2015 empire plan medicare rx eff 01/01/2015 dec update · 2014-12-31 · 2015 empire plan medicare...

2015 Empire Plan Medicare Rx eff 01/01/2015_Dec Update

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS 2

probenecid 1

ULORIC 2

ZYLOPRIM 3

MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

PRIALT 100mcg/ml, 500mcg/20ml

2 PA

NSAIDS ANAPROX 3

ANAPROX DS 3

CATAFLAM 3

CELEBREX CAP 50MG 2

CELEBREX CAP 100MG 2



DAYPRO 3

diclofenac potassium 1

diclofenac sodium (generic of VOLTAREN-XR) TB24

1

diclofenac sodium TBEC 1

diflunisal 1

EC-NAPROSYN 3

etodolac 1

etodolac er 1

FELDENE 3

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

Drug Name Drug Tier

Requirements/Limits

meloxicam tabs (generic of MOBIC)

1

MOBIC 3

nabumetone TABS 1

NAPROSYN 3

naproxen (generic of NAPROSYN) SUSP; TABS

1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 3

sulindac TABS 1

tolmetin sodium 1

VOLTAREN-XR 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

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


1 QL

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


1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE

1

butorphanol nasal spray 1

butorphanol tartrate SOLN 1

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

2 QL



2

Drug Name Drug Tier

Requirements/Limits

BUTRANS 7.5mcg/hr, 10mcg/hr

QL (8 patches / 28 days)

2 QL

BUTRANS 15mcg/hr, 20mcg/hr


2 QL

capital and codeine QL (5000 mL / 30 days)

3 QL

hycet QL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL

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


1 QL

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


1 QL

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


1 QL

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

QL (5400 mL / 30 days)

1 QL

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


1 QL

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


1 QL

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


1 QL

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

1

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

1

ibudone 5-200 mg (generic of REPREXAIN)

1

ibudone tab 10-200mg 1

Drug Name Drug Tier

Requirements/Limits

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


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

lortab tab 5-325mg (generic of NORCO)


1 QL

lortab tab 7.5-325 (generic of NORCO)


1 QL

lortab tab 10-325mg (generic of NORCO)


1 QL

norco QL (360 tabs / 30 days)

3 QL

reprexain 2.5/200 3

reprexain 5/200 3

reprexain 10/200 1

SYNALGOS-DC 3

TRAMADOL HCL TB24 Generic Ultram ER

1

tramadol hcl er (generic of ULTRAM ER) TB24 100mg, 200mg

Generic Ultram ER

1

tramadol hcl tab 50 mg (generic of ULTRAM)

1

tramadol-acetaminophen (generic of ULTRACET)


1 QL

tylenol with codeine QL (400 tabs / 30 days)

3 QL

ULTRACET QL (240 tabs / 30 days)

3 QL

ULTRAM 3

ULTRAM ER 3

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

1 QL

vicodin es (generic of XODOL)


1 QL



3

Drug Name Drug Tier

Requirements/Limits

vicodin hp (generic of XODOL)


1 QL

VICOPROFEN 3

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

3 QL

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

3 QL

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

3 QL

zamicet QL (5400 mL / 30 days)

1 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 3 QL PA

ACTIQ QL (120 lozenges / 30 days)

3 QL PA

AVINZA QL (60 caps / 30 days)

3 QL

CODEINE SULFATE TABS 1

DILAUDID INJ 3 B/D

DILAUDID TAB 3

DILAUDID-5 ORAL LIQD 3

DILAUDID-HP INJ 3 B/D

DILAUDID-HP INJ 250MG 2 B/D

DOLOPHINE QL (240 tabs / 30 days)

3 QL

DURAGESIC QL (10 patches / 30 days)

3 QL

DURAMORPH 1 B/D

endocet (generic of PERCOCET)


1 QL

ENDODAN TAB 1

EXALGO QL (60 tabs / 30 days)

3 QL

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

1 QL PA

fentanyl patch (generic of DURAGESIC)


1 QL

FENTORA QL (120 tabs / 30 days)

2 QL PA

Drug Name Drug Tier

Requirements/Limits

hydromorphone hcl (generic of DILAUDID) LIQD

1

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

1 B/D

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

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS

1

hydromorphone tab 8mg er (generic of EXALGO)


1 QL



1 QL



1 QL

HYDROMORPHONE TABS 32MG


1 QL

INFUMORPH 200 2 B/D

INFUMORPH 500 2 B/D

KADIAN QL (60 caps / 30 days)

3 QL

LAZANDA QL (30 bottles / 30 days)

2 QL PA

levorphanol tartrate TABS 1

methadone hcl (generic of METHADOSE) CONC

QL (120 mL / 30 days)

1 QL

methadone hcl SOLN QL (600 mL / 30 days)

1 QL

methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 2

METHADOSE CONC QL (120 mL / 30 days)

3 QL

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate (generic of KADIAN) CP24

QL (60 caps / 30 days)

1 QL



4

Drug Name Drug Tier

Requirements/Limits

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

1 B/D

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

2 B/D

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

1

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

1 B/D

MORPHINE SULFATE TABS

1

morphine sulfate beads (generic of AVINZA)

QL (60 caps / 30 days)

1 QL

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


1 QL

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


1 QL

MS CONTIN 15mg, 30mg, 60mg, 100mg


3 QL

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

3 QL

NUCYNTA 2

NUCYNTA ER 50mg, 100mg


2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

OPANA TABS 3

OPANA ER (CRUSH RESISTANT


2 QL

OXECTA 3

OXYCODONE HCL CAPS 1

OXYCODONE HCL CONC 1

oxycodone hcl SOLN 1

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

1

oxycodone hcl TABS 10mg, 20mg

1

Drug Name Drug Tier

Requirements/Limits

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


1 QL

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


1 QL

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


1 QL

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


1 QL

oxycodone-aspirin (generic of PERCODAN)

1

oxycodone-ibuprofen 1

OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS

1

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

3 QL

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

3 QL

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

3 QL

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

3 QL

PERCODAN 3

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tab 5-325mg (generic of PERCOCET)


1 QL

ROXICODONE 3

SUBSYS QL (4 boxes / 30 days)

3 QL PA

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

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

1 B/D



5

Drug Name Drug Tier

Requirements/Limits

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

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE) 1%

1 B/D

lidocaine inj 1% (generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

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

1 B/D

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

XYLOCAINE INJ 1% 3 B/D

XYLOCAINE-MPF 3 B/D

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

BETHKIS 3 B/D

gentamicin in saline inj 0.8 mg/ml

1


2

gentamicin in saline inj 1 mg/ml

1


1


2


1

gentamicin in saline inj 2 mg/ml

1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI NEB 3 B/D

TOBI PODHALER 2 PA

tobramycin (generic of TOBI) NEBU

1 B/D

tobramycin sulfate SOLN; SOLR

1

Drug Name Drug Tier

Requirements/Limits

tobramycin sulfate in saline 2

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

atovaquone (generic of MEPRON) SUSP

1

AZACTAM 3

AZACTAM/DEX INJ 1GM 2

AZACTAM/DEX INJ 2GM 2

aztreonam (generic of AZACTAM)

1

BACTRIM 3

BACTRIM DS 3

BILTRICIDE 2

CAYSTON 2 LA PA

CLEOCIN CAPS 3

cleocin SOLR 3

CLEOCIN CAP 75MG 3

CLEOCIN IN D5W 3

CLEOCIN INJ 3

CLEOCIN PHOSPHATE 3

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

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

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3

CUBICIN 2 B/D

dapsone TABS 1

DARAPRIM 2

DORIBAX 2



6

Drug Name Drug Tier

Requirements/Limits

e.s.p. 1

ees/sulfisox sus 200-600 1

FLAGYL 3

FLAGYL ER 3

FURADANTIN 90 day limit if >64 yr

3 PA

HIPREX 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 2

MACROBID 90 day limit if >64 yr

3 PA

MACRODANTIN 25mg 90 day limit if >64 yr

2 PA

MACRODANTIN 50mg, 100mg

90 day limit if >64 yr

3 PA

MEPRON 3

meropenem (generic of MERREM)

1

MERREM 3

methenamine hippurate (generic of HIPREX)

1

METRO IV 2

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 2 B/D

nitrofurantoin (generic of FURADANTIN) SUSP


1 PA

nitrofurantoin macrocrystal (generic of MACRODANTIN)


1 PA

nitrofurantoin monohyd macro (generic of MACROBID)


1 PA

PENTAM 300 2

polymyxin b sulfate SOLR 1

PRIMAXIN 3

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO SOLR 2

SIVEXTRO TABS 3

STROMECTOL 2

sulfamethoxazole-trimethop SUSP

1

Drug Name Drug Tier

Requirements/Limits

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 2

trimethoprim TABS 1

TYGACIL 2

VANCOCIN HCL 3

vancomycin hcl (generic of VANCOCIN HCL) CAPS

1

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

1 B/D

vancomycin hcl SOLR 750mg

2 B/D

XIFAXAN TAB 200MG 3

ZYVOX 2

ANTIFUNGALS ABELCET 2 B/D

AMBISOME 2 B/D

AMPHOTEC 2 B/D

amphotericin b SOLR 1 B/D

ANCOBON 3

CANCIDAS 2

DIFLUCAN 3

ERAXIS 2

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole inj nacl 100 2



flucytosine (generic of ANCOBON) CAPS

1

GRIS-PEG 3

griseofulvin microsize SUSP 1

griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1



7

Drug Name Drug Tier

Requirements/Limits

LAMISIL PACK 3 PA

LAMISIL TABS QL (90 tabs / 365 days)

3 QL

MYCAMINE 2

NOXAFIL 2

nystatin TABS 1

ONMEL 3 PA

SPORANOX 3 PA

SPORANOX PULSEPAK 3 PA

SPORANOX SOL 10MG/ML 3 PA

terbinafine hcl (generic of LAMISIL) TABS


1 QL

VFEND IV 3

VFEND SUS 40MG/ML 3

VFEND TAB 3

voriconazole (generic of VFEND) SUSR; TABS

1

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

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

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

MALARONE 3

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 2

QUALAQUIN 3

quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 2

CRIXIVAN 2

didanosine (generic of VIDEX EC)

1

EDURANT 2

Drug Name Drug Tier

Requirements/Limits

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

EPIVIR TABS 3

FUZEON 2

INTELENCE 2

INVIRASE 2

ISENTRESS 2

lamivudine (generic of EPIVIR) 150mg, 300mg

1

LEXIVA 2

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA 2

RESCRIPTOR 2

RETROVIR CAPS 3

RETROVIR IV INFUSION 2

RETROVIR SYRP 3

REYATAZ CAPS 2

SELZENTRY 2

stavudine (generic of ZERIT) 1

SUSTIVA 2

TIVICAY 2

TYBOST 2

VIDEX EC 3

VIDEX PEDIATRIC 2

VIRACEPT 2

VIRAMUNE 3

VIRAMUNE XR 100mg 2

VIRAMUNE XR 400mg 3

VIREAD 2

ZERIT 3

ZIAGEN SOLN 2

ZIAGEN TABS 3

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

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

1



8

Drug Name Drug Tier

Requirements/Limits

ATRIPLA 2

COMBIVIR 3

COMPLERA 2

EPZICOM 2

KALETRA SOL 2

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 2

lamivudine-zidovudine (generic of COMBIVIR)

1

STRIBILD 2

TRIUMEQ 2

TRIZIVIR 3

TRUVADA 2

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 2

cycloserine CAPS 1

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

MYAMBUTOL 3

MYCOBUTIN 3

paser d/r 3

PRIFTIN 2

pyrazinamide 1

rifabutin (generic of MYCOBUTIN)

1

rifadin CAPS 150mg 3

RIFADIN CAPS 300mg 3

RIFADIN SOLR 3

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 2

SIRTURO 3 LA

TRECATOR 2

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

1

acyclovir sodium 1 B/D

adefovir dipivoxil (generic of HEPSERA)

1

BARACLUDE 2

cidofovir (generic of VISTIDE) 1

Drug Name Drug Tier

Requirements/Limits

COPEGUS 3 PA

CYTOVENE 3 B/D

entecavir (generic of BARACLUDE)

1

EPIVIR HBV SOLN 2

EPIVIR HBV TABS 3

famciclovir (generic of FAMVIR) TABS

1

FAMVIR 3

FLUMADINE 3

foscarnet sodium 1

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HEPSERA 3

lamivudine (generic of EPIVIR HBV) 100mg

1

moderiba pak 2 PA

moderiba tab 200mg (generic of COPEGUS)

1 PA

OLYSIO 2 PA

REBETOL CAPS 3 PA

REBETOL SOLN 2 PA

RELENZA DISKHALER 2

ribapak mis 600/day 2 PA

ribasphere (generic of REBETOL) CAPS

1 PA

ribasphere (generic of COPEGUS) TABS 200mg

1 PA

ribasphere TABS 400mg, 600mg

1 PA

ribasphere ribapak 800 2 PA



ribavirin 200mg (generic of REBETOL) CAPS

1 PA

ribavirin 200mg (generic of COPEGUS) TABS

1 PA

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 2 PA

TAMIFLU 2

TYZEKA 2

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 2

VICTRELIS 2 PA

VISTIDE 3



9

Drug Name Drug Tier

Requirements/Limits

ZOVIRAX CAPS; SUSP 3

CEPHALOSPORINS CEDAX 3

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 2

cefdinir 1

CEFEPIME 1GM SOLN 2

CEFEPIME 2GM SOLN 2

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefotaxime sodium (generic of CLAFORAN)

1

cefotetan disodium 2

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

2

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ) 1gm, 2gm, 6gm

1

CEFTAZIDIME/DEXTROSE 2

ceftibuten 1

CEFTIN 3

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

1

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

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1

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

1

cefuroxime sodium soln iv 7.5 gm

2

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 2

Drug Name Drug Tier

Requirements/Limits

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

3

FORTAZ SOLN 2

FORTAZ SOLR 1gm, 2gm, 6gm

3

FORTAZ SOLR 500mg 2

KEFLEX 3

MAXIPIME 1gm, 2gm 2

MAXIPIME 1gm, 2gm 3

rocephin 3

SUPRAX CAPS 2

suprax CHEW 2

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

2

SUPRAX SUSR 500mg/5ml 2

suprax TABS 2

tazicef vial (generic of FORTAZ)

1

TEFLARO 2

ZINACEF SOLR 1.5gm, 7.5gm, 750mg

3

ZINACEF SOLR 750mg 2

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR 500mg

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

BIAXIN 3

BIAXIN XL 3

BIAXIN XL PAC 3

clarithromycin SUSR 125mg/5ml

1

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

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 2

e.e.s. 400 mg tab 1

E.E.S. GRANULES 3

ery-tab 3

ERYPED 200 3



10

Drug Name Drug Tier

Requirements/Limits

ERYPED 400 2

erythrocin lactobionate 500mg

2

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

FLUOROQUINOLONES AVELOX SOLN 2

AVELOX TABS 3

AVELOX ABC PACK 3

CIPRO 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin (generic of CIPRO) SUSR

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

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

1

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

1

ciprofloxacn inj 1

FACTIVE 3

LEVAQUIN 3

levofloxacin SOLN 25mg/ml 1

levofloxacin (generic of LEVAQUIN) SOLN 25mg/ml

1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 1

levofloxacin in d5w (generic of LEVAQUIN)

1

moxifloxacin hcl (generic of AVELOX) TABS

1

PENICILLINS amoxicillin 1

Drug Name Drug Tier

Requirements/Limits

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

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

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN 3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

BACTOCILL INJ DEX 1GM 2

BACTOCILL INJ DEX 2GM 2

BICILLIN C-R 2

BICILLIN L-A 2

dicloxacillin sodium 1

MOXATAG 3

nafcillin sodium 1

NALLPEN ISO-OSMOTIC IN DE

2

NALLPEN/DEXTROSE 2

oxacillin sodium 1



11

Drug Name Drug Tier

Requirements/Limits

PENICILLIN G POT IN DEXTROSE

2

penicillin g potassium 1

PENICILLIN G POTASSIUM IN

2

penicillin g procaine 2

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

TIMENTIN 2

UNASYN 3

UNASYN BULK PACK 3

ZOSYN 3

TETRACYCLINES demeclocycline hcl 1

doxycycline (monohydrate) CAPS 50mg

1

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

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

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

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 3

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN CAPS; SUSR 3

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS

Drug Name Drug Tier

Requirements/Limits

ALKERAN SOLR 3 B/D

BICNU 2 B/D

BUSULFEX 2 B/D

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 2 B/D

cyclophosphamide TABS 1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2

HEXALEN 2

IFEX 2 B/D

IFEX INJ 3GM 3 B/D

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

1 B/D

ifosfamide 3gm/60ml 3 B/D

ifosfamide for inj 1 gm (generic of IFEX)

1 B/D

IFOSFAMIDE FOR INJ 3 GM 2 B/D

ifosfamide inj 1gm/20ml 3 B/D

LEUKERAN 2

LOMUSTINE 1

melphalan hcl (generic of ALKERAN)

1 B/D

MUSTARGEN 2 B/D

TREANDA SOLR 2 B/D

ZANOSAR 2 B/D

ANTHRACYCLINES daunorubicin hcl 1 B/D

DOXIL 3 B/D

doxorubicin hcl 50mg 1 B/D

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

1 B/D

doxorubicin inj 50mg 1 B/D

ELLENCE 3 B/D

EPIRUBICIN INJ 50MG 2 B/D

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

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

1 B/D

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D



12

Drug Name Drug Tier

Requirements/Limits

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 2 B/D

ARRANON 2 B/D

azacitidine (generic of VIDAZA)

1 B/D

cladribine 1 B/D

CLOLAR 2 B/D

cytarabine inj 1 B/D

DACOGEN 3 B/D

decitabine (generic of DACOGEN)

1 B/D

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 2 B/D

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

1 B/D

gemcitabine hcl 2gm 1 B/D

GEMZAR 3 B/D

mercaptopurine (generic of PURINETHOL) TABS

1

methotrexate sodium inj 1 B/D

NIPENT 3 B/D

PURINETHOL 3

TABLOID 2

VIDAZA 3 B/D

ANTIMITOTIC, TAXOIDS ABRAXANE 2 B/D

DOCETAXEL CONC 20mg/ml, 80mg/4ml

1 B/D

docetaxel CONC 140mg/7ml 2 B/D

DOCETAXEL SOLN 80mg/8ml

2 B/D

paclitaxel 1 B/D

TAXOTERE 3 B/D

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS

Drug Name Drug Tier

Requirements/Limits

ARZERRA 2 B/D

AVASTIN 2 B/D

ERBITUX 2 B/D

ERIVEDGE 2 LA

HERCEPTIN 2 B/D

ISTODAX 2 B/D

KADCYLA 2 B/D

PROLEUKIN 2 B/D

RITUXAN 2

TORISEL 2 B/D

VECTIBIX 2 B/D

VELCADE 2 B/D

ZOLINZA 2

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARIMIDEX 3

AROMASIN 3

bicalutamide (generic of CASODEX)

1

CASODEX 3

DEPO-PROVERA INJ 400/ML 2 B/D

ELIGARD INJ 7.5MG 2 B/D

ELIGARD INJ 22.5MG 2 B/D

ELIGARD INJ 30MG 2 B/D

ELIGARD INJ 45MG 2 B/D

exemestane (generic of AROMASIN)

1

FARESTON 2

FASLODEX 2 B/D

FEMARA 3

FIRMAGON 2 B/D

flutamide 1

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 PA

LUPR DEP-PED INJ 15MG 2 PA

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

2 PA

LUPRON DEP INJ 11.25MG 2 PA

LUPRON DEPOT 2 PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

2 PA

LUPRON DEPOT INJ 30MG (3-MONTH)

2 PA

LUPRON DEPOT INJ 45MG 2 PA

LUPRON DEPOT-PED 2 PA



13

Drug Name Drug Tier

Requirements/Limits

LYSODREN 2

MEGACE ES 2

MEGACE ORAL 3 PA

megestrol acetate (generic of MEGACE ORAL) SUSP

1 PA

megestrol acetate TABS 1 PA

NILANDRON 2

SOLTAMOX 2

tamoxifen citrate TABS 1

TRELSTAR DEPOT MIXJECT

2 PA

TRELSTAR LA MIXJECT 2 PA

TRELSTAR MIXJECT 2 PA

VANTAS 2 PA

XTANDI 2 LA

ZOLADEX 2 PA

ZYTIGA 2

KINASE INHIBITORS AFINITOR 2

AFINITOR DISPERZ 2

BOSULIF 2

CAPRELSA 2 LA

COMETRIQ 2

GILOTRIF TAB 20MG 2 LA



GLEEVEC 2

ICLUSIG 2 LA

IMBRUVICA CAP 140MG 2 LA

INLYTA 2 LA

JAKAFI 2 LA

MEKINIST 2

NEXAVAR 2 LA

SPRYCEL 2

STIVARGA 2 LA

SUTENT 12.5mg, 25mg, 50mg

2

SUTENT 37.5mg 3

TAFINLAR 2

TARCEVA 2

TASIGNA 2

TYKERB 2 LA

VOTRIENT 2

XALKORI 2 LA

ZELBORAF 2 LA

ZYDELIG 3 LA

Drug Name Drug Tier

Requirements/Limits

ZYKADIA 2 LA

MISCELLANEOUS DROXIA 2

HALAVEN 2 B/D

HYDREA 3

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 2 B/D

MATULANE 2

mitoxantrone hcl 1 B/D

POMALYST 2 LA

SYLATRON KIT 296MCG 2



TARGRETIN CAPS 2

tretinoin CAPS 1

TRISENOX 2 B/D

UVADEX 2 B/D

PLATINUM-BASED AGENTS carboplatin SOLN 1 B/D

cisplatin 1 B/D

ELOXATIN 50mg/10ml, 100mg/20ml

3 B/D

oxaliplatin 1 B/D

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

1 B/D

dexrazoxane (generic of ZINECARD) 250mg

1 B/D

ELITEK 2 B/D

KEPIVANCE 2 B/D

leucovor ca inj 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

leucovorin calcium 500 mg 2 B/D

mesna (generic of MESNEX) 1 B/D

MESNEX SOLN 3 B/D

MESNEX TABS 2

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 40mg/2ml, 100mg/5ml

3 B/D

CAMPTOSAR 300mg/15ml 2 B/D

ETOPOPHOS 2 B/D

etoposide SOLN 500mg/25ml

1 B/D



14

Drug Name Drug Tier

Requirements/Limits

HYCAMTIN SOLR 3 B/D

irinotecan (generic of CAMPTOSAR)

1 B/D

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

1 B/D

irinotecan hcl 500mg/25ml 1 B/D

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

1 B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS ACCURETIC 3

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTREL 3

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

UNIRETIC 3

VASERETIC 3

ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3

ALTACE 3

benazepril hcl TABS 5mg 1

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

1

Drug Name Drug Tier

Requirements/Limits

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

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

1

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

1

LOTENSIN 20mg, 40mg 3

MAVIK 3

moexipril hcl (generic of UNIVASC)

1

perindopril erbumine 2mg 1

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

1

PRINIVIL 3

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

UNIVASC 3

VASOTEC 3

ZESTRIL 3

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 3

eplerenone (generic of INSPRA)

1

INSPRA 3

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS CARDURA 3

doxazosin mesylate (generic of CARDURA)

1

MINIPRESS 3

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

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

1



15

Drug Name Drug Tier

Requirements/Limits

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

1


1


1

AVALIDE 3

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

HYZAAR 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan potassium & hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 3

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS AVAPRO 3

BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

COZAAR 3

DIOVAN 3

EDARBI 3

eprosartan mesylate (generic of TEVETEN)

1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 3

TELMISARTAN 1

Drug Name Drug Tier

Requirements/Limits

valsartan (generic of DIOVAN)

1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg, 400mg

1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

BETAPACE 3

BETAPACE AF 3

disopyramide phosphate (generic of NORPACE)

1 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2

NORPACE 3 PA

NORPACE CR 2 PA

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

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

1

propafenone hcl TABS 300mg

1

quinidine gluconate er 1

quinidine sulfate TABS; TBCR

1

RYTHMOL 3

RYTHMOL SR 3

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

1

sorine 240mg 1

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

1

sotalol hcl 240mg 1

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

1

TIKOSYN 2

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS



16

Drug Name Drug Tier

Requirements/Limits

atorvastatin calcium (generic of LIPITOR) TABS

1

CRESTOR 2

fluvastatin sodium (generic of LESCOL)

1

LESCOL 3

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

PRAVACHOL 3

pravastatin sodium 10mg 1

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

1

simvastatin (generic of ZOCOR) TABS

1

ZOCOR 3

ANTILIPEMICS, MISCELLANEOUS ANTARA 3

cholestyramine (generic of QUESTRAN)

1

cholestyramine light 1

choline fenofibrate (generic of TRILIPIX)

1

COLESTID 3

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

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

1

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

1

fenofibrate micronized 43mg, 130mg

1

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

1

FENOFIBRIC ACID 1

FIBRICOR 3

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 3 PA

KYNAMRO 3 PA

LIPOFEN 3

Drug Name Drug Tier

Requirements/Limits

lofibra 3

LOPID 3

LOVAZA CAP 1GM 3

niacin (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

NIASPAN 3

omega-3-acid ethyl esters 1

prevalite (generic of QUESTRAN LIGHT)

1

questran 3

questran light 3

SIMCOR 2

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

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

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

CORZIDE 3

DUTOPROL 3

LOPRESSOR HCT 3

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

1

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

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

TENORETIC 50 3

TENORETIC 100 3

ZIAC 3

BETA-BLOCKERS



17

Drug Name Drug Tier

Requirements/Limits

acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG 3

CORGARD 3

INDERAL LA 3

labetalol hcl SOLN 1

labetalol hcl (generic of TRANDATE) TABS

1

LOPRESSOR SOLN 3

LOPRESSOR TABS 50mg 3

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate (generic of LOPRESSOR) SOLN

1

metoprolol tartrate TABS 25mg

1

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

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

SECTRAL 3

TENORMIN 3

timolol maleate TABS 1

TOPROL XL 3

TRANDATE 3

ZEBETA 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

afeditab cr (generic of ADALAT CC)

1

Drug Name Drug Tier

Requirements/Limits

amlodipine besylate (generic of NORVASC) TABS

1

CALAN 3

CALAN SR 3

CARDENE SR 3

CARDIZEM 60mg, 120mg 3

CARDIZEM CD 3

CARDIZEM LA 3

cartia xt (generic of CARDIZEM CD)

1

dilacor 3

dilt-cd cap (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

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

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 2

diltiazem inj 125/25ml 1

diltzac (generic of TIAZAC) 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 1

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

1



18

Drug Name Drug Tier

Requirements/Limits

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

1

NORVASC 3

NYMALIZE 3

PROCARDIA XL 3

SULAR 3

taztia xt (generic of TIAZAC) 1

TIAZAC 3

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

1

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

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

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

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES digoxin (generic of LANOXIN) 1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN INJ 0.25MG/ML 3

LANOXIN PEDIATRIC 2

LANOXIN TAB 3

DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE 2

TEKAMLO 2

TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

Drug Name Drug Tier

Requirements/Limits

ALDACTAZIDE TAB 50/50 2

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DEMADEX 3

DIAMOX 3

DIURIL SUS 250/5ML 3

DYAZIDE 3

DYRENIUM 3

EDECRIN 2

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 1

furosemide oral soln 8 mg/ml 2

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

LASIX 3

MAXZIDE 3

MAXZIDE-25 3

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone (generic of ZAROXOLYN) 2.5mg, 5mg

1

metolazone 10mg 1

MICROZIDE 3

SODIUM DIURIL 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 20mg/2ml 2

torsemide inj 50mg/5ml 2

torsemide tabs (generic of DEMADEX)

1

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

1

triamt/hctz cap 50-25mg 1

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

1



19

Drug Name Drug Tier

Requirements/Limits

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

1

ZAROXOLYN 3

MISCELLANEOUS BIDIL 2

CATAPRES TAB 3

CATAPRES-TTS 3

CATAPRES-TTS-3 3

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

1


1


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

DEMSER 2

DIBENZYLINE 2

hydralazine hcl 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

imdur 3

ISORDIL TITRADOSE 5mg 3

ISORDIL TITRADOSE 40mg 2

isosorbide dinitrate (generic of ISORDIL TITRADOSE) TABS 5mg

1

isosorbide dinitrate TABS 10mg, 20mg, 30mg

1

isosorbide dinitrate TBCR 1

isosorbide mononitrate 1

isosorbide mononitrate er (generic of IMDUR) 30mg

1

isosorbide mononitrate er 60mg, 120mg

1

minitran (generic of NITRO-DUR)

1

nitro-bid 3

Drug Name Drug Tier

Requirements/Limits

NITRO-DUR .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr

3

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

2

NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

3

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 3 PA

ADEMPAS 3 PA

FLOLAN 3 LA PA

LETAIRIS 2 LA PA

OPSUMIT 3 PA

ORENITRAM TAB 0.25MG 3 PA


ORENITRAM TAB 1MG 3 PA


REMODULIN 2 B/D LA

REVATIO SOLN; SUSR 2 PA

REVATIO TABS 3 PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO)

1 PA

TRACLEER 2 LA PA

TYVASO 2 B/D

VELETRI 2 LA PA

VENTAVIS 2 B/D

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of XANAX) TABS 1mg


1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL



20

Drug Name Drug Tier

Requirements/Limits

alprazolam (generic of XANAX) TABS .25mg


1 QL

ATIVAN SOLN 3

ATIVAN TABS QL (150 tabs / 30 days)

3 QL

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er (generic of LUVOX CR) 100mg

1

fluvoxamine maleate er 150mg

1

lorazepam CONC QL (150 mL / 30 days)

1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

LUVOX CR 3

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

3 QL

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

3 QL

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

3 QL

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

3 QL

ANTICONVULSANTS APTIOM 3

BANZEL SUS 40MG/ML 3

BANZEL TAB 200MG 3

BANZEL TAB 400MG 3

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CARBATROL 3

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

Drug Name Drug Tier

Requirements/Limits

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

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

1 QL

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

1 QL

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

1 QL


1 QL


1 QL

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


1 QL

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL

DEPACON 3

DEPAKENE 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

diazepam CONC QL (240 mL / 30 days)

2 QL

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

1 QL

diazepam SOLN 5mg/ml 1

diazepam (generic of VALIUM) TABS


1 QL

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin CAPS 30mg 2

dilantin CAPS 100mg 3

dilantin CHEW 3



21

Drug Name Drug Tier

Requirements/Limits

DILANTIN SUSP 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL)

1

FELBATOL 3

FYCOMPA 3

gabapentin (generic of NEURONTIN) CAPS; SOLN; TABS

1

GABITRIL 3

KEPPRA 3

KEPPRA XR 3

KLONOPIN 1mg QL (600 tabs / 30 days)

3 QL

KLONOPIN 2mg QL (300 tabs / 30 days)

3 QL

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

3 QL

LAMICTAL TABS 3

LAMICTAL CHEWABLE DISPERS

3

LAMICTAL ODT 2

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LYRICA 2

MYSOLINE 3

Drug Name Drug Tier

Requirements/Limits

NEURONTIN 3

ONFI SUS 2.5MG/ML 3

ONFI TAB 10MG 3

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS 1 PA

PHENOBARBITAL SODIUM 65mg/ml

2 PA

phenobarbital sodium 130mg/ml

1 PA

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

1

POTIGA 3

primidone (generic of MYSOLINE) TABS

1

QUDEXY XR 3

SABRIL 2 LA PA

TEGRETOL 3

TEGRETOL-XR 100mg 2

TEGRETOL-XR 200mg, 400mg

3

tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1

topiramate (generic of TOPAMAX) TABS

1

TRANXENE T 3.75mg, 7.5mg


3 QL



22

Drug Name Drug Tier

Requirements/Limits

TRANXENE T 15mg QL (180 tabs / 30 days)

3 QL

TRILEPTAL 3

TRILEPTAL SUSP 3

TROKENDI XR 3

VALIUM QL (120 tabs / 30 days)

3 QL

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT 2

ZARONTIN CAPS 3

zarontin SOLN 3

ZONEGRAN 3

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

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA ARICEPT 5mg, 10mg 3

ARICEPT ODT 3

donepezil odt 5mg 1

donepezil odt 10mg (generic of ARICEPT ODT)

1

donepezil tab hcl 23mg (generic of ARICEPT)

1

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON 3

EXELON PATCHES 2

galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide SOLN

1

galantamine hydrobromide (generic of RAZADYNE) TABS

1

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

2 PA

NAMENDA TAB PA if <30 yr

2 PA

Drug Name Drug Tier

Requirements/Limits

NAMENDA XR PA if <30 yr

3 PA

NAMENDA XR TITRATION PACK

PA if <30 yr

3 PA

RAZADYNE 3

RAZADYNE ER 3

rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS 1 PA

amoxapine 1

ANAFRANIL 3 PA

BRINTELLIX 3

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

CELEXA 3

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

1 PA

CYMBALTA 3

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC 1 PA

duloxetine hcl (generic of CYMBALTA) CPEP

1

EFFEXOR XR 3

EMSAM 3

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1



23

Drug Name Drug Tier

Requirements/Limits

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl (generic of TOFRANIL) TABS

1 PA

imipramine pamoate (generic of TOFRANIL-PM)

1 PA

LEXAPRO 3

maprotiline hcl 1

MARPLAN 2

mirtazapine TABS 7.5mg 1

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

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

mirtazapine odt (generic of REMERON SOLTAB)

1

NARDIL 3

nefazodone hcl 1

NORPRAMIN 3

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

PAMELOR 3

PARNATE 3

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl (generic of PAXIL)

1

PAXIL 3

PAXIL CR 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 3

protriptyline hcl 1

PROZAC 3

PROZAC WEEKLY 3

REMERON 3

REMERON SOLTAB 3

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3 PA

TOFRANIL 3 PA

TOFRANIL-PM 3 PA

Drug Name Drug Tier

Requirements/Limits

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl 1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

vivactil 3

WELLBUTRIN 3

WELLBUTRIN SR 3

WELLBUTRIN XL 3

ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 2 LA PA

AZILECT 2

benztropine mesylate (generic of COGENTIN) SOLN

1

benztropine mesylate TABS 1 PA

bromocriptine mesylate (generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of LODOSYN) TABS

1

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1


1


1


1



24

Drug Name Drug Tier

Requirements/Limits


1


1

COGENTIN 3

COMTAN 3

ELDEPRYL 3

entacapone (generic of COMTAN)

1

LODOSYN 3

MIRAPEX 3

MIRAPEX ER 2

NEUPRO 2

parcopa 3

pramipexole dihydrochloride .75mg

1

pramipexole dihydrochloride (generic of MIRAPEX) .125mg, .25mg, .5mg, 1mg, 1.5mg

1

REQUIP 3

ropinirole hydrochloride (generic of REQUIP) TABS

1

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

SINEMET 3

SINEMET CR 3

STALEVO 3

trihexyphenidyl hcl 1 PA

ZELAPAR 2

ANTIPSYCHOTICS ABILIFY 2

ABILIFY DISCMELT 3

ABILIFY MAIN INJ 300MG 2

ABILIFY MAIN INJ 400MG 2

chlorpromaz inj 25mg/ml 2

chlorpromazine hcl TABS 1

clozapine (generic of CLOZARIL) 25mg, 100mg

1

clozapine 50mg, 200mg 1

CLOZAPINE ODT 1

CLOZARIL 3

FANAPT 3

FANAPT TITRATION PACK 3

Drug Name Drug Tier

Requirements/Limits

FAZACLO 3

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON 3

GEODON INJ 2

HALDOL 3

HALDOL DECANOATE 50 3

HALDOL DECANOATE 100 3

haloperidol TABS 1

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

1

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

1

haloperidol lactate CONC 1

haloperidol lactate (generic of HALDOL) SOLN

1

INVEGA 3

INVEGA SUST INJ 39 MG/0.25 ML

2


2


2

INVEGA SUST INJ 156MG/ML

2


2

LATUDA 2

loxapine succinate 1

olanzapine (generic of ZYPREXA)

1

olanzapine odt (generic of ZYPREXA ZYDIS)

1

ORAP 2

perphenazine TABS 1

quetiapine fumarate (generic of SEROQUEL)

1

RISPERDAL 3

RISPERDAL INJ 12.5MG 2

RISPERDAL INJ 25MG 2

RISPERDAL INJ 37.5MG 2



25

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 50MG 2

RISPERDAL M-TAB 3

risperidone (generic of RISPERDAL)

1

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

1

risperidone odt .25mg 1

SAPHRIS 3

SEROQUEL 3

SEROQUEL XR 2

thioridazine hcl TABS 1 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3

ziprasidone hcl (generic of GEODON)

1

ZYPREXA 3

ZYPREXA ZYDI TAB 10MG 3

ZYPREXA ZYDIS 3

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 10MG 3

adderall tab 12.5mg 3

adderall tab 15mg 3

ADDERALL TAB 20MG 3

ADDERALL TAB 30MG 3

amphetamine cap 10mg er (generic of ADDERALL XR)

1


1


1


1


1

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

1

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)

1

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)

1

Drug Name Drug Tier

Requirements/Limits


1

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)

1


1


1


1

CONCERTA 3

DAYTRANA 2

INTUNIV 2

metadate er 20 mg 1

METHYLIN 3

METHYLIN CHEW TAB 2

methylphenidate hcl (generic of RITALIN LA) CP24

1

methylphenidate hcl (generic of METADATE CD) CPCR

1

methylphenidate hcl (generic of METHYLIN) SOLN

1

methylphenidate hcl (generic of RITALIN) TABS

1

methylphenidate hcl TBCR 1

methylphenidate hcl er 1

QUILLIVANT XR 3

STRATTERA 2

VYVANSE 2

HYPNOTICS AMBIEN

90 day limit if >64 yr 3 PA

RESTORIL 7.5mg QL (30 caps / 30 days)


3 QL PA

RESTORIL 15mg QL (60 caps / 30 days)


3 QL PA

ROZEREM QL (30 tabs / 30 days)

3 QL



26

Drug Name Drug Tier

Requirements/Limits

temazepam (generic of RESTORIL) 7.5mg

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

1 QL PA

temazepam (generic of RESTORIL) 15mg

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

1 QL PA

zolpidem tartrate (generic of AMBIEN) TABS


1 PA

MIGRAINE ALSUMA

QL (6 mL / 30 days) 3 QL

AMERGE QL (9 tabs / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 2

D.H.E. 45 3

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

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

1 QL

ergomar 2

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

3 QL

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

3 QL

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

3 QL

IMITREX TABS QL (9 tabs / 30 days)

3 QL

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

3 QL

IMITREX STATDOSE REFILL QL (6 mL / 30 days)

3 QL

IMITREX STATDOSE SYSTEM

QL (6 mL / 30 days)

3 QL

MAXALT QL (18 tabs / 30 days)

3 QL

MAXALT-MLT QL (18 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

migergot 1

MIGRANAL QL (8 mL / 30 days)

3 QL

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

SUMATRIPTAN SUCCINATE SOAJ

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOCT

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 20mg/act

QL (12 inhalers / 30 days)

1 QL

sumatriptan succinate SOSY QL (6 mL / 30 days)

1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

sumatriptan succinate inj (generic of IMITREX STATDOSE SYSTEM) SOAJ

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE INJ SOCT

QL (6 mL / 30 days)

1 QL

sumatriptan succinate inj (generic of IMITREX) SOLN

QL (6 mL / 30 days)

1 QL

SUMAVEL DOSEPRO 6mg/0.5ml

QL (6 mL / 30 days)

2 QL



27

Drug Name Drug Tier

Requirements/Limits

zolmitriptan (generic of ZOMIG) TABS


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG TABS QL (12 tabs / 30 days)

3 QL

ZOMIG ZMT QL (12 tabs / 30 days)

3 QL

MISCELLANEOUS BRISDELLE 3

EQUETRO 3

GRALISE 2

GRALISE STARTER 2

HETLIOZ 3 PA

HORIZANT 3

LITHIUM 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHOBID 3

MESTINON 3

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide (generic of MESTINON) TABS

1

RILUTEK 3

riluzole (generic of RILUTEK) 1

SAVELLA 2

SAVELLA TITRATION PACK 2

XENAZINE 2 LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 2 LA PA

AUBAGIO 3 PA

AVONEX 2 PA

AVONEX PEN 2 PA

COPAXONE INJ 40MG/ML 2 PA

COPAXONE KIT 20MG/ML 2 PA

EXTAVIA 2 PA

GILENYA CAP 0.5MG 2 PA

Drug Name Drug Tier

Requirements/Limits

REBIF 3 PA

REBIF TITRATION PACK 3 PA

TECFIDERA CAP 120MG 2 PA

TECFIDERA CAP 240MG 2 PA

TECFIDERA MIS STARTER 2 PA

TYSABRI 3 LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

cyclobenzaprine hcl TABS 5mg, 10mg

1

DANTRIUM 3

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

1

dantrolene sodium CAPS 100mg

1

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

ZANAFLEX 3

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL)

1 PA

NUVIGIL 3 PA

XYREM QL (540 mL / 30 days)

3 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium (generic of CAMPRAL)

1

antabuse 3

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban (generic of ZYBAN) 1

CAMPRAL 3

CHANTIX 2

CHANTIX STARTER PACK 2

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER 2

NICOTROL NS 2



28

Drug Name Drug Tier

Requirements/Limits

revia 3

SARAFEM 3

VIVITROL 2 PA

ZUBSOLV 2

ZYBAN 3

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2 PA

androxy 3 PA

AVEED 2 PA

AXIRON 2 PA

depo-testosterone 100mg/ml 2

depo-testosterone 200mg/ml 3

oxandrolone (generic of OXANDRIN) TABS

1 PA

STRIANT 3 PA

testosterone cypionate SOLN 100mg/ml

1

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

1

testosterone enanthate SOLN

1

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

BYDUREON 2

BYETTA 3

GAUZE PADS 2X2 2

HUMULIN R U-500 (CONCENTRATE)

2 B/D

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXPEN 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN N 2

NOVOLIN R 2

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

Drug Name Drug Tier

Requirements/Limits

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2

SYMLINPEN 120 2

TANZEUM 3

VICTOZA 2

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET TAB 15-500MG

3

ACTOPLUS MET TAB 15-850MG

3

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

AMARYL 3

DUETACT 3

FARXIGA 3

glimepiride (generic of AMARYL)

1

glipizide (generic of GLUCOTROL) TABS

1

glipizide er (generic of GLUCOTROL XL)

1

glipizide-metformin 2.5-250 mg

1

glipizide-metformin 2.5-500 mg

1

glipizide-metformin 5-500mg 1

GLUCOPHAGE 3

GLUCOPHAGE XR 3

GLUCOTROL 3

GLUCOTROL XL 3

GLYSET 3

INVOKAMET TAB 50-500MG 2

INVOKAMET TAB 50-1000 2



INVOKANA TAB 100MG 2

INVOKANA TAB 300MG 2

JANUMET 2

JANUMET XR TAB 50-500MG

2



29

Drug Name Drug Tier

Requirements/Limits

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JENTADUETO 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er (generic of GLUCOPHAGE XR)

1

metformin hcl (generic of GLUCOPHAGE) TABS

1

metformin hcl (generic of FORTAMET) TB24

1

nateglinide (generic of STARLIX)

1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl (generic of ACTOS)

1

pioglitazone hcl-glimepiride (generic of DUETACT)

1

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)

1

PRANDIMET 3

PRANDIN 3

PRECOSE 3

repaglinide (generic of PRANDIN)

1

RIOMET 3

STARLIX 3

TRADJENTA 2

BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

2

ACTONEL 150mg 3

alendronate sodium SOLN 1

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

1

Drug Name Drug Tier

Requirements/Limits

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

BONIVA 3 B/D

FOSAMAX 3

ibandronate sodium (generic of BONIVA)

1 B/D

pamidronate inj 6mg/ml 2 B/D

pamidronate inj 30/10ml 1 B/D

pamidronate inj 90/10ml 1 B/D

risedronate sodium (generic of ACTONEL)

1

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

1 B/D

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D

ZOMETA CONC 3 B/D

ZOMETA SOLN 2 B/D

CALCIUM RECEPTOR AGONISTS SENSIPAR 2

CHELATING AGENTS CHEMET 2

DEPEN TITRATABS 2

EXJADE 2 LA PA

FERRIPROX 3 PA

KAYEXALATE 3

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate 1

SYPRINE 3

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

aubra 0.1-0.02mg 1

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

BREVICON-28 3

briellyn 28 day (generic of OVCON-35)

1



30

Drug Name Drug Tier

Requirements/Limits

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

cryselle 28 1

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

1

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

1

CYCLESSA 3

delyla 0.1-0.02mg 1

DEPO-PROVERA CONTRACEPTIV

3

DEPO-SUBQ PROVERA 104 2

DESOGEN 3

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

ELLA 3

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

ESTROSTEP FE 3

falmina 1

FEMCON FE 3

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia (generic of OVCON-35)

1

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

1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLIVETTE 1

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

1

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

1

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

1

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

1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

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

1

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

1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1

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

1

levonorgestrel (emergency oc) (generic of PLAN B) .75mg

1

levonorgestrel-ethinyl estradiol (91-day)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

LO MINASTRIN FE 3

loestrin 1.5/30-21 3

loestrin 1/20-21 3

loestrin fe 1.5/30 3

loestrin fe 1/20 3

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

LOSEASONIQUE 3

low-ogestrel 28 day 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

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

1

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

1

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

1



31

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

MINASTRIN 24 FE 2

mircette 3

MODICON 3

MONONESSA 1

my way (generic of PLAN B ONE-STEP)

1

myzilra 1

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

1

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

1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

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

1

nikki 3-0.02mg (generic of YAZ)

1

NOR-QD 3

NORA-BE TAB 1

norethindrone (contraceptive) (generic of NOR-QD)

1

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

1

NORINYL 1+35 3

NORINYL 1+50 3

norlyroc 0.35mg (generic of NOR-QD)

1

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

1

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

1

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

1

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

1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

Drug Name Drug Tier

Requirements/Limits

orsythia 28 day 1

ORTHO EVRA 3

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN LO 2

ORTHO-CEPT 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

ovcon 35 28 day 3

philith (generic of OVCON-35) 1

pimtrea pack (generic of MIRCETTE)

1

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

1

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3

sharobel 0.35mg (generic of ORTHO MICRONOR)

1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

TRI-NORINYL 28 3

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

1

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

1

TRINESSA 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

viorele (generic of MIRCETTE)

1

vyfemia 28 day (generic of OVCON-35)

1



32

Drug Name Drug Tier

Requirements/Limits

xulane dis 150-35 (generic of ORTHO EVRA)

1

YASMIN 28 3

YAZ 3

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 PA

SYNAREL 2

ENZYME REPLACEMENTS ADAGEN 2 LA PA

ALDURAZYME 2 LA PA

CARBAGLU 2 LA PA

CARNITOR 3 B/D

CEREZYME 2 PA

CYSTADANE 2

CYSTAGON 2 PA

ELAPRASE 2 PA

ELELYSO 2 PA

FABRAZYME 2 PA

KUVAN 2 PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 2 PA

MYOZYME 2 PA

NAGLAZYME 2 LA PA

ORFADIN 3 PA

PROCYSBI 3 LA PA

sodium phenylbutyrate (generic of BUPHENYL)

1

VIMIZIM 2 PA

VPRIV 2 PA

ZAVESCA 2 LA PA

ESTROGENS ALORA 3 PA

CLIMARA 3 PA

COMBIPATCH 2 PA

DELESTROGEN 10mg/ml 2

Drug Name Drug Tier

Requirements/Limits

DELESTROGEN 20mg/ml, 40mg/ml

3

depo-estradiol 2

estrace CREA 2

estrace TABS 3 PA

estradiol (generic of CLIMARA) PTWK

1 PA

estradiol (generic of ESTRACE) TABS

1 PA

ESTRADIOL VALERATE OIL 10mg/ml

1

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

1

ESTRADIOL VALERATE OIL 40mg/ml

1

ESTRING 3

FEMRING 3

MENOSTAR 3 PA

MINIVELLE .037mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr

3 PA

PREMARIN 3 PA

PREMARIN CREAM 2

PREMARIN INJ 2

PREMPHASE 3 PA

PREMPRO 3 PA

VAGIFEM 2

VIVELLE-DOT 2 PA

GLUCOCORTICOIDS a-hydrocort 1

CORTEF 3

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

2 B/D


3 B/D


3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

fludrocortisone acetate TABS

1



33

Drug Name Drug Tier

Requirements/Limits

hydrocortisone (generic of CORTEF) TABS

1

MEDROL PAK 4MG 3 B/D

MEDROL TAB 2MG 2 B/D





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

1 B/D

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

1 B/D

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

1 B/D

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

1 B/D

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

1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1 B/D

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

millipred 3 B/D

orapred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D



pediapred sol 6.7/5ml 3 B/D

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

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml (generic of PRELONE)

1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D



Drug Name Drug Tier

Requirements/Limits



RAYOS TAB 1MG 2 B/D

RAYOS TAB 2MG 2 B/D

RAYOS TAB 5MG 2 B/D

SOLU-CORTEF 100MG 2

SOLU-CORTEF 250MG 2

SOLU-CORTEF 500MG 2

SOLU-CORTEF 1000MG 2

SOLU-MEDROL INJ 1GM 3 B/D

SOLU-MEDROL INJ 2GM 2 B/D

SOLU-MEDROL INJ 40MG 3 B/D



veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM SUS 50MG/ML 2

HUMAN GROWTH HORMONES HUMATROPE 2 PA

HUMATROPE COMBO PACK 2 PA

NORDITROPIN FLEXPRO 2 PA

NORDITROPIN NORDIFLEX PEN

2 PA

SEROSTIM 2 PA

ZORBTIVE 2 PA

MISCELLANEOUS cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1

EGRIFTA 1mg 3 PA

EGRIFTA 2mg 2 PA

EVISTA 3

FORTICAL SPR 200/ACT 3

H.P. ACTHAR 2 PA

INCRELEX 2 LA PA

KORLYM 3 LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 2 B/D



34

Drug Name Drug Tier

Requirements/Limits

MIACALCIN SPR 200/ACT 3

MYALEPT 2 PA

NOVAREL INJ 10000UNT 1

octreotide acetate (generic of SANDOSTATIN)

1 PA

PREGNYL W/DILUENT BENZYL

1

PROLIA 3

raloxifene hcl (generic of EVISTA)

1

RAVICTI 3 LA PA

SAMSCA 2 PA

SANDOSTATIN 3 PA

SANDOSTATIN LAR DEPOT 2 PA

SIGNIFOR 2 PA

SOMATULINE DEPOT 2 PA

SOMAVERT 2 LA PA

SUPPRELIN LA 2 PA

XGEVA 2

PARATHYROID HORMONES FORTEO 2 PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

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

1

eliphos 3

FOSRENOL 2

PHOSLO 3

PHOSLYRA 2

RENAGEL 3

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 2

PROGESTINS aygestin 3

CRINONE 2

ENDOMETRIN 3

MAKENA 2 PA

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

Drug Name Drug Tier

Requirements/Limits

progesterone micronized (generic of PROMETRIUM) CAPS

1

PROMETRIUM 3

PROVERA 3

THYROID AGENTS CYTOMEL 3

levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 3

tapazole 3

TIROSINT 3

TRIOSTAT 3

UNITHROID 1

VASOPRESSINS DDAVP 3

DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 2

GASTROINTESTINAL ANTIEMETICS ALOXI 2

CESAMET 3 B/D

compro supp 1

dronabinol (generic of MARINOL)

1 B/D

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D



35

Drug Name Drug Tier

Requirements/Limits

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

MARINOL 3 B/D

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 5 mg/ml

1

ondansetron hcl (generic of ZOFRAN) SOLN

1

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

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 1

ondansetron hcl inj 4 mg/2ml 1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz 1 PA

phenergan inj 3 PA

phenergan sup 12.5mg 1 PA

phenergan sup 25mg 1 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

1 PA

promethazine hcl SUPP; SYRP; TABS

1 PA

promethegan 1 PA

REGLAN 3

SANCUSO 2

TRANSDERM-SCOP 2 PA

ZOFRAN SOLN 4mg/5ml 3 B/D

ZOFRAN SOLN 40mg/20ml 3

ZOFRAN TABS 3 B/D

ZOFRAN ODT 3 B/D

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

1

BENTYL CAPS; TABS 3

BENTYL SOLN 2

CANTIL 3

Drug Name Drug Tier

Requirements/Limits

CUVPOSA 2

dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1

glycate 3

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3

PAMINE FORTE 3

ROBINUL 3

ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS AXID SOLN 3

cimetidine TABS 1

cimetidine sol 300/5ml 1

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

1

famotidine (generic of PEPCID) SUSR

1

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

1

nizatidine CAPS 150mg 1

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine (generic of AXID) SOLN

1

PEPCID SUSP 3

PEPCID TAB 3

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN 50mg/2ml, 150mg/6ml

1

ranitidine hcl SYRP 1

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

1



36

Drug Name Drug Tier

Requirements/Limits

ZANTAC SOLN 25mg/ml 3

ZANTAC TABS 3

INFLAMMATORY BOWEL DISEASE APRISO 2

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CP24

1

CANASA 2

COLAZAL 3

colocort (generic of CORTENEMA)

1

CORTENEMA 3

DIPENTUM 2

ENTOCORT EC 3

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

SF-ROWASA 3

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS TB24 3

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

Drug Name Drug Tier

Requirements/Limits

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

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

1

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

1

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

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS ACTIGALL 3

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1

CARAFATE SUSP 2

CARAFATE TABS 3

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

1

CYTOTEC 3

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GASTROCROM 3

GATTEX 3 LA PA

LINZESS 2

LOMOTIL 3

loperamide hcl CAPS 1

LOTRONEX 2

misoprostol (generic of CYTOTEC) TABS

1



37

Drug Name Drug Tier

Requirements/Limits

OMECLAMOX-PAK 3

PREVPAC 3

PYLERA 2

SUCRAID 2

sucralfate (generic of CARAFATE) TABS

1

URSO 250 3

URSO FORTE 3

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 2

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 2

ZENPEP 2

ZENPEP 3

PROTON PUMP INHIBITORS ACIPHEX 3

ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG 3

esomeprazole inj 20mg 1

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

1

lansoprazole (generic of PREVACID) CPDR

1

NEXIUM I.V. 3

omeprazole (generic of PRILOSEC) CPDR

1

pantoprazole sodium (generic of PROTONIX)

1

PRILOSEC 3

PROTONIX INJ 3

rabeprazole sodium (generic of ACIPHEX)

1

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

Drug Name Drug Tier

Requirements/Limits

AVODART 2

CARDURA XL 3

finasteride (generic of PROSCAR) TABS 5mg

1

FLOMAX 3

PROSCAR 3

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 2

POTASSIUM CITRATE (ALKALINIZER) TAB 15meq

1

POTASSIUM CITRATE (ALKALINIZER) TAB 540mg

1

POTASSIUM CITRATE (ALKALINIZER) TAB 1080mg

1

urecholine 3

UROCIT-K 3

UROCIT-K 15 3

URINARY ANTISPASMODICS DITROPAN XL 3

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

SANCTURA 3

TOLTERODINE TARTRATE ER

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN CREA 3

CLEOCIN VAG SUPP 100MG 2



38

Drug Name Drug Tier

Requirements/Limits

clindamycin cre 2% vag (generic of CLEOCIN)

1

METROGEL-VAGINAL 3

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole nitrate vaginal 1

TERAZOL 3 3

TERAZOL 7 3

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

1

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

1

terconazole vaginal SUPP 1

VANDAZOLE 1

zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS ARIXTRA 3

COUMADIN 3

COUMADIN INJ 2

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium (generic of LOVENOX)

1

fondaparinux sodium (generic of ARIXTRA)

1

FRAGMIN 2

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

2 B/D

HEPARIN SOD INJ 2500U/ML

2 B/D

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




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

2

Drug Name Drug Tier

Requirements/Limits

HEPARIN SODIUM/SODIUM CHL

1

jantoven (generic of COUMADIN)

1

LOVENOX 3

PRADAXA 2

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 PA

EPOGEN 2 PA

GRANIX 3 PA

LEUKINE 2 PA

MOZOBIL 2 PA

NEULASTA 2 PA

NEUMEGA 2 PA

NEUPOGEN 2 PA

PROCRIT 2 PA

MISCELLANEOUS AGRYLIN 3

anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 2 PA

cilostazol (generic of PLETAL) 1

CINRYZE 2 LA PA

CYKLOKAPRON 3

DESFERAL 2gm 3 PA

FIRAZYR 3 PA

KALBITOR 2 PA

LYSTEDA 3

NPLATE 250mcg 2 PA

pentoxifylline TBCR 1

PLETAL 3

PROMACTA 2 LA PA

SOLIRIS 2 PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

BRILINTA 2



39

Drug Name Drug Tier

Requirements/Limits

clopidogrel bisulfate (generic of PLAVIX)

1

EFFIENT 2

ZONTIVITY 3

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

ARAVA 3

CIMZIA 3 PA

ENBREL 2 PA

ENBREL SURECLICK 2 PA

HUMIRA KIT 2 PA

HUMIRA PEN 2 PA

HUMIRA PEN-CROHNS STARTER KIT

2 PA

HUMIRA PEN-PSORIASIS STARTER KIT

2 PA

hydroxychloroquine sulfate 1

KINERET 3 PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

ORENCIA 3 PA

OTEZLA 3 PA

OTREXUP 3 PA

PLAQUENIL 3

RASUVO 3 PA

REMICADE 3 PA

RHEUMATREX 2

SIMPONI SOSY 3 PA

SIMPONI ARIA 3 PA

trexall 2 B/D

XELJANZ 3 PA

IMMUNOGLOBULINS BIVIGAM 2 PA

CARIMUNE NANOFILTERED 2 PA

CYTOGAM 2 PA

FLEBOGAMMA 2 PA

FLEBOGAMMA DIF 2 PA

GAMASTAN S/D 2 B/D

GAMMAGARD LIQUID 2 PA

GAMMAGARD S/D 2 PA

GAMMAGARD S/D IGA LESS TH

2 PA

GAMMAKED 2 PA

Drug Name Drug Tier

Requirements/Limits

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

2 PA

GAMUNEX-C 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml

2 PA

GAMUNEX-C 1GM/10ML 2 PA

HIZENTRA 1gm/5ml 2 PA

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

2 PA

PRIVIGEN 2 PA

IMMUNOMODULATORS ACTIMMUNE 2 LA PA

ARCALYST 2 PA

GRASTEK 3

ILARIS 2 PA

INTRON-A INJ 10MU 2 B/D




PEG-INTRON 1 PA

PEG-INTRON REDIPEN 1 PA

PEGASYS SOLN 2 PA

PEGASYS PROCLICK 2 PA

RAGWITEK 3

REVLIMID 2 LA

THALOMID 2

IMMUNOSUPPRESSANTS ASTAGRAF XL 2 B/D

ATGAM 2 B/D

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

CELLCEPT CAP 3 B/D

CELLCEPT INTRAVENOUS 2 B/D

CELLCEPT SUSP 2 B/D

CELLCEPT TAB 3 B/D

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

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

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D



40

Drug Name Drug Tier

Requirements/Limits

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

1 B/D

gengraf (generic of NEORAL) 1 B/D

IMURAN 3 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate sodium (generic of MYFORTIC)

1 B/D

MYFORTIC 3 B/D

NEORAL 3 B/D

NULOJIX 2 B/D

PROGRAF CAPS 3 B/D

PROGRAF SOLN 2 B/D

RAPAMUNE SOLN 2 B/D

RAPAMUNE TABS 3 B/D

SANDIMMUNE CAPS 3 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 2 B/D

sirolimus tab 0.5 mg (generic of RAPAMUNE)

1 B/D

tacrolimus (generic of PROGRAF) CAPS

1 B/D

THYMOGLOBULIN 2 B/D

ZORTRESS TAB 0.5MG 2 B/D



MISCELLANEOUS BENLYSTA 2 PA

VACCINES ACTHIB 1

ADACEL 1

BCG VACCINE 2

BOOSTRIX 1

CERVARIX 1

COMVAX 1

DAPTACEL 1

DIPHTHERIA/TETANUS TOXOID

1 B/D

ENGERIX-B SUSP 1 B/D

GARDASIL 1

HAVRIX 1

HIBERIX 1

IMOVAX RABIES (H.D.C.V.) 2

Drug Name Drug Tier

Requirements/Limits

INFANRIX 1

IPOL INACTIVATED IPV 1

IXIARO 3

M-M-R II W/DILUENT 10 DOS

1

MENACTRA 1

MENOMUNE-A/C/Y/W-135 1

MENVEO 1

PEDVAX HIB 1

PROQUAD 1

RABAVERT 2

RECOMBIVAX HB 1 B/D

ROTARIX 1

ROTATEQ 1

SYNAGIS 2

TENIVAC 1 B/D

TETANUS TOXOID ADSORBED

1 B/D

TETANUS/DIPHTHERIA TOXOID

1 B/D

TWINRIX INJ 1

TYPHIM VI 2

VAQTA 1

VARIVAX 1

YF-VAX 2

ZOSTAVAX 1

INFLAMMATORY BOWEL AGENTS INFLAMMATORY BOWEL AGENTS ENTYVIO 3 PA

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 2

K-TAB 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20meq 1

MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

2

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE SOLN 50%

1



41

Drug Name Drug Tier

Requirements/Limits

MAGNESIUM SULFATE IN D5W

2

MICRO-K 3

potassium chloride LIQD 1

POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

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

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 2 B/D

AMINOSYN 7%/ELECTROLYTES

2 B/D

AMINOSYN II 2 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 2 B/D

AMINOSYN-HBC 2 B/D

AMINOSYN-PF 2 B/D

AMINOSYN-PF 7% 2 B/D

AMINOSYN-RF 2 B/D

CLINIMIX 2.75%/DEXTROSE 5%

2 B/D


2 B/D


2 B/D


2 B/D


2 B/D

CLINIMIX 5%/DEXTROSE 15%

2 B/D


2 B/D


2 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

2 B/D

Drug Name Drug Tier

Requirements/Limits


2 B/D

CLINIMIX E 4.25%/DEXTROSE

2 B/D


2 B/D


2 B/D

CLINIMIX E 5%/DEXTROSE 15%

2 B/D


2 B/D


2 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 2 B/D

FREAMINE III 2 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

LIPOSYN III INJ 10% 2 B/D

NEPHRAMINE 2 B/D

premasol 6% 1 B/D

premasol 10% 2 B/D

PROCALAMINE 2 B/D

PROSOL 2 B/D

travasol 10 2 B/D

TROPHAMINE 3 B/D

TROPHAMINE INJ 10% 2 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

2

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1







42

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

2

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

2

IONOSOL-B/DEXTROSE 5% 2

IONOSOL-MB/DEXTROSE 5%

2

ISOLYTE P 2

isolyte s 2

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

KCL0.15%/D5W/NACL0.225%

2

kcl 0.3%/d5w/lr iv lac ri 2

KCL 0.3%/D5W/NACL 0.9% 2

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 2

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 2

PLASMA-LYTE A 2

PLASMA-LYTE-56/D5W 2

PLASMA-LYTE-148 2

potassium chloride SOLN 1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

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

1

Drug Name Drug Tier

Requirements/Limits

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL)

1 B/D

HECTOROL CAPS 3 B/D

HECTOROL SOLN 4mcg/2ml

3 B/D

paricalcitol (generic of ZEMPLAR) CAPS

1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ROCALTROL 3 B/D

ZEMPLAR CAPS 3 B/D

ZEMPLAR SOLN 2 B/D

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

blephamide OINT 3

BLEPHAMIDE SUSP 3

MAXITROL 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX SUSP 3

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 3

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

BLEPH-10 3

CILOXAN OIN 0.3% OP 3



43

Drug Name Drug Tier

Requirements/Limits

CILOXAN SOL 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

garamycin 3

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) OINT

1

gentamicin sulfate (ophth) (generic of GARAMYCIN) SOLN

1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

neosporin solution 3

OCUFLOX 3

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3

sulfacetamide sodium (ophth) OINT

1

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

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

TOBREX SOL 0.3% OP 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

VIROPTIC 3

ZIRGAN 3

ANTI-INFLAMMATORIES ACULAR 3

ACULAR LS 3

ALREX 3

bromfenac sodium (ophth) 1

Drug Name Drug Tier

Requirements/Limits

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

FML LIQUIFILM 3

ILEVRO 3

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

1

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

1

LOTEMAX 3

MAXIDEX 3

NEVANAC 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) (generic of OPTIVAR)

1

BEPREVE 3

cromolyn sodium (ophth) 1

ELESTAT 3

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

OPTIVAR 3



44

Drug Name Drug Tier

Requirements/Limits

PATADAY 3

PATANOL 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 3

AZOPT 2

BETAGAN 3

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT 3

COSOPT PF 3

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 3

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 2

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 2

TRUSOPT 3

XALATAN 3

ZIOPTAN 3

MISCELLANEOUS

Drug Name Drug Tier

Requirements/Limits

alcaine 3

BOTOX INJ 100UNIT 2 PA

BOTOX INJ 200UNIT 2 PA

CYSTARAN 3 PA

DYSPORT 2 PA

LACRISERT 2

MYOBLOC 2500unit/0.5ml 2 PA

naphazoline 0.1% 1

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

XEOMIN 2 PA

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

COMBIVENT RESPIMAT 2

DUONEB 3 B/D

ipratropium-albuterol 1 B/D

ANTICHOLINERGICS ATROVENT 3

ATROVENT HFA 3

ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER 2

TUDORZA PRESSAIR 3

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

SEMPREX-D 3

ANTIHISTAMINES ASTELIN 3

ASTEPRO 3

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

1 PA



45

Drug Name Drug Tier

Requirements/Limits

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

1 PA

hydroxyzine pamoate CAPS 100mg

1 PA

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

1

levocetirizine tab 5 mg (generic of XYZAL)

1

PATANASE 3

VISTARIL 3 PA

XYZAL 3

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER 3

BROVANA 3 B/D

FORADIL AEROLIZER 2

levalbuterol conc 1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

levalbuterol hcl NEBU .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 3 B/D

PROAIR HFA 1

PROVENTIL HFA 3

SEREVENT DISKUS 2

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA 3

vospire 3

XOPENEX HFA 3

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3

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

1

SINGULAIR 3

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3

MAST CELL STABILIZERS

Drug Name Drug Tier

Requirements/Limits

cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 2 LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

GLASSIA 2 LA PA

KALYDECO 3 PA

PROLASTIN-C 2 LA PA

PULMOZYME 2 B/D

tyzine .05% 3

XOLAIR 2 LA PA

ZEMAIRA 2 LA PA

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) (generic of RHINOCORT AQUA)

1

FLONASE 3

flunisolide (nasal) 1

fluticasone propionate (nasal) (generic of FLONASE)

1

NASONEX 2

OMNARIS 3

QNASL 3

RHINOCORT AQUA 3

triamcinolone acetonide (nasal)

1

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ASMANEX 1

ASMANEX 14 METERED DOSES

1

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 1

FLOVENT HFA 1

PULMICORT FLEXHALER 1



46

Drug Name Drug Tier

Requirements/Limits

PULMICORT INH SUSP 0.5MG/2 ML

3 B/D

PULMICORT INH SUSP 0.25MG/2 ML

3 B/D

PULMICORT INH SUSP 1MG/2ML

3 B/D

QVAR 1

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 3

DULERA 2

SYMBICORT 2

XANTHINES aminophylline inj 1

elixophyllin 2

LUFYLLIN 3

theo-24 2

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA

1

adapalene (generic of DIFFERIN) GEL .1%

1

ADAPALENE GEL .3% 1

AKNE-MYCIN 3

amnesteem 1

ATRALIN 2 PA

AVITA CREA 1 PA

AVITA GEL 1 PA

AZELEX 3

BENZACLIN 3

BENZAMYCIN 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLEOCIN-T 3

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

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

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

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

1

DIFFERIN CREA; GEL 3

DIFFERIN LOTN 2

DUAC 3

ery pad 2% 1

erygel 3

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

FABIOR 3

KLARON 3

myorisan 1

neuac gel 1.2-5% (generic of DUAC)

1

RETIN-A 3 PA

sulfacetamide sodium (acne) (generic of KLARON)

1

tretinoin (generic of RETIN-A) CREA; GEL

1 PA

TRETINOIN MICROSPHERE 1 PA

zenatane 1

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN 3

BACTROBAN NASAL 2

CENTANY 3

CORTISPORIN CREA 2

CORTISPORIN OINT 3

gentamicin sulfate (topical) 1

mafenide acetate (generic of SULFAMYLON) PACK

1

mupirocin (generic of BACTROBAN) OINT

1



47

Drug Name Drug Tier

Requirements/Limits

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVADENE 3

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON 3

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

EXTINA 3

ketoconazole (topical) 1

ketodan aer 2% (generic of EXTINA)

1

LOPROX SHAMPOO 3

LUZU 3

MENTAX 2

NAFTIN 3

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 3

pedi-dri 1

DERMATOLOGY, ANTIPRURITIC anusol hc 3

CORTIFOAM 2

procto-pak 1

proctosol hc (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

1

Drug Name Drug Tier

Requirements/Limits

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

DOVONEX CRE 0.005% 3

methoxsalen rapid (generic of OXSORALEN ULTRA)

1

8-MOP 2

OXSORALEN ULTRA 3

SORIATANE 3

SORILUX 2

STELARA 3 PA

TAZORAC 3 PA

VECTICAL 3

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

NIZORAL 3

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS acyclovir topical (generic of ZOVIRAX)

1

DENAVIR 3

ZOVIRAX CREA; OINT 3

DERMATOLOGY, CORTICOSTEROIDS aclovate 3

ala-cort 1

ala-scalp 3

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1



48

Drug Name Drug Tier

Requirements/Limits

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotrien oin betameth (generic of TACLONEX)

1

CAPEX 2

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

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LOTN

1

clobetasol propionate emollient base (generic of TEMOVATE E)

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX LOTN 3

clocortolone pivalate 1

clodan sha 0.05% (generic of CLOBEX)

1

CLODERM PUMP 3

CORDRAN TAPE 3

CUTIVATE CREA; LOTN 3

DERMATOP 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN; OINT

1

DESOWEN CREA 3

desowen LOTN 3

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

DIPROLENE 3

DIPROLENE AF 3

ELOCON 3

fluocinolone acetonide CREA .01%

1

Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

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

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of VANOS) CREA .1%

1

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN; OINT

1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOKARA LOTN 0.05% 1

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

1

OLUX 3

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

SYNALAR 3



49

Drug Name Drug Tier

Requirements/Limits

TACLONEX 3

TEMOVATE CRE 0.05% 3

TEMOVATE E CREAM 3

TEMOVATE GEL 0.05% 3

TEMOVATE OIN 0.05% 3

TEMOVATE SOL 0.05% 3

texacort 2

topicort CREA 3

topicort GEL 3

TOPICORT LIQD 3

TOPICORT OINT .05% 3

topicort OINT .25% 3

triamcinolone acetonide (topical)

1

triderm 1

u-cort 1

ULTRAVATE 3

VANOS 3

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

LIDODERM 3 PA

SYNERA 3

XYLOCAINE 4% 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ALDARA 3

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

1

CARAC 2

CONDYLOX GEL 2

CONDYLOX SOLN 3

diclofenac gel 3% (generic of SOLARAZE)

1

diclofenac sol 1.5% (generic of PENNSAID)

1

EFUDEX 3

ELIDEL 2

Drug Name Drug Tier

Requirements/Limits

FINACEA 2

fluorouracil (topical) (generic of EFUDEX) CREA

1

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

LAC-HYDRIN 3

laclotion lot 12% (generic of LAC-HYDRIN)

1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (topical) (generic of METROCREAM) CREA

1

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

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

ORACEA 2

OXSORALEN 3

PANRETIN 2

PICATO 3

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 2

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOLARAZE 3

TARGRETIN GEL 2

VALCHLOR 3 LA

VOLTAREN GEL 1% 2

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 2

malathion (generic of OVIDE) 1

OVIDE 3

permethrin (generic of ELIMITE) CREA

1

SKLICE 3

ULESFIA 3



50

Drug Name Drug Tier

Requirements/Limits

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

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

1

REGRANEX 2

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

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

1

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

1

clotrimazole TROC 1

EVOXAC 3

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard soln 0.12% (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

1

SALAGEN 3

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN SOLN 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

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

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1

VOSOL HC 1

Drug Name Drug Tier

Requirements/Limits

_BONUS DRUGS COUGH AND COLD benzonatate (generic of TESSALON PERLES) 100mg

1

cheratussin 1

hydromet 1

iophen c-nr 1

promethazine dm 1

promethazine vc 1

promethazine/codeine 1

ERECTILE DYSFUNCTION CAVERJECT

QL (6 tabs / 30 days) 3 QL

CIALIS QL (6 tabs / 30 days)

3 QL

EDEX QL (6 ea / 30 days)

2 QL

LEVITRA TAB QL (6 tabs / 30 days)

3 QL

MUSE QL (6 ea / 30 days)

2 QL

STAXYN QL (6 tabs / 30 days)

3 QL

VIAGRA QL (6 tabs / 30 days)

2 QL

HEMORRHOIDS hydrocortisone acetate (rx) 1

hydrocortisone/pramoxine (rx) 1

INFLAMMATION salsalate TABS 1

IRRITABLE BOWEL hyoscyamine 1

NUTRITIONAL SUPPLEMENTS CEREFOLIN TAB 3

DEPLIN 3

folic acid TABS 1mg 1

FOLTX 2

L-METHYL-MC 3

METANX 3

vitamin d (generic of DRISDOL) CAPS 50000unit

1

WEIGHT LOSS benzphetamine (generic of DIDREX)

1 PA

diethylpropion 1 PA



51

Drug Name Drug Tier

Requirements/Limits

phendimetrazine CP24 1 PA

phendimetrazine (generic of BONTRIL PDM) TABS

1 PA

phentermine CAPS 15mg, 30mg

1 PA

phentermine (generic of ADIPEX-P) CAPS 37.5mg

1 PA

phentermine (generic of ADIPEX-P) TABS

1 PA


52

Index 8 8-MOP .............................. 47 A abacavir sulfate ...................7 abacavir sulfate-lamivudine-zidovudine ..........................................7 ABELCET............................6 ABILIFY............................. 24 ABILIFY DISCMELT ......... 24 ABILIFY MAIN INJ 300MG 24 ABILIFY MAIN INJ 400MG 24 ABRAXANE ...................... 12 ABSORICA ....................... 46 ABSTRAL............................3 acamprosate calcium ........ 27 ACANYA ........................... 46 acarbose ........................... 28 ACCOLATE ....................... 45

see zafirlukast ............... 45 ACCUPRIL ........................ 14

see quinapril hcl ............ 14 ACCURETIC ..................... 14

see quinapril-hydrochlorothiazide .................................. 14

acebutolol hcl .................... 17 ACEON

see perindopril erbumine ...................................... 14

acetaminophen w/ codeine .1 acetasol hc ........................ 50 acetazolamide ................... 18 acetazolamide sodium ...... 18 acetic acid ......................... 50 acetic acid (otic) ................ 50 acetic acid sol/hc ............... 50 acetic acid-aluminum acetate .......................................... 50 acetylcysteine ................... 45 ACIPHEX .......................... 37

see rabeprazole sodium 37 ACIPHEX SPR CAP 10MG .......................................... 37 ACIPHEX SPR CAP 5MG . 37 acitretin ............................. 47 aclovate............................. 47

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

ACTEMRA ........................ 39 ACTHIB ............................. 40 ACTIGALL ........................ 36

see ursodiol ................... 37 ACTIMMUNE .................... 39 ACTIQ ................................. 3

see fentanyl citrate .......... 3 ACTONEL ......................... 29

see risedronate sodium . 29 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 29

ACTOPLUS MET TAB 15-500MG ......................... 28 ACTOPLUS MET TAB 15-850MG ......................... 28 ACTOPLUS MET XR 15-1000MG ....................... 28 ACTOPLUS MET XR 30-1000MG ....................... 28 ACTOS

see pioglitazone hcl ....... 29 ACULAR ........................... 43

see ketorolac tromethamine (ophth) .... 43

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

acyclovir .............................. 8 acyclovir sodium ................. 8 acyclovir topical ................ 47 ACZONE ........................... 46 ADACEL ........................... 40 ADAGEN ........................... 32 ADALAT CC ...................... 17

see afeditab cr ............... 17 see nifedipine ................ 17

adapalene ......................... 46 ADAPALENE .................... 46 ADCIRCA .......................... 19 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg......... 25

see amphetamine-dextroamphetamine tab 12.5 mg ..... 25 see amphetamine-dextroamphetamine tab 15 mg ........ 25 see amphetamine-dextroamphetamine tab 20 mg ........ 25 see amphetamine-dextroamphetamine tab 30 mg ........ 25 see amphetamine-dextroamphetamine tab 5 mg .......... 25 see amphetamine-dextroamphetamine tab 7.5 mg ....... 25

ADDERALL TAB 10MG .... 25 adderall tab 12.5mg .......... 25 adderall tab 15mg ............. 25 ADDERALL TAB 20MG .... 25 ADDERALL TAB 30MG .... 25 ADDERALL XR

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

adefovir dipivoxil ................. 8 ADEMPAS ........................ 19 ADIPEX-P

see phentermine ........... 51 ADOXA

see doxycycline (monohydrate) ............... 11

ADRENACLICK ................ 45 adrucil ............................... 12


53

ADVAIR DISKUS .............. 46 ADVAIR HFA .................... 46 AEROSPAN ...................... 45 afeditab cr ......................... 17 AFINITOR ......................... 13 AFINITOR DISPERZ ......... 13 AGGRENOX ..................... 38 AGRYLIN .......................... 38

see anagrelide hcl ......... 38 a-hydrocort ........................ 32 AKNE-MYCIN ................... 46 ala-cort .............................. 47 ala-scalp............................ 47 ALBENZA............................5 albuterol sulfate ................. 45 albuterol sulfate er ............ 45 alcaine .............................. 44 ALCAINE

see proparacaine hcl ..... 44 alclometasone dipropionate .......................................... 47 ALCOHOL SWABS ........... 28 ALDACTAZIDE ................. 18

see spironolactone & hydrochlorothiazide ....... 18

ALDACTAZIDE TAB 50/50 .......................................... 18 ALDACTONE .................... 14

see spironolactone ........ 14 ALDARA............................ 49

see imiquimod ............... 49 ALDURAZYME ................. 32 alendronate sodium .......... 29 alfuzosin hcl ...................... 37 ALIMTA ............................. 12 ALINIA ................................5 ALKERAN ......................... 11

see melphalan hcl ......... 11 allopurinol tab ......................1 ALOCRIL........................... 43 ALOMIDE .......................... 43 ALOPRIM ............................1 ALORA .............................. 32 ALOXI ............................... 34 ALPHAGAN P 0.1% .......... 44 ALPHAGAN P 0.15% ........ 44 alprazolam .................. 19, 20 ALREX .............................. 43

ALSUMA ........................... 26 ALTABAX .......................... 46 ALTACE ............................ 14

see ramipril .................... 14 altavera ............................. 29 ALVESCO ......................... 45 amantadine hcl ................. 23 AMARYL ........................... 28

see glimepiride .............. 28 AMBIEN ............................ 25

see zolpidem tartrate ..... 26 AMBISOME ........................ 6 amcinonide ....................... 47 AMERGE .......................... 26

see naratriptan hcl ......... 26 amethia 91 day ................. 29 amethyst 28 day ............... 29 amifostine crystalline......... 13 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 18 amiloride hcl ...................... 18 aminophylline inj ............... 46 AMINOSYN ....................... 41 AMINOSYN 7%/ELECTROLYTES ....... 41 AMINOSYN II .................... 41 AMINOSYN II 8.5%/ELECTROL .............. 41 AMINOSYN INJ 8.5/LYTE 41 AMINOSYN M ................... 41 AMINOSYN-HBC .............. 41 AMINOSYN-PF ................. 41 AMINOSYN-PF 7% ........... 41 AMINOSYN-RF ................. 41 amiodarone hcl ................. 15 amiodarone inj 50mg/ml.... 15 AMITIZA ............................ 36 amitriptyline hcl ................. 22 amlodipine besylate .......... 17 amlodipine besylate-benazepril hcl ..... 14 amlodipine besylate-valsartan tab 10-160 mg ......................... 15 amlodipine besylate-valsartan tab 10-320 mg ......................... 15

amlodipine besylate-valsartan tab 5-160 mg ..................................... 14 amlodipine besylate-valsartan tab 5-320 mg ..................................... 15 ammonium chloride .......... 40 ammonium lactate ............ 49 amnesteem ....................... 46 amoxapine ........................ 22 amoxicillin ......................... 10 amoxicillin & pot clavulanate.......................................... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 36 amphetamine cap 10mg er.......................................... 25 amphetamine cap 15mg er.......................................... 25 amphetamine cap 20mg er.......................................... 25 amphetamine cap 25mg er.......................................... 25 amphetamine cap 30mg er.......................................... 25 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 25 amphetamine-dextroamphetamine tab 10 mg ............... 25 amphetamine-dextroamphetamine tab 12.5 mg ............ 25 amphetamine-dextroamphetamine tab 15 mg ............... 25 amphetamine-dextroamphetamine tab 20 mg ............... 25 amphetamine-dextroamphetamine tab 30 mg ............... 25 amphetamine-dextroamphetamine tab 5 mg ................. 25 amphetamine-dextroamphetamine tab 7.5 mg .............. 25 AMPHOTEC ....................... 6 amphotericin b .................... 6 ampicillin & sulbactam sodium .............................. 10 ampicillin cap 250mg ........ 10 ampicillin cap 500 mg ....... 10 ampicillin inj ...................... 10


54

ampicillin sodium ............... 10 ampicillin susp ................... 10 AMPYRA ........................... 27 AMTURNIDE ..................... 18 ANAFRANIL ...................... 22

see clomipramine hcl ..... 22 anagrelide hcl .................... 38 ANAPROX ..........................1

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

see naproxen sodium ......1 anastrozole ....................... 12 ANCOBON ..........................6

see flucytosine .................6 ANDRODERM .................. 28 androxy ............................. 28 ANORO ELLIPT AER 62.5-25 .............................. 44 antabuse ........................... 27 ANTABUSE

see disulfiram ................ 27 ANTARA ........................... 16 anusol hc........................... 47 ANUSOL-HC

see proctosol hc ............ 47 see proctozone hc ......... 47

APOKYN ........................... 23 apri 28 day ........................ 29 APRISO ............................ 36 APTIOM ............................ 20 APTIVUS.............................7 ARALAST NP .................... 45 ARALEN

see chloroquine phosphate ........................7

aranelle 28 ........................ 29 ARANESP ALBUMIN FREE .......................................... 38 ARAVA .............................. 39

see leflunomide ............. 39 ARCALYST ....................... 39 ARCAPTA NEOHALER .... 45 ARICEPT .......................... 22

see donepezil tab hcl 23mg ............................. 22 see donepezil tabs 10mg ...................................... 22 see donepezil tabs 5mg 22

ARICEPT ODT .................. 22 see donepezil odt 10mg 22

ARIMIDEX ........................ 12 see anastrozole ............. 12

ARIXTRA .......................... 38 see fondaparinux sodium ...................................... 38

AROMASIN ....................... 12 see exemestane ............ 12

ARRANON ........................ 12 ARTHROTEC 50

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

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

ARZERRA ......................... 12 ASMANEX ........................ 45 ASMANEX 14 METERED DOSES ............................. 45 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE ............................................ 1 ASTAGRAF XL ................. 39 ASTELIN ........................... 44 ASTEPRO ......................... 44

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

ATACAND see candesartan cilexetil ...................................... 15

ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 15

atenolol ............................. 17 atenolol & chlorthalidone ... 16 ATGAM ............................. 39 ATIVAN ............................. 20

see lorazepam ............... 20 atorvastatin calcium .......... 16 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ......................... 7 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 7 ATRALIN ........................... 46 ATRIPLA ............................. 8

ATROPINE SULFATE ...... 35 ATROVENT ...................... 44

see ipratropium bromide (nasal) ........................... 44

ATROVENT HFA .............. 44 AUBAGIO ......................... 27 aubra 0.1-0.02mg ............. 29 AUGMENTIN .................... 10

see amoxicillin & pot clavulanate .................... 10

AUGMENTIN ES-600 ....... 10 see amoxicillin & pot clavulanate .................... 10

AUGMENTIN XR .............. 10 see amoxicillin & pot clavulanate .................... 10

AUVI-Q ............................. 45 AVALIDE .......................... 15

see irbesartan-hydrochlorothiazide ............................... 15

AVAPRO ........................... 15 see irbesartan ............... 15

AVASTIN .......................... 12 AVEED ............................. 28 AVELOX ........................... 10

see moxifloxacin hcl ...... 10 AVELOX ABC PACK ........ 10 aviane 28 .......................... 29 AVINZA ............................... 3

see morphine sulfate beads .............................. 4

AVITA ............................... 46 AVODART ........................ 37 AVONEX ........................... 27 AVONEX PEN .................. 27 AXERT .............................. 26 AXID ................................. 35

see nizatidine ................ 35 AXIRON ............................ 28 aygestin ............................ 34 AYGESTIN

see norethindrone acetate ...................................... 34

azacitidine ......................... 12 AZACTAM .......................... 5

see aztreonam ................ 5 AZACTAM/DEX INJ 1GM ... 5


55

AZACTAM/DEX INJ 2GM ...5 azasan .............................. 39 AZASITE ........................... 42 azathioprine ...................... 39 azelastine hcl (ophth) ........ 43 azelastine spr 0.1% ........... 44 azelastine spr 0.15% ......... 44 AZELEX ............................ 46 AZILECT ........................... 23 azithromycin ........................9 AZITHROMYCIN .................9 AZOPT .............................. 44 AZOR ................................ 15 aztreonam ...........................5 AZULFIDINE ..................... 36

see sulfasalazine ir ........ 36 AZULFIDINE EN-TABS .... 36

see sulfasalazine dr ....... 36 B bacitracin (ophthalmic) ...... 42 bacitracin-polymyxin b (ophth) .............................. 42 bacitracin-poly-neomycin-hc .......................................... 42 baclofen ............................ 27 BACTOCILL INJ DEX 1GM .......................................... 10 BACTOCILL INJ DEX 2GM .......................................... 10 BACTRIM ............................5

see sulfamethoxazole-trimethop ......................................6

BACTRIM DS ......................5 see sulfamethoxazole-trimethop ......................................6

BACTROBAN .................... 46 see mupirocin ................ 46 see mupirocin calcium (topical).......................... 47

BACTROBAN NASAL ....... 46 balsalazide disodium ......... 36 balziva 28 day ................... 29 BANZEL SUS 40MG/ML ... 20 BANZEL TAB 200MG ....... 20 BANZEL TAB 400MG ....... 20 BARACLUDE ......................8

see entecavir ................... 8 BCG VACCINE ................. 40 BECONASE AQ ................ 45 benazepril & hydrochlorothiazide ........... 14 benazepril hcl .................... 14 BENICAR .......................... 15 BENICAR HCT ................. 15 BENLYSTA ....................... 40 BENTYL ............................ 35

see dicyclomine hcl ....... 35 BENZACLIN ...................... 46

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

BENZAMYCIN .................. 46 see benzoyl peroxide-erythromycin ... 46

benzonatate ...................... 50 benzoyl peroxide-erythromycin ...... 46 benzphetamine ................. 50 benztropine mesylate ........ 23 BEPREVE ......................... 43 BERINERT ........................ 38 BESIVANCE ..................... 42 BETAGAN ......................... 44

see levobunolol hcl ........ 44 betamethasone dipropionate (topical) ............................. 47 betamethasone dipropionate augmented ........................ 47 betamethasone valerate ... 48 BETAPACE ....................... 15

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

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

betaxolol hcl ...................... 17 betaxolol hcl (ophth) ......... 44 bethanechol chloride ......... 37 BETHKIS ............................ 5 BETIMOL .......................... 44 BETOPTIC-S .................... 44 BEYAZ .............................. 29 BIAXIN ................................ 9

see clarithromycin ........... 9 BIAXIN XL ........................... 9

see clarithromycin ........... 9 BIAXIN XL PAC .................. 9 bicalutamide ..................... 12 BICILLIN C-R .................... 10 BICILLIN L-A .................... 10 BICNU .............................. 11 BIDIL ................................. 19 BILTRICIDE ........................ 5 bisoprolol & hydrochlorothiazide ........... 16 bisoprolol fumarate ........... 17 BIVIGAM ........................... 39 bleomycin sulfate .............. 11 BLEPH-10 ......................... 42

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

blephamide ....................... 42 BLEPHAMIDE .................. 42 BONIVA ............................ 29

see ibandronate sodium 29 BONTRIL PDM

see phendimetrazine ..... 51 BOOSTRIX ....................... 40 BOSULIF .......................... 13 BOTOX INJ 100UNIT ....... 44 BOTOX INJ 200UNIT ....... 44 BREO ELLIPTA ................ 46 BREVICON-28 .................. 29

see necon 0.5/35 28 day ...................................... 31 see nortrel 0.5/35 28 day ...................................... 31

briellyn 28 day .................. 29 BRILINTA ......................... 38 BRIMONIDINE SOL 0.15%.......................................... 44 brimonidine sol 0.2% ........ 44 BRINTELLIX ..................... 22 BRISDELLE ...................... 27 bromfenac sodium (ophth) 43 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) .. 43 bromocriptine mesylate ..... 23 BROVANA ........................ 45 budesonide ....................... 36 budesonide (inhalation) .... 45 budesonide (nasal) ........... 45 bumetanide ....................... 18


56

BUPHENYL see sodium phenylbutyrate ...................................... 32

buprenorphine hcl ............. 27 buprenorphine hcl-naloxone hcl sl .................................. 27 buproban ........................... 27 bupropion hcl .................... 22 buspirone hcl ..................... 20 BUSULFEX ....................... 11 butorphanol nasal spray ......1 butorphanol tartrate .............1 BUTRANS ....................... 1, 2 BYDUREON ...................... 28 BYETTA ............................ 28 BYSTOLIC ........................ 17 C cabergoline ....................... 33 cafergot tab 1-100mg ........ 26 CALAN .............................. 17

see verapamil hcl .......... 18 CALAN SR ........................ 17

see verapamil hcl .......... 18 calcipotrien oin betameth .. 48 calcipotriene ...................... 47 calcitonin (salmon) nasal spray ................................. 33 calcitrene oin 0.005% ........ 47 calcitriol ............................. 42 CALCITRIOL ..................... 47 calcium acetate (phosphate binder) ............................... 34 camila 28 day .................... 30 CAMPRAL ......................... 27

see acamprosate calcium ...................................... 27

CAMPTOSAR ................... 13 see irinotecan ................ 14 see irinotecan hcl .......... 14

CAMRESE LO TAB .......... 30 CANASA ........................... 36 CANCIDAS .........................6 candesartan cilexetil ......... 15 candesartan cilexetil-hydrochlorothiazide .......................................... 15 CANTIL ............................. 35 CAPASTAT SULFATE ........8

CAPEX .............................. 48 capital

and codeine ..................... 2 CAPRELSA ....................... 13 captopril ............................ 14 captopril & hydrochlorothiazide ........... 14 CARAC ............................. 49 CARAFATE ....................... 36

see sucralfate ................ 37 CARBAGLU ...................... 32 carbamazepine ................. 20 CARBATROL .................... 20

see carbamazepine ....... 20 carbidopa .......................... 23 CARBIDOPA/LEVODOPA/ENTACAPONE ............. 23, 24 carbidopa-levodopa .......... 23 carboplatin ........................ 13 CARDENE SR .................. 17 CARDIZEM ....................... 17

see diltiazem hcl ............ 17 CARDIZEM CD ................. 17

see cartia xt ................... 17 see dilt-cd cap ............... 17 see diltiazem hcl coated beads ............................ 17

CARDIZEM LA .................. 17 see matzim la ................ 17

CARDURA ........................ 14 see doxazosin mesylate 14

CARDURA XL ................... 37 CARIMUNE NANOFILTERED .............. 39 CARNITOR ....................... 32

see levocarnitine (metabolic modifiers) ..... 32

carteolol hcl (ophth) .......... 44 cartia xt ............................. 17 carvedilol ........................... 17 CASODEX ........................ 12

see bicalutamide ........... 12 CATAFLAM ......................... 1 CATAPRES

see clonidine hcl ............ 19 CATAPRES TAB .............. 19 CATAPRES-TTS .............. 19 CATAPRES-TTS-1

see clonidine hcl ............ 19 CATAPRES-TTS-2

see clonidine hcl ............ 19 CATAPRES-TTS-3 ........... 19

see clonidine hcl ............ 19 CAVERJECT .................... 50 CAYSTON .......................... 5 CEDAX ............................... 9 cefaclor ............................... 9 cefaclor er tab 500mg ......... 9 cefadroxil ............................ 9 cefazolin inj ......................... 9 cefazolin sodium ................. 9 cefazolin/dextrose ............... 9 cefdinir ................................ 9 CEFEPIME 1GM SOLN ...... 9 CEFEPIME 2GM SOLN ...... 9 cefepime inj 1gm................. 9 cefepime inj 2gm................. 9 cefotaxime sodium .............. 9 cefotetan disodium .............. 9 cefoxitin sodium .................. 9 CEFOXITIN SODIUM IN DEXTROSE ........................ 9 cefpodoxime proxetil ........... 9 cefprozil .............................. 9 ceftazidime ......................... 9 CEFTAZIDIME/DEXTROSE............................................ 9 ceftibuten ............................ 9 CEFTIN ............................... 9

see cefuroxime axetil ...... 9 ceftriaxone sodium .............. 9 cefuroxime axetil ................. 9 cefuroxime sodium .............. 9 cefuroxime sodium soln iv 7.5 gm ................................. 9 CELEBREX CAP 100MG ... 1 CELEBREX CAP 200MG ... 1 CELEBREX CAP 400MG ... 1 CELEBREX CAP 50MG ..... 1 CELEXA ........................... 22

see citalopram hydrobromide ................ 22

CELLCEPT see mycophenolate mofetil ...................................... 40

CELLCEPT CAP ............... 39


57

CELLCEPT INTRAVENOUS .......................................... 39 CELLCEPT SUSP ............. 39 CELLCEPT TAB ............... 39 CELONTIN ........................ 20 CENTANY ......................... 46 cephalexin ...........................9 CEREFOLIN TAB ............. 50 CEREZYME ...................... 32 CERVARIX ........................ 40 CESAMET ......................... 34 cetirizine syrup .................. 44 cevimeline hcl ................... 50 CHANTIX .......................... 27 CHANTIX STARTER PACK .......................................... 27 CHEMET ........................... 29 cheratussin ........................ 50 chlorhexidine gluconate (mouth-throat) ................... 50 chloroquine phosphate ........7 chlorothiazide .................... 18 chlorpromaz inj 25mg/ml ... 24 chlorpromazine hcl ............ 24 chlorthalidone .................... 18 cholestyramine .................. 16 cholestyramine light .......... 16 choline fenofibrate ............. 16 CHORIONIC GONADOTROPIN ............ 33 CIALIS .............................. 50 ciclopirox ........................... 47 ciclopirox cre 0.77% .......... 47 ciclopirox shampoo 1% ..... 47 ciclopirox sus 0.77% ......... 47 cidofovir...............................8 cilostazol ........................... 38 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 43

CILOXAN OIN 0.3% OP ... 42 CILOXAN SOL 0.3% OP ... 43 cimetidine .......................... 35 cimetidine sol 300/5ml ...... 35 CIMZIA .............................. 39 CINRYZE .......................... 38 CIPRO .............................. 10

see ciprofloxacin ............ 10

see ciprofloxacin hcl ...... 10 CIPRO HC ........................ 50 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w 10 CIPRO XR

see ciprofloxacin er ....... 10 CIPRODEX ....................... 50 ciprofloxacin ...................... 10 ciprofloxacin er .................. 10 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 43 ciprofloxacin in d5w .......... 10 ciprofloxacn inj .................. 10 cisplatin ............................. 13 citalopram hydrobromide .. 22 cladribine .......................... 12 claforan ............................... 9 CLAFORAN ........................ 9

see cefotaxime sodium .... 9 claravis .............................. 46 CLARINEX ........................ 44

see desloratadine .......... 44 CLARINEX REDITABS

see desloratadine .......... 44 CLARINEX-D TAB 2.5-120 .......................................... 44 clarithromycin ...................... 9 cleocin ................................. 5 CLEOCIN ...................... 5, 37

see clindamycin cre 2% vag ................................ 38 see clindamycin hcl ......... 5

CLEOCIN CAP 75MG ......... 5 CLEOCIN IN D5W .............. 5

see clindamycin phosphate in d5w ............ 5

CLEOCIN INJ ..................... 5 CLEOCIN PEDIATRIC GRANULE

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

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

CLEOCIN VAG SUPP 100MG .............................. 37 CLEOCIN-T ...................... 46

see clindamycin

phosphate (topical) ........ 46 CLIMARA .......................... 32

see estradiol .................. 32 clindamycin cre 2% vag .... 38 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 5 clindamycin phosphate (topical) ............................. 46 clindamycin phosphate in d5w ..................................... 5 clindamycin phosphate-benzoyl peroxide.......................................... 46 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 46 CLINIMIX 2.75%/DEXTROSE 5% ..... 41 CLINIMIX 4.25%/DEXTROSE 10% ... 41 CLINIMIX 4.25%/DEXTROSE 20% ... 41 CLINIMIX 4.25%/DEXTROSE 25% ... 41 CLINIMIX 4.25%/DEXTROSE 5% ..... 41 CLINIMIX 5%/DEXTROSE 15% .................................. 41 CLINIMIX 5%/DEXTROSE 20% .................................. 41 CLINIMIX 5%/DEXTROSE 25% .................................. 41 CLINIMIX E 2.75%/DEXTROSE 10% ... 41 CLINIMIX E 2.75%/DEXTROSE 5% ..... 41 CLINIMIX E 4.25%/DEXTROSE ........... 41 CLINIMIX E 4.25%/DEXTROSE 25% ... 41 CLINIMIX E 4.25%/DEXTROSE 5% ..... 41 CLINIMIX E 5%/DEXTROSE 15% .................................. 41 CLINIMIX E 5%/DEXTROSE 20% .................................. 41


58

CLINIMIX E 5%/DEXTROSE 25% ................................... 41 clinisol 15 .......................... 41 clobetasol propionate ........ 48 clobetasol propionate emollient base ................... 48 clobetasol propionate emulsion............................ 48 CLOBEX ........................... 48

see clobetasol propionate ...................................... 48 see clodan sha 0.05% ... 48

clocortolone pivalate ......... 48 clodan sha 0.05% ............. 48 CLODERM PUMP ............. 48 CLOLAR............................ 12 clomipramine hcl ............... 22 clonazepam ....................... 20 clonidine hcl ...................... 19 clopidogrel bisulfate .......... 39 clorazepate dipotassium ... 20 clorpres ............................. 19 clotrimazole ....................... 50 clotrimazole (topical) ......... 47 clozapine ........................... 24 CLOZAPINE ODT ............. 24 CLOZARIL ........................ 24

see clozapine ................ 24 COARTEM ..........................7 codeine

and capital .......................2 CODEINE SULFATE ..........3 COGENTIN ....................... 24

see benztropine mesylate ...................................... 23

COLAZAL.......................... 36 see balsalazide disodium ...................................... 36

colchicine w/ probenecid .....1 COLCRYS ...........................1 COLESTID ........................ 16

see colestipol hcl ........... 16 colestipol hcl ..................... 16 colistimethate sodium .........5 colocort ............................. 36 COLY-MYCIN M .................5

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

COLY-MYCIN S ................ 50 COLYTE-FLAVOR PACKS .......................................... 36

see gavilyte-c ................ 36 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 36

COMBIGAN ...................... 44 COMBIPATCH .................. 32 COMBIVENT RESPIMAT . 44 COMBIVIR .......................... 8

see lamivudine-zidovudine ........................................ 8

COMETRIQ ...................... 13 COMPAZINE

see prochlorperazine maleate ......................... 35

COMPLERA ........................ 8 compro supp ..................... 34 COMTAN .......................... 24

see entacapone ............. 24 COMVAX .......................... 40 CONCERTA ...................... 25 CONDYLOX ...................... 49

see podofilox ................. 49 constulose ......................... 36 COPAXONE INJ 40MG/ML .......................................... 27 COPAXONE KIT 20MG/ML .......................................... 27 COPEGUS .......................... 8

see moderiba tab 200mg . 8 see ribasphere ................ 8 see ribavirin 200mg ......... 8

CORDARONE see amiodarone hcl ....... 15 see pacerone ................ 15

CORDRAN ........................ 48 COREG ............................. 17

see carvedilol ................ 17 CORGARD ....................... 17

see nadolol .................... 17 CORTEF ........................... 32

see hydrocortisone ........ 33 CORTENEMA ................... 36

see colocort ................... 36 CORTIFOAM .................... 47 cortisone acetate .............. 32

CORTISPORIN ........... 46, 50 see neomycin-polymyxin-hc (otic) .............................. 50

CORTISPORIN-TC ........... 50 CORZIDE ......................... 16

see nadolol & bendroflumethiazide ...... 16

COSMEGEN ..................... 11 COSOPT .......................... 44

see dorzolamide hcl-timolol maleate ........ 44

COSOPT PF ..................... 44 COUMADIN ...................... 38

see jantoven .................. 38 see warfarin sodium ...... 38

COUMADIN INJ ................ 38 COZAAR ........................... 15

see losartan potassium . 15 CREON ............................. 37 CRESTOR ........................ 16 CRINONE ......................... 34 CRIXIVAN ........................... 7 cromolyn sodium............... 45 cromolyn sodium (mastocytosis) .................. 36 cromolyn sodium (ophth) .. 43 cryselle 28 ........................ 30 CUBICIN ............................. 5 CUTIVATE ........................ 48

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

CUVPOSA ........................ 35 cyclafem 1/35 28 day ........ 30 cyclafem 7/7/7 28 day ....... 30 CYCLESSA ...................... 30

see velivet 28 day ......... 31 cyclobenzaprine hcl .......... 27 cyclophosphamide ............ 11 CYCLOPHOSPHAMIDE ... 11 cycloserine .......................... 8 cyclosporine ...................... 39 cyclosporine modified (for microemulsion) ........... 39, 40 CYKLOKAPRON .............. 38

see tranexamic acid ...... 38 CYMBALTA ...................... 22

see duloxetine hcl ......... 22


59

CYSTADANE .................... 32 CYSTAGON ...................... 32 CYSTARAN ...................... 44 cytarabine inj ..................... 12 CYTOGAM ........................ 39 CYTOMEL ......................... 34

see liothyronine sodium . 34 CYTOTEC ......................... 36

see misoprostol ............. 36 CYTOVENE ........................8

see ganciclovir inj 500mg 8 D D.H.E. 45 .......................... 26

see dihydroergotamine mesylate ........................ 26

dacarbazine ...................... 11 DACOGEN ........................ 12

see decitabine ............... 12 DALIRESP ........................ 45 danazol ............................. 32 DANTRIUM ....................... 27

see dantrolene sodium .. 27 dantrolene sodium ............ 27 dapsone ..............................5 DAPTACEL ....................... 40 DARAPRIM .........................5 daunorubicin hcl ................ 11 DAYPRO .............................1

see oxaprozin ..................1 DAYTRANA ...................... 25 DDAVP ............................. 34

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

decitabine.......................... 12 DELESTROGEN ............... 32

see estradiol valerate .... 32 delyla 0.1-0.02mg ............. 30 DEMADEX ........................ 18

see torsemide tabs ........ 18 demeclocycline hcl ............ 11 DEMSER........................... 19 DENAVIR .......................... 47 DEPACON ........................ 20

see valproate sodium .... 22

DEPAKENE ...................... 20 see valproate sodium .... 22 see valproic acid ........... 22

DEPAKOTE ...................... 20 see divalproex sodium ... 21

DEPAKOTE ER ................ 20 see divalproex sodium ... 21

DEPAKOTE SPRINKLES . 20 see divalproex sodium ... 21

DEPEN TITRATABS ......... 29 DEPLIN ............................. 50 depo-estradiol ................... 32 DEPO-MEDROL

see methylpr ace inj 40mg/ml ........................ 33 see methylpr ace inj 80mg/ml ........................ 33

DEPO-MEDROL INJ 20MG/ML .......................... 32 DEPO-MEDROL INJ 40MG/ML .......................... 32 DEPO-MEDROL INJ 80MG/ML .......................... 32 DEPO-PROVERA CONTRACEPTIV .............. 30

see medroxyprogesterone acetate (contraceptive) .. 30

DEPO-PROVERA INJ 400/ML .............................. 12 DEPO-SUBQ PROVERA 104 .................................... 30 depo-testosterone ............. 28 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 28

DERMA-SMOOTHE/FS BODY

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

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

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

DESFERAL ....................... 38 desipramine hcl ................. 22 desloratadine .................... 44 desmopressin acetate ....... 34

DESMOPRESSIN ACETATE.......................................... 34 desmopressin acetate inj .. 34 desmopressin acetate spray.......................................... 34 desmopressin acetate spray refrigerated ....................... 34 DESOGEN ........................ 30

see apri 28 day.............. 29 see emoquette .............. 30 see reclipsen 28 day ..... 31

DESONATE ...................... 48 desonide ........................... 48 DESONIDE ....................... 48 desowen ........................... 48 DESOWEN ....................... 48

see desonide ................. 48 desoximetasone................ 48 DESOXIMETASONE ........ 48 DETROL

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

dexamethasone ................ 32 dexamethasone sodium phosphate ......................... 32 dexamethasone sodium phosphate (ophth)............. 43 dexpak taperpak 13 day ... 32 dexrazoxane ..................... 13 dextrose ............................ 41 DEXTROSE ...................... 41 DEXTROSE 10% FLEX CONTAIN ......................... 42 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 42 DEXTROSE 10%/NACL 0.45% ............................... 42 DEXTROSE 2.5%/NACL 0.45% ............................... 41 DEXTROSE 5% ................ 41 DEXTROSE 5% /ELECTROLYTE ............... 41 DEXTROSE 5%/LACTATED RING ................................. 41 DEXTROSE 5%/NACL 0.2%


60

.......................................... 41 DEXTROSE 5%/NACL 0.225% .............................. 42 DEXTROSE 5%/NACL 0.3% .......................................... 41 DEXTROSE 5%/NACL 0.33% ................................ 41 DEXTROSE 5%/NACL 0.45% ................................ 41 DEXTROSE 5%/NACL 0.9% .......................................... 41 DEXTROSE 5%/POTASSIUM CHL ...... 42 DIAMOX ............................ 18

see acetazolamide ........ 18 DIASTAT ACUDIAL .......... 20 DIASTAT PEDIATRIC ....... 20 diazepam .......................... 20 DIAZEPAM GEL (ANTICONVULSANT) ....... 20 DIBENZYLINE .................. 19 diclofenac gel 3% .............. 49 diclofenac potassium ..........1 diclofenac sodium ...............1 diclofenac sodium (ophth) . 43 diclofenac sol 1.5% ........... 49 diclofenac w/ misoprostol ....1 dicloxacillin sodium ........... 10 dicyclomine hcl .................. 35 didanosine...........................7 DIDREX

see benzphetamine ....... 50 diethylpropion .................... 50 DIFFERIN ......................... 46

see adapalene ............... 46 DIFICID ...............................9 diflorasone diacetate ......... 48 DIFLUCAN ..........................6

see fluconazole ...............6 diflunisal ..............................1 digoxin .............................. 18 digoxin inj .......................... 18 DIGOXIN SOL 50MCG/ML .......................................... 18 dihydroergotamine mesylate .......................................... 26 DIHYDROERGOTAMINE MESYLATE ....................... 26

dilacor ............................... 17 dilantin .............................. 20 DILANTIN ......................... 21

see phenytoin ................ 21 see phenytoin sodium extended ....................... 21

DILANTIN INFATABS see phenytoin ................ 21

DILATRATE SR ................ 19 DILAUDID

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

see hydromorphone hcl ... 3 DILAUDID-HP INJ .............. 3 DILAUDID-HP INJ 250MG .. 3 dilt-cd cap ......................... 17 diltiazem cap 120mg/24hr . 17 diltiazem cap er/12hr......... 17 diltiazem hcl ...................... 17 diltiazem hcl coated beads 17 diltiazem hcl er .................. 17 diltiazem hcl extended release beads ................... 17 diltiazem inj 100mg ........... 17 diltiazem inj 125/25ml ....... 17 diltiazem inj 25mg/5ml ...... 17 diltiazem inj 50/10ml ......... 17 dilt-xr cap .......................... 17 diltzac ................................ 17 DIOVAN ............................ 15

see valsartan ................. 15 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 15

DIPENTUM ....................... 36 diphenhydram inj 50mg/ml 44 diphenoxylate w/ atropine . 36 DIPHTHERIA/TETANUS TOXOID ............................ 40 DIPROLENE ..................... 48

see betamethasone dipropionate augmented 47

DIPROLENE AF ............... 48 see betamethasone

dipropionate augmented 47 disopyramide phosphate ... 15 disulfiram .......................... 27 DITROPAN XL .................. 37

see oxybutynin chloride . 37 DIURIL SUS 250/5ML ....... 18 divalproex sodium ............. 21 docetaxel .......................... 12 DOCETAXEL .................... 12 DOLOPHINE ...................... 3

see methadone hcl .......... 3 DOLOPHINE HCL

see methadone hcl .......... 3 donepezil odt 10mg .......... 22 donepezil odt 5mg ............ 22 donepezil tab hcl 23mg ..... 22 donepezil tabs 10mg ......... 22 donepezil tabs 5mg ........... 22 DORIBAX ........................... 5 dorzolamide hcl................. 44 dorzolamide hcl-timolol maleate ............................. 44 DOVONEX

see calcipotriene ........... 47 DOVONEX CRE 0.005% .. 47 doxazosin mesylate .......... 14 doxepin hcl ....................... 22 doxercalciferol .................. 42 DOXIL ............................... 11

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 11

doxorubicin hcl .................. 11 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .... 11 doxorubicin inj 50mg ......... 11 doxycycline (monohydrate).......................................... 11 doxycycline hyclate ........... 11 DRISDOL

see vitamin d ................. 50 dronabinol ......................... 34 drospirenone-ethinyl estradiol ............................ 30 DROXIA ............................ 13 DUAC ............................... 46

see clindamycin phosphate-benzoyl


61

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

DUETACT ......................... 28 see pioglitazone hcl-glimepiride ............... 29

DULERA ........................... 46 duloxetine hcl .................... 22 DUONEB........................... 44 DURAGESIC .......................3

see fentanyl patch ...........3 DURAMORPH ....................3 DUREZOL ......................... 43 DUTOPROL ...................... 16 DYAZIDE .......................... 18

see triamt/hctz cap 37.5-25 .......................... 18

DYRENIUM ....................... 18 DYSPORT ......................... 44 E e.e.s. 400 mg tab ................9 E.E.S. GRANULES .............9 e.s.p. ...................................6 EC-NAPROSYN ..................1

see naproxen ...................1 econazole nitrate ............... 47 EDARBI............................. 15 EDARBYCLOR ................. 15 EDECRIN .......................... 18 EDEX ................................ 50 EDURANT ...........................7 ees/sulfisox sus 200-600.....6 EFFEXOR XR ................... 22

see venlafaxine cap er .. 23 EFFIENT ........................... 39 EFUDEX ........................... 49

see fluorouracil (topical) 49 EGRIFTA .......................... 33 ELAPRASE ....................... 32 ELDEPRYL ....................... 24

see selegiline hcl ........... 24 ELECTROLYTE-R IN DEXTROSE ...................... 42 ELELYSO.......................... 32 ELESTAT .......................... 43

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

ELIDEL ............................. 49 ELIGARD INJ 22.5MG ...... 12

ELIGARD INJ 30MG ......... 12 ELIGARD INJ 45MG ......... 12 ELIGARD INJ 7.5MG ........ 12 ELIMITE

see permethrin .............. 49 eliphos .............................. 34 ELIPHOS

see calcium acetate (phosphate binder) ........ 34

ELIQUIS TAB 2.5MG ........ 38 ELIQUIS TAB 5MG ........... 38 ELITEK ............................. 13 elixophyllin ........................ 46 ELLA ................................. 30 ELLENCE ......................... 11

see epirubicin inj 200mg 11 see epirubicin inj 50mg/25ml .................... 11

ELMIRON ......................... 37 ELOCON ........................... 48

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

ELOXATIN ........................ 13 EMADINE ......................... 43 EMCYT ............................. 11 EMEND CAP 125MG ........ 34 EMEND CAP 40MG .......... 34 EMEND CAP 80MG .......... 34 EMEND PAK 80 & 125 ..... 34 EMLA ................................ 49

see lidocaine-prilocaine . 49 emoquette ......................... 30 EMSAM ............................. 22 EMTRIVA ............................ 7 ENABLEX ......................... 37 enalapril maleate .............. 14 enalapril maleate & hydrochlorothiazide ........... 14 ENBREL ........................... 39 ENBREL SURECLICK ...... 39 endocet ............................... 3 ENDODAN TAB .................. 3 ENDOMETRIN .................. 34 ENGERIX-B ...................... 40 enoxaparin sodium ........... 38 enpresse 28 day ............... 30 entacapone ....................... 24 entecavir ............................. 8

ENTOCORT EC................ 36 see budesonide ............. 36

ENTYVIO .......................... 40 enulose ............................. 36 epinastine hcl (ophth) ....... 43 EPINEPHRINE ................. 45 EPIPEN 2-PAK ................. 45 EPIPEN-JR 2-PAK ............ 45 epirubicin inj 200mg .......... 11 EPIRUBICIN INJ 50MG .... 11 epirubicin inj 50mg/25ml ... 11 epitol ................................. 21 EPIVIR

see lamivudine ................ 7 EPIVIR HBV ....................... 8

see lamivudine ................ 8 EPIVIR SOL 10MG/ML ....... 7 EPIVIR TABS ..................... 7 eplerenone ........................ 14 EPOGEN .......................... 38 eprosartan mesylate ......... 15 EPZICOM ........................... 8 EQUETRO ........................ 27 ERAXIS .............................. 6 ERBITUX .......................... 12 ergomar ............................ 26 ERIVEDGE ....................... 12 errin 28 day ....................... 30 ERTACZO ........................ 47 ery pad 2% ....................... 46 erygel ................................ 46 ERYGEL

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

ERYPED 200 ...................... 9 ERYPED 400 .................... 10 ery-tab ................................ 9 erythrocin lactobionate ...... 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 46 erythromycin (ophth) ......... 43 erythromycin base ............ 10 erythromycin cap 250mg ec.......................................... 10 erythromycin ethylsuccinate.......................................... 10 escitalopram oxalate ......... 22 esomeprazole inj............... 37


62

estrace .............................. 32 ESTRACE

see estradiol .................. 32 estradiol ............................ 32 estradiol valerate ............... 32 ESTRADIOL VALERATE .. 32 ESTRING .......................... 32 ESTROSTEP FE ............... 30

see tri-legest 28 day ...... 31 ethambutol hcl .....................8 ethosuximide ..................... 21 ETHYOL

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

etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS ................... 13 etoposide .......................... 13 EURAX ............................. 49 EVISTA ............................. 33

see raloxifene hcl .......... 34 EVOCLIN

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

EVOXAC ........................... 50 see cevimeline hcl ......... 50

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

EXELDERM ...................... 47 EXELON ........................... 22

see rivastigmine tartrate 22 EXELON PATCHES ......... 22 exemestane ...................... 12 EXFORGE

see amlodipine besylate-valsartan tab 10-160 mg ..................... 15 see amlodipine besylate-valsartan tab 10-320 mg ..................... 15 see amlodipine besylate-valsartan tab 5-160 mg ....................... 14

see amlodipine besylate-valsartan tab 5-320 mg ....................... 15

EXJADE ............................ 29 EXTAVIA ........................... 27 EXTINA ............................. 47

see ketodan aer 2% ...... 47 F FABIOR ............................ 46 FABRAZYME .................... 32 FACTIVE ........................... 10 falmina .............................. 30 famciclovir ........................... 8 famotidine ......................... 35 FAMVIR .............................. 8

see famciclovir ................ 8 FANAPT ............................ 24 FANAPT TITRATION PACK .......................................... 24 FARESTON ...................... 12 FARXIGA .......................... 28 FASLODEX ....................... 12 FAZACLO ......................... 24 felbamate .......................... 21 FELBATOL ....................... 21

see felbamate ................ 21 FELDENE ........................... 1

see piroxicam .................. 1 felodipine .......................... 17 FEMARA ........................... 12

see letrozole .................. 12 FEMCON FE ..................... 30

see zenchent fe 28 day . 32 FEMRING ......................... 32 fenofibrate ......................... 16 FENOFIBRATE ................. 16 fenofibrate micronized....... 16 FENOFIBRIC ACID........... 16 fenoprofen calcium ............. 1 fentanyl citrate .................... 3 fentanyl patch ..................... 3 FENTORA ........................... 3 FERRIPROX ..................... 29 FETZIMA .......................... 22 FETZIMA TITRATION PACK .......................................... 22 FIBRICOR ......................... 16 FINACEA .......................... 49

finasteride ......................... 37 FIRAZYR .......................... 38 FIRMAGON ...................... 12 FLAGYL .............................. 6

see metronidazole ........... 6 FLAGYL ER ........................ 6 FLAREX ............................ 43 FLEBOGAMMA ................ 39 FLEBOGAMMA DIF .......... 39 flecainide acetate .............. 15 FLOLAN ............................ 19 FLOMAX ........................... 37

see tamsulosin hcl ......... 37 FLONASE ......................... 45

see fluticasone propionate (nasal) ........................... 45

FLOVENT DISKUS ........... 45 FLOVENT HFA ................. 45 fluconazole ......................... 6 fluconazole in dextrose ....... 6 fluconazole inj nacl 100 ...... 6 fluconazole inj nacl 200 ...... 6 fluconazole inj nacl 400 ...... 6 flucytosine ........................... 6 FLUDARA

see fludarabine phosphate ...................................... 12

fludarabine phosphate ...... 12 fludrocortisone acetate ..... 32 FLUMADINE ....................... 8

see rimantadine hydrochloride................... 8

flunisolide (nasal) .............. 45 fluocinolone acetonide ...... 48 fluocinolone acetonide (otic).......................................... 50 fluocinonide ...................... 48 fluocinonide emulsified base.......................................... 48 FLUOROMETHOLONE (OPHTH) ........................... 43 fluorouracil ........................ 12 fluorouracil (topical) .......... 49 fluoxetine hcl ..................... 22 FLUOXETINE HCL ........... 23 fluphenazine decanoate .... 24 fluphenazine hcl ................ 24 flurbiprofen .......................... 1


63

flurbiprofen sodium ........... 43 flutamide ........................... 12 fluticasone propionate ....... 48 fluticasone propionate (nasal) ............................... 45 fluvastatin sodium ............. 16 fluvoxamine maleate ......... 20 fluvoxamine maleate er ..... 20 FML ................................... 43 FML FORTE ...................... 43 FML LIQUIFILM ................ 43 folic acid ............................ 50 FOLTX .............................. 50 fondaparinux sodium ......... 38 FORADIL AEROLIZER ..... 45 FORFIVO XL ..................... 23 FORTAMET

see metformin hcl .......... 29 FORTAZ..............................9

see ceftazidime ...............9 see tazicef vial .................9

FORTEO ........................... 34 FORTICAL SPR 200/ACT . 33 FOSAMAX ........................ 29

see alendronate sodium 29 foscarnet sodium .................8 fosinopril sodium ............... 14 fosinopril sodium & hydrochlorothiazide ........... 14 FOSRENOL ...................... 34 FRAGMIN ......................... 38 FREAMINE HBC 6.9% ...... 41 FREAMINE III ................... 41 FROVA TAB 2.5MG .......... 26 FURADANTIN .....................6

see nitrofurantoin .............6 furosemide ........................ 18 furosemide inj .................... 18 furosemide oral soln 8 mg/ml .......................................... 18 FUZEON .............................7 FYCOMPA ........................ 21 G gabapentin ........................ 21 GABITRIL.......................... 21

see tiagabine hcl ........... 21 galantamine hydrobromide 22 GAMASTAN S/D ............... 39

GAMMAGARD LIQUID ..... 39 GAMMAGARD S/D ........... 39 GAMMAGARD S/D IGA LESS TH ........................... 39 GAMMAKED ..................... 39 GAMMAPLEX ................... 39 GAMUNEX-C .................... 39 GAMUNEX-C 1GM/10ML . 39 ganciclovir inj 500mg .......... 8 garamycin ......................... 43 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 43

GARDASIL ........................ 40 GASTROCROM ................ 36

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

gatifloxacin (ophth) ........... 43 GATTEX ........................... 36 GAUZE PADS 2X2 ........... 28 gaviltye-g .......................... 36 gavilyte-c ........................... 36 gavilyte-n .......................... 36 GELNIQUE ....................... 37 GEMCITABINE ................. 12 gemcitabine hcl ................. 12 gemfibrozil ........................ 16 GEMZAR .......................... 12

see gemcitabine hcl....... 12 GENERESS FE ................ 30 generlac ............................ 36 gengraf .............................. 40 gentak ............................... 43 gentamicin in saline inj 0.8 mg/ml .................................. 5 gentamicin in saline inj 0.9 mg/ml .................................. 5 gentamicin in saline inj 1 mg/ml .................................. 5 gentamicin in saline inj 1.2 mg/ml .................................. 5 gentamicin in saline inj 1.4 mg/ml .................................. 5 gentamicin in saline inj 1.6 mg/ml .................................. 5 gentamicin in saline inj 2 mg/ml .................................. 5 gentamicin sulfate ............... 5

gentamicin sulfate (ophth) 43 gentamicin sulfate (topical).......................................... 46 GEODON .......................... 24

see ziprasidone hcl ....... 25 GEODON INJ ................... 24 GIANVI TAB 3-0.02MG ..... 30 GIAZO .............................. 36 gildagia ............................. 30 gildess 1.5/30 ................... 30 GILENYA CAP 0.5MG ...... 27 GILOTRIF TAB 20MG ...... 13 GILOTRIF TAB 30MG ...... 13 GILOTRIF TAB 40MG ...... 13 GLASSIA .......................... 45 GLEEVEC ......................... 13 glimepiride ........................ 28 glipizide ............................. 28 glipizide er ........................ 28 glipizide-metformin 2.5-250 mg ..................................... 28 glipizide-metformin 2.5-500 mg ..................................... 28 glipizide-metformin 5-500mg.......................................... 28 GLUCAGEN HYPOKIT ..... 33 GLUCAGON EMERGENCY KIT .................................... 33 GLUCOPHAGE ................ 28

see metformin hcl .......... 29 GLUCOPHAGE XR .......... 28

see metformin er ........... 29 GLUCOTROL ................... 28

see glipizide .................. 28 GLUCOTROL XL .............. 28

see glipizide er .............. 28 glycate .............................. 35 glycopyrrolate ................... 35 GLYSET ........................... 28 GOLYTELY ....................... 36

see gaviltye-g ................ 36 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........................... 36

GRALISE .......................... 27 GRALISE STARTER ........ 27 granisetron hcl .................. 35 GRANIX ............................ 38


64

GRASTEK ......................... 39 GRIFULVIN V

see griseofulvin microsize ........................................6

griseofulvin microsize ..........6 griseofulvin ultramicrosize ...6 GRIS-PEG ..........................6

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

H H.P. ACTHAR ................... 33 HALAVEN ......................... 13 HALDOL............................ 24

see haloperidol lactate .. 24 HALDOL DECANOATE 100 .......................................... 24

see haloperidol decanoate ...................................... 24

HALDOL DECANOATE 50 .......................................... 24

see haloperidol decanoate ...................................... 24

halobetasol propionate ...... 48 HALOG ............................. 48 haloperidol ........................ 24 haloperidol decanoate ....... 24 haloperidol lactate ............. 24 HAVRIX............................. 40 heather .............................. 30 HECTOROL ...................... 42

see doxercalciferol ........ 42 HEP SOD/NACL INJ 25000 .......................................... 38 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 38 heparin sod inj 10000u/ml . 38 heparin sod inj 1000u/ml ... 38 heparin sod inj 20000u/ml . 38 HEPARIN SOD INJ 2000U/ML ......................... 38 HEPARIN SOD INJ 2500U/ML ......................... 38 heparin sod inj 5000u/0.5ml .......................................... 38 heparin sod inj 5000u/ml ... 38 HEPARIN SODIUM/D5W .. 38 HEPARIN SODIUM/NACL

0.45%................................ 38 HEPARIN SODIUM/SODIUM CHL .... 38 HEPATAMINE .................. 41 HEPSERA ........................... 8

see adefovir dipivoxil ....... 8 HERCEPTIN ..................... 12 HETLIOZ ........................... 27 HEXALEN ......................... 11 HIBERIX ........................... 40 HIPREX .............................. 6

see methenamine hippurate ......................... 6

HIZENTRA ........................ 39 HORIZANT ....................... 27 HUMATROPE ................... 33 HUMATROPE COMBO PACK ................................ 33 HUMIRA ............................ 39 HUMIRA PEN ................... 39 HUMIRA PEN-CROHNS STARTER KIT .................. 39 HUMIRA PEN-PSORIASIS STARTER KIT .................. 39 HUMULIN R U-500 (CONCENTRATE) ............ 28 HYCAMTIN ....................... 14

see topotecan hcl .......... 14 hycet ................................... 2 HYCET

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

hydralazine hcl .................. 19 HYDREA ........................... 13

see hydroxyurea ............ 13 hydrochlorothiazide ........... 18 hydrocodone-acetaminophen 10-300mg ............................ 2 hydrocodone-acetaminophen 2.5-325mg ........................... 2 hydrocodone-acetaminophen 5-300mg .............................. 2 hydrocodone-acetaminophen 5-325mg .............................. 2 hydrocodone-acetaminophen 7.5-300mg ........................... 2 hydrocodone-acetaminophen

7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg .......................... 2 hydrocodone-acetaminophen tab 10-325mg ..................... 2 hydrocodone-ibuprofen 2.5-200 mg ......................... 2 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 2 hydrocortisone .................. 33 HYDROCORTISONE (INTRARECTAL) .............. 36 hydrocortisone (topical) .... 48 hydrocortisone acetate (rx).......................................... 50 hydrocortisone butyrate .... 48 hydrocortisone butyrate hydrophilic lipo base ......... 48 hydrocortisone valerate .... 48 hydrocortisone/pramoxine (rx) .................................... 50 hydromet ........................... 50 hydromorphone hcl ............. 3 HYDROMORPHONE HCL . 3 hydromorphone tab 12mg er............................................ 3 hydromorphone tab 16mg er............................................ 3 hydromorphone tab 8mg er 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate.......................................... 39 hydroxyurea ...................... 13 hydroxyzine hcl ................. 44 hydroxyzine pamoate ........ 45 hyoscyamine ..................... 50 HYZAAR ........................... 15

see losartan potassium & hydrochlorothiazide ....... 15

I ibandronate sodium .......... 29 ibudone 5-200 mg ............... 2 ibudone tab 10-200mg ........ 2 ibuprofen ............................. 1 ICLUSIG ........................... 13 IDAMYCIN PFS ................ 11

see idarubicin hcl .......... 11


65

idarubicin hcl ..................... 11 IFEX .................................. 11

see ifosfamide for inj 1 gm ...................................... 11

IFEX INJ 3GM ................... 11 ifosfamide.......................... 11 IFOSFAMIDE

see ifosfamide ............... 11 ifosfamide for inj 1 gm ....... 11 IFOSFAMIDE FOR INJ 3 GM .................................... 11 ifosfamide inj 1gm/20ml .... 11 ILARIS .............................. 39 ILEVRO ............................. 43 IMBRUVICA CAP 140MG . 13 imdur ................................. 19 IMDUR

see isosorbide mononitrate er ............... 19

imipenem-cilastatin .............6 imipramine hcl ................... 23 imipramine pamoate ......... 23 imiquimod.......................... 49 IMITREX ........................... 26

see sumatriptan succinate ...................................... 26 see sumatriptan succinate inj ................................... 26

IMITREX INJ 6MG/0.5 ...... 26 IMITREX STATDOSE REFILL .............................. 26 IMITREX STATDOSE SYSTEM ........................... 26

see sumatriptan succinate inj ................................... 26

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

see azathioprine ............ 39 INCRELEX ........................ 33 indapamide ....................... 18 INDERAL LA ..................... 17

see propranolol hcl er .... 17 INFANRIX ......................... 40 INFUMORPH 200 ...............3 INFUMORPH 500 ...............3 INLYTA ............................. 13 INSPRA............................. 14

see eplerenone ............. 14 INSULIN PEN NEEDLES .. 28 INSULIN SAFETY NEEDLES ......................... 28 INSULIN SYRINGES ........ 28 INTELENCE ........................ 7 INTRALIPID INJ 20%........ 41 INTRALIPID INJ 30%........ 41 INTRON-A INJ 10MU........ 39 INTRON-A INJ 18MU........ 39 INTRON-A INJ 25MU........ 39 INTRON-A INJ 50MU........ 39 introvale 91 day ................ 30 INTUNIV ........................... 25 INVANZ ............................... 6 INVEGA ............................ 24 INVEGA SUST INJ 117 MG/0.75 ML ...................... 24 INVEGA SUST INJ 156MG/ML ........................ 24 INVEGA SUST INJ 234 MG/1.5 ML ........................ 24 INVEGA SUST INJ 39 MG/0.25 ML ...................... 24 INVEGA SUST INJ 78 MG/0.5 ML ........................ 24 INVIRASE ........................... 7 INVOKAMET TAB 150-1000 .......................................... 28 INVOKAMET TAB 150-500 .......................................... 28 INVOKAMET TAB 50-1000 .......................................... 28 INVOKAMET TAB 50-500MG ......................... 28 INVOKANA TAB 100MG ... 28 INVOKANA TAB 300MG ... 28 IONOSOL-B/DEXTROSE 5% .................................... 42 IONOSOL-MB/DEXTROSE 5% .................................... 42 iophen c-nr ........................ 50 IPOL INACTIVATED IPV .. 40 ipratropium bromide (nasal) .......................................... 44 ipratropium sol inhal .......... 44 ipratropium-albuterol ......... 44 irbesartan .......................... 15

irbesartan-hydrochlorothiazide........................................ 15 irinotecan .......................... 14 irinotecan hcl .................... 14 ISENTRESS ....................... 7 ISOLYTE P ....................... 42 isolyte s ............................. 42 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISOPTO CARPINE ........... 44 ISORDIL TITRADOSE ...... 19

see isosorbide dinitrate . 19 isosorbide dinitrate ............ 19 isosorbide mononitrate ..... 19 isosorbide mononitrate er . 19 isradipine .......................... 17 ISTALOL ........................... 44 ISTODAX .......................... 12 itraconazole ........................ 6 IXEMPRA KIT ................... 13 IXIARO ............................. 40 J JAKAFI ............................. 13 jantoven ............................ 38 JANUMET ......................... 28 JANUMET XR TAB 100-1000 .......................... 29 JANUMET XR TAB 50-1000.......................................... 29 JANUMET XR TAB 50-500MG ......................... 28 JANUVIA .......................... 29 JENTADUETO .................. 29 JOLIVETTE ...................... 30 junel 1.5/30 21 day ........... 30 junel 1/20 21 day .............. 30 junel fe 1.5/30 28 day ....... 30 junel fe 1/20 28 day .......... 30 JUXTAPID ........................ 16 K KADCYLA ......................... 12 KADIAN .............................. 3

see morphine sulfate ....... 3 KALBITOR ........................ 38 KALETRA SOL ................... 8 KALETRA TAB 100-25MG . 8 KALETRA TAB 200-50MG . 8 KALYDECO ...................... 45


66

kariva 28 day ..................... 30 KAYEXALATE ................... 29

see kionex ..................... 29 KAZANO ........................... 29 KCL 0.075%/D5W/NACL 0.45% ................................ 42 KCL 0.15%/D5W/LR ......... 42 KCL 0.15%/D5W/NACL 0.9% .................................. 42 kcl 0.3%/d5w/lr iv lac ri ...... 42 KCL 0.3%/D5W/NACL 0.45% ................................ 42 KCL 0.3%/D5W/NACL 0.9% .......................................... 42 KCL0.15%/D5W/NACL0.2% .......................................... 42 KCL0.15%/D5W/NACL0.225% ....................................... 42 KEFLEX ..............................9

see cephalexin ................9 kelnor 1/35 28 day ............ 30 KENALOG......................... 48 KEPIVANCE ..................... 13 KEPPRA ........................... 21

see levetiracetam .......... 21 KEPPRA XR ..................... 21

see levetiracetam .......... 21 KERLONE

see betaxolol hcl ............ 17 ketoconazole .......................6 ketoconazole (topical) ....... 47 ketoconazole shampoo ..... 47 ketodan aer 2% ................. 47 ketoprofen ...........................1 ketorolac tromethamine (ophth) .............................. 43 KINERET .......................... 39 kionex ............................... 29 KLARON ........................... 46

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

KLONOPIN ....................... 21 see clonazepam ............ 20

KLOR-CON 10 .................. 40 KLOR-CON 8 .................... 40 klor-con m15 ..................... 40 klor-con m20 ..................... 40 klor-con pow 20meq .......... 40

KOMBIGLYZE XR 2.5-1000MG ...................... 29 KOMBIGLYZE XR 5-1000MG ......................... 29 KOMBIGLYZE XR 5-500MG .......................................... 29 KORLYM ........................... 33 kristalose ........................... 36 K-TAB ............................... 40 KUVAN ............................. 32 KYNAMRO ........................ 16 L labetalol hcl ....................... 17 LAC-HYDRIN .................... 49

see ammonium lactate .. 49 see laclotion lot 12% ..... 49

laclotion lot 12% ................ 49 LACRISERT ...................... 44 LACTATED RINGERS VIAFLEX ........................... 42 lactulose ............................ 36 lactulose (encephalopathy) .......................................... 36 LAMICTAL ........................ 21

see lamotrigine .............. 21 LAMICTAL CHEWABLE DISPERS .......................... 21

see lamotrigine .............. 21 LAMICTAL ODT ................ 21 LAMICTAL STARTER....... 21 LAMICTAL XR .................. 21

see lamotrigine .............. 21 LAMISIL .............................. 7

see terbinafine hcl ........... 7 lamivudine ....................... 7, 8 lamivudine-zidovudine ........ 8 lamotrigine ........................ 21 LANOXIN

see digoxin .................... 18 see digoxin inj ............... 18

LANOXIN INJ 0.25MG/ML 18 LANOXIN PEDIATRIC ...... 18 LANOXIN TAB .................. 18 lansoprazole ..................... 37 LANTUS ............................ 28 LANTUS SOLOSTAR ....... 28 larin 1.5/30 ........................ 30 larin 1/20 ........................... 30

larin fe 1.5/30 .................... 30 larin fe 1/20 ....................... 30 LASIX ............................... 18

see furosemide.............. 18 LASTACAFT ..................... 43 latanoprost ........................ 44 LATUDA ........................... 24 LAZANDA ........................... 3 LEENA TAB ...................... 30 leflunomide ....................... 39 LESCOL ........................... 16

see fluvastatin sodium ... 16 lessina 28 day ................... 30 LETAIRIS .......................... 19 letrozole ............................ 12 leucovor ca inj ................... 13 leucovorin calcium ............ 13 leucovorin calcium 500 mg 13 LEUKERAN ...................... 11 LEUKINE .......................... 38 leuprolide acetate ............. 12 levalbuterol conc 1.25mg/0.5ml .................... 45 levalbuterol hcl .................. 45 LEVALBUTEROL HCL ..... 45 LEVAQUIN ....................... 10

see levofloxacin............. 10 see levofloxacin in d5w . 10

LEVEMIR .......................... 28 LEVEMIR FLEXPEN ......... 28 LEVEMIR FLEXTOUCH ... 28 levetiracetam .................... 21 LEVITRA TAB ................... 50 levobunolol hcl .................. 44 LEVOBUNOLOL HCL ....... 44 levocarnitine (metabolic modifiers) .......................... 32 levocetirizine soln 2.5mg/5ml.......................................... 45 levocetirizine tab 5 mg ...... 45 levofloxacin ....................... 10 levofloxacin (ophth) ........... 43 levofloxacin in d5w ............ 10 levonest 28 day ................ 30 levonorgestrel (emergency oc) ..................................... 30 levonorgestrel-ethinyl estradiol (91-day) .............. 30


67

levora 0.15/30 28 day ....... 30 levorphanol tartrate .............3 levothyroxine sodium ........ 34 LEVOXYL.......................... 34 LEXAPRO ......................... 23

see escitalopram oxalate ...................................... 22

LEXIVA ...............................7 LIALDA ............................. 36 lidocaine ............................ 49 lidocaine hcl ...................... 49 lidocaine hcl (local anesth.) 4, 5 lidocaine hcl (mouth-throat) .......................................... 50 lidocaine inj 0.5% ................5 lidocaine inj 1% ...................5 lidocaine inj 1.5% ................5 lidocaine inj 2% ...................5 lidocaine-prilocaine ........... 49 LIDODERM ....................... 49

see lidocaine ................. 49 LINZESS ........................... 36 liothyronine sodium ........... 34 LIPITOR

see atorvastatin calcium 16 LIPOFEN........................... 16 LIPOSYN II ....................... 41 LIPOSYN III ...................... 41 LIPOSYN III INJ 10% ........ 41 lisinopril ............................. 14 lisinopril & hydrochlorothiazide ........... 14 LITHIUM............................ 27 lithium carbonate ............... 27 LITHOBID ......................... 27

see lithium carbonate .... 27 LIVALO ............................. 16 L-METHYL-MC ................. 50 LO LOESTRIN FE ............. 30 LO MINASTRIN FE ........... 30 LOCOID

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

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

LODOSYN ........................ 24 see carbidopa ................ 23

loestrin 1.5/30-21 .............. 30 LOESTRIN 1.5/30-21

see gildess 1.5/30 ......... 30 see junel 1.5/30 21 day . 30 see larin 1.5/30 .............. 30 see microgestin 1.5/30 21 day ................................ 30

loestrin 1/20-21 ................. 30 LOESTRIN 1/20-21

see junel 1/20 21 day .... 30 see larin 1/20 ................. 30 see microgestin 1/20 21 day ................................ 30

loestrin fe 1.5/30 ............... 30 LOESTRIN FE 1.5/30

see junel fe 1.5/30 28 day ...................................... 30 see larin fe 1.5/30 .......... 30 see microgestin fe 1.5/30 28 day ........................... 31

loestrin fe 1/20 .................. 30 LOESTRIN FE 1/20

see junel fe 1/20 28 day 30 see larin fe 1/20 ............. 30 see microgestin fe 1/20 28 day ................................ 31

lofibra ................................ 16 LOFIBRA

see fenofibrate .............. 16 see fenofibrate micronized ...................................... 16

LOKARA LOTN 0.05%...... 48 lomedia 24 fe .................... 30 LOMOTIL .......................... 36

see diphenoxylate w/ atropine ......................... 36

LOMUSTINE ..................... 11 loperamide hcl .................. 36 LOPID ............................... 16

see gemfibrozil .............. 16 LOPRESSOR ................... 17

see metoprolol tartrate .. 17 LOPRESSOR HCT ........... 16

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

50-25mg ........................ 16 LOPROX SHAMPOO ....... 47

see ciclopirox shampoo 1% ................................. 47

lorazepam ......................... 20 lorcet hd tab 10-325mg ....... 2 lorcet plus tab 7.5-325 ........ 2 lorcet tab 5-325mg .............. 2 lortab tab 10-325mg ............ 2 lortab tab 5-325mg .............. 2 lortab tab 7.5-325................ 2 loryna 28 day .................... 30 losartan potassium ............ 15 losartan potassium & hydrochlorothiazide ........... 15 LOSEASONIQUE ............. 30 LOTEMAX ........................ 43 LOTENSIN ........................ 14

see benazepril hcl ......... 14 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 14

LOTREL ............................ 14 see amlodipine besylate-benazepril hcl . 14

LOTRONEX ...................... 36 lovastatin .......................... 16 LOVAZA CAP 1GM .......... 16 LOVENOX ........................ 38

see enoxaparin sodium . 38 low-ogestrel 28 day ........... 30 loxapine succinate ............ 24 LUFYLLIN ......................... 46 LUMIGAN ......................... 44 LUMIZYME ....................... 32 LUPANETA PACK ............ 32 LUPR DEP-PED INJ 15MG.......................................... 12 LUPR DEP-PED INJ 30MG (3-MONTH) ....................... 12 LUPRON DEP INJ 11.25MG.......................................... 12 LUPRON DEPOT ............. 12 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 12 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 12 LUPRON DEPOT INJ 45MG


68

.......................................... 12 LUPRON DEPOT-PED ..... 12 lutera 28 day ..................... 30 LUVOX CR ........................ 20

see fluvoxamine maleate er ................................... 20

LUXIQ see betamethasone valerate.......................... 48

LUZU ................................ 47 LYRICA ............................. 21 LYSODREN ...................... 13 LYSTEDA.......................... 38

see tranexamic acid ...... 38 lyza ................................... 30 M MACROBID .........................6

see nitrofurantoin monohyd macro ...............6

MACRODANTIN .................6 see nitrofurantoin macrocrystal ....................6

mafenide acetate .............. 46 magnesium sulfate ............ 40 MAGNESIUM SULFATE ... 40 MAGNESIUM SULFATE IN D5W .................................. 41 MAKENA ........................... 34 MALARONE ........................7

see atovaquone-proguanil hcl tab 250-100 mg ..........7

malathion .......................... 49 maprotiline hcl ................... 23 MARINOL.......................... 35

see dronabinol ............... 34 marlissa 28 day ................. 30 MARPLAN ......................... 23 MATULANE ...................... 13 matzim la........................... 17 MAVIK ............................... 14

see trandolapril .............. 14 MAXALT............................ 26

see rizatriptan benzoate 26 MAXALT-MLT ................... 26

see rizatriptan benzoate 26 MAXIDEX .......................... 43 MAXIPIME ..........................9

see cefepime inj 1gm ......9

see cefepime inj 2gm ...... 9 MAXITROL ....................... 42

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

MAXZIDE .......................... 18 see triamt/hctz tab 75-50mg ........................ 19

MAXZIDE-25 ..................... 18 see triamt/hctz tab 37.5-25 ...................................... 18

meclizine hcl ..................... 35 MEDROL

see methylpred tab 16mg ...................................... 33 see methylpred tab 32mg ...................................... 33 see methylpred tab 4mg 33 see methylpred tab 8mg 33

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 33

MEDROL PAK 4MG.......... 33 MEDROL TAB 16MG ........ 33 MEDROL TAB 2MG .......... 33 MEDROL TAB 32MG ........ 33 MEDROL TAB 4MG .......... 33 MEDROL TAB 8MG .......... 33 medroxyprogesterone acetate .............................. 34 medroxyprogesterone acetate (contraceptive) ..... 30 mefenamic acid ................... 1 mefloquine hcl ..................... 7 MEGACE ES .................... 13 MEGACE ORAL ............... 13

see megestrol acetate ... 13 megestrol acetate ............. 13 MEKINIST ......................... 13 MELOXICAM ...................... 1 meloxicam tabs ................... 1 melphalan hcl .................... 11 MENACTRA ...................... 40 MENOMUNE-A/C/Y/W-135 .......................................... 40 MENOSTAR ..................... 32 MENTAX ........................... 47 MENVEO .......................... 40

MEPRON ............................ 6 see atovaquone............... 5

mercaptopurine ................. 12 meropenem ........................ 6 MERREM ............................ 6

see meropenem .............. 6 mesalamine enema .......... 36 mesna ............................... 13 MESNEX .......................... 13

see mesna .................... 13 MESTINON ....................... 27

see pyridostigmine bromide ......................... 27

MESTINON SYRUP ......... 27 MESTINON TIMESPAN ... 27 METADATE CD

see methylphenidate hcl 25 metadate er 20 mg ............ 25 METANX ........................... 50 metformin er ..................... 29 metformin hcl .................... 29 methadone hcl .................... 3 METHADONE INJ 10MG/ML............................................ 3 METHADOSE ..................... 3

see methadone hcl .......... 3 methazolamide ................. 18 methenamine hippurate ...... 6 METHERGINE

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

methimazole ..................... 34 methotrexate sodium inj .... 12 methotrexate sodium tabs 39 methoxsalen rapid ............ 47 methscopolamine bromide 35 methyclothiazide ............... 18 methylergonovine maleate 33 METHYLIN ....................... 25

see methylphenidate hcl 25 METHYLIN CHEW TAB .... 25 methylphenidate hcl .......... 25 methylphenidate hcl er ...... 25 methylpr ace inj 40mg/ml .. 33 methylpr ace inj 80mg/ml .. 33 methylpr ss inj 125mg ....... 33 methylpr ss inj 1gm ........... 33 methylpr ss inj 40mg ......... 33


69

methylpred pak 4mg ......... 33 methylpred tab 16mg ........ 33 methylpred tab 32mg ........ 33 methylpred tab 4mg .......... 33 methylpred tab 8mg .......... 33 metipranolol ...................... 44 metoclopramide hcl ........... 35 metoclopramide hcl inj 5 mg/ml ................................ 35 metolazone ....................... 18 metoprolol & hctz tab 100-25mg .......................... 16 metoprolol & hctz tab 100-50mg .......................... 16 metoprolol & hctz tab 50-25mg ............................ 16 metoprolol succinate ......... 17 metoprolol tartrate ............. 17 METRO IV ...........................6 METROCREAM ................ 49

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

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

METROGEL-VAGINAL ..... 38 see metronidazole vaginal ...................................... 38

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

metronidazole .....................6 metronidazole (topical) ...... 49 metronidazole inj .................6 metronidazole vaginal ....... 38 MEVACOR

see lovastatin ................ 16 mexiletine hcl .................... 15 MIACALCIN

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

MIACALCIN INJ 200U/ML. 33 MIACALCIN SPR 200/ACT .......................................... 34 MICARDIS ........................ 15 MICARDIS HCT ................ 15

see

telmisartan-hydrochlorothiazide .............................. 15

miconazole nitrate vaginal 38 microgestin 1.5/30 21 day . 30 microgestin 1/20 21 day .... 30 microgestin fe 1.5/30 28 day .......................................... 31 microgestin fe 1/20 28 day 31 MICRO-K .......................... 41

see potassium chloride caps er .......................... 41

MICROZIDE ...................... 18 see hydrochlorothiazide 18

midodrine hcl .................... 19 migergot ............................ 26 MIGRANAL ....................... 26 millipred ............................ 33 MINASTRIN 24 FE ........... 31 MINIPRESS ...................... 14

see prazosin hcl ............ 14 minitran ............................. 19 MINIVELLE ....................... 32 MINOCIN

see minocycline hcl ....... 11 minocycline hcl ................. 11 minoxidil ............................ 19 MIRAPEX .......................... 24

see pramipexole dihydrochloride .............. 24

MIRAPEX ER .................... 24 mircette ............................. 31 MIRCETTE

see kariva 28 day .......... 30 see pimtrea pack ........... 31 see viorele ..................... 31

mirtazapine ....................... 23 mirtazapine odt ................. 23 misoprostol ....................... 36 mitomycin .......................... 12 mitoxantrone hcl ............... 13 M-M-R II W/DILUENT 10 DOS .................................. 40 MOBIC ................................ 1

see meloxicam tabs......... 1 modafinil ........................... 27 moderiba pak ...................... 8 moderiba tab 200mg ........... 8 MODICON ........................ 31

moexipril hcl ...................... 14 moexipril-hydrochlorothiazide........................................ 14 mometasone furoate ......... 48 MONODOX

see doxycycline (monohydrate) ............... 11

MONONESSA .................. 31 montelukast sodium .......... 45 MORPHINE SUL 20MG/ML ORAL SOL .......................... 3 morphine sulfate ............. 3, 4 MORPHINE SULFATE ....... 4 morphine sulfate beads ...... 4 morphine sulfate ext-rel tab 4 MOVIPREP ....................... 36 MOXATAG ........................ 10 MOXEZA .......................... 43 moxifloxacin hcl ................ 10 MOZOBIL ......................... 38 MS CONTIN ....................... 4

see morphine sulfate ext-rel tab ........................ 4

MULTAQ ........................... 15 mupirocin .......................... 46 mupirocin calcium (topical) 47 MUSE ............................... 50 MUSTARGEN ................... 11 my way ............................. 31 MYALEPT ......................... 34 MYAMBUTOL ..................... 8

see ethambutol hcl .......... 8 MYCAMINE ........................ 7 MYCOBUTIN ...................... 8

see rifabutin .................... 8 mycophenolate mofetil ...... 40 mycophenolate sodium ..... 40 MYFORTIC ....................... 40

see mycophenolate sodium .......................... 40

MYOBLOC ........................ 44 myorisan ........................... 46 MYOZYME ....................... 32 MYRBETRIQ .................... 37 MYSOLINE ....................... 21

see primidone................ 21 myzilra .............................. 31


70

N nabumetone ........................1 nadolol .............................. 17 nadolol & bendroflumethiazide .......... 16 nafcillin sodium ................. 10 NAFTIN ............................. 47 NAGLAZYME .................... 32 NALLPEN ISO-OSMOTIC IN DE ..................................... 10 NALLPEN/DEXTROSE ..... 10 naloxone hcl ...................... 27 naltrexone hcl .................... 27 NAMENDA SOL 10MG/5ML .......................................... 22 NAMENDA TAB ................ 22 NAMENDA XR .................. 22 NAMENDA XR TITRATION PACK ................................ 22 naphazoline 0.1% ............. 44 NAPROSYN ........................1

see naproxen ...................1 naproxen .............................1 naproxen sodium ................1 naratriptan hcl ................... 26 NARDIL ............................. 23

see phenelzine sulfate ... 23 NASONEX ........................ 45 NATACYN ......................... 43 nateglinide......................... 29 NAVELBINE

see vinorelbine tartrate .. 12 NEBUPENT ........................6 necon 0.5/35 28 day ......... 31 necon 1/35 28 day ............ 31 necon 10/11 28 day .......... 31 NECON 7/7/7 .................... 31 NECON TAB 1/50-28 ........ 31 nefazodone hcl .................. 23 neomycin sulfate .................5 neomycin/polymyxin b gu .. 50 neomycin-bacitracin zn-polymyxin ..................... 43 neomycin-polymy-dexameth .......................................... 42 neomycin-polymyxin-gramicidin ..................................... 43 neomycin-polymyxin-hc

(ophth) .............................. 42 neomycin-polymyxin-hc (otic) .......................................... 50 NEORAL ........................... 40

see cyclosporine modified (for microemulsion).. 39, 40 see gengraf ................... 40

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

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 50

neosporin solution ............. 43 NEPHRAMINE .................. 41 NEPTAZANE

see methazolamide ....... 18 NESINA ............................ 29 neuac gel 1.2-5% .............. 46 NEULASTA ....................... 38 NEUMEGA ........................ 38 NEUPOGEN ..................... 38 NEUPRO .......................... 24 NEURONTIN .................... 21

see gabapentin .............. 21 NEVANAC ........................ 43 nevirapine ........................... 7 NEVIRAPINE ...................... 7 NEXAVAR ......................... 13 NEXIUM I.V. ..................... 37

see esomeprazole inj .... 37 next choice tab 1.5mg ....... 31 niacin (antihyperlipidemic) 16 niacor ................................ 16 NIASPAN .......................... 16

see niacin (antihyperlipidemic) ....... 16

nicardipine hcl ................... 17 NICOTROL INHALER ....... 27 NICOTROL NS ................. 27 nifedical ............................. 17 nifedipine .......................... 17 nifedipine er ...................... 17 nikki 3-0.02mg .................. 31 NILANDRON ..................... 13 nimodipine ........................ 17 NIPENT ............................. 12

nisoldipine ................... 17, 18 nitro-bid ............................. 19 NITRO-DUR ..................... 19

see minitran .................. 19 nitrofurantoin ....................... 6 nitrofurantoin macrocrystal . 6 nitrofurantoin monohyd macro .................................. 6 NITROGLYCERIN ............ 19 NITROGLYCERIN LINGUAL.......................................... 19 nitroglycerin patches ......... 19 NITROLINGUAL SPR PUMPSPRA ..................... 19 NITROMIST ...................... 19 NITROSTAT ..................... 19 nizatidine .......................... 35 NIZORAL .......................... 47

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

NORA-BE TAB ................. 31 norco ................................... 2 NORCO

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

NORDITROPIN FLEXPRO.......................................... 33 NORDITROPIN NORDIFLEX PEN ............. 33 norethindrone (contraceptive) .................. 31 norethindrone acetate ....... 34 norgestimate-ethinyl


71

estradiol (triphasic) ............ 31 NORINYL 1+35 ................. 31

see cyclafem 1/35 28 day ...................................... 30 see necon 1/35 28 day .. 31 see nortrel 1/35 21 day .. 31 see nortrel 1/35 28 day .. 31 see pirmella 1/35 28 day ...................................... 31

NORINYL 1+50 ................. 31 norlyroc 0.35mg ................ 31 normosol-m ....................... 42 NORMOSOL-R ................. 42 NORPACE ........................ 15

see disopyramide phosphate ...................... 15

NORPACE CR .................. 15 NORPRAMIN .................... 23

see desipramine hcl ...... 22 NOR-QD ........................... 31

see camila 28 day ......... 30 see heather ................... 30 see norethindrone (contraceptive) ............... 31 see norlyroc 0.35mg ...... 31

nortrel 0.5/35 28 day ......... 31 nortrel 1/35 21 day ............ 31 nortrel 1/35 28 day ............ 31 nortrel 7/7/7 28 day ........... 31 nortriptyline hcl .................. 23 NORVASC ........................ 18

see amlodipine besylate 17 NORVIR ..............................7 NOVAREL INJ 10000UNT 34 NOVOLIN 70/30 ................ 28 NOVOLIN N ...................... 28 NOVOLIN R ...................... 28 NOVOLOG ........................ 28 NOVOLOG FLEXPEN ...... 28 NOVOLOG MIX 70/30 ...... 28 NOVOLOG MIX 70/30 PREFILL ........................... 28 NOVOLOG PENFILL ........ 28 NOXAFIL.............................7 NPLATE ............................ 38 NUCYNTA ...........................4 NUCYNTA ER .....................4 NUEDEXTA ...................... 27

NULOJIX ........................... 40 NULYTELY/FLAVOR PACKS .............................. 36

see gavilyte-n ................ 36 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 36 see trilyte ....................... 36

NUVARING ....................... 31 NUVIGIL ........................... 27 nyamyc ............................. 47 NYMALIZE ........................ 18 nystatin ............................... 7 nystatin (mouth-throat) ...... 50 nystatin (topical) ................ 47 nystatin pow 100000 ......... 47 nystop ............................... 47 O OCELLA TAB 3-0.03MG ... 31 OCTAGAM ........................ 39 octreotide acetate ............. 34 OCUFEN ........................... 43

see flurbiprofen sodium . 43 OCUFLOX ........................ 43

see ofloxacin (ophth) ..... 43 ofloxacin (ophth) ............... 43 ofloxacin (otic) ................... 50 ogestrel 28 day ................. 31 olanzapine ........................ 24 olanzapine odt .................. 24 OLUX ................................ 48

see clobetasol propionate ...................................... 48

OLUX-E see clobetasol propionate emulsion ........................ 48

OLYSIO .............................. 8 OMECLAMOX-PAK .......... 37 omega-3-acid ethyl esters . 16 omeprazole ....................... 37 OMNARIS ......................... 45 OMNIPRED ...................... 43 ondansetron hcl ................ 35 ondansetron hcl inj ............ 35 ondansetron hcl inj 4 mg/2ml .......................................... 35 ondansetron hcl oral soln .. 35

ondansetron odt ................ 35 ONFI SUS 2.5MG/ML ....... 21 ONFI TAB 10MG .............. 21 ONGLYZA ........................ 29 ONMEL ............................... 7 OPANA ............................... 4

see oxymorphone hcl ...... 4 OPANA ER (CRUSH RESISTANT ....................... 4 OPSUMIT ......................... 19 OPTIPRANOLOL .............. 44 OPTIVAR .......................... 43

see azelastine hcl (ophth) ...................................... 43

ORACEA .......................... 49 ORAP ............................... 24 orapred ............................. 33 ORAPRED ODT TAB 10MG.......................................... 33 ORAPRED ODT TAB 15MG.......................................... 33 ORAPRED ODT TAB 30MG.......................................... 33 ORENCIA ......................... 39 ORENITRAM TAB 0.125MG.......................................... 19 ORENITRAM TAB 0.25MG.......................................... 19 ORENITRAM TAB 1MG ... 19 ORENITRAM TAB 2.5MG 19 ORFADIN ......................... 32 orsythia 28 day ................. 31 ORTHO EVRA .................. 31

see xulane dis 150-35 ... 32 ORTHO MICRONOR ........ 31

see errin 28 day ............ 30 see lyza ......................... 30 see sharobel 0.35mg ..... 31

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 31 see tri-previfem 28 day .. 31 see tri-sprintec 28 day ... 31

ORTHO TRI-CYCLEN LO 31 ORTHO-CEPT .................. 31 ORTHO-CYCLEN ............. 31

see previfem 28 day ...... 31 see sprintec 28 day ....... 31


72

ORTHO-NOVUM 1/35 ...... 31 ORTHO-NOVUM 7/7/7 ..... 31

see cyclafem 7/7/7 28 day ...................................... 30 see nortrel 7/7/7 28 day . 31

OSENI TAB 12.5-15MG .... 29 OSENI TAB 12.5-30MG .... 29 OSENI TAB 12.5-45MG .... 29 OSENI TAB 25-15MG ....... 29 OSENI TAB 25-30MG ....... 29 OSENI TAB 25-45MG ....... 29 OSMOPREP ..................... 36 OTEZLA ............................ 39 OTREXUP ......................... 39 ovcon 35 28 day ................ 31 OVCON-35

see balziva 28 day ......... 29 see briellyn 28 day ........ 29 see gildagia ................... 30 see philith ...................... 31 see vyfemia 28 day ....... 31 see zenchent tab ........... 32

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

oxacillin sodium ................. 10 oxaliplatin .......................... 13 OXANDRIN

see oxandrolone ............ 28 oxandrolone ...................... 28 oxaprozin ............................1 oxcarbazepine ................... 21 OXECTA .............................4 OXISTAT........................... 47 OXSORALEN .................... 49 OXSORALEN ULTRA ....... 47

see methoxsalen rapid .. 47 OXTELLAR XR ................. 21 oxybutynin chloride ........... 37 oxycodone hcl .....................4 OXYCODONE HCL ............4 oxycodone w/ acetaminophen 10-325mg ..4 oxycodone w/ acetaminophen 2.5-325mg .4 oxycodone w/ acetaminophen 5-325mg ....4 oxycodone w/ acetaminophen 7.5-325mg .4

oxycodone-aspirin ............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone hcl ................ 4 P pacerone ........................... 15 paclitaxel ........................... 12 PAMELOR ........................ 23

see nortriptyline hcl ....... 23 pamidronate inj 30/10ml.... 29 pamidronate inj 6mg/ml ..... 29 pamidronate inj 90/10ml.... 29 PAMINE ............................ 35

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

PAMINE FORTE ............... 35 see methscopolamine bromide ......................... 35

PANCREAZE .................... 37 PANDEL ........................... 48 PANRETIN ........................ 49 pantoprazole sodium......... 37 parcopa ............................. 24 paricalcitol ......................... 42 PARLODEL

see bromocriptine mesylate ........................ 23

PARNATE ......................... 23 see tranylcypromine sulfate ............................ 23

paromomycin sulfate ........... 5 paroxetine er tab ............... 23 paroxetine hcl ................... 23 paser d/r .............................. 8 PATADAY ......................... 44 PATANASE ....................... 45 PATANOL ......................... 44 PAXIL................................ 23

see paroxetine hcl ......... 23 PAXIL CR ......................... 23

see paroxetine er tab..... 23 PCE .................................. 10 PEDIAPRED

see pred sod pho sol 5mg/5ml ........................ 33

pediapred sol 6.7/5ml........ 33 pedi-dri .............................. 47 PEDVAX HIB .................... 40

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 36 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 36 PEGANONE ..................... 21 PEGASYS ........................ 39 PEGASYS PROCLICK ..... 39 PEG-INTRON ................... 39 PEG-INTRON REDIPEN .. 39 PENICILLIN G POT IN DEXTROSE ...................... 11 penicillin g potassium ........ 11 PENICILLIN G POTASSIUM IN ...................................... 11 penicillin g procaine .......... 11 penicillin g sodium ............ 11 penicillin v potassium ........ 11 PENNSAID

see diclofenac sol 1.5% 49 PENTAM 300 ...................... 6 PENTASA ......................... 36 pentoxifylline ..................... 38 PEPCID

see famotidine ............... 35 PEPCID SUSP.................. 35 PEPCID TAB .................... 35 PERCOCET

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

percocet 10/325 .................. 4 percocet 2.5/325 ................. 4 percocet 7.5/325 ................. 4 percocet tab 5-325mg ......... 4 PERCODAN ....................... 4

see oxycodone-aspirin .... 4 PERFOROMIST ............... 45


73

PERIDEX see chlorhexidine gluconate (mouth-throat) ...................................... 50 see periogard soln 0.12% ...................................... 50

perindopril erbumine ......... 14 periogard soln 0.12% ........ 50 permethrin ......................... 49 perphenazine .................... 24 PERTZYE ......................... 37 PEXEVA............................ 23 pfizerpen ........................... 11 phenadoz .......................... 35 phendimetrazine ............... 51 phenelzine sulfate ............. 23 PHENERGAN

see promethazine hcl .... 35 phenergan inj .................... 35 phenergan sup 12.5mg ..... 35 phenergan sup 25mg ........ 35 phenobarbital .................... 21 phenobarbital sodium ........ 21 PHENOBARBITAL SODIUM .......................................... 21 phentermine ...................... 51 phenytek ........................... 21 PHENYTEK

see phenytoin sodium extended........................ 21

phenytoin .......................... 21 phenytoin inj 50mg/ml ....... 21 phenytoin sodium extended .......................................... 21 philith ................................ 31 PHOSLO ........................... 34

see calcium acetate (phosphate binder) ........ 34

PHOSLYRA ...................... 34 PHOSPHOLINE IODIDE ... 44 PICATO............................. 49 PILOCARPINE HCL .......... 44 pilocarpine hcl (oral) .......... 50 pimtrea pack ..................... 31 pindolol ............................. 17 pioglitazone hcl ................. 29 pioglitazone hcl-glimepiride .......................................... 29

pioglitazone hcl-metformin hcl ..................................... 29 piperacillin sodium-tazobactam sodium .......................................... 11 pirmella 1/35 28 day ......... 31 piroxicam ............................ 1 PLAN B

see levonorgestrel (emergency oc) ............. 30

PLAN B ONE-STEP see levonorgestrel (emergency oc) ............. 30 see my way ................... 31 see next choice tab 1.5mg ...................................... 31

PLAQUENIL ...................... 39 PLASMA-LYTE A .............. 42 PLASMA-LYTE-148 .......... 42 PLASMA-LYTE-56/D5W ... 42 PLAVIX

see clopidogrel bisulfate 39 PLETAL ............................ 38

see cilostazol ................. 38 podofilox ........................... 49 polyethylene glycol 3350 ... 36 polymyxin b sulfate ............. 6 polymyxin b-trimethoprim .. 43 POLYTRIM ....................... 43

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

POMALYST ...................... 13 PONSTEL ........................... 1

see mefenamic acid ........ 1 portia 28 day ..................... 31 potassium chloride ...... 41, 42 POTASSIUM CHLORIDE . 41 POTASSIUM CHLORIDE 0.15%................................ 42 POTASSIUM CHLORIDE 0.22%................................ 42 POTASSIUM CHLORIDE 0.3%/D .............................. 42 potassium chloride caps er .......................................... 41 potassium chloride in nacl . 42 POTASSIUM CHLORIDE IN NACL ................................ 42

potassium chloride microencapsulated crystals cr ....................................... 41 POTASSIUM CITRATE (ALKALINIZER) TAB ........ 37 POTIGA ............................ 21 PRADAXA ........................ 38 pramipexole dihydrochloride.......................................... 24 PRANDIMET .................... 29 PRANDIN ......................... 29

see repaglinide .............. 29 PRAVACHOL ................... 16

see pravastatin sodium . 16 pravastatin sodium ............ 16 prazosin hcl ...................... 14 PRECOSE ........................ 29

see acarbose................. 28 PRED FORTE .................. 43 PRED MILD ...................... 43 pred sod pho sol 5mg/5ml 33 PRED-G ............................ 42 PRED-G S.O.P. ................ 42 prednicarbate .................... 48 PREDNICARBATE ........... 48 PREDNISOLONE ACETATE (OPHTH) ........................... 43 prednisolone sodium phosphate (ophth)............. 43 prednisolone sol 15mg/5ml.......................................... 33 prednisolone sol 25mg/5ml.......................................... 33 prednisolone syrup 15 mg/5ml .............................. 33 prednisone con 5mg/ml .... 33 prednisone pak 10mg ....... 33 prednisone pak 5mg ......... 33 prednisone sol 5mg/5ml .... 33 prednisone tab 10mg ........ 33 prednisone tab 1mg .......... 33 prednisone tab 2.5mg ....... 33 prednisone tab 20mg ........ 33 prednisone tab 50mg ........ 33 prednisone tab 5mg .......... 33 PREGNYL W/DILUENT BENZYL ............................ 34 PRELONE


74

see prednisolone syrup 15 mg/5ml........................... 33

PREMARIN ....................... 32 PREMARIN CREAM ......... 32 PREMARIN INJ ................. 32 premasol 10% ................... 41 premasol 6% ..................... 41 PREMPHASE ................... 32 PREMPRO ........................ 32 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 42 PREPOPIK ........................ 36 PREVACID

see lansoprazole ........... 37 prevalite ............................ 16 previfem 28 day ................ 31 PREVPAC ......................... 37

see amoxicillin-clarithromycin w/ lansoprazole ............. 36

PREZISTA ..........................7 PRIALT ...............................1 PRIFTIN ..............................8 PRILOSEC ........................ 37

see omeprazole ............. 37 PRIMAQUINE PHOSPHATE ............................................7 PRIMAXIN ...........................6 PRIMAXIN IV

see imipenem-cilastatin ...6 primidone .......................... 21 PRIMSOL SOL 50MG/5ML .6 PRINIVIL ........................... 14

see lisinopril ................... 14 PRISTIQ............................ 23 PRIVIGEN ......................... 39 PROAIR HFA .................... 45 probenecid ..........................1 PROCALAMINE ................ 41 PROCARDIA XL ............... 18

see nifedical .................. 17 see nifedipine er ............ 17

prochlorperazine inj 5 mg/ml .......................................... 35 prochlorperazine maleate.. 35 prochlorperazine supp ...... 35 PROCRIT .......................... 38

procto-pak ......................... 47 proctosol hc ...................... 47 proctozone hc ................... 47 PROCYSBI ....................... 32 progesterone micronized .. 34 PROGLYCEM SUS 50MG/ML .......................... 33 PROGRAF ........................ 40

see tacrolimus ............... 40 PROLASTIN-C .................. 45 PROLEUKIN ..................... 12 PROLIA ............................. 34 PROMACTA ..................... 38 promethazine dm .............. 50 promethazine hcl .............. 35 promethazine vc ............... 50 promethazine/codeine....... 50 promethegan ..................... 35 PROMETRIUM ................. 34

see progesterone micronized ..................... 34

propafenone hcl ................ 15 proparacaine hcl ............... 44 propranolol & hydrochlorothiazide ........... 16 propranolol hcl er .............. 17 propranolol inj 1mg/ml....... 17 propranolol sol .................. 17 propranolol tab .................. 17 propylthiouracil .................. 34 PROQUAD ........................ 40 PROSCAR ........................ 37

see finasteride ............... 37 PROSOL ........................... 41 PROTONIX

see pantoprazole sodium ...................................... 37

PROTONIX INJ ................. 37 PROTOPIC ....................... 49 protriptyline hcl .................. 23 PROVENTIL HFA ............. 45 PROVERA ........................ 34

see medroxyprogesterone acetate .......................... 34

PROVIGIL see modafinil ................. 27

PROZAC ........................... 23 see fluoxetine hcl .......... 22

PROZAC WEEKLY ........... 23 see fluoxetine hcl .......... 22

PRUDOXIN CRE 5% ........ 47 PULMICORT

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

PULMICORT FLEXHALER.......................................... 45 PULMICORT INH SUSP 0.25MG/2 ML .................... 46 PULMICORT INH SUSP 0.5MG/2 ML ...................... 46 PULMICORT INH SUSP 1MG/2ML .......................... 46 PULMOZYME ................... 45 PURINETHOL .................. 12

see mercaptopurine ...... 12 PYLERA ........................... 37 pyrazinamide ...................... 8 pyridostigmine bromide ..... 27 Q QNASL ............................. 45 QUALAQUIN ...................... 7

see quinine sulfate .......... 7 QUARTETTE .................... 31 quasense 91 day .............. 31 QUDEXY XR .................... 21 questran ............................ 16 QUESTRAN

see cholestyramine ....... 16 questran light .................... 16 QUESTRAN LIGHT

see prevalite .................. 16 quetiapine fumarate .......... 24 QUILLIVANT XR ............... 25 quinapril hcl ...................... 14 quinapril-hydrochlorothiazide.......................................... 14 quinidine gluconate er ....... 15 quinidine sulfate ................ 15 quinine sulfate .................... 7 QVAR ............................... 46 R RABAVERT ...................... 40 rabeprazole sodium .......... 37 RAGWITEK ...................... 39 raloxifene hcl .................... 34 ramipril .............................. 14


75

RANEXA ........................... 19 ranitidine hcl ...................... 35 RAPAFLO ......................... 37 RAPAMUNE ...................... 40

see sirolimus tab 0.5 mg 40 RASUVO ........................... 39 RAVICTI ............................ 34 RAYOS TAB 1MG ............. 33 RAYOS TAB 2MG ............. 33 RAYOS TAB 5MG ............. 33 RAZADYNE ...................... 22

see galantamine hydrobromide ................ 22

RAZADYNE ER ................ 22 see galantamine hydrobromide ................ 22

REBETOL ...........................8 see ribasphere .................8 see ribavirin 200mg .........8

REBIF ............................... 27 REBIF TITRATION PACK . 27 RECLAST

see zoledronic inj 5/100ml ...................................... 29

reclipsen 28 day ................ 31 RECOMBIVAX HB ............ 40 RECTIV ............................. 49 REGLAN ........................... 35

see metoclopramide hcl. 35 REGRANEX ...................... 50 RELENZA DISKHALER ......8 RELISTOR ........................ 36 RELPAX ............................ 26 REMERON ........................ 23

see mirtazapine ............. 23 REMERON SOLTAB ........ 23

see mirtazapine ............. 23 see mirtazapine odt ....... 23

REMICADE ....................... 39 REMODULIN .................... 19 RENAGEL ......................... 34 RENVELA PAK ................. 34 RENVELA TAB 800MG .... 34 repaglinide ........................ 29 REPREXAIN

see hydrocodone-ibuprofen 2.5-200 mg ......................2

see ibudone 5-200 mg ..... 2 reprexain 10/200 ................. 2 reprexain 2.5/200 ................ 2 reprexain 5/200 ................... 2 REQUIP ............................ 24

see ropinirole hydrochloride ................. 24

RESCRIPTOR .................... 7 RESTASIS ........................ 44 RESTORIL ........................ 25

see temazepam ............. 26 RETIN-A ........................... 46

see tretinoin ................... 46 RETROVIR

see zidovudine ................ 7 RETROVIR CAPS .............. 7 RETROVIR IV INFUSION ... 7 RETROVIR SYRP .............. 7 REVATIO .......................... 19

see sildenafil citrate (pulmonary hypertension) ...................................... 19

revia .................................. 28 REVIA

see naltrexone hcl ......... 27 REVLIMID ......................... 39 REYATAZ ........................... 7 RHEUMATREX ................. 39 RHINOCORT AQUA ......... 45

see budesonide (nasal) . 45 ribapak mis 600/day ............ 8 ribasphere ........................... 8 ribasphere ribapak 1000 ..... 8 ribasphere ribapak 1200 ..... 8 ribasphere ribapak 800 ....... 8 ribavirin 200mg ................... 8 rifabutin ............................... 8 rifadin .................................. 8 RIFADIN ............................. 8

see rifampin ..................... 8 rifamate ............................... 8 rifampin ............................... 8 RIFATER ............................ 8 RILUTEK ........................... 27

see riluzole .................... 27 riluzole .............................. 27 rimantadine hydrochloride ... 8 RINGER'S ......................... 42

RIOMET ............................ 29 risedronate sodium ........... 29 RISPERDAL ..................... 24

see risperidone.............. 25 RISPERDAL INJ 12.5MG . 24 RISPERDAL INJ 25MG .... 24 RISPERDAL INJ 37.5MG . 24 RISPERDAL INJ 50MG .... 25 RISPERDAL M-TAB ......... 25

see risperidone odt ........ 25 risperidone ........................ 25 risperidone odt .................. 25 RITALIN

see methylphenidate hcl 25 RITALIN LA

see methylphenidate hcl 25 RITUXAN .......................... 12 rivastigmine tartrate .......... 22 rizatriptan benzoate .......... 26 ROBINUL .......................... 35

see glycopyrrolate ......... 35 ROBINUL FORTE ............. 35

see glycopyrrolate ......... 35 ROCALTROL .................... 42

see calcitriol .................. 42 rocephin .............................. 9 ROCEPHIN

see ceftriaxone sodium ... 9 ropinirole hydrochloride .... 24 rosadan cre 0.75% ............ 49 ROTARIX .......................... 40 ROTATEQ ........................ 40 ROWASA

see mesalamine enema 36 roxicet soln ......................... 4 roxicet tab 5-325mg ............ 4 ROXICODONE ................... 4

see oxycodone hcl .......... 4 ROZEREM ........................ 25 RYTHMOL ........................ 15

see propafenone hcl ...... 15 RYTHMOL SR .................. 15

see propafenone hcl ...... 15 S SABRIL ............................. 21 SALAGEN ......................... 50

see pilocarpine hcl (oral) ...................................... 50


76

salsalate ............................ 50 SAMSCA ........................... 34 SANCTURA ...................... 37 SANCUSO ........................ 35 SANDIMMUNE

see cyclosporine ............ 39 SANDIMMUNE CAPS ....... 40 SANDIMMUNE INJ ........... 40 SANDIMMUNE SOLN ....... 40 SANDOSTATIN ................ 34

see octreotide acetate ... 34 SANDOSTATIN LAR DEPOT ............................. 34 SANTYL ............................ 50 SAPHRIS .......................... 25 SARAFEM ......................... 28 SAVELLA .......................... 27 SAVELLA TITRATION PACK ................................ 27 SEASONIQUE .................. 31

see amethia 91 day ....... 29 SECTRAL ......................... 17

see acebutolol hcl .......... 17 selegiline hcl ..................... 24 selenium sulfide ................ 47 SELZENTRY .......................7 SEMPREX-D ..................... 44 SENSIPAR ........................ 29 SEREVENT DISKUS ........ 45 SEROQUEL ...................... 25

see quetiapine fumarate 24 SEROQUEL XR ................ 25 SEROSTIM ....................... 33 sertraline hcl ...................... 23 SF-ROWASA .................... 36 sharobel 0.35mg ............... 31 SIGNIFOR ......................... 34 sildenafil citrate (pulmonary hypertension) .................... 19 SILVADENE ...................... 47 SILVER SULFADIAZINE... 47 SIMBRINZA SUS 1-0.2% .. 44 SIMCOR............................ 16 SIMPONI ........................... 39 SIMPONI ARIA ................. 39 SIMULECT ........................ 40 simvastatin ........................ 16 SINEMET .......................... 24

see carbidopa-levodopa 23 SINEMET CR .................... 24

see carbidopa-levodopa 23 SINGULAIR ...................... 45

see montelukast sodium 45 sirolimus tab 0.5 mg .......... 40 SIRTURO ............................ 8 SIVEXTRO .......................... 6 SKLICE ............................. 49 SODIUM CHLORIDE .. 41, 42 SODIUM CHLORIDE 0.45% VIA .................................... 42 SODIUM CHLORIDE 0.9% .......................................... 50 SODIUM DIURIL ............... 18 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 41 sodium phenylbutyrate ...... 32 sodium polystyrene sulfonate .......................................... 29 SOLARAZE ....................... 49

see diclofenac gel 3% ... 49 SOLIA ............................... 31 SOLIRIS ............................ 38 SOLODYN ........................ 11 SOLTAMOX ...................... 13 SOLU-CORTEF 1000MG . 33 SOLU-CORTEF 100MG ... 33 SOLU-CORTEF 250MG ... 33 SOLU-CORTEF 500MG ... 33 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 33 see methylpr ss inj 1gm . 33 see methylpr ss inj 40mg ...................................... 33

SOLU-MEDROL INJ 125MG .......................................... 33 SOLU-MEDROL INJ 1GM 33 SOLU-MEDROL INJ 2GM 33 SOLU-MEDROL INJ 40MG .......................................... 33 SOLU-MEDROL INJ 500MG .......................................... 33 SOMATULINE DEPOT ..... 34 SOMAVERT ...................... 34 SORIATANE ..................... 47

see acitretin ................... 47 SORILUX .......................... 47 sorine ................................ 15 sotalol hcl .......................... 15 sotalol hcl (afib/afl) ............ 15 SOVALDI ............................ 8 SPIRIVA HANDIHALER ... 44 spironolactone .................. 14 spironolactone & hydrochlorothiazide ........... 18 SPORANOX ....................... 7

see itraconazole .............. 6 SPORANOX PULSEPAK ... 7 SPORANOX SOL 10MG/ML............................................ 7 sprintec 28 day ................. 31 SPRYCEL ......................... 13 sronyx 28 day ................... 31 SSD .................................. 47 STALEVO ......................... 24 STARLIX ........................... 29

see nateglinide .............. 29 stavudine ............................ 7 STAXYN ........................... 50 STELARA ......................... 47 STERILE WATER IRRIGATION ..................... 50 STIMATE .......................... 34 STIVARGA ....................... 13 STRATTERA .................... 25 streptomycin sulfate ............ 5 STRIANT .......................... 28 STRIBILD ........................... 8 STROMECTOL ................... 6 SUBSYS ............................. 4 SUCLEAR ......................... 36 SUCRAID ......................... 37 sucralfate .......................... 37 SULAR .............................. 18

see nisoldipine .............. 17 sulfacetamide sodium (acne).......................................... 46 sulfacetamide sodium (ophth) .............................. 43 sulfacetamide sod-prednisolone .............. 42 sulfadiazine ......................... 5 sulfamethoxazole-trimethop 6


77

sulfamethoxazole-trimethoprim inj ....................................6 SULFAMYLON .................. 47

see mafenide acetate .... 46 sulfasalazine dr ................. 36 sulfasalazine ir .................. 36 sulindac ...............................1 sumatriptan succinate ....... 26 SUMATRIPTAN SUCCINATE ..................... 26 sumatriptan succinate inj .. 26 SUMATRIPTAN SUCCINATE INJ ............... 26 SUMAVEL DOSEPRO ...... 26 SUPPRELIN LA ................ 34 suprax .................................9 SUPRAX .............................9 SUPREP BOWEL PREP... 36 SURMONTIL ..................... 23 SUSTIVA.............................7 SUTENT............................ 13 syeda ................................ 31 SYLATRON KIT 296MCG . 13 SYLATRON KIT 444MCG . 13 SYLATRON KIT 888MCG . 13 SYMBICORT ..................... 46 SYMLINPEN 120 .............. 28 SYMLINPEN 60 ................ 28 SYNAGIS .......................... 40 SYNALAR ......................... 48

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

SYNALGOS-DC ..................2 SYNAREL ......................... 32 SYNERA ........................... 49 SYNERCID .........................6 SYNTHROID ..................... 34

see levothyroxine sodium ...................................... 34

SYPRINE .......................... 29 T TABLOID........................... 12 TACLONEX ....................... 49

see calcipotrien oin betameth ....................... 48

tacrolimus.......................... 40 TAFINLAR ......................... 13 TAMIFLU.............................8

tamoxifen citrate ............... 13 tamsulosin hcl ................... 37 TANZEUM ........................ 28 tapazole ............................ 34 TAPAZOLE

see methimazole ........... 34 TARCEVA ......................... 13 TARGRETIN ............... 13, 49 TARKA .............................. 14 TASIGNA .......................... 13 TAXOTERE ...................... 12 tazicef vial ........................... 9 TAZORAC ......................... 47 taztia xt ............................. 18 TECFIDERA CAP 120MG 27 TECFIDERA CAP 240MG 27 TECFIDERA MIS STARTER .......................................... 27 TEFLARO ........................... 9 TEGRETOL ...................... 21

see carbamazepine ....... 20 see epitol ....................... 21

TEGRETOL-XR ................ 21 see carbamazepine ....... 20

TEKAMLO ......................... 18 TEKTURNA ...................... 18 TEKTURNA HCT .............. 18 TELMISARTAN ................. 15 telmisartan-amlodipine ...... 15 telmisartan-hydrochlorothiazide ...................................... 15 temazepam ....................... 26 TEMOVATE

see clobetasol propionate ...................................... 48

TEMOVATE CRE 0.05% .. 49 TEMOVATE E

see clobetasol propionate emollient base ............... 48

TEMOVATE E CREAM ..... 49 TEMOVATE GEL 0.05% ... 49 TEMOVATE OIN 0.05% .... 49 TEMOVATE SOL 0.05% ... 49 TENIVAC .......................... 40 TENORETIC 100 .............. 16

see atenolol & chlorthalidone ................ 16

TENORETIC 50 ................ 16

see atenolol & chlorthalidone ................ 16

TENORMIN ...................... 17 see atenolol ................... 17

TERAZOL 3 ...................... 38 see terconazole vaginal 38

TERAZOL 7 ...................... 38 see terconazole vaginal 38 see zazole ..................... 38

terazosin hcl ..................... 14 terbinafine hcl ..................... 7 terbutaline sulfate ............. 45 terconazole vaginal ........... 38 TESSALON PERLES

see benzonatate............ 50 testosterone cypionate ...... 28 testosterone enanthate ..... 28 TETANUS TOXOID ADSORBED ..................... 40 TETANUS/DIPHTHERIA TOXOID ............................ 40 TETRACYCLINE HCL ...... 11 TEVETEN

see eprosartan mesylate ...................................... 15

texacort ............................. 49 THALOMID ....................... 39 theo-24 ............................. 46 theophylline ...................... 46 thioridazine hcl .................. 25 thiothixene ........................ 25 THYMOGLOBULIN ........... 40 tiagabine hcl ..................... 21 TIAZAC ............................. 18

see diltiazem hcl er ....... 17 see diltiazem hcl extended release beads................ 17 see diltzac ..................... 17 see taztia xt ................... 18

TIKOSYN .......................... 15 TIMENTIN ......................... 11 timolol maleate ................. 17 timolol maleate (ophth) ..... 44 TIMOLOL MALEATE GEL 44 TIMOPTIC ........................ 44

see timolol maleate (ophth) ........................... 44

TIMOPTIC OCUDOSE ..... 44


78

TIMOPTIC-XE ................... 44 TIROSINT ......................... 34 TIVICAY ..............................7 tizanidine ........................... 27 TOBI

see tobramycin ................5 TOBI NEB ...........................5 TOBI PODHALER ...............5 TOBRADEX ...................... 42

see tobramycin-dexamethasone .................................... 42

tobramycin ..........................5 tobramycin (ophth) ............ 43 tobramycin sulfate ...............5 tobramycin sulfate in saline .5 tobramycin-dexamethasone .......................................... 42 TOBREX

see tobramycin (ophth) .. 43 TOBREX OINT 0.3% ........ 43 TOBREX SOL 0.3% OP .... 43 TOFRANIL ........................ 23

see imipramine hcl ........ 23 TOFRANIL-PM .................. 23

see imipramine pamoate ...................................... 23

tolmetin sodium ...................1 TOLTERODINE TARTRATE ER ..................................... 37 tolterodine tartrate tab 1 mg .......................................... 37 tolterodine tartrate tab 2 mg .......................................... 37 TOPAMAX ........................ 21

see topiramate ............... 21 TOPAMAX SPRINKLE ...... 21

see topiramate ............... 21 topicort .............................. 49 TOPICORT ....................... 49

see desoximetasone ..... 48 topiramate ......................... 21 TOPIRAMATE ................... 21 toposar .............................. 14 topotecan hcl ..................... 14 TOPROL XL ...................... 17

see metoprolol succinate ...................................... 17

TORISEL .......................... 12 torsemide inj 20mg/2ml ..... 18 torsemide inj 50mg/5ml ..... 18 torsemide tabs .................. 18 TPN ELECTROLYTES ..... 41 TRACLEER ....................... 19 TRADJENTA ..................... 29 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 TRANDATE ...................... 17

see labetalol hcl ............ 17 trandolapril ........................ 14 tranexamic acid ................. 38 TRANSDERM-SCOP ........ 35 TRANXENE T ............. 21, 22

see clorazepate dipotassium ................... 20

tranylcypromine sulfate ..... 23 travasol 10 ........................ 41 TRAVATAN Z ................... 44 trazodone hcl .................... 23 TREANDA ......................... 11 TRECATOR ........................ 8 TRELSTAR DEPOT MIXJECT .......................... 13 TRELSTAR LA MIXJECT . 13 TRELSTAR MIXJECT ....... 13 tretinoin ....................... 13, 46 TRETINOIN MICROSPHERE ............... 46 trexall ................................ 39 triamcinolone acetonide (mouth) ............................. 50 triamcinolone acetonide (nasal) ............................... 45 triamcinolone acetonide (topical) ............................. 49 triamt/hctz cap 37.5-25 ..... 18 triamt/hctz cap 50-25mg ... 18 triamt/hctz tab 37.5-25 ...... 18 triamt/hctz tab 75-50mg .... 19 TRICOR

see fenofibrate .............. 16 triderm ............................... 49 trifluoperazine hcl .............. 25 trifluridine .......................... 43

trihexyphenidyl hcl ............ 24 tri-legest 28 day ................ 31 TRILEPTAL ...................... 22

see oxcarbazepine ........ 21 TRILEPTAL SUSP ............ 22 TRILIPIX

see choline fenofibrate .. 16 trilyte ................................. 36 trimethoprim ........................ 6 TRINESSA ........................ 31 TRI-NORINYL 28 .............. 31

see aranelle 28.............. 29 TRIOSTAT ........................ 34

see liothyronine sodium 34 tri-previfem 28 day ............ 31 TRISENOX ....................... 13 tri-sprintec 28 day ............. 31 TRIUMEQ ........................... 8 trivora 28 day .................... 31 TRIZIVIR ............................. 8

see abacavir sulfate-lamivudine-zidovudine ................................... 7

TROKENDI XR ................. 22 TROPHAMINE .................. 41 TROPHAMINE INJ 10% ... 41 trospium chloride .............. 37 trospium chloride er .......... 37 TRUSOPT ........................ 44

see dorzolamide hcl ...... 44 TRUVADA .......................... 8 TUDORZA PRESSAIR ..... 44 TWINRIX INJ .................... 40 TWYNSTA

see telmisartan-amlodipine ...................................... 15

TYBOST ............................. 7 TYGACIL ............................ 6 TYKERB ........................... 13 tylenol with codeine ............ 2 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ........................... 1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ........................... 1

TYPHIM VI ........................ 40 TYSABRI .......................... 27


79

TYVASO ........................... 19 TYZEKA ..............................8 tyzine ................................ 45 U UCERIS ............................ 36 u-cort ................................. 49 ULESFIA ........................... 49 ULORIC ..............................1 ULTRACET .........................2

see tramadol-acetaminophen .2

ULTRAM .............................2 see tramadol hcl tab 50 mg ...................................2

ULTRAM ER .......................2 see tramadol hcl er ..........2

ULTRAVATE ..................... 49 see halobetasol propionate ..................... 48

ULTRESA ......................... 37 UNASYN ........................... 11

see ampicillin & sulbactam sodium ........................... 10

UNASYN BULK PACK ...... 11 see ampicillin & sulbactam sodium ........................... 10

UNIRETIC ......................... 14 UNITHROID ...................... 34 UNIVASC .......................... 14

see moexipril hcl ............ 14 urecholine ......................... 37 URECHOLINE

see bethanechol chloride ...................................... 37

UROCIT-K ......................... 37 UROCIT-K 15 .................... 37 UROXATRAL .................... 37

see alfuzosin hcl ............ 37 URSO 250......................... 37

see ursodiol ................... 37 URSO FORTE .................. 37

see ursodiol ................... 37 ursodiol ............................. 37 UVADEX ........................... 13 V VAGIFEM .......................... 32 valacyclovir hcl ....................8 VALCHLOR ....................... 49

VALCYTE ........................... 8 VALIUM ............................ 22

see diazepam ................ 20 valproate sodium .............. 22 valproic acid ...................... 22 valsartan ........................... 15 valsartan-hydrochlorothiazide ........................................ 15 VALTREX

see valacyclovir hcl ......... 8 VANCOCIN HCL ................. 6

see vancomycin hcl ......... 6 vancomycin hcl ................... 6 VANDAZOLE .................... 38 VANOS ............................. 49

see fluocinonide ............ 48 VANTAS ........................... 13 VAQTA .............................. 40 VARIVAX .......................... 40 VASCEPA ......................... 16 VASERETIC ..................... 14

see enalapril maleate & hydrochlorothiazide ....... 14

VASOTEC ......................... 14 see enalapril maleate .... 14

VECTIBIX ......................... 12 VECTICAL ........................ 47 VELCADE ......................... 12 VELETRI ........................... 19 velivet 28 day .................... 31 VELPHORO ...................... 34 venlafaxine cap er ............. 23 venlafaxine hcl .................. 23 VENLAFAXINE HCL ER

see venlafaxine tab er ... 23 VENLAFAXINE HCL ER TAB (VERT) ...................... 23 venlafaxine tab .................. 23 VENLAFAXINE TAB 225MG ER ..................................... 23 venlafaxine tab er ............. 23 VENTAVIS ........................ 19 VENTOLIN HFA ................ 45 verapamil hcl ..................... 18 VERAPAMIL HCL ............. 18 VERELAN ......................... 18

see verapamil hcl .......... 18 VERELAN PM ................... 18

see verapamil hcl .......... 18 veripred ............................. 33 VERSACLOZ .................... 25 VESICARE ....................... 37 vestura .............................. 31 VEXOL .............................. 43 VFEND

see voriconazole ............. 7 VFEND IV ........................... 7

see voriconazole inj 200mg ............................. 7

VFEND SUS 40MG/ML ...... 7 VFEND TAB ....................... 7 VIAGRA ............................ 50 VIBRAMYCIN ................... 11

see doxycycline (monohydrate) ............... 11 see doxycycline hyclate 11

vicodin ................................ 2 vicodin es ............................ 2 vicodin hp ........................... 3 VICOPROFEN .................... 3

see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 2

VICTOZA .......................... 28 VICTRELIS ......................... 8 VIDAZA ............................. 12

see azacitidine .............. 12 VIDEX EC ........................... 7

see didanosine ................ 7 VIDEX PEDIATRIC ............. 7 VIGAMOX ......................... 43 VIIBRYD ........................... 23 VIMIZIM ............................ 32 VIMPAT ............................ 22 vinblastine sulfate ............. 12 vincasar ............................ 12 vincristine sulfate .............. 12 vinorelbine tartrate ............ 12 VIOKACE 10 ..................... 37 VIOKACE 20 ..................... 37 viorele ............................... 31 VIRACEPT .......................... 7 VIRAMUNE ......................... 7

see nevirapine ................. 7 VIRAMUNE XR ................... 7

see nevirapine ................. 7


80

VIREAD...............................7 VIROPTIC ......................... 43

see trifluridine ................ 43 VISTARIL .......................... 45

see hydroxyzine pamoate ...................................... 45

VISTIDE ..............................8 see cidofovir ....................8

vitamin d............................ 50 vivactil ............................... 23 VIVELLE-DOT ................... 32 VIVITROL.......................... 28 VOLTAREN GEL 1% ........ 49 VOLTAREN-XR ..................1

see diclofenac sodium .....1 voriconazole ........................7 voriconazole inj 200mg .......7 VOSOL HC ....................... 50 vospire .............................. 45 VOSPIRE ER

see albuterol sulfate er .. 45 VOTRIENT ........................ 13 VPRIV ............................... 32 vyfemia 28 day .................. 31 VYTORIN .......................... 16 VYVANSE ......................... 25 W warfarin sodium ................. 38 WELCHOL ........................ 16 WELLBUTRIN ................... 23

see bupropion hcl .......... 22 WELLBUTRIN SR ............. 23

see bupropion hcl .......... 22 WELLBUTRIN XL ............. 23

see bupropion hcl .......... 22 WESTCORT

see hydrocortisone valerate.......................... 48

X XALATAN.......................... 44

see latanoprost .............. 44 XALKORI .......................... 13 XANAX

see alprazolam ........ 19, 20 XANAX TAB 0.25MG ........ 20 XANAX TAB 0.5MG .......... 20 XANAX TAB 1MG ............. 20 XANAX TAB 2MG ............. 20

XARELTO ......................... 38 XARELTO STARTER PACK .......................................... 38 XARTEMIS XR ................... 4 XELJANZ .......................... 39 XENAZINE ........................ 27 XEOMIN ............................ 44 XGEVA ............................. 34 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 37 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 2 see hydrocodone-acetaminophen 5-300mg ..................... 2 see hydrocodone-acetaminophen 7.5-300mg .................. 2 see vicodin ...................... 2 see vicodin es ................. 2 see vicodin hp ................. 3

xodol tab 10-300mg ............ 3 xodol tab 5-300mg .............. 3 xodol tab 7.5-300 ................ 3 XOLAIR ............................. 45 XOPENEX HFA ................ 45 XTANDI ............................. 13 xulane dis 150-35 ............. 32 XYLOCAINE ................. 5, 49

see lidocaine hcl ............ 49 see lidocaine hcl (local anesth.) ........................... 5 see lidocaine inj 1%......... 5 see lidocaine inj 2%......... 5

XYLOCAINE INJ 1% ........... 5 XYLOCAINE-MPF .............. 5

see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 0.5% ...... 5 see lidocaine inj 1%......... 5 see lidocaine inj 1.5% ...... 5 see lidocaine inj 2%......... 5

XYREM ............................. 27 XYZAL .............................. 45

see levocetirizine soln 2.5mg/5ml ..................... 45

see levocetirizine tab 5 mg ...................................... 45

Y YASMIN 28 ....................... 32

see drospirenone-ethinyl estradiol ........................ 30 see syeda ...................... 31 see zarah ...................... 32

YAZ ................................... 32 see loryna 28 day .......... 30 see nikki 3-0.02mg ........ 31 see vestura ................... 31

YF-VAX ............................. 40 Z zafirlukast ......................... 45 zamicet ............................... 3 ZANAFLEX ....................... 27

see tizanidine ................ 27 ZANOSAR ........................ 11 ZANTAC ........................... 36

see ranitidine hcl ........... 35 zarah ................................. 32 zarontin ............................. 22 ZARONTIN ....................... 22

see ethosuximide .......... 21 ZAROXOLYN ................... 19

see metolazone ............. 18 ZAVESCA ......................... 32 zazole ............................... 38 ZAZOLE ............................ 38 ZEBETA ............................ 17

see bisoprolol fumarate . 17 ZELAPAR ......................... 24 ZELBORAF ....................... 13 ZEMAIRA .......................... 45 ZEMPLAR ......................... 42

see paricalcitol .............. 42 zenatane ........................... 46 zenchent fe 28 day ........... 32 zenchent tab ..................... 32 ZENPEP ........................... 37 ZERIT ................................. 7

see stavudine .................. 7 ZESTORETIC ................... 14

see lisinopril & hydrochlorothiazide ....... 14

ZESTRIL ........................... 14 see lisinopril .................. 14


81

ZETIA TAB 10MG ............. 16 ZETONNA ......................... 45 ZIAC .................................. 16

see bisoprolol & hydrochlorothiazide ....... 16

ZIAGEN...............................7 see abacavir sulfate ........7

zidovudine ...........................7 ZINACEF.............................9

see cefuroxime sodium....9 ZINECARD ........................ 13

see dexrazoxane ........... 13 ZIOPTAN .......................... 44 ziprasidone hcl .................. 25 ZIRGAN ............................ 43 ZITHROMAX ..................... 10

see azithromycin .............9 ZITHROMAX TRI-PAK ...... 10 ZITHROMAX Z-PAK ......... 10 ZMAX ................................ 10 ZOCOR ............................. 16

see simvastatin .............. 16 ZOFRAN ........................... 35

see ondansetron hcl ...... 35 see ondansetron hcl oral soln ................................ 35

ZOFRAN ODT ................... 35 see ondansetron odt ...... 35

ZOLADEX ......................... 13 zoledronic inj 4mg/5ml ...... 29 zoledronic inj 5/100ml ....... 29 ZOLINZA ........................... 12 zolmitriptan ....................... 27 zolmitriptan odt ................. 27 ZOLOFT ............................ 23

see sertraline hcl ........... 23 zolpidem tartrate ............... 26 ZOMETA ........................... 29

see zoledronic inj 4mg/5ml ...................................... 29

ZOMIG .............................. 27 see zolmitriptan ............. 27

ZOMIG ZMT ...................... 27 see zolmitriptan odt ....... 27

ZONALON ........................ 47 ZONEGRAN ..................... 22

see zonisamide ............. 22 zonisamide ........................ 22 ZONTIVITY ....................... 39 ZORBTIVE ........................ 33 ZORTRESS TAB 0.25MG . 40 ZORTRESS TAB 0.5MG ... 40 ZORTRESS TAB 0.75MG . 40 ZOSTAVAX ....................... 40 ZOSYN ............................. 11

see piperacillin

sodium-tazobactam sodium .......................... 11

zovia 1/35e 28 day............ 32 zovia 1/50e 28 day............ 32 ZOVIRAX ...................... 9, 47

see acyclovir ................... 8 see acyclovir topical ...... 47

ZUBSOLV ......................... 28 ZYBAN .............................. 28

see buproban ................ 27 ZYDELIG .......................... 13 ZYFLO CR ........................ 45 ZYKADIA .......................... 13 ZYLET .............................. 42 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1 ZYMAXID

see gatifloxacin (ophth) . 43 ZYPREXA ......................... 25

see olanzapine .............. 24 ZYPREXA ZYDI TAB 10MG.......................................... 25 ZYPREXA ZYDIS ............. 25

see olanzapine odt ........ 24 ZYTIGA ............................. 13 ZYVOX ............................... 6

2015 empire plan medicare rx eff 01/01/2015 dec update · 2014-12-31 · 2015 empire plan medicare...

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