docPMD 2011 Comprehensive Formulary Publication Document
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PMD 2011 Comprehensive Formulary Publication Document
The symbol LTD next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. The symbol PA in the Restrictions column indicates that prior authorization may apply. The symbol QLL in the Restrictions column indicates that quantities dispensed may be limited. The symbol ST in the Restrictions column indicates that step therapy may apply. General Drug Table Drug Tier Restrictions ANESTHETICS LOCAL ANESTHETICS lidocaine hcl injection 1 TOPICAL ANESTHETICS anestacon lidocaine hcl cream, -jel, -lotion, -ointment, solution non-oral lidocaine hcl viscous lidocaine-prilocaine LIDODERM pre-attached lta kit SYNERA 1 1 1 1 3 1 3 PA, QLL (93/31) ANTIINFECTIVES AMEBICIDES paromomycin sulfate YODOXIN 1 2 AMINOGLYCOSIDES amikacin sulfate injection 1 Page 1 of 117 Drug GENTAMICIN 60 MG/NS 100 ML PB, -ISOTON GENTAMICIN 60 MG/100 ML, -80 MG/NS 100 ML PB, -ISOTON GENTAMICIN 80 MG/100 ML, -ISO GENTAMICIN 120 MG/100 ML Tier Restrictions 3 gentamicin 90 mg/ns 100 ml pb, -100 mg/ns 100 1 ml, -iso gentamicin 100 mg/100 ml, -60 mg/ns 50 ml pb, -isoton gentamicin 60 mg/50 ml, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -isoton gentamicin 80 mg/50 ml gentamicin sulfate injection 1 kanamycin sulfate injection 1 NEO-FRADIN neomycin sulfate tablet TOBI tobramycin sulfate in ns tobramycin sulfate injection 2 1 4 1 1 PA, QLL (280/28) ANTHELMINTICS ALBENZA BILTRICIDE mebendazole tablet chewable STROMECTOL 2 2 1 2 ANTIINFECTIVES SPECIALIZED INDICATIONS DAPSONE TABLET FLAGYL ER metro iv metronidazole capsule, -injection, -tablet 2 3 1 1 ANTIRETROVIRALS AND PROTEASE INH APTIVUS ATRIPLA COMBIVIR CRIXIVAN didanosine EDURANT EMTRIVA 4 4 4 2 1 3 2 Page 2 of 117 Drug EPIVIR EPZICOM FUZEON INCIVEK INTELENCE INVIRASE ISENTRESS KALETRA 100-25 MG TABLET KALETRA SOLUTION, -200-50 MG TABLET LEXIVA SUSPENSION ORAL LEXIVA TABLET NORVIR CAPSULE, -TABLET NORVIR SOLUTION PREZISTA 400 MG TABLET, -600 MG TABLET PREZISTA 75 MG TABLET, -150 MG TABLET RESCRIPTOR RETROVIR INJECTION REYATAZ SELZENTRY stavudine SUSTIVA TRIZIVIR TRUVADA VICTRELIS VIDEX VIRACEPT POWDER VIRACEPT TABLET VIRAMUNE VIRAMUNE XR VIREAD ZIAGEN zidovudine Tier 2 4 4 4 4 4 4 3 4 3 4 3 4 4 2 2 3 4 4 1 2 4 4 4 3 3 4 3 3 2 2 1 Restrictions PA, QLL (186/31) PA, QLL (372/31) ANTITUBERCULOSIS DRUGS CAPASTAT SULFATE ethambutol hcl isonarif isoniazid injection, -syrup, -tablet MYCOBUTIN 4 1 1 1 3 Page 3 of 117 Drug PASER PRIFTIN pyrazinamide RIFAMATE rifampin capsule rifampin injection RIFATER SEROMYCIN STREPTOMYCIN SULFATE INJECTION TRECATOR Tier Restrictions 3 3 1 3 1 4 3 3 2 3 CEPHALOSPORINS CEDAX 3 1 1 1 1 cefaclor cefaclor er cefadroxil cefazolin 20 gm bulk vial, -500 mg vial, -1 gm add-van vial, -1 gm vial, -1 gm-d5w bag, -10 gm vial cefazolin sod 100 gm bulk bag, -sod 300 gm bulk 1 bag cefdinir 1 CEFDITOREN PIVOXIL 400 MG TAB cefepime hcl cefotaxime sodium cefotetan cefoxitin cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime 500 mg vial ceftriaxone cefuroxime cefuroxime axetil CEFUROXIME SOD 75 GM BULK BAG cefuroxime sod 750 mg vial, -sod 1.5 gm vial, sod 7.5 gm vial cephalexin FORTAZ 500 MG VIAL 3 1 1 1 1 1 1 1 1 1 1 1 3 1 1 3 Page 4 of 117 Drug FORTAZ IN ISO-OSMOTIC DEXTROSE KEFLEX 750 MG CAPSULE SPECTRACEF SUPRAX TEFLARO Tier Restrictions 3 3 3 3 3 CHLORAMPHENICOLS chloramphenicol sod succinate 1 CLINDAMYCINS CLEOCIN HCL 75 MG CAPSULE CLEOCIN PALMITATE CLEOCIN PHOSPHATE IN D5W clindamycin hcl capsule clindamycin palmitate hcl clindamycin phosphate injection 3 2 3 1 1 1 ERYTHROMYCINS ERYPED 200 ERYPED 400 ERY-TAB ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin capsule enteric coated, -tablet erythromycin ethylsuccinate tablet PCE 3 3 3 3 1 1 1 3 ORAL ANTIFUNGAL DRUGS ANCOBON clotrimazole troche fluconazole suspension, -tablet GRIFULVIN V griseofulvin suspension oral GRIS-PEG itraconazole capsule ketoconazole tablet 4 1 1 2 1 2 1 1 PA, QLL (366/90) Page 5 of 117 Drug NOXAFIL nystatin 150,000,000 units pwd nystatin 50,000,000 units pwd, -500,000,000 units pwd, -suspension oral, -500,000 unit oral tab terbinafine hcl tablet VFEND voriconazole Tier 4 3 1 Restrictions PA 1 4 1 OTHER ANTIINFECTIVE DRUGS ALINIA AZACTAM 1 GM VIAL AZACTAM-ISO-OSMOT 1 GM/50 ML AZACTAM-ISO-OSMOT 2 GM/50 ML aztreonam baciim bacitracin injection CAYSTON colistimethate 150 mg vial CUBICIN DIFICID DORIBAX 500 MG VIAL INVANZ LINCOCIN MEPRON meropenem NEBUPENT polymyxin b sulfate injection PRIMAXIN 250 MG VIAL PRIMAXIN 500 MG VIAL PRIMAXIN I.M. SYNERCID TYGACIL VANCOCIN HCL VANCOMYCIN vancomycin 1 gm vial, -10 gm vial vancomycin 500 mg a/v vial, -500 mg vial, -750 mg vial, -1 gm add-van vial, -5 gm vial VANCOMYCIN HCL 1G/200 ML BAG 2 4 3 4 1 1 1 4 4 4 4 4 2 3 4 1 2 1 3 4 4 4 4 4 4 1 1 QLL (84 vials/28), LTD PA QLL (20/10), ST PA PA 4 Page 6 of 117 Drug VIBATIV XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET ZYVOX Tier 4 3 3 4 Restrictions QLL (93/31) PA, QLL (62/31) OTHER ANTIVIRAL DRUGS acyclovir capsule, -suspension oral, -tablet acyclovir sodium amantadine BARACLUDE SOLUTION BARACLUDE TABLET COPEGUS DENAVIR EPIVIR HBV famciclovir foscarnet sodium ganciclovir ganciclovir sodium HEPSERA REBETOL CAPSULE REBETOL SOLUTION RELENZA RIBAPAK RIBASPHERE 400 MG TABLET, -600 MG TABLET ribasphere capsule, -200 mg tablet RIBATAB 400-400 MG DOSEPACK, -600-600 MG DOSEPACK RIBAVIRIN 400 MG TABLET, -600 MG TABLET ribavirin capsule, -200 mg tablet rimantadine hcl TAMIFLU 30 MG GELCAP, -45 MG GELCAP, SUSPENSION TAMIFLU 75 MG GELCAP TYZEKA valacyclovir VALCYTE VIRAZOLE VISTIDE 1 1 1 3 4 4 2 2 1 1 4 1 4 4 4 2 QLL (186/31) QLL (186/31) QLL (120 inhalations/365) 4 4 1 4 4 1 1 2 2 3 1 4 4 4 QLL (56/365) Page 7 of 117 Drug ZOVIRAX CREAM, -OINTMENT Tier Restrictions 2 OTHER MACROLIDES azithromycin injection, -packet, -suspension, tablet clarithromycin er clarithromycin suspension, -tablet 1 1 1 OTHER TOPICAL ANTIFUNGALS ciclopirox cream, -gel, -solution non-oral, suspension topical clotrimazole cream, -solution non-oral econazole nitrate cream ketoconazole cream, -shampoo NAFTIN nyamyc nystatin cream, -ointment, -100,000 unit/gm powd nystop OXISTAT pedi-dri 1 1 1 1 3 1 1 1 3 1 PARENTERAL ANTIFUNGALS ABELCET AMBISOME AMPHOTEC amphotericin b injection CANCIDAS ERAXIS (WATER DILUENT) fluconazole in dextrose fluconazole in saline MYCAMINE VFEND IV 4 4 3 1 4 3 1 1 4 4 PENICILLINS amox tr-potassium clavulanate 1 Page 8 of 117 Drug amoxicillin amoxicillin-clavulanate er ampicillin sodium ampicillin trihydrate ampicillin-sulbactam BICILLIN C-R BICILLIN L-A dicloxacillin sodium NAFCILLIN 1 GM/ 50 ML INJ nafcillin 2 gm/ 100 ml inj nafcillin sodium OXACILLIN oxacillin 1 gm add-vantage vl, -1 gm vial OXACILLIN 10 GM VIAL oxacillin 2 gm add-vantage vl, -2 gm vial penicillin g potassium penicillin g procaine penicillin g sodium PENICILLIN GK-ISO-OSM DEXTROSE penicillin v potassium PFIZERPEN piperacillin piperacillin-tazobactam TIMENTIN UNASYN 1.5 GM ADD-VANTAGE VL, -1.5 GM PIGGYBACK BOTTLE, -3 GM ADD-VANTAGE VIAL, -3 GM PIGGYBACK BOTTLE ZOSYN 2.25 GRAM VIAL, -2.25 GM GALAXY BAG, -2.25 GM PRE-MIX BAG, -3.375 GM GALAXY BAG, -3.375 GM PRE MIX-BAG, -4.5 GM GALAXY BAG, -4.5 GM PRE-MIX BAG, -4.5 GRAM VIAL, 40.5 GRAM BULK VIAL Tier Restrictions 1 1 1 1 1 3 3 1 4 4 4 4 1 4 4 1 1 1 2 1 3 1 1 3 3 3 PLASMODICIDES atovaquone-proguanil hcl chloroquine phosphate tablet COARTEM DARAPRIM hydroxychloroquine sulfate tablet 1 1 2 2 1 Page 9 of 117 Drug MALARONE mefloquine hcl PRIMAQUINE Tier Restrictions 2 1 2 QUINOLONES AVELOX AVELOX ABC PACK AVELOX IV ciprofloxacin ciprofloxacin er 1,000 mg tab ciprofloxacin er 500 mg tablet ciprofloxacin hcl tablet ciprofloxacin-d5w FACTIVE LEVAQUIN levofloxacin injection, -solution, -tablet levofloxacin-d5w NOROXIN ofloxacin tablet 3 3 3 1 1 1 1 1 3 3 1 1 3 1 QLL (14/14) QLL (28/31) QLL (7/30) SULFONAMIDES erythromycin-sulfisoxazole sulfadiazine tablet sulfamethoxazole-trimethoprim 1 1 1 TETRACYCLINES demeclocycline hcl 1 doxycycline 1 doxycycline hyclate capsule, -hyc dr 75 mg cap, - 1 injection, -100 mg tab doxycycline mono 50 mg cap, -mono 100 mg 1 cap, -tablet minocycline hcl capsule, -tablet 1 tetracycline hcl capsule 1 VIBRAMYCIN SUSPENSION, -SYRUP 2 Page 10 of 117 Drug Tier TOPICAL ANTIBACTERIAL DRUGS BACTROBAN NASAL CHLORHEXIDINE GLUC 20% SOLN gentamicin sulfate cream, -0.1% ointment mupirocin ointment silver sulfadiazine cream ssd ssd af thermazene Restrictions 3 3 1 1 1 1 1 1 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB. clotrimazole-betamethasone nystatin-triamcinolone 1 1 URINARY ANTIINFECTIVES FURADANTIN MACRODANTIN 25 MG CAPSULE methenamine hippurate methenamine mandelate tablet MONUROL nitrofurantoin macrocrystal capsule nitrofurantoin mono-macro nitrofurantoin suspension oral trimethoprim tablet uretron d-s urogesic-blue UTIRA-C 2 2 1 1 2 1 1 1 1 1 1 2 VAGINAL ANTIFUNGALS miconazole 3 suppository vaginal nystatin vaginal tablet terconazole ZAZOLE SUPPOSITORY VAGINAL 1 1 1 2 Page 11 of 117 Drug Tier Restrictions ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ABRAXANE adriamycin 10 mg vial, -20 mg vial, -50 mg vial adriamycin 2 mg/ml vial adrucil AFINITOR ALIMTA ALKERAN INJECTION AMEVIVE amifostine anagrelide hcl anastrozole tablet AROMASIN ARRANON AVASTIN AZASAN AZATHIOPRINE SODIUM azathioprine tablet bicalutamide BICNU bleomycin sulfate 15 unit vial bleomycin sulfate 30 unit vial BUSULFEX CAMPATH CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET carboplatin 150 mg/15 ml vial carboplatin 450 mg/45 ml vial, -50 mg/5 ml vial, -600 mg/60 ml vial, -50 mg vial, -150 mg vial, 450 mg vial CEENU CELLCEPT INJECTION CELLCEPT SUSPENSION RECONSTITUTED ORAL CIMZIA 200 MG VIAL KIT, -200 MG/ML SYRINGE KIT cisplatin cladribine CLOLAR 4 1 1 1 4 4 3 4 1 1 1 3 3 4 2 2 1 1 3 4 4 3 4 4 4 1 1 2 3 4 4 PA, QLL (31/31) PA, QLL (24/365), LTD PA PA PA PA, QLL (93/31) PA, QLL (31/31) PA PA PA, QLL (6/28) 1 4 4 Page 12 of 117 Drug COSMEGEN cyclophosphamide injection cyclophosphamide tablet cyclosporine capsule, -injection, -solution cyclosporine modified cyclosporine unit cytarabine 100 mg vial, -1 gm vial, -2 gm vial cytarabine 20 mg/ml vial, -100 mg/ml vial, -500 mg vial dacarbazine 100 mg vial dacarbazine 200 mg vial DACOGEN dactinomycin daunorubicin hcl DAUNOXOME DEPO-PROVERA 400 MG/ML VIAL dexrazoxane 250 mg vial dexrazoxane 500 mg vial docetaxel 80 mg/8 ml vial DOXIL Tier 3 1 1 1 1 1 1 1 Restrictions PA PA PA 1 1 4 1 1 3 3 1 1 1 4 1 doxorubicin 10 mg/5 ml vial, -20 mg/10 ml vial, 50 mg/25 ml vial, -10 mg vial, -50 mg vial doxorubicin 200 mg/100 ml vial 1 DROXIA ELIGARD 22.5 MG SYRINGE ELIGARD 30 MG SYRINGE ELIGARD 45 MG SYRINGE ELIGARD 7.5 MG SYRINGE ELITEK ELLENCE ELOXATIN ELSPAR EMCYT ENBREL 25 MG KIT, -25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE ENBREL 50 MG/ML SURECLICK SYR epirubicin 200 mg/100 ml vial, -50 mg vial, -150 mg/75 ml vial, -200 mg vial epirubicin 50 mg/25 ml vial ERBITUX 3 3 3 3 3 4 3 3 4 3 4 PA, PA, PA, PA, QLL QLL QLL QLL (1/84) (1/112) (1/168) (1/28) PA, QLL (8/28) 4 1 1 4 Page 13 of 117 Drug ETHYOL ETOPOPHOS etoposide injection exemestane FARESTON FASLODEX FEMARA FIRMAGON 2 X 120 MG VIALS FIRMAGON 80 MG VIAL floxuridine FLUDARABINE 50 MG VIAL fludarabine 50 mg/2 ml vial fluorouracil injection flutamide fudr gemcitabine hcl GEMZAR gengraf GLEEVEC 100 MG TABLET GLEEVEC 400 MG TABLET HALAVEN HERCEPTIN HEXALEN HUMIRA HYCAMTIN INJECTION hydroxyurea capsule IDAMYCIN PFS idarubicin hcl ifosfamide ifosfamide-mesna IRESSA irinotecan hcl IXEMPRA leflunomide letrozole leucovorin calcium injection, -tablet LEUKERAN LUPRON DEPOT 45 MG 6MO KIT LYSODREN Tier 3 3 1 1 2 4 3 4 3 1 2 1 1 1 1 1 3 1 4 4 4 2 4 4 4 1 3 1 1 1 4 4 4 1 1 1 2 4 4 Restrictions PA, QLL (2/365) PA, QLL (4/28) PA PA, QLL (93/31) PA, QLL (62/31) PA, QLL (5.60 syringes/28) PA, QLL (31/31), LTD PA, QLL (1/168) Page 14 of 117 Drug MATULANE MEGACE ES megestrol acetate suspension oral, -tablet melphalan hcl mercaptopurine tablet MESNEX INJECTION MESNEX TABLET methotrexate injection, -tablet mitomycin injection mitoxantrone hcl MUSTARGEN mycophenolate mofetil MYFORTIC NEXAVAR NILANDRON NULOJIX octreotide acet 100 mcg/ml amp, -acet 100 mcg/ml syr, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml vl, -1,000 mcg/ml vial octreotide acet 50 mcg/ml amp octreotide acet 50 mcg/ml syr, -acet 50 mcg/ml vial ONCASPAR ONTAK ORENCIA 250 MG VIAL ORTHOCLONE OKT-3 oxaliplatin paclitaxel 100 mg/16.7 ml vial, -30 mg/5 ml vial paclitaxel 300 mg/50 ml vial pentostatin PHOTOFRIN PROGRAF INJECTION RAPAMUNE REMICADE REVLIMID RITUXAN SANDIMMUNE SOLUTION SANDOSTATIN SANDOSTATIN LAR Tier 4 3 1 1 1 2 4 1 1 1 3 1 2 4 2 4 4 Restrictions PA PA PA PA PA, QLL (124/31), LTD PA 1 3 4 4 4 3 1 1 1 1 3 3 3 4 4 4 2 4 4 PA PA PA PA PA PA, QLL (31/31), LTD PA PA PA, QLL (1/28) Page 15 of 117 Drug SIMPONI 50 MG/0.5 ML PEN INJEC SIMPONI 50 MG/0.5 ML SYRINGE SIMULECT SOMATULINE DEPOT SORIATANE 10 MG CAPSULE, -25 MG CAPSULE SORIATANE CK SPRYCEL 20 MG TABLET, -50 MG TABLET, -70 MG TABLET SPRYCEL 80 MG TABLET, -100 MG TABLET, -140 MG TABLET STELARA 45 MG/0.5 ML SYRINGE, -45 MG/0.5 ML VIAL STELARA 90 MG/ML SYRINGE SUTENT TABLOID tacrolimus capsule tamoxifen citrate tablet TARCEVA 100 MG TABLET, -150 MG TABLET TARCEVA 25 MG TABLET TARGRETIN CAPSULE TARGRETIN GEL TASIGNA TAXOTERE 20 MG/0.5 ML VIAL, -80 MG/2 ML VIAL THERACYS THIOTEPA INJECTION topotecan hcl TORISEL TRELSTAR TRELSTAR TRELSTAR TRELSTAR TRELSTAR TRELSTAR 11.25 MG SYRINGE 22.5 MG SYRINGE 22.5 MG VIAL 3.75 MG SYRINGE DEPOT LA tretinoin capsule TRISENOX TYKERB TYSABRI UVADEX VANDETANIB 100 MG TABLET Tier 4 4 3 4 4 4 4 Restrictions PA, QLL (0.50/28) PA PA, QLL (1/28) PA, QLL (62/31) 4 PA, QLL (31/31) 4 PA, QLL (0.50/28) 4 4 3 1 1 4 4 4 4 4 4 PA, QLL (1/28) PA, QLL (31/31) 3 3 4 4 3 4 4 3 3 3 4 3 4 4 3 4 PA PA, QLL (31/31) PA PA PA, QLL (124/31) PA, PA PA, PA, PA, PA, QLL (1/84) QLL QLL QLL QLL (1/84) (1/28) (1/28) (1/84) PA, QLL (186/31) PA, QLL (15/28), LTD PA, QLL (93/31), LTD Page 16 of 117 Drug VANDETANIB 300 MG TABLET VANTAS VECTIBIX 100 MG/5 ML VIAL VECTIBIX 400 MG/20 ML VIAL VELCADE VIDAZA vinblastine 1 mg/ml vial vinblastine sulf 10 mg vial vincristine 1 mg/ml vial vincristine 2 mg/2 ml vial vinorelbine 10 mg/ml vial vinorelbine 50 mg/5 ml vial VOTRIENT VUMON ZANOSAR ZEVALIN ZOLADEX ZOLINZA ZORTRESS 0.25 MG TABLET ZORTRESS 0.5 MG TABLET, -0.75 MG TABLET ZYTIGA Tier 4 4 4 2 4 4 1 1 1 1 1 1 4 3 3 4 3 4 2 4 4 Restrictions PA, QLL (31/31), LTD PA PA, QLL (124/31) PA PA, QLL (124/31) PA PA PA, QLL (124/31) AUTONOMIC AND CNS MEDICATIONS ANALGESICS acetaminophen-tramadol BUPRENORPHINE 0.3 MG/ML SYRN butorphanol tartrate injection nalbuphine hcl injection poly-650 PRIALT tramadol hcl tablet tramadol hcl-acetaminophen 1 2 1 1 1 3 1 1 QLL (248/31) QLL (40/5) ANTIDEMENTIA DRUGS COGNEX donepezil hcl EXELON PATCH TRANSDERMAL 24 HOURS EXELON SOLUTION galantamine hbr 3 1 2 3 1 Page 17 of 117 Drug galantamine hydrobromide NAMENDA RAZADYNE SOLUTION rivastigmine Tier Restrictions 1 2 3 1 ANTIMANIA DRUGS lithium lithium carbonate capsule, -tablet, -tablet sustained action 1 1 ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine mesylate injection, -tablet COGENTIN trihexyphenidyl hcl 1 3 1 ANTIPSYCHOTIC DRUGS ABILIFY ABILIFY ABILIFY ABILIFY DISCMELT INJECTION SOLUTION TABLET chlorpromazine hcl injection, -tablet clozapine FANAPT TABLET FANAPT TABLET DOSE PACK FAZACLO fluphenazine decanoate fluphenazine hcl GEODON CAPSULE GEODON INJECTION haloperidol dec 50 mg/ml vial, -dec 100 mg/ml vial haloperidol decanoate 100 haloperidol lactate haloperidol tablet INVEGA ER 1.5 MG TABLET, -ER 3 MG TABLET, ER 9 MG TABLET INVEGA ER 6 MG TABLET 3 3 3 3 1 1 3 3 3 1 1 2 2 1 PA, QLL (62/31) PA PA, QLL (900/30) PA, QLL (31/31) PA, QLL (62/31) PA QLL (62/31) 1 1 1 3 PA, QLL (31/31) 3 PA, QLL (62/31) Page 18 of 117 Drug INVEGA SUSTENNA 117 MG PREF SY, -156 MG PREF SY, -234 MG PREF SY INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR LATUDA loxapine NAVANE 20 MG CAPSULE ORAP perphenazine RISPERDAL CONSTA 12.5 MG SYR, -25 MG SYR RISPERDAL CONSTA 37.5 MG SYR, -50 MG SYR risperidone risperidone risperidone risperidone m-tab odt solution tablet SAPHRIS SEROQUEL SEROQUEL XR 150 MG TABLET, -200 MG TABLET SEROQUEL XR 50 MG TABLET, -300 MG TABLET, -400 MG TABLET thioridazine hcl thiothixene trifluoperazine hcl ZYPREXA 15 MG TABLET, -20 MG TABLET ZYPREXA 2.5 MG TABLET, -5 MG TABLET, -7.5 MG TABLET, -10 MG TABLET ZYPREXA INJECTION ZYPREXA RELPREVV ZYPREXA ZYDIS 15 MG TABLET, -20 MG TABLET ZYPREXA ZYDIS 5 MG TABLET, -10 MG TABLET Tier Restrictions 4 PA 3 PA 3 1 2 2 1 3 4 1 1 1 1 3 3 3 PA, QLL (31/31) 3 PA, QLL (62/31) 1 1 1 2 2 QLL (62/31) QLL (31/31) 2 4 2 2 QLL (62/31) QLL (31/31) PA PA QLL (62/31) QLL (62/31) PA, QLL (62/31) PA, QLL (93/31) PA, QLL (31/31) ANTIVERTIGO AND ANTIEMETIC DRUGS ALOXI ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET ANZEMET INJECTION compro dronabinol 2.5 mg capsule DRONABINOL 5 MG CAPSULE, -10 MG CAPSULE 4 3 3 3 1 1 4 PA, QLL (14/30), ST PA, QLL (7/30), ST PA PA Page 19 of 117 EMEND EMEND EMEND EMEND EMEND Drug 125 MG CAPSULE 40 MG CAPSULE 80 MG CAPSULE INJECTION TRIFOLD PACK granisetron hcl 0.1 mg/ml vial granisetron hcl 1 mg/ml vial, -4 mg/4 ml vial granisetron hcl tablet granisol meclizine hcl tablet ondansetron hcl 24 mg tablet ondansetron hcl 4 mg tablet, -8 mg tablet ondansetron hcl in dextrose ondansetron hcl injection ondansetron hcl solution ondansetron in sodium chloride ondansetron odt phenadoz prochlorperazine edisylate prochlorperazine maleate suppository rectal, tablet promethazine hcl suppository rectal promethegan SANCUSO TRANSDERM-SCOP trimethobenzamide hcl capsule, -injection Tier 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 Restrictions PA, QLL (2/31) PA, QLL (1/30) PA, QLL (4/30) PA PA, QLL (6/28) QLL (140/30) QLL (14/30) PA, QLL (31/31), ST PA, QLL (310 ml/31), ST PA, QLL (31/31) PA, QLL (93/31) PA, QLL (930 ml/31) PA, QLL (93/31) QLL (4/28), ST ANXIOLYTICS buspirone hcl tablet meprobamate 1 1 CARBAMAZEPINES carbamazepine capsule sustained action, suspension oral, -tablet, -tablet chewable carbamazepine xr CARBATROL epitol EQUETRO 1 1 3 1 3 Page 20 of 117 oxcarbazepine Drug TEGRETOL XR 100 MG TABLET TRILEPTAL SUSPENSION Tier Restrictions 1 2 3 CLASS II NARCOTICS ABSTRAL belladonna-opium codeine phosphate injection codeine sulfate DEMEROL 75 MG/ML SYRINGE diskets endocet endodan fentanyl 100 mcg/hr patch fentanyl 12 mcg/hr patch, -25 mcg/hr patch, -50 mcg/hr patch, -75 mcg/hr patch fentanyl citrate injection fentanyl citrate lozenge hydromorphone hcl 1 mg/ml amp, -1 mg/ml syringe, -2 mg/ml syringe, -2 mg/ml vial, -2 mg/ml amp, -2 mg/ml vl, -4 mg/ml syrin, -10 mg/ml vial, -50 mg/5 ml vial, -500 mg/50 ml via, -10 mg/ml amp, -suppository rectal, -tablet levorphanol tartrate tablet meperidine hcl injection, -solution, -tablet meperitab methadone hcl injection, -solution, -tablet, tablet soluble methadone intensol methadose morphine sulfate in dextrose morphine sulfate injection, -solution, suppository rectal, -tablet morphine sulfate tablet sustained action ONSOLIS OPANA ER oxycodone concentrate oxycodone hcl oxycodone hcl-acetaminophen oxycodone hcl-aspirin 4 1 1 1 2 1 1 1 1 1 1 4 1 PA, QLL (124/31) QLL (30/30) QLL (10/30) PA, QLL (120/30) 1 1 1 1 1 1 1 1 1 4 2 1 1 1 1 QLL (93/31) PA, QLL (124/31), LTD QLL (62/31) Page 21 of 117 Drug oxycodone hcl-ibuprofen oxycodone-acetaminophen oxycodone-aspirin oxymorphone hcl tablet oxymorphone hcl tablet sustained release 12hr roxicet 5-325 tablet ROXICET SOLUTION ROXICODONE INTENSOL ROXICODONE SOLUTION ROXICODONE TABLET sublimaze Tier 1 1 1 1 1 1 3 2 2 3 1 Restrictions QLL (124/31) QLL (62/31) CLASS III NARCOTICS acetaminoph-caff-dihydrocodein acetaminophen-codeine buprenorphine 2 mg tablet sl buprenorphine 8 mg tablet sl co-gesic hydrocodone bit-ibuprofen hydrocodone-acetaminophen solution, hydrocodon-acetaminoph 2.5-500, -hydrocodonacetaminophen 5-325, -hydrocodonacetaminophen 5-500, -hydrocodon-acetaminoph 7.5-325, -hydrocodon-acetaminoph 7.5-750, hydrocodon-acetaminophn 10-650, -hydrocodonacetaminophn 10-325, -hydrocodon-acetaminoph 7.5-500, -hydrocodon-acetaminophn 10-500, hydrocodon-acetaminoph 7.5-650, -hydrocodonacetaminophn 10-660, -hydrocodonacetaminophn 10-750 1 1 1 1 1 1 1 SUBOXONE 2 MG-0.5 MG SL FILM, -2 MG-0.5 MG 2 TABLET SL SUBOXONE 8 MG-2 MG SL FILM, -8 MG-2 MG 2 TABLET SL trezix 1 PA, QLL (186/31) PA, QLL (124/31) PA, QLL (186/31) PA, QLL (124/31) CLASS IV NARCOTICS buprenorphine 0.3 mg/ml vial pentazocine-acetaminophen 1 1 Page 22 of 117 Drug pentazocine-naloxone hcl Tier Restrictions 1 CNS STIMULANT DRUGS amphetamine amphetamine amphetamine amphetamine amphetamine amphetamine amphetamine salts 10 mg tab salts 12.5 mg tb salts 15 mg tab salts 20 mg tab salts 30 mg tab salts 5 mg tab salts 7.5 mg tab CONCERTA ER 18 MG TABLET, -ER 27 MG TABLET, -ER 54 MG TABLET CONCERTA ER 36 MG TABLET d-amphetamine er 10 mg capsule, -10 mg tab d-amphetamine er 15 mg capsule d-amphetamine er 5 mg capsule dexmethylphenidate 10 mg tab dexmethylphenidate 2.5 mg tab dexmethylphenidate 5 mg tab dextroamphetamine 5 mg tab dextroamphetamine-amphetamine metadate er methamphetamine hcl methylin 10 mg tablet methylin 20 mg tablet methylin 5 mg tablet methylin er 10 mg tablet methylin er 20 mg tablet methylphenidate 10 mg tablet methylphenidate 20 mg tablet methylphenidate 5 mg tablet methylphenidate er methylphenidate hcl solution METHYLPHENIDATE HCL UNKNOWN methylphenidate sr NUVIGIL PROVIGIL 1 1 1 1 1 1 1 3 QLL QLL QLL QLL QLL QLL QLL QLL (186/31) (155/31) (124/31) (93/31) (62/31) (372/31) (248/31) (31/31) 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 3 2 QLL QLL QLL QLL QLL QLL QLL QLL (62/31) (186/31) (124/31) (279/31) (62/31) (248/31) (124/31) (372/31) QLL (93/31) QLL QLL QLL QLL QLL QLL QLL QLL (310/31) (155/31) (620/31) (310/31) (155/31) (310/31) (155/31) (620/31) QLL (155/31) PA PA, QLL (62/31) Page 23 of 117 Drug Tier DRUGS TO PREVENT AND TREAT HEADACHES ascomp with codeine butalb-caff-acetaminoph-codein butalbital compound-codeine butorphanol tartrate aerosol spray dihydroergotamine mesylate injection ergotamine-caffeine MAXALT MAXALT MAXALT MAXALT 10 MG TABLET 5 MG TABLET MLT 10 MG TABLET MLT 5 MG TABLET migergot MIGRANAL naratriptan hcl SUMATRIPTAN sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml inject, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng sumatriptan 4 mg/0.5 ml vial sumatriptan 6 mg/0.5 ml vial sumatriptan succinate tablet 1 1 1 1 1 1 2 2 2 2 1 3 1 1 1 1 1 1 Restrictions QLL QLL QLL QLL (12/30) (24/30) (12/30) (24/30) QLL (9/28) QLL (4 ml/28) QLL (8 ml/28) QLL (9/31) HYDANTOINS CEREBYX DILANTIN 30 MG CAPSULE, -TABLET CHEWABLE fosphenytoin sodium PEGANONE PHENYTEK phenytoin sodium extended phenytoin sodium injection phenytoin suspension oral 3 2 1 3 2 1 1 1 MAO INHIBITORS EMSAM MARPLAN phenelzine sulfate tablet tranylcypromine sulfate 3 3 1 1 Page 24 of 117 Drug Tier Restrictions OTHER ANTICONVULSANTS BANZEL felbamate FELBATOL gabapentin capsule, -solution, -tablet GABITRIL GRALISE HORIZANT KEPPRA SOLUTION KEPPRA XR LAMICTAL ODT LAMICTAL ODT (BLUE) LAMICTAL ODT (GREEN) LAMICTAL ODT (ORANGE) lamotrigine levetiracetam LYRICA 225 MG CAPSULE, -300 MG CAPSULE LYRICA 25 MG CAPSULE, -50 MG CAPSULE, -75 MG CAPSULE, -100 MG CAPSULE, -150 MG CAPSULE, -200 MG CAPSULE primidone tablet SABRIL topiragen topiramate capsule sprinkle, -tablet VIMPAT zonisamide 3 1 3 1 2 3 3 2 3 3 3 3 3 1 1 3 3 1 4 1 1 3 1 PA PA PA, QLL (31/31) PA, QLL (62/31) PA, QLL (93/31) PA, QLL (186/31), LTD PA OTHER ANTIDEPRESSANTS budeprion sr budeprion xl 150 mg tablet budeprion xl 300 mg tablet bupropion hcl sr bupropion hcl tablet bupropion xl chlordiazepoxide-amitriptyline CYMBALTA 20 MG CAPSULE CYMBALTA 30 MG CAPSULE, -60 MG CAPSULE 1 1 1 1 1 1 1 2 2 QLL (93/31) QLL (31/31) QLL (62/31), ST QLL (31/31), ST Page 25 of 117 Drug maprotiline hcl mirtazapine nefazodone hcl perphenazine-amitriptyline PRISTIQ SAVELLA TABLET SAVELLA TABLET DOSE PACK trazodone hcl tablet venlafaxine hcl venlafaxine hcl er 150 mg cap venlafaxine hcl er 37.5 mg cap venlafaxine hcl er 75 mg cap Tier 1 1 1 1 3 3 3 1 1 1 1 1 Restrictions QLL (31/31), ST PA, QLL (62/31) PA, QLL (55/365) QLL (62/31), ST QLL (31/31), ST QLL (93/31), ST OTHER ANTIPARKINSON DRUGS APOKYN atamet AZILECT bromocriptine mesylate capsule, -tablet carbidopa-levodopa COMTAN LODOSYN pramipexole dihydrochloride ropinirole hcl selegiline hcl capsule, -tablet STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO ZELAPAR 100 125 150 200 50 75 4 1 3 1 1 2 2 1 1 1 2 2 2 2 2 2 3 QLL (93/31), LTD OTHER CNS/AUTONOMIC DRUGS ANTABUSE atropine sulfate injection CAMPRAL depade disulfiram tablet 3 1 2 1 1 Page 26 of 117 guanidine hcl Drug MESTINON SYRUP MYTELASE naloxone hcl injection naltrexone hcl tablet neostigmine methylsulfate NUEDEXTA physostigmine salicylate injection PROSTIGMIN pyridostigmine bromide tablet REGONOL STRATTERA 10 MG CAPSULE, -40 MG CAPSULE, -60 MG CAPSULE, -80 MG CAPSULE, -100 MG CAPSULE STRATTERA 18 MG CAPSULE STRATTERA 25 MG CAPSULE XENAZINE 12.5 MG TABLET XENAZINE 25 MG TABLET XYREM Tier 1 3 2 1 1 1 3 1 2 1 3 3 3 3 4 4 4 Restrictions PA, QLL (62/31) QLL (31/31) QLL (62/31) QLL (93/31) PA, QLL (93/31), LTD PA, QLL (124/31), LTD PA, QLL (558/31), LTD SECONDARY AMINES amoxapine desipramine hcl tablet nortriptyline hcl capsule, -solution protriptyline hcl 1 1 1 1 SEDATIVE/HYPNOTIC DRUGS chloral hydrate syrup LUNESTA zaleplon zolpidem tartrate tablet 1 3 1 1 QLL (31/31), ST SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram citalopram hbr fluoxetine hcl capsule, -solution, -tablet fluvoxamine maleate 1 1 1 1 Page 27 of 117 Drug LEXAPRO 10 MG TABLET LEXAPRO 5 MG TABLET, -20 MG TABLET LEXAPRO SOLUTION paroxetine hcl selfemra sertraline hcl solution, -tablet VIIBRYD 10 MG TABLET VIIBRYD 20 MG TABLET VIIBRYD 40 MG TABLET Tier 3 3 3 1 1 1 3 3 3 Restrictions PA, QLL (47/31) PA, QLL (31/31) PA, QLL (620/31) PA, QLL (124/31) PA, QLL (62/31) PA, QLL (31/31) SMOKING CESSATION PRODUCTS buproban CHANTIX TABLET CHANTIX TABLET DOSE PACK NICOTROL NICOTROL NS 1 3 3 2 2 QLL (336/365) QLL (106/365) SUCCINIMIDES CELONTIN ethosuximide capsule, -syrup 3 1 TERTIARY AMINES amitriptyline hcl tablet clomipramine hcl capsule doxepin hcl capsule, -solution imipramine hcl tablet imipramine pamoate SURMONTIL 1 1 1 1 1 2 VALPROIC ACID AND DERIVATIVES DEPACON divalproex sodium divalproex sodium er STAVZOR valproate sodium injection valproic acid capsule, -syrup 3 1 1 3 1 1 Page 28 of 117 Drug Tier Restrictions CARDIOVASCULAR MEDICATIONS AMIODARONES amiodarone hcl injection, -tablet pacerone 1 1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril hcl captopril tablet enalapril maleate tablet fosinopril sodium lisinopril tablet moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril 1 1 1 1 1 1 1 1 1 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS AVAPRO BENICAR DIOVAN losartan potassium MICARDIS 3 3 2 1 2 ST ST ANTIDYSRHYTHMIC DRUGS disopyramide phosphate flecainide acetate mexiletine hcl capsule NORPACE CR 100 MG CAPSULE procainamide hcl injection propafenone hcl quinidine gluconate quinidine sulfate tablet, -tablet sustained action 1 1 1 2 1 1 1 1 Page 29 of 117 Drug Tier BETA-ADRENERGIC ANTAGONIST DRUGS acebutolol hcl capsule atenolol tablet betaxolol hcl tablet bisoprolol fumarate BYSTOLIC carvedilol COREG CR labetalol hcl injection, -tablet LEVATOL metoprolol succinate metoprolol tartrate injection, -tablet nadolol tablet pindolol propranolol hcl capsule sustained action, injection, -solution, -tablet timolol maleate tablet 1 1 1 1 3 1 3 1 3 1 1 1 1 1 Restrictions PA QLL (31/31) 1 CALCIUM ANTAGONISTS afeditab cr amlodipine besylate tablet cartia xt dilt-cd diltiazem 24hr er diltiazem er diltiazem hcl injection, -tablet dilt-xr diltzac er felodipine er isradipine matzim la nicardipine hcl nifediac cc nifedical xl nifedipine capsule nifedipine er tablet sustained action nimodipine nisoldipine 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 1 Page 30 of 117 Drug taztia xt verapamil er verapamil er pm verapamil hcl capsule 24hr sustained release pellets, -injection, -tablet, -tablet sustained action Tier Restrictions 1 1 1 1 CARDIAC GLYCOSIDES digoxin injection, -solution, -tablet 1 CENTRALLY ACTING ANTIHYPERTENSIVES CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 clonidine clonidine hcl injection, -tablet DURACLON guanabenz acetate tablet guanfacine hcl methyldopa methyldopate hcl 1 1 1 1 1 3 1 1 1 1 DRUGS FOR PHEOCHROMOCYTOMA DEMSER DIBENZYLINE 2 2 ENDOTHELIN RECPTR ANTAGONIST LETAIRIS TRACLEER 4 4 PA, QLL (31/31), LTD PA, QLL (62/31), LTD HMG-COA REDUCTASE INHIBITORS CADUET LIPITOR lovastatin pravastatin sodium 2 2 1 1 Page 31 of 117 Drug SIMCOR simvastatin VYTORIN Tier 2 1 3 Restrictions ST ST HYPOLIPOPROTEINEMICS cholestyramine cholestyramine light colestipol hcl fenofibrate gemfibrozil tablet LOFIBRA 160 MG TABLET LOVAZA NIASPAN TRICOR TRILIPIX WELCHOL ZETIA 1 1 1 1 1 2 2 2 2 3 2 2 LOOP DIURETICS bumetanide EDECRIN furosemide injection, -solution, -tablet SODIUM EDECRIN torsemide 1 2 1 3 1 NITRATES DILATRATE-SR isoditrate ISORDIL isosorbide dinitrate isosorbide mononitrate nitro-bid NITRO-DUR 0.3 MG/HR PATCH, -0.8 MG/HR PATCH nitroglycerin injection nitroglycerin patch NITROLINGUAL 2 1 2 1 1 1 2 1 1 2 Page 32 of 117 Drug NITROSTAT Tier Restrictions 2 OTHER ANTIARRHYTHMICS ibutilide fumarate MULTAQ sorine sotalol sotalol af TIKOSYN 1 2 1 1 1 2 OTHER ANTIHYPERTENSIVES amlodipine besylate-benazepril AMTURNIDE atenolol-chlorthalidone AVALIDE benazepril-hydrochlorothiazide BENICAR HCT bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide CLORPRES DIOVAN HCT enalapril-hydrochlorothiazide EXFORGE EXFORGE HCT fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyldopa-hydrochlorothiazide metoprolol-hydrochlorothiazide MICARDIS HCT moexipril-hydrochlorothiazide nadolol-bendroflumethiazide propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide reserpine tablet TEKAMLO TEKTURNA TEKTURNA HCT 1 2 1 3 1 3 1 1 2 2 1 2 2 1 1 1 1 1 2 1 1 1 1 1 2 2 2 ST ST ST ST ST ST Page 33 of 117 trandolapril-verapamil Drug TRIBENZOR TWYNSTA VALTURNA Tier 1 3 2 2 Restrictions ST ST OTHER CARDIOVASCULAR DRUGS ISUPREL midodrine hcl pentopak pentoxifylline tablet sustained action phenylephrine hcl injection RANEXA ER 1,000 MG TABLET RANEXA ER 500 MG TABLET 3 1 1 1 1 2 2 QLL (62/31) QLL (124/31) OTHER VASODILATING DRUGS ADCIRCA BIDIL diluent for epoprostenol vial epoprostenol sodium papaverine hcl injection REMODULIN REVATIO TABLET veletri VENTAVIS 10 MCG/1 ML SOLUTION VENTAVIS 20 MCG/1 ML SOLUTION 4 2 1 4 1 4 4 4 4 4 PA, QLL (62/31) PA, LTD PA, QLL (93/31) PA POTASSIUM SPARING DIURETICS amiloride hcl tablet amiloride-hydrochlorothiazide DYRENIUM eplerenone spironolactone tablet spironolactone-hctz triamterene-hctz triamterene-hydrochlorothiazid 1 1 2 1 1 1 1 1 Page 34 of 117 Drug Tier THIAZIDE AND RELATED DRUGS chlorothiazide chlorothiazide sodium chlorthalidone DIURIL DIURIL SODIUM hydrochlorothiazide capsule, -tablet indapamide methyclothiazide metolazone Restrictions 1 1 1 2 3 1 1 1 1 VASODILATOR ANTIHYPERTENSIVES CARDURA XL doxazosin mesylate hydralazine hcl minoxidil tablet prazosin hcl terazosin hcl 3 1 1 1 1 1 QLL (31/31) 1 1 PA DERMATOLOGICAL MEDICATIONS ANTIACNE DRUGS adapalene benzoyl peroxide 2.5% wash, -4.5% cleanser, 5% wash, -5.75 % wash, -6.5% cleanser, -8.5% cleanser, -10% wash, -gel, -4% lotion, -8% lotion bp 10-1 clindacin p clindamycin phosphate gel, -lotion, -solution nonoral, -swab medicated clindamycin-benzoyl peroxide ery erythromycin gel, -solution non-oral, -swab medicated erythromycin-benzoyl peroxide metronidazole cream, -gel, -lotion prascion 1 1 1 1 1 1 1 1 1 Page 35 of 117 Drug rosaderm cleanser sodium sulf-sulfur cleanser, -sulf-sulfur wash, lotion, -suspensions, (not oral) topisulf tretinoin 0.025% cream, -0.05% cream, -0.1% cream, -gel vitazol zaclir Tier Restrictions 1 1 1 1 PA 1 1 ANTIPRURITIC DRUGS hydroxyzine hcl injection, -syrup, -tablet hydroxyzine pamoate capsule 1 1 ANTIPSORIASIS AND ANTIECZEMA DRUGS 10 wash calcipotriene DOVONEX CREAM salicylic acid shampoo seb-prev selenium sulfide shampoo, -suspension topical sodium sulfacetamide solution SORIATANE 17.5 MG CAPSULE, -22.5 MG CAPSULE sulfacetamide sodium lotion, -suspension topical VECTICAL ZITHRANOL-RR 1 1 3 1 1 1 1 4 1 4 3 KERATOLYTIC DRUGS CONDYLOX GEL DURASAL PODOCON-25 podofilox salicylic acid gel salicylic acid liquid 3 3 2 1 1 3 Page 36 of 117 Drug Tier ORAL DERMATOLOGICAL DRUGS 8-MOP amnesteem claravis OXSORALEN-ULTRA sotret Restrictions 4 1 1 4 1 SCABICIDES acticin LINDANE malathion permethrin cream ULESFIA 1 2 1 1 2 TOPICAL ANTI-INFLAMMATORY DRUGS VOLTAREN GEL 3 QLL (1000/31) TOPICAL CORTICOSTEROID DRUGS alclometasone dipropionate amcinonide betamethasone dipropionate cream, -gel, -lotion, -ointment betamethasone valerate cream, -lotion, ointment beta-val clobetasol emollient clobetasol propionate cream, -gel, -ointment, solution non-oral desonide cream, -lotion, -ointment desoximetasone cream, -gel, -ointment diflorasone diacetate fluocinolone acetonide cream, -ointment, solution non-oral fluocinonide cream, -gel, -ointment, -solution non-oral fluocinonide emollient 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 37 of 117 Drug fluocinonide-e fluticasone propionate cream, -ointment halobetasol propionate hydrocortisone 1% cream, -plus 1% cream, -aloe 1% cream, -2.5% cream, -lotion, -1% absorbase, -1% oint, -1% ointment, -2.5% ointment hydrocortisone acetate hydrocortisone butyrate hydrocortisone valerate lidocaine-hydrocortisone cream, -lidocaine 3%-hc 0.5% cream, -lotion mometasone furoate cream, -ointment, -solution non-oral prednicarbate triamcinolone acetonide cream, -lotion, ointment triderm U-CORT Tier Restrictions 1 1 1 1 1 1 1 1 1 1 1 1 3 TOPICAL DERMATOLOGICAL DRUGS ALDARA aluvea 40% cream ammonium lactate cream, -lotion CARAC ELIDEL FLUOROPLEX fluorouracil cream, -solution non-oral hypercare imiquimod cream lactic acid cream, -lotion PANRETIN PROTOPIC PRUDOXIN REGRANEX remeven SANTYL silver nitrate ointment, -solution SOLARAZE 2 1 1 3 3 3 1 1 1 1 4 3 2 4 1 2 1 3 PA PA Page 38 of 117 Drug u40 u-kera e urea emollient urea 40 urea 40% cream, -50% cream, -40% gel, -50% nail gel, -35% lotion, -40% lotion, -50% nail stick urea 40% nail film susp VEREGEN x-viate cream, -gel ZONALON Tier Restrictions 1 1 1 1 1 3 1 2 DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS DIAGNOSTIC PRODUCTS CHEMET EXJADE THYROGEN 2 4 2 LTD MISCELLANEOUS DRUGS ADAGEN 4 aminocaproic acid injection, -solution oral, -tablet 1 AMPYRA 4 BUPHENYL 4 COPAXONE 4 CYKLOKAPRON 2 ergoloid mesylates tablet 1 fomepizole 1 GILENYA 4 LYSTEDA 3 ORFADIN 4 THALOMID 150 MG CAPSULE, -200 MG CAPSULE 4 THALOMID 50 MG CAPSULE, -100 MG CAPSULE 4 PA, LTD PA, QLL (62/31), LTD PA QLL (30 ml/30) PA, PA, PA, PA, PA QLL (62/31) QLL (30/28) LTD QLL (62/31) EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR acetasol hc acetic acid solution non-oral acetic acid-aluminum aero otic hc antipyrine-benzocaine 1 1 1 1 1 Page 39 of 117 Drug aurodex auroguard borofair chloroxylenol-pramoxine hcl chlorphenylcaine CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN-TC cortomycin CRESYLATE DERMOTIC hydrocortisone-acetic acid neomycin-polymixin-hc ear susp, -ear susp neomycin-polymyxin-hydrocort ofloxacin 0.3% ear drops ZINOTIC ZINOTIC ES Tier Restrictions 1 1 1 1 1 3 3 3 3 1 2 2 1 1 1 1 2 2 DRUGS AFFECTING THE NOSE ASTEPRO azelastine hcl aerosol spray w/pump flunisolide aerosol spray fluticasone propionate nasal inhaled steroids ipratropium bromide aerosol spray NASONEX PATANASE TYZINE VERAMYST 3 1 1 1 1 3 3 2 2 ST DRUGS AFFECTING THE THROAT AND MOUTH chlorhexidine gluconate mouthwash doxycycline hyclate 20 mg tab EVOXAC pilocarpine hcl tablet triamcinolone acetonide paste 1 1 2 1 1 QLL (93/31) Page 40 of 117 Drug Tier Restrictions ENDOCRINE MEDICATIONS ANTITHYROID DRUGS methimazole tablet propylthiouracil 1 1 DIPEPTIDYL PEPTIDASE-IV INHIB AND COMBOS TRADJENTA 3 GLUCOCORTICOID DRUGS A-HYDROCORT a-methapred 40 mg vial ARISTOSPAN baycadron betamethasone acetate-sod phos CELESTONE cortisone acetate tablet DEPO-MEDROL 20 MG/ML VIAL dexamethasone elixir, -solution oral, -tablet dexamethasone intensol dexamethasone sodium phosphate injection hydrocortisone tablet KENALOG-10 KENALOG-40 methylprednisolone acetate injection methylprednisolone sod succ methylprednisolone tablet, -tablet dose pack prednisolone sodium phosphate solution prednisolone solution oral prednisone intensol prednisone solution, -tablet SOLU-CORTEF SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) triamcinolone acetonide injection zema-pak 10 day 1.5 mg tablet, -13 day 1.5 mg tablet 3 1 3 1 1 2 1 3 1 1 1 1 2 2 1 1 1 1 1 1 1 3 3 3 3 1 1 Page 41 of 117 Drug Tier Restrictions GLUCOSE ELEVATING DRUGS GLUCAGEN GLUCAGON EMERGENCY KIT PROGLYCEM 3 3 2 HYPOGLYCEMIC DRUGS BYETTA SYMLIN SYMLINPEN 120 SYMLINPEN 60 VICTOZA 2-PAK VICTOZA 3-PAK 2 2 2 2 2 2 QLL QLL QLL QLL (2.40 ml/28) (20 ml/28), ST (10.80 ml/28), ST (12 pens/28), ST INSULIN APIDRA APIDRA SOLOSTAR HUMALOG HUMALOG MIX 50-50 HUMALOG MIX 75-25 HUMULIN 70-30 HUMULIN N HUMULIN R LANTUS LANTUS SOLOSTAR LEVEMIR NOVOLIN 70-30 100 UNIT/ML VIAL NOVOLIN N 100 UNITS/ML VIAL NOVOLIN R NOVOLOG NOVOLOG MIX 70-30 RELION NOVOLIN 70-30 VIAL RELION NOVOLIN N 100 UNITS/ML 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 MINERALOCORTICOID DRUGS fludrocortisone acetate tablet 1 Page 42 of 117 Drug Tier ORAL HYPOGLYCEMICS AND COMBOS acarbose ACTOPLUS MET ACTOPLUS MET XR ACTOS AVANDAMET AVANDARYL AVANDIA chlorpropamide DUETACT FORTAMET glimepiride glipizide er glipizide tablet glipizide xl glipizide-metformin glyburide micronized glyburide tablet glyburide-metformin hcl glycron GLYSET JANUMET JANUVIA KOMBIGLYZE XR metformin hcl metformin hcl er tablet sustained release 24hr metformin hcl er unknown nateglinide ONGLYZA PRANDIN RIOMET tolazamide tolbutamide Restrictions 1 2 2 2 2 2 2 1 2 3 1 1 1 1 1 1 1 1 1 3 2 2 2 1 1 1 1 2 2 3 1 1 OTHER ENDOCRINE DRUGS ACTONEL 150 MG TABLET ACTONEL 35 MG TABLET ACTONEL 5 MG TABLET, -30 MG TABLET 2 2 2 QLL (1/28), ST QLL (4/28), ST QLL (31/31), ST Page 43 of 117 Drug ALDURAZYME alendronate sodium ATELVIA BONIVA INJECTION BONIVA TABLET cabergoline calcitonin-salmon CEREDASE CEREZYME 200 UNITS VIAL CEREZYME 400 UNITS VIAL desmopressin acetate aerosol spray w/pump, injection, -solution, -tablet ELAPRASE etidronate disodium EVISTA FABRAZYME 35 MG VIAL FABRAZYME 5 MG VIAL FORTEO fortical KUVAN LUMIZYME MIACALCIN INJECTION MYOZYME NAGLAZYME pamidronate 30 mg/10 ml vial, -90 mg/10 ml vial PAMIDRONATE 60 MG/10 ML VIAL pamidronate disod 30 mg vial, -disod 90 mg vial PROLIA RECLAST SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET SENSIPAR 30 MG TABLET SENSIPAR 60 MG TABLET, -90 MG TABLET SOMAVERT 10 MG VIAL, -20 MG VIAL SOMAVERT 15 MG VIAL STIMATE VPRIV XGEVA ZAVESCA ZOMETA Tier 4 1 2 3 3 1 1 4 4 4 1 4 1 2 4 4 4 1 4 4 3 4 4 1 1 1 3 3 4 4 2 4 4 4 3 4 4 4 4 Restrictions PA, LTD ST PA, QLL (3/90), ST QLL (1/28), ST LTD PA, LTD PA, LTD PA, LTD QLL (2.40 pens/28), ST PA, PA, PA PA, PA, PA PA LTD LTD LTD LTD PA, QLL (1/168) QLL (1/365), ST PA, QLL (31/31) PA, QLL (62/31) PA, LTD PA, QLL (62/31), LTD PA PA, QLL (1/28) PA, LTD Page 44 of 117 Drug Tier Restrictions THYROID SUPPLEMENTS ARMOUR THYROID levothroid levothyroxine sodium injection, -tablet levoxyl liothyronine sodium injection, -tablet nature-throid np thyroid THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 TRIOSTAT unithroid westhroid 2 1 1 1 1 1 1 2 2 2 2 2 2 1 1 GASTROINTESTINAL MEDICATIONS ANTIDIARRHEAL DRUGS diphenoxylate-atropine loperamide capsule MOTOFEN paregoric 1 1 3 1 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY BENTYL INJECTION CANTIL dicyclomine hcl capsule, -injection, -syrup, tablet ed-spaz glycopyrrolate injection, -tablet hyomax hyoscyamine sulfate drops, -elixir, -tablet, -tablet dispersible lingual, -tablet sublingual, -tablet sustained release 12hr LEVSIN INJECTION methscopolamine bromide tablet 3 2 1 1 1 1 1 2 1 Page 45 of 117 Drug metoclopramide hcl injection, -solution oral, tablet propantheline bromide tablet SAL-TROPINE SCOPACE SCOPOLAMINE HYDROBROMIDE INJECTION Tier Restrictions 1 1 2 2 2 ANTIULCER DRUGS cimetidine injection, -solution, -tablet famotidine injection, -suspension oral, -20 mg tablet, -40 mg tablet nizatidine pepcid injection ranitidine hcl capsule, -injection, -syrup, -150 mg tablet, -300 mg tablet 1 1 1 1 1 IRRITABLE BOWEL DRUGS AMITIZA LOTRONEX 2 4 QLL (62/31) LAXATIVES AND CATHARTICS OSMOPREP polyethylene glycol 3350 polyethylene glycol 3350 packet VISICOL 2 1 1 3 OTHER ANTIULCER DRUGS CARAFATE SUSPENSION ORAL misoprostol sucralfate suspension oral, -tablet 2 1 1 OTHER GI DRUGS APRISO ASACOL ASACOL HD 2 2 2 Page 46 of 117 balsalazide disodium budesonide ec Drug CANASA COLOCORT COLYTE WITH FLAVOR PACKETS COLYTE WITH FLAVOR PACKS CORTIFOAM CREON DIPENTUM ENTOCORT EC gavilyte-c gavilyte-g gavilyte-n HALFLYTELY-BISACODYL HELIDAC hydrocortisone enema LIALDA mesalamine enema PANCREAZE PANCRELIPASE 5,000 peg 3350-electrolyte peg-3350 and electrolytes peg-3350 with flavor packs PENTASA PREVPAC PROCTOFOAM-HC procto-pak proctozone-hc RELISTOR 12 MG/0.6 ML KIT RELISTOR 12 MG/0.6 ML VIAL sulfasalazine dr sulfasalazine tablet sulfazine sulfazine ec trilyte with flavor packets ursodiol capsule, -tablet ZENPEP Tier 1 1 3 2 3 3 3 2 3 2 1 1 1 3 3 1 3 1 3 3 1 1 1 3 3 2 1 1 3 3 1 1 1 1 1 1 2 Restrictions PA Page 47 of 117 Drug Tier PROTON PUMP INHIBITORS DEXILANT lansoprazole capsule enteric coated, -tablet omeprazole dr 10 mg capsule, -dr 20 mg capsule pantoprazole sodium PROTONIX IV Restrictions 3 1 1 1 3 QLL QLL QLL QLL (30/30), ST (31/31) (62/31) (62/31) 4 2 4 PA, QLL (62/31) PA PA 4 4 4 4 PA PA PA 4 4 4 4 PA PA PA 4 4 4 4 4 4 4 PA PA PA IMMUNOLOGICALS AND VACCINES GROWTH HORMONES AND RELATED DRUGS EGRIFTA GENOTROPIN MINIQUICK 0.2 MG GENOTROPIN MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -MINIQUICK 0.8 MG, -MINIQUICK 1 MG, -MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, MINIQUICK 2 MG, -5 MG CARTRIDGE, -12 MG CARTRIDGE HUMATROPE NORDITROPIN NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX 5 MG/1.5, NORDIFLX 15 MG/1.5 NORDITROPIN NORDIFLX 10 MG/1.5, -30 MG/3 NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN 10 PEN CART, -20 PEN CART NUTROPIN AQ NUSPIN 5 PEN CART OMNITROPE SAIZEN 5 MG VIAL, -8.8 MG CLICK.EASY CARTG SAIZEN 8.8 MG VIAL SEROSTIM TEV-TROPIN ZORBTIVE PA, LTD PA PA, LTD IMMUNOLOGICALS AND VACCINES ACTHIB 2 Page 48 of 117 Drug ADACEL ARANESP 25 MCG/0.42 ML SYRING, -25 MCG/ML VIAL, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL ARANESP 60 MCG/0.3 ML SYRINGE, -60 MCG/ML VIAL, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -200 MCG/0.4 ML SYRINGE, -150 MCG/0.3 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML SYRINGE, -300 MCG/ML VIAL, -500 MCG/1 ML SYRINGE, -150 MCG/0.75 ML VIAL ATGAM ATTENUVAX VACCINE WITH DILUENT BCG VACCINE (TICE STRAIN) BOOSTRIX CARIMUNE NF NANOFILTERED CERVARIX CINRYZE COMVAX DAPTACEL DECAVAC DIPHTHERIA-TETANUS TOXOID ENGERIX-B 10 MCG/0.5 ML PED VL, -10 MCG/0.5 ML SYRN, -20 MCG/ML SYRINGE, -20 MCG/ML VIAL ENGERIX-B 10 MCG/0.5 ML PEDI EPOGEN 10,000 UNITS/ML VIAL, -20,000 UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL EPOGEN 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL GAMASTAN S-D GAMMAGARD LIQUID GAMMAGARD S-D GAMMAPLEX GAMUNEX GAMUNEX-C GARDASIL SYRINGE GARDASIL VIAL HAVRIX HIZENTRA 1 GRAM/5 ML VIAL HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML Tier Restrictions 2 3 PA 4 PA 4 2 3 2 4 2 4 2 2 2 2 2 PA PA PA PA, QLL (20/30) 2 4 PA 2 PA 2 4 4 4 4 4 2 2 2 4 4 PA PA PA PA PA PA PA PA Page 49 of 117 Drug VIAL IMOVAX RABIES VACCINE INFANRIX INFANRIX PF IPOL IXIARO JE-VAX KEPIVANCE MENACTRA MENOMUNE-A-C-Y-W-135 MENVEO A-C-Y-W-135-DIP MERUVAX II VACCINE W-DILUENT M-M-R II VACCINE MOZOBIL PEDIARIX PEDVAXHIB PRIVIGEN PROCRIT 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, -10,000 UNITS/ML VIAL PROCRIT 20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL PROQUAD RABAVERT RECOMBIVAX HB ROTARIX ROTATEQ SYNAGIS 100 MG/1 ML VIAL SYNAGIS 50 MG/0.5 ML VIAL TETANUS DIPHTHERIA TOXOIDS tetanus toxoid adsorbed TETANUS-DIPHTERIA-DECAVAC THYMOGLOBULIN TRIHIBIT TRIPEDIA TWINRIX TYPHIM VI VAQTA VARIVAX VACCINE VIVAGLOBIN Tier 2 2 2 2 3 2 4 2 2 2 2 2 4 2 2 4 2 4 2 2 2 2 2 4 4 2 1 2 4 2 2 2 2 2 2 4 Restrictions LTD PA, QLL (9.60/4) PA PA PA PA PA, LTD PA PA Page 50 of 117 Drug YF-VAX ZOSTAVAX Tier Restrictions 2 2 PA, QLL (1/365) 4 PA, LTD 4 4 4 4 4 4 4 PA, LTD QLL (4 kits/28) QLL (4 kits/28) QLL (14/28), ST QLL (15 trays/30), ST PA, QLL (12/30) 2 PA 4 PA 4 4 4 4 PA, QLL (4 syringes/28) PA, QLL (4 vials/28) PA, QLL (4 kits/28) 4 4 PA, QLL (4 pens/28) QLL (12 ml/30) 4 4 4 QLL (12 syringes/30) PA PA 4 4 PA, QLL (40/28) 4 4 4 PA, QLL (10/28), LTD PA, QLL (1/56), LTD PA, QLL (20.10/30) INSULIN LIKE GROWTH FACTORS-1 INCRELEX INTERFERONS ACTIMMUNE AVONEX AVONEX ADMINISTRATION PACK BETASERON EXTAVIA INFERGEN INTRON A 10 MILLION UNIT/ML, -18 MILLION UNITS VIAL, -50 MILLION UNITS VIAL INTRON A 3 MILLION UNIT/ML PEN, -10 MILLION UNITS VIAL INTRON A 5 MILLION UNIT/ML PEN, -6 MILLION UNIT/ML VL, -10 MILLION UNIT PEN PEGASYS 180 MCG/0.5 ML CONV.PK PEGASYS 180 MCG/ML VIAL PEGINTRON 50 MCG KIT PEGINTRON 80 MCG KIT, -120 MCG KIT, -150 MCG KIT PEGINTRON REDIPEN REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5 ML SYRINGE REBIF TITRATION PACK SYLATRON SYLATRON 4-PACK INTERLEUKIN RECPTR ANTAGONIST ACTEMRA 200 MG/10 ML VIAL ACTEMRA 80 MG/4 ML VIAL, -400 MG/20 ML VIAL ARCALYST ILARIS KINERET Page 51 of 117 Drug Tier Restrictions INTERLEUKINS NEUMEGA PROLEUKIN 4 4 MYELOID STIMULANTS LEUKINE NEULASTA NEUPOGEN 4 4 4 PA PA 4 4 PA, QLL (93/31), LTD PA, QLL (31/31), LTD THROMBOPOIETIC AGENTS PROMACTA 25 MG TABLET PROMACTA 50 MG TABLET, -75 MG TABLET MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES AIMSCO INS SYR 0.3 ML 29GX1/2, -AIMSCO INS SYR 0.3 ML 30GX5/16, -AIMSCO INS SYR 0.5 ML 28GX1/2, -AIMSCO INS SYR 0.5 ML 29GX1/2, AIMSCO INS SYR 1 ML 28GX1/2, -AIMSCO INS SYR 1 ML 29GX1/2, -AIMSCO SYRING 0.3 ML 31GX5/16, -AIMSCO SYRING 0.5 ML 30GX5/16, AIMSCO SYRING 0.5 ML 31GX5/16, -BD INSULIN SYR 0.3 ML 28GX1/2, -BD INSULIN SYR 0.3 ML 29GX1/2, -BD INSULIN SYR 0.3 ML 30GX1/2, BD INSULIN SYR 0.3ML 31GX5/16, -BD INSULIN SYR 0.5 ML 28GX1/2, -BD INSULIN SYR 0.5 ML 29GX1/2, -BD INSULIN SYR 0.5 ML 30GX1/2, BD INSULIN SYR 0.5ML 31GX5/16, -BD INSULIN SYR 1 ML 25GX1, -BD INSULIN SYR 1 ML 25GX5/8, -BD INSULIN SYR 1 ML 26GX1/2, -BD INSULIN SYR 1 ML 27GX5/8, -BD INSULIN SYR 1 ML 28GX1/2, -BD INSULIN SYR 1 ML 29GX1/2, BD INSULIN SYR 1 ML 30GX1/2, -BD INSULIN SYR 1 ML 31GX5/16, -BD INSULIN SYRINGE 1 ML, -BD INSULIN U100-3/10 ML SYR, -FIFTY50 INSULIN SYRINGE 0.3 ML, -FIFTY50 INSULIN SYRINGE 0.5 ML, -FIFTY50 INSULIN SYRINGE 1 2 Page 52 of 117 Drug ML, -INS SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML 30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS SYR 0.5 ML 29GX1/2, -INS SYR 0.5 ML 30GX1/2, -INS SYR 0.5 ML 30GX5/16, -INS SYR 1 ML 28GX1/2, -INS SYR 1 ML 29GX1/2, -INS SYR 1 ML 31GX5/16, -INS SYR U100 1 ML 28GX1/2, -INS SYRIN 0.3 ML 30GX1/2, -INS SYRIN 1 ML 29GX1/2, -INS SYRING 0.3 ML 30GX5/16, -INS SYRINGE 1 ML 28GX1/2, -INS SYRINGE 3/10 ML, -INSUL SYR 0.3 ML 31GX5/16, -INSUL SYR 0.5 ML 28GX1/2, -INSUL SYR 0.5 ML 30GX1/2, INSUL SYR 0.5 ML 31GX5/16, -0.3 ML SYRINGE, -0.5 ML SYRINGE, -1 ML SYRINGE, -1/2 ML SYRINGE, -3/10 ML SYRINGE, -SYR 0.3 ML 29GX1/2, -SYR 0.5 ML 28GX1/2, -SYR 1 ML 29GX1/2, -SYR 1 ML 30GX5/16, -SYR 1 ML 31GX5/16, -SYRIN 0.3 ML 29GX1/2, -SYRIN 0.3 ML 30GX1/2, -SYRIN 0.3 ML 30GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.3 ML 31GX5/16, SYRIN 0.5 ML 28GX1/2, -SYRIN 0.5 ML 29GX1/2, -SYRIN 0.5 ML 30GX1/2, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 31GX5/16, -SYRIN 1 ML 29GX1/2, -1 ML 28GX1/2, -1 ML 29GX1/2, -1 ML 30GX1/2, -1 ML 31GX5/16, -1 ML-HARD PK, -U100 0.5 ML, -U100 1 ML, -INSULN SYR 1ST TIER UNIFINE PENTIPS PLUS AIMSCO INS SYR 1 ML 30GX5/16, -CAREONE INS SYR 1 ML 30GX5/16, -INS SYR 1 ML 30GX5/16, -INS SYRINGE 1 ML 30GX1/2, -INS SYRINGE 1 ML 30GX5/16, -1 ML 30GX5/16, 30GX1 ML SYR, -PREFPLS INS SYR 1 ML 30GX5/16, -RELION INS SYR 1 ML 30GX5/16, RELION INSULIN SYR 0.3 ML, -RELION INSULIN SYR 0.5 ML, -RELION INSULIN SYRINGE 1 ML, RELION SYRING 0.5 ML 31GX5/16, -U100 1 ML 30GX5/16, -ULTCARE INS SYR 1 ML 30GX5/16, WDMEDIC INS SYR 1 ML 30GX5/16 AIMSCO MINI ULTRA-THIN II AIMSCO ULTRA THIN II ALCOHOL PADS ALCOHOL PREP PADS ALCOHOL PREP SWABS Tier Restrictions 2 3 2 2 2 2 2 Page 53 of 117 Drug ALCOHOL SWAB ALCOHOL SWABS ALCOHOL WIPES AURORA PEN NEEDLE 6MM 31G, -AURORA PEN NEEDLES 12MM 29G, -AURORA PEN NEEDLES 8MM 31G, -BD PEN NEEDLE 29GX1/2, -BD PEN NEEDLE 29GX3/16, -BD PEN NEEDLE 29GX5/16, -BD PEN NEEDLE MINI 31GX3/16, -BD PEN NEEDLE NANO 32GX5/32, -BD PEN NEEDLE ORIG 29GX1/2, -BD PEN NEEDLE SHORT 31GX5/16, -CLICKFINE PEN NDL 31GX1/4, CLICKFINE PEN NDL 31GX5/16, -LIVE BETTER PEN NEEDLE 6MM 31G, -LIVE BETTER PEN NEEDLES 12MM, -LIVE BETTER PEN NEEDLES 8MM, -MS PEN NEEDLE 6MM 31G, -12MM 29G NEEDLES, -8MM 31G NEEDLES, -31GX3/16, 31GX5/16, -6MM 31G, -S 12MM 29G, -S 29G, -S 31G, -S 31G X 5/16, -S 8MM 31G, -TODAY'S HLT PN NEEDLE 12MM 29G, -TODAY'S HLTH PN NEEDLE 6MM 31G, -TODAY'S HLTH PN NEEDLE 8MM 31G, -UNIFINE PENTIP 6MM 31G AUTO INJECTOR AUTOJECT 2 AUTOPEN BD LUER-LOK SYRINGE 1 ML BD SAFETYGLIDE SYRINGE 27GX5/8 CLICKFINE CURAD GAUZE PADS CURITY ALCOHOL PREPS CURITY SPONGE DRUG MART ULTRA COMFORT SYR, -1 ML 30GX5/16, -1 ML SYRINGE EASY COMFORT 0.3 ML SYRINGE, -COMFORT 0.5 ML SYRINGE EASY COMFORT INSULIN 1 ML SYR EASY TOUCH INSULIN SYR 1 ML EASY TOUCH NEEDLE DISPOSABLE, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML EXEL INSULIN SYRINGE FREESTYLE PREC 0.5 ML 30GX5/16, -PREC 0.5 ML 31GX5/16, -PREC 1 ML 31GX5/16 FREESTYLE PREC 1 ML 30GX5/16 Tier Restrictions 2 2 2 2 2 2 2 2 2 2 2 2 3 3 2 3 3 2 2 2 3 Page 54 of 117 Drug GLUCOPRO INSUL SYR U100 0.3 ML, -INSUL SYR U100 0.5 ML, -INSULIN SYR 0.5 ML, -INSULIN SYR 1 ML, -U100 INSUL SYR 0.3 ML GLUCOPRO INSULIN SYR U100 1 ML, -SYRINGE U100 1 ML HUMAPEN LUXURA HD HUMAPEN MEMOIR IN CONTROL PEN NEEDLE INJECT-EASE INSULIN PEN NEEDLE INSULIN SYR 1/2 ML BULK PACK, -1 ML SYRN 27X1/2, -1 ML SYRN 28GX1/2, -INSUL SYR U100, -INSUL SYR U100 0.5 ML, -INSUL SYR U100 1 ML, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML, -INSULIN SYR U-100, -INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE 0.5 ML, -SYRINGE 1 ML INSULIN SYRINGE 0.3 ML, -INSULIN SYRINGE 0.5 ML, -INSULIN SYRINGE 1 ML, -0.3 ML, -0.5 ML INSUMED INSUPEN INTEGRA SYRINGE DISPOSABLE SYRINGE, -BD INTEGRA SYR 1 ML 29GX1/2 LISCO LITE TOUCH INSULIN 0.3 ML SYR, -INSULIN 0.5 ML SYR, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML, -INSULIN SYR 1 ML LITE TOUCH INSULIN 1 ML SYR LITE TOUCH INSULIN PEN NEEDLES MAGELLAN INSULIN SAFETY SYRNG MAGELLAN INSULIN SYRINGE MONOJECT 0.5 ML SYRN 28GX1/2 MONOJECT INSULIN SAFETY SYRNG MONOJECT INSULIN SYR 1 ML MONOJECT SAFETY SYRINGE NORDIPEN 15 NORDIPEN 5 NOVOFINE 32 NOVOFINE AUTOCOVER NOVOPEN 3 Tier Restrictions 2 3 2 2 2 2 2 2 2 3 2 2 3 2 3 2 2 2 2 2 3 2 2 2 2 2 2 Page 55 of 117 Drug NOVOPEN JR ORSINI INSUL SYR U100 0.5 ML ORSINI INSUL SYR U100 1 ML PEN NEEDLES PRECISION PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE RELION PEN 29G NEEDLE, -RELION PEN 31G NEEDLE SAFESNAP INSULIN SYRINGE SAFETY SYRINGE WITH SHIELD SAFETYGLIDE INSULIN SYRINGE SINGLE USE SWAB SURE COMFORT 1 ML SYRINGE SURE COMFORT ALCOHOL SURE COMFORT NEEDLE DISPOSABLE, -0.3 ML SYRINGE, -0.5 ML SYRINGE, -3/10 ML SYRINGE SURE-FINE PEN NEEDLES SURE-JECT INSU SYR U100 0.3 ML, -INSU SYR U100 0.5 ML, -INSU SYR U100 1 ML, -1 ML SURE-JECT INSUL SYR U100 1 ML SURE-PREP ALCOHOL PREP PADS TERUMO INSULIN SYRINGE TERUMO SURGUARD THINPRO INSULIN SYRINGE TOPCARE CLICKFINE TOPCARE ULTRA COMFORT ULTICARE NEEDLE DISPOSABLE, -INSUL SYR U100 0.3 ML, -INSUL SYR U100 0.5 ML, INSULIN SYR U100 1 ML ULTIGUARD SYRINGE EMPTY DISPOSABLE ULTILET ALCOHOL SWAB ULTILET INSULIN SYRINGE 1 ML ULTRA COMFORT NEEDLE DISPOSABLE, -0.3 ML 29GX1/2, -0.3 ML 30GX5/16, -0.3 ML 31GX5/16, -0.3 ML SYRINGE, -0.5 ML 28GX1/2, -0.5 ML 29GX1/2, -0.5 ML 30GX5/16, -0.5 ML 31GX5/16, -0.5 ML SYR, -0.5 ML SYRINGE, -1 ML 28GX1/2, -1 ML 29GX1/2, -1 ML 31GX5/16, -3/10 ML SYR ULTRACOMFORT 30GX0.5 ML SYR, -30GX1 ML SYRINGE, -31GX0.5 ML SYR, -31GX1 ML Tier Restrictions 2 2 3 2 2 2 2 3 2 2 2 2 3 2 2 2 2 3 2 2 2 2 2 3 2 2 2 3 2 2 Page 56 of 117 Drug SYRINGE, -NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE UNIFINE PENTIPS VANISHPOINT U-100 29X1/2 SYR VERSALON SPONGE WEBCOL Tier Restrictions 2 2 3 2 PHARMACEUTICAL NECESSITIES PEG 3350-GRX 3 MUSCULOSKELETAL MEDICATIONS CNS MUSCLE RELAXANTS cafgesic forte carisoprodol 350 mg tablet carisoprodol compound carisoprodol compound-codeine carisoprodol-aspirin chlorzoxazone cyclobenzaprine 5 mg tablet, -10 mg tablet methocarbamol tablet orphenadrine citrate injection, -tablet sustained action orphenadrine compound orphenadrine compound forte RILUTEK 1 1 1 1 1 1 1 1 1 1 1 4 DIRECT MUSCLE RELAXANTS baclofen tablet dantrolene sodium capsule DYSPORT GABLOFEN tizanidine hcl tablet XEOMIN 100 UNITS VIAL XEOMIN 50 UNITS VIAL 1 1 3 3 1 3 3 PA PA PA, QLL (8/84) DRUGS TO PREVENT AND TREAT GOUT allopurinol sodium 1 Page 57 of 117 allopurinol tablet Drug COLCRYS KRYSTEXXA probenecid probenecid-colchicine ULORIC 40 MG TABLET ULORIC 80 MG TABLET Tier 1 2 4 1 1 2 2 Restrictions QLL (31/31), ST ST NON-STEROIDAL ANTIINFLAMMATORY AGENTS ARTHROTEC 50 ARTHROTEC 75 CELEBREX diclofenac potassium diclofenac sodium tablet enteric coated, -tablet sustained release 24hr etodolac fenoprofen calcium tablet flurbiprofen tablet ibuprofen suspension oral, -400 mg tablet, -600 mg tablet, -800 mg tablet indomethacin capsule, -capsule sustained action, -injection ketoprofen capsule, -capsule 24hr sustained release pellets ketorolac tromethamine injection ketorolac tromethamine tablet meclofenamate sodium capsule meloxicam suspension oral, -tablet nabumetone naproxen sodium 275 mg tab, -550 mg tab naproxen suspension oral, -tablet, -tablet enteric coated oxaprozin piroxicam capsule sulindac tablet tolmetin sodium 3 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 QLL (20/5) 1 1 1 1 Page 58 of 117 Drug Tier OTHER DRUGS FOR ARTHRITIS CUPRIMINE DEPEN myochrysine RIDAURA SUPARTZ SYNVISC SYNVISC-ONE SYPRINE 2 2 1 2 4 4 4 2 Restrictions PA PA PA SALICYLATES AND RELATED DRUGS choline mag trisalicylate diflunisal tablet mst 600 salsalate tablet 1 1 1 1 NUTRITION,BLOOD MODIFIERS,ELECTROLYTES ANTIPLATELET DRUGS AGGRENOX cilostazol dipyridamole tablet EFFIENT PLAVIX ticlopidine hcl 2 1 1 2 2 1 QLL (31/31) BLOOD DETOXICANTS constulose enulose FOSRENOL generlac lactulose RENAGEL RENVELA 1 1 3 1 1 2 2 ELECTROLYTES, IRRIGATING SOLUTIONS, ETC. alcohol in dextrose 1 Page 59 of 117 Drug AMINOSYN AMINOSYN II AMINOSYN II 3.5% M-DEXTROSE 5% AMINOSYN II 3.5%-DEXTROSE 25% AMINOSYN II 3.5%-DEXTROSE 5% AMINOSYN II 4.25% M-DEXT 10% AMINOSYN II 4.25%-DEXTROSE 25% AMINOSYN II 5% IN 25% DEXTROSE AMINOSYN II IN DEXTROSE AMINOSYN II WITH LYTES-CA-DW AMINOSYN M AMINOSYN WITH ELECTROLYTES AMINOSYN-HBC AMINOSYN-HF AMINOSYN-PF AMINOSYN-RF AMMONIUM CHLORIDE INJECTION calcium gluconate injection CLINIMIX CLINIMIX E 2.75%-10% SOLUTION, -2.75%-5% SOLUTION, -4.25%-25% SOLUTION, -4.25%5% SOLUTION, -5%-15% SOLUTION, -5%-20% SOLUTION, -5%-25% SOLUTION CLINISOL CYSTAGON d5w/kcl 10 meq/l iv solution, -d5w-kcl 30 meq/l iv solution delflex with 1.5% dextrose delflex with 2.5% dextrose delflex with 4.25% dextrose dextrose 10%-1/4ns dextrose 10%-1/4ns-kcl dextrose 5%-1/2ns-kcl dextrose 5%-1/3ns-kcl dextrose 5%-1/4ns-kcl dextrose 5%-electrolyte #48 dextrose 5%-ns-kcl dextrose in ringers injection dextrose in water dextrose with sodium chloride Tier Restrictions 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 1 3 3 3 2 1 LTD 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 60 of 117 Drug DIANEAL PD-2 W-1.5% DEXTROSE DIANEAL PD-2 W-2.5% DEXTROSE DIANEAL PD-2 W-4.25% DEXTROSE DIANEAL WITH 1.5% DEXTROSE DIANEAL WITH 2.5% DEXTROSE DIANEAL WITH 4.25% DEXTROSE FREAMINE HBC FREAMINE III FREAMINE III WITH ELECTROLYTES HEPATAMINE HEPATASOL INPERSOL WITH 1.5% DEXTROSE INPERSOL WITH 4.25% DEXTROSE IONOSOL B WITH DEXTROSE 5% IONOSOL MB-DEXTROSE 5% IONOSOL T-DEXTROSE 5% ISOLYTE H WITH DEXTROSE ISOLYTE M WITH DEXTROSE ISOLYTE P WITH DEXTROSE ISOLYTE S ISOLYTE S WITH DEXTROSE lactated ringers magnesium sulfate injection MAGNESIUM SULFATE-D5W NEPHRAMINE NORMOSOL-M AND DEXTROSE NORMOSOL-R NORMOSOL-R AND DEXTROSE NORMOSOL-R PH 7.4 NOVAMINE nutrilyte nutrilyte ii PHYSIOLYTE PHYSIOSOL PLASMA-LYTE PLASMA-LYTE PLASMA-LYTE PLASMA-LYTE PLASMA-LYTE PLASMA-LYTE 148 148 IN DEXTROSE 56 56 IN DEXTROSE A PH 7.4 R Tier Restrictions 2 2 2 2 2 2 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 1 1 2 3 3 3 3 3 3 1 1 3 3 3 3 3 3 3 3 Page 61 of 117 Drug potassium chl-normal saline potassium chloride-nacl potassium ph 3mm/ml vial Tier Restrictions 1 1 1 PREMASOL 3 PROCALAMINE 3 PROSOL 3 RENAMIN 3 ringers injection 1 ringers irrigation 1 saline 0.45% soln-excel con, -0.45% soln, -saline 1 0.9% soln-excel cont, -0.9% soln, -0.9% soln., 0.9% solution, -cl 2.5 meq/ml vial, -3% iv soln, 4 meq/ml vl, -5% iv soln sodium acetate injection sodium bicarbonate injection sodium lactate injection sterile water for irrigation tis-u-sol TPN ELECTROLYTES TPN ELECTROLYTES II TRAVASOL TROPHAMINE 1 1 1 1 1 2 2 3 3 FLUORIDE PRODUCTS epiflur 0.5 mg tablet chewable, -1 mg tablet chewable fluor-a-day 0.5 mg tab chew, -1 mg tablet chew fluoride 0.5 mg chew tablet, -1 mg chew tablet fluoritab tablet chewable ludent fluoride 0.5 mg tb chew, -1 mg tab chew PREVIDENT 5000 PREVIDENT SOLUTION NON-ORAL renaf fluoride 0.5 mg tab chew, -fluoride 1 mg tab chew sf sf 5000 plus sodiphluor sodium fluoride drops, -tablet, -0.5 mg(1.1 mg) stannous fluoride solution 1 1 1 1 1 2 2 1 1 1 1 1 1 Page 62 of 117 Drug Tier Restrictions INJECTABLE ANTICOAGULANTS ARIXTRA 2.5 MG SYRINGE ARIXTRA 5 MG SYRINGE, -7.5 MG SYRINGE, -10 MG SYRINGE 3 4 QLL (60/365) QLL (60/365) enoxaparin 30 mg/0.3 ml syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr 1 ENOXAPARIN 80 MG/0.8 ML SYR, -100 MG/ML SYR, -120 MG/0.8 ML SYR, -150 MG/ML SYR 4 QLL (60/365) fondaparinux 2.5 mg/0.5 ml syr fondaparinux 5 mg/0.4 ml syr, -7.5 mg/0.6 ml syr, -10 mg/0.8 ml syr 1 4 QLL (60/365) QLL (60/365) FRAGMIN 2,500 UNITS SYRINGE, -5,000 UNITS SYRINGE FRAGMIN 7,500 UNITS SYRINGE, -10,000 UNITS SYRINGE, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, 25,000 UNITS/ML VIAL 3 QLL (60/365) 4 QLL (60/365) 1 1 PA heparin lock flush 100 unit/ml heparin sod 1,000 unit/ml vial, -sod 2,000 unit/ml vial, -sod 2,500 unit/ml vial, -sod 5,000 unit/ml vial, -sod 10,000 unit/ml vl, -sod 20,000 unit/ml vl heparin sod 5,000 unit/ml syr, -sod 5,000 unit/ 0.5 ml, -sod 5,000 unit/0.5 ml heparin sodium in 0.45% nacl heparin-d5w 20,000 unit/500 ml heparin-d5w 25,000 unit/500 ml, --d5w 10,000 unit/100 ml, --d5w 25,000 unit/250 ml heparin-ns 1,000 unit/500 ml heparin-ns 2,000 unit/1,000 ml LOVENOX 300 MG VIAL, -300 MG/3 ML VIAL 1 1 1 1 1 1 4 PA PA PA QLL (60/365) ORAL ANTICOAGULANTS, VITAMIN K jantoven PRADAXA warfarin sodium tablet 1 2 1 Page 63 of 117 Drug Tier POTASSIUM REMOVING RESINS kalexate KAYEXALATE kionex suspension oral sodium polystyrene sulfonate powder sodium polystyrene sulfonate suspension oral sps Restrictions 1 2 1 1 1 1 POTASSIUM SUPPLEMENTS dextrose in lactated ringers ed k+10 EFFER-K 10 MEQ TABLET EFF, -20 MEQ TABLET EFF epiklor k effervescent kaon-cl 10 kcl 20 meq in d5w solution, -kcl 40 meq in d5w solution klor-con 10 klor-con 20 meq packet klor-con 8 klor-con m10 klor-con m15 klor-con m20 MICRO-K 8 MEQ EXTENCAPS potassium acetate injection potassium bicarbonate tablet effervescent potassium chloride capsule sustained action, injection, -solution, -tablet effervescent, -tablet sust.releaseparticles/crystals, -tablet sustained action potassium chloride in d5lr sodium citrate & citric acid 1 1 3 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 THERAPEUTIC VITAMINS AND MINERALS calcitriol 1 mcg/ml vial calcitriol capsule, -1 mcg/ml ampul, -2 mcg/ml 1 1 PA Page 64 of 117 Drug vial, -solution calcium acetate capsule CARNITOR INJECTION eliphos HECTOROL 2 MCG/ML VIAL, -4 MCG/2 ML VIAL HECTOROL CAPSULE, -4 MCG/2 ML AMPUL levocarnitine injection, -solution, -tablet PHOSLYRA ZEMPLAR Tier 1 3 1 2 2 1 3 3 Restrictions PA PA PA PA VITAMINS AND MINERALS AND RELATED PRODUCTS INTRALIPID LIPOSYN II 2 3 1 1 1 1 liposyn iii multi-vitamin w-fluoride-iron multivitamins w-fluoride-iron multivitamins with fluoride drops, -multivit-fluor 0.25 mg tab chw, -mult-vit-fluor 0.5 mg tab chw, -multivit-fluor 0.5 mg tab, -multivit-fluor 0.5 mg tab chew multivit-fluor 0.25 mg tab chw, -multivit-fluor 0.5 1 mg tab chw multivit-fluor 0.5 mg tab chew 1 MVC-FLUORIDE 0.5 MG TAB CHEW phluorivit phluorivit + fe polyvitamin with iron-fluoride polyvitamins-fluoride triphluorivit tri-vit with fluoride-iron tri-vitamin with fluoride tri-vitamin with iron-fluoride 2 1 1 1 1 1 1 1 1 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ANDROGEN DRUGS ANADROL-50 ANDRODERM ANDROGEL 1% GEL PUMP, -1%(2.5G) GEL PACKET 4 2 3 PA PA Page 65 of 117 Drug ANDROGEL 1.62% GEL PUMP, -1%(5G) GEL PACKET danazol capsule FIRST-TESTOSTERONE FIRST-TESTOSTERONE MC oxandrolone tablet STRIANT TESTIM TESTOPEL testosterone cyp 100 mg/ml testosterone cyp 200 mg/ml testosterone enanthate injection Tier Restrictions 3 PA 1 3 3 1 3 3 3 1 1 1 PA PA PA PA CONTRACEPTIVES altavera amethia amethyst apri aranelle aviane azurette balziva briellyn camrese caziant cesia cryselle cyclafem emoquette enpresse gianvi gildess fe introvale jolessa junel junel fe kariva kelnor 1-35 leena 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 66 of 117 Drug lessina levonorgestrel levora-28 loryna low-ogestrel lutera microgestin microgestin fe mononessa necon next choice norgestimate-ethinyl estradiol norgestrel-ethiny estra nortrel NUVARING ocella ogestrel orsythia ORTHO EVRA PLAN B PLAN B ONE-STEP portia previfem quasense reclipsen solia sprintec sronyx syeda tilia fe tri-legest fe trinessa tri-previfem tri-sprintec trivora-28 velivet zarah zenchent zeosa zovia 1-35e Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Restrictions QLL (3/28) Page 67 of 117 zovia 1-50e Drug Tier Restrictions 1 ESTROGEN DRUGS CENESTIN DELESTROGEN DEPO-ESTRADIOL DIVIGEL ELESTRIN ENJUVIA ESTRACE CREAM WITH APPLICATOR estradiol patch transdermal weekly estradiol tablet estradiol valerate injection ESTRASORB ESTRING estropipate EVAMIST FEMRING FEMTRACE 0.45 MG TABLET, -0.9 MG TABLET GYNODIOL MENEST MENOSTAR PREMARIN CREAM WITH APPLICATOR, -TABLET PREMARIN INJECTION VAGIFEM 3 3 3 3 3 3 3 1 1 1 3 3 1 3 3 3 3 3 3 2 3 3 QLL (4/28) QLL (4/28) ESTROGEN/PROGESTIN COMBINATIONS ACTIVELLA 0.5-0.1 MG TABLET ANGELIQ CLIMARA PRO COMBIPATCH estradiol-norethindrone acetat FEMHRT 1/5 TABLET jevantique jinteli mimvey PREFEST PREMPHASE 2 3 3 3 1 3 1 1 1 3 2 QLL (4/28) QLL (8/28) Page 68 of 117 Drug PREMPRO Tier Restrictions 2 OB/GYN TOPICAL ANTIINFECTIVES ACID JELLY CLEOCIN SUPPOSITORY VAGINAL clindamycin phosphate cream with applicator metronidazole gel with applicator vandazole 2 2 1 1 1 OXYTOCICS METHERGINE INJECTION methylergonovine maleate oxytocin injection 3 1 1 PRENATAL VITAMINS cavan one omega cavan-folate ob cavan-heme ob cavan-heme omega co-natal fa corenate-dha dualvit ob edge ob elite-ob 400 folcal dha folcaps omega-3 inatal advance inatal gt inatal ultra multinatal plus tablet multi-nate dha extra mynatal mynatal advance mynatal plus mynatal-z mynate 90 plus ob + dha 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 69 of 117 Drug ob 90 + dha ob-natal one pnv-dha + docusate pnv-total pr natal 430 ec prenacare prenafirst prenaplus prenatabs fa prenatabs obn prenatabs rx prenatal 19 prenatal ad prenatal low iron prenatal multivitamin w-iron prenatal plus prenatal-u prenate plus re-nata 29 ob se-care conceive se-care gesture se-natal 19 se-natal 90 se-natal one se-plete dha setonet setonet-ec taron ec calcium taron-bc taron-duo ec taron-ec cal taron-prex prenatal tri rx triadvance triveen-duo dha triveen-ten triveen-u ultimatecare one vemavite-prx 2 vinacal Tier Restrictions 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 70 of 117 vinate az vinate az extra vinate c vinate calcium vinate care vinate gt vinate ic vinate ii vinate one vinate pn care vinate ultra vinate-m vitafol-ob vitafol-pn vitaphil vitaphil + dha vol-plus zatean-ch Drug Tier Restrictions 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PROGESTIN DRUGS camila DEPO-SUBQ PROVERA 104 errin heather jolivette MAKENA medroxyprogesterone acetate injection, -tablet MICRONOR nora-be norethindrone norethindrone acetate tablet PROMETRIUM 1 3 1 1 1 4 1 3 1 1 1 3 SPECIALIZED OB/GYN DRUGS chorionic gonadotropin injection leuprolide acetate injection LUPRON DEPOT 11.25 MG 3MO KIT, -22.5 MG 3MO KIT 1 1 3 PA PA PA, QLL (1/84) Page 71 of 117 LUPRON LUPRON LUPRON LUPRON LUPRON Drug DEPOT 3.75 MG KIT DEPOT 7.5 MG KIT DEPOT-4 MONTH KIT DEPOT-PED 11.25 MG KIT, -15 MG KIT DEPOT-PED 7.5 MG KIT novarel SUPPRELIN LA SYNAREL Tier 3 4 3 4 4 1 4 4 PA, PA, PA, PA, PA Restrictions QLL (1/28) QLL (1/28) QLL (1/112) QLL (1/28) PA OPHTHALMIC MEDICATIONS ANTIGLAUCOMA DRUGS acetazolamide capsule sustained action, -tablet acetazolamide sodium apraclonidine hcl AZOPT betaxolol hcl drops BETIMOL BETOPTIC S brimonidine tartrate carteolol hcl COMBIGAN dorzolamide hcl dorzolamide-timolol IOPIDINE ISOPTO CARBACHOL latanoprost levobunolol hcl LUMIGAN methazolamide tablet metipranolol PHOSPHOLINE IODIDE pilocarpine hcl drops PILOPINE HS timolol maleate drops, -gel-forming solution TIMOPTIC 0.5% EYE DROPS TRAVATAN Z XALATAN 1 1 1 3 1 3 3 1 1 3 1 1 3 3 1 1 2 1 1 3 1 3 1 2 3 2 Page 72 of 117 Drug Tier OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS BLEPHAMIDE BLEPHAMIDE S.O.P. dexasporin neomycin-bacitracin-poly-hc neomycin-poly-hc eye drops neomycin-polymyxin-dexameth poly-dex POLY-PRED PRED-G sulfacetamide-prednisolone TOBRADEX OINTMENT tobramycin-dexamethasone ZYLET Restrictions 3 3 1 1 1 1 1 3 3 1 2 1 3 OPHTHALMIC CORTICOSTEROID DRUGS ALREX dexamethasone sodium phosphate drops DUREZOL fluorometholone suspension drops FML FORTE FML S.O.P. LOTEMAX SUSPENSION DROPS MAXIDEX PRED MILD prednisolone acetate suspension drops prednisolone sodium phosphate drops VEXOL 3 1 3 1 3 3 3 3 3 1 1 3 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS ak-poly-bac aktob AZASITE bacitracin 500 unit/gm ointmnt bacitracin-polymyxin BESIVANCE CILOXAN OINTMENT 1 1 3 1 1 3 3 Page 73 of 117 Drug ciprofloxacin hcl drops erythromycin ointment garamycin drops gentak gentamicin sulfate drops, -3 mg/gm eye oint gentasol levofloxacin drops MOXEZA neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin ofloxacin 0.3% eye drops polycin-b polymyxin b sul-trimethoprim POLYTRIM romycin sulfacetamide sodium drops sulfamide tobramycin sulfate drops tobrasol TOBREX OINTMENT VIGAMOX ZYMAR ZYMAXID Tier Restrictions 1 1 1 1 1 1 1 3 1 1 1 1 1 3 1 1 1 1 1 2 3 2 2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine drops 1 OTHER OPHTHALMIC DRUGS ACUVAIL ak-con ak-dilate 10% eye drops akorn balanced salt ALAMAST ALOCRIL ALOMIDE altafrin atropine care atropine sulfate drops, -ointment 3 1 1 1 3 3 3 1 1 1 QLL (30/365) Page 74 of 117 azelastine hcl drops Drug BEPREVE BOTOX bromfenac sodium cromolyn sodium drops CYCLOGYL cyclopentolate hcl drops diclofenac sodium drops ELESTAT EMADINE epinastine hcl flurbiprofen sodium homatropaire ketorolac tromethamine drops LACRISERT LUCENTIS mydral naphazoline hcl drops NATACYN neofrin NEVANAC parcaine PATANOL phenylephrine hcl drops proparacaine hcl drops RESTASIS tropicacyl tropicamide drops XIBROM ZIRGAN Tier 1 3 3 1 1 3 1 1 3 3 1 1 1 1 2 4 1 1 2 1 3 1 3 1 1 3 1 1 3 2 Restrictions PA RESPIRATORY MEDICATIONS ANTIHISTAMINE/DECONGESTANT COMBINATIONS gripex pe promethazine vc SEMPREX-D 1 1 3 Page 75 of 117 ANTIHISTAMINES Drug arbinoxa brompheniramine tannate carbinoxamine maleate clemastine fumarate syrup, -fum 2.68 mg tab cyproheptadine hcl syrup, -tablet dexchlorpheniramine maleate diphenhydramine hcl capsule, -elixir, -injection fexofenadine hcl levocetirizine dihydrochloride promethazine hcl injection, -syrup, -tablet XYZAL Tier 1 1 1 1 1 1 1 1 1 1 3 Restrictions PA PA BETA-2 ADRENERGIC DRUGS albuterol sulfate nebs, -solution non-oral, -syrup, -tablet, -tablet sustained release 12hr albuterol sulfate vial nebulizer BROVANA ephedrine 50 mg/ml ampul FORADIL LEVALBUTEROL CONCENTRATE MAXAIR AUTOHALER metaproterenol sulfate syrup, -tablet PERFOROMIST PROAIR HFA PROVENTIL HFA SEREVENT DISKUS terbutaline sulfate injection, -tablet VENTOLIN HFA XOPENEX 0.31 MG/3 ML SOLUTION, -0.63 MG/3 ML SOLUTION XOPENEX 1.25 MG/3 ML SOLUTION XOPENEX CONCENTRATE XOPENEX HFA 1 1 3 1 2 1 3 1 3 3 3 2 1 2 3 PA PA PA PA ST ST PA, ST 3 3 3 LEUKOTRIENE MODIFIERS SINGULAIR 2 QLL (31/31) Page 76 of 117 zafirlukast Drug ZYFLO CR Tier Restrictions 1 2 METHYL XANTHINE DRUGS aminophylline injection, -tablet ELIXOPHYLLIN theochron theophylline anhydrous tablet sustained release 12hr theophylline tablet sustained action 1 2 1 1 1 OTHER DRUGS FOR ASTHMA acetylcysteine vial ADRENACLICK ADRENALIN CHLORIDE SOLUTION NON-ORAL ADVAIR DISKUS ADVAIR HFA ATROVENT HFA budesonide ampul for nebulization COMBIVENT cromolyn sodium ampul for nebulization DULERA epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial EPIPEN EPIPEN JR FLOVENT DISKUS FLOVENT HFA GASTROCROM ipratropium bromide solution non-oral ipratropium-albuterol QVAR SPIRIVA SYMBICORT TWINJECT XOLAIR 1 3 2 2 2 3 1 3 1 3 1 2 2 2 2 2 1 1 2 2 2 3 4 PA PA PA PA PA PA, LTD Page 77 of 117 Drug Tier OTHER RESPIRATORY DRUGS ARALAST NP 1,000 MG VIAL ARALAST NP 500 MG VIAL DALIRESP GLASSIA PROLASTIN 1,000 MG VIAL PROLASTIN 500 MG VIAL PROLASTIN C PULMOZYME ZEMAIRA 4 4 3 4 4 4 4 4 4 Restrictions PA, LTD PA PA PA, LTD PA, LTD PA PA, LTD UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DETROL DETROL LA flavoxate hcl GELNIQUE oxybutynin chloride er oxybutynin chloride syrup, -tablet TOVIAZ trospium chloride VESICARE 2 2 1 3 1 1 2 1 2 CHOLINERGIC STIMULANTS bethanechol chloride tablet 1 OTHER GENITOURINARY PRODUCTS acetic acid 0.25% irrig soln alfuzosin hcl AVODART CYSTADANE cytra-k ELMIRON finasteride tablet JALYN neomy-polymyxin b 40 mg/ml amp phenazopyridine plus 1 1 2 2 1 2 1 2 1 1 Page 78 of 117 Drug phosphasal potassium citrate TABLET SUSTAINED ACTION potassium citrate-citric acid tamsulosin hcl taron-crystals tricitrates urin d.s. Tier Restrictions 1 1 1 1 1 1 1 Page 79 of 117 Index: 10 wash, 36 1ST TIER UNIFINE PENTIPS PLUS, 53 8-MOP, 37 ABELCET, 8 ABILIFY DISCMELT, 18 ABILIFY INJECTION, 18 ABILIFY SOLUTION, 18 ABILIFY TABLET, 18 ABRAXANE, 12 ABSTRAL, 21 acarbose, 43 acebutolol hcl capsule, 30 acetaminoph-caff-dihydrocodein, 22 acetaminophen-codeine, 22 acetaminophen-tramadol, 17 acetasol hc, 39 acetazolamide capsule sustained action, -tablet, 72 acetazolamide sodium, 72 acetic acid 0.25% irrig soln, 78 acetic acid solution non-oral, 39 acetic acid-aluminum, 39 acetylcysteine vial, 77 ACID JELLY, 69 ACTEMRA 200 MG/10 ML VIAL, 51 ACTEMRA 80 MG/4 ML VIAL, -400 MG/20 ML VIAL, 51 ACTHIB, 48 acticin, 37 ACTIMMUNE, 51 ACTIVELLA 0.5-0.1 MG TABLET, 68 ACTONEL 150 MG TABLET, 43 ACTONEL 35 MG TABLET, 43 ACTONEL 5 MG TABLET, -30 MG TABLET, 43 ACTOPLUS MET, 43 ACTOPLUS MET XR, 43 ACTOS, 43 ACUVAIL, 74 acyclovir capsule, -suspension oral, tablet, 7 acyclovir sodium, 7 ADACEL, 49 ADAGEN, 39 adapalene, 35 ADCIRCA, 34 ADRENACLICK, 77 ADRENALIN CHLORIDE SOLUTION NON-ORAL, 77 adriamycin 10 mg vial, -20 mg vial, 50 mg vial, 12 adriamycin 2 mg/ml vial, 12 adrucil, 12 ADVAIR DISKUS, 77 ADVAIR HFA, 77 aero otic hc, 39 afeditab cr, 30 AFINITOR, 12 AGGRENOX, 59 A-HYDROCORT, 41 AIMSCO INS SYR 0.3 ML 29GX1/2, AIMSCO INS SYR 0.3 ML 30GX5/16, -AIMSCO INS SYR 0.5 ML 28GX1/2, -AIMSCO INS SYR 0.5 ML 29GX1/2, -AIMSCO INS SYR 1 ML 28GX1/2, AIMSCO INS SYR 1 ML 29GX1/2, AIMSCO SYRING 0.3 ML 31GX5/16, -AIMSCO SYRING 0.5 ML 30GX5/16, -AIMSCO SYRING 0.5 ML 31GX5/16, -BD INSULIN SYR 0.3 ML 28GX1/2, BD INSULIN SYR 0.3 ML 29GX1/2, BD INSULIN SYR 0.3 ML 30GX1/2, BD INSULIN SYR 0.3ML 31GX5/16, BD INSULIN SYR 0.5 ML 28GX1/2, BD INSULIN SYR 0.5 ML 29GX1/2, BD INSULIN SYR 0.5 ML 30GX1/2, BD INSULIN SYR 0.5ML 31GX5/16, BD INSULIN SYR 1 ML 25GX1, -BD INSULIN SYR 1 ML 25GX5/8, -BD INSULIN SYR 1 ML 26GX1/2, -BD INSULIN SYR 1 ML 27GX5/8, -BD INSULIN SYR 1 ML 28GX1/2, -BD Page 80 of 117 INSULIN SYR 1 ML 29GX1/2, -BD INSULIN SYR 1 ML 30GX1/2, -BD INSULIN SYR 1 ML 31GX5/16, -BD INSULIN SYRINGE 1 ML, -BD INSULIN U100-3/10 ML SYR, FIFTY50 INSULIN SYRINGE 0.3 ML, -FIFTY50 INSULIN SYRINGE 0.5 ML, -FIFTY50 INSULIN SYRINGE 1 ML, INS SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML 30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS SYR 0.5 ML 29GX1/2, -INS SYR 0.5 ML 30GX1/2, -INS SYR 0.5 ML 30GX5/16, -INS SYR 1 ML 28GX1/2, -INS SYR 1 ML 29GX1/2, INS SYR 1 ML 31GX5/16, -INS SYR U100 1 ML 28GX1/2, -INS SYRIN 0.3 ML 30GX1/2, -INS SYRIN 1 ML 29GX1/2, -INS SYRING 0.3 ML 30GX5/16, -INS SYRINGE 1 ML 28GX1/2, -INS SYRINGE 3/10 ML, INSUL SYR 0.3 ML 31GX5/16, INSUL SYR 0.5 ML 28GX1/2, -INSUL SYR 0.5 ML 30GX1/2, -INSUL SYR 0.5 ML 31GX5/16, -0.3 ML SYRINGE, -0.5 ML SYRINGE, -1 ML SYRINGE, 1/2 ML SYRINGE, -3/10 ML SYRINGE, -SYR 0.3 ML 29GX1/2, SYR 0.5 ML 28GX1/2, -SYR 1 ML 29GX1/2, -SYR 1 ML 30GX5/16, SYR 1 ML 31GX5/16, -SYRIN 0.3 ML 29GX1/2, -SYRIN 0.3 ML 30GX1/2, SYRIN 0.3 ML 30GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.5 ML 28GX1/2, -SYRIN 0.5 ML 29GX1/2, -SYRIN 0.5 ML 30GX1/2, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 31GX5/16, -SYRIN 1 ML 29GX1/2, -1 ML 28GX1/2, -1 ML 29GX1/2, -1 ML 30GX1/2, -1 ML 31GX5/16, -1 ML- HARD PK, -U100 0.5 ML, -U100 1 ML, -INSULN SYR, 52 AIMSCO INS SYR 1 ML 30GX5/16, CAREONE INS SYR 1 ML 30GX5/16, -INS SYR 1 ML 30GX5/16, -INS SYRINGE 1 ML 30GX1/2, -INS SYRINGE 1 ML 30GX5/16, -1 ML 30GX5/16, -30GX1 ML SYR, PREFPLS INS SYR 1 ML 30GX5/16, RELION INS SYR 1 ML 30GX5/16, RELION INSULIN SYR 0.3 ML, RELION INSULIN SYR 0.5 ML, RELION INSULIN SYRINGE 1 ML, RELION SYRING 0.5 ML 31GX5/16, U100 1 ML 30GX5/16, -ULTCARE INS SYR 1 ML 30GX5/16, WDMEDIC INS SYR 1 ML 30GX5/16, 53 AIMSCO MINI ULTRA-THIN II, 53 AIMSCO ULTRA THIN II, 53 ak-con, 74 ak-dilate 10% eye drops, 74 akorn balanced salt, 74 ak-poly-bac, 73 aktob, 73 ALAMAST, 74 ALBENZA, 2 albuterol sulfate nebs, -solution nonoral, -syrup, -tablet, -tablet sustained release 12hr, 76 albuterol sulfate vial nebulizer, 76 alclometasone dipropionate, 37 alcohol in dextrose, 59 ALCOHOL PADS, 53 ALCOHOL PREP PADS, 53 ALCOHOL PREP SWABS, 53 ALCOHOL SWAB, 54 ALCOHOL SWABS, 54 ALCOHOL WIPES, 54 ALDARA, 38 ALDURAZYME, 44 alendronate sodium, 44 Page 81 of 117 alfuzosin hcl, 78 ALIMTA, 12 ALINIA, 6 ALKERAN INJECTION, 12 allopurinol sodium, 57 allopurinol tablet, 58 ALOCRIL, 74 ALOMIDE, 74 ALOXI, 19 ALREX, 73 altafrin, 74 altavera, 66 aluvea 40% cream, 38 amantadine, 7 AMBISOME, 8 amcinonide, 37 AMEBICIDES, 1 a-methapred 40 mg vial, 41 amethia, 66 amethyst, 66 AMEVIVE, 12 amifostine, 12 amikacin sulfate injection, 1 amiloride hcl tablet, 34 amiloride-hydrochlorothiazide, 34 aminocaproic acid injection, -solution oral, -tablet, 39 AMINOGLYCOSIDES, 1 aminophylline injection, -tablet, 77 AMINOSYN, 60 AMINOSYN II, 60 AMINOSYN II 3.5% M-DEXTROSE 5%, 60 AMINOSYN II 3.5%-DEXTROSE 25%, 60 AMINOSYN II 3.5%-DEXTROSE 5%, 60 AMINOSYN II 4.25% M-DEXT 10%, 60 AMINOSYN II 4.25%-DEXTROSE 25%, 60 AMINOSYN II 5% IN 25% DEXTROSE, 60 AMINOSYN II IN DEXTROSE, 60 AMINOSYN II WITH LYTES-CA-DW, 60 AMINOSYN M, 60 AMINOSYN WITH ELECTROLYTES, 60 AMINOSYN-HBC, 60 AMINOSYN-HF, 60 AMINOSYN-PF, 60 AMINOSYN-RF, 60 amiodarone hcl injection, -tablet, 29 AMIODARONES, 29 AMITIZA, 46 amitriptyline hcl tablet, 28 amlodipine besylate tablet, 30 amlodipine besylate-benazepril, 33 AMMONIUM CHLORIDE INJECTION, 60 ammonium lactate cream, -lotion, 38 amnesteem, 37 amox tr-potassium clavulanate, 8 amoxapine, 27 amoxicillin, 9 amoxicillin-clavulanate er, 9 amphetamine salts 10 mg tab, 23 amphetamine salts 12.5 mg tb, 23 amphetamine salts 15 mg tab, 23 amphetamine salts 20 mg tab, 23 amphetamine salts 30 mg tab, 23 amphetamine salts 5 mg tab, 23 amphetamine salts 7.5 mg tab, 23 AMPHOTEC, 8 amphotericin b injection, 8 ampicillin sodium, 9 ampicillin trihydrate, 9 ampicillin-sulbactam, 9 AMPYRA, 39 AMTURNIDE, 33 ANADROL-50, 65 anagrelide hcl, 12 ANALGESICS, 17 anastrozole tablet, 12 ANCOBON, 5 ANDRODERM, 65 Page 82 of 117 ANDROGEL 1% GEL PUMP, -1%(2.5G) GEL PACKET, 65 ANDROGEL 1.62% GEL PUMP, 1%(5G) GEL PACKET, 66 ANDROGEN DRUGS, 65 anestacon, 1 ANESTHETICS, 1 ANGELIQ, 68 ANGIOTENSIN CONVERTING ENZYME INHIBITORS, 29 ANGIOTENSIN II RECEPTOR ANTAGONISTS, 29 ANTABUSE, 26 ANTHELMINTICS, 2 ANTICHOLINERGIC ANTISPASMODICS, 78 ANTIDEMENTIA DRUGS, 17 ANTIDIARRHEAL DRUGS, 45 ANTIDYSRHYTHMIC DRUGS, 29 ANTIGLAUCOMA DRUGS, 72 ANTIHISTAMINE/DECONGESTANT COMBINATIONS, 75 ANTIHISTAMINES, 76 ANTIINFECTIVES, 1 ANTIINFECTIVES SPECIALIZED INDICATIONS, 2 ANTIMANIA DRUGS, 18 ANTINEOPLASTIC/IMMUNOSUPPRESS ANT DRUGS, 12 ANTIPARKINSON ANTICHOLINERGIC DRUGS, 18 ANTIPLATELET DRUGS, 59 ANTIPRURITIC DRUGS, 36 ANTIPSORIASIS AND ANTIECZEMA DRUGS, 36 ANTIPSYCHOTIC DRUGS, 18 antipyrine-benzocaine, 39 ANTIRETROVIRALS AND PROTEASE INH, 2 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY, 45 ANTITHYROID DRUGS, 41 ANTITUBERCULOSIS DRUGS, 3 ANTIULCER DRUGS, 46 ANTIVERTIGO AND ANTIEMETIC DRUGS, 19 ANXIOLYTICS, 20 ANZEMET 100 MG TABLET, 19 ANZEMET 50 MG TABLET, 19 ANZEMET INJECTION, 19 APIDRA, 42 APIDRA SOLOSTAR, 42 APOKYN, 26 apraclonidine hcl, 72 apri, 66 APRISO, 46 APTIVUS, 2 ARALAST NP 1,000 MG VIAL, 78 ARALAST NP 500 MG VIAL, 78 aranelle, 66 ARANESP 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL, 49 ARANESP 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -200 MCG/0.4 ML SYRINGE, -150 MCG/0.3 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML SYRINGE, -300 MCG/ML VIAL, -500 MCG/1 ML SYRINGE, -150 MCG/0.75 ML VIAL, 49 arbinoxa, 76 ARCALYST, 51 ARISTOSPAN, 41 ARIXTRA 2.5 MG SYRINGE, 63 ARIXTRA 5 MG SYRINGE, -7.5 MG SYRINGE, -10 MG SYRINGE, 63 ARMOUR THYROID, 45 AROMASIN, 12 ARRANON, 12 ARTHROTEC 50, 58 ARTHROTEC 75, 58 ASACOL, 46 Page 83 of 117 ASACOL HD, 46 ascomp with codeine, 24 ASTEPRO, 40 atamet, 26 ATELVIA, 44 atenolol tablet, 30 atenolol-chlorthalidone, 33 ATGAM, 49 atovaquone-proguanil hcl, 9 ATRIPLA, 2 atropine care, 74 atropine sulfate drops, -ointment, 74 atropine sulfate injection, 26 ATROVENT HFA, 77 ATTENUVAX VACCINE WITH DILUENT, 49 aurodex, 40 auroguard, 40 AURORA PEN NEEDLE 6MM 31G, AURORA PEN NEEDLES 12MM 29G, -AURORA PEN NEEDLES 8MM 31G, BD PEN NEEDLE 29GX1/2, -BD PEN NEEDLE 29GX3/16, -BD PEN NEEDLE 29GX5/16, -BD PEN NEEDLE MINI 31GX3/16, -BD PEN NEEDLE NANO 32GX5/32, -BD PEN NEEDLE ORIG 29GX1/2, -BD PEN NEEDLE SHORT 31GX5/16, CLICKFINE PEN NDL 31GX1/4, CLICKFINE PEN NDL 31GX5/16, LIVE BETTER PEN NEEDLE 6MM 31G, -LIVE BETTER PEN NEEDLES 12MM, -LIVE BETTER PEN NEEDLES 8MM, -MS PEN NEEDLE 6MM 31G, 12MM 29G NEEDLES, -8MM 31G NEEDLES, -31GX3/16, -31GX5/16, 6MM 31G, -S 12MM 29G, -S 29G, -S 31G, -S 31G X 5/16, -S 8MM 31G, TODAY'S HLT PN NEEDLE 12MM 29G, -TODAY'S HLTH PN NEEDLE 6MM 31G, -TODAY'S HLTH PN NEEDLE 8MM 31G, -UNIFINE PENTIP 6MM 31G, 54 AUTO INJECTOR, 54 AUTOJECT 2, 54 AUTONOMIC AND CNS MEDICATIONS, 17 AUTOPEN, 54 AVALIDE, 33 AVANDAMET, 43 AVANDARYL, 43 AVANDIA, 43 AVAPRO, 29 AVASTIN, 12 AVELOX, 10 AVELOX ABC PACK, 10 AVELOX IV, 10 aviane, 66 AVODART, 78 AVONEX, 51 AVONEX ADMINISTRATION PACK, 51 AZACTAM 1 GM VIAL, 6 AZACTAM-ISO-OSMOT 1 GM/50 ML, 6 AZACTAM-ISO-OSMOT 2 GM/50 ML, 6 AZASAN, 12 AZASITE, 73 AZATHIOPRINE SODIUM, 12 azathioprine tablet, 12 azelastine hcl aerosol spray w/pump, 40 azelastine hcl drops, 75 AZILECT, 26 azithromycin injection, -packet, suspension, -tablet, 8 AZOPT, 72 aztreonam, 6 azurette, 66 baciim, 6 bacitracin 500 unit/gm ointmnt, 73 bacitracin injection, 6 bacitracin-polymyxin, 73 baclofen tablet, 57 BACTROBAN NASAL, 11 Page 84 of 117 balsalazide disodium, 47 balziva, 66 BANZEL, 25 BARACLUDE SOLUTION, 7 BARACLUDE TABLET, 7 baycadron, 41 BCG VACCINE (TICE STRAIN), 49 BD LUER-LOK SYRINGE 1 ML, 54 BD SAFETYGLIDE SYRINGE 27GX5/8, 54 belladonna-opium, 21 benazepril hcl, 29 benazepril-hydrochlorothiazide, 33 BENICAR, 29 BENICAR HCT, 33 BENTYL INJECTION, 45 benzoyl peroxide 2.5% wash, -4.5% cleanser, -5% wash, -5.75 % wash, -6.5% cleanser, -8.5% cleanser, 10% wash, -gel, -4% lotion, -8% lotion, 35 benztropine mesylate injection, -tablet, 18 BEPREVE, 75 BESIVANCE, 73 BETA-2 ADRENERGIC DRUGS, 76 BETA-ADRENERGIC ANTAGONIST DRUGS, 30 betamethasone acetate-sod phos, 41 betamethasone dipropionate cream, gel, -lotion, -ointment, 37 betamethasone valerate cream, lotion, -ointment, 37 BETASERON, 51 beta-val, 37 betaxolol hcl drops, 72 betaxolol hcl tablet, 30 bethanechol chloride tablet, 78 BETIMOL, 72 BETOPTIC S, 72 bicalutamide, 12 BICILLIN C-R, 9 BICILLIN L-A, 9 BICNU, 12 BIDIL, 34 BILTRICIDE, 2 bisoprolol fumarate, 30 bisoprolol-hydrochlorothiazide, 33 bleomycin sulfate 15 unit vial, 12 bleomycin sulfate 30 unit vial, 12 BLEPHAMIDE, 73 BLEPHAMIDE S.O.P., 73 BLOOD DETOXICANTS, 59 BONIVA INJECTION, 44 BONIVA TABLET, 44 BOOSTRIX, 49 borofair, 40 BOTOX, 75 bp 10-1, 35 briellyn, 66 brimonidine tartrate, 72 bromfenac sodium, 75 bromocriptine mesylate capsule, tablet, 26 brompheniramine tannate, 76 BROVANA, 76 budeprion sr, 25 budeprion xl 150 mg tablet, 25 budeprion xl 300 mg tablet, 25 budesonide ampul for nebulization, 77 budesonide ec, 47 bumetanide, 32 BUPHENYL, 39 BUPRENORPHINE 0.3 MG/ML SYRN, 17 buprenorphine 0.3 mg/ml vial, 22 buprenorphine 2 mg tablet sl, 22 buprenorphine 8 mg tablet sl, 22 buproban, 28 bupropion hcl sr, 25 bupropion hcl tablet, 25 bupropion xl, 25 buspirone hcl tablet, 20 BUSULFEX, 12 Page 85 of 117 butalb-caff-acetaminoph-codein, 24 butalbital compound-codeine, 24 butorphanol tartrate aerosol spray, 24 butorphanol tartrate injection, 17 BYETTA, 42 BYSTOLIC, 30 cabergoline, 44 CADUET, 31 cafgesic forte, 57 calcipotriene, 36 calcitonin-salmon, 44 calcitriol 1 mcg/ml vial, 64 calcitriol capsule, -1 mcg/ml ampul, -2 mcg/ml vial, -solution, 64 calcium acetate capsule, 65 CALCIUM ANTAGONISTS, 30 calcium gluconate injection, 60 camila, 71 CAMPATH, 12 CAMPRAL, 26 camrese, 66 CANASA, 47 CANCIDAS, 8 CANTIL, 45 CAPASTAT SULFATE, 3 CAPRELSA 100 MG TABLET, 12 CAPRELSA 300 MG TABLET, 12 captopril tablet, 29 captopril-hydrochlorothiazide, 33 CARAC, 38 CARAFATE SUSPENSION ORAL, 46 carbamazepine capsule sustained action, -suspension oral, -tablet, tablet chewable, 20 carbamazepine xr, 20 CARBAMAZEPINES, 20 CARBATROL, 20 carbidopa-levodopa, 26 carbinoxamine maleate, 76 carboplatin 150 mg/15 ml vial, 12 carboplatin 450 mg/45 ml vial, -50 mg/5 ml vial, -600 mg/60 ml vial, - 50 mg vial, -150 mg vial, -450 mg vial, 12 CARDIAC GLYCOSIDES, 31 CARDIOVASCULAR MEDICATIONS, 29 CARDURA XL, 35 CARIMUNE NF NANOFILTERED, 49 carisoprodol 350 mg tablet, 57 carisoprodol compound, 57 carisoprodol compound-codeine, 57 carisoprodol-aspirin, 57 CARNITOR INJECTION, 65 carteolol hcl, 72 cartia xt, 30 carvedilol, 30 CATAPRES-TTS 1, 31 CATAPRES-TTS 2, 31 CATAPRES-TTS 3, 31 cavan one omega, 69 cavan-folate ob, 69 cavan-heme ob, 69 cavan-heme omega, 69 CAYSTON, 6 caziant, 66 CEDAX, 4 CEENU, 12 cefaclor, 4 cefaclor er, 4 cefadroxil, 4 cefazolin 20 gm bulk vial, -500 mg vial, -1 gm add-van vial, -1 gm vial, -1 gm-d5w bag, -10 gm vial, 4 cefazolin sod 100 gm bulk bag, -sod 300 gm bulk bag, 4 cefdinir, 4 CEFDITOREN PIVOXIL 400 MG TAB, 4 cefepime hcl, 4 cefotaxime sodium, 4 cefotetan, 4 cefoxitin, 4 cefoxitin sodium, 4 cefpodoxime proxetil, 4 cefprozil, 4 Page 86 of 117 ceftazidime 500 mg vial, 4 ceftriaxone, 4 cefuroxime, 4 cefuroxime axetil, 4 CEFUROXIME SOD 75 GM BULK BAG, 4 cefuroxime sod 750 mg vial, -sod 1.5 gm vial, -sod 7.5 gm vial, 4 CELEBREX, 58 CELESTONE, 41 CELLCEPT INJECTION, 12 CELLCEPT SUSPENSION RECONSTITUTED ORAL, 12 CELONTIN, 28 CENESTIN, 68 CENTRALLY ACTING ANTIHYPERTENSIVES, 31 cephalexin, 4 CEPHALOSPORINS, 4 CEREBYX, 24 CEREDASE, 44 CEREZYME 200 UNITS VIAL, 44 CEREZYME 400 UNITS VIAL, 44 CERVARIX, 49 cesia, 66 CHANTIX TABLET, 28 CHANTIX TABLET DOSE PACK, 28 CHEMET, 39 chloral hydrate syrup, 27 chloramphenicol sod succinate, 5 CHLORAMPHENICOLS, 5 chlordiazepoxide-amitriptyline, 25 CHLORHEXIDINE GLUC 20% SOLN, 11 chlorhexidine gluconate mouthwash, 40 chloroquine phosphate tablet, 9 chlorothiazide, 35 chlorothiazide sodium, 35 chloroxylenol-pramoxine hcl, 40 chlorphenylcaine, 40 chlorpromazine hcl injection, -tablet, 18 chlorpropamide, 43 chlorthalidone, 35 chlorzoxazone, 57 cholestyramine, 32 cholestyramine light, 32 choline mag trisalicylate, 59 CHOLINERGIC STIMULANTS, 78 chorionic gonadotropin injection, 71 ciclopirox cream, -gel, -solution nonoral, -suspension topical, 8 cilostazol, 59 CILOXAN OINTMENT, 73 cimetidine injection, -solution, -tablet, 46 CIMZIA 200 MG VIAL KIT, -200 MG/ML SYRINGE KIT, 12 CINRYZE, 49 CIPRO HC, 40 CIPRODEX, 40 ciprofloxacin, 10 ciprofloxacin er 1,000 mg tab, 10 ciprofloxacin er 500 mg tablet, 10 ciprofloxacin hcl drops, 74 ciprofloxacin hcl tablet, 10 ciprofloxacin-d5w, 10 cisplatin, 12 citalopram, 27 citalopram hbr, 27 cladribine, 12 claravis, 37 clarithromycin er, 8 clarithromycin suspension, -tablet, 8 CLASS II NARCOTICS, 21 CLASS III NARCOTICS, 22 CLASS IV NARCOTICS, 22 clemastine fumarate syrup, -fum 2.68 mg tab, 76 CLEOCIN HCL 75 MG CAPSULE, 5 CLEOCIN PALMITATE, 5 CLEOCIN PHOSPHATE IN D5W, 5 CLEOCIN SUPPOSITORY VAGINAL, 69 CLICKFINE, 54 Page 87 of 117 CLIMARA PRO, 68 clindacin p, 35 clindamycin hcl capsule, 5 clindamycin palmitate hcl, 5 clindamycin phosphate cream with applicator, 69 clindamycin phosphate gel, -lotion, solution non-oral, -swab medicated, 35 clindamycin phosphate injection, 5 clindamycin-benzoyl peroxide, 35 CLINDAMYCINS, 5 CLINIMIX, 60 CLINIMIX E 2.75%-10% SOLUTION, 2.75%-5% SOLUTION, -4.25%-25% SOLUTION, -4.25%-5% SOLUTION, -5%-15% SOLUTION, -5%-20% SOLUTION, -5%-25% SOLUTION, 60 CLINISOL, 60 clobetasol emollient, 37 clobetasol propionate cream, -gel, ointment, -solution non-oral, 37 CLOLAR, 12 clomipramine hcl capsule, 28 clonidine, 31 clonidine hcl injection, -tablet, 31 CLORPRES, 33 clotrimazole cream, -solution non-oral, 8 clotrimazole troche, 5 clotrimazole-betamethasone, 11 clozapine, 18 CNS MUSCLE RELAXANTS, 57 CNS STIMULANT DRUGS, 23 COARTEM, 9 codeine phosphate injection, 21 codeine sulfate, 21 COGENTIN, 18 co-gesic, 22 COGNEX, 17 COLCRYS, 58 colestipol hcl, 32 colistimethate 150 mg vial, 6 COLOCORT, 47 COLY-MYCIN S, 40 COLYTE WITH FLAVOR PACKETS, 47 COLYTE WITH FLAVOR PACKS, 47 COMBIGAN, 72 COMBIPATCH, 68 COMBIVENT, 77 COMBIVIR, 2 compro, 19 COMTAN, 26 COMVAX, 49 co-natal fa, 69 CONCERTA ER 18 MG TABLET, -ER 27 MG TABLET, -ER 54 MG TABLET, 23 CONCERTA ER 36 MG TABLET, 23 CONDYLOX GEL, 36 constulose, 59 CONTRACEPTIVES, 66 COPAXONE, 39 COPEGUS, 7 COREG CR, 30 corenate-dha, 69 CORTIFOAM, 47 cortisone acetate tablet, 41 CORTISPORIN-TC, 40 cortomycin, 40 COSMEGEN, 13 CREON, 47 CRESYLATE, 40 CRIXIVAN, 2 cromolyn sodium ampul for nebulization, 77 cromolyn sodium drops, 75 cryselle, 66 CUBICIN, 6 CUPRIMINE, 59 CURAD GAUZE PADS, 54 CURITY ALCOHOL PREPS, 54 CURITY SPONGE, 54 cyclafem, 66 Page 88 of 117 cyclobenzaprine 5 mg tablet, -10 mg tablet, 57 CYCLOGYL, 75 cyclopentolate hcl drops, 75 cyclophosphamide injection, 13 cyclophosphamide tablet, 13 cyclosporine capsule, -injection, solution, 13 cyclosporine modified, 13 cyclosporine unit, 13 CYKLOKAPRON, 39 CYMBALTA 20 MG CAPSULE, 25 CYMBALTA 30 MG CAPSULE, -60 MG CAPSULE, 25 cyproheptadine hcl syrup, -tablet, 76 CYSTADANE, 78 CYSTAGON, 60 cytarabine 100 mg vial, -1 gm vial, -2 gm vial, 13 cytarabine 20 mg/ml vial, -100 mg/ml vial, -500 mg vial, 13 cytra-k, 78 d5w/kcl 10 meq/l iv solution, -d5w-kcl 30 meq/l iv solution, 60 dacarbazine 100 mg vial, 13 dacarbazine 200 mg vial, 13 DACOGEN, 13 dactinomycin, 13 DALIRESP, 78 d-amphetamine er 10 mg capsule, -10 mg tab, 23 d-amphetamine er 15 mg capsule, 23 d-amphetamine er 5 mg capsule, 23 danazol capsule, 66 dantrolene sodium capsule, 57 DAPSONE TABLET, 2 DAPTACEL, 49 DARAPRIM, 9 daunorubicin hcl, 13 DAUNOXOME, 13 DECAVAC, 49 DELESTROGEN, 68 delflex with 1.5% dextrose, 60 delflex with 2.5% dextrose, 60 delflex with 4.25% dextrose, 60 demeclocycline hcl, 10 DEMEROL 75 MG/ML SYRINGE, 21 DEMSER, 31 DENAVIR, 7 DEPACON, 28 depade, 26 DEPEN, 59 DEPO-ESTRADIOL, 68 DEPO-MEDROL 20 MG/ML VIAL, 41 DEPO-PROVERA 400 MG/ML VIAL, 13 DEPO-SUBQ PROVERA 104, 71 DERMATOLOGICAL MEDICATIONS, 35 DERMOTIC, 40 desipramine hcl tablet, 27 desmopressin acetate aerosol spray w/pump, -injection, -solution, tablet, 44 desonide cream, -lotion, -ointment, 37 desoximetasone cream, -gel, ointment, 37 DETROL, 78 DETROL LA, 78 dexamethasone elixir, -solution oral, tablet, 41 dexamethasone intensol, 41 dexamethasone sodium phosphate drops, 73 dexamethasone sodium phosphate injection, 41 dexasporin, 73 dexchlorpheniramine maleate, 76 DEXILANT, 48 dexmethylphenidate 10 mg tab, 23 dexmethylphenidate 2.5 mg tab, 23 dexmethylphenidate 5 mg tab, 23 dexrazoxane 250 mg vial, 13 dexrazoxane 500 mg vial, 13 dextroamphetamine 5 mg tab, 23 dextroamphetamine-amphetamine, 23 Page 89 of 117 dextrose 10%-1/4ns, 60 dextrose 10%-1/4ns-kcl, 60 dextrose 5%-1/2ns-kcl, 60 dextrose 5%-1/3ns-kcl, 60 dextrose 5%-1/4ns-kcl, 60 dextrose 5%-electrolyte #48, 60 dextrose 5%-ns-kcl, 60 dextrose in lactated ringers, 64 dextrose in ringers injection, 60 dextrose in water, 60 dextrose with sodium chloride, 60 DIABETIC SUPPLIES, 52 DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS, 39 DIAGNOSTIC PRODUCTS, 39 DIANEAL PD-2 W-1.5% DEXTROSE, 61 DIANEAL PD-2 W-2.5% DEXTROSE, 61 DIANEAL PD-2 W-4.25% DEXTROSE, 61 DIANEAL WITH 1.5% DEXTROSE, 61 DIANEAL WITH 2.5% DEXTROSE, 61 DIANEAL WITH 4.25% DEXTROSE, 61 DIBENZYLINE, 31 diclofenac potassium, 58 diclofenac sodium drops, 75 diclofenac sodium tablet enteric coated, -tablet sustained release 24hr, 58 dicloxacillin sodium, 9 dicyclomine hcl capsule, -injection, syrup, -tablet, 45 didanosine, 2 DIFICID, 6 diflorasone diacetate, 37 diflunisal tablet, 59 digoxin injection, -solution, -tablet, 31 dihydroergotamine mesylate injection, 24 DILANTIN 30 MG CAPSULE, -TABLET CHEWABLE, 24 DILATRATE-SR, 32 dilt-cd, 30 diltiazem 24hr er, 30 diltiazem er, 30 diltiazem hcl injection, -tablet, 30 dilt-xr, 30 diltzac er, 30 diluent for epoprostenol vial, 34 DIOVAN, 29 DIOVAN HCT, 33 DIPENTUM, 47 DIPEPTIDYL PEPTIDASE-IV INHIB AND COMBOS, 41 diphenhydramine hcl capsule, -elixir, injection, 76 diphenoxylate-atropine, 45 DIPHTHERIA-TETANUS TOXOID, 49 dipyridamole tablet, 59 DIRECT MUSCLE RELAXANTS, 57 diskets, 21 disopyramide phosphate, 29 disulfiram tablet, 26 DIURIL, 35 DIURIL SODIUM, 35 divalproex sodium, 28 divalproex sodium er, 28 DIVIGEL, 68 docetaxel 80 mg/8 ml vial, 13 donepezil hcl, 17 DORIBAX 500 MG VIAL, 6 dorzolamide hcl, 72 dorzolamide-timolol, 72 DOVONEX CREAM, 36 doxazosin mesylate, 35 doxepin hcl capsule, -solution, 28 DOXIL, 13 doxorubicin 10 mg/5 ml vial, -20 mg/10 ml vial, -50 mg/25 ml vial, 10 mg vial, -50 mg vial, 13 doxorubicin 200 mg/100 ml vial, 13 doxycycline, 10 doxycycline hyclate 20 mg tab, 40 doxycycline hyclate capsule, -hyc dr 75 mg cap, -injection, -100 mg tab, 10 Page 90 of 117 doxycycline mono 50 mg cap, -mono 100 mg cap, -tablet, 10 dronabinol 2.5 mg capsule, 19 DRONABINOL 5 MG CAPSULE, -10 MG CAPSULE, 19 DROXIA, 13 DRUG MART ULTRA COMFORT SYR, -1 ML 30GX5/16, -1 ML SYRINGE, 54 DRUGS AFFECTING THE EAR, 39 DRUGS AFFECTING THE NOSE, 40 DRUGS AFFECTING THE THROAT AND MOUTH, 40 DRUGS FOR PHEOCHROMOCYTOMA, 31 DRUGS TO PREVENT AND TREAT GOUT, 57 DRUGS TO PREVENT AND TREAT HEADACHES, 24 dualvit ob, 69 DUETACT, 43 DULERA, 77 DURACLON, 31 DURASAL, 36 DUREZOL, 73 DYRENIUM, 34 DYSPORT, 57 EAR-NOSE-THROAT MEDICATIONS, 39 EASY COMFORT 0.3 ML SYRINGE, COMFORT 0.5 ML SYRINGE, 54 EASY COMFORT INSULIN 1 ML SYR, 54 EASY TOUCH INSULIN SYR 1 ML, 54 EASY TOUCH NEEDLE DISPOSABLE, INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML, 54 econazole nitrate cream, 8 ed k+10, 64 EDECRIN, 32 edge ob, 69 ed-spaz, 45 EDURANT, 2 EFFER-K 10 MEQ TABLET EFF, -20 MEQ TABLET EFF, 64 EFFIENT, 59 EGRIFTA, 48 ELAPRASE, 44 ELECTROLYTES, IRRIGATING SOLUTIONS, ETC., 59 ELESTAT, 75 ELESTRIN, 68 ELIDEL, 38 ELIGARD 22.5 MG SYRINGE, 13 ELIGARD 30 MG SYRINGE, 13 ELIGARD 45 MG SYRINGE, 13 ELIGARD 7.5 MG SYRINGE, 13 eliphos, 65 ELITEK, 13 elite-ob 400, 69 ELIXOPHYLLIN, 77 ELLENCE, 13 ELMIRON, 78 ELOXATIN, 13 ELSPAR, 13 EMADINE, 75 EMCYT, 13 EMEND 125 MG CAPSULE, 20 EMEND 40 MG CAPSULE, 20 EMEND 80 MG CAPSULE, 20 EMEND INJECTION, 20 EMEND TRIFOLD PACK, 20 emoquette, 66 EMSAM, 24 EMTRIVA, 2 enalapril maleate tablet, 29 enalapril-hydrochlorothiazide, 33 ENBREL 25 MG KIT, -25 MG/0.5 ML SYRINGE, -50 MG/ML SYRINGE, 13 ENBREL 50 MG/ML SURECLICK SYR, 13 endocet, 21 ENDOCRINE MEDICATIONS, 41 endodan, 21 Page 91 of 117 ENDOTHELIN RECPTR ANTAGONIST, 31 ENGERIX-B 10 MCG/0.5 ML PED VL, 10 MCG/0.5 ML SYRN, -20 MCG/ML SYRINGE, -20 MCG/ML VIAL, 49 ENGERIX-B 10 MCG/0.5 ML PEDI, 49 ENJUVIA, 68 enoxaparin 30 mg/0.3 ml syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr, 63 ENOXAPARIN 80 MG/0.8 ML SYR, -100 MG/ML SYR, -120 MG/0.8 ML SYR, 150 MG/ML SYR, 63 enpresse, 66 ENTOCORT EC, 47 enulose, 59 ephedrine 50 mg/ml ampul, 76 epiflur 0.5 mg tablet chewable, -1 mg tablet chewable, 62 epiklor, 64 epinastine hcl, 75 epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial, 77 EPIPEN, 77 EPIPEN JR, 77 epirubicin 200 mg/100 ml vial, -50 mg vial, -150 mg/75 ml vial, -200 mg vial, 13 epirubicin 50 mg/25 ml vial, 13 epitol, 20 EPIVIR, 3 EPIVIR HBV, 7 eplerenone, 34 EPOGEN 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL, 49 EPOGEN 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, 49 epoprostenol sodium, 34 EPZICOM, 3 EQUETRO, 20 ERAXIS (WATER DILUENT), 8 ERBITUX, 13 ergoloid mesylates tablet, 39 ergotamine-caffeine, 24 errin, 71 ery, 35 ERYPED 200, 5 ERYPED 400, 5 ERY-TAB, 5 ERYTHROCIN LACTOBIONATE, 5 erythrocin stearate, 5 erythromycin capsule enteric coated, tablet, 5 erythromycin ethylsuccinate tablet, 5 erythromycin gel, -solution non-oral, swab medicated, 35 erythromycin ointment, 74 erythromycin-benzoyl peroxide, 35 ERYTHROMYCINS, 5 erythromycin-sulfisoxazole, 10 ESTRACE CREAM WITH APPLICATOR, 68 estradiol patch transdermal weekly, 68 estradiol tablet, 68 estradiol valerate injection, 68 estradiol-norethindrone acetat, 68 ESTRASORB, 68 ESTRING, 68 ESTROGEN DRUGS, 68 ESTROGEN/PROGESTIN COMBINATIONS, 68 estropipate, 68 ethambutol hcl, 3 ethosuximide capsule, -syrup, 28 ETHYOL, 14 etidronate disodium, 44 etodolac, 58 ETOPOPHOS, 14 etoposide injection, 14 EVAMIST, 68 EVISTA, 44 Page 92 of 117 EVOXAC, 40 EXEL INSULIN SYRINGE, 54 EXELON PATCH TRANSDERMAL 24 HOURS, 17 EXELON SOLUTION, 17 exemestane, 14 EXFORGE, 33 EXFORGE HCT, 33 EXJADE, 39 EXTAVIA, 51 FABRAZYME 35 MG VIAL, 44 FABRAZYME 5 MG VIAL, 44 FACTIVE, 10 famciclovir, 7 famotidine injection, -suspension oral, -20 mg tablet, -40 mg tablet, 46 FANAPT TABLET, 18 FANAPT TABLET DOSE PACK, 18 FARESTON, 14 FASLODEX, 14 FAZACLO, 18 felbamate, 25 FELBATOL, 25 felodipine er, 30 FEMARA, 14 FEMHRT 1/5 TABLET, 68 FEMRING, 68 FEMTRACE 0.45 MG TABLET, -0.9 MG TABLET, 68 fenofibrate, 32 fenoprofen calcium tablet, 58 fentanyl 100 mcg/hr patch, 21 fentanyl 12 mcg/hr patch, -25 mcg/hr patch, -50 mcg/hr patch, -75 mcg/hr patch, 21 fentanyl citrate injection, 21 fentanyl citrate lozenge, 21 fexofenadine hcl, 76 finasteride tablet, 78 FIRMAGON 2 X 120 MG VIALS, 14 FIRMAGON 80 MG VIAL, 14 FIRST-TESTOSTERONE, 66 FIRST-TESTOSTERONE MC, 66 FLAGYL ER, 2 flavoxate hcl, 78 flecainide acetate, 29 FLOVENT DISKUS, 77 FLOVENT HFA, 77 floxuridine, 14 fluconazole in dextrose, 8 fluconazole in saline, 8 fluconazole suspension, -tablet, 5 FLUDARABINE 50 MG VIAL, 14 fludarabine 50 mg/2 ml vial, 14 fludrocortisone acetate tablet, 42 flunisolide aerosol spray, 40 fluocinolone acetonide cream, ointment, -solution non-oral, 37 fluocinonide cream, -gel, -ointment, solution non-oral, 37 fluocinonide emollient, 37 fluocinonide-e, 38 fluor-a-day 0.5 mg tab chew, -1 mg tablet chew, 62 fluoride 0.5 mg chew tablet, -1 mg chew tablet, 62 FLUORIDE PRODUCTS, 62 fluoritab tablet chewable, 62 fluorometholone suspension drops, 73 FLUOROPLEX, 38 fluorouracil cream, -solution non-oral, 38 fluorouracil injection, 14 fluoxetine hcl capsule, -solution, tablet, 27 fluphenazine decanoate, 18 fluphenazine hcl, 18 flurbiprofen sodium, 75 flurbiprofen tablet, 58 flutamide, 14 fluticasone propionate cream, ointment, 38 fluticasone propionate nasal inhaled steroids, 40 Page 93 of 117 fluvoxamine maleate, 27 FML FORTE, 73 FML S.O.P., 73 folcal dha, 69 folcaps omega-3, 69 fomepizole, 39 fondaparinux 2.5 mg/0.5 ml syr, 63 fondaparinux 5 mg/0.4 ml syr, -7.5 mg/0.6 ml syr, -10 mg/0.8 ml syr, 63 FORADIL, 76 FORTAMET, 43 FORTAZ 500 MG VIAL, 4 FORTAZ IN ISO-OSMOTIC DEXTROSE, 5 FORTEO, 44 fortical, 44 foscarnet sodium, 7 fosinopril sodium, 29 fosinopril-hydrochlorothiazide, 33 fosphenytoin sodium, 24 FOSRENOL, 59 FRAGMIN 2,500 UNITS SYRINGE, 5,000 UNITS SYRINGE, 63 FRAGMIN 7,500 UNITS SYRINGE, 10,000 UNITS SYRINGE, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, -25,000 UNITS/ML VIAL, 63 FREAMINE HBC, 61 FREAMINE III, 61 FREAMINE III WITH ELECTROLYTES, 61 FREESTYLE PREC 0.5 ML 30GX5/16, PREC 0.5 ML 31GX5/16, -PREC 1 ML 31GX5/16, 54 FREESTYLE PREC 1 ML 30GX5/16, 54 fudr, 14 FURADANTIN, 11 furosemide injection, -solution, -tablet, 32 FUZEON, 3 gabapentin capsule, -solution, -tablet, 25 GABITRIL, 25 GABLOFEN, 57 galantamine hbr, 17 galantamine hydrobromide, 18 GAMASTAN S-D, 49 GAMMAGARD LIQUID, 49 GAMMAGARD S-D, 49 GAMMAPLEX, 49 GAMUNEX, 49 GAMUNEX-C, 49 ganciclovir, 7 ganciclovir sodium, 7 garamycin drops, 74 GARDASIL SYRINGE, 49 GARDASIL VIAL, 49 GASTROCROM, 77 GASTROINTESTINAL MEDICATIONS, 45 gavilyte-c, 47 gavilyte-g, 47 gavilyte-n, 47 GELNIQUE, 78 gemcitabine hcl, 14 gemfibrozil tablet, 32 GEMZAR, 14 generlac, 59 gengraf, 14 GENOTROPIN MINIQUICK 0.2 MG, 48 GENOTROPIN MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, -MINIQUICK 0.8 MG, -MINIQUICK 1 MG, MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, -MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, -MINIQUICK 2 MG, -5 MG CARTRIDGE, -12 MG CARTRIDGE, 48 gentak, 74 GENTAMICIN 60 MG/NS 100 ML PB, ISOTON GENTAMICIN 60 MG/100 ML, -80 MG/NS 100 ML PB, -ISOTON Page 94 of 117 GENTAMICIN 80 MG/100 ML, -ISO GENTAMICIN 120 MG/100 ML, 2 gentamicin 90 mg/ns 100 ml pb, -100 mg/ns 100 ml, -iso gentamicin 100 mg/100 ml, -60 mg/ns 50 ml pb, isoton gentamicin 60 mg/50 ml, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -isoton gentamicin 80 mg/50 ml, 2 gentamicin sulfate cream, -0.1% ointment, 11 gentamicin sulfate drops, -3 mg/gm eye oint, 74 gentamicin sulfate injection, 2 gentasol, 74 GEODON CAPSULE, 18 GEODON INJECTION, 18 gianvi, 66 gildess fe, 66 GILENYA, 39 GLASSIA, 78 GLEEVEC 100 MG TABLET, 14 GLEEVEC 400 MG TABLET, 14 glimepiride, 43 glipizide er, 43 glipizide tablet, 43 glipizide xl, 43 glipizide-metformin, 43 GLUCAGEN, 42 GLUCAGON EMERGENCY KIT, 42 GLUCOCORTICOID DRUGS, 41 GLUCOPRO INSUL SYR U100 0.3 ML, INSUL SYR U100 0.5 ML, -INSULIN SYR 0.5 ML, -INSULIN SYR 1 ML, U100 INSUL SYR 0.3 ML, 55 GLUCOPRO INSULIN SYR U100 1 ML, SYRINGE U100 1 ML, 55 GLUCOSE ELEVATING DRUGS, 42 glyburide micronized, 43 glyburide tablet, 43 glyburide-metformin hcl, 43 glycopyrrolate injection, -tablet, 45 glycron, 43 GLYSET, 43 GRALISE, 25 granisetron hcl 0.1 mg/ml vial, 20 granisetron hcl 1 mg/ml vial, -4 mg/4 ml vial, 20 granisetron hcl tablet, 20 granisol, 20 GRIFULVIN V, 5 gripex pe, 75 griseofulvin suspension oral, 5 GRIS-PEG, 5 GROWTH HORMONES AND RELATED DRUGS, 48 guanabenz acetate tablet, 31 guanfacine hcl, 31 guanidine hcl, 27 GYNODIOL, 68 HALAVEN, 14 HALFLYTELY-BISACODYL, 47 halobetasol propionate, 38 haloperidol dec 50 mg/ml vial, -dec 100 mg/ml vial, 18 haloperidol decanoate 100, 18 haloperidol lactate, 18 haloperidol tablet, 18 HAVRIX, 49 heather, 71 HECTOROL 2 MCG/ML VIAL, -4 MCG/2 ML VIAL, 65 HECTOROL CAPSULE, -4 MCG/2 ML AMPUL, 65 HELIDAC, 47 heparin lock flush 100 unit/ml, 63 heparin sod 1,000 unit/ml vial, -sod 2,000 unit/ml vial, -sod 2,500 unit/ml vial, -sod 5,000 unit/ml vial, -sod 10,000 unit/ml vl, -sod 20,000 unit/ml vl, 63 heparin sod 5,000 unit/ml syr, -sod 5,000 unit/ 0.5 ml, -sod 5,000 unit/0.5 ml, 63 Page 95 of 117 heparin sodium in 0.45% nacl, 63 heparin-d5w 20,000 unit/500 ml, 63 heparin-d5w 25,000 unit/500 ml, -d5w 10,000 unit/100 ml, --d5w 25,000 unit/250 ml, 63 heparin-ns 1,000 unit/500 ml, 63 heparin-ns 2,000 unit/1,000 ml, 63 HEPATAMINE, 61 HEPATASOL, 61 HEPSERA, 7 HERCEPTIN, 14 HEXALEN, 14 HIZENTRA 1 GRAM/5 ML VIAL, 49 HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML VIAL, 49 HMG-COA REDUCTASE INHIBITORS, 31 homatropaire, 75 HORIZANT, 25 HUMALOG, 42 HUMALOG MIX 50-50, 42 HUMALOG MIX 75-25, 42 HUMAPEN LUXURA HD, 55 HUMAPEN MEMOIR, 55 HUMATROPE, 48 HUMIRA, 14 HUMULIN 70-30, 42 HUMULIN N, 42 HUMULIN R, 42 HYCAMTIN INJECTION, 14 HYDANTOINS, 24 hydralazine hcl, 35 hydrochlorothiazide capsule, -tablet, 35 hydrocodone bit-ibuprofen, 22 hydrocodone-acetaminophen solution, -hydrocodon-acetaminoph 2.5-500, hydrocodon-acetaminophen 5-325, hydrocodon-acetaminophen 5-500, hydrocodon-acetaminoph 7.5-325, hydrocodon-acetaminoph 7.5-750, hydrocodon-acetaminophn 10-650, - hydrocodon-acetaminophn 10-325, hydrocodon-acetaminoph 7.5-500, hydrocodon-acetaminophn 10-500, hydrocodon-acetaminoph 7.5-650, hydrocodon-acetaminophn 10-660, hydrocodon-acetaminophn 10-750, 22 hydrocortisone 1% cream, -plus 1% cream, --aloe 1% cream, -2.5% cream, -lotion, -1% absorbase, -1% oint, -1% ointment, -2.5% ointment, 38 hydrocortisone acetate, 38 hydrocortisone butyrate, 38 hydrocortisone enema, 47 hydrocortisone tablet, 41 hydrocortisone valerate, 38 hydrocortisone-acetic acid, 40 hydromorphone hcl 1 mg/ml amp, -1 mg/ml syringe, -2 mg/ml syringe, -2 mg/ml vial, -2 mg/ml amp, -2 mg/ml vl, -4 mg/ml syrin, -10 mg/ml vial, 50 mg/5 ml vial, -500 mg/50 ml via, -10 mg/ml amp, -suppository rectal, -tablet, 21 hydroxychloroquine sulfate tablet, 9 hydroxyurea capsule, 14 hydroxyzine hcl injection, -syrup, tablet, 36 hydroxyzine pamoate capsule, 36 hyomax, 45 hyoscyamine sulfate drops, -elixir, tablet, -tablet dispersible lingual, tablet sublingual, -tablet sustained release 12hr, 45 hypercare, 38 HYPOGLYCEMIC DRUGS, 42 HYPOLIPOPROTEINEMICS, 32 ibuprofen suspension oral, -400 mg tablet, -600 mg tablet, -800 mg tablet, 58 ibutilide fumarate, 33 Page 96 of 117 IDAMYCIN PFS, 14 idarubicin hcl, 14 ifosfamide, 14 ifosfamide-mesna, 14 ILARIS, 51 imipramine hcl tablet, 28 imipramine pamoate, 28 imiquimod cream, 38 IMMUNOLOGICALS AND VACCINES, 48 IMOVAX RABIES VACCINE, 50 IN CONTROL PEN NEEDLE, 55 inatal advance, 69 inatal gt, 69 inatal ultra, 69 INCIVEK, 3 INCRELEX, 51 indapamide, 35 indomethacin capsule, -capsule sustained action, -injection, 58 INFANRIX, 50 INFANRIX PF, 50 INFERGEN, 51 INJECTABLE ANTICOAGULANTS, 63 INJECT-EASE, 55 INPERSOL WITH 1.5% DEXTROSE, 61 INPERSOL WITH 4.25% DEXTROSE, 61 INSULIN, 42 INSULIN LIKE GROWTH FACTORS-1, 51 INSULIN PEN NEEDLE, 55 INSULIN SYR 1/2 ML BULK PACK, -1 ML SYRN 27X1/2, -1 ML SYRN 28GX1/2, -INSUL SYR U100, -INSUL SYR U100 0.5 ML, -INSUL SYR U100 1 ML, -INSULIN SYR 0.3 ML, INSULIN SYR 0.5 ML, -INSULIN SYR U-100, -INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE 0.5 ML, -SYRINGE 1 ML, 55 INSULIN SYRINGE 0.3 ML, -INSULIN SYRINGE 0.5 ML, -INSULIN SYRINGE 1 ML, -0.3 ML, -0.5 ML, 55 INSUMED, 55 INSUPEN, 55 INTEGRA SYRINGE DISPOSABLE SYRINGE, -BD INTEGRA SYR 1 ML 29GX1/2, 55 INTELENCE, 3 INTERFERONS, 51 INTERLEUKIN RECPTR ANTAGONIST, 51 INTERLEUKINS, 52 INTRALIPID, 65 INTRON A 10 MILLION UNIT/ML, -18 MILLION UNITS VIAL, -50 MILLION UNITS VIAL, 51 INTRON A 3 MILLION UNIT/ML PEN, 10 MILLION UNITS VIAL, 51 INTRON A 5 MILLION UNIT/ML PEN, 6 MILLION UNIT/ML VL, -10 MILLION UNIT PEN, 51 introvale, 66 INVANZ, 6 INVEGA ER 1.5 MG TABLET, -ER 3 MG TABLET, -ER 9 MG TABLET, 18 INVEGA ER 6 MG TABLET, 18 INVEGA SUSTENNA 117 MG PREF SY, -156 MG PREF SY, -234 MG PREF SY, 19 INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR, 19 INVIRASE, 3 IONOSOL B WITH DEXTROSE 5%, 61 IONOSOL MB-DEXTROSE 5%, 61 IONOSOL T-DEXTROSE 5%, 61 IOPIDINE, 72 IPOL, 50 ipratropium bromide aerosol spray, 40 ipratropium bromide solution non-oral, 77 ipratropium-albuterol, 77 Page 97 of 117 IRESSA, 14 irinotecan hcl, 14 IRRITABLE BOWEL DRUGS, 46 ISENTRESS, 3 isoditrate, 32 ISOLYTE H WITH DEXTROSE, 61 ISOLYTE M WITH DEXTROSE, 61 ISOLYTE P WITH DEXTROSE, 61 ISOLYTE S, 61 ISOLYTE S WITH DEXTROSE, 61 isonarif, 3 isoniazid injection, -syrup, -tablet, 3 ISOPTO CARBACHOL, 72 ISORDIL, 32 isosorbide dinitrate, 32 isosorbide mononitrate, 32 isradipine, 30 ISUPREL, 34 itraconazole capsule, 5 IXEMPRA, 14 IXIARO, 50 JALYN, 78 jantoven, 63 JANUMET, 43 JANUVIA, 43 jevantique, 68 JE-VAX, 50 jinteli, 68 jolessa, 66 jolivette, 71 junel, 66 junel fe, 66 k effervescent, 64 KALETRA 100-25 MG TABLET, 3 KALETRA SOLUTION, -200-50 MG TABLET, 3 kalexate, 64 kanamycin sulfate injection, 2 kaon-cl 10, 64 kariva, 66 KAYEXALATE, 64 kcl 20 meq in d5w solution, -kcl 40 meq in d5w solution, 64 KEFLEX 750 MG CAPSULE, 5 kelnor 1-35, 66 KENALOG-10, 41 KENALOG-40, 41 KEPIVANCE, 50 KEPPRA SOLUTION, 25 KEPPRA XR, 25 KERATOLYTIC DRUGS, 36 ketoconazole cream, -shampoo, 8 ketoconazole tablet, 5 ketoprofen capsule, -capsule 24hr sustained release pellets, 58 ketorolac tromethamine drops, 75 ketorolac tromethamine injection, 58 ketorolac tromethamine tablet, 58 KINERET, 51 kionex suspension oral, 64 klor-con 10, 64 klor-con 20 meq packet, 64 klor-con 8, 64 klor-con m10, 64 klor-con m15, 64 klor-con m20, 64 KOMBIGLYZE XR, 43 KRYSTEXXA, 58 KUVAN, 44 labetalol hcl injection, -tablet, 30 LACRISERT, 75 lactated ringers, 61 lactic acid cream, -lotion, 38 lactulose, 59 LAMICTAL ODT, 25 LAMICTAL ODT (BLUE), 25 LAMICTAL ODT (GREEN), 25 LAMICTAL ODT (ORANGE), 25 lamotrigine, 25 lansoprazole capsule enteric coated, tablet, 48 LANTUS, 42 LANTUS SOLOSTAR, 42 Page 98 of 117 latanoprost, 72 LATUDA, 19 LAXATIVES AND CATHARTICS, 46 leena, 66 leflunomide, 14 lessina, 67 LETAIRIS, 31 letrozole, 14 leucovorin calcium injection, -tablet, 14 LEUKERAN, 14 LEUKINE, 52 LEUKOTRIENE MODIFIERS, 76 leuprolide acetate injection, 71 LEVALBUTEROL CONCENTRATE, 76 LEVAQUIN, 10 LEVATOL, 30 LEVEMIR, 42 levetiracetam, 25 levobunolol hcl, 72 levocarnitine injection, -solution, tablet, 65 levocetirizine dihydrochloride, 76 levofloxacin drops, 74 levofloxacin injection, -solution, tablet, 10 levofloxacin-d5w, 10 levonorgestrel, 67 levora-28, 67 levorphanol tartrate tablet, 21 levothroid, 45 levothyroxine sodium injection, -tablet, 45 levoxyl, 45 LEVSIN INJECTION, 45 LEXAPRO 10 MG TABLET, 28 LEXAPRO 5 MG TABLET, -20 MG TABLET, 28 LEXAPRO SOLUTION, 28 LEXIVA SUSPENSION ORAL, 3 LEXIVA TABLET, 3 LIALDA, 47 lidocaine hcl cream, -jel, -lotion, ointment, -solution non-oral, 1 lidocaine hcl injection, 1 lidocaine hcl viscous, 1 lidocaine-hydrocortisone cream, lidocaine 3%-hc 0.5% cream, lotion, 38 lidocaine-prilocaine, 1 LIDODERM, 1 LINCOCIN, 6 LINDANE, 37 liothyronine sodium injection, -tablet, 45 LIPITOR, 31 LIPOSYN II, 65 liposyn iii, 65 LISCO, 55 lisinopril tablet, 29 lisinopril-hydrochlorothiazide, 33 LITE TOUCH INSULIN 0.3 ML SYR, INSULIN 0.5 ML SYR, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML, INSULIN SYR 1 ML, 55 LITE TOUCH INSULIN 1 ML SYR, 55 LITE TOUCH INSULIN PEN NEEDLES, 55 lithium, 18 lithium carbonate capsule, -tablet, tablet sustained action, 18 LOCAL ANESTHETICS, 1 LODOSYN, 26 LOFIBRA 160 MG TABLET, 32 LOOP DIURETICS, 32 loperamide capsule, 45 loryna, 67 losartan potassium, 29 losartan-hydrochlorothiazide, 33 LOTEMAX SUSPENSION DROPS, 73 LOTRONEX, 46 lovastatin, 31 LOVAZA, 32 Page 99 of 117 LOVENOX 300 MG VIAL, -300 MG/3 ML VIAL, 63 low-ogestrel, 67 loxapine, 19 LUCENTIS, 75 ludent fluoride 0.5 mg tb chew, -1 mg tab chew, 62 LUMIGAN, 72 LUMIZYME, 44 LUNESTA, 27 LUPRON DEPOT 11.25 MG 3MO KIT, 22.5 MG 3MO KIT, 71 LUPRON DEPOT 3.75 MG KIT, 72 LUPRON DEPOT 45 MG 6MO KIT, 14 LUPRON DEPOT 7.5 MG KIT, 72 LUPRON DEPOT-4 MONTH KIT, 72 LUPRON DEPOT-PED 11.25 MG KIT, 15 MG KIT, 72 LUPRON DEPOT-PED 7.5 MG KIT, 72 lutera, 67 LYRICA 225 MG CAPSULE, -300 MG CAPSULE, 25 LYRICA 25 MG CAPSULE, -50 MG CAPSULE, -75 MG CAPSULE, -100 MG CAPSULE, -150 MG CAPSULE, 200 MG CAPSULE, 25 LYSODREN, 14 LYSTEDA, 39 MACRODANTIN 25 MG CAPSULE, 11 MAGELLAN INSULIN SAFETY SYRNG, 55 MAGELLAN INSULIN SYRINGE, 55 magnesium sulfate injection, 61 MAGNESIUM SULFATE-D5W, 61 MAKENA, 71 MALARONE, 10 malathion, 37 MAO INHIBITORS, 24 maprotiline hcl, 26 MARPLAN, 24 MATULANE, 15 matzim la, 30 MAXAIR AUTOHALER, 76 MAXALT 10 MG TABLET, 24 MAXALT 5 MG TABLET, 24 MAXALT MLT 10 MG TABLET, 24 MAXALT MLT 5 MG TABLET, 24 MAXIDEX, 73 mebendazole tablet chewable, 2 meclizine hcl tablet, 20 meclofenamate sodium capsule, 58 MEDICAL (MISCELLANEOUS) SUPPLIES, 52 medroxyprogesterone acetate injection, -tablet, 71 mefloquine hcl, 10 MEGACE ES, 15 megestrol acetate suspension oral, tablet, 15 meloxicam suspension oral, -tablet, 58 melphalan hcl, 15 MENACTRA, 50 MENEST, 68 MENOMUNE-A-C-Y-W-135, 50 MENOSTAR, 68 MENVEO A-C-Y-W-135-DIP, 50 meperidine hcl injection, -solution, tablet, 21 meperitab, 21 meprobamate, 20 MEPRON, 6 mercaptopurine tablet, 15 meropenem, 6 MERUVAX II VACCINE W-DILUENT, 50 mesalamine enema, 47 MESNEX INJECTION, 15 MESNEX TABLET, 15 MESTINON SYRUP, 27 metadate er, 23 metaproterenol sulfate syrup, -tablet, 76 metformin hcl, 43 metformin hcl er tablet sustained release 24hr, 43 Page 100 of 117 metformin hcl er unknown, 43 methadone hcl injection, -solution, tablet, -tablet soluble, 21 methadone intensol, 21 methadose, 21 methamphetamine hcl, 23 methazolamide tablet, 72 methenamine hippurate, 11 methenamine mandelate tablet, 11 METHERGINE INJECTION, 69 methimazole tablet, 41 methocarbamol tablet, 57 methotrexate injection, -tablet, 15 methscopolamine bromide tablet, 45 methyclothiazide, 35 METHYL XANTHINE DRUGS, 77 methyldopa, 31 methyldopa-hydrochlorothiazide, 33 methyldopate hcl, 31 methylergonovine maleate, 69 methylin 10 mg tablet, 23 methylin 20 mg tablet, 23 methylin 5 mg tablet, 23 methylin er 10 mg tablet, 23 methylin er 20 mg tablet, 23 methylphenidate 10 mg tablet, 23 methylphenidate 20 mg tablet, 23 methylphenidate 5 mg tablet, 23 methylphenidate er, 23 methylphenidate hcl solution, 23 METHYLPHENIDATE HCL UNKNOWN, 23 methylphenidate sr, 23 methylprednisolone acetate injection, 41 methylprednisolone sod succ, 41 methylprednisolone tablet, -tablet dose pack, 41 metipranolol, 72 metoclopramide hcl injection, -solution oral, -tablet, 46 metolazone, 35 metoprolol succinate, 30 metoprolol tartrate injection, -tablet, 30 metoprolol-hydrochlorothiazide, 33 metro iv, 2 metronidazole capsule, -injection, tablet, 2 metronidazole cream, -gel, -lotion, 35 metronidazole gel with applicator, 69 mexiletine hcl capsule, 29 MIACALCIN INJECTION, 44 MICARDIS, 29 MICARDIS HCT, 33 miconazole 3 suppository vaginal, 11 microgestin, 67 microgestin fe, 67 MICRO-K 8 MEQ EXTENCAPS, 64 MICRONOR, 71 midodrine hcl, 34 migergot, 24 MIGRANAL, 24 mimvey, 68 MINERALOCORTICOID DRUGS, 42 minocycline hcl capsule, -tablet, 10 minoxidil tablet, 35 mirtazapine, 26 MISCELLANEOUS DRUGS, 39 misoprostol, 46 mitomycin injection, 15 mitoxantrone hcl, 15 M-M-R II VACCINE, 50 moexipril hcl, 29 moexipril-hydrochlorothiazide, 33 mometasone furoate cream, ointment, -solution non-oral, 38 MONOJECT 0.5 ML SYRN 28GX1/2, 55 MONOJECT INSULIN SAFETY SYRNG, 55 MONOJECT INSULIN SYR 1 ML, 55 MONOJECT SAFETY SYRINGE, 55 mononessa, 67 MONUROL, 11 Page 101 of 117 morphine sulfate in dextrose, 21 morphine sulfate injection, -solution, suppository rectal, -tablet, 21 morphine sulfate tablet sustained action, 21 MOTOFEN, 45 MOXEZA, 74 MOZOBIL, 50 mst 600, 59 MULTAQ, 33 multinatal plus tablet, 69 multi-nate dha extra, 69 multi-vitamin w-fluoride-iron, 65 multivitamins w-fluoride-iron, 65 multivitamins with fluoride drops, multivit-fluor 0.25 mg tab chw, mult-vit-fluor 0.5 mg tab chw, multivit-fluor 0.5 mg tab, -multivitfluor 0.5 mg tab chew, 65 multivit-fluor 0.25 mg tab chw, multivit-fluor 0.5 mg tab chw, 65 multivit-fluor 0.5 mg tab chew, 65 mupirocin ointment, 11 MUSCULOSKELETAL MEDICATIONS, 57 MUSTARGEN, 15 MVC-FLUORIDE 0.5 MG TAB CHEW, 65 MYCAMINE, 8 MYCOBUTIN, 3 mycophenolate mofetil, 15 mydral, 75 MYELOID STIMULANTS, 52 MYFORTIC, 15 mynatal, 69 mynatal advance, 69 mynatal plus, 69 mynatal-z, 69 mynate 90 plus, 69 myochrysine, 59 MYOZYME, 44 MYTELASE, 27 nabumetone, 58 nadolol tablet, 30 nadolol-bendroflumethiazide, 33 NAFCILLIN 1 GM/ 50 ML INJ, 9 nafcillin 2 gm/ 100 ml inj, 9 nafcillin sodium, 9 NAFTIN, 8 NAGLAZYME, 44 nalbuphine hcl injection, 17 naloxone hcl injection, 27 naltrexone hcl tablet, 27 NAMENDA, 18 naphazoline hcl drops, 75 naproxen sodium 275 mg tab, -550 mg tab, 58 naproxen suspension oral, -tablet, tablet enteric coated, 58 naratriptan hcl, 24 NASONEX, 40 NATACYN, 75 nateglinide, 43 nature-throid, 45 NAVANE 20 MG CAPSULE, 19 NEBUPENT, 6 necon, 67 nefazodone hcl, 26 NEO-FRADIN, 2 neofrin, 75 neomycin sulfate tablet, 2 neomycin-bacitracin-poly-hc, 73 neomycin-bacitracin-polymyxin, 74 neomycin-poly-hc eye drops, 73 neomycin-polymixin-hc ear susp, -ear susp, 40 neomycin-polymyxin-dexameth, 73 neomycin-polymyxin-gramicidin, 74 neomycin-polymyxin-hydrocort, 40 neomy-polymyxin b 40 mg/ml amp, 78 neostigmine methylsulfate, 27 NEPHRAMINE, 61 NEULASTA, 52 NEUMEGA, 52 NEUPOGEN, 52 Page 102 of 117 NEVANAC, 75 NEXAVAR, 15 next choice, 67 NIASPAN, 32 nicardipine hcl, 30 NICOTROL, 28 NICOTROL NS, 28 nifediac cc, 30 nifedical xl, 30 nifedipine capsule, 30 nifedipine er tablet sustained action, 30 NILANDRON, 15 nimodipine, 30 nisoldipine, 30 NITRATES, 32 nitro-bid, 32 NITRO-DUR 0.3 MG/HR PATCH, -0.8 MG/HR PATCH, 32 nitrofurantoin macrocrystal capsule, 11 nitrofurantoin mono-macro, 11 nitrofurantoin suspension oral, 11 nitroglycerin injection, 32 nitroglycerin patch, 32 NITROLINGUAL, 32 NITROSTAT, 33 nizatidine, 46 NON-STEROIDAL ANTIINFLAMMATORY AGENTS, 58 nora-be, 71 NORDIPEN 15, 55 NORDIPEN 5, 55 NORDITROPIN, 48 NORDITROPIN FLEXPRO, 48 NORDITROPIN NORDIFLEX 5 MG/1.5, -NORDIFLX 15 MG/1.5, 48 NORDITROPIN NORDIFLX 10 MG/1.5, -30 MG/3, 48 norethindrone, 71 norethindrone acetate tablet, 71 norgestimate-ethinyl estradiol, 67 norgestrel-ethiny estra, 67 NORMOSOL-M AND DEXTROSE, 61 NORMOSOL-R, 61 NORMOSOL-R AND DEXTROSE, 61 NORMOSOL-R PH 7.4, 61 NOROXIN, 10 NORPACE CR 100 MG CAPSULE, 29 nortrel, 67 nortriptyline hcl capsule, -solution, 27 NORVIR CAPSULE, -TABLET, 3 NORVIR SOLUTION, 3 NOVAMINE, 61 novarel, 72 NOVOFINE 32, 55 NOVOFINE AUTOCOVER, 55 NOVOLIN 70-30 100 UNIT/ML VIAL, 42 NOVOLIN N 100 UNITS/ML VIAL, 42 NOVOLIN R, 42 NOVOLOG, 42 NOVOLOG MIX 70-30, 42 NOVOPEN 3, 55 NOVOPEN JR, 56 NOXAFIL, 6 np thyroid, 45 NUEDEXTA, 27 NULOJIX, 15 nutrilyte, 61 nutrilyte ii, 61 NUTRITION,BLOOD MODIFIERS,ELECTROLYTES, 59 NUTROPIN, 48 NUTROPIN AQ, 48 NUTROPIN AQ NUSPIN 10 PEN CART, -20 PEN CART, 48 NUTROPIN AQ NUSPIN 5 PEN CART, 48 NUVARING, 67 NUVIGIL, 23 nyamyc, 8 nystatin 150,000,000 units pwd, 6 Page 103 of 117 nystatin 50,000,000 units pwd, 500,000,000 units pwd, -suspension oral, -500,000 unit oral tab, 6 nystatin cream, -ointment, -100,000 unit/gm powd, 8 nystatin vaginal tablet, 11 nystatin-triamcinolone, 11 nystop, 8 ob + dha, 69 ob 90 + dha, 70 OB/GYN TOPICAL ANTIINFECTIVES, 69 ob-natal one, 70 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS, 65 ocella, 67 octreotide acet 100 mcg/ml amp, -acet 100 mcg/ml syr, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml vl, 1,000 mcg/ml vial, 15 octreotide acet 50 mcg/ml amp, 15 octreotide acet 50 mcg/ml syr, -acet 50 mcg/ml vial, 15 ofloxacin 0.3% ear drops, 40 ofloxacin 0.3% eye drops, 74 ofloxacin tablet, 10 ogestrel, 67 omeprazole dr 10 mg capsule, -dr 20 mg capsule, 48 OMNITROPE, 48 ONCASPAR, 15 ondansetron hcl 24 mg tablet, 20 ondansetron hcl 4 mg tablet, -8 mg tablet, 20 ondansetron hcl in dextrose, 20 ondansetron hcl injection, 20 ondansetron hcl solution, 20 ondansetron in sodium chloride, 20 ondansetron odt, 20 ONGLYZA, 43 ONSOLIS, 21 ONTAK, 15 OPANA ER, 21 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS , 73 OPHTHALMIC CORTICOSTEROID DRUGS, 73 OPHTHALMIC MEDICATIONS, 72 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS, 73 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS, 74 ORAL ANTICOAGULANTS, VITAMIN K, 63 ORAL ANTIFUNGAL DRUGS, 5 ORAL DERMATOLOGICAL DRUGS, 37 ORAL HYPOGLYCEMICS AND COMBOS, 43 ORAP, 19 ORENCIA 250 MG VIAL, 15 ORFADIN, 39 orphenadrine citrate injection, -tablet sustained action, 57 orphenadrine compound, 57 orphenadrine compound forte, 57 ORSINI INSUL SYR U100 0.5 ML, 56 ORSINI INSUL SYR U100 1 ML, 56 orsythia, 67 ORTHO EVRA, 67 ORTHOCLONE OKT-3, 15 OSMOPREP, 46 OTHER ANTIARRHYTHMICS, 33 OTHER ANTICONVULSANTS, 25 OTHER ANTIDEPRESSANTS, 25 OTHER ANTIHYPERTENSIVES, 33 OTHER ANTIINFECTIVE DRUGS, 6 OTHER ANTIPARKINSON DRUGS, 26 OTHER ANTIULCER DRUGS, 46 OTHER ANTIVIRAL DRUGS, 7 OTHER CARDIOVASCULAR DRUGS, 34 OTHER CNS/AUTONOMIC DRUGS, 26 OTHER DRUGS FOR ARTHRITIS, 59 Page 104 of 117 OTHER DRUGS FOR ASTHMA, 77 OTHER ENDOCRINE DRUGS, 43 OTHER GENITOURINARY PRODUCTS, 78 OTHER GI DRUGS, 46 OTHER MACROLIDES, 8 OTHER OPHTHALMIC DRUGS, 74 OTHER RESPIRATORY DRUGS, 78 OTHER TOPICAL ANTIFUNGALS, 8 OTHER VASODILATING DRUGS, 34 OXACILLIN, 9 oxacillin 1 gm add-vantage vl, -1 gm vial, 9 OXACILLIN 10 GM VIAL, 9 oxacillin 2 gm add-vantage vl, -2 gm vial, 9 oxaliplatin, 15 oxandrolone tablet, 66 oxaprozin, 58 oxcarbazepine, 21 OXISTAT, 8 OXSORALEN-ULTRA, 37 oxybutynin chloride er, 78 oxybutynin chloride syrup, -tablet, 78 oxycodone concentrate, 21 oxycodone hcl, 21 oxycodone hcl-acetaminophen, 21 oxycodone hcl-aspirin, 21 oxycodone hcl-ibuprofen, 22 oxycodone-acetaminophen, 22 oxycodone-aspirin, 22 oxymorphone hcl tablet, 22 oxymorphone hcl tablet sustained release 12hr, 22 OXYTOCICS, 69 oxytocin injection, 69 pacerone, 29 paclitaxel 100 mg/16.7 ml vial, -30 mg/5 ml vial, 15 paclitaxel 300 mg/50 ml vial, 15 pamidronate 30 mg/10 ml vial, -90 mg/10 ml vial, 44 PAMIDRONATE 60 MG/10 ML VIAL, 44 pamidronate disod 30 mg vial, -disod 90 mg vial, 44 PANCREAZE, 47 PANCRELIPASE 5,000, 47 PANRETIN, 38 pantoprazole sodium, 48 papaverine hcl injection, 34 parcaine, 75 paregoric, 45 PARENTERAL ANTIFUNGALS, 8 paromomycin sulfate, 1 paroxetine hcl, 28 PASER, 4 PATANASE, 40 PATANOL, 75 PCE, 5 PEDIARIX, 50 pedi-dri, 8 PEDVAXHIB, 50 peg 3350-electrolyte, 47 PEG 3350-GRX, 57 peg-3350 and electrolytes, 47 peg-3350 with flavor packs, 47 PEGANONE, 24 PEGASYS 180 MCG/0.5 ML CONV.PK, 51 PEGASYS 180 MCG/ML VIAL, 51 PEGINTRON 50 MCG KIT, 51 PEGINTRON 80 MCG KIT, -120 MCG KIT, -150 MCG KIT, 51 PEGINTRON REDIPEN, 51 PEN NEEDLES, 56 penicillin g potassium, 9 penicillin g procaine, 9 penicillin g sodium, 9 PENICILLIN GK-ISO-OSM DEXTROSE, 9 penicillin v potassium, 9 PENICILLINS, 8 PENTASA, 47 pentazocine-acetaminophen, 22 Page 105 of 117 pentazocine-naloxone hcl, 23 pentopak, 34 pentostatin, 15 pentoxifylline tablet sustained action, 34 pepcid injection, 46 PERFOROMIST, 76 perindopril erbumine, 29 permethrin cream, 37 perphenazine, 19 perphenazine-amitriptyline, 26 PFIZERPEN, 9 PHARMACEUTICAL NECESSITIES, 57 phenadoz, 20 phenazopyridine plus, 78 phenelzine sulfate tablet, 24 phenylephrine hcl drops, 75 phenylephrine hcl injection, 34 PHENYTEK, 24 phenytoin sodium extended, 24 phenytoin sodium injection, 24 phenytoin suspension oral, 24 phluorivit, 65 phluorivit + fe, 65 PHOSLYRA, 65 phosphasal, 79 PHOSPHOLINE IODIDE, 72 PHOTOFRIN, 15 PHYSIOLYTE, 61 PHYSIOSOL, 61 physostigmine salicylate injection, 27 pilocarpine hcl drops, 72 pilocarpine hcl tablet, 40 PILOPINE HS, 72 pindolol, 30 piperacillin, 9 piperacillin-tazobactam, 9 piroxicam capsule, 58 PLAN B, 67 PLAN B ONE-STEP, 67 PLASMA-LYTE 148, 61 PLASMA-LYTE 148 IN DEXTROSE, 61 PLASMA-LYTE 56, 61 PLASMA-LYTE 56 IN DEXTROSE, 61 PLASMA-LYTE A PH 7.4, 61 PLASMA-LYTE R, 61 PLASMODICIDES, 9 PLAVIX, 59 pnv-dha + docusate, 70 pnv-total, 70 PODOCON-25, 36 podofilox, 36 poly-650, 17 polycin-b, 74 poly-dex, 73 polyethylene glycol 3350, 46 polyethylene glycol 3350 packet, 46 polymyxin b sulfate injection, 6 polymyxin b sul-trimethoprim, 74 POLY-PRED, 73 POLYTRIM, 74 polyvitamin with iron-fluoride, 65 polyvitamins-fluoride, 65 portia, 67 potassium acetate injection, 64 potassium bicarbonate tablet effervescent, 64 potassium chl-normal saline, 62 potassium chloride capsule sustained action, -injection, -solution, -tablet effervescent, -tablet sust.releaseparticles/crystals, -tablet sustained action, 64 potassium chloride in d5lr, 64 potassium chloride-nacl, 62 potassium citrate TABLET SUSTAINED ACTION, 79 potassium citrate-citric acid, 79 potassium ph 3mm/ml vial, 62 POTASSIUM REMOVING RESINS, 64 POTASSIUM SPARING DIURETICS, 34 POTASSIUM SUPPLEMENTS, 64 pr natal 430 ec, 70 PRADAXA, 63 Page 106 of 117 pramipexole dihydrochloride, 26 PRANDIN, 43 prascion, 35 pravastatin sodium, 31 prazosin hcl, 35 pre-attached lta kit, 1 PRECISION, 56 PRED MILD, 73 PRED-G, 73 prednicarbate, 38 prednisolone acetate suspension drops, 73 prednisolone sodium phosphate drops, 73 prednisolone sodium phosphate solution, 41 prednisolone solution oral, 41 prednisone intensol, 41 prednisone solution, -tablet, 41 PREFEST, 68 PREMARIN CREAM WITH APPLICATOR, -TABLET, 68 PREMARIN INJECTION, 68 PREMASOL, 62 PREMPHASE, 68 PREMPRO, 69 prenacare, 70 prenafirst, 70 prenaplus, 70 prenatabs fa, 70 prenatabs obn, 70 prenatabs rx, 70 prenatal 19, 70 prenatal ad, 70 prenatal low iron, 70 prenatal multivitamin w-iron, 70 prenatal plus, 70 PRENATAL VITAMINS, 69 prenatal-u, 70 prenate plus, 70 PREVIDENT 5000, 62 PREVIDENT SOLUTION NON-ORAL, 62 previfem, 67 PREVPAC, 47 PREZISTA 400 MG TABLET, -600 MG TABLET, 3 PREZISTA 75 MG TABLET, -150 MG TABLET, 3 PRIALT, 17 PRIFTIN, 4 PRIMAQUINE, 10 PRIMAXIN 250 MG VIAL, 6 PRIMAXIN 500 MG VIAL, 6 PRIMAXIN I.M., 6 primidone tablet, 25 PRISTIQ, 26 PRIVIGEN, 50 PROAIR HFA, 76 probenecid, 58 probenecid-colchicine, 58 procainamide hcl injection, 29 PROCALAMINE, 62 prochlorperazine edisylate, 20 prochlorperazine maleate suppository rectal, -tablet, 20 PROCRIT 2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, -10,000 UNITS/ML VIAL, 50 PROCRIT 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL, 50 PROCTOFOAM-HC, 47 procto-pak, 47 proctozone-hc, 47 PRODIGY INSULIN SYRINGE, 56 PRODIGY PEN NEEDLE, 56 PROGESTIN DRUGS, 71 PROGLYCEM, 42 PROGRAF INJECTION, 15 PROLASTIN 1,000 MG VIAL, 78 PROLASTIN 500 MG VIAL, 78 PROLASTIN C, 78 PROLEUKIN, 52 PROLIA, 44 Page 107 of 117 PROMACTA 25 MG TABLET, 52 PROMACTA 50 MG TABLET, -75 MG TABLET, 52 promethazine hcl injection, -syrup, tablet, 76 promethazine hcl suppository rectal, 20 promethazine vc, 75 promethegan, 20 PROMETRIUM, 71 propafenone hcl, 29 propantheline bromide tablet, 46 proparacaine hcl drops, 75 propranolol hcl capsule sustained action, -injection, -solution, -tablet, 30 propranolol-hydrochlorothiazid, 33 propylthiouracil, 41 PROQUAD, 50 PROSOL, 62 PROSTIGMIN, 27 PROTON PUMP INHIBITORS, 48 PROTONIX IV, 48 PROTOPIC, 38 protriptyline hcl, 27 PROVENTIL HFA, 76 PROVIGIL, 23 PRUDOXIN, 38 PULMOZYME, 78 pyrazinamide, 4 pyridostigmine bromide tablet, 27 quasense, 67 quinapril hcl, 29 quinapril-hydrochlorothiazide, 33 quinidine gluconate, 29 quinidine sulfate tablet, -tablet sustained action, 29 QUINOLONES, 10 QVAR, 77 RABAVERT, 50 ramipril, 29 RANEXA ER 1,000 MG TABLET, 34 RANEXA ER 500 MG TABLET, 34 ranitidine hcl capsule, -injection, syrup, -150 mg tablet, -300 mg tablet, 46 RAPAMUNE, 15 RAZADYNE SOLUTION, 18 REBETOL CAPSULE, 7 REBETOL SOLUTION, 7 REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5 ML SYRINGE, 51 REBIF TITRATION PACK, 51 RECLAST, 44 reclipsen, 67 RECOMBIVAX HB, 50 REGONOL, 27 REGRANEX, 38 RELENZA, 7 RELION NOVOLIN 70-30 VIAL, 42 RELION NOVOLIN N 100 UNITS/ML, 42 RELION PEN 29G NEEDLE, -RELION PEN 31G NEEDLE, 56 RELISTOR 12 MG/0.6 ML KIT, 47 RELISTOR 12 MG/0.6 ML VIAL, 47 remeven, 38 REMICADE, 15 REMODULIN, 34 renaf fluoride 0.5 mg tab chew, fluoride 1 mg tab chew, 62 RENAGEL, 59 RENAMIN, 62 re-nata 29 ob, 70 RENVELA, 59 RESCRIPTOR, 3 reserpine tablet, 33 RESPIRATORY MEDICATIONS, 75 RESTASIS, 75 RETROVIR INJECTION, 3 REVATIO TABLET, 34 REVLIMID, 15 REYATAZ, 3 RIBAPAK, 7 Page 108 of 117 RIBASPHERE 400 MG TABLET, -600 MG TABLET, 7 ribasphere capsule, -200 mg tablet, 7 RIBATAB 400-400 MG DOSEPACK, 600-600 MG DOSEPACK, 7 RIBAVIRIN 400 MG TABLET, -600 MG TABLET, 7 ribavirin capsule, -200 mg tablet, 7 RIDAURA, 59 RIFAMATE, 4 rifampin capsule, 4 rifampin injection, 4 RIFATER, 4 RILUTEK, 57 rimantadine hcl, 7 ringers injection, 62 ringers irrigation, 62 RIOMET, 43 RISPERDAL CONSTA 12.5 MG SYR, -25 MG SYR, 19 RISPERDAL CONSTA 37.5 MG SYR, -50 MG SYR, 19 risperidone m-tab, 19 risperidone odt, 19 risperidone solution, 19 risperidone tablet, 19 RITUXAN, 15 rivastigmine, 18 romycin, 74 ropinirole hcl, 26 rosaderm cleanser, 36 ROTARIX, 50 ROTATEQ, 50 roxicet 5-325 tablet, 22 ROXICET SOLUTION, 22 ROXICODONE INTENSOL, 22 ROXICODONE SOLUTION, 22 ROXICODONE TABLET, 22 SABRIL, 25 SAFESNAP INSULIN SYRINGE, 56 SAFETY SYRINGE WITH SHIELD, 56 SAFETYGLIDE INSULIN SYRINGE, 56 SAIZEN 5 MG VIAL, -8.8 MG CLICK.EASY CARTG, 48 SAIZEN 8.8 MG VIAL, 48 SALICYLATES AND RELATED DRUGS, 59 salicylic acid gel, 36 salicylic acid liquid, 36 salicylic acid shampoo, 36 saline 0.45% soln-excel con, -0.45% soln, -saline 0.9% soln-excel cont, 0.9% soln, -0.9% soln., -0.9% solution, -cl 2.5 meq/ml vial, -3% iv soln, -4 meq/ml vl, -5% iv soln, 62 salsalate tablet, 59 SAL-TROPINE, 46 SAMSCA 15 MG TABLET, 44 SAMSCA 30 MG TABLET, 44 SANCUSO, 20 SANDIMMUNE SOLUTION, 15 SANDOSTATIN, 15 SANDOSTATIN LAR, 15 SANTYL, 38 SAPHRIS, 19 SAVELLA TABLET, 26 SAVELLA TABLET DOSE PACK, 26 SCABICIDES, 37 SCOPACE, 46 SCOPOLAMINE HYDROBROMIDE INJECTION, 46 seb-prev, 36 se-care conceive, 70 se-care gesture, 70 SECONDARY AMINES, 27 SEDATIVE/HYPNOTIC DRUGS, 27 SELECTIVE SEROTONIN REUPTAKE INHIBITORS, 27 selegiline hcl capsule, -tablet, 26 selenium sulfide shampoo, -suspension topical, 36 selfemra, 28 SELZENTRY, 3 SEMPREX-D, 75 Page 109 of 117 se-natal 19, 70 se-natal 90, 70 se-natal one, 70 SENSIPAR 30 MG TABLET, 44 SENSIPAR 60 MG TABLET, -90 MG TABLET, 44 se-plete dha, 70 SEREVENT DISKUS, 76 SEROMYCIN, 4 SEROQUEL, 19 SEROQUEL XR 150 MG TABLET, -200 MG TABLET, 19 SEROQUEL XR 50 MG TABLET, -300 MG TABLET, -400 MG TABLET, 19 SEROSTIM, 48 sertraline hcl solution, -tablet, 28 setonet, 70 setonet-ec, 70 sf, 62 sf 5000 plus, 62 silver nitrate ointment, -solution, 38 silver sulfadiazine cream, 11 SIMCOR, 32 SIMPONI 50 MG/0.5 ML PEN INJEC, 16 SIMPONI 50 MG/0.5 ML SYRINGE, 16 SIMULECT, 16 simvastatin, 32 SINGLE USE SWAB, 56 SINGULAIR, 76 SMOKING CESSATION PRODUCTS, 28 sodiphluor, 62 sodium acetate injection, 62 sodium bicarbonate injection, 62 sodium citrate & citric acid, 64 SODIUM EDECRIN, 32 sodium fluoride drops, -tablet, -0.5 mg(1.1 mg), 62 sodium lactate injection, 62 sodium polystyrene sulfonate powder, 64 sodium polystyrene sulfonate suspension oral, 64 sodium sulfacetamide solution, 36 sodium sulf-sulfur cleanser, -sulf-sulfur wash, -lotion, -suspensions, (not oral), 36 SOLARAZE, 38 solia, 67 SOLU-CORTEF, 41 SOLU-CORTEF (PF), 41 SOLU-MEDROL, 41 SOLU-MEDROL (PF), 41 SOMATULINE DEPOT, 16 SOMAVERT 10 MG VIAL, -20 MG VIAL, 44 SOMAVERT 15 MG VIAL, 44 SORIATANE 10 MG CAPSULE, -25 MG CAPSULE, 16 SORIATANE 17.5 MG CAPSULE, -22.5 MG CAPSULE, 36 SORIATANE CK, 16 sorine, 33 sotalol, 33 sotalol af, 33 sotret, 37 SPECIALIZED OB/GYN DRUGS, 71 SPECTRACEF, 5 SPIRIVA, 77 spironolactone tablet, 34 spironolactone-hctz, 34 sprintec, 67 SPRYCEL 20 MG TABLET, -50 MG TABLET, -70 MG TABLET, 16 SPRYCEL 80 MG TABLET, -100 MG TABLET, -140 MG TABLET, 16 sps, 64 sronyx, 67 ssd, 11 ssd af, 11 STALEVO 100, 26 STALEVO 125, 26 STALEVO 150, 26 STALEVO 200, 26 STALEVO 50, 26 Page 110 of 117 STALEVO 75, 26 stannous fluoride solution, 62 stavudine, 3 STAVZOR, 28 STELARA 45 MG/0.5 ML SYRINGE, -45 MG/0.5 ML VIAL, 16 STELARA 90 MG/ML SYRINGE, 16 sterile water for irrigation, 62 STIMATE, 44 STRATTERA 10 MG CAPSULE, -40 MG CAPSULE, -60 MG CAPSULE, -80 MG CAPSULE, -100 MG CAPSULE, 27 STRATTERA 18 MG CAPSULE, 27 STRATTERA 25 MG CAPSULE, 27 STREPTOMYCIN SULFATE INJECTION, 4 STRIANT, 66 STROMECTOL, 2 sublimaze, 22 SUBOXONE 2 MG-0.5 MG SL FILM, -2 MG-0.5 MG TABLET SL, 22 SUBOXONE 8 MG-2 MG SL FILM, -8 MG-2 MG TABLET SL, 22 SUCCINIMIDES, 28 sucralfate suspension oral, -tablet, 46 sulfacetamide sodium drops, 74 sulfacetamide sodium lotion, suspension topical, 36 sulfacetamide-prednisolone, 73 sulfadiazine tablet, 10 sulfamethoxazole-trimethoprim, 10 sulfamide, 74 sulfasalazine dr, 47 sulfasalazine tablet, 47 sulfazine, 47 sulfazine ec, 47 SULFONAMIDES, 10 sulindac tablet, 58 SUMATRIPTAN, 24 sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml inject, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng, 24 sumatriptan 4 mg/0.5 ml vial, 24 sumatriptan 6 mg/0.5 ml vial, 24 sumatriptan succinate tablet, 24 SUPARTZ, 59 SUPPRELIN LA, 72 SUPRAX, 5 SURE COMFORT 1 ML SYRINGE, 56 SURE COMFORT ALCOHOL, 56 SURE COMFORT NEEDLE DISPOSABLE, -0.3 ML SYRINGE, 0.5 ML SYRINGE, -3/10 ML SYRINGE, 56 SURE-FINE PEN NEEDLES, 56 SURE-JECT INSU SYR U100 0.3 ML, INSU SYR U100 0.5 ML, -INSU SYR U100 1 ML, -1 ML, 56 SURE-JECT INSUL SYR U100 1 ML, 56 SURE-PREP ALCOHOL PREP PADS, 56 SURMONTIL, 28 SUSTIVA, 3 SUTENT, 16 syeda, 67 SYLATRON, 51 SYLATRON 4-PACK, 51 SYMBICORT, 77 SYMLIN, 42 SYMLINPEN 120, 42 SYMLINPEN 60, 42 SYNAGIS 100 MG/1 ML VIAL, 50 SYNAGIS 50 MG/0.5 ML VIAL, 50 SYNAREL, 72 SYNERA, 1 SYNERCID, 6 SYNVISC, 59 SYNVISC-ONE, 59 SYPRINE, 59 TABLOID, 16 tacrolimus capsule, 16 TAMIFLU 30 MG GELCAP, -45 MG GELCAP, -SUSPENSION, 7 Page 111 of 117 TAMIFLU 75 MG GELCAP, 7 tamoxifen citrate tablet, 16 tamsulosin hcl, 79 TARCEVA 100 MG TABLET, -150 MG TABLET, 16 TARCEVA 25 MG TABLET, 16 TARGRETIN CAPSULE, 16 TARGRETIN GEL, 16 taron ec calcium, 70 taron-bc, 70 taron-crystals, 79 taron-duo ec, 70 taron-ec cal, 70 taron-prex prenatal, 70 TASIGNA, 16 TAXOTERE 20 MG/0.5 ML VIAL, -80 MG/2 ML VIAL, 16 taztia xt, 31 TEFLARO, 5 TEGRETOL XR 100 MG TABLET, 21 TEKAMLO, 33 TEKTURNA, 33 TEKTURNA HCT, 33 terazosin hcl, 35 terbinafine hcl tablet, 6 terbutaline sulfate injection, -tablet, 76 terconazole, 11 TERTIARY AMINES, 28 TERUMO INSULIN SYRINGE, 56 TERUMO SURGUARD, 56 TESTIM, 66 TESTOPEL, 66 testosterone cyp 100 mg/ml, 66 testosterone cyp 200 mg/ml, 66 testosterone enanthate injection, 66 TETANUS DIPHTHERIA TOXOIDS, 50 tetanus toxoid adsorbed, 50 TETANUS-DIPHTERIA-DECAVAC, 50 tetracycline hcl capsule, 10 TETRACYCLINES, 10 TEV-TROPIN, 48 THALOMID 150 MG CAPSULE, -200 MG CAPSULE, 39 THALOMID 50 MG CAPSULE, -100 MG CAPSULE, 39 theochron, 77 theophylline anhydrous tablet sustained release 12hr, 77 theophylline tablet sustained action, 77 THERACYS, 16 THERAPEUTIC VITAMINS AND MINERALS, 64 thermazene, 11 THIAZIDE AND RELATED DRUGS, 35 THINPRO INSULIN SYRINGE, 56 thioridazine hcl, 19 THIOTEPA INJECTION, 16 thiothixene, 19 THROMBOPOIETIC AGENTS, 52 THYMOGLOBULIN, 50 THYROGEN, 39 THYROID SUPPLEMENTS, 45 THYROLAR-1, 45 THYROLAR-1/2, 45 THYROLAR-1/4, 45 THYROLAR-2, 45 THYROLAR-3, 45 ticlopidine hcl, 59 TIKOSYN, 33 tilia fe, 67 TIMENTIN, 9 timolol maleate drops, -gel-forming solution, 72 timolol maleate tablet, 30 TIMOPTIC 0.5% EYE DROPS, 72 tis-u-sol, 62 tizanidine hcl tablet, 57 TOBI, 2 TOBRADEX OINTMENT, 73 tobramycin sulfate drops, 74 tobramycin sulfate in ns, 2 tobramycin sulfate injection, 2 Page 112 of 117 tobramycin-dexamethasone, 73 tobrasol, 74 TOBREX OINTMENT, 74 tolazamide, 43 tolbutamide, 43 tolmetin sodium, 58 TOPCARE CLICKFINE, 56 TOPCARE ULTRA COMFORT, 56 TOPICAL ANESTHETICS, 1 TOPICAL ANTIBACTERIAL DRUGS, 11 TOPICAL ANTIFUNGALCORTICOSTEROID COMB., 11 TOPICAL ANTI-INFLAMMATORY DRUGS, 37 TOPICAL CORTICOSTEROID DRUGS, 37 TOPICAL DERMATOLOGICAL DRUGS, 38 topiragen, 25 topiramate capsule sprinkle, -tablet, 25 topisulf, 36 topotecan hcl, 16 TORISEL, 16 torsemide, 32 TOVIAZ, 78 TPN ELECTROLYTES, 62 TPN ELECTROLYTES II, 62 TRACLEER, 31 TRADJENTA, 41 tramadol hcl tablet, 17 tramadol hcl-acetaminophen, 17 trandolapril, 29 trandolapril-verapamil, 34 TRANSDERM-SCOP, 20 tranylcypromine sulfate, 24 TRAVASOL, 62 TRAVATAN Z, 72 trazodone hcl tablet, 26 TRECATOR, 4 TRELSTAR 11.25 MG SYRINGE, 16 TRELSTAR 22.5 MG SYRINGE, 16 TRELSTAR 22.5 MG VIAL, 16 TRELSTAR 3.75 MG SYRINGE, 16 TRELSTAR DEPOT, 16 TRELSTAR LA, 16 tretinoin 0.025% cream, -0.05% cream, -0.1% cream, -gel, 36 tretinoin capsule, 16 trezix, 22 tri rx, 70 triadvance, 70 triamcinolone acetonide cream, -lotion, -ointment, 38 triamcinolone acetonide injection, 41 triamcinolone acetonide paste, 40 triamterene-hctz, 34 triamterene-hydrochlorothiazid, 34 TRIBENZOR, 34 tricitrates, 79 TRICOR, 32 triderm, 38 trifluoperazine hcl, 19 trifluridine drops, 74 trihexyphenidyl hcl, 18 TRIHIBIT, 50 tri-legest fe, 67 TRILEPTAL SUSPENSION, 21 TRILIPIX, 32 trilyte with flavor packets, 47 trimethobenzamide hcl capsule, injection, 20 trimethoprim tablet, 11 trinessa, 67 TRIOSTAT, 45 TRIPEDIA, 50 triphluorivit, 65 tri-previfem, 67 TRISENOX, 16 tri-sprintec, 67 triveen-duo dha, 70 triveen-ten, 70 triveen-u, 70 tri-vit with fluoride-iron, 65 tri-vitamin with fluoride, 65 Page 113 of 117 tri-vitamin with iron-fluoride, 65 trivora-28, 67 TRIZIVIR, 3 TROPHAMINE, 62 tropicacyl, 75 tropicamide drops, 75 trospium chloride, 78 TRUVADA, 3 TWINJECT, 77 TWINRIX, 50 TWYNSTA, 34 TYGACIL, 6 TYKERB, 16 TYPHIM VI, 50 TYSABRI, 16 TYZEKA, 7 TYZINE, 40 u40, 39 U-CORT, 38 u-kera e urea emollient, 39 ULESFIA, 37 ULORIC 40 MG TABLET, 58 ULORIC 80 MG TABLET, 58 ULTICARE NEEDLE DISPOSABLE, INSUL SYR U100 0.3 ML, -INSUL SYR U100 0.5 ML, -INSULIN SYR U100 1 ML, 56 ULTIGUARD SYRINGE EMPTY DISPOSABLE, 56 ULTILET ALCOHOL SWAB, 56 ULTILET INSULIN SYRINGE 1 ML, 56 ultimatecare one, 70 ULTRA COMFORT NEEDLE DISPOSABLE, -0.3 ML 29GX1/2, -0.3 ML 30GX5/16, -0.3 ML 31GX5/16, 0.3 ML SYRINGE, -0.5 ML 28GX1/2, -0.5 ML 29GX1/2, -0.5 ML 30GX5/16, -0.5 ML 31GX5/16, -0.5 ML SYR, -0.5 ML SYRINGE, -1 ML 28GX1/2, -1 ML 29GX1/2, -1 ML 31GX5/16, -3/10 ML SYR, 56 ULTRACOMFORT 30GX0.5 ML SYR, 30GX1 ML SYRINGE, -31GX0.5 ML SYR, -31GX1 ML SYRINGE, -NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE, 56 UNASYN 1.5 GM ADD-VANTAGE VL, 1.5 GM PIGGYBACK BOTTLE, -3 GM ADD-VANTAGE VIAL, -3 GM PIGGYBACK BOTTLE, 9 UNIFINE PENTIPS, 57 unithroid, 45 urea 40, 39 urea 40% cream, -50% cream, -40% gel, -50% nail gel, -35% lotion, 40% lotion, -50% nail stick, 39 urea 40% nail film susp, 39 uretron d-s, 11 urin d.s., 79 URINARY ANTIINFECTIVES, 11 urogesic-blue, 11 UROLOGICAL MEDICATIONS, 78 ursodiol capsule, -tablet, 47 UTIRA-C, 11 UVADEX, 16 VAGIFEM, 68 VAGINAL ANTIFUNGALS, 11 valacyclovir, 7 VALCYTE, 7 valproate sodium injection, 28 VALPROIC ACID AND DERIVATIVES, 28 valproic acid capsule, -syrup, 28 VALTURNA, 34 VANCOCIN HCL, 6 VANCOMYCIN, 6 vancomycin 1 gm vial, -10 gm vial, 6 vancomycin 500 mg a/v vial, -500 mg vial, -750 mg vial, -1 gm add-van vial, -5 gm vial, 6 VANCOMYCIN HCL 1G/200 ML BAG, 6 vandazole, 69 VANDETANIB 100 MG TABLET, 16 Page 114 of 117 VANDETANIB 300 MG TABLET, 17 VANISHPOINT U-100 29X1/2 SYR, 57 VANTAS, 17 VAQTA, 50 VARIVAX VACCINE, 50 VASODILATOR ANTIHYPERTENSIVES, 35 VECTIBIX 100 MG/5 ML VIAL, 17 VECTIBIX 400 MG/20 ML VIAL, 17 VECTICAL, 36 VELCADE, 17 veletri, 34 velivet, 67 vemavite-prx 2, 70 venlafaxine hcl, 26 venlafaxine hcl er 150 mg cap, 26 venlafaxine hcl er 37.5 mg cap, 26 venlafaxine hcl er 75 mg cap, 26 VENTAVIS 10 MCG/1 ML SOLUTION, 34 VENTAVIS 20 MCG/1 ML SOLUTION, 34 VENTOLIN HFA, 76 VERAMYST, 40 verapamil er, 31 verapamil er pm, 31 verapamil hcl capsule 24hr sustained release pellets, -injection, -tablet, tablet sustained action, 31 VEREGEN, 39 VERSALON SPONGE, 57 VESICARE, 78 VEXOL, 73 VFEND, 6 VFEND IV, 8 VIBATIV, 7 VIBRAMYCIN SUSPENSION, -SYRUP, 10 VICTOZA 2-PAK, 42 VICTOZA 3-PAK, 42 VICTRELIS, 3 VIDAZA, 17 VIDEX, 3 VIGAMOX, 74 VIIBRYD 10 MG TABLET, 28 VIIBRYD 20 MG TABLET, 28 VIIBRYD 40 MG TABLET, 28 VIMPAT, 25 vinacal, 70 vinate az, 71 vinate az extra, 71 vinate c, 71 vinate calcium, 71 vinate care, 71 vinate gt, 71 vinate ic, 71 vinate ii, 71 vinate one, 71 vinate pn care, 71 vinate ultra, 71 vinate-m, 71 vinblastine 1 mg/ml vial, 17 vinblastine sulf 10 mg vial, 17 vincristine 1 mg/ml vial, 17 vincristine 2 mg/2 ml vial, 17 vinorelbine 10 mg/ml vial, 17 vinorelbine 50 mg/5 ml vial, 17 VIRACEPT POWDER, 3 VIRACEPT TABLET, 3 VIRAMUNE, 3 VIRAMUNE XR, 3 VIRAZOLE, 7 VIREAD, 3 VISICOL, 46 VISTIDE, 7 vitafol-ob, 71 vitafol-pn, 71 VITAMINS AND MINERALS AND RELATED PRODUCTS, 65 vitaphil, 71 vitaphil + dha, 71 vitazol, 36 VIVAGLOBIN, 50 vol-plus, 71 Page 115 of 117 VOLTAREN GEL, 37 voriconazole, 6 VOTRIENT, 17 VPRIV, 44 VUMON, 17 VYTORIN, 32 warfarin sodium tablet, 63 WEBCOL, 57 WELCHOL, 32 westhroid, 45 XALATAN, 72 XENAZINE 12.5 MG TABLET, 27 XENAZINE 25 MG TABLET, 27 XEOMIN 100 UNITS VIAL, 57 XEOMIN 50 UNITS VIAL, 57 XGEVA, 44 XIBROM, 75 XIFAXAN 200 MG TABLET, 7 XIFAXAN 550 MG TABLET, 7 XOLAIR, 77 XOPENEX 0.31 MG/3 ML SOLUTION, 0.63 MG/3 ML SOLUTION, 76 XOPENEX 1.25 MG/3 ML SOLUTION, 76 XOPENEX CONCENTRATE, 76 XOPENEX HFA, 76 x-viate cream, -gel, 39 XYREM, 27 XYZAL, 76 YF-VAX, 51 YODOXIN, 1 zaclir, 36 zafirlukast, 77 zaleplon, 27 ZANOSAR, 17 zarah, 67 zatean-ch, 71 ZAVESCA, 44 ZAZOLE SUPPOSITORY VAGINAL, 11 ZELAPAR, 26 ZEMAIRA, 78 zema-pak 10 day 1.5 mg tablet, -13 day 1.5 mg tablet, 41 ZEMPLAR, 65 zenchent, 67 ZENPEP, 47 zeosa, 67 ZETIA, 32 ZEVALIN, 17 ZIAGEN, 3 zidovudine, 3 ZINOTIC, 40 ZINOTIC ES, 40 ZIRGAN, 75 ZITHRANOL-RR, 36 ZOLADEX, 17 ZOLINZA, 17 zolpidem tartrate tablet, 27 ZOMETA, 44 ZONALON, 39 zonisamide, 25 ZORBTIVE, 48 ZORTRESS 0.25 MG TABLET, 17 ZORTRESS 0.5 MG TABLET, -0.75 MG TABLET, 17 ZOSTAVAX, 51 ZOSYN 2.25 GRAM VIAL, -2.25 GM GALAXY BAG, -2.25 GM PRE-MIX BAG, -3.375 GM GALAXY BAG, 3.375 GM PRE MIX-BAG, -4.5 GM GALAXY BAG, -4.5 GM PRE-MIX BAG, -4.5 GRAM VIAL, -40.5 GRAM BULK VIAL, 9 zovia 1-35e, 67 zovia 1-50e, 68 ZOVIRAX CREAM, -OINTMENT, 8 ZYFLO CR, 77 ZYLET, 73 ZYMAR, 74 ZYMAXID, 74 ZYPREXA 15 MG TABLET, -20 MG TABLET, 19 Page 116 of 117 ZYPREXA 2.5 MG TABLET, -5 MG TABLET, -7.5 MG TABLET, -10 MG TABLET, 19 ZYPREXA INJECTION, 19 ZYPREXA RELPREVV, 19 ZYPREXA ZYDIS 15 MG TABLET, -20 MG TABLET, 19 ZYPREXA ZYDIS 5 MG TABLET, -10 MG TABLET, 19 ZYTIGA, 17 ZYVOX, 7 Page 117 of 117
