2.5mg 29loperamide cap 2mg 29loperamide tab 2mg 29lorazepam tab 0.5mg 15lorazepam tab 1mg 15lorazepam tab 2mg 15loryna tab 3-0.02mg 59LORZONE TAB 375MG 95LORZONE TAB 750MG 95losartan pot tab 100mg 36losartan pot tab 25mg 36losartan pot tab 50mg 36losartan/hct tab 100-12.5 37losartan/hct tab 100-25 37losartan/hct tab 50-12.5 37LOTEMAX SUS 0.5% 99LOTRIMIN ULT CRE 1% 67LOTRONEX TAB 0.5MG 80LOTRONEX TAB 1MG 80lovastatin tab 10mg 34lovastatin tab 20mg 34lovastatin tab 40mg 34LOVAZA CAP 1GM 33low-ogestrel tab 59loxapine cap 10mg 45loxapine cap 25mg 45loxapine cap 50mg 46loxapine cap 5mg 45ludent chw 0.25mg f 89ludent chw 0.5mg f 89ludent chw 1mg f 89LUFYLLIN TAB 200MG 18LUFYLLIN TAB 400MG 18LUMIGAN SOL 0.03% 100LUMIZYME INJ 50MG 76LUNESTA TAB 1MG 83LUNESTA TAB 2MG 83LUNESTA TAB 3MG 83LUPR DEP-PED INJ 11.25MG 76LUPR DEP-PED INJ 15MG 76LUPR DEP-PED INJ 30MG 76LUPR DEP-PED INJ 7.5MG 76LUPRON DEPOT INJ 11.25MG 40

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LUPRON DEPOT INJ 22.5MG 40LUPRON DEPOT INJ 3.75MG 40LUPRON DEPOT INJ 30MG 40LUPRON DEPOT INJ 7.5MG 40lutera tab 59LYCELLE GEL 73LYRICA CAP 100MG 21LYRICA CAP 150MG 21LYRICA CAP 200MG 21LYRICA CAP 225MG 21LYRICA CAP 25MG 21LYRICA CAP 300MG 21LYRICA CAP 50MG 21LYRICA CAP 75MG 21LYSODREN TAB 500MG 40

MM-VIT TAB 27-1MG 94MACRODANTIN CAP 25MG 113magnesium su inj 50% 90malathion lot 0.5% 73maprotiline tab 25mg 23maprotiline tab 50mg 23maprotiline tab 75mg 23margesic cap 6marlissa tab 0.15/30 59MARPLAN TAB 10MG 24marten-tab tab 50-325mg 6MATULANE CAP 50MG 42MAXAIR AUTOH AER 200MCG 18MAXIDEX SUS 0.1% OP 99mebendazole chw 100mg 12meclizine tab 12.5mg 30meclizine tab 25mg 30meclofen sod cap 100mg 4meclofen sod cap 50mg 4med-derm hc cre 1% 70med-lice gel combing 73medi-meclizi tab 25mg 30medi-phedrin tab 30mg 96medi-phedryl cap 25mg 32medi-phedryl elx 12.5/5ml 32medi-tuss dm liq diabetic 62mediproxen tab 220mg 4medroxypr ac inj 150mg/ml 60medroxypr ac tab 10mg 103medroxypr ac tab 2.5mg 103medroxypr ac tab 5mg 103mefenam acid cap 250mg 4mefloquine tab 250mg 38megestrol ac sus 400mg/10 40megestrol ac sus 40mg/ml 40megestrol ac tab 20mg 40megestrol ac tab 40mg 40meloxicam sus 7.5/5ml 5meloxicam tab 15mg 5meloxicam tab 7.5mg 5melphalan inj 50mg 39MENEST TAB 0.3MG 78

MENEST TAB 0.625MG 78MENEST TAB 1.25MG 78MENEST TAB 2.5MG 78MENOSTAR DIS 14MCG 78MENTAX CRE 1% 67meperidine tab 100mg 9meperidine tab 50mg 9meperitab tab 100mg 9meperitab tab 50mg 9MEPHYTON TAB 5MG 116meprobamate tab 200mg 15meprobamate tab 400mg 15MEPRON SUS 13mercaptopur tab 50mg 39mesalamine ene 4gm 80mesalamine kit 4gm 80MESNEX TAB 400MG 42MESTINON SYP 60MG/5ML 38metadate tab 20mg er 2metaproteren syp 10mg/5ml 18metaproteren tab 10mg 18metaproteren tab 20mg 18metaxalone tab 800mg 95metformin er tab 1000mg 26metformin tab 1000mg 27metformin tab 500mg 26metformin tab 500mg er 26metformin tab 750mg er 26metformin tab 850mg 27methadone con 10mg/ml 9methadone sol 10mg/5ml 9methadone sol 5mg/5ml 9methadone tab 10mg 9methadone tab 40mg 9methadone tab 5mg 9methadose con 10mg/ml 9methadose sf con 10mg/ml 9methadose tab 10mg 9methadose tab 40mg 9methadose tab 5mg 9methamphetam tab 5mg 1methazolamid tab 25mg 74methazolamid tab 50mg 74methenam hip tab 1gm 113methimazole tab 10mg 109methimazole tab 5mg 109METHITEST TAB 10MG 12methocarbam tab 500mg 95methocarbam tab 750mg 95methotrexate tab 2.5mg 40methscopolam tab 2.5mg 112methyclothia tab 5mg 75methyldopa tab 250mg 36methyldopa tab 500mg 36methylergon tab 0.2mg 101METHYLIN CHW 10MG 2METHYLIN CHW 2.5MG 2METHYLIN CHW 5MG 2methylin tab 10mg 2methylin tab 10mg er 2

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methylin tab 20mg 2methylin tab 20mg er 2methylin tab 5mg 2methylphenid cap 10mg 2methylphenid cap 20mg 2methylphenid cap 20mg er 2methylphenid cap 30mg 2methylphenid cap 30mg er 2methylphenid cap 40mg 2methylphenid cap 40mg er 2methylphenid cap 50mg 2methylphenid cap 60mg 2methylphenid sol 10mg/5ml 2methylphenid sol 5mg/5ml 2methylphenid tab 10mg 2methylphenid tab 10mg er 2methylphenid tab 18mg er 3methylphenid tab 20mg 3methylphenid tab 20mg er 3methylphenid tab 20mg sr 3methylphenid tab 27mg er 3methylphenid tab 36mg er 3methylphenid tab 54mg er 3methylphenid tab 5mg 2methylpred pak 4mg 61methylpred tab 16mg 61methylpred tab 32mg 61methylpred tab 4mg 61methylpred tab 8mg 61metipranolol sol 0.3% 97metipranolol sol 0.3% oph 97metoclopram sol 10/10ml 79metoclopram sol 5mg/5ml 79metoclopram tab 10mg 80metoclopram tab 5mg 80metolazone tab 10mg 75metolazone tab 2.5mg 75metolazone tab 5mg 75metoprol tar tab 100mg 52metoprol tar tab 25mg 52metoprol tar tab 50mg 52metoprolol tab 100mg er 52metoprolol tab 200mg er 52metoprolol tab 25mg er 52metoprolol tab 50mg er 52METROGEL GEL 1% 72metronidazol cap 375mg 12metronidazol cre 0.75% 72metronidazol gel 0.75% 72metronidazol gel 0.75%vag 115metronidazol lot 0.75% 72metronidazol tab 250mg 12metronidazol tab 500mg 12mexiletine cap 150mg 16mexiletine cap 200mg 16mexiletine cap 250mg 16micaderm cre 2% 67MICARDIS TAB 20MG 36MICARDIS TAB 40MG 36MICARDIS TAB 80MG 36

miconazole 1 kit 115miconazole 1 kit 1200-2% 115miconazole 1 kit 1200mg2% 115miconazole 3 kit combo pk 115miconazole 3 sup 200mg 115miconazole cre 2% 67MICONAZOLE POW NITRATE 67micro guard cre 2% 67microgestin tab 1.5/30 59microgestin tab 1/20 59microgestin tab fe 1/20 59microgestin tab fe1.5/30 59midol extend tab 220mg 5MIGERGOT SUP 2/100 87migragesic cap ida 87MILLIPRED SOL 10MG/5ML 61MILLIPRED TAB 5MG 61miniprin low tab 81mg ec 7minitran dis 0.1mg/hr 14minitran dis 0.2mg/hr 14minitran dis 0.4mg/hr 14minitran dis 0.6mg/hr 14MINIVELLE DIS 0.0375MG 78MINIVELLE DIS 0.05MG 78MINIVELLE DIS 0.075MG 78MINIVELLE DIS 0.1MG 78minocycline cap 100mg 109minocycline cap 50mg 109minocycline cap 75mg 109minoxidil tab 10mg 38minoxidil tab 2.5mg 38MIRENA IUD SYSTEM 60mirtazapine tab 15mg 23mirtazapine tab 15mg odt 23mirtazapine tab 30mg 23mirtazapine tab 30mg odt 23mirtazapine tab 45mg 23mirtazapine tab 45mg odt 23mirtazapine tab 7.5mg 23misoprostol tab 100mcg 113misoprostol tab 200mcg 113mm aspirin tab 325mg 7modafinil tab 100mg 3modafinil tab 200mg 3moexipril tab 15mg 35moexipril tab 7.5mg 35moist skin cre 12% 71moist skin lot 12% 71mometasone cre 0.1% 70mometasone oin 0.1% 70mometasone sol 0.1% 70mono-linyah tab 0.25-35 59mononessa tab 59montelukast chw 4mg 16montelukast chw 5mg 16montelukast gra 4mg 16montelukast tab 10mg 16morgidox cap 1x100mg 109morgidox cap 2x100mg 109morphine sul cap 100mg er 9

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morphine sul cap 20mg er 9morphine sul cap 30mg er 9morphine sul cap 50mg er 9morphine sul cap 60mg er 9morphine sul cap 80mg er 9morphine sul tab 100mg er 9morphine sul tab 15mg 9morphine sul tab 15mg er 9morphine sul tab 200mg er 9morphine sul tab 30mg 9morphine sul tab 30mg er 9motion relf tab 25mg 30motion sick tab 25mg 30motion sick tab 50mg 30MOTOFEN TAB 29MOVIPREP SOL 84MOXATAG TAB 775MG 102mp aller med cap 25mg 32mp clotrimaz cre 1% 67mp hydrocort cre 1% 70mp hydrocort oin 1% 70mtest hs/est tab estrogen 77mtest/est tab estrogen 77mucinex chld liq 100/5ml 63mucinex/kids liq 100/5ml 63mucus relief liq 100/5ml 63mucus relief liq 400/20ml 63mucus+chst liq 100/5ml 64mult vitamin tab daily 92mult vitamin tab essent 92mult vitamin tab mens 92mult-vit/fl chw 0.5mg 93MULTAQ TAB 400MG 16MULTI PRENAT TAB 94multi-day tab 92multi-vit tab 92multi-vit/fe dro /fl 0.25 93multi-vit/fl chw 0.25mg 93multi-vit/fl chw 0.5mg 93multi-vit/fl chw 1mg 93multi-vit/fl dro /fe 0.25 93multi-vit/fl dro 0.25mg 93multi-vit/fl dro 0.5mg/ml 93multi-vitamn tab 92multiple vit tab 92multiple vit tab folic 92multivit/fl chw 0.25mg 93multivit/fl chw 0.5mg 93multivit/fl chw 1mg 93mupirocin ca cre 2% 66mupirocin cre 2% 66mupirocin oin 2% 66MUSE SUP 1000MCG 56MUSE SUP 125MCG 56MUSE SUP 250MCG 56MUSE SUP 500MCG 56mvc-fluoride chw 0.25mg 93mvc-fluoride chw 0.5mg 93mvc-fluoride chw 1mg 93my way tab 1.5mg 60

myci-gc sol 100-10/5 62MYCOBUTIN CAP 150MG 39mycophenolat cap 250mg 51mycophenolat tab 500mg 51mydral sol 0.5% op 97mydral sol 1% op 97MYFORTIC TAB 180MG 51MYFORTIC TAB 360MG 51MYLERAN TAB 2MG 39myorisan cap 10mg 65myorisan cap 20mg 65myorisan cap 40mg 65MYOZYME INJ 50MG 76MYTELASE TAB 10MG 38mytussin ac syp 100-10/5 62mytussin dac sol 62myzilra tab 59

Nnabumetone tab 500mg 5nabumetone tab 750mg 5nadolol tab 20mg 53nadolol tab 40mg 53nadolol tab 80mg 53nafrinse chw 1mg f 89nafrinse dro 0.125mg 89NAFTIN CRE 1% 67NAFTIN CRE 2% 67NAFTIN GEL 1% 67naltrexone tab 50mg 29NAMENDA SOL 10MG/5ML 103NAMENDA TAB 10MG 103NAMENDA TAB 5MG 103naphazoline sol 0.1% op 99naproxen dr tab 375mg 5naproxen dr tab 500mg 5naproxen sod tab 220mg 5naproxen sod tab 275mg 5naproxen sod tab 550mg 5naproxen sus 125/5ml 5naproxen tab 250mg 5naproxen tab 375mg 5naproxen tab 500mg 5naratriptan tab 1mg 88naratriptan tab 2.5mg 88nasal decon syp 30mg/5ml 96nasal decong tab 30mg 96NASONEX SPR 50MCG/AC 96NATACYN SUS 5% OP 98NATAL-V RX TAB 29-1MG 94nateglinide tab 120mg 28nateglinide tab 60mg 28natura-lax pow 3350 nf 84naturalyte sol bubblegm 88naturalyte sol fruit 88naturalyte sol grape 88naturalyte sol unflavor 88NAVANE CAP 20MG 47NEBUPENT INH 300MG 12

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necon tab 0.5/35 59necon tab 1/35 59necon tab 1/50-28 59necon tab 7/7/7 59nefazodone tab 100mg 23nefazodone tab 150mg 23nefazodone tab 200mg 23nefazodone tab 250mg 23nefazodone tab 50mg 23NEO-FRADIN SOL 125/5ML 3neo-polycin oin hc 1%op 99neo-polycin oin op 98NEO-SYNEPHRI SPR 0.5% 96neo/bac/poly oin op 98neo/poly/bac oin /hc 1%op 99neo/poly/dex oin 0.1% op 99neo/poly/dex sus 0.1% op 99neo/poly/gra sol op 98neo/poly/hc sol 1% otic 101neo/poly/hc sus 1% otic 101neo/poly/hc sus op 99neomycin tab 500mg 3neosporin af cre 2% jock 67neosporin cre eczema 70nephronex tab 1mg 91NEUPOGEN INJ 300/0.5 82NEUPOGEN INJ 300MCG 82NEUPOGEN INJ 480/0.8 82NEUPOGEN INJ 480MCG 82NEVANAC SUS 0.1% 100nevirapine sus 50mg/5ml 48nevirapine tab 200mg 48NEXAVAR TAB 200MG 41NEXIUM CAP 20MG 113NEXIUM CAP 40MG 113NEXPLANON IMP 68MG 60next choice tab 0.75mg 60next choice tab 1.5mg 60niacor tab 500mg 34NIASPAN TAB 1000 ER 34NIASPAN TAB 500MG ER 34NIASPAN TAB 750MG ER 34nicardipine cap 20mg 55nicardipine cap 30mg 55nicorelief gum 2mg mint 106nicorelief gum 2mg orig 106nicorelief gum 4mg mint 106nicorelief gum 4mg orig 106nicorelief loz 2mg mint 106nicorelief loz 4mg mint 106nicotine dis 14mg/24h 106nicotine dis 21mg/24h 106nicotine dis 7mg/24hr 106nicotine dis step 1 106nicotine dis step 2 106nicotine dis step 3 106nicotine gum 2mg 106nicotine gum 2mgfruit 106nicotine gum 4mg 106nicotine loz 2mg chry 106

nicotine loz 2mg mint 106nicotine loz 4mg chry 106nicotine loz 4mg cinn 106nicotine loz 4mg mint 106nicotine pol gum 2mg 106nicotine pol gum 2mg cinn 106nicotine pol gum 2mg mint 106nicotine pol gum 2mg orig 107nicotine pol gum 2mg ref 107nicotine pol gum 2mg strt 107nicotine pol gum 2mgfruit 107nicotine pol gum 4mg 107nicotine pol gum 4mg mint 107nicotine pol gum 4mg orig 107nicotine pol gum 4mg ref 107nicotine pol gum 4mg strt 107nicotine pol gum 4mgfruit 107nicotine pol loz 2mg cinn 107nicotine pol loz 2mg mint 107nicotine pol loz 4mg chry 107nicotine pol loz 4mg mint 107NICOTINE SYS KIT TRANSDER 107nicotine td dis 14mg/24h 107nicotine td dis 21mg/24h 107nicotine td dis 7mg/24hr 107NICOTROL INH 107NICOTROL NS SPR 10MG/ML 107nifediac cc tab 30mg er 55nifediac cc tab 60mg er 55nifediac cc tab 90mg er 55nifedical xl tab 30mg 55nifedical xl tab 60mg 55nifedipine cap 10mg 55nifedipine cap 20mg 55nifedipine tab 30mg er 55nifedipine tab 60mg er 55nifedipine tab 90mg er 55NILANDRON TAB 150MG 40nimodipine cap 30mg 55nisoldipine tab 17mg er 55nisoldipine tab 20mg 55nisoldipine tab 25.5mg 55nisoldipine tab 30mg 55nisoldipine tab 34mg er 55nisoldipine tab 40mg 55nisoldipine tab 8.5mg er 55NITRO-BID OIN 2% 14nitro-time cap 2.5mg cr 14nitro-time cap 6.5mg cr 14nitro-time cap 9mg cr 14nitrofur mac cap 100mg 113nitrofur mac cap 50mg 113nitrofurantn cap 100mg 113nitrofurantn sus 25mg/5ml 113nitroglycer aer 400mcg 14nitroglycer cap 2.5mg er 14nitroglycer cap 2.5mg sr 14nitroglycer cap 6.5mg cr 14nitroglycer cap 6.5mg er 14nitroglycer cap 9mg cr 14

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nitroglycer cap 9mg er 14nitroglycer dis 0.1mg/hr 14nitroglycer dis 0.2mg/hr 14nitroglycer dis 0.4mg/hr 14nitroglycer dis 0.6mg/hr 14nitroglyceri dis 0.6mg/hr 14nitroglycrn spr lingual 14NITROSTAT SUB 0.3MG 14NITROSTAT SUB 0.4MG 14NITROSTAT SUB 0.6MG 14nix combing gel 73NIX LICE SPR CONTROL 73nizatidine cap 150mg 112nizatidine cap 300mg 112noble formul cre hc 1% 70nodolor cap 87nora-be tab 0.35mg 61norethin ace tab 5mg 103norethindron tab 0.35mg 61norgest/eth tab estrad 59norgest/ethi tab 0.25/35 59norgest/ethi tab estradio 59NORITATE CRE 1% 72NOROXIN TAB 400MG 79NORPACE CAP 100MG CR 15NORPACE CAP 150MG CR 15nortrel tab 0.5/35 59nortrel tab 1/35 59nortrel tab 7/7/7 59nortriptylin cap 10mg 26nortriptylin cap 25mg 26nortriptylin cap 50mg 26nortriptylin cap 75mg 26nortriptylin sol 10mg/5ml 26NORVIR CAP 100MG 48NORVIR SOL 80MG/ML 48NORVIR TAB 100MG 48norwich asa tab 325mg 7novagest/cod sol expect 62novarel inj 10000unt 75NOVOLIN INJ 70/30 27NOVOLIN N INJ RELION 27NOVOLIN N INJ U-100 27NOVOLIN R INJ RELION 28NOVOLIN R INJ U-100 28NOVOLIN70/30 INJ RELION 27NOVOLOG INJ 100/ML 28NOVOLOG INJ FLEXPEN 28NOVOLOG INJ PENFILL 28NOVOLOG MIX INJ 70/30 28NOVOLOG MIX INJ FLEXPEN 28np thyroid tab 30mg 110np thyroid tab 60mg 110np thyroid tab 90mg 110NUCYNTA ER TAB 100MG 9NUCYNTA ER TAB 150MG 9NUCYNTA ER TAB 200MG 9NUCYNTA ER TAB 250MG 9NUCYNTA ER TAB 50MG 9NUCYNTA TAB 100MG 9

NUCYNTA TAB 50MG 9NUCYNTA TAB 75MG 9NUEDEXTA CAP 20-10MG 104nulev tab 0.125mg 112NUVARING MIS 60NUVIGIL TAB 150MG 3NUVIGIL TAB 250MG 3NUVIGIL TAB 50MG 3nuzole cre 2% 67nyamyc pow 100000 67nystat/triam cre 67nystat/triam oin 67nystatin cre 100000 67nystatin oin 100000 67nystatin pow 30nystatin pow 100000 67nystatin sus 100000 91nystatin tab 500000 30NYSTATIN VAG TAB 100000 115nystop pow 100000 67

OO-CAL FA TAB 94ocella tab 3-0.03mg 59OCTAGAM INJ 10GM 102OCTAGAM INJ 1GM 102OCTAGAM INJ 2.5GM 102OCTAGAM INJ 25GM 102OCTAGAM INJ 5GM 102octreotide inj 1000mcg 77octreotide inj 100mcg 77octreotide inj 200mcg 77octreotide inj 500mcg 77octreotide inj 50mcg/ml 77ofloxacin dro 0.3% op 98ofloxacin dro 0.3%otic 100ofloxacin tab 200mg 79ofloxacin tab 300mg 79ofloxacin tab 400mg 79OFORTA TAB 10MG 40ogestrel tab 59olanzapine tab 10mg 46olanzapine tab 10mg odt 46olanzapine tab 15mg 46olanzapine tab 15mg odt 46olanzapine tab 2.5mg 46olanzapine tab 20mg 46olanzapine tab 20mg odt 46olanzapine tab 5mg 46olanzapine tab 5mg odt 46olanzapine tab 7.5mg 46OLEPTRO TAB 24HR150 23OLEPTRO TAB 24HR300 23omeprazole cap 10mg 113omeprazole cap 20mg 113omeprazole cap 40mg 113OMNIFLEX DPR 86once daily tab 92ondansetron inj 32/50ml 29

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ondansetron sol 4mg/5ml 29ondansetron tab 24mg 29ondansetron tab 4mg 29ondansetron tab 4mg odt 29ondansetron tab 8mg 29ondansetron tab 8mg odt 29one daily tab 92one daily tab essent 92one daily tab essentl 92one-daily tab mult vit 92ONGLYZA TAB 2.5MG 27ONGLYZA TAB 5MG 27ONSOLIS MIS 1200MCG 9ONSOLIS MIS 200MCG 9ONSOLIS MIS 400MCG 9ONSOLIS MIS 600MCG 9ONSOLIS MIS 800MCG 9oralone pst 0.1% 91oralyte sol 88oralyte sol freeze 88ORAP TAB 1MG 104ORAP TAB 2MG 104ORAVIG TAB 50MG 91ORAXYL CAP 20MG 109orazinc cap 220mg 91ORFADIN CAP 10MG 76ORFADIN CAP 2MG 76ORFADIN CAP 5MG 76organ-i nr tab 200mg 64orph/asa/caf tab 95orphen cpd tab ds 95orphenadrine tab 100mg er 95orsythia tab 59ORTHO COIL DPR KIT 100 86ORTHO COIL DPR KIT 105 86ORTHO COIL DPR KIT 50 86ORTHO EVRA DIS WEEK 60ORTHO FLAT DPR KIT 55 86ORTHO FLAT DPR KIT 60 86ORTHO FLAT DPR KIT 65 86ORTHO FLAT DPR KIT 70 86ORTHO FLAT DPR KIT 75 86ORTHO FLAT DPR KIT 80 86ORTHO FLAT DPR KIT 85 86ORTHO FLAT DPR KIT 90 86ORTHO FLAT DPR KIT 95 86ORTHO FLEX DPR 65MM 86ORTHO FLEX DPR 70MM 86ORTHO FLEX DPR 75MM 86ORTHO FLEX DPR 80MM 86ortho-est tab 0.625 79ortho-est tab 1.25 79oscimin sr tab 0.375mg 112oscimin sub 0.125mg 112oscimin tab 0.125mg 112OSMOPREP TAB 1.5GM 85oxacillin inj 10gm 103oxacillin inj 1gm 103oxacillin inj 2gm 103oxandrolone tab 10mg 11

oxandrolone tab 2.5mg 11oxaprozin tab 600mg 5oxazepam cap 10mg 15oxazepam cap 15mg 15oxazepam cap 30mg 15oxcarbazepin sus 300mg/5m 21oxcarbazepin tab 150mg 21oxcarbazepin tab 300mg 21oxcarbazepin tab 600mg 21OXECTA TAB 5MG 9OXECTA TAB 7.5MG 9OXISTAT CRE 1% 67OXISTAT LOT 1% 67OXSORALEN LOT 1% 72OXSORALEN-UL CAP 10MG 68OXTELLAR XR TAB 150MG 21OXTELLAR XR TAB 300MG 21OXTELLAR XR TAB 600MG 21oxybutynin syp 5mg/5ml 114oxybutynin tab 10mg er 114oxybutynin tab 15mg er 114oxybutynin tab 5mg 114oxybutynin tab 5mg er 114oxycod/apap cap 5-500mg 11oxycod/asa tab 11oxycod/ibu tab 5-400mg 11oxycodone cap 5mg 10oxycodone con 100/5ml 10oxycodone con 20mg/ml 10oxycodone sol 5mg/5ml 10oxycodone tab 10mg 10oxycodone tab 15mg 10oxycodone tab 20mg 10oxycodone tab 30mg 10oxycodone tab 5mg 10OXYCONTIN TAB 10MG CR 10OXYCONTIN TAB 15MG CR 10OXYCONTIN TAB 20MG CR 10OXYCONTIN TAB 30MG CR 10OXYCONTIN TAB 40MG CR 10OXYCONTIN TAB 60MG CR 10OXYCONTIN TAB 80MG CR 10oxymorphone tab 10mg er 10oxymorphone tab 15mg er 10oxymorphone tab 20mg er 10oxymorphone tab 30mg er 10oxymorphone tab 40mg er 10oxymorphone tab 5mg er 10oxymorphone tab 7.5mg er 10oxymorphone tab hcl 10mg 10oxymorphone tab hcl 5mg 10

PPACERONE TAB 100MG 16pacerone tab 200mg 16pamidronate inj 30/10ml 75pamidronate inj 30mg 75pamidronate inj 90/10ml 75pamidronate inj 90mg 75

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pamprin tab 220mg 5PANCREAZE CAP 10500UNT 73PANCREAZE CAP 16800UNT 74PANCREAZE CAP 21000UNT 74PANCREAZE CAP 4200UNIT 73pancrelipase cap 5000unit 74panoxyl wash liq 10% 65PANRETIN GEL 0.1% 67pantoprazole tab 20mg 113pantoprazole tab 40mg 113PARAGARD IUD T380A 86parcaine sol 0.5% op 99paromomycin cap 250mg 3paroxetin er tab 12.5mg 24paroxetin er tab 37.5mg 24paroxetine sus 10mg/5ml 24paroxetine tab 10mg 24paroxetine tab 20mg 24paroxetine tab 25mg er 24paroxetine tab 30mg 24paroxetine tab 40mg 24PASER GRA 4GM 39PATADAY SOL 0.2% 100PATANOL SOL 0.1% OP 100pc ped elect sol fruit 88pc ped elect sol grape 88pc pediatric sol electrol 88PCE TAB 333MG EC 85PCE TAB 500MG EC 85ped elctrlyt sol 88ped elctrlyt sol /zinc 88ped elctrlyt sol apple 88ped elctrlyt sol bubblegm 88ped elctrlyt sol bubblgum 89ped elctrlyt sol freeze 89ped elctrlyt sol freezer 89ped elctrlyt sol freezpop 89ped elctrlyt sol fruit 89ped elctrlyt sol grape 89ped elctrlyt sol mango 89ped elctrlyt sol strawbry 89ped elctrlyt sol unflavor 89ped elctrlyt sol unflavrd 89ped formula liq 100-10/5 62pedi-dri pow 100000 67pedia vance sol apple 89pedia vance sol grape 89peg 3350 pow 84peg 3350 sol electrol 84peg-3350 sol electrol 84peg-3350/kcl sol /sodium 84PEG-INTRON KIT 120 RP 50PEG-INTRON KIT 120MCG 50PEG-INTRON KIT 150 RP 50PEG-INTRON KIT 150MCG 50PEG-INTRON KIT 50MCG 50PEG-INTRON KIT 50MCG RP 50PEG-INTRON KIT 80MCG 50PEG-INTRON KIT 80MCG RP 50PEGANONE TAB 250MG 22

PEGASYS INJ 50PEGASYS INJ PROCLICK 50PEGASYS KIT 50penicilln vk sol 125/5ml 102penicilln vk sol 250/5ml 102penicilln vk tab 250mg 102penicilln vk tab 500mg 102PENTAM 300 INJ 300MG 12PENTASA CAP 250MG CR 80PENTASA CAP 500MG CR 80pentaz/nalox tab 50-0.5mg 11pentoxifylli tab 400mg er 81PERFOROMIST NEB 20MCG 18perindopril tab 2mg 35perindopril tab 4mg 35perindopril tab 8mg 35periogard sol 0.12% 91permethrin cre 5% 73perphen/amit tab 2-10mg 104perphen/amit tab 2-25mg 104perphen/amit tab 4-10mg 104perphen/amit tab 4-25mg 104perphen/amit tab 4-50mg 104perphenazine tab 16mg 47perphenazine tab 2mg 46perphenazine tab 4mg 46perphenazine tab 8mg 47persa-gel gel 10% 65persa-gel xs gel 5% 65pharbedryl cap 25mg 32pharbedryl cap 50mg 32phenadoz sup 12.5mg 33phenadoz sup 25mg 33phenazo tab 200mg 81phenazopyrid tab 100mg 81phenazopyrid tab 200mg 81phenelzine tab 15mg 24phenobarb elx 20mg/5ml 83phenobarb sol 20mg/5ml 83phenobarb tab 100mg 83phenobarb tab 15mg 83phenobarb tab 16.2mg 83phenobarb tab 30mg 83phenobarb tab 32.4mg 83phenobarb tab 60mg 83phenobarb tab 64.8mg 83phenobarb tab 97.2mg 83phenytoin chw 50mg 22phenytoin ex cap 100mg 22phenytoin ex cap 200mg 22phenytoin ex cap 300mg 22phenytoin sus 125/5ml 22philith tab 0.4-35 59PHISOHEX LIQ 3% 47phospha 250 tab neutral 90PHOSPHOLINE SOL 0.125%OP 97PHRENILIN CAP FORTE 6PICATO GEL 0.015% 67PICATO GEL 0.05% 67pilocarpine sol 1% op 97

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pilocarpine sol 2% op 98pilocarpine sol 4% op 98pilocarpine tab 5mg 91pilocarpine tab 7.5mg 91PILOPINE HS GEL 4% OP 98pindolol tab 10mg 53pindolol tab 5mg 53pioglitazone tab 15mg 28pioglitazone tab 30mg 28pioglitazone tab 45mg 28piroxicam cap 10mg 5piroxicam cap 20mg 5PNV FOLIC AC TAB + IRON 94PNV PRENATAL TAB PLUS 94podactin cre 2% 67podofilox sol 0.5% 72POLY HUB MIS 27GX1.25 87POLY HUB MIS 27GX1/2" 87poly-dex oin 0.1% op 99poly-vi-flor chw 0.25mg 93poly-vi-flor chw 0.5mg 93poly-vi-flor chw 1mg 93POLY-VI-FLOR CHW W/IRON 93poly-vit/fe dro /fl 0.25 93poly-vit/fe dro /fl 0.5 93poly-vit/fl dro 0.25mg 93polycin b oin op 98polycin oin op 98polyeth glyc pow 3350 nf 85polyeth glyc pow 3350-grx 85polymyxin b inj 500000 13polymyxin b/ sol trimethp 98polyvit/fl dro 0.5mg/ml 93portia-28 tab 59pot bicarbon tab 25meq ef 90pot chloride cap 10meq er 90pot chloride cap 8meq er 90pot chloride liq 10% 90pot chloride liq 20% 90pot chloride liq 20% sf 90pot chloride sol 10% sf 90pot chloride tab 10meq cr 90pot chloride tab 10meq er 90pot chloride tab 8meq er 90pot chloride tab 8meq sr 90pot citrate tab 1080mg 81pot citrate tab 540mg 81pot cl micro tab 10meq cr 90pot cl micro tab 10meq er 90pot cl micro tab 20meq er 90potassium tab 25meq ef 90pramcort cre 1-1% 70pramipexole tab 0.125mg 43pramipexole tab 0.25mg 43pramipexole tab 0.5mg 43pramipexole tab 0.75mg 43pramipexole tab 1.5mg 43pramipexole tab 1mg 43PRANDIN TAB 0.5MG 28PRANDIN TAB 1MG 28

PRANDIN TAB 2MG 28pravastatin tab 10mg 34pravastatin tab 20mg 34pravastatin tab 40mg 34pravastatin tab 80mg 34prazosin hcl cap 1mg 36prazosin hcl cap 2mg 36prazosin hcl cap 5mg 36PRECISIONGLI MIS 27GX1.5" 87PRED MILD SUS 0.12% OP 99PRED SOD PHO SOL 1% OP 99pred sod pho sol 5mg/5ml 61pred sod pho sol 6.7/5ml 61prednicarbat cre 0.1% 71prednicarbat oin 0.1% 71prednisolone sol 15mg/5ml 61prednisolone sol 25mg/5ml 61prednisolone sus 1% op 99prednisone pak 10mg 61prednisone pak 5mg 61prednisone sol 5mg/5ml 61prednisone tab 10mg 61prednisone tab 1mg 61prednisone tab 2.5mg 61prednisone tab 20mg 62prednisone tab 50mg 62prednisone tab 5mg 61pregnyl inj 10000unt 75PREMARIN TAB 0.3MG 79PREMARIN TAB 0.45MG 79PREMARIN TAB 0.625MG 79PREMARIN TAB 0.9MG 79PREMARIN TAB 1.25MG 79PREMARIN VAG CRE 0.625MG 115PREMPHASE TAB 77PREMPRO TAB .625-2.5 77PREMPRO TAB 0.3-1.5 77PREMPRO TAB 0.45-1.5 77PREMPRO TAB 0.625-5 77prenaplus tab 94prenatabs rx tab 94PRENATAL 19 CHW 29-1MG 94prenatal 19 chw tab 94prenatal 19 tab 94PRENATAL 19 TAB 29-1MG 94PRENATAL ONE TAB DAILY 94PRENATAL TAB 94PRENATAL TAB 27-0.8MG 94PRENATAL TAB 27-1MG 94PRENATAL TAB 28-0.8MG 94PRENATAL TAB COMPLETE 94PRENATAL TAB FORMULA 94PRENATAL TAB LOW IRON 94PRENATAL TAB PLUS 94prenatal tab plus fe 94PRENATAL VIT TAB PLUS 94PRENATAL+DHA MIS 94PRENATAL+DHA MIS WOMENS 94PRENATAL+FE TAB 29-1MG 94PRENATAL-U CAP 94

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PRENTIF MIS 22MM 86PRENTIF MIS 25MM 86PRENTIF MIS 28MM 86PRENTIF MIS 31MM 86PRENTIF MIS FITTING 86prep h hc cre 1% 71PREPOPIK PAK 84prevalite pow 4gm 33prevalite pow 4gm pk 33previfem tab 59PREVPAC MIS 113PREZISTA TAB 150MG 48PREZISTA TAB 400MG 48PREZISTA TAB 600MG 48PREZISTA TAB 75MG 48PREZISTA TAB 800MG 48PRIFTIN TAB 150MG 39PRIMAQUINE TAB 26.3MG 38primidone tab 250mg 21primidone tab 50mg 21PRISTIQ TAB 100MG 25PRISTIQ TAB 50MG 25PRIVIGEN INJ 10GRAMS 102PRIVIGEN INJ 20GRAMS 102PRIVIGEN INJ 5 GRAMS 102PROAIR HFA AER 18proben/colch tab 500-0.5 81probenecid tab 500mg 81procainamide inj 100mg/ml 15prochlorper sup 25mg 47prochlorper tab 10mg 47prochlorper tab 5mg 47PROCORT CRE 12PROCRIT INJ 10000/ML 82PROCRIT INJ 2000/ML 82PROCRIT INJ 20000/ML 82PROCRIT INJ 3000/ML 82PROCRIT INJ 4000/ML 82PROCRIT INJ 40000/ML 83procto-pak cre 1% 12proctocream cre hc 2.5% 12PROCTOFOAM AER HC 1% 12proctosol hc cre 2.5% 12proctozone cre -hc 2.5% 12progesterone cap 100mg 103progesterone cap 200mg 103PROLASTIN INJ 1000MG 108PROLASTIN INJ 500MG 108PROLASTIN-C INJ 1000MG 108promacet tab 50-650mg 6prometh vc syp 6.25-5/5 62prometh vc syp plain 63prometh vc/ syp codeine 63prometh/cod syp 6.25-10 63promethazine sol 6.25/5ml 33promethazine sup 12.5mg 33promethazine sup 25mg 33promethazine syp 6.25/5ml 33promethazine syp dm 63promethazine tab 12.5mg 33

promethazine tab 25mg 33promethazine tab 50mg 33promethegan sup 12.5mg 33promethegan sup 25mg 33promethegan sup 50mg 33PRONTO AER 0.4% 73propafenone cap 225mg er 16propafenone cap 325mg er 16propafenone cap 425mg sr 16propafenone tab 150mg 16propafenone tab 225mg 16propafenone tab 300mg 16propanthelin tab 15mg 112proparacaine sol 0.5% op 99propran/hctz tab 40/25 37propran/hctz tab 80/25 37propranolol cap 120mg er 53propranolol cap 160mg er 53propranolol cap 60mg er 53propranolol cap 80mg er 53propranolol sol 20mg/5ml 53propranolol sol 40mg/5ml 53propranolol tab 10mg 53propranolol tab 20mg 53propranolol tab 40mg 53propranolol tab 60mg 53propranolol tab 80mg 53propylthiour tab 50mg 109PROSTIGMIN TAB 15MG 38PROTOPIC OIN 0.03% 72PROTOPIC OIN 0.1% 72protriptylin tab 10mg 26protriptylin tab 5mg 26prudoxin cre 5% 67pseudoephedr syp 30mg/5ml 96pseudoephedr tab 30mg 96pseudoephedr tab 60mg 96psudatabs tab 30mg 96PULMICORT INH 180MCG 17PULMICORT INH 90MCG 17PULMICORT SUS 1MG/2ML 17PULMOZYME SOL 1MG/ML 108px allergy cap 25mg 32px aspirin chw 81mg 7px aspirin tab 325mg 7px aspirin tab 325mg ec 7px aspirin tab 81mg ec 7PX PRENATAL TAB MULTIVIT 94px tussin dm liq 100-10/5 63px tussin sol 100/5ml 64pyrazinamide tab 500mg 39PYRE/PIPERON LIQ 73pyridostigm tab 60mg 38

Qq-dryl cap 25mg 32qc aspirin tab 325mg 7qc aspirin tab 325mg ec 7qc child asa chw 81mg 7

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qc essential tab 92qc heartburn tab 200mg 112qc hydrocort cre 1% 71qc medifin liq mucus rl 64qc medifin tab 200mg 64QC PRENATAL TAB 28-0.8MG 94quadrapax elx 112quenalin syp 12.5/5ml 32quetiapine tab 100mg 46quetiapine tab 200mg 46quetiapine tab 25mg 46quetiapine tab 300mg 46quetiapine tab 400mg 46quetiapine tab 50mg 46QUILLIVANT SUS XR 3quinapril tab 10mg 35quinapril tab 20mg 35quinapril tab 40mg 35quinapril tab 5mg 35quinidine gl tab 324mg cr 15quinidine gl tab 324mg er 15quinidine su tab 200mg 16quinidine su tab 300mg 16quinidine su tab 300mg er 16quinine sulf cap 324mg 38QVAR AER 40MCG 17QVAR AER 80MCG 17

Rra anti-itch cre 1% 71ra anti-itch oin 1% 71ra aspirin chw 81mg 7ra aspirin tab 325mg 7ra aspirin tab 325mg ec 7ra aspirin tab 81mg ec 7ra child asa chw 81mg 7ra hydrocort cre 1% 71ra hydrocort cre 1%pls 12 71ra laxative pow 85ra lice egg gel remover 73ra nicotine dis 14mg/24h 107ra nicotine dis 21mg/24h 107ra nicotine dis 7mg/24hr 107ra nicotine gum 2mg 107ra nicotine gum 2mg cinn 107ra nicotine gum 2mg mint 107ra nicotine gum 2mgfruit 107ra nicotine gum 4mg 107ra nicotine gum 4mg frut 107ra nicotine gum 4mg mint 107ra nicotine loz 2mg mint 107ra nicotine loz 4mg mint 107ra one daily tab essentia 92ra one daily tab multivit 92ra pediatric sol electrol 89RA PRENATAL TAB 28-0.8MG 94RA PRENATAL TAB FORMULA 94ra renewal gel 10% 65ra suphedrin tab 30mg 96

ra tussin dm liq 100-10/5 63ra tussin liq 100/5ml 64ramipril cap 1.25mg 35ramipril cap 10mg 35ramipril cap 2.5mg 35ramipril cap 5mg 35RANEXA TAB 1000MG 13RANEXA TAB 500MG 13ranitidine cap 150mg 113ranitidine cap 300mg 113ranitidine syp 150/10ml 113ranitidine syp 15mg/ml 113ranitidine syp 75mg/5ml 113ranitidine tab 150mg 113ranitidine tab 300mg 113RAPAFLO CAP 4MG 81RAPAFLO CAP 8MG 81RAPAMUNE SOL 1MG/ML 51RAPAMUNE TAB 1MG 51RAPAMUNE TAB 2MG 51REBIF INJ 22/0.5 104REBIF INJ 44/0.5 104REBIF REBIDO INJ 22/0.5 104REBIF REBIDO INJ 44/0.5 104REBIF REBIDO SOL TITRATN 104REBIF TITRTN SOL PACK 104reclipsen tab 59recort plus cre 1% 71rectacort-hc sup 25mg 12rederm lot 1% 71refenesen tab 200mg 64refissa cre 0.05% 66regenecare gel ha 2% 72REGRANEX GEL 0.01% 73rehydralyte sol 89RELENZA MIS DISKHALE 50RELISTOR KIT 12/0.6ML 80RELPAX TAB 20MG 88RELPAX TAB 40MG 88remedy cre antifung 67REMICADE INJ 100MG 80REMODULIN INJ 10MG/ML 56REMODULIN INJ 1MG/ML 56REMODULIN INJ 2.5MG/ML 56REMODULIN INJ 5MG/ML 56rena-vite rx tab 91rena-vite tab 91RENAGEL TAB 400MG 80RENAGEL TAB 800MG 80renal tab multivit 91renal/zinc tab multivit 92RENVELA PAK 0.8GM 80RENVELA PAK 2.4GM 80RENVELA TAB 800MG 80repan tab 6RESCRIPTOR TAB 100 MG 49RESCRIPTOR TAB 200MG 49reserpine tab 0.1mg 36reserpine tab 0.25mg 37RESTASIS EMU 0.05% 99

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revital frzr sol pops 89revital jell sol cups 89revital lqd sol squeezer 89REVLIMID CAP 10MG 51REVLIMID CAP 15MG 51REVLIMID CAP 25MG 51REVLIMID CAP 5MG 51REYATAZ CAP 100MG 49REYATAZ CAP 150MG 49REYATAZ CAP 200MG 49REYATAZ CAP 300MG 49RHEUMATREX TAB 2.5MG 3RIBAPAK PAK 1200/DAY 50RIBAPAK PAK 800/DAY 50ribasphere cap 200mg 50ribasphere tab 200mg 50ribasphere tab 400mg 50ribasphere tab 600mg 50RIBATAB TAB 1200/DAY 50RIBATAB TAB 800/DAY 50ribavirin cap 200mg 50ribavirin tab 200mg 50RID LICE KIL AER MOUSSE 73RIDAURA CAP 3MG 3rifampin cap 150mg 39rifampin cap 300mg 39RIFATER TAB 39RIGHT STEP TAB PRENATAL 94RILUTEK TAB 50MG 96riluzole tab 50mg 96rimantadine tab 100mg 50ringers irr sol 52ringworm cre 1% 67RIOMET SOL 27RISPERDAL INJ 12.5MG 45RISPERDAL INJ 25MG 45RISPERDAL INJ 37.5MG 45RISPERDAL INJ 50MG 45risperidone sol 1mg/ml 45risperidone tab 0.25 odt 45risperidone tab 0.25mg 45risperidone tab 0.5mg 45risperidone tab 0.5mg od 45risperidone tab 1mg 45risperidone tab 1mg odt 45risperidone tab 2mg 45risperidone tab 2mg odt 45risperidone tab 3mg 45risperidone tab 3mg odt 45risperidone tab 4mg 45risperidone tab 4mg odt 45RITALIN LA CAP 10MG 3RITUXAN INJ 100MG 40RITUXAN INJ 500MG 40rivastigmine cap 1.5mg 103rivastigmine cap 3mg 103rivastigmine cap 4.5mg 104rivastigmine cap 6mg 104rizatriptan tab 10mg 88rizatriptan tab 5mg 88

robafen ac syp 100-10/5 63ROBAXIN INJ 100MG/ML 95robitussin liq cgh/cong 63robitussin liq to go dm 63romilar ac sol 100-10/5 63romycin oin op 98ropinirole tab 0.25mg 43ropinirole tab 0.5mg 43ropinirole tab 12mg er 44ropinirole tab 1mg 43ropinirole tab 2mg 43ropinirole tab 2mg er 43ropinirole tab 3mg 43ropinirole tab 4mg 43ropinirole tab 4mg er 43ropinirole tab 5mg 44ropinirole tab 6mg er 44ropinirole tab 8mg er 44rosadan cre 0.75% 72rosadan gel 0.75% 72ROXICET SOL 5-325/5 11ROZEREM TAB 8MG 84

SSABRIL TAB 500MG 22safe tussin liq 10-100/5 63SAFETYGLIDE MIS 27GX5/8" 87SAL-TROPINE TAB 0.4MG 112salsalate tab 500mg 7salsalate tab 750mg 7SAMSCA TAB 15MG 77SAMSCA TAB 30MG 77SANDIMMUNE SOL 100MG/ML 51SANDOSTATIN KIT LAR 10MG 77SANDOSTATIN KIT LAR 20MG 77SANDOSTATIN KIT LAR 30MG 77SANTYL OIN 250/GM 72SAPHRIS SUB 10MG 46SAPHRIS SUB 5MG 46sarnol-hc lot 1% 71SAVELLA TAB 100MG 104SAVELLA TAB 12.5MG 104SAVELLA TAB 25MG 104SAVELLA TAB 50MG 104sb aspirin tab 325mg 7sb aspirin tab 325mg ec 7sb cgh contr liq dm 63sb child asa chw 81mg 7sb coughtab tab 200mg 64sb hydrocort cre 1% 71sb hydrocort oin 1% 71sb pseudophe tab 30mg 96scalacort lot 2% 71SCOPACE TAB 0.4MG 30scot-tussin liq expct sf 64se-donna elx pb hyos 112SE-NATAL 19 CHW 94SE-NATAL 19 TAB 94SE-NATAL ONE TAB 94

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selegiline cap 5mg 44selegiline tab 5mg 44selenium sul lot 2.5% 68selenium sul sha 2.5% 68SELZENTRY TAB 150MG 49SELZENTRY TAB 300MG 49SENSIPAR TAB 30MG 76SENSIPAR TAB 60MG 76SENSIPAR TAB 90MG 76SEREVENT DIS AER 50MCG 18SEROQUEL XR TAB 150MG 46SEROQUEL XR TAB 200MG 46SEROQUEL XR TAB 300MG 46SEROQUEL XR TAB 400MG 46SEROQUEL XR TAB 50MG 46sertraline con 20mg/ml 24sertraline tab 100mg 24sertraline tab 25mg 24sertraline tab 50mg 24SFROWASA ENE 4GM 80sigtab tab 92sildec pe-dm syp 63sildenafil tab 20mg 57silphen coug syp 12.5/5ml 32siltuss das liq 100/5ml 64siltussin dm liq das 63siltussin-dm liq diabetic 63silver sulfa cre 1% 68simply stuff tab 30mg 96simvastatin tab 10mg 34simvastatin tab 20mg 34simvastatin tab 40mg 34simvastatin tab 5mg 34simvastatin tab 80mg 34SKELID TAB 200MG 75skin trtment lot 12% 71SKYLA IUD 13.5MG 60sm acid redu tab 200mg 113sm anti-diar tab 2mg 29sm antifungl cre 2% 67sm aspirin chw 81mg 7sm aspirin tab 325mg 7sm aspirin tab 325mg ec 7sm aspirin tab 81mg ec 7sm child asa chw 81mg 7sm clearlax pow 85sm folic acd tab 400mcg 82sm hydrocort cre 1% 71sm hydrocort oin 1% 71SM IPECAC SYP 29sm multiple tab vitamins 92sm nasal dec tab 30mg 96sm nicotine dis 14mg/24h 107sm nicotine dis 21mg 107sm nicotine dis 7mg/24hr 107sm nicotine gum 2mg 107sm nicotine gum 2mg mint 107sm nicotine gum 4mg 107sm nicotine gum 4mg mint 107sm nicotine loz 2mg mint 107

sm nicotine loz 4mg mint 107SM PRENATAL TAB VITAMINS 94sm vitamin d tab 400unit 116smooth lax pow 85smooth lax pow 3350 nf 85smz-tmp sus 13smz-tmp sus 200-40/5 13smz-tmp tab 400-80mg 13smz/tmp ds tab 800-160 13sod chloride inj 0.45% 90sod chloride inj 0.9% 90sod chloride inj 2.5/ml 91sod chloride inj 3% 91sod chloride inj 5% 91sod chloride neb 0.9% 64sod fluoride chw 0.25mg f 89sod fluoride chw 0.5mg f 89sod fluoride chw 1.1mg 89sod fluoride chw 1mg f 89sod fluoride chw 2.2mg 89sod fluoride dro 0.5mg/ml 90sod fluoride tab 0.5mg f 90sod fluoride tab 1mg f 90sod poly sul pow 52sod poly sul sus 15gm/60 52sod sulfacet sol 10% op 98sodium chlor neb 7% 64sodium chlor sol 0.9% irr 81solia tab 59SOLTAMOX SOL 10MG/5ML 40SOMATULINE INJ 120/.5ML 77SOMATULINE INJ 60/0.2ML 77SOMATULINE INJ 90/0.3ML 77SOMAVERT INJ 10MG 76SOMAVERT INJ 15MG 76SOMAVERT INJ 20MG 76SOMNOTE CAP 500MG 84soothe&cool cre inzo 2% 67SORIATANE CAP 10MG 68SORIATANE CAP 17.5MG 68SORIATANE CAP 25MG 68sorine tab 120mg 53sorine tab 160mg 53sorine tab 240mg 53sorine tab 80mg 53sotalol af tab 120mg 53sotalol af tab 160mg 53sotalol af tab 80mg 53sotalol hcl tab 120mg 53sotalol hcl tab 160mg 53sotalol hcl tab 240mg 53sotalol hcl tab 80mg 53sotret cap 10mg 65sotret cap 20mg 65sotret cap 30mg 65SPACERS 87spinosad sus 0.9% 73SPIRIVA CAP HANDIHLR 16spirono/hctz tab 25/25 74spironolact tab 100mg 74

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spironolact tab 25mg 74spironolact tab 50mg 74SPORANOX SOL 10MG/ML 31sprintec 28 tab 28 day 59SPRIX SPR 15.75MG 5SPRYCEL TAB 100MG 41SPRYCEL TAB 140MG 41SPRYCEL TAB 20MG 41SPRYCEL TAB 50MG 41SPRYCEL TAB 70MG 41SPRYCEL TAB 80MG 41sps sus 15gm/60 52sronyx tab 59ssd af cre 1% 68ssd cre 1% 68SSKI SOL 1GM/ML 90st joseph as chw 81mg 7stavudine cap 15mg 49stavudine cap 20mg 49stavudine cap 30mg 49stavudine cap 40mg 49stavudine sol 1mg/ml 49STAXYN TAB 10MG 56STELARA INJ 45MG/0.5 68STELARA INJ 90MG/ML 68STIMATE SOL 1.5MG/ML 76STIVARGA TAB 40MG 41stop lice gel step 2 73stop smoking gum 2mg mint 107stop smoking gum 2mg orig 107stop smoking gum 4mg 108stop smoking loz 2mg mint 108stop smoking loz 4mg mint 108STRATTERA CAP 100MG 2STRATTERA CAP 10MG 1STRATTERA CAP 18MG 1STRATTERA CAP 25MG 1STRATTERA CAP 40MG 2STRATTERA CAP 60MG 2STRATTERA CAP 80MG 2stress form tab 92stress form tab 500/biot 92stress formu tab 92STRIBILD TAB 49STROMECTOL TAB 3MG 12STUART PREN TAB 94SUBSYS SPR 100MCG 10SUBSYS SPR 1200MCG 10SUBSYS SPR 200MCG 10SUBSYS SPR 400MCG 10SUBSYS SPR 800MCG 10sucralfate tab 1gm 113sudanyl tab 30mg 96sudogest tab 30mg 96sudogest tab 60mg 96sudophed tab 30mg 96SULF LIME SOL USP 73sulf/pred na sol op 99sulfacet sod oin 10% op 98sulfacet sod sol 10% op 98

SULFADIAZINE TAB 500MG 108SULFAMYLON CRE 85MG/GM 68sulfasalazin tab 500mg 80sulfasalazin tab 500mg dr 80sulfazine ec tab 500mg 80sulfazine tab 500mg 80sulindac tab 150mg 5sulindac tab 200mg 5sumatriptan inj 4mg/0.5 88sumatriptan inj 6mg/0.5 88sumatriptan spr 20mg/act 88sumatriptan spr 5mg/act 88sumatriptan tab 100mg 88sumatriptan tab 25mg 88sumatriptan tab 50mg 88suphedrine tab 30mg 96SUPRAX SUS 100/5ML 58SUPRAX SUS 200/5ML 58SUPRAX TAB 400MG 58SURGUARD2 MIS 27GX1/2" 87SUSTIVA CAP 200MG 49SUSTIVA CAP 50MG 49SUSTIVA TAB 600MG 49SUTENT CAP 12.5MG 41SUTENT CAP 25MG 41SUTENT CAP 50MG 41sw clearlax pow 85sw nasal dec tab 30mg 96sw nicotine gum 2mg mint 108sw nicotine gum 4mg 108sw nicotine loz 2mg mint 108sw nicotine loz 4mg mint 108syeda tab 3-0.03mg 59symax fastab tab 0.125mg 112symax-sl sub 0.125mg 112symax-sr tab 0.375mg 112SYMBICORT AER 160-4.5 18SYMBICORT AER 80-4.5 18SYMLIN INJ 600MCG 26SYMLINPEN 60 INJ 1000MCG 26SYMLNPEN 120 INJ 1000MCG 26SYNAREL SOL 2MG/ML 76SYNERA DIS 70-70MG 72SYPRINE CAP 250MG 51

Ttab-a-vite tab 92tab-a-vite tab beta car 92TABLOID TAB 40MG 40TACLONEX OIN 71TACLONEX SUS 71tacrolimus cap 0.5mg 51tacrolimus cap 1mg 52tacrolimus cap 5mg 52TAMIFLU CAP 30MG 50TAMIFLU CAP 45MG 50TAMIFLU CAP 75MG 50TAMIFLU SUS 12MG/ML 51TAMIFLU SUS 6MG/ML 50

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tamoxifen tab 10mg 40tamoxifen tab 20mg 40tamsulosin cap 0.4mg 81TARCEVA TAB 100MG 41TARCEVA TAB 150MG 41TARCEVA TAB 25MG 41TARGRETIN CAP 75MG 42TARKA TAB 1-240 CR 37TARKA TAB 2-180 CR 37TARKA TAB 2-240 CR 37TARKA TAB 4-240 CR 37TARON-C DHA CAP 94TASIGNA CAP 150MG 41TASIGNA CAP 200MG 41TASMAR TAB 100MG 43TAZORAC CRE 0.05% 68TAZORAC CRE 0.1% 68TAZORAC GEL 0.05% 68TAZORAC GEL 0.1% 68taztia xt cap 120mg/24 55taztia xt cap 180mg/24 55taztia xt cap 240mg/24 55taztia xt cap 300mg/24 55taztia xt cap 360mg/24 55TEGRETOL XR TAB 100MG 21TEGRIN-LT KIT 73TEKTURNA TAB 150MG 38TEKTURNA TAB 300MG 38temazepam cap 15mg 84temazepam cap 30mg 84temazepam cap 7.5mg 84TEMODAR CAP 100MG 39TEMODAR CAP 140MG 39TEMODAR CAP 180MG 39TEMODAR CAP 20MG 39TEMODAR CAP 250MG 39TEMODAR CAP 5MG 39terazosin cap 10mg 37terazosin cap 1mg 37terazosin cap 2mg 37terazosin cap 5mg 37terbinafine tab 250mg 30terbutaline inj 1mg/ml 18terbutaline tab 2.5mg 18terbutaline tab 5mg 18terconazole cre 0.4% 115terconazole cre 0.8% 115terconazole sup 80mg 115TESTIM GEL 1%(50MG) 12testost cyp inj 100mg/ml 12testost cyp inj 200mg/ml 12testost enan inj 200mg/ml 12tetracycline cap 250mg 109tetracycline cap 500mg 109TEV-TROPIN INJ 5MG 76TEVETEN TAB 400MG 36tgt aspirin chw 81mg 8tgt aspirin chw child 8tgt aspirin tab 325mg 8tgt aspirin tab 81mg ec 8

tgt cough liq form dm 63tgt nicotine dis 14mg/24h 108tgt nicotine dis 21mg/24h 108tgt nicotine dis 7mg/24hr 108tgt nicotine gum 2mg mint 108tgt nicotine gum 2mg orig 108tgt nicotine gum 2mgfruit 108tgt nicotine gum 4mg 108tgt nicotine gum 4mg mint 108tgt nicotine gum 4mg orig 108tgt nicotine loz 2mg chry 108tgt nicotine loz 2mg mint 108tgt nicotine loz 4mg chry 108tgt nicotine loz 4mg mint 108th aspirin tab 325mg 8th aspirin tab 325mg ec 8th aspirin tab 81mg ec 8th hydrocort cre 1% 71th naproxen tab 220mg 5TH PRENATAL TAB VITAMINS 94th tussin liq 100/5ml 64THALITONE TAB 15MG 75THALOMID CAP 100MG 51THALOMID CAP 150MG 51THALOMID CAP 200MG 51THALOMID CAP 50MG 51THEO-24 CAP 100MG CR 18THEO-24 CAP 200MG CR 18THEO-24 CAP 300MG CR 18THEO-24 CAP 400MG ER 18theochron tab 100mg cr 18theochron tab 200mg cr 18theochron tab 300mg cr 18theophylline sol 80/15ml 18theophylline tab 100mg cr 18theophylline tab 100mg er 18theophylline tab 200mg cr 18theophylline tab 200mg er 18theophylline tab 300mg er 18theophylline tab 400mg er 18theophylline tab 450mg er 18theophylline tab 600mg er 18thera tab 92thera-mill tab 92thera-tabs tab 92theracort lot 1% 71THERANATAL TAB 27-1 94therapeutic tab 92therems tab 92thermazene cre 1% 68thioridazine tab 100mg 47thioridazine tab 10mg 47thioridazine tab 25mg 47thioridazine tab 50mg 47thiothixene cap 10mg 47thiothixene cap 1mg 47thiothixene cap 2mg 47thiothixene cap 5mg 47thrive gum 2mg mint 108thrive gum 4mg mint 108

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THYROLAR-1 TAB 60MG 110THYROLAR-1/2 TAB 30MG 110THYROLAR-1/4 TAB 15MG 110THYROLAR-2 TAB 120MG 110THYROLAR-3 TAB 180MG 110tiagabine tab 2mg 22tiagabine tab 4mg 22ticlopidine tab 250mg 82tilia fe tab 60timolol gel sol 0.25% op 97timolol gel sol 0.5% op 97timolol mal sol 0.25% op 97timolol mal sol 0.5% op 97timolol mal tab 10mg 53timolol mal tab 20mg 53timolol mal tab 5mg 53TIMOPTIC OCU SOL 0.25% OP 97TIMOPTIC OCU SOL 0.5% OP 97tis-u-sol sol 52tizanidine cap 2mg 95tizanidine cap 4mg 95tizanidine cap 6mg 95tizanidine tab 2mg 95tizanidine tab 4mg 95TOBI NEB 300/5ML 3tobra/dexame sus 0.3-0.1% 99TOBRADEX OIN 0.3-0.1% 99TOBRADEX ST SUS 0.3-0.05 99tobramycin sol 0.3% op 98tobrasol sol 0.3% op 98TOBREX OIN 0.3% OP 98TODAY SPONGE MIS 86tolazamide tab 250mg 28tolazamide tab 500mg 28tolbutamide tab 500mg 28tolmetin sod cap 400mg 5tolmetin sod tab 200mg 5tolmetin sod tab 600mg 5tolterodine tab 1mg 114tolterodine tab 2mg 114tolu-sed dm liq 100-10/5 63topiragen tab 100mg 21topiragen tab 200mg 21topiragen tab 25mg 21topiragen tab 50mg 21topiramate cap 15mg 21topiramate cap 25mg 21topiramate tab 100mg 21topiramate tab 200mg 22topiramate tab 25mg 21topiramate tab 50mg 21toposar inj 100/5ml 42toposar inj 1gm/50ml 42toposar inj 20mg/ml 42toposar inj 500/25ml 42TORISEL SOL 25MG/ML 42torsemide tab 100mg 74torsemide tab 10mg 74torsemide tab 20mg 74torsemide tab 5mg 74

TOVIAZ TAB 4MG 114TOVIAZ TAB 8MG 114TRACLEER TAB 125MG 57TRACLEER TAB 62.5MG 57TRADJENTA TAB 5MG 27tramadol hcl tab 100mg er 10tramadol hcl tab 200mg er 10tramadol hcl tab 300mg er 10tramadol hcl tab 50mg 10trandolapril tab 1mg 35trandolapril tab 2mg 35trandolapril tab 4mg 35tranexamic inj acid 83TRANSDERM-SC DIS 1.5MG 30tranylcyprom tab 10mg 24trav-tabs tab 50mg 30TRAVATAN Z DRO 0.004% 100travel sick tab 50mg 30travoprost dro 0.004% 100trazodone tab 100mg 23trazodone tab 150mg 23trazodone tab 300mg 23trazodone tab 50mg 23TRECATOR TAB 250MG 39TRETIN-X CRE 0.0375% 65tretinoin cap 10mg 42tretinoin cre 0.025% 65tretinoin cre 0.05% 65tretinoin cre 0.1% 65tretinoin em cre 0.05% 66tretinoin gel 0.01% 65tretinoin gel 0.025% 65TREXALL TAB 10MG 40TREXALL TAB 15MG 40TREXALL TAB 5MG 40TREXALL TAB 7.5MG 40tri-estaryll tab 60tri-legest tab fe 60tri-linyah tab 60tri-previfem tab 60tri-sprintec tab 60tri-vit/fe dro /fl 0.25 93tri-vit/fl dro 0.25mg 93tri-vit/fl dro 0.5mg 93tri-vit/fluo dro 0.25mg 93tri-vit/fluo dro 0.5mg 93tri-vita/fl dro 0.25mg 93triamcin/ora pst 0.1% 91triamcinolon cre 0.025% 71triamcinolon cre 0.1% 71triamcinolon cre 0.5% 71triamcinolon lot 0.1% 71triamcinolon oin 0.025% 71triamcinolon oin 0.05% 71triamcinolon oin 0.1% 71triamcinolon oin 0.5% 71triamcinolon pst 0.1% 91triamcinolon spr 55mcg/ac 96triamt/hctz cap 37.5-25 74triamt/hctz tab 37.5-25 74

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triamt/hctz tab 75-50mg 74triazolam tab 0.125mg 84triazolam tab 0.25mg 84TRICARE TAB PRENATAL 95triderm cre 0.1% 71trifluoperaz tab 10mg 47trifluoperaz tab 1mg 47trifluoperaz tab 2mg 47trifluoperaz tab 5mg 47trifluridine sol 1% op 98trihexyphen elx 0.4mg/ml 43trihexyphen tab 2mg 43trihexyphen tab 5mg 43trilyte sol 84trimethobenz cap 300mg 30trimethoprim sol polymyxn 98trimethoprim tab 100mg 13trimipramine cap 100mg 26trimipramine cap 25mg 26trimipramine cap 50mg 26TRINATAL RX TAB 1 95trinessa tab 60triptone tab 50mg 30TRIVEEN-U CAP 95trivora-28 tab 60TRIZIVIR TAB 49TROJAN MIS NAT LAMB 86tropicamide sol 0.5% op 97tropicamide sol 1% op 97trospium chl cap 60mg er 114TRUERESULT KIT 87TRUETEST TES 73TRUVADA TAB 200-300 49TUDORZA PRES AER 400/ACT 16tusnel diabt liq 10-100/5 63tussin adult liq 100/5ml 64tussin adult liq cgh/cong 63tussin cough liq 10-100/5 63tussin cough liq congesti 63tussin dm liq 63tussin dm liq 100-10/5 63tussin dm liq clear 63TWINJECT INJ 0.15MG 116TWINJECT INJ 0.3MG 116TYKERB TAB 250MG 42TYSABRI INJ 104TYZEKA TAB 600MG 50TYZINE PED DRO 0.05% 96TYZINE SOL 0.1% 96

UULESFIA LOT 5% 73ULORIC TAB 40MG 81ULORIC TAB 80MG 81unith direct tab 100mcg 110unith direct tab 112mcg 110unith direct tab 125mcg 110unith direct tab 150mcg 111unith direct tab 175mcg 111

unith direct tab 200mcg 111unith direct tab 25mcg 110unith direct tab 300mcg 111unith direct tab 50mcg 110unith direct tab 75mcg 110unith direct tab 88mcg 110unithroid tab 100mcg 111unithroid tab 112mcg 111unithroid tab 125mcg 111unithroid tab 137mcg 111unithroid tab 150mcg 111unithroid tab 175mcg 111unithroid tab 200mcg 111unithroid tab 25mcg 111unithroid tab 300mcg 111unithroid tab 50mcg 111unithroid tab 75mcg 111unithroid tab 88mcg 111UROCIT-K 15 TAB 81ursodiol cap 300mg 79ursodiol tab 250mg 79ursodiol tab 500mg 79

Vvagistat-3 kit combo pk 115valacyclovir tab 1gm 50valacyclovir tab 500mg 50VALCYTE TAB 450MG 49valproic acd cap 250mg 22valproic acd sol 250/5ml 22valproic acd syp 250/5ml 22valsart/hctz tab 160-12.5 38valsart/hctz tab 160-25mg 38valsart/hctz tab 320-12.5 38valsart/hctz tab 320-25mg 38valsart/hctz tab 80-12.5 38VALSTAR SOL 40MG/ML 41vancomycin cap 125mg 13vancomycin cap 250mg 13vandazole gel 0.75% 115VANDETANIB TAB 100MG 42VANDETANIB TAB 300MG 42VANOS CRE 0.1% 71velivet pak 60VELTIN GEL 65venlafaxine cap 150mg er 25venlafaxine cap 37.5mg 25venlafaxine cap 75mg er 25venlafaxine tab 100mg 25venlafaxine tab 150mg er 25venlafaxine tab 225mg er 25venlafaxine tab 25mg 25venlafaxine tab 37.5 er 25venlafaxine tab 37.5mg 25venlafaxine tab 50mg 25venlafaxine tab 75mg 25venlafaxine tab 75mg er 25VENTAVIS SOL 10MCG/ML 56VENTOLIN HFA AER 18

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verapamil cap 120mg er 55verapamil cap 120mg sr 55verapamil cap 180mg er 55verapamil cap 180mg sr 55verapamil cap 240mg er 55verapamil cap 240mg sr 55verapamil cap 360mg sr 55verapamil tab 120mg 55verapamil tab 120mg er 55verapamil tab 120mg sr 55verapamil tab 180mg er 56verapamil tab 180mg sr 56verapamil tab 240mg er 56verapamil tab 240mg sr 56verapamil tab 40mg 55verapamil tab 80mg 55VEREGEN OIN 15% 66VERIPRED 20 SOL 20MG/5ML 62VESICARE TAB 5MG 114vestura tab 3-0.02mg 60VEXOL SUS 1% OP 99VIAGRA TAB 100MG 56VIAGRA TAB 25MG 56VIAGRA TAB 50MG 56VIBRAMYCIN SYP 50MG/5ML 109VICTOZA INJ 18MG/3ML 27VICTRELIS CAP 200MG 50VIDEX SOL 2GM 49VIDEX SOL 4GM 49vigomar tab 92VIIBRYD KIT 23VIIBRYD TAB 10MG 23VIIBRYD TAB 20MG 24VIIBRYD TAB 40MG 24vimar hp tab 93VIMPAT SOL 10MG/ML 22VIMPAT TAB 100MG 22VIMPAT TAB 150MG 22VIMPAT TAB 200MG 22VIMPAT TAB 50MG 22VINATE AZ EX TAB 95VINATE II TAB 95VINATE ONE TAB 95viorele tab 60VIRACEPT POW 50MG/GM 49VIRACEPT TAB 250MG 49VIRACEPT TAB 625MG 49VIRAMUNE XR TAB 400MG 49VIREAD POW 40MG/GM 49VIREAD TAB 150MG 49VIREAD TAB 200MG 49VIREAD TAB 250MG 49VIREAD TAB 300MG 49virt-vite tab plus 91VISICOL TAB 1.5GM 85vit d gummie chw 400unit 116vitalee tab 93VITAMIN A CAP 25000UNT 116vitamin d cap 50000unt 116vitamin d chw 400unit 116

vitamin d dro 400unit 116vitamin d tab 400unit 116vitamin d3 chw 400unit 116vitamin d3 dro 400unit 116vitamin d3 tab 400unit 116vitazol cre 0.75% 72VIVAGLOBIN SOL 160MG/ML 102VIVELLE-DOT DIS 0.025MG 79VIVELLE-DOT DIS 0.0375MG 79VIVELLE-DOT DIS 0.05MG 79VIVELLE-DOT DIS 0.075MG 79VIVELLE-DOT DIS 0.1MG 79vol-care rx tab 91VOL-PLUS TAB 95VOL-TAB RX TAB 95VOLTAREN GEL 1% 66voriconazole tab 200mg 31voriconazole tab 50mg 31VOTRIENT TAB 200MG 42VPRIV INJ 400UNIT 82VYTORIN TAB 10-10MG 33VYTORIN TAB 10-20MG 33VYTORIN TAB 10-40MG 33VYTORIN TAB 10-80MG 33VYVANSE CAP 20MG 1VYVANSE CAP 30MG 1VYVANSE CAP 40MG 1VYVANSE CAP 50MG 1VYVANSE CAP 60MG 1VYVANSE CAP 70MG 1

Wwal-dram ii tab 25mg 30wal-dram tab 50mg 30wal-dryl cap 25mg 32wal-fex allr tab 180mg 33wal-fex alrg tab 60mg 33wal-phed tab 30mg 96wal-proxen tab 220mg 5wal-tussin liq dm 63wal-zan tab 150mg 113wal-zyr dro 0.025%op 100wal-zyr sol 1mg/ml 33wal-zyr sol 5mg/5ml 33warfarin tab 10mg 19warfarin tab 1mg 19warfarin tab 2.5mg 19warfarin tab 2mg 19warfarin tab 3mg 19warfarin tab 4mg 19warfarin tab 5mg 19warfarin tab 6mg 19warfarin tab 7.5mg 19wee care sus 15/1.25 83WELCHOL PAK 3.75GM 33WELCHOL TAB 625MG 33wera tab 0.5/35 60WIDE-SEAL DPR KIT 60 86WIDE-SEAL DPR KIT 65 87

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WIDE-SEAL DPR KIT 70 87WIDE-SEAL DPR KIT 75 87WIDE-SEAL DPR KIT 80 87WIDE-SEAL DPR KIT 85 87WIDE-SEAL DPR KIT 90 87WIDE-SEAL DPR KIT 95 87wymzya fe chw 0.4mg-35 60

XXALKORI CAP 200MG 42XALKORI CAP 250MG 42XARELTO TAB 10MG 19XARELTO TAB 15MG 19XARELTO TAB 20MG 19XELODA TAB 150MG 40XELODA TAB 500MG 40XENAZINE TAB 12.5MG 104XENAZINE TAB 25MG 104XIFAXAN TAB 200MG 13XIFAXAN TAB 550MG 13XOPENEX HFA AER 18XTANDI CAP 40MG 40XYREM SOL 500MG/ML 103

Yyl folic aci tab 400mcg 82YODOXIN TAB 210MG 3YODOXIN TAB 650MG 3yohimbine tab 5.4mg 56

Zzafirlukast tab 10mg 16zafirlukast tab 20mg 16zaleplon cap 10mg 84zaleplon cap 5mg 84zarah tab 3-0.03mg 60ZAVESCA CAP 100MG 82zazole cre 0.4% 115zazole cre 0.8% 115zazole sup 80mg 115ZELBORAF TAB 240MG 42ZEMAIRA INJ 1000MG 108zenatane cap 10mg 65zenatane cap 20mg 66zenatane cap 40mg 66zenchent fe chw 60zenchent fe chw 0.4mg-35 60zenchent tab 60ZENPEP CAP 10000UNT 74ZENPEP CAP 15000UNT 74ZENPEP CAP 20000UNT 74zenzedi tab 10mg 1zenzedi tab 5mg 1zeosa chw 60ZETIA TAB 10MG 34ZIAGEN SOL 20MG/ML 49ZIANA GEL 66zidovudine cap 100mg 49zidovudine syp 50mg/5ml 49

zidovudine tab 300mg 49zinc sulfate cap 220mg 91zinc-220 cap 91zincate cap 220mg 91ziprasidone cap 20mg 44ziprasidone cap 40mg 44ziprasidone cap 60mg 44ziprasidone cap 80mg 44ZIRGAN GEL 0.15% 99ZMAX SUS 2GM 85ZOLINZA CAP 100MG 42zolmitriptan tab 2.5 mg 88zolmitriptan tab 2.5mg 88zolmitriptan tab 5mg 88zolpidem tab 10mg 84zolpidem tab 5mg 84ZOMIG SPR 5MG 88zonisamide cap 100mg 22zonisamide cap 25mg 22zonisamide cap 50mg 22zovia 1/35e tab 60zovia 1/50e tab 60ZUPLENZ MIS 4MG 30ZUPLENZ MIS 8MG 30ZYCLARA CRE 3.75% 72ZYCLARA PUMP CRE 2.5% 72ZYCLARA PUMP CRE 3.75% 72ZYFLO CR TAB 600MG 16ZYFLO TAB 600MG 16ZYMAXID SOL 0.5% 99ZYPREXA RELP INJ 210MG 46ZYPREXA RELP INJ 300MG 46ZYPREXA RELP INJ 405MG 46zyrtec itchy dro 0.025%op 100ZYTIGA TAB 250MG 41ZYVOX SUS 100MG/5M 13ZYVOX TAB 600MG 13

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