healthselect medicare rx (effective november 1)...healthselect medicare rx (effective november 1) pa...

HealthSelect Medicare Rx (Effective November 1)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1

colchicine w/ probenecid 1

COLCRYS 2

KRYSTEXXA 3 NM PA

probenecid 1

ULORIC 2

MISCELLANEOUS diclofenac w/ misoprostol 1

DUEXIS 3

ILARIS 2 NM PA

PRIALT 100mcg/ml, 500mcg/20ml

3 NM PA

VIMOVO 2

NSAIDS CELEBREX 2

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

etodolac 1

etodolac er 1

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid CAPS 1

MELOXICAM SUSP 7.5 MG/5ML

1

meloxicam tabs 1

nabumetone TABS 1

NALFON 3

NAPRELAN 3

naproxen SUSP; TABS; TBEC

1

naproxen sodium TABS 275mg, 550mg

1

oxaprozin 1

piroxicam CAPS 1

sulindac TABS 1

tolmetin sodium 1

Drug Name Drug Tier

Requirements/Limits

ZIPSOR 3

ZORVOLEX 3 NM

OPIOID ANALGESICS acetaminophen w/ codeine 1

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 5mcg/hr, 10mcg/hr, 20mcg/hr

2

BUTRANS 15mcg/hr 2 NM

capital and codeine 3

CONZIP 3

hydrocodone-acetaminophen 2.5-325mg

1

hydrocodone-acetaminophen 5-300mg

1


1


1

hydrocodone-acetaminophen 7.5-325 mg/15ml

1


1


1

hydrocodone-acetaminophen tab 10-325mg

1

hydrocodone-ibuprofen 2.5-200mg

1

hydrocodone-ibuprofen 7.5-200mg

1

ibudone tab 5-200mg 1

lorcet 1

lorcet plus tab 7.5-325 1

lortab 1

lortab elx 10-300mg 3 NM

reprexain 10/200 1

SYNALGOS-DC 3

tramadol hcl er TB24 100mg, 200mg

1

TRAMADOL HCL ER TB24 300mg

1

TRAMADOL HCL ER (BIPHASIC) 100MG

1

TRAMADOL HCL ER (BIPHASIC) 200MG

1



2

Drug Name Drug Tier

Requirements/Limits

tramadol hcl er (biphasic) 300mg

1

tramadol hcl tab 50 mg 1

tramadol-acetaminophen 1

vicodin 1

vicodin es 1

vicodin hp 1

zamicet 3

OPIOID ANALGESICS, CII ABSTRAL

QL (120 ea / 30 days) 3 QL NM

CODEINE SULFATE TABS 1

DILAUDID-HP INJ 3 B/D

DURAMORPH 1 B/D

endocet 5/325 1

endocet 7.5/325 1

endocet 10/325 1

ENDODAN 1

EXALGO 8mg, 12mg 2

EXALGO 16mg, 32mg 2 NM

fentanyl citrate LPOP QL (120 lpop / 30 days)

1 QL NM

fentanyl patch 1

FENTORA QL (120 tabs / 30 days)

2 QL NM

hydromorphone hcl LIQD 1

hydromorphone hcl SOLN 500mg/50ml

1 B/D

hydromorphone hcl T24A 8mg, 12mg, 16mg

1

HYDROMORPHONE HCL T24A 32mg

1

hydromorphone hcl TABS 1

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 2

LAZANDA QL (30 bottles / 30 days)

2 QL NM

levorphanol tartrate TABS 1

methadone hcl CONC 1

methadone hcl SOLN 1

methadone hcl TABS 1

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

Drug Name Drug Tier

Requirements/Limits

morphine sulfate CP24 1 NM

MORPHINE SULFATE SOLN 2mg/ml

1 B/D

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

1

MORPHINE SULFATE TABS

1

morphine sulfate beads cap sr QL (60 ea / 30 days)

1 QL

morphine sulfate ext-rel tab 1

MORPHINE SULFATE INJ 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 15mg/ml

1 B/D

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

1 B/D

NUCYNTA 2

NUCYNTA ER 2

OPANA ER (CRUSH RESISTANT

2

OXECTA 3

OXYCODONE HCL CAPS; CONC; SOLN

1

oxycodone hcl TABS 1

oxycodone w/ acetaminophen 2.5-325mg

1

oxycodone w/ acetaminophen 5-325mg

1

oxycodone w/ acetaminophen 7.5-325mg

1

oxycodone w/ acetaminophen 10-325mg

1

oxycodone-aspirin 1

oxycodone-ibuprofen 1

OXYCONTIN 10mg, 15mg, 20mg, 30mg

2

OXYCONTIN 40mg, 60mg, 80mg

QL (120 tabs / 30 days)

2 QL

oxymorphone hcl TABS 1

roxicet soln 2

roxicet tab 5-325mg 1 NM

SUBSYS QL (120 ea / 30 days)

3 QL NM

XARTEMIS XR 3

ANESTHETICS LOCAL ANESTHETICS



3

Drug Name Drug Tier

Requirements/Limits

lidocaine hcl (local anesth.) 4%

1

lidocaine hcl (local anesth.) .5%

1 B/D

lidocaine inj 0.5% 1 B/D

lidocaine inj 1% 1 B/D

lidocaine inj 1.5% 1 B/D

lidocaine inj 2% 1 B/D

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

BETHKIS 3 B/D NM

gentamicin in saline 0.9mg/ml 1

gentamicin in saline 1.4mg/ml 1

gentamicin in saline 60mg 1



gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI PODHALER 3 NM PA

tobramycin NEBU 1 B/D NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 2

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 3

ALINIA 2

atovaquone SUSP 1 NM

AZACTAM 2gm 3

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3 NM

aztreonam 1

BILTRICIDE 2

clindamycin hcl CAPS 1

clindamycin palmitate hydrochloride

1

clindamycin phosphate SOLN

1

clindamycin phosphate in d5w 1

colistimethate sodium SOLR 1

CUBICIN 3 B/D NM

dapsone TABS 1

Drug Name Drug Tier

Requirements/Limits

DARAPRIM 3

DORIBAX 3

erythromycin-sulfisoxazole 1

FLAGYL ER 3

imipenem-cilastatin 1

INVANZ 3

MACRODANTIN 25mg 2

MEPRON 3 NM

meropenem 1

methenamine hippurate 1

METRO IV 2

metronidazole CAPS; TABS 1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin SUSP 1

nitrofurantoin macrocrystal 1

nitrofurantoin monohyd macro 1

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO 3 NM

STROMECTOL 3

sulfamethoxazole-trimethoprim

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3 NM

trimethoprim TABS 1

TYGACIL 3 NM

vancomycin hcl CAPS 1 NM

vancomycin hcl SOLR 1 B/D

VIBATIV 3

XIFAXAN TAB 200MG 3 NM

ZYVOX SOLN 3 NM

ZYVOX SUSR; TABS 2 NM

ANTIFUNGALS ABELCET 3 B/D NM

AMBISOME 3 B/D NM

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

CANCIDAS 3 NM

ERAXIS 3 NM

fluconazole SUSR; TABS 1

fluconazole in dextrose 1

fluconazole in nacl 100mg 1



4

Drug Name Drug Tier

Requirements/Limits



flucytosine CAPS 1 NM

griseofulvin microsize 1

griseofulvin ultramicrosize 1

itraconazole CAPS 1

ketoconazole TABS 1

LAMISIL PACK 3

MYCAMINE 50mg 3

MYCAMINE 100mg 3 NM

NOXAFIL 3 NM

nystatin TABS 1

ONMEL 3

SPORANOX SOL 10MG/ML 3 NM

terbinafine hcl TABS 1

voriconazole SUSR; TABS 1 NM

voriconazole inj 200mg 1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

atovaquone-proguanil hcl tab 250-100 mg

1

chloroquine phosphate TABS

1

COARTEM 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 2

quinine sulfate CAPS 1

ANTIRETROVIRAL AGENTS abacavir sulfate 1

APTIVUS 3 NM

CRIXIVAN 3

didanosine 1

EDURANT 2 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

FUZEON 2 NM

INTELENCE 25mg 2

INTELENCE 100mg, 200mg 2 NM

INVIRASE CAPS 3

INVIRASE TABS 3 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 2 NM

ISENTRESS PACK 2

ISENTRESS TABS 2 NM

Drug Name Drug Tier

Requirements/Limits

lamivudine 150mg, 300mg 1

LEXIVA SUSP 3

LEXIVA TABS 3 NM

NEVIRAPINE SUSP 1

nevirapine TABS; TB24 1

NORVIR 2

PREZISTA SUSP 2 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

2 NM

RESCRIPTOR 2

RETROVIR IV INFUSION 2

REYATAZ 100mg 2

REYATAZ 150mg, 200mg, 300mg

2 NM

SELZENTRY 3 NM

stavudine 1

SUSTIVA 2

TIVICAY 3 NM

VIDEX PEDIATRIC 3

VIRACEPT 3 NM

VIRAMUNE SUSP 2

VIRAMUNE XR 2

VIREAD 2 NM

ZIAGEN SOLN 3

zidovudine 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine

1 NM

ATRIPLA 2 NM

COMPLERA 3 NM

EPZICOM 3 NM

KALETRA SOL 2 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 2 NM

lamivudine-zidovudine 1 NM

STRIBILD 3 NM

TRUVADA 2 NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3 NM

cycloserine CAPS 1

ethambutol hcl TABS 1

isoniazid SOLN; SYRP 1



5

Drug Name Drug Tier

Requirements/Limits

isoniazid tabs 1

MYCOBUTIN 3

paser d/r 2

PRIFTIN 3

pyrazinamide 1

rifabutin 1

rifamate 3

rifampin CAPS; SOLR 1

RIFATER 3

seromycin 3

SIRTURO 3 NM LA

TRECATOR 3

ANTIVIRALS acyclovir CAPS; SUSP; TABS

1

acyclovir sodium 1 B/D

adefovir dipivoxil 1 NM

BARACLUDE SOLN 2

BARACLUDE TABS 2 NM

cidofovir 1

COPEGUS 3 NM PA

entecavir 1 NM

EPIVIR HBV SOLN 2

famciclovir TABS 1

foscarnet sodium 1

ganciclovir inj 500mg 1 B/D

INCIVEK TAB 375MG 2 NM PA

lamivudine 100mg 1 NM

moderiba pak 3 NM PA

moderiba tab 200mg 1 NM PA

OLYSIO 3 NM PA

REBETOL 3 NM PA

REBETOL SOL 40MG/ML 2 NM PA

RELENZA DISKHALER 2

ribapak mis 600/day 3 NM PA

ribasphere 1 NM PA

ribasphere ribapak 800 3 NM PA



ribavirin cap 200mg 1 NM PA

ribavirin tab 200mg 1 NM PA

rimantadine hydrochloride 1

SOVALDI 3 NM PA

TAMIFLU 2

TYZEKA 3 NM

Drug Name Drug Tier

Requirements/Limits

valacyclovir hcl TABS 1

VALCYTE 2 NM

VICTRELIS CAP 200MG 2 NM PA

CEPHALOSPORINS CEDAX 3

cefaclor 1

cefaclor monohydrate 2

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 2

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm 1

cefepime inj 2gm 1

cefotaxime sodium 1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

ceftazidime 1gm, 2gm, 6gm 1

CEFTAZIDIME/DEXTROSE 2

ceftibuten 1 NM

CEFTIN SUSR 3

ceftriaxone sodium SOLR 1

cefuroxime axetil 1

cefuroxime sodium 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium 7.5mg soln

1

cephalexin 1

claforan 1gm, 2gm 3

FORTAZ SOLN 3

FORTAZ SOLR 2gm, 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

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

2

SUPRAX SUSR 500mg/5ml 2

suprax TABS 2



6

Drug Name Drug Tier

Requirements/Limits

tazicef vial 1

TEFLARO 3

ZINACEF SOLR 750mg 3 NM

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin SOLR 500mg 1

azithromycin SUSR 1

azithromycin TABS 1

clarithromycin SUSR; TABS; TB24

1

DIFICID 2 NM

e.e.s. 1

E.E.S. GRANULES 3

ery-tab 2

ERYPED 200 3

ERYPED 400 2

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin ethylsuccinate 1

PCE 3

ZMAX 2

FLUOROQUINOLONES AVELOX SOLN 3

CIPRO SUSR 2

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin SUSR 1

ciprofloxacin er 1

ciprofloxacin hcl TABS 1

ciprofloxacin in d5w 1

ciprofloxacn inj 1

FACTIVE 3

levofloxacin SOLN; TABS 1

levofloxacin in d5w 1

moxifloxacin hcl 1

NOROXIN 3

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate 1

ampicillin 1

ampicillin & sulbactam sodium 1

ampicillin inj 1

Drug Name Drug Tier

Requirements/Limits

ampicillin sodium 1

AUGMENTIN SUSR 3

BACTOCILL IN DEXTROSE 3

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

MOXATAG 3

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 1 NM

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 1 NM

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM SOLN

3

penicillin g potassium SOLR 1

penicillin g procaine 2

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

piperacillin sodium-tazobactam sodium

1

TIMENTIN 3

TIMENTIN INJ 3.1GM 3

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

DORYX 3

doxycycline (monohydrate) 1

doxycycline hyclate CAPS; SOLR; TABS; TBEC

1

minocycline hcl CAPS; TABS; TB24

1

SOLODYN 3 NM

TETRACYCLINE HCL CAPS

1 NM

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D

BUSULFEX 3 B/D

CEENU 2



7

Drug Name Drug Tier

Requirements/Limits

CYCLOPHOSPHAMIDE CAPS

3 B/D

cyclophosphamide SOLR; TABS

1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2

HEXALEN 2 NM

IFEX INJ 3GM 3 B/D

ifosfamide 1 B/D

IFOSFAMIDE FOR INJ 3 GM 3 B/D NM

LEUKERAN 2

LOMUSTINE 1 NM

melphalan hcl 1 B/D NM

MUSTARGEN 3 B/D

TREANDA 3 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES adriamycin 20mg 1 B/D

daunorubicin hcl 1 B/D

DOXIL 3 B/D NM

doxorubicin hcl SOLN 1 B/D

doxorubicin hcl SOLR 50mg 1 B/D

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

1 B/D NM

EPIRUBICIN INJ 50MG 3 B/D

epirubicin inj 50mg/25ml 1 B/D

epirubicin inj 200mg 1 B/D

idarubicin hcl 1 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D NM

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D NM

ARRANON 3 B/D

azacitidine 1 B/D NM

cladribine 1 B/D NM

CLOLAR 3 B/D

cytarabine inj 1 B/D

decitabine 1 B/D NM

fludarabine phosphate 1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 3 B/D NM

gemcitabine hcl 1 B/D NM

mercaptopurine TABS 1

Drug Name Drug Tier

Requirements/Limits

methotrexate sodium inj 1 B/D

NIPENT 3 B/D NM

OTREXUP INJ 10MG 3 PA




RASUVO INJ 7.5 MG 3 NM PA

RASUVO INJ 10 MG 3 NM PA








TABLOID 2

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM

DOCETAXEL CONC 20mg/0.5ml

3 B/D NM

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

1 B/D NM

docetaxel CONC 140mg/7ml 3 B/D NM

DOCETAXEL SOLN 80mg/8ml

3 B/D NM

paclitaxel 1 B/D

TAXOTERE 3 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 2 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 3 B/D NM

BELEODAQ INJ 500MG 3 NM PA

ERBITUX 3 B/D NM

ERIVEDGE 3 NM LA PA

HERCEPTIN 3 B/D NM

ISTODAX 3 B/D NM

KADCYLA 3 B/D NM

PROLEUKIN 3 B/D NM

RITUXAN 3 NM PA

TORISEL 3 B/D NM

VECTIBIX 3 B/D NM

VELCADE 3 B/D NM

ZOLINZA 2 NM PA

HORMONAL ANTINEOPLASTIC AGENTS



8

Drug Name Drug Tier

Requirements/Limits

anastrozole TABS 1

ARZERRA 3 B/D NM

bicalutamide 1

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD 3 B/D NM

exemestane 1

FARESTON 2 NM

FASLODEX 2 B/D NM

FIRMAGON 3 B/D NM

flutamide 1

letrozole TABS 1

leuprolide acetate KIT 1 NM PA

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

2 NM PA

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

2 NM PA

LUPRON DEPOT 2 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

2 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

2 NM PA

LUPRON DEPOT-PED 11.25mg, 15mg

2 NM PA

LYSODREN 2

MEGACE ES 2

megestrol acetate SUSP; TABS

1

NILANDRON 2 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR DEPOT MIXJECT

2 NM PA

TRELSTAR LA MIXJECT 2 NM PA

TRELSTAR MIXJECT 2 NM PA

XTANDI 3 NM LA PA

ZYTIGA 3 NM PA

KINASE INHIBITORS AFINITOR 2 NM PA

AFINITOR DISPERZ 2 NM PA

BOSULIF 3 NM PA

CAPRELSA 3 NM LA PA

COMETRIQ 3 NM PA

GILOTRIF 3 NM PA

GLEEVEC 2 NM PA

ICLUSIG 3 NM LA PA

IMBRUVICA 3 NM PA

Drug Name Drug Tier

Requirements/Limits

INLYTA 3 NM LA PA

IRESSA 3 NM

JAKAFI 3 NM LA PA

MEKINIST 3 NM PA

NEXAVAR 2 NM LA PA

SPRYCEL 2 NM PA

STIVARGA 3 NM LA PA

SUTENT 2 NM PA

SUTENT CAP 37.5MG 2 NM PA

TAFINLAR 3 NM PA

TARCEVA 2 NM PA

TASIGNA 2 NM PA

TYKERB 2 NM LA PA

VOTRIENT 2 NM PA

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

ZYDELIG 3 NM LA PA

ZYKADIA 3 NM LA PA

MISCELLANEOUS DROXIA 2

FOLOTYN INJ 3 NM PA

FUSILEV 3 NM PA

GAZYVA 3 PA

HALAVEN 3 B/D NM

hydroxyurea CAPS 1

IXEMPRA KIT 3 B/D NM

JEVTANA 3 NM PA

MATULANE 2 NM

mitoxantrone hcl 1 B/D NM

ONCASPAR 3 NM PA

PERJETA 3 NM PA

POMALYST CAP 3 NM LA PA

SUPPRELIN LA 3 NM PA

SYLATRON 2 NM PA

SYNRIBO 3 NM PA

TARGRETIN CAPS 2 NM PA

tretinoin CAPS 1 NM

TRISENOX 3 B/D NM

UVADEX 3 B/D

VANTAS 3 NM PA

YERVOY 3 NM PA

ZALTRAP 3 NM PA

ZOLADEX 2 NM PA

PLATINUM-BASED AGENTS carboplatin SOLN 1 B/D

cisplatin 1 B/D



9

Drug Name Drug Tier

Requirements/Limits

ELOXATIN 3 B/D NM

oxaliplatin 1 B/D NM

PROTECTIVE AGENTS amifostine crystalline 1 B/D NM

dexrazoxane 250mg 4 B/D NM

ELITEK 3 B/D NM

KEPIVANCE 3 B/D NM

leucovor ca inj 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

leucovorin calcium inj 10 mg/ml

1 B/D

mesna 1 B/D

MESNEX TABS 3 NM

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

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

irinotecan hcl 1 B/D NM

toposar 1gm/50ml 1 B/D

topotecan hcl SOLR 1 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1

benazepril & hydrochlorothiazide

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide

1

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide 1

TARKA 2

ACE INHIBITORS benazepril hcl TABS 1

captopril TABS 1

enalapril maleate TABS 1

fosinopril sodium 1

lisinopril TABS 1

moexipril hcl 1

Drug Name Drug Tier

Requirements/Limits

perindopril erbumine 1

quinapril hcl 1

ramipril 1

trandolapril 1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1

spironolactone TABS 1

ALPHA BLOCKERS doxazosin mesylate 1

prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR 3

EXFORGE 2

EXFORGE HCT 2

irbesartan-hydrochlorothiazide 1

losartan potassium & hydrochlorothiazide

1

telmisartan-amlodipine 1 NM

TELMISARTAN-HYDROCHLOROTHIAZIDE

1

TEVETEN HCT 3

TRIBENZOR 2

valsartan-hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2

candesartan cilexetil 1

DIOVAN 2

EDARBI 3

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

TELMISARTAN 1 NM

TEVETEN 400mg 3

valsartan 1

ANTIARRHYTHMICS amiodarone hcl SOLN 1



10

Drug Name Drug Tier

Requirements/Limits

amiodarone hcl TABS 100mg

1 NM

amiodarone hcl TABS 200mg, 400mg

1

amiodarone inj 50mg/ml 1

disopyramide phosphate 1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE CR 2

pacerone 100mg, 400mg 1 NM

pacerone 200mg 1

propafenone hcl 1

quinidine gluconate er 1

quinidine sulfate TABS; TBCR

1

sorine 1

sotalol hcl 80mg, 160mg, 240mg

1

sotalol hcl 120mg 1 NM

sotalol hcl (afib/afl) 1

TIKOSYN CAP 125MCG 2 NM PA



ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium 1

CRESTOR 2

fluvastatin sodium 1

LESCOL XL 2

LIVALO 3

lovastatin 1

pravastatin sodium 1

simvastatin TABS 1

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 2 NM

cholestyramine 1

cholestyramine light 1

choline fenofibrate 1

colestipol hcl 1

fenofibrate 1

FENOFIBRATE CAP 1

Drug Name Drug Tier

Requirements/Limits

FENOFIBRATE MICRONIZED 43mg, 130mg

1

fenofibrate micronized 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1

FENOGLIDE 3

gemfibrozil TABS 1

JUXTAPID 3 NM PA

KYNAMRO 3 NM PA

LIPOFEN 2

LIPTRUZET 3 NM

LOVAZA 2

niacin er TBCR 1

niacor 1

omega-3-acid ethyl esters 1

prevalite 1

SIMCOR 2

TRIGLIDE 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1

bisoprolol & hydrochlorothiazide

1

DUTOPROL 3 NM

metoprolol & hctz tab 50-25mg

1


1


1

nadolol & bendroflumethiazide 1

propranolol & hydrochlorothiazide

1

BETA-BLOCKERS acebutolol hcl CAPS 1

atenolol TABS 1

betaxolol hcl 1

bisoprolol fumarate 1

BYSTOLIC 2

carvedilol 1

COREG CR 2



11

Drug Name Drug Tier

Requirements/Limits

labetalol hcl SOLN; TABS 1

metoprolol succinate 1

metoprolol tartrate SOLN; TABS

1

nadolol TABS 1

pindolol 1

propranolol hcl er 1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CALCIUM CHANNEL BLOCKERS afeditab cr 1

amlodipine besylate TABS 1

CARDIZEM LA 120mg 3

cartia xt 1

dilt-cd 1

dilt-cd cap 120mg 1

dilt-xr 1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl SOLN; TABS 1

diltiazem hcl SOLR 3

diltiazem hcl coated beads 1

diltiazem hcl er 1

diltiazem hcl extended release beads

1

diltzac 1

felodipine 1

isradipine 1

matzim la 1

nicardipine hcl CAPS 1

nifedical 1

nifedipine TB24 1

nifedipine er 1

nimodipine CAPS 1

nisoldipine 1

NYMALIZE 3 NM

taztia xt 1

Drug Name Drug Tier

Requirements/Limits

verapamil hcl CP24 100mg, 120mg, 180mg, 200mg, 240mg, 300mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 1

verapamil hcl TBCR 1

DIGITALIS GLYCOSIDES digoxin 1

digoxin inj 1

DIGOXIN SOL 50MCG/ML 1

LANOXIN TABS 2

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE 2

TEKAMLO 2

TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide CP12; TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DIURIL SUS 250/5ML 2

DYRENIUM 3

EDECRIN 3

furosemide SOLN; TABS 1

furosemide inj 1

furosemide oral soln 8 mg/ml 1

hydrochlorothiazide CAPS; TABS

1

indapamide 1

methazolamide TABS 1

methyclothiazide 1

metolazone 1



12

Drug Name Drug Tier

Requirements/Limits

spironolactone & hydrochlorothiazide

1

torsemide inj 1

torsemide tabs 1

triamterene & hydrochlorothiazide cap 37.5-25 mg

1

triamterene & hydrochlorothiazide cap 50-25 mg

1

triamterene & hydrochlorothiazide tab 37.5-25 mg

1

triamterene & hydrochlorothiazide tab 75-50 mg

1

MISCELLANEOUS BIDIL 2

clonidine hcl PTWK; TABS 1

clorpres 0.1/15 1

clorpres 0.2/15 1

clorpres 0.3/15 1

DEMSER 3 NM

DIBENZYLINE 3

guanfacine hcl 1 NM

hydralazine hcl 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 2

isosorbide dinitrate 1

isosorbide dinitrate sl tab 2.5 mg

1

isosorbide mononitrate 1

minitran 1

nitro-bid 2

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

2

NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

Drug Name Drug Tier

Requirements/Limits

NITROMIST 2

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 2 NM PA

ADEMPAS 3 NM PA

FLOLAN 2 NM PA

LETAIRIS 2 NM LA PA

OPSUMIT 3 NM PA

ORENITRAM 3 NM PA

REMODULIN 2 B/D NM LA

REVATIO SOLN; TABS 3 NM PA

sildenafil citrate (pulmonary hypertension)

1 NM PA

TRACLEER 2 NM LA PA

TYVASO 2 NM PA

VELETRI 3 NM PA

VENTAVIS 2 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC; TABS 1

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

fluvoxamine tabs 1

lorazepam CONC; SOLN; TABS

1

ANTICONVULSANTS APTIOM 3

BANZEL SUSP 3 NM

BANZEL TABS 200mg 3

BANZEL TABS 400mg 3 NM

carbamazepine CHEW; CP12; SUSP; TABS; TB12

1

CELONTIN 3

clonazepam TABS; TBDP 1

clorazepate dipotassium 1

diazepam CONC; SOLN; TABS

1

DIAZEPAM GEL 1

diazepam inj 1

dilantin CAPS; CHEW 2

DILANTIN SUSP 2

divalproex sodium 1

epitol 1



13

Drug Name Drug Tier

Requirements/Limits

ethosuximide CAPS; SOLN 1

felbamate SUSP 1 NM

felbamate TABS 400mg 1

felbamate TABS 600mg 1 NM

FYCOMPA 3

gabapentin CAPS; SOLN; TABS

1

GABITRIL 12mg, 16mg 2

LAMICTAL ODT 2

LAMICTAL STARTER 2

LAMICTAL XR KIT 2

lamotrigine CHEW; TABS; TB24

1

levetiracetam SOLN; TABS; TB24

1

LYRICA 2

ONFI SUSP 3 NM

ONFI TABS 3

oxcarbazepine 1

OXTELLAR XR 3 NM

PEGANONE 3

phenobarbital ELIX; TABS 1

PHENOBARBITAL SODIUM 65mg/ml

1

phenobarbital sodium 130mg/ml

1

phenytek 3

phenytoin CHEW; SUSP 1

phenytoin inj 50mg/ml 1

phenytoin sodium extended 1

POTIGA 3

primidone TABS 1

QUDEXY XR 3

SABRIL 2 NM LA PA

STAVZOR 3

TEGRETOL 2

TEGRETOL-XR 2

tiagabine hcl 1

topiramate CPSP; TABS 1

TOPIRAMATE ER 1

TRILEPTAL SUSP 2

TROKENDI XR 3 NM

valproate sodium SOLN; SYRP

1

valproic acid CAPS 1

Drug Name Drug Tier

Requirements/Limits

VIMPAT 2

zonisamide 1

ANTIDEMENTIA donepezil odt 5mg 1

donepezil odt 10mg 1

donepezil tab hcl 23mg 1 NM

donepezil tabs 5mg 1

donepezil tabs 10mg 1

EXELON PATCHES 2

galantamine hydrobromide 1

NAMENDA 2

NAMENDA TITRATION PAK 2

NAMENDA XR 2

NAMENDA XR TITRATION PACK

2

rivastigmine tartrate 1

ANTIDEPRESSANTS amitriptyline hcl TABS 1

amoxapine 1

APLENZIN 3

BRINTELLIX 3 NM

budeprion 1

bupropion hcl TABS; TB12; TB24

1

citalopram hydrobromide 1

clomipramine hcl CAPS 1

desipramine hcl TABS 1

doxepin hcl CAPS; CONC 1

duloxetine hcl CPEP 1 NM

EMSAM 3

escitalopram oxalate 1

FETZIMA 3 NM

FETZIMA TITRATION PACK 3 NM

fluoxetine hcl CAPS 1

fluoxetine hcl CPDR 1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl TABS 1

imipramine pamoate 1

maprotiline hcl 1



14

Drug Name Drug Tier

Requirements/Limits

MARPLAN 2

mirtazapine 1

nefazodone hcl 1

nortriptyline hcl CAPS; SOLN

1

OLEPTRO 3

paroxetine er tab 1

paroxetine hcl 1

PAXIL SUSP 3

PEXEVA 3

phenelzine sulfate TABS 1

PRISTIQ 2

protriptyline hcl 1

sertraline hcl CONC; TABS 1

SURMONTIL 3 NM

tranylcypromine sulfate 1

trazodone hcl TABS 1

trimipramine maleate 1

venlafaxine cap er 1

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1 NM

venlafaxine tab er 1

VIIBRYD 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 2 NM LA PA

AZILECT 2

benztropine mesylate 1

bromocriptine mesylate CAPS; TABS

1

carbidopa TABS 1

carbidopa-levodopa 1

CARBIDOPA/LEVODOPA/ENTACA

1

ENTACAPONE 1

MIRAPEX .75mg 3

MIRAPEX ER 2

NEUPRO 2

PARLODEL 2

pramipexole dihydrochloride 1

ropinirole hydrochloride 1

selegiline hcl CAPS; TABS 1

Drug Name Drug Tier

Requirements/Limits

trihexyphenidyl hcl 1 NM

ZELAPAR 2

ANTIPSYCHOTICS ABILIFY SOLN 2 NM

ABILIFY TABS 2mg, 5mg, 10mg, 15mg

2

ABILIFY TABS 20mg, 30mg 2 NM

ABILIFY DISCMELT 2 NM

ABILIFY INJ 2

ABILIFY MAINTENA 3 NM

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

CLOZAPINE ODT 1

clozapine tab 1

FANAPT 3

FANAPT TITRATION PACK 3

FAZACLO 3

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON INJ 3

haloperidol TABS 1

haloperidol decanoate SOLN 1

haloperidol lactate 1

INVEGA 3

INVEGA SUSTENNA 39mg/0.25ml, 78mg/0.5ml

3

INVEGA SUSTENNA 117mg/0.75ml, 156mg/ml, 234mg/1.5ml

3 NM

LATUDA 20mg, 40mg, 80mg, 120mg

2

LATUDA 60mg 2 NM

loxapine succinate 1

olanzapine 1

olanzapine odt 5mg, 10mg, 15mg

1

olanzapine odt 20mg 1 NM

ORAP 3

perphenazine TABS 1

quetiapine fumarate 1

RISPERDAL CONSTA 12.5mg, 25mg

2

RISPERDAL CONSTA 37.5mg, 50mg

2 NM



15

Drug Name Drug Tier

Requirements/Limits

risperidone 1

risperidone odt 1

SAPHRIS 3

SEROQUEL XR 2

thioridazine hcl TABS 1

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3 NM

ziprasidone hcl 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg

1

amphetamine-dextroamphetamine cap sr 24hr 10 mg

1


1


1


1


1

amphetamine-dextroamphetamine tab 5 mg

1

amphetamine-dextroamphetamine tab 7.5 mg

1


1

amphetamine-dextroamphetamine tab 12.5 mg

1


1


1


1

DAYTRANA 2

INTUNIV 2

metadate tab 20mg er 1

METHYLIN CHEW TAB 2

methylphenidate hcl CP24; CPCR; SOLN; TABS

1

METHYLPHENIDATE HCL ER 18mg

1

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl er 27mg, 36mg, 54mg

1

methylphenidate tab 10mg er 1

methylphenidate tab 20mg er 1

QUILLIVANT XR 2

RITALIN LA 10mg 2

STRATTERA 2

VYVANSE 2

HYPNOTICS EDLUAR 3

eszopiclone 1

HETLIOZ 3 PA

INTERMEZZO 3

ROZEREM 3

SILENOR 2

temazepam 7.5mg, 15mg 1

zaleplon 1

zolpidem tartrate 1

ZOLPIMIST 3

MIGRAINE ALSUMA 3

AXERT 3

cafergot tab 1-100mg 2

dihydroergotamine mesylate 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

1

ergomar 3

FROVA TAB 2.5MG 3

migergot 1

naratriptan hcl 1

RELPAX 2

rizatriptan benzoate 1

SUMATRIPTAN SUCCINATE SOLN 5mg/act, 20mg/act

1

sumatriptan succinate TABS 1

SUMATRIPTAN SUCCINATE INJ SOAJ 4mg/0.5ml

1

sumatriptan succinate inj SOAJ 6mg/0.5ml

1

SUMATRIPTAN SUCCINATE INJ SOCT

1

sumatriptan succinate inj SOLN

1



16

Drug Name Drug Tier

Requirements/Limits

sumatriptan succinate inj SOSY

1

SUMAVEL DOSEPRO 6mg/0.5ml

2

TREXIMET 2

zolmitriptan TABS 1

zolmitriptan odt 1

ZOMIG NASAL SPRAY 2.5mg

2 NM

ZOMIG NASAL SPRAY 5mg 2

MISCELLANEOUS BRISDELLE 3 NM

EQUETRO 3

GRALISE 2

GRALISE STARTER 2

HORIZANT 300mg 3 NM

HORIZANT 600mg 3

LITHIUM 2

lithium carbonate CAPS; TABS; TBCR

1

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide TABS

1

RILUTEK 3 NM

riluzole 1

SAVELLA 2

SAVELLA TITRATION PACK 2

XENAZINE 2 NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO 3 NM PA

AVONEX 2 NM PA

AVONEX PEN 2 NM PA

BETASERON 2 NM PA

COPAXONE 2 NM PA

COPAXONE INJ 40MG/ML 2 NM PA

EXTAVIA 2 NM PA

GILENYA 2 NM PA

REBIF 3 NM PA

REBIF TITRATION PACK 3 NM PA

TECFIDERA CAP 120MG 2 NM PA

TECFIDERA CAP 240MG 2 NM PA

TECFIDERA MIS STARTER 2 NM PA

TYSABRI 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

MUSCULOSKELETAL THERAPY AGENTS AMRIX 3

baclofen TABS 1

carisoprodol TABS 350mg 1 NM

chlorzoxazone 1

cyclobenzaprine hcl TABS 1

dantrolene sodium CAPS 1

methocarbamol TABS 1

tizanidine 1

NARCOLEPSY/CATAPLEXY modafinil 100mg 1

modafinil 200mg 1 NM

NUVIGIL 2

XYREM 2 NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1 NM

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban 1

CHANTIX PAK 0.5& 1MG QL (106 tabs / year)

2 QL NM

CHANTIX TAB 0.5MG QL (336 tabs / year)

2 QL NM

CHANTIX TAB 1MG QL (336 tabs / year)

2 QL NM

disulfiram TABS 1

naloxone hcl SOLN 1

naltrexone hcl TABS 1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG 3

SUBOXONE MIS 4-1MG 3



VIVITROL 3 NM PA

ZUBSOLV 2 NM

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2

ANDROGEL 1% 3

ANDROGEL 1.62% 3

androxy 3



17

Drug Name Drug Tier

Requirements/Limits

AVEED 3 PA

AXIRON 2

FORTESTA 2

oxandrolone TABS 1

STRIANT 3

TESTIM 2

testosterone cypionate SOLN

1

testosterone enanthate SOLN

1

VOGELXO 3

VOGELXO PUMP 3

ANTIDIABETICS, INJECTABLE ALCOHOL PREPS PADS 2

APIDRA 2

APIDRA SOLOSTAR 2

BYDUREON 2

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 PEN 3

HUMULIN N 3

HUMULIN N U-100 PEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

2 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXPEN 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

Drug Name Drug Tier

Requirements/Limits

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2

SYMLINPEN 120 2

TANZEUM 3

VICTOZA 2

ANTIDIABETICS, ORAL acarbose 1

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

FARXIGA 3

glimepiride 1

glipizide TABS 1

glipizide er 1

glipizide-metformin 2.5-250mg 1

glipizide-metformin 2.5-500mg 1

glipizide-metformin 5-500mg 1

GLUMETZA 3

glyburide 1

glyburide micronized 1

glyburide-metformin 1.25-250mg

1

glyburide-metformin 2.5-500mg

1

glyburide-metformin 5-500mg 1

GLYSET 3

INVOKAMET TAB 50-500 MG 2

INVOKAMET TAB 50-1000 MG

2


2


2

INVOKANA 2

JANUMET 2



18

Drug Name Drug Tier

Requirements/Limits

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JENTADUETO 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er 1

metformin hcl TABS; TB24 1

nateglinide 1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl 1

pioglitazone hcl-glimepiride 1

pioglitazone hcl-metformin hcl 1

PRANDIMET 3

repaglinide 1 NM

RIOMET 3

TRADJENTA 2

BISPHOSPHONATES ACTONEL 2

alendronate sodium 1

ATELVIA 2

BINOSTO 3

FOSAMAX PLUS D 3

ibandronate sodium 1 B/D

pamidronate disodium SOLN 1 B/D

RECLAST 3 B/D

risedronate sodium 1

zoledronic inj 4mg 3 B/D

zoledronic inj 4mg/5ml 1 B/D NM

ZOMETA 3 B/D NM

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 2 NM PA

Drug Name Drug Tier

Requirements/Limits

CHELATING AGENTS CHEMET 3

DESFERAL 2gm 3 NM PA

EXJADE 3 NM LA PA

FERRIPROX 3 NM PA

kionex 1

sodium polystyrene sulfonate 1

sps sus 15gm/60ml 1

SYPRINE 3 NM

CONTRACEPTIVES altavera 1

amethia 91 day 1

amethyst 28 day 1

apri 28 day 1

aranelle 28 1

aubra 28 day 1

aviane 28 1

balziva 28 day 1

BEYAZ 2

briellyn 28 day 1

camila 28 day 1

CAMRESE LO TAB 1

cryselle 28 1

cyclafem 1/35 28 day 1

cyclafem 7/7/7 28 day 1

delyla 28 day 1

DEPO-SUBQ PROVERA 104 2

drospirenone-ethinyl estradiol 1

ELLA 2

emoquette 1

enpresse 28 day 1

errin 28 day 1

falmina 28 day 1

GENERESS FE 3

GIANVI 1

gildagia 1

gildess 1.5/30 21 day 1

heather tab 0.35mg 1

introvale 91 day 1

JOLIVETTE 1

junel 1.5/30 21 day 1

junel 1/20 21 day 1

junel fe 1.5/30 28 day 1



19

Drug Name Drug Tier

Requirements/Limits

junel fe 1/20 28 day 1

kariva 28 day 1

kelnor 1/35 28 day 1

larin 1.5/30 1

larin 1/20 1

larin fe 1.5/30 1

larin fe 1/20 1

LEENA 1

lessina 28 day 1

levonest 28 day 1

levonorgestrel (emergency oc)

1 NM

levonorgestrel-ethinyl estradiol (91-day)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

LO MINASTRIN FE 3 NM

LOESTRIN 24 FE 2

lomedia 24 fe 1 NM

loryna 28 day 1

low-ogestrel 28 day 1

lutera 28 day 1

lyza 1 NM

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive)

1

MICROGESTIN TAB 1.5/30 1

MICROGESTIN TAB 1/20 1

MINASTRIN 24 FE 2

MONONESSA 1

my way 1 NM

myzilra 1

necon 0.5/35 28 day 1

necon 1/35 28 day 1

NECON 1/50-28 1

NECON 7/7/7 1

necon 10/11 28 day 2

next choice tab 1.5mg 1

nikki 28 day 1

NORA-BE 1

norethindrone (contraceptive) 1

norgestimate-ethinyl estradiol (triphasic)

1

NORINYL 1+50 2

Drug Name Drug Tier

Requirements/Limits

norlyroc 28 day 1

nortrel 0.5/35 28 day 1

nortrel 1/35 21 day 1

nortrel 1/35 28 day 1

nortrel 7/7/7 28 day 1

NUVARING 2

OCELLA 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO TRI-CYCLEN LO 2

philith 1

pimtrea pack 1

pirmella 1/35 28 day 1 NM

portia 28 day 1

previfem 28 day 1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day 1

SOLIA 1

sprintec 28 day 1

sronyx 28 day 1

syeda 1

tri-legest 28 day 1

tri-previfem 28 day 1

tri-sprintec 28 day 1

TRINESSA 1

trivora 28 day 1

velivet 28 day 1

vestura 1

viorele 1

vyfemla 1

xulane 1

zarah 1

zenchent 28 day 1

zenchent fe 28 day 1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 NM PA

SYNAREL 2 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA



20

Drug Name Drug Tier

Requirements/Limits

ALDURAZYME 3 NM LA PA

BUPHENYL TAB 500MG 3 NM

CARBAGLU 3 NM LA PA

CEREZYME 3 NM PA

CYSTADANE 3 NM

CYSTAGON 3 NM PA

ELAPRASE 3 NM PA

ELELYSO 3 NM PA

FABRAZYME 3 NM PA

KUVAN 2 NM PA

levocarnitine (metabolic modifiers)

1 B/D

LUMIZYME 3 NM PA

MYOZYME 3 NM PA

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM LA PA

PROCYSBI 3 NM LA PA

sodium phenylbutyrate 1 NM

VIMIZIM 3 NM PA

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGEN/PROGESTINS estradiol & norethindrone acetate

1

jinteli 1

mimvey lo 28 day 1

ESTROGENS ALORA 3

COMBIPATCH 2

DELESTROGEN 10mg/ml 3

depo-estradiol 3

estrace CREA 2

estradiol PTWK; TABS 1

ESTRADIOL VALERATE OIL 10mg/ml

1

estradiol valerate OIL 20mg/ml, 40mg/ml

1

ESTRING 3

estropipate 1

FEMRING 3

menest 2

MENOSTAR 3

MINIVELLE 2

PREMARIN 2

PREMARIN CREAM 2

Drug Name Drug Tier

Requirements/Limits

PREMARIN INJ 3

PREMPHASE 2

PREMPRO 2

VAGIFEM 2

VIVELLE-DOT 2

GLUCOCORTICOIDS a-hydrocort inj 100mg 1

cortisone acetate TABS 1

DEPO-MEDROL 20mg/ml 3

dexamethasone CONC; ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

FLO-PRED 3

fludrocortisone acetate TABS

1

hydrocortisone TABS 1

MEDROL 2mg 2

methylprednisolone TABS 1

methylprednisolone acetate 1

methylprednisolone sod succ 1

millipred 3

ORAPRED ODT 2

prednisolone 1

prednisolone sodium phosphate

1

prednisone CONC 2

prednisone SOLN; TABS 1

RAYOS 3

SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 2

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL 2gm 3

veripred 3

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM 3 NM

HUMAN GROWTH HORMONES GENOTROPIN 3 NM PA

GENOTROPIN MINIQUICK 3 NM PA



21

Drug Name Drug Tier

Requirements/Limits

HUMATROPE 2 NM PA

HUMATROPE COMBO PACK 2 NM PA

NORDITROPIN FLEXPRO 2 NM PA

NORDITROPIN NORDIFLEX PEN

2 NM PA

NUTROPIN 3 NM PA

NUTROPIN AQ NUSPIN 5 3 NM PA

NUTROPIN AQ PEN 3 NM PA

OMNITROPE 5.8MG 3 NM PA

OMNITROPE 5MG 3 NM PA

OMNITROPE 10MG 3 NM PA

SAIZEN 3 NM PA

SAIZEN CLICK.EASY 3 NM PA

SEROSTIM 3 NM PA

TEV-TROPIN 3 NM PA

ZORBTIVE 3 NM PA

MISCELLANEOUS ACTHAR HP 3 NM PA

cabergoline 1

calcitonin (salmon) nasal spray

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 3 NM PA

FORTICAL SPR 200/ACT 2

INCRELEX 3 NM LA PA

methylergonovine maleate TABS

1

MIACALCIN INJ 200U/ML 2 B/D

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate 1 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM PA

RAVICTI 3 NM PA

SAMSCA 3 NM PA

SANDOSTATIN 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 10mg, 15mg, 20mg

3 NM LA PA

XGEVA 3 NM PA

PARATHYROID HORMONES FORTEO 2 NM PA

PHOSPHATE BINDER AGENTS

Drug Name Drug Tier

Requirements/Limits

calcium acetate (phosphate binder)

1

FOSRENOL 2

PHOSLYRA 2

RENAGEL 3

RENVELA 2

VELPHORO 3 NM

PROGESTINS CRINONE 2

ENDOMETRIN 2

KORLYM 3 NM PA

MAKENA 3 NM PA

medroxyprogesterone acetate 1

norethindrone acetate TABS 1

progesterone micronized CAPS

1

SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA 2

raloxifene hcl 1

THYROID AGENTS levothyroxine sodium TABS 1

LEVOXYL 1

liothyronine sodium SOLN; TABS

1

methimazole TABS 1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

UNITHROID 1

VASOPRESSINS DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate TABS 1

desmopressin acetate inj 1

desmopressin acetate spray 1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM PA

GASTROINTESTINAL ANTIEMETICS ALOXI 3 NM

ANTIVERT 3

CESAMET 3 B/D NM

compro supp 1



22

Drug Name Drug Tier

Requirements/Limits

dronabinol 2.5mg, 5mg 1 B/D

dronabinol 10mg 1 B/D NM

EMEND CAPS 40mg 2

EMEND CAPS 80mg, 125mg

2 B/D

EMEND PAK 80 & 125 2 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

meclizine hcl TABS 1

metoclopramide hcl SOLN; TABS

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

ondansetron hcl TABS 1 B/D

ondansetron hcl inj 1

ondansetron hcl oral soln 1 B/D

ondansetron odt 1 B/D

phenadoz 1

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate TABS

1

prochlorperazine supp 1

promethazine hcl SOLN; SUPP; SYRP; TABS

1

promethegan 1

SANCUSO 2 NM

TRANSDERM-SCOP 2

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

1

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl 1

glycate 3 NM

glycopyrrolate SOLN; TABS 1

methscopolamine bromide TABS

1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine SOLN 20mg/2ml 1

famotidine SUSR 1

Drug Name Drug Tier

Requirements/Limits

famotidine TABS 20mg, 40mg

1

famotidine inj 1

nizatidine 1

ranitidine hcl CAPS 1

ranitidine hcl SOLN 1

ranitidine hcl SYRP 1

ranitidine hcl TABS 150mg, 300mg

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 2

balsalazide disodium 1

budesonide CP24 1 NM

CANASA 2

colocort 1

DELZICOL 3

DIPENTUM 2 NM

ENTYVIO 3 NM

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema 1

mesalamine enema kit 1

PENTASA 2

SF-ROWASA 2

sulfasalazine dr 1

sulfasalazine ir 1

UCERIS 3

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g 1

gavilyte-c 1

gavilyte-n 1

generlac 1

GOLYTELY 2

HALFLYTELY BOWEL PREP/FLA

3

kristalose 2

lactulose 1

lactulose (encephalopathy) 1



23

Drug Name Drug Tier

Requirements/Limits

MOVIPREP 2

NULYTELY/FLAVOR PACKS 2

OSMOPREP 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

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

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte 1

VISICOL 3

MISCELLANEOUS AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole

1 NM

CARAFATE SUSP 2

cromolyn sodium (mastocytosis)

1 NM

diphenoxylate w/ atropine 1

GATTEX 3 NM LA PA

LINZESS CAP 145MCG 2

LINZESS CAP 290MCG 2

loperamide hcl CAPS 1

LOTRONEX 2 NM

misoprostol TABS 1

OMECLAMOX-PAK 3

PYLERA 2

SUCRAID 3 NM

sucralfate TABS 1

ursodiol CAPS; TABS 1

XIFAXAN TAB 550MG 2 NM

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10440 UNIT 2

Drug Name Drug Tier

Requirements/Limits

VIOKACE 20880 UNIT 2 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3 NM

ACIPHEX SPR CAP 10MG 3 NM

DEXILANT 3

esomeprazole sodium inj 1

lansoprazole CPDR 1

NEXIUM 3

NEXIUM GRANULES 2.5MG DR

3

NEXIUM GRANULES 5MG DR

3


3


3


3

NEXIUM I.V. 3

omeprazole CPDR 1

omeprazole cap 20mg 1 NM

pantoprazole sodium 1

PREVACID SOLUTAB 3

PROTONIX PACK 3

rabeprazole sodium 1 NM

ZEGERID PACK 3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 1

AVODART 2

CARDURA XL 3

finasteride TABS 5mg 1

JALYN 2

RAPAFLO 2

tamsulosin hcl 1

MISCELLANEOUS bethanechol chloride TABS 1

ELMIRON 2

POTASSIUM CITRATE (ALKALINIZER)

1

UROCIT-K 2

URINARY ANTISPASMODICS ENABLEX 3

GELNIQUE 2



24

Drug Name Drug Tier

Requirements/Limits

MYRBETRIQ 3

oxybutynin chloride 1

OXYTROL 3

tolterodine tartrate 1

TOLTERODINE TARTRATE ER

1 NM

TOVIAZ 2

trospium chloride 1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN VAG SUPP 100MG 2

clindamycin cre 2% vag 1

metronidazole vaginal 1

miconazole nitrate vaginal 1

terconazole vaginal 1

VANDAZOLE 1

zazole .4% 1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

COUMADIN INJ 3

ELIQUIS 2

enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium 100mg/ml, 120mg/0.8ml, 150mg/ml

1 NM

fondaparinux sodium 2.5mg/0.5ml

1

fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

1 NM

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 25000unit/ml

2 NM

HEP SOD/NACL INJ 25000 2

Drug Name Drug Tier

Requirements/Limits

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

2

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

2 B/D

HEPARIN SOD INJ 2500U/ML

2 B/D

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




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/SODIUM CHL

1

jantoven 1

PRADAXA 2

warfarin sodium 1

XARELTO 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg/0.42ml, 25mcg/ml, 40mcg/0.4ml, 40mcg/ml, 60mcg/0.3ml, 60mcg/ml, 100mcg/0.5ml, 100mcg/ml, 150mcg/0.3ml, 200mcg/0.4ml, 200mcg/ml, 300mcg/0.6ml, 300mcg/ml, 500mcg/ml

2 NM PA

ARANESP ALBUMIN FREE 150mcg/0.75ml

3 NM PA

EPOGEN 2 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MOZOBIL 2 NM PA

NEULASTA 2 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 2 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS anagrelide hcl 1

BERINERT 3 NM PA

cilostazol 1

CINRYZE 3 NM PA

FIRAZYR 3 NM PA

KALBITOR 3 NM PA

NPLATE 250mcg 3 NM PA

pentoxifylline TBCR 1



25

Drug Name Drug Tier

Requirements/Limits

PROMACTA 2 NM LA PA

SOLIRIS 2 NM PA

tranexamic acid SOLN; TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

BRILINTA 2

clopidogrel bisulfate 1

dipyridamole TABS 1

EFFIENT 2

ZONTIVITY 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA INJ 80MG/4ML 3 NM PA

ACTEMRA INJ 162/0.9 3 NM PA

ACTEMRA INJ 200/10ML 3 NM PA

ACTEMRA INJ 400/20ML 3 NM PA

BENLYSTA 3 NM PA

CIMZIA KIT 3 NM PA

CIMZIA KIT STARTER 3 NM PA

CIMZIA PREFL KIT 200MG/ML

3 NM PA

ENBREL INJ 25/0.5ML 2 NM PA

ENBREL INJ 25MG 2 NM PA

ENBREL INJ 50MG/ML 2 NM PA

ENBREL SURECLICK 2 NM PA

HUMIRA KIT 20MG/0.4 2 NM PA

HUMIRA KIT 40MG/0.8 2 NM PA

HUMIRA PEN KIT 40MG/0.8 2 NM PA

HUMIRA PEN KIT CROHNS 2 NM PA

HUMIRA PEN KIT PSORIASI 2 NM PA

hydroxychloroquine sulfate 1

KINERET INJ 3 NM PA

leflunomide TABS 1

methotrexate sodium tabs 1

ORENCIA INJ 125MG/ML 3 NM PA

ORENCIA INJ 250MG 3 NM PA

OTEZLA 3 NM PA

REMICADE INJ 100MG 3 NM PA

RHEUMATREX 2

SIMPONI SOSY 3 NM PA

SIMPONI ARIA 3 NM PA

SIMPONI INJ 50MG 3 NM PA

trexall 2 B/D

XELJANZ 3 NM PA

Drug Name Drug Tier

Requirements/Limits

IMMUNOGLOBULINS BIVIGAM 10gm/100ml 3 NM PA

CARIMUNE NANOFILTERED 12gm

3 NM PA

CYTOGAM 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAKED 3 NM PA

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

3 NM PA

GAMUNEX 3 NM PA

GAMUNEX-C 3 NM PA

GAMUNEX-C 1GM/10ML 3 NM PA

HIZENTRA 1gm/5ml 3 NM PA

HIZENTRA 10gm/50ml 3 PA

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

3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

GRASTEK 3

INFERGEN 2 NM PA

INFERGEN INJ 9MCG 2 NM PA

INTRON-A 2 B/D NM

INTRON-A W/DILUENT 2 B/D NM

PEG-INTRON 2 NM PA

PEG-INTRON KIT 50MCG 2 NM PA

PEG-INTRON KIT 50MCG RP

2 NM PA

PEGASYS INJ 2 NM PA

PEGASYS INJ 180MCG/M 2 NM PA

PEGASYS INJ PROCLICK 2 NM PA

PEGASYS KIT 2 NM PA

RAGWITEK 3

REVLIMID 2 NM LA PA

THALOMID 2 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 3 B/D NM

ATGAM 3 B/D

azasan 2 B/D

azathioprine TABS 1 B/D

CELLCEPT SUSR 2 B/D NM



26

Drug Name Drug Tier

Requirements/Limits

CELLCEPT INTRAVENOUS 3 B/D

cyclosporine CAPS; SOLN 1 B/D

cyclosporine modified (for microemulsion)

1 B/D

gengraf 1 B/D

mycophenolate mofetil 1 B/D

mycophenolate sodium 1 B/D NM

NEORAL 2 B/D

NULOJIX 3 B/D NM

PROGRAF CAPS 5mg 2 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 2 B/D NM

RAPAMUNE TABS 1mg, 2mg

2 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 3 B/D

sirolimus tab 0.5 mg 1 B/D

tacrolimus CAPS 5mg 1 B/D NM

tacrolimus CAPS .5mg, 1mg 1 B/D

THYMOGLOBULIN 3 B/D NM

ZORTRESS 3 B/D NM

VACCINES ACTHIB 2

ADACEL 2

BCG VACCINE 3

BOOSTRIX 2

CERVARIX 2

COMVAX 2

DAPTACEL 2

DECAVAC 2 B/D

DIPHTHERIA/TETANUS TOXOID

2 B/D

ENGERIX-B SUSP 2 B/D

GARDASIL 2

HAVRIX 2

HIBERIX 2

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

INFANRIX 2

IPOL INACTIVATED IPV 2

IXIARO 2

M-M-R II W/DILUENT 10 DOS

2

Drug Name Drug Tier

Requirements/Limits

MENACTRA 2

MENHIBRIX 2

MENOMUNE-A/C/Y/W-135 2

MENVEO 2

PEDVAX HIB 2

PROQUAD 2

RABAVERT 2

RECOMBIVAX HB 2 B/D

ROTARIX 3

ROTATEQ 2

SYNAGIS 3 NM

TENIVAC 2 B/D NM

TETANUS TOXOID ADSORBED

2 B/D

TETANUS/DIPHTHERIA TOXOID

2 B/D

TWINRIX 2

TYPHIM VI 2

VAQTA 2

VARIVAX 2

YF-VAX 2

ZOSTAVAX 2

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 1

klor-con m20 1

klor-con pow 20meq 1 NM

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

2

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W 1%

2

MAGNESIUM SULFATE IN D5W 2%

2

potassium chloride LIQD 1 NM

POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er 1

potassium chloride microencapsulated crystals cr

1

SOD FLUORIDE 2.2MG TAB 1



27

Drug Name Drug Tier

Requirements/Limits

SODIUM CHLORIDE SOLN 2.5meq/ml

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

Drug Name Drug Tier

Requirements/Limits

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 2 B/D

NEPHRAMINE 3 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

travasol 10 3 B/D

TROPHAMINE 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

2

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

2

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

isolyte s 3

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



28

Drug Name Drug Tier

Requirements/Limits

KCL0.15%/D5W/NACL0.225%

2

kcl 0.3%/d5w/lr iv lac ri 3

KCL 0.3%/D5W/NACL 0.9% 1

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.2% INJ

1

kcl 20 meq/l (0.15%) in nacl 0.45% inj

1

KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ

1


1


1

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

POTASSIUM CHLORIDE SOLN 10meq/100ml, 20meq/100ml, 30meq/100ml

1

potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/50ml, 40meq/100ml

1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

RINGER'S 1

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

1

Drug Name Drug Tier

Requirements/Limits

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol CAPS; SOLN 1 B/D

doxercalciferol 1 B/D

paricalcitol 1mcg, 2mcg 1 B/D NM

paricalcitol 4mcg 1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ZEMPLAR SOLN 3 B/D

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

blephamide OINT 2

BLEPHAMIDE SUSP 3

neomycin-polymy-dexameth 1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX ST 2

tobramycin-dexamethasone 1

ZYLET 2

ANTI-INFECTIVES AZASITE 2

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OIN 0.3% OP 2

ciprofloxacin hcl (ophth) 1

erythromycin (ophth) 1

gatifloxacin (ophth) 1 NM

gentak 1

gentamicin sulfate (ophth) 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymy-gramicid 1

ofloxacin (ophth) 1

polymyxin b-trimethoprim 1



29

Drug Name Drug Tier

Requirements/Limits

sulfacetamide sodium (ophth) 1

tobramycin sulfate (ophth) 1

TOBREX OINT 0.3% 2

trifluridine SOLN 1

VIGAMOX 2

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 3

ALREX 2

BROMDAY 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1 NM

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium 1

FML 2

FML FORTE 2

ILEVRO 3

ketorolac tromethamine (ophth)

1

LOTEMAX 2

MAXIDEX 2

NEVANAC 3

PRED MILD 2

PREDNISOLONE ACETATE SUSP

1

prednisolone sodium phosphate (ophth)

2

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) 1

BEPREVE 2

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) 1

LASTACAFT 2

Drug Name Drug Tier

Requirements/Limits

PATADAY 2

PATANOL 2

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

AZOPT 2

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT PF 2

dorzolamide hcl 1

dorzolamide hcl-timolol maleate

1

ISOPTO CARPINE 3

ISTALOL 2

latanoprost 1

levobunolol hcl .5% 1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 2

metipranolol 1

PHOSPHOLINE IODIDE 2

PILOCARPINE HCL SOLN 1

SIMBRINZA 2 NM

timolol maleate (ophth) 1

TIMOLOL MALEATE GEL 1

TIMOPTIC OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS BOTOX 3 NM PA

CYSTARAN 3 NM PA

DYSPORT 3 NM PA

EYLEA 3 NM PA

LACRISERT 3

LUCENTIS 3 NM PA

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl SOLN 1

RESTASIS 2

XEOMIN 3 NM PA

RESPIRATORY



30

Drug Name Drug Tier

Requirements/Limits

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA 3

COMBIVENT RESPIMAT 2

ipratropium-albuterol 1 B/D

ANTICHOLINERGICS ATROVENT HFA 3

ipratropium bromide (nasal) 1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER 2

TUDORZA PRESSAIR 2

ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D 3

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 2

azelastine hcl SOLN 1

azelastine hcl soln (nasal) 1

cetirizine syrup 1

CLARINEX SYRP 3

cyproheptadine hcl SYRP; TABS

1

desloratadine 1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

1

hydroxyzine pamoate CAPS 1

levocetirizine soln 2.5mg/5ml 1

levocetirizine tab 5 mg 1

PATANASE 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1

albuterol sulfate er 1

ARCAPTA NEOHALER 2

BROVANA 3 B/D

FORADIL AEROLIZER 2

levalbuterol conc 1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL 1 B/D

PERFOROMIST 2 B/D

PROAIR HFA 2

Drug Name Drug Tier

Requirements/Limits

PROVENTIL HFA 2

SEREVENT DISKUS 2

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA 3

XOPENEX HFA 2

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; PACK; TABS

1

zafirlukast 1

ZYFLO CR 3 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 3 NM LA PA

AUVI-Q 2

CAYSTON 3 NM LA PA

DALIRESP 2

DYMISTA 3

EPINEPHRINE INJ 0.3MG 1

EPINEPHRINE INJ 0.15MG 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

GLASSIA 3 NM LA PA

KALYDECO 3 NM PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 2 B/D NM

tyzine .05% 3

XOLAIR 2 NM LA PA

ZEMAIRA 3 NM LA PA

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) 1

flunisolide (nasal) 1

fluticasone propionate (nasal) 1

NASONEX 2

OMNARIS 3

QNASL 3

RHINOCORT AQUA 3

triamcinolone acetonide (nasal)

1



31

Drug Name Drug Tier

Requirements/Limits

VERAMYST 3

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ASMANEX 2

ASMANEX 14 METERED DOSES

2

budesonide (inhalation) 1 B/D

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

PULMICORT INH SUSP 3 B/D NM

QVAR 2

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 3 NM

DULERA 2

SYMBICORT 2

XANTHINES aminophylline inj 1

elixophyllin 2

LUFYLLIN 3

theo-24 2

theophylline TB12; TB24 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NM

ACANYA 2

ACZONE 3

adapalene CREA 1

adapalene GEL .1% 1

ADAPALENE GEL .3% 1

AKNE-MYCIN 3

amnesteem 1

ATRALIN 2

AVITA 1

AZELEX 3

benzoyl peroxide-erythromycin

1

claravis 1

CLINDAGEL 3

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate (topical)

1

clindamycin phosphate-benzoyl peroxide

1

DIFFERIN GEL .3% 2

DIFFERIN LOTN 2

EPIDUO 2

erythromycin (acne aid) 1

FABIOR 3 NM

myorisan 1

neuac 1

RETIN-A MICRO PUMP .08%

2

sulfacetamide sodium (acne) 1

tretin-x CREA .038% 3

tretin-x CREA .075% 3 NM

tretin-x KIT 3

tretinoin CREA; GEL 1

TRETINOIN MICROSPHERE 1

VELTIN 2

zenatane 1

ZIANA 3

DERMATOLOGY, ACTINIC KERATOSIS CARAC 2

diclofenac sodium (actinic keratoses)

1 NM

fluorouracil (topical) 1

PICATO 2

DERMATOLOGY, ANTIBIOTICS ALTABAX 2

BACTROBAN NASAL 3

CENTANY 3 NM

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

mafenide acetate PACK 1

mupirocin OINT 1

mupirocin calcium (topical) 1

PHISOHEX 3

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 2

THERMAZENE 1

DERMATOLOGY, ANTIFUNGALS



32

Drug Name Drug Tier

Requirements/Limits

ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% 1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) 1

LUZU 3

MENTAX 2

NAFTIN CREA 3

NAFTIN GEL 1% 3

NAFTIN GEL 2% 3 NM

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 2

pedi-dri 1

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

procto-pak 1

proctocream 1

proctosol 1

proctozone hc 1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS acitretin 1 NM

calcipotriene CREA; OINT; SOLN

1

CALCITRIOL OINT 1

methoxsalen rapid 1 NM

8-MOP 3

OXSORALEN ULTRA 2 NM

SORILUX 2

STELARA INJ 45MG/0.5 3 NM PA

STELARA INJ 90MG/ML 3 NM PA

TAZORAC 2

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS

Drug Name Drug Tier

Requirements/Limits

acyclovir topical 1

DENAVIR 3

XERESE 3

ZOVIRAX CREA 3

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate 1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon 3 NM

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented

1

betamethasone valerate CREA; FOAM; LOTN; OINT

1

calcipotriene-betamethasone dipropionate

1

CAPEX 2

clobetasol propionate CREA; FOAM; GEL; LOTN; OINT; SHAM; SOLN

1

clobetasol propionate emollient base

1

clobetasol propionate emulsion

1

CLOBEX LIQD 2

CLOCORTOLONE PIVALATE 1

clodan 1

CLODERM PUMP 2

CORDRAN TAPE 3

DESONATE 3

DESONIDE CREA 1

desonide LOTN; OINT 1

desowen oint kit 0.05% 2

desoximetasone CREA 1

desoximetasone GEL 1

DESOXIMETASONE OINT .05%

1

desoximetasone OINT .25% 1

diflorasone diacetate 1

fluocinolone acetonide CREA; OIL; OINT; SOLN

1

fluocinonide CREA; GEL; OINT; SOLN

1



33

Drug Name Drug Tier

Requirements/Limits

fluocinonide emulsified base 1

fluticasone propionate CREA; LOTN; OINT

1

halobetasol propionate 1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate 1

hydrocortisone butyrate hydrophilic lipo base

1

hydrocortisone valerate 1

KENALOG 3

LOCOID LOTN 2

LOKARA LOTN 0.05% 1

mometasone furoate CREA; OINT; SOLN

1

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate OINT 1

TACLONEX 3

texacort 2

TOPICORT LIQD 3

triamcinolone acetonide (topical)

1

triderm 1

u-cort 1

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine PTCH 1 NM

lidocaine hcl GEL 1

lidocaine hcl SOLN 4% 1

lidocaine-prilocaine 1 B/D

SYNERA 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

1

CONDYLOX GEL 2

diclofenac sodium (topical) 1

ELIDEL CRE 1% 2 NM

FINACEA 2

imiquimod CREA 1

laclotion lotn 12% 1

metronidazole (topical) 1

metronidazole gel 0.75% 1

Drug Name Drug Tier

Requirements/Limits

NORITATE 3 NM

ORACEA 2

OXSORALEN 3

PANRETIN 3 NM

PENNSAID 2

podofilox SOLN 1

PROTOPIC OIN 0.1% 2 NM

PROTOPIC OIN 0.03% 2 NM

RECTIV 3

rosadan cre 0.75% 1

TARGRETIN GEL 3 NM PA

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

ZYCLARA 2 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion 1

permethrin CREA 1

SKLICE 3

ULESFIA 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu 1

REGRANEX 3 NM

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 1

chlorhexidine gluconate (mouth-throat)

1

clotrimazole TROC 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard sol 0.12% 1

pilocarpine hcl (oral) 1

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1



34

Drug Name Drug Tier

Requirements/Limits

acetic acid-aluminum acetate 1

CIPRO HC 2

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) 1

neomycin-polymyxin-hc (otic) 1

ofloxacin (otic) 1


35

Index 8 8-MOP .............................. 32 A abacavir sulfate ...................4 abacavir sulfate-lamivudine-zidovudine ..........................................4 ABELCET............................3 ABILIFY............................. 14 ABILIFY DISCMELT ......... 14 ABILIFY INJ ...................... 14 ABILIFY MAINTENA ......... 14 ABRAXANE ........................7 ABSORICA ....................... 31 ABSTRAL............................2 acamprosate calcium ........ 16 ACANYA ........................... 31 acarbose ........................... 17 acebutolol hcl .................... 10 acetaminophen w/ codeine .1 acetasol hc ........................ 33 acetazolamide ................... 11 acetazolamide sodium ...... 11 acetic acid ......................... 33 acetic acid (otic) ................ 33 acetic acid sol/hc ............... 33 acetic acid-aluminum acetate .......................................... 34 acetylcysteine ................... 30 ACIPHEX SPR CAP 10MG .......................................... 23 ACIPHEX SPR CAP 5MG . 23 acitretin ............................. 32 ACTEMRA INJ 162/0.9 ..... 25 ACTEMRA INJ 200/10ML . 25 ACTEMRA INJ 400/20ML . 25 ACTEMRA INJ 80MG/4ML .......................................... 25 ACTHAR HP ..................... 21 ACTHIB ............................. 26 ACTIMMUNE .................... 25 ACTONEL ......................... 18 ACTOPLUS MET XR 15-1000MG ....................... 17 ACTOPLUS MET XR 30-1000MG ....................... 17 ACUVAIL........................... 29

acyclovir .............................. 5 acyclovir sodium ................. 5 acyclovir topical ................ 32 ACZONE ........................... 31 ADACEL ........................... 26 ADAGEN ........................... 19 adapalene ......................... 31 ADAPALENE .................... 31 ADCIRCA .......................... 12 adefovir dipivoxil ................. 5 ADEMPAS ........................ 12 ADRENACLICK ................ 30 adriamycin .......................... 7 adrucil ................................. 7 ADVAIR DISKUS .............. 31 ADVAIR HFA .................... 31 ADVICOR ......................... 10 AEROSPAN ...................... 31 afeditab cr ......................... 11 AFINITOR ........................... 8 AFINITOR DISPERZ........... 8 AGGRENOX ..................... 25 a-hydrocort inj 100mg ....... 20 AKNE-MYCIN ................... 31 ala-cort .............................. 32 ALBENZA ........................... 3 albuterol sulfate ................ 30 albuterol sulfate er ............ 30 alclometasone dipropionate .......................................... 32 ALCOHOL PREPS ........... 17 ALDACTAZIDE ................. 11 ALDURAZYME ................. 20 alendronate sodium .......... 18 alfuzosin hcl ...................... 23 ALIMTA ............................... 7 ALINIA ................................ 3 allopurinol tab ..................... 1 ALOCRIL .......................... 29 ALOMIDE .......................... 29 ALORA .............................. 20 ALOXI ............................... 21 ALPHAGAN P 0.1% .......... 29 alprazolam ........................ 12 ALREX .............................. 29 ALSUMA ........................... 15 ALTABAX .......................... 31

altavera ............................. 18 ALTOPREV ...................... 10 ALVESCO ......................... 31 amantadine hcl ................. 14 AMBISOME ........................ 3 amcinonide ....................... 32 amethia 91 day ................. 18 amethyst 28 day ............... 18 amifostine crystalline .......... 9 amikacin sulfate .................. 3 amiloride & hydrochlorothiazide ........... 11 amiloride hcl ..................... 11 aminophylline inj ............... 31 AMINOSYN ...................... 27 AMINOSYN 7%/ELECTROLYTES ....... 27 AMINOSYN II ................... 27 AMINOSYN II 8.5%/ELECTROL.............. 27 AMINOSYN INJ 8.5/LYTE 27 AMINOSYN M .................. 27 AMINOSYN-HBC .............. 27 AMINOSYN-PF ................. 27 AMINOSYN-PF 7% ........... 27 AMINOSYN-RF................. 27 amiodarone hcl ............. 9, 10 amiodarone inj 50mg/ml ... 10 AMITIZA ........................... 23 amitriptyline hcl ................. 13 amlodipine besylate .......... 11 AMLODIPINE BESYLATE/ATORV .......... 11 amlodipine besylate-benazepril hcl ....... 9 ammonium chloride .......... 26 ammonium lactate ............ 33 amnesteem ....................... 31 amoxapine ........................ 13 amoxicillin ........................... 6 amoxicillin & pot clavulanate............................................ 6 amoxicillin-clarithromycin w/ lansoprazole ..................... 23 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 15 amphetamine-dextroamphet


36

amine cap sr 24hr 15 mg .. 15 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 15 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 15 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 15 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 15 amphetamine-dextroamphetamine tab 10 mg ............... 15 amphetamine-dextroamphetamine tab 12.5 mg ............ 15 amphetamine-dextroamphetamine tab 15 mg ............... 15 amphetamine-dextroamphetamine tab 20 mg ............... 15 amphetamine-dextroamphetamine tab 30 mg ............... 15 amphetamine-dextroamphetamine tab 5 mg ................. 15 amphetamine-dextroamphetamine tab 7.5 mg .............. 15 AMPHOTEC ........................3 amphotericin b ....................3 ampicillin .............................6 ampicillin & sulbactam sodium ................................6 ampicillin inj .........................6 ampicillin sodium .................6 AMPYRA ........................... 16 AMRIX .............................. 16 AMTURNIDE ..................... 11 anagrelide hcl .................... 24 anastrozole .........................8 ANDRODERM .................. 16 ANDROGEL 1% ................ 16 ANDROGEL 1.62% ........... 16 androxy ............................. 16 ANORO ELLIPTA ............. 30 ANTARA ........................... 10 ANTIVERT ........................ 21 apexicon............................ 32 APIDRA............................. 17 APIDRA SOLOSTAR ........ 17 APLENZIN ........................ 13 APOKYN ........................... 14 apri 28 day ........................ 18

APRISO ............................ 22 APTIOM ............................ 12 APTIVUS ............................ 4 ARALAST NP ................... 30 aranelle 28 ........................ 18 ARANESP ALBUMIN FREE .......................................... 24 ARCALYST ....................... 25 ARCAPTA NEOHALER .... 30 ARRANON .......................... 7 ARZERRA ........................... 8 ASACOL HD ..................... 22 ASMANEX ........................ 31 ASMANEX 14 METERED DOSES ............................. 31 ASTAGRAF XL ................. 25 ASTEPRO ......................... 30 ATELVIA ........................... 18 atenolol ............................. 10 atenolol & chlorthalidone ... 10 ATGAM ............................. 25 atorvastatin calcium .......... 10 atovaquone ......................... 3 atovaquone-proguanil hcl tab 250-100 mg ......................... 4 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 4 ATRALIN ........................... 31 ATRIPLA ............................. 4 ATROPINE SULFATE ...... 22 ATROVENT HFA .............. 30 AUBAGIO ......................... 16 aubra 28 day ..................... 18 AUGMENTIN ...................... 6 AUVI-Q ............................. 30 AVASTIN ............................ 7 AVEED .............................. 17 AVELOX ............................. 6 aviane 28 .......................... 18 AVITA ............................... 31 AVODART ........................ 23 AVONEX ........................... 16 AVONEX PEN .................. 16 AXERT .............................. 15 AXIRON ............................ 17 azacitidine ........................... 7 AZACTAM ........................... 3 AZACTAM/DEX INJ 1GM ... 3

AZACTAM/DEX INJ 2GM ... 3 azasan .............................. 25 AZASITE ........................... 28 azathioprine ...................... 25 azelastine hcl .................... 30 azelastine hcl (ophth) ........ 29 azelastine hcl soln (nasal) 30 AZELEX ............................ 31 AZILECT ........................... 14 azithromycin ....................... 6 AZITHROMYCIN ................ 6 AZOPT .............................. 29 AZOR .................................. 9 aztreonam ........................... 3 B bacitracin (ophthalmic) ...... 28 bacitracin-polymyxin b (ophth) .............................. 28 bacitracin-poly-neomycin-hc.......................................... 28 baclofen ............................ 16 BACTOCILL IN DEXTROSE............................................ 6 BACTROBAN NASAL ....... 31 balsalazide disodium ........ 22 balziva 28 day ................... 18 BANZEL ............................ 12 BARACLUDE ...................... 5 BCG VACCINE ................. 26 BECONASE AQ................ 30 BELEODAQ INJ 500MG ..... 7 benazepril & hydrochlorothiazide ............. 9 benazepril hcl ..................... 9 BENICAR ............................ 9 BENICAR HCT ................... 9 BENLYSTA ....................... 25 BENTYL ............................ 22 benzoyl peroxide-erythromycin ...... 31 benztropine mesylate ........ 14 BEPREVE ......................... 29 BERINERT ....................... 24 BESIVANCE ..................... 28 betamethasone dipropionate (topical) ............................. 32 betamethasone dipropionate augmented ........................ 32


37

betamethasone valerate ... 32 BETASERON .................... 16 betaxolol hcl ...................... 10 betaxolol hcl (ophth) .......... 29 bethanechol chloride ......... 23 BETHKIS.............................3 BETIMOL .......................... 29 BETOPTIC-S .................... 29 BEYAZ .............................. 18 bicalutamide ........................8 BICILLIN C-R ......................6 BICILLIN L-A .......................6 BICNU .................................6 BIDIL ................................. 12 BILTRICIDE ........................3 BINOSTO .......................... 18 bisoprolol & hydrochlorothiazide ........... 10 bisoprolol fumarate ........... 10 BIVIGAM ........................... 25 bleomycin sulfate ................7 blephamide ....................... 28 BLEPHAMIDE ................... 28 BOOSTRIX ....................... 26 BOSULIF.............................8 BOTOX ............................. 29 BREO ELLIPTA ................ 31 briellyn 28 day ................... 18 BRILINTA .......................... 25 BRIMONIDINE SOL 0.15% .......................................... 29 brimonidine sol 0.2% ......... 29 BRINTELLIX ..................... 13 BRISDELLE ...................... 16 BROMDAY ........................ 29 bromfenac sodium (ophth) 29 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 29 bromocriptine mesylate ..... 14 BROVANA ........................ 30 budeprion .......................... 13 budesonide ....................... 22 budesonide (inhalation) ..... 31 budesonide (nasal) ........... 30 bumetanide ....................... 11 BUPHENYL TAB 500MG .. 20 buprenorphine hcl ............. 16 buprenorphine hcl-naloxone

hcl sl.................................. 16 buproban ........................... 16 bupropion hcl .................... 13 buspirone hcl .................... 12 BUSULFEX ......................... 6 butorphanol nasal spray ...... 1 butorphanol tartrate ............ 1 BUTRANS ........................... 1 BYDUREON ..................... 17 BYETTA ............................ 17 BYSTOLIC ........................ 10 C cabergoline ....................... 21 cafergot tab 1-100mg ........ 15 calcipotriene ...................... 32 calcipotriene-betamethasone dipropionate ...................... 32 calcitonin (salmon) nasal spray ................................. 21 calcitriol ............................. 28 CALCITRIOL ..................... 32 calcium acetate (phosphate binder) ............................... 21 camila 28 day .................... 18 CAMPTOSAR ..................... 9 CAMRESE LO TAB .......... 18 CANASA ........................... 22 CANCIDAS ......................... 3 candesartan cilexetil ........... 9 candesartan cilexetil-hydrochlorothiazide 9 CANTIL ............................. 22 CAPASTAT SULFATE ........ 4 CAPEX .............................. 32 capital

and codeine ..................... 1 CAPRELSA ......................... 8 captopril .............................. 9 captopril & hydrochlorothiazide ............. 9 CARAC ............................. 31 CARAFATE ....................... 23 CARBAGLU ...................... 20 carbamazepine ................. 12 carbidopa .......................... 14 CARBIDOPA/LEVODOPA/ENTACA .............................. 14 carbidopa-levodopa .......... 14

carboplatin .......................... 8 CARDIZEM LA.................. 11 CARDURA XL .................. 23 CARIMUNE NANOFILTERED .............. 25 carisoprodol ...................... 16 carteolol hcl (ophth) .......... 29 cartia xt ............................. 11 carvedilol .......................... 10 CAYSTON ........................ 30 CEDAX ............................... 5 CEENU ............................... 6 cefaclor ............................... 5 cefaclor monohydrate ......... 5 cefadroxil ............................ 5 cefazolin inj ......................... 5 cefazolin sodium ................. 5 cefazolin/dextrose ............... 5 cefdinir ................................ 5 CEFEPIME 1GM SOLN ...... 5 CEFEPIME 2GM SOLN ...... 5 cefepime inj 1gm................. 5 cefepime inj 2gm................. 5 cefotaxime sodium .............. 5 cefotetan disodium .............. 5 cefoxitin sodium .................. 5 CEFOXITIN SODIUM IN DEXTROSE ........................ 5 cefpodoxime proxetil ........... 5 cefprozil .............................. 5 ceftazidime ......................... 5 CEFTAZIDIME/DEXTROSE............................................ 5 ceftibuten ............................ 5 CEFTIN ............................... 5 ceftriaxone sodium .............. 5 cefuroxime axetil ................. 5 cefuroxime sodium .............. 5 cefuroxime sodium 7.5mg soln ..................................... 5 CELEBREX ........................ 1 CELLCEPT ....................... 25 CELLCEPT INTRAVENOUS.......................................... 26 CELONTIN ....................... 12 CENTANY ........................ 31 cephalexin .......................... 5 CEREZYME ...................... 20


38

CERVARIX ........................ 26 CESAMET ......................... 21 cetirizine syrup .................. 30 cevimeline hcl ................... 33 CHANTIX PAK 0.5& 1MG . 16 CHANTIX TAB 0.5MG ...... 16 CHANTIX TAB 1MG ......... 16 CHEMET ........................... 18 chlorhexidine gluconate (mouth-throat) ................... 33 chloroquine phosphate ........4 chlorothiazide .................... 11 chlorpromaz inj 25mg/ml ... 14 chlorpromazine hcl ............ 14 chlorthalidone .................... 11 chlorzoxazone ................... 16 cholestyramine .................. 10 cholestyramine light .......... 10 choline fenofibrate ............. 10 CHORIONIC GONADOTROPIN ............ 21 ciclopirox ........................... 32 ciclopirox cre 0.77% .......... 32 ciclopirox shampoo 1% ..... 32 ciclopirox sus 0.77% ......... 32 cidofovir...............................5 cilostazol ........................... 24 CILOXAN OIN 0.3% OP ... 28 cimetidine .......................... 22 cimetidine sol 300/5ml ...... 22 CIMZIA KIT ....................... 25 CIMZIA KIT STARTER ..... 25 CIMZIA PREFL KIT 200MG/ML ........................ 25 CINRYZE .......................... 24 CIPRO ................................6 CIPRO HC ........................ 34 CIPRODEX ....................... 34 ciprofloxacin ........................6 ciprofloxacin er ....................6 ciprofloxacin hcl ..................6 ciprofloxacin hcl (ophth) .... 28 ciprofloxacin in d5w .............6 ciprofloxacn inj ....................6 cisplatin ...............................8 citalopram hydrobromide... 13 cladribine.............................7 claforan ...............................5

claravis .............................. 31 CLARINEX ........................ 30 CLARINEX-D .................... 30 clarithromycin ...................... 6 CLEOCIN VAG SUPP 100MG .............................. 24 CLINDAGEL ..................... 31 clindamycin cre 2% vag .... 24 clindamycin hcl ................... 3 clindamycin palmitate hydrochloride ...................... 3 clindamycin phosphate ....... 3 clindamycin phosphate (topical) ............................. 31 clindamycin phosphate in d5w ..................................... 3 clindamycin phosphate-benzoyl peroxide .......................................... 31 CLINIMIX 2.75%/DEXTROSE 5% ..... 27 CLINIMIX 4.25%/DEXTROSE 10% ... 27 CLINIMIX 4.25%/DEXTROSE 20% ... 27 CLINIMIX 4.25%/DEXTROSE 25% ... 27 CLINIMIX 4.25%/DEXTROSE 5% ..... 27 CLINIMIX 5%/DEXTROSE 15%................................... 27 CLINIMIX 5%/DEXTROSE 20%................................... 27 CLINIMIX 5%/DEXTROSE 25%................................... 27 CLINIMIX E 2.75%/DEXTROSE 10% ... 27 CLINIMIX E 2.75%/DEXTROSE 5% ..... 27 CLINIMIX E 4.25%/DEXTROSE ........... 27 CLINIMIX E 4.25%/DEXTROSE 25% ... 27 CLINIMIX E 4.25%/DEXTROSE 5% ..... 27 CLINIMIX E 5%/DEXTROSE 15%................................... 27 CLINIMIX E 5%/DEXTROSE

20% .................................. 27 CLINIMIX E 5%/DEXTROSE 25% .................................. 27 clinisol 15 .......................... 27 clobetasol propionate ........ 32 clobetasol propionate emollient base .................. 32 clobetasol propionate emulsion ........................... 32 CLOBEX ........................... 32 CLOCORTOLONE PIVALATE ........................ 32 clodan ............................... 32 CLODERM PUMP ............ 32 CLOLAR ............................. 7 clomipramine hcl ............... 13 clonazepam ...................... 12 clonidine hcl ...................... 12 clopidogrel bisulfate .......... 25 clorazepate dipotassium ... 12 clorpres 0.1/15 .................. 12 clorpres 0.2/15 .................. 12 clorpres 0.3/15 .................. 12 clotrimazole ...................... 33 clotrimazole (topical) ......... 32 CLOZAPINE ODT ............. 14 clozapine tab .................... 14 COARTEM .......................... 4 codeine

and capital ....................... 1 CODEINE SULFATE .......... 2 colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 colestipol hcl ..................... 10 colistimethate sodium ......... 3 colocort ............................. 22 COLY-MYCIN S ................ 34 COLYTE-FLAVOR PACKS.......................................... 22 COMBIGAN ...................... 29 COMBIPATCH .................. 20 COMBIVENT RESPIMAT . 30 COMETRIQ ........................ 8 COMPLERA ....................... 4 compro supp ..................... 21 COMVAX .......................... 26 CONDYLOX ..................... 33 constulose ........................ 22


39

CONZIP ..............................1 COPAXONE ...................... 16 COPAXONE INJ 40MG/ML .......................................... 16 COPEGUS ..........................5 CORDRAN ........................ 32 COREG CR ....................... 10 CORTIFOAM .................... 32 cortisone acetate ............... 20 CORTISPORIN ................. 31 CORTISPORIN-TC ........... 34 COSMEGEN .......................7 COSOPT PF ..................... 29 COUMADIN ...................... 24 COUMADIN INJ ................ 24 CREON ............................. 23 CRESTOR ........................ 10 CRINONE ......................... 21 CRIXIVAN ...........................4 cromolyn sodium ............... 30 cromolyn sodium (mastocytosis) ................... 23 cromolyn sodium (ophth) .. 29 cryselle 28 ......................... 18 CUBICIN .............................3 CUVPOSA ........................ 22 cyclafem 1/35 28 day ........ 18 cyclafem 7/7/7 28 day ....... 18 cyclobenzaprine hcl .......... 16 cyclophosphamide ..............7 CYCLOPHOSPHAMIDE .....7 cycloserine ..........................4 cyclosporine ...................... 26 cyclosporine modified (for microemulsion) .................. 26 cyproheptadine hcl ............ 30 CYSTADANE .................... 20 CYSTAGON ...................... 20 CYSTARAN ...................... 29 cytarabine inj .......................7 CYTOGAM ........................ 25 D dacarbazine ........................7 DALIRESP ........................ 30 danazol ............................. 19 dantrolene sodium ............ 16 dapsone ..............................3 DAPTACEL ....................... 26

DARAPRIM ......................... 3 daunorubicin hcl .................. 7 DAYTRANA ...................... 15 DECAVAC ........................ 26 decitabine ........................... 7 DELESTROGEN ............... 20 delyla 28 day ..................... 18 DELZICOL ........................ 22 demeclocycline hcl .............. 6 DEMSER .......................... 12 DENAVIR .......................... 32 depo-estradiol ................... 20 DEPO-MEDROL ............... 20 DEPO-PROVERA INJ 400/ML ................................ 8 DEPO-SUBQ PROVERA 104 .................................... 18 DESFERAL ....................... 18 desipramine hcl ................. 13 desloratadine .................... 30 desmopressin acetate ....... 21 DESMOPRESSIN ACETATE .......................................... 21 desmopressin acetate inj .. 21 desmopressin acetate spray .......................................... 21 desmopressin acetate spray refrigerated ....................... 21 DESONATE ...................... 32 desonide ........................... 32 DESONIDE ....................... 32 desowen oint kit 0.05% ..... 32 desoximetasone ................ 32 DESOXIMETASONE ........ 32 dexamethasone ................ 20 dexamethasone sodium phosphate ......................... 20 dexamethasone sodium phosphate (ophth) ............. 29 DEXILANT ........................ 23 dexpak taperpak 13 day.... 20 dexrazoxane ....................... 9 dextrose ............................ 27 DEXTROSE ...................... 27 DEXTROSE 10% FLEX CONTAIN .......................... 27 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

.......................................... 27 DEXTROSE 10%/NACL 0.45% ............................... 27 DEXTROSE 2.5%/NACL 0.45% ............................... 27 DEXTROSE 5% ................ 27 DEXTROSE 5% /ELECTROLYTE ............... 27 DEXTROSE 5%/LACTATED RING ................................. 27 DEXTROSE 5%/NACL 0.2%.......................................... 27 DEXTROSE 5%/NACL 0.225% ............................. 27 DEXTROSE 5%/NACL 0.3%.......................................... 27 DEXTROSE 5%/NACL 0.33% ............................... 27 DEXTROSE 5%/NACL 0.45% ............................... 27 DEXTROSE 5%/NACL 0.9%.......................................... 27 DEXTROSE 5%/POTASSIUM CHL ...... 27 diazepam .......................... 12 DIAZEPAM GEL ............... 12 diazepam inj ..................... 12 DIBENZYLINE .................. 12 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 31 diclofenac sodium (ophth) . 29 diclofenac sodium (topical) 33 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ............. 6 dicyclomine hcl ................. 22 didanosine .......................... 4 DIFFERIN ......................... 31 DIFICID ............................... 6 diflorasone diacetate ......... 32 diflunisal .............................. 1 digoxin .............................. 11 digoxin inj .......................... 11 DIGOXIN SOL 50MCG/ML.......................................... 11 dihydroergotamine mesylate.......................................... 15


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DIHYDROERGOTAMINE MESYLATE ....................... 15 dilantin .............................. 12 DILANTIN.......................... 12 DILATRATE SR ................ 12 DILAUDID-HP INJ ...............2 dilt-cd ................................ 11 dilt-cd cap 120mg .............. 11 diltiazem cap 120mg/24hr . 11 diltiazem cap er/12hr ......... 11 diltiazem hcl ...................... 11 diltiazem hcl coated beads 11 diltiazem hcl er .................. 11 diltiazem hcl extended release beads ................... 11 dilt-xr ................................. 11 diltzac ................................ 11 DIOVAN ..............................9 DIPENTUM ....................... 22 diphenhydram inj 50mg/ml 30 diphenoxylate w/ atropine . 23 DIPHTHERIA/TETANUS TOXOID ............................ 26 dipyridamole ...................... 25 disopyramide phosphate ... 10 disulfiram........................... 16 DIURIL SUS 250/5ML ....... 11 divalproex sodium ............. 12 docetaxel.............................7 DOCETAXEL ......................7 donepezil odt 10mg ........... 13 donepezil odt 5mg ............. 13 donepezil tab hcl 23mg ..... 13 donepezil tabs 10mg ......... 13 donepezil tabs 5mg ........... 13 DORIBAX ............................3 DORYX ...............................6 dorzolamide hcl ................. 29 dorzolamide hcl-timolol maleate ............................. 29 doxazosin mesylate ............9 doxepin hcl ........................ 13 doxercalciferol ................... 28 DOXIL .................................7 doxorubicin hcl ....................7 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .......7 doxycycline (monohydrate) .6

doxycycline hyclate ............. 6 dronabinol ......................... 22 drospirenone-ethinyl estradiol ............................ 18 DROXIA .............................. 8 DUEXIS .............................. 1 DULERA ........................... 31 duloxetine hcl .................... 13 DURAMORPH .................... 2 DUREZOL ......................... 29 DUTOPROL ...................... 10 DYMISTA .......................... 30 DYRENIUM ....................... 11 DYSPORT ........................ 29 E e.e.s. ................................... 6 E.E.S. GRANULES ............. 6 econazole nitrate .............. 32 EDARBI .............................. 9 EDARBYCLOR ................... 9 EDECRIN .......................... 11 EDLUAR ........................... 15 EDURANT .......................... 4 EFFIENT ........................... 25 EGRIFTA .......................... 21 ELAPRASE ....................... 20 ELECTROLYTE-R IN DEXTROSE ...................... 27 ELELYSO ......................... 20 ELIDEL CRE 1% ............... 33 ELIGARD ............................ 8 ELIQUIS ............................ 24 ELITEK ............................... 9 elixophyllin ........................ 31 ELLA ................................. 18 ELMIRON ......................... 23 ELOXATIN .......................... 9 EMADINE ......................... 29 EMCYT ............................... 7 EMEND ............................. 22 EMEND PAK 80 & 125 ..... 22 emoquette ......................... 18 EMSAM ............................. 13 EMTRIVA ............................ 4 ENABLEX ......................... 23 enalapril maleate ................ 9 enalapril maleate & hydrochlorothiazide ............. 9

ENBREL INJ 25/0.5ML ..... 25 ENBREL INJ 25MG .......... 25 ENBREL INJ 50MG/ML .... 25 ENBREL SURECLICK ...... 25 endocet 10/325 ................... 2 endocet 5/325 ..................... 2 endocet 7.5/325 .................. 2 ENDODAN .......................... 2 ENDOMETRIN.................. 21 ENGERIX-B ...................... 26 enoxaparin sodium ........... 24 enpresse 28 day ............... 18 ENTACAPONE ................. 14 entecavir ............................. 5 ENTYVIO .......................... 22 enulose ............................. 22 EPIDUO ............................ 31 epinastine hcl (ophth) ....... 29 EPINEPHRINE INJ 0.15MG.......................................... 30 EPINEPHRINE INJ 0.3MG 30 EPIPEN 2-PAK ................. 30 EPIPEN-JR 2-PAK ............ 30 epirubicin inj 200mg ............ 7 EPIRUBICIN INJ 50MG ...... 7 epirubicin inj 50mg/25ml ..... 7 epitol ................................. 12 EPIVIR HBV ....................... 5 EPIVIR SOL 10MG/ML ....... 4 eplerenone .......................... 9 EPOGEN .......................... 24 eprosartan mesylate ........... 9 EPZICOM ........................... 4 EQUETRO ........................ 16 ERAXIS .............................. 3 ERBITUX ............................ 7 ergomar ............................ 15 ERIVEDGE ......................... 7 errin 28 day ....................... 18 ERTACZO ........................ 32 ERYPED 200 ...................... 6 ERYPED 400 ...................... 6 ery-tab ................................ 6 erythrocin lactobionate ........ 6 erythrocin stearate .............. 6 erythromycin (acne aid) .... 31 erythromycin (ophth) ......... 28 erythromycin base .............. 6


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erythromycin ethylsuccinate 6 erythromycin-sulfisoxazole ..3 escitalopram oxalate ......... 13 esomeprazole sodium inj .. 23 estrace .............................. 20 estradiol ............................ 20 estradiol & norethindrone acetate .............................. 20 estradiol valerate ............... 20 ESTRADIOL VALERATE .. 20 ESTRING .......................... 20 estropipate ........................ 20 eszopiclone ....................... 15 ethambutol hcl .....................4 ethosuximide ..................... 13 etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS .....................9 etoposide ............................9 EURAX ............................. 33 EVISTA ............................. 21 EXALGO .............................2 EXELDERM ...................... 32 EXELON PATCHES ......... 13 exemestane ........................8 EXFORGE ..........................9 EXFORGE HCT ..................9 EXJADE ............................ 18 EXTAVIA ........................... 16 EYLEA .............................. 29 F FABIOR............................. 31 FABRAZYME .................... 20 FACTIVE .............................6 falmina 28 day ................... 18 famciclovir ...........................5 famotidine ......................... 22 famotidine inj ..................... 22 FANAPT ............................ 14 FANAPT TITRATION PACK .......................................... 14 FARESTON ........................8 FARXIGA .......................... 17 FASLODEX .........................8 FAZACLO ......................... 14 felbamate .......................... 13 felodipine........................... 11 FEMRING ......................... 20

fenofibrate ......................... 10 FENOFIBRATE CAP ........ 10 fenofibrate micronized....... 10 FENOFIBRATE MICRONIZED ................... 10 FENOFIBRIC ACID........... 10 FENOGLIDE ..................... 10 fenoprofen calcium ............. 1 fentanyl citrate .................... 2 fentanyl patch ..................... 2 FENTORA ........................... 2 FERRIPROX ..................... 18 FETZIMA .......................... 13 FETZIMA TITRATION PACK .......................................... 13 FINACEA .......................... 33 finasteride ......................... 23 FIRAZYR .......................... 24 FIRMAGON ........................ 8 FLAGYL ER ........................ 3 FLAREX ............................ 29 FLEBOGAMMA ................ 25 FLEBOGAMMA DIF .......... 25 flecainide acetate .............. 10 FLOLAN ............................ 12 FLO-PRED ........................ 20 FLOVENT DISKUS ........... 31 FLOVENT HFA ................. 31 fluconazole .......................... 3 fluconazole in dextrose ....... 3 fluconazole in nacl 100mg .. 3 fluconazole in nacl 200mg .. 4 fluconazole in nacl 400mg .. 4 flucytosine ........................... 4 fludarabine phosphate ........ 7 fludrocortisone acetate...... 20 flunisolide (nasal) .............. 30 fluocinolone acetonide ...... 32 fluocinolone acetonide (otic) .......................................... 34 fluocinonide ....................... 32 fluocinonide emulsified base .......................................... 33 FLUOROMETHOLONE (OPHTH) ........................... 29 fluorouracil .......................... 7 fluorouracil (topical) .......... 31 fluoxetine hcl ..................... 13

FLUOXETINE HCL ........... 13 fluphenazine decanoate .... 14 fluphenazine hcl ................ 14 flurbiprofen .......................... 1 flurbiprofen sodium ........... 29 flutamide ............................. 8 fluticasone propionate ....... 33 fluticasone propionate (nasal) ............................... 30 fluvastatin sodium ............. 10 fluvoxamine maleate ......... 12 fluvoxamine maleate er ..... 12 fluvoxamine tabs ............... 12 FML .................................. 29 FML FORTE ..................... 29 FOLOTYN INJ .................... 8 fondaparinux sodium ........ 24 FORADIL AEROLIZER ..... 30 FORFIVO XL .................... 13 FORTAZ ............................. 5 FORTEO ........................... 21 FORTESTA ...................... 17 FORTICAL SPR 200/ACT 21 FOSAMAX PLUS D .......... 18 foscarnet sodium ................ 5 fosinopril sodium ................. 9 fosinopril sodium & hydrochlorothiazide ............. 9 FOSRENOL ...................... 21 FRAGMIN ......................... 24 FREAMINE HBC 6.9% ..... 27 FREAMINE III ................... 27 FROVA TAB 2.5MG .......... 15 furosemide ........................ 11 furosemide inj ................... 11 furosemide oral soln 8 mg/ml.......................................... 11 FUSILEV ............................. 8 FUZEON ............................. 4 FYCOMPA ........................ 13 G gabapentin ........................ 13 GABITRIL ......................... 13 galantamine hydrobromide 13 GAMASTAN S/D............... 25 GAMMAGARD LIQUID ..... 25 GAMMAGARD S/D ........... 25 GAMMAKED ..................... 25


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GAMMAPLEX ................... 25 GAMUNEX ........................ 25 GAMUNEX-C .................... 25 GAMUNEX-C 1GM/10ML . 25 ganciclovir inj 500mg ..........5 GARDASIL ........................ 26 gatifloxacin (ophth) ............ 28 GATTEX............................ 23 GAUZE PADS 2X2 ........... 17 gaviltye-g........................... 22 gavilyte-c ........................... 22 gavilyte-n........................... 22 GAZYVA .............................8 GELNIQUE ....................... 23 GEMCITABINE ...................7 gemcitabine hcl ...................7 gemfibrozil......................... 10 GENERESS FE ................ 18 generlac ............................ 22 gengraf .............................. 26 GENOTROPIN .................. 20 GENOTROPIN MINIQUICK .......................................... 20 gentak ............................... 28 gentamicin in saline 0.9mg/ml .............................3 gentamicin in saline 1.4mg/ml .............................3 gentamicin in saline 100mg.3 gentamicin in saline 60mg...3 gentamicin in saline 80mg...3 gentamicin sulfate ...............3 gentamicin sulfate (ophth) . 28 gentamicin sulfate (topical) .......................................... 31 GEODON INJ .................... 14 GIANVI .............................. 18 GIAZO ............................... 22 gildagia ............................. 18 gildess 1.5/30 21 day ........ 18 GILENYA .......................... 16 GILOTRIF ...........................8 GLASSIA........................... 30 GLEEVEC ...........................8 glimepiride......................... 17 glipizide ............................. 17 glipizide er ......................... 17 glipizide-metformin

2.5-250mg ......................... 17 glipizide-metformin 2.5-500mg ......................... 17 glipizide-metformin 5-500mg .......................................... 17 GLUCAGEN HYPOKIT ..... 20 GLUCAGON EMERGENCY KIT .................................... 20 GLUMETZA ...................... 17 glyburide ........................... 17 glyburide micronized ......... 17 glyburide-metformin 1.25-250mg ....................... 17 glyburide-metformin 2.5-500mg ......................... 17 glyburide-metformin 5-500mg ............................ 17 glycate .............................. 22 glycopyrrolate ................... 22 GLYSET ............................ 17 GOLYTELY ....................... 22 GRALISE .......................... 16 GRALISE STARTER......... 16 granisetron hcl .................. 22 GRANIX ............................ 24 GRASTEK ......................... 25 griseofulvin microsize.......... 4 griseofulvin ultramicrosize ... 4 guanfacine hcl ................... 12 H HALAVEN ........................... 8 HALFLYTELY BOWEL PREP/FLA ........................ 22 halobetasol propionate...... 33 HALOG ............................. 33 haloperidol ........................ 14 haloperidol decanoate....... 14 haloperidol lactate ............. 14 HAVRIX ............................ 26 heather tab 0.35mg ........... 18 HEP SOD/NACL INJ 25000 .......................................... 24 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 24 heparin sod inj 10000u/ml . 24 heparin sod inj 1000u/ml ... 24 heparin sod inj 20000u/ml . 24

HEPARIN SOD INJ 2000U/ML ......................... 24 HEPARIN SOD INJ 2500U/ML ......................... 24 heparin sod inj 5000u/0.5ml.......................................... 24 heparin sod inj 5000u/ml ... 24 HEPARIN SODIUM/D5W . 24 HEPARIN SODIUM/SODIUM CHL .... 24 HEPATAMINE .................. 27 HERCEPTIN ....................... 7 HETLIOZ .......................... 15 HEXALEN ........................... 7 HIBERIX ........................... 26 HIZENTRA ........................ 25 HORIZANT ....................... 16 HUMALOG ....................... 17 HUMALOG KWIKPEN ...... 17 HUMALOG MIX 50/50 ...... 17 HUMALOG MIX 50/50 KWIKPEN ......................... 17 HUMALOG MIX 75/25 ...... 17 HUMALOG MIX 75/25 KWIKPEN ......................... 17 HUMATROPE ................... 21 HUMATROPE COMBO PACK ................................ 21 HUMIRA KIT 20MG/0.4 .... 25 HUMIRA KIT 40MG/0.8 .... 25 HUMIRA PEN KIT 40MG/0.8.......................................... 25 HUMIRA PEN KIT CROHNS.......................................... 25 HUMIRA PEN KIT PSORIASI ......................... 25 HUMULIN 70/30 ............... 17 HUMULIN 70/30 PEN ....... 17 HUMULIN N ...................... 17 HUMULIN N U-100 PEN ... 17 HUMULIN R ...................... 17 HUMULIN R U-500 (CONCENTRATE) ............ 17 hydralazine hcl .................. 12 hydrochlorothiazide ........... 11 hydrocodone-acetaminophen 10-300mg ........................... 1 hydrocodone-acetaminophen


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2.5-325mg ...........................1 hydrocodone-acetaminophen 5-300mg ..............................1 hydrocodone-acetaminophen 5-325mg ..............................1 hydrocodone-acetaminophen 7.5-300mg ...........................1 hydrocodone-acetaminophen 7.5-325 mg/15ml .................1 hydrocodone-acetaminophen 7.5-325mg ...........................1 hydrocodone-acetaminophen tab 10-325mg ......................1 hydrocodone-ibuprofen 2.5-200mg ...........................1 hydrocodone-ibuprofen 7.5-200mg ...........................1 hydrocortisone .................. 20 HYDROCORTISONE (INTRARECTAL) ............... 22 hydrocortisone (topical) ..... 33 hydrocortisone butyrate .... 33 hydrocortisone butyrate hydrophilic lipo base ......... 33 hydrocortisone valerate ..... 33 hydromorphone hcl .............2 HYDROMORPHONE HCL ..2 hydroxychloroquine sulfate .......................................... 25 hydroxyurea ........................8 hydroxyzine hcl ................. 30 hydroxyzine pamoate ........ 30 I ibandronate sodium .......... 18 ibudone tab 5-200mg ..........1 ibuprofen .............................1 ICLUSIG..............................8 idarubicin hcl .......................7 IFEX INJ 3GM .....................7 ifosfamide............................7 IFOSFAMIDE FOR INJ 3 GM ......................................7 ILARIS ................................1 ILEVRO ............................. 29 IMBRUVICA ........................8 imipenem-cilastatin .............3 imipramine hcl ................... 13 imipramine pamoate ......... 13

imiquimod ......................... 33 IMOVAX RABIES (H.D.C.V.) .......................................... 26 INCIVEK TAB 375MG ......... 5 INCRELEX ........................ 21 indapamide ....................... 11 INFANRIX ......................... 26 INFERGEN ....................... 25 INFERGEN INJ 9MCG ...... 25 INFUMORPH 200 ............... 2 INFUMORPH 500 ............... 2 INLYTA ............................... 8 INSULIN PEN NEEDLES .. 17 INSULIN SAFETY NEEDLES ......................... 17 INSULIN SYRINGES ........ 17 INTELENCE ........................ 4 INTERMEZZO .................. 15 INTRALIPID INJ 20%........ 27 INTRALIPID INJ 30%........ 27 INTRON-A ........................ 25 INTRON-A W/DILUENT .... 25 introvale 91 day ................ 18 INTUNIV ........................... 15 INVANZ ............................... 3 INVEGA ............................ 14 INVEGA SUSTENNA ........ 14 INVIRASE ........................... 4 INVOKAMET TAB 150-1000 MG .................................... 17 INVOKAMET TAB 150-500 MG .................................... 17 INVOKAMET TAB 50-1000 MG .................................... 17 INVOKAMET TAB 50-500 MG .................................... 17 INVOKANA ....................... 17 IONOSOL-B/DEXTROSE 5% .................................... 27 IONOSOL-MB/DEXTROSE 5% .................................... 27 IPOL INACTIVATED IPV .. 26 ipratropium bromide (nasal) .......................................... 30 ipratropium sol inhal .......... 30 ipratropium-albuterol ......... 30 irbesartan ............................ 9 irbesartan-hydrochlorothiazid

e.......................................... 9 IRESSA .............................. 8 irinotecan hcl ...................... 9 ISENTRESS ....................... 4 ISOLYTE P ....................... 27 isolyte s ............................. 27 isoniazid .............................. 4 isoniazid tabs ...................... 5 ISOPTO CARPINE ........... 29 ISORDIL TITRADOSE ...... 12 isosorbide dinitrate ............ 12 isosorbide dinitrate sl tab 2.5 mg ..................................... 12 isosorbide mononitrate ..... 12 isradipine .......................... 11 ISTALOL ........................... 29 ISTODAX ............................ 7 itraconazole ........................ 4 IXEMPRA KIT ..................... 8 IXIARO ............................. 26 J JAKAFI ............................... 8 JALYN .............................. 23 jantoven ............................ 24 JANUMET ......................... 17 JANUMET XR TAB 100-1000 .......................... 18 JANUMET XR TAB 50-1000.......................................... 18 JANUMET XR TAB 50-500MG ......................... 18 JANUVIA .......................... 18 JENTADUETO .................. 18 JEVTANA ........................... 8 jinteli ................................. 20 JOLIVETTE ...................... 18 junel 1.5/30 21 day ........... 18 junel 1/20 21 day .............. 18 junel fe 1.5/30 28 day ....... 18 junel fe 1/20 28 day .......... 19 JUXTAPID ........................ 10 K KADCYLA ........................... 7 KADIAN .............................. 2 KALBITOR ........................ 24 KALETRA SOL ................... 4 KALETRA TAB 100-25MG . 4 KALETRA TAB 200-50MG . 4


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KALYDECO ...................... 30 kariva 28 day ..................... 19 KAZANO ........................... 18 KCL 0.075%/D5W/NACL 0.45% ................................ 28 KCL 0.15%/D5W/LR ......... 28 KCL 0.15%/D5W/NACL 0.9% .................................. 28 kcl 0.3%/d5w/lr iv lac ri ...... 28 KCL 0.3%/D5W/NACL 0.45% ................................ 28 KCL 0.3%/D5W/NACL 0.9% .......................................... 28 KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 28 kcl 20 meq/l (0.15%) in nacl 0.45% inj ........................... 28 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ ............... 28 KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 28 KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 28 KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ ................. 28 KCL0.15%/D5W/NACL0.2% .......................................... 27 KCL0.15%/D5W/NACL0.225% ....................................... 28 kelnor 1/35 28 day ............ 19 KENALOG......................... 33 KEPIVANCE .......................9 ketoconazole .......................4 ketoconazole (topical) ....... 32 ketoconazole shampoo ..... 32 ketoprofen ...........................1 ketorolac tromethamine (ophth) .............................. 29 KINERET INJ .................... 25 kionex ............................... 18 KLOR-CON 10 .................. 26 KLOR-CON 8 .................... 26 klor-con m15 ..................... 26 klor-con m20 ..................... 26 klor-con pow 20meq .......... 26

KOMBIGLYZE XR 2.5-1000MG ...................... 18 KOMBIGLYZE XR 5-1000MG ......................... 18 KOMBIGLYZE XR 5-500MG .......................................... 18 KORLYM ........................... 21 kristalose ........................... 22 KRYSTEXXA ...................... 1 KUVAN ............................. 20 KYNAMRO ........................ 10 L labetalol hcl ....................... 11 laclotion lotn 12% .............. 33 LACRISERT ...................... 29 LACTATED RINGERS VIAFLEX ........................... 28 lactulose ............................ 22 lactulose (encephalopathy) .......................................... 22 LAMICTAL ODT ................ 13 LAMICTAL STARTER....... 13 LAMICTAL XR .................. 13 LAMISIL .............................. 4 lamivudine ....................... 4, 5 lamivudine-zidovudine ........ 4 lamotrigine ........................ 13 LANOXIN .......................... 11 LANOXIN PEDIATRIC ...... 11 LANOXIN TAB .................. 11 lansoprazole ..................... 23 LANTUS ............................ 17 LANTUS SOLOSTAR ....... 17 larin 1.5/30 ........................ 19 larin 1/20 ........................... 19 larin fe 1.5/30 .................... 19 larin fe 1/20 ....................... 19 LASTACAFT ..................... 29 latanoprost ........................ 29 LATUDA ............................ 14 LAZANDA ........................... 2 LEENA .............................. 19 leflunomide ....................... 25 LESCOL XL ...................... 10 lessina 28 day ................... 19 LETAIRIS .......................... 12 letrozole .............................. 8 leucovor ca inj ..................... 9

leucovorin calcium .............. 9 leucovorin calcium inj 10 mg/ml .................................. 9 LEUKERAN ........................ 7 LEUKINE .......................... 24 leuprolide acetate ............... 8 levalbuterol conc 1.25mg/0.5ml .................... 30 LEVALBUTEROL HCL ..... 30 LEVEMIR .......................... 17 LEVEMIR FLEXPEN ......... 17 LEVEMIR FLEXTOUCH ... 17 levetiracetam .................... 13 levobunolol hcl .................. 29 LEVOBUNOLOL HCL ....... 29 levocarnitine (metabolic modifiers) .......................... 20 levocetirizine soln 2.5mg/5ml.......................................... 30 levocetirizine tab 5 mg ...... 30 levofloxacin ......................... 6 levofloxacin (ophth) ........... 28 levofloxacin in d5w .............. 6 levonest 28 day ................ 19 levonorgestrel (emergency oc) ..................................... 19 levonorgestrel-ethinyl estradiol (91-day) .............. 19 levora 0.15/30 28 day ....... 19 levorphanol tartrate ............. 2 levothyroxine sodium ........ 21 LEVOXYL ......................... 21 LEXIVA ............................... 4 LIALDA ............................. 22 lidocaine ........................... 33 lidocaine hcl ...................... 33 lidocaine hcl (local anesth.) 3 lidocaine hcl (mouth-throat).......................................... 33 lidocaine inj 0.5% ................ 3 lidocaine inj 1% ................... 3 lidocaine inj 1.5% ................ 3 lidocaine inj 2% ................... 3 lidocaine-prilocaine ........... 33 LINZESS CAP 145MCG ... 23 LINZESS CAP 290MCG ... 23 liothyronine sodium ........... 21 LIPOFEN .......................... 10


45

LIPTRUZET ...................... 10 lisinopril ...............................9 lisinopril & hydrochlorothiazide .............9 LITHIUM............................ 16 lithium carbonate ............... 16 LIVALO ............................. 10 LO LOESTRIN FE ............. 19 LO MINASTRIN FE ........... 19 LOCOID ............................ 33 LOESTRIN 24 FE ............. 19 LOKARA LOTN 0.05% ...... 33 lomedia 24 fe .................... 19 LOMUSTINE .......................7 loperamide hcl ................... 23 lorazepam ......................... 12 lorcet ...................................1 lorcet plus tab 7.5-325 ........1 lortab ...................................1 lortab elx 10-300mg ............1 loryna 28 day .................... 19 losartan potassium ..............9 losartan potassium & hydrochlorothiazide .............9 LOTEMAX ......................... 29 LOTRONEX ...................... 23 lovastatin ........................... 10 LOVAZA ............................ 10 low-ogestrel 28 day ........... 19 loxapine succinate ............ 14 LUCENTIS ........................ 29 LUFYLLIN ......................... 31 LUMIGAN.......................... 29 LUMIZYME ....................... 20 LUPANETA PACK ............ 19 LUPR DEP-PED INJ 11.25MG (3-MONTH) .........8 LUPR DEP-PED INJ 30MG (3-MONTH) .........................8 LUPRON DEPOT ................8 LUPRON DEPOT INJ 22.5MG (3-MONTH) ...........8 LUPRON DEPOT INJ 30MG (3-MONTH) .........................8 LUPRON DEPOT-PED .......8 lutera 28 day ..................... 19 LUZU ................................ 32 LYRICA ............................. 13

LYSODREN ........................ 8 lyza ................................... 19 M MACRODANTIN ................. 3 mafenide acetate .............. 31 magnesium sulfate ............ 26 MAGNESIUM SULFATE ... 26 MAGNESIUM SULFATE IN D5W 1% ............................ 26 MAGNESIUM SULFATE IN D5W 2% ............................ 26 MAKENA ........................... 21 malathion .......................... 33 maprotiline hcl ................... 13 marlissa 28 day ................. 19 MARPLAN ........................ 14 MATULANE ........................ 8 matzim la .......................... 11 MAXIDEX .......................... 29 MAXIPIME .......................... 5 meclizine hcl ..................... 22 MEDROL .......................... 20 medroxyprogesterone acetate .............................. 21 medroxyprogesterone acetate (contraceptive) ..... 19 mefenamic acid ................... 1 mefloquine hcl ..................... 4 MEGACE ES ...................... 8 megestrol acetate ............... 8 MEKINIST ........................... 8 MELOXICAM SUSP 7.5 MG/5ML .............................. 1 meloxicam tabs ................... 1 melphalan hcl ...................... 7 MENACTRA ...................... 26 menest .............................. 20 MENHIBRIX ...................... 26 MENOMUNE-A/C/Y/W-135 .......................................... 26 MENOSTAR ..................... 20 MENTAX ........................... 32 MENVEO .......................... 26 MEPRON ............................ 3 mercaptopurine ................... 7 meropenem ......................... 3 mesalamine enema .......... 22 mesalamine enema kit ...... 22

mesna ................................. 9 MESNEX ............................ 9 MESTINON SYRUP ......... 16 MESTINON TIMESPAN ... 16 metadate tab 20mg er ....... 15 metformin er ..................... 18 metformin hcl .................... 18 methadone hcl .................... 2 METHADONE INJ 10MG/ML............................................ 2 methazolamide ................. 11 methenamine hippurate ...... 3 methimazole ..................... 21 methocarbamol ................. 16 methotrexate sodium inj ...... 7 methotrexate sodium tabs 25 methoxsalen rapid ............ 32 methscopolamine bromide 22 methyclothiazide ............... 11 methylergonovine maleate 21 METHYLIN CHEW TAB .... 15 methylphenidate hcl .......... 15 methylphenidate hcl er ...... 15 METHYLPHENIDATE HCL ER ..................................... 15 methylphenidate tab 10mg er.......................................... 15 methylphenidate tab 20mg er.......................................... 15 methylprednisolone ........... 20 methylprednisolone acetate.......................................... 20 methylprednisolone sod succ.......................................... 20 metipranolol ...................... 29 metoclopramide hcl ........... 22 metoclopramide hcl inj 5 mg/ml ................................ 22 metolazone ....................... 11 metoprolol & hctz tab 100-25mg ......................... 10 metoprolol & hctz tab 100-50mg ......................... 10 metoprolol & hctz tab 50-25mg ........................... 10 metoprolol succinate ......... 11 metoprolol tartrate............. 11 METOZOLV ODT ............. 22


46

METRO IV ...........................3 metronidazole .....................3 metronidazole (topical) ...... 33 metronidazole gel 0.75% .. 33 metronidazole inj .................3 metronidazole vaginal ....... 24 mexiletine hcl .................... 10 MIACALCIN INJ 200U/ML. 21 miconazole nitrate vaginal. 24 MICROGESTIN TAB 1.5/30 .......................................... 19 MICROGESTIN TAB 1/20 . 19 midodrine hcl ..................... 12 migergot ............................ 15 millipred............................. 20 mimvey lo 28 day .............. 20 MINASTRIN 24 FE ............ 19 minitran ............................. 12 MINIVELLE ....................... 20 minocycline hcl ....................6 minoxidil ............................ 12 MIRAPEX .......................... 14 MIRAPEX ER .................... 14 mirtazapine ....................... 14 misoprostol ........................ 23 mitomycin ............................7 mitoxantrone hcl ..................8 M-M-R II W/DILUENT 10 DOS .................................. 26 modafinil............................ 16 moderiba pak ......................5 moderiba tab 200mg ...........5 moexipril hcl ........................9 moexipril-hydrochlorothiazide ..........................................9 mometasone furoate ......... 33 MONONESSA ................... 19 montelukast sodium .......... 30 MORPHINE SUL 20MG/ML ORAL SOL ..........................2 morphine sulfate .................2 MORPHINE SULFATE .......2 morphine sulfate beads cap sr .........................................2 morphine sulfate ext-rel tab.2 morphine sulfate inj .............2 MORPHINE SULFATE INJ .2 MOVIPREP ....................... 23

MOXATAG .......................... 6 MOXEZA ........................... 28 moxifloxacin hcl .................. 6 MOZOBIL .......................... 24 MULTAQ ........................... 10 mupirocin .......................... 31 mupirocin calcium (topical) 31 MUSTARGEN ..................... 7 my way .............................. 19 MYCAMINE ........................ 4 MYCOBUTIN ...................... 5 mycophenolate mofetil ...... 26 mycophenolate sodium ..... 26 myorisan ........................... 31 MYOZYME ........................ 20 MYRBETRIQ .................... 24 myzilra .............................. 19 N nabumetone ........................ 1 nadolol .............................. 11 nadolol & bendroflumethiazide ......... 10 nafcillin sodium ................... 6 NAFTIN ............................. 32 NAGLAZYME .................... 20 NALFON ............................. 1 NALLPEN ISO-OSMOTIC IN DE ....................................... 6 NALLPEN/DEXTROSE ....... 6 naloxone hcl ...................... 16 naltrexone hcl ................... 16 NAMENDA ........................ 13 NAMENDA TITRATION PAK .......................................... 13 NAMENDA XR .................. 13 NAMENDA XR TITRATION PACK ................................ 13 naphazoline 0.1% ............. 29 NAPRELAN ........................ 1 naproxen ............................. 1 naproxen sodium ................ 1 naratriptan hcl ................... 15 NASONEX ........................ 30 NATACYN ......................... 28 nateglinide ........................ 18 NEBUPENT ........................ 3 necon 0.5/35 28 day ......... 19 necon 1/35 28 day ............ 19

NECON 1/50-28................ 19 necon 10/11 28 day .......... 19 NECON 7/7/7 .................... 19 nefazodone hcl ................. 14 neomycin sulfate ................. 3 neomycin/polymyxin b gu . 33 neomycin-bacitracin zn-polymyxin ..................... 28 neomycin-polymy-dexameth.......................................... 28 neomycin-polymy-gramicid.......................................... 28 neomycin-polymyxin-hc (ophth) .............................. 28 neomycin-polymyxin-hc (otic).......................................... 34 NEORAL ........................... 26 NEPHRAMINE .................. 27 NESINA ............................ 18 neuac ................................ 31 NEULASTA ....................... 24 NEUMEGA ....................... 24 NEUPOGEN ..................... 24 NEUPRO .......................... 14 NEVANAC ........................ 29 nevirapine ........................... 4 NEVIRAPINE ...................... 4 NEXAVAR .......................... 8 NEXIUM ............................ 23 NEXIUM GRANULES 10MG DR .................................... 23 NEXIUM GRANULES 2.5MG DR .................................... 23 NEXIUM GRANULES 20MG DR .................................... 23 NEXIUM GRANULES 40MG DR .................................... 23 NEXIUM GRANULES 5MG DR .................................... 23 NEXIUM I.V. ..................... 23 next choice tab 1.5mg ....... 19 niacin er ............................ 10 niacor ................................ 10 nicardipine hcl ................... 11 NICOTROL INHALER ....... 16 NICOTROL NS ................. 16 nifedical ............................ 11 nifedipine .......................... 11


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nifedipine er ...................... 11 nikki 28 day ....................... 19 NILANDRON .......................8 nimodipine......................... 11 NIPENT ...............................7 nisoldipine ......................... 11 nitro-bid ............................. 12 NITRO-DUR ...................... 12 nitrofurantoin .......................3 nitrofurantoin macrocrystal ..3 nitrofurantoin monohyd macro ..................................3 NITROGLYCERIN ............ 12 NITROGLYCERIN LINGUAL .......................................... 12 nitroglycerin patches ......... 12 NITROLINGUAL SPR PUMPSPRA ...................... 12 NITROMIST ...................... 12 NITROSTAT ...................... 12 nizatidine ........................... 22 NORA-BE.......................... 19 NORDITROPIN FLEXPRO .......................................... 21 NORDITROPIN NORDIFLEX PEN ............. 21 norethindrone (contraceptive) .................. 19 norethindrone acetate ....... 21 norgestimate-ethinyl estradiol (triphasic) ............ 19 NORINYL 1+50 ................. 19 NORITATE ........................ 33 norlyroc 28 day ................. 19 normosol-m ....................... 28 NORMOSOL-R ................. 28 NOROXIN ...........................6 NORPACE CR .................. 10 nortrel 0.5/35 28 day ......... 19 nortrel 1/35 21 day ............ 19 nortrel 1/35 28 day ............ 19 nortrel 7/7/7 28 day ........... 19 nortriptyline hcl .................. 14 NORVIR ..............................4 NOVAREL INJ 10000UNT 21 NOVOLIN 70/30 ................ 17 NOVOLIN 70/30 RELION.. 17 NOVOLIN N ...................... 17

NOVOLIN N RELION ........ 17 NOVOLIN R ...................... 17 NOVOLIN R RELION ........ 17 NOVOLOG ........................ 17 NOVOLOG FLEXPEN ...... 17 NOVOLOG MIX 70/30 ...... 17 NOVOLOG MIX 70/30 PREFILL ........................... 17 NOVOLOG PENFILL ........ 17 NOXAFIL ............................ 4 NPLATE ............................ 24 NUCYNTA .......................... 2 NUCYNTA ER .................... 2 NUEDEXTA ...................... 16 NULOJIX ........................... 26 NULYTELY/FLAVOR PACKS .............................. 23 NUTROPIN ....................... 21 NUTROPIN AQ NUSPIN 5 21 NUTROPIN AQ PEN......... 21 NUVARING ....................... 19 NUVIGIL ........................... 16 nyamyc ............................. 32 NYMALIZE ........................ 11 nystatin ............................... 4 nystatin (mouth-throat) ...... 33 nystatin (topical) ................ 32 nystatin pow 100000 ......... 32 nystop ............................... 32 O OCELLA ............................ 19 OCTAGAM ........................ 25 octreotide acetate ............. 21 ofloxacin (ophth) ............... 28 ofloxacin (otic) ................... 34 ogestrel 28 day ................. 19 olanzapine ........................ 14 olanzapine odt .................. 14 OLEPTRO ......................... 14 OLYSIO .............................. 5 OMECLAMOX-PAK .......... 23 omega-3-acid ethyl esters . 10 omeprazole ....................... 23 omeprazole cap 20mg ...... 23 OMNARIS ......................... 30 OMNITROPE 10MG ......... 21 OMNITROPE 5.8MG ........ 21 OMNITROPE 5MG ........... 21

ONCASPAR ....................... 8 ondansetron hcl ................ 22 ondansetron hcl inj............ 22 ondansetron hcl oral soln .. 22 ondansetron odt ................ 22 ONFI ................................. 13 ONGLYZA ........................ 18 ONMEL ............................... 4 OPANA ER (CRUSH RESISTANT ....................... 2 OPSUMIT ......................... 12 ORACEA .......................... 33 ORAP ............................... 14 ORAPRED ODT ............... 20 ORENCIA INJ 125MG/ML 25 ORENCIA INJ 250MG ...... 25 ORENITRAM .................... 12 ORFADIN ......................... 20 orsythia 28 day ................. 19 ORTHO TRI-CYCLEN LO 19 OSENI TAB 12.5-15MG .... 18 OSENI TAB 12.5-30MG .... 18 OSENI TAB 12.5-45MG .... 18 OSENI TAB 25-15MG ....... 18 OSENI TAB 25-30MG ....... 18 OSENI TAB 25-45MG ....... 18 OSMOPREP ..................... 23 OTEZLA ............................ 25 OTREXUP INJ 10MG ......... 7 OTREXUP INJ 15MG ......... 7 OTREXUP INJ 20MG ......... 7 OTREXUP INJ 25MG ......... 7 oxacillin sodium .................. 6 oxaliplatin ............................ 9 oxandrolone ...................... 17 oxaprozin ............................ 1 oxcarbazepine .................. 13 OXECTA ............................. 2 OXISTAT .......................... 32 OXSORALEN ................... 33 OXSORALEN ULTRA ....... 32 OXTELLAR XR ................. 13 oxybutynin chloride ........... 24 oxycodone hcl ..................... 2 OXYCODONE HCL ............ 2 oxycodone w/ acetaminophen 10-325mg .. 2 oxycodone w/


48

acetaminophen 2.5-325mg .2 oxycodone w/ acetaminophen 5-325mg ....2 oxycodone w/ acetaminophen 7.5-325mg .2 oxycodone-aspirin ...............2 oxycodone-ibuprofen ..........2 OXYCONTIN .......................2 oxymorphone hcl .................2 OXYTROL ......................... 24 P pacerone ........................... 10 paclitaxel .............................7 pamidronate disodium ....... 18 PANCREAZE .................... 23 PANDEL............................ 33 PANRETIN ........................ 33 pantoprazole sodium ......... 23 paricalcitol ......................... 28 PARLODEL ....................... 14 paromomycin sulfate ...........3 paroxetine er tab ............... 14 paroxetine hcl .................... 14 paser d/r ..............................5 PATADAY ......................... 29 PATANASE ....................... 30 PATANOL ......................... 29 PAXIL ................................ 14 PCE ....................................6 pedi-dri .............................. 32 PEDVAX HIB .................... 26 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 23 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 23 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 23 PEGANONE ...................... 13 PEGASYS INJ .................. 25 PEGASYS INJ 180MCG/M .......................................... 25 PEGASYS INJ PROCLICK .......................................... 25 PEGASYS KIT .................. 25 PEG-INTRON ................... 25

PEG-INTRON KIT 50MCG 25 PEG-INTRON KIT 50MCG RP ..................................... 25 PENICILLIN G POT IN DEXTROSE ........................ 6 penicillin g potassium .......... 6 PENICILLIN G POTASSIUM ............................................ 6 penicillin g procaine ............ 6 penicillin g sodium .............. 6 penicillin v potassium .......... 6 PENNSAID ....................... 33 PENTAM 300 ...................... 3 PENTASA ......................... 22 pentoxifylline ..................... 24 PERFOROMIST ............... 30 perindopril erbumine ........... 9 periogard sol 0.12% .......... 33 PERJETA ............................ 8 permethrin ......................... 33 perphenazine .................... 14 PERTZYE ......................... 23 PEXEVA ........................... 14 pfizerpen ............................. 6 phenadoz .......................... 22 phenelzine sulfate ............. 14 phenobarbital .................... 13 phenobarbital sodium........ 13 PHENOBARBITAL SODIUM .......................................... 13 phenytek ........................... 13 phenytoin .......................... 13 phenytoin inj 50mg/ml ....... 13 phenytoin sodium extended .......................................... 13 philith ................................ 19 PHISOHEX ....................... 31 PHOSLYRA ...................... 21 PHOSPHOLINE IODIDE ... 29 PICATO ............................ 31 PILOCARPINE HCL.......... 29 pilocarpine hcl (oral).......... 33 pimtrea pack ..................... 19 pindolol ............................. 11 pioglitazone hcl ................. 18 pioglitazone hcl-glimepiride .......................................... 18 pioglitazone hcl-metformin

hcl ..................................... 18 piperacillin sodium-tazobactam sodium 6 pirmella 1/35 28 day ......... 19 piroxicam ............................ 1 PLASMA-LYTE A.............. 28 PLASMA-LYTE-148 .......... 28 PLASMA-LYTE-56/D5W ... 28 podofilox ........................... 33 polyethylene glycol 3350 .. 23 polymyxin b sulfate ............. 3 polymyxin b-trimethoprim .. 28 POMALYST CAP ................ 8 portia 28 day ..................... 19 potassium chloride ...... 26, 28 POTASSIUM CHLORIDE 26, 28 POTASSIUM CHLORIDE 0.15% ............................... 28 POTASSIUM CHLORIDE 0.22% ............................... 28 POTASSIUM CHLORIDE 0.3%/D .............................. 28 potassium chloride caps er.......................................... 26 potassium chloride microencapsulated crystals cr ....................................... 26 POTASSIUM CITRATE (ALKALINIZER) ................ 23 POTIGA ............................ 13 PRADAXA ........................ 24 pramipexole dihydrochloride.......................................... 14 PRANDIMET .................... 18 pravastatin sodium ............ 10 prazosin hcl ........................ 9 PRED MILD ...................... 29 PRED-G ............................ 28 PRED-G S.O.P. ................ 28 prednicarbate .................... 33 PREDNICARBATE ........... 33 prednisolone ..................... 20 PREDNISOLONE ACETATE.......................................... 29 prednisolone sodium phosphate ......................... 20 prednisolone sodium


49

phosphate (ophth) ............. 29 prednisone ........................ 20 PREGNYL W/DILUENT BENZYL ............................ 21 PREMARIN ....................... 20 PREMARIN CREAM ......... 20 PREMARIN INJ ................. 20 premasol 10% ................... 27 premasol 6% ..................... 27 PREMPHASE ................... 20 PREMPRO ........................ 20 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 28 PREPOPIK ........................ 23 PREVACID SOLUTAB ...... 23 prevalite ............................ 10 previfem 28 day ................ 19 PREZISTA ..........................4 PRIALT ...............................1 PRIFTIN ..............................5 PRIMAQUINE PHOSPHATE ............................................4 primidone .......................... 13 PRIMSOL SOL 50MG/5ML .3 PRISTIQ............................ 14 PRIVIGEN ......................... 25 PROAIR HFA .................... 30 probenecid ..........................1 PROCALAMINE ................ 27 prochlorperazine inj 5 mg/ml .......................................... 22 prochlorperazine maleate.. 22 prochlorperazine supp ...... 22 PROCRIT .......................... 24 proctocream ...................... 32 procto-pak ......................... 32 proctosol ........................... 32 proctozone hc ................... 32 PROCYSBI ....................... 20 progesterone micronized... 21 PROGLYCEM ................... 20 PROGRAF ........................ 26 PROLASTIN-C .................. 30 PROLENSA ...................... 29 PROLEUKIN .......................7 PROLIA ............................. 21 PROMACTA ...................... 25

promethazine hcl .............. 22 promethegan ..................... 22 propafenone hcl ................ 10 proparacaine hcl ............... 29 propranolol & hydrochlorothiazide ........... 10 propranolol hcl er .............. 11 propranolol inj 1mg/ml....... 11 propranolol sol .................. 11 propranolol tab .................. 11 propylthiouracil .................. 21 PROQUAD ........................ 26 PROSOL ........................... 27 PROTONIX ....................... 23 PROTOPIC OIN 0.03% ..... 33 PROTOPIC OIN 0.1%....... 33 protriptyline hcl .................. 14 PROVENTIL HFA ............. 30 PRUDOXIN CRE 5% ........ 32 PULMICORT FLEXHALER .......................................... 31 PULMICORT INH SUSP ... 31 PULMOZYME ................... 30 PYLERA ............................ 23 pyrazinamide ...................... 5 pyridostigmine bromide ..... 16 Q QNASL .............................. 30 QUARTETTE .................... 19 quasense 91 day .............. 19 QUDEXY XR ..................... 13 quetiapine fumarate .......... 14 QUILLIVANT XR ............... 15 quinapril hcl ......................... 9 quinapril-hydrochlorothiazide ............................................ 9 quinidine gluconate er ....... 10 quinidine sulfate ................ 10 quinine sulfate ..................... 4 QVAR ................................ 31 R RABAVERT ...................... 26 rabeprazole sodium .......... 23 RAGWITEK ....................... 25 raloxifene hcl ..................... 21 ramipril ................................ 9 RANEXA ........................... 12 ranitidine hcl ...................... 22

RAPAFLO ......................... 23 RAPAMUNE ..................... 26 RASUVO INJ 10 MG .......... 7 RASUVO INJ 12.5 MG ....... 7 RASUVO INJ 15 MG .......... 7 RASUVO INJ 17.5 MG ....... 7 RASUVO INJ 22.5 MG ....... 7 RASUVO INJ 25 MG .......... 7 RASUVO INJ 27.5 MG ....... 7 RASUVO INJ 30 MG .......... 7 RASUVO INJ 7.5 MG ......... 7 RAVICTI ........................... 21 RAYOS ............................. 20 REBETOL ........................... 5 REBETOL SOL 40MG/ML .. 5 REBIF ............................... 16 REBIF TITRATION PACK 16 RECLAST ......................... 18 reclipsen 28 day................ 19 RECOMBIVAX HB ............ 26 RECTIV ............................ 33 REGRANEX ..................... 33 RELENZA DISKHALER ...... 5 RELISTOR ........................ 23 RELPAX ........................... 15 REMICADE INJ 100MG .... 25 REMODULIN .................... 12 RENAGEL ........................ 21 RENVELA ......................... 21 repaglinide ........................ 18 reprexain 10/200 ................. 1 RESCRIPTOR .................... 4 RESTASIS ........................ 29 RETIN-A MICRO PUMP ... 31 RETROVIR IV INFUSION ... 4 REVATIO .......................... 12 REVLIMID ......................... 25 REYATAZ ........................... 4 RHEUMATREX................. 25 RHINOCORT AQUA ......... 30 ribapak mis 600/day ............ 5 ribasphere ........................... 5 ribasphere ribapak 1000 ..... 5 ribasphere ribapak 1200 ..... 5 ribasphere ribapak 800 ....... 5 ribavirin cap 200mg ............ 5 ribavirin tab 200mg ............. 5 rifabutin ............................... 5


50

rifamate ...............................5 rifampin ...............................5 RIFATER.............................5 RILUTEK ........................... 16 riluzole .............................. 16 rimantadine hydrochloride ...5 RINGER'S ......................... 28 RIOMET ............................ 18 risedronate sodium ........... 18 RISPERDAL CONSTA ...... 14 risperidone ........................ 15 risperidone odt .................. 15 RITALIN LA ....................... 15 RITUXAN ............................7 rivastigmine tartrate .......... 13 rizatriptan benzoate .......... 15 ropinirole hydrochloride ..... 14 rosadan cre 0.75% ............ 33 ROTARIX .......................... 26 ROTATEQ ......................... 26 roxicet soln ..........................2 roxicet tab 5-325mg ............2 ROZEREM ........................ 15 S SABRIL ............................. 13 SAIZEN ............................. 21 SAIZEN CLICK.EASY ....... 21 SAMSCA ........................... 21 SANCUSO ........................ 22 SANDIMMUNE CAPS ....... 26 SANDIMMUNE SOLN ....... 26 SANDOSTATIN ................ 21 SANDOSTATIN LAR DEPOT ............................. 21 SANTYL ............................ 33 SAPHRIS .......................... 15 SARAFEM ......................... 16 SAVELLA .......................... 16 SAVELLA TITRATION PACK ................................ 16 selegiline hcl ..................... 14 selenium sulfide ................ 32 SELZENTRY .......................4 SEMPREX-D ..................... 30 SENSIPAR ........................ 18 SEREVENT DISKUS ........ 30 seromycin............................5 SEROQUEL XR ................ 15

SEROSTIM ....................... 21 sertraline hcl ..................... 14 SF-ROWASA .................... 22 SIGNIFOR ........................ 21 sildenafil citrate (pulmonary hypertension) .................... 12 SILENOR .......................... 15 SILVER SULFADIAZINE .. 31 SIMBRINZA ...................... 29 SIMCOR ........................... 10 SIMPONI ........................... 25 SIMPONI ARIA ................. 25 SIMPONI INJ 50MG.......... 25 SIMULECT ........................ 26 simvastatin ........................ 10 sirolimus tab 0.5 mg .......... 26 SIRTURO ............................ 5 SIVEXTRO .......................... 3 SKLICE ............................. 33 SOD FLUORIDE 2.2MG TAB ................................... 26 SODIUM CHLORIDE .. 27, 28 SODIUM CHLORIDE 0.45% VIA .................................... 28 SODIUM CHLORIDE 0.9% .......................................... 33 sodium phenylbutyrate ...... 20 sodium polystyrene sulfonate .......................................... 18 SOLIA ............................... 19 SOLIRIS ............................ 25 SOLODYN .......................... 6 SOLTAMOX ........................ 8 SOLU-CORTEF 1000MG . 20 SOLU-CORTEF 100MG ... 20 SOLU-CORTEF 250MG ... 20 SOLU-CORTEF 500MG ... 20 SOLU-MEDROL ............... 20 SOMATULINE DEPOT ..... 21 SOMAVERT ...................... 21 SORILUX .......................... 32 sorine ................................ 10 sotalol hcl .......................... 10 sotalol hcl (afib/afl) ............ 10 SOVALDI ............................ 5 SPIRIVA HANDIHALER .... 30 spironolactone .................... 9 spironolactone &

hydrochlorothiazide ........... 12 SPORANOX SOL 10MG/ML............................................ 4 sprintec 28 day ................. 19 SPRYCEL ........................... 8 sps sus 15gm/60ml ........... 18 sronyx 28 day ................... 19 SSD .................................. 31 stavudine ............................ 4 STAVZOR ......................... 13 STELARA INJ 45MG/0.5 .. 32 STELARA INJ 90MG/ML .. 32 STERILE WATER IRRIGATION ..................... 33 STIMATE .......................... 21 STIVARGA ......................... 8 STRATTERA .................... 15 streptomycin sulfate ............ 3 STRIANT .......................... 17 STRIBILD ........................... 4 STROMECTOL ................... 3 SUBOXONE MIS 12-3MG 16 SUBOXONE MIS 2-0.5MG.......................................... 16 SUBOXONE MIS 4-1MG .. 16 SUBOXONE MIS 8-2MG .. 16 SUBSYS ............................. 2 SUCLEAR ......................... 23 SUCRAID ......................... 23 sucralfate .......................... 23 sulfacetamide sodium (acne).......................................... 31 sulfacetamide sodium (ophth) .............................. 29 sulfacetamide sod-prednisolone .............. 28 sulfadiazine ......................... 3 sulfamethoxazole-trimethoprim ......................................... 3 sulfamethoxazole-trimethoprim inj .................................... 3 SULFAMYLON ................. 31 sulfasalazine dr ................. 22 sulfasalazine ir .................. 22 sulindac .............................. 1 sumatriptan succinate ....... 15 SUMATRIPTAN SUCCINATE ..................... 15


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sumatriptan succinate inj .15, 16 SUMATRIPTAN SUCCINATE INJ ............... 15 SUMAVEL DOSEPRO ...... 16 SUPPRELIN LA ..................8 suprax .................................5 SUPRAX .............................5 SUPREP BOWEL PREP... 23 SURMONTIL ..................... 14 SUSTIVA.............................4 SUTENT..............................8 SUTENT CAP 37.5MG .......8 syeda ................................ 19 SYLATRON .........................8 SYMBICORT ..................... 31 SYMLINPEN 120 .............. 17 SYMLINPEN 60 ................ 17 SYNAGIS .......................... 26 SYNALGOS-DC ..................1 SYNAREL ......................... 19 SYNERA ........................... 33 SYNERCID .........................3 SYNRIBO ............................8 SYNTHROID ..................... 21 SYPRINE .......................... 18 T TABLOID.............................7 TACLONEX ....................... 33 tacrolimus.......................... 26 TAFINLAR ...........................8 TAMIFLU.............................5 tamoxifen citrate ..................8 tamsulosin hcl ................... 23 TANZEUM ......................... 17 TARCEVA ...........................8 TARGRETIN ................. 8, 33 TARKA ................................9 TASIGNA ............................8 TAXOTERE .........................7 tazicef vial ...........................6 TAZORAC ......................... 32 taztia xt ............................. 11 TECFIDERA CAP 120MG. 16 TECFIDERA CAP 240MG. 16 TECFIDERA MIS STARTER .......................................... 16 TEFLARO ...........................6

TEGRETOL ...................... 13 TEGRETOL-XR ................ 13 TEKAMLO ......................... 11 TEKTURNA ...................... 11 TEKTURNA HCT .............. 11 TELMISARTAN ................... 9 telmisartan-amlodipine ........ 9 TELMISARTAN-HYDROCHLOROTHIAZIDE ................... 9 temazepam ....................... 15 TENIVAC .......................... 26 terazosin hcl ........................ 9 terbinafine hcl ..................... 4 terbutaline sulfate ............. 30 terconazole vaginal ........... 24 TESTIM ............................. 17 testosterone cypionate ...... 17 testosterone enanthate ..... 17 TETANUS TOXOID ADSORBED ...................... 26 TETANUS/DIPHTHERIA TOXOID ............................ 26 TETRACYCLINE HCL ........ 6 TEVETEN ........................... 9 TEVETEN HCT ................... 9 TEV-TROPIN .................... 21 texacort ............................. 33 THALOMID ....................... 25 theo-24 .............................. 31 theophylline ....................... 31 THERMAZENE ................. 31 thioridazine hcl .................. 15 thiothixene ........................ 15 THYMOGLOBULIN ........... 26 tiagabine hcl ...................... 13 TIKOSYN CAP 125MCG .. 10 TIKOSYN CAP 250MCG .. 10 TIKOSYN CAP 500MCG .. 10 TIMENTIN ........................... 6 TIMENTIN INJ 3.1GM ......... 6 timolol maleate .................. 11 timolol maleate (ophth) ..... 29 TIMOLOL MALEATE GEL 29 TIMOPTIC OCUDOSE ...... 29 TIROSINT ......................... 21 TIVICAY .............................. 4 tizanidine ........................... 16 TOBI PODHALER ............... 3

TOBRADEX ...................... 28 TOBRADEX ST ................ 28 tobramycin .......................... 3 tobramycin sulfate............... 3 tobramycin sulfate (ophth) 29 tobramycin sulfate in saline 3 tobramycin-dexamethasone.......................................... 28 TOBREX OINT 0.3% ........ 29 tolmetin sodium................... 1 tolterodine tartrate............. 24 TOLTERODINE TARTRATE ER ..................................... 24 TOPICORT ....................... 33 topiramate ......................... 13 TOPIRAMATE ER ............ 13 toposar ................................ 9 topotecan hcl ...................... 9 TORISEL ............................ 7 torsemide inj ..................... 12 torsemide tabs .................. 12 TOVIAZ ............................. 24 TPN ELECTROLYTES ..... 27 TRACLEER ...................... 12 TRADJENTA .................... 18 tramadol hcl er .................... 1 TRAMADOL HCL ER .......... 1 TRAMADOL HCL ER (BIPHASIC) 100MG ............ 1 TRAMADOL HCL ER (BIPHASIC) 200MG ............ 1 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 trandolapril .......................... 9 tranexamic acid................. 25 TRANSDERM-SCOP ........ 22 tranylcypromine sulfate ..... 14 travasol 10 ........................ 27 TRAVATAN Z ................... 29 trazodone hcl .................... 14 TREANDA .......................... 7 TRECATOR ........................ 5 TRELSTAR DEPOT MIXJECT ............................ 8 TRELSTAR LA MIXJECT ... 8 TRELSTAR MIXJECT ......... 8


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tretinoin ......................... 8, 31 TRETINOIN MICROSPHERE ............... 31 tretin-x ............................... 31 trexall ................................ 25 TREXIMET ........................ 16 triamcinolone acetonide (mouth) ............................. 33 triamcinolone acetonide (nasal) ............................... 30 triamcinolone acetonide (topical) ............................. 33 triamterene & hydrochlorothiazide cap 37.5-25 mg ........................ 12 triamterene & hydrochlorothiazide cap 50-25 mg ........................... 12 triamterene & hydrochlorothiazide tab 37.5-25 mg ........................ 12 triamterene & hydrochlorothiazide tab 75-50 mg ........................... 12 TRIBENZOR .......................9 triderm ............................... 33 trifluoperazine hcl .............. 15 trifluridine .......................... 29 TRIGLIDE ......................... 10 trihexyphenidyl hcl ............ 14 tri-legest 28 day ................ 19 TRILEPTAL ....................... 13 trilyte ................................. 23 trimethoprim ........................3 trimipramine maleate ........ 14 TRINESSA ........................ 19 tri-previfem 28 day ............ 19 TRISENOX ..........................8 tri-sprintec 28 day ............. 19 trivora 28 day .................... 19 TROKENDI XR ................. 13 TROPHAMINE .................. 27 trospium chloride ............... 24 TRUVADA ...........................4 TUDORZA PRESSAIR ..... 30 TWINRIX ........................... 26 TYGACIL.............................3 TYKERB..............................8

TYPHIM VI ........................ 26 TYSABRI .......................... 16 TYVASO ........................... 12 TYZEKA .............................. 5 tyzine ................................ 30 U UCERIS ............................ 22 u-cort................................. 33 ULESFIA ........................... 33 ULORIC .............................. 1 ULTRESA ......................... 23 UNITHROID ...................... 21 UROCIT-K ........................ 23 ursodiol ............................. 23 UVADEX ............................. 8 V VAGIFEM .......................... 20 valacyclovir hcl .................... 5 VALCHLOR ...................... 33 VALCYTE ........................... 5 valproate sodium .............. 13 valproic acid ...................... 13 valsartan ............................. 9 valsartan-hydrochlorothiazide .......................................... 9 vancomycin hcl ................... 3 VANDAZOLE .................... 24 VANTAS ............................. 8 VAQTA .............................. 26 VARIVAX .......................... 26 VASCEPA ......................... 10 VECTIBIX ........................... 7 VELCADE ........................... 7 VELETRI ........................... 12 velivet 28 day .................... 19 VELPHORO ...................... 21 VELTIN ............................. 31 venlafaxine cap er ............. 14 venlafaxine tab .................. 14 VENLAFAXINE TAB 225MG ER ..................................... 14 venlafaxine tab er ............. 14 VENTAVIS ........................ 12 VENTOLIN HFA ................ 30 VERAMYST ...................... 31 verapamil hcl ..................... 11 VERAPAMIL HCL ............. 11 veripred ............................. 20

VERSACLOZ .................... 15 VESICARE ....................... 24 vestura .............................. 19 VEXOL .............................. 29 VIBATIV .............................. 3 VIBRAMYCIN ..................... 6 vicodin ................................ 2 vicodin es ............................ 2 vicodin hp ........................... 2 VICTOZA .......................... 17 VICTRELIS CAP 200MG .... 5 VIDEX PEDIATRIC ............. 4 VIGAMOX ......................... 29 VIIBRYD ........................... 14 VIMIZIM ............................ 20 VIMOVO ............................. 1 VIMPAT ............................ 13 vinblastine sulfate ............... 7 vincasar .............................. 7 vincristine sulfate ................ 7 vinorelbine tartrate .............. 7 VIOKACE 10440 UNIT ..... 23 VIOKACE 20880 UNIT ..... 23 viorele ............................... 19 VIRACEPT .......................... 4 VIRAMUNE ......................... 4 VIRAMUNE XR ................... 4 VIREAD .............................. 4 VISICOL ........................... 23 VIVELLE-DOT .................. 20 VIVITROL ......................... 16 VOGELXO ........................ 17 VOGELXO PUMP ............. 17 VOLTAREN GEL 1% ........ 33 voriconazole ....................... 4 voriconazole inj 200mg ....... 4 VOTRIENT ......................... 8 VPRIV ............................... 20 vyfemla ............................. 19 VYTORIN .......................... 10 VYVANSE ......................... 15 W warfarin sodium ................ 24 WELCHOL ........................ 10 X XALKORI ............................ 8 XARELTO ......................... 24 XARTEMIS XR ................... 2


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XELJANZ .......................... 25 XENAZINE ........................ 16 XEOMIN ............................ 29 XERESE ........................... 32 XGEVA ............................. 21 XIFAXAN TAB 200MG ........3 XIFAXAN TAB 550MG ...... 23 XOLAIR ............................. 30 XOPENEX HFA ................ 30 XTANDI ...............................8 xulane ............................... 19 XYREM ............................. 16 Y YERVOY .............................8 YF-VAX ............................. 26 Z zafirlukast .......................... 30 zaleplon ............................ 15 ZALTRAP ............................8 zamicet ...............................2 ZANOSAR ...........................7 zarah ................................. 19 ZAVESCA ......................... 20 zazole ............................... 24 ZAZOLE ............................ 24

ZEGERID .......................... 23 ZELAPAR ......................... 14 ZELBORAF ......................... 8 ZEMAIRA .......................... 30 ZEMPLAR ......................... 28 zenatane ........................... 31 zenchent 28 day ............... 19 zenchent fe 28 day ........... 19 ZENPEP ........................... 23 ZETIA ................................ 10 ZETONNA ......................... 31 ZIAGEN .............................. 4 ZIANA ............................... 31 zidovudine ........................... 4 ZINACEF ............................ 6 ZIOPTAN .......................... 29 ziprasidone hcl .................. 15 ZIPSOR .............................. 1 ZIRGAN ............................ 29 ZMAX .................................. 6 ZOLADEX ........................... 8 zoledronic inj 4mg ............. 18 zoledronic inj 4mg/5ml ...... 18 ZOLINZA ............................. 7 zolmitriptan ....................... 16

zolmitriptan odt ................. 16 zolpidem tartrate ............... 15 ZOLPIMIST ....................... 15 ZOMETA ........................... 18 ZOMIG NASAL SPRAY .... 16 ZONALON ........................ 32 zonisamide ....................... 13 ZONTIVITY ....................... 25 ZORBTIVE ........................ 21 ZORTRESS ...................... 26 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 26 ZOSYN ............................... 6 zovia 1/35e 28 day............ 19 zovia 1/50e 28 day............ 19 ZOVIRAX .......................... 32 ZUBSOLV ......................... 16 ZYCLARA ......................... 33 ZYDELIG ............................ 8 ZYFLO CR ........................ 30 ZYKADIA ............................ 8 ZYLET .............................. 28 ZYTIGA ............................... 8 ZYVOX ............................... 3

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