formulary 2014comprehensive - ebview

2014

Comprehensive

FORMULARY(Complete list of covered drugs)

UnitedHealthcare® MedicareRx for Groups (PDP)Insurance Trust for Delta Retirees

Please read: This document contains information about the drugs we cover in this plan.

For more recent information or if you have other questions, please contact UnitedHealthcare MedicareRx for Groups at:

1-877-717-9517, TTY 7118 a.m. to 8 p.m. local time, Monday through Friday

00014409, 10Y0066_130712_093334 Last updated August 1, 2013

1

2

This document includes a complete list of the drugs (formulary) for our plan and is current as of August 1, 2013. For an updated formulary (drug list), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan” or “our plan,” it means UnitedHealthcare MedicareRx for Groups.

Note to existing members: This complete formulary has changed since last year. Please review this document to make sure the plan still covers the drugs you take. You must generally use network pharmacies to use your prescription drug benefit.

3

The UnitedHealthcare MedicareRx for Groups COMPREHENSIVE FORMULARY

(drug list)A formulary is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in our formulary (drug list) as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

This document is a complete formulary (drug list) of the drugs covered by your plan.

For your drug to be covered by your plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered:

1. See if your drug is included in this complete drug list.2. If you cannot find your drug in this complete list, call Customer Service. Our contact information

appears on the front and back cover pages.

4

When the formulary (drug list) may changeWe try to make as few changes to the formulary (drug list) as possible during the plan year. If there are changes to the formulary (drug list), such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If there are changes to the formulary (drug list) outside of regular or necessary updates, members may receive a special mailing.

The formulary (drug list) may change throughout the year when your plan:

• Adds a new drug.• Removes a drug.• Changes the requirements or limits for a drug.• Moves a drug into a different tier.

Generally, if you are taking a drug on the 2014 formulary (drug list) that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released.

Other types of formulary (drug list) changes, such as removing a drug from the formulary (drug list), will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the coverage year. We feel it is important for you to have access for the entire coverage year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern.

If we remove drugs from our formulary (drug list), or move a drug to a higher cost-sharing tier, we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug.

If the Food and Drug Administration (FDA) declares a drug on our formulary (drug list) to be unsafe or if the drug’s manufacturer removes the drug from the market, your plan will immediately remove the drug from the formulary (drug list) and notify members who take the drug. The enclosed formulary (drug list) is current as of the date printed on the front and back cover pages. To get updated information about the drugs covered by your plan, please call Customer Service using the information provided on the front and back cover pages of this formulary (drug list).

5

Drug tiers and drug payment stagesThe amount you pay for a covered drug will depend on:

· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you’re in.

· The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a different copay or coinsurance amount. The chart below shows the differences between the tiers.

For more information about drug payment stages and copay or coinsurance amounts for each tier, please review your Evidence of Coverage.

Drug Tier Includes

Tier 1:Generic

All generic drugs.

Tier 2:Preferred brand

Many common brand name drugs.

Tier 3:Non-preferred brand

Non-preferred brand name drugs.

Tier 4:Specialty tier

Unique and/or very high-cost drugs.

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also contact Customer Service. Our contact information appears on the front and back cover pages.

6

How to use the formulary (drug list)There are two ways to find your prescription drugs in this complete formulary (drug list):

1. Medical condition: Turn to the “Covered drugs by medical condition” section, whichbegins on page 10, to look for drugs based on your medical conditions. For example,if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Drugs”category and look under “Cholesterol Control Drugs”.

2. Alphabetical list (index): If you are not sure what category to look under, turn to the“Index of covered drugs” section, which begins on page 75. Find the name of yourdrug. The page number where you can find the drug will be next to it.

Important page numbersCovered drugs by medical condition.........................................................................................10Index of covered drugs ............................................................................................................75

Generic drugsYour plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name version. Generally, generic drugs cost less than brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions.

The formulary (drug list) shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin).

Drug Name

Alkylating Agents - Chemotherapy Agents

Antiangiogenic Agents - ChemotherapyAgents

Leukeran

Revlimid(10mg Capsule,15mg Capsule,25mg Capsule,5mg Capsule)

Anthelmintics - Worm Infection Drugs

AlbenzaStromectol

Antiprotozoals - Protozoal Infection Drugs

Antineoplastics - Drugs to Treat Cancer

Cyclophosphamide(Tablet) B/D

Antineoplastics - Drugs to Treat ParasiticInfections

Atovaquone/Proguanil HCI(250mg; 100mg Tablet)

HydroxychloroquineSulfate

33

3

2 PA

3

3

5 PA,LA

Drug RequirementsTier & Limits Drug Name Drug Requirements

Tier & Limits

SAMPLE

7

Restrictions on your coverageSome of your plan’s drugs may have additional requirements or limits on coverage. If your drug has any requirements or limits, there will be a code(s) in the “Requirements & Limits” column of the drug list. The codes and what they mean are shown below.

B/D Medicare Part B or Part DDepending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

LA Limited accessDrugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

You can find out if your drug has any additional requirements or limits by looking it up in the “Covered drugs by medical condition” section that begins on page 10. You can also get more information about the restrictions on specific covered drugs by calling Customer Service. Our contact information, along with the date we last updated the formulary (drug list), appears on the front and back cover pages.

You and your doctor may ask your plan for an exception to the requirement and/or limit for your drug. See “How to request an exception to the UnitedHealthcare MedicareRx for Groups formulary (drug list)” on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from your plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug.

8

If your drug is not on the formulary (drug list)If your drug is not included in this complete formulary (list of covered drugs), you should contact Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the formulary (drug list), appears on the front and back cover pages.

If you learn that your plan does not cover your drug, you have two options:

1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the drugs from the list.

2. Ask your plan to make an exception and cover your drug. See below for information about how to request an exception.

How to request an exception to the UnitedHealthcare MedicareRx for Groups formulary (drug list)At times you may need to ask for drug coverage that’s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination).

You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask your plan to make.

· Formulary exception: You can ask your plan to cover your drug even if it is not on the formulary (drug list). If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

· Tiering exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

· Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug.

Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan’s formulary (drug list), the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects.

Who can ask for a coverage decisionYou, your authorized representative or your doctor can ask for an initial coverage decision for a

formulary exception, tiering exception or utilization restriction exception.

When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request.

Receiving a coverage decisionGenerally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your prescriber’s or prescribing physician’s supporting statement.

9

What to do while you talk to your doctor about changing your drugs or requesting an exception

New or continuing membersAs a new or continuing member in your plan, you may be taking drugs that are not on the formulary (drug list). You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan.

For each of your drugs that is not on the formulary (drug list), or if your ability to get your drugs is limited, your plan will cover a temporary 30-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After your first 30-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days.

Long-term care facility residentsIf you’re a resident of a long-term care facility, your plan will allow you to refill your prescription until we have provided you with a 91- and may be up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that’s not on the formulary (drug list) or if you have limited ability to get your drugs but you are past the first 90 days of membership in the plan, your plan will cover a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.

Other transitionsYou may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use your plan’s exception process. You may ask for a one-time emergency supply of up to 30 days to give you time to talk to your

doctor about other treatment options or to try to get a formulary exception.

For more informationFor more information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please contact us. Our contact information, along with the date we last updated the formulary (drug list), appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or visit www.medicare.gov.

1 tRACK

10

Covered drugs by medical conditionThe comprehensive formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered drugs”, which begins on page 75.Remember: If your drug is not in this Comprehensive formulary (drug list), please contact us. Our contact information, along with the date we last updated the formulary (drug list), appears on the front and back cover pages.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin).

The information in the second column of the chart shows you which coverage level (tier) your drug is in.

The Requirements & Limits column shows you if your plan has any special coverage requirements for the drug.

Drug NameDrugTier

Requirements& Limits

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Analgesics - Miscellaneous Analgesics

Alagesic LQAlagesic LQ 3

BupapBupap (650mg; 50mg Tablet)

3

Butalbital/AcetaminophenButalbital/Acetaminophen

♦1

Butalbital/Acetaminophen/Caffeine

Butalbital/Acetaminophen/Caffeine

♦

1

Butalbital/Aspirin/CaffeineButalbital/Aspirin/Caffeine

♦1

Dolgic PlusDolgic Plus 3

EsgicEsgic (Tablet) 3

Esgic-PlusEsgic-Plus 3

FioricetFioricet 3

FiorinalFiorinal 3

GraliseGralise 3

Gralise StarterGralise Starter 3

Drug NameDrugTier


Orbivan CFOrbivan CF 3

Phrenilin FortePhrenilin Forte 3

TenconTencon ♦ 1

ZebutalZebutal ♦ 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs

AnaproxAnaprox 3

Anaprox DSAnaprox DS 3

ArthrotecArthrotec 3

CambiaCambia 3

CataflamCataflam 3

CelebrexCelebrex 2

DayproDaypro 3

Diclofenac PotassiumDiclofenac Potassium

♦1

Diclofenac Sodium DRDiclofenac Sodium DR

♦1

Diclofenac Sodium ERDiclofenac Sodium ER

♦1

Bold type = Brand name drug Plain type = Generic drug

B/D = Medicare Part B or Part D LA = Limited access drug♦ Tier 1 drugs – We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information.

2

11

Drug NameDrugTier


Diclofenac Sodium/MisoprostolDiclofenac Sodium/Misoprostol

♦1

DiflunisalDiflunisal ♦ 1

DuexisDuexis 3

EC-NaprosynEC-Naprosyn 3

EtodolacEtodolac ♦ 1

Etodolac EREtodolac ER ♦ 1

FeldeneFeldene 3

Fenoprofen CalciumFenoprofen Calcium ♦ 1

FlectorFlector 3

FlurbiprofenFlurbiprofen ♦ 1

IbuprofenIbuprofen (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

♦

1

IndocinIndocin (Suspension)

3

IndomethacinIndomethacin (Capsule)

♦1

Indomethacin ERIndomethacin ER ♦ 1

KetoprofenKetoprofen ♦ 1

Ketoprofen ERKetoprofen ER ♦ 1

Ketorolac TromethamineKetorolac Tromethamine (15mg/ml Injection, 30mg/ml Injection, Tablet)

♦

1

Meclofenamate SodiumMeclofenamate Sodium

♦1

Mefenamic AcidMefenamic Acid ♦ 1

MeloxicamMeloxicam ♦ 1

MobicMobic 3

Drug NameDrugTier


NabumetoneNabumetone ♦ 1

NalfonNalfon 3

NaprelanNaprelan (750mg Tablet Extended Release 24 Hour)

3

NaprosynNaprosyn 3

NaproxenNaproxen ♦ 1

Naproxen DRNaproxen DR ♦ 1

Naproxen SodiumNaproxen Sodium (275mg Tablet, 550mg Tablet)

♦

1

OxaprozinOxaprozin ♦ 1

Oxycodone/IbuprofenOxycodone/Ibuprofen

♦1

PiroxicamPiroxicam ♦ 1

PonstelPonstel 3

SprixSprix 3

SulindacSulindac ♦ 1

Tolmetin SodiumTolmetin Sodium ♦ 1

TreximetTreximet 3

Voltaren-XRVoltaren-XR 3

Opioid Analgesics, Long-acting - Opioid Pain Relievers

AstramorphAstramorph ♦ 1

AvinzaAvinza 2

ConzipConzip 3

DolophineDolophine 3

Dolophine HClDolophine HCl 3



3

12

Drug NameDrugTier


DuragesicDuragesic (12mcg/Hr Patch 72 Hour, 25mcg/Hr Patch 72 Hour, 50mcg/Hr Patch 72 Hour)

3

DuragesicDuragesic (100mcg/Hr Patch 72 Hour, 75mcg/Hr Patch 72 Hour)

4

DuramorphDuramorph ♦ 1

FentanylFentanyl (Patch) ♦ 1

KadianKadian (10mg Capsule Extended Release 24 Hour, 20mg Capsule Extended Release 24 Hour, 30mg Capsule Extended Release 24 Hour, 50mg Capsule Extended Release 24 Hour)

3

KadianKadian (100mg Capsule Extended Release 24 Hour, 200mg Capsule Extended Release 24 Hour, 60mg Capsule Extended Release 24 Hour, 80mg Capsule Extended Release 24 Hour)

4

Levorphanol TartrateLevorphanol Tartrate ♦ 1

Methadone HClMethadone HCl (Concentrate, Oral Solution, 10mg Tablet, 5mg Tablet)

♦

1

Drug NameDrugTier


Methadone HClMethadone HCl (Injection)

3

Morphine SulfateMorphine Sulfate (Oral Solution, Tablet)

♦

1

Morphine Sulfate ERMorphine Sulfate ER ♦ 1

MS ContinMS Contin (100mg Tablet Extended Release, 15mg Tablet Extended Release, 30mg Tablet Extended Release, 60mg Tablet Extended Release)

3

MS ContinMS Contin (200mg Tablet Extended Release)

4

Nucynta ERNucynta ER 2

Opana EROpana ER (Crush Resistant)

2

OxycontinOxycontin 2

Oxymorphone HCl EROxymorphone HCl ER

♦1

Tramadol HCl ER 100mg, 200mg Tablet Extended Release 24 Hour

Tramadol HCl ER 100mg, 200mg Tablet Extended Release 24 Hour (Generic Ultram ER)

♦

1

Tramadol HCl ER 300mg Tablet Extended Release 24 Hour

Tramadol HCl ER 300mg Tablet Extended Release 24 Hour (Generic Ryzolt)

♦

1

Ultram ERUltram ER 3

Opioid Analgesics, Short-acting - Opioid Pain Relievers

AbstralAbstral 4

4

13

Drug NameDrugTier


Acetaminophen/Caffeine/Dihydrocodeine Bitartrate

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate

♦

1

Acetaminophen/CodeineAcetaminophen/Codeine

♦1

ActiqActiq 4

Butalbital/Aspirin/Caffeine/CodeineButalbital/Aspirin/Caffeine/Codeine

♦1

Butorphanol TartrateButorphanol Tartrate ♦ 1

Capital/CodeineCapital/Codeine 3

Carisoprodol/Aspirin/CodeineCarisoprodol/Aspirin/Codeine

♦1

Co-GesicCo-Gesic ♦ 1

Codeine SulfateCodeine Sulfate (Tablet)

♦1

DemerolDemerol (50mg/ml Injection)

3

DemerolDemerol (50mg Tablet)

3

DilaudidDilaudid 3

Dilaudid-5Dilaudid-5 3

Dilaudid-HPDilaudid-HP (10mg/ml Injection)

3

EndocetEndocet ♦ 1

EndodanEndodan ♦ 1

Drug NameDrugTier


ExalgoExalgo (12mg Tablet Extended Release 24 Hour, 16mg Tablet Extended Release 24 Hour, 8mg Tablet Extended Release 24 Hour)

2

Fentanyl Citrate Oral TransmucosalFentanyl Citrate Oral Transmucosal

♦1

FentoraFentora 4

Fiorinal/CodeineFiorinal/Codeine 3

HycetHycet 3



5

14

Drug NameDrugTier


Hydrocodone/AcetaminophenHydrocodone/Acetaminophen (Oral Solution, 300mg; 10mg Tablet, 300mg; 5mg Tablet, 300mg; 7.5mg Tablet, 325mg; 10mg Tablet, 325mg; 5mg Tablet, 325mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg; 2.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet)

♦

1

Hydrocodone/IbuprofenHydrocodone/Ibuprofen (7.5mg; 200mg Tablet)

♦

1

Hydromorphone HClHydromorphone HCl (500mg/50ml Injection, Immediate-Release Tablet)

♦

1

LazandaLazanda 4

LorcetLorcet 3

LortabLortab 3

MagnacetMagnacet (400mg; 5mg Tablet, 400mg; 7.5mg Tablet)

3

MaxidoneMaxidone 3

Drug NameDrugTier


Meperidine HClMeperidine HCl (100mg/ml Injection, 25mg/ml Injection, 50mg/ml Injection)

♦

1

Meperidine HClMeperidine HCl (Oral Solution)

♦1

MeperitabMeperitab ♦ 1

Nalbuphine HClNalbuphine HCl ♦ 1

NorcoNorco 3

NucyntaNucynta 3

OnsolisOnsolis 4

OpanaOpana (Tablet) 3

OxectaOxecta 3

Oxycodone HClOxycodone HCl (Capsule, Concentrate, Tablet)

♦

1

Oxycodone/AcetaminophenOxycodone/Acetaminophen

♦1

Oxycodone/AspirinOxycodone/Aspirin ♦ 1

Oxymorphone HClOxymorphone HCl ♦ 1

Pentazocine/AcetaminophenPentazocine/Acetaminophen

♦1

Pentazocine/Naloxone HClPentazocine/Naloxone HCl

♦1

PercocetPercocet 3

PercodanPercodan 3

ReprexainReprexain 3

RoxicetRoxicet (Oral Solution)

♦1

RoxicodoneRoxicodone (30mg Tablet)

3

StagesicStagesic ♦ 1

6

15

Drug NameDrugTier


SubsysSubsys (100mcg Liquid, 1200mcg Liquid, 200mcg Liquid, 400mcg Liquid, 800mcg Liquid)

4

Synalgos-DCSynalgos-DC 3

TalwinTalwin 3

Tramadol HClTramadol HCl ♦ 1

Tramadol HCl/AcetaminophenTramadol HCl/Acetaminophen

♦1

Tylenol/CodeineTylenol/Codeine 3

UltracetUltracet 3

UltramUltram 3

VicodinVicodin ♦ 1

Vicodin ESVicodin ES ♦ 1

Vicodin HPVicodin HP ♦ 1

VicoprofenVicoprofen 3

XodolXodol 3

ZamicetZamicet 3

ZydoneZydone 3

Anesthetics - Drugs for Numbing

Local Anesthetics

EMLAEMLA 3

LidocaineLidocaine (Ointment)

♦1

Lidocaine 2% Viscous SolutionLidocaine 2% Viscous Solution

♦1

Lidocaine HClLidocaine HCl (External Solution)

♦1

Drug NameDrugTier


Lidocaine HClLidocaine HCl (0.5% Injection, 1% Injection)

♦

1 B/D

Lidocaine HClLidocaine HCl (Gel) ♦ 1

Lidocaine/PrilocaineLidocaine/Prilocaine (Cream)

♦1

LidodermLidoderm 2

SyneraSynera 3 B/D

XylocaineXylocaine (External Solution)

3

XylocaineXylocaine (1% Injection)

3 B/D

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrents

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants

AntabuseAntabuse 3

CampralCampral 3

DisulfiramDisulfiram ♦ 1

Naltrexone HClNaltrexone HCl ♦ 1

ReviaRevia 3

VivitrolVivitrol 4

Opioid Antagonists - Antidotes/Deterrents/Protectants

BuprenexBuprenex 4

Buprenorphine HClBuprenorphine HCl ♦ 1

Buprenorphine HCl/Naloxone HClBuprenorphine HCl/Naloxone HCl

♦1

ButransButrans 3

Naloxone HClNaloxone HCl (1mg/ml Injection)

♦1



7

16

Drug NameDrugTier


SuboxoneSuboxone 3

Smoking Cessation Agents - Deterrents

BuprobanBuproban ♦ 1

ChantixChantix 3

Chantix Starting Month PakChantix Starting Month Pak

3

Nicotrol InhalerNicotrol Inhaler 3

Nicotrol NSNicotrol NS 2

ZybanZyban 3

Anti-inflammatory Agents - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs

NaprelanNaprelan (375mg Tablet Extended Release 24 Hour, 500mg Tablet Extended Release 24 Hour)

3

Antibacterials - Drugs to Treat Bacterial Infections

Aminoglycosides - Antibiotics

Amikacin SulfateAmikacin Sulfate (1gm/4ml Injection, 50mg/ml Injection)

♦

1

GentakGentak (Ointment) ♦ 1

Gentamicin SulfateGentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution)

♦

1

Gentamicin Sulfate/NaClGentamicin Sulfate/NaCl (0.9mg/ml; 0.9% Injection, 1.4mg/ml; 0.9% Injection)

♦

1

Drug NameDrugTier


Gentamicin Sulfate/NaClGentamicin Sulfate/NaCl (1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection)

♦

1

Isotonic GentamicinIsotonic Gentamicin (0.8mg/ml; 0.9% Injection, 1.2mg/ml; 0.9% Injection)

♦

1

Neomycin SulfateNeomycin Sulfate (Tablet)

♦1

Neomycin/Polymyxin B Sulfates

Neomycin/Polymyxin B Sulfates

♦

1

Paromomycin SulfateParomomycin Sulfate

♦1

Streptomycin SulfateStreptomycin Sulfate

3

TOBITOBI 4 B/D

TOBI PodhalerTOBI Podhaler 4

Tobramycin SulfateTobramycin Sulfate (10mg/ml Injection, 80mg/2ml Injection, Ophthalmic Solution)

♦

1

Tobramycin Sulfate/NaClTobramycin Sulfate/NaCl

♦1

TobrexTobrex (Ointment)

2

TobrexTobrex (Ophthalmic Solution)

3

Antibacterials, Other - Antibiotics

Alcohol PrepsAlcohol Preps (Pad)

♦1

AltabaxAltabax 3

BACiiMBACiiM ♦ 1

BacitracinBacitracin ♦ 1

8

17

Drug NameDrugTier


Bacitracin/Polymyxin BBacitracin/Polymyxin B

♦1

BactrobanBactroban 3

Bactroban NasalBactroban Nasal 3

Chloramphenicol Sodium SuccinateChloramphenicol Sodium Succinate

♦1

CleocinCleocin 3

Cleocin in D5WCleocin in D5W 3

Cleocin Pediatric GranulesCleocin Pediatric Granules

3

Cleocin PhosphateCleocin Phosphate (900mg/6ml Injection)

3

Clindamycin HClClindamycin HCl ♦ 1

Clindamycin PhosphateClindamycin Phosphate (Cream)

♦1

Clindamycin PhosphateClindamycin Phosphate (150mg/ml Injection)

♦

1

Clindamycin Phosphate in D5WClindamycin Phosphate in D5W

♦1

Colistimethate SodiumColistimethate Sodium

♦1

Coly-Mycin MColy-Mycin M 3

CortisporinCortisporin (Cream, Ointment)

3

CubicinCubicin 4 B/D

FlagylFlagyl 3

Flagyl ERFlagyl ER 3

FuradantinFuradantin 3

HiprexHiprex 3

Drug NameDrugTier


LincocinLincocin 3

MacrobidMacrobid 3

MacrodantinMacrodantin (100mg Capsule, 25mg Capsule)

3

Mafenide AcetateMafenide Acetate ♦ 1

Methenamine HippurateMethenamine Hippurate

♦1

MetroCreamMetroCream 3

MetroGelMetroGel (1% Gel)

3

MetroGel-VaginalMetroGel-Vaginal 3

MetroLotionMetroLotion 3

MetronidazoleMetronidazole (Cream, 0.75% Gel, Lotion, Tablet)

♦

1

Metronidazole in NaCl 0.79%Metronidazole in NaCl 0.79%

♦1

Metronidazole VaginalMetronidazole Vaginal

♦1

MonurolMonurol 3

MupirocinMupirocin ♦ 1

Neomycin/Bacitracin/Polymyxin

Neomycin/Bacitracin/Polymyxin

♦

1

Neomycin/Polymyxin/Gramicidin

Neomycin/Polymyxin/Gramicidin

♦

1

NeosporinNeosporin 3

NitrofurantoinNitrofurantoin ♦ 1

Nitrofurantoin MacrocrystallineNitrofurantoin Macrocrystalline (50mg Capsule)

♦

1



9

18

Drug NameDrugTier


Nitrofurantoin MonohydrateNitrofurantoin Monohydrate

♦1

Omeclamox-PakOmeclamox-Pak 3

pHisoHexpHisoHex 3

Polymyxin B SulfatePolymyxin B Sulfate ♦ 1

PolytrimPolytrim 3

PrevpacPrevpac 3

PrimsolPrimsol 3

SilvadeneSilvadene 3

Silver SulfadiazineSilver Sulfadiazine ♦ 1

SSDSSD ♦ 1

SulfamylonSulfamylon 3

SynercidSynercid 4

TrimethoprimTrimethoprim ♦ 1

Trimethoprim Sulfate/Polymyxin B Sulfate

Trimethoprim Sulfate/Polymyxin B Sulfate

♦

1

TygacilTygacil 4

Vancocin HClVancocin HCl 4

Vancomycin HClVancomycin HCl (Capsule)

♦1

Vancomycin HClVancomycin HCl (1000mg Injection, 10gm Injection, 500mg Injection)

♦

1 B/D

VandazoleVandazole ♦ 1

VibativVibativ (250mg Injection)

3

XifaxanXifaxan 4

ZyvoxZyvox 4

Beta-Lactam, Cephalosporins - Antibiotics

CedaxCedax (Capsule) 3

CefaclorCefaclor (Capsule) ♦ 1

Cefaclor ERCefaclor ER ♦ 1

CefadroxilCefadroxil ♦ 1

Drug NameDrugTier


Cefazolin SodiumCefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection)

♦

1

CefdinirCefdinir ♦ 1

CefepimeCefepime (1gm Injection, 2gm Injection)

♦

1

Cefotaxime SodiumCefotaxime Sodium (10gm Injection)

♦1

Cefoxitin SodiumCefoxitin Sodium (10gm Injection, 1gm Injection, 2gm Injection)

♦

1

Cefoxitin SodiumCefoxitin Sodium (1gm; 4% Injection, 2gm; 2.2% Injection)

♦

1

Cefpodoxime ProxetilCefpodoxime Proxetil

♦1

CefprozilCefprozil ♦ 1

CeftazidimeCeftazidime (1gm Injection, 2gm Injection, 6gm Injection)

♦

1

Ceftazidime/DextroseCeftazidime/Dextrose

♦1

CeftinCeftin 3

Ceftriaxone SodiumCeftriaxone Sodium ♦ 1

Cefuroxime AxetilCefuroxime Axetil (Tablet)

♦1

Cefuroxime SodiumCefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection)

♦

1

10

19

Drug NameDrugTier


CephalexinCephalexin (250mg Capsule, 500mg Capsule, Suspension Reconstituted, Tablet)

♦

1

ClaforanClaforan 3

FortazFortaz (1gm/50ml; 5% Injection, 2gm Injection, 2gm/50ml; 5% Injection, 6gm Injection)

3

KeflexKeflex (250mg Capsule, 500mg Capsule)

3

RocephinRocephin (500mg Injection)

3

SupraxSuprax 2

TeflaroTeflaro 3

Beta-Lactam, Other - Antibiotics

AzactamAzactam (2gm Injection)

2

Azactam in Iso-Osmotic DextroseAzactam in Iso-Osmotic Dextrose

3

AztreonamAztreonam (1gm Injection)

♦1

CaystonCayston 4 LA

CefotetanCefotetan 3

DoribaxDoribax (500mg Injection)

3

Imipenem/CilastatinImipenem/Cilastatin ♦ 1

InvanzInvanz 3

Drug NameDrugTier


MeropenemMeropenem (500mg Injection)

♦1

MerremMerrem (500mg Injection)

3

PrimaxinPrimaxin 3

Beta-Lactam, Penicillins - Antibiotics

AmoxicillinAmoxicillin ♦ 1

Amoxicillin/Potassium Clavulanate

Amoxicillin/Potassium Clavulanate

♦

1

Amoxicillin/Potassium Clavulanate ER

Amoxicillin/Potassium Clavulanate ER

♦

1

AmpicillinAmpicillin ♦ 1

Ampicillin SodiumAmpicillin Sodium (10gm Injection, 125mg Injection, 1gm Injection)

♦

1

Ampicillin/SulbactamAmpicillin/Sulbactam (10gm; 5gm Injection, 2gm; 1gm Injection)

♦

1

Bactocill in DextroseBactocill in Dextrose (1gm/50ml Injection)

3

Bactocill in DextroseBactocill in Dextrose (2gm/50ml Injection)

4

Bicillin C-RBicillin C-R 3

Bicillin L-ABicillin L-A 3

Dicloxacillin SodiumDicloxacillin Sodium ♦ 1

MoxatagMoxatag 3



11

20

Drug NameDrugTier


Nafcillin SodiumNafcillin Sodium (10gm Injection, 1gm Injection)

♦

1

Nallpen/DextroseNallpen/Dextrose 3

Oxacillin SodiumOxacillin Sodium (10gm Injection, 1gm Injection)

♦

1

Penicillin G PotassiumPenicillin G Potassium (5mu Injection)

♦

1

Penicillin G Potassium in Iso-Osmotic Dextrose

Penicillin G Potassium in Iso-Osmotic Dextrose (Injection)

2

Penicillin G ProcainePenicillin G Procaine ♦ 1

Penicillin G SodiumPenicillin G Sodium ♦ 1

Penicillin V PotassiumPenicillin V Potassium

♦1

Pfizerpen-GPfizerpen-G (20mu Injection)

3

Piperacillin Sodium/Tazobactam SodiumPiperacillin Sodium/Tazobactam Sodium (3gm; 0.375gm Injection, 4gm; 0.5gm Injection)

♦

1

TimentinTimentin (0.1gm; 3gm Injection)

3

UnasynUnasyn (2gm; 1gm Injection)

3

Unasyn Bulk PackUnasyn Bulk Pack

3

ZosynZosyn (3gm; 0.375gm Injection, 5%; 2gm/50ml; 0.25gm/50ml Injection, 5%; 3gm/50ml; 0.375gm/50ml Injection)

3

Drug NameDrugTier


Macrolides - Antibiotics

Akne-MycinAkne-Mycin 3

AzasiteAzasite 2

AzithromycinAzithromycin (500mg Injection, Suspension Reconstituted, Tablet)

♦

1

BiaxinBiaxin 3

Biaxin XLBiaxin XL 3

Biaxin XL PacBiaxin XL Pac 3

ClarithromycinClarithromycin ♦ 1

Clarithromycin ERClarithromycin ER ♦ 1

DificidDificid 4

E.E.S. 400E.E.S. 400 ♦ 1

E.E.S. GranulesE.E.S. Granules 2

Ery Pad 2%Ery Pad 2% ♦ 1

Ery-TabEry-Tab 2

EryPedEryPed 2

Erythrocin LactobionateErythrocin Lactobionate (500mg Injection)

3

Erythrocin StearateErythrocin Stearate

3

ErythromycinErythromycin (External Solution, Gel, Ointment)

♦

1

Erythromycin BaseErythromycin Base ♦ 1

Erythromycin EthylsuccinateErythromycin Ethylsuccinate

♦1

KetekKetek 3

PCEPCE 3

ZithromaxZithromax 3

Zithromax Tri-PakZithromax Tri-Pak 3

Zithromax Z-PakZithromax Z-Pak 3

ZmaxZmax 3

Quinolones - Antibiotics

12

21

Drug NameDrugTier


AveloxAvelox (Tablet) 2

AveloxAvelox (Injection) 3

Avelox ABC PackAvelox ABC Pack 2

BesivanceBesivance 2

CiloxanCiloxan 3

CiproCipro (Immediate-Release Tablet, Oral Suspension)

3

Cipro HCCipro HC 3

Cipro IVCipro IV (200mg/100ml; 5% Injection)

3

CiprodexCiprodex 2

CiprofloxacinCiprofloxacin (400mg/40ml Injection)

♦

1

Ciprofloxacin ERCiprofloxacin ER ♦ 1

Ciprofloxacin HClCiprofloxacin HCl ♦ 1

Ciprofloxacin I.V. in D5WCiprofloxacin I.V. in D5W (200mg/100ml; 5% Injection)

♦

1

LevaquinLevaquin (5%; 750mg/150ml Injection, Oral Solution, Tablet)

3

LevofloxacinLevofloxacin ♦ 1

Levofloxacin in D5WLevofloxacin in D5W (5%; 500mg/100ml Injection)

♦

1

MoxezaMoxeza 2

NoroxinNoroxin 3

Drug NameDrugTier


OcufloxOcuflox 3

OfloxacinOfloxacin ♦ 1

VigamoxVigamox 2

ZymaxidZymaxid 2

Sulfonamides - Antibiotics

BactrimBactrim 3

Bactrim DSBactrim DS 3

Bleph-10Bleph-10 3

Sulfacetamide SodiumSulfacetamide Sodium (Ointment, Ophthalmic Solution)

♦

1

SulfadiazineSulfadiazine ♦ 1

Sulfamethoxazole/TrimethoprimSulfamethoxazole/Trimethoprim

♦1

Sulfamethoxazole/Trimethoprim DSSulfamethoxazole/Trimethoprim DS

♦1

Tetracyclines - Antibiotics

Demeclocycline HClDemeclocycline HCl ♦ 1

DoryxDoryx (150mg Tablet Delayed Release)

3

DoxycyclineDoxycycline (75mg Capsule, Suspension Reconstituted)

♦

1

Doxycycline HyclateDoxycycline Hyclate (Capsule, Injection, Tablet)

♦

1

Doxycycline Hyclate DRDoxycycline Hyclate DR

♦1



13

22

Drug NameDrugTier


Doxycycline MonohydrateDoxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet)

♦

1

DynacinDynacin 3

MinocinMinocin (Capsule)

3

Minocycline HClMinocycline HCl ♦ 1

Minocycline HCl ERMinocycline HCl ER ♦ 1

OraceaOracea 3

SolodynSolodyn 3

VibramycinVibramycin 3

Anticonvulsants - Drugs to Treat Seizures

Anticonvulsants, Other - Seizure Control Drugs

KeppraKeppra (Oral Solution, Tablet)

3

Keppra XRKeppra XR 3

LevetiracetamLevetiracetam (500mg/5ml Injection, Oral Solution, Tablet)

♦

1

Levetiracetam ERLevetiracetam ER ♦ 1

PhenobarbitalPhenobarbital (Elixir, Tablet)

♦1

PotigaPotiga 3

Calcium Channel Modifying Agents - Seizure Control Drugs

CelontinCelontin 3

EthosuximideEthosuximide ♦ 1

LyricaLyrica 2

ZarontinZarontin 3

ZonegranZonegran 3

ZonisamideZonisamide ♦ 1

Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs

Drug NameDrugTier


ClonazepamClonazepam ♦ 1

Clonazepam ODTClonazepam ODT ♦ 1

Clorazepate DipotassiumClorazepate Dipotassium

♦1

DepaconDepacon 3

DepakeneDepakene 3

DepakoteDepakote 3

Depakote ERDepakote ER 3

Depakote SprinklesDepakote Sprinkles

3

DiazepamDiazepam (Gel) ♦ 1

Divalproex SodiumDivalproex Sodium ♦ 1

Divalproex Sodium DRDivalproex Sodium DR

♦1

Divalproex Sodium ERDivalproex Sodium ER

♦1

GabapentinGabapentin ♦ 1

GabitrilGabitril 3

HorizantHorizant 3

KlonopinKlonopin 3

MysolineMysoline 3

NeurontinNeurontin 3

OnfiOnfi 3

PrimidonePrimidone ♦ 1

SabrilSabril 4 LA

StavzorStavzor 3

Tiagabine HClTiagabine HCl ♦ 1

Tranxene TTranxene T 3

Valproate SodiumValproate Sodium (100mg/ml Injection)

♦

1

Valproic AcidValproic Acid ♦ 1

Glutamate Reducing Agents - Seizure Control Drugs

14

23

Drug NameDrugTier


FelbamateFelbamate (Suspension, 400mg Tablet)

♦

1

FelbamateFelbamate (600mg Tablet)

4

FelbatolFelbatol 4

LamictalLamictal (Tablet) 3

Lamictal Chewable DispersibleLamictal Chewable Dispersible

3

Lamictal ODTLamictal ODT (Tablet Dispersible)

3

Lamictal Starter KitLamictal Starter Kit

3

Lamictal XRLamictal XR 3

LamotrigineLamotrigine ♦ 1

Lamotrigine ERLamotrigine ER ♦ 1

TopamaxTopamax 3

Topamax SprinkleTopamax Sprinkle 3

TopiramateTopiramate ♦ 1

Sodium Channel Agents - Seizure Control Drugs

BanzelBanzel (200mg Tablet)

3

BanzelBanzel (Suspension, 400mg Tablet)

4

CarbamazepineCarbamazepine ♦ 1

Carbamazepine ERCarbamazepine ER ♦ 1

CarbatrolCarbatrol 3

DilantinDilantin 2

Dilantin InfatabsDilantin Infatabs 2

Drug NameDrugTier


EpitolEpitol ♦ 1

EquetroEquetro 3

Fosphenytoin SodiumFosphenytoin Sodium (100mg pe/2ml Injection)

♦

1

OxcarbazepineOxcarbazepine ♦ 1

PeganonePeganone 3

PhenytekPhenytek ♦ 1

PhenytoinPhenytoin ♦ 1

Phenytoin SodiumPhenytoin Sodium (Injection)

♦1

Phenytoin Sodium ExtendedPhenytoin Sodium Extended (Capsule)

♦1

TegretolTegretol 3

Tegretol-XRTegretol-XR (100mg Tablet Extended Release 12 Hour)

2

Tegretol-XRTegretol-XR (200mg Tablet Extended Release 12 Hour, 400mg Tablet Extended Release 12 Hour)

3

TrileptalTrileptal 3

VimpatVimpat (Injection) 3

VimpatVimpat (Oral Solution, Tablet)

3

Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia

Antidementia Agents, Other

Ergoloid MesylatesErgoloid Mesylates ♦ 1



15

24

Drug NameDrugTier


Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs

AriceptAricept 3

Aricept ODTAricept ODT 3

Donepezil HClDonepezil HCl (10mg Tablet Dispersible, 5mg Tablet Dispersible, 10mg Tablet, 5mg Tablet)

♦

1

ExelonExelon (Capsule, Oral Solution)

3

ExelonExelon (Patch 24 Hour)

3

Galantamine HydrobromideGalantamine Hydrobromide

♦1

RazadyneRazadyne 3

Razadyne ERRazadyne ER 3

Rivastigmine TartrateRivastigmine Tartrate

♦1

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs

NamendaNamenda 2

Namenda Titration PakNamenda Titration Pak

2

Namenda XRNamenda XR 3

Namenda XR Titration PackNamenda XR Titration Pack

3

Antidepressants - Drugs to Treat Depression

Antidepressants, Other - Antidepressants

AplenzinAplenzin 3

Budeprion SRBudeprion SR ♦ 1

Bupropion HClBupropion HCl ♦ 1

Bupropion HCl SRBupropion HCl SR ♦ 1

Bupropion HCl XLBupropion HCl XL ♦ 1

Forfivo XLForfivo XL 3

Drug NameDrugTier


Maprotiline HClMaprotiline HCl ♦ 1

MirtazapineMirtazapine ♦ 1

Mirtazapine ODTMirtazapine ODT (30mg Tablet Dispersible, 45mg Tablet Dispersible)

♦

1

Nefazodone HClNefazodone HCl ♦ 1

OleptroOleptro 3

RemeronRemeron 3

Remeron SoltabRemeron Soltab 3

Trazodone HClTrazodone HCl ♦ 1

WellbutrinWellbutrin 3

Wellbutrin SRWellbutrin SR 3

Wellbutrin XLWellbutrin XL 3

Monoamine Oxidase Inhibitors - Antidepressants

EmsamEmsam 4

MarplanMarplan 3

NardilNardil 3

ParnateParnate 3

Phenelzine SulfatePhenelzine Sulfate ♦ 1

Tranylcypromine SulfateTranylcypromine Sulfate

♦1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants

CelexaCelexa 3

Citalopram HydrobromideCitalopram Hydrobromide

♦1

CymbaltaCymbalta 3

Desvenlafaxine ERDesvenlafaxine ER

3

Effexor XREffexor XR 3

Escitalopram OxalateEscitalopram Oxalate

♦1

Fluoxetine DRFluoxetine DR ♦ 1

Fluoxetine HClFluoxetine HCl ♦ 1

16

25

Drug NameDrugTier


Fluvoxamine MaleateFluvoxamine Maleate

♦1

Fluvoxamine Maleate ERFluvoxamine Maleate ER

♦1

LexaproLexapro 3

Luvox CRLuvox CR 3

Olanzapine/FluoxetineOlanzapine/Fluoxetine (25mg; 3mg Capsule)

♦

1

Paroxetine HClParoxetine HCl ♦ 1

Paroxetine HCl ERParoxetine HCl ER ♦ 1

PaxilPaxil 3

Paxil CRPaxil CR 3

PexevaPexeva 3

PristiqPristiq 3

ProzacProzac 3

Prozac WeeklyProzac Weekly 3

SarafemSarafem 3

Sertraline HClSertraline HCl ♦ 1

Venlafaxine HClVenlafaxine HCl ♦ 1

Venlafaxine HCl ERVenlafaxine HCl ER ♦ 1

ViibrydViibryd 3

ZoloftZoloft 3

Tricyclics - Antidepressants

Amitriptyline HClAmitriptyline HCl ♦ 1

AmoxapineAmoxapine (100mg Tablet, 25mg Tablet, 50mg Tablet)

♦

1

AmoxapineAmoxapine (150mg Tablet)

♦1

AnafranilAnafranil 4

Clomipramine HClClomipramine HCl ♦ 1

Drug NameDrugTier


Desipramine HClDesipramine HCl ♦ 1

Doxepin HClDoxepin HCl ♦ 1

Imipramine HClImipramine HCl ♦ 1

Imipramine PamoateImipramine Pamoate ♦ 1

NorpraminNorpramin 3

Nortriptyline HClNortriptyline HCl (Capsule)

♦1

PamelorPamelor 4

Perphenazine/AmitriptylinePerphenazine/Amitriptyline

♦1

Protriptyline HClProtriptyline HCl ♦ 1

SurmontilSurmontil 3

TofranilTofranil 3

Tofranil-PMTofranil-PM 3

Trimipramine MaleateTrimipramine Maleate

♦1

VivactilVivactil 3

Antiemetics - Drugs to Treat Nausea and Vomiting

Antiemetics, Other - Nausea and Vomiting Drugs

AntivertAntivert 3

Meclizine HClMeclizine HCl (Tablet)

♦1

TiganTigan 3

Transderm-ScopTransderm-Scop 3

Trimethobenzamide HClTrimethobenzamide HCl (Capsule)

♦1

Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs

AloxiAloxi 3



17

26

Drug NameDrugTier


AnzemetAnzemet (Injection)

3

AnzemetAnzemet (Tablet) 4 B/D

CesametCesamet 4 B/D

DronabinolDronabinol ♦ 1 B/D

EmendEmend (Capsule) 2 B/D

Granisetron HClGranisetron HCl (0.1mg/ml Injection, 1mg/ml Injection)

♦

1

Granisetron HClGranisetron HCl (Tablet)

♦1 B/D

GranisolGranisol ♦ 1 B/D

MarinolMarinol (2.5mg Capsule)

3 B/D

MarinolMarinol (10mg Capsule, 5mg Capsule)

4 B/D

Ondansetron HClOndansetron HCl (40mg/20ml Injection)

♦

1

Ondansetron HClOndansetron HCl (Oral Solution, Tablet)

♦

1 B/D

Ondansetron ODTOndansetron ODT ♦ 1 B/D

SancusoSancuso 4

ZofranZofran (Injection) 4

ZofranZofran (Oral Solution, Tablet)

4 B/D

Zofran ODTZofran ODT 4 B/D

Antifungals - Drugs to Treat Fungal Infections

Antifungals - Fungal Infection Drugs

AbelcetAbelcet 4 B/D

AmBisomeAmBisome 4 B/D

Amphotericin BAmphotericin B ♦ 1 B/D

AncobonAncobon 4

CancidasCancidas 4

Drug NameDrugTier


CiclopiroxCiclopirox ♦ 1

Ciclopirox Nail LacquerCiclopirox Nail Lacquer

♦1

Ciclopirox OlamineCiclopirox Olamine ♦ 1

ClotrimazoleClotrimazole ♦ 1

Clotrimazole/Betamethasone Dipropionate

Clotrimazole/Betamethasone Dipropionate

♦

1

DiflucanDiflucan 3

Econazole NitrateEconazole Nitrate ♦ 1

EraxisEraxis (100mg Injection)

4

ExeldermExelderm 3

ExtinaExtina 3

FluconazoleFluconazole ♦ 1

Fluconazole in DextroseFluconazole in Dextrose (56mg/ml; 400mg/200ml Injection)

♦

1

FlucytosineFlucytosine ♦ 1

Gris-PEGGris-PEG 3

Griseofulvin MicrosizeGriseofulvin Microsize

♦1

Griseofulvin UltramicrosizeGriseofulvin Ultramicrosize

♦1

Gynazole-1Gynazole-1 3

ItraconazoleItraconazole ♦ 1

KetoconazoleKetoconazole (Cream, Foam, Shampoo, Tablet)

♦

1

Ketodan KitKetodan Kit 3

LamisilLamisil 3

Loprox ShampooLoprox Shampoo 3

LotrisoneLotrisone 3

MentaxMentax 3

Miconazole 3Miconazole 3 ♦ 1

MycamineMycamine 4

18

27

Drug NameDrugTier


NaftinNaftin (1% Cream, Gel)

3

NatacynNatacyn 2

NizoralNizoral 3

NoxafilNoxafil 4

NyamycNyamyc ♦ 1

NystatinNystatin (Cream, Ointment, 100000unit/gm Powder, Suspension, Tablet)

♦

1

Nystatin/TriamcinoloneNystatin/Triamcinolone

♦1

NystopNystop ♦ 1

ONMELONMEL 4

OxistatOxistat 3

Pedi-DriPedi-Dri ♦ 1

SporanoxSporanox 4

Sporanox PulsepakSporanox Pulsepak

3

TerazolTerazol 3

Terbinafine HClTerbinafine HCl (Tablet)

♦1

TerconazoleTerconazole ♦ 1

VfendVfend 4

Vfend IVVfend IV 3

VoriconazoleVoriconazole ♦ 1

ZazoleZazole (Cream) ♦ 1

Antigout Agents - Drugs to Treat Gout

Antigout Agents - Gout Drugs

AllopurinolAllopurinol (Tablet) ♦ 1

Drug NameDrugTier


Allopurinol SodiumAllopurinol Sodium (Injection)

♦1

AloprimAloprim 3

ColcrysColcrys 2

ProbenecidProbenecid ♦ 1

Probenecid/ColchicineProbenecid/Colchicine

♦1

UloricUloric 2

ZyloprimZyloprim 3

Antimigraine Agents - Drugs to Treat Migraines

Ergot Alkaloids - Migraine Drugs

Dihydroergotamine MesylateDihydroergotamine Mesylate (Injection)

♦1

ErgomarErgomar 3

MigergotMigergot ♦ 1

MigranalMigranal 4

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs

AlsumaAlsuma 3

AmergeAmerge 3

AxertAxert 3

FrovaFrova 3

ImitrexImitrex 3

Imitrex Statdose RefillImitrex Statdose Refill

3

MaxaltMaxalt 3

Maxalt-MLTMaxalt-MLT 3

Naratriptan HClNaratriptan HCl ♦ 1

RelpaxRelpax 3

Rizatriptan BenzoateRizatriptan Benzoate ♦ 1



19

28

Drug NameDrugTier


Sumatriptan SuccinateSumatriptan Succinate (6mg/0.5ml Injection, Tablet)

♦

1

Sumavel DoseProSumavel DosePro 3

ZomigZomig 3

Zomig ZMTZomig ZMT 3

Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis

Parasympathomimetics - Myasthenia Gravis Drugs

Guanidine HClGuanidine HCl 3

MestinonMestinon 3

Mestinon TimespanMestinon Timespan

3

Pyridostigmine BromidePyridostigmine Bromide

♦1

RegonolRegonol ♦ 1

Antimycobacterials - Drugs to Treat Infections

Antimycobacterials, Other - Miscellaneous Anti-Infectives

DapsoneDapsone 2

MycobutinMycobutin 3

Antituberculars - Tuberculosis Drugs

Capastat SulfateCapastat Sulfate 3

Ethambutol HClEthambutol HCl ♦ 1

IsoniazidIsoniazid ♦ 1

MyambutolMyambutol (400mg Tablet)

3

PaserPaser 3

PriftinPriftin 3

PyrazinamidePyrazinamide ♦ 1

RifadinRifadin 3

RifamateRifamate 3

RifampinRifampin ♦ 1

RifaterRifater 3

Drug NameDrugTier


SeromycinSeromycin 3

SirturoSirturo 4

TrecatorTrecator 3

Antineoplastics - Drugs to Treat Cancer

Alkylating Agents - Chemotherapy Agents

AlkeranAlkeran (Injection)

3

BiCNUBiCNU 3

BusulfexBusulfex 4

CeeNUCeeNU (10mg Capsule, 40mg Capsule)

3

CyclophosphamideCyclophosphamide (Tablet)

♦1 B/D

DacarbazineDacarbazine (200mg Injection)

♦1

HexalenHexalen 4

IfexIfex (3gm Injection)

3

IfosfamideIfosfamide (1gm Injection)

♦1

LeukeranLeukeran 2

MatulaneMatulane 4

Melphalan HClMelphalan HCl ♦ 1

MustargenMustargen 4

ThiotepaThiotepa ♦ 1

TreandaTreanda (100mg Injection)

4

ZanosarZanosar 3

Antiangiogenic Agents - Chemotherapy Agents

CaprelsaCaprelsa 4 LA

RevlimidRevlimid (10mg Capsule, 15mg Capsule, 25mg Capsule, 5mg Capsule)

4 LA

20

29

Drug NameDrugTier


ThalomidThalomid 4

Antiestrogens/Modifiers - Chemotherapy Agents

EmcytEmcyt 3

FarestonFareston 4

FaslodexFaslodex 4

SoltamoxSoltamox 3

Tamoxifen CitrateTamoxifen Citrate ♦ 1

Antimetabolites - Chemotherapy Agents

CladribineCladribine ♦ 1 B/D

ClolarClolar 4

CytarabineCytarabine (500mg Injection)

♦1 B/D

Cytarabine AqueousCytarabine Aqueous ♦ 1 B/D

DroxiaDroxia 3

ElitekElitek (1.5mg Injection)

4

FluorouracilFluorouracil (2.5gm/50ml Injection)

♦1 B/D

FolotynFolotyn (40mg/2ml Injection)

4

Gemcitabine HClGemcitabine HCl (1gm Injection)

♦1

GemzarGemzar (1gm Injection)

4

HydreaHydrea 3

HydroxyureaHydroxyurea ♦ 1

MercaptopurineMercaptopurine ♦ 1

NipentNipent 4

PentostatinPentostatin ♦ 1

PurinetholPurinethol 3

TabloidTabloid 3

Drug NameDrugTier


Antineoplastics - Chemotherapy Agents

TafinlarTafinlar 4

Antineoplastics, Other - Chemotherapy Agents

AbraxaneAbraxane 4

AdriamycinAdriamycin (2mg/ml Injection)

♦1 B/D

AlimtaAlimta (500mg Injection)

4

AmifostineAmifostine ♦ 1

ArranonArranon 4

Bleomycin SulfateBleomycin Sulfate (30unit Injection)

♦1 B/D

CamptosarCamptosar (100mg/5ml Injection)

3

CarboplatinCarboplatin (150mg/15ml Injection)

♦

1

CerubidineCerubidine 3

CisplatinCisplatin (100mg/100ml Injection)

♦1

CometriqCometriq 4

CosmegenCosmegen 4

DacogenDacogen 4

Daunorubicin HClDaunorubicin HCl (5mg/ml Injection)

♦1

DexrazoxaneDexrazoxane (500mg Injection)

♦1

DocefrezDocefrez 4

DocetaxelDocetaxel (80mg/4ml Injection, 80mg/8ml Injection)

♦

1



21

30

Drug NameDrugTier


DoxilDoxil 4

Doxorubicin HClDoxorubicin HCl (2mg/ml Injection)

♦1 B/D

EllenceEllence (200mg/100ml Injection)

4

EloxatinEloxatin (100mg/20ml Injection)

4

ElsparElspar 3

Epirubicin HClEpirubicin HCl (50mg/25ml Injection)

♦

1

ErivedgeErivedge 4

Fludarabine PhosphateFludarabine Phosphate (50mg Injection)

♦

1

FusilevFusilev 4

HalavenHalaven 4

IclusigIclusig 4

Idamycin PFSIdamycin PFS (20mg/20ml Injection)

4

Idarubicin HClIdarubicin HCl (10mg/10ml Injection)

♦

1

IrinotecanIrinotecan (100mg/5ml Injection)

♦1

IstodaxIstodax 4

Ixempra KitIxempra Kit (45mg Injection)

4

JakafiJakafi 4 LA

JevtanaJevtana 4

Leucovorin CalciumLeucovorin Calcium (100mg Injection, 350mg Injection, Tablet)

♦

1

MekinistMekinist 4

MenestMenest ♦ 1

MesnaMesna ♦ 1

Drug NameDrugTier


MesnexMesnex (Injection)

3

MesnexMesnex (Tablet) 4

MitomycinMitomycin (20mg Injection)

♦1

Mitoxantrone HClMitoxantrone HCl ♦ 1

OntakOntak 4

OxaliplatinOxaliplatin (100mg/20ml Injection)

♦1

PaclitaxelPaclitaxel (300mg/50ml Injection)

♦1

PicatoPicato 3

PomalystPomalyst 4

ProleukinProleukin 4

SylatronSylatron 4

SynriboSynribo 4

TaxotereTaxotere (80mg/4ml Injection)

4

TrisenoxTrisenox 3

VelcadeVelcade 4

VidazaVidaza 4

Vinblastine SulfateVinblastine Sulfate (10mg Injection)

♦1 B/D

Vincasar PFSVincasar PFS ♦ 1 B/D

Vincristine SulfateVincristine Sulfate ♦ 1 B/D

Vinorelbine TartrateVinorelbine Tartrate (50mg/5ml Injection)

♦

1

ZaltrapZaltrap (100mg/4ml Injection)

4

ZinecardZinecard (250mg Injection)

4

ZolinzaZolinza 4

ZytigaZytiga 4

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents

AnastrozoleAnastrozole ♦ 1

22

31

Drug NameDrugTier


ArimidexArimidex 3

AromasinAromasin 3

ExemestaneExemestane ♦ 1

FemaraFemara 3

LetrozoleLetrozole ♦ 1

Enzyme Inhibitors - Chemotherapy Agents

EtopophosEtopophos 4

EtoposideEtoposide (Injection) ♦ 1

HycamtinHycamtin (Injection)

4

ToposarToposar ♦ 1

Topotecan HClTopotecan HCl (4mg Injection)

♦1

Molecular Target Inhibitors - Chemotherapy Agents

AfinitorAfinitor 4

BosulifBosulif 4

GleevecGleevec 4

InlytaInlyta 4

NexavarNexavar 4

SprycelSprycel 4

StivargaStivarga 4

SutentSutent 4

TarcevaTarceva 4

TasignaTasigna 4

TykerbTykerb 4

VotrientVotrient 4

XalkoriXalkori 4 LA

ZelborafZelboraf 4

Drug NameDrugTier


Monoclonal Antibodies - Chemotherapy Agents

ArzerraArzerra (100mg/5ml Injection)

4

AvastinAvastin (100mg/4ml Injection)

4

ErbituxErbitux (100mg/50ml Injection)

4

HerceptinHerceptin 4

KadcylaKadcyla (100mg Injection)

4

PerjetaPerjeta 4

RituxanRituxan 4

VectibixVectibix (100mg/5ml Injection)

4

YervoyYervoy (50mg/10ml Injection)

4

Retinoids - Chemotherapy Agents

PanretinPanretin 4

TargretinTargretin 4

TretinoinTretinoin (Capsule) ♦ 1

Antiparasitics - Drugs to Treat Parasitic Infections

Anthelmintics - Worm Infection Drugs

AlbenzaAlbenza 2

BiltricideBiltricide 2

StromectolStromectol 2

Antiprotozoals - Protozoal Infection Drugs

AliniaAlinia 3



23

32

Drug NameDrugTier


Atovaquone/Proguanil HClAtovaquone/Proguanil HCl (250mg; 100mg Tablet)

♦

1

Chloroquine PhosphateChloroquine Phosphate

♦1

CoartemCoartem 3

DaraprimDaraprim 2

Hydroxychloroquine SulfateHydroxychloroquine Sulfate

♦1

MalaroneMalarone 3

Mefloquine HClMefloquine HCl ♦ 1

MepronMepron 4

NebupentNebupent 3 B/D

Pentam 300Pentam 300 3

PlaquenilPlaquenil 3

Primaquine PhosphatePrimaquine Phosphate

3

QualaquinQualaquin 3

Quinine SulfateQuinine Sulfate ♦ 1

TinidazoleTinidazole ♦ 1

Pediculicides/Scabicides - Scabies and Lice Drugs

EuraxEurax 3

LindaneLindane ♦ 1

MalathionMalathion ♦ 1

OvideOvide 3

PermethrinPermethrin (Cream) ♦ 1

SkliceSklice 3

SpinosadSpinosad ♦ 1

UlesfiaUlesfia 3

Antiparkinson Agents - Drugs to Treat Parkinson's Disease

Anticholinergics - Parkinson's Disease Drugs

Benztropine MesylateBenztropine Mesylate

♦1

Drug NameDrugTier


CogentinCogentin 3

Trihexyphenidyl HClTrihexyphenidyl HCl ♦ 1

Antiparkinson Agents, Other - Parkinson's Disease Drugs

ComtanComtan 3

EntacaponeEntacapone ♦ 1

NeuproNeupro 3

TasmarTasmar 4

Dopamine Agonists - Parkinson's Disease Drugs

ApokynApokyn 4

Bromocriptine MesylateBromocriptine Mesylate

♦1

MirapexMirapex 3

Mirapex ERMirapex ER 3

ParlodelParlodel 3

Pramipexole DihydrochloridePramipexole Dihydrochloride (Immediate-Release Tablet)

♦

1

RequipRequip 3

Requip XLRequip XL 3

Ropinirole ERRopinirole ER ♦ 1

Ropinirole HClRopinirole HCl ♦ 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs

Carbidopa/LevodopaCarbidopa/Levodopa

♦1

Carbidopa/Levodopa ERCarbidopa/Levodopa ER

♦1

Carbidopa/Levodopa ODTCarbidopa/Levodopa ODT

♦1

LodosynLodosyn 3

ParcopaParcopa 3

SinemetSinemet 3

Sinemet CRSinemet CR 3

24

33

Drug NameDrugTier


StalevoStalevo 3

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs

AzilectAzilect 2

EldeprylEldepryl 3

Selegiline HClSelegiline HCl ♦ 1

ZelaparZelapar 3

Antipsychotics - Drugs to Treat Mood Disorders

1st Generation/Typical - Mood Disorder Drugs

Chlorpromazine HClChlorpromazine HCl (Injection, Tablet)

♦1

ComproCompro ♦ 1

Fluphenazine DecanoateFluphenazine Decanoate

♦1

Fluphenazine HClFluphenazine HCl (Concentrate, Elixir)

♦

1

Fluphenazine HClFluphenazine HCl (Injection, Tablet)

♦1

HaldolHaldol 3

Haldol DecanoateHaldol Decanoate 3

HaloperidolHaloperidol ♦ 1

Haloperidol DecanoateHaloperidol Decanoate (Injection)

♦

1

Haloperidol LactateHaloperidol Lactate (Injection)

♦1

Loxapine SuccinateLoxapine Succinate (10mg Capsule, 25mg Capsule, 50mg Capsule)

♦

1

Drug NameDrugTier


Loxapine SuccinateLoxapine Succinate (5mg Capsule)

♦1

LoxitaneLoxitane (10mg Capsule, 25mg Capsule)

3

LoxitaneLoxitane (5mg Capsule)

3

OrapOrap 2

PerphenazinePerphenazine ♦ 1

ProchlorperazineProchlorperazine ♦ 1

Prochlorperazine EdisylateProchlorperazine Edisylate (Injection)

♦1

Prochlorperazine MaleateProchlorperazine Maleate

♦1

Thioridazine HClThioridazine HCl ♦ 1

ThiothixeneThiothixene ♦ 1

Trifluoperazine HClTrifluoperazine HCl ♦ 1

2nd Generation/Atypical - Mood Disorder Drugs

AbilifyAbilify (9.75mg/1.3ml Injection)

3

AbilifyAbilify (Oral Solution, Tablet)

4

Abilify DiscmeltAbilify Discmelt 4

Abilify MaintenaAbilify Maintena (300mg Injection)

4

FanaptFanapt (1mg Tablet, 2mg Tablet)

3



25

34

Drug NameDrugTier


FanaptFanapt (10mg Tablet, 12mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Tablet)

4

Fanapt Titration PackFanapt Titration Pack

3

GeodonGeodon (Capsule) 3

GeodonGeodon (Injection)

3

InvegaInvega 3

Invega SustennaInvega Sustenna (39mg/0.25ml Injection, 78mg/0.5ml Injection)

3

Invega SustennaInvega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, 234mg/1.5ml Injection)

4

LatudaLatuda 3

OlanzapineOlanzapine (Injection)

♦1

OlanzapineOlanzapine (Tablet) ♦ 1

Olanzapine ODTOlanzapine ODT ♦ 1

Quetiapine FumarateQuetiapine Fumarate

♦1

RisperdalRisperdal 3

Risperdal ConstaRisperdal Consta (12.5mg Injection, 25mg Injection)

3

Risperdal ConstaRisperdal Consta (37.5mg Injection, 50mg Injection)

4

Risperdal M-TabRisperdal M-Tab 3

RisperidoneRisperidone ♦ 1

Risperidone ODTRisperidone ODT ♦ 1

Drug NameDrugTier


SaphrisSaphris (10mg Tablet Sublingual)

3

SaphrisSaphris (5mg Tablet Sublingual)

3

SeroquelSeroquel 3

Seroquel XRSeroquel XR 2

Ziprasidone HClZiprasidone HCl (Capsule)

♦1

ZyprexaZyprexa (Injection)

3

ZyprexaZyprexa (Tablet) 3

Zyprexa ZydisZyprexa Zydis 3

Treatment-Resistant - Mood Disorder Drugs

ClozapineClozapine ♦ 1

ClozarilClozaril 3

FazacloFazaclo (100mg Tablet Dispersible, 150mg Tablet Dispersible, 200mg Tablet Dispersible, 25mg Tablet Dispersible)

2

FazacloFazaclo (12.5mg Tablet Dispersible)

2

Antispasticity Agents - Drugs to Treat Spasms

Antispasticity Agents - Muscle Spasm Drugs

BaclofenBaclofen ♦ 1

DantriumDantrium 3

Dantrolene SodiumDantrolene Sodium (Capsule)

♦1

26

35

Drug NameDrugTier


GablofenGablofen (10000mcg/20ml Injection, 50mcg/ml Injection)

2 B/D

GablofenGablofen (40000mcg/20ml Injection)

4 B/D

Lioresal IntrathecalLioresal Intrathecal (0.05mg/ml Injection, 10mg/20ml Injection)

2 B/D

Lioresal IntrathecalLioresal Intrathecal (10mg/5ml Injection)

4 B/D

Tizanidine HClTizanidine HCl ♦ 1

ZanaflexZanaflex 3

Antivirals - Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs

CidofovirCidofovir ♦ 1

CytoveneCytovene 3 B/D

Foscarnet SodiumFoscarnet Sodium ♦ 1 B/D

GanciclovirGanciclovir ♦ 1 B/D

ValcyteValcyte 4

VistideVistide 4

ZirganZirgan 3

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs

AtriplaAtripla 4

CompleraComplera 4

EdurantEdurant 4

Drug NameDrugTier


IntelenceIntelence (100mg Tablet, 200mg Tablet)

4

NevirapineNevirapine (Tablet) ♦ 1

RescriptorRescriptor 3

StribildStribild 4

SustivaSustiva 3

ViramuneViramune 3

Viramune XRViramune XR 2

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs

AbacavirAbacavir ♦ 1

CombivirCombivir 4

DidanosineDidanosine ♦ 1

EmtrivaEmtriva 3

EpivirEpivir (Oral Solution)

2

EpivirEpivir (Tablet) 3

Epivir HBVEpivir HBV 2

EpzicomEpzicom 4

LamivudineLamivudine ♦ 1

Lamivudine/ZidovudineLamivudine/Zidovudine

♦1

RetrovirRetrovir 3

Retrovir IV InfusionRetrovir IV Infusion

3

StavudineStavudine ♦ 1

TrizivirTrizivir 4

TruvadaTruvada 4

Videx ECVidex EC 3



27

36

Drug NameDrugTier


Videx PediatricVidex Pediatric (2gm Oral Solution)

3

VireadViread 4

ZeritZerit 3

ZiagenZiagen 3

ZidovudineZidovudine ♦ 1

Anti-HIV Agents, Other - HIV Drugs

FuzeonFuzeon 4

IsentressIsentress (25mg Tablet Chewable)

2

IsentressIsentress (Tablet, 100mg Tablet Chewable)

4

SelzentrySelzentry 4

Anti-HIV Agents, Protease Inhibitors - HIV Drugs

AptivusAptivus 4

CrixivanCrixivan 2

InviraseInvirase (Capsule) 3

InviraseInvirase (Tablet) 4

KaletraKaletra (100mg; 25mg Tablet)

3

KaletraKaletra (Oral Solution, 200mg; 50mg Tablet)

4

LexivaLexiva (Suspension)

3

LexivaLexiva (Tablet) 4

NorvirNorvir 3

PrezistaPrezista (150mg Tablet, 75mg Tablet)

3

PrezistaPrezista (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

4

Drug NameDrugTier


ReyatazReyataz (100mg Capsule)

2

ReyatazReyataz (150mg Capsule, 200mg Capsule, 300mg Capsule)

4

ViraceptViracept 4

Anti-Influenza Agents - Flu Drugs

Amantadine HClAmantadine HCl ♦ 1

Relenza DiskhalerRelenza Diskhaler

3

Rimantadine HClRimantadine HCl ♦ 1

TamifluTamiflu 2

Antihepatitis Agents - Hepatitis Drugs

BaracludeBaraclude (Oral Solution)

3

BaracludeBaraclude (Tablet)

4

CopegusCopegus 4

HepseraHepsera 4

IncivekIncivek 4

InfergenInfergen (15mcg/0.5ml Injection)

4

Intron-AIntron-A (6000000unit/ml Injection)

3

Intron-A W/DiluentIntron-A W/Diluent (10mu Injection)

4

Peg-IntronPeg-Intron (50mcg/0.5ml Injection)

4

Peg-Intron RedipenPeg-Intron Redipen

4

PegasysPegasys 4

Pegasys ProClickPegasys ProClick (135mcg/0.5ml Injection)

4

28

37

Drug NameDrugTier


RebetolRebetol 4

RibapakRibapak (Tablet) ♦ 1

RibasphereRibasphere ♦ 1

RibavirinRibavirin ♦ 1

TyzekaTyzeka 4

VictrelisVictrelis 4

VirazoleVirazole 4

Antiherpetic Agents - Herpes Drugs

AcyclovirAcyclovir ♦ 1

Acyclovir SodiumAcyclovir Sodium (500mg Injection)

♦1 B/D

DenavirDenavir 3

FamciclovirFamciclovir ♦ 1

FamvirFamvir 3

TrifluridineTrifluridine ♦ 1

Valacyclovir HClValacyclovir HCl ♦ 1

ValtrexValtrex 3

ViropticViroptic 3

XereseXerese 3

ZoviraxZovirax 3

Anxiolytics - Drugs to Treat Anxiety

Anxiolytics, Other - Anxiety Drugs

AlprazolamAlprazolam (Immediate-Release Tablet)

♦

1

Alprazolam ERAlprazolam ER (0.5mg Tablet Extended Release 24 Hour)

♦

1

Alprazolam IntensolAlprazolam Intensol (Oral Solution)

♦1

Alprazolam ODTAlprazolam ODT ♦ 1

Drug NameDrugTier


Alprazolam XRAlprazolam XR (1mg Tablet Extended Release 24 Hour, 2mg Tablet Extended Release 24 Hour, 3mg Tablet Extended Release 24 Hour)

♦

1

AtivanAtivan (Tablet) 3

Buspirone HClBuspirone HCl ♦ 1

Chlordiazepoxide HClChlordiazepoxide HCl

♦1

Chlordiazepoxide/AmitriptylineChlordiazepoxide/Amitriptyline

♦1

DiazepamDiazepam (Oral Solution, Tablet)

♦1

Diazepam IntensolDiazepam Intensol (Oral Solution)

♦

1

EstazolamEstazolam ♦ 1

LorazepamLorazepam (Tablet) ♦ 1

Lorazepam IntensolLorazepam Intensol (Oral Solution)

♦1

MeprobamateMeprobamate ♦ 1

NiravamNiravam 3

OxazepamOxazepam ♦ 1

ValiumValium 3

XanaxXanax 3

Xanax XRXanax XR 3

Bipolar Agents - Drugs to Treat Mood Disorders

Bipolar Agents, Other - Mood Disorder Drugs



29

38

Drug NameDrugTier


Olanzapine/FluoxetineOlanzapine/Fluoxetine (25mg; 12mg Capsule, 25mg; 6mg Capsule, 50mg; 12mg Capsule, 50mg; 6mg Capsule)

♦

1

SymbyaxSymbyax 3

Mood Stabilizers - Mood Disorder Drugs

Lithium CarbonateLithium Carbonate ♦ 1

Lithium Carbonate ERLithium Carbonate ER

♦1

Lithium CitrateLithium Citrate ♦ 1

LithobidLithobid 3

Blood Glucose Regulators - Drugs to Regulate Blood Sugar

Antidiabetic Agents - Diabetic Drugs

AcarboseAcarbose ♦ 1

Actoplus MetActoplus Met 3

Actoplus Met XRActoplus Met XR 3

ActosActos 3

AmarylAmaryl 3

AvandametAvandamet 3 LA

AvandarylAvandaryl 3 LA

AvandiaAvandia 3 LA

BydureonBydureon 3

ByettaByetta 2

ChlorpropamideChlorpropamide ♦ 1

CyclosetCycloset 3

DiabetaDiabeta 3

DuetactDuetact 3

FortametFortamet 3

GlimepirideGlimepiride ♦ 1

GlipizideGlipizide (Immediate-Release Tablet)

♦

1

Glipizide ERGlipizide ER ♦ 1

Drug NameDrugTier


Glipizide/Metformin HClGlipizide/Metformin HCl

♦1

GlucophageGlucophage 3

Glucophage XRGlucophage XR 3

GlucotrolGlucotrol 3

Glucotrol XLGlucotrol XL 3

GlucovanceGlucovance (2.5mg; 500mg Tablet, 5mg; 500mg Tablet)

3

GlumetzaGlumetza 3

GlyburideGlyburide ♦ 1

Glyburide MicronizedGlyburide Micronized

♦1

Glyburide/Metformin HClGlyburide/Metformin HCl

♦1

GlynaseGlynase 3

GlysetGlyset 3

InvokanaInvokana 3

JanumetJanumet 2

Janumet XRJanumet XR 2

JanuviaJanuvia 2

JentaduetoJentadueto 3

JuvisyncJuvisync 3

KazanoKazano 3

Kombiglyze XRKombiglyze XR 2

Metformin HClMetformin HCl ♦ 1

Metformin HCl ER 1000mg Tablet Extended Release 24 Hour

Metformin HCl ER 1000mg Tablet Extended Release 24 Hour (Generic Fortamet)

♦

1

Metformin HCl ER 500mg, 750mg Tablet Extended Release 24 Hour

Metformin HCl ER 500mg, 750mg Tablet Extended Release 24 Hour (Generic Glucophage XR)

♦

1

30

39

Drug NameDrugTier


NateglinideNateglinide ♦ 1

NesinaNesina 3

OnglyzaOnglyza 2

OseniOseni 3

Pioglitazone HClPioglitazone HCl ♦ 1

Pioglitazone HCl/GlimepiridePioglitazone HCl/Glimepiride

♦1

Pioglitazone HCl/Metformin HClPioglitazone HCl/Metformin HCl

♦1

PrandiMetPrandiMet 3

PrandinPrandin 3

PrecosePrecose 3

RiometRiomet 3

StarlixStarlix 3

SymlinPen 120SymlinPen 120 3

SymlinPen 60SymlinPen 60 3

TolazamideTolazamide ♦ 1

TolbutamideTolbutamide ♦ 1

TradjentaTradjenta 3

VictozaVictoza 2

Glycemic Agents - Diabetic Drugs

Clinimix 4.25%/Dextrose 20%Clinimix 4.25%/Dextrose 20%

3 B/D

Clinimix 5%/Dextrose 15%Clinimix 5%/Dextrose 15%

3 B/D


3 B/D

Clinimix E 2.75%/Dextrose 10%Clinimix E 2.75%/Dextrose 10%

3 B/D


3 B/D

Drug NameDrugTier



3 B/D


3 B/D

Clinimix E 5%/Dextrose 15%Clinimix E 5%/Dextrose 15%

3 B/D


3 B/D

Dextrose 10% Flex ContainerDextrose 10% Flex Container

♦1

Dextrose 10%/NaCl 0.2%Dextrose 10%/NaCl 0.2%

♦1


♦1

Dextrose 2.5%/NaCl 0.45%Dextrose 2.5%/NaCl 0.45%

♦1

Dextrose 5%Dextrose 5% ♦ 1


♦1


♦1


♦1


♦1


♦1

Glucagen HypoKitGlucagen HypoKit 3

Glucagon Emergency KitGlucagon Emergency Kit

2

Ionosol-B/Dextrose 5%Ionosol-B/Dextrose 5%

3

Ionosol-MB/Dextrose 5%Ionosol-MB/Dextrose 5%

3



31

40

Drug NameDrugTier


KCl 0.075%/D5W/NaCl 0.45%KCl 0.075%/D5W/NaCl 0.45%

♦1

KCl 0.15%/D5W/LRKCl 0.15%/D5W/LR

♦1


♦1


♦1


♦1


♦1


♦1

Normosol-R in D5WNormosol-R in D5W

♦1

Potassium Chloride 0.15%/D5W/NaCl 0.33%


♦

1

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex

♦

1



♦

1

ProglycemProglycem 3

Insulins - Diabetic Drugs

ApidraApidra 2

Apidra SoloStarApidra SoloStar 2

HumalogHumalog (Vial) 2

Humalog KwikPenHumalog KwikPen

2

HumulinHumulin (Vial) 2

Humulin PenHumulin Pen 2

LantusLantus 2

Lantus SoloStarLantus SoloStar 2

LevemirLevemir 2

Levemir FlexPenLevemir FlexPen 2

Drug NameDrugTier


NovolinNovolin (Vial) 2

NovologNovolog (Vial) 2

Novolog FlexPenNovolog FlexPen 2

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders

Anticoagulants - Blood Thinners

ArgatrobanArgatroban (100mg/ml Injection, 125mg/125ml; 0.9% Injection)

♦

1

ArixtraArixtra (2.5mg/0.5ml Injection)

3

ArixtraArixtra (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

4

CoumadinCoumadin (Tablet)

2

CoumadinCoumadin (Injection)

3

EliquisEliquis 3

Enoxaparin SodiumEnoxaparin Sodium ♦ 1

Fondaparinux SodiumFondaparinux Sodium

♦1

FragminFragmin (2500unit/0.2ml Injection, 5000unit/0.2ml Injection)

3

32

41

Drug NameDrugTier


FragminFragmin (10000unit/ml Injection, 12500unit/0.5ml Injection, 15000unit/0.6ml Injection, 18000unt/0.72ml Injection, 25000unit/ml Injection, 7500unit/0.3ml Injection)

4

Heparin SodiumHeparin Sodium (10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/ml Injection)

♦

1

Heparin Sodium/D5WHeparin Sodium/D5W (5%; 40unit/ml Injection)

♦

1

Heparin Sodium/NaClHeparin Sodium/NaCl (100unit/ml; 0.45% Injection, 50unit/ml; 0.45% Injection)

♦

1

Heparin Sodium/NaCl 0.9% PremixHeparin Sodium/NaCl 0.9% Premix

♦1

JantovenJantoven ♦ 1

LovenoxLovenox (30mg/0.3ml Injection, 40mg/0.4ml Injection)

3

Drug NameDrugTier


LovenoxLovenox (100mg/ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection, 300mg/3ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection)

4

PradaxaPradaxa 2

Warfarin SodiumWarfarin Sodium ♦ 1

XareltoXarelto 2

Blood Formation Modifiers - Blood Formation Drugs

AgrylinAgrylin 3

Anagrelide HClAnagrelide HCl ♦ 1

Aranesp Albumin FreeAranesp Albumin Free (25mcg/0.42ml Injection, 25mcg/ml Injection, 40mcg/0.4ml Injection, 40mcg/ml Injection, 60mcg/0.3ml Injection, 60mcg/ml Injection)

3 B/D



33

42

Drug NameDrugTier


Aranesp Albumin FreeAranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 150mcg/0.3ml Injection, 200mcg/0.4ml Injection, 200mcg/ml Injection, 300mcg/0.6ml Injection, 300mcg/ml Injection, 500mcg/ml Injection)

4 B/D

EpogenEpogen 3 B/D

LeukineLeukine 4

MozobilMozobil 4

NeulastaNeulasta 4

NeumegaNeumega 4

NeupogenNeupogen (300mcg/0.5ml Injection, 480mcg/0.8ml Injection, 480mcg/1.6ml Injection)

4

ProcritProcrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml Injection, 4000unit/ml Injection)

3 B/D

Drug NameDrugTier


ProcritProcrit (20000unit/ml Injection, 40000unit/ml Injection)

4 B/D

PromactaPromacta 4

Blood Products/Modifiers/Volume Expanders

CinryzeCinryze 4

Coagulants - Blood Clotting Drugs

BrilintaBrilinta 2

CyklokapronCyklokapron 3

LystedaLysteda 3

Tranexamic AcidTranexamic Acid ♦ 1

Platelet Modifying Agents - Platelet Modifying Drugs

AggrenoxAggrenox 2

CilostazolCilostazol ♦ 1

ClopidogrelClopidogrel ♦ 1

DipyridamoleDipyridamole (Tablet)

♦1

EffientEffient 2

PersantinePersantine 3

PlavixPlavix 3

PletalPletal 3

Ticlopidine HClTiclopidine HCl ♦ 1

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions

Alpha-Adrenergic Agonists - Blood Pressure Drugs

CatapresCatapres 3

Catapres-TTSCatapres-TTS 3

Clonidine HClClonidine HCl (Patch Weekly, Tablet)

♦

1

ClorpresClorpres 3

34

43

Drug NameDrugTier


Guanfacine HClGuanfacine HCl (Generic Tenex)

♦1

MethyldopaMethyldopa ♦ 1

Methyldopa/HydrochlorothiazideMethyldopa/Hydrochlorothiazide

♦1

Methyldopate HClMethyldopate HCl ♦ 1

Midodrine HClMidodrine HCl ♦ 1

TenexTenex 3

Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs

Cardura XLCardura XL 3

DibenzylineDibenzyline 3

MinipressMinipress 3

Prazosin HClPrazosin HCl ♦ 1

ReserpineReserpine ♦ 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs

AtacandAtacand 3

Atacand HCTAtacand HCT 3

AvalideAvalide 3

AvaproAvapro 3

BenicarBenicar 2

Benicar HCTBenicar HCT 2

CozaarCozaar 3

DiovanDiovan 2

Diovan HCTDiovan HCT 3

EdarbiEdarbi 3

EdarbyclorEdarbyclor 3

Eprosartan MesylateEprosartan Mesylate ♦ 1

HyzaarHyzaar 3

IrbesartanIrbesartan ♦ 1

Drug NameDrugTier


Irbesartan/HydrochlorothiazideIrbesartan/Hydrochlorothiazide

♦1

Losartan PotassiumLosartan Potassium ♦ 1

Losartan Potassium/Hydrochlorothiazide

Losartan Potassium/Hydrochlorothiazide

♦

1

MicardisMicardis 3

Micardis HCTMicardis HCT 3

TevetenTeveten 3

Teveten HCTTeveten HCT 3

Valsartan/HydrochlorothiazideValsartan/Hydrochlorothiazide

♦1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs

AccuprilAccupril 3

AccureticAccuretic 3

AltaceAltace 3

Benazepril HClBenazepril HCl ♦ 1

Benazepril HCl/HydrochlorothiazideBenazepril HCl/Hydrochlorothiazide

♦1

CaptoprilCaptopril ♦ 1

Captopril/HydrochlorothiazideCaptopril/Hydrochlorothiazide

♦1

Enalapril MaleateEnalapril Maleate ♦ 1

Enalapril Maleate/HydrochlorothiazideEnalapril Maleate/Hydrochlorothiazide

♦1

Fosinopril SodiumFosinopril Sodium ♦ 1

Fosinopril Sodium/HydrochlorothiazideFosinopril Sodium/Hydrochlorothiazide

♦1

LisinoprilLisinopril ♦ 1

Lisinopril/HydrochlorothiazideLisinopril/Hydrochlorothiazide

♦1



35

44

Drug NameDrugTier


LotensinLotensin 3

Lotensin HCTLotensin HCT 3

MavikMavik 3

Moexipril HClMoexipril HCl ♦ 1

Moexipril/HydrochlorothiazideMoexipril/Hydrochlorothiazide

♦1

Perindopril ErbuminePerindopril Erbumine

♦1

PrinivilPrinivil 3

Quinapril HClQuinapril HCl ♦ 1

Quinapril/HydrochlorothiazideQuinapril/Hydrochlorothiazide

♦1

RamiprilRamipril ♦ 1

TarkaTarka 3

TrandolaprilTrandolapril ♦ 1

UnireticUniretic 3

UnivascUnivasc 3

VasereticVaseretic 3

VasotecVasotec 3

ZestoreticZestoretic 3

ZestrilZestril 3

Antiarrhythmics - Heart Regulation Drugs

Amiodarone HClAmiodarone HCl (50mg/ml Injection, Tablet)

♦

1

BetapaceBetapace (120mg Tablet, 160mg Tablet)

3

Betapace AFBetapace AF (80mg Tablet)

3

CordaroneCordarone 3

Disopyramide PhosphateDisopyramide Phosphate

♦1

Flecainide AcetateFlecainide Acetate ♦ 1

Mexiletine HClMexiletine HCl ♦ 1

MultaqMultaq 2

Drug NameDrugTier


NexteroneNexterone 3

NorpaceNorpace 3

Norpace CRNorpace CR 3

PaceronePacerone (200mg Tablet)

♦1

PaceronePacerone (100mg Tablet, 400mg Tablet)

3

Procainamide HClProcainamide HCl ♦ 1

Propafenone HClPropafenone HCl ♦ 1

Propafenone HCl ERPropafenone HCl ER

♦1

Quinidine GluconateQuinidine Gluconate

3

Quinidine Gluconate CRQuinidine Gluconate CR

♦1

Quinidine SulfateQuinidine Sulfate ♦ 1

Quinidine Sulfate ERQuinidine Sulfate ER

♦1

RythmolRythmol 3

Rythmol SRRythmol SR 3

SorineSorine ♦ 1

Sotalol HClSotalol HCl (Injection, 160mg Tablet, 240mg Tablet, 80mg Tablet)

♦

1

Sotalol HClSotalol HCl (AF) (120mg Tablet)

♦1

TikosynTikosyn 3

Beta-Adrenergic Blocking Agents - Blood Pressure Drugs

Acebutolol HClAcebutolol HCl ♦ 1

AtenololAtenolol ♦ 1

Atenolol/ChlorthalidoneAtenolol/Chlorthalidone

♦1

Betaxolol HClBetaxolol HCl (Tablet)

♦1

Bisoprolol FumarateBisoprolol Fumarate ♦ 1

36

45

Drug NameDrugTier


Bisoprolol Fumarate/Hydrochlorothiazide

Bisoprolol Fumarate/Hydrochlorothiazide

♦

1

BystolicBystolic 2

CarvedilolCarvedilol (12.5mg Tablet, 25mg Tablet, 3.125mg Tablet, 6.25mg Tablet)

♦

1

CoregCoreg 3

Coreg CRCoreg CR 3

CorgardCorgard 3

CorzideCorzide 3

DUTOPROLDUTOPROL 3

Inderal LAInderal LA 3

Innopran XLInnopran XL 3

Labetalol HClLabetalol HCl ♦ 1

LevatolLevatol 3

LopressorLopressor 3

Lopressor HCTLopressor HCT 3

Metoprolol Succinate ERMetoprolol Succinate ER

♦1

Metoprolol TartrateMetoprolol Tartrate ♦ 1

Metoprolol/HydrochlorothiazideMetoprolol/Hydrochlorothiazide

♦1

NadololNadolol ♦ 1

Nadolol/BendroflumethiazideNadolol/Bendroflumethiazide

♦1

PindololPindolol ♦ 1

Propranolol HClPropranolol HCl ♦ 1

Propranolol HCl ERPropranolol HCl ER ♦ 1

Propranolol/HydrochlorothiazidePropranolol/Hydrochlorothiazide

♦1

Drug NameDrugTier


SectralSectral 3

TenoreticTenoretic 3

TenorminTenormin 3

Timolol MaleateTimolol Maleate (Tablet)

♦1

Toprol XLToprol XL 3

ZebetaZebeta 3

ZiacZiac 3

Calcium Channel Blocking Agents - Blood Pressure Drugs

Adalat CCAdalat CC 3

Afeditab CRAfeditab CR ♦ 1

Amlodipine BesylateAmlodipine Besylate ♦ 1

Amlodipine Besylate/Benazepril HCl

Amlodipine Besylate/Benazepril HCl

♦

1

AzorAzor 2

CaduetCaduet 3

CalanCalan 3

Calan SRCalan SR 3

CardizemCardizem 3

Cardizem CDCardizem CD 3

Cardizem LACardizem LA 3

Cartia XTCartia XT ♦ 1

Dilacor XRDilacor XR 3

Dilt-CDDilt-CD (120mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

♦

1



37

46

Drug NameDrugTier


Dilt-XRDilt-XR (180mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour)

♦

1

Diltiazem CDDiltiazem CD (120mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

♦

1

Diltiazem HClDiltiazem HCl (100mg Injection, 50mg/10ml Injection, Tablet)

♦

1

Diltiazem HCl ERDiltiazem HCl ER (Capsule Extended Release 12 Hour, 180mg Capsule Extended Release 24 Hour, 360mg Capsule Extended Release 24 Hour, 420mg Capsule Extended Release 24 Hour)

♦

1

ExforgeExforge 2

Exforge HCTExforge HCT 2

Felodipine ERFelodipine ER ♦ 1

IsradipineIsradipine ♦ 1

LotrelLotrel 3

Matzim LAMatzim LA ♦ 1

Nicardipine HClNicardipine HCl ♦ 1

Nifediac CCNifediac CC (90mg Tablet Extended Release 24 Hour)

♦

1

Drug NameDrugTier


Nifedical XLNifedical XL ♦ 1

NifedipineNifedipine (Capsule) ♦ 1

Nifedipine ERNifedipine ER ♦ 1

NimodipineNimodipine ♦ 1

NisoldipineNisoldipine ♦ 1

Nisoldipine ERNisoldipine ER ♦ 1

NorvascNorvasc 3

ProcardiaProcardia 3

Procardia XLProcardia XL 3

SularSular 3

Taztia XTTaztia XT ♦ 1

TiazacTiazac 3

TribenzorTribenzor 2

TwynstaTwynsta 3

Verapamil HClVerapamil HCl ♦ 1

Verapamil HCl ERVerapamil HCl ER ♦ 1

Verapamil HCl SRVerapamil HCl SR (360mg Capsule Extended Release 24 Hour)

♦

1

VerelanVerelan 3

Verelan PMVerelan PM 3

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs

AmturnideAmturnide 3

DemserDemser 4

DigoxinDigoxin ♦ 1

LanoxinLanoxin (Tablet) 3

Pentoxifylline ERPentoxifylline ER ♦ 1

RanexaRanexa 2

TekamloTekamlo 3

TekturnaTekturna 3

Tekturna HCTTekturna HCT 3

TrentalTrental 3

VecamylVecamyl 4

38

47

Drug NameDrugTier


Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs

Acetazolamide SodiumAcetazolamide Sodium (Injection)

♦1

Diuretics, Loop - Cardiac Drugs

BumetanideBumetanide ♦ 1

DemadexDemadex (10mg Tablet, 20mg Tablet, 5mg Tablet)

3

EdecrinEdecrin 3

FurosemideFurosemide ♦ 1

LasixLasix 3

TorsemideTorsemide (20mg/2ml Injection, Tablet)

♦1

Diuretics, Potassium-sparing - Cardiac Drugs

AldactazideAldactazide 3

AldactoneAldactone 3

Amiloride HClAmiloride HCl ♦ 1

Amiloride/HydrochlorothiazideAmiloride/Hydrochlorothiazide

♦1

DyazideDyazide 3

DyreniumDyrenium 3

EplerenoneEplerenone ♦ 1

InspraInspra 3

MaxzideMaxzide 3

SpironolactoneSpironolactone ♦ 1

Spironolactone/HydrochlorothiazideSpironolactone/Hydrochlorothiazide

♦1

Triamterene/HydrochlorothiazideTriamterene/Hydrochlorothiazide

♦1

Drug NameDrugTier


Diuretics, Thiazide - Cardiac Drugs

Candesartan Cilexetil/Hydrochlorothiazide

Candesartan Cilexetil/Hydrochlorothiazide

♦

1

ChlorothiazideChlorothiazide ♦ 1

Chlorothiazide SodiumChlorothiazide Sodium (Injection)

♦1

ChlorthalidoneChlorthalidone (25mg Tablet, 50mg Tablet)

♦

1

DiurilDiuril 3

HydrochlorothiazideHydrochlorothiazide ♦ 1

IndapamideIndapamide ♦ 1

MethyclothiazideMethyclothiazide ♦ 1

MetolazoneMetolazone ♦ 1

MicrozideMicrozide 3

Sodium DiurilSodium Diuril 3

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs

AntaraAntara 2

FenofibrateFenofibrate (Tablet) ♦ 1

Fenofibrate MicronizedFenofibrate Micronized

♦1

FenoglideFenoglide 3

FibricorFibricor 3

GemfibrozilGemfibrozil ♦ 1

LipofenLipofen 3

LofibraLofibra 3

LopidLopid 3

TricorTricor 3

TrilipixTrilipix 2



39

48

Drug NameDrugTier


Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs

AdvicorAdvicor 3

AltoprevAltoprev 3

Atorvastatin CalciumAtorvastatin Calcium ♦ 1

CrestorCrestor 2

FluvastatinFluvastatin (Capsule)

♦1

LescolLescol 3

Lescol XLLescol XL 3

LipitorLipitor 3

LivaloLivalo 3

LovastatinLovastatin ♦ 1

MevacorMevacor 3

PravacholPravachol 3

Pravastatin SodiumPravastatin Sodium ♦ 1

SimcorSimcor 3

SimvastatinSimvastatin ♦ 1

ZocorZocor 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs

Cholestyramine LightCholestyramine Light (Packet)

♦1

ColestidColestid (Granules, Tablet)

3

Colestipol HClColestipol HCl ♦ 1

JuxtapidJuxtapid 4

KynamroKynamro 4

LovazaLovaza 3

NiaspanNiaspan 2

PrevalitePrevalite (Powder) ♦ 1

QuestranQuestran (Packet)

3

VascepaVascepa 3

VytorinVytorin 3

WelcholWelchol 2

Drug NameDrugTier


ZetiaZetia 2

Vasodilators, Direct-acting Arterial - Chest Pain Drugs

Hydralazine HClHydralazine HCl ♦ 1

MinoxidilMinoxidil (Tablet) ♦ 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs

BiDilBiDil 2

Dilatrate SRDilatrate SR 3

Isordil TitradoseIsordil Titradose 3

Isosorbide DinitrateIsosorbide Dinitrate ♦ 1

Isosorbide Dinitrate ERIsosorbide Dinitrate ER

♦1

Isosorbide MononitrateIsosorbide Mononitrate

♦1

Isosorbide Mononitrate ERIsosorbide Mononitrate ER

♦1

MinitranMinitran ♦ 1

Nitro-BidNitro-Bid 3

Nitro-DurNitro-Dur 3

NitroglycerinNitroglycerin (Injection, Patch)

♦1

Nitrolingual PumpsprayNitrolingual Pumpspray

3

NitroMistNitroMist 3

NitrostatNitrostat 2

RectivRectiv 3

Central Nervous System Agents - Drugs to Treat Nerve Conditions

Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs

Adderall XRAdderall XR 3

Amphetamine/DextroamphetamineAmphetamine/Dextroamphetamine

♦1

DesoxynDesoxyn 3

DexedrineDexedrine 3

40

49

Drug NameDrugTier


Dextroamphetamine SulfateDextroamphetamine Sulfate (Tablet)

♦1

Dextroamphetamine Sulfate ERDextroamphetamine Sulfate ER

♦1

Methamphetamine HClMethamphetamine HCl

♦1

ProCentraProCentra 3

VyvanseVyvanse 3

ZenzediZenzedi 3

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs

ConcertaConcerta 3

DaytranaDaytrana 3

Dexmethylphenidate HClDexmethylphenidate HCl

♦1

FocalinFocalin 3

Focalin XRFocalin XR 3

IntunivIntuniv 3

KapvayKapvay 3

Metadate CDMetadate CD 3

Metadate ERMetadate ER ♦ 1

MethylinMethylin 3

Methylphenidate HClMethylphenidate HCl (Oral Solution, Tablet)

♦

1

Drug NameDrugTier


Methylphenidate HCl CDMethylphenidate HCl CD (10mg Capsule Extended Release, 50mg Capsule Extended Release, 60mg Capsule Extended Release)

♦

1

Methylphenidate HCl ERMethylphenidate HCl ER (Capsule Extended Release 24 Hour, 20mg Tablet Extended Release, 27mg Tablet Extended Release, 36mg Tablet Extended Release, 54mg Tablet Extended Release)

♦

1

Quillivant XRQuillivant XR 3

RitalinRitalin 3

Ritalin LARitalin LA 3

Ritalin SRRitalin SR 3

StratteraStrattera 3

Central Nervous System, Other - Miscellaneous Central Nervous System Drugs

Butalbital/Acetaminophen/Caffeine/Codeine

Butalbital/Acetaminophen/Caffeine/Codeine

♦

1

Fioricet/CodeineFioricet/Codeine 3

NuedextaNuedexta 3

OrbivanOrbivan 3



41

50

Drug NameDrugTier


RilutekRilutek 4

RiluzoleRiluzole ♦ 1

XenazineXenazine 4 LA

Fibromyalgia Agents - Fibromyalgia Drugs

SavellaSavella 2

Savella Titration PackSavella Titration Pack

2

Multiple Sclerosis Agents - Multiple Sclerosis Drugs

AmpyraAmpyra 4

AubagioAubagio 4

CopaxoneCopaxone 4

GilenyaGilenya 4

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions

Dental and Oral Agents

Cevimeline HClCevimeline HCl ♦ 1

Chlorhexidine Gluconate Oral Rinse

Chlorhexidine Gluconate Oral Rinse

♦

1

EvoxacEvoxac 3

KepivanceKepivance 4

PeriogardPeriogard ♦ 1

Pilocarpine HClPilocarpine HCl (Tablet)

♦1

SalagenSalagen 3

Triamcinolone in OrabaseTriamcinolone in Orabase

♦1

Dermatological Agents - Drugs to Treat Skin Conditions

Dermatological Agents - Skin Agents

8-MOP8-MOP 3

AbsoricaAbsorica 4

AcanyaAcanya 3

AczoneAczone 3

AdapaleneAdapalene ♦ 1

Drug NameDrugTier


AldaraAldara 3

Ammonium LactateAmmonium Lactate ♦ 1

AmnesteemAmnesteem ♦ 1

AtralinAtralin 3

AvitaAvita ♦ 1

AzelexAzelex 3

BenzamycinBenzamycin 3

CalcipotrieneCalcipotriene ♦ 1

CaracCarac 3

ClaravisClaravis ♦ 1

Cleocin-TCleocin-T 3

Clindacin PACClindacin PAC 3

ClindagelClindagel 3

Clindamycin PhosphateClindamycin Phosphate (External Solution, Foam, Gel, Lotion, Swab)

♦

1

Clindamycin/Benzoyl PeroxideClindamycin/Benzoyl Peroxide (1%-5% Gel)

♦

1

CondyloxCondylox (Gel) 3

DifferinDifferin 3

DovonexDovonex 3

EfudexEfudex 3

ElidelElidel 3

EpiduoEpiduo 3

Erythromycin/Benzoyl PeroxideErythromycin/Benzoyl Peroxide

♦1

EvoclinEvoclin 3

FinaceaFinacea 2

FluorouracilFluorouracil (Cream, External Solution)

♦1

ImiquimodImiquimod ♦ 1

KlaronKlaron 3

Lac-HydrinLac-Hydrin 3

42

51

Drug NameDrugTier


MyorisanMyorisan (20mg Capsule, 40mg Capsule)

♦

1

MyorisanMyorisan (10mg Capsule)

2

OxsoralenOxsoralen 3

Oxsoralen UltraOxsoralen Ultra 4

PennsaidPennsaid 3

PodofiloxPodofilox ♦ 1

ProtopicProtopic 3

PrudoxinPrudoxin ♦ 1

Retin-ARetin-A 3

Retin-A MicroRetin-A Micro 3

SantylSantyl 3

Selenium SulfideSelenium Sulfide (Lotion)

♦1

SolarazeSolaraze 3

SoriataneSoriatane 4

SoriluxSorilux 3

StelaraStelara 4

Sulfacetamide SodiumSulfacetamide Sodium (Suspension)

♦

1

Synalar Cream KitSynalar Cream Kit

3

TaclonexTaclonex 3

TazoracTazorac 3

Tretin-XTretin-X (Kit) 3

TretinoinTretinoin (Cream, 0.01% Gel, 0.025% Gel)

♦

1

UvadexUvadex 3

Drug NameDrugTier


VecticalVectical 3

VeltinVeltin 3

VeregenVeregen 3

VoltarenVoltaren (Gel) 2

ZianaZiana 3

ZonalonZonalon 3

ZyclaraZyclara 2

Enzyme Replacement/Modifiers - Drugs to Treat Enzyme Deficiency

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs

AdagenAdagen 4 LA

AldurazymeAldurazyme 4

BuphenylBuphenyl 4

CarbagluCarbaglu 4 LA

CerezymeCerezyme (200unit Injection)

4

CreonCreon 2

CystadaneCystadane 4

CystagonCystagon 3

ElapraseElaprase 4

ElelysoElelyso 4

FabrazymeFabrazyme (35mg Injection)

4

KuvanKuvan 4

LumizymeLumizyme 4

MyozymeMyozyme 4

NaglazymeNaglazyme 4

OrfadinOrfadin 4 LA

PancreazePancreaze 3



43

52

Drug NameDrugTier


PertzyePertzye 3

RAVICTIRAVICTI 4

Sodium PhenylbutyrateSodium Phenylbutyrate

♦1

SucraidSucraid 4

UltresaUltresa 4

ViokaceViokace (39150unit; 10440unit; 39150unit Tablet)

3

ViokaceViokace (78300unit; 20880unit; 78300unit Tablet)

4

VPRIVVPRIV 4

ZavescaZavesca 4 LA

ZenpepZenpep 2

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs

Atropine SulfateAtropine Sulfate (0.05mg/ml Injection, 0.1mg/ml Injection)

♦

1

BentylBentyl 3

CantilCantil 3

CuvposaCuvposa 3

Dicyclomine HClDicyclomine HCl (Capsule, Oral Solution, Tablet)

♦

1

GlycopyrrolateGlycopyrrolate (4mg/20ml Injection, Tablet)

♦

1

HelidacHelidac 3

Methscopolamine BromideMethscopolamine Bromide

♦1

PaminePamine 3

Drug NameDrugTier


Pamine FortePamine Forte 3

Propantheline BromidePropantheline Bromide

♦1

RobinulRobinul (Tablet) 3

Robinul ForteRobinul Forte 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs

ActigallActigall 3

ChenodalChenodal 4

Cromolyn SodiumCromolyn Sodium (Concentrate)

♦1

Diphenoxylate/AtropineDiphenoxylate/Atropine

♦1

FulyzaqFulyzaq 3

GastrocromGastrocrom 4

GattexGattex 4

HalfLytely Bowel Prep/Flavor PacksHalfLytely Bowel Prep/Flavor Packs

2

LomotilLomotil 3

Loperamide HClLoperamide HCl (Capsule)

♦1

Metoclopramide HClMetoclopramide HCl ♦ 1

Metozolv ODTMetozolv ODT 3

MotofenMotofen 3

OsmoPrepOsmoPrep 3

PyleraPylera 3

ReglanReglan 3

RelistorRelistor (12mg/0.6ml Injection)

3

UrsoUrso 3

UrsodiolUrsodiol ♦ 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs

AxidAxid (Oral Solution)

3

CimetidineCimetidine ♦ 1

44

53

Drug NameDrugTier


Cimetidine HClCimetidine HCl ♦ 1

FamotidineFamotidine (Injection, Suspension Reconstituted, 20mg Tablet, 40mg Tablet)

♦

1

Famotidine PremixedFamotidine Premixed

♦1

NizatidineNizatidine ♦ 1

PepcidPepcid 3

Ranitidine HClRanitidine HCl (Capsule, 150mg/6ml Injection, Syrup, 150mg Tablet, 300mg Tablet)

♦

1

ZantacZantac (Syrup, Tablet)

3

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs

AmitizaAmitiza 2

LinzessLinzess 3

LotronexLotronex 4

Laxatives - Bowel Treatment Drugs

Colyte-Flavor PacksColyte-Flavor Packs (240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm Oral Solution)

3

ConstuloseConstulose ♦ 1

EnuloseEnulose ♦ 1

GaviLyte-CGaviLyte-C ♦ 1

GaviLyte-GGaviLyte-G ♦ 1

Drug NameDrugTier


GaviLyte-N/Flavor PackGaviLyte-N/Flavor Pack

♦1

GenerlacGenerlac ♦ 1

GoLYTELYGoLYTELY 3

KristaloseKristalose 3

LactuloseLactulose ♦ 1

MoviPrepMoviPrep 3

NuLYTELY/Flavor PacksNuLYTELY/Flavor Packs

3

Polyethylene Glycol 3350Polyethylene Glycol 3350 (Powder)

♦1

PrepopikPrepopik 3

Suprep Bowel PrepSuprep Bowel Prep

3

TriLyteTriLyte ♦ 1

Protectants - Ulcer and Stomach Acid Drugs

CarafateCarafate 3

CytotecCytotec 3

MisoprostolMisoprostol ♦ 1

SucralfateSucralfate ♦ 1

Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs

AciphexAciphex 3

DexilantDexilant 3

LansoprazoleLansoprazole ♦ 1

NexiumNexium 2

Nexium I.V.Nexium I.V. 3

OmeprazoleOmeprazole (Capsule Delayed Release)

♦

1



45

54

Drug NameDrugTier


Pantoprazole SodiumPantoprazole Sodium

♦1

PrevacidPrevacid 3

Prevacid SoluTabPrevacid SoluTab 3

PrilosecPrilosec (Capsule Delayed Release)

3

ProtonixProtonix (Injection, Tablet Delayed Release)

3

ProtonixProtonix (Packet) 3

VimovoVimovo 2

ZegeridZegerid (Capsule) 3

ZegeridZegerid (Packet) 3

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions

Antispasmodics, Urinary - Bladder Control Drugs

DetrolDetrol 3

Detrol LADetrol LA 3

Ditropan XLDitropan XL 3

EnablexEnablex 3

Flavoxate HClFlavoxate HCl ♦ 1

GelniqueGelnique 2

MyrbetriqMyrbetriq 2

Oxybutynin ChlorideOxybutynin Chloride ♦ 1

Oxybutynin Chloride EROxybutynin Chloride ER

♦1

OxytrolOxytrol 2

SancturaSanctura 3

Sanctura XRSanctura XR 3

Tolterodine TartrateTolterodine Tartrate (Tablet)

♦1

ToviazToviaz 2

Trospium ChlorideTrospium Chloride ♦ 1

Trospium Chloride ERTrospium Chloride ER

♦1

VesicareVesicare 2

Drug NameDrugTier


Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs

Alfuzosin HCl ERAlfuzosin HCl ER ♦ 1

AvodartAvodart 2

CarduraCardura 3

Doxazosin MesylateDoxazosin Mesylate ♦ 1

FinasterideFinasteride (5mg Tablet)

♦1

FlomaxFlomax 3

JalynJalyn 3

ProscarProscar 3

RapafloRapaflo 2

Tamsulosin HClTamsulosin HCl ♦ 1

Terazosin HClTerazosin HCl ♦ 1

UroxatralUroxatral 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs

Bethanechol ChlorideBethanechol Chloride

♦1

CialisCialis (2.5mg Tablet, 5mg Tablet)

3

ElmironElmiron 3

UrecholineUrecholine 3

Phosphate Binders - Phosphate-Removing Agents

FosrenolFosrenol 4

RenagelRenagel 2

RenvelaRenvela 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs

A-HydrocortA-Hydrocort ♦ 1

Ala-CortAla-Cort ♦ 1

46

55

Drug NameDrugTier


Ala-ScalpAla-Scalp 3

Alclometasone DipropionateAlclometasone Dipropionate

♦1

AmcinonideAmcinonide ♦ 1

Anusol-HCAnusol-HC (Cream)

3

Augmented Betamethasone Dipropionate

Augmented Betamethasone Dipropionate

♦

1

Betamethasone DipropionateBetamethasone Dipropionate

♦1

Betamethasone ValerateBetamethasone Valerate

♦1

CapexCapex 3

Carmol-HCCarmol-HC 3

CelestoneCelestone 3

Clobetasol PropionateClobetasol Propionate (External Solution, Foam, Gel, Lotion, Ointment, Shampoo)

♦

1

Clobetasol Propionate EClobetasol Propionate E

♦1

ClobexClobex 3

Cloderm PumpCloderm Pump 3

Cordran TapeCordran Tape 3

CortefCortef 3

CortifoamCortifoam 3

Cortisone AcetateCortisone Acetate ♦ 1

CutivateCutivate (Cream, Lotion)

3

Depo-MedrolDepo-Medrol 3

Drug NameDrugTier


Derma-Smoothe/FSDerma-Smoothe/FS

3

DermatopDermatop 3

DesonateDesonate 3

DesonideDesonide ♦ 1

DesowenDesowen (Cream, Lotion)

3

DesoximetasoneDesoximetasone ♦ 1

DexamethasoneDexamethasone (Elixir, Tablet)

♦1

Dexamethasone IntensolDexamethasone Intensol (Oral Solution)

♦

1

Dexamethasone Sodium PhosphateDexamethasone Sodium Phosphate (4mg/ml Injection)

♦

1

DexPak 13 DayDexPak 13 Day 3

Diflorasone DiacetateDiflorasone Diacetate

♦1

DiproleneDiprolene 3

Diprolene AFDiprolene AF 3

EloconElocon 3

Flo-PredFlo-Pred 3

Fludrocortisone AcetateFludrocortisone Acetate

♦1

Fluocinolone AcetonideFluocinolone Acetonide

♦1

Fluocinolone Acetonide Body OilFluocinolone Acetonide Body Oil

♦1

FluocinonideFluocinonide (External Solution, Gel, Ointment)

♦

1

Fluocinonide-EFluocinonide-E ♦ 1



47

56

Drug NameDrugTier


Fluticasone PropionateFluticasone Propionate (Cream, Lotion, Ointment)

♦

1

Halobetasol PropionateHalobetasol Propionate

♦1

HalogHalog 3

HydrocortisoneHydrocortisone (1% Cream, 2.5% Cream, 2.5% Lotion, 1% Ointment, 2.5% Ointment, Tablet)

♦

1

Hydrocortisone ButyrateHydrocortisone Butyrate

♦1

Hydrocortisone ValerateHydrocortisone Valerate

♦1

KenalogKenalog 3

LocoidLocoid (External Solution, Lotion, Ointment)

3

Locoid LipocreamLocoid Lipocream 3

LoKaraLoKara ♦ 1

LuxiqLuxiq 3

MedrolMedrol (16mg Tablet, 32mg Tablet, 4mg Tablet, 8mg Tablet)

3

Medrol DosepakMedrol Dosepak 3

MethylprednisoloneMethylprednisolone (Tablet)

♦1

Methylprednisolone AcetateMethylprednisolone Acetate (Injection)

♦1

Methylprednisolone Dose PackMethylprednisolone Dose Pack

♦1

Methylprednisolone Sodium SuccinateMethylprednisolone Sodium Succinate (125mg Injection, 40mg Injection)

♦

1

Drug NameDrugTier


MillipredMillipred (Oral Solution)

3

Mometasone FuroateMometasone Furoate (Cream, Lotion, Ointment)

♦

1

Olux-EOlux-E 3

OrapredOrapred 3

Orapred ODTOrapred ODT (15mg Tablet Dispersible, 30mg Tablet Dispersible)

3

PandelPandel 3

PrednicarbatePrednicarbate ♦ 1

Prednisolone Sodium PhosphatePrednisolone Sodium Phosphate (Oral Solution)

♦

1

PrednisonePrednisone ♦ 1

Prednisone IntensolPrednisone Intensol (Oral Solution)

♦1

Procto-PakProcto-Pak ♦ 1

ProctoCream HCProctoCream HC ♦ 1

Proctozone-HCProctozone-HC ♦ 1

RayosRayos 3

Solu-CortefSolu-Cortef (100mg Injection, 250mg Injection)

3

Solu-MedrolSolu-Medrol (125mg Injection, 2gm Injection, 40mg Injection, 500mg Injection)

3

TemovateTemovate (Cream, Ointment)

3

TopicortTopicort 3

Triamcinolone AcetonideTriamcinolone Acetonide (Cream, Lotion, Ointment)

♦

1

48

57

Drug NameDrugTier


TridermTriderm ♦ 1

U-CortU-Cort ♦ 1

UltravateUltravate 3

VanosVanos 3

VerdesoVerdeso 3

Veripred 20Veripred 20 3

WestcortWestcort 3

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs

Acthar HPActhar HP 4

Chorionic GonadotropinChorionic Gonadotropin

♦1

DDAVPDDAVP (Nasal Solution, Tablet)

3

DDAVPDDAVP (Injection) 4

Desmopressin AcetateDesmopressin Acetate

♦1

GenotropinGenotropin (12mg Injection, 5mg Injection)

4

Genotropin MiniquickGenotropin Miniquick (0.2mg Injection)

3

Drug NameDrugTier


Genotropin MiniquickGenotropin Miniquick (0.4mg Injection, 0.6mg Injection, 0.8mg Injection, 1.2mg Injection, 1.4mg Injection, 1.6mg Injection, 1.8mg Injection, 1mg Injection, 2mg Injection)

4

HumatropeHumatrope 4

IncrelexIncrelex 4

Norditropin FlexProNorditropin FlexPro

4

Norditropin NordiFlex PenNorditropin NordiFlex Pen

4

NovarelNovarel ♦ 1

NutropinNutropin 4

Nutropin AQNutropin AQ 4

OmnitropeOmnitrope 4

Pregnyl W/Diluent Benzyl Alcohol/NaClPregnyl W/Diluent Benzyl Alcohol/NaCl

♦1

SaizenSaizen 4

SerostimSerostim 4

StimateStimate 3

Tev-TropinTev-Tropin 4

ZorbtiveZorbtive 4

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones



49

58

Drug NameDrugTier


Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs

KorlymKorlym 4

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones

Anabolic Steroids - Hormone Replacement/Modifying Drugs

OxandroloneOxandrolone ♦ 1

Androgens - Hormone Replacement/Modifying Drugs

AndrodermAndroderm 2

AndrogelAndrogel (50mg/5gm Gel)

2

Androgel PumpAndrogel Pump (1.62% Gel)

2

AndroidAndroid 3

AndroxyAndroxy ♦ 1

AxironAxiron 3

DanazolDanazol ♦ 1

DelatestrylDelatestryl 3

Depo-TestosteroneDepo-Testosterone

3

FortestaFortesta 3 B/D

MethitestMethitest 3

TestimTestim 3

Testosterone CypionateTestosterone Cypionate

♦1

Testosterone EnanthateTestosterone Enanthate

♦1

TestredTestred 3

Estrogens - Hormone Replacement/Modifying Drugs

ActivellaActivella 3

AloraAlora 3

Drug NameDrugTier


AmethiaAmethia ♦ 1

AmethystAmethyst ♦ 1

AngeliqAngeliq (0.5mg; 1mg Tablet)

3

ApriApri ♦ 1

AranelleAranelle ♦ 1

AvianeAviane ♦ 1

BalzivaBalziva ♦ 1

BeyazBeyaz 3

BreviconBrevicon 3

BriellynBriellyn ♦ 1

CenestinCenestin 3

ClimaraClimara 3

Climara ProClimara Pro 3

CombiPatchCombiPatch 3

CryselleCryselle ♦ 1

Cyclafem 1/35Cyclafem 1/35 ♦ 1

Cyclafem 7/7/7Cyclafem 7/7/7 ♦ 1

CyclessaCyclessa 3

DelestrogenDelestrogen 3

Depo-EstradiolDepo-Estradiol 3

DesogenDesogen 3

DivigelDivigel (1mg/gm Gel)

3

Drospirenone/Ethinyl EstradiolDrospirenone/Ethinyl Estradiol

♦1

ElestrinElestrin 3

EmoquetteEmoquette ♦ 1

EnjuviaEnjuvia 2

EnpresseEnpresse ♦ 1

EstraceEstrace 3

EstradiolEstradiol (Tablet) ♦ 1

Estradiol ValerateEstradiol Valerate (20mg/ml Injection, 40mg/ml Injection)

♦

1

50

59

Drug NameDrugTier


Estradiol/Norethindrone Acetate

Estradiol/Norethindrone Acetate

♦

1

EstringEstring 3

EstropipateEstropipate ♦ 1

Estrostep FeEstrostep Fe 3

EvamistEvamist 3

Femcon FeFemcon Fe 3

FemringFemring 3

Generess FeGeneress Fe 3

GianviGianvi ♦ 1

GildagiaGildagia ♦ 1

IntrovaleIntrovale ♦ 1

JinteliJinteli ♦ 1

JunelJunel ♦ 1

Junel FeJunel Fe ♦ 1

KarivaKariva ♦ 1

KelnorKelnor ♦ 1

LeenaLeena ♦ 1

LessinaLessina ♦ 1

LevonestLevonest ♦ 1

Levonorgestrel/Ethinyl EstradiolLevonorgestrel/Ethinyl Estradiol (0.03mg; 0.15mg Tablet)

♦

1

LevoraLevora ♦ 1

Lo Loestrin FeLo Loestrin Fe 3

Loestrin FeLoestrin Fe (20mcg; 75mg; 1mg Tablet)

3

LorynaLoryna ♦ 1

Drug NameDrugTier


LoSeasoniqueLoSeasonique 3

Low-OgestrelLow-Ogestrel ♦ 1

LuteraLutera ♦ 1

MarlissaMarlissa ♦ 1

MenostarMenostar 3

MicrogestinMicrogestin ♦ 1

Microgestin FeMicrogestin Fe ♦ 1

Minastrin 24 FeMinastrin 24 Fe 3

MinivelleMinivelle 3

ModiconModicon 3

MonoNessaMonoNessa ♦ 1

NeconNecon ♦ 1

Necon 1/35Necon 1/35 ♦ 1

NordetteNordette 3

NorinylNorinyl (35mcg; 1mg Tablet)

3

NortrelNortrel ♦ 1

Nortrel 1/35Nortrel 1/35 ♦ 1

NuvaRingNuvaRing 2

OcellaOcella ♦ 1

OgestrelOgestrel ♦ 1

OrsythiaOrsythia ♦ 1

Ortho EvraOrtho Evra 3

Ortho Tri-CyclenOrtho Tri-Cyclen 3

Ortho Tri-Cyclen LoOrtho Tri-Cyclen Lo

3

Ortho-CeptOrtho-Cept 3

Ortho-CyclenOrtho-Cyclen 3

Ortho-Novum 7/7/7Ortho-Novum 7/7/7

3

Ovcon-35Ovcon-35 3



51

60

Drug NameDrugTier


PortiaPortia ♦ 1

PrefestPrefest 3

PremarinPremarin (Cream, Tablet)

2

PremarinPremarin (Injection)

3

PremphasePremphase 2

PremproPrempro 2

PrevifemPrevifem ♦ 1

QuasenseQuasense ♦ 1

ReclipsenReclipsen ♦ 1

SafyralSafyral 3

SeasoniqueSeasonique 3

SprintecSprintec ♦ 1

SronyxSronyx ♦ 1

Tri-Legest FeTri-Legest Fe ♦ 1

Tri-NorinylTri-Norinyl 3

Tri-PrevifemTri-Previfem ♦ 1

Tri-SprintecTri-Sprintec ♦ 1

TrinessaTrinessa ♦ 1

TrivoraTrivora ♦ 1

VagifemVagifem 3

VelivetVelivet ♦ 1

Vivelle-DotVivelle-Dot 2

YasminYasmin 3

YazYaz 3

Zenchent FeZenchent Fe ♦ 1

ZoviaZovia ♦ 1

Progesterone Agonists/Antagonists - Hormone Replacement/Modifying Drugs

EllaElla 3

Progestins - Hormone Replacement/Modifying Drugs

AygestinAygestin 3

CamilaCamila ♦ 1

Drug NameDrugTier


CrinoneCrinone 3

Depo-ProveraDepo-Provera 3

Depo-SubQ Provera 104Depo-SubQ Provera 104

3

EndometrinEndometrin 3

ErrinErrin ♦ 1

JolivetteJolivette ♦ 1

Medroxyprogesterone AcetateMedroxyprogesterone Acetate

♦1

Megace ESMegace ES 3

Megace OralMegace Oral 3

Megestrol AcetateMegestrol Acetate ♦ 1

Nor-QDNor-QD 3

Nora-BENora-BE ♦ 1

Norethindrone AcetateNorethindrone Acetate

♦1

Ortho MicronorOrtho Micronor 3

ProgesteroneProgesterone (Capsule)

♦1

PrometriumPrometrium 3

ProveraProvera 3

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs

EvistaEvista 2

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs

CytomelCytomel 3

LevothroidLevothroid 2

Levothyroxine SodiumLevothyroxine Sodium (Tablet)

♦1

LevoxylLevoxyl ♦ 1

Liothyronine SodiumLiothyronine Sodium ♦ 1

52

61

Drug NameDrugTier


SynthroidSynthroid 2

ThyrolarThyrolar 2

Thyrolar-1/2Thyrolar-1/2 2

TirosintTirosint 3

UnithroidUnithroid (100mcg Tablet, 112mcg Tablet, 125mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet)

♦

1

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants

LysodrenLysodren 2

Hormonal Agents, Suppressant (Parathyroid) - Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Parathyroid) - Hormone Suppressants

SensiparSensipar (30mg Tablet)

2

SensiparSensipar (60mg Tablet, 90mg Tablet)

4

Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants

Drug NameDrugTier


CabergolineCabergoline ♦ 1

EligardEligard (22.5mg Injection, 30mg Injection, 7.5mg Injection)

3

EligardEligard (45mg Injection)

4

FirmagonFirmagon (80mg Injection)

3

FirmagonFirmagon (120mg Injection)

4

Leuprolide AcetateLeuprolide Acetate ♦ 1

Lupron DepotLupron Depot (22.5mg Injection, 3.75mg Injection, 30mg Injection, 45mg Injection, 7.5mg Injection)

4

Lupron Depot-PEDLupron Depot-PED (11.25mg Injection - 3 Month)

3

Lupron Depot-PEDLupron Depot-PED (11.25mg Injection - 1 Month, 15mg Injection - 1 Month)

4

Octreotide AcetateOctreotide Acetate ♦ 1

SandostatinSandostatin 4

Sandostatin LAR DepotSandostatin LAR Depot

4

SigniforSignifor 4



53

62

Drug NameDrugTier


Somatuline DepotSomatuline Depot

4

SomavertSomavert 4

SynarelSynarel 4

Trelstar DepotTrelstar Depot 4

Trelstar LATrelstar LA 4

Trelstar MixjectTrelstar Mixject 4

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) - Drugs to Regulate Hormones

Antiandrogens - Hormone Suppressants

BicalutamideBicalutamide ♦ 1

CasodexCasodex 3

FlutamideFlutamide ♦ 1

NilandronNilandron 3

XtandiXtandi 4

Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones

Antithyroid Agents - Thyroid Suppressing Drugs

MethimazoleMethimazole ♦ 1

PropylthiouracilPropylthiouracil ♦ 1

TapazoleTapazole 3

Immunological Agents - Drugs that Stimulate or Suppress the Immune System

Immune Suppressants - Immune System Drugs

AzasanAzasan 3

AzathioprineAzathioprine ♦ 1

Azathioprine SodiumAzathioprine Sodium (Injection)

♦

1

BenlystaBenlysta (120mg Injection)

4

CellceptCellcept 4 B/D

Drug NameDrugTier


Cellcept IntravenousCellcept Intravenous

3 B/D

CimziaCimzia 4

CyclosporineCyclosporine (Capsule)

♦1 B/D

CyclosporineCyclosporine (Injection)

♦1

Cyclosporine ModifiedCyclosporine Modified

♦1 B/D

EnbrelEnbrel 4

GengrafGengraf ♦ 1 B/D

HumiraHumira 4

Humira Starter KitHumira Starter Kit

4

ImuranImuran 3

KineretKineret 4

MethotrexateMethotrexate (Tablet)

♦1

Methotrexate SodiumMethotrexate Sodium (Injection)

♦1

Mycophenolate MofetilMycophenolate Mofetil

♦1 B/D

MyforticMyfortic (180mg Tablet Delayed Release)

3 B/D

MyforticMyfortic (360mg Tablet Delayed Release)

4 B/D

NeoralNeoral 3 B/D

NulojixNulojix 4 B/D

OrenciaOrencia 4

PrografPrograf (0.5mg Capsule, 1mg Capsule, Injection)

3 B/D

PrografPrograf (5mg Capsule)

4 B/D

54

63

Drug NameDrugTier


RapamuneRapamune (0.5mg Tablet)

3 B/D

RapamuneRapamune (Oral Solution, 1mg Tablet, 2mg Tablet)

4 B/D

RemicadeRemicade 4

RheumatrexRheumatrex 3

SandimmuneSandimmune (Capsule, Oral Solution)

3 B/D

SandimmuneSandimmune (Injection)

3

SimponiSimponi (50mg/0.5ml Injection)

4

TacrolimusTacrolimus ♦ 1 B/D

ToriselTorisel 4

TrexallTrexall 3

ZortressZortress 4 B/D

Immunizing Agents, Passive - Immune System Drugs

AtgamAtgam 4

Carimune NanofilteredCarimune Nanofiltered (3gm Injection)

4 B/D

Gamastan S/DGamastan S/D 2

Gammagard LiquidGammagard Liquid

4 B/D

GammaplexGammaplex (10gm/200ml Injection)

4 B/D

Gamunex-CGamunex-C (1gm/10ml Injection)

4 B/D

Drug NameDrugTier


PrivigenPrivigen (20gm/200ml Injection)

4 B/D

ThymoglobulinThymoglobulin 4

Immunomodulators - Immune System Drugs

ActemraActemra (200mg/10ml Injection)

4

ActimmuneActimmune 4

AravaArava 3

ArcalystArcalyst 4 LA

AvonexAvonex 4

BetaseronBetaseron 4

ExtaviaExtavia 4

IlarisIlaris 4

LeflunomideLeflunomide ♦ 1

RebifRebif 4

Rebif Titration PackRebif Titration Pack

4

RidauraRidaura 4

SimulectSimulect (20mg Injection)

4

SynagisSynagis (50mg/0.5ml Injection)

4

TecfideraTecfidera 4

Tecfidera Starter PackTecfidera Starter Pack

4

TysabriTysabri 4

XeljanzXeljanz 4

Vaccines

ActHIBActHIB 2

AdacelAdacel 2

BoostrixBoostrix 2



55

64

Drug NameDrugTier


CervarixCervarix 3

ComvaxComvax 2

DaptacelDaptacel 2

Engerix-BEngerix-B 2 B/D

GardasilGardasil 2

HavrixHavrix 2

Imovax RabiesImovax Rabies (H.D.C.V.)

2 B/D

InfanrixInfanrix 2

IPOLIPOL 2

IxiaroIxiaro 2

M-M-R IIM-M-R II 2

MenactraMenactra 2

Menomune-A/C/Y/W-135Menomune-A/C/Y/W-135

2

MenveoMenveo 2

Pedvax HIBPedvax HIB 2

ProQuadProQuad 2

RabavertRabavert 2

Recombivax HBRecombivax HB (10mcg/ml Injection, 40mcg/ml Injection)

2 B/D

RotaTeqRotaTeq 2

Tetanus Toxoid AdsorbedTetanus Toxoid Adsorbed

♦1

Tetanus/Diphtheria Toxoids-Adsorbed Adult

Tetanus/Diphtheria Toxoids-Adsorbed Adult

♦

1

TwinrixTwinrix 2

Typhim ViTyphim Vi 2

VAQTAVAQTA (25unit/0.5ml Injection)

2

VarivaxVarivax 2

YF-VaxYF-Vax 2

ZostavaxZostavax 3

Drug NameDrugTier


Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease

Aminosalicylates - Inflammatory Bowel Disease Drugs

AprisoApriso 2

AsacolAsacol 3

Asacol HDAsacol HD 3

Balsalazide DisodiumBalsalazide Disodium

♦1

CanasaCanasa 2

ColazalColazal 3

DelzicolDelzicol 3

DipentumDipentum 4

GiazoGiazo 4

LialdaLialda 2

MesalamineMesalamine (Kit) ♦ 1

PentasaPentasa 3

sfRowasasfRowasa 4

Glucocorticoids - Inflammatory Bowel Disease Drugs

BudesonideBudesonide (Capsule Extended Release 24 Hour)

♦

1

ColocortColocort ♦ 1

Entocort ECEntocort EC 4

HydrocortisoneHydrocortisone (Enema)

♦1

MillipredMillipred (Tablet) 3

UcerisUceris 4

Sulfonamides - Inflammatory Bowel Disease Drugs

AzulfidineAzulfidine 3

Azulfidine EN-TabsAzulfidine EN-Tabs

3

SulfasalazineSulfasalazine (Tablet)

♦1

56

65

Drug NameDrugTier


Sulfazine ECSulfazine EC ♦ 1

Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs

ActonelActonel 2

Alendronate SodiumAlendronate Sodium (Oral Solution, 10mg Tablet, 35mg Tablet, 40mg Tablet, 5mg Tablet, 70mg Tablet)

♦

1

AtelviaAtelvia 3

BinostoBinosto 3

BonivaBoniva (Injection) 3 B/D

BonivaBoniva (Tablet) 3

Calcitonin-SalmonCalcitonin-Salmon ♦ 1

CalcitriolCalcitriol (Capsule, Injection, Oral Solution)

♦

1 B/D

DidronelDidronel 3

Etidronate DisodiumEtidronate Disodium ♦ 1

ForteoForteo 3 B/D

ForticalFortical 3

FosamaxFosamax 3

Fosamax Plus DFosamax Plus D 3

HectorolHectorol 2 B/D

Ibandronate SodiumIbandronate Sodium ♦ 1

MiacalcinMiacalcin (Injection)

3 B/D

MiacalcinMiacalcin (Nasal Solution)

3

Drug NameDrugTier


Pamidronate DisodiumPamidronate Disodium (30mg/10ml Injection, 90mg/10ml Injection)

♦

1 B/D

Pamidronate DisodiumPamidronate Disodium (6mg/ml Injection)

♦

1 B/D

ProliaProlia 3

ReclastReclast 3

RocaltrolRocaltrol 3 B/D

SkelidSkelid 3

XgevaXgeva 4

ZemplarZemplar 3 B/D

Zoledronic AcidZoledronic Acid (4mg/5ml Injection)

♦1

Zoledronic AcidZoledronic Acid (5mg/100ml Injection)

♦

1

ZometaZometa 4

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

BotoxBotox (100unit Injection)

4

CarnitorCarnitor 3 B/D

DysportDysport (300unit Injection)

3

FerriproxFerriprox 4

FirazyrFirazyr 4

FomepizoleFomepizole ♦ 1

Gauze PadsGauze Pads 2

Insulin Syringes, NeedlesInsulin Syringes, Needles

2



57

66

Drug NameDrugTier


IntralipidIntralipid (2.25%; 20% Injection)

♦1 B/D

IntralipidIntralipid (1.7%; 30% Injection)

3 B/D

Lactated Ringers IrrigationLactated Ringers Irrigation

♦1

LevocarnitineLevocarnitine ♦ 1 B/D

Liposyn IIILiposyn III (1.2%; 2.5%; 10% Injection, 1.2%; 2.5%; 20% Injection)

3 B/D

Methylergonovine MaleateMethylergonovine Maleate (Tablet)

♦1

PhysiolytePhysiolyte 3

Physiosol IrrigationPhysiosol Irrigation

3

Ringers IrrigationRingers Irrigation ♦ 1

Sodium Chloride 0.9%Sodium Chloride 0.9% (Irrigation Solution)

♦

1

Sterile Water IrrigationSterile Water Irrigation

♦1

XeominXeomin (50unit Injection)

3

Ophthalmic Agents - Drugs to Treat Eye Conditions

Ophthalmic Agents, Other - Miscellaneous Eye Drugs

AlcaineAlcaine 3

CystaranCystaran 4

LacrisertLacrisert 3

Naphazoline HClNaphazoline HCl ♦ 1

Proparacaine HClProparacaine HCl ♦ 1

RestasisRestasis 2

Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs

AlocrilAlocril 3

Drug NameDrugTier


AlomideAlomide 3

Azelastine HClAzelastine HCl (Ophthalmic Solution)

♦

1

BepreveBepreve 3

Cromolyn SodiumCromolyn Sodium (Ophthalmic Solution)

♦

1

ElestatElestat 3

EmadineEmadine 3

Epinastine HClEpinastine HCl ♦ 1

LastacaftLastacaft 2

OptivarOptivar 3

PatadayPataday 2

PatanolPatanol 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs

AcularAcular 3

Acular LSAcular LS 3

AcuvailAcuvail 3

AlrexAlrex 2

BlephamideBlephamide 3

Blephamide S.O.P.Blephamide S.O.P.

3

BromdayBromday 3

BromfenacBromfenac ♦ 1

Dexamethasone Sodium PhosphateDexamethasone Sodium Phosphate (Ophthalmic Solution)

♦

1

Diclofenac SodiumDiclofenac Sodium (Ophthalmic Solution)

♦

1

DurezolDurezol 2

FlarexFlarex 3

Flurbiprofen SodiumFlurbiprofen Sodium ♦ 1

FMLFML 3

58

67

Drug NameDrugTier


FML ForteFML Forte 3

FML LiquifilmFML Liquifilm 3

IlevroIlevro 2

Ketorolac TromethamineKetorolac Tromethamine (Ophthalmic Solution)

♦

1

LotemaxLotemax 3

MaxidexMaxidex 3

MaxitrolMaxitrol 3

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

♦

1

Neomycin/Polymyxin/Dexamethasone

Neomycin/Polymyxin/Dexamethasone

♦

1

NevanacNevanac 2

OcufenOcufen 3

OmnipredOmnipred 3

Pred FortePred Forte 3

Pred MildPred Mild 3

Pred-GPred-G 3

Pred-G S.O.P.Pred-G S.O.P. 3

Prednisolone AcetatePrednisolone Acetate

♦1

Prednisolone Sodium PhosphatePrednisolone Sodium Phosphate (Ophthalmic Solution)

♦

1

ProlensaProlensa 3

Drug NameDrugTier


Sulfacetamide Sodium/Prednisolone Sodium Phosphate

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

♦

1

TobradexTobradex (Ointment)

2

TobradexTobradex (0.1%; 0.3% Suspension)

3

Tobradex STTobradex ST (0.05%; 0.3% Suspension)

3

Tobramycin/DexamethasoneTobramycin/Dexamethasone

♦1

VexolVexol 3

ZyletZylet 3

Ophthalmic Antiglaucoma Agents - Glaucoma Drugs

AcetazolamideAcetazolamide ♦ 1

Acetazolamide ERAcetazolamide ER ♦ 1

Alphagan PAlphagan P 2

ApraclonidineApraclonidine ♦ 1

AzoptAzopt 2

BetaganBetagan 3

Betaxolol HClBetaxolol HCl (Ophthalmic Solution)

♦

1

BetimolBetimol 3

Betoptic-SBetoptic-S 3

Brimonidine TartrateBrimonidine Tartrate ♦ 1

Carteolol HClCarteolol HCl ♦ 1

CombiganCombigan 2

CosoptCosopt 3



59

68

Drug NameDrugTier


DiamoxDiamox 3

Dorzolamide HClDorzolamide HCl ♦ 1

Dorzolamide HCl/Timolol MaleateDorzolamide HCl/Timolol Maleate

♦1

IopidineIopidine 3

Isopto CarpineIsopto Carpine 3

IstalolIstalol 3

Levobunolol HClLevobunolol HCl (0.5% Ophthalmic Solution)

♦

1

MethazolamideMethazolamide ♦ 1

MetipranololMetipranolol ♦ 1

Phospholine IodidePhospholine Iodide

3

Pilopine HSPilopine HS 2

SimbrinzaSimbrinza 3

Timolol MaleateTimolol Maleate (Gel Forming Solution, Ophthalmic Solution)

♦

1

Timoptic OcudoseTimoptic Ocudose

3

Timoptic-XETimoptic-XE 3

TrusoptTrusopt 3

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs

LatanoprostLatanoprost ♦ 1

LumiganLumigan 2

ResculaRescula 3

Travatan ZTravatan Z 2

TravoprostTravoprost ♦ 1

XalatanXalatan 3

ZioptanZioptan 3

Otic Agents - Drugs to Treat Ear Conditions

Otic Agents - Ear Drugs

Acetasol HCAcetasol HC 3

Drug NameDrugTier


Acetic AcidAcetic Acid (Otic Solution)

♦1

Coly-Mycin SColy-Mycin S 3

CortisporinCortisporin (Otic Solution, Suspension)

3

DermOticDermOtic 3

Hydrocortisone/Acetic AcidHydrocortisone/Acetic Acid

♦1

Neomycin/Polymyxin/Hydrocortisone

Neomycin/Polymyxin/Hydrocortisone

♦

1

Respiratory Tract Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs

Advair DiskusAdvair Diskus 2

Advair HFAAdvair HFA 2

AlvescoAlvesco 3

AsmanexAsmanex 3

Beconase AQBeconase AQ 3

BudesonideBudesonide (Inhalation Suspension)

♦

1 B/D

DuleraDulera 3

FlonaseFlonase 3

Flovent DiskusFlovent Diskus 2

Flovent HFAFlovent HFA 2

FlunisolideFlunisolide ♦ 1

Fluticasone PropionateFluticasone Propionate (Suspension)

♦

1

Nasacort AQNasacort AQ 3

NasonexNasonex 3

OmnarisOmnaris 3

PulmicortPulmicort 3 B/D

60

69

Drug NameDrugTier


Pulmicort FlexhalerPulmicort Flexhaler

2

QnaslQnasl 3

QVARQVAR 2

Rhinocort AquaRhinocort Aqua 3

SymbicortSymbicort 2

Triamcinolone AcetonideTriamcinolone Acetonide (Inhaler)

♦1

VeramystVeramyst 3

ZetonnaZetonna 3

Antihistamines - Allergy Drugs

AstelinAstelin 3

AsteproAstepro 2

Azelastine HClAzelastine HCl (Nasal Solution)

♦1

Carbinoxamine MaleateCarbinoxamine Maleate

♦1

Cetirizine HClCetirizine HCl (Syrup)

♦1

ClarinexClarinex 3

Clarinex ReditabsClarinex Reditabs 3

Clarinex-DClarinex-D 3

Clemastine FumarateClemastine Fumarate (2.68mg Tablet)

♦

1

Cyproheptadine HClCyproheptadine HCl ♦ 1

DesloratadineDesloratadine ♦ 1

Desloratadine ODTDesloratadine ODT ♦ 1

Diphenhydramine HClDiphenhydramine HCl (50mg Capsule, Injection)

♦

1

DymistaDymista 2

Drug NameDrugTier


Hydroxyzine HClHydroxyzine HCl ♦ 1

Hydroxyzine PamoateHydroxyzine Pamoate

♦1

Levocetirizine DihydrochlorideLevocetirizine Dihydrochloride

♦1

PalgicPalgic 3

PatanasePatanase 2

PhenadozPhenadoz (12.5mg Suppository)

♦1

PhenerganPhenergan 3

Promethazine HClPromethazine HCl ♦ 1

Promethazine VCPromethazine VC ♦ 1

PrometheganPromethegan (25mg Suppository, 50mg Suppository)

♦

1

Semprex-DSemprex-D 3

VistarilVistaril 3

XyzalXyzal 3

Antileukotrienes - Asthma/Lung Drugs

AccolateAccolate 3

Montelukast SodiumMontelukast Sodium ♦ 1

SingulairSingulair 3

ZafirlukastZafirlukast ♦ 1

ZyfloZyflo 4

Zyflo CRZyflo CR 4

Bronchodilators, Anticholinergic - Asthma/Lung Drugs

AtroventAtrovent 3

Atrovent HFAAtrovent HFA 3

CombiventCombivent 2

Combivent RespimatCombivent Respimat

2



61

70

Drug NameDrugTier


DuoNebDuoNeb 3 B/D

Ipratropium BromideIpratropium Bromide (Inhalation Solution)

♦1 B/D

Ipratropium BromideIpratropium Bromide (Nasal Solution)

♦1

Ipratropium Bromide/Albuterol Sulfate

Ipratropium Bromide/Albuterol Sulfate

♦

1 B/D

Spiriva HandihalerSpiriva Handihaler

2

Tudorza PressairTudorza Pressair 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs

AminophyllineAminophylline ♦ 1

ElixophyllinElixophyllin 3

LufyllinLufyllin 3

Theophylline ERTheophylline ER (Tablet Extended Release 12 Hour, Tablet Extended Release 24 Hour)

♦

1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs

AccunebAccuneb 3 B/D

Albuterol SulfateAlbuterol Sulfate (Nebulization Solution)

♦

1 B/D

Albuterol SulfateAlbuterol Sulfate (Syrup, Tablet)

♦1

Albuterol Sulfate ERAlbuterol Sulfate ER ♦ 1

Arcapta NeohalerArcapta Neohaler 3

Auvi-QAuvi-Q 3

BrovanaBrovana 3 B/D

EpiPenEpiPen 2

Foradil AerolizerForadil Aerolizer 2

Drug NameDrugTier


Levalbuterol HClLevalbuterol HCl (0.31mg/3ml Nebulization Solution, 0.63mg/3ml Nebulization Solution, 1.25mg/0.5ml Nebulization Solution)

♦

1 B/D

Maxair AutohalerMaxair Autohaler 3

Metaproterenol SulfateMetaproterenol Sulfate

♦1

PerforomistPerforomist 3 B/D

Proair HFAProair HFA 2

Proventil HFAProventil HFA 3

Serevent DiskusSerevent Diskus 2

Terbutaline SulfateTerbutaline Sulfate ♦ 1

Ventolin HFAVentolin HFA 3

Vospire ERVospire ER 3

XopenexXopenex (0.31mg/3ml Nebulization Solution, 0.63mg/3ml Nebulization Solution, 1.25mg/3ml Nebulization Solution)

3 B/D

Xopenex HFAXopenex HFA 3

Mast Cell Stabilizers - Asthma/Lung Drugs

Cromolyn SodiumCromolyn Sodium (Nebulization Solution)

♦

1 B/D

Pulmonary Antihypertensives - Asthma/Lung Drugs

AdcircaAdcirca 4

LetairisLetairis 4 LA

RemodulinRemodulin 4 B/D, LA

RevatioRevatio 4

62

71

Drug NameDrugTier


Sildenafil CitrateSildenafil Citrate ♦ 1

TracleerTracleer 4

TyvasoTyvaso 4 B/D

VentavisVentavis 4 B/D

Respiratory Tract Agents, Other - Asthma/Lung Drugs

AcetylcysteineAcetylcysteine (Inhalation Solution)

♦1 B/D

Aralast NPAralast NP (400mg Injection)

4 LA

DalirespDaliresp 3

GlassiaGlassia 4 LA

KalydecoKalydeco 4

Prolastin-CProlastin-C 4 LA

PulmozymePulmozyme 4 B/D

TyzineTyzine 2

XolairXolair 4

ZemairaZemaira 4 LA

Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs

AmrixAmrix 3

CarisoprodolCarisoprodol (350mg Tablet)

♦1

Carisoprodol/AspirinCarisoprodol/Aspirin ♦ 1

ChlorzoxazoneChlorzoxazone ♦ 1

Cyclobenzaprine HClCyclobenzaprine HCl (Immediate-Release Tablet)

♦

1

FexmidFexmid 3

Drug NameDrugTier


LorzoneLorzone 3

MethocarbamolMethocarbamol ♦ 1

Orphenadrine CitrateOrphenadrine Citrate

♦1

Orphenadrine Citrate EROrphenadrine Citrate ER

♦1

Orphenadrine/Aspirin/CaffeineOrphenadrine/Aspirin/Caffeine

♦1

Parafon Forte DSCParafon Forte DSC

3

SkelaxinSkelaxin 3

SomaSoma 3

Sleep Disorder Agents - Drugs for Sedation and Sleep

GABA Receptor Modulators - Sedation and Sleep Drugs

AmbienAmbien 3

Ambien CRAmbien CR 3

EdluarEdluar 3

Flurazepam HClFlurazepam HCl ♦ 1

HalcionHalcion 3

LunestaLunesta 2

RestorilRestoril 3

SonataSonata 3

TemazepamTemazepam ♦ 1

TriazolamTriazolam ♦ 1

ZaleplonZaleplon ♦ 1

Zolpidem TartrateZolpidem Tartrate ♦ 1

Zolpidem Tartrate ERZolpidem Tartrate ER

♦1

ZolpimistZolpimist 3



63

72

Drug NameDrugTier


Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs

Butisol SodiumButisol Sodium 3

ModafinilModafinil ♦ 1

NuvigilNuvigil (250mg Tablet, 50mg Tablet)

3

ProvigilProvigil 4

RozeremRozerem 3

SeconalSeconal 3

SilenorSilenor 3

XyremXyrem 4 LA

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies

Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs

Ammonium ChlorideAmmonium Chloride

3

ChemetChemet 3

Depen TitratabsDepen Titratabs 3

ExjadeExjade 4

KayexalateKayexalate 3

KionexKionex (Powder) ♦ 1

SamscaSamsca 4

Sodium LactateSodium Lactate (Injection)

♦1

Sodium Polystyrene SulfonateSodium Polystyrene Sulfonate (15gm/60ml Suspension)

♦

1

SyprineSyprine 4

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs

Aminosyn 8.5%/ElectrolytesAminosyn 8.5%/Electrolytes

♦1 B/D

Aminosyn IIAminosyn II 3 B/D

Drug NameDrugTier


Aminosyn II 8.5%/ElectrolytesAminosyn II 8.5%/Electrolytes

♦1 B/D

Aminosyn MAminosyn M 3 B/D

Aminosyn-HBCAminosyn-HBC 3 B/D

Aminosyn-PFAminosyn-PF 3 B/D

Calcium AcetateCalcium Acetate (Capsule)

♦1


3 B/D


3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

Clinisol SF 15%Clinisol SF 15% ♦ 1 B/D

Dextrose 5%/Lactated RingersDextrose 5%/Lactated Ringers

♦1

Dextrose 5%/Potassium Chloride 0.15%

Dextrose 5%/Potassium Chloride 0.15%

♦

1

EliphosEliphos ♦ 1

FreAmine IIIFreAmine III (8.5% Injection)

♦1 B/D

HepatAmineHepatAmine ♦ 1 B/D

HepatasolHepatasol ♦ 1 B/D

Isolyte-M/Dextrose 5%Isolyte-M/Dextrose 5%

♦1

Isolyte-P/Dextrose 5%Isolyte-P/Dextrose 5%

3

Isolyte-SIsolyte-S 3

K-TabsK-Tabs 2

Klor-Con 10Klor-Con 10 ♦ 1

Klor-Con 8Klor-Con 8 ♦ 1

64

73

Drug NameDrugTier


Klor-Con M15Klor-Con M15 2

Klor-Con M20Klor-Con M20 ♦ 1

Lactated Ringers ViaflexLactated Ringers Viaflex

♦1

Magnesium SulfateMagnesium Sulfate (50% Injection)

♦1

NephramineNephramine 3 B/D

Normosol-M in D5WNormosol-M in D5W ♦ 1

Normosol-RNormosol-R ♦ 1

PhosLoPhosLo 2

PhoslyraPhoslyra 3

Plasma-LytePlasma-Lyte 3

Plasma-Lyte/D5WPlasma-Lyte/D5W 3

Potassium ChloridePotassium Chloride (10meq/100ml Injection, 20meq/100ml Injection, 2meq/ml Injection, 30meq/100ml Injection, 40meq/100ml Injection)

♦

1

Potassium Chloride 0.15%/NaCl 0.45% Viaflex

Potassium Chloride 0.15%/NaCl 0.45% Viaflex

♦

1

Potassium Chloride 0.15%/NaCl 0.9%Potassium Chloride 0.15%/NaCl 0.9%

♦1

Potassium Chloride 0.3%/D5WPotassium Chloride 0.3%/D5W

♦1

Potassium Chloride 0.3%/NaCl 0.9%Potassium Chloride 0.3%/NaCl 0.9%

♦1

Drug NameDrugTier


Potassium Chloride ERPotassium Chloride ER (Capsule Extended Release, 10meq Tablet Extended Release, 20meq Tablet Extended Release)

♦

1

Potassium CitratePotassium Citrate (Tablet Extended Release)

♦

1

PremasolPremasol (6% Injection)

♦1 B/D

PremasolPremasol (10% Injection)

3 B/D

ProcalamineProcalamine 3 B/D

ProsolProsol 3 B/D

Ringers InjectionRingers Injection ♦ 1

Sodium ChlorideSodium Chloride (0.9% Injection, 2.5meq/ml Injection, 3% Injection, 5% Injection)

♦

1

Sodium Chloride 0.45% ViaflexSodium Chloride 0.45% Viaflex (Injection)

♦

1

TPN ElectrolytesTPN Electrolytes ♦ 1

TravasolTravasol 3 B/D

TrophamineTrophamine (6% Injection)

♦1 B/D

TrophamineTrophamine (10% Injection)

3 B/D

Urocit-K 10Urocit-K 10 3





65

74

Drug NameDrugTier


Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs

Sodium FluorideSodium Fluoride (Tablet)

♦1

Drug NameDrugTier


Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs

NiacorNiacor ♦ 1

Prenatabs OBNPrenatabs OBN ♦ 1

track

Index of covered drugs

75

#

8-MOP.............................. 50

A

A-Hydrocort...................... 54

Abacavir..............................35

Abelcet............................... 26

Abilify.................................33

Abilify Discmelt................. 33

Abilify Maintena................ 33

Abraxane............................ 29

Absorica..............................50

Abstral................................12

Acanya................................50

Acarbose.............................38

Accolate..............................69

Accuneb..............................70

Accupril.............................. 43

Accuretic............................ 43

Acebutolol HCl..................44

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate13

Acetaminophen/Codeine... 13

Acetasol HC.......................68

Acetazolamide.................... 67

Acetazolamide ER..............67

Acetazolamide Sodium.......47

Acetic Acid.........................68

Acetylcysteine.....................71

Aciphex.............................. 53

Actemra..............................63

Acthar HP..........................57

ActHIB.............................. 63

Actigall............................... 52

Actimmune.........................63

Actiq...................................13

Activella..............................58

Actonel............................... 65

Actoplus Met......................38

Actoplus Met XR............... 38

Actos.................................. 38

Acular.................................66

Acular LS........................... 66

Acuvail................................66

Acyclovir.............................37

Acyclovir Sodium............... 37

Aczone................................50

Adacel.................................63

Adagen............................... 51

Adalat CC.......................... 45

Adapalene...........................50

Adcirca............................... 70

Adderall XR....................... 48

Adriamycin.........................29

Advair Diskus.....................68

Advair HFA....................... 68

Advicor...............................48

Afeditab CR....................... 45

Afinitor...............................31

Aggrenox............................ 42

Agrylin............................... 41

Akne-Mycin....................... 20

Ala-Cort.............................54

Ala-Scalp............................55

Alagesic LQ....................... 10

Albenza.............................. 31

Albuterol Sulfate................ 70

Albuterol Sulfate ER.......... 70

Alcaine............................... 66

Alclometasone Dipropionate......................................... 55

Alcohol Preps..................... 16

Aldactazide.........................47

Aldactone........................... 47

Aldara.................................50

Aldurazyme........................ 51

Alendronate Sodium.......... 65

Alfuzosin HCl ER............. 54

Alimta................................ 29

Alinia..................................31

Alkeran...............................28

Allopurinol......................... 27

Allopurinol Sodium............27

Alocril.................................66

Alomide..............................66

Aloprim.............................. 27

Alora...................................58

Aloxi...................................25

Alphagan P.........................67

Alprazolam......................... 37

Alprazolam ER...................37

Alprazolam Intensol........... 37

Alprazolam ODT...............37

Alprazolam XR...................37

Alrex...................................66

Alsuma............................... 27

Altabax............................... 16

Altace................................. 43

Altoprev..............................48

Alvesco............................... 68

Amantadine HCl................36

Amaryl................................38

Ambien...............................71

76

Ambien CR........................ 71

AmBisome..........................26

Amcinonide........................55

Amerge...............................27

Amethia..............................58

Amethyst............................ 58

Amifostine..........................29

Amikacin Sulfate................ 16

Amiloride HCl................... 47

Amiloride/Hydrochlorothiazide........ 47

Aminophylline....................70

Aminosyn 8.5%/Electrolytes......................................... 72

Aminosyn II....................... 72

Aminosyn II 8.5%/Electrolytes.......................72

Aminosyn M...................... 72

Aminosyn-HBC.................72

Aminosyn-PF.....................72

Amiodarone HCl............... 44

Amitiza...............................53

Amitriptyline HCl..............25

Amlodipine Besylate...........45

Amlodipine Besylate/Benazepril HCl................ 45

Ammonium Chloride.........72

Ammonium Lactate........... 50

Amnesteem........................ 50

Amoxapine......................... 25

Amoxicillin.........................19

Amoxicillin/Potassium Clavulanate...................... 19

Amoxicillin/Potassium Clavulanate ER................ 19

Amphetamine/Dextroamphetamine........ 48

Amphotericin B..................26

Ampicillin...........................19

Ampicillin Sodium............. 19

Ampicillin/Sulbactam.........19

Ampyra...............................50

Amrix................................. 71

Amturnide.......................... 46

Anafranil............................ 25

Anagrelide HCl..................41

Anaprox..............................10

Anaprox DS....................... 10

Anastrozole.........................30

Ancobon.............................26

Androderm.........................58

Androgel.............................58

Androgel Pump.................. 58

Android.............................. 58

Androxy..............................58

Angeliq...............................58

Antabuse............................ 15

Antara.................................47

Antivert.............................. 25

Anusol-HC........................ 55

Anzemet............................. 26

Apidra................................ 40

Apidra SoloStar.................. 40

Aplenzin............................. 24

Apokyn...............................32

Apraclonidine..................... 67

Apri.................................... 58

Apriso.................................64

Aptivus............................... 36

Aralast NP..........................71

Aranelle.............................. 58

Aranesp Albumin Free. 41, 42

Arava.................................. 63

Arcalyst...............................63

Arcapta Neohaler............... 70

Argatroban......................... 40

Aricept................................24

Aricept ODT..................... 24

Arimidex.............................31

Arixtra................................ 40

Aromasin............................31

Arranon.............................. 29

Arthrotec............................ 10

Arzerra............................... 31

Asacol.................................64

Asacol HD......................... 64

Asmanex.............................68

Astelin................................ 69

Astepro...............................69

Astramorph........................ 11

Atacand.............................. 43

Atacand HCT.................... 43

Atelvia................................ 65

Atenolol..............................44

Atenolol/Chlorthalidone.... 44

Atgam.................................63

Ativan.................................37

Atorvastatin Calcium..........48

Atovaquone/Proguanil HCl......................................... 32

Atralin................................ 50

Atripla................................ 35

Atropine Sulfate................. 52

77

Atrovent............................. 69

Atrovent HFA....................69

Aubagio.............................. 50

Augmented Betamethasone Dipropionate....................55

Auvi-Q............................... 70

Avalide............................... 43

Avandamet......................... 38

Avandaryl........................... 38

Avandia.............................. 38

Avapro................................43

Avastin............................... 31

Avelox.................................21

Avelox ABC Pack.............. 21

Aviane................................ 58

Avinza................................ 11

Avita...................................50

Avodart...............................54

Avonex............................... 63

Axert...................................27

Axid....................................52

Axiron................................ 58

Aygestin............................. 60

Azactam............................. 19

Azactam in Iso-Osmotic Dextrose...........................19

Azasan................................ 62

Azasite................................20

Azathioprine.......................62

Azathioprine Sodium......... 62

Azelastine HCl.............66, 69

Azelex.................................50

Azilect................................ 33

Azithromycin......................20

Azopt..................................67

Azor....................................45

Aztreonam..........................19

Azulfidine...........................64

Azulfidine EN-Tabs...........64

B

BACiiM............................. 16

Bacitracin............................16

Bacitracin/Polymyxin B......17

Baclofen..............................34

Bactocill in Dextrose.......... 19

Bactrim...............................21

Bactrim DS........................ 21

Bactroban........................... 17

Bactroban Nasal................. 17

Balsalazide Disodium......... 64

Balziva................................ 58

Banzel.................................23

Baraclude............................36

Beconase AQ......................68

Benazepril HCl.................. 43

Benazepril HCl/Hydrochlorothiazide........ 43

Benicar............................... 43

Benicar HCT..................... 43

Benlysta.............................. 62

Bentyl................................. 52

Benzamycin........................ 50

Benztropine Mesylate.........32

Bepreve...............................66

Besivance............................ 21

Betagan...............................67

Betamethasone Dipropionate......................................... 55

Betamethasone Valerate..... 55

Betapace............................. 44

Betapace AF....................... 44

Betaseron............................63

Betaxolol HCl.............. 44, 67

Bethanechol Chloride.........54

Betimol...............................67

Betoptic-S.......................... 67

Beyaz.................................. 58

Biaxin................................. 20

Biaxin XL........................... 20

Biaxin XL Pac.................... 20

Bicalutamide.......................62

Bicillin C-R........................19

Bicillin L-A........................ 19

BiCNU...............................28

BiDil...................................48

Biltricide.............................31

Binosto............................... 65

Bisoprolol Fumarate........... 44

Bisoprolol Fumarate/Hydrochlorothiazide........ 45

Bleomycin Sulfate...............29

Bleph-10.............................21

Blephamide........................ 66

Blephamide S.O.P..............66

Boniva................................ 65

Boostrix.............................. 63

Bosulif................................ 31

Botox.................................. 65

Brevicon............................. 58

Briellyn............................... 58

Brilinta............................... 42

Brimonidine Tartrate......... 67

78

Bromday............................. 66

Bromfenac.......................... 66

Bromocriptine Mesylate..... 32

Brovana.............................. 70

Budeprion SR.....................24

Budesonide................... 64, 68

Bumetanide........................ 47

Bupap................................. 10

Buphenyl............................ 51

Buprenex............................ 15

Buprenorphine HCl........... 15

Buprenorphine HCl/Naloxone HCl..................15

Buproban............................16

Bupropion HCl.................. 24

Bupropion HCl SR............ 24

Bupropion HCl XL............24

Buspirone HCl................... 37

Busulfex..............................28

Butalbital/Acetaminophen. 10

Butalbital/Acetaminophen/Caffeine............................10

Butalbital/Acetaminophen/Caffeine/Codeine.............49

Butalbital/Aspirin/Caffeine10

Butalbital/Aspirin/Caffeine/Codeine............................13

Butisol Sodium...................72

Butorphanol Tartrate..........13

Butrans............................... 15

Bydureon............................ 38

Byetta................................. 38

Bystolic...............................45

C

Cabergoline........................ 61

Caduet................................45

Calan.................................. 45

Calan SR............................ 45

Calcipotriene...................... 50

Calcitonin-Salmon............. 65

Calcitriol.............................65

Calcium Acetate................. 72

Cambia............................... 10

Camila................................ 60

Campral..............................15

Camptosar.......................... 29

Canasa................................ 64

Cancidas............................. 26

Candesartan Cilexetil/Hydrochlorothiazide........ 47

Cantil................................. 52

Capastat Sulfate..................28

Capex................................. 55

Capital/Codeine................. 13

Caprelsa..............................28

Captopril............................ 43

Captopril/Hydrochlorothiazide........ 43

Carac.................................. 50

Carafate.............................. 53

Carbaglu............................. 51

Carbamazepine...................23

Carbamazepine ER............ 23

Carbatrol............................ 23

Carbidopa/Levodopa..........32

Carbidopa/Levodopa ER... 32

Carbidopa/Levodopa ODT32

Carbinoxamine Maleate..... 69

Carboplatin.........................29

Cardizem............................45

Cardizem CD.....................45

Cardizem LA..................... 45

Cardura.............................. 54

Cardura XL........................ 43

Carimune Nanofiltered.......63

Carisoprodol.......................71

Carisoprodol/Aspirin..........71

Carisoprodol/Aspirin/Codeine............................13

Carmol-HC........................55

Carnitor..............................65

Carteolol HCl.................... 67

Cartia XT........................... 45

Carvedilol........................... 45

Casodex.............................. 62

Cataflam.............................10

Catapres..............................42

Catapres-TTS.................... 42

Cayston.............................. 19

Cedax................................. 18

CeeNU............................... 28

Cefaclor.............................. 18

Cefaclor ER........................18

Cefadroxil...........................18

Cefazolin Sodium...............18

Cefdinir.............................. 18

Cefepime............................ 18

Cefotaxime Sodium............18

Cefotetan............................19

Cefoxitin Sodium............... 18

Cefpodoxime Proxetil.........18

Cefprozil.............................18

Ceftazidime........................ 18

79

Ceftazidime/Dextrose.........18

Ceftin................................. 18

Ceftriaxone Sodium............18

Cefuroxime Axetil.............. 18

Cefuroxime Sodium........... 18

Celebrex............................. 10

Celestone............................55

Celexa.................................24

Cellcept.............................. 62

Cellcept Intravenous...........62

Celontin............................. 22

Cenestin............................. 58

Cephalexin..........................19

Cerezyme............................51

Cerubidine..........................29

Cervarix.............................. 64

Cesamet..............................26

Cetirizine HCl................... 69

Cevimeline HCl................. 50

Chantix...............................16

Chantix Starting Month Pak......................................... 16

Chemet...............................72

Chenodal............................ 52

Chloramphenicol Sodium Succinate.......................... 17

Chlordiazepoxide HCl....... 37

Chlordiazepoxide/Amitriptyline....................37

Chlorhexidine Gluconate Oral Rinse........................50

Chloroquine Phosphate......32

Chlorothiazide....................47

Chlorothiazide Sodium...... 47

Chlorpromazine HCl......... 33

Chlorpropamide................. 38

Chlorthalidone................... 47

Chlorzoxazone....................71

Cholestyramine Light.........48

Chorionic Gonadotropin....57

Cialis.................................. 54

Ciclopirox...........................26

Ciclopirox Nail Lacquer..... 26

Ciclopirox Olamine............ 26

Cidofovir............................ 35

Cilostazol............................42

Ciloxan............................... 21

Cimetidine..........................52

Cimetidine HCl................. 53

Cimzia................................62

Cinryze............................... 42

Cipro.................................. 21

Cipro HC...........................21

Cipro IV............................. 21

Ciprodex.............................21

Ciprofloxacin......................21

Ciprofloxacin ER............... 21

Ciprofloxacin HCl..............21

Ciprofloxacin I.V. in D5W 21

Cisplatin............................. 29

Citalopram Hydrobromide.24

Cladribine...........................29

Claforan..............................19

Claravis...............................50

Clarinex.............................. 69

Clarinex Reditabs............... 69

Clarinex-D......................... 69

Clarithromycin................... 20

Clarithromycin ER.............20

Clemastine Fumarate......... 69

Cleocin............................... 17

Cleocin in D5W.................17

Cleocin Pediatric Granules.17

Cleocin Phosphate..............17

Cleocin-T...........................50

Climara...............................58

Climara Pro........................ 58

Clindacin PAC...................50

Clindagel............................ 50

Clindamycin HCl...............17

Clindamycin Phosphate17, 50

Clindamycin Phosphate in D5W................................17

Clindamycin/Benzoyl Peroxide........................... 50

Clinimix 2.75%/Dextrose 5%......................................... 72

Clinimix 4.25%/Dextrose 10%.................................. 72



Clinimix 4.25%/Dextrose 5%......................................... 72

Clinimix 5%/Dextrose 15% 39



Clinimix E 2.75%/Dextrose 10%.................................. 39

Clinimix E 2.75%/Dextrose 5%.................................... 39

Clinimix E 4.25%/Dextrose 25%.................................. 39

80

Clinimix E 4.25%/Dextrose 5%.................................... 39

Clinimix E 5%/Dextrose 15%......................................... 39



Clinisol SF 15%..................72

Clobetasol Propionate........ 55

Clobetasol Propionate E.....55

Clobex................................ 55

Cloderm Pump...................55

Clolar..................................29

Clomipramine HCl............ 25

Clonazepam........................22

Clonazepam ODT............. 22

Clonidine HCl................... 42

Clopidogrel.........................42

Clorazepate Dipotassium... 22

Clorpres..............................42

Clotrimazole.......................26

Clotrimazole/Betamethasone Dipropionate....................26

Clozapine........................... 34

Clozaril...............................34

Co-Gesic............................ 13

Coartem............................. 32

Codeine Sulfate.................. 13

Cogentin.............................32

Colazal................................64

Colcrys................................27

Colestid.............................. 48

Colestipol HCl................... 48

Colistimethate Sodium.......17

Colocort............................. 64

Coly-Mycin M................... 17

Coly-Mycin S.....................68

Colyte-Flavor Packs........... 53

Combigan...........................67

CombiPatch....................... 58

Combivent..........................69

Combivent Respimat..........69

Combivir............................ 35

Cometriq............................ 29

Complera............................35

Compro.............................. 33

Comtan.............................. 32

Comvax.............................. 64

Concerta.............................49

Condylox............................ 50

Constulose..........................53

Conzip................................11

Copaxone........................... 50

Copegus..............................36

Cordarone.......................... 44

Cordran Tape..................... 55

Coreg..................................45

Coreg CR........................... 45

Corgard.............................. 45

Cortef................................. 55

Cortifoam...........................55

Cortisone Acetate...............55

Cortisporin................... 17, 68

Corzide...............................45

Cosmegen...........................29

Cosopt................................ 67

Coumadin...........................40

Cozaar................................ 43

Creon................................. 51

Crestor................................48

Crinone.............................. 60

Crixivan..............................36

Cromolyn Sodium.. 52, 66, 70

Cryselle...............................58

Cubicin...............................17

Cutivate.............................. 55

Cuvposa..............................52

Cyclafem 1/35.................... 58

Cyclafem 7/7/7...................58

Cyclessa.............................. 58

Cyclobenzaprine HCl.........71

Cyclophosphamide............. 28

Cycloset.............................. 38

Cyclosporine.......................62

Cyclosporine Modified.......62

Cyklokapron.......................42

Cymbalta............................ 24

Cyproheptadine HCl..........69

Cystadane........................... 51

Cystagon.............................51

Cystaran............................. 66

Cytarabine.......................... 29

Cytarabine Aqueous........... 29

Cytomel..............................60

Cytotec............................... 53

Cytovene.............................35

D

Dacarbazine........................28

Dacogen............................. 29

Daliresp.............................. 71

Danazol.............................. 58

Dantrium............................34

81

Dantrolene Sodium............ 34

Dapsone............................. 28

Daptacel............................. 64

Daraprim............................ 32

Daunorubicin HCl............. 29

Daypro................................10

Daytrana.............................49

DDAVP............................. 57

Delatestryl.......................... 58

Delestrogen........................ 58

Delzicol.............................. 64

Demadex............................ 47

Demeclocycline HCl.......... 21

Demerol............................. 13

Demser............................... 46

Denavir...............................37

Depacon............................. 22

Depakene............................22

Depakote............................ 22

Depakote ER......................22

Depakote Sprinkles............ 22

Depen Titratabs................. 72

Depo-Estradiol...................58

Depo-Medrol..................... 55

Depo-Provera..................... 60

Depo-SubQ Provera 104....60

Depo-Testosterone.............58

Derma-Smoothe/FS...........55

Dermatop........................... 55

DermOtic........................... 68

Desipramine HCl...............25

Desloratadine..................... 69

Desloratadine ODT........... 69

Desmopressin Acetate........ 57

Desogen..............................58

Desonate.............................55

Desonide............................ 55

Desowen.............................55

Desoximetasone..................55

Desoxyn..............................48

Desvenlafaxine ER............. 24

Detrol................................. 54

Detrol LA...........................54

Dexamethasone.................. 55

Dexamethasone Intensol.... 55

Dexamethasone Sodium Phosphate...................55, 66

Dexedrine........................... 48

Dexilant..............................53

Dexmethylphenidate HCl.. 49

DexPak 13 Day.................. 55

Dexrazoxane....................... 29

Dextroamphetamine Sulfate......................................... 49

Dextroamphetamine Sulfate ER....................................49

Dextrose 10% Flex Container......................................... 39

Dextrose 10%/NaCl 0.2%.. 39

Dextrose 10%/NaCl 0.45% 39

Dextrose 2.5%/NaCl 0.45%......................................... 39

Dextrose 5%....................... 39

Dextrose 5%/Lactated Ringers.............................72

Dextrose 5%/NaCl 0.2%.... 39

Dextrose 5%/NaCl 0.225%.39



Dextrose 5%/NaCl 0.9%.... 39

Dextrose 5%/Potassium Chloride 0.15%................ 72

Diabeta............................... 38

Diamox...............................68

Diazepam..................... 22, 37

Diazepam Intensol............. 37

Dibenzyline........................ 43

Diclofenac Potassium......... 10

Diclofenac Sodium............. 66

Diclofenac Sodium DR...... 10

Diclofenac Sodium ER.......10

Diclofenac Sodium/Misoprostol...................... 11

Dicloxacillin Sodium.......... 19

Dicyclomine HCl............... 52

Didanosine......................... 35

Didronel............................. 65

Differin...............................50

Dificid................................ 20

Diflorasone Diacetate.........55

Diflucan..............................26

Diflunisal............................11

Digoxin.............................. 46

Dihydroergotamine Mesylate......................................... 27

Dilacor XR......................... 45

Dilantin.............................. 23

Dilantin Infatabs................ 23

Dilatrate SR....................... 48

Dilaudid............................. 13

Dilaudid-5..........................13

Dilaudid-HP...................... 13

Dilt-CD............................. 45

Dilt-XR..............................46

82

Diltiazem CD.....................46

Diltiazem HCl................... 46

Diltiazem HCl ER............. 46

Diovan................................43

Diovan HCT......................43

Dipentum........................... 64

Diphenhydramine HCl...... 69

Diphenoxylate/Atropine.....52

Diprolene........................... 55

Diprolene AF..................... 55

Dipyridamole......................42

Disopyramide Phosphate....44

Disulfiram.......................... 15

Ditropan XL.......................54

Diuril..................................47

Divalproex Sodium.............22

Divalproex Sodium DR......22

Divalproex Sodium ER...... 22

Divigel................................58

Docefrez............................. 29

Docetaxel............................29

Dolgic Plus......................... 10

Dolophine.......................... 11

Dolophine HCl.................. 11

Donepezil HCl...................24

Doribax...............................19

Doryx..................................21

Dorzolamide HCl.............. 68

Dorzolamide HCl/Timolol Maleate............................ 68

Dovonex............................. 50

Doxazosin Mesylate............54

Doxepin HCl......................25

Doxil...................................30

Doxorubicin HCl............... 30

Doxycycline........................ 21

Doxycycline Hyclate...........21

Doxycycline Hyclate DR.... 21

Doxycycline Monohydrate..22

Dronabinol......................... 26

Drospirenone/Ethinyl Estradiol...........................58

Droxia.................................29

Duetact...............................38

Duexis................................ 11

Dulera.................................68

DuoNeb..............................70

Duragesic............................12

Duramorph.........................12

Durezol...............................66

DUTOPROL.................... 45

Dyazide.............................. 47

Dymista.............................. 69

Dynacin.............................. 22

Dyrenium........................... 47

Dysport...............................65

E

E.E.S. 400.......................... 20

E.E.S. Granules..................20

EC-Naprosyn..................... 11

Econazole Nitrate...............26

Edarbi.................................43

Edarbyclor.......................... 43

Edecrin............................... 47

Edluar.................................71

Edurant.............................. 35

Effexor XR......................... 24

Effient................................ 42

Efudex................................ 50

Elaprase.............................. 51

Eldepryl.............................. 33

Elelyso................................ 51

Elestat................................ 66

Elestrin............................... 58

Elidel.................................. 50

Eligard................................61

Eliphos............................... 72

Eliquis................................ 40

Elitek..................................29

Elixophyllin........................ 70

Ella..................................... 60

Ellence................................30

Elmiron.............................. 54

Elocon................................ 55

Eloxatin.............................. 30

Elspar................................. 30

Emadine............................. 66

Emcyt................................. 29

Emend................................26

EMLA............................... 15

Emoquette..........................58

Emsam............................... 24

Emtriva...............................35

Enablex...............................54

Enalapril Maleate............... 43

Enalapril Maleate/Hydrochlorothiazide........ 43

Enbrel.................................62

Endocet.............................. 13

Endodan.............................13

Endometrin........................ 60

Engerix-B...........................64

83

Enjuvia............................... 58

Enoxaparin Sodium............40

Enpresse............................. 58

Entacapone.........................32

Entocort EC.......................64

Enulose...............................53

Epiduo................................50

Epinastine HCl.................. 66

EpiPen................................70

Epirubicin HCl.................. 30

Epitol................................. 23

Epivir..................................35

Epivir HBV........................35

Eplerenone......................... 47

Epogen............................... 42

Eprosartan Mesylate...........43

Epzicom............................. 35

Equetro...............................23

Eraxis..................................26

Erbitux............................... 31

Ergoloid Mesylates.............23

Ergomar............................. 27

Erivedge............................. 30

Errin................................... 60

Ery Pad 2%.........................20

Ery-Tab..............................20

EryPed................................20

Erythrocin Lactobionate.....20

Erythrocin Stearate.............20

Erythromycin..................... 20

Erythromycin Base............. 20

Erythromycin Ethylsuccinate......................................... 20

Erythromycin/Benzoyl Peroxide........................... 50

Escitalopram Oxalate......... 24

Esgic...................................10

Esgic-Plus.......................... 10

Estazolam...........................37

Estrace................................58

Estradiol............................. 58

Estradiol Valerate............... 58

Estradiol/Norethindrone Acetate............................. 59

Estring................................59

Estropipate......................... 59

Estrostep Fe....................... 59

Ethambutol HCl................ 28

Ethosuximide..................... 22

Etidronate Disodium..........65

Etodolac............................. 11

Etodolac ER.......................11

Etopophos.......................... 31

Etoposide........................... 31

Eurax.................................. 32

Evamist...............................59

Evista..................................60

Evoclin............................... 50

Evoxac................................ 50

Exalgo................................ 13

Exelderm............................ 26

Exelon................................ 24

Exemestane........................ 31

Exforge...............................46

Exforge HCT.....................46

Exjade.................................72

Extavia................................63

Extina................................. 26

F

Fabrazyme.......................... 51

Famciclovir......................... 37

Famotidine......................... 53

Famotidine Premixed......... 53

Famvir................................ 37

Fanapt.......................... 33, 34

Fanapt Titration Pack........ 34

Fareston..............................29

Faslodex..............................29

Fazaclo............................... 34

Felbamate........................... 23

Felbatol...............................23

Feldene............................... 11

Felodipine ER.................... 46

Femara................................31

Femcon Fe..........................59

Femring..............................59

Fenofibrate......................... 47

Fenofibrate Micronized......47

Fenoglide............................47

Fenoprofen Calcium...........11

Fentanyl..............................12

Fentanyl Citrate Oral Transmucosal................... 13

Fentora............................... 13

Ferriprox.............................65

Fexmid............................... 71

Fibricor...............................47

Finacea............................... 50

Finasteride..........................54

Fioricet............................... 10

Fioricet/Codeine................ 49

84

Fiorinal............................... 10

Fiorinal/Codeine................ 13

Firazyr................................ 65

Firmagon............................61

Flagyl..................................17

Flagyl ER........................... 17

Flarex..................................66

Flavoxate HCl.................... 54

Flecainide Acetate.............. 44

Flector................................ 11

Flo-Pred............................. 55

Flomax................................54

Flonase............................... 68

Flovent Diskus....................68

Flovent HFA......................68

Fluconazole........................ 26

Fluconazole in Dextrose..... 26

Flucytosine......................... 26

Fludarabine Phosphate....... 30

Fludrocortisone Acetate..... 55

Flunisolide..........................68

Fluocinolone Acetonide......55

Fluocinolone Acetonide Body Oil....................................55

Fluocinonide.......................55

Fluocinonide-E.................. 55

Fluorouracil.................. 29, 50

Fluoxetine DR....................24

Fluoxetine HCl.................. 24

Fluphenazine Decanoate.... 33

Fluphenazine HCl..............33

Flurazepam HCl.................71

Flurbiprofen....................... 11

Flurbiprofen Sodium.......... 66

Flutamide........................... 62

Fluticasone Propionate. 56, 68

Fluvastatin.......................... 48

Fluvoxamine Maleate......... 25

Fluvoxamine Maleate ER...25

FML...................................66

FML Forte......................... 67

FML Liquifilm...................67

Focalin................................49

Focalin XR......................... 49

Folotyn............................... 29

Fomepizole.........................65

Fondaparinux Sodium........ 40

Foradil Aerolizer................ 70

Forfivo XL..........................24

Fortamet.............................38

Fortaz................................. 19

Forteo.................................65

Fortesta...............................58

Fortical............................... 65

Fosamax..............................65

Fosamax Plus D..................65

Foscarnet Sodium...............35

Fosinopril Sodium.............. 43

Fosinopril Sodium/Hydrochlorothiazide........ 43

Fosphenytoin Sodium.........23

Fosrenol..............................54

Fragmin........................ 40, 41

FreAmine III......................72

Frova.................................. 27

Fulyzaq............................... 52

Furadantin..........................17

Furosemide.........................47

Fusilev................................ 30

Fuzeon................................36

G

Gabapentin.........................22

Gabitril...............................22

Gablofen.............................35

Galantamine Hydrobromide......................................... 24

Gamastan S/D....................63

Gammagard Liquid............63

Gammaplex........................ 63

Gamunex-C....................... 63

Ganciclovir......................... 35

Gardasil.............................. 64

Gastrocrom.........................52

Gattex.................................52

Gauze Pads.........................65

GaviLyte-C........................ 53

GaviLyte-G........................53

GaviLyte-N/Flavor Pack....53

Gelnique.............................54

Gemcitabine HCl...............29

Gemfibrozil........................ 47

Gemzar...............................29

Generess Fe........................ 59

Generlac............................. 53

Gengraf.............................. 62

Genotropin.........................57

Genotropin Miniquick....... 57

Gentak................................16

Gentamicin Sulfate.............16

Gentamicin Sulfate/NaCl...16

Geodon...............................34

Gianvi.................................59

85

Giazo..................................64

Gildagia..............................59

Gilenya............................... 50

Glassia................................ 71

Gleevec............................... 31

Glimepiride........................ 38

Glipizide.............................38

Glipizide ER...................... 38

Glipizide/Metformin HCl. 38

Glucagen HypoKit............. 39

Glucagon Emergency Kit... 39

Glucophage........................ 38

Glucophage XR..................38

Glucotrol............................ 38

Glucotrol XL......................38

Glucovance......................... 38

Glumetza............................38

Glyburide........................... 38

Glyburide Micronized........ 38

Glyburide/Metformin HCl 38

Glycopyrrolate.................... 52

Glynase...............................38

Glyset................................. 38

GoLYTELY...................... 53

Gralise................................ 10

Gralise Starter.................... 10

Granisetron HCl................ 26

Granisol..............................26

Gris-PEG...........................26

Griseofulvin Microsize....... 26

Griseofulvin Ultramicrosize26

Guanfacine HCl.................43

Guanidine HCl.................. 28

Gynazole-1.........................26

H

Halaven.............................. 30

Halcion...............................71

Haldol................................ 33

Haldol Decanoate...............33

HalfLytely Bowel Prep/Flavor Packs................................ 52

Halobetasol Propionate...... 56

Halog..................................56

Haloperidol........................ 33

Haloperidol Decanoate.......33

Haloperidol Lactate............33

Havrix.................................64

Hectorol............................. 65

Helidac............................... 52

Heparin Sodium.................41

Heparin Sodium/D5W...... 41

Heparin Sodium/NaCl.......41

Heparin Sodium/NaCl 0.9% Premix..............................41

HepatAmine.......................72

Hepatasol........................... 72

Hepsera.............................. 36

Herceptin........................... 31

Hexalen.............................. 28

Hiprex................................ 17

Horizant............................. 22

Humalog............................ 40

Humalog KwikPen.............40

Humatrope......................... 57

Humira...............................62

Humira Starter Kit............. 62

Humulin.............................40

Humulin Pen......................40

Hycamtin............................31

Hycet..................................13

Hydralazine HCl................48

Hydrea................................29

Hydrochlorothiazide...........47

Hydrocodone/Acetaminophen................14

Hydrocodone/Ibuprofen.....14

Hydrocortisone.............56, 64

Hydrocortisone Butyrate.... 56

Hydrocortisone Valerate.....56

Hydrocortisone/Acetic Acid......................................... 68

Hydromorphone HCl.........14

Hydroxychloroquine Sulfate......................................... 32

Hydroxyurea....................... 29

Hydroxyzine HCl...............69

Hydroxyzine Pamoate........ 69

Hyzaar................................ 43

I

Ibandronate Sodium...........65

Ibuprofen............................11

Iclusig................................. 30

Idamycin PFS.....................30

Idarubicin HCl...................30

Ifex..................................... 28

Ifosfamide...........................28

Ilaris....................................63

Ilevro.................................. 67

Imipenem/Cilastatin.......... 19

Imipramine HCl.................25

Imipramine Pamoate.......... 25

Imiquimod..........................50

Imitrex................................27

86

Imitrex Statdose Refill........27

Imovax Rabies.................... 64

Imuran................................62

Incivek................................ 36

Increlex...............................57

Indapamide.........................47

Inderal LA..........................45

Indocin............................... 11

Indomethacin..................... 11

Indomethacin ER...............11

Infanrix...............................64

Infergen.............................. 36

Inlyta.................................. 31

Innopran XL...................... 45

Inspra................................. 47

Insulin Syringes, Needles....65

Intelence............................. 35

Intralipid............................ 66

Intron-A.............................36

Intron-A W/Diluent.......... 36

Introvale............................. 59

Intuniv................................49

Invanz.................................19

Invega................................. 34

Invega Sustenna..................34

Invirase............................... 36

Invokana.............................38

Ionosol-B/Dextrose 5%...... 39

Ionosol-MB/Dextrose 5%.. 39

Iopidine.............................. 68

IPOL..................................64

Ipratropium Bromide......... 70

Ipratropium Bromide/Albuterol Sulfate.............. 70

Irbesartan............................43

Irbesartan/Hydrochlorothiazide........ 43

Irinotecan........................... 30

Isentress..............................36

Isolyte-M/Dextrose 5%...... 72

Isolyte-P/Dextrose 5%........72

Isolyte-S............................. 72

Isoniazid............................. 28

Isopto Carpine....................68

Isordil Titradose................. 48

Isosorbide Dinitrate............48

Isosorbide Dinitrate ER..... 48

Isosorbide Mononitrate...... 48

Isosorbide Mononitrate ER48

Isotonic Gentamicin...........16

Isradipine............................46

Istalol..................................68

Istodax................................ 30

Itraconazole........................ 26

Ixempra Kit........................ 30

Ixiaro.................................. 64

J

Jakafi...................................30

Jalyn....................................54

Jantoven..............................41

Janumet.............................. 38

Janumet XR........................38

Januvia................................ 38

Jentadueto...........................38

Jevtana................................ 30

Jinteli.................................. 59

Jolivette...............................60

Junel................................... 59

Junel Fe.............................. 59

Juvisync...............................38

Juxtapid.............................. 48

K

K-Tabs............................... 72

Kadcyla...............................31

Kadian................................ 12

Kaletra................................ 36

Kalydeco............................. 71

Kapvay................................49

Kariva................................. 59

Kayexalate...........................72

Kazano................................38

KCl 0.075%/D5W/NaCl 0.45%............................... 40

KCl 0.15%/D5W/LR.........40

KCl 0.15%/D5W/NaCl 0.2%......................................... 40

KCl 0.15%/D5W/NaCl 0.225%............................. 40

KCl 0.15%/D5W/NaCl 0.9%......................................... 40

KCl 0.3%/D5W/NaCl 0.45%......................................... 40

KCl 0.3%/D5W/NaCl 0.9%......................................... 40

Keflex................................. 19

Kelnor.................................59

Kenalog.............................. 56

Kepivance........................... 50

Keppra................................ 22

Keppra XR......................... 22

Ketek.................................. 20

Ketoconazole...................... 26

Ketodan Kit........................26

87

Ketoprofen..........................11

Ketoprofen ER................... 11

Ketorolac Tromethamine.. 11, 67

Kineret................................62

Kionex................................ 72

Klaron.................................50

Klonopin.............................22

Klor-Con 10.......................72

Klor-Con 8.........................72

Klor-Con M15................... 73

Klor-Con M20................... 73

Kombiglyze XR.................. 38

Korlym............................... 58

Kristalose............................ 53

Kuvan................................. 51

Kynamro.............................48

L

Labetalol HCl.................... 45

Lac-Hydrin........................ 50

Lacrisert..............................66

Lactated Ringers Irrigation 66

Lactated Ringers Viaflex.... 73

Lactulose............................ 53

Lamictal............................. 23

Lamictal Chewable Dispersible....................... 23

Lamictal ODT................... 23

Lamictal Starter Kit............23

Lamictal XR....................... 23

Lamisil................................26

Lamivudine........................ 35

Lamivudine/Zidovudine.....35

Lamotrigine........................23

Lamotrigine ER................. 23

Lanoxin.............................. 46

Lansoprazole...................... 53

Lantus................................ 40

Lantus SoloStar.................. 40

Lasix................................... 47

Lastacaft............................. 66

Latanoprost........................ 68

Latuda................................ 34

Lazanda.............................. 14

Leena..................................59

Leflunomide....................... 63

Lescol................................. 48

Lescol XL...........................48

Lessina................................59

Letairis............................... 70

Letrozole............................ 31

Leucovorin Calcium........... 30

Leukeran............................ 28

Leukine.............................. 42

Leuprolide Acetate............. 61

Levalbuterol HCl............... 70

Levaquin.............................21

Levatol................................45

Levemir.............................. 40

Levemir FlexPen................ 40

Levetiracetam..................... 22

Levetiracetam ER...............22

Levobunolol HCl............... 68

Levocarnitine......................66

Levocetirizine Dihydrochloride...............69

Levofloxacin....................... 21

Levofloxacin in D5W.........21

Levonest............................. 59

Levonorgestrel/Ethinyl Estradiol...........................59

Levora.................................59

Levorphanol Tartrate......... 12

Levothroid..........................60

Levothyroxine Sodium....... 60

Levoxyl............................... 60

Lexapro.............................. 25

Lexiva................................. 36

Lialda................................. 64

Lidocaine............................15

Lidocaine 2% Viscous Solution............................15

Lidocaine HCl................... 15

Lidocaine/Prilocaine...........15

Lidoderm............................15

Lincocin............................. 17

Lindane.............................. 32

Linzess................................53

Lioresal Intrathecal.............35

Liothyronine Sodium......... 60

Lipitor................................ 48

Lipofen...............................47

Liposyn III......................... 66

Lisinopril............................ 43

Lisinopril/Hydrochlorothiazide........ 43

Lithium Carbonate.............38

Lithium Carbonate ER...... 38

Lithium Citrate.................. 38

Lithobid............................. 38

Livalo................................. 48

Lo Loestrin Fe....................59

Locoid................................ 56

88

Locoid Lipocream.............. 56

Lodosyn..............................32

Loestrin Fe......................... 59

Lofibra................................47

LoKara............................... 56

Lomotil.............................. 52

Loperamide HCl................ 52

Lopid..................................47

Lopressor............................45

Lopressor HCT..................45

Loprox Shampoo................26

Lorazepam..........................37

Lorazepam Intensol............37

Lorcet................................. 14

Lortab.................................14

Loryna................................ 59

Lorzone.............................. 71

Losartan Potassium............ 43

Losartan Potassium/Hydrochlorothiazide........ 43

LoSeasonique..................... 59

Lotemax............................. 67

Lotensin............................. 44

Lotensin HCT................... 44

Lotrel..................................46

Lotrisone............................ 26

Lotronex.............................53

Lovastatin...........................48

Lovaza................................ 48

Lovenox..............................41

Low-Ogestrel..................... 59

Loxapine Succinate.............33

Loxitane............................. 33

Lufyllin...............................70

Lumigan............................. 68

Lumizyme.......................... 51

Lunesta...............................71

Lupron Depot.................... 61

Lupron Depot-PED...........61

Lutera.................................59

Luvox CR...........................25

Luxiq.................................. 56

Lyrica................................. 22

Lysodren.............................61

Lysteda............................... 42

M

M-M-R II..........................64

Macrobid............................ 17

Macrodantin.......................17

Mafenide Acetate............... 17

Magnacet............................14

Magnesium Sulfate.............73

Malarone............................ 32

Malathion...........................32

Maprotiline HCl................ 24

Marinol...............................26

Marlissa.............................. 59

Marplan..............................24

Matulane............................ 28

Matzim LA........................ 46

Mavik................................. 44

Maxair Autohaler............... 70

Maxalt................................ 27

Maxalt-MLT..................... 27

Maxidex..............................67

Maxidone........................... 14

Maxitrol..............................67

Maxzide..............................47

Meclizine HCl....................25

Meclofenamate Sodium......11

Medrol................................56

Medrol Dosepak.................56

Medroxyprogesterone Acetate......................................... 60

Mefenamic Acid.................11

Mefloquine HCl.................32

Megace ES......................... 60

Megace Oral.......................60

Megestrol Acetate.............. 60

Mekinist............................. 30

Meloxicam..........................11

Melphalan HCl.................. 28

Menactra............................ 64

Menest................................30

Menomune-A/C/Y/W-135......................................... 64

Menostar............................ 59

Mentax............................... 26

Menveo...............................64

Meperidine HCl.................14

Meperitab........................... 14

Meprobamate..................... 37

Mepron...............................32

Mercaptopurine.................. 29

Meropenem........................ 19

Merrem.............................. 19

Mesalamine........................ 64

Mesna.................................30

Mesnex............................... 30

Mestinon............................ 28

Mestinon Timespan........... 28

Metadate CD..................... 49

89

Metadate ER......................49

Metaproterenol Sulfate.......70

Metformin HCl..................38

Metformin HCl ER 1000mg Tablet Extended Release 24 Hour................................ 38

Metformin HCl ER 500mg, 750mg Tablet Extended Release 24 Hour...............38

Methadone HCl.................12

Methamphetamine HCl.....49

Methazolamide...................68

Methenamine Hippurate....17

Methimazole...................... 62

Methitest............................ 58

Methocarbamol.................. 71

Methotrexate...................... 62

Methotrexate Sodium.........62

Methscopolamine Bromide 52

Methyclothiazide................47

Methyldopa........................ 43

Methyldopa/Hydrochlorothiazide........ 43

Methyldopate HCl............. 43

Methylergonovine Maleate.66

Methylin.............................49

Methylphenidate HCl........ 49

Methylphenidate HCl CD.49

Methylphenidate HCl ER..49

Methylprednisolone............56

Methylprednisolone Acetate......................................... 56

Methylprednisolone Dose Pack................................. 56

Methylprednisolone Sodium Succinate.......................... 56

Metipranolol.......................68

Metoclopramide HCl......... 52

Metolazone.........................47

Metoprolol Succinate ER...45

Metoprolol Tartrate............45

Metoprolol/Hydrochlorothiazide........ 45

Metozolv ODT.................. 52

MetroCream.......................17

MetroGel............................17

MetroGel-Vaginal..............17

MetroLotion...................... 17

Metronidazole.................... 17

Metronidazole in NaCl 0.79%............................... 17

Metronidazole Vaginal....... 17

Mevacor..............................48

Mexiletine HCl.................. 44

Miacalcin............................65

Micardis............................. 43

Micardis HCT................... 43

Miconazole 3...................... 26

Microgestin........................ 59

Microgestin Fe................... 59

Microzide........................... 47

Midodrine HCl.................. 43

Migergot.............................27

Migranal.............................27

Millipred.......................56, 64

Minastrin 24 Fe..................59

Minipress............................43

Minitran............................. 48

Minivelle............................ 59

Minocin..............................22

Minocycline HCl................22

Minocycline HCl ER......... 22

Minoxidil............................48

Mirapex.............................. 32

Mirapex ER........................32

Mirtazapine........................ 24

Mirtazapine ODT.............. 24

Misoprostol........................ 53

Mitomycin..........................30

Mitoxantrone HCl............. 30

Mobic................................. 11

Modafinil............................72

Modicon.............................59

Moexipril HCl....................44

Moexipril/Hydrochlorothiazide........ 44

Mometasone Furoate..........56

MonoNessa........................ 59

Montelukast Sodium.......... 69

Monurol............................. 17

Morphine Sulfate............... 12

Morphine Sulfate ER......... 12

Motofen............................. 52

MoviPrep............................53

Moxatag............................. 19

Moxeza...............................21

Mozobil.............................. 42

MS Contin......................... 12

Multaq................................44

Mupirocin...........................17

Mustargen.......................... 28

Myambutol.........................28

Mycamine...........................26

Mycobutin.......................... 28

90

Mycophenolate Mofetil......62

Myfortic............................. 62

Myorisan............................ 51

Myozyme............................51

Myrbetriq........................... 54

Mysoline.............................22

N

Nabumetone.......................11

Nadolol...............................45

Nadolol/Bendroflumethiazide......................................... 45

Nafcillin Sodium................ 20

Naftin................................. 27

Naglazyme..........................51

Nalbuphine HCl................ 14

Nalfon................................ 11

Nallpen/Dextrose............... 20

Naloxone HCl.................... 15

Naltrexone HCl..................15

Namenda............................ 24

Namenda Titration Pak......24

Namenda XR......................24

Namenda XR Titration Pack......................................... 24

Naphazoline HCl............... 66

Naprelan....................... 11, 16

Naprosyn............................ 11

Naproxen............................11

Naproxen DR..................... 11

Naproxen Sodium...............11

Naratriptan HCl.................27

Nardil................................. 24

Nasacort AQ...................... 68

Nasonex..............................68

Natacyn.............................. 27

Nateglinide......................... 39

Nebupent............................32

Necon................................. 59

Necon 1/35.........................59

Nefazodone HCl................ 24

Neomycin Sulfate............... 16

Neomycin/Bacitracin/Polymyxin........................ 17

Neomycin/Polymyxin B Sulfates.............................16

Neomycin/Polymyxin/Bacitracin/Hydrocortisone......................................... 67

Neomycin/Polymyxin/Dexamethasone................67

Neomycin/Polymyxin/Gramicidin.......................17

Neomycin/Polymyxin/Hydrocortisone................ 68

Neoral.................................62

Neosporin...........................17

Nephramine........................73

Nesina................................ 39

Neulasta..............................42

Neumega............................ 42

Neupogen........................... 42

Neupro............................... 32

Neurontin........................... 22

Nevanac..............................67

Nevirapine.......................... 35

Nexavar...............................31

Nexium...............................53

Nexium I.V.........................53

Nexterone........................... 44

Niacor.................................74

Niaspan.............................. 48

Nicardipine HCl................ 46

Nicotrol Inhaler..................16

Nicotrol NS........................16

Nifediac CC....................... 46

Nifedical XL.......................46

Nifedipine.......................... 46

Nifedipine ER.................... 46

Nilandron........................... 62

Nimodipine........................ 46

Nipent................................ 29

Niravam..............................37

Nisoldipine......................... 46

Nisoldipine ER...................46

Nitro-Bid........................... 48

Nitro-Dur...........................48

Nitrofurantoin.................... 17

Nitrofurantoin Macrocrystalline...............17

Nitrofurantoin Monohydrate......................................... 18

Nitroglycerin...................... 48

Nitrolingual Pumpspray..... 48

NitroMist........................... 48

Nitrostat............................. 48

Nizatidine...........................53

Nizoral................................27

Nor-QD............................. 60

Nora-BE............................ 60

Norco................................. 14

Nordette............................. 59

Norditropin FlexPro...........57

Norditropin NordiFlex Pen57

Norethindrone Acetate.......60

91

Norinyl............................... 59

Normosol-M in D5W........73

Normosol-R....................... 73

Normosol-R in D5W.........40

Noroxin.............................. 21

Norpace.............................. 44

Norpace CR....................... 44

Norpramin..........................25

Nortrel................................59

Nortrel 1/35........................59

Nortriptyline HCl.............. 25

Norvasc...............................46

Norvir................................. 36

Novarel............................... 57

Novolin...............................40

Novolog..............................40

Novolog FlexPen................ 40

Noxafil................................27

Nucynta.............................. 14

Nucynta ER........................12

Nuedexta............................ 49

Nulojix................................62

NuLYTELY/Flavor Packs. 53

Nutropin.............................57

Nutropin AQ......................57

NuvaRing........................... 59

Nuvigil................................72

Nyamyc.............................. 27

Nystatin..............................27

Nystatin/Triamcinolone..... 27

Nystop................................ 27

O

Ocella................................. 59

Octreotide Acetate............. 61

Ocufen................................67

Ocuflox...............................21

Ofloxacin............................21

Ogestrel.............................. 59

Olanzapine......................... 34

Olanzapine ODT............... 34

Olanzapine/Fluoxetine. 25, 38

Oleptro............................... 24

Olux-E............................... 56

Omeclamox-Pak.................18

Omeprazole........................ 53

Omnaris..............................68

Omnipred...........................67

Omnitrope..........................57

Ondansetron HCl.............. 26

Ondansetron ODT.............26

Onfi....................................22

Onglyza.............................. 39

ONMEL............................ 27

Onsolis............................... 14

Ontak................................. 30

Opana.................................14

Opana ER.......................... 12

Optivar............................... 66

Oracea................................ 22

Orap................................... 33

Orapred.............................. 56

Orapred ODT.................... 56

Orbivan.............................. 49

Orbivan CF........................ 10

Orencia...............................62

Orfadin...............................51

Orphenadrine Citrate......... 71

Orphenadrine Citrate ER...71

Orphenadrine/Aspirin/Caffeine............................71

Orsythia..............................59

Ortho Evra......................... 59

Ortho Micronor................. 60

Ortho Tri-Cyclen...............59

Ortho Tri-Cyclen Lo......... 59

Ortho-Cept........................ 59

Ortho-Cyclen..................... 59

Ortho-Novum 7/7/7.......... 59

Oseni.................................. 39

OsmoPrep.......................... 52

Ovcon-35........................... 59

Ovide..................................32

Oxacillin Sodium................20

Oxaliplatin..........................30

Oxandrolone.......................58

Oxaprozin...........................11

Oxazepam...........................37

Oxcarbazepine.................... 23

Oxecta................................ 14

Oxistat................................27

Oxsoralen........................... 51

Oxsoralen Ultra.................. 51

Oxybutynin Chloride..........54

Oxybutynin Chloride ER... 54

Oxycodone HCl................. 14

Oxycodone/Acetaminophen......................................... 14

Oxycodone/Aspirin............ 14

Oxycodone/Ibuprofen........ 11

Oxycontin...........................12

Oxymorphone HCl............ 14

Oxymorphone HCl ER......12

92

Oxytrol............................... 54

P

Pacerone............................. 44

Paclitaxel............................ 30

Palgic..................................69

Pamelor.............................. 25

Pamidronate Disodium...... 65

Pamine............................... 52

Pamine Forte......................52

Pancreaze............................51

Pandel.................................56

Panretin..............................31

Pantoprazole Sodium......... 54

Parafon Forte DSC............ 71

Parcopa...............................32

Parlodel.............................. 32

Parnate............................... 24

Paromomycin Sulfate......... 16

Paroxetine HCl.................. 25

Paroxetine HCl ER............ 25

Paser................................... 28

Pataday............................... 66

Patanase..............................69

Patanol............................... 66

Paxil....................................25

Paxil CR............................. 25

PCE................................... 20

Pedi-Dri............................. 27

Pedvax HIB........................64

Peg-Intron..........................36

Peg-Intron Redipen........... 36

Peganone............................ 23

Pegasys............................... 36

Pegasys ProClick................ 36

Penicillin G Potassium....... 20

Penicillin G Potassium in Iso-Osmotic Dextrose......20

Penicillin G Procaine..........20

Penicillin G Sodium........... 20

Penicillin V Potassium....... 20

Pennsaid............................. 51

Pentam 300........................ 32

Pentasa............................... 64

Pentazocine/Acetaminophen......................................... 14

Pentazocine/Naloxone HCl14

Pentostatin......................... 29

Pentoxifylline ER............... 46

Pepcid.................................53

Percocet.............................. 14

Percodan.............................14

Perforomist.........................70

Perindopril Erbumine.........44

Periogard............................ 50

Perjeta.................................31

Permethrin......................... 32

Perphenazine...................... 33

Perphenazine/Amitriptyline......................................... 25

Persantine...........................42

Pertzye................................52

Pexeva.................................25

Pfizerpen-G........................20

Phenadoz............................69

Phenelzine Sulfate.............. 24

Phenergan...........................69

Phenobarbital..................... 22

Phenytek.............................23

Phenytoin........................... 23

Phenytoin Sodium..............23

Phenytoin Sodium Extended......................................... 23

pHisoHex........................... 18

PhosLo............................... 73

Phoslyra..............................73

Phospholine Iodide.............68

Phrenilin Forte................... 10

Physiolyte........................... 66

Physiosol Irrigation............ 66

Picato..................................30

Pilocarpine HCl................. 50

Pilopine HS........................68

Pindolol.............................. 45

Pioglitazone HCl................39

Pioglitazone HCl/Glimepiride......................39

Pioglitazone HCl/Metformin HCl..................................39

Piperacillin Sodium/Tazobactam Sodium........ 20

Piroxicam............................11

Plaquenil.............................32

Plasma-Lyte....................... 73

Plasma-Lyte/D5W.............73

Plavix..................................42

Pletal.................................. 42

Podofilox............................ 51

Polyethylene Glycol 3350...53

Polymyxin B Sulfate........... 18

Polytrim..............................18

Pomalyst.............................30

Ponstel................................11

Portia..................................60

Potassium Chloride............ 73

93

Potassium Chloride 0.15%/D5W/NaCl 0.33%........... 40

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex......................................... 40

Potassium Chloride 0.15%/NaCl 0.45% Viaflex......... 73

Potassium Chloride 0.15%/NaCl 0.9%........................73

Potassium Chloride 0.22%/D5W/NaCl 0.45%...........40

Potassium Chloride 0.3%/D5W................................73

Potassium Chloride 0.3%/NaCl 0.9%........................73

Potassium Chloride ER......73

Potassium Citrate............... 73

Potiga................................. 22

Pradaxa...............................41

Pramipexole Dihydrochloride......................................... 32

PrandiMet.......................... 39

Prandin...............................39

Pravachol............................ 48

Pravastatin Sodium.............48

Prazosin HCl......................43

Precose............................... 39

Pred Forte.......................... 67

Pred Mild........................... 67

Pred-G............................... 67

Pred-G S.O.P.................... 67

Prednicarbate......................56

Prednisolone Acetate..........67

Prednisolone Sodium Phosphate...................56, 67

Prednisone..........................56

Prednisone Intensol............56

Prefest.................................60

Pregnyl W/Diluent Benzyl Alcohol/NaCl.................. 57

Premarin.............................60

Premasol.............................73

Premphase.......................... 60

Prempro..............................60

Prenatabs OBN.................. 74

Prepopik............................. 53

Prevacid.............................. 54

Prevacid SoluTab............... 54

Prevalite..............................48

Previfem............................. 60

Prevpac............................... 18

Prezista............................... 36

Priftin................................. 28

Prilosec............................... 54

Primaquine Phosphate........32

Primaxin............................. 19

Primidone...........................22

Primsol............................... 18

Prinivil................................44

Pristiq................................. 25

Privigen.............................. 63

Proair HFA........................ 70

Probenecid..........................27

Probenecid/Colchicine....... 27

Procainamide HCl............. 44

Procalamine........................73

Procardia............................ 46

Procardia XL...................... 46

ProCentra...........................49

Prochlorperazine.................33

Prochlorperazine Edisylate. 33

Prochlorperazine Maleate...33

Procrit.................................42

Procto-Pak......................... 56

ProctoCream HC...............56

Proctozone-HC..................56

Progesterone.......................60

Proglycem...........................40

Prograf................................62

Prolastin-C.........................71

Prolensa.............................. 67

Proleukin............................ 30

Prolia.................................. 65

Promacta............................ 42

Promethazine HCl............. 69

Promethazine VC...............69

Promethegan...................... 69

Prometrium........................ 60

Propafenone HCl............... 44

Propafenone HCl ER.........44

Propantheline Bromide...... 52

Proparacaine HCl...............66

Propranolol HCl................ 45

Propranolol HCl ER.......... 45

Propranolol/Hydrochlorothiazide........ 45

Propylthiouracil.................. 62

ProQuad.............................64

Proscar................................54

Prosol................................. 73

Protonix..............................54

Protopic..............................51

Protriptyline HCl............... 25

Proventil HFA................... 70

94

Provera............................... 60

Provigil............................... 72

Prozac.................................25

Prozac Weekly....................25

Prudoxin.............................51

Pulmicort............................68

Pulmicort Flexhaler............ 69

Pulmozyme.........................71

Purinethol...........................29

Pylera..................................52

Pyrazinamide......................28

Pyridostigmine Bromide.....28

Q

Qnasl.................................. 69

Qualaquin...........................32

Quasense............................ 60

Questran.............................48

Quetiapine Fumarate..........34

Quillivant XR..................... 49

Quinapril HCl....................44

Quinapril/Hydrochlorothiazide........ 44

Quinidine Gluconate..........44

Quinidine Gluconate CR... 44

Quinidine Sulfate............... 44

Quinidine Sulfate ER.........44

Quinine Sulfate.................. 32

QVAR................................69

R

Rabavert............................. 64

Ramipril............................. 44

Ranexa................................46

Ranitidine HCl...................53

Rapaflo............................... 54

Rapamune.......................... 63

RAVICTI.......................... 52

Rayos.................................. 56

Razadyne............................ 24

Razadyne ER......................24

Rebetol............................... 37

Rebif...................................63

Rebif Titration Pack...........63

Reclast................................ 65

Reclipsen............................ 60

Recombivax HB................. 64

Rectiv................................. 48

Reglan................................ 52

Regonol.............................. 28

Relenza Diskhaler...............36

Relistor............................... 52

Relpax.................................27

Remeron.............................24

Remeron Soltab..................24

Remicade............................63

Remodulin..........................70

Renagel...............................54

Renvela...............................54

Reprexain........................... 14

Requip................................ 32

Requip XL..........................32

Rescriptor........................... 35

Rescula............................... 68

Reserpine............................43

Restasis...............................66

Restoril............................... 71

Retin-A.............................. 51

Retin-A Micro................... 51

Retrovir.............................. 35

Retrovir IV Infusion........... 35

Revatio............................... 70

Revia...................................15

Revlimid............................. 28

Reyataz............................... 36

Rheumatrex........................ 63

Rhinocort Aqua..................69

Ribapak.............................. 37

Ribasphere..........................37

Ribavirin.............................37

Ridaura............................... 63

Rifadin................................28

Rifamate............................. 28

Rifampin............................ 28

Rifater.................................28

Rilutek................................50

Riluzole.............................. 50

Rimantadine HCl...............36

Ringers Injection................ 73

Ringers Irrigation............... 66

Riomet................................39

Risperdal.............................34

Risperdal Consta................ 34

Risperdal M-Tab................34

Risperidone........................ 34

Risperidone ODT.............. 34

Ritalin.................................49

Ritalin LA.......................... 49

Ritalin SR...........................49

Rituxan............................... 31

Rivastigmine Tartrate.........24

Rizatriptan Benzoate.......... 27

Robinul...............................52

Robinul Forte..................... 52

95

Rocaltrol.............................65

Rocephin............................ 19

Ropinirole ER.................... 32

Ropinirole HCl.................. 32

RotaTeq............................. 64

Roxicet............................... 14

Roxicodone.........................14

Rozerem............................. 72

Rythmol..............................44

Rythmol SR........................44

S

Sabril.................................. 22

Safyral.................................60

Saizen................................. 57

Salagen............................... 50

Samsca................................72

Sanctura..............................54

Sanctura XR....................... 54

Sancuso...............................26

Sandimmune...................... 63

Sandostatin.........................61

Sandostatin LAR Depot.....61

Santyl..................................51

Saphris................................34

Sarafem...............................25

Savella.................................50

Savella Titration Pack.........50

Seasonique..........................60

Seconal............................... 72

Sectral.................................45

Selegiline HCl.................... 33

Selenium Sulfide.................51

Selzentry.............................36

Semprex-D......................... 69

Sensipar.............................. 61

Serevent Diskus.................. 70

Seromycin...........................28

Seroquel..............................34

Seroquel XR....................... 34

Serostim............................. 57

Sertraline HCl.................... 25

sfRowasa.............................64

Signifor...............................61

Sildenafil Citrate................ 71

Silenor................................ 72

Silvadene............................ 18

Silver Sulfadiazine.............. 18

Simbrinza........................... 68

Simcor................................ 48

Simponi.............................. 63

Simulect..............................63

Simvastatin......................... 48

Sinemet.............................. 32

Sinemet CR........................32

Singulair............................. 69

Sirturo................................ 28

Skelaxin.............................. 71

Skelid..................................65

Sklice.................................. 32

Sodium Chloride................ 73

Sodium Chloride 0.45% Viaflex.............................. 73

Sodium Chloride 0.9%....... 66

Sodium Diuril.................... 47

Sodium Fluoride.................74

Sodium Lactate.................. 72

Sodium Phenylbutyrate...... 52

Sodium Polystyrene Sulfonate......................................... 72

Solaraze.............................. 51

Solodyn...............................22

Soltamox.............................29

Solu-Cortef........................ 56

Solu-Medrol.......................56

Soma.................................. 71

Somatuline Depot.............. 62

Somavert.............................62

Sonata.................................71

Soriatane.............................51

Sorilux................................ 51

Sorine................................. 44

Sotalol HCl........................ 44

Spinosad............................. 32

Spiriva Handihaler............. 70

Spironolactone....................47

Spironolactone/Hydrochlorothiazide........ 47

Sporanox.............................27

Sporanox Pulsepak............. 27

Sprintec.............................. 60

Sprix................................... 11

Sprycel................................ 31

Sronyx................................ 60

SSD.................................... 18

Stagesic...............................14

Stalevo................................ 33

Starlix................................. 39

Stavudine............................35

Stavzor................................22

Stelara.................................51

Sterile Water Irrigation...... 66

96

Stimate............................... 57

Stivarga...............................31

Strattera..............................49

Streptomycin Sulfate.......... 16

Stribild................................35

Stromectol.......................... 31

Suboxone............................ 16

Subsys.................................15

Sucraid................................52

Sucralfate............................53

Sular................................... 46

Sulfacetamide Sodium.. 21, 51

Sulfacetamide Sodium/Prednisolone Sodium Phosphate.........................67

Sulfadiazine........................ 21

Sulfamethoxazole/Trimethoprim.................. 21

Sulfamethoxazole/Trimethoprim DS............ 21

Sulfamylon..........................18

Sulfasalazine....................... 64

Sulfazine EC...................... 65

Sulindac..............................11

Sumatriptan Succinate........28

Sumavel DosePro............... 28

Suprax.................................19

Suprep Bowel Prep............. 53

Surmontil........................... 25

Sustiva................................ 35

Sutent................................. 31

Sylatron.............................. 30

Symbicort........................... 69

Symbyax............................. 38

SymlinPen 120................... 39

SymlinPen 60..................... 39

Synagis............................... 63

Synalar Cream Kit.............. 51

Synalgos-DC......................15

Synarel................................62

Synera.................................15

Synercid..............................18

Synribo............................... 30

Synthroid............................61

Syprine............................... 72

T

Tabloid............................... 29

Taclonex............................. 51

Tacrolimus..........................63

Tafinlar...............................29

Talwin................................ 15

Tamiflu...............................36

Tamoxifen Citrate.............. 29

Tamsulosin HCl.................54

Tapazole............................. 62

Tarceva............................... 31

Targretin............................ 31

Tarka.................................. 44

Tasigna...............................31

Tasmar............................... 32

Taxotere............................. 30

Tazorac...............................51

Taztia XT...........................46

Tecfidera............................ 63

Tecfidera Starter Pack........ 63

Teflaro................................19

Tegretol..............................23

Tegretol-XR.......................23

Tekamlo............................. 46

Tekturna.............................46

Tekturna HCT...................46

Temazepam........................ 71

Temovate............................56

Tencon............................... 10

Tenex..................................43

Tenoretic............................ 45

Tenormin........................... 45

Terazol............................... 27

Terazosin HCl....................54

Terbinafine HCl.................27

Terbutaline Sulfate............. 70

Terconazole........................ 27

Testim................................ 58

Testosterone Cypionate......58

Testosterone Enanthate......58

Testred............................... 58

Tetanus Toxoid Adsorbed..64

Tetanus/Diphtheria Toxoids-Adsorbed Adult................64

Tev-Tropin.........................57

Teveten...............................43

Teveten HCT.....................43

Thalomid............................29

Theophylline ER................70

Thioridazine HCl...............33

Thiotepa............................. 28

Thiothixene........................ 33

Thymoglobulin...................63

Thyrolar..............................61

Thyrolar-1/2.......................61

Tiagabine HCl................... 22

Tiazac................................. 46

Ticlopidine HCl.................42

97

Tigan.................................. 25

Tikosyn...............................44

Timentin............................ 20

Timolol Maleate...........45, 68

Timoptic Ocudose..............68

Timoptic-XE......................68

Tinidazole.......................... 32

Tirosint...............................61

Tizanidine HCl.................. 35

TOBI................................. 16

TOBI Podhaler.................. 16

Tobradex............................ 67

Tobradex ST...................... 67

Tobramycin Sulfate............ 16

Tobramycin Sulfate/NaCl.. 16

Tobramycin/Dexamethasone......................................... 67

Tobrex................................ 16

Tofranil.............................. 25

Tofranil-PM.......................25

Tolazamide.........................39

Tolbutamide.......................39

Tolmetin Sodium............... 11

Tolterodine Tartrate...........54

Topamax.............................23

Topamax Sprinkle.............. 23

Topicort..............................56

Topiramate.........................23

Toposar.............................. 31

Topotecan HCl.................. 31

Toprol XL.......................... 45

Torisel................................ 63

Torsemide.......................... 47

Toviaz.................................54

TPN Electrolytes................73

Tracleer.............................. 71

Tradjenta............................ 39

Tramadol HCl....................15

Tramadol HCl ER 100mg, 200mg Tablet Extended Release 24 Hour...............12

Tramadol HCl ER 300mg Tablet Extended Release 24 Hour................................ 12

Tramadol HCl/Acetaminophen................15

Trandolapril........................44

Tranexamic Acid................ 42

Transderm-Scop.................25

Tranxene T.........................22

Tranylcypromine Sulfate.... 24

Travasol.............................. 73

Travatan Z..........................68

Travoprost.......................... 68

Trazodone HCl.................. 24

Treanda.............................. 28

Trecator..............................28

Trelstar Depot.................... 62

Trelstar LA.........................62

Trelstar Mixject..................62

Trental................................46

Tretin-X............................. 51

Tretinoin...................... 31, 51

Trexall................................ 63

Treximet.............................11

Tri-Legest Fe..................... 60

Tri-Norinyl........................ 60

Tri-Previfem.......................60

Tri-Sprintec........................60

Triamcinolone Acetonide..56, 69

Triamcinolone in Orabase.. 50

Triamterene/Hydrochlorothiazide........ 47

Triazolam........................... 71

Tribenzor............................46

Tricor................................. 47

Triderm.............................. 57

Trifluoperazine HCl...........33

Trifluridine.........................37

Trihexyphenidyl HCl......... 32

Trileptal..............................23

Trilipix............................... 47

TriLyte............................... 53

Trimethobenzamide HCl...25

Trimethoprim.....................18

Trimethoprim Sulfate/Polymyxin B Sulfate.........18

Trimipramine Maleate....... 25

Trinessa.............................. 60

Trisenox..............................30

Trivora................................60

Trizivir................................35

Trophamine........................73

Trospium Chloride.............54

Trospium Chloride ER...... 54

Trusopt...............................68

Truvada.............................. 35

Tudorza Pressair.................70

Twinrix...............................64

Twynsta..............................46

Tygacil................................18

Tykerb................................ 31

Tylenol/Codeine.................15

98

Typhim Vi..........................64

Tysabri................................63

Tyvaso................................ 71

Tyzeka................................ 37

Tyzine................................ 71

U

U-Cort............................... 57

Uceris................................. 64

Ulesfia.................................32

Uloric..................................27

Ultracet...............................15

Ultram................................ 15

Ultram ER..........................12

Ultravate............................. 57

Ultresa................................ 52

Unasyn................................20

Unasyn Bulk Pack.............. 20

Uniretic.............................. 44

Unithroid............................61

Univasc............................... 44

Urecholine.......................... 54

Urocit-K 10........................ 73

Urocit-K 15........................ 73

Urocit-K 5.......................... 73

Uroxatral.............................54

Urso....................................52

Ursodiol..............................52

Uvadex................................51

V

Vagifem.............................. 60

Valacyclovir HCl................ 37

Valcyte................................35

Valium................................37

Valproate Sodium...............22

Valproic Acid..................... 22

Valsartan/Hydrochlorothiazide........ 43

Valtrex................................ 37

Vancocin HCl.................... 18

Vancomycin HCl............... 18

Vandazole...........................18

Vanos..................................57

VAQTA.............................64

Varivax................................64

Vascepa...............................48

Vaseretic............................. 44

Vasotec............................... 44

Vecamyl..............................46

Vectibix.............................. 31

Vectical...............................51

Velcade............................... 30

Velivet................................ 60

Veltin..................................51

Venlafaxine HCl.................25

Venlafaxine HCl ER.......... 25

Ventavis..............................71

Ventolin HFA.................... 70

Veramyst............................ 69

Verapamil HCl...................46

Verapamil HCl ER............ 46

Verapamil HCl SR.............46

Verdeso...............................57

Veregen.............................. 51

Verelan............................... 46

Verelan PM........................ 46

Veripred 20.........................57

Vesicare.............................. 54

Vexol.................................. 67

Vfend..................................27

Vfend IV............................ 27

Vibativ................................ 18

Vibramycin......................... 22

Vicodin...............................15

Vicodin ES......................... 15

Vicodin HP........................ 15

Vicoprofen..........................15

Victoza............................... 39

Victrelis.............................. 37

Vidaza.................................30

Videx EC............................35

Videx Pediatric................... 36

Vigamox............................. 21

Viibryd................................25

Vimovo...............................54

Vimpat................................23

Vinblastine Sulfate..............30

Vincasar PFS...................... 30

Vincristine Sulfate.............. 30

Vinorelbine Tartrate...........30

Viokace...............................52

Viracept.............................. 36

Viramune............................35

Viramune XR..................... 35

Virazole.............................. 37

Viread.................................36

Viroptic.............................. 37

Vistaril................................69

Vistide................................ 35

Vivactil............................... 25

Vivelle-Dot.........................60

Vivitrol............................... 15

Voltaren..............................51

99

Voltaren-XR.......................11

Voriconazole.......................27

Vospire ER.........................70

Votrient.............................. 31

VPRIV............................... 52

Vytorin............................... 48

Vyvanse.............................. 49

W

Warfarin Sodium................41

Welchol.............................. 48

Wellbutrin.......................... 24

Wellbutrin SR.................... 24

Wellbutrin XL....................24

Westcort.............................57

X

Xalatan............................... 68

Xalkori................................31

Xanax..................................37

Xanax XR........................... 37

Xarelto................................41

Xeljanz................................63

Xenazine.............................50

Xeomin...............................66

Xerese................................. 37

Xgeva..................................65

Xifaxan............................... 18

Xodol..................................15

Xolair..................................71

Xopenex..............................70

Xopenex HFA.................... 70

Xtandi.................................62

Xylocaine............................ 15

Xyrem.................................72

Xyzal...................................69

Y

Yasmin............................... 60

Yaz..................................... 60

Yervoy................................ 31

YF-Vax...............................64

Z

Zafirlukast.......................... 69

Zaleplon............................. 71

Zaltrap................................30

Zamicet.............................. 15

Zanaflex..............................35

Zanosar...............................28

Zantac................................ 53

Zarontin............................. 22

Zavesca............................... 52

Zazole.................................27

Zebeta................................ 45

Zebutal............................... 10

Zegerid............................... 54

Zelapar............................... 33

Zelboraf..............................31

Zemaira.............................. 71

Zemplar..............................65

Zenchent Fe....................... 60

Zenpep............................... 52

Zenzedi.............................. 49

Zerit................................... 36

Zestoretic............................44

Zestril................................. 44

Zetia................................... 48

Zetonna.............................. 69

Ziac.................................... 45

Ziagen................................ 36

Ziana.................................. 51

Zidovudine......................... 36

Zinecard............................. 30

Zioptan...............................68

Ziprasidone HCl................ 34

Zirgan.................................35

Zithromax.......................... 20

Zithromax Tri-Pak.............20

Zithromax Z-Pak............... 20

Zmax.................................. 20

Zocor..................................48

Zofran................................ 26

Zofran ODT...................... 26

Zoledronic Acid................. 65

Zolinza............................... 30

Zoloft................................. 25

Zolpidem Tartrate..............71

Zolpidem Tartrate ER....... 71

Zolpimist............................71

Zometa............................... 65

Zomig.................................28

Zomig ZMT...................... 28

Zonalon.............................. 51

Zonegran............................ 22

Zonisamide.........................22

Zorbtive..............................57

Zortress.............................. 63

Zostavax............................. 64

Zosyn..................................20

Zovia.................................. 60

Zovirax............................... 37

Zyban................................. 16

Zyclara................................51

Zydone............................... 15

Zyflo...................................69

100

Zyflo CR............................ 69

Zylet................................... 67

Zyloprim............................ 27

Zymaxid............................. 21

Zyprexa...............................34

Zyprexa Zydis.....................34

Zytiga................................. 30

Zyvox..................................18

OVEX14MP3542914_000 Last Updated August 1, 2013

For more recent information or if you have other questions, please contact UnitedHealthcare MedicareRx for Groups at:

1-877-717-9517, TTY 7118 a.m. to 8 p.m. local time, Monday through Friday

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change each plan year.

This information is available for free in other languages. Please call our Customer Service number listed above.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

formulary 2014comprehensive - ebview

Documents