pdl list.xls 10/15/02 - favorite healthcare staffing drug list.pdfambien 10mg tablet pb ambien 5mg...

PDL list.xls 10/15/02MEDICATION G/P/NP B/G MAINT. GENERIC ALTERNATIVE PREFERRED BRAND ALTERNATIVE NOTES

A/B OTIC DROPS G GA/T/S 2% GEL G GA/T/S 2% TOPICAL SOLUTION NP B erythromycin topicalACCOLATE 10MG TABLET P B xACCOLATE 20MG TABLET P B xACCUNEB 0.21MG/ML SOLUTION NP B x albuterol solutionACCUPRIL 10MG TABLET P B xACCUPRIL 20MG TABLET P B xACCUPRIL 40MG TABLET P B xACCUPRIL 5MG TABLET P B xACCURETIC 10/12.5 P B xACCURETIC 20/12.5 P B xACCURETIC 20/25 P B xACCUTANE 10MG CAPSULE P BACCUTANE 20MG CAPSULE P BACCUTANE 40MG CAPSULE P BACEBUTOLOL 200MG CAPSULE G G xACEBUTOLOL 400MG CAPSULE G G xACEON 2MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinACEON 4MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinACEON 8MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinACETAMINOPHEN/COD #2 TABLET G GACETAMINOPHEN/COD #3 TABLET G G Quantity limitACETAMINOPHEN/COD #4 TABLET G GACETAMINOPHEN/COD ELIXIR G GACETASOL 2% EAR SOLUTION G GACETASOL HC EAR DROPS G GACETAZOLAMIDE 125MG TABLET G G xACETAZOLAMIDE 250MG TABLET G G xACETIC ACID W/HC EAR DROPS G GACHROMYCIN V 250MG CAPSULE G GACHROMYCIN V 500MG CAPSULE G GACI-JEL JELLY P BACIPHEX 20MG TABLET EC P B x Prior authorization after 12 weeks ACLOVATE 0.05% CREAM P BACLOVATE 0.05% OINTMENT P BACTICIN 5% CREAM G GACTIGALL 300MG CAPSULE NP B x urosodiolACTIQ LOZENGES NP B morphine sulfate SRACTIVELLA TABLETS P BACTONEL 30MG P BACTONEL 5MG P B xACTOS 15MG TABLET P B xACTOS 30MG TABLET P B xACTOS 45MG TABLET P B xACULAR 0.5% EYE DROPS P BACYCLOVIR 200MG CAPSULE G GACYCLOVIR 200MG/5ML SUSP G GACYCLOVIR 400MG TABLET G GACYCLOVIR 800MG TABLET G GADALAT CC 30MG TABLET SA NP B x nifedipine saADALAT CC 60MG TABLET SA NP B x nifedipine saADALAT CC 90MG TABLET SA NP B x nifedipine saADDERALL 10MG TABLET NP B x amphetamine mixADDERALL 12.5MG TABLET P B xADDERALL 15MG TABLET P B xADDERALL 20MG TABLET NP B x amphetamine mixADDERALL 30MG TABLET NP B x amphetamine mixADDERALL 5MG TABLET NP B x amphetamine mixADDERALL 7.5MG TABLET P B xADDERALL XR 5MG CAPSULE P B x

G=Generic, P=Preferred, NP=Non-preferred, B=Brand drug, G=Generic drug of 61


ADDERALL XR 10MG CAPSULE P B xADDERALL XR 15MG CAPSULE P B xADDERALL XR 20MG CAPSULE P B xADDERALL XR 25MG CAPSULE P B xADDERALL XR 30MG CAPSULE P B xADVAIR DISKUS 100-50MCG P B xADVAIR DISKUS 250-50MCG P B xADVAIR DISKUS 500-50MCG P B xADVICOR 20-500MG TABLET NP B x lovastatin and niacinADVICOR 20-750MG TABLET NP B x lovastatin and niacinADVICOR 20-1000MG TABLET NP B x lovastatin and niacinAEROBID AEROSOL W/ADAPTER NP B x Flovent, Pulmicort, Qvar AEROBID-M AEROSOL W/ADAPTER NP B x Flovent, Pulmicort, Qvar AGENERASE 150MG CAPSULE P B xAGGRENOX CAPSULE SA NP B x dipyridamole, PlavixAGRYLIN 0.5MG CAPSULE P B xAGRYLIN 1MG CAPSULE P B xAH-CHEW D TABLET CHEW P BAH-CHEW TABLET CHEW G GAKBETA 0.5% EYE DROPS G GAK-CIDE 0.5% EYE DROPS G GAKNE-MYCIN 2% OINTMENT P BAK-POLY-BAC EYE OINTMENT G GAK-PRED 1% EYE DROPS G GAK-SPORE EYE DROPS G GAK-SPORE EYE OINTMENT G GAK-SULF 10% EYE DROPS G GAKTOB 0.3% EYE DROPS G GAK-TROL EYE DROPS G GALAMAST 0.1% OPHTH. DROPS NP BALBALON LIQUIFILM 0.1% DROP NP B naphazolineALBUTEROL .83MG/ML SOLUTION G G xALBUTEROL 5MG/ML SOLUTION G G xALBUTEROL 90MCG INH G G x Quantity limitALBUTEROL SULF 2MG/5ML SYRP G G xALBUTEROL SULFATE 2MG TAB G G xALBUTEROL SULFATE 4MG TAB G G xALDACTAZIDE 25/25 TABLET NP B x spironolactone/hctzALDACTAZIDE 50/50 TABLET NP B x spironolactone/hctzALDACTONE 100MG TABLET NP B x spironolactone ALDACTONE 25MG TABLET NP B x spironolactone ALDACTONE 50MG TABLET NP B x spironolactone ALDARA 5% CREAM P BALDOMET 250MG TABLET NP B x methyldopaALDOMET 500MG TABLET NP B x methyldopaALESSE-21 TABLET P B x Covered by rider only.ALESSE-28 TABLET P B x Covered by rider only.ALLEGRA 180MG TABLET P BALLEGRA 30MG TABLET P B xALLEGRA 60MG CAPSULE P B xALLEGRA 60MG TABLET P B xALLEGRA-D TABLET SA P BALLERGEN EAR DROPS G GALLERX TABLET P BALLFEN-DM TABLET SA P BALLOPURINOL 100MG TABLET G G xALLOPURINOL 300MG TABLET G G xALOCRIL 2% EYE DROPS P BALOMIDE 0.1% EYE DROPS P BALORA 0.05MG PATCH P B xALORA 0.075MG PATCH P B x



ALORA 0.1MG PATCH P B xALPHAGAN 0.2% EYE DROPS P B xALPHAGAN-P 0.15% EYE DROPS NP B xALPRAZOLAM 0.25MG TABLET G GALPRAZOLAM 0.5MG TABLET G GALPRAZOLAM 1MG TABLET G GALPRAZOLAM 2MG TABLET G GALREX 0.2% EYE DROPS P BALTACE 1.25MG CAPSULE P B xALTACE 10MG CAPSULE P B xALTACE 2.5MG CAPSULE P B xALTACE 5MG CAPSULE P B xALTOCOR 10MG TABLET NP B x lovastatinALTOCOR 20MG TABLET NP B x lovastatinALTOCOR 40MG TABLET NP B x lovastatinALTOCOR 60MG TABLET NP B x lovastatinALUPENT 650MCG INHALER COMP NP B x albuterol Maxair Autohaler, Proventil HFAAMANTADINE 100MG CAPSULE G G xAMARYL 1MG TABLET P B xAMARYL 2MG TABLET P B xAMARYL 4MG TABLET P B xAMBIEN 10MG TABLET P BAMBIEN 5MG TABLET P BAMCINONIDE 0.1% CREAM G GAMERGE 1MG TABLET P B Quantity limitAMERGE 2.5MG TABLET P B Quantity limitAMERICAINE 20% EAR DROPS P BAMERIFED LIQUID NP BAMIBID DM TABLET SA G GAMIBID LA TABLET SA G GAMIDRINE CAPSULE G GAMIGESIC 500MG TABLET G GAMIGESIC 750MG CAPLET G GAMILORIDE HCL 5MG TABLET G G xAMILORIDE HCL/HCTZ 5/50 TAB G G xAMINO ACID CERVICAL CREAM G GAMINO-CERV CREAM P BAMINOPHYLLINE 200MG TABLET G G xAMIODARONE HCL 200MG TABLET G G xAMI-TEX CAPSULE G GAMI-TEX LA TABLET SA G GAMI-TEX PSE 600/120 TAB SA G GAMITRIP/CDP 12.5-5 TABLET G G xAMITRIP/CDP 25-10 TABLET G G xAMITRIP/PERPHEN 10-2 TABLET G G xAMITRIP/PERPHEN 25-2 TABLET G G xAMITRIP/PERPHEN 25-4 TABLET G G xAMITRIP/PERPHEN 50-4 TABLET G G xAMITRIPTYLINE HCL 100MG TAB G G xAMITRIPTYLINE HCL 10MG TAB G G xAMITRIPTYLINE HCL 150MG TAB G G xAMITRIPTYLINE HCL 25MG TAB G G xAMITRIPTYLINE HCL 50MG TAB G G xAMITRIPTYLINE HCL 75MG TAB G G xAMLACTIN 12% LOTION NP B laclotionAMLACTIN 12% CREAM G GAMLACTIN AP 1% CREAM NP BAMOXAPINE 100MG TABLET G G xAMOXICILLIN 125MG TAB CHEW G GAMOXICILLIN 125MG/5ML SUSP G GAMOXICILLIN 250MG CAPSULE G G



AMOXICILLIN 250MG TAB CHEW G GAMOXICILLIN 250MG/5ML SUSP G GAMOXICILLIN 500MG CAPSULE G GAMOXIL 125MG/5ML SUSPENSION G GAMOXIL 200MG/5ML SUSPENSION P BAMOXIL 250MG CAPSULE G GAMOXIL 250MG TABLET CHEW NP B amoxicillinAMOXIL 250MG/5ML SUSPENSION G GAMOXIL 400MG TABLET CHEW P BAMOXIL 400MG/5ML SUSPENSION P BAMOXIL 500MG CAPSULE G GAMOXIL 50MG/ML PED DROPS G GAMOXIL 875MG TABLET P BAMPHETAMINE SALT COMBO 5MG G G xAMPHETAMINE SALT COMBO 10MG G G xAMPHETAMINE SALT COMBO 20MG G G xAMPHETAMINE SALT COMBO 30MG G G xAMPICILLIN 125MG/5ML SUSP G GAMPICILLIN 250MG/5ML SUSP G GAMPICILLIN TR 250MG CAPSULE G GAMPICILLIN TR 500MG CAPSULE G GANAFRANIL 25MG CAPSULE NP B x clomipramineANAFRANIL 50MG CAPSULE NP B x clomipramineANA-KIT ANAPHYLAX EMERG KIT P BANALPRAM-HC 1% CREAM P BANALPRAM-HC 2.5% CREAM P BANAPLEX DM COUGH SYRUP P BANAPLEX HD LIQUID P BANAPROX 275MG TABLET NP B x naproxen sodium Quantity limitANAPROX DS 550MG TABLET NP B x naproxen sodium Quantity limitANDRODERM 2.5MG/24HR PATCH P B xANDRODERM 5MG/24HR PATCH P B xANDROGEL 1% (25MG) NP B AndrodermANDROGEL 1% (50MG) NP B AndrodermANDROID 10MG CAPSULE NP B x testosteroneANEMAGEN CAPSULE G GANEMAGEN FA CAPSULE G GANSAID 100MG TABLET NP B flurbiprofen Quantity limitANTABUSE 250MG TABLET P B xANTIBIOTIC EAR SOLUTION G GANTIBIOTIC EAR SUSPENSION G GANTIBIOTIC HC EAR SOLUTION G GANTIPYR/BENZOCAINE EAR DROP G GANTISPASMODIC ELIXIR G GANTIVERT 12.5MG TABLET NP B meclizineANTIVERT 25MG TABLET NP B meclizineANUCORT-HC 25MG SUPPOSITORY G GANUSOL-HC 2.5% CREAM NP B hydrocortisone rectal productsANUSOL-HC 25MG SUPPOSITORY NP B hydrocortisone rectal productsANZEMET 100MG TABLET NP B Kytril, Zofran Quantity limitAPAP/ISOMETHEP/DICHLPHEN CP G GAPHTHASOL 5% PASTE P BAPRI TABLET G G Covered by rider only.AQUABID-DM TABLET SA G GAQUATAB C TABLET SA NP B guiafenesin/decongestant productsAQUATAB D TABLET SA NP B guiafenesin/decongestant productsAQUATAB DM TABLET SA NP B guaifenesin/dextromethorphan productsAQUATAB DM SYRUP NP B guaifenesin/dextromethorphan productsARALEN PHOSPHATE 500MG TAB NP B chloroquineARAVA 10MG TABLET NP B x methotrexateARAVA 20MG TABLET NP B x methotrexate



ARICEPT 10MG TABLET P B xARICEPT 5MG TABLET P B xARIMIDEX 1MG TABLET P B xARISTOCORT 0.1% OINTMENT NP B triamcinoloneARISTOCORT A 0.1% CREAM P BARIXTRA 2.5MG/0.5ML SYRINGE NP B LovenoxARMOUR THYROID 120MG TABLET P B xARMOUR THYROID 15MG TABLET P B xARMOUR THYROID 180MG TABLET P B xARMOUR THYROID 240MG TABLET P B xARMOUR THYROID 300MG TABLET P B xARMOUR THYROID 30MG TABLET P B xARMOUR THYROID 60MG TABLET P B xARMOUR THYROID 90MG TABLET P B xAROMASIN 25MG TABLET NP B xARTANE 5MG TABLET NP B x trihexiphenidylARTHROTEC 50 TABLET EC NP B x generic NSAID's Quantity limitARTHROTEC 75 TABLET EC NP B x generic NSAID's Quantity limitASACOL 400MG TABLET EC P B xASPIRIN/CODEINE 325/30 TAB G GASTELIN 137MCG NASAL SPRAY P BATACAND 16MG TABLET P B xATACAND 32MG TABLET P B xATACAND 4MG TABLET P B xATACAND 8MG TABLET P B xATACAND HCT 16-12.5MG TABLET P B xATACAND HCT 32-12.5MG TABLET P B xATARAX 10MG/5ML SYRUP NP B hydroxyzine HClATARAX 25MG TABLET NP B hydroxyzine HClATENOLOL 100MG TABLET G G xATENOLOL 25MG TABLET G G xATENOLOL 50MG TABLET G G xATENOLOL/CHLORTHAL 100/25 G G xATENOLOL/CHLORTHAL 50/25 G G xATIVAN 0.5MG TABLET NP B lorazepamATIVAN 1MG TABLET NP B lorazepamATIVAN 2MG TABLET NP B lorazepamATROHIST PEDIATRIC CAPSULE P BATROHIST PEDIATRIC SUSP D/F P BATROHIST PLUS TABLET SA P BATROPINE 1% EYE DROPS G GATROVENT 0.02% SOLUTION NP B x ipratropiumATROVENT 0.03% SPRAY P B xATROVENT 0.06% SPRAY P B xATROVENT INHALER P B xATUSS DM LIQUID P BATUSS EX LIQUID G GATUSS EX SYRUP P BATUSS G SYRUP P BATUSS HD LIQUID G GATUSS MS LIQUID P BATUSS MS SYRUP G GAUGMENTIN 125-31.25 SUSPEN P BAUGMENTIN 200-28.5 SUSPEN P BAUGMENTIN 200-28.5 TAB CHEW P BAUGMENTIN 250-125 TABLET P BAUGMENTIN 250-62.5 SUSPEN P BAUGMENTIN 250-62.5 TAB CHEW P BAUGMENTIN 400-57 SUSPEN P BAUGMENTIN 400-57 TAB CHEW P BAUGMENTIN 500-125 TABLET P B



AUGMENTIN 875-125 TABLET P BAUGMENTIN XR 1000-62.5 NP BAURALGAN EAR DROPS P BAUROTO EAR DROPS G GAVALIDE 150-12.5MG TABLET P B xAVALIDE 300-12.5MG TABLET P B xAVANDIA 2MG TABLET P B xAVANDIA 4MG TABLET P B xAVANDIA 8MG TABLET P B xAVAPRO 150MG TABLET P B xAVAPRO 300MG TABLET P B xAVAPRO 75MG TABLET P B xAVC 15% CREAM P BAVELOX 400MG TABLET NP B Cipro, Levaquin, TequinAVINZA 30MG CAPSULE NP BAVINZA 60MG CAPSULE NP BAVINZA 90MG CAPSULE NP BAVINZA 120MG CAPSULE NP BAVITA 0.025% CREAM NP B tretinoinAVITA 0.025% GEL P BAXERT 6.25MG TABLET P BAXERT 12.5MG TABLET P BAXID 150MG PULVULE NP B x nizatidineAXID 300MG PULVULE NP B x nizatidineAXOCET CAPSULE NP B Phrenilin ForteAYGESTIN 5MG TABLET NP B x norethindroneAZATHIOPRINE 50MG TABLET G G xAZELEX 20% CREAM P BAZMACORT INHALER NP B x Flovent, Pulmicort, Qvar AZOPT 1% EYE DROPS P BAZULFIDINE 500MG TABLET NP B x sulfasalazineAZULFIDINE ENTAB 500MG NP B x sulfasalazineB & O SUPPRETTES NO.15-A P BBACIT/POLYMYXIN EYE OINT G GBACITRACIN 500U/GM EYE OINT G GBACLOFEN 10MG TABLET G G xBACLOFEN 20MG TABLET G G xBACTRIM 400-80MG TABLET NP B sulfamethoxazole/trimethoprimBACTRIM DS TABLET NP B sulfamethoxazole/trimethoprimBACTRIM SUSPENSION NP B sulfamethoxazole/trimethoprimBACTROBAN 2% CREAM P BBACTROBAN 2% OINTMENT P BBECLOVENT INHALER NP B x Flovent, Pulmicort, Qvar BECONASE 42MCG INHALER NP B x Flonase, Nasacort, Nasonex, RhinocortBECONASE AQ 0.042% SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortBEEPEN VK 250MG TABLET G GBEEPEN-VK 500MG TABLET G GBELLADONNA/PHENOBARB ELIXIR G GBELLADONNA/PHENOBARB TABLET G GBELLAMINE-S TABLET G GBELLASPAS TABLET G GBELLERGAL-S TABLET P BBEL-PHEN-ERGOT S TABLET G GBEL-TABS TABLET G GBENICAR 5MG TABLET NP B x Atacand, Avapro, DiovanBENICAR 20MG TABLET NP B x Atacand, Avapro, DiovanBENICAR 40MG TABLET NP B x Atacand, Avapro, DiovanBENTYL 10MG CAPSULE NP B dicyclomineBENTYL 10MG/5ML SYRUP P BBENTYL 20MG TABLET NP B dicyclomineBENZAC 10% GEL P B



BENZAC 5% GEL P BBENZAC AC 10% GEL P BBENZAC AC 2.5% GEL P BBENZAC AC 5% GEL P BBENZAC AC WASH 10% LIQUID P BBENZAC AC WASH 5% LIQUID P BBENZAC W 10% GEL P BBENZAC W 5% GEL P BBENZAC W WASH 5% LIQUID P BBENZACLIN GEL NP B BenzamycinBENZAMYCIN GEL P BBENZASHAVE 10 CREAM G GBENZASHAVE 5 CREAM G GBENZONATATE 100MG CAPSULE G GBENZONATATE 200MG CAPSULE G GBENZOYL PEROXIDE 10% GEL G GBENZOYL PEROXIDE 10% WASH G GBENZOYL PEROXIDE 2.5% GEL G GBENZOYL PEROXIDE 5% GEL G GBENZOYL PEROXIDE 5% WASH G GBENZTROPINE MES 0.5MG TAB G G xBENZTROPINE MES 1MG TABLET G G xBENZTROPINE MES 2MG TABLET G G xBEROCCA TABLET P BBETAGAN 0.25% EYE DROPS NP B x levobunololBETAGAN 0.5% EYE DROPS NP B x levobunololBETAMETHASONE DP 0.05% CRM G GBETAMETHASONE DP 0.05% LOT G GBETAMETHASONE DP 0.05% OINT G GBETAMETHASONE VA 0.1% CREAM G GBETAMETHASONE VA 0.1% LOT G GBETAMETHASONE VA 0.1% OINT G GBETAPACE 120MG TABLET NP B x sotalolBETAPACE 160MG TABLET NP B x sotalolBETAPACE 240MG TABLET NP B x sotalolBETAPACE 80MG TABLET NP B xBETAPACE AF 120MG TABLET P B xBETAPACE AF 160MG TABLET P B xBETAPACE AF 80MG TABLET P B xBETA-VAL 0.1% CREAM G GBETA-VAL 0.1% LOTION G GBETHANECHOL 25MG TABLET G GBETHANECHOL 50MG TABLET G GBETHANECHOL 5MG TABLET G GBETIMOL 0.25% EYE DROPS P B xBETIMOL 0.5% EYE DROPS P B xBETOPTIC S 0.25% EYE DROPS P B xBEXTRA 10MG TABLET NP B x generic NSAID'sBEXTRA 20MG TABLET NP B x generic NSAID'sBIAXIN 125MG/5ML SUSPENSION P BBIAXIN 250MG TABLET P BBIAXIN 250MG/5ML SUSPENSION P BBIAXIN 500MG TABLET P BBIAXIN XL 500MG TABLET P BBICITRA SOLUTION P BBIDEX 800MG TABLET SA P BBIDEX DM TABLET SA P BBIOHIST-LA TABLET P BBISOPROLOL 5MG TABLET G G xBLEPH-10 10% EYE DROPS NP B sulfacetamide sodiumBLEPHAMIDE 0.2% EYE DROPS P B



BLEPHAMIDE 0.2% EYE OINT P BBLOCADREN 5MG TABLET NP B x timololBOCA-TEX LA TABLET SA G GB-PLEX PLUS TABLET G GBRETHAIRE NP B x albuterol Maxair Autohaler, Proventil HFA Quantity limitBRETHINE 2.5MG TABLET NP B x terbutalineBRETHINE 5MG TABLET NP B x terbutalineBREVICON 28 TABLET P B x Covered by rider only.BREVOXYL 4% CLEANSING LOT P BBREVOXYL 4% GEL P BBREVOXYL 8% GEL P BBREVOXYL-8 CLEANSING LOTION P BBREVOXYL-8 CREAMY WASH P BBROMANATE-DC COUGH SYRUP G GBROMATANE DX COUGH SYRUP G GBROMFED CAPSULE SA P BBROMFED TABLET P BBROMFED-DM COUGH SYRUP NP B Bromonate DXBROMFED-PD CAPSULE SA P BBROMFENEX CAPSULE SA G GBROMFENEX-PD CAPSULE SA G GBROMOCRIPTINE 2.5MG TABLET G G xBROMOCRIPTINE 5MG CAPSULE G G xBROMOPHED DX SYRUP G GBROMPHENIRAMINE DC SYRUP G GBROMPHENR/P-EPHED 12/120 CP G GBROMPHENR/P-EPHED 6/60 CAP G GBRONCHOLATE SYRUP P BBRONTEX TABLET P BBUMETANIDE 0.5MG TABLET G G xBUMETANIDE 1MG TABLET G G xBUMETANIDE 2MG TABLET G G xBUMEX 0.5MG TABLET NP B x bumetanideBUMEX 1MG TABLET NP B x bumetanideBUMEX 2MG TABLET NP B x bumetanideBUPAP TABLET G GBUPROPION HCL 100MG TABLET G G xBUPROPION HCL 75MG TABLET G G xBUSPAR 10MG TABLET NP B x buspironeBUSPAR 15MG TABLET NP B x buspironeBUSPAR 30MG TABLET NP B x buspironeBUSPAR 5MG TABLET NP B x buspironeBUTALBITAL COMP/COD #3 CAP G G Quantity limitBUTALBITAL COMPOUND CAPSULE G GBUTALBITAL COMPOUND TABLET G GBUTALBITAL/APAP/CAFFEINE TB G GBUTISOL SODIUM 50MG TABLET P BBUTORPHANOL 10MG/ML NS G GCAFERGOT SUPPOSITORY P BCALAN SR 120MG CAPLET SA NP B x verapamil SACALAN SR 180MG CAPLET SA NP B x verapamil SACALAN SR 240MG CAPLET SA NP B x verapamil SACALDEROL 20MCG CAPSULE P B xCANASA 500MG SUPPOSITORY NP B x Rowasa SuppositoryCAPITAL W/CODEINE ORAL SUSP P BCAPITROL 2% SHAMPOO P BCAPOTEN 100MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinCAPOTEN 12.5MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinCAPOTEN 25MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinCAPOTEN 50MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinCAPOZIDE 25/15 TABLET NP B x captopril/hctz, enalapril/hctz, lisinopril/hctz Accuretic, Lotensin HCT



CAPOZIDE 25/25 TABLET NP B x captopril/hctz, enalapril/hctz, lisinopril/hctz Accuretic, Lotensin HCTCAPOZIDE 50/15 TABLET NP B x captopril/hctz, enalapril/hctz, lisinopril/hctz Accuretic, Lotensin HCTCAPOZIDE 50/25 TABLET NP B x captopril/hctz, enalapril/hctz, lisinopril/hctz Accuretic, Lotensin HCTCAPTOPRIL 100MG TABLET G G xCAPTOPRIL 12.5MG TABLET G G xCAPTOPRIL 25MG TABLET G G xCAPTOPRIL 50MG TABLET G G xCAPTOPRIL/HCTZ 25/15 TABLET G G xCAPTOPRIL/HCTZ 25/25 TABLET G G xCAPTOPRIL/HCTZ 50/15 TABLET G G xCAPTOPRIL/HCTZ 50/25 TABLET G G xCARAFATE 1GM TABLET NP B x sucralfateCARAFATE 1GM/10ML SUSP P B xCARBAMAZEPINE 100MG TAB CHW G G xCARBAMAZEPINE 200MG TABLET G G xCARBATROL 200MG CAPSULE SA P B xCARBATROL 300MG CAPSULE SA P B xCARBATUSS SYRUP P BCARBIDOPA/LEVO 10/100 TAB G G xCARBIDOPA/LEVO 25/100 TAB G G xCARBIDOPA/LEVO 25/100 TB SA G G xCARBIDOPA/LEVO 25/250 TAB G G xCARBIDOPA/LEVO 50/200 TB SA G G xCARBINOXAMINE COMPOUND DROP G GCARBINOXAMINE COMPOUND SYRP G GCARBINOXAMINE DROPS G GCARBINOXAMINE SYRUP G GCARBODEC DROPS G GCARBOFED-DM DROPS G GCARBOFED-DM SYRUP G GCARDEC DROPS G GCARDEC SYRUP G GCARDEC-DM DROPS G GCARDEC-DM SYRUP G GCARDEC-S SYRUP G GCARDENE 20MG CAPSULE NP B x nicardipineCARDENE SR 30MG CAPSULE SA NP B x nifedipine xr Adalat CC, Norvasc, PlendilCARDENE SR 45MG CAPSULE SA NP B x nifedipine xr Adalat CC, Norvasc, PlendilCARDIZEM CD 120MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM CD 180MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM CD 240MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM CD 300MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM CD 360MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM SR 120MG CAP SA NP B x diltiazem HCl SR 24hr TiazacCARDIZEM SR 60MG CAPSULE SA NP B x diltiazem HCl SR 12hrCARDIZEM SR 90MG CAPSULE SA NP B x diltiazem HCl SR 12hrCARDURA 1MG TABLET NP B x doxazosinCARDURA 2MG TABLET NP B x doxazosinCARDURA 4MG TABLET NP B x doxazosinCARDURA 8MG TABLET NP B x doxazosinCARISOPRODOL 350MG TABLET G GCARISOPRODOL COMPOUND TAB G GCARISOPRODOL CPD/CODEINE TB G GCARMOL 40 CREAM P BCARNITOR 100MG/ML ORAL SOLN P BCARTEOLOL HCL 1% EYE DROPS G G xCARTIA XT 120MG CAPSULE SA G G xCARTIA XT 180MG CAPSULE SA G G xCARTIA XT 240MG CAPSULE SA G G xCARTIA XT 300MG CAPSULE SA G G xCASODEX 50MG TABLET P B x



CATAFLAM 50MG TABLET NP B x diclofenac Quantity limitCATAPRES 0.1MG TABLET NP B x clonidine oral tabsCATAPRES 0.2MG TABLET NP B x clonidine oral tabsCATAPRES 0.3MG TABLET NP B x clonidine oral tabsCATAPRES-TTS 1 PATCH P B x clonidine oral tabsCATAPRES-TTS 2 PATCH P B x clonidine oral tabsCATAPRES-TTS 3 PATCH P B x clonidine oral tabsCAVERJECT 10MCG KIT NP B not applicable not applicable Prior authorization; quantity limitCAVERJECT 20MCG KIT NP B not applicable not applicable Prior authorization; quantity limitCAVERJECT 40MCG VIAL NP B not applicable not applicable Prior authorization; quantity limitC-COF HC LIQUID G GC-COF XP LIQUID G GCECLOR 250MG PULVULE NP B cefaclor Cefzil, OmnicefCECLOR CD 375MG TABLET SA NP B cefaclor Cefzil, OmnicefCECLOR CD 500MG TABLET SA P B Cefzil, OmnicefCEDAX 400MG CAPSULE NP B cefaclor Cefzil, OmnicefCEDAX 90MG/5ML SUSPENSION NP B cefaclor Cefzil, OmnicefCEENU 100MG CAPSULE P BCEENU 40MG CAPSULE P BCEFACLOR 125MG/5ML SUSPEN G GCEFACLOR 187MG/5ML SUSPEN G GCEFACLOR 250MG CAPSULE G GCEFACLOR 250MG/5ML SUSPEN G GCEFACLOR 375MG/5ML SUSPEN G GCEFACLOR 500MG CAPSULE G GCEFADROXIL 500MG CAPSULE G GCEFOL FILMTAB P BCEFTIN 125MG/5ML ORAL SUSP NP B cefaclor Cefzil, OmnicefCEFTIN 250MG TABLET NP B cefaclor Cefzil, OmnicefCEFTIN 250MG/5ML ORAL SUSP NP B cefaclor Cefzil, OmnicefCEFTIN 500MG TABLET NP B cefaclor Cefzil, OmnicefCEFZIL 125MG/5ML SUSPENSION P BCEFZIL 250MG TABLET P BCEFZIL 250MG/5ML SUSPENSION P BCEFZIL 500MG TABLET P BCELEBREX 100MG CAPSULE NP B x generic NSAID's Quantity limitCELEBREX 200MG CAPSULE NP B x generic NSAID's Quantity limitCELESTONE 0.6MG TABLET P BCELEXA 20MG TABLET P B xCELEXA 40MG TABLET P B xCELLCEPT 250MG CAPSULE P B xCELLCEPT 500MG TABLET P B xCENESTIN 0.3MG TABLET P B xCENESTIN 0.625MG TABLET P B xCENESTIN 0.9MG TABLET P B xCEPHALEXIN 125MG/5ML SUSPEN G GCEPHALEXIN 250MG CAPSULE G GCEPHALEXIN 250MG/5ML SUSPEN G GCEPHALEXIN 500MG CAPSULE G GCEPHALEXIN 500MG TABLET P BCEPHRADINE 250MG CAPSULE G GCEPHRADINE 500MG CAPSULE G GCERUMENEX 10% EAR DROPS P BCERVICAL AMINO ACID CREAM G GCHEMET 100MG CAPSULE P BCHERATUSSIN AC SYRUP G GCHERATUSSIN DAC SYRUP G GCHLORAL HYDRATE G GCHLORDIAZEPOXIDE 10MG CAP G GCHLORDIAZEPOXIDE 25MG CAP G GCHLORDIAZEPOXIDE 5MG CAP G G



CHLORDRINE CAPSULE SA G GCHLORHEXIDINE 0.12% RINSE G GCHLOROPTIC 0.5% EYE DROPS P BCHLOROQUINE 500MG TABLET G G xCHLOROTHIAZIDE 250MG TABLET G G xCHLOROTHIAZIDE 500MG TABLET G G xCHLORPHEDRINE SR CAPSULE SA G GCHLORPHENIRAMINE 12MG CP SA G GCHLORPROMAZINE 100MG TABLET G G xCHLORPROMAZINE 10MG TABLET G G xCHLORPROMAZINE 25MG TABLET G G xCHLORPROMAZINE 50MG TABLET G G xCHLORPROPAMIDE 100MG TABLET G G xCHLORPROPAMIDE 250MG TABLET G G xCHLORTHALIDONE 100MG TABLET G G xCHLORTHALIDONE 25MG TABLET G G xCHLORTHALIDONE 50MG TABLET G G xCHLORZOXAZONE 500MG CAPLET G GCHOLESTYRAMINE LIGHT POWDER G G xCHOLESTYRAMINE POWDER G G xCHOLINE MAG TRISAL 1GM TAB G G Quantity limitCHROMAGEN CAPSULE P BCHROMAGEN FA CAPSULE P BCHROMAGEN FORTE CAPSULE P BCHROMAGEN OB CAPSULE P BCILOXAN 0.3% EYE DROPS P BCILOXAN 0.3% OINTMENT P BCIMETIDINE 200MG TABLET G G xCIMETIDINE 300MG TABLET G G xCIMETIDINE 300MG/5ML LIQUID G G xCIMETIDINE 400MG TABLET G G xCIMETIDINE 800MG TABLET G G xCINOBAC 250MG CAPSULE NP B Cipro, Levaquin, TequinCIPRO 10% SUSPENSION P BCIPRO 100MG TABLET P BCIPRO 250MG TABLET P BCIPRO 500MG TABLET P BCIPRO 750MG TABLET P BCIPRO HC OTIC SUSPENSION P BCLARINEX 5 MG TABLET NP B x Allegra, Zyrtec Syrup, Astelin Nasal SprayCLARITIN 10MG REDI-TABS NP B x Allegra, Zyrtec Syrup, Astelin Nasal SprayCLARITIN 10MG TABLET NP B x Allegra, Zyrtec Syrup, Astelin Nasal SprayCLARITIN 10MG/10ML SYRUP NP B x Zyrtec Syrup, Allegra 30mg TabletCLARITIN-D 12 HOUR TAB SA NP B Allegra-DCLARITIN-D 24 HOUR TAB SA NP B Allegra-DCLEOCIN 2% VAGINAL CREAM P BCLEOCIN 75MG/5ML GRANULES P BCLEOCIN HCL 150MG CAPSULE NP B clindamycinCLEOCIN HCL 300MG CAPSULE P BCLEOCIN T 1% GEL P BCLEOCIN T 1% LOTION P BCLEOCIN T 1% PLEDGETS P BCLEOCIN T 1% SOLUTION NP B clindamycin topical solutionCLIDINIUM/CDP CAPSULE G GCLIMARA 0.025MG/DAY PATCH NP B x estridiol patchCLIMARA 0.05MG/DAY PATCH NP B x estridiol patchCLIMARA 0.075MG/DAY PATCH NP B x estridiol patchCLIMARA 0.1MG/DAY PATCH NP B x estridiol patchCLINDAMYCIN HCL 150MG CAPS G GCLINDAMYCIN PH 1% SOLUTION G GCLINDETS 1% PLEDGETS P B



CLOBETASOL 0.05% CREAM G GCLOBETASOL 0.05% GEL G GCLOBETASOL 0.05% OINTMENT G GCLOBETASOL 0.05% SOLUTION G GCLODERM 0.1% CREAM P BCLOMIPRAMINE 25MG CAPSULE G G xCLOMIPRAMINE 50MG CAPSULE G G xCLOMIPRAMINE 75MG CAPSULE G G xCLONAZEPAM 0.5MG TABLET G G xCLONAZEPAM 1MG TABLET G G xCLONAZEPAM 2MG TABLET G G xCLONIDINE HCL 0.1MG TABLET G G xCLONIDINE HCL 0.2MG TABLET G G xCLONIDINE HCL 0.3MG TABLET G G xCLORAZEPATE 15MG TABLET G GCLORAZEPATE 3.75MG TABLET G GCLORAZEPATE 7.5MG TABLET G GCLORPRES 0.1/15 TABLET G G xCLORPRES 0.2/15 TABLET G G xCLOTRIMAZOLE 1% CREAM G GCLOZARIL 100MG TABLET NP B x clozapineCLOZARIL 25MG TABLET NP B x clozapineCODAL-DH SYRUP G GCODAL-DM SYRUP G GCODAMINE SYRUP G GCODEINE SULFATE 30MG TABLET G GCODICLEAR DH SYRUP P BCODIMAL DH SYRUP P BCODIMAL LA CAPSULE SA P BCODITUSS DH SYRUP G GCODOTUSS LIQUID G GCOGENTIN 1MG TABLET NP B x benztropineCOLAZAL 750MG CAPSULE NP BCOLCHICINE 0.5MG TABLET G GCOLCHICINE 0.6MG TABLET G GCOLESTID 1GM TABLET P B xCOLESTID FLAVORED GRANULES P B xCOL-PROBENECID TABLET G GCOLREX COMPOUND CAPSULE P BCOLY-MYCIN S EAR DROPS P BCOLYTE FLAVORED SOLUTION NP B PEG/electrolytesCOLYTE SOLUTION NP B PEG/electrolytesCOMBIPATCH .05/.14MG PATCH P B xCOMBIPATCH .05/.25MG PATCH P B xCOMBIVENT INHALER P B xCOMBIVIR TABLET P B xCOMPAZINE 25MG SUPPOSITORY NP B prochlorperazineCOMPAZINE 5MG SUPPOSITORY P BCOMPAZINE 5MG/5ML SYRUP P BCOMPAZINE SPANSULE 10MG P BCOMPAZINE SPANSULE 15MG P BCOMTAN 200MG TABLET P B xCONCERTA 18MG SA TABLET P B xCONCERTA 36MG SA TABLET P B xCONCERTA 54MG SA TABLET P B xCONDYLOX 0.5% GEL NP B AldaraCONDYLOX 0.5% TOPICAL SOLN NP B AldaraCONSTULOSE 10GM/15ML SYRUP G GCONTRIN CAPSULE G GCORDARONE 200MG TABLET NP B x amiodaroneCORDRAN 0.05% LOTION P B



CORDRAN 4MCG/SQ CM TAPE P BCORDRAN SP 0.05% CREAM P BCOREG 12.5MG TABLET P B xCOREG 25MG TABLET P B xCOREG 3.125MG TABLET P B xCOREG 6.25MG TABLET P B xCORGARD 20MG TABLET NP B x nadololCORGARD 40MG TABLET NP B x nadololCORGARD 80MG TABLET NP B x nadololCORMAX 0.05% CREAM NP B clobetasol propionateCORMAX 0.05% OINTMENT NP B clobetasol propionateCORMAX 0.05% SOLUTION G GCORTANE-B AQUEOUS DROPS G GCORTANE-B EAR LOTION P BCORTANE-B OTIC DROPS G GCORTEF 10MG TABLET P BCORTEF 10MG/5ML ORAL SUSP P BCORTEF 20MG TABLET P BCORTEF 5MG TABLET P BCORTENEMA 100MG ENEMA NP B hydrocortisone enemaCORTIFOAM 10% AEROSOL P BCORTISONE 10MG TABLET P BCORTISONE 25MG TABLET G GCORTISPORIN CREAM P BCORTISPORIN EAR SOLUTION NP B neomycin/polymixin-B/HCCORTISPORIN EAR SUSPENSION NP B neomycin/polymixin-B/HCCORTISPORIN EYE DROPS P BCORTISPORIN EYE OINTMENT P BCORTISPORIN OINTMENT P BCORTISPORIN-TC EAR SUSP P BCORTOMYCIN EAR SOLUTION G GCORZIDE 5/40 TABLET P B xCORZIDE 5/80 TABLET P B xCOSOPT EYE DROPS P B xCOTAZYM CAPSULE P BCOTRIM DS TABLET G GCOUMADIN 10MG TABLET P B xCOUMADIN 1MG TABLET P B xCOUMADIN 2.5MG TABLET P B xCOUMADIN 2MG TABLET P B xCOUMADIN 3MG TABLET P B xCOUMADIN 4MG TABLET P B xCOUMADIN 5MG TABLET P B xCOUMADIN 6MG TABLET P B xCOUMADIN 7.5MG TABLET P B xCOVERA-HS 180MG TABLET SA NP B x verapamil SACOVERA-HS 240MG TABLET SA NP B x verapamil SACOZAAR 100MG TABLET NP B x Atacand, Avapro, DiovanCOZAAR 25MG TABLET NP B x Atacand, Avapro, DiovanCOZAAR 50MG TABLET NP B x Atacand, Avapro, DiovanCREON 10 CAPSULE EC P BCREON 20 CAPSULE SA P BCRINONE 8% GEL P BCRIXIVAN 100MG CAPSULE P B xCRIXIVAN 200MG CAPSULE P B xCRIXIVAN 400MG CAPSULE P B xCROLOM 4% EYE DROPS NP B cromolyn eye dropsCROMOLYN 4% EYE DROPS G GCROMOLYN NEBULIZER SOLUTION G GCROMOLYN SODIUM 4% EYE DROP G GCUPRIMINE 250MG CAPSULE P B



CUTIVATE 0.005% OINTMENT P BCUTIVATE 0.05% CREAM P BCYCLESSA 7-7-7 TABLET NP B xCYCLOBENZAPRINE 10MG TABLET G GCYCLOCORT 0.1% CREAM NP B amcinonide 0.1% creamCYCLOCORT 0.1% LOTION P BCYCLOCORT 0.1% OINTMENT P BCYCLOGYL 1% EYE DROPS NP B cyclopentolateCYCLOSPORINE 25MG CAPSULE G G xCYCLOSPORINE 100MG CAPSULE G G xCYCRIN 10MG TABLET G G xCYCRIN 2.5MG TABLET G G xCYCRIN 5MG TABLET G G xCYDEC DROPS G GCYDEC-DM DROPS G GCYLERT 18.75MG TABLET NP B x pemolineCYLERT 37.5MG TABLET NP B x pemolineCYLERT 37.5MG TABLET CHEW NP B x pemolineCYLERT 75MG TABLET NP B x pemolineCYNDAL EXPECTORANT G GCYNDAL HD SYRUP G GCYNTEX LIQUID G GCYPROHEPTADINE 2MG/5ML SYRUP G GCYPROHEPTADINE 4MG TABLET G GCYSTOSPAZ 0.15MG TABLET P BCYTOMEL 25MCG TABLET P B xCYTOMEL 50MCG TABLET P B xCYTOMEL 5MCG TABLET P B xCYTOTEC 100MCG TABLET NP B x misoprostilCYTOTEC 200MCG TABLET NP B x misoprostilCYTOVENE 250MG CAPSULE P BCYTOVENE 500MG CAPSULE P BCYTOXAN 25MG TABLET P BCYTOXAN 50MG TABLET P BCYTUSS HC SYRUP G GD.A. CHEWABLE TABLET P BD.A. II TABLET SA P BDALLERGY CAPLET SA G GDALLERGY SYRUP P BDALLERGY-JR CAPSULE SA G GDALMANE 15MG CAPSULE NP B flurazepamDALMANE 30MG CAPSULE NP B flurazepamD-AMINE-SR CAPSULE SA G GDANAZOL 100MG CAPSULE G GDANAZOL 200MG CAPSULE G GDANAZOL 50MG CAPSULE G GDANOCRINE 100MG CAPSULE NP B danazolDANOCRINE 200MG CAPSULE NP B danazolDANOCRINE 50MG CAPSULE NP B danazolDANTRIUM 100MG CAPSULE P BDANTRIUM 25MG CAPSULE P BDAPSONE 100MG TABLET P B xDAPSONE 25MG TABLET P B xDARVOCET-N 100 TABLET NP B propoxyphene naps./apap Quantity limitDARVOCET-N 50 TABLET NP B propoxyphene naps./apap Quantity limitDARVON 65MG PULVULE NP B propoxyphene HClDARVON CMPD-65 NP B propoxyphene/asa/caffeineDAYPRO 600MG CAPLET NP B x oxaprozin Quantity limitDDAVP 0.01% NASAL SPRAY NP B x desmopressinDDAVP 0.1MG TABLET P B xDDAVP 0.2MG TABLET P B x



DECADRON 0.1% EYE DROPS NP B dexamethasoneDECADRON 0.75MG TABLET NP B dexamethasoneDECADRON 4MG TABLET NP B dexamethasoneDECOHISTINE DH LIQUID G GDECOHISTINE EXPECTORANT G GDECONAMINE SR CAPSULE SA P BDECONAMINE SYRUP DYE-FREE P BDECONAMINE TABLET DYE-FREE P BDECONGESTANT SR CAPSULE SA G GDECONGESTANT SR TABLET G GDECONGESTANT TABLET SA G GDE-CONGESTINE TR CAPSULE SA G GDECONHIST LA TABLET SA G GDECONOMED SR CAPSULE SA G GDECONSAL II TABLET SA P BDELTASONE 10MG TABLET G GDELTASONE 2.5MG TABLET G GDELTASONE 20MG TABLET G GDELTASONE 50MG TABLET G GDELTASONE 5MG TABLET G GDEMADEX 100MG TABLET NP B x bumetanide, furosemideDEMADEX 10MG TABLET NP B x bumetanide, furosemideDEMADEX 20MG TABLET NP B x bumetanide, furosemideDEMEROL 100MG TABLET NP B meperidine DEMEROL 50MG TABLET NP B meperidine DEMULEN 1/35-21 TABLET P B x Covered by rider only.DEMULEN 1/35-28 TABLET P B x Covered by rider only.DEMULEN 1/50-28 TABLET P B x Covered by rider only.DENAVIR 1% CREAM P BDENAVIR 1% CREAM P B xDEPAKENE 250MG/5ML SYRUP P B xDEPAKOTE 125MG SPRINKLE CAP P B xDEPAKOTE 125MG TABLET EC P B xDEPAKOTE 250MG TABLET EC P B xDEPAKOTE 500MG TABLET EC P B xDERMA-SMOOTHE/FS ATOPIC PAK P BDERMA-SMOOTHE/FS OIL P BDERMATOP 0.1% OINTMENT P BDERMATOP EMOLLIENT 0.1% CRM P BDESAL-II TABLET SA G GDESIPRAMINE 100MG TABLET G G xDESIPRAMINE 10MG TABLET G G xDESIPRAMINE 150MG TABLET G G xDESIPRAMINE 25MG TABLET G G xDESIPRAMINE 50MG TABLET G G xDESMOPRESSIN 0.1MG/ML SPRAY G G xDESOGEN 28 DAY TABLET P B x Covered by rider only.DESONIDE 0.05% CREAM G GDESONIDE 0.05% OINTMENT G GDESOWEN 0.05% CREAM NP B desonide creamDESOWEN 0.05% LOTION P BDESOWEN 0.05% OINTMENT NP B desonide ointmentDESOXIMETASONE 0.05% CREAM G GDESOXIMETASONE 0.05% GEL G GDESOXIMETASONE 0.25% CREAM G GDESOXIMETASONE 0.25% OINT G GDESOXYN 5MG TABLET P BDESQUAM-E 2.5% GEL P BDESQUAM-E 5% GEL P BDESQUAM-X 10% GEL P BDESQUAM-X 10% WASH P B



DESYREL 100MG TABLET NP B x trazodoneDESYREL 150MG TABLET NP B x trazodoneDESYREL 300MG TABLET NP B x trazodoneDETROL 1MG TABLET P B xDETROL 2MG TABLET P B xDETROL LA 2MG CAPSULE SA P B xDETROL LA 4MG CAPSULE SA P B xDETUSSIN SOLUTION G GDEXACIDIN EYE DROPS G GDEXAMETHASONE 0.1% EYE DROP G GDEXAMETHASONE 0.25MG TABLET P BDEXAMETHASONE 0.5MG TABLET G GDEXAMETHASONE 0.5MG/5ML ELX G GDEXAMETHASONE 0.75MG TABLET G GDEXAMETHASONE 1MG TABLET P BDEXAMETHASONE 4MG TABLET G GDEXASPORIN EYE DROPS G GDEXEDRINE 5MG TABLET NP B dextroamphetamineDEXEDRINE SPANSULE 10MG P BDEXEDRINE SPANSULE 15MG P BDEXEDRINE SPANSULE 5MG P BDEXTROAMPHETAMINE 10MG TABLET G GDEXTROSTAT 10MG TABLET NP B dextroamphetamineDEXTROSTAT 5MG TABLET G GDHT 0.2MG TABLET P BDIABETA 1.25MG TABLET NP B x glyburideDIABETA 2.5MG TABLET NP B x glyburideDIABETA 5MG TABLET NP B x glyburideDIAMOX 250MG TABLET NP B x acetazolamideDIAMOX SEQUELS 500MG CAP SA P B xDIASTAT 5MG PEDI SYSTEM P BDIAZEPAM 10MG TABLET G GDIAZEPAM 2MG TABLET G GDIAZEPAM 5MG TABLET G GDICLOFENAC 0.1% EYE DROPS G GDICLOFENAC POT 50MG TABLET G G x Quantity limitDICLOFENAC SOD 100MG TAB SA G G x Quantity limitDICLOFENAC SOD 25MG TAB EC G G x Quantity limitDICLOFENAC SOD 50MG TAB EC G G x Quantity limitDICLOFENAC SOD 75MG TAB EC G G x Quantity limitDICLOXACILLIN 250MG CAPSULE G GDICLOXACILLIN 500MG CAPSULE G GDICOMAL-DH SYRUP G GDICYCLOMINE 10MG CAPSULE G GDICYCLOMINE 20MG TABLET G GDIDRONEL 200MG TABLET P B xDIDRONEL 400MG TABLET P B xDIFFERIN 0.1% GEL P BDIFFERIN 0.1% SOLUTION P BDIFLORASONE 0.05% CREAM G GDIFLORASONE 0.05% OINTMENT G GDIFLUCAN 100MG TABLET P B Prior authorization.DIFLUCAN 10MG/ML SUSPENSION P BDIFLUCAN 150MG TABLET P B Quantity limitDIFLUCAN 200MG TABLET P B Prior authorization.DIFLUCAN 40MG/ML SUSPENSION P BDIFLUCAN 50MG TABLET P B Prior authorization.DIFLUNISAL 250MG TABLET G G x Quantity limitDIFLUNISAL 500MG TABLET G G x Quantity limitDIGITEK 125MCG TABLET P G xDIGITEK 250MCG TABLET P G x



DIGOXIN 125MCG TABLET G G xDIGOXIN 250MCG TABLET G G xDIGOXIN 50MCG/ML ELIXIR G G xDIHISTINE DH LIQUID G GDIHISTINE EXPECTORANT GDILACOR XR 120MG CAPSULE SA NP B x diltiazem HCl SR 24hr TiazacDILACOR XR 180MG CAPSULE SA NP B x diltiazem HCl SR 24hr TiazacDILACOR XR 240MG CAPSULE SA NP B x diltiazem HCl SR 24hr TiazacDILANTIN 100MG KAPSEAL P B xDILANTIN 30MG KAPSEAL P B xDILANTIN 50MG INFATAB P B xDILATRATE-SR 40MG CAPSULE P B xDILAUDID 2MG TABLET NP B hydromorphoneDILAUDID 4MG TABLET NP B hydromorphoneDILTIA XT 120MG CAPSULE SA G G xDILTIA XT 180MG CAPSULE SA G G xDILTIA XT 240MG CAPSULE SA G G xDILTIAZEM 120MG CAPSULE SA G G xDILTIAZEM 30MG TABLET G G xDILTIAZEM 60MG CAPSULE SA G G xDILTIAZEM 60MG TABLET G G xDILTIAZEM 90MG CAPSULE SA G G xDILTIAZEM 90MG TABLET G G xDILTIAZEM ER 120MG CAP SA G G xDILTIAZEM ER 180MG CAP SA G G xDILTIAZEM ER 240MG CAP SA G G xDILTIAZEM ER 60MG CAP SA G G xDILTIAZEM HCL 120MG CAP SA G G xDILTIAZEM HCL 180MG CAP SA G G xDILTIAZEM HCL 240MG CAP SA G G xDILTIAZEM HCL 300MG CAP SA G G xDILTIAZEM XR 120MG CAP SA G G xDILTIAZEM XR 180MG CAP SA G G xDILTIAZEM XR 240MG CAP SA G G xDIOVAN 40MG TABLET P B xDIOVAN 80MG TABLET P B xDIOVAN 160MG TABLET P B xDIOVAN 320MG TABLET P B xDIOVAN 160MG CAPSULE P B xDIOVAN 80MG CAPSULE P B xDIOVAN HCT 160/12.5MG TAB P B xDIOVAN HCT 160/25MG TAB P B xDIOVAN HCT 80/12.5MG TABLET P B xDIPENTUM 250MG CAPSULE P B xDIPHENHYDRAMINE 50MG CAPS G GDIPHENOXYLATE/ATROPINE TAB G GDIPIVEFRIN 0.1% EYE DROPS G GDIPROLENE 0.05% GEL P BDIPROLENE 0.05% LOTION P BDIPROLENE 0.05% OINTMENT NP B betamethasone diprop ointDIPROLENE AF 0.05% CREAM P BDIPYRIDAMOLE 25MG TABLET G G xDIPYRIDAMOLE 50MG TABLET G G xDIPYRIDAMOLE 75MG TABLET G G xDISALCID 500MG TABLET NP B salsalateDISALCID 750MG TABLET NP B salsalateDISOPYRAMIDE 100MG CAPSULE G G xDISOPYRAMIDE 150MG CAP SA G G xDISOPYRAMIDE 150MG CAPSULE G G xDISULFIRAM 250MG TABLET G G xDISULFIRAM 500MG TABLET G G x



DITROPAN 5MG TABLET NP B x oxybutininDITROPAN 5MG/5ML SYRUP NP B x oxybutininDITROPAN XL 10MG TABLET SA NP B x oxybutinin DetrolDITROPAN XL 15MG TABLET SA NP B x oxybutinin DetrolDITROPAN XL 5MG TABLET SA NP B x oxybutinin DetrolDOLOBID 250MG TABLET NP B x diflunisalDOLOBID 500MG TABLET NP B x diflunisalDOMEBORO EAR DROPS NP B acetic acid/aluminmum acetate dropsDONATUSSIN DC SYRUP P BDONATUSSIN PEDIATRIC DROPS P BDONATUSSIN SYRUP P BDONNAPINE ELIXIR G GDONNATAL CAPSULE P BDONNATAL ELIXIR P BDONNATAL EXTENTABS P BDONNATAL TABLET P BDORAL 15MG TABLET NP B Ambien, SonataDORYX 100MG CAPSULE EC NP B doxycyclineDOSTINEX 0.5MG TABLET P BDOVONEX 0.005% CREAM P BDOVONEX 0.005% OINTMENT P BDOVONEX 0.005% SOLUTION P BDOXAZOSIN 1MG TABLET G G xDOXAZOSIN 2MG TABLET G G xDOXAZOSIN 4MG TABLET G G xDOXAZOSIN 8MG TABLET G G xDOXEPIN 100MG CAPSULE G G xDOXEPIN 10MG CAPSULE G G xDOXEPIN 150MG CAPSULE G G xDOXEPIN 25MG CAPSULE G G xDOXEPIN 50MG CAPSULE G G xDOXEPIN 75MG CAPSULE G G xDOXYCYCLINE 100MG CAPSULE G GDOXYCYCLINE 100MG TABLET G GDOXYCYCLINE 50MG CAPSULE G GDRISDOL 50000IU CAPSULE P BDRITHO-SCALP 0.5% CREAM P BDRITUSS DM ELIXIR G GDRITUSS HD ELIXIR G GDRIXOMED TABLET SA G GDRYSOL DAB-O-MATIC SOLUTION P BDRYSOL SOLUTION P BDUONEB SOLUTION NP B x albuterol and ipatropiumDUPHALAC 10GM/15ML SYRUP G GDURADAL HD PLUS LIQUID G GDURADAL HD SYRUP G GDURADRIN CAPSULE G GDURADRYL SYRUP G GDURAGESIC 100MCG/HR PATCH NP B morphine sulf ext. release Oxycontin Quantity limitDURAGESIC 25MCG/HR PATCH NP B morphine sulf ext. release Oxycontin Quantity limitDURAGESIC 50MCG/HR PATCH NP B morphine sulf ext. release Oxycontin Quantity limitDURAGESIC 75MCG/HR PATCH NP B morphine sulf ext. release Oxycontin Quantity limitDURAHISTINE DM SYRUP G GDURASAL II TABLET SA G GDURATEX CAPSULE G GDURATUSS 600/120 TABLET SA P BDURATUSS DM ELIXIR P BDURATUSS G 1200MG TABLET SA P BDURATUSS GP TABLET SA P BDURATUSS HD ELIXIR P BDURA-VENT 600/75 TABLET SA P B



DURA-VENT 900/75 TABLET SA P BDURA-VENT/DA TABLET SA P BDURICEF 125MG/5ML ORAL SUSP P BDURICEF 1GM TABLET P BDURICEF 250MG/5ML ORAL SUSP P BDURICEF 500MG CAPSULE NP B cefadroxil 500mg capsule DURICEF 500MG/5ML ORAL SUSP P BDYAZIDE 37.5/25 CAPSULE NP B x triamterenee/hctzDYNABAC 250MG TABLET EC NP B erythromycinDYNACIN 100MG CAPSULE NP B minocyclineDYNACIN 50MG CAPSULE NP B minocyclineDYNACIN 75MG CAPSULE P BDYNACIRC 2.5MG CAPSULE NP B x Adalat CC, Norvasc, PlendilDYNACIRC 5MG CAPSULE NP B x Adalat CC, Norvasc, PlendilDYNACIRC CR 10MG TABLET SA NP B x Adalat CC, Norvasc, PlendilDYNACIRC CR 5MG TABLET SA NP B x Adalat CC, Norvasc, PlendilDYNAHIST ER CAPSULE SA G GDYNEX TABLET P BDYPHYLLINE/GUAIFENESIN TAB G GE.E.S. 200MG/5ML GRANULES P BE.E.S. 200MG/5ML SUSPENSION G GE.E.S. 400 FILMTAB G GEAR-GESIC DROPS G GEASPRIN 975MG TABLET EC NP B aspirin ec EC-NAPROSYN 375MG TABLET EC NP B x naproxen ec Quantity limitEC-NAPROSYN 500MG TABLET EC NP B x naproxen ec Quantity limitECONOPRED 0.125% EYE DROPS P BECONOPRED PLUS 1% EYE DROPS NP B prednisolone acetate 1%EDECRIN 25MG TABLET P B xEDECRIN 50MG TABLET P B xED-FLEX CAPSULE G GEFFEXOR 100MG TABLET NP B x Effexor XREFFEXOR 25MG TABLET NP B x Effexor XREFFEXOR 37.5MG TABLET NP B x Effexor XREFFEXOR 50MG TABLET NP B x Effexor XREFFEXOR 75MG TABLET NP B x Effexor XREFFEXOR XR 150MG CAPSULE SA P B xEFFEXOR XR 37.5MG CAP SA P B xEFFEXOR XR 75MG CAPSULE SA P B xEFLONE 0.1% EYE DROPS G GEFUDEX 2% SOLUTION P BEFUDEX 5% CREAM P BELAVIL 10MG TABLET NP B x amitriptylineELAVIL 25MG TABLET NP B x amitriptylineELAVIL 50MG TABLET NP B x amitriptylineELDEPRYL 5MG CAPSULE NP B x selegilineELDOQUIN FORTE 4% CREAM P BELIDEL 1% CREAM P BELIMITE 5% CREAM NP B ActicinELMIRON 100MG CAPSULE P BELOCON 0.1% CREAM P BELOCON 0.1% LOTION P BELOCON 0.1% OINTMENT P BEMADINE 0.05% EYE DROPS P BEMBELINE E 0.05% CREAM G GEMBELINE 0.05% OINTMENT G GEMBELINE 0.05% SOLUTION G GEMGEL 2% TOPICAL GEL NP B erythromycinEMLA ANESTHETIC DISC P BEMLA CREAM P BEMLA CREAM W/TEGADERM P B



E-MYCIN 250MG TABLET EC P BE-MYCIN 333MG TABLET EC NP B erythromycinENALAPRIL 10MG TABLET G GENALAPRIL 2.5MG TABLET G GENALAPRIL 20MG TABLET G GENALAPRIL 5MG TABLET G GENBREL 25MG KIT P B x Prior authorizationENDAL-HD LIQUID P BENDAL-HD SYRUP P BENDOCET 5/325 TABLET G GENDODAN 4.88/325 TABLET G GENDURON 5MG TABLET NP B x methyclothiazideENDURONYL TABLET P B xENDURONYL FORTE TABLET P B xENFAMIL NATALINS RX TABLET P BENPLUS-HD LIQUID G GENTAC LIQUID G GENTEX CAPSULE NP B multiple generic versionsENTEX LA TABLET SA NP B multiple generic versionsENTEX LIQUID NP B multiple generic versionsENTEX PSE 600/120 TABLET SA NP B multiple generic versionsENTOCORT EC 3MG CAPSULE P BENULOSE 10GM/15ML SYRUP G GEPIFOAM FOAM P BEPIPEN 0.3MG AUTO-INJECTOR P BEPIPEN JR 0.15MG AUTO-INJCT P BEPITOL 200MG TABLET G G xEPIVIR 150MG TABLET P B xEPIVIR HBV 100MG TABLET P B xEQUAGESIC TABLET G GEQUANIL 400MG TABLET NP B meprobamateERCAF TABLET G GERY 2% PADS G GERYC 250MG CAPSULE EC NP B erythromycinERYCETTE 2% PLEDGETS NP B erythromycinERYMAX 2% TOPICAL SOLUTION NP B erythromycinERYPED 200MG TABLET CHEW P BERYPED 200MG/5ML GRANULES NP B erythromycinERY-TAB 250MG TABLET EC P BERY-TAB 333MG TABLET EC P BERY-TAB 500MG TABLET EC P BERYTHROCIN 250MG FILMTAB G GERYTHROCIN 500MG FILMTAB G GERYTHROMYCIN 2% GEL G GERYTHROMYCIN 2% PLEDGETS G GERYTHROMYCIN 2% TOPICAL SOL G GERYTHROMYCIN 200MG/5ML SUSP G GERYTHROMYCIN 250MG CAP EC G GERYTHROMYCIN 250MG FILMTAB P BERYTHROMYCIN 400MG/5ML SUSP G GERYTHROMYCIN 500MG FILMTAB P BERYTHROMYCIN ES 400MG TAB G GERYTHROMYCIN EST 125MG/5ML G GERYTHROMYCIN EST 250MG CAP G GERYTHROMYCIN EST 250MG/5ML P BERYTHROMYCIN EYE OINTMENT G GERYTHROMYCIN ST 250MG TAB G GERYTHROMYCIN ST 500MG TAB G GERYTHROMYCIN/SULFISOX SUSP G GESCLIM 0.025MG PATCH P B xESCLIM 0.0375MG PATCH G G x



ESCLIM 0.05MG PATCH G G xESCLIM 0.075MG PATCH G G xESCLIM 0.1MG PATCH G G xESGIC CAPSULE NP B butalbitial/apap/caffieneESGIC PLUS CAPSULE P BESGIC TABLET NP B butalbitial/apap/caffieneESGIC-PLUS TABLET NP B ZebutalESKALITH 300MG CAPSULE NP B x lithium carbonateESKALITH CR 450MG TABLET SA P B xESTAZOLAM 1MG TABLET G GESTAZOLAM 2MG TABLET G GESTINYL 0.02MG TABLET P B xESTINYL 0.05MG TABLET P B xESTRACE 0.01% CREAM P BESTRACE 0.5MG TABLET NP B x estradiolESTRACE 1MG TABLET NP B x estradiolESTRACE 2MG TABLET NP B x estradiolESTRADERM 0.05MG PATCH P B xESTRADERM 0.1MG PATCH P B xESTRADIOL 0.05MG/DAY PATCH G G xESTRADIOL 0.1MG/DAY PATCH G G xESTRADIOL 0.5MG TABLET G G xESTRADIOL 1MG TABLET G G xESTRADIOL 2MG TABLET G G xESTRATAB 0.3MG TABLET P B xESTRATAB 0.625MG TABLET P B xESTRATAB 2.5MG TABLET P B xESTRATEST H.S. TABLET P B xESTRATEST TABLET P B xESTRING 2MG VAGINAL RING P B xESTROPIPATE 0.625 TABLET G G xESTROPIPATE 1.25 TABLET G G xESTROPIPATE 2.5 TABLET G G xESTROSTEP FE-28 TABLET P B x Covered by rider only.ETHMOZINE 200MG TABLET P B xETHOSUXIMIDE 250MG/5ML SYRP G G xETODOLAC 200MG CAPSULE G G x Quantity limitETODOLAC 300MG CAPSULE G G x Quantity limitETODOLAC 400MG TABLET G G x Quantity limitETODOLAC 500MG TABLET G G x Quantity limitEULEXIN 125MG CAPSULE NP B x flutamideEURAX 10% CREAM P BEURAX 10% LOTION P BEVISTA 60MG TABLET P B xEXELDERM 1% CREAM P BEXELDERM 1% SOLUTION P BEXELON 1.5MG CAPSULE P B xEXELON 2MG/ML ORAL SOLN P B xEXELON 3MG CAPSULE P B xEXELON 4.5MG CAPSULE P B xEXELON 6MG CAPSULE P B xEXGEST LA TABLET SA P BEXTENDRYL CHEWABLE TABLET G GEXTENDRYL JR CAPSULE SA P BEXTENDRYL SR CAPSULE SA G GEXTENDRYL SYRUP P BFAMVIR 125MG TABLET NP B acyclovir ValtrexFAMVIR 250MG TABLET NP B acyclovir ValtrexFAMVIR 500MG TABLET NP B acyclovir ValtrexFARESTON 60MG TABLET P BFELBATOL 400MG TABLET P B x



FELBATOL 600MG TABLET P B xFELBATOL 600MG/5ML SUSP P B xFELDENE 20MG CAPSULE NP B x piroxicam Quantity limitFEMARA 2.5MG TABLET P B xFEMHRT 1/5 TABLET P B xFENESIN 600MG TABLET SA G GFENESIN DM TABLET SA G GFENOPROFEN 600MG TABLET G GFEROCON CAPSULE G GFERO-FOLIC-500 FILMTAB P BFERREX 150 CAPSULE G GFERREX 150 FORTE CAPSULE G GFE-TINIC 150 FORTE CAPSULE G GFIORICET TABLET NP B butalbital/apap/caffeineFIORICET W/CODEINE CAPSULE P BFIORINAL CAPSULE NP B butalbital/asa/caffeineFIORINAL/CODEINE #3 CAPSULE NP B butalbital/asa/caffeine/codeineFIORPAP TABLET G GFIORTAL CAPSULE G GFIORTAL/CODEINE #3 CAPSULE G GFIV-ASA 500MG SUPPOSITORY P B xFLAGYL 250MG TABLET NP B metronidazoleFLAGYL 375 CAPSULE NP B metronidazoleFLAGYL 500MG TABLET NP B metronidazoleFLAGYL ER 750MG TABLET SA NP B metronidazoleFLECAINIDE 50MG TABLET G G xFLECAINIDE 100MG TABLET G G xFLECAINIDE 150MG TABLET G G xFLEXERIL 10MG TABLET NP B cyclobenzaprineFLEXTRA-DS TABLET P BFLOMAX 0.4MG CAPSULE SA P B xFLONASE 0.05% NASAL SPRAY P B xFLORINEF ACETATE 0.1MG TABS NP B x fludrocortisoneFLOVENT 100MCG ROTADISK P B xFLOVENT 110MCG INHALER P B xFLOVENT 220MCG INHALER P B xFLOVENT 250MCG ROTADISK P B xFLOVENT 44MCG INHALER P B xFLOVENT 50MCG ROTADISK P B xFLOXIN 0.3% EAR DROPS P BFLOXIN 200MG TABLET NP B Cipro, Levaquin, TequinFLOXIN 300MG TABLET NP B Cipro, Levaquin, TequinFLOXIN 400MG TABLET NP B Cipro, Levaquin, TequinFLUDROCORTISONE 0.1MG TABS G G xFLUMADINE 100MG TABLET P BFLUOCINOLONE 0.01% SOLUTION G GFLUOCINOLONE 0.025% CREAM G GFLUOCINOLONE 0.025% OINT G GFLUOCINONIDE 0.05% CREAM G GFLUOCINONIDE 0.05% GEL G GFLUOCINONIDE 0.05% OINTMENT G GFLUOCINONIDE 0.05% SOLUTION G GFLUOCINONIDE-E 0.05% CREAM G GFLUORIDE 1MG TABLET CHEW G GFLUOROMETHOLONE 0.1% DROPS G GFLUOR-OP 0.1% EYE DROPS G GFLUOROPLEX 1% CREAM P BFLUOXETINE 20MG/5ML SOLUTION G G xFLUOXETINE 10MG CAPSULES G G xFLUOXETINE 20MG CAPSULES G G xFLUOXETINE 40MG CAPSULES G G x



FLUOXYMESTERONE 10MG TABLET G GFLUPHENAZINE 1MG TABLET G G xFLUPHENAZINE 2.5MG TABLET G G xFLUPHENAZINE 5MG TABLET G G xFLURAZEPAM 15MG CAPSULE G GFLURAZEPAM 30MG CAPSULE G GFLURBIPROFEN 100MG TABLET G G x Quantity limitFLURBIPROFEN 50MG TABLET G G x Quantity limitFLUTAMIDE 125MG CAPSULE G G xFLUVOXAMINE 25MG TABLET G G xFLUVOXAMINE 50MG TABLET G G xFLUVOXAMINE 100MG TABLET G G xFML FORTE 0.25% EYE DROPS P BFML LIQUIFILM 0.1% EYE DROP NP B fluorometholoneFML S.O.P. 0.1% OINTMENT P BFOCALIN 2.5MG TABLET NP BFOCALIN 5MG TABLET NP BFOCALIN 10MG TABLET NP BFOLGARD RX 2.2 TABLET P BFOLIC ACID 1MG TABLET G G xFOLTRIN CAPSULE G GFORADIL 12MCG CAP W/ INHALER P BFORMULA B PLUS TABLET G GFORTOVASE 200MG SOFTGEL CAP P B xFOSAMAX 10MG TABLET P B xFOSAMAX 35MG TABLET P B xFOSAMAX 40MG TABLET P B xFOSAMAX 5MG TABLET P B xFOSAMAX 70MG TABLET P B xFROVA 2.5MG TABLET NP B Amerge, Axert, Imitrex, Maxalt, Zomig Quantity limitFS SHAMPOO P BFULVICIN U/F 500MG TABLET P BFURADANTIN 25MG/5ML SUSP P BFUROSEMIDE 10MG/ML SOLUTION G G xFUROSEMIDE 20MG TABLET G G xFUROSEMIDE 40MG TABLET G G xFUROSEMIDE 80MG TABLET G G xFUROXONE 50MG/15ML LIQUID P BGABITRIL 12MG FILMTAB P B xGABITRIL 2MG TABLET P B xGABITRIL 4MG FILMTAB P B xGANI-TUSS NR LIQUID G GGANI-TUSS-DM NR LIQUID G GGANTRISIN PED 500MG/5ML SUS P BGARAMYCIN 3MG/ML EYE DROPS NP B gentamicinGASTROCROM 100MG/5ML CONC P BGEL-KAM 0.63% DENTAL RINSE P BGEMFIBROZIL 600MG TABLET G G xGENERLAC 10GM/15ML SOLUTION G GGENORA 0.5/35-28 TABLET G G x Covered by rider only.GENTAK 3MG/GM EYE OINTMENT G GGENTAK 3MG/ML EYE DROPS G GGENTAMICIN 0.1% CREAM G GGENTAMICIN 0.1% OINTMENT G GGENTAMICIN 3MG/ML EYE DROPS G GGG 200 NR TABLET G GGLEEVEC 100MG CAPSULE B P xGLIPIZIDE 10MG TABLET G G xGLIPIZIDE 5MG TABLET G G xGLUCAGON 1MG EMERGENCY KIT P BGLUCOPHAGE 1000MG TABLET NP B x metformin



GLUCOPHAGE 500MG TABLET NP B x metforminGLUCOPHAGE 850MG TABLET NP B x metforminGLUCOPHAGE XR 500MG TABLET P B xGLUCOTROL 10MG TABLET NP B x glipizideGLUCOTROL 5MG TABLET NP B x glipizideGLUCOTROL XL 10MG TABLET SA P B xGLUCOTROL XL 2.5MG TAB SA P B xGLUCOTROL XL 5MG TABLET SA P B xGLUCOVANCE 1.25MG/250MG TABLET P B xGLUCOVANCE 2.5MG/500MG TABLET P B xGLUCOVANCE 5MG/500MG TABLET P B xGLYBURIDE 1.25MG TABLET G G xGLYBURIDE 2.5MG TABLET G G xGLYBURIDE 5MG TABLET G G xGLYBURIDE MICRO 3MG TABLET G G xGLYBURIDE MICRO 6MG TABLET G G xGLYNASE 1.5MG PRESTAB NP B x glyburide, micronizedGLYNASE 3MG PRESTAB NP B x glyburide, micronizedGLYNASE 6MG PRESTAB NP B x glyburide, micronizedGLYSET 50MG TABLET NP B x PrecoseGOLYTELY SOLUTION NP B PEG/electrolytesG-PHED CAPSULE SA G GG-PHED-PD CAPSULE SA G GGRIFULVIN V 125MG/5ML SUSP P BGRIFULVIN V 250MG TABLET P BGRIFULVIN V 500MG TABLET P BGRISACTIN 250MG CAPSULE P BGRISACTIN 500MG TABLET P BGRISEOFULVIN 500MG TABLET G GGRISEOFULVIN ULTRA 250MG TB G GGRIS-PEG 250MG TABLET NP B griseofulvin ultramicrosizeGUAIBID DM TABLET SA G GGUAIBID LA CAPLET SA G GGUAIFED CAPSULE SA P BGUAIFED-PD CAPSULE SA P BGUAIFEN PSE 600/120 CPLT SA G GGUAIFEN/P-EPHED TABLET SA G GGUAIFEN/P-EPHED/COD SYRUP G GGUAIFEN/P-PROP 400/75 TB SA G GGUAIFENESIN 1200MG TAB SA G GGUAIFENESIN 200MG TABLET G GGUAIFENESIN 600MG TABLET SA G GGUAIFENESIN DM TABLET SA G GGUAIFENESIN LA 600MG CAPLET G GGUAIFENESIN W/CODEINE LIQ G GGUAIFENESIN W/CODEINE SYRUP G GGUAIFENESIN/CODEINE TABLET G GGUAIFENESIN/D-METHORPHAN TB G GGUAIFENESIN/P-EPHED CAP SA G GGUAIFENESIN/P-EPHEDRINE TAB G GGUAIFENESIN/PPA CAPLET SA G GGUAIFENESIN-P-PD CAPSULE SA G GGUAIFENEX DM TABLET SA G GGUAIFENEX G 1200MG TAB SA G GGUAIFENEX LA 600MG TAB SA G GGUAIFENEX LA CAPLET SA G GGUAIFENEX PPA 75 TABLET SA G GGUAIFENEX PSE 600/120 TB SA G GGUAIFENEX PSE 600/60 TAB SA G GGUAIFENEX-RX 14 TAB SR SEQ G GGUAIFENEX-RX DM TABLET SA G G



GUAIFEN-PSE 600/120 CPLT SA G GGUAIMAX-D TABLET SA G GGUAIPAX 400/75 TABLET SA G GGUAIPAX PSE 600/120 TAB SA G GGUAIVENT 600/75 TABLET SA G GGUAIVENT CAPSULE SA G GGUAI-VENT/PSE 120/600 TB SA G GGUAIVENT-PD CAPSULE SA G GGUAL-CO LIQUID G GGUANABENZ ACETATE 4MG TAB G G xGUANABENZ ACETATE 8MG TAB G G xGUANFACINE 1MG TABLET G G xGUANFACINE 2MG TABLET G G xGUIADRINE DM TABLET SA G GGUIADRINE G-1200 TABLET SA G GGUIADRINE PSE 600/120 TB SA G GGUIATEX PSE 600/120 CPTB SA G GGUIATUSS AC SYRUP G GGUIATUSS DAC SYRUP G GGYNODIOL 0.5MG TABLET G G xGYNODIOL 1.5MG TABLET P B xGYNODIOL 1MG TABLET G G xGYNODIOL 2MG TABLET G G xH 9600 SR TABLET SA G GHALCION 0.125MG TABLET NP B triazolamHALCION 0.25MG TABLET NP B triazolamHALDOL DECANOATE 100 VIAL NP B haloperidol decanoateHALOG 0.1% CREAM P BHALOG 0.1% OINTMENT P BHALOPERIDOL 0.5MG TABLET G GHALOPERIDOL 10MG TABLET G G xHALOPERIDOL 1MG TABLET G G xHALOPERIDOL 2MG TABLET G G xHALOPERIDOL 5MG TABLET G G xHALOPERIDOL LAC 2MG/ML CONC G G xHALOTESTIN 10MG TABLET P B xHALOTESTIN 2MG TABLET P B xHALOTUSSIN-AC LIQUID G GHALOTUSSIN-DAC LIQUID S/F G GH-C TUSSIVE SYRUP G GHC TUSSIVE-D SOLUTION G GH-CORTISONE/IODOQUINOL CRM G GHCTZ 12.5MG CAPSULE G G xHELIDAC THERAPY P BHEMOCYTE PLUS TABULE P BHEMOCYTE-F TABLET P BHEMORRHOIDAL HC 25MG SUPPOS G GHISTADE CAPSULE SA G GHISTA-VENT DA TABLET SA G GHISTEX HC LIQUID P BHISTEX PD PEDIATRIC LIQUID P BHISTEX SR TABLET SA P BHISTINEX D SOLUTION G GHISTINEX DM SYRUP G GHISTINEX HC SYRUP G GHISTINEX PV SYRUP G GHISTUSSIN D SOLUTION P BHISTUSSIN HC SYRUP P BHIVID 0.750MG TABLET P B xHMS LIQUIFILM 1% EYE DROPS P BHOMATROPINE 5% EYE DROPS G G x



HT-TUSS DM ELIXIR G GHUMALOG 100U/ML CARTRIDGE P B xHUMALOG 100U/ML PEN P B xHUMALOG 100U/ML VIAL P B xHUMALOG MIX 75/25 PEN P B xHUMIBID DM SPRINKLE P BHUMIBID DM TABLET SA P BHUMIBID L.A. TABLET SA P BHUMIBID PEDIATRIC CAPSULE P BHUMIBID SPRINKLE CAPSULE P BHUMULIN 50/50 P B xHUMULIN 70/30 P B xHUMULIN L P B xHUMULIN N P B xHUMULIN R P B xHUMULIN U P B xHYCODAN SYRUP NP B hydrocodone cmpd cough syrupHYCODAN TABLET NP B TussigonHYCOMINE COMPOUND TABLET P BHYCOMINE SYRUP P BHYCOSIN EXPECTORANT G GHYCOTUSS EXPECTORANT P BHYDRALAZINE 100MG TABLET G G xHYDRALAZINE 10MG TABLET G G xHYDRALAZINE 25MG TABLET G G xHYDRALAZINE 50MG TABLET G G xHYDRALAZINE/HCTZ 25/25 CAP G G xHYDROCHLOROTHIAZIDE 25MG TB G G xHYDROCHLOROTHIAZIDE 50MG TB G G xHYDROCODONE COMPOUND SYRUP G GHYDROCODONE CP SYRUP G GHYDROCODONE GF SYRUP G GHYDROCODONE HD SYRUP G GHYDROCODONE PA SYRUP G GHYDROCODONE W/APAP ELIXIR G GHYDROCODONE/APAP 10/500 TAB G G Quantity limitHYDROCODONE/APAP 10/650 TAB G G Quantity limitHYDROCODONE/APAP 2.5/500 TB G G Quantity limitHYDROCODONE/APAP 5/500 TAB G G Quantity limitHYDROCODONE/APAP 7.5/500 TB G G Quantity limitHYDROCODONE/APAP 7.5/650 TB G G Quantity limitHYDROCODONE/APAP 7.5/750 TB G G Quantity limitHYDROCODONE/GUAIFENESIN SYR G GHYDROCORTISONE 0.2% CREAM G GHYDROCORTISONE 0.2% OINT G GHYDROCORTISONE 100MG ENEMA G GHYDROCORTISONE 2.5% CREAM G GHYDROCORTISONE 2.5% LOTION G GHYDROCORTISONE 2.5% OINT G GHYDROCORTISONE 20MG TABLET G GHYDROCORTISONE AC 25MG SUPP G GHYDROCORTONE 10MG TABLET P BHYDRODIURIL 25MG TABLET NP B x hydrochlorothiazideHYDRODIURIL 50MG TABLET NP B x hydrochlorothiazideHYDROMET SYRUP G GHYDROMORPHONE 2MG TABLET G GHYDROMORPHONE 4MG TABLET G GHYDROPANE SYRUP G GHYDROPHENE DH SYRUP G GHYDROQUINONE 3% SOLUTION G GHYDROQUINONE 4% CREAM G G



HYDRO-TUSSIN DM LIQUID G GHYDRO-TUSSIN HD LIQUID G GHYDRO-TUSSIN HD SOLUTION G GHYDROXYCHLOROQUINE 200MG TB G G xHYDROXYUREA 500MG CAPSULE G G xHYDROXYZINE 10MG/5ML SYRUP G GHYDROXYZINE HCL 10MG TABLET G GHYDROXYZINE HCL 25MG TABLET G GHYDROXYZINE HCL 50MG TABLET G GHYDROXYZINE PAM 25MG CAP G GHYDROXYZINE PAM 50MG CAP G GHYOSCYAMINE 0.125MG/ML DROP G GHYOSCYAMINE 0.375MG CAP SA G GHYOSCYAMINE 0.375MG TAB SA G GHYOSCYAMINE 125MCG/5ML ELIX G GHYOSCYAMINE SU .125MG TB SL G GHYOSCYAMINE SU 0.125MG TAB G GHYOSOPHEN TABLET G GHYPHED SYRUP G GHYPHEN-HD SYRUP G GHYTONE 2.5% CREAM NP B hydrocortisoneHYTONE 2.5% LOTION NP B hydrocortisoneHYTONE 2.5% OINTMENT NP B hydrocortisoneHYTRIN 10MG CAPSULE NP B x terazosinHYTRIN 1MG CAPSULE NP B x terazosinHYTRIN 2MG CAPSULE NP B x terazosinHYTRIN 5MG CAPSULE NP B x terazosinHYZAAR 100-25 TABLET NP B x Avalide, Diovan HCTHYZAAR 50-12.5 TABLET NP B x Avalide, Diovan HCTI.D.A. CAPSULE G GIBERET-FOLIC 500 FILMTAB P BIBUPROFEN 400MG TABLET G G Quantity limitIBUPROFEN 600MG TABLET G G Quantity limitIBUPROFEN 800MG TABLET G G Quantity limitILETIN I NPH P B xILETIN I REGULAR P B xILETIN II NPH (PORK) P B xILETIN II REGULAR (PORK) P B xILOTYCIN EYE OINTMENT NP B erythromycin ophth ointIMDUR 120MG TABLET SA P B xIMDUR 30MG TABLET SA NP B x isosorbide mononitrate SAIMDUR 60MG TABLET SA NP B x isosorbide mononitrate SAIMIPRAMINE HCL 10MG TABLET G G xIMIPRAMINE HCL 25MG TABLET G G xIMIPRAMINE HCL 50MG TABLET G G xIMITREX 100MG TABLET P B Quantity LimitIMITREX 20MG NASAL SPRAY P BIMITREX 25MG TABLET P B Quantity LimitIMITREX 50MG TABLET P B Quantity LimitIMITREX 5MG NASAL SPRAY P BIMITREX 6MG/0.5ML KIT REFLL P B Quantity LimitIMITREX 6MG/0.5ML SYRNG KIT P B Quantity LimitIMITREX 6MG/0.5ML VIAL P B Quantity LimitIMURAN 50MG TABLET NP B x azathioprineINDAPAMIDE 1.25MG TABLET G G xINDAPAMIDE 2.5MG TABLET G G xINDERAL 10MG TABLET NP B x propranololINDERAL 20MG TABLET NP B x propranololINDERAL 40MG TABLET NP B x propranololINDERAL 60MG TABLET NP B x propranololINDERAL 80MG TABLET NP B x propranolol



INDERAL LA 120MG CAPSULE SA P B xINDERAL LA 160MG CAPSULE SA P B xINDERAL LA 60MG CAPSULE SA P B xINDERAL LA 80MG CAPSULE SA P B xINDERIDE LA-120/50 CAP SA P B xINDERIDE LA-160/50 CAP SA P B xINDERIDE LA-80/50 CAP SA P B xINDOCIN 25MG CAPSULE NP B indomethacin Quantity limitINDOCIN 50MG CAPSULE NP B indomethacin Quantity limitINDOCIN 50MG SUPPOSITORY P B Quantity limitINDOCIN SR 75MG CAPSULE SA NP B indomethacin SR Quantity limitINDOMETHACIN 25MG CAPSULE G G Quantity limitINDOMETHACIN 50MG CAPSULE G G Quantity limitINDOMETHACIN 75MG CAP SA G G Quantity limitINFLAMASE FORTE 1% EYE DROP NP B prednisolone sodium phosphateINFLAMASE MILD 0.125% DROPS P BINSULIN LENTE BEEF P B xINSULIN LENTE PURIFIED PORK P B xINSULIN NPH PURIFIED PORK P B xINTAL INHALER P B xINTAL NEBULIZER SOLUTION P B xIOHIST DM SYRUP G GIOPHEN-C NR LIQUID G GIOPHEN-DM NR LIQUID G GIOTEX PSE 600/120 TABLET SA G GIOTUSSIN HC SYRUP G GIPRATROPIUM BR 0.02% SOLN G GISMO 20MG TABLET NP B x isosorbide mononitrateISO-ACETAZONE CAPSULE G GISOMETH/D-CHLORALPHENZ/APAP G GISONIAZID 300MG TABLET G G xISOPTIN S.R. 120MG TAB SA NP B x verapamil SAISOPTIN S.R. 180MG TAB SA NP B x verapamil SAISOPTIN S.R. 240MG TAB SA NP B x verapamil SAISOPTO ATROPINE 1% EYE DROPS P B xISOPTO CETAPRED 0.25% DROPS P BISORDIL 10MG ORAL TABLET NP B x isosorbide dinitrateISORDIL 10MG SL TABLET NP B x isosorbide dinitrateISORDIL 2.5MG SL TABLET NP B x isosorbide dinitrateISORDIL 20MG ORAL TABLET NP B x isosorbide dinitrateISORDIL 30MG ORAL TABLET NP B x isosorbide dinitrateISORDIL 40MG ORAL TABLET NP B x isosorbide dinitrateISORDIL 5MG ORAL TABLET NP B x isosorbide dinitrateISORDIL 5MG SL TABLET NP B x isosorbide dinitrateISOSORBIDE DN 10MG TABLET G G xISOSORBIDE DN 2.5MG SL TABLET G G xISOSORBIDE DN 20MG TABLET G G xISOSORBIDE DN 30MG TABLET G G xISOSORBIDE DN 40MG TAB SA G G xISOSORBIDE DN 5MG SL TABLET G G xISOSORBIDE MN 10MG TABLET G G xISOSORBIDE MN 20MG TABLET G G xISOSORBIDE MN 30MG TAB SA G G xISOSORBIDE MN 60MG TAB SA G G xISOTRATE ER 60MG TABLET SA G G xISOXSUPRINE 10MG TABLET G G xJAYCOF-HC LIQUID P BJENEST-28 TABLET P B x Covered by rider only.KARIVA TABLET G G x Covered by rider only.K EFFERVESCENT 25MEQ TABLET G G xK+10 TABLET SA G G x



KALETRA ORAL SOLUTION P BKALETRA SOFTGEL P BKAON-CL 10MEQ TABLET SA P B xK-DUR 10MEQ TABLET SA NP B x potassium chlorideK-DUR 20MEQ TABLET SA NP B x potassium chlorideKEFLEX 250MG PULVULE NP B cephalexinKEFLEX 500MG PULVULE NP B cephalexinKEFTAB 500MG TABLET NP B cephalexinKENALOG 0.025% LOTION NP B triamcinoloneKENALOG AEROSOL SPRAY P BKENALOG-ORABASE 0.1% PASTE NP B triamcinolone dental pasteKEPPRA 250MG TABLET P B xKEPPRA 500MG TABLET P B xKEPPRA 750MG TABLET P B xKERLONE 10MG TABLET NP B x betaxololKERLONE 20MG TABLET NP B x betaxololKETOCONAZOLE 200MG TABLET G GKETOPROFEN 100MG CAPSULE SA G G Quantity limitKETOPROFEN 150MG CAPSULE SA G G Quantity limitKETOPROFEN 200MG CAPSULE SA G G Quantity limitKETOPROFEN 50MG CAPSULE G G Quantity limitKETOPROFEN 75MG CAPSULE G G Quantity limitKETOROLAC 10MG TABLET G G Quantity limitKINERET 100MG SYRINGE P B x Prior AuthKLARON 10% LOTION P BKLONOPIN 0.5MG TABLET NP B x clonazepamKLONOPIN 1MG TABLET NP B x clonazepamKLONOPIN 2MG TABLET NP B x clonazepamK-LOR 20MEQ PACKET P B xKLOR-CON 10MEQ TABLET SA G G xKLOR-CON 20MEQ PACKET G G xKLOR-CON 8MEQ TABLET SA G G xKLOR-CON/EF 25MEQ TAB EFF G G xKLOTRIX 10MEQ TABLET SA P B xK-LYTE DS TABLET EFF P B xK-LYTE TABLET EFF P B xK-LYTE/CL 25MEQ TABLET EFF P B xK-PHOS M.F. TABLET P BK-PHOS NEUTRAL TABLET G GKRISTALOSE PACKET P BKRONOFED-A KRONOCAPS SA G GKRONOFED-A-JR KRONOCAPS P BK-TAB 10MEQ TABLET SA P B xKUTRASE CAPSULE P BKU-ZYME CAPSULE P BKWELCOF LIQUID G GKYTRIL 1MG TABLET P B Quantity limitLABETALOL HCL 100MG TABLET G G xLABETALOL HCL 200MG TABLET G G xLABETALOL HCL 300MG TABLET G G xLAC-HYDRIN 12% CREAM P BLAC-HYDRIN 12% LOTION P BLACTICARE-HC 2.5% LOTION G GLACTULOSE 10GM/15ML SYRUP G GLAMICTAL 100MG TABLET P B xLAMICTAL 150MG TABLET P B xLAMICTAL 200MG TABLET P B xLAMICTAL 25MG DISPER TABLET P B xLAMICTAL 25MG TABLET P B xLAMICTAL 5MG DISPER TABLET P B xLAMISIL 1% SOLUTION P B



LAMISIL 250MG TABLET P B Prior authorizationLANOXICAPS 0.2MG CAPSULE P B xLANOXIN 125MCG TABLET P B xLANOXIN 250MCG TABLET P B xLANOXIN 50MCG/ML ELIXIR P B xLANTUS 100IU/ML VIAL P B xLARIAM 250MG TABLET NP BLARODOPA 500MG TABLET P B xLASIX 20MG TABLET NP B x furosemideLASIX 40MG TABLET NP B x furosemideLASIX 80MG TABLET NP B x furosemideLESCOL 20MG CAPSULE NP B x lovastatin Lipitor, PravacholLESCOL 40MG CAPSULE NP B x lovastatin Lipitor, PravacholLESCOL XL 80MG TABLET NP B x lovastatin Lipitor, PravacholLESSINA 0.1-0.02 TABLET G G x Covered by rider only.LEUCOVORIN CALCIUM 5MG TAB G GLEUKERAN 2MG TABLET P BLEVALL 5.0 LIQUID P BLEVALL LIQUID P BLEVAQUIN 250MG TABLET P BLEVAQUIN 500MG TABLET P BLEVAQUIN 750MG TABLET P BLEVATOL 20MG TABLET NP B x atenolol, metoprolol, propranololLEVBID 0.375MG TABLET SA P BLEVLEN 28 TABLET P B x Covered by rider only.LEVLITE-28 TABLET NP B x Lessina Covered by rider only.LEVOBUNOLOL 0.25% EYE DROPS G G xLEVOBUNOLOL 0.5% EYE DROPS G G xLEVORA-28 TABLET G G x Covered by rider only.LEVO-T 50MCG TABLET G G xLEVOTABS 100MCG TABLET G G xLEVOTABS 150MCG TABLET G G xLEVOTABS 50MCG TABLET G G xLEVOTABS 75MCG TABLET G G xLEVOTHROID 100MCG TABLET G G xLEVOTHROID 112MCG TABLET G G xLEVOTHROID 125MCG TABLET G G xLEVOTHROID 137MCG TABLET G G xLEVOTHROID 150MCG TABLET G G xLEVOTHROID 175MCG TABLET G G xLEVOTHROID 200MCG TABLET G G xLEVOTHROID 25MCG TABLET G G xLEVOTHROID 300MCG TABLET G G xLEVOTHROID 50MCG TABLET G G xLEVOTHROID 75MCG TABLET G G xLEVOTHROID 88MCG TABLET G G xLEVOTHYROXINE 100MCG TABLET G G xLEVOTHYROXINE 125MCG TAB G G xLEVOTHYROXINE 150MCG TABLET G G xLEVOTHYROXINE 200MCG TABLET G G xLEVOTHYROXINE 25MCG TAB G G xLEVOTHYROXINE 300MCG TABLET G G xLEVOTHYROXINE 50MCG TABLET G G xLEVOTHYROXINE 75MCG TAB G G xLEVOXYL 100MCG TABLET G G xLEVOXYL 112MCG TABLET G G xLEVOXYL 125MCG TABLET G G xLEVOXYL 137MCG TABLET G G xLEVOXYL 150MCG TABLET G G xLEVOXYL 175MCG TABLET G G xLEVOXYL 200MCG TABLET G G x



LEVOXYL 25MCG TABLET G G xLEVOXYL 300MCG TABLET G G xLEVOXYL 50MCG TABLET G G xLEVOXYL 75MCG TABLET G G xLEVOXYL 88MCG TABLET G G xLEVSIN 0.125MG TABLET NP B hyoscyamineLEVSIN 0.125MG/5ML ELIXIR NP B hyoscyamineLEVSIN 0.125MG/ML DROPS NP B hyoscyamineLEVSIN/SL 0.125MG TABLET SL NP B hyoscyamineLEVSINEX 0.375MG CAPSULE SA NP B hyoscyamineLEXAPRO 10MG TABLET NP B fluoxetine Celexa, Paxil, ZoloftLEXAPRO 20MG TABELT NP B fluoxetine Celexa, Paxil, ZoloftLEXXEL 5-5MG TABLET SA NP B xLIBRAX CAPSULE P BLIBRIUM 10MG CAPSULE NP B chlordiazepoxideLIBRIUM 25MG CAPSULE NP B chlordiazepoxideLIBRIUM 5MG CAPSULE NP B chlordiazepoxideLIDEX 0.05% CREAM NP B fluocinonideLIDEX 0.05% GEL NP B fluocinonideLIDEX 0.05% OINTMENT NP B fluocinonideLIDEX-E 0.05% CREAM NP B fluocinonide emollientLIDOCAINE 2% VISCOUS SOLN G GLIDOCAINE 5% OINTMENT G GLIDOCAINE HCL 2% JELLY G GLIDODERM 5% PATCH P BLIMBITROL DS TABLET NP B amitriptyline/chlordiazepoxideLIMBITROL TABLET NP B amitriptyline/chlordiazepoxideLINDANE 1% LOTION G GLINDANE 1% SHAMPOO P BLIPEX 10MG TABLET NP BLIPITOR 10MG TABLET P B xLIPITOR 20MG TABLET P B xLIPITOR 40MG TABLET P B xLIPITOR 80MG TABLET P B xLIQUIBID 1200 TABLET SA P BLIQUIBID TABLET SA G GLIQUIBID-D TABLET SA P BLISINOPRIL 2.5MG TABLET G G xLISINOPRIL 5MG TABLET G G xLISINOPRIL 10MG TABLET G G xLISINOPRIL 20MG TABLET G G xLISINOPRIL 30MG TABLET G G xLISINOPRIL 40MG TABLET G G xLISINOPRIL-HCTZ 10-12.5 TABLET G G xLISINOPRIL-HCTZ 20-12.5 TABLET G G xLISINOPRIL-HCTZ 20-25 TABLET G G xLITHIUM CARBONATE 150MG CAP P B xLITHIUM CARBONATE 300MG CAP G G xLITHIUM CARBONATE 300MG TAB P B xLITHIUM CIT 8MEQ/5ML SYRUP G G xLITHOBID 300MG TABLET SA P B xLIVOSTIN 0.05% EYE DROPS P BLO/OVRAL-21 TABLET P B x Covered by rider only.LO/OVRAL-28 TABLET P B x Covered by rider only.LOCHOLEST PACKET NP B x cholestyramineLOCOID 0.1% CREAM P BLOCOID 0.1% LIPOCREAM P BLOCOID 0.1% SOLUTION P BLODINE 300MG CAPSULE NP B x etodolac Quantity limitLODINE 400MG TABLET NP B x etodolac Quantity limitLODINE 500MG TABLET NP B x etodolac Quantity limit



LODINE XL 400MG TABLET SA NP B x etodolac Quantity limitLODINE XL 500MG TABLET SA NP B x etodolac Quantity limitLODINE XL 600MG TABLET SA NP B x etodolac Quantity limitLOESTRIN 21 1.5/30 TABLET P B x Covered by rider only.LOESTRIN 21 1/20 TABLET P B x Covered by rider only.LOESTRIN FE 1.5/30 TABLET P B x Covered by rider only.LOESTRIN FE 1/20 TABLET P B x Covered by rider only.LOMOTIL LIQUID NP B diphenoxylate/atropineLOMOTIL TABLET NP B diphenoxylate/atropineLONOX TABLET G GLOPERAMIDE 2MG CAPSULE G GLOPID 600MG TABLET NP B x gemfibrozilLOPRESSOR 100MG TABLET NP B x metoprololLOPRESSOR 50MG TABLET NP B x metoprololLOPRESSOR HCT 100/25 TABLET P B xLOPRESSOR HCT 100/50 TABLET P B xLOPRESSOR HCT 50/25 TABLET P B xLOPROX 0.77% CREAM P BLOPROX 0.77% LOTION P BLOPROX 1% CREAM P BLOPROX 1% LOTION P BLORABID 100MG/5ML SUSP NP B cefaclor Ceftin, CefzilLORABID 200MG PULVULE NP B cefaclor Ceftin, CefzilLORABID 200MG/5ML SUSP NP B cefaclor Ceftin, CefzilLORABID 400MG PULVULE NP B cefaclor Ceftin, CefzilLORAZEPAM 0.5MG TABLET G GLORAZEPAM 1MG TABLET G GLORAZEPAM 2MG TABLET G GLORAZEPAM INTENSOL 2MG/ML P BLORCET 10/650 TABLET NP B hydrocodone/apap Quantity limitLORCET PLUS TABLET NP B hydrocodone/apap Quantity limitLORTAB 10/500 TABLET NP B hydrocodone/apap Quantity limitLORTAB 5/500 TABLET NP B hydrocodone/apap Quantity limitLORTAB 7.5/500 TABLET NP B hydrocodone/apap Quantity limitLORTAB ELIXIR NP B hydrocodone/apap Quantity limitLOTEMAX 0.5% EYE DROPS P BLOTENSIN 10MG TABLET P B xLOTENSIN 20MG TABLET P B xLOTENSIN 40MG TABLET P B xLOTENSIN 5MG TABLET P B xLOTENSIN HCT 10/12.5 TABLET P B xLOTENSIN HCT 20/12.5 TABLET P B xLOTENSIN HCT 20/25 TABLET P B xLOTENSIN HCT 5/6.25 TABLET P B xLOTREL 2.5/10MG CAPSULE NP B x Norvasc, LotensinLOTREL 5/10MG CAPSULE NP B x Norvasc, LotensinLOTREL 5/20MG CAPSULE NP B x Norvasc, LotensinLOTRISONE CREAM P BLOTRISONE LOTION P BLOTRONEX 1MG TABLET NP B x dicyclomine, diphenoxylate/atropineLOVASTATIN 10MG TABLET G G xLOVASTATIN 20MG TABLET G G xLOVASTATIN 40MG TABLET G G xLOVENOX SYRINGES P BLOW-OGESTREL-21 TABLET P B x Covered by rider only.LOW-OGESTREL-28 TABLET P B x Covered by rider only.LOXAPINE SUCCINATE 10MG CAP G G xLOXAPINE SUCCINATE 50MG CAP G G xLOXAPINE SUCCINATE 5MG CAP G G xLOZOL 1.25MG TABLET NP B x indapamideLOZOL 2.5MG TABLET NP B x indapamide



LUDIOMIL 25MG TABLET NP B x maprotilineLUDIOMIL 50MG TABLET NP B x maprotilineLUDIOMIL 75MG TABLET NP B x maprotilineLUMIGAN 0.03% DROPS NP B xLURIDE LOZI-TABS 0.25MG CHW P BLURIDE LOZI-TABS 0.5MG CHEW P BLURIDE LOZI-TABS 1MG TAB CHEW P BLUSTRA 4% CREAM P BLUSTRA-AF 4% CREAM P BLUVOX 100MG TABLET NP B x fluvoxamine Celexa, Paxil, ZoloftLUVOX 25MG TABLET NP B x fluvoxamine Celexa, Paxil, ZoloftLUVOX 50MG TABLET NP B x fluvoxamine Celexa, Paxil, ZoloftLUXIQ 0.12% FOAM NP B betamethasone valerate lotion, creamMACROBID 100MG CAPSULE P BMACRODANTIN 100MG CAPSULE NP B nitrofurantoinMACRODANTIN 25MG CAPSULE P BMACRODANTIN 50MG CAPSULE NP B nitrofurantoinMAPROTILINE 25MG TABLET G G xMAPROTILINE 50MG TABLET G G xMAPROTILINE 75MG TABLET G G xMARCOF SOLUTION G GMARINOL 2.5MG CAPSULE P BMARINOL 5MG CAPSULE P BMATERNA TABLET P BMATERNITY-90 TABLET SA G GMATULANE 50MG CAPSULE P BMAVIK 1MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMAVIK 2MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMAVIK 4MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMAXAIR 0.2MG AEROSOL W/ADAP NP B x Maxair Autohaler Quantity limitMAXAIR AUTOHALER 0.2MG AERO P B x Quantity limitMAXALT 10MG TABLET P B Quantity limitMAXALT 5MG TABLET P B Quantity limitMAXALT MLT 10MG TABLET P B Quantity limitMAXALT MLT 5MG TABLET P B Quantity limitMAXIDONE 10/750 MG TABLET NP B hydrocodone/APAP productsMAXIFED-G TABLET SA P BMAXITROL EYE DROPS NP B neomycin/polymixin-B/dexamethasoneMAXITROL EYE OINTMENT NP B neomycin/polymixin-B/dexamethasoneMAXZIDE 50/75 TABLET NP B x triamterene/hctzMAXZIDE-25MG TABLET NP B x triamterene/hctzMEBARAL 50MG TABLET P B xMEBENDAZOLE 100MG TAB CHEW G GMECLIZINE 12.5MG TABLET G GMECLIZINE 25MG TABLET G GMECLOFENAMATE 100MG CAPSULE G G Quantity limitMECLOFENAMATE 50MG CAPSULE G G Quantity limitMEDCODIN LIQUID G GMEDENT LD 800/60 TABLET SA P BMEDROL 16MG TABLET P BMEDROL 4MG DOSEPAK NP B methylprednisoloneMEDROL 4MG TABLET NP B methylprednisoloneMEDROL 8MG TABLET P BMEDROXYPROGESTERONE 10MG TB G G xMEDROXYPROGESTERONE 2.5MG G G xMEDROXYPROGESTERONE 5MG TAB G G xMEDTUSS HD ELIXIR G GMEFLOQUINE 250MG TABLET G G xMEGACE 20MG TABLET NP B megestrol acetateMEGACE 40MG TABLET NP B megestrol acetateMEGACE 40MG/ML ORAL SUSP P B



MEGESTROL 20MG TABLET G GMEGESTROL 40MG TABLET G GMELANEX 3% SOLUTION P BMELLARIL 100MG TABLET NP B x thioridazineMELLARIL 25MG TABLET NP B x thioridazineMELLARIL 50MG TABLET NP B x thioridazineM-END SYRUP G GMENEST 0.3MG TABLET P B xMENEST 0.625MG TABLET P B xMENEST 1.25MG TABLET P B xMENTAX 1% CREAM P BMEPERGAN FORTIS 50/25 CAP P BMEPERIDINE 50MG TABLET G GMEPERIDINE/PROMETHAZINE CAP G GMEPHYTON 5MG TABLET P BMEPROBAMATE 200MG TABLET G GMEPROBAMATE 400MG TABLET G GMEPROLONE UNIPAK 4MG TAB G GMEPROZINE 50/25 CAPSULE G GMESCOLOR TABLET P BMESTINON 180MG TIMESPAN P B xMESTINON 60MG TABLET P B xMETADATE CD 20MG CAPSULE P B xMETADATE ER 10MG TABLET SA P B xMETADATE ER 20MG TABLET SA G G xMETAPROTERENOL 10MG TABLET G G xMETAPROTERENOL 10MG/5ML SYR G G xMETFORMIN 1000MG TABLET G G xMETFORMIN 500MG TABLET G G xMETFORMIN 850MG TABLET G G xMETHADONE HCL 10MG TABLET G GMETHADONE HCL 5MG TABLET G GMETHADOSE 10MG TABLET G GMETHADOSE 5MG TABLET G GMETHAZOLAMIDE 25MG TABLET G G xMETHAZOLAMIDE 50MG TABLET G G xMETHERGINE 0.2MG TABLET P BMETHIMAZOLE 10MG TABLET G G xMETHIMAZOLE 5MG TABLET G G xMETHITEST 10MG TABLET P B xMETHITEST 25MG TABLET P B xMETHOCARBAMOL 500MG TABLET G GMETHOCARBAMOL 750MG TABLET G GMETHOCARBAMOL W/ASA TABLET G GMETHOTREXATE 2.5MG TABLET G G xMETHYCLOTHIAZIDE 5MG TABLET G G xMETHYLDOPA 250MG TABLET G G xMETHYLDOPA 500MG TABLET G G xMETHYLDOPA/HCTZ 250-15 TAB G G xMETHYLDOPA/HCTZ 250-25 TAB G G xMETHYLIN 10MG TABLET G G xMETHYLIN 20MG TABLET G G xMETHYLIN 5MG TABLET G G xMETHYLPHENIDATE 10MG TABLET G G xMETHYLPHENIDATE 20MG TAB SA G G xMETHYLPHENIDATE 20MG TABLET G G xMETHYLPHENIDATE 5MG TABLET G G xMETHYLPREDNISOLONE 4MG TAB G GMETHYLTESTOSTERONE 10MG TAB P BMETOCLOPRAMIDE 10MG TABLET G GMETOCLOPRAMIDE 5MG TABLET G G



METOCLOPRAMIDE 5MG/5ML SYRP G GMETOPROLOL 100MG TABLET G G xMETOPROLOL 50MG TABLET G G xMETROCREAM 0.75% CREAM P BMETROGEL TOPICAL 0.75% GEL P BMETROGEL-VAGINAL 0.75% GEL P BMETROLOTION TOPICAL 0.75% P BMETRONIDAZOLE 250MG TABLET G GMETRONIDAZOLE 500MG TABLET G GMEVACOR 10MG TABLET NP B x lovastatin Lipitor, PravacholMEVACOR 20MG TABLET NP B x lovastatin Lipitor, PravacholMEVACOR 40MG TABLET NP B x lovastatin Lipitor, PravacholMEXILETINE 150MG CAPSULE G G xMEXILETINE 200MG CAPSULE G G xMIACALCIN 200U NASAL SPRAY P B xMICARDIS 20MG TABLET NP B xMICARDIS 40MG TABLET NP B x Atacand, Avapro, DiovanMICARDIS 80MG TABLET NP B x Atacand, Avapro, DiovanMICARDIS HCT 40/12.5MG TABLET NP B x Atacand HCT, Avalide, Diovan HCTMICARDIS HCT 80/12.5MG TABLET NP B x Atacand HCT, Avalide, Diovan HCTMICRO-K 10MEQ EXTENCAPS NP B x potassium chlorideMICRO-K 8MEQ EXTENCAPS P B xMICRONASE 2.5MG TABLET NP B x glyburideMICRONASE 5MG TABLET NP B x glyburideMICRONOR TABLET P B x Covered by rider only.MICROZIDE 12.5MG CAPSULE NP B x hydrochlorothiazideMIDRIN CAPSULE P BMIGQUIN CAPSULE G GMIGRANAL 4MG/ML NASAL SPRAY NP B Imitrex Nasal SprayMIGRAZONE CAPSULE G GMINIPRESS 1MG CAPSULE NP B x prazosinMINIPRESS 2MG CAPSULE NP B x prazosinMINIPRESS 5MG CAPSULE NP B x prazosinMINITRAN 0.2MG/HR PATCH NP B x Nitro-DURMINITRAN 0.4MG/HR PATCH NP B x Nitro-DURMINIZIDE 2 CAPSULE P B xMINOCIN 100MG PELLETIZED CP NP B minocyclineMINOCIN 50MG PELLETIZED CAP NP B minocyclineMINOCYCLINE 100MG CAPSULE G GMINOCYCLINE 50MG CAPSULE G GMINOXIDIL 10MG TABLET G G xMINOXIDIL 2.5MG TABLET G G xMIRALAX POWDER P BMIRAPEX 0.125MG TABLET P B xMIRAPEX 0.25MG TABLET P B xMIRAPEX 0.5MG TABLET P B xMIRAPEX 1.5MG TABLET P B xMIRAPEX 1MG TABLET P B xMIRAPHEN LA TABLET SA G GMIRAPHEN PSE TABLET SA G GMIRCETTE 28 DAY TABLET NP B x Kariva Covered by rider only.MISOPROSTIL 100MG TABLET G G xMISOPROSTIL 200MG TABLET G G xMOBAN 100MG TABLET P B xMOBAN 10MG TABLET P B xMOBAN 25MG TABLET P B xMOBAN 50MG TABLET P B xMOBAN 5MG TABLET P B xMOBIC 15MG TABLET NP B generic NSAID'sMOBIC 7.5MG TABLET NP B generic NSAID'sMODICON 28 TABLET P B x Covered by rider only.



MODURETIC 5/50 TABLET NP B x amiloride/hctzMONISTAT DUAL-PAK P BMONISTAT-DERM 2% CREAM P BMONODOX 100MG CAPSULE NP B doxycyclineMONODOX 50MG CAPSULE NP B doxycyclineMONOKET 20MG TABLET NP B x isosorbide mononitrateMONOPRIL 10MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMONOPRIL 20MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMONOPRIL 40MG TABLET NP B x captopril, enalapril, lisinopril Accupril, Altace, LotensinMONUROL 3GM SACHET P B Quantity limitMORPHINE SULF 15MG TAB SA G GMORPHINE SULF 30MG TAB SA G GMORPHINE SULF 60MG TAB SA G GMORPHINE SULFATE 15MG TAB G GMORPHINE SULFATE 30MG TAB G GMORPHINE SULFATE IR 30MG TB G GMOTRIN 400MG TABLET NP B ibuprofen Quantity limitMOTRIN 600MG TABLET NP B ibuprofen Quantity limitMOTRIN 800MG TABLET NP B ibuprofen Quantity limitMS CONTIN 100MG TABLET SA NP B morphine sulfate SAMS CONTIN 15MG TABLET SA NP B morphine sulfate SAMS CONTIN 200MG TABLET SA P BMS CONTIN 30MG TABLET SA NP B morphine sulfate SAMS CONTIN 60MG TABLET SA NP B morphine sulfate SAMSIR 15MG TABLET G GMSIR 30MG TABLET G GMUCOBID-L.A. 600MG TAB SA G GMUCO-FEN 1200 TABLET SA G GMUCO-FEN 800 DM TABLET SA NP BMUCO-FEN 800MG TABLET SA P BMUCO-FEN DM TABLET SA NP BMUCOMYST 20% VIAL G GMULTI VIT/FL 0.25MG TAB CHW G GMULTI VITA-BETS/FL .25MG TB G GMULTIHISTAMINE-D CAPSULE SA G GMULTI-RET FOLIC 500 TABLET G GMULTIVIT W/F 0.25MG/ML DROP G GMULTIVIT/FL/FE .5MG TAB CHW G GMULTI-VITA BETS/FL .5MG TAB G GMULTI-VITA/FLUOR 0.25MG/ML G GMULTIVITS W/F .25MG/ML DROP G GMULTVIT/FLUOR .5MG TAB CHEW G GMUSE 1000MCG URETHRAL SUPP NP B not applicable not applicable Prior authorization, qty. limitMUSE 250MCG URETHRAL SUPPOS NP B not applicable not applicable Prior authorization, qty. limitMUSE 500MCG URETHRAL SUPPOS NP B not applicable not applicable Prior authorization, qty. limitMYAMBUTOL 100MG TABLET P B xMYAMBUTOL 400MG TABLET P B xMYCELEX 10MG TROCHE P BMYCOLOG II CREAM NP B nystatin/triamcinoloneMYCOLOG II OINTMENT NP B nystatin/triamcinoloneMYCOSTATIN 100,000U/GM POWD NP B nystatin powderMYKROX 0.5MG TABLET P BMYPHETANE DC COUGH SYRUP G GMYPHETANE DX COUGH SYRUP G GMYSOLINE 250MG TABLET P B xMYSOLINE 50MG TABLET P B xMYTEX LIQUID G GMYTUSSIN AC SYRUP G GMYTUSSIN DAC SYRUP G GNABUMETONE 500MG TABLET G G xNABUMETONE 750MG TABLET G G x



NADOLOL 120MG TABLET G G xNADOLOL 160MG TABLET G G xNADOLOL 20MG TABLET G G xNADOLOL 40MG TABLET G G xNADOLOL 80MG TABLET G G xNAFTIN 1% CREAM P BNAFTIN 1% GEL P BNALDECON PEDIATRIC DROPS P BNALDECON TABLET SA P BNALDELATE PEDIATRIC DROPS G GNALDELATE PEDIATRIC SYRUP G GNALDELATE SYRUP G GNALEX DH LIQUID P BNALEX EXPECTORANT G GNALEX-A LIQUID P BNALEX-A TABLET P BNALGEST TABLET SA G GNALTREXONE 50MG TABLET G GNAPRELAN 375 TABLET SA NP B x naproxen sodiumNAPRELAN 500 TABLET SA NP B x naproxen sodium Quantity limitNAPROSYN 125MG/5ML SUSPEN NP B x naproxen Quantity limitNAPROSYN 250MG TABLET NP B x naproxen Quantity limitNAPROSYN 375MG TABLET NP B x naproxen Quantity limitNAPROSYN 500MG TABLET NP B x naproxen Quantity limitNAPROXEN 125MG/5ML SUSPEN G G xNAPROXEN 250MG TABLET G G x Quantity limitNAPROXEN 375MG TABLET G G x Quantity limitNAPROXEN 375MG TABLET EC G G x Quantity limitNAPROXEN 500MG TABLET G G x Quantity limitNAPROXEN 500MG TABLET EC G G x Quantity limitNAPROXEN SODIUM 275MG TAB G G x Quantity limitNAPROXEN SODIUM 550MG TAB G G x Quantity limitNAQUA 4MG TABLET P B xNARDIL 15MG TABLET P B xNASABID SR TABLET SA P BNASACORT AQ NASAL SPRAY P B xNASACORT NASAL INHALER P B xNASALIDE 0.025% SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortNASAREL 0.025% SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortNASONEX 50MCG NASAL SPRAY P B xNATACHEW TABLET CHEW P BNATAFORT TABLET P BNATALCARE CAPLET G GNATALCARE CFE 60 TABLET G GNATALCARE PIC FORTE TABLET G GNATALCARE PIC TABLET G GNATALCARE PLUS TABLET G GNATALCARE RX TABLET G GNATATAB CFE TABLET G GNATATAB FA TABLET G GNAVANE 1MG CAPSULE NP B x thiothixeneNAVANE 2MG CAPSULE NP B x thiothixeneNECON 0.5/35-28 TABLET G G x Covered by rider only.NECON 1/35-21 TABLET G G x Covered by rider only.NECON 1/35-28 TABLET G G x Covered by rider only.NECON 1/50-28 TABLET G G x Covered by rider only.NELOVA 1/35E-28 TABLET G G x Covered by rider only.NEMBUTAL SODIUM 100MG CAPS P BNEO/BACIT/POLY EYE OINTMENT G GNEO/BACIT/POLY/HC EYE OINT G GNEO/POLY/DEXAMET EYE OINT G G



NEO/POLYMYXIN/DEXAMETH DROP G GNEO/POLYMYXIN/HC EAR SOLN G GNEO/POLYMYXIN/HC EAR SUSP G GNEODECADRON EYE DROPS NP B neomycin/dexamethasoneNEOMYCIN 500MG TABLET G GNEOMYCIN/POLY/GRAM EYE DROP G GNEORAL 100MG GELATN CAPSULE NP B x cyclosporineNEORAL 100MG/ML SOLUTION NP B x SangcyaNEORAL 25MG GELATIN CAPSULE NP B x cyclosporineNEOSPORIN EYE DROPS NP B neomyc/bacitr/polymixin-BNEOSPORIN EYE OINTMENT NP B neomyc/bacitr/polymixin-BNEO-SYNEPHRINE 10% EYE DROP P BNEO-SYNEPHRINE 2.5% EYE DRP P BNEPHROCAPS CAPSULE NP B RenalcapsNEPHRO-FER RX TABLET G GNEPHRO-VITE RX TABLET P BNEPTAZANE 25MG TABLET P BNESTABS CBF TABLET P BNESTABS FA TABLET P BNEURONTIN 100MG CAPSULE P B xNEURONTIN 250MG/5ML SOLUTION P B xNEURONTIN 300MG CAPSULE P B xNEURONTIN 400MG CAPSULE P B xNEURONTIN 600MG TABLET P B xNEURONTIN 800MG TABLET P B xNEXIUM 20MG CAPSULE P B Prior authorization after 12 weeksNEXIUM 40MG CAPSULE P B Prior authorization after 12 weeksNIASPAN 1000MG TABLET SA P B xNIASPAN 500MG TABLET SA P B xNIASPAN 750MG TABLET SA P B xNICARDIPINE 20MG CAPSULE G G xNICARDIPINE 30MG CAPSULE G G xNIFEDIPINE 10MG CAPSULE G G xNIFEDIPINE 20MG CAPSULE G G xNIFEDIPINE SA 30MG TABLET G G xNIFEDIPINE SA 60MG TABLET G G xNIFEDIPINE SA 90MG TABLET G G xNIFEDIPINE XR 30MG TABLET G G xNIFEDIPINE XR 60MG TABLET G G xNIFEDIPINE XR 90MG TABLET G G xNIFEREX-150 FORTE CAPSULE P BNIFEREX-PN FORTE TABLET P BNILANDRON 50MG TABLET P B xNITREK 0.4MG/HR PATCH NP B x Nitro-DURNITRO-DUR 0.1MG/HR PATCH P B xNITRO-DUR 0.2MG/HR PATCH P B xNITRO-DUR 0.3MG/HR PATCH P B xNITRO-DUR 0.4MG/HR PATCH P B xNITRO-DUR 0.6MG/HR PATCH P B xNITROFURANTOIN MCR 100MG CP G GNITROFURANTOIN MCR 50MG CAP G GNITROGLYCERIN .2MG/HR PATCH G G xNITROGLYCERIN .4MG/HR PATCH G G xNITROGLYCERIN 2% OINTMENT G G xNITROGLYCERIN 2.5MG CAP SA G G xNITROGLYCERIN 6.5MG CAP SA G G xNITROGLYCERIN 9MG CAP SA G G xNITROLINGUAL 0.4MG SPRAY P B xNITROQUICK 0.4MG TABLET SL G G xNITROSTAT 0.3MG TABLET SL P B xNITROSTAT 0.4MG TABLET SL P B x



NITROSTAT 0.6MG TABLET SL P B xNITROTAB 0.4MG TABLET SL G G xNIZATIDINE 150MG PULVULE G G xNIZATIDINE 300MG PULVULE G G xNIZORAL 2% CREAM NP B ketoconazoleNIZORAL 200MG TABLET NP B ketoconazole DiflucanNOLAMINE TABLET SA P BNOLVADEX 10MG TABLET P B xNOLVADEX 20MG TABLET P B xNORCO 10/325 TABLET P BNORCO 5/325 TABLET P BNORCO 7.5/325 TABLET P BNORDETTE-21 TABLET NP B x Portia Covered by rider only.NORDETTE-28 TABLET NP B x Portia Covered by rider only.NORETHIN 1/35E-28 TABLET G G x Covered by rider only.NORETHINDRONE 5MG TABLET G G xNORFLEX 100MG TABLET SA NP B orphenadrineNORGESIC FORTE TABLET NP B orphenadrine/asa/caffeineNORINYL 1+35-28 TABLET P B x Covered by rider only.NORINYL 1+50-28 TABLET P B x Covered by rider only.NORITATE 1% CREAM P BNORMODYNE 100MG TABLET NP B x labetalolNORMODYNE 200MG TABLET NP B x labetalolNORMODYNE 300MG TABLET NP B x labetalolNOROXIN 400MG TABLET NP B Cipro, Levaquin, TequinNORPACE CR 100MG CAPSULE SA P B xNORPACE CR 150MG CAPSULE SA NP B x disopyramideNORPRAMIN 100MG TABLET NP B x desipramineNORPRAMIN 150MG TABLET NP B x desipramineNORPRAMIN 25MG TABLET NP B x desipramineNORPRAMIN 50MG TABLET NP B x desipramineNOR-Q-D TABLET P B x Covered by rider only.NORTRIPTYLINE HCL 10MG CAP G G xNORTRIPTYLINE HCL 25MG CAP G G xNORTRIPTYLINE HCL 50MG CAP G G xNORTRIPTYLINE HCL 75MG CAP G G xNORVASC 10MG TABLET P B xNORVASC 2.5MG TABLET P B xNORVASC 5MG TABLET P B xNORVIR 100MG SOFTGEL CAP P B xNORVIR 80MG/ML SOLUTION P B xNOTUSS LIQUID P BNOVACET LOTION P BNOVAFED A CAPSULE SA P BNOVAHISTINE DH LIQUID P BNOVAHISTINE EXPECTORANT P BNOVOLIN 70/30 P B xNOVOLIN L P B xNOVOLIN N P B xNOVOLIN R P B xNOVOLOG P B xNUCOFED CAPSULE P BNUCOFED SYRUP P BNUCOTUSS EXPECTORANT G GNULYTELY SOLUTION P BNYSTATIN 100000U/GM CREAM G GNYSTATIN 100000U/GM OINT G GNYSTATIN 100000U/ML SUSP G GNYSTATIN 50000000U POWDER P BNYSTATIN 500000U ORAL TAB G GNYSTATIN/TRIAMCINOLONE CRM G G



NYSTATIN/TRIAMCINOLONE OINT G GNYSTOP 100,000U/GM POWDER G GOBSTETRIX-100 P BO-CAL FA TABLET P BOCUFEN 0.03% EYE DROPS P BOCUFLOX 0.3% EYE DROPS P BOCUPRESS 1% EYE DROPS P B xOCUSERT PILO-40 SYSTEMS P B xOGEN 0.625 TABLET NP B x estropipateOGEN 1.25 TABLET NP B x estropipateOGEN 2.5 TABLET NP B x estropipateOGEN VAGINAL CREAM P BOMNICEF 125MG/5ML SUSP P BOMNICEF 300MG CAPSULE P BOMNIHIST L.A. TABLET SA G GOPIUM TINCTURE P BOPTICROM 4% EYE DROPS P BOPTIMINE 1MG TABLET P BOPTIPRANOLOL 0.3% EYE DROPS P B xOPTIVAR 0.05% EYE DROPS P BORAMORPH SR 100MG TABLET SA G GORAMORPH SR 15MG TABLET SA G GORAMORPH SR 30MG TABLET SA G GORAMORPH SR 60MG TABLET SA G GORAP 1MG TABLET P B xORAP 2MG TABLET P B xORAPRED 15MG/ML SOLUTION P BORDRINE CAPSULE SA G GORGANIDIN NR 200MG TABLET P BORNADE SPANSULE P BOR-PHEN-ADE 75/12 CAP SA G GORPHENADRINE 100MG TAB SA G GORPHENADRINE COMP FORTE TAB G GORPHENGESIC FORTE TABLET G GORTHO EVRA 20-150/24 HR PATCH NP B x Covered by rider only.ORTHO TRI-CYCLEN 21 TABLET P B x Covered by rider only.ORTHO TRI-CYCLEN 28 TABLET P B x Covered by rider only.ORTHO TRI-CYCLEN-LO TABLET NP B x Covered by rider only.ORTHO-CEPT 21 DAY TABLET P B x Covered by rider only.ORTHO-CEPT 28 DAY TABLET P B x Covered by rider only.ORTHO-CYCLEN 28 TABLET P B x Covered by rider only.ORTHO-DIENESTROL 0.01% CREAM P BORTHO-EST 0.625 TABLET G G xORTHO-EST 1.25 TABLET G G xORTHO-NOVUM 1/35-21 TABLET NP B x Covered by rider only.ORTHO-NOVUM 1/35-28 TABLET NP B x Covered by rider only.ORTHO-NOVUM 1/50-28 TABLET NP B x Covered by rider only.ORTHO-NOVUM 10/11-28 TABLET NP B x Covered by rider only.ORTHO-NOVUM 7/7/7-21 TABLET P B x Covered by rider only.ORTHO-NOVUM 7/7/7-28 TABLET P B x Covered by rider only.ORTHO-PREFEST TABLET P B x Covered by rider only.ORUVAIL 100MG CAPSULE SA NP B ketoprofenORUVAIL 150MG CAPSULE SA NP B ketoprofenORUVAIL 200MG CAPSULE SA NP B ketoprofenOTICAINE 20% EAR DROPS G GOVCON-35 28 TABLET P B x Covered by rider only.OVCON-50 28 TABLET P B x Covered by rider only.OVRAL-28 TABLET P B x Covered by rider only.OVRETTE TABLET P B x Covered by rider only.OXANDRIN 2.5MG TABLET P B xOXAPROZIN 600MG TABLET G G x Quantity limit



OXAZEPAM 10MG CAPSULE G GOXAZEPAM 15MG CAPSULE G GOXAZEPAM 30MG CAPSULE G GOXISTAT 1% CREAM P BOXISTAT 1% LOTION P BOXSORALEN-ULTRA 10MG CAP P BOXYBUTYNIN 5MG TABLET G G xOXYBUTYNIN 5MG/5ML SYRUP G G xOXYCODONE 5MG CAPSULE G GOXYCODONE 5MG TABLET G GOXYCODONE W/APAP 5/325 TAB G G Quantity limitOXYCODONE W/APAP 5/500 CAP G G Quantity limitOXYCODONE/ASA 4.88/325 TAB G GOXYCONTIN 10MG TABLET SA P B Quantity limitOXYCONTIN 20MG TABLET SA P B Quantity limitOXYCONTIN 40MG TABLET SA P B Quantity limitOXYCONTIN 80MG TABLET SA P B Quantity limitOXYFAST P BOXYIR 5MG CAPSULE P BPACERONE 200MG TABLET G G xPACERONE 400MG TABLET P B xPALGIC D TABLET SA G GPALGIC DS SYRUP P BPAMELOR 25MG CAPSULE NP B x nortriptylinePAMELOR 50MG CAPSULE NP B x nortriptylinePAMELOR 75MG CAPSULE NP B x nortriptylinePAMINE 2.5MG TABLET P BPANCOF HC LIQUID P BPANCOF-XP LIQUID P BPANCREASE CAPSULE EC P BPANCREASE MT 16 CAPSULE EC P BPANCREASE MT 20 CAPSULE EC P BPANCREASE MT 4 CAPSULE EC P BPANCRECARB MS-8 CAPSULE EC P BPANCRELIPASE CAPSULE EC G GPANCRELIPASE MT-16 CAP EC G GPANCRELIPASE TABLET G GPANDEL 0.1% CREAM P BPANLOR DC CAPSULE P BPANMIST DM SYRUP P BPANMIST DM TABLET SA P BPANMIST JR 600/45 TABLET SA P BPANMIST LA 600/90 TABLET SA P BPANMIST LA 800/80 TABLET SA P BPANMIST S SYRUP P BPANNAZ TABLET P BPANOKASE TABLET G GPANOXYL 10 GEL P BPANOXYL 5 GEL P BPANOXYL AQ 10 ACNE GEL P BPARAFON FORTE DSC 500MG CPT NP B chlorzaxozonePAREGORIC LIQUID G GPARLODEL 2.5MG TABLET NP B x bromocriptine mesylatePARLODEL 5MG TABLET NP B x bromocriptine mesylatePARNATE 10MG TABLET P B xPATANOL 0.1% EYE DROPS P BPAXIL 10MG TABLET P B xPAXIL 10MG/5ML SUSPENSION P B xPAXIL 20MG TABLET P B xPAXIL 30MG TABLET P B xPAXIL 40MG TABLET P B x



PAXIL CR 12.5MG TABLET NP B x PaxilPAXIL CR 25MG TABLET NP B x PaxilPAXIL CR 37.5MG TABLET NP B x PaxilPCE 333MG DISPERTAB NP B erythromycin PCE 500MG DISPERTAB NP B erythromycin PEDIAPRED 6.7MG/5ML SOLN P BPEDIAZOLE ORAL SUSPENSION NP B erythromycin/sulfisoxazolePEDIOTIC EAR SUSPENSION P BPEG 3350/ELECTROLYTE SOLN G GPEG-INTRON 50MCG/0.5ML P BPEG-INTRON 80MCG/0.5ML P BPEG-INTRON 120MCG/0.5ML P BPEG-INTRON 150MCG/0.5ML P BPEMOLINE 37.5MG TABLET G G xPEMOLINE 75MG TABLET G G xPENICILLIN VK 125MG/5ML LIQ G GPENICILLIN VK 250MG TABLET G GPENICILLIN VK 250MG/5ML LIQ G GPENICILLIN VK 500MG TABLET G GPENLAC 8% SOLUTION NP B Lamisil (prior auth)PENTASA 250MG CAPSULE SA P B xPENTAZOCINE/NALOXONE TABLET G GPENTOXIFYLLINE 400MG TAB SA G G xPEN-VEE K 250MG/5ML SUSP G GPEPCID 20MG TABLET NP B x famotidine, cimetidine, ranitidinePEPCID 40MG TABLET NP B x famotidine, cimetidine, ranitidinePEPCID 40MG/5ML ORAL SUSP NP B x cimetidine, ranitidinePEPCID RPD 20MG TABLET NP B x famotidine, cimetidine, ranitidinePEPCID RPD 40MG TABLET NP B x famotidine, cimetidine, ranitidineP-EPHED/CPM 120/8 CAP SA G GP-EPHED/CPM CAP SA G GPERCOCET 10/650MG TABLET P B Quantity limitPERCOCET 2.5/325MG TABLET P BPERCOCET 5/325MG TABLET NP B apap/oxycodone Quantity limitPERCOCET 7.5/325MG TABLET NP BPERCOCET 7.5/500MG TABLET P B Quantity limitPERCODAN TABLET NP B aspirin/oxycodonePERIACTIN 4MG TABLET NP B cyproheptadinePERIDEX 0.12% LIQUID NP B chlorhexidine gluconatePERIOGARD 0.12% ORAL RINSE G GPERIOSTAT 20MG CAPSULE P BPERIOSTAT 20MG TABLET P BPERMAX 0.05MG TABLET P B xPERMAX 0.25MG TABLET P B xPERMAX 1MG TABLET P B xPERPHENAZINE 16MG TABLET G G xPERPHENAZINE 4MG TABLET G G xPERPHENAZINE 8MG TABLET G G xPERSANTINE 25MG TABLET NP B x dipyridamolePERSANTINE 50MG TABLET NP B x dipyridamolePERSANTINE 75MG TABLET NP B x dipyridamolePHENAZOPYRIDINE 100MG TAB G GPHENAZOPYRIDINE 200MG TAB G GPHENERGAN 12.5MG SUPPOS P BPHENERGAN 12.5MG TABLET NP B promethazinePHENERGAN 25MG SUPPOSITORY P BPHENERGAN 25MG TABLET NP B promethazinePHENERGAN 50MG SUPPOSITORY P BPHENERGAN 50MG TABLET NP B promethazinePHENERGAN FORTIS 25MG/5ML P BPHENERGAN VC SYRUP NP B promethazine VC



PHENERGAN VC W/CODEINE SYR NP B promethazine/VC/codeinePHENERGAN W/CODEINE SYRUP NP B promethazine/codeinePHENERGAN W/DM SYRUP NP B promethazine DMPHENOBARB/ERGOT/BELL TAB G GPHENOBARBITAL 100MG TABLET G G xPHENOBARBITAL 15MG TABLET G G xPHENOBARBITAL 16.2MG TABLET G G xPHENOBARBITAL 20MG/5ML ELIX G G xPHENOBARBITAL 30MG TABLET G G xPHENOBARBITAL 32.4MG TABLET G G xPHENOBARBITAL 60MG TABLET G G xPHENOBARBITAL 64.8MG TABLET G G xPHENOBARBITAL 97.2MG TABLET G G xPHENTEX LA 400/75 TABLET SA G GPHENYLFENESIN LA TABLET SA G GPHENYLFENESIN TABLET SA G GPHENYLHISTINE DH LIQUID G GPHENYLHISTINE EXPECTORANT G GPHENYTOIN 125MG/5ML SUSPEN G G xPHENYTOIN SOD 100MG CAPSULE G G xPHENYTOIN SOD EXT 100MG CAP G G xPHISOHEX 3% CLEANSER P BPHOS-FLUR 1.1% GEL P BPHOSLO 667MG TABLET P B xPHRENILIN FORTE CAPSULE G GPHRENILIN TABLET P BPILOCAR 1% EYE DROPS NP B x pilocarpinePILOCAR 2% EYE DROPS NP B x pilocarpinePILOCAR 4% EYE DROPS NP B x pilocarpinePILOCARPINE 1% EYE DROPS P G xPILOCARPINE 2% EYE DROPS G G xPILOCARPINE 4% EYE DROPS G G xPINDOLOL 10MG TABLET G G xPINDOLOL 5MG TABLET G G xPIROXICAM 10MG CAPSULE G G x Quantity limitPIROXICAM 20MG CAPSULE G G x Quantity limitPLACIDYL 500MG CAPSULE NP BPLACIDYL 750MG CAPSULE NP BPLAQUENIL 200MG TABLET NP B x hydroxychloroquine sulfatePLAVIX 75MG TABLET P B xPLENDIL 10MG TABLET SA P B xPLENDIL 2.5MG TABLET SA P B xPLENDIL 5MG TABLET SA P B xPLETAL 100MG TABLET P B xPLEXION EMULSION P BPLEXION TS SUSPENSION NP BPOLY CS SYRUP G GPOLY HIST FORTE TABLET SA G GPOLYCITRA-K CRYSTALS PACKET P BPOLY-D CAPSULE SA G GPOLY-D ELIXIR G GPOLY-DM SYRUP G GPOLYMYXIN B/TMP EYE DROPS G GPOLYSPORIN EYE OINTMENT NP B bacitracin/polymixin-bPOLYTINE CS SYRUP G GPOLYTRIM EYE DROPS NP B polymixin-b/trimethoprimPOLY-VI-FLOR .25MG/ML DROPS P BPOLY-VI-FLOR 0.25MG TAB CHW P BPOLY-VI-FLOR 0.5MG TABLET P BPOLY-VI-FLOR 1MG TABLET P BPOLY-VI-FLOR/FE 1MG TAB CHEW P B



POLY-VI-FLOR/IRON .25MG TAB NP B multi-vit/fluouride/ironPOLYVIT/FLUORIDE .25MG DROP G GPOLYVIT/FLUORIDE .5MG DROPS G GPOLY-VIT/IRON/FL 0.25MG/ML G GPOLYVITS W/F .25MG/ML DROPS G GPOLYVITS W/F 0.5MG/ML DROPS G GPONSTEL 250MG KAPSEALS NP B meclofenamatePORTIA-21 TABLETS G G x Covered by rider only.PORTIA-28 TABLETS G G x Covered by rider only.POTABA 500MG TABLET P B xPOTASSIUM CHLORIDE 10% LIQ G G xPOTASSIUM CHLORIDE 20% LIQ G G xPOTASSIUM CL 10MEQ CAP SA G G xPOTASSIUM CL 10MEQ TAB SA G G xPOTASSIUM CL 20MEQ TAB SA G G xPOTASSIUM CL 8MEQ TABLET SA G G xPOTASSIUM IODIDE 1GM/ML SOL G G xPRAMOSONE 1% CREAM G GPRAMOSONE 1% LOTION G GPRAMOSONE 2.5% CREAM P BPRAMOSONE 2.5% LOTION P BPRANDIN 0.5MG TABLET P B xPRANDIN 1MG TABLET P B xPRANDIN 2MG TABLET P B xPRAVACHOL 10MG TABLET P B xPRAVACHOL 20MG TABLET P B xPRAVACHOL 40MG TABLET P B xPRAZOSIN 1MG CAPSULE G G xPRAZOSIN 2MG CAPSULE G G xPRAZOSIN 5MG CAPSULE G G xPRECARE CAPLET P BPRECARE CHEWABLE TABLET P BPRECARE CONCEIVE TABLET P BPRECARE TABLET P BPRECOSE 100MG TABLET P B xPRECOSE 25MG TABLET P B xPRECOSE 50MG TABLET P B xPRED FORTE 1% EYE DROPS NP B prednisolone fortePRED MILD 0.12% EYE DROPS P BPRED-G 1% EYE DROPS P BPREDNISOLONE 15MG/5ML SYRUP G GPREDNISOLONE 5MG/5ML SYRUP G GPREDNISOLONE AC 1% EYE DROP G GPREDNISOLONE SOD 1% EYE DROP G GPREDNISONE 10MG TABLET G GPREDNISONE 1MG TABLET G GPREDNISONE 20MG TABLET G GPREDNISONE 50MG TABLET G GPREDNISONE 5MG TABLET G GPRELONE 15MG/5ML SYRUP NP B prednisolone PRELONE 5MG/5ML SYRUP NP B prednisolonePREMARIN 0.3MG TABLET P B xPREMARIN 0.625MG TABLET P B xPREMARIN 0.9MG TABLET P B xPREMARIN 1.25MG TABLET P B xPREMARIN 2.5MG TABLET P B xPREMARIN VAGINAL CREAM/APPL P B xPREMESIS RX TABLET P BPREMPHASE 0.625/5MG TABLET P B xPREMPRO 0.625/2.5MG TABLET P B xPREMPRO 0.625/5MG TABLET P B x



PRENATAL MR 90 FE TABLET SA G GPRENATAL MTR TABLET G GPRENATAL PLUS TABLET P BPRENATAL PLUS W/27MG IRON G GPRENATAL RX TABLET G GPRENATAL Z TABLET G GPRENATE ADVANCE TABLET P BPRENATE ULTRA TABLET P BPREVACID 15MG CAPSULE DR P B x Prior authorization after 12 weeksPREVACID 30MG CAPSULE DR P B x Prior authorization after 12 weeksPREVALITE POWDER G G xPREVEN CONTRACEPTIVE KIT P B Covered by rider only.PREVIDENT 1.1% GEL P BPREVIDENT 5000 PLUS CREAM P BPREVPAC PATIENT PACK P BPRILOSEC 10MG CAPSULE DR NP B x Aciphex,Prevacid,Protonix Prior authorization after 12 weeksPRILOSEC 20MG CAPSULE DR NP B x Aciphex,Prevacid,Protonix Prior authorization after 12 weeksPRILOSEC 40MG CAPSULE DR NP B x Aciphex,Prevacid,Protonix Prior authorization after 12 weeksPRIMIDONE 250MG TABLET G G xPRIMSOL 50MG/5ML ORAL SOLN P BPRINCIPEN 125MG/5ML SUSP G GPRINCIPEN 250MG CAPSULE G GPRINCIPEN 250MG/5ML SUSP G GPRINCIPEN 500MG CAPSULE G GPRINIVIL 10MG TABLET NP B x lisinoprilPRINIVIL 2.5MG TABLET NP B x lisinoprilPRINIVIL 20MG TABLET NP B x lisinoprilPRINIVIL 40MG TABLET NP B x lisinoprilPRINIVIL 5MG TABLET NP B x lisinoprilPRINZIDE 10/12.5 TABLET NP B x lisinopril/HCTZPRINZIDE 20/12.5 TABLET NP B x lisinopril/HCTZPRINZIDE 20/25 TABLET NP B x lisinopril/HCTZPRO TUSS TABLET SA G GPROAMATINE 2.5MG TABLET P BPROAMATINE 5MG TABLET P BPROAMATINE 10MG TABLET P BPROBENECID 500MG TABLET G GPROBENECID/COLCHICINE TABS P BPROCAINAMIDE 500MG TAB SA G G xPROCANBID 1000MG TABLET SA P B xPROCANBID 500MG TABLET SA P B xPROCARDIA 10MG CAPSULE NP B x nifedipinePROCARDIA 2OMG CAPSULE NP B x nifedipinePROCARDIA XL 30MG TABLET SA NP B x nifedipine XR Adalat CC, Norvasc, PlendilPROCARDIA XL 60MG TABLET SA NP B x nifedipine XR Adalat CC, Norvasc, PlendilPROCARDIA XL 90MG TABLET SA NP B x nifedipine XR Adalat CC, Norvasc, PlendilPROCHLORPERAZINE 10MG TAB G GPROCHLORPERAZINE 25MG SUPP G GPROCHLORPERAZINE 5MG TABLET G GPROCHLORPERAZINE 5MG/ML VL G GPRO-CLEAR SYRUP NP BPROCTOCORT 1% CREAM P BPROCTOCORT 30MG SUPPOSITORY P BPROCTOCREAM-HC 2.5% CREAM P BPROCTOFOAM-HC FOAM P BPROCTO-KIT 1% CREAM G GPROCTOSOL-HC 2.5% CREAM G GPROCTOSOL-HC 25MG SUPPOS G GPROFEN FORTE DM TABLET SA P BPROFEN FORTE TABLET SA P BPROFEN II DM LIQUID P B



PROFEN II DM TABLET SA P BPROFEN II TABLET SA P BPROGLYCEM 50MG/ML ORAL SUSP P BPROGRAF 0.5MG CAPSULE P B xPROGRAF 1MG CAPSULE P B xPROLEX D TABLET SA P BPROLEX DH LIQUID P BPROLEX DH SOLUTION G GPROLEX DM LIQUID P BPROLEX-DH TABLET G GPROMETHAZINE 12.5MG TABLET G GPROMETHAZINE 25MG TABLET G GPROMETHAZINE 50MG TABLET G GPROMETHAZINE 6.25MG/5ML SYR G GPROMETHAZINE VC SYRUP G GPROMETHAZINE VC/COD SYRUP G GPROMETHAZINE W/COD SYRUP G GPROMETHAZINE W/DM SYRUP G GPROMETHEGAN 50MG SUPPOS G GPROMETRIUM 100MG CAPSULE P B xPROMETRIUM 200MG CAPSULE P B xPROPACET 100-650 TABLET G GPROPADE CAPSULE SA G GPROPANTHELINE 15MG TABLET G GPROPOXY-N/APAP 100-650 TAB G G Quantity limitPROPOXYPHENE COMP-65 CAP G GPROPOXYPHENE HCL 65MG CAP G GPROPOXYPHENE/APAP 65/650 TB G G Quantity limitPROPRANOLOL 10MG TABLET G G xPROPRANOLOL 120MG CAP SA G G xPROPRANOLOL 160MG CAP SA G G xPROPRANOLOL 20MG TABLET G G xPROPRANOLOL 20MG/5ML SOLN P B xPROPRANOLOL 40MG TABLET G G xPROPRANOLOL 60MG CAPSULE SA G G xPROPRANOLOL 60MG TABLET G G xPROPRANOLOL 80MG CAPSULE SA G G xPROPRANOLOL 80MG TABLET G G xPROPRANOLOL/HCTZ 40/25 TAB G G xPROPYLTHIOURACIL 50MG TABS G G xPRO-RED SYRUP NP BPROSCAR 5MG TABLET NP B x terazosin terazosinPROSOM 1MG TABLET NP B Ambien, SonataPROSOM 2MG TABLET NP B Ambien, SonataPRO-TABS TABLET SA G GPROTONIX 40MG TABLET EC P B x Prior authorization after 12 weeksPROTOPIC 0.03% OINTMENT P BPROTOPIC 0.1% OINTMENT P BPROTRIPTYLINE 10MG TABLET G G xPROTUSS DM TABLET SA P BPROTUSS LIQUID P BPROTUSS SOLUTION P BPRO-TUSS TABLET G GPROVENTIL .83MG/ML SOLUTION P B xPROVENTIL 4MG REPETABS P B xPROVENTIL 4MG TABLET NP B x albuterolPROVENTIL 5MG/ML SOLUTION NP B x albuterolPROVENTIL 90MCG INH REFILL NP B x albuterol Quantity limitPROVENTIL HFA 90MCG INHALER P B x Quantity limitPROVERA 10MG TABLET NP B x medroxyprogesterone, CycrinPROVERA 2.5MG TABLET NP B x medroxyprogesterone, Cycrin



PROVERA 5MG TABLET NP B x medroxyprogesterone, CycrinPROVIGIL 100MG TABLET P B xPROVIGIL 200MG TABLET P B xPROZAC 10MG PULVULE NP B x fluoxetine Celexa, Paxil, ZoloftPROZAC 10MG TABLET NP B x fluoxetine Celexa, Paxil, ZoloftPROZAC 20MG PULVULE NP B x fluoxetine Celexa, Paxil, ZoloftPROZAC 20MG/5ML SOLUTION NP B x fluoxetine solution Celexa, Paxil, ZoloftPROZAC 40MG PULVULE NP B x fluoxetine Celexa, Paxil, ZoloftPSEUBROM CAPSULE SA G GPSEUBROM-PD CAPSULE SA G GPSEUDO-CHLOR CAPSULE SA G GPSEUDOEPHED/GUAIFEN TAB SA G GPSEUDOVENT CAPSULE SA G GPSEUDOVENT PED CAPSULE SA G GPSORCON 0.05% CREAM NP B diflorasone diacetatePSORCON 0.05% OINTMENT NP B diflorasone diacetatePSORCON E 0.05% CREAM P BPSORCON E 0.05% OINTMENT P BPULMICORT 0.25MG/2ML RESPULE P B xPULMICORT 0.5MG/2ML RESPULE P B xPULMICORT 200MCG TURBUHALER P BPURINETHOL 50MG TABLET P BP-V-TUSSIN SYRUP P BPYRAZINAMIDE 500MG TABLET G GPYRIDIUM PLUS TABLET P BQ-BID LA CAPLET SA G GQ-BID-DM TABLET SA G GQ-TUSS HC LIQUID G GQ-TUSS TABLET SA G GQUADRA-HIST D CAPSULE SA G GQUADRA-HIST D PED CAP SA G GQUADRATUSS PEDIATRIC SUSP G GQUAD-TUSS TANNATE PED SUSP G GQUESTRAN LIGHT POWDER NP B x cholestyramineQUESTRAN POWDER NP B x cholestyramineQUIBRON-T P B xQUINAGLUTE 324MG NP B x quinidine gluconateQUINDAL-HD LIQUID G GQUINDAL-HD PLUS LIQUID G GQUINIDEX EXTENTABS 300MG NP B x quinidine sulf ext relQUINIDINE GLUC 324MG TAB SA G G xQUINIDINE SULF 300MG TAB SA G G xQUINIDINE SULFATE 200MG TAB G G xQUININE SULFATE 200MG CAP G GQUININE SULFATE 260MG TAB G GQUININE SULFATE 325MG CAP G GQUINTEX CAPSULE G GQUINTEX LIQUID G GQUIXIN 0.5% EYE DROPS P BQVAR 40MCG INHALER P B xQVAR 80MCG INHALER P B xRADIACARE GEL G GRANITIDINE 150MG CAPSULE G G xRANITIDINE 150MG TABLET G G xRANITIDINE 300MG TABLET G G xREBETOL 200MG CAPSULE P BREBETRON 1200 THERAPY PACK P BREBIF 22MG/0.5ML SYRINGE NP B xREBIF 44MG/0.5ML SYRINGE NP B xRECTASOL-HC 25MG SUPPOS G GREGLAN 10MG TABLET NP B metoclopramide



REGLAN 5MG TABLET NP B metoclopramideREGRANEX 0.01% GEL NP B not applicable not applicable Prior authorization, Qty. limitRELAFEN 500MG TABLET NP B x nabumetone Quantity limitRELAFEN 750MG TABLET NP B x nabumetone Quantity limitRELENZA 5MG DISKHALER NP B amantadine FlumadineREMERON 15MG TABLET P B xREMERON 30MG TABLET P B xREMERON 45MG TABLET P B xREMERON 15MG SOLTAB P B xREMERON 30MG SOLTAB P B xREMERON 45MG SOLTAB P B xREMINYL 4MG TABLET P B xREMINYL 8MG TABLET P B xREMINYL 12 MG TABLET P B xREMINYL 4MG/5ML SOLUTION P B xRENAGEL 403MG CAPSULE P B xRENAGEL 800MG CAPSULE P B xRENALCAPS G G xRENAX CAPLET P BRENTAMINE PEDIATRIC SUSP G GRENTAMINE TABLET G GREQUIP 0.25MG TABLET P B xREQUIP 0.5MG TABLET P B xREQUIP 1MG TABLET P B xREQUIP 2MG TABLET P B xREQUIP 4MG TABLET P B xRESAID CAPSULE SA G GRESCAPS-D SR CAPSULE G GRESCON MX TABLET P BRESCRIPTOR 100MG TABLET P B xRESCRIPTOR 200MG TABLET P B xRESCULA 0.15% DROPS NP B xRESERPINE 0.25MG TABLET G G xRESPA-1ST TABLET SA P BRESPAIRE-60 SR CAPSULE P BRESTORIL 15MG CAPSULE NP B temazepamRESTORIL 30MG CAPSULE NP B temazepamRESTORIL 7.5MG CAPSULE P BRETIN-A 0.01% GEL NP B tretinoin Not covered for cosmetic useRETIN-A 0.025% CREAM NP B tretinoin Not covered for cosmetic useRETIN-A 0.025% GEL NP B tretinoin Not covered for cosmetic useRETIN-A 0.05% CREAM NP B tretinoin Not covered for cosmetic useRETIN-A 0.05% LIQUID NP B tretinoin Not covered for cosmetic useRETIN-A 0.1% CREAM NP B tretinoin Not covered for cosmetic useRETIN-A MICRO 0.04% GEL NP B Not covered for cosmetic useRETIN-A MICRO 0.1% GEL P B Not covered for cosmetic useRETROVIR 100MG CAPSULE P B xRETROVIR 300MG TABLET P B xREVIA 50MG TABLET NP B naltrexoneRHEUMATREX 2.5MG TABLET NP B x methotrexateRHINOCORT AQUA NASAL SPRAY P B xRHINOCORT NASAL INHALER P B xRIDAURA 3MG CAPSULE P B xRIFADIN 150MG CAPSULE NP B rifampinRIFADIN 300MG CAPSULE NP B rifampinRIFAMPIN 150MG CAPSULE G GRIFAMPIN 300MG CAPSULE G GRISPERDAL 0.25MG TABLET P B xRISPERDAL 0.5MG TABLET P B xRISPERDAL 1MG TABLET P B xRISPERDAL 1MG/ML SOLUTION P B x



RISPERDAL 2MG TABLET P B xRISPERDAL 3MG TABLET P B xRISPERDAL 4MG TABLET P B xRITALIN 10MG TABLET NP B x methylphenidateRITALIN 20MG TABLET NP B x methylphenidateRITALIN 5MG TABLET NP B x methylphenidateRITALIN LA 20MG CAPSULE NP B x methylphenidateRITALIN LA 30MG CAPSULE NP B x methylphenidateRITALIN LA 40MG CAPSULE NP B x methylphenidateRITALIN-SR 20MG TABLET SA NP B x methylphenidateROBINUL 1MG TABLET P BROBINUL FORTE 2MG TABLET P BROBITUSSIN A-C SYRUP P BROBITUSSIN-DAC SYRUP P BROBOMOL 750MG TABLET G GROCALTROL 0.25MCG CAPSULE P B xROCALTROL 0.5MCG CAPSULE P B xROLATUSS SR TABLET G GROLATUSS/HYDROCODONE LIQ G GRONDAMINE TABLET SA G GRONDEC DROPS P BRONDEC SYRUP P BRONDEC TABLET P BRONDEC-DM DROPS P BRONDEC-DM SYRUP P BRONDEC-TR TABLET SA P BROWASA 4GM/60ML ENEMA P B xROXANOL 20MG/ML SOLUTION P BROXICET 5/325 ORAL SOLUTION P BROXICET 5/325 TABLET G GROXICET 5/500 CAPLET P BROXICODONE 15MG TABLET P BROXICODONE 30MG TABLET P BROXICODONE 5MG TABLET G GROXICODONE 5MG/5ML ORAL SOLN P BROXICODONE INTENSOL 20MG/ML NP B OxyfastROXILOX 500/5 CAPSULE G GROXIPRIN 4.88/325 TABLET G GR-TANNAMINE SUSPENSION G GR-TANNATE PEDIATRIC SUSP G GR-TANNATE TABLET G GRX-OTIC EAR DROPS G GRYNA-12 S SUPSENSION NP B R-TannateRYNATAN TABLET P BRYNATAN-S PEDIATRIC SUSP P BRYNATUSS PEDIATRIC SUSP P BRYNATUSS TABLET P BRYTHMOL 150MG TABLET P B xRYTHMOL 225MG TABLET P B xRYTHMOL 300MG TABLET P B xSALAGEN 5MG TABLET P BSALSALATE 500MG TABLET G G Quantity limitSALSALATE 750MG TABLET G G Quantity limitSALUTENSIN TABLET P B xSANDIMMUNE 100MG CAPSULE NP B x cyclosporineSANDIMMUNE 25MG CAPSULE NP B x cyclosporineSANSERT 2MG TABLET P BSANTYL OINTMENT P BSARAFEM 10MG CAPSULE NP BSARAFEM 20MG CAPSULE NP BSEBA-GEL 5% P B



SECONAL SODIUM 100MG PULVUL P BSECTRAL 200MG CAPSULE NP B x acebutololSECTRAL 400MG CAPSULE NP B x acebutololSELEGILINE HCL 5MG CAPSULE G G xSELEGILINE HCL 5MG TABLET G G xSELENIUM SULF 2.5% SHAMPOO G GSEMPREX-D 60MG/8MG CAPSULE P BSEPTRA 40/800MG TABLET NP B sulfamethoxazole/trimethoprimSEPTRA DS TABLET NP B sulfamethoxazole/trimethoprimSEPTRA SUSPENSION NP B sulfamethoxazole/trimethoprimSERENTIL 25MG TABLET P B xSEREVENT 21MCG INHALER P B xSEREVENT DISKUS 50MCG P B xSEROQUEL 100MG TABLET NP B x Risperdal, ZyprexaSEROQUEL 200MG TABLET NP B x Risperdal, ZyprexaSEROQUEL 25MG TABLET NP B x Risperdal, ZyprexaSERZONE 100MG TABLET P B xSERZONE 150MG TABLET P B xSERZONE 200MG TABLET P B xSERZONE 250MG TABLET P B xSERZONE 50MG TABLET P B xSF 5000 PLUS CREAM G GSILVADENE 1% CREAM NP B silver sulfadiazineSILVER SULFADIAZINE 1% CRM G GSINEMET CR 25/100 TABLET SA NP B x carbidopa/levodopa SASINEMET CR 50/200 TABLET SA NP B x carbidopa/levodopa SASINEMET-10/100 TABLET NP B x carbidopa/levodopa SINEMET-25/100 TABLET NP B x carbidopa/levodopa SINEQUAN 100MG CAPSULE NP B x doxepinSINEQUAN 10MG CAPSULE NP B x doxepinSINEQUAN 150MG CAPSULE NP B x doxepinSINEQUAN 25MG CAPSULE NP B x doxepinSINEQUAN 50MG CAPSULE NP B x doxepinSINEQUAN 75MG CAPSULE NP B x doxepinSINGULAIR 10MG TABLET P B xSINGULAIR 4MG TABLET CHEW P B xSINGULAIR 5MG TABLET CHEW P B xSINUVENT TABLET SA G GSKELAXIN 400MG TABLET P BSLO-BID 100 GYROCAPS P B xSLO-BID 200 GYROCAPS P B xSLO-BID 300 GYROCAPS P B xSLO-BID 50 GYROCAPS P B xSLOW-K 8MEQ TABLET SA NP B x potassium chlorideSOD FLUORIDE 0.5MG(1.1MG)TB G GSOD.SULFACET/SULFUR LOTION G GSODIUM FLUORIDE 0.125MG/DRP G GSODIUM SULAMYD 10% EYE DROP NP B sulfacetamide sodiumSOLAQUIN FORTE 4% CREAM P BSOLAQUIN FORTE 4% GEL P BSOLARAZE 3% GEL P BSOMA 350MG TABLET NP B carisoprodolSOMA COMPOUND TABLET NP B carisoprodol/asaSONATA 10MG CAPSULE P BSONATA 5MG CAPSULE P BSORIATANE 25MG CAPSULE P BS-PACK 14 DAY TABLET SR SEQ G GS-PACK-DM TABLET SA G GSPASTRIN TABLET P BSPECTAZOLE 1% CREAM NP B Loprox, NaftinSPECTRACEF 200MG TABLET P B



SPIRONOLACT/HCTZ 25/25 TAB G G xSPIRONOLACTONE 100MG TABLET G G xSPIRONOLACTONE 25MG TABLET G G xSPIRONOLACTONE 50MG TABLET G G xSPORANOX 100MG CAPSULE NP B Lamisil Prior authorizationSPORANOX 10MG/ML SOLUTION NP B LamisilSPS 15GM/60ML SUSPENSION G GSSD 1% CREAM G GSSD AF 1% CREAM G GSSKI 1GM/ML SOLUTION P B xSTADOL NS 10MG/ML SPRAY NP B butorphanol NS, oral analgesics Quantity limitSTAGESIC 5/500 CAPSULE G GSTAMOIST E TABLET SA G G xSTARLIX 120MG TABLET P B xSTARLIX 60MG TABLET P BSTELAZINE 10MG TABLET NP B x trifluoperazineSTELAZINE 1MG TABLET NP B x trifluoperazineSTELAZINE 2MG TABLET NP B x trifluoperazineSTELAZINE 5MG TABLET NP B x trifluoperazineSTERAPRED 5MG TABLET UNIPAK NP B prednisoneSTERAPRED DS 10MG TB UNIPAK NP B prednisoneSTROMECTOL 3MG TABLET P BSTUART PRENATAL TABLET P BSTUARTNATAL PLUS TABLET P BSUCRALFATE 1GM TABLET G GSUDAL 120/600 TABLET SA G GSUDAL 60/500 TABLET SA G GSUDAL DM TABLET SA P BSULAR 10MG TABLET SA NP B x Adalat CC, Norvasc, PlendilSULAR 20MG TABLET SA NP B x Adalat CC, Norvasc, PlendilSULAR 30MG TABLET SA NP B x Adalat CC, Norvasc, PlendilSULAR 40MG TABLET SA NP B x Adalat CC, Norvasc, PlendilSULF/PRED 0.25% EYE DROPS G GSULFACETAMIDE 10% EYE DROPS G GSULFACETAMIDE 10% EYE OINT G GSULFACET-R LOTION P BSULFAMETHOXAZOLE W/TMP SUSP G GSULFAMETHOXAZOLE/TMP DS TAB G GSULFAMETHOXAZOLE/TMP SS TAB G GSULFASALAZINE 500MG TABLET G GSULFATRIM SUSPENSION G GSULFOXYL REGULAR LOTION P BSULINDAC 150MG TABLET G G Quantity limitSULINDAC 200MG TABLET G G Quantity limitSULTRIN TRIPLE SULFA CREAM NP B triple sulfa vaginal creamSUMYCIN 125MG/5ML ORAL SUSP P BSUMYCIN 250MG CAPSULE G GSUMYCIN 250MG TABLET P BSUMYCIN 500MG CAPSULE G GSUMYCIN 500MG TABLET P BSUPRAX 100MG/5ML SUSPENSION NP B cefaclor Ceftin, CefzilSUPRAX 400MG TABLET NP B cefaclor Ceftin, CefzilSURMONTIL 25MG CAPSULE P B xSURMONTIL 50MG CAPSULE P B xSUSTIVA 200MG CAPSULE P B xSUSTIVA 600MG TABLET P B xSU-TUSS DM ELIXIR G GSU-TUSS HD ELIXIR G GSYMAX-SL 0.125MG TABLET SL P BSYMMETREL 100MG TABLET P BSYNALAR 0.01% SOLUTION NP B fluocinolone acetonide



SYNALAR 0.025% CREAM NP B fluocinolone acetonideSYNALAR 0.025% OINTMENT NP B fluocinolone acetonideSYNALGOS-DC CAPSULE P BSYN-RX 14 DAY TABLET SR SEQ P BSYN-RX DM 14 DAY TABLET SA P BSYNTHROID 100MCG TABLET P B xSYNTHROID 112MCG TABLET P B xSYNTHROID 125MCG TABLET P B xSYNTHROID 150MCG TABLET P B xSYNTHROID 175MCG TABLET P B xSYNTHROID 200MCG TABLET P B xSYNTHROID 25MCG TABLET P B xSYNTHROID 300MCG TABLET P B xSYNTHROID 50MCG TABLET P B xSYNTHROID 75MCG TABLET P B xSYNTHROID 88MCG TABLET P B xTAGAMET 300MG TABLET NP B x cimetidineTAGAMET 400MG TABLET NP B x cimetidineTALACEN CAPLET P BTALWIN NX TABLET NP B pentazocine/naloxoneTAMBOCOR 100MG TABLET NP B x flecainideTAMBOCOR 150MG TABLET NP B x flecainideTAMBOCOR 50MG TABLET NP B x flecainideTAMIFLU 60MG/5ML SUSP NP BTAMIFLU 75MG GELCAP NP B amantadine FlumadineTAMOXIFEN 10MG TABLET P B xTAMOXIFEN 20MG TABLET P B xTANAFED SUSPENSION P BTANNATE-12 SUSPENSION G GTANNIHIST-12 SUSPENSION G GTANORAL PEDIATRIC SUSP G GTAO 250MG CAPSULE P BTAPAZOLE 10MG TABLET NP B x methimazoleTAPAZOLE 5MG TABLET NP B x methimazoleTARGRETIN 75MG SOFTGEL P BTARKA 1/240MG TABLET SA NP B xTARKA 2/180MG TABLET SA NP B xTARKA 2/240MG TABLET SA NP B xTARKA 4/240MG TABLET SA NP B xTASMAR 100MG TABLET NP B x ComtanTAVIST 2.68MG TABLET NP B clemastine fumarateTAZORAC 0.05% CREAM P BTAZORAC 0.05% GEL P BTAZORAC 0.1% CREAM P BTAZORAC 0.1% GEL P BTEBAMIDE 100MG SUPPOSITORY G GTEBAMIDE 200MG SUPPOSITORY G GTECZEM 5/180 TABLET SA NP B xTEGRETOL 100MG TABLET CHEW P B xTEGRETOL 100MG/5ML SUSP P B xTEGRETOL 200MG TABLET P B xTEGRETOL XR 100MG TABLET SA P B xTEGRETOL XR 200MG TABLET SA P B xTEGRETOL XR 400MG TABLET SA P B xTEMAZEPAM 15MG CAPSULE G GTEMAZEPAM 30MG CAPSULE G GTEMAZEPAM 7.5MG CAPSULE G GTEMODAR 100MG CAPSULE P BTEMODAR 20MG CAPSULE P BTEMODAR 250MG CAPSULE P BTEMOVATE 0.05% CREAM NP B clobetasol propionate



TEMOVATE 0.05% GEL NP B clobetasol propionateTEMOVATE 0.05% OINTMENT NP B clobetasol propionateTEMOVATE 0.05% SOLUTION NP B clobetasol propionateTEMOVATE EMOLLIENT 0.05% CRM NP B clobetasol propionateTENEX 1MG TABLET NP B x guanfacineTENEX 2MG TABLET NP B x guanfacineTENORETIC 100 TABLET NP B x atenolol/chlorthalidoneTENORETIC 50 TABLET NP B x atenolol/chlorthalidoneTENORMIN 100MG TABLET NP B x atenolol TENORMIN 25MG TABLET NP B x atenololTENORMIN 50MG TABLET NP B x atenololTEQUIN 200MG TABLET P BTEQUIN 400MG TABLET P BTERAZOL 3 80MG SUPPOSITORY P BTERAZOL 3 CREAM P BTERAZOL 7 CREAM P BTERAZOSIN 10MG CAPSULE G G xTERAZOSIN 1MG CAPSULE G G xTERAZOSIN 2MG CAPSULE G G xTERAZOSIN 5MG CAPSULE G G xTERBUTALINE 2.5MG TABLET G G xTERBUTALINE 5MG TABLET G G xTESSALON 200MG CAPSULE NP B benzonatateTESSALON PERLE 100MG CAP NP B benzonatateTESTODERM 4MG/24HR PATCH NP B x AndrodermTESTODERM 6MG/24HR PATCH NP B x AndrodermTESTODERM TTS 5MG/24HR PTCH P B xTESTRED 10MG CAPSULE NP B x testosteroneTETRA TANNATE PEDI SUSPEN G GTETRACYCLINE 250MG CAPSULE G GTETRACYCLINE 500MG CAPSULE G GTEVETEN 400MG TABLET NP B x Atacand, Avapro, DiovanTEVETEN 600MG TABLET NP B x Atacand, Avapro, DiovanTEXACORT 1% SOLUTION P BTHALOMID 50MG CAPSULE P BTHEO-24 200MG CAPSULE SA P B xTHEO-24 300MG CAPSULE SA P B xTHEO-24 400MG CAPSULE SA P B xTHEO-DUR 200MG TABLET SA P B xTHEO-DUR 300MG TABLET SA P B xTHEO-DUR 450MG TABLET SA P B xTHEOLAIR-SR 300MG TABLET P B xTHEOPHYLLINE 100MG TAB SA G G xTHEOPHYLLINE 200MG CAP SA G G xTHEOPHYLLINE 200MG TAB SA G G xTHEOPHYLLINE 300MG CAP SA G G xTHEOPHYLLINE 300MG TAB SA G G xTHEOPHYLLINE 450MG TAB SA G G xTHEOPHYLLINE 80MG/15ML SOLN G G xTHERAGRAN HEMATINIC TABLET P BTHERMAZENE 1% CREAM G GTHEROBEC PLUS TABLET G GTHIORIDAZINE 100MG TABLET G G xTHIORIDAZINE 10MG TABLET G G xTHIORIDAZINE 15MG TABLET G G xTHIORIDAZINE 25MG TABLET G G xTHIORIDAZINE 50MG TABLET G G xTHIOTHIXENE 10MG CAPSULE G G xTHIOTHIXENE 1MG CAPSULE G G xTHIOTHIXENE 2MG CAPSULE G G xTHIOTHIXENE 5MG CAPSULE G G x



THORAZINE 100MG TABLET NP B x chlorpromazineTHORAZINE 10MG TABLET NP B x chlorpromazineTHORAZINE 150MG TABLET NP B x chlorpromazineTHORAZINE 200MG TABLET NP B x chlorpromazineTHORAZINE 25MG TABLET NP B x chlorpromazineTHORAZINE 30MG SPANSULE P B xTHORAZINE 50MG TABLET NP B x chlorpromazineTHORAZINE 75MG TABLET P B xTHORAZINE SYRUP P B xTHYROID 120MG TABLET G G xTHYROID 60MG TABLET G G xTHYROLAR-1 TABLET P B xTHYROLAR-1/4 TABLET P B xTHYROLAR-2 TABLET P B xTHYROLAR-3 TABLET P B xTIAZAC 120MG CAPSULE SA P B xTIAZAC 180MG CAPSULE SA P B xTIAZAC 240MG CAPSULE SA P B xTIAZAC 300MG CAPSULE SA P B xTIAZAC 360MG CAPSULE SA P B xTIAZAC 420MG CAPSULE SA P B xTICLID 250MG TABLET NP B x ticlopidineTICLOPIDINE 250MG TABLET G G xTIGAN 100MG CAPSULE P BTIGAN 100MG SUPPOSITORY P BTIGAN 200MG SUPPOSITORY P BTIGAN 250MG CAPSULE P BTIKOSYN 0.125MG CAPSULE NP B Betapace AFTIKOSYN 0.25MG CAPSULE NP B Betapace AFTIKOSYN 0.5MG CAPSULE NP B Betapace AFTILADE INHALER P B xTIMOLOL 0.25% EYE DROPS G G xTIMOLOL 0.25% GEL /SOLUTION G G xTIMOLOL 0.5% EYE DROPS G G xTIMOLOL 0.5% GEL/SOLUTION G G xTIMOLOL MALEATE 10MG TABLET G G xTIMOPTIC 0.25% EYE DROPS NP B x timololTIMOPTIC 0.5% EYE DROPS NP B x timololTIMOPTIC-XE 0.25% EYE SOLN NP B x timololTIMOPTIC-XE 0.5% EYE SOLN NP B x timololTOBI 300MG/5ML SOLUTION P BTOBRADEX EYE DROPS P BTOBRADEX EYE OINTMENT P BTOBRAMYCIN 0.3% EYE DROPS G GTOBREX 0.3% EYE DROPS NP B tobramycinTOBREX 0.3% EYE OINTMENT P BTOFRANIL 25MG TABLET NP B x imipramineTOFRANIL 50MG TABLET NP B x imipramineTOFRANIL-PM 125MG CAPSULE P B xTOFRANIL-PM 150MG CAPSULE P B xTOFRANIL-PM 75MG CAPSULE P B xTOLBUTAMIDE 500MG TABLET G G xTOLECTIN DS 400MG CAPSULE NP B tolmetin Quantity limitTOLMETIN SODIUM 400MG CAP G G Quantity limitTOLMETIN SODIUM 600MG TAB G G Quantity limitTONOCARD 400MG TABLET P B xTONOCARD 600MG TABLET P B xTOPAMAX 100MG TABLET P B xTOPAMAX 15MG SPRINKLE CAP P B xTOPAMAX 200MG TABLET P B xTOPAMAX 25MG SPRINKLE CAP P B x



TOPAMAX 25MG TABLET P B xTOPICORT 0.05% GEL NP B desoximetasoneTOPICORT 0.25% CREAM NP B desoximetasoneTOPROL XL 100MG TABLET SA P B xTOPROL XL 200MG TABLET SA P B xTOPROL XL 50MG TABLET SA P B xTORADOL 10MG TABLET NP B ketorolac Quantity limitTORECAN 10MG TABLET NP B prochlorperazine, trimethobenzamideTORNALATE 0.2% SOLUTION NP B x albuterolTOTACILLIN 500MG CAPSULE G GTOURO LA TABLET SA G GT-PHYL 200MG TABLET SA P BTRAMADOL 50MG TABLET G G Quantity limitTRANDATE 100MG TABLET NP B x labetalolTRANDATE 200MG TABLET NP B x labetalolTRANSDERM-SCOP 1.5MG/72HR NP B dimenhydrinate (OTC), meclizine (OTC)TRANXENE SD 22.5MG TAB SA P BTRANXENE T-TAB 3.75MG NP B clorazepateTRANXENE T-TAB 7.5MG NP B clorazepateTRAVATAN 0.004% DROPS NP B x XalatanTRAZODONE 100MG TABLET G G xTRAZODONE 150MG TABLET G G xTRAZODONE 300MG TABLET G G xTRAZODONE 50MG TABLET G G xTRENTAL 400MG TABLET SA NP B x pentoxifyllineTRETINOIN 0.025% CREAM G G Cosmetic use not coveredTRETINOIN 0.05% CREAM G G Cosmetic use not coveredTRETINOIN 0.1% CREAM G G Cosmetic use not coveredTRIAD CAPSULE G GTRIAMCINOLONE 0.025% CREAM G GTRIAMCINOLONE 0.025% OINT G GTRIAMCINOLONE 0.1% CREAM G GTRIAMCINOLONE 0.1% LOTION G GTRIAMCINOLONE 0.1% OINTMENT G GTRIAMCINOLONE 0.1% PASTE G GTRIAMCINOLONE 0.5% CREAM G GTRIAMCINOLONE 0.5% OINTMENT G GTRIAMTERENE/HCTZ 37.5/25 CP G G xTRIAMTERENE/HCTZ 37.5/25 TB G G xTRIAMTERENE/HCTZ 50/25 CAP G G xTRIAMTERENE/HCTZ 75/50 TAB G G xTRIAZ 10% CLEANSER P BTRIAZ 10% GEL P BTRIAZ 3% CLEANSER P BTRIAZ 3% GEL P BTRIAZ 6% CLEANSER P BTRIAZ 6% GEL P BTRIAZ 9% CLEANSER P BTRIAZ 9% GEL P BTRIAZOLAM 0.125MG TABLET G GTRIAZOLAM 0.25MG TABLET G GTRICOR 160MG TABLET P B xTRICOR 200MG CAPSULE P B xTRICOR 54MG TABLET P B xTRICOR 67MG CAPSULE P B xTRIFLUOPERAZINE 1MG TABLET G G xTRIFLUOPERAZINE 2MG TABLET G G xTRI-GESTAN-S PEDIATRIC SUSP G GTRIHEXYPHENIDYL 2MG TABLET G G xTRIHEXYPHENIDYL 5MG TABLET G G xTRIHIST-CS COUGH SYRUP G G



TRIHIST-D ELIXIR G GTRIHIST-DM SYRUP G GTRIKOF-D TABLET SA G GTRILAFON 4MG TABLET NP B x perphenazineTRILEPTAL 150MG TABLET P B xTRILEPTAL 300MG TABLET P B xTRILEPTAL 600MG TABLET P B xTRILEPTAL 300MG/5ML SUSPENSION P B xTRI-LEVLEN 28 TABLET P B x Covered by rider only.TRILISATE 1000MG TABLET NP B choline magnesium trisalicylateTRILISATE 500MG TABLET NP B choline magnesium trisalicylateTRILISATE 750MG TABLET NP B choline magnesium trisalicylateTRIMETHOBENZAMIDE 100MG SUP G GTRIMETHOBENZAMIDE 200MG SUP G GTRIMETHOBENZAMIDE 250MG CAP G GTRIMETHOPRIM 100MG TABLET G GTRIMETHOPRIM 200MG TABLET G GTRIMOX 125MG/5ML SUSPENSION G GTRIMOX 250MG CAPSULE G GTRIMOX 250MG TABLET CHEW G GTRIMOX 250MG/5ML SUSPENSION G GTRIMOX 500MG CAPSULE G GTRIMPEX 100MG TABLET NP B trimethoprimTRINALIN REPETABS P BTRI-NASAL 50MCG NASAL SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortTRI-NORINYL 28 TABLET P B x Covered by rider only.TRINSICON CAPSULE P BTRIOTANN PEDIATRIC SUSP G GTRIOTANN TABLET G GTRIOTANN-S PEDIATRIC SUSPEN G GTRIPHASIL-21 TABLET P B x Covered by rider only.TRIPHASIL-28 TABLET P B x Covered by rider only.TRIPLE ANTIBIOTIC EYE OINT G GTRIPLE SULFA VAGINAL CREAM G GTRIPLE TANNATE PEDI SUSPEN G GTRIPLE-VIT/FLUOR .25MG/ML G GTRI-TANNATE PLUS PED SUSPEN G GTRI-TANNATE SUSPENSION G GTRI-TEX LIQUID G GTRI-VI-FLOR 0.25MG/ML DROPS P BTRI-VIT/FLUOR 0.25MG DROPS G GTRI-VIT/FLUOR/IRON .25MG/ML G GTRIVORA-28 TABLET G G x Covered by rider only.TRIZIVIR P B xTRUSOPT 2% EYE DROPS P B xT-STAT 2% PADS NP B erythromycinTUSSAFED-LA CAPLET SA G GTUSSEND EXPECTORANT P BTUSSEND SYRUP P BTUSSI-12 SUSPENSION P BTUSSI-12 TABLET P BTUSSIGON TABLET G GTUSSIONEX PENNKINETIC SUSP P BTUSSI-ORGANIDIN DM NR LIQ P BTUSSI-ORGANIDIN NR LIQUID P BTUSSI-ORGANIDIN-S NR LIQ P BTUSS-TAN TABLET G GTYLENOL W/CODEINE #3 TABLET NP B acetaminophen/codeine Quantity limitTYLENOL W/CODEINE #4 TABLET NP B acetaminophen/codeineTYLOX 5/500 CAPSULE NP B acetaminophen/oxycodone, Roxilox Quantity limitTYMPAGESIC EAR DROPS P B



ULR-LA TABLET SA G GULTRA NATALCARE TABLET G GULTRABROM CAPSULE SA G GULTRABROM PD CAPSULE SA G GULTRACET TABLET NP B tramadol Quantity limitULTRAM 50MG TABLET NP B tramadol Quantity limitULTRA-NATAL TABLET G GULTRASE MT 12 CAPSULE EC P BULTRASE MT 18 CAPSULE EC P BULTRASE MT 20 CAPSULE EC P BULTRAVATE 0.05% CREAM P BULTRAVATE 0.05% OINTMENT P BUNI MULTIHIST DM SYRUP G GUNI TUSS HC SYRUP S/F G GUNI-DUR 400MG TABLET SA P B xUNI-DUR 600MG TABLET SA P B xUNI-MULTIHIST D CAPSULE SA G GUNIPHYL 400MG TABLET SA P B xUNIPHYL 600MG TABLET SA P B xUNIRETIC 15/25 TABLET NP B x captopril, enalapril/hctz Accuretic, Lotensin HCT, Prinzide, ZestoreticUNIRETIC 7.5/12.5 TABLET NP B x captopril, enalapril/hctz Accuretic, Lotensin HCT, Prinzide, ZestoreticUNITHROID 100MCG TABLET G G xUNITHROID 112MCG TABLET G G xUNITHROID 125MCG TABLET G G xUNITHROID 150MCG TABLET G G xUNITHROID 175MCG TABLET G G xUNITHROID 200MCG TABLET G G xUNITHROID 25MCG TABLET G G xUNITHROID 300MCG TABLET G G xUNITHROID 50MCG TABLET G G xUNITHROID 75MCG TABLET G G xUNITHROID 88MCG TABLET G G xUNIVASC 15MG TABLET NP B x captopril, enalapril,lisinopril Accupril, Altace, LotensinUNIVASC 7.5MG TABLET NP B x captopril, enalapril,lisinopril Accupril, Altace, LotensinURISED TABLET P BURISPAS 100MG TABLET P BURL-TANNATE PED SUSPENSION G GUROCIT-K 1080MG TABLET SA P BUROCIT-K 540MG TABLET SA P BURSO 250MG TABLET P B xURSODIOL 300MG TABLET P G xUSEPT TABLET P BVAGIFEM 25MCG VAGINAL TABLET P BVALCYTE 450MG TABLET P B xVALIUM 10MG TABLET NP B diazepamVALIUM 2MG TABLET NP B diazepamVALIUM 5MG TABLET NP B diazepamVALPROIC ACID 250MG CAPSULE G G xVALPROIC ACID 250MG/5ML SYR G G xVALTREX 1GM CAPLET P BVALTREX 500MG CAPLET P B Use 1/2 of 1GM tabletVANCENASE 42MCG POCKETHALER NP B x Flonase, Nasacort, Nasonex, RhinocortVANCENASE AQ 0.042% SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortVANCENASE AQ 84MCG SPRAY NP B x Flonase, Nasacort, Nasonex, RhinocortVANCERIL 84MCG INHALER NP B x Flovent, Pulmicort, Qvar VANCERIL INHALER NP B x Flovent, Pulmicort, Qvar VANCOCIN HCL 125MG PULVULE P BVANCOCIN HCL 250MG PULVULE P BVANOXIDE-HC LOTION P BVANTIN 100MG TABLET NP B cefaclor Ceftin, Cefzil, OmnicefVANTIN 100MG/5ML SUSPENSION NP B cefaclor Ceftin, Cefzil, Omnicef



VANTIN 200MG TABLET NP B cefaclor Ceftin, Cefzil, OmnicefVANTIN 50MG/5ML SUSPENSION NP B cefaclor Ceftin, Cefzil, OmnicefVASCOR 200MG TABLET P B xVASERETIC 10-25MG TABLET NP B x captopril, enalapril/hctz Accuretic, Prinzide, Lotensin HCTVASERETIC 5-12.5MG TABLET NP B x captopril, enalapril/hctz Accuretic, Prinzide, Lotensin HCTVASOCIDIN 0.25% EYE DROPS NP B sulfacetamide sodium/prednisoloneVASOCINE 0.5% EYE OINTMENT G GVASOTEC 10MG TABLET NP B x enalapril Accupril, Altace, LotensinVASOTEC 2.5MG TABLET NP B x enalapril Accupril, Altace, LotensinVASOTEC 20MG TABLET NP B x enalapril Accupril, Altace, LotensinVASOTEC 5MG TABLET NP B x enalapril Accupril, Altace, LotensinVECTRIN 100MG CAPSULE NP B minocyclineVEETIDS 250MG TABLET G GVEETIDS 250MG/5ML ORAL SUSP G GVEETIDS 500MG TABLET G GVELOSEF 250MG CAPSULE NP B cephradineVELOSEF 500MG CAPSULE NP B cephradineVELOSULIN HUMAN BR P B xVENTOLIN 5MG/ML SOLUTION NP B x albuterolVENTOLIN 90MCG INHALER NP B x albuterol Quantity limitVENTOLIN ROTACAPS 200MCG P B xVEPESID 50MG CAPSULE P BVERAPAMIL 120MG CAP PELLET G G xVERAPAMIL 120MG TABLET G G xVERAPAMIL 120MG TABLET SA G G xVERAPAMIL 180MG CAP PELLET G G xVERAPAMIL 180MG TABLET SA G G xVERAPAMIL 240MG CAP PELLET G G xVERAPAMIL 240MG TABLET SA G G xVERAPAMIL 360MG CAP PELLET G G xVERAPAMIL 80MG TABLET G G xVERELAN 120MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN 180MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN 240MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN 360MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN PM 100MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN PM 200MG CAP PELLET NP B x verapamil cap 24hr pelletVERELAN PM 300MG CAP PELLET NP B x verapamil cap 24hr pelletVERMOX 100MG TABLET CHEW NP B mebendazoleVETUSS HC SYRUP P BVEXOL 1% EYE DROPS P BVIAGRA 100MG TABLET NP B not applicable not applicable Prior authorization. Qty. limitVIAGRA 25MG TABLET NP B not applicable not applicable Prior authorization. Qty. limitVIAGRA 50MG TABLET NP B not applicable not applicable Prior authorization. Qty. limitVICOCLEAR DH LIQUID G GVICODIN 5/500 TABLET NP B hydrocodone/APAP Quantity limitVICODIN ES TABLET NP B hydrocodone/APAP Quantity limitVICODIN HP TABLET NP B hydrocodone/APAP Quantity limitVICODIN TUSS SYRUP P BVICON FORTE CAPSULE P BVICOPROFEN 200/7.5 TABLET P B Quantity limitVI-DAYLIN/F ADC IRON .25MG P BVI-DAYLIN/F+IRON .25MG/ML P BVIDEX 100MG TABLET CHEWABLE P BVIDEX 200MG TABLET CHEWABLE P B xVIDEX EC 125MG CAP SA P B xVIDEX EC 200MG CAP SA P B xVIDEX EC 250MG CAP SA P B xVIDEX EC 400MG CAP SA P B xVINATE ULTRA TABLET G GVIOKASE TABLET P B



VIOXX 12.5MG TABLET NP B generic NSAID's Quantity limitVIOXX 12.5MG/5ML ORAL SUSP NP B generic NSAID'sVIOXX 25MG TABLET NP B generic NSAID's Quantity limitVIOXX 50MG TABLET NP B generic NSAID's Quantity limitVI-Q-TUSS SYRUP G GVIRACEPT 250MG TABLET P B xVIRAMUNE 200MG TABLET P B xVIREAD 300MG TABLET P B xVIROPTIC 1% EYE DROPS P BVISICOL TABLETS P BVISKEN 5MG TABLET NP B pindololVISTARIL 100MG CAPSULE NP B hydroxyzine pamoateVISTARIL 25MG CAPSULE NP B hydroxyzine pamoateVISTARIL 50MG CAPSULE NP B hydroxyzine pamoateVITAMIN D 50000IU CAPSULE G GVIVELLE 0.0375MG PATCH P B xVIVELLE 0.05MG PATCH P B xVIVELLE 0.075MG PATCH P B xVIVELLE 0.1MG PATCH P B xVIVELLE-DOT 0.0375MG PATCH P B xVIVELLE-DOT 0.05MG PATCH P B xVIVELLE-DOT 0.075MG PATCH P B xVIVELLE-DOT 0.1MG PATCH P B xVOLMAX 4MG TABLET SA NP B x Proventil RepetabsVOLMAX 8MG TABLET SA NP B x Proventil RepetabsVOLTAREN 0.1% EYE DROPS P BVOLTAREN 50MG TABLET EC NP B diclofenac Quantity limitVOLTAREN 75MG TABLET EC NP B diclofenac Quantity limitVOLTAREN-XR 100MG TABLET SA NP B diclofenac Quantity limitVYTONE 1/1 CREAM P BWARFARIN SODIUM 10MG TABLET G G xWARFARIN SODIUM 1MG TABLET G G xWARFARIN SODIUM 2.5MG TAB G G xWARFARIN SODIUM 2MG TABLET G G xWARFARIN SODIUM 3MG TABLET G G xWARFARIN SODIUM 4MG TABLET G G xWARFARIN SODIUM 5MG TABLET G G xWARFARIN SODIUM 6MG TABLET G G xWARFARIN SODIUM 7.5MG TAB G G xWE MIST LA TABLET SA G GWELCHOL 625MG TABLET P BWELLBUTRIN 100MG TABLET NP B x bupropionWELLBUTRIN 75MG TABLET NP B x bupropionWELLBUTRIN SR 100MG TAB SA P B xWELLBUTRIN SR 150MG TAB SA P B x Prior authorizationWELLBUTRIN SR 200MG TAB SA P B xWEST DECON TABLET SA G GWESTCORT 0.2% CREAM NP B hydrocortisone valerateWESTCORT 0.2% OINTMENT NP B hydrocortisone valerateWIGRAINE TABLET P BXALATAN 0.005% EYE DROPS P B xXANAX 0.25MG TABLET NP B alprazolamXANAX 0.5MG TABLET NP B alprazolamXANAX 1MG TABLET NP B alprazolamXANAX 2MG TABLET NP B alprazolamXELODA 500MG TABLET P BXOPENEX 0.63MG/3ML SOLUTION NP B x albuterol inhalant solutionXOPENEX 1.25MG/3ML SOLUTION NP B x albuterol inhalant solutionXYLOCAINE 2% JELLY NP B lidocaine 2% jellyXYLOCAINE 2% VISCOUS SOLN NP B lidocaine 2% viscous solnXYLOCAINE 5% OINTMENT NP B lidocaine 5% ointment



YASMIN 28 TABLET P B xYOHIMBINE 5.4MG TABLET G GZADITOR 0.025% EYE DROPS NP B Livostin, PatanolZAGAM 200MG TABLET NP B Cipro, Levaquin, TequinZANAFLEX 4MG TABLET NP B x cyclobenzaprine, methocarbamolZANTAC 150MG TABLET NP B x ranitidineZANTAC 15MG/ML SYRUP P B xZANTAC 300MG TABLET NP B x ranitidineZARONTIN 250MG CAPSULE P B xZARONTIN 250MG/5ML SYRUP P B xZAROXOLYN 10MG TABLET P B xZAROXOLYN 2.5MG TABLET P B xZAROXOLYN 5MG TABLET P B xZEBETA 5MG TABLET NP B x bisoprololZEBUTAL CAPSULE G GZEPHREX TABLET P BZEPHREX-LA TABLET SA P BZERIT 20MG CAPSULE P B xZERIT 30MG CAPSULE P B xZERIT 40MG CAPSULE P B xZESTORETIC 10/12.5 TABLET NP B x lisinopril/HCTZZESTORETIC 20/12.5 TABLET NP B x lisinopril/HCTZZESTORETIC 20/25 TABLET NP B x lisinopril/HCTZZESTRIL 10MG TABLET NP B x lisinopril ZESTRIL 2.5MG TABLET NP B x lisinopril ZESTRIL 20MG TABLET NP B x lisinopril ZESTRIL 30MG TABLET NP B x lisinopril ZESTRIL 40MG TABLET NP B x lisinopril ZESTRIL 5MG TABLET NP B x lisinopril ZIAC 10/6.25MG TABLET NP B x bisoprolol/HCTZZIAC 2.5/6.25MG TABLET NP B x bisoprolol/HCTZZIAC 5/6.25MG TABLET NP B x bisoprolol/HCTZZIAGEN 300MG TABLET P BZINCATE 220MG CAPSULE G GZITHROMAX 100MG/5ML SUSP NP B amoxicillin, cephalexin, erythromycin Augmentin, Biaxin, Cefzil, OmnicefZITHROMAX 1GM POWDER PACKET NP B amoxicillin, cephalexin, erythromycin Augmentin, Biaxin, Cefzil, OmnicefZITHROMAX 200MG/5ML SUSP NP B amoxicillin, cephalexin, erythromycin Augmentin, Biaxin, Cefzil, OmnicefZITHROMAX 250MG TABLET NP B amoxicillin, cephalexin, erythromycin Augmentin, Biaxin, Cefzil, OmnicefZITHROMAX 600MG TABLET NP B amoxicillin, cephalexin, erythromycin Augmentin, Biaxin, Cefzil, OmnicefZOCOR 10MG TABLET NP B x lovastatin Lipitor, PravacholZOCOR 20MG TABLET NP B x lovastatin Lipitor, PravacholZOCOR 40MG TABLET NP B x lovastatin Lipitor, PravacholZOCOR 5MG TABLET NP B x lovastatin Lipitor, PravacholZOCOR 80MG TABLET NP B x lovastatin Lipitor, PravacholZOFRAN 4MG TABLET P B Quantity limitZOFRAN 8MG TABLET P B Quantity limitZOFRAN 24MG TABLET P B Quantity limitZOFRAN ODT 4MG TABLET P B Quantity limitZOFRAN ODT 8MG TABLET P B Quantity limitZOLOFT 100MG TABLET P B xZOLOFT 25MG TABLET P B xZOLOFT 50MG TABLET P B x Use 1/2 of 100mg for 50mg doseZOMIG 2.5MG TABLET P B Quantity limitZOMIG 5MG TABLET P B Quantity limitZOMIG ZMT 2.5MG TABLET P BZOMIG ZMT 5MG TABLET P BZONALON 5% CREAM P BZONE-A FORTE 2.5% LOTION G GZONEGRAN P BZORPRIN 800MG TABLET SA P BZOTO-HC EAR DROPS G G



ZOVIA 1/35E TABLET G G x Covered by rider only.ZOVIA 1/50E TABLET G G x Covered by rider only.ZOVIRAX 200MG CAPSULE NP B acyclovirZOVIRAX 200MG/5ML SUSP NP B acyclovirZOVIRAX 400MG TABLET NP B acyclovirZOVIRAX 5% OINTMENT P BZOVIRAX 800MG TABLET NP B acyclovirZYDONE 10/400MG TABLET P BZYFLO 600MG FILMTAB NP B x Accolate, SingulairZYLOPRIM 300MG TABLET NP B allopurinolZYPREXA 10MG TABLET NP B x Seroquel, RisperdalZYPREXA 15MG TABLET NP B x Seroquel, RisperdalZYPREXA 2.5MG TABLET NP B x Seroquel, RisperdalZYPREXA 5MG TABLET NP B x Seroquel, RisperdalZYPREXA 7.5MG TABLET NP B x Seroquel, RisperdalZYPREXA ZYDIS 10MG TABLET NP B x Seroquel, RisperdalZYPREXA ZYDIS 5MG TABLET NP B x Seroquel, RisperdalZYRTEC 10MG TABLET NP B x Allegra, Zyrtec Syrup, Astelin Nasal SprayZYRTEC 1MG/ML SYRUP P B xZYRTEC 5MG TABLET NP B Allegra, Zyrtec Syrup, Astelin Nasal SprayZYVOX 100MG/5ML ORAL SUSP NP B not applicable not applicableZYVOX 600MG TABLET NP B not applicable not applicable


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