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PA Medicaid - Gateway Health Plan
Gateway HealthSM 2014 Medicaid Formulary i INTRODUCTION The Gateway Healthsm formulary is a list of FDA-approved covered medications reviewed and approved by our Pharmacy and Therapeutics (P&T) Committee and the Department of Public Welfare (DPW). The P&T Committee is made up of actively participating network physicians and pharmacists who select products on the basis of their safety, efficacy, quality and cost to the plan. Physicians are requested to prescribe medications included in the formulary whenever medically appropriate. All drugs in the formulary are not necessarily covered by each patient’s prescription drug coverage. Providers can contact Provider/Pharmacy Services with any questions related to a member’s prescription coverage limitations. The drug formulary is divided into major therapeutic categories (chapters) for easy use. Products that are approved for more than one therapeutic indication may be included in more than one chapter. Covered formulary drugs are listed in the first column under the Drug heading. The Notes column in the formulary book will tell you which drugs may have any additional requirements or limits on them. The P&T Committee meets on a quarterly basis to review and revise the formulary. All providers (both participating pharmacies and physicians) are provided access to the Gateway Healthsm formulary and are periodically notified of formulary updates. Providers may request the addition of a medication to the formulary. Requests must include the drug name, rationale for inclusion on the formulary, role in therapy and formulary medications that may be replaced by the addition. The committee will review requests. All requests should be forwarded in writing to: Gateway Healthsm -P&T Committee Pharmacy Department Four Gateway Center 444 Liberty Avenue Suite 2100 Pittsburgh, PA 15222 The formulary is accessible online at www.gatewayhealthplan.com. It may be searched by drug name or drug class. Future updates to our formulary will be available, both by provider publication and online. Additional hard copies of the formulary may be printed directly from our formulary website, or requested as follows: Physician Practices: 1-800-392-1145 Pharmacy Network Providers: 1-800-528-6738 Questions about the formulary can be directed to: Pharmacy Services Department…….1-800-528-6738 ii PHARMACY CO-PAYMENTS Co-payments will apply to Gateway members 18 years of age and older. These co-payments do not apply to any member who is pregnant or in a nursing home. Please note, members cannot be denied a service if they are unable to pay their co-pay. Members may fall into two medical assistance categories, Medical Assistance (MA) and General Assistance (GA). Practitioners can verify a member’s medical assistance benefit category through the Department of Public Welfare PROMISe TM Eligibility Verification System (EVS). For Medical Assistance (MA) members 18 years of age and older, the benefit structure for prescription drugs is as follows: $1.00 for formulary generic prescription drugs $3.00 for formulary brand prescription drugs Copays will apply to any approved prior authorization for a non-formulary drug Medications within the following specified therapeutic categories will be excluded from the copay requirements for MA recipients only, which will be noted at the point of sale transaction: o Antipsychotics o Family Planning o Antidiabetic Agents, including Insulin o Antineoplastic Agents o Antiparkinson Agents o Antiglaucoma Agents o Antihypertensive Agents o Anticonvulsants o HIV/AIDS medications o Cardiovascular preparations (Antiarrhythmics, Antianginals, Anticoagulants, Lipid Lowering Agents) For General Assistance (GA) members 18 years of age and older, the benefit structure for prescription drugs is as follows: $1.00 for formulary generic prescription drugs $3.00 for formulary brand prescription drugs Copays will apply to any approved prior authorization for a non-formulary drug There are NO COPAY exceptions for GA members SIX PRESCRIPTION BENEFIT LIMIT Members can get up to 6 prescriptions each month. This rule does not apply if: iii • Member is under 21 years of age; or • Member is pregnant; or • Member lives in a nursing home or an intermediate care facility In some instances, Gateway can approve more than 6 prescriptions per month. This is called a benefit limit exception. Gateway can grant a benefit limit exception if: • Member has a serious chronic illness or health condition and without the additional service, the life of the member would be in danger; or • Member has a serious chronic illness or health condition and without the additional service, the member’s health would get much worse; or • Member would need more expensive services if the exception is not granted; or • It would be against federal law for Gateway Healthsm to deny the exception Some exceptions can happen automatically at the pharmacy. A benefit limit exception can be made automatically at the pharmacy if the member has a prescription for one of the drugs listed below: Drugs to treat: • Abnormal or irregular heartbeat • Angina • Asthma or COPD (chronic obstructive pulmonary disease) • Bipolar disease • Cancer • Cholesterol (statins) • Depression • Diabetes • Enzyme deficiencies • Glaucoma • Hemophilia • Hepatitis • High blood pressure • HIV/AIDS • Immune deficiency • Infection • Multiple sclerosis • Nausea and vomiting • Opiate dependency • Parkinson’s disease • Pulmonary hypertension • Serious mental illness • Thyroid disorders Drugs to prevent: iv • Blood clots • Pregnancy • Seizures Drugs to: • Reduce stomach acid • Replace potassium • Stop migraine headaches • Suppress the immune system If the prescription is not automatically approved at the pharmacy, the doctor or provider who prescribed the drug can ask Gateway for an exception. To request a benefit limit exception, the doctor or provider who prescribed the drug should complete a Six Script Pharmacy Benefit Limit Exception Request Form found at the back of the book and fax it back to the Pharmacy Department at 1-888-245-2049. The doctor or provider may also call the pharmacy department and give our staff person: Member name, address, date of birth, and Gateway Healthsm ID number Provider name, address, telephone and fax number, medical license number and National Provider Identifier number. Information about the drug being prescribed, member’s diagnosis and why the exception is needed. Once Gateway has the needed information, we will respond to the request within 24 to 72 hours. The member and doctor will get a written notice of the decision. If the member needs the drug right away, his/her pharmacist may give up to a 5 day emergency supply to the member. If a request for an exception is denied, the member and prescribing doctor will get a written notice of the decision. The written notice will explain how to appeal. The written notice will explain how and when to ask for a Fair Hearing with the Department of Public Welfare or file a complaint or grievance with Gateway Healthsm. If the member needs help filing an appeal they can call Gateway Healthsm Member Services at 1-800-392-1147, TTY/TDD: 711. FORMULARY MEDICATION COVERAGE Approved Medications Only FDA-approved medications are eligible for coverage. Investigational/Experimental Drug Use Drugs prescribed for investigational or experimental purposes are not eligible for reimbursement. v Formulary Drugs Formulary drugs are those reviewed and recommended for inclusion by Gateway’s P&T Committee. These drugs are selected based upon their safety, efficacy, quality and cost. Physicians and pharmacists should use formulary drugs when they believe it medically appropriate to do so. Nonformulary Drugs A non-formulary drug is one that has not been recommended for inclusion by Gateway’s P&T Committee on the basis of safety, efficacy, quality and cost. Physicians are requested to comply with the drug formulary when prescribing medications for participants when medically appropriate. A physician may request a non-formulary medication only if medical necessity or failure of formulary alternatives are documented by the physician on the Gateway Healthsm Medicaid Drug Exception Form found at the back of the book and fax it back to the Pharmacy Department at 1-888-245-2049. When presented a prescription for a non-formulary drug, a pharmacist should attempt to contact the prescribing physician in order to suggest formulary alternatives. If the physician is unavailable, the pharmacist should contact Gateway Healthsm at 1-800-528-6738 to help secure a formulary alternative. The pharmacist may dispense up to a 5 day supply after hours, weekends and holidays. Generic Substitution When there is a generic version of a brand name drug available, Gateway requires the generic drug be given. Generic drugs are subject to specific reimbursement levels, such as Maximum Allowable Cost (MAC) price reimbursements. Drugs that are available in generic form will appear in bold in the formulary book. The bold font indicates that the generic drug product is on the formulary but the branded product is not. Requests for “Brand Necessary” medications will be considered a nonformulary medication request and will require authorization. The Gateway Healthsm Medicaid Drug Exception Form must be submitted with sufficient documentation to substantiate medical necessity of the Brand Name medication. Physicians are encouraged to prescribe generic medications whenever clinically appropriate. Prior Authorization Prior Authorization (prior approval) is necessary for coverage of certain medications. In these cases, clinical criteria, based on current medical information and approved by Gateway’s P&T Committee and the Department of Public Welfare, must be met or additional information must be provided before coverage is approved. To avoid interruptions in therapy for ongoing medication, Gateway Healthsm will provide a 15-day supply of the medication to the member. Prior authorizations are processed by calling Gateway Healthsm at 1-800-528-6738 or physicians may complete a drug specific prior authorization form by accessing the website at www.gatewayhealthplan.com. Physicians should fax the completed prior authorization form to 1-888-245-2049 for processing. All requests for prior authorization will receive a response within 24 hours. Drugs that are vi available in generic form will appear in bold in the formulary book. The bold font indicates that the generic drug product requires a prior authorization. Brand Name Abilfy** Avonex Compound Copaxone Elidel Enbrel Exelon Geodon* Gleevec Generic Name aripiprazole interferon beta- 1a compound glatiramer acetate pimecrolimus etanercept rivastigmine ziprasidone imatinib Brand Name Peg-Intron Pegasys Procrit Pulmozyme Remicade Risperdal* Saphris* Seroquel* Suboxone Film Humira Latuda* Lupron Lupron Depot Neupogen Norditropin adalimumab lurasidone Leuprolide Leuprolide Subutex Synagis Synvisc Synvisc One Generic Name peginterferon alfa-2b Peginterferon alfa-2b epoetin alfa dornase alfa infliximab risperidone asenapine quetiapine buprenorphine/naloxo ne buprenorphine palivizumab hylan G-F 20 Hylan G-F 20 filgrastim somatripin Victrelis Voltaren Gel boceprevir diclofenac sodium *The following atypical antipsychotics require prior authorization in certain situations: 1.) All strengths for children less than 18 years of age 2.) Low dose strengths for adults aged 18 to 60 for the following atypical only: a. Seroquel 25mg, 50mg, and 100mg ** Abilify requires a prior authorization for all ages Once Daily Medications Some medications are indicated to be taken as a once daily dose rather than several times throughout the day. In these situations, Gateway Healthsm will cover only the larger dose for 30 days. For example, your physician writes you a prescription to take a 5mg tablet twice a day. If a 10mg tablet exists in that medication, Gateway Healthsm will cover this strength rather than two of the 5mg tablets. Should there be a medical explanation as to why you would need to take a lesser dose twice a day; your physician may call Gateway Healthsm at 1-800-528-6738 or fax 1-888-245-2049 to request an exception. Quantity Limits For certain drugs, Gateway Healthsm has established quantity limits (limits on the amount of drug you can have filled). Quantity limits are put in place to ensure that you do not receive a quantity greater than the recommended limit (daily, monthly or yearly based on FDA recommendations) and to promote efficient drug dosing regimens. Prescriptions in vii excess of the covered quantity would require a medical exception request from the prescribing physician. For example, Gateway provides coverage for 9 tablets of sumatriptan (generic Imitrex) 100mg every 30 days. Medications with quantity limits are denoted by QL in the formulary booklet. Below is a list of quantity limits based on FDA recommended dosing and medical literature. Brand Name Abilify Generic Name aripiprazole Quantity Limit 30 tablets per month Accolate zafirlukast Accuneb albuterol inhalation solution Actos pioglitazone 60 tablets per month 120 vials or 360mL per month 30 tablets per month ActoPlus Met pioglitazone/metformin 90 tablets per month Adderall Adderall XR 5mg, 10mg, 15mg Adderall XR 20mg, 25mg, 30mg amphetamine salt combination amphetamine salt combination extended release amphetamine salt combination extended release 60 tablets per month Advair HFA/Advair Diskus fluticasone propionate/salmeterol Albuterol 2.5mg/0.5ml albuterol inhalation soln 1 inhaler or diskus per month 160ml per month Albuterol 2.5mg/3ml albuterol inhalation soln 375ml per month Albuterol 5mg/ml albuterol inhalation soln 80ml per month Amaryl 1mg, 2mg glimepiride 30 tablets per month Ambien zolpidem 30 tablets per month Arava leflunomide 30 tablets per month Aricept donepezil 30 tablets per month Arixtra fondaparinux 10 syringes per month Asmanex mometasone furoate 1 inhaler per month Atrovent HFA ipratropium bromide inhaler ipratropium bromide inhalation solution 30 capsules per month 60 capsules per month Atrovent Nasal Spray 0.06% ipratropium bromide nasal spray Atrovent Nasal Spray 0.03% ipratropium bromide nasal spray Avandamet rosiglitazone/metformin 2 inhalers per month 120 vials or 300mL per month 2 bottles per month (30mL total) 1 bottle per month (30mL) 60 tablets per month Avandaryl 4/1mg rosiglitazone/glimepiride 30 tablets per month Avandaryl 4/2mg, 4/4mg rosiglitazone/glimepiride 60 tablets per month Avandia rosiglitazone 30 tablets per month Avelox moxifloxacin 10 tablets per month Atrovent Inhalation Solution viii Brand Name Generic Name Avonex interferon beta-1a Biaxin, Biaxin XL clarithromycin Quantity Limit 1 package (4 vials) per month 28 tablets per 30 days Calan SR verapamil 30 tablets per month Celexa citalopram 30 tablets per month Codeine phosphate codeine phosphate injection 180 syringes per month Codeine sulfate codeine sulfate 180 tablets per month Codeine sulfate solution codeine sulfate 1000 ml per month Combivent ipratropium bromide/albuterol 2 inhalers per month Concerta 18mg, 27mg, 54mg methylphenidate extended release 30 tablets per month Concerta 36mg methylphenidate extended release Copaxone glatiramer acetate Cymbalta 20mg, 30mg duloxetine 60 tablets per month 1 package of 30 vials per month 60 capsules per month Cymbalta 60mg duloxetine 60 capsules per month Demerol meperidine 180 tablets per month Demerol solution meperidine solution 1000 ml per month Desoxyn methamphetamine 150 tablets per month Dexedrine 5mg d-amphetamine sulfate 90 tablets per month Dexedrine 10mg d-amphetamine sulfate 60 tablets per month Dexedrine 15mg d-amphetamine sulfate 120 tablets per month Dilaudid hydromorphone 180 tablets per month Dilaudid solution hydromorphone solution 1000 ml per month Ditropan XL5mg oxybutynin extended release 30 tablets per month Ditropan XL 10mg, 15mg oxybutynin extended release 60 tablets per month Duetact pioglitazone/glimepiride Dulera formoterol/mometasone Duragesic fentanyl transdermal patches 30 tablets per month 1 inhalation aerosol per month 10 patches per month Effexor XR venlafaxine XR 30 capsules per month Effexor XR 150 mg venlafaxine XR 60 capsules per month Enbrel 25mg etanercept 8 vials per month Enbrel 50mg etanercept 4 vials per month Exelon rivastigmine 60 tablets per month Flomax tamsulosin Flonase fluticasone propionate nasal spray Flovent HFA fluticasone propionate inhaler 30 capsules per month 1 nasal spray devices per month 2 inhalers per month Focalin dexmethylphenidate 60 tablets per month ix Brand Name Focalin XR Generic Name dexmethylphenidate XR Forteo teriparatide Fragmin dalteparin Quantity Limit 30 tablets per month 1 prefilled pen per month 10 syringes per month Geodon 60mg ziprasidone 90 capsules per month Geodon 20mg, 40mg, 80mg ziprasidone 60 capsules per month Glucotrol XL glipizide xl 30 tablets per month Humira adalimumab 2 syringes per month Hycodan hydrocodone/homatropine 900 ml per month Hycodan hydrocodone/homatropine Hydrocodone/acetaminophen hydrocodone/acetaminophen 2.5/500 Imitrex 25mg, 50mg sumatriptan 180 tablets per month Imitrex 100mg sumatriptan Imitrex Injection sumatriptan Imitrex Nasal Spray sumatriptan Intal cromolyn sodium inhalation solution Intuniv guanfacine 9 tablets per month 2 boxes (4 injections) per month 1 box (6 spray units) per month 120 vials or 240mL per month 30 tablets per month Isentress raltegravir potassium 60 tablets per month Janumet sitagliptin/metformin 60 tablets per month Janumet XR 100/1000 sitagliptin/metformin XR 30 tablets per month Janumet XR 50/1000, 50/500 sitagliptin/metformin XR 60 tablets per month Januvia sitagliptin 30 tablets per month Lamisil terbinafine 90 tablets per year Latuda lurasidone 30 tablets per month Latuda 80mg lurasidone 60 tablets per month Letairis ambrisentan 30 tablets per month Lexapro escitalopram 30 tablets per month Lorcet hydrocodone/acetaminophen 180 tablets per month Lorcet HD hydrocodone/acetaminophen 180 capsules per month Lorcet Plus hydroconde/acetaminophen 180 tablets per month Lortab hydrocone/acetaminophen 180 tablets per month Lortab Elixir hydrocodone/acetaminophen elixir 2700 ml per month Lovenox enoxaparin 28 syringes per month Lupron Depot leuprolide acetate 1 kit per month Luvox 25mg, 50mg fluvoxamine maleate 30 tablets per month x 180 tablets per month 18 tablets per month Brand Name Maxair Autohaler Generic Name pirbuterol acetate Quantity Limit 1 inhaler per month Maxalt, Maxalt MLT rizatriptan 18 tablets per month Meperidine Solution meperidine 1000ml per month Meperidine meperidine 180 tablets per month Metadate CD methylphenidate extended release 30 capsules per month Methadone methadone 300 tablets per month Methylin methylphenidate solution 900 ml per month Migranal Nasasl Spray dihydroergotamine mesylate 8ml per month MS Contin morphine sulfate controlled-release 90 tablets per month MSIR morphine sulfate immediate-release 180 tablets per month Morphine sulfate solution Neurontin 100, 300, 400, 600mg Neurontin 800mg morphine sulfate solution gabapentin 1000 ml per month 180 tablets or capsules per month 120 tablets per month Norco 5/325, 7.5/325, 10/325 hydrocodone/acetaminophen 180 tablets per month Opana IR oxymorphone 150 tablets per month Opana ER oxymorphone ER 60 tablets per month Paxil paroxetine 30 tablets per month Percocet oxycodone/acetaminophen 150 tablets per month Percodan oxycodone/aspirin 150 tablets per month Phenergan with Codeine Plan B codeine/promethazine syrup 1000 ml per month phenylephrine/codeine/promethazine 1000 ml per month solution levonorgestrel 2 tablets per month Plan B One-Step levonorgestrel 1 tablet per month Premarin estrogens, conjugated 30 tablets per month Prevacid lansoprazole 60 capsules per month Prilosec omeprazole 60 capsules per month Pristiq desvenlavaxine 30 tablets per month Protonix pantoprazole 60 tablets per month Prozac 10mg fluoxetine 60 capsules per month Prozac 20mg Pulmicort Respules 0.25, 0.5mg fluoxetine Pulmicort Respules 1mg budesonide Pulmozyme dornase alfa Razadyne galantamine 120 capsules per month 60 vials or 120mL per month 30 vials or 60mL per month 60 vials or 150mL per month 60 tablets per month Phenergan VC with Codeine gabapentin budesonide xi Brand Name Relenza Generic Name zanamivir Quantity Limit 20 blisters per 6 months Remeron mirtazapine 30 tablets per month Risperdal risperidone 60 tablets per month Risperdal Consta risperidone 2 syringes per 28 days Ritalin 5mg, 10mg methylphenidate 90 tablets per month Ritalin 20mg methylphenidate 120 tablets per month Ritalin SR methylphenidate extended release 120 tablet per month Roxicet solution oxycodone/acetaminophen solution 1000 ml per month Roxicodone oxycodone immediate release 150 tablets per month Roxicodone solution oxycodone 5 mg/5 ml solution 1000 ml per month Saphris asenapine 60 SL tablets per month Serevent Diskus salmeterol 1 inhaler per month Seroquel quetiapine 90 tablets per month Seroquel 400mg quetiapine 60 tablets per month Seroquel XR quetiapine XR 60 tablets per month Singulair montelukast 30 tablets per month Sonata zaleplon Spiriva Handihaler tiotropium 30 tablets per month 30 capsules (1 handihaler) per month Strattera 10mg, 18mg, 25mg, 40mg Strattera 60mg, 80mg, 100mg atomoxetine 60 capsules per month atomoxetine 30 tablets per month Suboxone Film buprenorphine/naloxone 60 film strips per month Subutex buprenorphine Symbicort budesonide;formoterol Synagis 50mg, 100mg palivizumab 60 tablets per month 1 inhalation aerosol per month 1 vial per month Synvisc hylan G-F 20 Tamiflu oseltamivir Tamiflu 6mg/ml oseltamivir 3 syringes per 20 days 10 capsules per 6 months 180ml per 6 months Tylenol with codeine codeine/acetaminophen 180 tablets per month Tylenol with codeine elixir codeine/acetaminophen 2700 ml per month Ultracet tramadol/acetaminophen 240 tablets per month Ultram tramadol 240 tablets per month Ventolin HFA albuterol inhaler 2 inhalers per month Vicodin hydrocodone/acetaminophen 180 tablets per month Vicodin ES hydrocodone /acetaminophen 150 tablets per month Vicodin HP hydrocodone/acetaminophen 180 tablets per month xii Brand Name Vicoprofen Generic Name hydrocodone/ibuprofen Quantity Limit 150 tablets per month Viibryd vilazodone 30 tablets per month Vyvanse lisdexamfetamine 30 capsules per month Xarelto 10mg, 20mg rivaroxaban 30 tablets per month Xarelto 15mg rivaroxaban 60 tablets per month Zenzedi 5mg dextroamphetamine sulfate 90 tablets per month Zenzedi 10mg dextroamphetamine sulfate 180 tablets per month Zoloft sertraline 30 tablets per month Zyprexa olanzapine 30 tablets per month Step Therapy In some cases, Gateway Healthsm requires you to first try certain drugs to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Gateway may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Gateway will then cover Drug B. The following medications require step therapy. Brand Name Janumet Januvia Restasis Generic Name sitagliptan-metformin sitagliptan phosphate cyclosporine ophthalmic suspension Specialty Pharmacy Information Some medications, including injectable medications, listed in the formulary booklet are available through a specialty pharmacy network. These medications are denoted as SPN in the formulary drug listing. Compounded Prescriptions A claim for a compounded prescription should be submitted with all NDCs used in the compound. Only valid NDCs are permitted. The compound cost will automatically calculate based upon coverage of the submitted ingredients. Payment will only be made for FDA approved drugs and drugs not excluded from payment by Medical Assistance. A compounded medication may require prior authorization to determine medical necessity. Prior authorizations are processed by calling Gateway Healthsm at 1-800-528-6738, or physicians may complete a Medicaid Drug Exception Form found in the back of the book or by accessing the website at www.gatewayhealthplan.com. Physicians should fax the completed form to 1-888-245-2049 for processing. All requests will receive a response within 24 hours. xiii Over-the-counter (OTC) Medications Gateway Healthsm provides coverage for a number of OTC medications written as a prescription. Please refer to the Gateway Healthsm OTC Formulary referenced on page xviii in the introduction section for a specific listing of covered categories. Drug Efficacy Study Implementation (DESI) Drug A DESI drug is one that was approved by the FDA solely on the basis of their safety prior to 1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs. Gateway Healthsm excludes all DESI drugs as defined by the FDA. Non-rebated Manufacturers Gateway Healthsm, by direction of DPW, excludes coverage for any drug marketed by a drug company who does not participate in the Medicaid Drug Rebate Program. Medications Covered by Other Insurers (Coordination of Benefits and Third Party Liability) As an agent of the Commonwealth of Pennsylvania Medical Assistance Program, Gateway Healthsm is always the payer of last resort in the event that a member receives a medication that is covered by another payer source. The claim must be billed to the primary insurance, and subsequently billed on-line or submitted on a Universal Claim Form (UCF) to Gateway Healthsm for any outstanding balance. Non-covered Drugs Non-covered drugs include the following categories: Drugs and other items prescribed for obesity or appetite control Over the counter drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes and similar items Drugs and devices not approved by the FDA or whose use is not approved by the FDA Placebos Prescription and over the counter soaps, cleansing agents, dentifrices, mouthwashes, douche solutions, diluents, ear wax removal agents, deodorants, liniments, antiseptics, irrigants, emollients and other personal care items Prescription and over the counter food supplements and substitutes Durable Medical Equipment (DME) items Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program Fertility promoting agents Drugs for the treatment of erectile dysfunction xiv Agents prescribed for cosmetic purposes or approved by the FDA for cosmetic purposes only REQUEST FOR NONFORMULARY DRUG COVERAGE If changing to a formulary medication is not medically advisable for a patient, a physician must initiate a Request for Nonformulary Drug Coverage by faxing the request form found at the back of the book to: 1-888-245-2049 during normal business hours, or call 1-800-3921147 during off-hours and weekends, with all of the information requested on the form. All requests for exception will receive a response within 24 hours. In the event a decision has not been made in 24 hours, Gateway Healthsm will authorize a temporary supply of the nonformulary medication. For new therapies, up to a 5 day supply may be dispensed and for ongoing therapies, a 15-day supply of the nonformulary medication must be dispensed, pending the final determination of the request. Gateway Healthsm members have the right to appeal any decision regarding prescription drug coverage. PROVIDER NUMBER When processing a prescription claim for a Gateway Healthsm member, a valid NPI number is required. DAYS SUPPLY DISPENSING LIMITATIONS Gateway Healthsm members may receive up to a 34-day supply of a pharmaceutical product per prescription order or refill. A 34-day supply shall be interpreted to mean consecutive 34day supply, i.e., if a physician prescribes a medication b.i.d. (two times a day), a 34-day supply corresponds to a quantity of 68. The prescriber is urged to prescribe in amounts that adhere to FDA guidelines and accepted standards of care. The dispensing pharmacist must accurately calculate the days supply. VACATION SUPPLIES All requests for an early refill or a quantity in excess of a 34 day supply due to upcoming travel must be made by the prescribing physician. The physician must include the following in a request for a vacation supply of maintenance medication: your destination, your departure and return dates, any travel documentation including flight reservations or hotel confirmations, the dose, strength, frequency, and quantity of the medications that are being requested. xv Medications being requested that have abuse potential will be reviewed on a case by case basis with the prescribing physician and Gateway Clinical Pharmacist and/or Medical Director. If approved upon review of information submitted, a vacation supply of no more than one month will be allowed. Gateway Healthsm will only allow one vacation supply per year through this process. In addition, a Gateway Healthsm member can get their medications filled anywhere in the United States at a participating network pharmacy. RECIPIENT RESTRICTION PROGRAM Gateway’s Recipient Restriction Program is a program to detect and deter member misutilization and/or fraud/abuse. This program restricts members to one PCP and/or one Participating Pharmacy of the member’s choice for a period of five years. Gateway Healthsm contacts the member’s physician and pharmacy of choice to ask if they would be willing to accept a restricted member. Our program interfaces with the DPW (Department of Public Welfare) centralized Recipient Restriction program. This enables DPW to continue the restrictions for a five-year period across the Pennsylvania Medical Assistance Program. Once a member is identified for this program through referrals from participating pharmacies or physicians or generated utilization reports, a complete review of pharmacy and medical claims data is performed. Upon completion of the review, if misutilization, fraud and/or abuse can be documented and has met the DPW approved restriction criteria, the member is recommended for restriction to a PCP and/or Participating Pharmacy. Upon approval from Gateway’s Recipient Restriction Committee and the Department of Public Welfare, the member is then restricted or “locked-in” to one PCP and/or one Participating Pharmacy. Please note: the restriction is not enforced in the case of an emergency. Please contact Gateway Healthsm for assistance if this situation occurs. If you suspect member misutilization and/or fraud and/or abuse please contact our Pharmacy Services Department at 1-800-5286738 or our Special Investigations Unit at 1-800-685-5235. APPEALS AND COMPLAINTS Gateway Healthsm providers and members have the right to appeal any denial made by the plan. Details regarding appeals, complaints, and grievances may be found in the Member Handbook or the Provider Manual. To request a Member Handbook, call Member Services at: 1-800-392-1147. To request a Provider Manual, call Provider Relations at: 1-800-392-1145. Both manuals are available online at www.gatewayhealthplan.com. ELECTRONIC PRESCRIBING Gateway Healthsm is able to accept and administer the transmittal of electronic prescriptions and is highly interested in expanding the use of electronic prescribing across all network physicians and pharmacies. Physicians who use electronic prescribing will have access to a number of electronic prescribing features though Gateway’s connectivity with Surescripts including the ability to see: xvi Plan formularies Member eligibility data Plan gender edits Plan quantity limits Drugs that require prior authorization or part of specific step therapies Gateway feels that the most significant advantage of electronic prescribing is its propensity to reduce medication errors, increase compliance, and improve the overall care to patients. Electronic prescribing will also enhance physician efficiency in handling prescriptions for initial coverage and refills, thus saving administrative time and effort. PHARMACY BENEFIT INQUIRIES Providers having questions regarding a member’s pharmacy benefit, please call 1-800-528-6738. If you are a member with a question regarding your pharmacy benefit, please call Pharmacy Member Services at 1-800-392-1147 (TTY/TDD users: 711). xvii GATEWAY HEALTHSM OTC FORMULARY (FOR COVERAGE, DRUGS MUST BE WRITTEN AS A PRESCRIPTION) Drugs are listed alphabetically by category. Specific OTC drugs are listed as examples and are not inclusive of all covered products. Analgesics Acetaminophen Acetaminophen combinations Aspirin Aspirin combinations Nonsteroidal anti-inflammatory agents Salicylates Obstetrics & Gynecology Contraceptives (condoms, contraceptive jellies) Contraceptive devices Pregnancy Test Kits Vaginal fungicides Dermatologicals/Topical Therapy Ophthalmic Preparations Acne (benzoyl peroxide) Anesthetics (benzocaine, dibucaine, lidocaine, cyclomethycaine, pramoxine, tetracaine) Antibacterials (bacitracin, neomycin, triple antibiotic preparation, povidone-iodine) Anti-inflammatory agents (hydrocortisone 1%) Dermatological baths (colloidal oatmeal) Fungicides (clotrimazole, miconazole, tolnaftate, terbinafine, undecylenic acid, salicyclic acid, triacetin) Tar preparations (not including soaps and cleansing agents) Wet dressings (aluminum acetate) Scabicides/pediculicides (permethrin, RID) Ocular lubricants (polyvinyl alcohol or cellulose derivatives) Antihistamine (Alaway) Decongestants (Naphcon, Visine) Phenylephrine 0.12% Sodium chloride Respiratory, Allergy, Cough & Cold Antihistamines (diphenhydramine, loratadine) Bronchodilators Cough and cold products Nasal preparations (naphazoline, xylometazoline, oxymetazoline, phenylephrine, saline) Saline for inhalation Endocrine/Diabetes Insulin Insulin needles and syringes Diagnostic devices Diabetic supplies (FreeStyle Lite, FreeStyle InsuLinx, and Precision Xtra products, lancets, strips, alcohol swabs) Smoking Cessation Products Nicotine replacement Vitamins, Hematinics & Electrolytes Vitamins Prenatal vitamins Calcium salts Iron products (not including long-acting products) Nicotinic acid Oral electrolyte mixtures Gastroenterology Antacids Antidiarrheals (kaolin-pectin combinations, loperamide) Antiflatulents (simethicone) Antinauseants (cyclizine, meclizine, dimenhydrinate) Laxatives and stool softeners (Miralax, Milk of Magnesia, bisacodyl, docusate) Histamine-2 receptor antagonists Prilosec OTC Medical Supplies Please check with Gateway Health Plan for coverage xviii Table of Contents Antihistamine Drugs ........................................................................................................................................................................................................................................................................ 3 Anti-Infective Agents ...................................................................................................................................................................................................................................................................... 4 Antineoplastic Agents ................................................................................................................................................................................................................................................................. 13 Autonomic Drugs ............................................................................................................................................................................................................................................................................. 15 Blood Formation,Coagulation & Thrombosis ....................................................................................................................................................................................... 19 Cardiovascular Drugs ................................................................................................................................................................................................................................................................. 23 Central Nervous System Agents .................................................................................................................................................................................................................................. 28 Devices .............................................................................................................................................................................................................................................................................................................. 38 Electrolytic, Caloric, And Water Balance ...................................................................................................................................................................................................... 38 Enzymes .......................................................................................................................................................................................................................................................................................................... 40 Eye, Ear, Nose And Throat (Eent) Preps. ..................................................................................................................................................................................................... 40 Gastrointestinal Drugs .............................................................................................................................................................................................................................................................. 44 Gold Compounds .............................................................................................................................................................................................................................................................................. 46 Heavy Metal Antagonists ...................................................................................................................................................................................................................................................... 46 Hormones And Synthetic Substitutes .................................................................................................................................................................................................................. 46 Local Anesthetics (Parenteral) ....................................................................................................................................................................................................................................... 55 Miscellaneous Therapeutic Agents .......................................................................................................................................................................................................................... 56 Oxytocics ....................................................................................................................................................................................................................................................................................................... 58 Pharmaceutical Aids ..................................................................................................................................................................................................................................................................... 58 Respiratory Tract Agents ...................................................................................................................................................................................................................................................... 59 Skin And Mucous Membrane Agents ................................................................................................................................................................................................................. 60 Smooth Muscle Relaxants .................................................................................................................................................................................................................................................... 65 Vitamins .......................................................................................................................................................................................................................................................................................................... 66 1 2 CURRENT AS OF 1/1/2014 UPPERCASE = Brand name drugs lowercase bold = Generic drugs Drug Name Tier 1 = Covered Drug Tier Notes PA = Prior Authorization ST = Step Therapy SPN = Specialty Pharmacy QL = Quantity Limit Notes Antihistamine Drugs First Generation Antihistamines clemastine syrup 0.67 mg/5 ml 1 cyproheptadine syrup 2 mg/5 ml 1 cyproheptadine tablet 4 mg 1 diphenhydramine injection solution 50 mg/ml 1 Phenothiazine Derivatives PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG 1 promethazine rectal suppository 12.5 mg, 25 mg 1 promethazine syrup 6.25 mg/5 ml 1 promethazine tablet 1 PROMETHAZINE VC SYRUP 6.25-5 MG/5 ML 1 PROMETHAZINE VC-CODEINE SYRUP 6.25-5-10 MG/5 ML 1 promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5 ml 1 PROMETHEGAN 1 QL (1000 ML per 30 day(s)) Piperazine Derivatives hydroxyzine hcl syrup 10 mg/5 ml 1 hydroxyzine hcl tablet 1 hydroxyzine pamoate capsule 1 3 Drug Name Tier Notes Propylamine Derivatives dexchlorpheniramine maleate er tablet,extended release 6 mg 1 Second Generation Antihistamines fexofenadine tablet 30 mg 1 SEMPREX-D CAPSULE 8-60 MG 1 Anti-Infective Agents Adamantanes amantadine hcl capsule 100 mg 1 amantadine hcl syrup 50 mg/5 ml 1 amantadine hcl tablet 100 mg 1 Allylamines terbinafine tablet 250 mg 1 Amebicides FLAGYL CAPSULE 375 MG 1 FLAGYL ER TABLET,EXTENDED RELEASE 750 MG 1 metronidazole capsule 375 mg 1 metronidazole tablet 250 mg, 500 mg 1 YODOXIN TABLET 210 MG, 650 MG 1 Aminoglycosides gentamicin injection solution 40 mg/ml 1 gentamicin in sodium chloride(iso-osm) intravenous piggyback 1 neomycin tablet 500 mg 1 paromomycin capsule 250 mg 1 TOBI SOLUTION FOR NEBULIZATION 300 MG/5 ML 1 tobramycin injection solution 40 mg/ml 1 Aminopenicillins amoxicillin capsule 250 mg, 500 mg 1 amoxicillin chewable tablet 125 mg, 250 mg 1 amoxicillin oral suspension 1 amoxicillin tablet 500 mg, 875 mg 1 amoxicillin-potassium clavulanate chewable tablet 200-28.5 mg, 400-57 mg 1 4 QL (90 EA per 365 day(s)) Drug Name Tier amoxicillin-potassium clavulanate oral suspension 1 amoxicillin-potassium clavulanate tablet 1 amoxicillin-potassium clavulanate tablet ext.release 12 hr 1,000-62.5 mg 1 ampicillin capsule 250 mg, 500 mg 1 ampicillin oral suspension 125 mg/5 ml, 250 mg/5 ml 1 ampicillin intravenous solution 1 gram, 2 gram 1 ampicillin solution for injection 1 ampicillin-sulbactam inj 1 ampicillin-sulbactam intravenous solution 1.5 gram, 3 gram 1 AUGMENTIN ORAL SUSPENSION 125-31.25 MG/5 ML 1 Notes Anthelmintics ALBENZA TABLET 200 MG 1 BILTRICIDE TABLET 600 MG 1 Antifungals, Miscellaneous griseofulvin microsize oral suspension 125 mg/5 ml 1 griseofulvin microsize tablet 500 mg 1 griseofulvin ultramicrosize tablet 125 mg, 250 mg 1 triacetin liquid 100 % 1 Antimalarials atovaquone-proguanil tablet 250-100 mg, 62.5-25 mg 1 chloroquine tablet 250 mg, 500 mg 1 DARAPRIM TABLET 25 MG 1 hydroxychloroquine tablet 200 mg 1 mefloquine tablet 250 mg 1 primaquine tablet 26.3 mg 1 quinidine er tablet,extended release 324 mg 1 quinidine sulfate er tablet,extended release 300 mg 1 quinidine tablet 200 mg, 300 mg 1 quinine capsule 324 mg 1 5 Drug Name Tier Antimycobacterials, Miscellaneous dapsone tablet 100 mg, 25 mg 1 Antiprotozoals, Miscellaneous MEPRON ORAL SUSPENSION 750 MG/5 ML 1 NEBUPENT SOLUTION FOR INHALATION 300 MG 1 Antituberculosis Agents cycloserine capsule 250 mg 1 ethambutol tablet 100 mg, 400 mg 1 isoniazid oral solution 50 mg/5 ml 1 isoniazid tablet 100 mg, 300 mg 1 pyrazinamide tablet 500 mg 1 SEROMYCIN CAPSULE 250 MG 1 Azoles fluconazole 1 fluconazole oral suspension 10 mg/ml, 40 mg/ml 1 fluconazole in dextrose (iso-osmotic) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml 1 fluconazole in sodium chloride (iso-osmotic) iv piggyback 200 mg/100 ml, 400 mg/200 ml 1 ketoconazole tablet 200 mg 1 Carbapenems imipenem-cilastatin intravenous solution 250 mg, 500 mg 1 meropenem intravenous solution 1 gram, 500 mg 1 PRIMAXIN IV SOLUTION 250 MG, 500 MG 1 Erythromycins erythromycin-sulfisoxazole oral suspension 200-600 mg/5 ml 1 Extended-Spectrum Penicillins piperacillin-tazobactam intravenous solution 1 TIMENTIN INTRAVENOUS SOLUTION 31 G 1 First Generation Cephalosporins cefadroxil capsule 500 mg 6 1 Notes Drug Name Tier cefadroxil oral suspension 250 mg/5 ml, 500 mg/5 ml 1 cefadroxil tablet 1 gram 1 cefazolin intravenous solution 1 gram 1 cefazolin solution for injection 1 cefazolin in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml 1 cephalexin capsule 250 mg, 500 mg 1 cephalexin oral suspension 125 mg/5 ml, 250 mg/5 ml 1 cephalexin tablet 250 mg, 500 mg 1 Notes Fourth Generation Cephalosporins cefepime solution for injection 1 gram, 2 gram 1 cefepime in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/100 ml 1 Glycopeptides vancomycin capsule 125 mg, 250 mg 1 vancomycin intravenous solution 1 vancomycin in dextrose 5% intravenous piggyback 500 mg/100 ml 1 Hcv Protease Inhibitors VICTRELIS CAPSULE 200 MG 1 PA; SPN Hiv Protease Inhibitors APTIVUS CAPSULE 250 MG 1 CRIXIVAN CAPSULE 200 MG, 400 MG 1 INVIRASE CAPSULE 200 MG 1 INVIRASE TABLET 500 MG 1 KALETRA ORAL SOLUTION 400-100 MG/5 ML 1 KALETRA TABLET 100-25 MG, 200-50 MG 1 LEXIVA TABLET 700 MG 1 NORVIR CAPSULE 100 MG 1 NORVIR ORAL SOLUTION 80 MG/ML 1 NORVIR TABLET 100 MG 1 PREZISTA TABLET 1 REYATAZ CAPSULE 1 VIRACEPT TABLET 250 MG, 625 MG 1 7 Drug Name Tier Notes Integrase Inhibitors ISENTRESS TABLET 400 MG 1 STRIBILD TABLET 150-150-200-300 MG 1 QL (60 EA per 30 day(s)) Interferons PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML 1 PA; SPN PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML 1 PA; SPN PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML 1 PA; SPN PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML 1 PA PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML 1 PA; SPN PEGINTRON 1 PA; SPN PEGINTRON REDIPEN 1 PA; SPN Lincomycins clindamycin hcl 1 clindamycin oral solution 75 mg/5 ml 1 CLINDAMYCIN PEDIATRIC ORAL SOLUTION 75 MG/5 ML 1 clindamycin intravenous solution 1 Macrolides E.E.S. 400 TABLET 400 MG 1 E.E.S. GRANULES ORAL SUSPENSION 200 MG/5 ML 1 ERY-TAB 1 ERYPED 200 ORAL SUSPENSION 200 MG/5 ML 1 ERYPED 400 ORAL SUSPENSION 400 MG/5 ML 1 ERYTHROCIN STEARATE TABLET 250 MG 1 erythromycin capsule,delayed release 250 mg 1 erythromycin tablet 250 mg, 500 mg 1 erythromycin ethylsuccinate tablet 400 mg 1 Monoclonal Antibodies 8 Drug Name SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML Tier 1 Notes PA; SPN; QL (1 ML per 30 day(s)) Natural Penicillins penicillin v potassium oral solution 125 mg/5 ml, 250 mg/5 ml 1 penicillin v potassium tablet 250 mg, 500 mg 1 Neuraminidase Inhibitors RELENZA DISKHALER POWDER FOR INHALATION 5 MG/ACTUATION 1 QL (30 EA per 180 day(s)) TAMIFLU CAPSULE 1 QL (10 EA per 180 day(s)) TAMIFLU ORAL SUSPENSION 6 MG/ML 1 QL (180 ML per 180 day(s)) Nonnucleoside Rev.Transcriptase Inhib. ATRIPLA TABLET 600-200-300 MG 1 COMPLERA TABLET 200-25-300 MG 1 EDURANT TABLET 25 MG 1 INTELENCE TABLET 100 MG, 200 MG 1 nevirapine oral suspension 50 mg/5 ml 1 nevirapine tablet 200 mg 1 RESCRIPTOR DISPERSIBLE TABLET 100 MG 1 RESCRIPTOR TABLET 200 MG 1 SUSTIVA CAPSULE 200 MG, 50 MG 1 SUSTIVA TABLET 600 MG 1 VIRAMUNE XR TABLET,EXTENDED RELEASE 400 MG 1 Nucleoside,Nucleotide Rev.Trnscrip.Inhib abacavir tablet 300 mg 1 didanosine capsule,delayed release 1 EMTRIVA CAPSULE 200 MG 1 EMTRIVA ORAL SOLUTION 10 MG/ML 1 EPIVIR ORAL SOLUTION 10 MG/ML 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) 1 SPN EPIVIR HBV TABLET 100 MG 1 SPN EPZICOM TABLET 600-300 MG 1 lamivudine tablet 150 mg, 300 mg 1 lamivudine-zidovudine tablet 150-300 mg 1 9 Drug Name Tier stavudine oral solution 1 mg/ml 1 TRIZIVIR TABLET 300-150-300 MG 1 TRUVADA TABLET 200-300 MG 1 VIDEX 2 GRAM PEDIATRIC ORAL SOLUTION 10 MG/ML (FINAL) 1 VIDEX 4 GRAM PEDIATRIC ORAL SOLUTION 10 MG/ML (FINAL) 1 VIREAD TABLET 300 MG 1 ZIAGEN ORAL SOLUTION 20 MG/ML 1 zidovudine capsule 100 mg 1 zidovudine syrup 10 mg/ml 1 zidovudine tablet 300 mg 1 Notes Nucleosides And Nucleotides acyclovir capsule 200 mg 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir tablet 400 mg, 800 mg 1 famciclovir 1 REBETOL ORAL SOLUTION 40 MG/ML 1 RIBAPAK DOSE PACK TABLETS 200 MG (28)- 400 MG (28) 1 RIBASPHERE CAPSULE 200 MG 1 ribavirin capsule 200 mg 1 SPN ribavirin tablet 200 mg 1 SPN valacyclovir tablet 1 g, 500 mg 1 VALCYTE TABLET 450 MG 1 Other Macrolides amoxicillin-clarithromycin-lansoprazole oral combo pack 500-500-30 mg 1 azithromycin oral packet 1 gram 1 azithromycin oral suspension 100 mg/5 ml, 200 mg/5 ml 1 azithromycin tablet 1 clarithromycin er tablet,extended release 24 hr 500 mg 1 clarithromycin oral suspension 125 mg/5 ml, 250 mg/5 ml 1 clarithromycin tablet 250 mg, 500 mg 1 10 QL (28 EA per 30 day(s)) QL (28 EA per 30 day(s)) Drug Name Tier Notes Penicillinase-Resistant Penicillins dicloxacillin capsule 250 mg, 500 mg 1 nafcillin intravenous solution 1 gram, 2 gram 1 nafcillin solution for injection 1 oxacillin intravenous solution 1 gram, 2 gram 1 oxacillin solution for injection 1 oxacillin in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 Polyenes amphotericin b solution for injection 50 mg 1 nystatin oral powder 1 nystatin oral suspension 100,000 unit/ml 1 nystatin tablet 500,000 unit 1 Pyrimidines flucytosine capsule 250 mg, 500 mg 1 Quinolones AVELOX TABLET 400 MG 1 AVELOX ABC PACK TABLET 400 MG 1 AVELOX IN SODIUM CHLORIDE (ISO-OSMOTIC) IV PIGGYBACK 400 MG/250 ML 1 CIPRO ORAL SUSPENSION 250 MG/5 ML, 500 MG/5 ML 1 ciprofloxacin intravenous solution 200 mg/20 ml, 400 mg/40 ml 1 ciprofloxacin tablet 1 ciprofloxacin in dextrose 5 % intravenous piggyback 200 mg/100 ml, 400 mg/200 ml 1 levofloxacin oral 1 levofloxacin oral solution 250 mg/10 ml 1 ofloxacin oral 1 QL (10 EA per 30 day(s)) Rifamycins MYCOBUTIN CAPSULE 150 MG 1 PRIFTIN TABLET 150 MG 1 rifampin capsule 150 mg, 300 mg 1 Second Generation Cephalosporins cefaclor capsule 250 mg, 500 mg 1 11 Drug Name Tier cefaclor er tablet,extended release,12 hr 500 mg 1 cefaclor oral suspension 1 cefotetan intravenous solution 10 gram 1 cefotetan solution for injection 1 gram, 2 gram 1 cefotetan in dextrose, iso-osmotic intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 cefoxitin iv 1 cefoxitin in dextrose, iso-osmotic intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 cefprozil oral suspension 125 mg/5 ml, 250 mg/5 ml 1 cefprozil tablet 250 mg, 500 mg 1 cefuroxime axetil tablet 250 mg, 500 mg 1 cefuroxime sodium intravenous solution 7.5 gram 1 cefuroxime sodium solution for injection 1.5 gram, 750 mg 1 cefuroxime in dextrose (iso-osmotic) intravenous piggyback 1.5 gram/50 ml, 750 mg/50 ml 1 Sulfonamides (Systemic) sulfadiazine tablet 500 mg 1 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml 1 sulfamethoxazole-trimethoprim tablet 400-80 mg, 800-160 mg 1 sulfasalazine tablet 500 mg 1 sulfasalazine tablet,delayed release 500 mg 1 SULFAZINE TABLET 500 MG 1 SULFAZINE EC TABLET,DELAYED RELEASE 500 MG 1 Tetracyclines demeclocycline tablet 150 mg, 300 mg 1 doxycycline hyclate capsule 100 mg, 50 mg 1 doxycycline hyclate tablet 100 mg 1 doxycycline monohydrate oral suspension 25 mg/5 ml 1 HELIDAC ORAL PACK 250-500-262.4 MG 1 minocycline capsule 1 12 Notes Drug Name Tier minocycline tablet 1 MORGIDOX CAPSULE 100 MG 1 tetracycline capsule 250 mg, 500 mg 1 VIBRAMYCIN SYRUP 50 MG/5 ML 1 Notes Third Generation Cephalosporins cefdinir capsule 300 mg 1 cefdinir oral suspension 125 mg/5 ml, 250 mg/5 ml 1 cefpodoxime oral suspension 100 mg/5 ml, 50 mg/5 ml 1 cefpodoxime tablet 100 mg, 200 mg 1 ceftazidime solution for injection 1 ceftriaxone intravenous solution 1 gram, 2 gram 1 ceftriaxone solution for injection 1 ceftriaxone in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 SUPRAX ORAL SUSPENSION 100 MG/5 ML 1 SUPRAX TABLET 400 MG 1 TAZICEF INJ 1 TAZICEF INTRAVENOUS SOLUTION 1 GRAM, 2 GRAM 1 Urinary Anti-Infectives MACRODANTIN CAPSULE 25 MG 1 methenamine mandelate tablet 0.5 g, 1 gram 1 nitrofurantoin oral suspension 25 mg/5 ml 1 nitrofurantoin macrocrystal capsule 100 mg, 50 mg 1 nitrofurantoin monohydrate/macrocrystals capsule 100 mg 1 PRIMSOL ORAL SOLUTION 50 MG/5 ML 1 trimethoprim tablet 100 mg 1 Antineoplastic Agents Antineoplastic Agents ALKERAN TABLET 2 MG 1 anastrozole tablet 1 mg 1 13 Drug Name Tier Notes AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 1 bicalutamide tablet 50 mg 1 cyclophosphamide tablet 25 mg, 50 mg 1 DROXIA 1 FARESTON TABLET 60 MG 1 fludarabine intravenous powder for solution 50 mg 1 flutamide capsule 125 mg 1 GLEEVEC TABLET 100 MG, 400 MG 1 HEXALEN CAPSULE 50 MG 1 hydroxyurea capsule 500 mg 1 letrozole tablet 2.5 mg 1 LEUKERAN TABLET 2 MG 1 leuprolide subcutaneous kit 1 mg/0.2 ml 1 lomustine capsule 1 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG 1 PA; SPN; QL (1 EA per 30 day(s)) LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG 1 PA; SPN; QL (1 EA per 30 day(s)) LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG 1 PA; SPN; QL (1 EA per 30 day(s)) LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG 1 PA; SPN; QL (1 EA per 30 day(s)) LUPRON DEPOT-PED 1 PA; SPN; QL (1 EA per 30 day(s)) LYSODREN TABLET 500 MG 1 MATULANE CAPSULE 50 MG 1 megestrol oral suspension 400 mg/10 ml (40 mg/ml) 1 megestrol tablet 20 mg, 40 mg 1 mercaptopurine tablet 50 mg 1 methotrexate sodium injection solution 25 mg/ml 1 methotrexate sodium tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 25 mg/ml 1 14 PA; SPN PA; SPN Drug Name Tier methotrexate sodium (pf) solution for injection 1 gram 1 MYLERAN TABLET 2 MG 1 NILANDRON TABLET 150 MG 1 TABLOID TABLET 40 MG 1 tamoxifen tablet 10 mg, 20 mg 1 temozolomide oral 1 tretinoin (chemotherapy) capsule 10 mg 1 TREXALL 1 Notes QL (10 EA per 180 day(s)) SPN Autonomic Drugs Alpha- And Beta-Adrenergic Agonists BROMFED DM SYRUP 2-30-10 MG/5 ML 1 epinephrine injection,auto-injector 0.3 mg/0.3 ml (1:1,000) 1 EPIPEN 2-PAK INJECTION,AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000) 1 EPIPEN JR 2-PAK INJECTION,AUTO-INJECTOR 0.15 MG/0.3 ML (1:2,000) 1 REZIRA ORAL SOLUTION 60-5 MG/5 ML 1 Alpha-Adrenergic Agonists methyldopa tablet 250 mg, 500 mg 1 methyldopa-hydrochlorothiazide tablet 250-15 mg, 250-25 mg 1 Antimuscarinics/Antispasmodics ATROVENT HFA AEROSOL INHALER 17 MCG/ACTUATION 1 QL (2 GM per 30 day(s)) COMBIVENT AEROSOL INHALER 18-103 MCG/ACTUATION 1 QL (2 GM per 30 day(s)) COMBIVENT RESPIMAT AEROSOL INHALER 20-100 MCG/ACTUATION 1 QL (2 GM per 30 day(s)) dicyclomine capsule 10 mg 1 dicyclomine oral solution 10 mg/5 ml 1 dicyclomine tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 1 diphenoxylate-atropine tablet 2.5-0.025 mg 1 15 Drug Name Tier Notes DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML 1 DONNATAL TABLET 16.2-0.1037 -0.0194 MG 1 hydrocodone-homatropine syrup 5-1.5 mg/5 ml 1 QL (900 ML per 30 day(s)) hydrocodone-homatropine tablet 5-1.5 mg 1 QL (180 EA per 30 day(s)) HYDROMET SYRUP 5-1.5 MG/5 ML 1 ipratropium bromide solution for inhalation 0.02 % 1 ipratropium-albuterol solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml 1 phenobarb-hyoscyamn-atropine-scop tablet 16.2-0.1037 -0.0194 mg 1 propantheline tablet 15 mg 1 SPIRIVA WITH HANDIHALER & INHALATION CAPSULES 18 MCG 1 TUSSIGON TABLET 5-1.5 MG 1 PA; QL (1 EA per 30 day(s)) Antiparkinsonian Agents benztropine oral 1 trihexyphenidyl oral elixir 0.4 mg/ml 1 trihexyphenidyl tablet 2 mg, 5 mg 1 Autonomic Drugs, Miscellaneous NICOTROL INHALATION CARTRIDGE 10 MG 1 NICOTROL NS NASAL SPRAY 10 MG/ML 1 Centrally Acting Skeletal Muscle Relaxnt chlorzoxazone tablet 500 mg 1 cyclobenzaprine tablet 10 mg, 5 mg 1 methocarbamol tablet 500 mg, 750 mg 1 tizanidine tablet 2 mg, 4 mg 1 Direct-Acting Skeletal Muscle Relaxants dantrolene oral 1 Gaba-Derivative Skeletal Muscle Relaxant baclofen tablet 10 mg, 20 mg 1 Non-Sel. Beta-Adrenergic Blocking Agents nadolol tablet 1 pindolol tablet 10 mg, 5 mg 1 16 SPN Drug Name Tier propranolol er capsule,24 hr,extended release 1 propranolol oral solution 20 mg/5 ml, 40 mg/5 ml 1 propranolol tablet 1 propranolol-hydrochlorothiazide tablet 40-25 mg, 80-25 mg 1 SORINE 1 sotalol oral 1 SOTALOL AF 1 timolol maleate oral 1 Notes Non-Sel.Alpha-1-Adrenergic Blocking Agts doxazosin tablet 1 prazosin oral 1 terazosin capsule 1 Non-Sel.Alpha-Adrenergic Blocking Agents DIBENZYLINE CAPSULE 10 MG 1 dihydroergotamine injection solution 1 mg/ml 1 dihydroergotamine nasal spray 0.5 mg/pump act. (4 mg/ml) 1 ERGOMAR SUBLINGUAL TABLET 2 MG 1 ergotamine-caffeine tablet 1-100 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG 1 QL (8 ML per 30 day(s)) Parasympathomimetic (Cholinergic Agents) bethanechol chloride oral 1 cevimeline capsule 30 mg 1 donepezil disintegrating tablet 10 mg, 5 mg 1 QL (30 EA per 30 day(s)) donepezil tablet 1 QL (30 EA per 30 day(s)) EXELON ORAL SOLUTION 2 MG/ML 1 PA EXELON TRANSDERMAL 24 HOUR PATCH 4.6 MG/24 HOUR, 9.5 MG/24 HOUR 1 PA galantamine tablet 1 QL (60 EA per 30 day(s)) MESTINON SYRUP 60 MG/5 ML 1 MESTINON TIMESPAN TABLET,EXTENDED RELEASE 180 MG 1 pilocarpine tablet 5 mg 1 17 Drug Name Tier PROSTIGMIN TABLET 15 MG 1 pyridostigmine bromide tablet 60 mg 1 rivastigmine capsule 1 Notes PA; QL (60 EA per 30 day(s)) Selective Alpha-1-Adrenergic Block.Agent alfuzosin er tablet,extended release 24 hr 10 mg 1 carvedilol 1 labetalol oral 1 tamsulosin er capsule,extended release 24 hr 0.4 mg 1 QL (30 EA per 30 day(s)) ADVAIR DISKUS 1 QL (1 EA per 30 day(s)) ADVAIR HFA 1 QL (1 GM per 30 day(s)) albuterol sulfate er tablet,extended release,12 hr 4 mg, 8 mg 1 albuterol sulfate solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml 1 QL (360 ML per 30 day(s)) albuterol sulfate solution for nebulization 2.5 mg /3 ml (0.083 %) 1 QL (375 ML per 30 day(s)) albuterol sulfate solution for nebulization 2.5 mg/0.5 ml 1 QL (160 EA per 30 day(s)) albuterol sulfate solution for nebulization 5 mg/ml 1 QL (80 ML per 30 day(s)) albuterol sulfate syrup 2 mg/5 ml 1 albuterol sulfate tablet 2 mg, 4 mg 1 DULERA HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION 1 metaproterenol syrup 10 mg/5 ml 1 metaproterenol tablet 10 mg, 20 mg 1 SEREVENT DISKUS POWDER FOR INHALATION 50 MCG/DOSE 1 QL (1 EA per 30 day(s)) SYMBICORT HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION 1 QL (1 GM per 30 day(s)) terbutaline tablet 2.5 mg, 5 mg 1 VENTOLIN HFA AEROSOL INHALER 90 MCG/ACTUATION 1 Selective Beta-2-Adrenergic Agonists Selective Beta-Adrenergic Blocking Agent 18 QL (1 GM per 30 day(s)) QL (2 GM per 30 day(s)) Drug Name Tier acebutolol capsule 200 mg, 400 mg 1 atenolol oral 1 atenolol-chlorthalidone tablet 100-25 mg, 50-25 mg 1 betaxolol tablet 10 mg, 20 mg 1 bisoprolol fumarate tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide 1 metoprolol succinate er tablet,extended release 24 hr 1 metoprolol ta-hydrochlorothiaz 1 metoprolol tartrate oral 1 Notes Skeletal Muscle Relaxants, Miscellaneous orphenadrine citrate er tablet,extended release 100 mg 1 Blood Formation,Coagulation & Thrombosis Coumarin Derivatives COUMADIN ORAL 1 JANTOVEN 1 warfarin oral 1 Direct Factor Xa Inhibitors ELIQUIS TABLET 2.5 MG, 5 MG 1 fondaparinux 1 QL (10 ML per 30 day(s)) XARELTO TABLET 10 MG, 20 MG 1 QL (30 EA per 30 day(s)) XARELTO TABLET 15 MG 1 QL (60 EA per 30 day(s)) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 1 PA; SPN NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 1 PA; SPN PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 1 PA; SPN Hematopoietic Agents Hemorrheologic Agents pentoxifylline er tablet,extended release 400 mg 1 Hemostatics aminocaproic acid oral solution 25 % 1 aminocaproic acid tablet 1,000 mg, 500 mg 1 19 Drug Name Tier ASTRINGYN TOPICAL SOLUTION 259 MG/G 1 desmopressin injection solution 4 mcg/ml 1 desmopressin nasal solution 0.1 mg/ml (refrig) 1 desmopressin nasal spray 10 mcg/spray (0.1 ml) 1 desmopressin tablet 0.1 mg, 0.2 mg 1 Notes Heparins enoxaparin subcutaneous solution 300 mg/3 ml 1 QL (28 ML per 30 day(s)) enoxaparin subcutaneous syringe 1 QL (28 ML per 30 day(s)) FRAGMIN SUBCUTANEOUS SOLUTION 25,000 UNIT/ML 1 QL (10 ML per 30 day(s)) FRAGMIN SUBCUTANEOUS SYRINGE 1 QL (10 ML per 30 day(s)) heparin (porcine) injection solution 1 heparin (porcine) in dextrose 5 % intravenous solution 1 heparin (porcine) in 0.9 % sodium chloride (pf) iv solution 1,000 unit/500 ml, 2,000 unit/1,000 ml 1 HEPARIN FLUSH INTRAVENOUS KIT 10 UNIT/ML 1 heparin flush(porcine)-0.9 % sodium chloride intravenous kit 100 unit/ml 1 HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML 1 HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION 10 UNIT/ML 1 heparin lock flush (porcine) intravenous solution 10 unit/ml, 100 unit/ml 1 heparin (porcine) in 0.45 % nacl intravenous solution 1 Iron Preparations B-PLEX PLUS TABLET 27-0.8 MG 1 BACMIN TABLET 27-1 MG 1 FE C PLUS TABLET 100-250-25-1 MG-MG-MCG-MG 1 FEROCON CAPSULE 110-0.5 MG 1 FERREX 150 FORTE CAPSULE 150-25-1 MG-MCG-MG 1 FERROCITE PLUS TABLET 106 MG IRON- 1 MG 1 20 Drug Name Tier FERROGELS FORTE CAPSULE 460-60-0.01-1 MG 1 HEMATINIC PLUS VIT/MINERALS TABLET 106 MG IRON- 1 MG 1 HEMATINIC/FOLIC ACID TABLET 324 MG (106 MG IRON)-1 MG 1 HEMATOGEN FA CAPSULE 200-250-0.01-1 MG 1 HEMATOGEN FORTE CAPSULE 460-60-0.01-1 MG 1 HEMATRON ORAL LIQUID 50 MG IRON-1 MG/5 ML 1 IFEREX 150 FORTE CAPSULE 150-25-1 MG-MCG-MG 1 INATAL ADVANCE TABLET 90-1-50 MG 1 INATAL ULTRA TABLET 90-1-50 MG 1 INFED INJECTION SOLUTION 100 MG/2 ML (50 MG/ML) 1 M-VIT TABLET 27-1 MG 1 MULTI VIT-FLUORIDE-IRON ORAL DROPS 0.25-10 MG/ML 1 MULTI-VIT W/IRON & FLUORIDE ORAL DROPS 0.25-10 MG/ML 1 MYFERON 150 FORTE CAPSULE 150-25-1 MG-MCG-MG 1 MYNATAL CAPSULE 65-1 MG 1 MYNATAL ADVANCE TABLET 90-1-50 MG 1 MYNATAL PLUS TABLET 65-1 MG 1 MYNATAL-Z TABLET 65-1 MG 1 NATAL-V RX TABLET 29 MG IRON- 1 MG 1 NATALVIRT 90 DHA ORAL PACK 90-1-50-300 MG 1 NATALVIRT CA ORAL PACK 35-1-50-300 MG 1 NATALVIT TABLET 75-1 MG 1 NEPHRON FA TABLET 1 NUTRICAP TABLET 1 MG 1 Notes 21 Drug Name Tier O-CAL FA TABLET 66-1 MG 1 O-CAL PRENATAL TABLET 15-1 MG 1 ped multivitamin-fl-iron oral drops 0.25-10 mg/ml 1 PNV OB+DHA ORAL PACK 27-1-50-250 MG 1 prenatal vitamin with calcium no.72-iron-fa tablet 27-1 mg 1 PNV-SELECT TABLET 27-1 MG 1 POLY-IRON 150 FORTE CAPSULE 150-25-1 MG-MCG-MG 1 POLYSACCHARIDE IRON FORTE CAPSULE 150-25-1 MG-MCG-MG 1 PRENAISSANCE 90 DHA ORAL PACK 90-1-50-300 MG 1 PRENAISSANCE DHA ORAL PACK 27-1-50-250 MG 1 PRENAISSANCE PROMISE ORAL PACK 35-1-50-300 MG 1 PRENAPLUS TABLET 27-1 MG 1 PRENATAL AD TABLET 90-1-50 MG 1 PRENATAL PLUS (CALCIUM CARBONATE) TABLET 27-1 MG 1 SIDEROL ORAL LIQUID 1 SIDEROL TABLET 1 THERAPEUTIC FORMULA/HEMATINICS TABLET 1 TL ICON CAPSULE 110-0.5 MG 1 TL-FOL 500 TABLET,EXTENDED RELEASE 105 MG IRON- 500 MG-800 MCG 1 TRI-VIT WITH FLUORIDE & IRON ORAL DROPS 0.25-10 MG/ML 1 TRIADVANCE TABLET 90-1-50 MG 1 TRICON CAPSULE 110-0.5 MG 1 TRIGELS-F FORTE CAPSULE 460-60-0.01-1 MG 1 TRINATAL GT TABLET 90-1-50 MG 1 TRINATAL ULTRA TABLET 90-1-50 MG 1 22 Notes Drug Name Tier VINATE GT TABLET 90-1-50 MG 1 VINATE ULTRA TABLET 90-1-50 MG 1 VIRT-PN TABLET 27-1 MG 1 VITAFOL TABLET 65-1 MG 1 VITAFOL-OB TABLET 65-1 MG 1 VITAFOL-PN (UD) TABLET 65-1 MG 1 VOL-PLUS TABLET 27-1 MG 1 VOL-TAB RX TABLET 29 MG IRON- 1 MG 1 VYNATAL FA TABLET 65-1 MG 1 ZATEAN-PN TABLET 27-1 MG 1 Notes Platelet-Aggregation Inhibitors AGGRENOX CAPSULE, EXTENDED RELEASE 200-25 MG 1 BUTALBITAL COMPOUND TABLET 50-325-40 MG 1 butalbital-aspirin-caffeine capsule 50-325-40 mg 1 butalbital-aspirin-caffeine tablet 50-325-40 mg 1 cilostazol tablet 100 mg, 50 mg 1 clopidogrel tablet 300 mg, 75 mg 1 dipyridamole oral 1 ticlopidine tablet 250 mg 1 Platelet-Reducing Agents anagrelide capsule 0.5 mg, 1 mg 1 Cardiovascular Drugs Angiotensin Ii Receptor Antagon.(Hypotn) irbesartan 1 losartan 1 Angiotensin-Convert.Enzyme Inhib(Hypotn) benazepril 1 captopril 1 enalapril maleate tablet 1 fosinopril 1 lisinopril 1 quinapril 1 ramipril capsule 1 23 Drug Name Tier Notes Antiarrhythmics, Miscellaneous digoxin oral solution 50 mcg/ml 1 digoxin tablet 125 mcg, 250 mcg 1 LANOXIN TABLET 125 MCG, 250 MCG 1 Antilipemic Agents, Miscellaneous niacin er tablet,extended release 24 hr 1 NIACOR TABLET 500 MG 1 Bile Acid Sequestrants cholestyramine (with sugar) oral powder 4 gram 1 cholestyramine (with sugar) powder for susp in a packet 4 gram 1 CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM 1 CHOLESTYRAMINE LIGHT POWDER FOR SUSP IN A PACKET 4 GRAM 1 COLESTID FLAVORED PACKET 7.5 GRAM 1 colestipol oral granules 5 gram 1 colestipol oral packet 5 gram 1 colestipol tablet 1 gram 1 PREVALITE ORAL POWDER 4 GRAM 1 PREVALITE POWDER FOR SUSP IN A PACKET 4 GRAM 1 Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide tablet 125 mg, 250 mg 1 Cardiac Drugs, Miscellaneous RANEXA TABLET,EXTENDED RELEASE 1,000 MG, 500 MG 1 Central Alpha-Agonists clonidine tablet 1 clonidine weekly transdermal patch 1 CLORPRES 1 guanfacine tablet 1 mg, 2 mg 1 INTUNIV ER 1 Class Ia Antiarrhythmics disopyramide capsule 100 mg, 150 mg 24 1 QL (30 EA per 30 day(s)) Drug Name NORPACE CR CAPSULE,EXTENDED RELEASE 100 MG, 150 MG Tier Notes 1 Class Ib Antiarrhythmics DILANTIN CAPSULE 30 MG 1 mexiletine 1 phenytoin chewable tablet 50 mg 1 phenytoin oral suspension 125 mg/5 ml 1 phenytoin sodium extended capsule 100 mg 1 Class Ic Antiarrhythmics flecainide 1 propafenone tablet 1 Class Iii Antiarrhythmics amiodarone intravenous syringe 150 mg/3 ml 1 amiodarone tablet 1 MULTAQ TABLET 400 MG 1 PACERONE TABLET 200 MG 1 TIKOSYN 1 Class Iv Antiarrhythmics CARTIA XT CAPSULE,EXTENDED RELEASE 1 DILT-CD 1 DILT-XR 1 diltiazem cd capsule,extended release 24 hr 1 diltiazem er (xr/xt) capsule,extended release,controlled 1 diltiazem er capsule,extended release 1 diltiazem er capsule,extended release 12 hr 1 diltiazem intravenous powder for solution 100 mg 1 diltiazem tablet 1 DILTZAC ER 1 TAZTIA XT 1 verapamil er (sr) tablet,extended release 1 verapamil er 24 hr capsule,extended release 1 verapamil tablet 1 SPN QL (30 EA per 30 day(s)) Dihydropyridines (Hypotensive Agents) 25 Drug Name Tier AFEDITAB CR TABLET,EXTENDED RELEASE 30 MG, 60 MG 1 amlodipine 1 amlodipine-benazepril 1 felodipine er tablet,extended release 24 hr 1 NIFEDICAL XL TABLET,EXTENDED RELEASE 30 MG, 60 MG 1 nifedipine er tablet,extended release 1 nifedipine er tablet,extended release 24 hr 1 nimodipine capsule 30 mg 1 Direct Vasodilators hydralazine oral 1 minoxidil tablet 10 mg, 2.5 mg 1 Diuretics, Miscellaneous (Hypotensive) ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 1 THEOCHRON TABLET,EXTENDED RELEASE 1 theophylline er tablet,extended release 400 mg, 600 mg 1 theophylline er tablet,extended release,12 hr 1 theophylline oral elixir 80 mg/15 ml 1 theophylline oral solution 80 mg/15 ml 1 theophylline in dextrose 5 % intravenous solution 1 Fibric Acid Derivatives fenofibrate tablet 160 mg, 54 mg 1 fenofibrate micronized capsule 1 fenofibrate nanocrystallized tablet 145 mg, 48 mg 1 gemfibrozil tablet 600 mg 1 LOFIBRA 1 LOFIBRA TABLET 160 MG, 54 MG 1 Hmg-Coa Reductase Inhibitors atorvastatin 1 lovastatin tablet 1 pravastatin 1 26 Notes Drug Name simvastatin Tier Notes 1 Loop Diuretics (Hypotensive Agents) bumetanide oral 1 EDECRIN TABLET 25 MG 1 furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 furosemide tablet 1 torsemide oral 1 Nitrates And Nitrites DILATRATE-SR CAPSULE,EXTENDED RELEASE 40 MG 1 ISOCHRON TABLET,EXTENDED RELEASE 40 MG 1 ISODITRATE TABLET,EXTENDED RELEASE 40 MG 1 ISORDIL TABLET 40 MG 1 isosorbide dinitrate er tablet,extended release 40 mg 1 isosorbide dinitrate sublingual tablet 2.5 mg, 5 mg 1 isosorbide dinitrate tablet 1 isosorbide mononitrate er tablet,extended release 24 hr 1 isosorbide mononitrate tablet 10 mg, 20 mg 1 MINITRAN 1 NITRO-BID TRANSDERMAL OINTMENT 2 % 1 NITRO-DUR TRANSDERMAL 24 HOUR PATCH 0.3 MG/HR, 0.8 MG/HR 1 NITRO-TIME 1 nitroglycerin oral 1 nitroglycerin transdermal 24 hour patch 1 nitroglycerin translingual spray 0.4 mg/dose 1 nitroglycerin translingual spray, aerosol 0.4 mg/dose 1 NITROSTAT SUBLINGUAL 1 Peripheral Adrenergic Inhibitors reserpine tablet 0.1 mg, 0.25 mg 1 Potassium-Sparing Diuretics (Hypoten) 27 Drug Name Tier amiloride tablet 5 mg 1 amiloride-hydrochlorothiazide tablet 5-50 mg 1 DYRENIUM CAPSULE 100 MG, 50 MG 1 spironolactone-hydrochlorothiazide tablet 25-25 mg 1 spironolactone 1 triamterene-hydrochlorothiazide capsule 37.5-25 mg 1 triamterene-hydrochlorothiazide tablet 37.5-25 mg, 75-50 mg 1 Notes Thiazide Diuretics(Hypotensive Agents) benazepril-hydrochlorothiazide 1 captopril-hydrochlorothiazide 1 chlorothiazide tablet 250 mg, 500 mg 1 DIURIL ORAL SUSPENSION 250 MG/5 ML 1 enalapril-hydrochlorothiazide tablet 10-25 mg, 5-12.5 mg 1 fosinopril-hydrochlorothiazide tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide capsule 12.5 mg 1 hydrochlorothiazide tablet 1 irbesartan-hydrochlorothiazide tablet 150-12.5 mg, 300-12.5 mg 1 lisinopril-hydrochlorothiazide tablet 1 losartan-hydrochlorothiazide 1 methyclothiazide tablet 5 mg 1 quinapril-hydrochlorothiazide 1 Thiazide-Like Diuretics(Hypotensive Agt) chlorthalidone tablet 25 mg, 50 mg 1 indapamide tablet 1.25 mg, 2.5 mg 1 metolazone tablet 1 Vasodilating Agents, Miscellaneous alprostadil injection solution 500 mcg/ml 1 LETAIRIS TABLET 10 MG, 5 MG 1 Central Nervous System Agents Amphetamines 28 SPN; QL (30 EA per 30 day(s)) Drug Name Tier Notes AMPHETAMINE SALT COMBO 1 QL (60 EA per 30 day(s)) dextroamphetamine er capsule,extended release 10 mg 1 QL (60 EA per 30 day(s)) dextroamphetamine er capsule,extended release 15 mg 1 QL (120 EA per 30 day(s)) dextroamphetamine er capsule,extended release 5 mg 1 QL (90 EA per 30 day(s)) dextroamphetamine tablet 10 mg 1 QL (180 EA per 30 day(s)) dextroamphetamine tablet 5 mg 1 QL (90 EA per 30 day(s)) dextroamphetamine-amphetamine er 24hr capsule,extend release 10 mg, 15 mg, 5 mg 1 QL (30 EA per 30 day(s)) dextroamphetamine-amphetamine er 24hr capsule,extend release 20 mg, 25 mg, 30 mg 1 QL (60 EA per 30 day(s)) methamphetamine tablet 5 mg 1 QL (150 EA per 30 day(s)) VYVANSE 1 QL (30 EA per 30 day(s)) ZENZEDI TABLET 10 MG, 5 MG 1 Analgesics And Antipyretics, Misc. ALAGESIC LQ ORAL SOLUTION 50-325-40 MG/15 ML 1 butalbital-acetaminophen tablet 50-325 mg 1 butalbital-acetaminophen-caffeine capsule 50-325-40 mg 1 butalbital-acetaminophen-caffeine tablet 50-325-40 mg, 50-500-40 mg 1 CAPACET CAPSULE 50-325-40 MG 1 FIORICET TABLET 50-325-40 MG 1 gabapentin capsule 1 gabapentin oral solution 250 mg/5 ml 1 gabapentin tablet 600 mg 1 QL (180 EA per 30 day(s)) gabapentin tablet 800 mg 1 QL (120 EA per 30 day(s)) PHRENILIN FORTE CAPSULE 50-650 MG 1 PROMACET TABLET 50-650 MG 1 TENCON TABLET 50-650 MG 1 ZEBUTAL CAPSULE 50-500-40 MG 1 QL (180 EA per 30 day(s)) Anticonvulsants, Miscellaneous carbamazepine chewable tablet 100 mg 1 carbamazepine er tablet,extended release,12 hr 200 mg, 400 mg 1 29 Drug Name Tier carbamazepine oral suspension 100 mg/5 ml 1 carbamazepine tablet 200 mg 1 DEPAKENE CAPSULE 250 MG 1 DEPAKENE ORAL SOLUTION 250 MG/5 ML 1 divalproex er tablet,extended release 24 hr 250 mg, 500 mg 1 divalproex sprinkle capsule 125 mg 1 divalproex tablet,delayed release 1 EPITOL TABLET 200 MG 1 felbamate oral suspension 600 mg/5 ml 1 felbamate tablet 400 mg, 600 mg 1 GABITRIL TABLET 12 MG, 16 MG 1 LAMICTAL STARTER (GREEN) KIT TABLETS, DOSE PACK 25 MG (84) -100 MG (14) 1 LAMICTAL STARTER (ORANGE) KIT TABLETS, DOSE PACK 25 MG (42) -100 MG (7) 1 lamotrigine chewable dispersible tablet 25 mg, 5 mg 1 lamotrigine tablet 1 lamotrigine tablets in a dose pack 25 mg (35) 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam tablet 1 oxcarbazepine tablet 1 TEGRETOL XR TABLET,EXTENDED RELEASE 100 MG 1 tiagabine tablet 2 mg, 4 mg 1 TOPIRAGEN 1 topiramate sprinkle capsule 15 mg, 25 mg 1 topiramate tablet 1 valproic acid capsule 250 mg 1 valproic acid (as sodium salt) oral solution 250 mg/5 ml 1 zonisamide 1 Antidepressants, Miscellaneous 30 Notes Drug Name Tier BUDEPRION SR TABLET,EXTENDED RELEASE 150 MG 1 BUPROBAN TABLET,EXTENDED RELEASE 150 MG 1 bupropion hcl sr tablet,sustained-release 1 bupropion hcl tablet 100 mg, 75 mg 1 bupropion hcl xl 24 hr tablet, extended release 150 mg, 300 mg 1 mirtazapine tablet 1 Notes QL (30 EA per 30 day(s)) Antimanic Agents lithium carbonate er tablet,extended release 300 mg, 450 mg 1 lithium carbonate tablet 300 mg 1 lithium citrate oral solution 8 meq/5 ml 1 Antipsychotics, Miscellaneous loxapine succinate 1 ORAP TABLET 1 MG, 2 MG 1 Anxiolytics, Sedatives & Hypnotics,Misc. buspirone 1 droperidol injection solution 2.5 mg/ml 1 zaleplon capsule 10 mg, 5 mg 1 QL (30 EA per 30 day(s)) zolpidem tablet 10 mg, 5 mg 1 QL (30 EA per 30 day(s)) ABILIFY TABLET 1 PA; QL (30 EA per 30 day(s)) clozapine tablet 1 LATUDA TABLET 120 MG, 20 MG, 40 MG 1 PA; QL (30 EA per 30 day(s)) LATUDA TABLET 80 MG 1 PA; QL (60 EA per 30 day(s)) olanzapine tablet 1 PA; QL (30 EA per 30 day(s)) quetiapine tablet 100 mg, 200 mg, 25 mg, 300 mg, 50 mg 1 PA; QL (90 EA per 30 day(s)) quetiapine tablet 400 mg 1 PA; QL (60 EA per 30 day(s)) RISPERDAL CONSTA 1 QL (2 EA per 28 day(s)) risperidone disintegrating tablet 0.25 mg 1 PA; QL (60 EA per 30 day(s)) risperidone oral solution 1 mg/ml 1 PA risperidone tablet 1 PA; QL (60 EA per 30 day(s)) SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG 1 PA; QL (60 EA per 30 day(s)) Atypical Antipsychotics 31 Drug Name Tier Notes SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG 1 PA; QL (60 EA per 30 day(s)) SEROQUEL XR 1 QL (60 EA per 30 day(s)) ziprasidone capsule 20 mg, 40 mg, 80 mg 1 PA; QL (60 EA per 30 day(s)) ziprasidone capsule 60 mg 1 PA; QL (90 EA per 30 day(s)) Barbiturates (Anticonvulsants) MYSOLINE TABLET 250 MG, 50 MG 1 phenobarbital oral elixir 20 mg/5 ml 1 phenobarbital tablet 1 primidone tablet 250 mg, 50 mg 1 Benzodiazepines (Anticonvulsants) clonazepam tablet 1 clorazepate dipotassium tablet 1 diazepam oral solution 5 mg/5 ml 1 diazepam rectal kit 1 diazepam tablet 1 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 1 Benzodiazepines (Anxiolytic,Sedativ/Hyp) alprazolam tablet 1 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML 1 chlordiazepoxide hcl oral 1 lorazepam oral 1 lorazepam oral concentrate 2 mg/ml 1 LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML 1 oxazepam capsule 1 temazepam capsule 1 triazolam tablet 0.125 mg, 0.25 mg 1 Butyrophenones haloperidol 1 haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml 1 haloperidol injection solution 5 mg/ml 1 haloperidol oral concentrate 2 mg/ml 1 32 Drug Name Tier Notes Catechol-O-Methyltransferase(Comt)Inhib. entacapone tablet 200 mg 1 Central Nervous System Agents, Misc. riluzole tablet 50 mg 1 STRATTERA CAPSULE 10 MG, 18 MG, 25 MG, 40 MG 1 QL (60 EA per 30 day(s)) STRATTERA CAPSULE 100 MG, 60 MG, 80 MG 1 QL (30 EA per 30 day(s)) Dopamine Precursors carbidopa-levodopa er tablet,extended release 25-100 mg, 50-200 mg 1 carbidopa-levodopa tablet 1 Ergot-Deriv. Dopamine Receptor Agonists bromocriptine capsule 5 mg 1 bromocriptine tablet 2.5 mg 1 Inhalation Anesthetics sevoflurane inhalation liquid 1 SOJOURN INHALATION LIQUID 1 SUPRANE INHALATION LIQUID 1 Monoamine Oxidase Inhibitors phenelzine tablet 15 mg 1 selegiline capsule 5 mg 1 selegiline tablet 5 mg 1 tranylcypromine tablet 10 mg 1 Nonergot-Deriv.Dopamine Receptor Agonist pramipexole tablet 1 ropinirole tablet 1 Opiate Agonists acetaminophen-codeine oral solution 120-12 mg/5 ml 1 QL (2700 ML per 30 day(s)) acetaminophen-codeine tablet 1 QL (180 EA per 30 day(s)) belladonna alkaloids-opium rectal suppository 16.2-60 mg 1 BELLADONNA-OPIUM RECTAL SUPPOSITORY 16.2-30 MG 1 codeine sulfate tablet 1 ENDOCET TABLET 1 QL (180 EA per 30 day(s)) 33 Drug Name Tier Notes fentanyl transdermal patch 1 QL (10 EA per 30 day(s)) hydrocodone-acetaminophen oral solution 7.5-500 mg/15 ml 1 QL (2700 ML per 30 day(s)) hydrocodone-acetaminophen tablet 10-325 mg, 10-500 mg, 10-650 mg, 10-660 mg, 2.5-500 mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg, 7.5-650 mg 1 QL (180 EA per 30 day(s)) hydrocodone-acetaminophen tablet 7.5-750 mg 1 QL (150 EA per 30 day(s)) hydromorphone oral liquid 1 mg/ml 1 QL (1000 ML per 30 day(s)) hydromorphone rectal suppository 3 mg 1 hydromorphone tablet 1 LORTAB TABLET 5-500 MG 1 meperidine oral solution 50 mg/5 ml 1 QL (1000 ML per 30 day(s)) meperidine tablet 100 mg, 50 mg 1 QL (180 EA per 30 day(s)) MEPERITAB TABLET 100 MG 1 QL (180 EA per 30 day(s)) methadone tablet 10 mg, 5 mg 1 QL (300 EA per 30 day(s)) morphine er tablet,extended release 1 QL (90 EA per 30 day(s)) morphine oral solution 10 mg/5 ml, 20 mg/5 ml 1 QL (1000 ML per 30 day(s)) morphine rect 1 morphine tablet 15 mg, 30 mg 1 QL (180 EA per 30 day(s)) morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) 1 QL (1000 ML per 30 day(s)) OPANA ER TABLET, CRUSH RESISTANT, EXT. REL. 1 oxycodone capsule 5 mg 1 QL (150 EA per 30 day(s)) oxycodone oral concentrate 20 mg/ml 1 QL (1000 ML per 30 day(s)) oxycodone oral solution 5 mg/5 ml 1 QL (1000 ML per 30 day(s)) oxycodone tablet 1 QL (150 EA per 30 day(s)) oxycodone-acetaminophen capsule 5-500 mg 1 QL (150 EA per 30 day(s)) oxycodone-acetaminophen tablet 1 QL (150 EA per 30 day(s)) oxymorphone er tablet,extended release,12 hr 1 QL (60 EA per 30 day(s)) oxymorphone tablet 10 mg, 5 mg 1 QL (150 EA per 30 day(s)) ROXICET ORAL SOLUTION 5-325 MG/5 ML 1 QL (1000 ML per 30 day(s)) ROXICET TABLET 5-325 MG 1 tramadol tablet 50 mg 1 QL (240 EA per 30 day(s)) tramadol-acetaminophen tablet 37.5-325 mg 1 QL (240 EA per 30 day(s)) 34 QL (180 EA per 30 day(s)) Drug Name Tier Notes Opiate Antagonists DEPADE TABLET 50 MG 1 naltrexone tablet 50 mg 1 REVIA TABLET 50 MG 1 Opiate Partial Agonists buprenorphine sublingual tablet 2 mg, 8 mg 1 PA; QL (60 EA per 30 day(s)) SUBOXONE SUBLINGUAL FILM 1 PA; QL (60 EA per 30 day(s)) Other Nonsteroidal Anti-Inflam. Agents diclofenac er tablet,extended release 24 hr 100 mg 1 diclofenac sodium tablet,delayed release 1 diflunisal tablet 500 mg 1 etodolac capsule 200 mg, 300 mg 1 etodolac er tablet,extended release 24 hr 1 etodolac tablet 400 mg, 500 mg 1 flurbiprofen tablet 100 mg, 50 mg 1 hydrocodone-ibuprofen tablet 7.5-200 mg 1 ibuprofen tablet 1 indomethacin capsule 25 mg, 50 mg 1 indomethacin er capsule,extended release 75 mg 1 ketoprofen capsule 50 mg, 75 mg 1 ketoprofen er 24 hr capsule,extended release 200 mg 1 meloxicam oral suspension 7.5 mg/5 ml 1 meloxicam tablet 15 mg, 7.5 mg 1 nabumetone tablet 500 mg, 750 mg 1 naproxen oral suspension 125 mg/5 ml 1 naproxen tablet 1 naproxen tablet,delayed release 375 mg, 500 mg 1 naproxen sodium tablet 275 mg, 550 mg 1 piroxicam capsule 10 mg, 20 mg 1 sulindac tablet 150 mg, 200 mg 1 VOLTAREN TOPICAL GEL 1 % 1 QL (150 EA per 30 day(s)) PA Phenothiazines chlorpromazine tablet 1 COMPRO RECTAL SUPPOSITORY 25 MG 1 35 Drug Name Tier fluphenazine decanoate injection solution 25 mg/ml 1 fluphenazine oral concentrate 5 mg/ml 1 fluphenazine oral elixir 2.5 mg/5 ml 1 fluphenazine tablet 1 perphenazine tablet 1 prochlorperazine rectal suppository 25 mg 1 prochlorperazine maleate tablet 10 mg, 5 mg 1 thioridazine tablet 1 trifluoperazine tablet 1 Notes Respiratory And Cns Stimulants dexmethylphenidate tablet 1 QL (60 EA per 30 day(s)) FOCALIN XR 1 QL (30 EA per 30 day(s)) METADATE ER TABLET,EXTENDED RELEASE 20 MG 1 methylphenidate er multiphase capsule 30-70,extended release 1 methylphenidate er tablet,extended release 10 mg 1 methylphenidate er tablet,extended release 20 mg 1 QL (120 EA per 30 day(s)) methylphenidate er tablet,extended release 24 hr 18 mg, 27 mg, 54 mg 1 QL (30 EA per 30 day(s)) methylphenidate er tablet,extended release 24 hr 36 mg 1 QL (60 EA per 30 day(s)) methylphenidate oral solution 10 mg/5 ml 1 QL (900 ML per 30 day(s)) methylphenidate oral solution 5 mg/5 ml 1 methylphenidate tablet 10 mg, 5 mg 1 QL (90 EA per 30 day(s)) methylphenidate tablet 20 mg 1 QL (120 EA per 30 day(s)) QL (30 EA per 30 day(s)) Salicylates choline & magnesium salicylate oral liquid 500 mg/5 ml 1 ENDODAN TABLET 4.8355-325 MG 1 oxycodone-aspirin tablet 4.8355-325 mg 1 salsalate tablet 500 mg, 750 mg 1 QL (150 EA per 30 day(s)) Sel. Serotonin & Norepi Reuptake Inhibtr CYMBALTA 36 1 QL (60 EA per 30 day(s)) Drug Name Tier Notes PRISTIQ TABLET,EXTENDED RELEASE 100 MG, 50 MG 1 QL (30 EA per 30 day(s)) venlafaxine er capsule,extended release 24 hr 150 mg 1 QL (60 EA per 30 day(s)) venlafaxine er capsule,extended release 24 hr 37.5 mg, 75 mg 1 QL (30 EA per 30 day(s)) venlafaxine er tablet,extended release 24 hr 225 mg 1 venlafaxine tablet 1 Selective Serotonin Agonists rizatriptan disintegrating tablet 10 mg, 5 mg 1 QL (18 EA per 30 day(s)) rizatriptan tablet 10 mg, 5 mg 1 QL (18 EA per 30 day(s)) sumatriptan nasal spray 20 mg/actuation, 5 mg/actuation 1 QL (1 EA per 30 day(s)) sumatriptan subcutaneous cartridge (refill) 4 mg/0.5 ml, 6 mg/0.5 ml 1 QL (2 ML per 30 day(s)) sumatriptan subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml 1 QL (2 ML per 30 day(s)) sumatriptan subcutaneous solution 6 mg/0.5 ml 1 QL (2 ML per 30 day(s)) sumatriptan subcutaneous syringe 6 mg/0.5 ml 1 QL (2 ML per 30 day(s)) sumatriptan tablet 100 mg 1 QL (9 EA per 30 day(s)) sumatriptan tablet 25 mg, 50 mg 1 QL (18 EA per 30 day(s)) Selective-Serotonin Reuptake Inhibitors citalopram oral solution 10 mg/5 ml 1 citalopram tablet 1 QL (30 EA per 30 day(s)) escitalopram tablet 1 QL (30 EA per 30 day(s)) fluoxetine capsule 10 mg 1 QL (60 EA per 30 day(s)) fluoxetine capsule 20 mg 1 QL (120 EA per 30 day(s)) fluoxetine capsule 40 mg 1 fluoxetine oral solution 20 mg/5 ml 1 fluoxetine tablet 10 mg 1 QL (60 EA per 30 day(s)) fluoxetine tablet 20 mg 1 QL (120 EA per 30 day(s)) fluvoxamine tablet 100 mg 1 fluvoxamine tablet 25 mg, 50 mg 1 QL (30 EA per 30 day(s)) paroxetine tablet 1 QL (30 EA per 30 day(s)) PAXIL ORAL SUSPENSION 10 MG/5 ML 1 sertraline oral concentrate 20 mg/ml 1 37 Drug Name sertraline tablet Tier 1 Notes QL (30 EA per 30 day(s)) Serotonin Modulators nefazodone 1 trazodone tablet 1 VIIBRYD 1 QL (30 EA per 30 day(s)) VIIBRYD TABLETS IN A DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) 1 QL (30 EA per 30 day(s)) Succinimides ethosuximide capsule 250 mg 1 ethosuximide oral solution 250 mg/5 ml 1 Thioxanthenes thiothixene capsule 1 Trycyclics & Other Norepineph.-Ru Inhib amitriptyline oral 1 amoxapine 1 clomipramine 1 desipramine oral 1 doxepin capsule 1 doxepin oral concentrate 10 mg/ml 1 imipramine hcl 1 maprotiline 1 nortriptyline 1 nortriptyline oral solution 10 mg/5 ml 1 protriptyline tablet 10 mg, 5 mg 1 SURMONTIL 1 Devices Devices SYNVISC INTRA-ARTICULAR SYRINGE 16 MG/2 ML 1 PA; SPN; QL (3 ML per 20 day(s)) SYNVISC-ONE INTRA-ARTICULAR SYRINGE 48 MG/6 ML 1 PA; SPN Electrolytic, Caloric, And Water Balance Acidifying Agents PHOSPHA 250 NEUTRAL TABLET 250 MG Alkalinizing Agents 38 1 Drug Name potassium citrate er tablet,extended release 10 meq, 5 meq Tier Notes 1 Ammonia Detoxicants CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML 1 ENULOSE ORAL SOLUTION 10 GRAM/15 ML 1 GENERLAC ORAL SOLUTION 10 GRAM/15 ML 1 lactulose oral solution 10 gram/15 ml 1 Caloric Agents LYSIPLEX PLUS TABLET 1 Irrigating Solutions acetic acid irrigation solution 0.25 % 1 RENACIDIN IRRIGATION SOLUTION 6.602-0.198 GRAM/100 ML 1 RESECTISOL URETHRAL SOLUTION 5 % 1 Phosphate-Removing Agents calcium acetate capsule 667 mg 1 calcium acetate tablet 667 mg 1 ELIPHOS TABLET 667 MG 1 RENAGEL TABLET 400 MG, 800 MG 1 RENVELA TABLET 800 MG 1 Potassium-Removing Agents KALEXATE ORAL POWDER 1 KIONEX ORAL POWDER 1 KIONEX ORAL SUSPENSION 15 GRAM/60 ML 1 MARLEXATE ORAL POWDER 1 SODIUM POLYSTYRENE SULFONATE (SORBITOL FREE) ORAL SUSPENSION 15 GRAM/60 ML 1 sodium polystyrene sulfonate enema 30 gram/120 ml 1 sodium polystyrene sulfonate oral powder 1 sodium polystyrene sulfonate oral suspension 15 gram/60 ml 1 Replacement Preparations 39 Drug Name Tier EFFER-K EFFERVESCENT TABLET 25 MEQ 1 K-EFFERVESCENT TABLET 25 MEQ 1 KAOCHLOR EFFERVESCENT TABLET 20 MEQ 1 KLOR-CON ORAL PACKET 20 MEQ, 25 MEQ 1 KLOR-CON M10 TABLET,EXTENDED RELEASE 10 MEQ 1 KLOR-CON M15 TABLET,EXTENDED RELEASE 15 MEQ 1 KLOR-CON M20 TABLET,EXTENDED RELEASE 20 MEQ 1 KLOR-CON/EF EFFERVESCENT TABLET 25 MEQ 1 potassium bicarb & chloride effervescent tablet 25 meq 1 potassium bicarbonate-citric acid effervescent tablet 25 meq 1 potassium chloride er capsule,extended release 10 meq, 8 meq 1 potassium chloride er tablet,extended release 10 meq, 8 meq 1 potassium chloride er tablet,extended release(part/cryst) 10 meq, 20 meq 1 potassium chloride oral liquid 10 % 1 potassium chloride oral liquid 20 % 1 sodium chloride for nebulization 3 % 1 Notes Uricosuric Agents probenecid tablet 500 mg 1 Enzymes Enzymes PULMOZYME SOLUTION FOR INHALATION 1 MG/ML 1 Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) ALPHAGAN P EYE DROPS 0.1 % 1 brimonidine eye drops 0.15 % 1 brimonidine eye drops 0.2 % 1 40 PA; QL (60 ML per 30 day(s)) Drug Name Tier Notes Antiallergic Agents ALOMIDE EYE DROPS 0.1 % 1 ASTEPRO NASAL SPRAY 0.15 % (205.5 MCG) 1 azelastine nasal spray aerosol 137 mcg 1 PATADAY EYE DROPS 0.2 % 1 Antibacterials (Eent) AK-POLY-BAC EYE OINTMENT 500-10,000 UNIT/GRAM 1 bacitracin eye ointment 500 unit/gram 1 bacitracin-polymyxin b eye ointment 500-10,000 unit/gram 1 BACTROBAN NASAL OINTMENT 2 % 1 BLEPHAMIDE EYE DROPS,SUSPENSION 10-0.2 % 1 BLEPHAMIDE S.O.P. EYE OINTMENT 10-0.2 % 1 CILOXAN EYE OINTMENT 0.3 % 1 CIPRODEX EAR DROPS,SUSPENSION 0.3-0.1 % 1 ciprofloxacin eye drops 0.3 % 1 doxycycline hyclate tablet 20 mg 1 erythromycin eye ointment 5 mg/gram (0.5 %) 1 GENTAK EYE DROPS 0.3 % 1 GENTAK EYE OINTMENT 0.3 % (3 MG/GRAM) 1 gentamicin eye drops 0.3 % 1 gentamicin eye ointment 0.3 % (3 mg/gram) 1 NEO-POLYCIN EYE OINTMENT 3.5-400-10,000 MG-UNIT-UNIT/G 1 NEO-POLYCIN HC EYE OINTMENT 3.5-400-10,000 MG-UNIT/G-1% 1 neomycin-bacitracin-poly-hc eye ointment 3.5-400-10,000 mg-unit/g-1% 1 neomycin-bacitracin-polymyxin eye ointment 3.5-400-10,000 mg-unit-unit/g 1 neomycin-polymyxin-dexameth eye drops,suspension 3.5-10,000-0.1 mg/ml-unit/ml-% 1 41 Drug Name Tier neomycin-polymyxin-dexameth eye ointment 3.5-10,000-0.1 mg-unit/g-% 1 neomycin-polymyxin-hydrocort ear drops,suspension 3.5-10,000-1 mg-unit/ml-% 1 neomycin-polymyxin-hydrocort ear solution 3.5-10,000-1 mg-unit/ml-% 1 neomycin-polymyxin-hydrocort eye drops,suspension 3.5-10,000-10 mg-unit-mg/ml 1 ofloxacin ear drops 0.3 % 1 ofloxacin eye drops 0.3 % 1 POLYCIN EYE OINTMENT 500-10,000 UNIT/GRAM 1 sulfacetamide sodium eye drops 10 % 1 sulfacetamide sodium eye ointment 10 % 1 sulfacetamide-prednisolone eye drops 10 %-0.23 % (0.25 %) 1 TOBRADEX EYE OINTMENT 0.3-0.1 % 1 tobramycin eye drops 0.3 % 1 tobramycin-dexamethasone eye drops,suspension 0.3-0.1 % 1 TOBREX EYE OINTMENT 0.3 % 1 trimethoprim-polymyxin b eye drops 0.1-10,000 %-unit/ml 1 VIGAMOX EYE DROPS 0.5 % 1 Antivirals (Eent) trifluridine eye drops 1 % 1 Beta-Adrenergic Blocking Agents (Eent) betaxolol eye drops 0.5 % 1 BETOPTIC S EYE DROPS,SUSPENSION 0.25 % 1 carteolol eye drops 1 % 1 dorzolamide-timolol eye drops 2-0.5 % 1 levobunolol eye drops 0.25 % 1 levobunolol eye drops 0.5 % 1 timolol eye gel forming solution 0.25 %, 0.5 % 1 timolol maleate eye drops 0.25 %, 0.5 % 1 TIMOPTIC OCUDOSE (PF) EYE DROPS IN A DROPPERETTE 0.25 %, 0.5 % 1 42 Notes Drug Name Tier Notes Carbonic Anhydrase Inhibitors (Eent) dorzolamide eye drops 2 % 1 methazolamide tablet 25 mg, 50 mg 1 Corticosteroids (Eent) dexamethasone eye drops 0.1 % 1 FLAREX EYE DROPS,SUSPENSION 0.1 % 1 fluorometholone eye drops,suspension 0.1 % 1 FML FORTE EYE DROPS,SUSPENSION 0.25 % 1 MAXIDEX EYE DROPS,SUSPENSION 0.1 % 1 PRED MILD EYE DROPS,SUSPENSION 0.12 % 1 prednisolone acetate eye drops,suspension 1 % 1 prednisolone sodium phosphate eye drops 1 % 1 VEXOL EYE DROPS,SUSPENSION 1 % 1 Eent Anti-Infectives, Miscellaneous ACETASOL HC EAR DROPS 1-2 % 1 acetic acid ear solution 2 % 1 acetic acid-aluminum acetate ear drops 2 % 1 chlorhexidine gluconate mouthwash 0.12 % 1 hydrocortisone-acetic acid ear drops 1-2 % 1 PERIOGARD MOUTHWASH 0.12 % 1 Eent Anti-Inflammatory Agents, Misc. RESTASIS EYE DROPS IN A DROPPERETTE 0.05 % 1 ST Eent Drugs, Miscellaneous apraclonidine eye drops 0.5 % 1 IOPIDINE EYE DROPS IN A DROPPERETTE 1 % 1 ipratropium bromide nasal spray 0.03 %, 0.06 % 1 LACRISERT EYE INSERTS 5 MG 1 Eent Nonsteroidal Anti-Inflam. Agents diclofenac eye drops 0.1 % 1 flurbiprofen eye drops 0.03 % 1 ketorolac eye drops 0.4 %, 0.5 % 1 43 Drug Name Tier Local Anesthetics (Eent) antipyrine-benzocaine ear drops 5.4-1.4 % 1 AURODEX EAR DROPS 5.4-1.4 % 1 AUROGUARD EAR DROPS 5.4-1.4 % 1 lidocaine mucosal gel 2 % 1 lidocaine mucosal solution 2 % 1 lidocaine mucous membrane jelly in applicator 2 % 1 LIDOCAINE VISCOUS MUCOSAL SOLUTION 2 % 1 Miotics ISOPTO CARBACHOL EYE DROPS 1.5 %, 3% 1 PHOSPHOLINE IODIDE EYE DROPS 0.125 % 1 pilocarpine eye drops 1 PILOPINE HS EYE GEL 4 % 1 Mydriatics atropine eye drops 1 % 1 atropine eye ointment 1 % 1 ATROPINE-CARE EYE DROPS 1 % 1 CYCLOGYL EYE DROPS 0.5 % 1 cyclopentolate eye drops 1 %, 2 % 1 HOMATROPAIRE EYE DROPS 5 % 1 homatropine eye drops 5 % 1 tropicamide eye drops 0.5 %, 1 % 1 Prostaglandin Analogs latanoprost eye drops 0.005 % 1 TRAVATAN Z EYE DROPS 0.004 % 1 Vasoconstrictors ADRENALIN NASAL SOLUTION 1:1,000 (0.1 %) 1 ALTAFRIN EYE DROPS 10 %, 2.5 % 1 MYDFRIN EYE DROPS 2.5 % 1 phenylephrine eye drops 10 %, 2.5 % 1 Gastrointestinal Drugs 44 Notes Drug Name Tier Notes 5-Ht3 Receptor Antagonists ondansetron disintegrating tablet 4 mg, 8 mg 1 ondansetron hcl oral 1 ondansetron hcl oral solution 4 mg/5 ml 1 Anti-Inflammatory Agents (Gi Drugs) ASACOL HD TABLET,DELAYED RELEASE 800 MG 1 balsalazide capsule 750 mg 1 DELZICOL CAPSULE,DELAYED RELEASE 400 MG 1 DIPENTUM CAPSULE 250 MG 1 mesalamine enema 4 gram/60 ml 1 PENTASA CAPSULE,EXTENDED RELEASE 250 MG, 500 MG 1 Cathartics And Laxatives GAVILYTE-C ORAL SOLUTION 240-22.72-6.72 GRAM 1 GAVILYTE-N ORAL SOLUTION 420 GRAM 1 peg 3350-electrolytes oral solution 240-22.72-6.72 gram 1 PEG-3350 WITH FLAVOR PACKS ORAL SOLUTION 420 GRAM 1 peg-electrolyte solution oral powder for solution 420 gram 1 TRILYTE WITH FLAVOR PACKETS ORAL SOLUTION 420 GRAM 1 Cholelitholytic Agents ursodiol capsule 300 mg 1 ursodiol tablet 250 mg, 500 mg 1 Digestants CREON CAPSULE,DELAYED RELEASE 1 Histamine H2-Antagonists cimetidine oral solution 300 mg/5 ml 1 cimetidine tablet 1 famotidine tablet 40 mg 1 famotidine (pf) intravenous solution 20 mg/2 ml 1 45 Drug Name Tier famotidine (pf) in nacl (iso-osmotic) intravenous piggyback 20 mg/50 ml 1 ranitidine capsule 150 mg, 300 mg 1 ranitidine syrup 15 mg/ml 1 ranitidine tablet 300 mg 1 Notes Prokinetic Agents metoclopramide oral solution 5 mg/5 ml 1 metoclopramide tablet 10 mg, 5 mg 1 Prostaglandins misoprostol tablet 100 mcg, 200 mcg 1 Protectants sucralfate oral suspension 100 mg/ml 1 sucralfate tablet 1 gram 1 Proton-Pump Inhibitors lansoprazole capsule,delayed release 30 mg 1 QL (60 EA per 30 day(s)) omeprazole capsule,delayed release 1 QL (60 EA per 30 day(s)) pantoprazole tablet,delayed release 20 mg, 40 mg 1 QL (60 EA per 30 day(s)) PREVACID SOLUTAB DELAYED RELEASE,DISINTEGRATING TABLET 15 MG, 30 MG 1 Gold Compounds Gold Compounds RIDAURA CAPSULE 3 MG 1 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET CAPSULE 100 MG 1 CUPRIMINE CAPSULE 250 MG 1 DEPEN TITRATABS TABLET 250 MG 1 Hormones And Synthetic Substitutes Adrenals A-METHAPRED SOLUTION FOR INJECTION 40 MG/ML 1 BAYCADRON ORAL ELIXIR 0.5 MG/5 ML 1 cortisone tablet 25 mg 1 46 Drug Name Tier DEPO-MEDROL SUSPENSION FOR INJECTION 20 MG/ML 1 dexamethasone oral elixir 0.5 mg/5 ml 1 dexamethasone oral solution 0.5 mg/5 ml 1 dexamethasone tablet 1 DEXAMETHASONE INTENSOL DROPS (CONCENTRATE) 1 MG/ML 1 DEXPAK 13 DAY TABLETS IN A DOSE PACK 1.5 MG (51 TABS) 1 fludrocortisone tablet 0.1 mg 1 hydrocortisone oral 1 MEDROL TABLET 2 MG 1 methylprednisolone tablet 1 methylprednisolone tablets in a dose pack 4 mg 1 methylprednisolone sodium succ intravenous solution 1,000 mg 1 methylprednisolone sodium succ solution for injection 40 mg 1 MILLIPRED TABLET 5 MG 1 prednisolone oral solution 15 mg/5 ml 1 prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) 1 prednisone oral solution 5 mg/5 ml 1 prednisone tablet 1 prednisone tablets in a dose pack 10 mg, 5 mg 1 PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML 1 SOLU-MEDROL INTRAVENOUS SOLUTION 2 GRAM, 500 MG 1 SOLU-MEDROL SOLUTION FOR INJECTION 125 MG/2 ML 1 Notes Alpha-Glucosidase Inhibitors acarbose 1 GLYSET 1 Androgens ANDRODERM TRANSDERMAL 24 HOUR PATCH 2 MG/24 HOUR, 4 MG/24 HR 1 47 Drug Name Tier ANDROID CAPSULE 10 MG 1 ANDROXY TABLET 10 MG 1 COVARYX TABLET 1.25-2.5 MG 1 COVARYX H.S. TABLET 0.625-1.25 MG 1 danazol oral 1 EEMT TABLET 1.25-2.5 MG 1 EEMT HS TABLET 0.625-1.25 MG 1 esterified estrogens-methyltestosterone tablet 0.625-1.25 mg, 1.25-2.5 mg 1 METHITEST TABLET 10 MG 1 STRIANT BUCCAL SYSTEM,SUSTAINED RELEASE 30 MG 1 testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml 1 testosterone enanthate intramuscular oil 200 mg/ml 1 TESTRED CAPSULE 10 MG 1 Notes Antithyroid Agents methimazole tablet 10 mg, 5 mg 1 propylthiouracil tablet 50 mg 1 Biguanides AVANDAMET TABLET 1 glipizide-metformin tablet 2.5-500 mg, 5-500 mg 1 glyburide-metformin 1 JANUMET TABLET 50-1,000 MG, 50-500 MG 1 ST; QL (60 EA per 30 day(s)) JANUMET XR TABLET,EXTENDED RELEASE 100-1,000 MG 1 ST; QL (30 EA per 30 day(s)) JANUMET XR TABLET,EXTENDED RELEASE 50-1,000 MG, 50-500 MG 1 ST; QL (60 EA per 30 day(s)) metformin er tablet,extended release 24 hr 500 mg, 750 mg 1 metformin er tablet,extended release 24hr 1,000 mg 1 metformin tablet 1 pioglitazone-metformin tablet 15-500 mg, 15-850 mg 1 Contraceptives 48 QL (60 EA per 30 day(s)) QL (90 EA per 30 day(s)) Drug Name Tier ALTAVERA (28) TABLET 0.15-30 MG-MCG 1 ALYACEN 1/35 (28) TABLET 1-35 MG-MCG 1 ALYACEN 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG 1 APRI TABLET 0.15-30 MG-MCG 1 AVIANE TABLET 0.1-20 MG-MCG 1 AZURETTE (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 1 BALZIVA (28) TABLET 0.4-35 MG-MCG 1 BRIELLYN TABLET 0.4-35 MG-MCG 1 CAMILA TABLET 0.35 MG 1 CAZIANT (28) TABLET 0.1/.125/.15-25 MG-MCG 1 CHATEAL TABLET 0.15-30 MG-MCG 1 CRYSELLE (28) TABLET 0.3-30 MG-MCG 1 CYCLAFEM 1/35 (28) TABLET 1-35 MG-MCG 1 CYCLAFEM 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG 1 DASETTA 1/35 (28) TABLET 1-35 MG-MCG 1 DASETTA 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG 1 ELINEST TABLET 0.3-30 MG-MCG 1 EMOQUETTE TABLET 0.15-30 MG-MCG 1 ENPRESSE TABLET 50-30 (6)/75-40 (5)/125-30(10) 1 ENSKYCE TABLET 0.15-30 MG-MCG 1 ERRIN TABLET 0.35 MG 1 ESTARYLLA TABLET 0.25-35 MG-MCG 1 FALMINA (28) TABLET 0.1-20 MG-MCG 1 GILDAGIA TABLET 0.4-35 MG-MCG 1 GILDESS TABLET 1-20 MG-MCG, 1.5-30 MG-MCG 1 GILDESS FE TABLET 1-20 MG-MCG, 1.5-30 MG-MCG 1 Notes 49 Drug Name Tier Notes HEATHER TABLET 0.35 MG 1 INTROVALE TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG 1 JENCYCLA TABLET 0.35 MG 1 JOLESSA TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG 1 JOLIVETTE TABLET 0.35 MG 1 JUNEL 1.5/30 (21) TABLET 1.5-30 MG-MCG 1 JUNEL 1/20 (21) TABLET 1-20 MG-MCG 1 JUNEL FE 1.5/30 (28) TABLET 1.5-30 MG-MCG 1 JUNEL FE 1/20 (28) TABLET 1-20 MG-MCG 1 KARIVA (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 1 KELNOR 1/35 (28) TABLET 1-35 MG-MCG 1 KURVELO TABLET 0.15-30 MG-MCG 1 LESSINA TABLET 0.1-20 MG-MCG 1 LEVONEST (28) TABLET 50-30 (6)/75-40 (5)/125-30(10) 1 levonorgestrel tablet 0.75 mg 1 QL (2 EA per 30 day(s)) levonorgestrel tablet 1.5 mg 1 QL (1 EA per 30 day(s)) levonorgestrel-ethinyl estradiol tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 levonorgestrel-ethinyl estradiol tablets,3 month pack 0.15-30 mg-mcg 1 LEVORA-28 TABLET 0.15-30 MG-MCG 1 LOW-OGESTREL (28) TABLET 0.3-30 MG-MCG 1 LUTERA (28) TABLET 0.1-20 MG-MCG 1 LYZA TABLET 0.35 MG 1 MARLISSA TABLET 0.15-30 MG-MCG 1 MICROGESTIN 1.5/30 (21) TABLET 1.5-30 MG-MCG 1 MICROGESTIN 1/20 (21) TABLET 1-20 MG-MCG 1 MICROGESTIN FE 1.5/30 (28) TABLET 1.5-30 MG-MCG 1 50 Drug Name Tier MICROGESTIN FE 1/20 (28) TABLET 1-20 MG-MCG 1 MONO-LINYAH TABLET 0.25-35 MG-MCG 1 MONONESSA (28) TABLET 0.25-35 MG-MCG 1 MY WAY TABLET 1.5 MG 1 MYZILRA TABLET 50-30 (6)/75-40 (5)/125-30(10) 1 NECON 0.5/35 (28) TABLET 0.5-35 MG-MCG 1 NECON 1/35 (28) TABLET 1-35 MG-MCG 1 NECON 1/50 (28) TABLET 1-50 MG-MCG 1 NECON 10/11 (28) TABLET 0.5-35/1-35 MG-MCG/MG-MCG 1 NECON 7/7/7 (28) TABLET 0.5/0.75/1 MG35 MCG 1 NEXT CHOICE ONE DOSE TABLET 1.5 MG 1 NORA-BE TABLET 0.35 MG 1 norethindrone (contraceptive) tablet 0.35 mg 1 norgestimate-ethinyl estradiol tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg 1 NORINYL 1+50 (28) TABLET 1-50 MG-MCG 1 NORTREL 0.5/35 (28) TABLET 0.5-35 MG-MCG 1 NORTREL 1/35 (21) TABLET 1-35 MG-MCG 1 NORTREL 1/35 (28) TABLET 1-35 MG-MCG 1 NORTREL 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG 1 NUVARING VAGINAL 0.12-0.015 MG/24 HR 1 OGESTREL (28) TABLET 0.5-50 MG-MCG 1 ORSYTHIA TABLET 0.1-20 MG-MCG 1 ORTHO TRI-CYCLEN LO (28) TABLET 0.18/0.215/0.25 MG-25 MCG (28) 1 Notes 51 Drug Name Tier PHILITH TABLET 0.4-35 MG-MCG 1 PIRMELLA TABLET 1-35 MG-MCG 1 PORTIA TABLET 0.15-30 MG-MCG 1 PREVIFEM TABLET 0.25-35 MG-MCG 1 QUASENSE TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG 1 RECLIPSEN (28) TABLET 0.15-30 MG-MCG 1 SPRINTEC (28) TABLET 0.25-35 MG-MCG 1 SRONYX TABLET 0.1-20 MG-MCG 1 TILIA FE TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) 1 TRI-ESTARYLLA TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1 TRI-LEGEST FE TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) 1 TRI-LINYAH TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1 TRI-PREVIFEM (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1 TRI-SPRINTEC (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1 TRINESSA (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1 TRIVORA (28) TABLET 50-30 (6)/75-40 (5)/125-30(10) 1 VELIVET TRIPHASIC REGIMEN (28) TABLET 0.1/.125/.15-25 MG-MCG 1 VIORELE (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 1 WERA (28) TABLET 0.5-35 MG-MCG 1 ZENCHENT (28) TABLET 0.4-35 MG-MCG 1 ZOVIA 1/35E (28) TABLET 1-35 MG-MCG 1 ZOVIA 1/50E (28) TABLET 1-50 MG-MCG 1 Notes Dipeptidyl Peptidase-4(Dpp-4) Inhibitors JANUVIA 1 Estrogen Agonist-Antagonists EVISTA TABLET 60 MG 52 1 ST; QL (30 EA per 30 day(s)) Drug Name Tier Notes Estrogens COMBIPATCH TRANSDERMAL 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR 1 estradiol tablet 1 estradiol weekly transdermal patch 1 ESTRING VAGINAL 2 MG 1 estropipate tablet 1 FEMHRT LOW DOSE TABLET 0.5-2.5 MG-MCG 1 JINTELI TABLET 1-5 MG-MCG 1 MENEST 1 PREMARIN TABLET 1 PREMARIN VAGINAL CREAM 0.625 MG/GRAM 1 PREMPHASE TABLET 0.625 MG (14)/ 0.625MG-5MG(14) 1 PREMPRO 1 QL (30 EA per 30 day(s)) Glycogenolytic Agents GLUCAGON EMERGENCY INJECTION KIT 1 MG 1 Gonadotropins SYNAREL NASAL SPRAY 2 MG/ML 1 Insulins APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 1 HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 1 HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 HUMALOG KWIKPEN SUBCUTANEOUS 100 UNIT/ML 1 HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) 1 HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS 100 UNIT/ML (50-50) 1 HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) 1 53 Drug Name Tier HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS 100 UNIT/ML (75-25) 1 HUMULIN R U-500 "CONCENTRATED" INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML 1 LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 1 LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 NOVOLOG FLEXPEN SUBCUTANEOUS 100 UNIT/ML 1 NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) 1 NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS 100 UNIT/ML (70-30) 1 NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 1 Notes Meglitinides repaglinide 1 Parathyroid calcitonin (salmon) nasal spray 200 unit/actuation 1 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML 1 SPN; QL (1 ML per 30 day(s)) Pituitary desmopressin nasal spray (non-refrigerated) 10 mcg/spray 1 NORDITROPIN FLEXPRO 1 PA; SPN NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR 30 MG/3 ML (10 MG/ML) 1 PA; SPN Progestins medroxyprogesterone intramuscular suspension 150 mg/ml 54 1 Drug Name Tier medroxyprogesterone intramuscular syringe 150 mg/ml 1 medroxyprogesterone oral 1 norethindrone acetate tablet 5 mg 1 progesterone intramuscular oil 50 mg/ml 1 PROGESTERONE IN OIL INTRAMUSCULAR 50 MG/ML 1 Notes Somatostatin Agonists octreotide acetate injection solution 1 SPN SANDOSTATIN LAR DEPOT 1 SPN AVANDARYL TABLET 4-1 MG, 8-2 MG, 8-4 MG 1 QL (30 EA per 30 day(s)) AVANDARYL TABLET 4-2 MG, 4-4 MG 1 QL (60 EA per 30 day(s)) glimepiride tablet 1 mg, 2 mg 1 QL (30 EA per 30 day(s)) glimepiride tablet 4 mg 1 glipizide er tablet, extended release 24 hr 1 glipizide tablet 10 mg, 5 mg 1 glyburide tablet 1 glyburide micronized tablet 1 pioglitazone-glimepiride tablet 30-2 mg, 30-4 mg 1 QL (30 EA per 30 day(s)) AVANDIA 1 QL (30 EA per 30 day(s)) pioglitazone 1 QL (30 EA per 30 day(s)) Sulfonylureas QL (30 EA per 30 day(s)) Thiazolidinediones Thyroid Agents ARMOUR THYROID TABLET 1 levothyroxine tablet 1 liothyronine oral 1 NP THYROID 1 THYROLAR-1 TABLET 12.5-50 MCG 1 THYROLAR-1/2 TABLET 6.25-25 MCG 1 THYROLAR-1/4 TABLET 3.1-12.5 MCG 1 THYROLAR-2 TABLET 25-100 MCG 1 THYROLAR-3 TABLET 37.5-150 MCG 1 Local Anesthetics (Parenteral) Local Anesthetics (Parenteral) 55 Drug Name Tier lidocaine (pf) injection solution 1 lidocaine injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 1 XYLOCAINE INJECTION SOLUTION 5 MG/ML (0.5 %) 1 XYLOCAINE-MPF INJECTION SOLUTION 15 MG/ML (1.5 %) 1 Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors AVODART CAPSULE 0.5 MG 1 finasteride tablet 5 mg 1 Alcohol Deterrents disulfiram tablet 250 mg, 500 mg 1 Antidotes leucovorin calcium injection solution 500 mg/50 ml 1 leucovorin calcium oral 1 leucovorin calcium solution for injection 500 mg 1 Antigout Agents allopurinol tablet 100 mg, 300 mg 1 COLCRYS TABLET 0.6 MG 1 Bone Resorption Inhibitors ACTONEL TABLET 1 alendronate tablet 1 etidronate disodium tablet 200 mg, 400 mg 1 Cariostatic Agents DENTA 5000 PLUS CREAM 1.1 % 1 DENTAGEL 1.1 % 1 FLUOR-A-DAY ORAL DROPS 2.5 MG/ML 1 FLUORABON ORAL DROPS 0.25 MG FLUORID (0.55MG)/0.6 ML 1 FLUORIDEX DAILY DEFENSE DENTAL GEL 1.1 % 1 FLUORITAB CHEWABLE TABLET 0.5 MG FLUORIDE (1.1 MG) 1 FLUORITAB ORAL DROPS 0.125 MG FLUOR (0.275 MG)/DROP 1 56 Notes Drug Name Tier FLURA-DROPS ORAL 0.25 MG FLUORID (0.55 MG)/DROP 1 LUDENT FLUORIDE 1 NAFRINSE 0.05 % 1 PREVIDENT GEL 1.1 % 1 SF DENTAL GEL 1.1 % 1 SF 5000 PLUS DENTAL CREAM 1.1 % 1 sodium fluoride chewable tablet 1 sodium fluoride dental solution 0.2 % 1 sodium fluoride oral drops 0.5 mg fluoride (1.1 mg)/ml 1 sodium fluoride tablet 1 mg fluoride (2.2 mg) 1 Notes Disease-Modifying Antirheumatic Agents ENBREL SUBCUTANEOUS KIT 25 MG (1 ML) 1 PA; SPN; QL (8 EA per 30 day(s)) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) 1 PA; SPN; QL (8 ML per 30 day(s)) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) 1 PA; SPN; QL (4 ML per 30 day(s)) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) 1 PA; SPN; QL (4 ML per 30 day(s)) HUMIRA SUBCUTANEOUS KIT 20 MG/0.4 ML, 40 MG/0.8 ML 1 PA; SPN; QL (2 EA per 30 day(s)) HUMIRA CROHN'S DISEASE STARTER PACK SUBCUTANEOUS PEN KIT 40 MG/0.8 ML 1 PA; SPN; QL (2 EA per 30 day(s)) HUMIRA PEN SUBCUTANEOUS KIT 40 MG/0.8 ML 1 PA; SPN; QL (2 EA per 30 day(s)) HUMIRA PSORIASIS STARTER PACK SUBCUTANEOUS PEN KIT 40 MG/0.8 ML 1 PA; SPN; QL (2 EA per 30 day(s)) leflunomide tablet 10 mg, 20 mg 1 QL (30 EA per 30 day(s)) REMICADE INTRAVENOUS SOLUTION 100 MG 1 PA; SPN AVONEX INTRAMUSCULAR KIT 30 MCG 1 PA; SPN; QL (1 EA per 30 day(s)) AVONEX INTRAMUSCULAR PEN KIT 30 MCG/0.5 ML 1 PA; SPN; QL (1 EA per 30 day(s)) Immunomodulatory Agents 57 Drug Name Tier Notes AVONEX ADMINISTRATION PACK INTRAMUSCULAR KIT 30 MCG/0.5 ML 1 PA; SPN; QL (1 EA per 30 day(s)) COPAXONE SUBCUTANEOUS SYRINGE KIT 20 MG/ML 1 PA; SPN Immunosuppressive Agents azathioprine tablet 50 mg 1 CELLCEPT ORAL SUSPENSION 200 MG/ML 1 cyclosporine capsule 100 mg, 25 mg 1 cyclosporine modified 1 cyclosporine modified oral solution 100 mg/ml 1 GENGRAF CAPSULE 100 MG, 25 MG 1 GENGRAF ORAL SOLUTION 100 MG/ML 1 HECORIA 1 mycophenolate mofetil capsule 250 mg 1 mycophenolate mofetil tablet 500 mg 1 NEORAL CAPSULE 100 MG, 25 MG 1 NEORAL ORAL SOLUTION 100 MG/ML 1 RAPAMUNE 1 RAPAMUNE ORAL SOLUTION 1 MG/ML 1 SANDIMMUNE ORAL SOLUTION 100 MG/ML 1 tacrolimus capsule 1 Other Miscellaneous Therapeutic Agents CARNITOR SUGAR-FREE ORAL SOLUTION 100 MG/ML 1 DEMSER CAPSULE 250 MG 1 ELMIRON CAPSULE 100 MG 1 levocarnitine tablet 330 mg 1 levocarnitine (with sugar) oral solution 100 mg/ml 1 Protective Agents MESNEX TABLET 400 MG 1 Oxytocics Oxytocics methylergonovine tablet 0.2 mg Pharmaceutical Aids 58 1 Drug Name Tier Notes Pharmaceutical Aids STERILE WATER FOR INJECTION 1 water for injection, sterile injection solution 1 Respiratory Tract Agents Antitussives benzonatate capsule 100 mg, 200 mg 1 Expectorants SSKI ORAL SOLUTION 1 GRAM/ML 1 First Generation Antihist.(Respir Tract) promethazine-codeine syrup 6.25-10 mg/5 ml 1 promethazine-dm syrup 6.25-15 mg/5 ml 1 QL (1000 ML per 30 day(s)) Leukotriene Modifiers montelukast chewable tablet 4 mg, 5 mg 1 QL (30 EA per 30 day(s)) montelukast oral granules in packet 4 mg 1 QL (30 EA per 30 day(s)) montelukast tablet 10 mg 1 QL (30 EA per 30 day(s)) zafirlukast tablet 10 mg, 20 mg 1 QL (60 EA per 30 day(s)) Mast-Cell Stabilizers cromolyn eye drops 4 % 1 cromolyn solution for nebulization 20 mg/2 ml 1 QL (240 ML per 30 day(s)) Mucolytic Agents acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 1 Nasal Preparations (Steroids) fluticasone nasal spray,suspension 50 mcg/actuation 1 triamcinolone acetonide nasal spray aerosol 55 mcg 1 QL (1 GM per 30 day(s)) Orally Inhaled Preparations (Steroids) ASMANEX TWISTHALER BREATH ACTIVATED 1 QL (1 EA per 30 day(s)) budesonide suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 1 QL (60 ML per 30 day(s)) FLOVENT DISKUS 1 FLOVENT HFA 1 QL (2 GM per 30 day(s)) PULMICORT SUSPENSION FOR NEBULIZATION 1 MG/2 ML 1 QL (30 ML per 30 day(s)) 59 Drug Name PULMICORT FLEXHALER BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION Tier 1 Pulmonary Surfactants INFASURF INTRATRACHEAL SUSPENSION 35 MG/ML 1 Skin And Mucous Membrane Agents Antibacterials (Skin & Mucous Membrane) BENZAMYCINPAK TOPICAL GEL 3-5 % 1 CLEOCIN VAGINAL SUPPOSITORY 100 MG 1 CLINDACIN ETZ TOPICAL SWAB 1 % 1 CLINDACIN P TOPICAL SWAB 1 % 1 clindamycin lotion 1 % 1 clindamycin phosphate topical swab 1 % 1 clindamycin topical gel 1 % 1 clindamycin topical solution 1 % 1 clindamycin vaginal cream 2 % 1 ERY PADS TOPICAL SWAB 2 % 1 erythromycin with ethanol topical gel 2 % 1 erythromycin with ethanol topical solution 2 % 1 erythromycin with ethanol topical swab 2 % 1 erythromycin-benzoyl peroxide topical gel 3-5 % 1 gentamicin topical cream 0.1 % 1 gentamicin topical ointment 0.1 % 1 metronidazole lotion 0.75 % 1 metronidazole topical cream 0.75 % 1 metronidazole topical gel 0.75 %, 1 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin topical ointment 2 % 1 ROSADAN TOPICAL CREAM 0.75 % 1 ROSADAN TOPICAL GEL 0.75 % 1 Anti-Inflammatory Agents (Skin & Mucous) ANUCORT-HC SUPPOSITORY 25 MG 1 ANUSOL-HC SUPPOSITORY 25 MG 1 betamethasone dipropionate lotion 0.05 % 1 60 Notes Drug Name Tier betamethasone dipropionate topical cream 0.05 % 1 betamethasone dipropionate topical ointment 0.05 % 1 betamethasone valerate lotion 0.1 % 1 betamethasone valerate topical cream 0.1 % 1 betamethasone valerate topical ointment 0.1 % 1 betamethasone, augmented topical cream 0.05 % 1 betamethasone, augmented topical gel 0.05 % 1 betamethasone, augmented topical ointment 0.05 % 1 clobetasol topical cream 0.05 % 1 clobetasol topical gel 0.05 % 1 clobetasol topical ointment 0.05 % 1 clobetasol topical solution 0.05 % 1 clobetasol-emollient topical cream 0.05 % 1 COLOCORT ENEMA 100 MG/60 ML 1 CORDRAN TAPE 4 MCG/CM2 1 CORMAX TOPICAL SOLUTION 0.05 % 1 CORTIFOAM RECTAL 10 % (80 MG) 1 desonide lotion 0.05 % 1 desonide topical cream 0.05 % 1 desonide topical ointment 0.05 % 1 desoximetasone topical cream 0.05 %, 0.25 % 1 desoximetasone topical gel 0.05 % 1 desoximetasone topical ointment 0.25 % 1 EPIFOAM TOPICAL 1-1 % 1 FIRST-HYDROCORTISONE TOPICAL GEL 10 % 1 fluocinolone topical body oil 0.01 % 1 fluocinolone topical cream 0.01 %, 0.025 % 1 fluocinolone topical ointment 0.025 % 1 fluocinolone topical solution 0.01 % 1 fluocinolone-shower cap topical oil 0.01 % 1 fluocinonide topical cream 0.05 % 1 fluocinonide topical gel 0.05 % 1 Notes QL (1 EA per 30 day(s)) 61 Drug Name Tier fluocinonide topical ointment 0.05 % 1 fluocinonide topical solution 0.05 % 1 FLUOCINONIDE-E TOPICAL CREAM 0.05 % 1 fluocinonide-emollient topical cream 0.05 % 1 HEMRIL-30 RECTAL SUPPOSITORY 30 MG 1 hydrocortisone enema 100 mg/60 ml 1 hydrocortisone lotion 2.5 % 1 hydrocortisone topical cream 2.5 % 1 hydrocortisone topical ointment 2.5 % 1 hydrocortisone acetate rectal suppository 25 mg 1 hydrocortisone acetate rectal suppository 30 mg 1 hydrocortisone valerate topical cream 0.2 % 1 hydrocortisone valerate topical ointment 0.2 % 1 KENALOG TOPICAL AEROSOL 0.147 MG/GRAM 1 lidocaine-hydrocortisone topical cream 3-0.5 % 1 mometasone lotion 0.1 % 1 mometasone topical cream 0.1 % 1 mometasone topical ointment 0.1 % 1 ORALONE DENTAL PASTE 0.1 % 1 PROCTOCREAM-HC RECTAL 2.5 % 1 PROCTOFOAM HC 1-1 % 1 PROCTOSOL HC RECTAL CREAM 2.5 % 1 PROCTOZONE-HC RECTAL CREAM 2.5 % 1 RECTACORT-HC RECTAL SUPPOSITORY 25 MG 1 SCALACORT LOTION 2 % 1 TEXACORT TOPICAL SOLUTION 2.5 % 1 TOPICORT TOPICAL CREAM 0.05 % 1 triamcinolone acetonide dental paste 0.1 % 1 triamcinolone acetonide lotion 0.025 %, 0.1 % 1 triamcinolone acetonide topical cream 1 triamcinolone acetonide topical ointment 1 62 Notes Drug Name Tier TRIANEX TOPICAL OINTMENT 0.05 % 1 TRIDERM TOPICAL CREAM 0.1 % 1 Notes Antipruritics And Local Anesthetics lidocaine topical ointment 5 % 1 lidocaine hcl topical cream 3 % 1 phenazopyridine tablet 100 mg, 200 mg 1 PONTOCAINE TOPICAL SOLUTION 2 % 1 Astringents HYPERCARE TOPICAL SOLUTION 20 % 1 Azoles (Skin & Mucous Membrane) clotrimazole troche 10 mg 1 clotrimazole-betamethasone topical cream 1-0.05 % 1 econazole topical cream 1 % 1 GYNAZOLE-1 VAGINAL CREAM 2 % 1 ketoconazole shampoo 2 % 1 ketoconazole topical cream 2 % 1 MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG 1 terconazole vaginal cream 0.4 %, 0.8 % 1 Basic Lotions And Liniments lactic acid lotion 10 % 1 Basic Ointments And Protectants LACTIC ACID E TOPICAL CREAM 10 % 1 Cell Stimulants And Proliferants tretinoin topical cream 1 tretinoin topical gel 0.01 %, 0.025 % 1 Keratoplastic Agents coal tar topical solution 20 % 1 DRITHOCREME HP TOPICAL 1 % 1 Local Anti-Infectives, Miscellaneous AVAR TOPICAL CLEANSER 10-5 % (W/W) 1 AVAR-E TOPICAL CREAM 10-5 % (W/W) 1 AVAR-E GREEN TOPICAL CREAM 10-5 % (W/W) 1 AVC VAGINAL CREAM 15 % 1 63 Drug Name Tier ROSANIL TOPICAL CLEANSER 10-5 % (W/W) 1 selenium sulfide shampoo 2.25 % 1 selenium sulfide topical suspension 2.5 % 1 silver sulfadiazine topical cream 1 % 1 SSS 10-5 TOPICAL CREAM 10-5 % (W/W) 1 sulfacetamide sodium (acne) topical suspension 10 % 1 sulfacetamide sodium-sulfur lotion 10-5 % (w/w) 1 sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) 1 sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) 1 sulfacetamide sodium-sulfur topical suspension 10-5 % 1 VIRTI-SULF TOPICAL CREAM 10-5 % (W/W) 1 Pigmenting Agents 8-MOP CAPSULE 10 MG 1 OXSORALEN LOTION 1 % 1 OXSORALEN ULTRA CAPSULE 10 MG 1 Polyenes (Skin & Mucous Membrane) NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM 1 nystatin topical cream 100,000 unit/gram 1 nystatin topical ointment 100,000 unit/gram 1 nystatin topical powder 100,000 unit/gram 1 nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% 1 nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% 1 NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM 1 PEDI-DRI TOPICAL POWDER 100,000 UNIT/GRAM 1 Scabicides And Pediculicides ELIMITE TOPICAL CREAM 5 % 1 EURAX TOPICAL CREAM 10 % 1 64 Notes Drug Name Tier lindane lotion 1 % 1 lindane shampoo 1 % 1 malathion lotion 0.5 % 1 permethrin topical cream 5 % 1 Notes Skin And Mucous Membrane Agents, Misc. acitretin capsule 1 adapalene topical cream 0.1 % 1 adapalene topical gel 0.1 % 1 AMNESTEEM 1 calcipotriene topical cream 0.005 % 1 calcipotriene topical ointment 0.005 % 1 calcipotriene topical solution 0.005 % 1 CALCITRENE TOPICAL OINTMENT 0.005 % 1 CLARAVIS 1 CONDYLOX TOPICAL GEL 0.5 % 1 DIFFERIN TOPICAL GEL 0.3 % 1 ELIDEL TOPICAL CREAM 1 % 1 FLUOROPLEX TOPICAL CREAM 1 % 1 fluorouracil topical cream 5 % 1 fluorouracil topical solution 2 %, 5 % 1 imiquimod topical cream packet 5 % 1 MYORISAN 1 PODOCON TOPICAL LIQUID 25 % 1 podofilox topical solution 0.5 % 1 SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 1 SOTRET CAPSULE 20 MG 1 TARGRETIN TOPICAL GEL 1 % 1 ZENATANE 1 PA Smooth Muscle Relaxants Antimuscarinics flavoxate tablet 100 mg 1 oxybutynin chloride er tablet,extended release 24 hr 10 mg, 15 mg 1 QL (60 EA per 30 day(s)) 65 Drug Name Tier oxybutynin chloride er tablet,extended release 24 hr 5 mg 1 oxybutynin chloride syrup 5 mg/5 ml 1 oxybutynin chloride tablet 5 mg 1 TOVIAZ TABLET,EXTENDED RELEASE 4 MG, 8 MG 1 Vitamins Multivitamin Preparations COMPLETENATE CHEWABLE TABLET 29-1 MG 1 MATERNITY TABLET 27-1 MG 1 MULTI-VITAMIN WITH FLUORIDE 1 MULTI-VITAMINS/FLUORIDE ORAL DROPS 0.25 MG/ML 1 MULTIVITAMIN WITH FLUORIDE CHEWABLE TABLET 0.5 MG 1 MULTIVITAMINS WITH FLUORIDE 1 MULTIVITAMINS WITH FLUORIDE ORAL DROPS 0.5 MG/ML 1 MYNATAL TABLET 90-1-50 MG 1 MYNATE 90 PLUS TABLET,EXTENDED RELEASE 90-1 MG 1 pediatric multivitamin-fl oral drops 0.25 mg/ml, 0.5 mg/ml 1 POLY-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG/ML 1 PRENATAL-U CAPSULE 106.5-1 MG 1 TRIVEEN-U CAPSULE 106.5-1 MG 1 VINATE CALCIUM TABLET 27-1-50 MG 1 VINATE M TABLET 27-1 MG 1 Vitamin B Complex cyanocobalamin (vit b-12) injection solution 1,000 mcg/ml 1 FOLBEE PLUS TABLET 5 MG 1 folic acid injection solution 5 mg/ml 1 hydroxocobalamin intramuscular solution 1,000 mcg/ml 1 MYNEPHROCAPS CAPSULE 1 MG 1 66 Notes QL (30 EA per 30 day(s)) Drug Name Tier NASCOBAL NASAL SPRAY 500 MCG 1 NEURIN-SL SUBLINGUAL TABLET 600-600 MCG 1 RENAL CAPS CAPSULE 1 MG 1 RENO CAPS CAPSULE 1 MG 1 TRIPHROCAPS CAPSULE 1 MG 1 Notes Vitamin D calcitriol capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 ergocalciferol (vitamin d2) capsule 50,000 unit 1 VITAMIN D2 CAPSULE 50,000 UNIT 1 Vitamin K Activity MEPHYTON TABLET 5 MG 1 67 68 Index 8-MOP CAPSULE 10 MG .......... 64 abacavir tablet 300 mg .............................. 9 ABILIFY TABLET ................................ 31 acarbose ................................................................... 47 acebutolol capsule 200 mg, 400 mg ................................................................................................ 19 acetaminophen-codeine oral solution 120-12 mg/5 ml ...................... 33 acetaminophen-codeine tablet ................................................................................................ 33 ACETASOL HC EAR DROPS 1-2 % .............................................................................. 43 acetazolamide tablet 125 mg, 250 mg ...................................................................................... 24 acetic acid ear solution 2 % ............ 43 acetic acid irrigation solution 0.25 % ......................................................................................... 39 acetic acid-aluminum acetate ear drops 2 % ................................................................. 43 acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) ................. 59 acitretin capsule ............................................ 65 ACTONEL TABLET .......................... 56 acyclovir capsule 200 mg .................... 10 acyclovir oral suspension 200 mg/5 ml ........................................................................................ 10 acyclovir tablet 400 mg, 800 mg ................................................................................................ 10 adapalene topical cream 0.1 % ................................................................................................ 65 adapalene topical gel 0.1 % ............ 65 ADRENALIN NASAL SOLUTION 1:1,000 (0.1 %) ................................................................................................ 44 ADVAIR DISKUS ................................. 18 ADVAIR HFA .............................................. 18 AFEDITAB CR TABLET,EXTENDED RELEASE 30 MG, 60 MG ................................................................................................ 26 AGGRENOX CAPSULE, EXTENDED RELEASE 200-25 MG .................................................................................. 23 AK-POLY-BAC EYE OINTMENT 500-10,000 UNIT/GRAM ................................................. 41 ALAGESIC LQ ORAL SOLUTION 50-325-40 MG/15 ML ................................................................................... 29 ALBENZA TABLET 200 MG .................................................................................................... 5 albuterol sulfate er tablet,extended release,12 hr 4 mg, 8 mg ..................... 18 albuterol sulfate solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml ....................................................................... 18 albuterol sulfate solution for nebulization 2.5 mg /3 ml (0.083 %) ....................................................................................... 18 albuterol sulfate solution for nebulization 2.5 mg/0.5 ml ............... 18 albuterol sulfate solution for nebulization 5 mg/ml ................................ 18 albuterol sulfate syrup 2 mg/5 ml ................................................................................................ 18 albuterol sulfate tablet 2 mg, 4 mg ................................................................................................ 18 alendronate tablet ...................................... 56 alfuzosin er tablet,extended release 24 hr 10 mg .................................... 18 ALKERAN TABLET 2 MG ................................................................................................ 13 allopurinol tablet 100 mg, 300 mg ................................................................................................ 56 ALOMIDE EYE DROPS 0.1 % ................................................................................................ 41 ALPHAGAN P EYE DROPS 0.1 % .............................................................................. 40 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML .................................................................... 32 alprazolam tablet ........................................ 32 alprostadil injection solution 500 mcg/ml ......................................................................... 28 ALTAFRIN EYE DROPS 10 %, 2.5 % .............................................................................. 44 ALTAVERA (28) TABLET 0.15-30 MG-MCG .................................... 49 ALYACEN 1/35 (28) TABLET 1-35 MG-MCG .............................................. 49 ALYACEN 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG .................. 49 amantadine hcl capsule 100 mg .................................................................................................... 4 amantadine hcl syrup 50 mg/5 ml .................................................................................................... 4 amantadine hcl tablet 100 mg .................................................................................................... 4 A-METHAPRED SOLUTION FOR INJECTION 40 MG/ML ................................................................................................ 46 amiloride tablet 5 mg ............................... 28 amiloride-hydrochlorothiazide tablet 5-50 mg ................................................... 28 aminocaproic acid oral solution 25 % ......................................................................................... 19 aminocaproic acid tablet 1,000 mg, 500 mg ............................................................ 19 amiodarone intravenous syringe 150 mg/3 ml .......................................................... 25 amiodarone tablet ...................................... 25 amitriptyline oral ........................................ 38 amlodipine ............................................................ 26 amlodipine-benazepril ........................... 26 AMNESTEEM ............................................. 65 amoxapine ............................................................ 38 amoxicillin capsule 250 mg, 500 mg .......................................................................................... 4 amoxicillin chewable tablet 125 mg, 250 mg ................................................................ 4 amoxicillin oral suspension ............... 4 amoxicillin tablet 500 mg, 875 mg .................................................................................................... 4 amoxicillin-clarithromycin-lansopr azole oral combo pack 500-500-30 mg ...................................................................................... 10 amoxicillin-potassium clavulanate chewable tablet 200-28.5 mg, 400-57 mg ................................................................... 4 amoxicillin-potassium clavulanate oral suspension ................................................... 5 amoxicillin-potassium clavulanate tablet ................................................................................ 5 amoxicillin-potassium clavulanate tablet ext.release 12 hr 1,000-62.5 mg .......................................................................................... 5 AMPHETAMINE SALT COMBO ................................................................... 29 amphotericin b solution for injection 50 mg ................................................. 11 ampicillin capsule 250 mg, 500 mg .................................................................................................... 5 ampicillin intravenous solution 1 gram, 2 gram .......................................................... 5 ampicillin oral suspension 125 mg/5 ml, 250 mg/5 ml ................................. 5 ampicillin solution for injection .................................................................................................... 5 ampicillin-sulbactam inj ........................ 5 ampicillin-sulbactam intravenous solution 1.5 gram, 3 gram ..................... 5 anagrelide capsule 0.5 mg, 1 mg ................................................................................................ 23 anastrozole tablet 1 mg ........................ 13 69 ANDRODERM TRANSDERMAL 24 HOUR PATCH 2 MG/24 HOUR, 4 MG/24 HR ........................................................... 47 ANDROID CAPSULE 10 MG ................................................................................................ 48 ANDROXY TABLET 10 MG ................................................................................................ 48 antipyrine-benzocaine ear drops 5.4-1.4 % .................................................................. 44 ANUCORT-HC SUPPOSITORY 25 MG ................. 60 ANUSOL-HC SUPPOSITORY 25 MG ......................................................................... 60 APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ............................... 53 APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML ................................................................................................ 53 apraclonidine eye drops 0.5 % ................................................................................................ 43 APRI TABLET 0.15-30 MG-MCG ............................................................. 49 APTIVUS CAPSULE 250 MG .................................................................................................... 7 ARMOUR THYROID TABLET ................................................................. 55 ASACOL HD TABLET,DELAYED RELEASE 800 MG ................................ 45 ASMANEX TWISTHALER BREATH ACTIVATED ................ 59 ASTEPRO NASAL SPRAY 0.15 % (205.5 MCG) ............................................. 41 ASTRINGYN TOPICAL SOLUTION 259 MG/G ................... 20 atenolol oral ....................................................... 19 atenolol-chlorthalidone tablet 100-25 mg, 50-25 mg ............................... 19 atorvastatin ......................................................... 26 atovaquone-proguanil tablet 250-100 mg, 62.5-25 mg ......................... 5 ATRIPLA TABLET 600-200-300 MG .............................................. 9 atropine eye drops 1 % .......................... 44 atropine eye ointment 1 % ................ 44 ATROPINE-CARE EYE DROPS 1 % ........................................................ 44 ATROVENT HFA AEROSOL INHALER 17 MCG/ACTUATION ............................ 15 70 AUGMENTIN ORAL SUSPENSION 125-31.25 MG/5 ML ....................................................................................... 5 AURODEX EAR DROPS 5.4-1.4 % .................................................................. 44 AUROGUARD EAR DROPS 5.4-1.4 % .................................................................. 44 AVANDAMET TABLET ............ 48 AVANDARYL TABLET 4-1 MG, 8-2 MG, 8-4 MG ........................ 55 AVANDARYL TABLET 4-2 MG, 4-4 MG ..................................................... 55 AVANDIA .......................................................... 55 AVAR TOPICAL CLEANSER 10-5 % (W/W) ................................................... 63 AVAR-E GREEN TOPICAL CREAM 10-5 % (W/W) .................... 63 AVAR-E TOPICAL CREAM 10-5 % (W/W) ................................................... 63 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML ................. 14 AVC VAGINAL CREAM 15 % ................................................................................................ 63 AVELOX ABC PACK TABLET 400 MG ..................................................................... 11 AVELOX IN SODIUM CHLORIDE (ISO-OSMOTIC) IV PIGGYBACK 400 MG/250 ML ................................................................................... 11 AVELOX TABLET 400 MG ................................................................................................ 11 AVIANE TABLET 0.1-20 MG-MCG ............................................................. 49 AVODART CAPSULE 0.5 MG ................................................................................................ 56 AVONEX ADMINISTRATION PACK INTRAMUSCULAR KIT 30 MCG/0.5 ML .......................... 58 AVONEX INTRAMUSCULAR KIT 30 MCG .................................................... 57 AVONEX INTRAMUSCULAR PEN KIT 30 MCG/0.5 ML ................................................................................................ 57 azathioprine tablet 50 mg .................. 58 azelastine nasal spray aerosol 137 mcg ................................................................................... 41 azithromycin oral packet 1 gram ................................................................................................ 10 azithromycin oral suspension 100 mg/5 ml, 200 mg/5 ml ............................. 10 azithromycin tablet .................................. 10 AZURETTE (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 ................................................................................................ 49 bacitracin eye ointment 500 unit/gram .................................................................. 41 bacitracin-polymyxin b eye ointment 500-10,000 unit/gram ................................................................................................ 41 baclofen tablet 10 mg, 20 mg ................................................................................................ 16 BACMIN TABLET 27-1 MG ................................................................................................ 20 BACTROBAN NASAL OINTMENT 2 % ....................................... 41 balsalazide capsule 750 mg ............. 45 BALZIVA (28) TABLET 0.4-35 MG-MCG ............................................................. 49 BAYCADRON ORAL ELIXIR 0.5 MG/5 ML ................................................... 46 belladonna alkaloids-opium rectal suppository 16.2-60 mg ........................ 33 BELLADONNA-OPIUM RECTAL SUPPOSITORY 16.2-30 MG ......................................................... 33 benazepril .............................................................. 23 benazepril-hydrochlorothiazide ................................................................................................ 28 BENZAMYCINPAK TOPICAL GEL 3-5 % ............................................................ 60 benzonatate capsule 100 mg, 200 mg ...................................................................................... 59 benztropine oral ............................................ 16 betamethasone dipropionate lotion 0.05 % .......................................................................... 60 betamethasone dipropionate topical cream 0.05 % ............................... 61 betamethasone dipropionate topical ointment 0.05 % ....................... 61 betamethasone valerate lotion 0.1 % ......................................................................................... 61 betamethasone valerate topical cream 0.1 % ......................................................... 61 betamethasone valerate topical ointment 0.1 % ................................................. 61 betamethasone, augmented topical cream 0.05 % ...................................................... 61 betamethasone, augmented topical gel 0.05 % ............................................................... 61 betamethasone, augmented topical ointment 0.05 % ............................................. 61 betaxolol eye drops 0.5 % ................. 42 betaxolol tablet 10 mg, 20 mg ................................................................................................ 19 bethanechol chloride oral ................. 17 BETOPTIC S EYE DROPS,SUSPENSION 0.25 % ................................................................................................ 42 bicalutamide tablet 50 mg ................. 14 BILTRICIDE TABLET 600 MG .................................................................................................... 5 bisoprolol fumarate tablet 10 mg, 5 mg ................................................................................. 19 bisoprolol-hydrochlorothiazide ................................................................................................ 19 BLEPHAMIDE EYE DROPS,SUSPENSION 10-0.2 % ................................................................................................ 41 BLEPHAMIDE S.O.P. EYE OINTMENT 10-0.2 % ........................ 41 B-PLEX PLUS TABLET 27-0.8 MG .................................................................................. 20 BRIELLYN TABLET 0.4-35 MG-MCG ............................................................. 49 brimonidine eye drops 0.15 % ................................................................................................ 40 brimonidine eye drops 0.2 % ................................................................................................ 40 BROMFED DM SYRUP 2-30-10 MG/5 ML ..................................... 15 bromocriptine capsule 5 mg ............ 33 bromocriptine tablet 2.5 mg ........... 33 BUDEPRION SR TABLET,EXTENDED RELEASE 150 MG ................................ 31 budesonide suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml ....................................................................... 59 bumetanide oral ............................................. 27 buprenorphine sublingual tablet 2 mg, 8 mg ................................................................... 35 BUPROBAN TABLET,EXTENDED RELEASE 150 MG ................................ 31 bupropion hcl sr tablet,sustained-release ....................... 31 bupropion hcl tablet 100 mg, 75 mg ...................................................................................... 31 bupropion hcl xl 24 hr tablet, extended release 150 mg, 300 mg ................................................................................................ 31 buspirone ................................................................ 31 BUTALBITAL COMPOUND TABLET 50-325-40 MG ................. 23 butalbital-acetaminophen tablet 50-325 mg ............................................................... 29 butalbital-acetaminophen-caffeine capsule 50-325-40 mg ............................. 29 butalbital-acetaminophen-caffeine tablet 50-325-40 mg, 50-500-40 mg ...................................................................................... 29 butalbital-aspirin-caffeine capsule 50-325-40 mg ...................................................... 23 butalbital-aspirin-caffeine tablet 50-325-40 mg ...................................................... 23 calcipotriene topical cream 0.005 % ......................................................................................... 65 calcipotriene topical ointment 0.005 % ...................................................................... 65 calcipotriene topical solution 0.005 % ......................................................................................... 65 calcitonin (salmon) nasal spray 200 unit/actuation ........................................ 54 CALCITRENE TOPICAL OINTMENT 0.005 % .......................... 65 calcitriol capsule 0.25 mcg, 0.5 mcg ................................................................................... 67 calcitriol oral solution 1 mcg/ml ................................................................................................ 67 calcium acetate capsule 667 mg ................................................................................................ 39 calcium acetate tablet 667 mg ................................................................................................ 39 CAMILA TABLET 0.35 MG ................................................................................................ 49 CAPACET CAPSULE 50-325-40 MG .................................................................................. 29 captopril .................................................................. 23 captopril-hydrochlorothiazide ................................................................................................ 28 carbamazepine chewable tablet 100 mg ......................................................................... 29 carbamazepine er tablet,extended release,12 hr 200 mg, 400 mg ................................................................................................ 29 carbamazepine oral suspension 100 mg/5 ml .......................................................... 30 carbamazepine tablet 200 mg ................................................................................................ 30 carbidopa-levodopa er tablet,extended release 25-100 mg, 50-200 mg ............................................................... 33 carbidopa-levodopa tablet ............... 33 CARNITOR SUGAR-FREE ORAL SOLUTION 100 MG/ML .................................................................... 58 carteolol eye drops 1 % ........................ 42 CARTIA XT CAPSULE,EXTENDED RELEASE ............................................................ 25 carvedilol ................................................................ 18 CAZIANT (28) TABLET 0.1/.125/.15-25 MG-MCG ............. 49 cefaclor capsule 250 mg, 500 mg ................................................................................................ 11 cefaclor er tablet,extended release,12 hr 500 mg ................................. 12 cefaclor oral suspension ..................... 12 cefadroxil capsule 500 mg .................... 6 cefadroxil oral suspension 250 mg/5 ml, 500 mg/5 ml ................................. 7 cefadroxil tablet 1 gram .......................... 7 cefazolin in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml ............................................................................................ 7 cefazolin intravenous solution 1 gram ................................................................................... 7 cefazolin solution for injection .................................................................................................... 7 cefdinir capsule 300 mg ........................ 13 cefdinir oral suspension 125 mg/5 ml, 250 mg/5 ml .............................................. 13 cefepime in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/100 ml ............................................ 7 cefepime solution for injection 1 gram, 2 gram .......................................................... 7 cefotetan in dextrose, iso-osmotic intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ............................................ 12 cefotetan intravenous solution 10 gram ................................................................................ 12 cefotetan solution for injection 1 gram, 2 gram ...................................................... 12 cefoxitin in dextrose, iso-osmotic intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ............................................ 12 cefoxitin iv ............................................................ 12 cefpodoxime oral suspension 100 mg/5 ml, 50 mg/5 ml ................................. 13 cefpodoxime tablet 100 mg, 200 mg ...................................................................................... 13 cefprozil oral suspension 125 mg/5 ml, 250 mg/5 ml .............................................. 12 cefprozil tablet 250 mg, 500 mg ................................................................................................ 12 ceftazidime solution for injection ................................................................................................ 13 ceftriaxone in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ............................................................. 13 ceftriaxone intravenous solution 1 gram, 2 gram ...................................................... 13 ceftriaxone solution for injection ................................................................................................ 13 cefuroxime axetil tablet 250 mg, 500 mg ......................................................................... 12 71 cefuroxime in dextrose (iso-osmotic) intravenous piggyback 1.5 gram/50 ml, 750 mg/50 ml ................................................................... 12 cefuroxime sodium intravenous solution 7.5 gram ........................................... 12 cefuroxime sodium solution for injection 1.5 gram, 750 mg .............. 12 CELLCEPT ORAL SUSPENSION 200 MG/ML ................................................................................................ 58 cephalexin capsule 250 mg, 500 mg .......................................................................................... 7 cephalexin oral suspension 125 mg/5 ml, 250 mg/5 ml ................................. 7 cephalexin tablet 250 mg, 500 mg .................................................................................................... 7 cevimeline capsule 30 mg ................... 17 CHATEAL TABLET 0.15-30 MG-MCG ............................................................. 49 CHEMET CAPSULE 100 MG ................................................................................................ 46 chlordiazepoxide hcl oral ................. 32 chlorhexidine gluconate mouthwash 0.12 % ...................................... 43 chloroquine tablet 250 mg, 500 mg .................................................................................................... 5 chlorothiazide tablet 250 mg, 500 mg ...................................................................................... 28 chlorpromazine tablet ........................... 35 chlorthalidone tablet 25 mg, 50 mg ................................................................................................ 28 chlorzoxazone tablet 500 mg ................................................................................................ 16 cholestyramine (with sugar) oral powder 4 gram .................................................. 24 cholestyramine (with sugar) powder for susp in a packet 4 gram ................................................................................ 24 CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM ................................................................................................ 24 CHOLESTYRAMINE LIGHT POWDER FOR SUSP IN A PACKET 4 GRAM ................................ 24 choline & magnesium salicylate oral liquid 500 mg/5 ml ......................... 36 cilostazol tablet 100 mg, 50 mg ................................................................................................ 23 CILOXAN EYE OINTMENT 0.3 % .............................................................................. 41 cimetidine oral solution 300 mg/5 ml ........................................................................................ 45 cimetidine tablet ........................................... 45 72 CIPRO ORAL SUSPENSION 250 MG/5 ML, 500 MG/5 ML ................................................................................................ 11 CIPRODEX EAR DROPS,SUSPENSION 0.3-0.1 % ......................................................................................... 41 ciprofloxacin eye drops 0.3 % ................................................................................................ 41 ciprofloxacin in dextrose 5 % intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ....................................... 11 ciprofloxacin intravenous solution 200 mg/20 ml, 400 mg/40 ml ................................................................................................ 11 ciprofloxacin tablet .................................. 11 citalopram oral solution 10 mg/5 ml ........................................................................................ 37 citalopram tablet ......................................... 37 CLARAVIS ........................................................ 65 clarithromycin er tablet,extended release 24 hr 500 mg ................................. 10 clarithromycin oral suspension 125 mg/5 ml, 250 mg/5 ml ............................. 10 clarithromycin tablet 250 mg, 500 mg ...................................................................................... 10 clemastine syrup 0.67 mg/5 ml .................................................................................................... 3 CLEOCIN VAGINAL SUPPOSITORY 100 MG .............. 60 CLINDACIN ETZ TOPICAL SWAB 1 % ............................................................ 60 CLINDACIN P TOPICAL SWAB 1 % ............................................................ 60 clindamycin hcl .................................................. 8 clindamycin intravenous solution .................................................................................................... 8 clindamycin lotion 1 % .......................... 60 clindamycin oral solution 75 mg/5 ml ............................................................................................ 8 CLINDAMYCIN PEDIATRIC ORAL SOLUTION 75 MG/5 ML ....................................................................................... 8 clindamycin phosphate topical swab 1 % ................................................................... 60 clindamycin topical gel 1 % ............ 60 clindamycin topical solution 1 % ................................................................................................ 60 clindamycin vaginal cream 2 % ................................................................................................ 60 clobetasol topical cream 0.05 % ................................................................................................ 61 clobetasol topical gel 0.05 % ................................................................................................ 61 clobetasol topical ointment 0.05 % ................................................................................................ 61 clobetasol topical solution 0.05 % ................................................................................................ 61 clobetasol-emollient topical cream 0.05 % .......................................................................... 61 clomipramine .................................................... 38 clonazepam tablet ...................................... 32 clonidine tablet ............................................... 24 clonidine weekly transdermal patch ............................................................................. 24 clopidogrel tablet 300 mg, 75 mg ................................................................................................ 23 clorazepate dipotassium tablet ................................................................................................ 32 CLORPRES ....................................................... 24 clotrimazole troche 10 mg ................ 63 clotrimazole-betamethasone topical cream 1-0.05 % ......................... 63 clozapine tablet .............................................. 31 coal tar topical solution 20 % ................................................................................................ 63 codeine sulfate tablet ............................. 33 COLCRYS TABLET 0.6 MG ................................................................................................ 56 COLESTID FLAVORED PACKET 7.5 GRAM .......................... 24 colestipol oral granules 5 gram ................................................................................................ 24 colestipol oral packet 5 gram ................................................................................................ 24 colestipol tablet 1 gram ........................ 24 COLOCORT ENEMA 100 MG/60 ML ........................................................... 61 COMBIPATCH TRANSDERMAL 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR .................................................................................... 53 COMBIVENT AEROSOL INHALER 18-103 MCG/ACTUATION ............................ 15 COMBIVENT RESPIMAT AEROSOL INHALER 20-100 MCG/ACTUATION ............................ 15 COMPLERA TABLET 200-25-300 MG .................................................. 9 COMPLETENATE CHEWABLE TABLET 29-1 MG .................................................................................. 66 COMPRO RECTAL SUPPOSITORY 25 MG ................. 35 CONDYLOX TOPICAL GEL 0.5 % .............................................................................. 65 CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML ................................................................................................ 39 COPAXONE SUBCUTANEOUS SYRINGE KIT 20 MG/ML ........................................... 58 CORDRAN TAPE 4 MCG/CM2 .......................................................... 61 CORMAX TOPICAL SOLUTION 0.05 % ................................ 61 CORTIFOAM RECTAL 10 % (80 MG) .................................................................... 61 cortisone tablet 25 mg ............................ 46 COUMADIN ORAL ........................... 19 COVARYX H.S. TABLET 0.625-1.25 MG ................................................ 48 COVARYX TABLET 1.25-2.5 MG .................................................................................. 48 CREON CAPSULE,DELAYED RELEASE ............................................................ 45 CRIXIVAN CAPSULE 200 MG, 400 MG ........................................................ 7 cromolyn eye drops 4 % ....................... 59 cromolyn solution for nebulization 20 mg/2 ml .............................................................. 59 CRYSELLE (28) TABLET 0.3-30 MG-MCG ........................................ 49 CUPRIMINE CAPSULE 250 MG .................................................................................. 46 cyanocobalamin (vit b-12) injection solution 1,000 mcg/ml ................................................................................................ 66 CYCLAFEM 1/35 (28) TABLET 1-35 MG-MCG .............................................. 49 CYCLAFEM 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG ............................................................................. 49 cyclobenzaprine tablet 10 mg, 5 mg ...................................................................................... 16 CYCLOGYL EYE DROPS 0.5 % ......................................................................................... 44 cyclopentolate eye drops 1 %, 2 % ................................................................................................ 44 cyclophosphamide tablet 25 mg, 50 mg ............................................................................. 14 cycloserine capsule 250 mg ................. 6 cyclosporine capsule 100 mg, 25 mg ...................................................................................... 58 cyclosporine modified ............................ 58 cyclosporine modified oral solution 100 mg/ml ............................................................... 58 CYMBALTA ................................................... 36 cyproheptadine syrup 2 mg/5 ml .................................................................................................... 3 cyproheptadine tablet 4 mg ................. 3 danazol oral ........................................................ 48 dantrolene oral ............................................... 16 dapsone tablet 100 mg, 25 mg .................................................................................................... 6 DARAPRIM TABLET 25 MG .................................................................................................... 5 DASETTA 1/35 (28) TABLET 1-35 MG-MCG .............................................. 49 DASETTA 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG .................. 49 DELZICOL CAPSULE,DELAYED RELEASE 400 MG ................................ 45 demeclocycline tablet 150 mg, 300 mg ...................................................................................... 12 DEMSER CAPSULE 250 MG ................................................................................................ 58 DENTA 5000 PLUS CREAM 1.1 % .............................................................................. 56 DENTAGEL 1.1 % ................................. 56 DEPADE TABLET 50 MG ................................................................................................ 35 DEPAKENE CAPSULE 250 MG .................................................................................. 30 DEPAKENE ORAL SOLUTION 250 MG/5 ML ................................................................................................ 30 DEPEN TITRATABS TABLET 250 MG ..................................................................... 46 DEPO-MEDROL SUSPENSION FOR INJECTION 20 MG/ML ............... 47 desipramine oral ........................................... 38 desmopressin injection solution 4 mcg/ml ......................................................................... 20 desmopressin nasal solution 0.1 mg/ml (refrig) ..................................................... 20 desmopressin nasal spray (non-refrigerated) 10 mcg/spray ................................................................................................ 54 desmopressin nasal spray 10 mcg/spray (0.1 ml) ...................................... 20 desmopressin tablet 0.1 mg, 0.2 mg ...................................................................................... 20 desonide lotion 0.05 % ........................... 61 desonide topical cream 0.05 % ................................................................................................ 61 desonide topical ointment 0.05 % ................................................................................................ 61 desoximetasone topical cream 0.05 %, 0.25 % ................................................................ 61 desoximetasone topical gel 0.05 % ................................................................................................ 61 desoximetasone topical ointment 0.25 % .......................................................................... 61 dexamethasone eye drops 0.1 % ................................................................................................ 43 DEXAMETHASONE INTENSOL DROPS (CONCENTRATE) 1 MG/ML ................................................................................................ 47 dexamethasone oral elixir 0.5 mg/5 ml ....................................................................... 47 dexamethasone oral solution 0.5 mg/5 ml ....................................................................... 47 dexamethasone tablet ........................... 47 dexchlorpheniramine maleate er tablet,extended release 6 mg .................................................................................................... 4 dexmethylphenidate tablet ............. 36 DEXPAK 13 DAY TABLETS IN A DOSE PACK 1.5 MG (51 TABS) ......................................................................... 47 dextroamphetamine er capsule,extended release 10 mg ................................................................................................ 29 dextroamphetamine er capsule,extended release 15 mg ................................................................................................ 29 dextroamphetamine er capsule,extended release 5 mg ................................................................................................ 29 dextroamphetamine tablet 10 mg ................................................................................................ 29 dextroamphetamine tablet 5 mg ................................................................................................ 29 dextroamphetamine-amphetamine er 24hr capsule,extend release 10 mg, 15 mg, 5 mg ............................................. 29 dextroamphetamine-amphetamine er 24hr capsule,extend release 20 mg, 25 mg, 30 mg ......................................... 29 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML .................................................................... 32 diazepam oral solution 5 mg/5 ml ................................................................................................ 32 diazepam rectal kit ................................... 32 diazepam tablet ............................................. 32 DIBENZYLINE CAPSULE 10 MG .................................................................................. 17 diclofenac er tablet,extended release 24 hr 100 mg ................................. 35 diclofenac eye drops 0.1 % ............... 43 diclofenac sodium tablet,delayed release ......................................................................... 35 73 dicloxacillin capsule 250 mg, 500 mg ...................................................................................... 11 dicyclomine capsule 10 mg ............... 15 dicyclomine oral solution 10 mg/5 ml ........................................................................................ 15 dicyclomine tablet 20 mg .................... 15 didanosine capsule,delayed release ................................................................................................... 9 DIFFERIN TOPICAL GEL 0.3 % ......................................................................................... 65 diflunisal tablet 500 mg ........................ 35 digoxin oral solution 50 mcg/ml ................................................................................................ 24 digoxin tablet 125 mcg, 250 mcg ................................................................................................ 24 dihydroergotamine injection solution 1 mg/ml ............................................. 17 dihydroergotamine nasal spray 0.5 mg/pump act. (4 mg/ml) ....................... 17 DILANTIN CAPSULE 30 MG ................................................................................................ 25 DILATRATE-SR CAPSULE,EXTENDED RELEASE 40 MG .................................... 27 DILT-CD ............................................................... 25 diltiazem cd capsule,extended release 24 hr ....................................................... 25 diltiazem er (xr/xt) capsule,extended release,controlled ........................................ 25 diltiazem er capsule,extended release ......................................................................... 25 diltiazem er capsule,extended release 12 hr ....................................................... 25 diltiazem intravenous powder for solution 100 mg ............................................... 25 diltiazem tablet .............................................. 25 DILT-XR ............................................................... 25 DILTZAC ER ................................................ 25 DIPENTUM CAPSULE 250 MG .................................................................................. 45 diphenhydramine injection solution 50 mg/ml ....................................................................... 3 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml ........................................ 15 diphenoxylate-atropine tablet 2.5-0.025 mg ........................................................ 15 dipyridamole oral ........................................ 23 disopyramide capsule 100 mg, 150 mg ...................................................................................... 24 disulfiram tablet 250 mg, 500 mg ................................................................................................ 56 DIURIL ORAL SUSPENSION 250 MG/5 ML ................................................. 28 74 divalproex er tablet,extended release 24 hr 250 mg, 500 mg ................................................................................................ EEMT TABLET 1.25-2.5 MG 48 EFFER-K EFFERVESCENT TABLET 25 MEQ .................................... 40 ELIDEL TOPICAL CREAM 1 % ......................................................................................... 65 ELIMITE TOPICAL CREAM 5 % ......................................................................................... 64 ELINEST TABLET 0.3-30 MG-MCG ............................................................. 49 ELIPHOS TABLET 667 MG ................................................................................................ 39 ELIQUIS TABLET 2.5 MG, 5 MG .................................................................................. 19 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML ..................... 26 ELMIRON CAPSULE 100 MG ................................................................................................ 58 EMOQUETTE TABLET 0.15-30 MG-MCG .................................... 49 EMTRIVA CAPSULE 200 MG .................................................................................................... 9 EMTRIVA ORAL SOLUTION 10 MG/ML .............................................................. 9 enalapril maleate tablet ...................... 23 enalapril-hydrochlorothiazide tablet 10-25 mg, 5-12.5 mg ............. 28 ENBREL SUBCUTANEOUS KIT 25 MG (1 ML) ................................. 57 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ................................................................................................ 57 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ................................................................................. 57 ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ................................................................................. 57 ENDOCET TABLET ......................... 33 ENDODAN TABLET 4.8355-325 MG .............................................. 36 enoxaparin subcutaneous solution 300 mg/3 ml .......................................................... 20 enoxaparin subcutaneous syringe ................................................................................................ 20 ENPRESSE TABLET 50-30 (6)/75-40 (5)/125-30(10) ...................... 49 ENSKYCE TABLET 0.15-30 MG-MCG ............................................................. 49 entacapone tablet 200 mg .................. 33 ENULOSE ORAL SOLUTION 10 GRAM/15 ML ...................................... 39 ................................................................................................ 30 divalproex sprinkle capsule 125 mg ...................................................................................... 30 divalproex tablet,delayed release ................................................................................................ 30 donepezil disintegrating tablet 10 mg, 5 mg ................................................................... 17 donepezil tablet .............................................. 17 DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML ................................................................................................ 16 DONNATAL TABLET 16.2-0.1037 -0.0194 MG .................... 16 dorzolamide eye drops 2 % .............. 43 dorzolamide-timolol eye drops 2-0.5 % ........................................................................ 42 doxazosin tablet ............................................ 17 doxepin capsule ............................................. 38 doxepin oral concentrate 10 mg/ml ................................................................................................ 38 doxycycline hyclate capsule 100 mg, 50 mg ................................................................ 12 doxycycline hyclate tablet 100 mg ................................................................................................ 12 doxycycline hyclate tablet 20 mg ................................................................................................ 41 doxycycline monohydrate oral suspension 25 mg/5 ml ............................ 12 DRITHOCREME HP TOPICAL 1 % ................................................ 63 droperidol injection solution 2.5 mg/ml ............................................................................ 31 DROXIA ................................................................ 14 DULERA HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION ............................ 18 DYRENIUM CAPSULE 100 MG, 50 MG ........................................................ 28 E.E.S. 400 TABLET 400 MG .................................................................................................... 8 E.E.S. GRANULES ORAL SUSPENSION 200 MG/5 ML .................................................................................................... 8 econazole topical cream 1 % ................................................................................................ 63 EDECRIN TABLET 25 MG ................................................................................................ 27 EDURANT TABLET 25 MG .................................................................................................... 9 EEMT HS TABLET 0.625-1.25 MG .................................................................................. 48 EPIFOAM TOPICAL 1-1 % 61 epinephrine injection,auto-injector 0.3 mg/0.3 ml (1:1,000) ......................... 15 EPIPEN 2-PAK INJECTION,AUTO-INJECTO R 0.3 MG/0.3 ML (1:1,000) ................................................................................................ 15 EPIPEN JR 2-PAK INJECTION,AUTO-INJECTO R 0.15 MG/0.3 ML (1:2,000) ................................................................................................ 15 EPITOL TABLET 200 MG ................................................................................................ 30 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) ..................................................................... 9 EPIVIR HBV TABLET 100 MG .................................................................................................... 9 EPIVIR ORAL SOLUTION 10 MG/ML ........................................................................ 9 EPZICOM TABLET 600-300 MG ...................................................................................... 9 ergocalciferol (vitamin d2) capsule 50,000 unit ............................................................. 67 ERGOMAR SUBLINGUAL TABLET 2 MG ............................................ 17 ergotamine-caffeine tablet 1-100 mg ...................................................................................... 17 ERRIN TABLET 0.35 MG ................................................................................................ 49 ERY PADS TOPICAL SWAB 2 % ......................................................................................... 60 ERYPED 200 ORAL SUSPENSION 200 MG/5 ML .................................................................................................... 8 ERYPED 400 ORAL SUSPENSION 400 MG/5 ML .................................................................................................... 8 ERY-TAB ................................................................. 8 ERYTHROCIN STEARATE TABLET 250 MG ......................................... 8 erythromycin capsule,delayed release 250 mg ...................................................... 8 erythromycin ethylsuccinate tablet 400 mg ............................................................................. 8 erythromycin eye ointment 5 mg/gram (0.5 %) ............................................ 41 erythromycin tablet 250 mg, 500 mg .......................................................................................... 8 erythromycin with ethanol topical gel 2 % ......................................................................... 60 erythromycin with ethanol topical solution 2 % .......................................................... 60 ................................................................................................ erythromycin with ethanol topical swab 2 % ................................................................... 60 erythromycin-benzoyl peroxide topical gel 3-5 % ............................................ 60 erythromycin-sulfisoxazole oral suspension 200-600 mg/5 ml .............. 6 escitalopram tablet ................................... 37 ESTARYLLA TABLET 0.25-35 MG-MCG ............................................................. 49 esterified estrogens-methyltestosterone tablet 0.625-1.25 mg, 1.25-2.5 mg ................................................................................................ 48 estradiol tablet ................................................ 53 estradiol weekly transdermal patch ............................................................................. 53 ESTRING VAGINAL 2 MG ................................................................................................ 53 estropipate tablet ......................................... 53 ethambutol tablet 100 mg, 400 mg .................................................................................................... 6 ethosuximide capsule 250 mg ................................................................................................ 38 ethosuximide oral solution 250 mg/5 ml ....................................................................... 38 etidronate disodium tablet 200 mg, 400 mg ......................................................................... 56 etodolac capsule 200 mg, 300 mg ................................................................................................ 35 etodolac er tablet,extended release 24 hr .............................................................................. 35 etodolac tablet 400 mg, 500 mg ................................................................................................ 35 EURAX TOPICAL CREAM 10 % ......................................................................................... 64 EVISTA TABLET 60 MG ........... 52 EXELON ORAL SOLUTION 2 MG/ML .................................................................... 17 EXELON TRANSDERMAL 24 HOUR PATCH 4.6 MG/24 HOUR, 9.5 MG/24 HOUR ................................................................................................ 17 FALMINA (28) TABLET 0.1-20 MG-MCG ............................................................. 49 famciclovir ............................................................ 10 famotidine (pf) in nacl (iso-osmotic) intravenous piggyback 20 mg/50 ml ......................... 46 famotidine (pf) intravenous solution 20 mg/2 ml .................................... 45 famotidine tablet 40 mg ....................... 45 FARESTON TABLET 60 MG ................................................................................................ 14 FE C PLUS TABLET 100-250-25-1 MG-MG-MCG-MG ............................. 20 felbamate oral suspension 600 mg/5 ml ....................................................................... 30 felbamate tablet 400 mg, 600 mg ................................................................................................ 30 felodipine er tablet,extended release 24 hr ....................................................... 26 FEMHRT LOW DOSE TABLET 0.5-2.5 MG-MCG ................................................................................................ 53 fenofibrate micronized capsule ................................................................................................ 26 fenofibrate nanocrystallized tablet 145 mg, 48 mg ................................................... 26 fenofibrate tablet 160 mg, 54 mg ................................................................................................ 26 fentanyl transdermal patch ............ 34 FEROCON CAPSULE 110-0.5 MG .................................................................................. 20 FERREX 150 FORTE CAPSULE 150-25-1 MG-MCG-MG ............................................. 20 FERROCITE PLUS TABLET 106 MG IRON- 1 MG ........................ 20 FERROGELS FORTE CAPSULE 460-60-0.01-1 MG ................................................................................................ 21 fexofenadine tablet 30 mg .................... 4 finasteride tablet 5 mg ........................... 56 FIORICET TABLET 50-325-40 MG .................................................................................. 29 FIRST-HYDROCORTISONE TOPICAL GEL 10 % ........................... 61 FLAGYL CAPSULE 375 MG .................................................................................................... 4 FLAGYL ER TABLET,EXTENDED RELEASE 750 MG .................................... 4 FLAREX EYE DROPS,SUSPENSION 0.1 % ................................................................................................ 43 flavoxate tablet 100 mg ........................ 65 flecainide ................................................................ 25 FLOVENT DISKUS ............................ 59 FLOVENT HFA ........................................ 59 fluconazole ............................................................... 6 fluconazole in dextrose (iso-osmotic) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ................................................................... 6 75 fluconazole in sodium chloride (iso-osmotic) iv piggyback 200 mg/100 ml, 400 mg/200 ml .................. 6 fluconazole oral suspension 10 mg/ml, 40 mg/ml ................................................ 6 flucytosine capsule 250 mg, 500 mg ...................................................................................... 11 fludarabine intravenous powder for solution 50 mg ........................................ 14 fludrocortisone tablet 0.1 mg ................................................................................................ 47 fluocinolone topical body oil 0.01 % ......................................................................................... 61 fluocinolone topical cream 0.01 %, 0.025 % ...................................................................... 61 fluocinolone topical ointment 0.025 % ...................................................................... 61 fluocinolone topical solution 0.01 % ......................................................................................... 61 fluocinolone-shower cap topical oil 0.01 % .......................................................................... 61 fluocinonide topical cream 0.05 % ................................................................................................ 61 fluocinonide topical gel 0.05 % ................................................................................................ 61 fluocinonide topical ointment 0.05 % ......................................................................................... 62 fluocinonide topical solution 0.05 % ......................................................................................... 62 FLUOCINONIDE-E TOPICAL CREAM 0.05 % ............................................ 62 fluocinonide-emollient topical cream 0.05 % ...................................................... 62 FLUORABON ORAL DROPS 0.25 MG FLUORID (0.55MG)/0.6 ML ....................................... 56 FLUOR-A-DAY ORAL DROPS 2.5 MG/ML ............................. 56 FLUORIDEX DAILY DEFENSE DENTAL GEL 1.1 % ......................................................................................... 56 FLUORITAB CHEWABLE TABLET 0.5 MG FLUORIDE (1.1 MG) .................................................................. 56 FLUORITAB ORAL DROPS 0.125 MG FLUOR (0.275 MG)/DROP ........................................................ 56 fluorometholone eye drops,suspension 0.1 % ......................... 43 FLUOROPLEX TOPICAL CREAM 1 % ..................................................... 65 fluorouracil topical cream 5 % ................................................................................................ 65 76 fluorouracil topical solution 2 %, 5 % ......................................................................................... 65 fluoxetine capsule 10 mg .................... 37 fluoxetine capsule 20 mg .................... 37 fluoxetine capsule 40 mg .................... 37 fluoxetine oral solution 20 mg/5 ml ........................................................................................ 37 fluoxetine tablet 10 mg ......................... 37 fluoxetine tablet 20 mg ......................... 37 fluphenazine decanoate injection solution 25 mg/ml ......................................... 36 fluphenazine oral concentrate 5 mg/ml ............................................................................ 36 fluphenazine oral elixir 2.5 mg/5 ml ........................................................................................ 36 fluphenazine tablet .................................... 36 FLURA-DROPS ORAL 0.25 MG FLUORID (0.55 MG)/DROP ........................................................ 57 flurbiprofen eye drops 0.03 % ................................................................................................ 43 flurbiprofen tablet 100 mg, 50 mg ................................................................................................ 35 flutamide capsule 125 mg .................. 14 fluticasone nasal spray,suspension 50 mcg/actuation ........................................... 59 fluvoxamine tablet 100 mg ............... 37 fluvoxamine tablet 25 mg, 50 mg ................................................................................................ 37 FML FORTE EYE DROPS,SUSPENSION 0.25 % ................................................................................................ 43 FOCALIN XR ............................................... 36 FOLBEE PLUS TABLET 5 MG ................................................................................................ 66 folic acid injection solution 5 mg/ml ............................................................................ 66 fondaparinux ..................................................... 19 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML ................................................................................................ 54 fosinopril ................................................................. 23 fosinopril-hydrochlorothiazide tablet 10-12.5 mg, 20-12.5 mg ................................................................................................ 28 FRAGMIN SUBCUTANEOUS SOLUTION 25,000 UNIT/ML ................................................................................................ 20 FRAGMIN SUBCUTANEOUS SYRINGE ............................................................ 20 furosemide oral solution 10 mg/ml, 40 mg/5 ml .............................................................. 27 furosemide tablet ......................................... 27 gabapentin capsule .................................... 29 gabapentin oral solution 250 mg/5 ml ........................................................................................ 29 gabapentin tablet 600 mg ................... 29 gabapentin tablet 800 mg ................... 29 GABITRIL TABLET 12 MG, 16 MG .................................................................................. 30 galantamine tablet ..................................... 17 GAVILYTE-C ORAL SOLUTION 240-22.72-6.72 GRAM ....................................................................... 45 GAVILYTE-N ORAL SOLUTION 420 GRAM ................ 45 gemfibrozil tablet 600 mg .................. 26 GENERLAC ORAL SOLUTION 10 GRAM/15 ML ................................................................................................ 39 GENGRAF CAPSULE 100 MG, 25 MG ........................................................ 58 GENGRAF ORAL SOLUTION 100 MG/ML ....................................................... 58 GENTAK EYE DROPS 0.3 % ................................................................................................ 41 GENTAK EYE OINTMENT 0.3 % (3 MG/GRAM) .......................... 41 gentamicin eye drops 0.3 % ............ 41 gentamicin eye ointment 0.3 % (3 mg/gram) .................................................................. 41 gentamicin in sodium chloride(iso-osm) intravenous piggyback .................................................................. 4 gentamicin injection solution 40 mg/ml ................................................................................ 4 gentamicin topical cream 0.1 % ................................................................................................ 60 gentamicin topical ointment 0.1 % ................................................................................................ 60 GILDAGIA TABLET 0.4-35 MG-MCG ............................................................. 49 GILDESS FE TABLET 1-20 MG-MCG, 1.5-30 MG-MCG ................................................................................................ 49 GILDESS TABLET 1-20 MG-MCG, 1.5-30 MG-MCG ................................................................................................ 49 GLEEVEC TABLET 100 MG, 400 MG ..................................................................... 14 glimepiride tablet 1 mg, 2 mg ................................................................................................ 55 glimepiride tablet 4 mg ......................... 55 glipizide er tablet, extended release 24 hr ....................................................... 55 glipizide tablet 10 mg, 5 mg ........... 55 glipizide-metformin tablet 2.5-500 mg, 5-500 mg ...................................................... 48 GLUCAGON EMERGENCY INJECTION KIT 1 MG ................. 53 glyburide micronized tablet ........... 55 glyburide tablet .............................................. 55 glyburide-metformin ............................... 48 GLYSET ................................................................. 47 griseofulvin microsize oral suspension 125 mg/5 ml ............................ 5 griseofulvin microsize tablet 500 mg .......................................................................................... 5 griseofulvin ultramicrosize tablet 125 mg, 250 mg ................................................... 5 guanfacine tablet 1 mg, 2 mg ................................................................................................ 24 GYNAZOLE-1 VAGINAL CREAM 2 % ..................................................... 63 haloperidol ........................................................... 32 haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml ................................................................... 32 haloperidol injection solution 5 mg/ml ............................................................................ 32 haloperidol oral concentrate 2 mg/ml ............................................................................ 32 HEATHER TABLET 0.35 MG ................................................................................................ 50 HECORIA ........................................................... 58 HELIDAC ORAL PACK 250-500-262.4 MG ..................................... 12 HEMATINIC PLUS VIT/MINERALS TABLET 106 MG IRON- 1 MG ..................................... 21 HEMATINIC/FOLIC ACID TABLET 324 MG (106 MG IRON)-1 MG ................................................... 21 HEMATOGEN FA CAPSULE 200-250-0.01-1 MG .................................. 21 HEMATOGEN FORTE CAPSULE 460-60-0.01-1 MG ................................................................................................ 21 HEMATRON ORAL LIQUID 50 MG IRON-1 MG/5 ML ................................................................................................ 21 HEMRIL-30 RECTAL SUPPOSITORY 30 MG ................. 62 heparin (porcine) in 0.45 % nacl intravenous solution ................................. 20 heparin (porcine) in 0.9 % sodium chloride (pf) iv solution 1,000 unit/500 ml, 2,000 unit/1,000 ml ................................................................................................ 20 heparin (porcine) in dextrose 5 % intravenous solution ................................. 20 heparin (porcine) injection solution ................................................................................................ 20 HEPARIN FLUSH INTRAVENOUS KIT 10 UNIT/ML ............................................................. 20 heparin flush(porcine)-0.9 % sodium chloride intravenous kit 100 unit/ml ............................................................. 20 heparin lock flush (porcine) intravenous solution 10 unit/ml, 100 unit/ml ............................................................. 20 HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION 10 UNIT/ML .................................................... 20 HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML ................................................ 20 HEXALEN CAPSULE 50 MG ................................................................................................ 14 HOMATROPAIRE EYE DROPS 5 % ........................................................ 44 homatropine eye drops 5 % ............. 44 HUMALOG KWIKPEN SUBCUTANEOUS 100 UNIT/ML ............................................................. 53 HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS 100 UNIT/ML (50-50) ........................ 53 HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) ......................................................................... 53 HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS 100 UNIT/ML (75-25) ........................ 54 HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) ......................................................................... 53 HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML ................................................................................................ 53 HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML ................................................ 53 HUMIRA CROHN'S DISEASE STARTER PACK SUBCUTANEOUS PEN KIT 40 MG/0.8 ML ......................................................... 57 HUMIRA PEN SUBCUTANEOUS KIT 40 MG/0.8 ML ......................................................... 57 HUMIRA PSORIASIS STARTER PACK SUBCUTANEOUS PEN KIT 40 MG/0.8 ML ......................................................... 57 HUMIRA SUBCUTANEOUS KIT 20 MG/0.4 ML, 40 MG/0.8 ML ................................................................................... 57 HUMULIN R U-500 "CONCENTRATED" INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML ................................................................................................ 54 hydralazine oral ............................................ 26 hydrochlorothiazide capsule 12.5 mg ...................................................................................... 28 hydrochlorothiazide tablet .............. 28 hydrocodone-acetaminophen oral solution 7.5-500 mg/15 ml ................. 34 hydrocodone-acetaminophen tablet 10-325 mg, 10-500 mg, 10-650 mg, 10-660 mg, 2.5-500 mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg, 7.5-650 mg .......... 34 hydrocodone-acetaminophen tablet 7.5-750 mg .......................................... 34 hydrocodone-homatropine syrup 5-1.5 mg/5 ml ..................................................... 16 hydrocodone-homatropine tablet 5-1.5 mg ..................................................................... 16 hydrocodone-ibuprofen tablet 7.5-200 mg ............................................................. 35 hydrocortisone acetate rectal suppository 25 mg ........................................ 62 hydrocortisone acetate rectal suppository 30 mg ........................................ 62 hydrocortisone enema 100 mg/60 ml ........................................................................................ 62 hydrocortisone lotion 2.5 % ........... 62 hydrocortisone oral .................................. 47 hydrocortisone topical cream 2.5 % ......................................................................................... 62 hydrocortisone topical ointment 2.5 % .............................................................................. 62 hydrocortisone valerate topical cream 0.2 % ......................................................... 62 hydrocortisone valerate topical ointment 0.2 % ................................................. 62 hydrocortisone-acetic acid ear drops 1-2 % ........................................................... 43 HYDROMET SYRUP 5-1.5 MG/5 ML .............................................................. 16 77 hydromorphone oral liquid 1 mg/ml ............................................................................ 34 hydromorphone rectal suppository 3 mg ................................................................................. 34 hydromorphone tablet ........................... 34 hydroxocobalamin intramuscular solution 1,000 mcg/ml ............................. 66 hydroxychloroquine tablet 200 mg .................................................................................................... 5 hydroxyurea capsule 500 mg ................................................................................................ 14 hydroxyzine hcl syrup 10 mg/5 ml .................................................................................................... 3 hydroxyzine hcl tablet .............................. 3 hydroxyzine pamoate capsule .................................................................................................... 3 HYPERCARE TOPICAL SOLUTION 20 % ...................................... 63 ibuprofen tablet ............................................. 35 IFEREX 150 FORTE CAPSULE 150-25-1 MG-MCG-MG ............................................. 21 imipenem-cilastatin intravenous solution 250 mg, 500 mg ......................... 6 imipramine hcl ................................................ 38 imiquimod topical cream packet 5 % ......................................................................................... 65 INATAL ADVANCE TABLET 90-1-50 MG ......................................................... 21 INATAL ULTRA TABLET 90-1-50 MG ......................................................... 21 indapamide tablet 1.25 mg, 2.5 mg ................................................................................................ 28 indomethacin capsule 25 mg, 50 mg ...................................................................................... 35 indomethacin er capsule,extended release 75 mg ...................................................... 35 INFASURF INTRATRACHEAL SUSPENSION 35 MG/ML ................................................................................................ 60 INFED INJECTION SOLUTION 100 MG/2 ML (50 MG/ML) ................................................................. 21 INTELENCE TABLET 100 MG, 200 MG ........................................................ 9 INTROVALE TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG ............................................................. 50 INTUNIV ER ................................................. 24 INVIRASE CAPSULE 200 MG .................................................................................................... 7 INVIRASE TABLET 500 MG .................................................................................................... 7 78 IOPIDINE EYE DROPS IN A DROPPERETTE 1 % ......................... 43 ipratropium bromide nasal spray 0.03 %, 0.06 % ................................................. 43 ipratropium bromide solution for inhalation 0.02 % .......................................... 16 ipratropium-albuterol solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml ................................................................ 16 irbesartan ............................................................... 23 irbesartan-hydrochlorothiazide tablet 150-12.5 mg, 300-12.5 mg ................................................................................................ 28 ISENTRESS TABLET 400 MG .................................................................................................... 8 ISOCHRON TABLET,EXTENDED RELEASE 40 MG .................................... 27 ISODITRATE TABLET,EXTENDED RELEASE 40 MG .................................... 27 isoniazid oral solution 50 mg/5 ml .................................................................................................... 6 isoniazid tablet 100 mg, 300 mg .................................................................................................... 6 ISOPTO CARBACHOL EYE DROPS 1.5 %, 3 % ................................... 44 ISORDIL TABLET 40 MG ................................................................................................ 27 isosorbide dinitrate er tablet,extended release 40 mg ................................................................................................ 27 isosorbide dinitrate sublingual tablet 2.5 mg, 5 mg ..................................... 27 isosorbide dinitrate tablet ................ 27 isosorbide mononitrate er tablet,extended release 24 hr ................................................................................................ 27 isosorbide mononitrate tablet 10 mg, 20 mg ................................................................ 27 JANTOVEN ...................................................... 19 JANUMET TABLET 50-1,000 MG, 50-500 MG .......................................... 48 JANUMET XR TABLET,EXTENDED RELEASE 100-1,000 MG ............. 48 JANUMET XR TABLET,EXTENDED RELEASE 50-1,000 MG, 50-500 MG .................................................................................. 48 JANUVIA ............................................................. 52 JENCYCLA TABLET 0.35 MG ................................................................................................ 50 JINTELI TABLET 1-5 MG-MCG ............................................................. 53 JOLESSA TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG ............................................................. 50 JOLIVETTE TABLET 0.35 MG ................................................................................................ 50 JUNEL 1.5/30 (21) TABLET 1.5-30 MG-MCG ........................................ 50 JUNEL 1/20 (21) TABLET 1-20 MG-MCG ............................................................. 50 JUNEL FE 1.5/30 (28) TABLET 1.5-30 MG-MCG ........................................ 50 JUNEL FE 1/20 (28) TABLET 1-20 MG-MCG .............................................. 50 KALETRA ORAL SOLUTION 400-100 MG/5 ML ........................................ 7 KALETRA TABLET 100-25 MG, 200-50 MG .............................................. 7 KALEXATE ORAL POWDER ................................................................................................ 39 KAOCHLOR EFFERVESCENT TABLET 20 MEQ .............................................................................. 40 KARIVA (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 ................................................................................................ 50 K-EFFERVESCENT TABLET 25 MEQ .................................................................... 40 KELNOR 1/35 (28) TABLET 1-35 MG-MCG .............................................. 50 KENALOG TOPICAL AEROSOL 0.147 MG/GRAM ................................................................................................ 62 ketoconazole shampoo 2 % ............. 63 ketoconazole tablet 200 mg ................ 6 ketoconazole topical cream 2 % ................................................................................................ 63 ketoprofen capsule 50 mg, 75 mg ................................................................................................ 35 ketoprofen er 24 hr capsule,extended release 200 mg ................................................................................................ 35 ketorolac eye drops 0.4 %, 0.5 % ................................................................................................ 43 KIONEX ORAL POWDER ................................................................................................ 39 KIONEX ORAL SUSPENSION 15 GRAM/60 ML ...................................... 39 KLOR-CON M10 TABLET,EXTENDED RELEASE 10 MEQ ............................... 40 KLOR-CON M15 TABLET,EXTENDED RELEASE 15 MEQ ............................... 40 KLOR-CON M20 TABLET,EXTENDED RELEASE 20 MEQ ............................... 40 KLOR-CON ORAL PACKET 20 MEQ, 25 MEQ ..................................... 40 KLOR-CON/EF EFFERVESCENT TABLET 25 MEQ .............................................................................. 40 KURVELO TABLET 0.15-30 MG-MCG ............................................................. 50 labetalol oral ..................................................... 18 LACRISERT EYE INSERTS 5 MG .................................................................................. 43 LACTIC ACID E TOPICAL CREAM 10 % ................................................. 63 lactic acid lotion 10 % ............................ 63 lactulose oral solution 10 gram/15 ml ........................................................................................ 39 LAMICTAL STARTER (GREEN) KIT TABLETS, DOSE PACK 25 MG (84) -100 MG (14) .................................................................... 30 LAMICTAL STARTER (ORANGE) KIT TABLETS, DOSE PACK 25 MG (42) -100 MG (7) ........................................................................ 30 lamivudine tablet 150 mg, 300 mg .................................................................................................... 9 lamivudine-zidovudine tablet 150-300 mg ............................................................... 9 lamotrigine chewable dispersible tablet 25 mg, 5 mg ....................................... 30 lamotrigine tablet ....................................... 30 lamotrigine tablets in a dose pack 25 mg (35) ............................................................... 30 LANOXIN TABLET 125 MCG, 250 MCG ................................................................ 24 lansoprazole capsule,delayed release 30 mg ...................................................... 46 LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) ................................................................................................ 54 LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML ................................................................................................ 54 latanoprost eye drops 0.005 % ................................................................................................ 44 LATUDA TABLET 120 MG, 20 MG, 40 MG ........................................................ 31 LATUDA TABLET 80 MG ................................................................................................ leflunomide tablet 10 mg, 20 mg 31 57 LESSINA TABLET 0.1-20 MG-MCG ............................................................. 50 LETAIRIS TABLET 10 MG, 5 MG .................................................................................. 28 letrozole tablet 2.5 mg ........................... 14 leucovorin calcium injection solution 500 mg/50 ml ............................ 56 leucovorin calcium oral ....................... 56 leucovorin calcium solution for injection 500 mg ............................................. 56 LEUKERAN TABLET 2 MG ................................................................................................ 14 leuprolide subcutaneous kit 1 mg/0.2 ml ................................................................. 14 LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML ................................................................................................ 54 levetiracetam oral solution 100 mg/ml ............................................................................ 30 levetiracetam tablet ................................. 30 levobunolol eye drops 0.25 % ................................................................................................ 42 levobunolol eye drops 0.5 % ........... 42 levocarnitine (with sugar) oral solution 100 mg/ml ...................................... 58 levocarnitine tablet 330 mg ............. 58 levofloxacin oral ........................................... 11 levofloxacin oral solution 250 mg/10 ml ................................................................... 11 LEVONEST (28) TABLET 50-30 (6)/75-40 (5)/125-30(10) ...................... 50 levonorgestrel tablet 0.75 mg ................................................................................................ 50 levonorgestrel tablet 1.5 mg ........... 50 levonorgestrel-ethinyl estradiol tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg ....................................................................... 50 levonorgestrel-ethinyl estradiol tablets,3 month pack 0.15-30 mg-mcg ....................................................................... 50 LEVORA-28 TABLET 0.15-30 MG-MCG ............................................................. 50 levothyroxine tablet ................................. 55 LEXIVA TABLET 700 MG .................................................................................................... 7 lidocaine (pf) injection solution ................................................................................................ 56 lidocaine hcl topical cream 3 % ................................................................................................ 63 ................................................................................................ lidocaine injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 56 lidocaine mucosal gel 2 % ................. 44 lidocaine mucosal solution 2 % ................................................................................................ 44 lidocaine mucous membrane jelly in applicator 2 % ........................................... 44 lidocaine topical ointment 5 % ................................................................................................ 63 LIDOCAINE VISCOUS MUCOSAL SOLUTION 2 % ................................................................................................ 44 lidocaine-hydrocortisone topical cream 3-0.5 % ................................................... 62 lindane lotion 1 % ........................................ 65 lindane shampoo 1 % ............................... 65 liothyronine oral ........................................... 55 lisinopril ................................................................... 23 lisinopril-hydrochlorothiazide tablet ............................................................................ 28 lithium carbonate er tablet,extended release 300 mg, 450 mg ......................................................................... 31 lithium carbonate tablet 300 mg ................................................................................................ 31 lithium citrate oral solution 8 meq/5 ml .................................................................... 31 LOFIBRA ............................................................. 26 LOFIBRA TABLET 160 MG, 54 MG ......................................................................... 26 lomustine capsule ........................................ 14 LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML .................................................................... 32 lorazepam oral ................................................ 32 lorazepam oral concentrate 2 mg/ml ............................................................................ 32 LORTAB TABLET 5-500 MG ................................................................................................ 34 losartan ..................................................................... 23 losartan-hydrochlorothiazide ................................................................................................ 28 lovastatin tablet ............................................. 26 LOW-OGESTREL (28) TABLET 0.3-30 MG-MCG ................................................................................................ 50 loxapine succinate ...................................... 31 LUDENT FLUORIDE .................... 57 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG .................................................................................. 14 ................................................................................................ 79 LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG .................... 14 LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG .................... 14 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG .................................................................................. 14 LUPRON DEPOT-PED ................. 14 LUTERA (28) TABLET 0.1-20 MG-MCG ............................................................. 50 LYSIPLEX PLUS TABLET ................................................................................................ 39 LYSODREN TABLET 500 MG ................................................................................................ 14 LYZA TABLET 0.35 MG ............ 50 MACRODANTIN CAPSULE 25 MG ......................................................................... 13 malathion lotion 0.5 % .......................... 65 maprotiline ........................................................... 38 MARLEXATE ORAL POWDER ............................................................. 39 MARLISSA TABLET 0.15-30 MG-MCG ............................................................. 50 MATERNITY TABLET 27-1 MG .................................................................................. 66 MATULANE CAPSULE 50 MG .................................................................................. 14 MAXIDEX EYE DROPS,SUSPENSION 0.1 % ................................................................................................ 43 MEDROL TABLET 2 MG ................................................................................................ 47 medroxyprogesterone intramuscular suspension 150 mg/ml ............................................................................ 54 medroxyprogesterone intramuscular syringe 150 mg/ml ................................................................................................ 55 medroxyprogesterone oral .............. 55 mefloquine tablet 250 mg ...................... 5 megestrol oral suspension 400 mg/10 ml (40 mg/ml) ................................ 14 megestrol tablet 20 mg, 40 mg ................................................................................................ 14 meloxicam oral suspension 7.5 mg/5 ml ....................................................................... 35 meloxicam tablet 15 mg, 7.5 mg ................................................................................................ 35 MENEST ............................................................... 53 meperidine oral solution 50 mg/5 ml ........................................................................................ 34 80 meperidine tablet 100 mg, 50 mg ................................................................................................ 34 MEPERITAB TABLET 100 MG ................................................................................................ 34 MEPHYTON TABLET 5 MG ................................................................................................ 67 MEPRON ORAL SUSPENSION 750 MG/5 ML .................................................................................................... 6 mercaptopurine tablet 50 mg ................................................................................................ 14 meropenem intravenous solution 1 gram, 500 mg ......................................................... 6 mesalamine enema 4 gram/60 ml ................................................................................................ 45 MESNEX TABLET 400 MG ................................................................................................ 58 MESTINON SYRUP 60 MG/5 ML ................................................................................... 17 MESTINON TIMESPAN TABLET,EXTENDED RELEASE 180 MG ................................ 17 METADATE ER TABLET,EXTENDED RELEASE 20 MG .................................... 36 metaproterenol syrup 10 mg/5 ml ................................................................................................ 18 metaproterenol tablet 10 mg, 20 mg ...................................................................................... 18 metformin er tablet,extended release 24 hr 500 mg, 750 mg ................................................................................................ 48 metformin er tablet,extended release 24hr 1,000 mg ............................. 48 metformin tablet ........................................... 48 methadone tablet 10 mg, 5 mg ................................................................................................ 34 methamphetamine tablet 5 mg ................................................................................................ 29 methazolamide tablet 25 mg, 50 mg ...................................................................................... 43 methenamine mandelate tablet 0.5 g, 1 gram ................................................................... 13 methimazole tablet 10 mg, 5 mg ................................................................................................ 48 METHITEST TABLET 10 MG ................................................................................................ 48 methocarbamol tablet 500 mg, 750 mg ...................................................................................... 16 methotrexate sodium (pf) injection solution 25 mg/ml ......................................... 14 methotrexate sodium (pf) solution for injection 1 gram ................................... 15 methotrexate sodium injection solution 25 mg/ml ......................................... 14 methotrexate sodium tablet 2.5 mg ................................................................................................ 14 methyclothiazide tablet 5 mg ................................................................................................ 28 methyldopa tablet 250 mg, 500 mg ................................................................................................ 15 methyldopa-hydrochlorothiazide tablet 250-15 mg, 250-25 mg ................................................................................................ 15 methylergonovine tablet 0.2 mg ................................................................................................ 58 methylphenidate er multiphase capsule 30-70,extended release ................................................................................................ 36 methylphenidate er tablet,extended release 10 mg ................................................................................................ 36 methylphenidate er tablet,extended release 20 mg ................................................................................................ 36 methylphenidate er tablet,extended release 24 hr 18 mg, 27 mg, 54 mg ......................................... 36 methylphenidate er tablet,extended release 24 hr 36 mg ...................................................................................... 36 methylphenidate oral solution 10 mg/5 ml ....................................................................... 36 methylphenidate oral solution 5 mg/5 ml ....................................................................... 36 methylphenidate tablet 10 mg, 5 mg ...................................................................................... 36 methylphenidate tablet 20 mg ................................................................................................ 36 methylprednisolone sodium succ intravenous solution 1,000 mg ................................................................................................ 47 methylprednisolone sodium succ solution for injection 40 mg ............ 47 methylprednisolone tablet ............... 47 methylprednisolone tablets in a dose pack 4 mg ................................................. 47 metoclopramide oral solution 5 mg/5 ml ....................................................................... 46 metoclopramide tablet 10 mg, 5 mg ...................................................................................... 46 metolazone tablet ........................................ 28 metoprolol succinate er tablet,extended release 24 hr ................................................................................................ 19 metoprolol ta-hydrochlorothiaz ................................................................................................ 19 metoprolol tartrate oral ..................... 19 metronidazole capsule 375 mg .................................................................................................... 4 metronidazole lotion 0.75 % ................................................................................................ 60 metronidazole tablet 250 mg, 500 mg .......................................................................................... 4 metronidazole topical cream 0.75 % ......................................................................................... 60 metronidazole topical gel 0.75 %, 1 % .................................................................................... 60 metronidazole vaginal gel 0.75 % ................................................................................................ 60 mexiletine .............................................................. 25 MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG .............. 63 MICROGESTIN 1.5/30 (21) TABLET 1.5-30 MG-MCG ................................................................................................ 50 MICROGESTIN 1/20 (21) TABLET 1-20 MG-MCG ............. 50 MICROGESTIN FE 1.5/30 (28) TABLET 1.5-30 MG-MCG ................................................................................................ 50 MICROGESTIN FE 1/20 (28) TABLET 1-20 MG-MCG ............. 51 MIGERGOT RECTAL SUPPOSITORY 2-100 MG ................................................................................................ 17 MILLIPRED TABLET 5 MG ................................................................................................ 47 MINITRAN ...................................................... 27 minocycline capsule ................................. 12 minocycline tablet ...................................... 13 minoxidil tablet 10 mg, 2.5 mg ................................................................................................ 26 mirtazapine tablet ...................................... 31 misoprostol tablet 100 mcg, 200 mcg ................................................................................... 46 mometasone lotion 0.1 % ................... 62 mometasone topical cream 0.1 % ................................................................................................ 62 mometasone topical ointment 0.1 % ......................................................................................... 62 MONO-LINYAH TABLET 0.25-35 MG-MCG .................................... 51 MONONESSA (28) TABLET 0.25-35 MG-MCG .................................... 51 montelukast chewable tablet 4 mg, 5 mg ................................................................................. 59 montelukast oral granules in packet 4 mg .......................................................... 59 montelukast tablet 10 mg .................. 59 MORGIDOX CAPSULE 100 MG .................................................................................. 13 morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) ....................... 34 morphine er tablet,extended release ......................................................................... 34 morphine oral solution 10 mg/5 ml, 20 mg/5 ml .................................................. 34 morphine rect .................................................... 34 morphine tablet 15 mg, 30 mg ................................................................................................ 34 MULTAQ TABLET 400 MG ................................................................................................ 25 MULTI VIT-FLUORIDE-IRON ORAL DROPS 0.25-10 MG/ML ............... 21 MULTI-VIT W/IRON & FLUORIDE ORAL DROPS 0.25-10 MG/ML ........................................... 21 MULTI-VITAMIN WITH FLUORIDE ...................................................... 66 MULTIVITAMIN WITH FLUORIDE CHEWABLE TABLET 0.5 MG ....................................... 66 MULTIVITAMINS WITH FLUORIDE ...................................................... 66 MULTIVITAMINS WITH FLUORIDE ORAL DROPS 0.5 MG/ML .................................................................... 66 MULTI-VITAMINS/FLUORID E ORAL DROPS 0.25 MG/ML ................................................................................................ 66 mupirocin topical ointment 2 % ................................................................................................ 60 M-VIT TABLET 27-1 MG .......... 21 MY WAY TABLET 1.5 MG ................................................................................................ 51 MYCOBUTIN CAPSULE 150 MG .................................................................................. 11 mycophenolate mofetil capsule 250 mg ...................................................................................... 58 mycophenolate mofetil tablet 500 mg ...................................................................................... 58 MYDFRIN EYE DROPS 2.5 % ................................................................................................ 44 MYFERON 150 FORTE CAPSULE 150-25-1 MG-MCG-MG ............................................. 21 MYLERAN TABLET 2 MG ................................................................................................ 15 MYNATAL ADVANCE TABLET 90-1-50 MG ......................... 21 MYNATAL CAPSULE 65-1 MG .................................................................................. 21 MYNATAL PLUS TABLET 65-1 MG ................................................................... 21 MYNATAL TABLET 90-1-50 MG .................................................................................. 66 MYNATAL-Z TABLET 65-1 MG .................................................................................. 21 MYNATE 90 PLUS TABLET,EXTENDED RELEASE 90-1 MG .............................. 66 MYNEPHROCAPS CAPSULE 1 MG ............................................................................. 66 MYORISAN .................................................... 65 MYSOLINE TABLET 250 MG, 50 MG ......................................................................... 32 MYZILRA TABLET 50-30 (6)/75-40 (5)/125-30(10) ...................... 51 nabumetone tablet 500 mg, 750 mg ...................................................................................... 35 nadolol tablet .................................................... 16 nafcillin intravenous solution 1 gram, 2 gram ...................................................... 11 nafcillin solution for injection ................................................................................................ 11 NAFRINSE 0.05 % ................................ 57 naltrexone tablet 50 mg ....................... 35 naproxen oral suspension 125 mg/5 ml ....................................................................... 35 naproxen sodium tablet 275 mg, 550 mg ......................................................................... 35 naproxen tablet .............................................. 35 naproxen tablet,delayed release 375 mg, 500 mg ............................................... 35 NASCOBAL NASAL SPRAY 500 MCG ................................................................ 67 NATAL-V RX TABLET 29 MG IRON- 1 MG .................................................... 21 NATALVIRT 90 DHA ORAL PACK 90-1-50-300 MG .................... 21 NATALVIRT CA ORAL PACK 35-1-50-300 MG ........................................... 21 NATALVIT TABLET 75-1 MG ................................................................................................ 21 NEBUPENT SOLUTION FOR INHALATION 300 MG .................... 6 NECON 0.5/35 (28) TABLET 0.5-35 MG-MCG ........................................ 51 NECON 1/35 (28) TABLET 1-35 MG-MCG ............................................................. 51 NECON 1/50 (28) TABLET 1-50 MG-MCG ............................................................. 51 NECON 10/11 (28) TABLET 0.5-35/1-35 MG-MCG/MG-MCG ........................ 51 81 NECON 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG .................. 51 nefazodone ........................................................... 38 neomycin tablet 500 mg ........................... 4 neomycin-bacitracin-poly-hc eye ointment 3.5-400-10,000 mg-unit/g-1% ..................................................... 41 neomycin-bacitracin-polymyxin eye ointment 3.5-400-10,000 mg-unit-unit/g .................................................... 41 neomycin-polymyxin-dexameth eye drops,suspension 3.5-10,000-0.1 mg/ml-unit/ml-% ................................................................................................ 41 neomycin-polymyxin-dexameth eye ointment 3.5-10,000-0.1 mg-unit/g-% ......................................................... 42 neomycin-polymyxin-hydrocort ear drops,suspension 3.5-10,000-1 mg-unit/ml-% ..................................................... 42 neomycin-polymyxin-hydrocort ear solution 3.5-10,000-1 mg-unit/ml-% ..................................................... 42 neomycin-polymyxin-hydrocort eye drops,suspension 3.5-10,000-10 mg-unit-mg/ml ................................................................................................ 42 NEO-POLYCIN EYE OINTMENT 3.5-400-10,000 MG-UNIT-UNIT/G ............................. 41 NEO-POLYCIN HC EYE OINTMENT 3.5-400-10,000 MG-UNIT/G-1% ....................................... 41 NEORAL CAPSULE 100 MG, 25 MG ......................................................................... 58 NEORAL ORAL SOLUTION 100 MG/ML ....................................................... 58 NEPHRON FA TABLET ............ 21 NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML ................................................... 19 NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML ...................................... 19 NEURIN-SL SUBLINGUAL TABLET 600-600 MCG .................. 67 nevirapine oral suspension 50 mg/5 ml ............................................................................................ 9 nevirapine tablet 200 mg ........................ 9 NEXT CHOICE ONE DOSE TABLET 1.5 MG ....................................... 51 niacin er tablet,extended release 24 hr .............................................................................. 24 82 NIACOR TABLET 500 MG ................................................................................................ 24 NICOTROL INHALATION CARTRIDGE 10 MG ........................ 16 NICOTROL NS NASAL SPRAY 10 MG/ML ............................... 16 NIFEDICAL XL TABLET,EXTENDED RELEASE 30 MG, 60 MG ................................................................................................ 26 nifedipine er tablet,extended release ......................................................................... 26 nifedipine er tablet,extended release 24 hr ....................................................... 26 NILANDRON TABLET 150 MG .................................................................................. 15 nimodipine capsule 30 mg ................. 26 NITRO-BID TRANSDERMAL OINTMENT 2 % ....................................... 27 NITRO-DUR TRANSDERMAL 24 HOUR PATCH 0.3 MG/HR, 0.8 MG/HR .................................................................... 27 nitrofurantoin macrocrystal capsule 100 mg, 50 mg ........................... 13 nitrofurantoin monohydrate/macrocrystals capsule 100 mg ................................................. 13 nitrofurantoin oral suspension 25 mg/5 ml ....................................................................... 13 nitroglycerin oral ......................................... 27 nitroglycerin transdermal 24 hour patch ............................................................................. 27 nitroglycerin translingual spray 0.4 mg/dose ........................................................... 27 nitroglycerin translingual spray, aerosol 0.4 mg/dose .................................... 27 NITROSTAT SUBLINGUAL ................................................................................................ 27 NITRO-TIME ................................................ 27 NORA-BE TABLET 0.35 MG ................................................................................................ 51 NORDITROPIN FLEXPRO ................................................................................................ 54 NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR 30 MG/3 ML (10 MG/ML) ................................................................. 54 norethindrone (contraceptive) tablet 0.35 mg .................................................... 51 norethindrone acetate tablet 5 mg ................................................................................................ 55 norgestimate-ethinyl estradiol tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg .............................. 51 NORINYL 1+50 (28) TABLET 1-50 MG-MCG .............................................. 51 NORPACE CR CAPSULE,EXTENDED RELEASE 100 MG, 150 MG ................................................................................................ 25 NORTREL 0.5/35 (28) TABLET 0.5-35 MG-MCG ........................................ 51 NORTREL 1/35 (21) TABLET 1-35 MG-MCG .............................................. 51 NORTREL 1/35 (28) TABLET 1-35 MG-MCG .............................................. 51 NORTREL 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG .................. 51 nortriptyline ....................................................... 38 nortriptyline oral solution 10 mg/5 ml ........................................................................................ 38 NORVIR CAPSULE 100 MG .................................................................................................... 7 NORVIR ORAL SOLUTION 80 MG/ML .............................................................. 7 NORVIR TABLET 100 MG .................................................................................................... 7 NOVOLOG FLEXPEN SUBCUTANEOUS 100 UNIT/ML ............................................................. 54 NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS 100 UNIT/ML (70-30) ........................ 54 NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) ........................ 54 NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML ................................................................................................ 54 NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML ................................................................................................ 54 NP THYROID .............................................. 55 NUTRICAP TABLET 1 MG ................................................................................................ 21 NUVARING VAGINAL 0.12-0.015 MG/24 HR ......................... 51 NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM ................................................. 64 nystatin oral powder ............................... 11 nystatin oral suspension 100,000 unit/ml .......................................................................... 11 nystatin tablet 500,000 unit ............ 11 nystatin topical cream 100,000 unit/gram .................................................................. 64 nystatin topical ointment 100,000 unit/gram .................................................................. 64 nystatin topical powder 100,000 unit/gram .................................................................. 64 nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% ........... 64 nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% ................................................................................................ 64 NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM ....................... 64 O-CAL FA TABLET 66-1 MG ................................................................................................ 22 O-CAL PRENATAL TABLET 15-1 MG ................................................................... 22 octreotide acetate injection solution ...................................................................... 55 ofloxacin ear drops 0.3 % ................. 42 ofloxacin eye drops 0.3 % ................. 42 ofloxacin oral ................................................... 11 OGESTREL (28) TABLET 0.5-50 MG-MCG ........................................ 51 olanzapine tablet .......................................... 31 omeprazole capsule,delayed release ......................................................................... 46 ondansetron disintegrating tablet 4 mg, 8 mg ................................................................... 45 ondansetron hcl oral ................................ 45 ondansetron hcl oral solution 4 mg/5 ml ....................................................................... 45 OPANA ER TABLET, CRUSH RESISTANT, EXT. REL. ............ 34 ORALONE DENTAL PASTE 0.1 % .............................................................................. 62 ORAP TABLET 1 MG, 2 MG ................................................................................................ 31 orphenadrine citrate er tablet,extended release 100 mg ................................................................................................ 19 ORSYTHIA TABLET 0.1-20 MG-MCG ............................................................. 51 ORTHO TRI-CYCLEN LO (28) TABLET 0.18/0.215/0.25 MG-25 MCG (28) ............................................................... 51 oxacillin in dextrose (iso-osmotic) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ............................................ 11 oxacillin intravenous solution 1 gram, 2 gram ...................................................... 11 oxacillin solution for injection ................................................................................................ 11 oxazepam capsule ...................................... 32 oxcarbazepine tablet .............................. 30 OXSORALEN LOTION 1 % ................................................................................................ 64 OXSORALEN ULTRA CAPSULE 10 MG .................................... 64 oxybutynin chloride er tablet,extended release 24 hr 10 mg, 15 mg ................................................................ 65 oxybutynin chloride er tablet,extended release 24 hr 5 mg ................................................................................................ 66 oxybutynin chloride syrup 5 mg/5 ml ........................................................................................ 66 oxybutynin chloride tablet 5 mg ................................................................................................ 66 oxycodone capsule 5 mg ...................... 34 oxycodone oral concentrate 20 mg/ml ............................................................................ 34 oxycodone oral solution 5 mg/5 ml ................................................................................................ 34 oxycodone tablet .......................................... 34 oxycodone-acetaminophen capsule 5-500 mg ................................................................... 34 oxycodone-acetaminophen tablet ................................................................................................ 34 oxycodone-aspirin tablet 4.8355-325 mg .................................................. 36 oxymorphone er tablet,extended release,12 hr ....................................................... 34 oxymorphone tablet 10 mg, 5 mg ................................................................................................ 34 PACERONE TABLET 200 MG ................................................................................................ 25 pantoprazole tablet,delayed release 20 mg, 40 mg ................................ 46 paromomycin capsule 250 mg .................................................................................................... 4 paroxetine tablet .......................................... 37 PATADAY EYE DROPS 0.2 % ................................................................................................ 41 PAXIL ORAL SUSPENSION 10 MG/5 ML ..................................................... 37 ped multivitamin-fl-iron oral drops 0.25-10 mg/ml .................................................... 22 pediatric multivitamin-fl oral drops 0.25 mg/ml, 0.5 mg/ml ................................................................................................ 66 PEDI-DRI TOPICAL POWDER 100,000 UNIT/GRAM ................................................. 64 peg 3350-electrolytes oral solution 240-22.72-6.72 gram ................................ 45 PEG-3350 WITH FLAVOR PACKS ORAL SOLUTION 420 GRAM ....................................................................... 45 PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML .......................................... 8 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML .................................................................................................... 8 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML .................................................................................................... 8 PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML .................................................................................................... 8 PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML .................................................................................................... 8 peg-electrolyte solution oral powder for solution 420 gram ................................................................................................ 45 PEGINTRON .................................................... 8 PEGINTRON REDIPEN ................ 8 penicillin v potassium oral solution 125 mg/5 ml, 250 mg/5 ml .................... 9 penicillin v potassium tablet 250 mg, 500 mg ................................................................ 9 PENTASA CAPSULE,EXTENDED RELEASE 250 MG, 500 MG ................................................................................................ 45 pentoxifylline er tablet,extended release 400 mg .................................................. 19 PERIOGARD MOUTHWASH 0.12 % ........................................................................... 43 permethrin topical cream 5 % ................................................................................................ 65 perphenazine tablet .................................. 36 PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG ...................................................................................... 3 phenazopyridine tablet 100 mg, 200 mg ......................................................................... 63 phenelzine tablet 15 mg ........................ 33 phenobarb-hyoscyamn-atropine-sc op tablet 16.2-0.1037 -0.0194 mg ................................................................................................ 16 phenobarbital oral elixir 20 mg/5 ml ........................................................................................ 32 phenobarbital tablet ................................ 32 phenylephrine eye drops 10 %, 2.5 % ......................................................................................... 44 83 phenytoin chewable tablet 50 mg ................................................................................................ 25 phenytoin oral suspension 125 mg/5 ml ....................................................................... 25 phenytoin sodium extended capsule 100 mg ................................................. 25 PHILITH TABLET 0.4-35 MG-MCG ............................................................. 52 PHOSPHA 250 NEUTRAL TABLET 250 MG ..................................... 38 PHOSPHOLINE IODIDE EYE DROPS 0.125 % ........................................... 44 PHRENILIN FORTE CAPSULE 50-650 MG ...................... 29 pilocarpine eye drops ............................. 44 pilocarpine tablet 5 mg .......................... 17 PILOPINE HS EYE GEL 4 % ................................................................................................ 44 pindolol tablet 10 mg, 5 mg ............. 16 pioglitazone ......................................................... 55 pioglitazone-glimepiride tablet 30-2 mg, 30-4 mg .......................................... 55 pioglitazone-metformin tablet 15-500 mg, 15-850 mg ........................... 48 piperacillin-tazobactam intravenous solution .................................... 6 PIRMELLA TABLET 1-35 MG-MCG ............................................................. 52 piroxicam capsule 10 mg, 20 mg ................................................................................................ 35 PNV OB+DHA ORAL PACK 27-1-50-250 MG ........................................... 22 PNV-SELECT TABLET 27-1 MG .................................................................................. 22 PODOCON TOPICAL LIQUID 25 % ................................................................................ 65 podofilox topical solution 0.5 % ................................................................................................ 65 POLYCIN EYE OINTMENT 500-10,000 UNIT/GRAM ............. 42 POLY-IRON 150 FORTE CAPSULE 150-25-1 MG-MCG-MG ............................................. 22 POLYSACCHARIDE IRON FORTE CAPSULE 150-25-1 MG-MCG-MG ............................................. 22 POLY-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG/ML .................................................................... 66 PONTOCAINE TOPICAL SOLUTION 2 % .......................................... 63 PORTIA TABLET 0.15-30 MG-MCG ............................................................. 52 84 potassium bicarb & chloride effervescent tablet 25 meq ................ 40 potassium bicarbonate-citric acid effervescent tablet 25 meq ................ 40 potassium chloride er capsule,extended release 10 meq, 8 meq ................................................................................... 40 potassium chloride er tablet,extended release 10 meq, 8 meq ................................................................................... 40 potassium chloride er tablet,extended release(part/cryst) 10 meq, 20 meq ................................................ 40 potassium chloride oral liquid 10 % ......................................................................................... 40 potassium chloride oral liquid 20 % ......................................................................................... 40 potassium citrate er tablet,extended release 10 meq, 5 meq ................................................................................... 39 pramipexole tablet .................................... 33 pravastatin ........................................................... 26 prazosin oral ...................................................... 17 PRED MILD EYE DROPS,SUSPENSION 0.12 % ................................................................................................ 43 prednisolone acetate eye drops,suspension 1 % ............................... 43 prednisolone oral solution 15 mg/5 ml ........................................................................................ 47 prednisolone sodium phosphate eye drops 1 % ..................................................... 43 prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) ........................ 47 PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML .................................................................... 47 prednisone oral solution 5 mg/5 ml ................................................................................................ 47 prednisone tablet .......................................... 47 prednisone tablets in a dose pack 10 mg, 5 mg .......................................................... 47 PREMARIN TABLET ..................... 53 PREMARIN VAGINAL CREAM 0.625 MG/GRAM ................................................................................................ 53 PREMPHASE TABLET 0.625 MG (14)/ 0.625MG-5MG(14) ................................................................................................ 53 PREMPRO ......................................................... 53 PRENAISSANCE 90 DHA ORAL PACK 90-1-50-300 MG ................................................................................................ 22 PRENAISSANCE DHA ORAL PACK 27-1-50-250 MG .................... 22 PRENAISSANCE PROMISE ORAL PACK 35-1-50-300 MG ................................................................................................ 22 PRENAPLUS TABLET 27-1 MG .................................................................................. 22 PRENATAL AD TABLET 90-1-50 MG ......................................................... 22 PRENATAL PLUS (CALCIUM CARBONATE) TABLET 27-1 MG .................................................................................. 22 prenatal vitamin with calcium no.72-iron-fa tablet 27-1 mg ................................................................................................ 22 PRENATAL-U CAPSULE 106.5-1 MG ......................................................... 66 PREVACID SOLUTAB DELAYED RELEASE,DISINTEGRATIN G TABLET 15 MG, 30 MG ................................................................................................ 46 PREVALITE ORAL POWDER 4 GRAM ................................................................. 24 PREVALITE POWDER FOR SUSP IN A PACKET 4 GRAM ................................................................................................ 24 PREVIDENT GEL 1.1 % ............. 57 PREVIFEM TABLET 0.25-35 MG-MCG ............................................................. 52 PREZISTA TABLET .............................. 7 PRIFTIN TABLET 150 MG ................................................................................................ 11 primaquine tablet 26.3 mg .................... 5 PRIMAXIN IV SOLUTION 250 MG, 500 MG ........................................................ 6 primidone tablet 250 mg, 50 mg ................................................................................................ 32 PRIMSOL ORAL SOLUTION 50 MG/5 ML ..................................................... 13 PRISTIQ TABLET,EXTENDED RELEASE 100 MG, 50 MG ................................................................................................ 37 probenecid tablet 500 mg ................... 40 prochlorperazine maleate tablet 10 mg, 5 mg ................................................................... 36 prochlorperazine rectal suppository 25 mg ........................................ 36 PROCRIT INJECTION SOLUTION 40,000 UNIT/ML ................................................................................................ 19 PROCTOCREAM-HC RECTAL 2.5 % ............................................. 62 PROCTOFOAM HC 1-1 % ................................................................................................ 62 PROCTOSOL HC RECTAL CREAM 2.5 % ............................................... 62 PROCTOZONE-HC RECTAL CREAM 2.5 % ............................................... 62 PROGESTERONE IN OIL INTRAMUSCULAR 50 MG/ML .................................................................... 55 progesterone intramuscular oil 50 mg/ml ............................................................................ 55 PROMACET TABLET 50-650 MG .................................................................................. 29 promethazine rectal suppository 12.5 mg, 25 mg .................................................... 3 promethazine syrup 6.25 mg/5 ml .................................................................................................... 3 promethazine tablet ..................................... 3 PROMETHAZINE VC SYRUP 6.25-5 MG/5 ML ............................................. 3 PROMETHAZINE VC-CODEINE SYRUP 6.25-5-10 MG/5 ML ................................... 3 promethazine-codeine syrup 6.25-10 mg/5 ml .............................................. 59 promethazine-dm syrup 6.25-15 mg/5 ml ....................................................................... 59 promethazine-phenylephrine-codei ne syrup 6.25-5-10 mg/5 ml ................ 3 PROMETHEGAN ..................................... 3 propafenone tablet ..................................... 25 propantheline tablet 15 mg .............. 16 propranolol er capsule,24 hr,extended release ................................... 17 propranolol oral solution 20 mg/5 ml, 40 mg/5 ml .................................................. 17 propranolol tablet ....................................... 17 propranolol-hydrochlorothiazide tablet 40-25 mg, 80-25 mg ............... 17 propylthiouracil tablet 50 mg ................................................................................................ 48 PROSTIGMIN TABLET 15 MG .................................................................................. 18 protriptyline tablet 10 mg, 5 mg ................................................................................................ 38 PULMICORT FLEXHALER BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION ............................ 60 PULMICORT SUSPENSION FOR NEBULIZATION 1 MG/2 ML ................................................................................... 59 PULMOZYME SOLUTION FOR INHALATION 1 MG/ML ................................................................................................ 40 pyrazinamide tablet 500 mg ............... 6 pyridostigmine bromide tablet 60 mg ...................................................................................... 18 QUASENSE TABLETS,3 MONTH DOSE PACK 0.15-30 MG-MCG ............................................................. 52 quetiapine tablet 100 mg, 200 mg, 25 mg, 300 mg, 50 mg ............................ 31 quetiapine tablet 400 mg ..................... 31 quinapril .................................................................. 23 quinapril-hydrochlorothiazide ................................................................................................ 28 quinidine er tablet,extended release 324 mg ...................................................... 5 quinidine sulfate er tablet,extended release 300 mg .................................................................................................... 5 quinidine tablet 200 mg, 300 mg .................................................................................................... 5 quinine capsule 324 mg ............................. 5 ramipril capsule ............................................. 23 RANEXA TABLET,EXTENDED RELEASE 1,000 MG, 500 MG ................................................................................................ 24 ranitidine capsule 150 mg, 300 mg ................................................................................................ 46 ranitidine syrup 15 mg/ml ................. 46 ranitidine tablet 300 mg ....................... 46 RAPAMUNE .................................................. 58 RAPAMUNE ORAL SOLUTION 1 MG/ML .................... 58 REBETOL ORAL SOLUTION 40 MG/ML ........................................................... 10 RECLIPSEN (28) TABLET 0.15-30 MG-MCG .................................... 52 RECTACORT-HC RECTAL SUPPOSITORY 25 MG ................. 62 RELENZA DISKHALER POWDER FOR INHALATION 5 MG/ACTUATION ............................... 9 REMICADE INTRAVENOUS SOLUTION 100 MG ........................... 57 RENACIDIN IRRIGATION SOLUTION 6.602-0.198 GRAM/100 ML ............................................ 39 RENAGEL TABLET 400 MG, 800 MG ..................................................................... 39 RENAL CAPS CAPSULE 1 MG .................................................................................. 67 RENO CAPS CAPSULE 1 MG ................................................................................................ 67 RENVELA TABLET 800 MG ................................................................................................ 39 repaglinide ............................................................ 54 RESCRIPTOR DISPERSIBLE TABLET 100 MG ......................................... 9 RESCRIPTOR TABLET 200 MG ...................................................................................... 9 RESECTISOL URETHRAL SOLUTION 5 % .......................................... 39 reserpine tablet 0.1 mg, 0.25 mg ................................................................................................ 27 RESTASIS EYE DROPS IN A DROPPERETTE 0.05 % ................ 43 REVIA TABLET 50 MG .............. 35 REYATAZ CAPSULE ........................ 7 REZIRA ORAL SOLUTION 60-5 MG/5 ML ............................................... 15 RIBAPAK DOSE PACK TABLETS 200 MG (28)- 400 MG (28) .................................................................... 10 RIBASPHERE CAPSULE 200 MG .................................................................................. 10 ribavirin capsule 200 mg ..................... 10 ribavirin tablet 200 mg .......................... 10 RIDAURA CAPSULE 3 MG ................................................................................................ 46 rifampin capsule 150 mg, 300 mg ................................................................................................ 11 riluzole tablet 50 mg ................................. 33 RISPERDAL CONSTA .................. 31 risperidone disintegrating tablet 0.25 mg ....................................................................... 31 risperidone oral solution 1 mg/ml ................................................................................................ 31 risperidone tablet ......................................... 31 rivastigmine capsule ................................ 18 rizatriptan disintegrating tablet 10 mg, 5 mg ................................................................... 37 rizatriptan tablet 10 mg, 5 mg ................................................................................................ 37 ropinirole tablet ............................................. 33 ROSADAN TOPICAL CREAM 0.75 % ........................................................................... 60 ROSADAN TOPICAL GEL 0.75 % ........................................................................... 60 ROSANIL TOPICAL CLEANSER 10-5 % (W/W) ................................................................................................ 64 ROXICET ORAL SOLUTION 5-325 MG/5 ML ........................................... 34 ROXICET TABLET 5-325 MG ................................................................................................ 34 85 salsalate tablet 500 mg, 750 mg ................................................................................................ 36 SANDIMMUNE ORAL SOLUTION 100 MG/ML ............. 58 SANDOSTATIN LAR DEPOT ................................................................................................ 55 SANTYL TOPICAL OINTMENT 250 UNIT/GRAM ................................................................................................ 65 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG ........................................................... 32 SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG .................. 31 SCALACORT LOTION 2 % ................................................................................................ 62 selegiline capsule 5 mg ........................... 33 selegiline tablet 5 mg ............................... 33 selenium sulfide shampoo 2.25 % ................................................................................................ 64 selenium sulfide topical suspension 2.5 % .............................................................................. 64 SEMPREX-D CAPSULE 8-60 MG ...................................................................................... 4 SEREVENT DISKUS POWDER FOR INHALATION 50 MCG/DOSE ............................................. 18 SEROMYCIN CAPSULE 250 MG ...................................................................................... 6 SEROQUEL XR ........................................ 32 sertraline oral concentrate 20 mg/ml ............................................................................ 37 sertraline tablet ............................................. 38 sevoflurane inhalation liquid ................................................................................................ 33 SF 5000 PLUS DENTAL CREAM 1.1 % ............................................... 57 SF DENTAL GEL 1.1 % ............... 57 SIDEROL ORAL LIQUID ................................................................................................ 22 SIDEROL TABLET ............................. 22 silver sulfadiazine topical cream 1 % ......................................................................................... 64 simvastatin ........................................................... 27 sodium chloride for nebulization 3 % ......................................................................................... 40 sodium fluoride chewable tablet ................................................................................................ 57 sodium fluoride dental solution 0.2 % ......................................................................................... 57 sodium fluoride oral drops 0.5 mg fluoride (1.1 mg)/ml ................................... 57 sodium fluoride tablet 1 mg fluoride (2.2 mg) ............................................. 57 86 SODIUM POLYSTYRENE SULFONATE (SORBITOL FREE) ORAL SUSPENSION 15 GRAM/60 ML ............................................... 39 sodium polystyrene sulfonate enema 30 gram/120 ml .......................... 39 sodium polystyrene sulfonate oral powder ...................................................................... 39 sodium polystyrene sulfonate oral suspension 15 gram/60 ml ................. 39 SOJOURN INHALATION LIQUID ................................................................... 33 SOLU-MEDROL INTRAVENOUS SOLUTION 2 GRAM, 500 MG ......................................... 47 SOLU-MEDROL SOLUTION FOR INJECTION 125 MG/2 ML ................................................................................... 47 SORINE .................................................................. 17 SOTALOL AF ............................................... 17 sotalol oral ........................................................... 17 SOTRET CAPSULE 20 MG ................................................................................................ 65 SPIRIVA WITH HANDIHALER & INHALATION CAPSULES 18 MCG ............................................................................. 16 spironolactone ................................................. 28 spironolactone-hydrochlorothiazid e tablet 25-25 mg ........................................... 28 SPRINTEC (28) TABLET 0.25-35 MG-MCG .................................... 52 SRONYX TABLET 0.1-20 MG-MCG ............................................................. 52 SSKI ORAL SOLUTION 1 GRAM/ML ........................................................ 59 SSS 10-5 TOPICAL CREAM 10-5 % (W/W) ................................................... 64 stavudine oral solution 1 mg/ml ................................................................................................ 10 STERILE WATER FOR INJECTION ...................................................... 59 STRATTERA CAPSULE 10 MG, 18 MG, 25 MG, 40 MG ................................................................................................ 33 STRATTERA CAPSULE 100 MG, 60 MG, 80 MG ............................. 33 STRIANT BUCCAL SYSTEM,SUSTAINED RELEASE 30 MG .................................... 48 STRIBILD TABLET 150-150-200-300 MG ................................ 8 SUBOXONE SUBLINGUAL FILM ............................................................................ 35 sucralfate oral suspension 100 mg/ml ............................................................................ 46 sucralfate tablet 1 gram ....................... 46 sulfacetamide sodium (acne) topical suspension 10 % ....................... 64 sulfacetamide sodium eye drops 10 % ......................................................................................... 42 sulfacetamide sodium eye ointment 10 % ................................................................................ 42 sulfacetamide sodium-sulfur lotion 10-5 % (w/w) ....................................................... 64 sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) ................................................................................................ 64 sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) ............ 64 sulfacetamide sodium-sulfur topical suspension 10-5 % ................. 64 sulfacetamide-prednisolone eye drops 10 %-0.23 % (0.25 %) ................................................................................................ 42 sulfadiazine tablet 500 mg ................ 12 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml ................................................................................................ 12 sulfamethoxazole-trimethoprim tablet 400-80 mg, 800-160 mg ................................................................................................ 12 sulfasalazine tablet 500 mg ............. 12 sulfasalazine tablet,delayed release 500 mg .................................................. 12 SULFAZINE EC TABLET,DELAYED RELEASE 500 MG ................................ 12 SULFAZINE TABLET 500 MG ................................................................................................ 12 sulindac tablet 150 mg, 200 mg ................................................................................................ 35 sumatriptan nasal spray 20 mg/actuation, 5 mg/actuation ................................................................................................ 37 sumatriptan subcutaneous cartridge (refill) 4 mg/0.5 ml, 6 mg/0.5 ml ................................................................. 37 sumatriptan subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml ................................................................................................ 37 sumatriptan subcutaneous solution 6 mg/0.5 ml ............................................................ 37 sumatriptan subcutaneous syringe 6 mg/0.5 ml ............................................................ 37 sumatriptan tablet 100 mg ............... 37 sumatriptan tablet 25 mg, 50 mg ................................................................................................ 37 SUPRANE INHALATION LIQUID ................................................................... 33 SUPRAX ORAL SUSPENSION 100 MG/5 ML ................................................. 13 SUPRAX TABLET 400 MG ................................................................................................ 13 SURMONTIL ................................................ 38 SUSTIVA CAPSULE 200 MG, 50 MG ............................................................................. 9 SUSTIVA TABLET 600 MG .................................................................................................... 9 SYMBICORT HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION ............................ 18 SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML ............................................................ 9 SYNAREL NASAL SPRAY 2 MG/ML .................................................................... 53 SYNVISC INTRA-ARTICULAR SYRINGE 16 MG/2 ML ................ 38 SYNVISC-ONE INTRA-ARTICULAR SYRINGE 48 MG/6 ML ................ 38 TABLOID TABLET 40 MG ................................................................................................ 15 tacrolimus capsule ..................................... 58 TAMIFLU CAPSULE ......................... 9 TAMIFLU ORAL SUSPENSION 6 MG/ML ................ 9 tamoxifen tablet 10 mg, 20 mg ................................................................................................ 15 tamsulosin er capsule,extended release 24 hr 0.4 mg .................................. 18 TARGRETIN TOPICAL GEL 1 % ......................................................................................... 65 TAZICEF INJ ................................................ 13 TAZICEF INTRAVENOUS SOLUTION 1 GRAM, 2 GRAM ....................................................................... 13 TAZTIA XT ...................................................... 25 TEGRETOL XR TABLET,EXTENDED RELEASE 100 MG ................................ 30 temazepam capsule ................................... 32 temozolomide oral ..................................... 15 TENCON TABLET 50-650 MG ................................................................................................ 29 terazosin capsule .......................................... 17 terbinafine tablet 250 mg ....................... 4 terbutaline tablet 2.5 mg, 5 mg 18 terconazole vaginal cream 0.4 %, 0.8 % .............................................................................. 63 testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml ............................................................................ 48 testosterone enanthate intramuscular oil 200 mg/ml ................................................................................................ 48 TESTRED CAPSULE 10 MG ................................................................................................ 48 tetracycline capsule 250 mg, 500 mg ...................................................................................... 13 TEXACORT TOPICAL SOLUTION 2.5 % .................................... 62 THEOCHRON TABLET,EXTENDED RELEASE ............................................................ 26 theophylline er tablet,extended release 400 mg, 600 mg ........................ 26 theophylline er tablet,extended release,12 hr ....................................................... 26 theophylline in dextrose 5 % intravenous solution ................................. 26 theophylline oral elixir 80 mg/15 ml ........................................................................................ 26 theophylline oral solution 80 mg/15 ml ................................................................... 26 THERAPEUTIC FORMULA/HEMATINICS TABLET ................................................................. 22 thioridazine tablet ...................................... 36 thiothixene capsule ................................... 38 THYROLAR-1 TABLET 12.5-50 MCG .................................................... 55 THYROLAR-1/2 TABLET 6.25-25 MCG .................................................... 55 THYROLAR-1/4 TABLET 3.1-12.5 MCG .................................................. 55 THYROLAR-2 TABLET 25-100 MCG ............................................................................. 55 THYROLAR-3 TABLET 37.5-150 MCG ................................................ 55 tiagabine tablet 2 mg, 4 mg ............. 30 ticlopidine tablet 250 mg .................... 23 TIKOSYN ............................................................ 25 TILIA FE TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) ....................................................................................... 52 TIMENTIN INTRAVENOUS SOLUTION 31 G .......................................... 6 timolol eye gel forming solution 0.25 %, 0.5 % ..................................................... 42 ................................................................................................ timolol maleate eye drops 0.25 %, 0.5 % .............................................................................. 42 timolol maleate oral ................................ 17 TIMOPTIC OCUDOSE (PF) EYE DROPS IN A DROPPERETTE 0.25 %, 0.5 % ................................................................................................ 42 tizanidine tablet 2 mg, 4 mg ........... 16 TL ICON CAPSULE 110-0.5 MG .................................................................................. 22 TL-FOL 500 TABLET,EXTENDED RELEASE 105 MG IRON- 500 MG-800 MCG ................................................ 22 TOBI SOLUTION FOR NEBULIZATION 300 MG/5 ML ....................................................................................... 4 TOBRADEX EYE OINTMENT 0.3-0.1 % .................................................................. 42 tobramycin eye drops 0.3 % ........... 42 tobramycin injection solution 40 mg/ml ................................................................................ 4 tobramycin-dexamethasone eye drops,suspension 0.3-0.1 % ............. 42 TOBREX EYE OINTMENT 0.3 % ......................................................................................... 42 TOPICORT TOPICAL CREAM 0.05 % ........................................................................... 62 TOPIRAGEN ................................................. 30 topiramate sprinkle capsule 15 mg, 25 mg ................................................................ 30 topiramate tablet ......................................... 30 torsemide oral .................................................. 27 TOVIAZ TABLET,EXTENDED RELEASE 4 MG, 8 MG ................. 66 tramadol tablet 50 mg ............................ 34 tramadol-acetaminophen tablet 37.5-325 mg .......................................................... 34 tranylcypromine tablet 10 mg ................................................................................................ 33 TRAVATAN Z EYE DROPS 0.004 % ....................................................................... 44 trazodone tablet ............................................ 38 tretinoin (chemotherapy) capsule 10 mg ............................................................................. 15 tretinoin topical cream ......................... 63 tretinoin topical gel 0.01 %, 0.025 % ......................................................................................... 63 TREXALL ........................................................... 15 triacetin liquid 100 % ................................. 5 TRIADVANCE TABLET 90-1-50 MG ......................................................... 22 87 triamcinolone acetonide dental paste 0.1 % ............................................................ 62 triamcinolone acetonide lotion 0.025 %, 0.1 % ................................................. 62 triamcinolone acetonide nasal spray aerosol 55 mcg ............................... 59 triamcinolone acetonide topical cream ........................................................................... 62 triamcinolone acetonide topical ointment ................................................................... 62 triamterene-hydrochlorothiazide capsule 37.5-25 mg ..................................... 28 triamterene-hydrochlorothiazide tablet 37.5-25 mg, 75-50 mg ................................................................................................ 28 TRIANEX TOPICAL OINTMENT 0.05 % .............................. 63 triazolam tablet 0.125 mg, 0.25 mg ...................................................................................... 32 TRICON CAPSULE 110-0.5 MG .................................................................................. 22 TRIDERM TOPICAL CREAM 0.1 % .............................................................................. 63 TRI-ESTARYLLA TABLET 0.18/0.215/0.25 MG-35 MCG (28) ................................................................................... 52 trifluoperazine tablet .............................. 36 trifluridine eye drops 1 % .................. 42 TRIGELS-F FORTE CAPSULE 460-60-0.01-1 MG ...................................... 22 trihexyphenidyl oral elixir 0.4 mg/ml ............................................................................ 16 trihexyphenidyl tablet 2 mg, 5 mg ................................................................................................ 16 TRI-LEGEST FE TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) ....................................................................................... 52 TRI-LINYAH TABLET 0.18/0.215/0.25 MG-35 MCG (28) ................................................................................... 52 TRILYTE WITH FLAVOR PACKETS ORAL SOLUTION 420 GRAM .......................................................... 45 trimethoprim tablet 100 mg ............ 13 trimethoprim-polymyxin b eye drops 0.1-10,000 %-unit/ml ............ 42 TRINATAL GT TABLET 90-1-50 MG ......................................................... 22 TRINATAL ULTRA TABLET 90-1-50 MG ......................................................... 22 TRINESSA (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) ................................................................................... 52 88 TRIPHROCAPS CAPSULE 1 MG .................................................................................. 67 TRI-PREVIFEM (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) ................................................................................... 52 TRI-SPRINTEC (28) TABLET 0.18/0.215/0.25 MG-35 MCG (28) ................................................................................... 52 TRIVEEN-U CAPSULE 106.5-1 MG .................................................................................. 66 TRI-VIT WITH FLUORIDE & IRON ORAL DROPS 0.25-10 MG/ML .................................................................... 22 TRIVORA (28) TABLET 50-30 (6)/75-40 (5)/125-30(10) ...................... 52 TRIZIVIR TABLET 300-150-300 MG .......................................... 10 tropicamide eye drops 0.5 %, 1 % ................................................................................................ 44 TRUVADA TABLET 200-300 MG .................................................................................. 10 TUSSIGON TABLET 5-1.5 MG ................................................................................................ 16 ursodiol capsule 300 mg ....................... 45 ursodiol tablet 250 mg, 500 mg ................................................................................................ 45 valacyclovir tablet 1 g, 500 mg ................................................................................................ 10 VALCYTE TABLET 450 MG ................................................................................................ 10 valproic acid (as sodium salt) oral solution 250 mg/5 ml ................................ 30 valproic acid capsule 250 mg ................................................................................................ 30 vancomycin capsule 125 mg, 250 mg .......................................................................................... 7 vancomycin in dextrose 5% intravenous piggyback 500 mg/100 ml ............................................................................................ 7 vancomycin intravenous solution .................................................................................................... 7 VELIVET TRIPHASIC REGIMEN (28) TABLET 0.1/.125/.15-25 MG-MCG ............. 52 venlafaxine er capsule,extended release 24 hr 150 mg ................................. 37 venlafaxine er capsule,extended release 24 hr 37.5 mg, 75 mg ................................................................................................ 37 venlafaxine er tablet,extended release 24 hr 225 mg ................................. 37 venlafaxine tablet ....................................... 37 VENTOLIN HFA AEROSOL INHALER 90 MCG/ACTUATION ............................ 18 verapamil er (sr) tablet,extended release ......................................................................... 25 verapamil er 24 hr capsule,extended release ................... 25 verapamil tablet ............................................ 25 VEXOL EYE DROPS,SUSPENSION 1 % ................................................................................................ 43 VIBRAMYCIN SYRUP 50 MG/5 ML .............................................................. 13 VICTRELIS CAPSULE 200 MG ...................................................................................... 7 VIDEX 2 GRAM PEDIATRIC ORAL SOLUTION 10 MG/ML (FINAL) .................................................................. 10 VIDEX 4 GRAM PEDIATRIC ORAL SOLUTION 10 MG/ML (FINAL) .................................................................. 10 VIGAMOX EYE DROPS 0.5 % ................................................................................................ 42 VIIBRYD .............................................................. 38 VIIBRYD TABLETS IN A DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) ................................................ 38 VINATE CALCIUM TABLET 27-1-50 MG ......................................................... 66 VINATE GT TABLET 90-1-50 MG .................................................................................. 23 VINATE M TABLET 27-1 MG ................................................................................................ 66 VINATE ULTRA TABLET 90-1-50 MG ......................................................... 23 VIORELE (28) TABLET 0.15-0.02MG X21 /0.01 MG X 5 ................................................................................................ 52 VIRACEPT TABLET 250 MG, 625 MG ......................................................................... 7 VIRAMUNE XR TABLET,EXTENDED RELEASE 400 MG .................................... 9 VIREAD TABLET 300 MG ................................................................................................ 10 VIRTI-SULF TOPICAL CREAM 10-5 % (W/W) .................... 64 VIRT-PN TABLET 27-1 MG ................................................................................................ 23 VITAFOL TABLET 65-1 MG ................................................................................................ 23 VITAFOL-OB TABLET 65-1 MG .................................................................................. 23 VITAFOL-PN (UD) TABLET 65-1 MG ................................................................... 23 VITAMIN D2 CAPSULE 50,000 UNIT ............................................................................ 67 VOL-PLUS TABLET 27-1 MG ................................................................................................ 23 VOL-TAB RX TABLET 29 MG IRON- 1 MG .................................................... 23 VOLTAREN TOPICAL GEL 1 % ......................................................................................... 35 VYNATAL FA TABLET 65-1 MG .................................................................................. 23 VYVANSE .......................................................... 29 warfarin oral ..................................................... 19 water for injection, sterile injection solution .................................................................... 59 WERA (28) TABLET 0.5-35 MG-MCG ............................................................. 52 XARELTO TABLET 10 MG, 20 MG .................................................................................. 19 XARELTO TABLET 15 MG ................................................................................................ 19 XYLOCAINE INJECTION SOLUTION 5 MG/ML (0.5 %) ................................................................................................ 56 XYLOCAINE-MPF INJECTION SOLUTION 15 MG/ML (1.5 %) ............................................ 56 YODOXIN TABLET 210 MG, 650 MG ......................................................................... 4 zafirlukast tablet 10 mg, 20 mg ................................................................................................ 59 zaleplon capsule 10 mg, 5 mg ................................................................................................ 31 ZATEAN-PN TABLET 27-1 MG .................................................................................. 23 ZEBUTAL CAPSULE 50-500-40 MG .................................................. 29 ZENATANE .................................................... 65 ZENCHENT (28) TABLET 0.4-35 MG-MCG ........................................ 52 ZENZEDI TABLET 10 MG, 5 MG .................................................................................. 29 ZIAGEN ORAL SOLUTION 20 MG/ML .................................................................... 10 zidovudine capsule 100 mg ............... 10 zidovudine syrup 10 mg/ml ............... 10 zidovudine tablet 300 mg .................... 10 ziprasidone capsule 20 mg, 40 mg, 80 mg ............................................................................. 32 ziprasidone capsule 60 mg ................ 32 zolpidem tablet 10 mg, 5 mg ................................................................................................ 31 zonisamide ............................................................ 30 ZOVIA 1/35E (28) TABLET 1-35 MG-MCG ............................................................. 52 ZOVIA 1/50E (28) TABLET 1-50 MG-MCG ............................................................. 52 89 MEDICAID DRUG EXCEPTION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE: (800) 528-6738 Monday through Friday 8:30am to 4:30pm First name: SECTION A - MEMBER INFORMATION Last name: Allergies: Pharmacy Name: Drug Name Requested: Date of Birth: Member ID: Type of reaction(s): SECTION B - PHARMACY INFORMATION Pharmacy Phone Number: SECTION C - CLINICAL INFORMATION Dosage and Frequency: Quantity: Length of therapy: Diagnosis for which drug is being requested: Date Medication Initiated: Is the Patient currently receiving requested medication? Yes No You must be able to document the therapeutic failure or contraindication to formulary products for a request to be approved. FORMULARY ALTERNATIVES THAT HAVE BEEN USED BY THE PATIENT Drug Name/ Strength Dates Tried: Reason therapy failed or discontinued Is member currently or recently hospitalized? Yes No Date of Discharge: Additional Clinical or Supporting Information: Please include office notes, lab data, and other supporting medical literature. Prescriber Name (printed): Office Phone: SECTION D - PRESCRIBER INFORMATION Prescriber Specialty: Contact Person: Prescriber Signature: Extension: NPI Number: Office Fax: Date: If the request is denied, the prescriber can change the prescription to an appropriate formulary alternative or with written member consent file an appeal with Gateway. The Drug Formulary is available on the website at http://www.gatewayhealthplan.com/providers/pharmacy-tools. Revised 11/2013 May Photocopy for Office Use 15 SIX SCRIPT BENEFIT LIMIT EXCEPTION REQUEST FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE: (800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: MEDICAL INFORMATION Diagnosis:_________________________________________________________________________ MEDICATION(S) REQUIRING EXCEPTION TO THE BENEFIT LIMIT Drug Name Strength Frequency Duration/Refills BENEFIT LIMIT REVIEW CRITERIA 1. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the member. Yes No If yes, please explain and provide supporting documentation from the medical record. 2. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the member. Yes No If yes, please explain and provide supporting documentation from the medical record. 3. Patient would require more expensive services if the exception is not granted. Yes No If yes, please explain and provide supporting documentation from the medical record. 4. Granting the exception is necessary in order to comply with Federal law. Yes No If yes, please explain and provide supporting documentation from the medical record. SUPPORTING INFORMATION (Attach additional documentation as needed.) Is this a prescription for a drug that requires prior authorization? □ Yes* □ No *If yes, submit the documentation to support a request for prior authorization of the drug. I attest that the information provided and statements made herein are true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to civil and criminal liability. Prescribing Physician Signature Date Revised 3/21/2013 May Photocopy for Office Use
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Printable Formulary - AmeriHealth Caritas Louisiana
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