2015 custom commercial prescription drug guidethe php custom commercial prescription drug guide is a...

2015 Custom Commercial Prescription Drug GuidePlease bring this guide with you on your next doctor visit.

© 2015 Express Scripts Holding Company. All Rights Reserved.

If you have questions about your prescription drug benefit, visit Express-Scripts.com or call Member Services using the toll-free number on the back of your prescription drug ID card.

Express Scripts manages your prescription benefit for your employer, plan sponsor, or health plan.

The benefiTs of The CommerCial PresCriPTion Drug guiDeThe PHP Custom Commercial Prescription Drug Guide is a list of medications which may be covered under your prescription drug plan.* This list was reviewed by an independent group of practicing doctors and pharmacists, and it contains medications made by most pharmaceutical manufacturers. It includes medications for many covered conditions.

• Specific Over-The-Counter (OTC) medications are covered based upon Health Care Reform (HCR) and the Member’s benefit. Member’s must refer to their Prescription Drug Rider for coverage and benefit information.

*Please Note: Not all the medications in this guide are covered by all pharmacy benefit programs. The PHP Custom Commercial Prescription Drug Guide only lists the most frequently prescribed medications and is subject to change. For the most up-to-date information on coverage and cost of a medication you can call the PHP Customer Service Department at 1 800 832-9186 or go to Express-Scripts.com. You will need to register if you are a first time user of the Express Scripts website.

Your plan may prefer some medications over others. These are called plan-preferred drugs, and their copayment may be lower. The amount of your copayment depends on which drug your doctor prescribes for you.

Tier 0A select list of prescription and over-the-counter medications considered to be preventive based upon the Health Care Reform (HCR) Affordable Care Act (ACA) guidelines. Member’s must refer to their Prescription Drug Rider for coverage and benefit information..

Tier 1Tier 1 represents your lowest copayment option.

Tier 2Tier 2 is your middle copayment option.

Tier 3Tier 3/Non-Preferred products are your highest copayment option. Coverage for Tier 3/Non-Preferred products is determined by the prescription drug benefit plan.

Note: If the member has a “closed” pharmacy benefit (two-tier pharmacy plan) then medications on the non-preferred list are generally not covered except under certain processes consistent with applicable law.

Note: Medications listed in parentheses ( ) only indicate the trade name/generic name of the medications. Coverage is determined by the consumer’s prescription drug benefit plan

safeTy ConsiDeraTion symbolsHere is a quick guide for you and your doctor, which explains our safety symbols. These symbols appear next to certain medications.

N Notification required. QL Quantity limit.QD Quantity per duration limit.A Age edit. ST Step therapy.ACA Preventive Medication.

This information is in effect at the time of printing and may be subject to change.

Note: This Prescription Drug List (PDL) is for Physicians Health Plan HMO, and PPO Products. Coverage is based on member’s benefit.

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Tier 0apri ACA aspir-low ACA aspirin ACA aspirin low dose ACA bayer aspirin ACA BAYER CHEWABLE ASPIRIN ACA buproban ACA QD calcium 600 + d(3) ACA calcium 600 with vitamin d3 ACA calcium carbonate-vitamin d2 ACA calcium carbonate-vitamin d3 ACA calcium citrate-vitamin d2 ACA calcium citrate-vitamin d3 ACA camila ACA CHANTIX ACA QD cholecalciferol (vitamin d3) ACA citrus calcium ACA d-vi-sol ACA delta d3 ACA e.c. prin ACA ECOTRIN ACA ecotrin low strength ACA enpresse ACA FER-IN-SOL ACA fer-iron ACA fluor-a-day (with xylitol) oral tablet, chewable 0.25 mg f (0.55 mg)-

236.79mg, 0.5 mg f (1.1 mg)-236.79 mg ACA FLUORABON ACA fluoritab oral tablet,chewable 0.5 mg fluoride (1.1 mg) ACA FLURA-DROPS ACA folic acid oral tablet 400 mcg, 800 mcg ACA gavilyte ACA junel fe ACA kariva (28) ACA levonorgestrel oral tablet 0.75 mg ACA QD low-ogestrel (28) ACA ludent fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg

fluoride (1.1 mg) ACA NATAZIA ACA NICODERM CQ ACA QD nicorelief ACA QD NICORETTE ACA QD NICORETTE BUCCAL LOZENGE 4 MG N ACA QD nicotine ACA QD NICOTROL N ACA QD NOVAFERRUM ACA nts step 1 ACA QD oysco ACA oyster shell calcium with d ACA peg 3350-electrolytes ACA quit ACA QD sodium fluoride ACA sprintec (28) ACA tri-sprintec (28) ACA trilyte with flavor packets ACA VAGINAL CONTRACEPTIVE FILM ACA vaginal contraceptive foam ACA velivet triphasic regimen (28) ACA vitamin d3 ACA

ZYBAN ACA QD

Tier 1abacavir abacavir-lamivudine-zidovudine acamprosate acarbose acebutolol acetaminophen-codeine acetasol hc acetazolamide acetic acid acetic acid-aluminum acetate acetylcysteine acitretin acyclovir adapalene N adefovir afeditab cr ak-poly-bac ala-cort alagesic lq albuterol sulfate alclometasone alendronate QD QL alfuzosin QD QL allopurinol alprazolam alprazolam intensol altavera (28) alyacen amantadine hcl amcinonide amethia amethia lo amethyst amiloride amiloride-hydrochlorothiazide aminocaproic acid amiodarone amitriptyline amlodipine amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 5-40 mg amlodipine-benazepril oral capsule 2.5-10 mg, 5-10 mg, 5-20 mg QD QL amlodipine-valsartan ammonium lactate amnesteem amoxapine amoxicillin amoxicillin-pot clavulanate amphetamine salt combo ampicillin anagrelide anaspaz antipyrine-benzocaine anucort-hc apexicon e aranelle (28) ascomp with codeine atenolol atenolol-chlorthalidone

SeCTion I

Key: N = Notification required. QL = Quantity limit. QD = Quantity per duration limit.

A = Age edit.ST = Step Therapy.ACA = Preventive Medication.

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atorvastatin QD atovaquone QD QL atovaquone-proguanil atropine aubra avar topical cleanser aviane avidoxy avita topical cream azathioprine azelastine azelastine nasal aerosol, spray QD QL azelastine nasal spray, non-aerosol azithromycin azurette (28) bacitracin baclofen balsalazide balziva (28) benazepril benazepril-hydrochlorothiazide benzepro benzonatate benzoyl peroxide benztropine betamethasone dipropionate betamethasone valerate betamethasone, augmented betaxolol bethanechol chloride bicalutamide bisoprolol fumarate bisoprolol-hydrochlorothiazide bp 10-1 bp foam bp wash bpo briellyn brimonidine ophthalmic drops 0.15 % QD QL brimonidine ophthalmic drops 0.2 % bromfenac bromocriptine brompheniramin-phenylephrin-dm budesonide bumetanide buprenorphine hcl buprenorphine-naloxone bupropion hcl oral tablet QD QL bupropion hcl buspirone butalbital compound w/codeine butalbital-acetaminop-caf-cod butalbital-acetaminophen butalbital-aspirin-caffeine butorphanol tartrate nasal cabergoline calcipotriene calcitonin (salmon) QD QL calcitrene calcitriol calcium acetate camrese camrese lo candesartan QD

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg QD candesartan-hydrochlorothiazid oral tablet 32-25 mg captopril captopril-hydrochlorothiazide carafate oral suspension carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carisoprodol carisoprodol-aspirin carteolol cartia xt carvedilol caziant (28) cefaclor cefadroxil cefdinir oral capsule QD QL cefdinir oral suspension for reconstitution cefditoren pivoxil cefpodoxime cefprozil cefuroxime axetil cem-urea centergy dm cephalexin cevimeline chateal cheratussin ac cheratussin dac chlordiazepoxide hcl chlordiazepoxide-clidinium chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpromazine chlorpropamide cholestyramine choline,magnesium salicylate chorionic gonadotropin, human N QD QL ciclopirox ciclopirox topical solution QD QL cilostazol cimetidine ciprofloxacin citalopram citalopram oral tablet 20 mg, 40 mg QL claravis claris clarifying wash clarithromycin clemastine clindamycin hcl clindamycin palmitate hcl clindamycin phosphate clindamycin-benzoyl peroxide clobetasol clomiphene citrate N clomipramine clonazepam clonidine QD QL clonidine hcl clopidogrel clorazepate dipotassium clotrimazole



clotrimazole-betamethasone clozapine codeine sulfate oral tablet codeine-guaifenesin colchicine-probenecid colestipol colocort compro constulose cormax cortisone covaryx covaryx h.s. cpm-pseudoephed-hydrocodone cromolyn cryselle (28) cyclafem cyclobenzaprine cyclopentolate cyclosporine cyproheptadine oral tablet danazol dantrolene dasetta daysee delyla (28) depade desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sodium phosphate dexedrine dexmethylphenidate oral capsule,er biphasic 50-50 30 mg, 40 mg dexmethylphenidate oral tablet QD QL dextroamphetamine QD QL dextroamphetamine oral solution dextroamphetamine-amphetamine oral capsule,extended release 24hr

10 mg, 15 mg, 5 mg QD QL dextroamphetamine-amphetamine oral capsule,extended release 24hr

20 mg, 25 mg, 30 mg diazepam diazepam intensol diclofenac dicloxacillin dicyclomine didanosine diflorasone diflunisal digox digoxin dihydrocodeine-aspirin-caff dihydroergotamine injection dilt-xr diltiazem hcl diphenhydramine hcl diphenoxylate-atropine dipyridamole diskets disopyramide phosphate disulfiram

divalproex donepezil QD QL donepezil oral tablet 23 mg N dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxycycline hyclate doxycycline monohydrate drithocreme hp dronabinol drospirenone-ethinyl estradiol duloxetine QD QL e.e.s. 400 econazole ed-spaz eemt eemt hs effer-k oral tablet, effervescent 25 meq elinest eliphos elite-ob emoquette enalapril maleate enalapril-hydrochlorothiazide endocet endodan enoxaparin QD enskyce entacapone entecavir oral tablet 0.5 mg QD QL entecavir oral tablet 1 mg QD enulose epinastine epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000) epinephrine injection auto-injector 0.3 mg/0.3 ml (1:1,000) QD QL epitol eplerenone eprosartan QD errin ery pads ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg erygel erythrocin (as stearate) erythromycin erythromycin ethylsuccinate erythromycin with ethanol erythromycin-benzoyl peroxide escitalopram oxalate estarylla estazolam estradiol oral estradiol transdermal QD QL estradiol-norethindrone acet estrogens-methyltestosterone estropipate eszopiclone ST QD ethambutol ethosuximide etidronate disodium etodolac exemestane fabb

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falmina (28) famciclovir famotidine felbamate felodipine fenofibrate fenofibric acid fenoprofen fentanyl QD fentanyl citrate N ST QD ferrex 150 forte plus finasteride FIRST-LANSOPRAZOLE FIRST-OMEPRAZOLE flavoxate flecainide fluconazole flucytosine fludrocortisone flunisolide QD QL fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluocinonide-emollient fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) fluorometholone fluorouracil fluoxetine fluphenazine hcl flurazepam flurbiprofen flurbiprofen sodium flutamide fluticasone QD QL fluvastatin QD fluvoxamine folbee folic acid oral tablet 1 mg fondaparinux QD fortical QD QL fosinopril fosinopril-hydrochlorothiazide furosemide gabapentin galantamine oral capsule,ext rel. pellets 24 hr galantamine QD QL garamycin gatifloxacin gemfibrozil generlac gengraf gentak gentamicin gianvi (28) gildagia gildess glimepiride glipizide glipizide-metformin glyburide glycopyrrolate granisetron hcl

griseofulvin microsize griseofulvin ultramicrosize guaiatussin ac guaifenesin guaifenesin ac guaifenesin dac guanfacine halobetasol propionate haloperidol heather homatropaire homatropine hbr hydralazine hydrochlorothiazide hydrocodone-acetaminophen hydrocodone-chlorpheniramine hydrocodone-homatropine oral tablet hydrocodone-ibuprofen hydrocortisone hydrocortisone acetate hydrocortisone butyr-emollient hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet hydrocortisone-pramoxine hydromet hydromorphone hydroxychloroquine hydroxyurea hydroxyzine hyophen hyoscyamine sulfate hypercare ibandronate QD QL ibuprofen oral tablet ibuprofen-oxycodone QD QL iferex 150 forte imipramine hcl imiquimod N indapamide indomethacin introvale ipratropium bromide ipratropium-albuterol irbesartan QD irbesartan-hydrochlorothiazide QD isomethepten-caf-acetaminophen isoniazid isosorbide dinitrate isosorbide mononitrate isoxsuprine isradipine itraconazole jantoven jencycla jinteli jolessa jolivette junel k-effervescent k-phos-neutral kelnor 1/35 (28) ketoconazole

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ketodan ketoprofen ketorolac kionex klor-con klor-con/ef kurvelo l norgest&e estradiol-e estrad labetalol lactic acid lactulose lamivudine lamivudine-zidovudine lamotrigine oral tablet lamotrigine oral tablet, chewable larin latanoprost QD QL latrix leena 28 leflunomide QL lessina letrozole leucovorin calcium leuprolide levacet levalbuterol hcl levetiracetam levobunolol levofloxacin levonest (28) levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad levora-28 levothyroxine levoxyl lidocaine lidocaine hcl-hydrocortison ac lidocaine viscous lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram) lidocaine-prilocaine lindane liothyronine lisinopril lisinopril-hydrochlorothiazide lithium loperamide lorazepam lorazepam intensol lorcet lortab 10-325 loryna (28) losartan losartan-hydrochlorothiazide lovastatin QD loxapine succinate ludent fluoride oral tablet, chewable 1 mg fluoride (2.2 mg) lutera (28) lyza m-clear wc malathion maprotiline margesic marlissa marten-tab

matzim la meclizine meclofenamate medroxyprogesterone mefloquine QD QL megestrol meloxicam QD QL meperidine meperitab mercaptopurine mesalamine metadate er QD QL metaproterenol metformin methadone methadone intensol methadose methazolamide methenamine methimazole methocarbamol methotrexate sodium methoxsalen rapid methscopolamine methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylergonovine methylphenidate QD QL methylphenidate oral solution methylprednisolone metoclopramide hcl metolazone metoprolol metoprolol hydrochlorothiaz metronidazole mexiletine miconazole-3 QD QL microgestin midazolam midodrine migragesic ida millipred mimvey minocycline minoxidil mirtazapine misoprostol modafinil N moderiba N moderiba dose pack N moexipril moexipril-hydrochlorothiazide mometasone mono-linyah mononessa (28) montelukast morphine morphine oral capsule, extend.release pellets QD QL morphine oral tablet extended release QD moxifloxacin multi-vitamin with fluoride mupirocin my way



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mycophenolate myferon 150 forte myorisan myzilra nabumetone nadolol naltrexone naproxen naratriptan QD nateglinide QD QL nature-throid necon neo-polycin neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc nevirapine NEXIUM next choice one dose niacin nifedical xl nifedipine nikki (28) nimodipine nisoldipine nitro-bid nitrofurantoin nitroglycerin nizatidine nodolor nora-be norethindrone (contraceptive) norethindrone ac-eth estradiol norethindrone acetate norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc nortrel nortriptyline novarel N QD QL np thyroid nyamyc nystatin nystatin-triamcinolone nystop ocella octreotide acetate injection solution N ofloxacin ogestrel (28) olanzapine omeprazole ondansetron orsythia oscimin oxaprozin oxazepam oxcarbazepine oxybutynin chloride oxybutynin chloride oral tablet extended release 24hr QD QL oxycodone oxycodone-acetaminophen

oxycodone-aspirin oxymorphone oral tablet pacerone pancrelipase 5000 pantoprazole paregoric paricalcitol QD QL paroex oral rinse paromomycin paroxetine hcl QD QL penicillin v potassium pentazocine-naloxone pentoxifylline perindopril erbumine periogard permethrin perphenazine phenadoz phenazopyridine phenelzine phenergan phenobarb-hyoscy-atropine-scop phenobarbital phenylhistine dh phenytoin philith phospha 250 neutral phosphasal pilocarpine hcl pimtrea (28) pindolol pioglitazone QD QL pioglitazone-glimepiride pirmella piroxicam pnv-dha + docusate pnv-omega pnv-total podofilox poly-iron 150 forte polycin polymyxin b sulf-trimethoprim portia potassium bicarb and chloride potassium bicarb-citric acid potassium chloride potassium citrate pramcort pramipexole pravastatin QD prazosin prednisolone prednisolone acetate prednisolone sodium phosphate prednisone prednisone intensol prevalite previfem primidone PROAIR HFA probenecid procentra prochlorperazine maleate procto-pak



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proctosol hc proctozone-hc progesterone micronized promethazine promethazine vc promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil protriptyline pyrazinamide pyridostigmine bromide quasense quetiapine quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate raloxifene ramipril ranitidine hcl reclipsen (28) rectacort-hc relcof c remeven reno caps repaglinide QD QL reprexain reserpine ribapak dose pack N ribasphere N QD ribasphere oral tablet 400 mg, 600 mg N ribavirin N QD rifabutin QD QL rifampin riluzole risedronate risperidone rivastigmine tartrate QD QL rizatriptan QD ropinirole oral tablet rosadan topical cream roxicet oral tablet salacyn topical lotion salicylic acid sr-ceramides topical combo pack salicylic acid topical liquid salsalate scalacort seb-prev selegiline hcl selenium sulfide serophene N sertraline sharobel sildenafil N QD silver nitrate applicators silver sulfadiazine simvastatin QD

sirolimus sodium chloride sorine sotalol spinosad spironolacton-hydrochlorothiaz spironolactone sronyx ssd sss 10-5 stavudine strong iodine sucralfate sulfacetamide sod-sulfur-urea topical cleanser sulfacetamide sodium sulfacetamide sodium-sulfur sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfazine sulfazine ec sulindac sumatriptan QD sumatriptan succinate QD syeda symax fastabs symaxtacrolimus tamoxifen tamsulosin taztia xt telmisartan QD telmisartan-amlodipine telmisartan-hydrochlorothiazid QD temazepam temozolomide terazosin terbinafine hcl terbutaline terconazole QD QL tetracycline theochron theophylline thermazene thiothixene tiagabine ticlopidine tilia fe timolol maleate tinidazole QD QL tizanidine tl gard rx tl-select tobramycin tobramycin in 0.225 % nacl N tobramycin-dexamethasone tolazamide tolbutamide tolmetin tolterodine oral capsule, extended release 24hr QD QL tolterodine oral tablet topiramate torsemide



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tramadol tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid tranylcypromine travoprost (benzalkonium) QD QL trazodone tretinoin tretinoin (chemotherapy) tretinoin microspheres N tri-estarylla tri-legest fe tri-linyah tri-previfem (28) tri-vit with fluoride & iron tri-vitamin with fluoride triadvance triamcinolone acetonide QD QL triamterene-hydrochlorothiazid trianex triazolam N A triderm trifluoperazine trifluridine trihexyphenidyl trimethobenzamide trimethoprim trinessa (28) trivora (28) tropicamide trospium oral capsule, extended release 24hr trospium oral tablet QD QL trymine cg tusnel c tussigon umecta topical foam unithroid ur n-c urea urea-hyaluronate sodium urin ds ursodiol uryl valacyclovir QD QL valproic acid valsartan QD valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 80-12.5

mg QD valsartan-hydrochlorothiazide oral tablet 320-12.5 mg, 320-25 mg vancomycin vandazole vasolex vemavite-prx-2 venlafaxine QD QL verapamil veripred 20 vestura (28) viorele (28) virt-vite voriconazole N vp-zel vyfemla (28) wera (28)

westhroid wymzya fe x-viate zaleplon zarah zebutal zenatane zenchent (28) zenchent fe zencia zenzedi oral tablet 5 mg,10 mg zeosa zidovudine zinc sulfate ziprasidone hcl zolmitriptan QD zolpidem zonisamide zovia

Tier 2ABSORICA ACTIMMUNE N ACTOPLUS MET XR ADCIRCA N ADVAIR DISKUS QD QL ADVICOR AFLURIA 2014-2015 (PF) A AGGRENOX ALBENZA ALDACTAZIDE ORAL TABLET 50-50 MG ALINIA QD QL ALOMIDE ALPHAGAN P OPHTHALMIC DROPS 0.1 % QD QL ALREX ALTOPREV AMINOCAPROIC ACID ORAL TABLET 1,000 MG AMITIZA QD ANDRODERM ANDROGEL QD ANTARA ANZEMET QD APIDRA APOKYN APRISO APTIVUS ARANESP (IN POLYSORBATE) N QD ARMOUR THYROID ASACOL HD ASMANEX TWISTHALER ASTEPRO ATRIPLA ATROVENT HFA AUGMENTIN ORAL SUSPENSION 125-31.25 MG/5 ML AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML (1:1,000) AUVI-Q INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000) QD QL AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG QD QL AVANDARYL ORAL TABLET 8-4 MG AVANDIA QL AVC VAGINAL AVODART N QD AVONEX (WITH ALBUMIN) QD QL AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE KIT QD QL



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AZASAN AZELEX BARACLUDE QD QL BETASERON QD QL BETIMOL BETOPTIC S BIDIL BILTRICIDE BRAVELLE N BRILINTA BUPHENYL ORAL TABLET BYDUREON SUBCUTANEOUS PEN INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

N BYETTA QD QL CAFERGOT CANASA CAPEX CARAC CAVERJECT QD CAVERJECT IMPULSE QD CEFTIN ORAL SUSPENSION CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG QD CELEBREX ORAL CAPSULE 50 MG CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION CETRAXAL CETROTIDE N QD QL CHEMET CIALIS QD CILOXAN OPHTHALMIC OINTMENT CIPRODEX CLEOCIN ORAL CAPSULE CLINDESSE COARTEM N COLCRYS COLESTID FLAVORED COMBIPATCH QD QL COMBIVENT RESPIMAT CONDYLOX TOPICAL GEL COPAXONE N QD CORDRAN TAPE SMALL ROLL QD QL CORDRAN TOPICAL CREAM COREG CR CORTIFOAM COUMADIN CREON CRESTOR QD CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % N CRIXIVAN CUPRIMINE CYCLOGYL OPHTHALMIC DROPS 0.5 % CYCLOSERINE CYSTAGON N DALIRESP DAPSONE DARAPRIM DAYTRANA QD QL DELZICOL DEMSER DIASTAT QD QL DIBENZYLINE DIFFERIN TOPICAL LOTION N A DILANTIN

DORYX ORAL TABLET, DELAYED RELEASE (DR/EC) 200 MG DROXIA DULERA EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ EFFIENT ELENZAPATCH ELIDEL N ELIQUIS ELLA ELMIRON EMCYT EMEND QD EMTRIVA ORAL CAPSULE ENABLEX ENBREL ST QD ENDOMETRIN N ENJUVIA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ERGOMAR ERTACZO ESTRING QD QL EURAX TOPICAL CREAM EXELON TRANSDERMAL EXFORGE EXFORGE HCT EXJADE N FEMHRT LOW DOSE FINACEA FIORICET WITH CODEINE FLUARIX 2014-2015 (PF) A FLUBLOK 2014-2015 (PF) A FLUCELVAX 2014-2015 (PF) A FLULAVAL QUAD 2014-2015 (PF) A FLUOXETINE ORAL TABLET 60 MG FLUVIRIN 2014-2015 (PF) A FLUZONE HIGH-DOSE 2014-15 (PF) A FOLTRATE FORADIL AEROLIZER QD QL FORTEO N FOSRENOL FRAGMIN QD GABITRIL ORAL TABLET 12 MG, 16 MG GENOTROPIN N GLEEVEC N GLUCAGON EMERGENCY KIT (HUMAN) QD QL GOLYTELY ORAL POWDER IN PACKET GONAL-F N HECTOROL ORAL CAPSULE 2.5 MCG HEXALEN HORIZANT HUMALOG HUMATROPE N QD HUMIRA ST QD HUMULIN 70/30 HUMULIN N HUMULIN R HYDROCODONE-HOMATROPINE ORAL SYRUP IBUDONE ORAL TABLET 5-200 MG INNOPRAN XL INTELENCE INTRON A N INVIRASE



11

ISORDIL JANUMET JANUMET XR JANUVIA KALETRA KALYDECO N KINERET ST QD KUVAN N LACRISERT N LAMICTAL LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG LANTUS LANTUS SOLOSTAR LETAIRIS N LEUKERAN LEVEMIR LEVEMIR FLEXTOUCH LEXIVA LOCOID TOPICAL LOTION LOMUSTINE LORTAB ELIXIR LORZONE LOTEMAX OPHTHALMIC DROPS,SUSPENSION LOTRONEX ORAL TABLET 0.5 MG N QD LOTRONEX ORAL TABLET 1 MG N ST QD LOVAZA QD QL LUMIGAN LUNESTA ST QD LUPRON DEPOT LYRICA QD LYSODREN M-END PE MATULANE MEDROL ORAL TABLET 2 MG MENEST MEPHYTON MESTINON ORAL SYRUP METHITEST METHYLIN ORAL TABLET,CHEWABLE QD QL MICARDIS QD MIRAPEX ER MOTOFEN MOVIPREP MULTAQ MUSE QD MYLERAN NASONEX QD QL NATACYN NEBUPENT QD QL NEORAL NEUMEGA N NEUPOGEN QD QL NEXAVAR QD QL NEXIUM PACKET NIASPAN EXTENDED-RELEASE NITROSTAT NORDITROPIN N NORVIR NOVOLIN NOVOLOG NOXAFIL ORAL SUSPENSION NUVARING ONGLYZA ORAP

ORFADIN ORTHO TRI-CYCLEN LO (28) OSMOPREP OVIDREL N QD QL OXSORALEN OXSORALEN ULTRA OXYCONTIN QD OXYTROL PANRETIN PATANOL PAXIL ORAL SUSPENSION PEGASYS N QD PEGINTRON N QD PENTASA PERFOROMIST PHOSPHOLINE IODIDE PNEUMOVAX 23 INJECTION SOLUTION A polyethylene glycol 3350 PRADAXA PRED MILD PREGNYL N QD QL PREMARIN PREMPHASE PREMPRO PREPOPIK PREVNAR 13 (PF) A PREZISTA ORAL TABLET PRIMAQUINE PRISTIQ PROCRIT N QD PROCTOFOAM HC PROTOPIC N PULMICORT FLEXHALER QD QL PULMOZYME N QNASL QVAR QD QL RAPAMUNE REBIF QD QL RELENZA DISKHALER QD RELPAX QD RENAGEL RENVELA ORAL TABLET RESCRIPTOR RESTASIS QD QL REVLIMID REYATAZ RIDAURA SANDIMMUNE SANDOSTATIN LAR DEPOT N SENSIPAR SEREVENT DISKUS QD QL SEROQUEL XR SINGLE USE EZ FLU 2014-15(PF) A SOLARAZE SOMAVERT N SPIRIVA WITH HANDIHALER QD QL SPORANOX ORAL SOLUTION QD QL SPRYCEL STRATTERA QD STRIBILD STROMECTOL SUMAXIN SUPREP N SUSTIVA



12

SUTENT SYMBICORT QD QL SYMLINPEN SYNAREL SYNTHROID TABLOID TACLONEX TOPICAL OINTMENT TAMIFLU QD TARCEVA N QD QL TAZORAC N A TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG TEKTURNA TEKTURNA HCT THALOMID N TIKOSYN TOBI N TOBI PODHALER N TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST TOBREX OPHTHALMIC OINTMENT TOVIAZ TRACLEER N QD TRANSDERM-SCOP TREXALL TRIGLIDE TRIZIVIR TRUVADA TUDORZA PRESSAIR TYKERB N ULESFIA URAMAXIN TOPICAL FOAM VAGIFEM VALCYTE ORAL TABLET QD QL VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML

N QD VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 20 MCG/ML

N VESICARE QD QL VIAGRA QD VICTOZA 2-PAK N ST VIDEX VIGAMOX VIOKACE VIRACEPT VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ORAL TABLET VIVELLE-DOT QD QL VOLTAREN VYTORIN QD VYVANSE QD QL WELCHOL ORAL TABLET WP THYROID ORAL TABLET 130 MG, 32.5 MG, 65 MG XARELTO XELODA XOPENEX HFA XYREM N QD ZEMPLAR QD QL ZENPEP ZETIA QD ZIAGEN ORAL SOLUTION ZOSTAVAX (PF) A ZOVIRAX TOPICAL CREAM ZYLET ZYMAXID ZYVOX N



13

ABILIFY N

ABILIFY DISCMELT N

ABSTRAL QD

ACANYA

ACCOLATE

ACCUPRIL

ACCURETIC

ACIPHEX ST QD

ACIPHEX SPRINKLE ST

ACTEMRA N

ACTIGALL

ACTIQ N ST

ACTIVELLA

ACTOPLUS MET

ACTOS QD QL

ACULAR

ACULAR LS

ACUVAIL (PF)

ACZONE

ADALAT CC

ADASUVE

ADDERALL

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG QD QL

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 20 MG, 25 MG, 30 MG

ADEMPAS N

ADOXA

ADRENACLICK INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML (1:1,000)

ADRENACLICK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000) QD QL

AEROSPAN

AFINITOR N

AFINITOR DISPERZ N

AGRYLIN

AKTEN (PF)

ALA-QUIN

ALA-SCALP

ALCAINE

ALCORTIN A

ALDACTAZIDE ORAL TABLET 25-25 MG

ALDACTONE

ALOCRIL

ALOQUIN

ALORA QD QL

ALPHAGAN P OPHTHALMIC DROPS 0.15 % QD QL

ALSUMA QD

ALTABAX

altacaine

ALTACE

ALUVEA

ALVESCO ST

AMARYL

AMBIEN ST QD

AMERGE ST QD

amitriptyline-chlordiazepoxide

amlodipine-atorvastatin QD QL

amlodipine-atorvastatin oral tablet 5-10 mg QL

amoxicil-clarithromy-lansopraz QD QL

AMOXICILLIN ORAL TABLET, ER MULTIPHASE 24 HR

AMPYRA N

AMRIX

AMTURNIDE

ANACAINE

ANADROL-50

ANAFRANIL

ANALPRAM E

ANALPRAM-HC

ANAPROX

ANAPROX DS

anastrozole

ANCOBON

ANDROID

ANGELIQ

ANIMI-3 WITH VITAMIN D

ANORO ELLIPTA

ANTABUSE

ANTIVERT

ANUSOL-HC

APLENZIN

apraclonidine

APTIOM

AQUA GLYCOLIC HC

ARAVA QD QL

arbinoxa

ARCALYST N QD

ARCAPTA NEOHALER

ARICEPT ORAL TABLET 10 MG, 5 MG QD QL

ARICEPT ORAL TABLET 23 MG N

ARIMIDEX

ARIXTRA QD

Nonpreferred/Tier 3 Products Nonpreferred/Tier 3 Products

SeCTion II: NonPreferreD/Tier 3 Drugs



14

AROMASIN

ARTHROTEC

ASTAGRAF XL

ASTRINGYN

ATACAND ST QD

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG ST QD

ATACAND HCT ORAL TABLET 32-25 MG ST

ATELVIA ST

ATIVAN

ATRALIN N

ATROVENT

AUBAGIO N

AUGMENTIN

AUGMENTIN XR

AVAILNEX

AVALIDE ST QD

AVAPRO ST QD

AVAR LS

AVAR TOPICAL PADS, MEDICATED

AVAR-E GREEN

AVAR-E LS

AVELOX

AVELOX ABC PACK

AVIDOXY DK

AVINZA QD

AVITA TOPICAL GEL N A

AXERT ST QD

AXIRON

AYGESTIN

AZASITE

AZILECT

AZOPT

AZOR

AZULFIDINE

AZULFIDINE EN-TABS

BACTRIM

BACTRIM DS

BACTROBAN

BANZEL

BARACLUDE ORAL TABLET 0.5 MG QD QL

BECONASE AQ ST QD

belladonna alkaloids-opium

belladonna-opium

BENICAR ST QD

BENSAL HP

BENTYL

BENZACLIN

BENZAMYCIN

BENZEFOAM

BENZEFOAM ULTRA

BEPREVE

BESIVANCE N

BETAGAN

BETAPACE

BETHKIS

BEYAZ N

BIAXIN

BIFERA RX

BINOSTO ST

BIONECT

BLEPH-10

BLEPHAMIDE

BLEPHAMIDE S.O.P.

BONIVA ST QD

BOSULIF N

BP WASH TOPICAL CLEANSER 2.5 %, 7 %

bp-50% urea

BREO ELLIPTA

BREVICON (28)

BRINTELLIX

BRISDELLE

BROMFED DM

BROVANA

BUCALSEP

BUPAP

BUPHENYL ORAL POWDER

BUTISOL

butorphanol tartrate injection

BUTRANS QL

BYSTOLIC

CADUET QD QL

caffeine citrated

CALAN

CALAN SR

calcitriol N

CAMBIA N

CANTIL

CAPCOF

CAPITAL WITH CODEINE

CAPRELSA N

CARAFATE ORAL TABLET

CARBAGLU N

CARBATROL

carbinoxamine maleate




15

CARDENE SR

CARDIZEM

CARDIZEM CD

CARDIZEM LA

CARDURA

CARDURA XL

carisoprodol-asa-codeine

CASODEX

CATAPRES

CATAPRES-TTS QD QL

CAYSTON N

CEDAX

cefaclor oral tablet extended release 12 hr QD QL

ceftibuten

CEFTIN ORAL TABLET

CELEXA QD QL

CELLCEPT

CELONTIN

CENTANY

centergy

cephalexin oral capsule 750 mg

CERVIDIL

CESAMET

CETACAINE

cetirizine

CHENODAL

chlorthalidone

ciclodan topical cream

ciclodan topical solution QD QL

CILOXAN OPHTHALMIC DROPS

CIMZIA N

CIMZIA POWDER FOR RECONST N

CIPRO

CIPRO HC

CIPRO XR

ciprofloxacin (mixture)

CITRANATAL B-CALM (FE GLUC)

CLARIFOAM EF

CLEOCIN

CLEOCIN ORAL RECON SOLN

CLEOCIN T

CLIMARA QD QL

CLINDACIN ETZ

CLINDACIN PAC

CLINDAGEL

CLOBEX

CLOCORTOLONE PIVALATE

CLODAN KIT

CLODERM

clonidine hcl N

clorpres

CLOZARIL

CNL 8 NAIL

CODEINE SULFATE ORAL SOLUTION

COLAZAL

COLESTID

COLY-MYCIN S

COLYTE WITH FLAVOR PACKS

COMBIGAN

COMBIVIR

COMETRIQ N

COMPAZINE

COMPLERA

COMTAN

CONCEPT OB

CONCERTA QD QL

CONDYLOX TOPICAL SOLUTION

CONZIP

COPEGUS N QD

CORDARONE

CORDRAN

COREG

CORGARD

CORTANE-B

cortane-b

CORTEF

CORTENEMA

CORTISPORIN

CORTISPORIN-TC

CORZIDE

COSOPT QD QL

COZAAR ST

CUTIVATE

CUVPOSA

CYCLESSA (28)

CYCLOGYL OPHTHALMIC DROPS 1 %, 2 %

CYCLOMYDRIL

CYCLOPHOSPHAMIDE

CYCLOSET N

CYMBALTA QD QL

CYPROHEPTADINE ORAL SYRUP

CYSTADANE

CYSTARAN N

CYTOMEL

CYTOTEC

cytra-2




16

cytra-3

cytra-k

D.H.E.45

DANTRIUM

DAYPRO

DDAVP

DEBACTEROL

DEMADEX

demeclocycline

DEMEROL

DENAVIR

DEPAKENE

DEPAKOTE

DEPAKOTE ER

DEPAKOTE SPRINKLES

DEPEN TITRATABS

DERMA-SMOOTHE/FS SCALP OIL

DERMASORB AF COMPLETE KIT

DERMASORB HC COMPLETE KIT

DERMASORB TA COMPLETE KIT

DERMASORB XM COMPLETE KIT

DERMATOP

dermazene

DERMOTIC OIL

desmopressin injection

DESOGEN

DESONATE

DESOWEN

DESOXYN

DESVENLAFAXINE

DESVENLAFAXINE FUMARATE

DETROL

DETROL LA QD QL

DEXEDRINE SPANSULE QD QL

DEXILANT ST QD

dexmethylphenidate oral capsule,er biphasic 50-50 15 mg QD QL

DEXPAK

DIABETA

DIALYVITE 800 WITH IRON

DIAMOX SEQUELS

DIASTAT ACUDIAL QD QL

diclofenac-misoprostol

DIFFERIN N A

DIFICID

DIFLUCAN QD

dihydroergotamine nasal QD

DILANTIN EXTENDED

DILANTIN INFATABS

DILANTIN-125

DILAUDID

DIOVAN QD

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 80-12.5 MG ST QD

DIOVAN HCT ORAL TABLET 320-12.5 MG, 320-25 MG ST

DIPENTUM

DIPROLENE

DIPROLENE AF

DITROPAN XL QD QL

DIURIL

DIVIGEL QD QL

DOLOPHINE

DONNATAL

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 150 MG

DOVONEX

DRISDOL

DRYSOL DAB-O-MATIC

DUAC

DUAVEE N

DUETACT

DURAGESIC QD

DUREZOL

DUTOPROL

DYAZIDE

DYMISTA N ST

DYRENIUM

E.E.S. GRANULES

EC-NAPROSYN

ECOZA

EDARBI ST

EDARBYCLOR ST

EDECRIN

EDEX QD

EDURANT

EFFEXOR XR QD QL

EFUDEX

8-MOP

ELDEPRYL

ELESTAT

ELESTRIN QD QL

ELIMITE

ELIXOPHYLLIN

ELOCON

EMADINE

EMLA

EMSAM QD QL

EMTRIVA ORAL SOLUTION




17

ENTEREG

ENTOCORT EC

EPANED

EPIDUO N A

EPIFOAM

EPIVIR HBV ORAL TABLET

EPIVIR ORAL TABLET

EPOGEN N QD

EQUETRO

ergoloid

ERIVEDGE N

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

ERYPED

ESGIC

ESTRACE

ESTROGEL QD QL

ESTROSTEP FE-28

ethyl chloride

EURAX TOPICAL LOTION

EVAMIST

EVISTA

EVOCLIN

EVOXAC

EXALGO ER

EXELDERM

EXELON ORAL QD QL

EXODERM

exotic-hc

EXTAVIA QD QL

EXTINA

FABIOR

FACTIVE

FAMVIR QD QL

FANAPT N

FARESTON

FARXIGA N

FAZACLO

fe c plus

FELBATOL

FELDENE

fem ph

FEMARA

FEMCON FE

FEMRING QD QL

FENOFIBRATE ORAL CAPSULE

FENOGLIDE

FENTORA BUCCAL N QD

FERRALET 90 DUAL-IRON DELIVERY

ferraplus 90

FERRIPROX

ferrogels forte

FETZIMA

FEXMID

FIBRICOR

FIORICET

FIORINAL

FIORINAL-CODEINE #3

FIRAZYR

FLAGYL

FLAGYL ER

FLAREX

FLECTOR

FLO-PRED

FLOMAX

FLOVENT ST QD

flucaine

FLUMADINE

FLUOR-A-DAY

fluorescein-proparacaine

FLUORITAB ORAL DROPS

FLUOROPLEX

flurox

FML FORTE

FML LIQUIFILM

FML S.O.P.

FOCALIN QD QL

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 30 MG, 35 MG, 40 MG

folinatal plus b

folivane-f

FOLLISTIM AQ N

FORFIVO XL

formadon

FORTAMET

FORTESTA ST

FOSAMAX ST QD

FOSAMAX PLUS D ORAL TABLET 70-5,600 MG-UNIT ST

FROVA ST QD

FURADANTIN

FUZEON

FYCOMPA N

GABITRIL ORAL TABLET 2 MG, 4 MG

GALZIN

GANIRELIX N

GASTROCROM

GASTROMARK

GATTEX 30-VIAL N




18

GELNIQUE

GENERESS FE

GEODON

GIAZO N

GILENYA N

GILOTRIF

GLUCAGEN HYPOKIT QD QL

GLUCOPHAGE

GLUCOPHAGE XR

GLUCOTROL

GLUCOTROL XL

GLUCOVANCE

GLUMETZA

GLYNASE

GLYSET

GOLYTELY ORAL RECON SOLN

GONAL-F RFF REDI-JECT N

goniovisc

GORDONS UREA

GRALISE

GRALISE 30-DAY STARTER PACK

GRANIX N

GRANULEX

GRIFULVIN V

GRIS-PEG (ULTRAMICROSIZE)

guanidine

HALCION N

HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG

hematogen fa

hematogen forte

HEMAX

HEMOCYTE-F

HEPSERA

HIPREX

HYCAMTIN

HYCET

HYDREA

HYDRO

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

hydrocortisone-pramox-e-pram#1

HYPER-SAL

HYZAAR ST

IBUDONE ORAL TABLET 10-200 MG

ibuprofen oral suspension

ICAR-C PLUS

ICLUSIG N

ILEVRO

ILOTYCIN

IMBRUVICA N

imipramine pamoate

IMITREX QD

IMITREX ORAL ST QD

IIMURAN

INCRELEX N

INDERAL LA

INDOCIN

INLYTA N

INOVA

INSPRA

INTEGRA F

INTUNIV ER N

INVEGA N

INVOKAMET

INVOKANA N

IODOFLEX

iodoquinol-hc

IODOSORB

IOPIDINE

ipecac

IPRIVASK

IROSPAN 24/6

ISENTRESS

ISOCHRON

ISOPTO ATROPINE

ISOPTO CARPINE

ISORDIL TITRADOSE

ISTALOL

JAKAFI N

JALYN N

JARDIANCE

JENTADUETO ST

JUBLIA

K-PHOS NO 2

K-PHOS ORIGINAL

K-TAB

KADIAN QL

KAPVAY N

KAYEXALATE

KAZANO ST

KEPPRA

KEPPRA XR

KERAFOAM

KERALYT RX

KERALYT SCALP COMPLETE

KETEK

KHEDEZLA




19

KLARON

KLONOPIN

klor-con

KOMBIGLYZE XR

KORLYM N

KRISTALOSE

l-methyl-mc

LAMICTAL

LAMICTAL ODT

LAMICTAL XR

LAMISIL QD

lamotrigine oral tablet extended release 24hr

LANOXIN ORAL TABLET 125 MCG, 250 MCG

lansoprazole QD

LASIX

LASTACAFT

LATUDA

LAZANDA

LESCOL QD

LESCOL XL QD

LEVAQUIN

LEVBID

LEVITRA QD

levorphanol tartrate

LEVSIN

LEVSIN/SL

LEXAPRO ST QD

LIALDA

LIBRAX (WITH CLIDINIUM)

lidocaine-hydrocortisone-aloe

LIDODERM

LIDORX

LIDOVIR

LINZESS

LIPITOR QD

LIPOFEN

LIPTRUZET

LITHOBID

LITHOSTAT

LIVALO

LO LOESTRIN FE

LOCOID

LOESTRIN

LOESTRIN FE

LOFIBRA

lomedia 24 fe

LOMOTIL

LOPID

LOPRESSOR

LOPRESSOR HCT

LOPROX

LOSEASONIQUE

LOTEMAX

LOTENSIN

LOTENSIN HCT

LOTREL QD QL

LOTRISONE

LOVENOX QD

LUFYLLIN

lugols

LUPANETA

LUXIQ

LUZU N

LYCELLE

LYRICA ORAL SOLUTION

LYSTEDA

M-END MAX D

MACRODANTIN

MAGNEBIND 400

MALARONE

MALARONE PEDIATRIC

MAR-COF BP

MAR-COF CG

MARINOL

MARNATAL-F

MARPLAN

MAVIK

MAXALT ST QD

MAXALT-MLT ST QD

MAXIDEX

MAXITROL

MAXZIDE

MEDROL

mefenamic acid

MEGACE

MEGACE ES

MEKINIST N

meloxicam oral tablet 15 mg QD QL

MENOPUR N

MENOSTAR QD QL

MENTAX

meprobamate

MEPRON QD QL

MESNEX

MESTINON ORAL TABLET

MESTINON TIMESPAN




20

METADATE CD QD QL

metformin oral tablet extended release 24hr 1,000 mg

methamphetamine

METHYLIN ORAL SOLUTION

METOPIRONE

METOZOLV ODT N

METROCREAM

METROGEL

METROLOTION

MIACALCIN INJECTION

MIACALCIN NASAL QD QL

MICROZIDE

MIGRANAL QD

MILLIPRED ORAL SOLUTION

MINASTRIN 24 FE

MINIPRESS

MINIVELLE QD QL

MINOCIN

minocycline oral tablet extended release 24 hr

MIRAPEX

MIRCETTE (28)

MIRVASO

MOBIC QD QL

MODICON (28)

MONODOX

MONSEL’S

MONUROL QD QL

morgidox

morphine oral capsule, er multiphase 24 hr 120 mg, 45 mg, 75 mg QL

morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg, 90 mg QD

MOXEZA

MOZOBIL

MS CONTIN QD

MYAMBUTOL

MYCOBUTIN QD QL

MYDRIACYL

MYFORTIC

MYRBETRIQ

MYSOLINE

nadolol-bendroflumethiazide

NAFTIN

NALFON

NAMENDA QD

NAMENDA ORAL SOLUTION

NAMENDA XR

NAPRELAN CR

NAPROSYN

naproxen oral tablet 500 mg

NARDIL

NASCOBAL

NATELLE ONE

NATROBA

NEBUSAL

nefazodone QD QL

NEOSPORIN (NEO-POLYM-GRAMICID)

NEPHROCAPS

NEPHROCAPS QT

NEPTAZANE

NESINA ST

NEUAC KIT

NEULASTA N QD

NEUPRO

NEURIN-SL

NEURONTIN

NEVANAC

NIACOR

nicardipine

NICAZEL

NICOMIDE

NILANDRON

NITRO-DUR

NITROLINGUAL

NITROMIST

NIZORAL

NOR-QD

NORCO

NORINYL

NORITATE

NORPACE

NORPACE CR

NORPRAMIN

NORVASC

NORVIR ORAL TABLET

NOVACORT

NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC)

NUCORT

NUCYNTA N

NUCYNTA ER N

NUEDEXTA N

NULEV

NULYTELY WITH FLAVOR PACKS

NUOX

NUTRESTORE

NUTROPIN AQ N

NUTROPIN AQ NUSPIN N

NUVIGIL N




21

NYMALIZE

octreotide acetate injection syringe N

OCUFEN

OCUFLOX

olanzapine-fluoxetine

OLEPTRO ER

OLUX

OLYSIO N

OMECLAMOX-PAK

omeprazole-sodium bicarbonate QD

OMEPRAZOLE+SYRSPEND SF ALKA

OMNARIS ST QD

OMNIPRED

OMNITROPE N

ONFI

ONMEL QD

OPANA

OPANA ER

OPSUMIT N

ORACEA

ORACIT

ORAPRED ODT

ORAVIG N

ORENCIA N

orphenadrine citrate

ORTHO

ORTHO EVRA QD QL

OSENI

OSPHENA N

OTEZLA N ST

OTIC CARE (ANTIPYRINE)

oticin

oticin hc (bak free)

otomax-hc

otozin

OTREXUP (PF) N

OVACE PLUS

OVCON-35 (28)

OVIDE

OXANDRIN

oxandrolone

OXECTA

OXISTAT

OXTELLAR XR

oxymorphone oral tablet extended release 12 hr

PACNEX

PACNEX HP

PACNEX LP

PACNEX MX

PAMELOR

PANCREAZE

PANDEL

PARAFON FORTE DSC

PAREMYD

PARLODEL

PARNATE

PASER

PATADAY

PATANASE

PAXIL CR

PAXIL ORAL TABLET 10 MG, 20 MG QL

PAXIL ORAL TABLET 30 MG QD QL

PCE

PEDIADERM AF

PEDIADERM HC

PEDIADERM TA

PEDIAPRED

PEGANONE

PEGASYS PROCLICK N

PENLAC

PENNSAID

PEPCID

PERCOCET

PERCODAN

PERIDEX

perphenazine-amitriptyline

PERSANTINE

PERTZYE

PEXEVA QD QL

PHENYTEK

PHOSLO

PHOSLYRA

PICATO N

PINNACAINE

PLAQUENIL

PLAVIX

PLETAL

PLIAGLIS

PNEUMOVAX 23 INJECTION SYRINGE A

pnv-dha

PODOCON

poly-tussin

poly-tussin d

POLYTRIM

POMALYST N

PONSTEL




22

PONTOCAINE

POTABA

potassium citrate-citric acid

POTASSIUM HYDROXIDE

POTIGA N

PRAMOSONE

PRAMOSONE E

PRANDIMET

PRANDIN QD QL

PRAVACHOL QD

PRECOSE

PRED FORTE

PRED-G

PRED-G S.O.P.

prednicarbate

PREFERA-OB ONE

PREFEST

PRENATE DHA (FERR ASP GLYCIN)

PRENATE ENHANCE

PRENATE MINI

PRENATE RESTORE

PREPIDIL

PREVACID ST QD

PREVPAC QD QL

PREZISTA ORAL SUSPENSION

PRIFTIN QD QL

PRILOSEC ST

PRIMLEV

PRIMSOL

PRINIVIL

PRO-RED AC (W/ DEXCHLORPHENIR)

PROCARDIA

PROCARDIA XL

PROCORT

PROCTOCORT

PROCYSBI N

PRODRIN

PROFERRIN-FORTE

PROGLYCEM

PROGRAF

PROLENSA

PROMACTA N

PROMETRIUM

PROSCAR

PROSTIN E2

PROTONIX ST QD

PROVENTIL HFA QD QL

PROVERA

PROVIGIL N

PROZAC

PROZAC WEEKLY

prudoxin

PULMICORT

PUREFE PLUS

PYLERA

PYRIDIUM

PYROGALLIC ACID

QUALAQUIN

QUARTETTE

QUDEXY XR

QUESTRAN

QUFLORA PEDIATRIC

QUILLIVANT XR

QUTENZA

rabeprazole QD

RAPAFLO

RAPAMUNE ORAL TABLET 0.5 MG

RASUVO (PF) N ST

RAVICTI N

RAZADYNE QD QL

RAZADYNE ER

REBETOL N QD

REBIF REBIDOSE

RECOTHROM

RECTIV

REGENECARE WITH ALOE

REGLAN

REGRANEX N QD

RELAGARD

RELISTOR N

REMERON QD QL

REMERON ORAL TABLET 15 MG, 30 MG

RENVELA ORAL POWDER IN PACKET

REQUIP

REQUIP XL

RESCULA ST

RESECTISOL

RESPA-AR

RESTORIL

RETIN-A N A

RETROVIR

REVATIO ORAL SUSPENSION FOR RECONSTITUTION N

REVATIO ORAL TABLET N QD

REVIA

REZIRA

RHEUMATREX




23

RHINOCORT AQUA ST QD

RIAX

RIBATAB DOSE PACK N

RIFADIN

RIFAMATE

RIFATER

RILUTEK

rimantadine

RIOMET

RISPERDAL

RISPERDAL M-TAB

RITALIN QD QL

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG

ROBAXIN-750

ROBINUL

ROBINUL FORTE

ROCALTROL

ropinirole oral tablet extended release 24 hr

rosadan topical gel

ROWASA

ROXICET ORAL SOLUTION

ROXICODONE

ROZEREM ST QD

RYTHMOL

RYTHMOL SR

SABRIL N

SAFYRAL

SAIZEN N QD

salacyn topical cream

SALAGEN

SALEX

salicylic acid

SALKERA

salvax

SAMSCA N

SANCUSO N QD

SANDOSTATIN N

SANTYL

SAPHRIS ST

SAPHRIS (BLACK CHERRY) ST

SARAFEM

SAVELLA N

SCALACORT DK

se-natal 19 (with docusate)

SEASONIQUE

seconal sodium

SECTRAL

SELRX

SEMPREX-D

SEROQUEL

SEROSTIM N

SHOHL’S MODIFIED

SIGNIFOR N

SILENOR ST

SILVADENE

silver nitrate

SIMBRINZA

SIMCOR

SIMPONI N

SINEMET

SINEMET CR

SINGULAIR

SIRTURO N

SITAVIG

SKELAXIN

SKLICE

sodium

SOLODYN N

SOLTAMOX

SOMA

SONATA ST QD

SORBITOL-MANNITOL

SORIATANE

SORILUX

SOVALDI N

SPECTRACEF

SPORANOX QD QL

SPRIX

STALEVO

STARLIX QD QL

STAXYN QD

STELARA

STENDRA

STIMATE

STIVARGA N

STRIANT ST QD

SUBOXONE

SUCLEAR

SUCRAID

SULAR

SULFACETAMIDE SOD-SULFUR-UREA TOPICAL GEL

sulfacetamide sodium

SULFAMYLON

SULFATRIM

SUMADAN

SUMAVEL DOSEPRO QD




24

SUMAXIN CP

SUMAXIN TS

SUPRAX

SURMONTIL

SYLATRON N

SYMBYAX

SYNALAR

SYNALGOS-DC

SYNERA

SYPRINE

TACLONEX TOPICAL SUSPENSION

TAFINLAR N

TANDEM PLUS

TANZEUM N

TAPAZOLE

TARGRETIN

TARKA

taron-prex prenatal-dha

TASIGNA N

TASMAR

TECFIDERA N

TEGRETOL

TEKAMLO

TEMODAR

TEMOVATE

TEMOVATE E

TENEX

TENORETIC

TENORMIN

TERAZOL QD QL

TERSI FOAM

TESSALON PERLES

TESTOSTERONE QD QL

TESTRED

tetcaine

tetracaine hcl (pf)

TEV-TROPIN N QD

TEVETEN ST QD

TEVETEN HCT ST QD

TEXACORT

THEO-24

theophylline oral solution

THIOLA

thioridazine

THROMBIN-JMI

THYROLAR

TIAZAC

TIGAN

TIMOPTIC-XE

TINDAMAX QD QL

TIROSINT

TIVICAY

tizanidine oral tablet 4 mg

tl-hem 150

TOBREX OPHTHALMIC DROPS

TOFRANIL

TOFRANIL-PM

TOPAMAX

TOPICORT

TOPIRAMATE ORAL CAPSULE, SPRINKLE,ER 24HR

TOPROL XL

TRADJENTA ST

TRAMADOL ORAL CAPSULE, ER BIPHASE 24 HR 25-75

TRANDATE

TRANXENE T-TAB

TRAVATAN Z QD QL

TRECATOR

TRETIN-X N

TREXIMET ST QD

tri-chlor

TRI-NORINYL (28)

TRIBENZOR

tricitrates

tricon

TRICOR

trigels-f forte

TRILEPTAL

TRILIPIX

TRIOXIN

TRIUMEQ

TROKENDI XR

TRUSOPT

TUSNEL PEDIATRIC

TUSSICAPS

TUSSIONEX PENNKINETIC ER

TWYNSTA

TYLENOL-CODEINE #3

TYLENOL-CODEINE #4

TYZEKA

TYZINE

U-CORT

UCERIS N

ULORIC N

ULTRACET

ULTRAM

ULTRAM ER




25

ULTRAVATE X

ULTRESA

UMECTA PD

UMECTA TOPICAL EMULSION

URAMAXIN GT

URAMAXIN

urea 50%

URECHOLINE

URELLE

uretron d-s

URIBEL

urimar-t

UROCIT-K

UROQID-ACID NO.2

UROXATRAL

URSO 250

URSO FORTE

ustell

UTA (WITH PHENYL SALICYLATE)

utira-c

UTOPIC

VALCHLOR

VALCYTE ORAL RECON SOLN N

VALIUM

VALTREX QD QL

VANCOCIN

VANOS

VANOXIDE-HC

VASCEPA N

VASERETIC

VASOTEC

VAYACOG

VAYARIN

VAYAROL

VECAMYL

VECTICAL N

VELPHORO

VELTIN N

VENELEX

venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg QD QL

venlafaxine oral tablet extended release 24hr 225 mg

VENTOLIN HFA QD QL

VERAMYST ST QD

VERDESO

VEREGEN

VERELAN

VERELAN PM

VERSACLOZ

VEXOL

VFEND N

VIBRAMYCIN

VICOPROFEN

VIDEX EC

VIIBRYD

VIMOVO

VIMPAT N

VIRAMUNE

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG

VIRASAL

VIRAZOLE

VIREAD ORAL POWDER N

VIROPTIC

virt-pn dha

VISTARIL

VITA-RESPA

VITAFOL ULTRA

VITAFOL-ONE

VITUZ

VOGELXO QD QL

VOLTAREN-XR

VOSPIRE ER

VOTRIENT N

VUSION

VYTONE

WELCHOL ORAL POWDER IN PACKET

WELLBUTRIN QD QL

WELLBUTRIN SR

WELLBUTRIN XL

WIDE-SEAL DIAPHRAGM 60

WP THYROID ORAL TABLET 113.75 MG, 16.25 MG, 48.75 MG, 97.5 MG

XALATAN ST QD

XALKORI

XANAX

XANAX XR

XARTEMIS XR

XELJANZ N

XENAZINE N

XERAC AC

XERESE

XIFAXAN QL

XOLEGEL

XOPENEX

XTANDI N

xulane QD QL

XYLOCAINE

YASMIN (28)




26

YAZ (28)

Z-TUSS AC

ZANAFLEX

ZANTAC

ZARONTIN

ZAVESCA QD QL

ZEBETA

ZEGERID ST QD

ZELAPAR

ZELBORAF N

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 7.5 MG

ZERIT

ZESTORETIC

ZESTRIL

ZETONNA ST

ZIAC

ZIAGEN ORAL TABLET

ZIANA N A

ZIOPTAN (PF) ST

ZIPSOR N

ZIRGAN

ZITHRANOL

ZITHRANOL-RR

ZITHROMAX

ZMAX QD QL

ZOCOR QD

ZODRYL AC

ZODRYL DAC

ZODRYL DEC

ZOFRAN (AS HYDROCHLORIDE) QD

ZOFRAN ODT QD

ZOHYDRO ER N

ZOLINZA

ZOLOFT ORAL CONCENTRATE

ZOLOFT ORAL TABLET QD QL

ZOMIG NASAL QD

ZOMIG ST QD

ZONALON

ZONEGRAN

ZONTIVITY

ZORBTIVE N

ZORTRESS N

ZORVOLEX

ZOVIRAX

ZOVIRAX TOPICAL OINTMENT

ZUBSOLV

ZUPLENZ QD

ZUTRIPRO

ZYCLARA N

ZYDELIG N

ZYFLO

ZYFLO CR

ZYKADIA

ZYLOPRIM

ZYPRAM

ZYPREXA

ZYPREXA ZYDIS

ZYTIGA




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