Formulary_120512 Formulary 120512

User Manual: Formulary_120512

Open the PDF directly: View PDF .
Page Count: 139

Download
Open PDF In Browser	View PDF

GuildNet Gold HMO-POS SNP GuildNet
Health Advantage HMO-POS SNP
2012 Formulary
(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, and copayments may change on January 1, 2013.
GuildNet Gold HMO-POS SNP is a Coordinated Care plan with a Medicare Advantage contract and a contract
with the New York Medicaid program.
This information is available for free in other languages. Please contact our Member Services number at 1-800815-0000 for additional information. (TTY users should call 1-800-662-1220). Hours are Monday through
Friday, 8 am to 8 pm. Member Services has free language interpreter services available for non-English
speakers.
Esta información está disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al 1-800815-0000 para obtener información adicional. (Los usuarios de TTY deben llamar al 1-800-662-122). Se
atiende lunes a viernes, 8 a. m. a 8 p. m. Servicios a Los Clientes tienen servicios gratuitos de intérprete de
idioma disponibles para altavoces de no-inglés.
H6864 MEM12_06v3 File & Use 08242011
HPMS Approved Formulary File Submission 12309, Version 19
Updated 11/2012
Page 1 of 139

What is the GuildNet Gold and GuildNet Health Advantage Formulary?
A formulary is a list of covered drugs selected by GuildNet in consultation with a team of health care providers,
which represents the prescription therapies believed to be a necessary part of a quality treatment program.
GuildNet Gold and Guild Net Health Advantage will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a GuildNet network pharmacy, and other plan
rules are followed. For more information on how to fill your prescriptions, please review your Evidence of
Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning of the year, we will
not discontinue or reduce coverage of the drug during the 2012 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness of
a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of November 1, 2012. To get updated information about the drugs covered by
GuildNet, please visit our Web site at www.guildnetny.org or call Member Services at 1-800-815-0000,
Monday through Friday, 8 am to 8 pm. TTY/TDD users should call 1-800-662-1220. We will update the
formulary booklet by inserting errata sheets in the event of a mid-year formulary change.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for,
look for the category name in the list that begins on page 6. Then look under the category name for your
drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 100. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.

Page 2 of 139

What are generic drugs?
GuildNet Gold and GuildNet Health Advantage cover both brand name drugs and generic drugs. A generic
drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic
drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:


Prior Authorization: GuildNet Gold/ GuildNet Health Advantage requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from GuildNet
Gold/ GuildNet Health Advantage before you fill your prescriptions. If you don’t get approval,
GuildNet Gold/ GuildNet Health Advantage may not cover the drug.



Quantity Limits: For certain drugs, GuildNet Gold/ GuildNet Health Advantage limits the amount of
the drug that GuildNet Gold/ GuildNet Health Advantage will cover. For example, GuildNet Gold/
GuildNet Health Advantage provides 30 tabs per prescription for Lipitor. This may be in addition to a
standard one month or three month supply.



Step Therapy: In some cases, GuildNet Gold/ GuildNet Health Advantage requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, GuildNet Gold/ GuildNet Health
Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you,
GuildNet Gold/ GuildNet Health Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 6. You can also get more information about the restrictions applied to specific covered drugs by
visiting our Web site at www.guildnetny.org.

You can ask GuildNet Gold/ GuildNet Health Advantage to make an exception to these restrictions or limits.
See the section, “How do I request an exception to the GuildNet Gold/ GuildNet Health Advantage formulary?”
on this page for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that your
drug is not covered. If you learn that GuildNet does not cover your drug, you have two options:


You can ask Member Services for a list of similar drugs that are covered by GuildNet. When you
receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by
GuildNet.



You can ask GuildNet to make an exception and cover your drug. See below for information about how
to request an exception.
Page 3 of 139

How do I request an exception to the GuildNet Gold and GuildNet Health Advantage Formulary?
You can ask GuildNet Gold/ GuildNet Health Advantage to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.



You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
GuildNet Gold/ GuildNet Health Advantage limit the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, GuildNet Gold/ GuildNet Health Advantage will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction
exception. When you are requesting a formulary, or utilization restriction exception you should submit a
statement from your physician supporting your request. Generally, we must make our decision within 72
hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an
expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting
up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than
24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a
prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover
your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 98-day transition supply, consistent with the dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 31days you
are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited; but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply
of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you are a current member in our plan and you experience a change in the level of care, such as an admission
or discharge from the long care facility, you will be allowed an “early” refill of your medications, as needed, to
assist with your transition to your new level of care.
Page 4 of 139

For more information
For more detailed information about your GuildNet Gold/ GuildNet Health Advantage prescription drug
coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about GuildNet, please call Member Services at 1-800-815-0000, Monday through
Friday, 8 am to 8 pm. TTY/TDD users should call 1-800-662-1220. Or visit www.guildnetny.org.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048.
Or, visit www.medicare.gov.
GuildNet Gold and GuildNet Health Advantage Formulary
The formulary that begins on page 6 provides coverage information about some of the drugs covered by
GuildNet Gold/ GuildNet Health Advantage. If you have trouble finding your drug in the list, turn to the Index
that begins on page 100.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and generic
drugs are listed in lower-case italics (e.g., lovastatin).
The information in the Requirements/Limits column tells you if GuildNet Gold/ GuildNet Health Advantage
has any special requirements for coverage of your drug.
Note: The following symbols or abbreviations are used to identify drugs that require prior approval, quantity
limits, subject to a protocol or covered with the generic copayment.
The symbol [MNT] in the Requirements/Limits column indicates that the drug is a maintenance medication
available at mail order and select retail pharmacies.
The symbol [G] next to a drug name indicates that the drug may be available in a generic form.
The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted to certain
pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated
pharmacies able to appropriately handle the drugs.
The symbol [OTC] next to a drug name indicates that the drug is available Over-the-Counter.
The symbol [PA] in the Requirements/Limits column indicates that prior authorization may apply.
The symbol [PAN] in the Requirements/Limits column indicates that prior authorization may apply to
individuals who are starting the medication for the first time or for the first time in a long time.
The symbol [PAB] in the Requirements/Limits column indicates that prior authorization may apply to ensure
drug is paid under Medicare Part B if required by Medicare.
The symbol [QLL] in the Requirements/Limits column indicates that quantities dispensed may be limited.
The symbol [SP] next to the drug name indicates that the drug may be considered a specialty product under this
plan.
Page 5 of 139

The symbol [ST] in the Requirements/Limits column indicates that step therapy may apply.

General Drug Table
Drug

Generic

Tier

Requirements/Limits

ANALGESICS

GOUT

allopurinol sodium
allopurinol tablet
COLCRYS

colchicine

1
1
2

febuxostat

1
1
2

probenecid
probenecid-colchicine
ULORIC

[MO][MNT]
[MO][MNT][QLL,
60/30]
[MO][MNT]
[MO][MNT][ST]

NARCOTIC ANALGESICS
acetaminophen-codeine
ascomp with codeine
butalb-caff-acetaminophcodein
butorphanol tartrate aerosol,
-injection
co-gesic
hydrocodon-acetaminophen
5-300, -hydrocodonacetaminoph 7.5-300, hydrocodon-acetaminophn
10-300
hydrocodone bit-ibuprofen
hydrocodone-acetaminophen
elix, -solution, -hydrocodonacetaminoph 2.5-500, hydrocodon-acetaminophen
5-325, -hydrocodonacetaminophen 5-500, hydrocodon-acetaminoph
7.5-325, -hydrocodonacetaminoph 7.5-750, hydrocodon-acetaminophn
10-650, -hydrocodonacetaminophn 10-325, hydrocodon-acetaminoph
7.5-500, -hydrocodon-

1
1
1
1
1
1

[MO]

1
1

Page 6 of 139

Drug
acetaminophn 10-500, hydrocodon-acetaminoph
7.5-650, -hydrocodonacetaminophn 10-660, hydrocodon-acetaminophn
10-750
margesic h
reprexain
stagesic
vicodin hp
zamicet

Generic

Tier

Requirements/Limits

1
1
1
1
1

NARCOTIC ANALGESICS, CII
acetaminoph-caffdihydrocodein
astramorph-pf 1 mg/ml
ampul
astramorph-pf 5 mg/10 ml
vial, -10 mg/10 ml vial [G]
codeine sulfate
DILAUDID SOLUTION [G]

1

hydromorphone

duramorph
endocet
endodan
fentanyl
fentanyl 0.05 mg/ml syringe
fentanyl citrate otfc 200 mcg
fentanyl citrate otfc 400
mcg, -otfc 600 mcg, -otfc
800 mcg, -cit otfc 1,200
mcg, -cit otfc 1,600 mcg
hydromorphone 10 mg/ml
vial, -50 mg/5 ml vial, -500
mg/50 ml via
hydromorphone hcl 10
mg/ml amp
hydromorphone hcl tablet
KADIAN ER 10 MG CAPSULE,
-ER 200 MG CAPSULE

morphine

1

[PAB]

1

[PAB]

1
2
1
1
1
1
1
2
4

[PAB]

[PA][QLL, 10/30]
[PAB]
[PA][QLL, 120/30]
[PA][QLL, 120/30]

1

[MO][PAB]

1

[PAB]

1
2

[QLL, 60/30]

Page 7 of 139

Drug
KADIAN ER 20 MG CAPSULE,
-ER 30 MG CAPSULE, -ER 50
MG CAPSULE, -ER 60 MG
CAPSULE, -ER 80 MG
CAPSULE, -ER 100 MG
CAPSULE [G]

levorphanol tartrate tablet
meperidine 10 mg/ml
syringe, -25 mg/ml vial, -50
mg/ml vial, -100 mg/ml vial
methadone hcl 5 mg tablet, 10 mg tablet
methadone hcl injection, solution
methadose 5 mg tablet, -10
mg tablet
morphine 0.5 mg/ml vial, -1
mg/ml vial p-f
MORPHINE SULF 10 MG/5
ML SOLN, -SULF 20 MG/5 ML
SOLN

morphine

Tier Requirements/Limits
2
[QLL, 60/30]

1
1
1

[QLL, 240/30]

1

morphine

morphine sulf 100 mg/5 ml
soln, -tablet
morphine sulf er 15 mg
tablet, -sulf er 30 mg tablet,
-sulf er 60 mg tablet, -sulf er
100 mg tab
morphine sulf er 200 mg tab
morphine sulfate er 20 mg
cap, -30 mg cap, -50 mg
cap, -80 mg cap, -100 mg
cap
morphine sulfate er 60 mg
cap
oxycodone concentrate
oxycodone hcl capsule, -5
mg tablet, -15 mg tablet, -30
mg tablet
oxycodone hclacetaminophen
oxycodone hcl-aspirin
oxycodone hcl-ibuprofen
oxycodone-acetaminophen
oxycodone-aspirin
OXYCONTIN

Generic

1

[QLL, 240/30]

1

[PAB]

2
1
1

[QLL, 90/30]

1
1

[QLL, 60/30]
[MO][QLL, 60/30]

1

[MO][QLL, 90/30]

1
1
1

oxycodone

1
1
1
1
3

[MO]

Page 8 of 139

Drug
oxymorphone hcl tablet
oxymorphone hcl tablet
sustained action
ROXICET SOLUTION

Generic

oxycodone/acetaminophen

roxicet tablet

Tier Requirements/Limits
1
1
[QLL, 90/30]
2
1

NON-NARCOTIC ANALGESICS
buprenorphine 0.3 mg/ml
syrn
nalbuphine 100 mg/10 ml
vial, -200 mg/10 ml vial
tramadol hcl er 100 mg
tablet, -200 mg tablet
tramadol hcl er 100 mg
tablet, -er 200 mg tablet, -er
300 mg tablet
tramadol hcl tablet
tramadol hcl-acetaminophen

1
1
1
1
1
1

[QLL, 240/30]
[QLL, 240/30]

3
3
2
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

NSAIDS
ARTHROTEC 50
ARTHROTEC 75
CELEBREX

diclofenac potassium
diclofenac sodium e.c. tab, tablet sustained action
diflunisal tablet
etodolac capsule, -tablet, tablet sustained action
fenoprofen calcium tablet
flurbiprofen tablet
ibuprofen oral susp, -400 mg
tablet, -600 mg tablet, -800
mg tablet
INDOCIN ORAL SUSP

indomethacin capsule, capsule sustained action
ketoprofen capsule, -capsule
sustained action
ketorolac 15 mg/ml vial, -30
mg/ml vial, -30 mg/ml vial, tablet

diclofenac sodium/misoprostol
diclofenac sodium/misoprostol
celecoxib

indomethacin

[MO][MNT]

2
1
1

[MO][MNT]

1

Page 9 of 139

Drug
meclofenamate sodium
capsule
mefenamic acid capsule
meloxicam oral susp, -tablet
nabumetone
NAPRELAN

Generic

naproxen

naproxen e.c. tab, -oral
susp, -tablet
naproxen sodium 275 mg
tab, -550 mg tab
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium
VIMOVO

naproxen/esomeprazole mag

Tier Requirements/Limits
1
[MO][MNT]
1
1
1
3
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1
1
1
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

ANESTHETICS

LOCAL ANESTHETICS
lidocaine hcl 0.5% vial, -1%
vial
lidocaine hcl 1% ampul, 1.5% ampul, -2% ampul, 4% ampul, -2% vial

1
1

[MO]

2
1
1

[MO]

1

[MO]

1

[MO]

TOPICAL ANESTHETICS
ALCOHOL PREP PADS

lidocaine hcl cream, -lotion
pre-attached lta kit

ANTIINFECTIVES

AMINOGLYCOSIDES
amikacin 1,000 mg/4 ml vial,
-1,000 mg/4 ml
gentamicin ped 10 mg/ml
vial
ISO GENTAMICIN 120
MG/100 ML

gentamicin/sodium chloride

2

Page 10 of 139

Drug

Generic

ANTIBACTERIALS
gentamicin 90 mg/ns 100 ml
pb, -70 mg/ns 50 ml pb
kanamycin sulfate injection
tobramycin sulfate in ns

Tier

Requirements/Limits

1
1
1

ANTIINFECTIVES SPECIALIZED INDICATIONS
metro iv

1

[MO]

2
1

[MO][MNT]
[MO][MNT]

4
2
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1
1
1

[MO]
[MO]
[MO]

1

[MO]

1
1

[MO]
[MO]

ANTIRETROVIRAL AGENTS
INTELENCE 200 MG TABLET

etravirine

nevirapine tablet

ANTIRETROVIRALS AND PROTEASE INH
FUZEON 90 MG VIAL
INTELENCE 25 MG TABLET
ISENTRESS CHEW TAB

nevirapine oral susp

enfuvirtide
etravirine
raltegravir potassium

CEPHALOSPORINS
cefazolin
cefazolin 1 gm add-van vial
ceftazidime 500 mg vial
ceftriaxone 1 gm piggyback,
-2 gm piggyback, -2 gm vial

CLINDAMYCINS
clindamycin hcl 75 mg
capsule
clindamycin palmitate hcl
clindamycin ph 300 mg/2 ml
vl, -ph 600 mg/4 ml vl, -ph 9
g/60 ml vial, -ph 900 mg/6
ml vl

Page 11 of 139

Drug

Generic

ERYTHROMYCINS
ERYTHROCIN 500 MG VIAL

erythromycin lactobionate

erythromycin e.c. cap

Tier

Requirements/Limits

2
1

ORAL ANTIFUNGAL DRUGS
nystatin 50,000,000 units
pwd, -150,000,000 units
pwd, -500,000,000 units pwd

1

OTHER ANTIINFECTIVE DRUGS
aztreonam 2 gm vial
INVANZ 1 GM ADD-VANTAGE ertapenem sodium
VIAL

meropenem iv 1 gm vial
vancomycin 500 mg vial, 750 mg vial, -1 gm add-van
vial, -5 gm vial
ZYVOX 200 MG/100 ML IV
SOLN

linezolid

1
2

[MO]

1
1

[MO]
[MO][PAB]

4

OTHER ANTIVIRAL DRUGS
acyclovir sodium 1 gm vial
ribapak 200-400 mg
dosepack

1
4

[MO]

OTHER MACROLIDES
azithromycin packet

1

OTHER TOPICAL ANTIFUNGALS
ciclodan cream
ciclodan soln, top
ciclopirox kit
ketodan foam (noncontraceptive)

1
1
1
1

[MO]

Page 12 of 139

Drug

PARENTERAL ANTIFUNGALS
fluconazole-dext 200 mg/100
ml

Generic

Tier

Requirements/Limits

1

[MO]

1

[MO]

1

[MO]

1

[MO]

1
1

[MO]
[MO]

1
1
1

[MO]
[MO]
[MO]

1

[MO]

1

[MO]

1

[MO]

PENICILLINS
ampicillin 250 mg vial, -500
mg vial, -1 gm a-v vial, -2
gm a-v vial, -2 gm vial
ampicillin-sulbactam 1.5 gm
vl, -sulb 3 gm add vial
nafcillin 1 gm add-van vial, 2 gm add-vant vial, -2 gm
vial
nafcillin 2 gm/ 100 ml inj
oxacillin 1 gm add-vantage
vl, -2 gm add-vantage vl, -2
gm vial
penicillin g 600,000 unit/1 ml
penicillin gk 20 million unit
piperacil-tazo 2.25 gm add
vl, -piperacil-tazobact 2.25
gm vl, -piperacil-tazobact
40.5 gram

PLASMODICIDES
atovaquone-proguanil 62.525

QUINOLONES
ciprofloxacin 200 mg/20 ml
vl

TETRACYCLINES
doxycycline mono 100 mg
tablet
doxycycline mono 50 mg
cap, -mono 100 mg cap, mono 150 mg cap

1

Page 13 of 139

Drug

Generic

URINARY ANTIINFECTIVES
nitrofurantoin mcr 100 mg cp

Tier

Requirements/Limits

1

[MO]

ANTI-INFECTIVES

ANTIBACTERIALS

amikacin sulfate 100 mg/2
ml, -500 mg/2 ml, -500 mg/2
ml
amox tr-potassium
clavulanate
amoxicillin
amoxicillin-clavulanate er
ampicillin 125 mg vial, -1 gm
vial, -10 gm vial
ampicillin trihydrate
ampicillin-sulbactam 3 gm
vial, -15 gm vl
AVELOX
AVELOX ABC PACK
AVELOX IV

azithromycin injection, suspension, -tablet
BICILLIN C-R
BICILLIN L-A

1
1
1
1
1
1
1

moxifloxacin
moxifloxacin
moxifloxacin

2
2
2
1

pen g procaine/pen g benz
penicillin g benzathine

2
2
1
2
1
2
1
1

cefaclor
CEFACLOR ER

cefaclor

cefadroxil
CEFAZOLIN 1 GM-D5W BAG

cefazolin 10 gm vial
cefazolin 20 gm bulk vial, 500 mg vial, -1 gm vial
cefdinir
cefepime hcl
cefotaxime sodium
cefotetan
cefoxitin
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime 1 gm vial, -2 gm
vial, -6 gm vial

cefazolin

[MO]

1
1
1
1
1
1
1
1
1

Page 14 of 139

Drug
ceftriaxone 1 gm vial, -2 gm
add vial
ceftriaxone 250 mg vial, -500
mg vial, -1 gm-d5w bag, -2
gm-d5w bag, -10 gm vial
cefuroxime axetil
cefuroxime sod 750 mg vial,
-sod 1.5 gm vial, -sod 7.5
gm vial
cefuroxime tablet
cephalexin
chloramphenicol sod
succinate
CIPRO SUSPENSION

Generic

1
1
1
1
1
1

ciprofloxacin

ciprofloxacin 400 mg/40 ml
vl
ciprofloxacin er
ciprofloxacin hcl tablet
clarithromycin er
clarithromycin suspension, tablet
demeclocycline hcl tablet
dicloxacillin sodium
doxycycline hyclate capsule,
-e.c. cap, -e.c. tab, injection, -tablet
doxycycline mono 75 mg
capsule, -mono 50 mg tablet,
-mono 75 mg tablet, -mono
150 mg tablet
e.e.s. 400
ERYPED 200
ERYTHROCIN 500 MG
ADDVNT VL

erythrocin stearate
erythromycin ethylsuccinate
tablet
erythromycin tablet
gentamicin 10 mg/ml vial, 40 mg/ml vial

Tier Requirements/Limits
1
[MO]

2
1
1
1
1
1
1
1
1
1

erythromycin ethylsuccinate
erythromycin lactobionate

1
2
2
1
1

[MO]

1
1

Page 15 of 139

Drug
isoton gentamicin 60 mg/100
ml, -80 mg/ns 100 ml pb, isoton gentamicin 80 mg/100
ml, -100 mg/ns 100 ml, -iso
gentamicin 100 mg/100 ml, 60 mg/ns 50 ml pb, -isoton
gentamicin 60 mg/50 ml, -80
mg/ns 50 ml pb, -isoton
gentamicin 80 mg/50 ml
levofloxacin injection, solution, -tablet
levofloxacin-d5w 500
mg/100 ml
minocycline hcl capsule, tablet, -tablet sustained
action
nafcillin 1 gm vial, -10 gm
bulk vial, -10 gm vial
nafcillin 1 gm/ 50 ml inj
neomycin sulfate tablet
ofloxacin tablet
oxacillin 1 gm vial
oxacillin 1 gm/ 50 ml inj
oxacillin 10 gm vial
oxacillin 2 gm/ 50 ml inj
paromomycin sulfate capsule
PEN G 1.2 MILLION UNIT/2
ML

Generic

tetracycline hcl capsule
tobramycin 10 mg/ml vial, 40 mg/ml vial

Requirements/Limits

1
1
1
1

penicillin g procaine

penicillin g k 5 million unit
penicillin g sodium
penicillin v potassium
piperacillin
piperacil-tazobact 3.375 gm
vl
piperacil-tazobact 4.5 gm vial
streptomycin sulfate injection
SULFADIAZINE TABLET
SUPRAX

Tier
1

4
1
1
1
1
4
4
1
2
1
1
1
1
1

sulfadiazine
cefixime

1
1
2
3
1
1

[MO]

Page 16 of 139

Drug

Generic

ANTIFUNGALS

amphotericin b injection
ANCOBON [G]
CANCIDAS

flucytosine
caspofungin acetate

clotrimazole lozenge
fluconazole suspension, tablet
fluconazole-dext 400 mg/200
ml
flucytosine capsule
griseofulvin oral susp
GRIS-PEG

1
2
4
1
1

[PAB]

1
1
2
1
1
4
1
1
2
4
4
1
1

[MO]

1

[MO]
[MO][MNT]

artemether/lumefantrine
pyrimethamine
atovaquone/proguanil hcl

1
3
2
2

atovaquone/proguanil hcl

2

griseofulvin ultramicrosize
posaconazole

nystatin tablet
terbinafine hcl tablet
VFEND IV [G]
VFEND SUSPENSION
VFEND TABLET [G]

Requirements/Limits

1

itraconazole capsule
ketoconazole tablet
NOXAFIL

Tier

voriconazole
voriconazole
voriconazole

voriconazole injection
voriconazole tablet

[PA]

[QLL, 90/365]

[QLL, 29/30]

ANTIMALARIALS
atovaquone-proguanil 250100
chloroquine phosphate tablet
COARTEM
DARAPRIM
MALARONE 250-100 MG
TABLET [G]
MALARONE 62.5-25 MG PED
TAB

mefloquine hcl

1

[MO][MNT]

1
2
4
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

ANTIRETROVIRAL AGENTS
abacavir
APTIVUS
ATRIPLA
COMBIVIR [G]

tipranavir
emtricitabine/tenofovir/efavir
lamivudine/zidovudine

Page 17 of 139

Drug

Generic
emtricitab/rilpivirine/tenofov
indinavir

EDURANT
EMTRIVA
EPIVIR SOLUTION
EPIVIR TABLET [G]
EPZICOM
FUZEON CONVENIENCE KIT
INTELENCE 100 MG TABLET
INVIRASE
ISENTRESS TABLET
KALETRA

rilpivirine hydrochloride
emtricitabine
lamivudine
lamivudine
abacavir sulfate/lamivudine
enfuvirtide
etravirine
saquinavir mesylate
raltegravir potassium
ritonavir/lopinavir

COMPLERA
CRIXIVAN

fosamprenavir calcium
ritonavir
darunavir ethanolate

Tier
4
2
1
3
2
2
2
2
4
2
2
4
2
1
1
2
2
4

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

darunavir ethanolate

2

[MO][MNT]

delavirdine mesylate
zidovudine
atazanavir sulfate
maraviroc

2
2
2
4
1
4
2
2
2
2

[MO][MNT]

nelfinavir mesylate
nevirapine
tenofovir disproxil fumarate
abacavir sulfate
abacavir sulfate

2
2
2
2
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

capreomycin

3
1

[MO][MNT]

didanosine

lamivudine
lamivudine-zidovudine
LEXIVA
NORVIR
PREZISTA 400 MG TABLET, 600 MG TABLET
PREZISTA 75 MG TABLET, 150 MG TABLET
RESCRIPTOR
RETROVIR INJECTION
REYATAZ
SELZENTRY

stavudine
STRIBILD
SUSTIVA
TRIZIVIR
TRUVADA
VIDEX 2 GM PEDIATRIC
SOLN
VIRACEPT
VIRAMUNE [G]
VIREAD
ZIAGEN SOLUTION
ZIAGEN TABLET [G]

elvitegr/cobicist/emtric/tenof
efavirenz
zidovudine/lamivudine/abacavir
emtricitabine/tenofovir
didanosine

zidovudine

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

ANTITUBERCULAR AGENTS
CAPASTAT SULFATE

ethambutol hcl

Page 18 of 139

Drug
isonarif
isoniazid injection
isoniazid syrup, -tablet
MYCOBUTIN
PASER
PRIFTIN

Generic

rifabutin
aminosalicylic acid
rifapentine

pyrazinamide
rifampin capsule, -injection
SEROMYCIN
TRECATOR

cycloserine
ethionamide

Tier Requirements/Limits
1
1
1
[MO][MNT]
2
3
[MO][MNT]
3
1
[MO][MNT]
1
3
3

ANTIVIRALS
acyclovir capsule, -oral susp,
-tablet
acyclovir sodium 500 mg vial
BARACLUDE SOLUTION
BARACLUDE TABLET
EPIVIR HBV

1

entecavir
entecavir
lamivudine

famciclovir
foscarnet sodium
ganciclovir 250 mg capsule
ganciclovir 500 mg capsule
ganciclovir sodium
HEPSERA
INCIVEK
REBETOL SOLUTION
RELENZA

[MO][MNT]
[MO][MNT]
[MO][MNT]

4

[PAB]
[PA]
[MO]
[PA]
[QLL, 60
inhalations/180]
[PA]

4

[MO][PA]

4

[PA]

1

[PA]
[PA]

oseltamivir phosphate

1
1
2

oseltamivir phosphate

2

[QLL, 84/180]

adefovir dipivoxil
telaprevir
ribavirin
zanamivir

ribapak 400-400 mg
dosepack, -600-600 mg
dosepack
ribapak 600-400 mg
dosepack
ribasphere 400 mg tablet, 600 mg tablet
ribasphere capsule, -200 mg
tablet
ribavirin capsule, -tablet
rimantadine hcl
TAMIFLU 12 MG/ML
SUSPENSION
TAMIFLU 30 MG GELCAP

1
2
4
2
1
1
1
4
1
4
2
4
2

[MO][MNT]

[QLL, 262.5 ml/180]

Page 19 of 139

Drug
TAMIFLU 45 MG GELCAP, 75 MG GELCAP
TAMIFLU 6 MG/ML
SUSPENSION
TYZEKA

Generic
oseltamivir phosphate

Tier Requirements/Limits
2
[QLL, 42/180]

oseltamivir phosphate

2

[QLL, 600 ml/180]

telbivudine

4
1
4

[MO][MNT][PA]
[MO][MNT]
[MO][MNT]

valacyclovir
VALCYTE

valganciclovir

MISCELLANEOUS
ALBENZA
ALINIA ORAL SUSP
ALINIA TABLET

albendazole
nitazoxanide
nitazoxanide

aztreonam 1 gm vial
baciim
bacitracin injection
CLEOCIN HCL 75 MG
CAPSULE [G]
CLEOCIN PALMITATE [G]

clindamycin hcl
clindamycin palmitate

clindamycin 150 mg/ml
addvan
clindamycin hcl 150 mg caps,
-300 mg capsule
colistimethate 150 mg vial
CUBICIN

daptomycin

ertapenem sodium
nitrofurantoin macrocrystal

mebendazole chew tab
MEPRON

atovaquone

meropenem iv 500 mg vial
methenamine hippurate
metronidazole capsule, injection, -tablet
nitrofurantoin mcr 50 mg cap
nitrofurantoin mono-macro
nitrofurantoin oral susp
polymyxin b sulfate injection
PRIMAXIN [G]
PRIMAXIN I.M.

[QLL, 180/30]
[QLL, 12/30]

2
1
1

dapsone tablet
erythromycin-sulfisoxazole
imipenem-cilastatin sodium
INVANZ 1 GM VIAL
MACRODANTIN 25 MG
CAPSULE

2
2
2
1
1
1
2

imipenem/cilastatin sodium
imipenem/cilastatin sodium

1
4
1
1
1
2
2

[PAB]
[PAB]
[MO][MNT]
[MO]

1
4
1
1
1
1
1
1
1
2
2
Page 20 of 139

Drug
sulfamethoxazoletrimethoprim
tinidazole tablet
trimethoprim tablet
TYGACIL
VANCOCIN HCL [G]

vancomycin 1 gm vial, -10
gm vial
VANCOMYCIN 500 MG A/V
VIAL, -1G/200 ML BAG
VANCOMYCIN HCL CAPSULE
ZYVOX 600 MG/300 ML IV
SOLN, -ORAL SUSP, -TABLET

Generic

Tier
1

Requirements/Limits

1
1
3
4
1

[PAB]

vancomycin

2

[PAB]

vancomycin
linezolid

4
4

carmustine
busulfan
lomustine

2
2
2
1
1
2
4
2
2
2
1
2
4

[PAB]
[PAB]

1
1
1
4
1

[PAB]
[MO][PAB]
[PAB]
[PAB]
[PAB]

1

[PAB]

4
1

[PAB]
[PAB]

tigecycline
vancomycin

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS
BICNU [PartB]
BUSULFEX [PartB]
CEENU

cyclophosphamide tablet
dacarbazine [PartB]
EMCYT
HEXALEN
IFEX [PartB][G]
ifosfamide [PartB]
LEUKERAN
melphalan hcl [PartB]
MUSTARGEN [PartB]
TREANDA [PartB]

estramustine phosphate sodium
altretamine
ifosfamide
chlorambucil
mechlorethamine
bendamustine hcl

[PAB]
[PAB]

[PAB]
[PAB]
[PAB]
[PAB]
[PAB]

ANTHRACYCLINES
adriamycin [PartB]
cerubidine [PartB]
daunorubicin hcl
DOXIL [PartB]

doxorubicin 150 mg/75 ml
vial
doxorubicin 200 mg/100 ml
vial [PartB]
epirubicin hcl [PartB]
idarubicin hcl [PartB]

doxorubicin hcl liposome

Page 21 of 139

Drug

Generic

Tier

Requirements/Limits

1
2
1

[PAB]
[PAB]
[PAB]

4
1

[PAB]
[PAB]

1

[MO][PAB]

1

[PAB]

4
4
1
1

[MO][PAB]
[PAB]

1
2
4

[PAB]

1
2

[MO][PAB]
[PAB]

4

[PAB]

2

[PAB]

1
1

[PAB]
[PAB]

ANTIBIOTICS
bleomycin sulfate [PartB]
COSMEGEN [PartB][G]
mitomycin injection [PartB]

dactinomycin

ANTIMETABOLITES
ALIMTA 500 MG VIAL

cytarabine 20 mg/ml vial, 500 mg vial [PartB]
cytarabine 500 mg/25 ml
vial, -100 mg/ml vial, -2 g/20
ml vial [PartB]
fluorouracil 500 mg/10 ml
vial [PartB]
GEMCITABINE HCL [PartB]
GEMZAR [PartB][G]

pemetrexed disodium

gemcitabine
gemcitabine

mercaptopurine tablet
methotrexate 25 mg/ml vial,
-250 mg/10 ml vial, -50
mg/2 ml vial, -1 gm vial
pentostatin [PartB]
TABLOID
VIDAZA

thioguanine
azacitidine

[PAB]

[PAB]

ANTIMITOTIC, TAXOIDS
docetaxel [PartB]
paclitaxel 300 mg/50 ml vial
[PartB]
TAXOTERE [PartB]

docetaxel

ANTIMITOTIC, VINCA ALKALOIDS
VINBLASTINE SULFATE
[PartB]
vincristine sulfate [PartB]
vinorelbine tartrate [PartB]

vinblastine

Page 22 of 139

Drug

Tier

Requirements/Limits

4
2
4
4
2
4
4
4
4

[PAB]
[PAB]
[PAB]
[PAB]
[PAB]
[PAB]
[PA]
[PAB]

1
2
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][PAB]

leuprolide

1
2
4
2
1
1
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT][PAB]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[PA]
[PA]

leuprolide

4

[MO][PA]

leuprolide

4

[PA]

leuprolide

4

[PA]

megestrol

2
1
1
2
1
4
2

[MO][MNT]
[MO][MNT]

BIOLOGIC RESPONSE MODIFIERS
AVASTIN 100 MG/4 ML VIAL
CAMPATH
HERCEPTIN [PartB]
ISTODAX [PartB]
ONTAK [PartB]
PROLEUKIN
RITUXAN
VELCADE
ZOLINZA

Generic

bevacizumab
alemtuzumab
trastuzumab
romidepsin
denileukin diftitox
aldesleukin
rituximab
bortezomib
vorinostat

HORMONAL ANTINEOPLASTIC AGENTS
anastrozole tablet
AROMASIN [G]

exemestane

bicalutamide
DEPO-PROVERA 400 MG/ML
VIAL

medroxyprogesterone

exemestane

FARESTON
FASLODEX
FEMARA [G]

toremifene
fulvestrant
letrozole

flutamide
letrozole
leuprolide acetate injection
LUPRON DEPOT 3.75 MG
KIT, -11.25 MG 3MO KIT
LUPRON DEPOT 45 MG 6MO
KIT
LUPRON DEPOT 7.5 MG KIT,
-22.5 MG 3MO KIT, --4
MONTH KIT
LUPRON DEPOT-PED 11.25
MG KIT, -15 MG KIT
MEGACE ES

megestrol acetate oral susp
megestrol acetate tablet
NILANDRON

nilutamide

tamoxifen citrate tablet
TRELSTAR 22.5 MG VIAL
TRELSTAR 3.75 MG
SYRINGE, -11.25 MG
SYRINGE

triptorelin pamoate
triptorelin pamoate

[MO][MNT]
[MO][MNT]
[MO][PAB]
[PAB]

Page 23 of 139

Drug

Generic

Tier

Requirements/Limits

everolimus
vandetanib
imatinib mesylate
axitinib
ruxolitinib phosphate
sorafenib tosylate
basiliximab
dasatinib

4
4
4
3
4
4
2
4

[MO][MNT][PAN]

dasatinib

3

[MO][MNT][PAN]

sunitinib malate
erlotinib hcl
nilotinib hydrochloride
lapatinib ditosylate
vandetanib
pazopanib
crizotinib
vemurafenib

4
4
4
4
4
4
4
4

[PAN]
[MO][MNT][PAN]
[MO][MNT][PAN]
[MO][MNT][PAN]

hydroxyurea
asparaginase
vismodegib

2
2
3
1
4
4
4
1

[MO][MNT]
[PAB]
[MO][MNT]
[MO][MNT]
[PAB]

4
4
2
4

[MO][MNT][PAN]

1

[PAB]

KINASE INHIBITORS
AFINITOR
CAPRELSA
GLEEVEC
INLYTA
JAKAFI
NEXAVAR
SIMULECT 20 MG VIAL
SPRYCEL 20 MG TABLET, -50
MG TABLET, -70 MG
TABLET, -100 MG TABLET
SPRYCEL 80 MG TABLET, 140 MG TABLET
SUTENT
TARCEVA
TASIGNA
TYKERB
VANDETANIB
VOTRIENT
XALKORI
ZELBORAF

[MO][MNT][PAN]
[MO]
[MO][MNT]
[PAN]
[MO][PAB]
[MO][MNT][PAN]

[PAN]
[MO][MNT][PAN]
[MO][MNT][PAN]

MISCELLANEOUS
DROXIA
ELSPAR [PartB]
ERIVEDGE

hydroxyurea capsule
irinotecan hcl [PartB]
LYSODREN
MATULANE

mitoxantrone 25 mg/12.5 ml
vl
TARGRETIN CAPSULE

mitotane
procarbazine
bexarotene

tretinoin capsule
TRISENOX [PartB]
ZYTIGA

arsenic trioxide
abiraterone acetate

[MO][MNT][PAB]

[PAB]
[MO][MNT]

NUCLEOSIDE ANALOGS
cladribine [PartB]

Page 24 of 139

Drug
fludarabine phosphate

Generic

Tier Requirements/Limits
4
[PAB]

[PartB]

PLATINUM COORDINATION COMPLEX
carboplatin [PartB]
cisplatin 1 mg/ml vial [PartB]
cisplatin 100 mg/100 ml vial

1
1
1

[PAB]
[PAB]
[MO][PAB]

oxaliplatin 100 mg/20 ml vial

4

[PAB]

3
4
1
4
1
2

[MO]
[PAB]
[PAB]
[PAB]
[PAB]

1

[MO][PAB]

[PartB]
[PartB]

PROTECTIVE AGENTS
AMEVIVE

alefacept

amifostine
dexrazoxane [PartB]
ELITEK 1.5 MG VIAL
ifosfamide-mesna [PartB]
LEUCOVORIN CALCIUM 10
MG TAB, -15 MG TAB

rasburicase
leucovorin

leucovorin calcium 100 mg
vial, -350 mg vial
leucovorin calcium 5 mg tab,
-25 mg tab
mesna 1 gram/10 ml vial
mesna 100 mg/ml vial
MESNEX TABLET

1
1
1
4

[MO][PAB]
[PAB]

1
1
4

[PAB]
[PAB]
[PAB]

bevacizumab

4

[MO]

certolizumab pegol

4

[MO][MNT][PA]

1

[MO][MNT][PAB]

mesna

TOPOISOMERASE INHIBITORS
etoposide injection [PartB]
toposar [PartB]
topotecan hcl [PartB]

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
AVASTIN 400 MG/16 ML
VIAL
CIMZIA 200 MG/ML
STARTER KIT

cyclosporine modified 25 mg

Page 25 of 139

Drug
ENBREL 50 MG/ML
SURECLICK SYR

hecoria
leucovorin calcium 50 mg
vial, -200 mg vial
leucovorin calcium 500 mg vl
methotrexate 1 gm/40 ml
vial, -100 mg/4 ml vial, -200
mg/8 ml vial, -250 mg/10 ml
vial, -50 mg/2 ml vial
methotrexate 100 mg/4 ml
vial
mitoxantrone 20 mg/10 ml
vial, -30 mg/15 ml vial
octreotide acet 50 mcg/ml
syr, -acet 50 mcg/ml vial, acet 100 mcg/ml syr, -acet
100 mcg/ml vl, -acet 500
mcg/ml syr, -acet 500
mcg/ml vl
REVLIMID 2.5 MG CAPSULE
TRELSTAR 22.5 MG SYRINGE
TRELSTAR DEPOT
TRELSTAR LA

etanercept

Generic

lenalidomide
triptorelin pamoate
triptorelin pamoate
triptorelin pamoate

Tier Requirements/Limits
4
[MO][MNT]
1
1

[MO][MNT][PAB]
[MO]

1
1

[MO][PAB]
[PAB]

1

[MO][PAB]

1

[MO][MNT][PAB]

1

[MO][MNT][PA]

4
4
2
2

[MO][MNT]
[MO]
[MO][PAB]
[MO][PAB]

1

[MO]

1

[MO]

AUTONOMIC AND CNS MEDICATIONS

ANALGESICS

buprenorphine 0.3 mg/ml
vial
nalbuphine 10 mg/ml ampul,
-20 mg/ml ampul
tramadol er 100 mg tablet, er 200 mg tablet
tramadol hcl er 300 mg
tablet

1
1

[MO]

2

[MO][MNT][QLL,
30/30]

ANTIDEMENTIA DRUGS
EXELON 13.3 MG/24HR
PATCH

rivastigmine tartrate

Page 26 of 139

Drug

Generic

Tier

Requirements/Limits

1

[MO]

clozapine odt
haloperidol decan 50 mg/ml
amp
haloperidol decanoate 100
haloperidol injection
risperidone m-tab 0.5 mg odt

1
1

[MO][MNT][PA]
[MO][MNT]

1
1
1

risperidone m-tab 1 mg odt,
-2 mg odt, -3 mg odt
risperidone m-tab 4 mg odt

1
1

[MO][MNT]
[MO]
[MO][MNT][QLL,
90/30]
[MO][MNT][QLL,
60/30]
[MO][MNT]

1

[MO][PAB]

1

[MO][PA]

1

[MO][MNT]

1

[PAB]

1

[MO][PAB]

1

[PA]

ANTIPARKINSON ANTICHOLINERGIC DRUGS
benztropine 2 mg/2 ml
ampule

ANTIPSYCHOTIC DRUGS

ANTIVERTIGO AND ANTIEMETIC DRUGS
ondansetron 40 mg/20 ml
vial, -4 mg/2 ml syr, -4 mg/2
ml ampule
promethegan 12.5 mg
suppos

CARBAMAZEPINES
carbamazepine er

CLASS II NARCOTICS
ASTRAMORPH-PF 0.5 MG/ML
AMP [G]

fentanyl 0.05 mg/ml ampul, 0.05 mg/ml vial, -1 mg/20 ml
vial, -100 mcg/2 ml vial, -250
mcg/5 ml vial
fentanyl 2,500 mcg/50 ml
vial

morphine

Page 27 of 139

Drug
hydromorphone hcl 1 mg/ml
amp, -1 mg/ml syringe, -2
mg/ml syringe, -2 mg/ml
vial, -2 mg/ml amp, -2
mg/ml vl, -4 mg/ml syrin, -4
mg/ml amp
KADIAN ER 40 MG CAPSULE,
-ER 70 MG CAPSULE, -ER
130 MG CAPSULE, -ER 150
MG CAPSULE

meperidine 10 mg/ml
cartrdge, -solution
methadone 40 mg tablet
dispr
methadone intensol
methadose 40 mg tablet
dispr
methadose solution
morphine 0.5 mg/ml ampul
p-f, -1 mg/ml ampul p-f, -1
mg/ml syringe, -1 mg/ml
vial, -2 mg/ml syringe, -4
mg/ml syringe, -5 mg/ml
vial, -8 mg/ml ampule, -8
mg/ml syringe, -8 mg/ml
vial, -10 mg/ml ampul, -10
mg/ml syringe, -10 mg/ml
vial, -15 mg/ml syringe, -15
mg/ml vial, -25 mg/ml vial, 25 mg/ml vl, -50 mg/ml vial
morphine 4 mg/ml carpuject,
-100 mg/10 ml vial, -300
mg/20 ml vial
oxycodone hcl 10 mg tablet,
-20 mg tablet
oxycodone hcl solution
sublimaze

Generic

morphine

Tier Requirements/Limits
1
[MO][PAB]

2

[QLL, 60/30]

1

[MO]

1
1
1

[MO]

1
1

[MO]
[MO]

1
1

[MO]

1
1

[PA]

CLASS III NARCOTICS
hydrocodon-acetaminoph
2.5-325
hydrocodone-ibuprofen
hydrogesic

1
1
1

[MO]
Page 28 of 139

Drug

Generic

CNS STIMULANT DRUGS
methylphenidate er 10 mg
tab, -20 mg tab, -54 mg tab

Tier

Requirements/Limits

1

[MO][MNT]

1
1
1

[MO]

1

[MO][QLL, 10/30]

DRUGS TO PREVENT AND TREAT HEADACHES
butalbital compound-codeine
naratriptan
sumatriptan 4 mg/0.5 ml
cart, -4 mg/0.5 ml inject
sumatriptan 4 mg/0.5 ml kit,
-4 mg/0.5 ml refill, -6 mg/0.5
ml refill, -6 mg/0.5 ml syrng
SUMATRIPTAN 5 MG NASAL
SPRAY

sumatriptan

1

HYDANTOINS
phenytoin 100 mg/2 ml vial
phenytoin 250 mg/5 ml vial,
-50 mg/ml syringe, -50
mg/ml vial

1
1

[MO]

2
1

[MO][MNT]
[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1

[MO][MNT]

OTHER ANTICONVULSANTS
LYRICA SOLUTION

pregabalin

topiragen

OTHER ANTIDEPRESSANTS
bupropion xl
venlafaxine hcl er 225 mg
tab

OTHER ANTIPARKINSON DRUGS
carbidopa-levodopaentacapone

Page 29 of 139

Drug

OTHER CNS/AUTONOMIC DRUGS

Generic

atropine 0.4 mg/0.5 ml
ampul, -0.4 mg/ml vial, -1
mg/ml ampul, -1 mg/ml vial
atropine 8 mg/20 ml vial
naloxone 0.4 mg/ml ampul, 0.4 mg/ml vial

Tier

Requirements/Limits

1

[MO]

1
1

[MO]

1

[MO][MNT]

1
1

[MO][MNT][QLL,
30/30]
[MO][MNT]

1

[MO][MNT]

1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1
1
1
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

SELECTIVE SEROTONIN REUPTAKE INHIBITORS
citalopram

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS
amlodipine-benazepril 2.510, --benazepril 5-10 mg
amlodipine-benazepril 5-40
mg, --benazepril 10-20 mg, -benazepril 5-20 mg, -benazepril 10-40 mg
benazeprilhydrochlorothiazide
captopril-hydrochlorothiazide
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide

ACE INHIBITORS
benazepril hcl tablet
captopril tablet
enalapril maleate tablet
eprosartan mesylate
fosinopril sodium
lisinopril tablet
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril

Page 30 of 139

trandolapril

Drug

Generic

Tier Requirements/Limits
1
[MO][MNT]

ADRENOLYTICS, CENTRAL
clonidine
clonidine hcl tablet
guanabenz acetate tablet
guanfacine hcl

1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT][PA]
[MO][MNT]

1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone tablet

ALPHA BLOCKERS
doxazosin mesylate
prazosin hcl
terazosin hcl

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
AVALIDE 150-12.5 MG
TABLET, -300-12.5 MG
TABLET [G]
AVALIDE 300-25 MG TABLET
AZOR
BENICAR HCT 20-12.5 MG
TABLET
BENICAR HCT 40-25 MG
TABLET, -40-12.5 MG
TABLET
DIOVAN HCT 160-25 MG
TABLET, -320-12.5 MG TAB,
-320-25 MG TABLET [G]
DIOVAN HCT 80-12.5 MG
TABLET, -160-12.5 MG TAB
[G]
EXFORGE 5-160 MG TABLET

irbesartan/hctz

2

[MO][MNT]

irbesartan/hctz
amlodipine bes/olmesartan med
olmesartan medoxomil/hctz

2
2
2

olmesartan medoxomil/hctz

2

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]

hctz/valsartan

2

[MO][MNT]

hctz/valsartan

2

[MO][MNT][QLL,
30/30]

amlodipine/valsartan

2

EXFORGE 5-320 MG TABLET,
-10-160 MG TABLET, -10320 MG TABLET

amlodipine/valsartan

2

[MO][MNT][QLL,
30/30]
[MO][MNT]

Page 31 of 139

Drug
Generic
EXFORGE HCT 5-160-12.5
amlodipine/valsartan/hctz
MG TAB
EXFORGE HCT 5-160-25 MG amlodipine/valsartan/hctz
TAB, -10-160-12.5 MG TAB, 10-160-25 MG TAB, -10-32025 MG TAB

irbesartanhydrochlorothiazide
losartan-hydrochlorothiazide
TRIBENZOR

olmesartan med/amlodipine/hct

Tier Requirements/Limits
2
[MO][MNT][QLL,
30/30]
2
[MO][MNT]

1

[MO][MNT]

1
2

[MO][MNT]
[MO][MNT]

2
2
2
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[PAB]

1
1

[MO][MNT]

1
1
1
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2
1

[MO][MNT]
[MO][MNT]

ANGIOTENSIN II RECEPTOR ANTAGONISTS
AVAPRO [G]
BENICAR
DIOVAN

irbesartan
olmesartan medoxomil
valsartan

irbesartan
losartan potassium

ANTIARRHYTHMICS
amiodarone 150 mg/3 ml
amp
amiodarone hcl tablet
atropine 0.1 mg/ml abboject,
-0.1 mg/ml syringe, -0.05
mg/ml syringe
disopyramide phosphate
flecainide acetate
mexiletine hcl capsule
MULTAQ
NORPACE CR 100 MG
CAPSULE
PACERONE 100 MG TABLET

pacerone 200 mg tablet, 400 mg tablet
procainamide hcl injection
propafenone hcl
quinidine gluconate injection
quinidine gluconate tablet
sustained action
quinidine sulfate tablet, tablet sustained action
sorine

dronedarone
disopyramide
amiodarone

1
1
1
1

[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1

[MO][MNT]
Page 32 of 139

sotalol

Drug

TIKOSYN

Generic

dofetilide

Tier Requirements/Limits
1
[MO][MNT]
2
[MO][MNT]

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium
CRESTOR 40 MG TABLET
CRESTOR 5 MG TABLET, -10
MG TABLET, -20 MG TABLET

rosuvastatin calcium
rosuvastatin calcium

fluvastatin sodium
LIPITOR [G]

atorvastatin calcium

lovastatin
LOVAZA

pravastatin sodium 10 mg
tab, -10 mg tab, -20 mg tab,
-20 mg tab, -40 mg tab, -40
mg tab
pravastatin sodium 80 mg
tab
SIMCOR

simvastatin 5 mg tablet, -5
mg tablet, -10 mg tablet, -10
mg tablet, -20 mg tablet, -20
mg tablet, -40 mg tablet, -40
mg tablet
simvastatin 80 mg tablet, -80
mg tablet
VYTORIN
ZETIA

omega-3 acid ethyl esters

niacin/simvastatin

ezetimibe/simvastatin
ezetimibe

1
2
2
1
3
1
3
1

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]

1

[MO][MNT]

3
1

[MO][MNT]
[MO][MNT][QLL,
30/30]

1

[MO][MNT]

2
2

[MO][MNT]
[MO][MNT]

2
1
1
1
1
2
1
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

ANTILIPEMICS, MISCELLANEOUS
ANTARA

fenofibrate

cholestyramine light packet
colestipol hcl powder, -tablet
fenofibrate
gemfibrozil tablet
NIASPAN

niacin

prevalite powder
TRICOR
TRILIPIX
WELCHOL

fenofibrate
fenofibric acid
colesevelam

Page 33 of 139

Drug

Generic

BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol-chlorthalidone
bisoprololhydrochlorothiazide
metoprololhydrochlorothiazide
nadolol-bendroflumethiazide
propranololhydrochlorothiazid

Tier

Requirements/Limits

1
1

[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1
1
1
1
2
1
3
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT]

1
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

BETA-BLOCKERS
acebutolol hcl capsule
atenolol tablet
betaxolol hcl tablet
bisoprolol fumarate
BYSTOLIC

nebivolol hcl

carvedilol
COREG CR

carvedilol

labetalol hcl 5 mg/ml vial
labetalol hcl tablet
metoprolol succinate
metoprolol tart 5 mg/5 ml
vial
metoprolol tartrate tablet
nadolol tablet
pindolol
propranolol hcl capsule
sustained action, -solution, tablet
propranolol hcl injection
timolol maleate tablet

[MO][MNT]
[MO][MNT]

CALCIUM CHANNEL BLOCKERS
afeditab cr
amlodipine besylate tablet
CARDIZEM CD 360 MG
CAPSULE [G]

cartia xt
dilt xr 180 mg capsule, -dilt
xr 240 mg capsule

diltiazem

Page 34 of 139

Drug
dilt-cd 120 mg capsule, -er
300 mg capsule
diltiazem 24hr cd 120 mg
cap, -240 mg cap, -300 mg
cap
diltiazem 24hr er 120 mg
cap, -240 mg cap, -300 mg
cap
diltiazem 25 mg/5 ml vial, 100 mg vial
diltiazem er 60 mg 12-hr
cap, -90 mg 12-hr cap, -120
mg 12-hr cap, -180 mg
capsule, -hcl er 360 mg cap,
-hcl er 420 mg cap
diltiazem hcl tablet
diltzac er 120 mg capsule, 180 mg capsule, -240 mg
capsule, -300 mg capsule
felodipine er
isradipine
matzim la
nicardipine 25 mg/10 ml vial
nicardipine hcl capsule
nifediac cc
nifedical xl
nifedipine er 30 mg tablet, 60 mg tablet, -90 mg tablet
nimodipine
nisoldipine
taztia xt
verapamil 2.5 mg/ml ampul
verapamil er
verapamil er pm
verapamil hcl tablet

Generic

Tier Requirements/Limits
1
[MO][MNT]
1

[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1
1
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

2
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

DIGITALIS GLYCOSIDES
digoxin 0.25 mg/ml ampul
digoxin solution, -tablet
LANOXIN TABLET [G]

digoxin

1
1
2

[MO][MNT]
[MO][MNT]

Page 35 of 139

Drug

Generic

DIRECT RENIN INHIBITORS/COMBINATIONS

Tier

Requirements/Limits

AMTURNIDE
TEKAMLO
TEKTURNA 150 MG TABLET

aliskiren/amlodipine/hctz
aliskiren/amlodipine
aliskiren hemifumarate

2
2
2

TEKTURNA 300 MG TABLET
TEKTURNA HCT
VALTURNA 150-160 MG
TABLET
VALTURNA 300-320 MG
TABLET

aliskiren hemifumarate
aliskiren/hydrochlorothiazid
aliskiren/valsartan

2
2
2

aliskiren/valsartan

2

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

DIURETICS
acetazolamide capsule
sustained action, -tablet
amiloride hcl tablet
amiloridehydrochlorothiazide
bumetanide injection
bumetanide tablet
chlorothiazide
chlorothiazide sodium
chlorthalidone
furosemide 10 mg/ml vial
furosemide solution, -tablet
hydrochlorothiazide capsule,
-tablet
indapamide
methazolamide tablet
methyclothiazide
metolazone
spironolactone-hctz
TORSEMIDE INJECTION

1
1
1
4
1
1
1
1

torsemide

torsemide tablet
triamterene-hctz
triamterenehydrochlorothiazid

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1
1
1
1
2
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2
1

[MO][MNT]

[MO][MNT]
[MO][MNT]
[MO][MNT]

MISCELLANEOUS
BIDIL

hydralazine hcl injection

isosorb dinit/hydralazine hcl

Page 36 of 139

Drug
hydralazine hcl tablet
methyldopa
methyldopahydrochlorothiazide
methyldopate hcl
midodrine hcl
minoxidil tablet
RANEXA

Generic

Tier Requirements/Limits
1
[MO][MNT]
1
[MO][MNT]
1
[MO][MNT]
1
1
1
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

nitroglycerin

1
2
1
1
1
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

nitroglycerin
nitroglycerin

1
1
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

4
4
4
4
4

[MO][MNT][PAN]
[MO][MNT][PAN]
[PAB]
[PAN]
[MNT][PAN]

1

[MO][PAB]

ranolazine

reserpine tablet

NITRATES
isochron
ISORDIL

isosorbide dinitrate

isosorbide dinitrate
isosorbide mononitrate
isosorbide mononitrate er
nitro-bid
NITRO-DUR 0.3 MG/HR
PATCH, -0.8 MG/HR PATCH

nitroglycerin injection
nitroglycerin patch
NITROLINGUAL
NITROSTAT

PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
LETAIRIS
REMODULIN
REVATIO TABLET
TRACLEER [LA]

adcirca (tadalafil)
ambrisentan
treprostinil sodium
revatio (sildenafil citrate)
bosentan

CARDIOVASCULAR MEDICATIONS

AMIODARONES

amiodarone 150 mg/3 ml
vial, -450 mg/9 ml vial, -900
mg/18 ml vial

BETA-ADRENERGIC ANTAGONIST DRUGS
labetalol hcl 20 mg/4 ml crpj

1
Page 37 of 139

Drug
metoprolol 1 mg/ml
carpuject, -tart 5 mg/5 ml
amp

Generic

Tier Requirements/Limits
1
[MO]

CALCIUM ANTAGONISTS
dilt xr 120 mg capsule
dilt-cd 180 mg capsule, -240
mg capsule
diltiazem 125 mg/25 ml vial,
-50 mg/10 ml vial
diltiazem 24hr cd 180 mg
cap, -360 mg cap
diltiazem 24hr er 180 mg
cap, -360 mg cap
diltiazem er 120 mg capsule,
-240 mg capsule, -hcl er 240
mg cap, -hcl er 300 mg cap
diltzac er 360 mg capsule
nicardipine 25 mg/10 ml
ampule
nifedipine er 90mg tablet
verapamil 2.5 mg/ml syringe,
-2.5 mg/ml vial
verapamil hcl capsule
sustained action

1
1

[MO][MNT]
[MO][MNT]

1

[MO]

1

[MO][MNT]

1

[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]
[MO]

1
1

[MO]

1

[MO][MNT]

1

[MO]

1

[MO][MNT]

1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

CARDIAC GLYCOSIDES
digoxin 0.25 mg/ml syringe

HMG-COA REDUCTASE INHIBITORS
amlodipine-atorvastatin

HYPOLIPOPROTEINEMICS
cholestyramine
cholestyramine light powder
colestipol hcl packet
prevalite packet

Page 38 of 139

Drug

Generic

LOOP DIURETICS
furosemide 10 mg/ml syringe

Tier

Requirements/Limits

1

[MO]

1

[MO][MNT]

1

[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1

[MO][MNT][QLL,
45/30]

NITRATES
isoditrate

OTHER ANTIARRHYTHMICS
sotalol af

OTHER ANTIHYPERTENSIVES
valsartan-hydrochlorothiazide

CENTRAL NERVOUS SYSTEM

ANTIANXIETY

buspirone hcl tablet
fluvoxamine maleate 100 mg
tab
fluvoxamine maleate 25 mg
tab, -50 mg tab
meprobamate

1

ANTICONVULSANTS
BANZEL

rufinamide

3
1

[MO][MNT][PAN]
[MO][MNT]

carbamazepine
methsuximide
phenytoin sodium

1
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

phenytoin

2

[MO][MNT]

phenytoin sodium

2
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

carbamazepine capsule
sustained action, -chew tab,
-oral susp, -tablet
carbamazepine xr
CARBATROL [G]
CELONTIN
DILANTIN 100 MG CAPSULE
[G]
DILANTIN 30 MG CAPSULE, CHEW TAB
DILANTIN-125 [G]

divalproex sodium
divalproex sodium er
epitol

Page 39 of 139

Drug
ethosuximide capsule, -syrup
felbamate
FELBATOL [G]

Generic

felbamate

fosphenytoin 100 mg pe/2
ml vl
fosphenytoin 500 mg pe/10
ml
gabapentin 100 mg capsule

Tier Requirements/Limits
1
[MO][MNT]
1
[MO][MNT]
3
[MO][MNT]
1
1

[MO]

1

gabapentin 300 mg capsule

1

gabapentin 400 mg capsule

1

gabapentin 600 mg tablet

1

gabapentin 800 mg tablet

1

gabapentin solution
tiagabine

1
3

[MO][MNT][QLL,
1080/30]
[MO][MNT][QLL,
360/30]
[MO][MNT][QLL,
270/30]
[MO][MNT][QLL,
180/30]
[MO][MNT][QLL,
120/30]
[MO][MNT]
[MO][MNT]

tiagabine

3

[MO][MNT]

1
1
1

[MO][MNT]

GABITRIL 12 MG TABLET, 12 MG TABLET, -16 MG
TABLET, -16 MG TABLET
GABITRIL 2 MG TABLET, -2
MG TABLET, -4 MG TABLET,
-4 MG TABLET [G]

lamotrigine
levetiracetam injection
levetiracetam solution, tablet, -tablet sustained
action

[MO][MNT]

LYRICA 25 MG CAPSULE, -50
MG CAPSULE, -75 MG
CAPSULE, -100 MG
CAPSULE, -150 MG
CAPSULE, -200 MG
CAPSULE, -225 MG CAPSULE
LYRICA 300 MG CAPSULE

pregabalin

2

[MO][MNT][QLL,
120/30]

pregabalin

2

NEURONTIN SOLUTION [G]

gabapentin

2

[MO][MNT][QLL,
60/30]
[MO][MNT][QLL,
2350/30]
[MO][MNT]
[MO][MNT]

oxcarbazepine
PEGANONE

ethotoin

phenytoin 50 mg/ml ampul
phenytoin oral susp
phenytoin sodium extended
POTIGA

ezogabine

1
2
1
1
1
3

[MO][MNT]
[MO][MNT]
[MO][MNT]
Page 40 of 139

Drug
primidone tablet
SABRIL
TEGRETOL XR 100 MG
TABLET

Generic

vigabatrin
carbamazepine

topiramate sprinkle, -tablet
valproate sodium injection
valproic acid capsule, -syrup
VIMPAT INJECTION
lacosamide
VIMPAT SOLUTION, -TABLET lacosamide

zonisamide

Tier Requirements/Limits
1
[MO][MNT]
4
[PAN]
2
[MO][MNT]
1
1
1
2
2
1

[MO][MNT]

2

[MO][MNT][QLL,
30/30]
[MO][MNT]

[MO][MNT]
[PAN]
[MO][MNT][PAN]
[MO][MNT]

ANTIDEMENTIA
ARICEPT 23 MG TABLET

donepezil hcl 10 mg tablet, odt 10 mg tablet
donepezil hcl 5 mg tablet, odt 5 mg tablet
EXELON 4.6 MG/24HR
PATCH, -9.5 MG/24HR
PATCH
EXELON SOLUTION

donepezil

1
1

rivastigmine tartrate

2

rivastigmine tartrate

2

[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
240/30]
[MO][MNT]

galantamine er 16 mg
capsule, -er 24 mg capsule, tablet
galantamine er 8 mg capsule

1

galantamine hydrobromide
memantine hcl

1
2

memantine hcl

2

[MO][MNT]

rivastigmine 1.5 mg capsule

1

rivastigmine 3 mg capsule

1

rivastigmine 4.5 mg capsule,
-6 mg capsule

1

[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
60/30]

NAMENDA 5-10 MG
TITRATION PK
NAMENDA SOLUTION, -5 MG
TABLET, -10 MG TABLET

1

[MO][MNT][QLL,
30/30]
[MO][MNT]

ANTIDEPRESSANTS
amitriptyline hcl tablet

1

[MO][MNT]
Page 41 of 139

Drug
AMOXAPINE

amoxapine

Generic

budeprion sr
budeprion xl
bupropion hcl sr
bupropion hcl tablet
citalopram hbr 10 mg tablet,
-20 mg tablet
citalopram hbr solution, -40
mg tablet
clomipramine hcl capsule
CYMBALTA 20 MG CAPSULE,
-30 MG CAPSULE
CYMBALTA 60 MG CAPSULE

desipramine hcl tablet
doxepin hcl capsule, solution
EMSAM

Tier
2
1
1
1
1
1
1

duloxetine

1
2

duloxetine

2
1
1

selegiline

2

escitalopram oxalate solution
escitalopram oxalate tablet

1
1

fluoxetine dr
fluoxetine hcl 10 mg capsule,
-20 mg capsule
fluoxetine hcl 10 mg tablet

1
1

fluoxetine hcl 40 mg capsule,
-solution, -20 mg tablet
imipramine hcl tablet
imipramine pamoate

1

1

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
45/30]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][PAN][QLL,
30/30]
[MO][MNT]
[MO][MNT][QLL,
45/30]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
45/30]
[MO][MNT]

LEXAPRO 5 MG TABLET, -10
MG TABLET, -10 MG TABLET
[G]
LEXAPRO SOLUTION, -20
MG TABLET, -20 MG TABLET
[G]

escitalopram oxalate

1
1
3

escitalopram oxalate

3

[MO][MNT]

MARPLAN

isocarboxazid

1
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT][QLL,
45/30]
[MO][MNT]
[MO][MNT]

maprotiline hcl

mirtazapine 30 mg odt, -30
mg tablet, -45 mg odt, -45
mg tablet
mirtazapine 7.5 mg tablet, 15 mg odt, -15 mg tablet
NARDIL [G]

nefazodone hcl

phenelzine

2
1

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
45/30]

Page 42 of 139

Drug
nortriptyline hcl capsule, solution
paroxetine cr 12.5 mg tablet,
-cr 37.5 mg tablet, -er 37.5
mg tablet
paroxetine hcl 10 mg tablet,
-20 mg tablet
paroxetine hcl oral susp, -30
mg tablet, -40 mg tablet, -cr
25 mg tablet
phenelzine sulfate tablet
PRISTIQ ER 100 MG TABLET
PRISTIQ ER 50 MG TABLET

Generic

selfemra
sertraline hcl 25 mg tablet, 50 mg tablet
sertraline hcl solution, -100
mg tablet
SURMONTIL 100 MG
CAPSULE [G]

[MO][MNT][QLL,
30/30]

1

[MO][MNT][QLL,
45/30]
[MO][MNT]

desvenlafaxine succinate
desvenlafaxine succinate

1
3
3

milnacipran hcl

1
1
2

milnacipran hcl

2
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]
[MO][MNT][QLL,
45/30]
[MO][MNT]

2

[MO][MNT]

1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

1
1

[MO][MNT][QLL,
30/30]
[MO][MNT]

vilazodone hydrochloride

2

[MO][MNT]

vilazodone hydrochloride

2

trimipramine

tranylcypromine sulfate
trazodone hcl tablet
trimipramine maleate
capsule
venlafaxine hcl
venlafaxine hcl er 150 mg
cap
venlafaxine hcl er 37.5 mg
cap, -75 mg cap
venlafaxine hcl er 37.5 mg
tab, -75 mg tab, -150 mg tab
[G]
VIIBRYD 10 MG TABLET, -20
MG TABLET, -40 MG TABLET
VIIBRYD TITRATION PACK

1

1

protriptyline hcl
rapiflux
SAVELLA 12.5 MG TABLET, 25 MG TABLET, -50 MG
TABLET, -100 MG TABLET
SAVELLA TITRATION PACK

Tier Requirements/Limits
1
[MO][MNT]

Page 43 of 139

Drug

Tier

Requirements/Limits

1
4
2
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
2
1
1
1
2
2
2
2
2
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

aripiprazole

3

aripiprazole
aripiprazole
aripiprazole

3
3
3

[MO][MNT][QLL,
30/30][ST]
[MO][MNT][ST]

chlorpromazine

2

iloperidone

1
1
3

[MO][MNT]
[MO][MNT]
[MO][MNT][ST]

3
3
1

[ST]
[MO][MNT][PAN]

ANTIPARKINSONIAN AGENTS

Generic

amantadine
apomorphine hcl
rasagiline mesylate

APOKYN
AZILECT

benztropine 2 mg/2 ml vial
benztropine mesylate tablet
bromocriptine mesylate
capsule, -tablet
carbidopa-levodopa
COMTAN [G]

entacapone

pramipexole dihydrochloride
ropinirole hcl
selegiline hcl capsule, -tablet
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO

100 [G]
125
150 [G]
200
50
75

carbidopa/levodopa/entacap
carbidopa/levodopa/entacap
carbidopa/levodopa/entacap
carbidopa/levodopa/entacap
carbidopa/levodopa/entacap
carbidopa/levodopa/entacap

trihexyphenidyl hcl

[MO][MNT]
[MO][MNT]

ANTIPSYCHOTICS
ABILIFY 5 MG TABLET, -10
MG TABLET, -15 MG TABLET
ABILIFY DISCMELT
ABILIFY INJECTION
ABILIFY SOLUTION, -2 MG
TABLET, -20 MG TABLET, 30 MG TABLET
CHLORPROMAZINE HCL
INJECTION

chlorpromazine hcl tablet
clozapine

FANAPT 1 MG TABLET, -2
MG TABLET, -4 MG TABLET,
-6 MG TABLET, -8 MG
TABLET, -10 MG TABLET, 12 MG TABLET
FANAPT TITRATION PACK
FAZACLO

fluphenazine decanoate
injection

iloperidone
clozapine

[MO][MNT][ST]

Page 44 of 139

Drug
fluphenazine hcl elix, -tablet
fluphenazine hcl injection, solution
GEODON 20 MG CAPSULE
[G]
GEODON 40 MG CAPSULE
[G]
GEODON 60 MG CAPSULE, 80 MG CAPSULE [G]
GEODON INJECTION

Generic

Tier Requirements/Limits
1
[MO][MNT]
1

ziprasidone

3

ziprasidone

3

ziprasidone

3

ziprasidone

3
1

haloperidol dec 50 mg/ml
vial, -dec 100 mg/ml vial
haloperidol lactate injection
haloperidol lactate solution
haloperidol tablet

[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
60/30]
[MO][MNT]

paliperidone

1
1
1
3

paliperidone

3

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30][ST]
[MO][MNT][ST]

paliperidone

4

[MO][MNT][PAN]

paliperidone

3

[MO][MNT][PAN]

lurasidone hcl

olanzapine odt

3
1
3
1

olanzapine tablet

1

olanzapine-fluoxetine hcl

risperidone

1
2
1
1
2

risperidone

4

[MO][MNT][ST]
[MO][MNT]
[PAB]
[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][PAN][QLL,
2/30]
[MO][MNT][PAN][QLL,
2/30]
[MO][MNT][QLL,
90/30]
[MO][MNT][QLL,
90/30]
[MO][MNT][QLL,
60/30]

INVEGA ER 1.5 MG TABLET,
-ER 3 MG TABLET
INVEGA ER 6 MG TABLET, ER 9 MG TABLET
INVEGA SUSTENNA 117 MG
PREF SY, -156 MG PREF SY,
-234 MG PREF SY
INVEGA SUSTENNA 39 MG
PREF SYR, -78 MG PREF SYR
LATUDA

loxapine
OLANZAPINE INJECTION

ORAP

olanzapine

pimozide

perphenazine
quetiapine fumarate
RISPERDAL CONSTA 12.5
MG SYR, -25 MG SYR
RISPERDAL CONSTA 37.5
MG SYR, -50 MG SYR

risperidone 0.25 mg odt, -0.5
mg odt
risperidone 0.25 mg tablet, 0.5 mg tablet
risperidone 1 mg odt, -2 mg
odt, -3 mg odt

1
1
1

Page 45 of 139

Drug
risperidone 1 mg tablet, -2
mg tablet, -3 mg tablet
risperidone 4 mg odt
risperidone solution, -4 mg
tablet
SAPHRIS
SEROQUEL 100 MG TABLET
[G]
SEROQUEL 200 MG TABLET
[G]
SEROQUEL 25 MG TABLET
[G]
SEROQUEL 300 MG TABLET,
-400 MG TABLET [G]
SEROQUEL 50 MG TABLET
[G]
SEROQUEL XR

Generic

asenapine
quetiapine fumarate

3
2

quetiapine fumarate

2

quetiapine fumarate

2

quetiapine fumarate

2

quetiapine fumarate

2

quetiapine fumarate

2
1
1
1
1

olanzapine

3

olanzapine

3

olanzapine
olanzapine

3
3

olanzapine

3

[MO][MNT][QLL,
30/30]

1
1
1

[MO][MNT][PA]
[MO][MNT]
[MO][MNT][PA]

1

[MO][MNT]

1

[MO][MNT][PA]

thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl
ZYPREXA 10 MG TABLET, 15 MG TABLET, -20 MG
TABLET [G]
ZYPREXA 2.5 MG TABLET, -5
MG TABLET, -7.5 MG
TABLET [G]
ZYPREXA INJECTION [G]
ZYPREXA ZYDIS 10 MG
TABLET, -15 MG TABLET, 20 MG TABLET [G]
ZYPREXA ZYDIS 5 MG
TABLET [G]

Tier Requirements/Limits
1
[MO][MNT][QLL,
60/30]
1
[MO][MNT]
1
[MO][MNT]
[MO][MNT][ST]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
960/30]
[MO][MNT][QLL,
60/30]
[MO][MNT][QLL,
480/30]
[MO][MNT]
[MO][MNT][PAN]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
60/30]
[MO][MNT]
[MO][MNT][QLL,
30/30]

[MO][MNT]

ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine salt combo
dexmethylphenidate hcl
dextroamphetamine sulfate
capsule sustained action, tablet
dextroamphetamineamphetamine
metadate er

Page 46 of 139

Drug
methamphetamine hcl
methylin 5 mg tablet, -10 mg
tablet, -20 mg tablet
methylin er
methylphenidate er capsule
sustained action
methylphenidate hcl solution
methylphenidate hcl tablet
methylphenidate sr
STRATTERA

Generic

atomoxetine

Tier Requirements/Limits
1
1
[MO][MNT][PA]
1
1

[MO][MNT]
[MO][MNT]

1
1
1
2

[MO][MNT]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT]

3
1
1
1

[QLL, 30/30]
[QLL, 30/30]

HYPNOTICS
LUNESTA

eszopiclone

zaleplon
zolpidem tartrate
zolpidem tartrate er

MIGRAINE
dihydroergotamine 1 mg/ml
am
dihydroergotamine 1 mg/ml
vl
ergoloid mesylates tablet
ergotamine-caffeine
MAXALT
MAXALT MLT
MIGERGOT

1

rizatriptan benzoate
rizatriptan benzoate
ergotamine tartrate/caffeine

naratriptan hcl
sumatriptan 4 mg/0.5 ml vial
sumatriptan 6 mg/0.5 ml
inject
sumatriptan 6 mg/0.5 ml vial
sumatriptan succinate tablet

1

[MO]

1
1
2
2
2
1
1
1

[MO][MNT]

1
1

[QLL, 10 vials/30]
[QLL, 9/30]

2
2
1

[MO][MNT]
[MO][MNT]

[QLL, 12/30]
[QLL, 12/30]

[QLL, 10/30]
[MO][QLL, 10/30]

MISCELLANEOUS
GUANIDINE HCL
LITHIUM

lithium carbonate capsule, tablet, -tablet sustained
action

guanidine
lithium citrate

Page 47 of 139

Drug
MESTINON SYRUP, -TABLET
SUSTAINED ACTION
NUEDEXTA

pyridostigmine bromide
tablet
REGONOL
RILUTEK
XENAZINE

Generic
pyridostigmine

Tier Requirements/Limits
2
[MO][MNT]

dextromethorphan/quinidine

3
1

[PA]
[MO][MNT]

pyridostigmine
riluzole
tetrabenazine

2
4
4

[MO][MNT]
[MO][MNT][PA]

MULTIPLE SCLEROSIS AGENTS
AMPYRA
AVONEX

dalfampridine
interferon beta-1a

4
4

AVONEX ADMINISTRATION
PACK
COPAXONE

interferon beta-1a

4

glatiramer acetate

4

EXTAVIA

interferon beta-1b

4

GILENYA
REBIF 22 MCG/0.5 ML
SYRINGE, -44 MCG/0.5 ML
SYRINGE
REBIF TITRATION PACK

fingolimod hydrochloride
interferon beta-1a/albumin

4
4

interferon beta-1a/albumin

4

[MO][MNT][PAN][QLL,
6 syringes/28]

1
1
1
1

[MO][MNT]
[PA][QLL, 120/30]
[PA]
[MO][PA]

1

[PA]

1
1
1
1

[MO][MNT]
[PA]
[PA]

[MO][MNT][PA]
[MO][MNT][PAN][QLL,
2 kits/28]
[MO][MNT][PAN][QLL,
2 kits/28]
[MO][MNT][PAN][QLL,
30 ml/30]
[MO][MNT][PAN][QLL,
14 trays/28]
[MO][MNT][PAN]
[MO][MNT][PAN][QLL,
6 ml/28]

MUSCULOSKELETAL THERAPY AGENTS
baclofen tablet
carisoprodol 350 mg tablet
chlorzoxazone
cyclobenzaprine 7.5 mg
tablet
cyclobenzaprine hcl capsule
sustained action, -5 mg
tablet, -5 mg tablet, -10 mg
tablet
dantrolene sodium capsule
metaxalone
methocarbamol tablet
orphenadrine 30 mg/ml vial,
-60 mg/2 ml vial

Page 48 of 139

Drug
orphenadrine citrate tablet
sustained action
orphenadrine compound
orphenadrine compound
forte
ROBAXIN INJECTION

Generic

methocarbamol

tizanidine hcl capsule, -tablet

Tier Requirements/Limits
1
[PA]
1
1

[PA]
[PA]

2
1

[MO][MNT]

1
2
3
4

[MO][MNT]
[MO][MNT][PA]
[MO][MNT]
[PA]

2
1
1
2
3
1
1
1

[MO][MNT]

NARCOLEPSY/CATAPLEXY
modafinil
NUVIGIL
PROVIGIL [G]
XYREM [LA]

armodafinil
modafinil
sodium oxybate

PSYCHOTHERAPEUTIC-MISCELLANEOUS
ANTABUSE [G]

disulfiram

buprenorphine hcl tab, sl
buproban
CAMPRAL
CHANTIX

acamprosate calcium
varenicline tartrate

depade
disulfiram tablet
naloxone 0.4 mg/ml syringe,
-1 mg/ml syringe, -2 mg/2
ml syringe
naltrexone hcl tablet
NICOTROL
NICOTROL NS

nicotine inhaler
nicotine ns

perphenazine-amitriptyline
SUBOXONE ORALLY
DISSOLVING STRIPS

buprenorphine/naloxone

1
3
3
1
2

[PA]
[PA]
[MO][MNT]

[PA]
[PA]
[MO][MNT]

DERMATOLOGICAL MEDICATIONS

ANTIACNE DRUGS

clinda-benzoyl perox 1-5%
gel
clindacin p
clindamycin phos-benzoyl
perox
erythromycin swabs,
applicators

1
1
1

[MO]

1

[MO]
Page 49 of 139

vitazol

Drug

Generic

Tier Requirements/Limits
1
[MO]

ORAL DERMATOLOGICAL DRUGS
myorisan

1

TOPICAL CORTICOSTEROID DRUGS
betamethasone dipropionate
gel
clobetasol propionate cream
cormax
desoximetasone 0.05%
ointment
fluocinonide cream
trianex

1
1
1
1
1
1

[MO]

[MO]

TOPICAL DERMATOLOGICAL DRUGS
urea 40% cream, -45%
cream, -40% gel, -40%
lotion
ZYCLARA 2.5% CREAM
PUMP

1

imiquimod

2

EAR-NOSE-THROAT MEDICATIONS

DRUGS AFFECTING THE NOSE
flunisolide 29 mcg-0.025%
spr

1

[MO][MNT]

[PA]
[MO][MNT][PA][QLL,
30/30]
[MO][MNT]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA][QLL,
300/30]

ENDOCRINE AND METABOLIC

ANDROGENS

ANADROL-50
ANDRODERM

oxymetholone
testosterone

4
2

ANDROGEL
ANDROXY

testosterone
fluoxymesterone

3
2
4
1
3

oxandrolone 10 mg tablet
oxandrolone 2.5 mg tablet
TESTIM

testosterone

Page 50 of 139

Drug
testosterone cyp 100 mg/ml
testosterone cyp 200 mg/ml
testosterone enanthate
injection

Generic

Tier Requirements/Limits
1
1
[MO]
1

ANTIDIABETICS, INJECTABLE
AIMSCO INS SYR 1 ML
29GX1/2, -AIMSCO SYRING
0.3 ML 31GX5/16, -BD
INSULIN SYR 0.5 ML
30GX1/2, -BD INSULIN SYR
1 ML 31GX5/16, -FIFTY50
INS SYR 1 ML 31GX5/16, FIFTY50 INSULIN SYRINGE
0.3 ML, -INS SYR 0.5 ML
30GX5/16, -INS SYR 1 ML
29GX1/2, -INS SYR 1 ML
31GX5/16, -INS SYRIN 1 ML
29GX1/2, -INSUL SYR 0.3 ML
31GX5/16, -INSUL SYR 0.5
ML 30GX1/2, -1 ML
SYRINGE, -SYR 1 ML
29GX1/2, -SYR 1 ML
31GX5/16, -SYRIN 0.3 ML
31GX5/16, -SYRIN 0.5 ML
30GX1/2, -SYRIN 0.5 ML
30GX5/16, -SYRIN 1 ML
29GX1/2, -0.5 ML, -1 ML, -1
ML 29GX1/2, -1 ML
31GX5/16, -KINRAY INS SYR
1 ML 31GX5/16, -KINRAY
SYRING 0.3 ML 31GX5/16, PREF PLUS SYRING 1 ML
29GX1/2, -RELI-ON INSULIN
1 ML SYR, -RELION INS SYR
1 ML 29GX1/2, -RELION INS
SYR 1 ML 31GX5/16, RELION SYRING 0.3 ML
31GX5/16, -SURE-JECT
INSULIN SYR 0.3 ML, SYRING 0.3 ML 31GX5/16, SYRINGE 1/2 ML, -U100 INS
SYR 1 ML 29GX1/2, ULTCARE INS SYR 1 ML
31GX5/16, -ULTICARE INS

2

[MO][MNT]

Page 51 of 139

Drug
SYR 1 ML 29GX1/2, ULTICARE SYR 0.3 ML
31GX5/16, -VH INS SYR 1
ML 29GX1/2, -WD MEDIC
SYR 1 ML 29GX1/2
ALCOHOL SWABS
APIDRA
APIDRA SOLOSTAR
BYETTA 10 MCG DOSE PEN
INJ
BYETTA 5 MCG DOSE PEN
INJ
HUMALOG 100 UNITS/ML
KWIKPEN, -100 UNITS/ML
VIAL
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN 70-30 PEN, -VIAL,
-RELION HUMULIN 70-30
VIAL
HUMULIN N 100 UNITS/ML
PEN, -100 UNITS/ML VIAL, RELION HUMULIN N 100
UNIT/ML
HUMULIN R 100 UNITS/ML
VIAL, -RELION HUMULIN R
100 UNIT/ML, -500
UNITS/ML VIAL
INSULIN SYRINGE 0.5 ML, INSULIN SYRINGE 1 ML
LANTUS
LANTUS SOLOSTAR
LEVEMIR
NOVOLIN 70-30 INJECTION,
-VIAL
NOVOLIN N
NOVOLIN R INJECTION
NOVOLOG 100 UNIT/ML
VIAL, -FLEXPEN SYRINGE
NOVOLOG MIX 70-30
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
VICTOZA 3-PAK

Generic

Tier

exenatide

2
2
2
2

exenatide

2

pramlintide acetate
pramlintide acetate
pramlintide acetate
liraglutide

Requirements/Limits

2

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL, 2.4
ml/30]
[MO][MNT][QLL, 1.2
ml/30]
[MO][MNT]

2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

2
2
2
2
2

[MO][MNT]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT]
Page 52 of 139

Drug

ANTIDIABETICS, ORAL

Generic

acarbose

Tier

Requirements/Limits

[MO][MNT]
[MO][MNT][QLL,
90/30]
[MO][MNT]
[MO][MNT][QLL,
90/30]
[MO][MNT][QLL,
45/30]
[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
30/30]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
60/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
60/30]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
60/30]
[MO][MNT][QLL,
120/30]
[MO][MNT]
[MO][MNT][QLL,
480/30]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]
[MO][MNT][QLL,
240/30]
[MO][MNT][QLL,
120/30]

ACTOPLUS MET [G]

pioglitazone hcl/metformin hc

1
2

ACTOPLUS MET XR
ACTOS 15 MG TABLET [G]

pioglitazone hcl/metformin hc
pioglitazone hcl

2
2

ACTOS 30 MG TABLET [G]

pioglitazone hcl

2

ACTOS 45 MG TABLET [G]

pioglitazone hcl

2

DUETACT

pioglitazone/glimepiride

2

glimepiride 1 mg tablet

1

glimepiride 2 mg tablet

1

glimepiride 4 mg tablet

1

glipizide 10 mg tablet

1

glipizide 5 mg tablet

1

glipizide er 10 mg tablet

1

glipizide er 2.5 mg tablet

1

glipizide er 5 mg tablet

1

glipizide xl 10 mg tablet

1

glipizide xl 5 mg tablet

1

glipizide-metformin
glyburide 1.25 mg tablet

1
1

glyburide 2.5 mg tablet

1

glyburide 5 mg tablet

1

glyburide micro 1.5 mg tab

1

glyburide micro 3 mg tablet

1

Page 53 of 139

Drug
glyburide micro 6 mg tablet

Generic

glyburide-metformin hcl
glycron 1.5 mg tablet
glycron 3 mg tablet
glycron 4.5 mg tablet
glycron 6 mg tablet
JANUMET
JANUMET XR

sitagliptin phos/metformin hcl
sitagliptin phos/metformin hcl

JANUVIA 100 MG TABLET
JANUVIA 25 MG TABLET, -50
MG TABLET
KOMBIGLYZE XR

sitagliptin phosphate
sitagliptin phosphate
saxagliptin hcl/metformin hcl

metformin hcl 500 mg tablet
metformin hcl 850 mg tablet,
-1,000 mg tablet
metformin hcl er 500 mg tab
metformin hcl er 750 mg
tablet
nateglinide
ONGLYZA 2.5 MG TABLET

saxagliptin hydrochloride

ONGLYZA 5 MG TABLET

saxagliptin hydrochloride

pioglitazone-metformin
PRANDIN

repaglinide

tolazamide
tolbutamide

Tier Requirements/Limits
1
[MO][MNT][QLL,
60/30]
1
[MO][MNT]
1
[MO][MNT][QLL,
240/30]
1
[MO][MNT][QLL,
120/30]
1
[MO][MNT]
1
[MO][MNT][QLL,
60/30]
2
[MO][MNT]
2
[MO][MNT][QLL,
68/30]
2
[MO][MNT]
2
[MO][MNT][QLL,
30/30]
2
[MO][MNT]
1
[MO][MNT][QLL,
150/30]
1
[MO][MNT][QLL,
90/30]
1
[MO][MNT][QLL,
120/30]
1
[MO][MNT][QLL,
90/30]
1
[MO][MNT]
2
[MO][MNT][QLL,
30/30]
2
[MO][MNT]
1
[MO][MNT][QLL,
90/30]
2
[MO][MNT]
1
[MO][MNT]
1
[MO][MNT]

BISPHOSPHONATES
ACTONEL 30 MG TABLET
ACTONEL 5 MG TABLET, -35
MG TABLET, -150 MG
TABLET

alendronate sodium 35 mg
tab, -70 mg tab

risedronate
risedronate

2
2
1

[MO][MNT]
[MO][MNT][QLL,
4/30]

Page 54 of 139

Drug
alendronate sodium 5 mg
tablet, -10 mg tab, -40 mg
tab
etidronate disodium
ibandronate sodium
pamidronate 30 mg/10 ml
vial, -60 mg/10 ml vial, -90
mg/10 ml vial
PROLIA
RECLAST
ZOMETA 4 MG/100 ML
INJECTION
ZOMETA 4 MG/5 ML VIAL

Generic

Tier Requirements/Limits
1
[MO][MNT]
1
1
1

[MO][MNT]
[MNT][QLL, 1/30]

denosumab
zoledronic acid
zoledronic acid

3
3
4

[MO][MNT]
[MO][MNT]
[MO][MNT][PAB]

zoledronic acid

4

[PAB]

calcitonin

1
1
2

[MO][MNT]
[MO][MNT]
[PAB]

cinacalcet hcl
cinacalcet hcl

2
4

[MO][MNT]
[MO][MNT]

deferasirox
deferasirox

2
4

[MO][MNT][PA]
[MO][MNT][PA]

trientine

1
1
2

CALCITONINS
calcitonin-salmon
fortical
MIACALCIN INJECTION

CALCIUM RECEPTOR ANTAGONISTS
SENSIPAR 30 MG TABLET
SENSIPAR 60 MG TABLET, 90 MG TABLET

CHELATING AGENTS
EXJADE 125 MG TABLET
EXJADE 250 MG TABLET, 500 MG TABLET

kionex powder
sodium polystyrene sulfonate
SYPRINE

CONTRACEPTIVES
amethia
amethyst
apri
aranelle
aviane
balziva

1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
Page 55 of 139

Drug
briellyn
camila
cesia
cryselle
cyclafem
emoquette
enpresse
errin
gianvi
introvale
jinteli
jolivette
junel
junel fe
kariva
kelnor 1-35
leena
lessina
levora-28
low-ogestrel
lutera
marlissa
medroxyprogesterone
acetate injection
microgestin
microgestin fe
mononessa
necon 0.5-35-28 tablet, 1/35-28 tablet, -7-7-7-28
tablet
NECON 10-11-28 TABLET

Generic

1
1
1
1

norethindrone-ethin estradiol

next choice
nora-be
nortrel
NUVARING

etonogestrel/ethin estradiol

ocella
ogestrel
orsythia
ORTHO EVRA
ORTHO TRI-CYCLEN LO

portia
previfem
quasense

Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

ethinyl estradiol/norelgest
norgestimate-ethinyl estradiol

2
1
1
1
2
1
1
1
2
2
1
1
1

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
1/90]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
Page 56 of 139

reclipsen
solia
sprintec
sronyx
tri-legest fe
trinessa
tri-previfem
tri-sprintec
trivora-28
velivet
vestura
zeosa
zovia 1-35e
zovia 1-50e

Drug

Generic

Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

ENDOMETRIOSIS
danazol capsule
SYNAREL

nafarelin

1
2

ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CEREZYME 200 UNITS VIAL
CYSTADANE
CYSTAGON
ELAPRASE

pegademase bovine
laronidase
sodium phenylbutyrate
imiglucerase
betaine hcl
cysteamine
idursulfase

[PA]
[PA]

alglucosidase alfa
galsulfase
nitisinone
velaglucerase alfa
miglustat

4
4
4
4
4
2
4
1
4
4
1
1
4
4
4
4
4

estradiol/noreth ac

2

[MO][MNT]

eliphos
FABRAZYME 35 MG VIAL
KUVAN

agalsidase
sapropterin dihydrochloride

levocarnitine injection
levocarnitine solution, -tablet
MYOZYME
NAGLAZYME
ORFADIN
VPRIV
ZAVESCA

[MO][MNT][PA]
[MO][MNT]
[MO][MNT][PA]
[MO][MNT]
[PA]
[MO][MNT][PA]
[MO][MNT][PAB]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]

ESTROGENS
COMBIPATCH

Page 57 of 139

Drug
ESTRACE
ESTRADERM

Tier
3
2
1
1
1

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]

[MO][MNT][PA]
[MO][MNT]
[MO][MNT][PA]

estrogens,conjugated
estrogens,conjugated
estrogens,conjugated

1
3
1
3
2
3

estrogen/medroxyprogesterone
estradiol
estradiol

3
3
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

estradiol
estradiol

Generic

estradiol adh. patch, -tablet
estradiol valerate injection
estradiol-noreth 1-0.5 mg
tab
estropipate
MENEST

estrogens,esterified

ortho-est
PREMARIN INJECTION
PREMARIN TABLET
PREMARIN VAGINAL
PRODUCTS
PREMPRO
VAGIFEM
VIVELLE-DOT

[MO][MNT]

[MO][MNT]
[MO][MNT]

GLUCOCORTICOIDS
a-hydrocort
a-methapred 40 mg univial, 125 mg vial
a-methapred 40 mg vial
cortisone acetate tablet
dexamethasone 0.5 mg/5 ml
elx, -tablet
dexamethasone 120 mg/30
ml vl, -20 mg/5 ml vial, -4
mg/ml vial
DEXAMETHASONE
INTENSOL

fludrocortisone acetate tablet
hydrocortisone tablet
methylprednisolone 40 mg
vial, -125 mg vial, -ss 1 gm
vl
methylprednisolone acetate
injection
methylprednisolone tab(in
convenience package), tablet
prednisolone 15 mg/5 ml
soln

1
1
1
1
1

[MO]

1

dexamethasone

2
1
1
1

[MO][MNT]
[MO][MNT]

1
1
1

Page 58 of 139

Drug
prednisolone 5 mg/5 ml soln,
-6.7 mg/5 ml soln, -15 mg/5
ml soln
PREDNISONE INTENSOL

prednisone solution, -tab(in
convenience package), tablet
RAYOS
SOLU-CORTEF 100 MG VIAL
[G]
SOLU-CORTEF 250 MG VIAL

Generic

Tier
1

prednisone

2
1

prednisone
hydrocortisone sod succinate

3
2

hydrocortisone sod succinate

2
1

veripred 20

Requirements/Limits

[PA]

GLUCOSE ELEVATING AGENTS
GLUCAGEN 1 MG HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM

glucagon, human recombinant
glucagon, human recombinant
diazoxide

2
2
2

[MO][MNT]

4
4

[MO][MNT][PA]
[MO][MNT][PA]

1
1

[MO][MNT]
[PA]

1
4
1

[PA]

1
2

[PA]
[MO][MNT][PA]

4

[MO][MNT][PA]

1
4
4
4

[PA]
[MO][MNT][PA]
[MO][MNT][PA]
[MO][MNT][PA]

HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX

somatropin
somatropin

MISCELLANEOUS
cabergoline
chorionic gonadotropin
injection
fomepizole
INCRELEX

mecasermin

methylergonovine maleate
tablet
novarel
octreotide acet 50 mcg/ml
amp, -acet 100 mcg/ml amp,
-acet 200 mcg/ml vl
octreotide acet 500 mcg/ml
amp, -1,000 mcg/ml vial
pregnyl [G]
SANDOSTATIN LAR
SOMATULINE DEPOT
SOMAVERT

octreotide
lanreotide acetate
pegvisomant

Page 59 of 139

Drug

Generic

PARATHYROID HORMONES
FORTEO

teriparatide

Tier

Requirements/Limits

4

[MO][MNT]

1

[MO][MNT]

2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1
1
3

[MO][MNT]
[MO][MNT]
[MO][MNT]

2

[MO][MNT]

1
1
1
1
1
1
1
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

PHOSPHATE BINDER AGENTS
calcium acetate capsule, tablet
FOSRENOL
PHOSLO [G]
RENAGEL
RENVELA

lanthanum carbonate
calcium acetate
sevelamer
sevelamer carbonate

PROGESTINS
medroxyprogesterone
acetate tablet
norethindrone acetate tablet
progesterone capsule
PROMETRIUM [G]

progesterone

SELECTIVE ESTROGEN RECEPTOR MODULATORS
EVISTA

raloxifene

THYROID AGENTS
levothroid
levothyroxine sodium tablet
levoxyl
liothyronine sodium injection
liothyronine sodium tablet
methimazole tablet
propylthiouracil tablet
SYNTHROID [G]

unithroid 25 mcg tablet, -50
mcg tablet, -75 mcg tablet, 88 mcg tablet, -100 mcg
tablet, -112 mcg tablet, -125
mcg tablet, -150 mcg tablet,
-175 mcg tablet, -200 mcg
tablet, -300 mcg tablet

levothyroxine

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

Page 60 of 139

Drug

Generic

VASOPRESSINS

desmopressin 0.01%
solution, -0.01% spray, tablet
desmopressin ac 4 mcg/ml vl

Tier

Requirements/Limits

1

[MO][MNT]

1

ENDOCRINE MEDICATIONS

GLUCOCORTICOID DRUGS
baycadron
dexamethasone 0.5 mg/5 ml
liq
dexamethasone 10 mg/ml
vial, -100 mg/10 ml vl
methylprednisolone 500 mg
vial

1
1

[MO]

1

[MO]

1

[MO]

GLUCOSE ELEVATING DRUGS
glucagon, human recombinant

2

liraglutide

2

[MO][MNT]

2

[MO][MNT]

2
2

[MO][MNT]
[MO][MNT]

glipizide xl 2.5 mg tablet

1

metformin hcl er 1,000 mg
tab
metformin hcl er 500 mg
tablet
pioglitazone
pioglitazone hcl

1

[MO][MNT][QLL,
240/30]
[MO][MNT]

GLUCAGEN 1 MG VIAL

HYPOGLYCEMIC DRUGS
VICTOZA 2-PAK

INSULIN
HUMALOG 100 UNITS/ML
CARTRIDGE
NOVOLIN R VIAL
NOVOLOG 100 UNIT/ML
CARTRIDGE

ORAL HYPOGLYCEMICS AND COMBOS

1
1
1

[MO][MNT][QLL,
120/30]
[MO][MNT]
[MO][MNT]
Page 61 of 139

Drug

Generic

Tier

Requirements/Limits

4
1

[MO][MNT][PA]
[MO][MNT]

1

[MO]

1

[MO]

1

[MO][MNT]

1
4
2

[PAB][QLL, 60/30]
[PAB][QLL, 60/30]

OTHER ENDOCRINE DRUGS
CEREZYME 400 UNITS VIAL

imiglucerase

desmopressin 0.1 mg/ml
spray
desmopressin ac 4 mcg/ml
amp
pamidronate disod 30 mg
vial, -disod 90 mg vial

THYROID SUPPLEMENTS
unithroid 137 mcg tablet

GASTROINTESTINAL

ANTIEMETICS

compro
dronabinol 10 mg capsule
dronabinol 2.5 mg capsule, 5 mg capsule
EMEND 125 MG CAPSULE
EMEND 40 MG CAPSULE
EMEND TRIFOLD PACK, -80
MG CAPSULE

granisetron hcl 0.1 mg/ml
vial, -4 mg/4 ml vial, -tablet
granisetron hcl 1 mg/ml vial
granisol
meclizine hcl tablet
metoclopramide 5 mg/ml
vial, -syrup, -tablet
ondansetron hcl 4 mg/2 ml
vial, -solution, -tablet
ondansetron odt
phenadoz
prochlorperazine edisylate
injection
prochlorperazine maleate
rectal, -tablet
promethazine 25 mg/ml
syringe, -50 mg/ml vial

aprepitant
aprepitant
aprepitant

2
2
2

[PAB][QLL, 2/30]

1

[PAB]

1
1
1
1

[MO][PAB]

1

[PAB]

1
1
1

[PAB]
[PA]

[PAB][QLL, 4/30]

1
1

Page 62 of 139

Drug
promethazine hcl rectal, syrup, -tablet
promethegan 25 mg supp, 50 mg suppository
SANCUSO
TRANSDERM-SCOP

Generic

granisetron
scopolamine

trimethobenzamide hcl
capsule, -100 mg/ml

Tier Requirements/Limits
1
[PA]
1

[PA]

2
2
1

[PA][QLL, 2/15]
[PA][QLL, 24/365]
[PA]

1

[PA]

ANTISPASMODICS
dicyclomine hcl capsule, syrup, -tablet
dicyclomine hcl injection
glycopyrrolate injection, tablet
methscopolamine bromide
tablet

1
1
1

H2-RECEPTOR ANTAGONISTS
cimetidine injection
cimetidine solution, -tablet
famotidine 20 mg/2 ml vial, 20 mg piggyback
famotidine oral susp, -20 mg
tablet, -40 mg tablet
nizatidine
ranitidine hcl 25 mg/ml vial
ranitidine hcl capsule, -syrup,
-150 mg tablet, -300 mg
tablet

1
1
1

[MO][MNT]

1

[MO][MNT]

1
1
1

[MO][MNT]

2
3
3
1
4
2
4

[MO][MNT]
[MO][MNT]
[MO][MNT]

[MO][MNT]

INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL
ASACOL HD

mesalamine
mesalamine
mesalamine

balsalazide disodium
budesonide ec
CANASA
CIMZIA 200 MG VIAL KIT, 200 MG/ML SYRINGE KIT

colocort

mesalamine
certolizumab pegol

[MO]
[MO][MNT]
[MO][MNT][PA]

1
Page 63 of 139

Drug
ENTOCORT EC [G]

budesonide

Generic

hydrocortisone rectal
LIALDA

mesalamine

mesalamine rectal
PENTASA

mesalamine

sulfasalazine tablet
sulfazine ec

Tier
4
1
2
1
2
1
1

Requirements/Limits

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

LAXATIVES
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n
lactulose
MOVIPREP

polyethylene glycol 3350
packet
RELISTOR 12 MG/0.6 ML
VIAL

electrolyte solution/peg's
methylnaltrexone bromide

trilyte with flavor packets

1
1
1
1
1
1
2
1

[MO][MNT]
[MO][MNT]

[MO][MNT]

2
1

MISCELLANEOUS
AMITIZA

lubiprostone

2

CARAFATE ORAL SUSP

sucralfate

rifaximin

2
1
4
1
2
1
1
1
4

amylase/lipase/protease
amylase/lipase/protease
amylase/lipase/protease

3
2
2

diphenoxylate-atropine
GASTROCROM [G]

cromolyn

loperamide 2 mg capsule
LOTRONEX

alosetron

misoprostol
sucralfate tablet
ursodiol capsule, -tablet
XIFAXAN 550 MG TABLET

[MO][MNT][QLL,
60/30][ST]
[MO][MNT]
[PA]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

PANCREATIC ENZYMES
CREON
PANCREAZE
ZENPEP

[MO][MNT][ST]
[MO][MNT]
[MO][MNT]
Page 64 of 139

Drug

Generic

Tier

Requirements/Limits

lansoprazole/amox tr/clarith

2

[QLL, 14/365]

dexlansoprazole

2
1

[MO][MNT]
[MO][MNT]

esomeprazole mag trihyd

2

[MO][MNT]

esomeprazole mag trihyd

2
1

[MO][MNT]

1

[MO][MNT]

1

[MO][MNT]

1

[MO]

1

[MO]

1

[MO]

1

[MO][MNT]

1
1
1

[MO][MNT]
[MO]
[MO]

PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS
PREVPAC

PROTON PUMP INHIBITORS
DEXILANT

lansoprazole dr 15 mg
capsule, -dr 15 mg capsule, dr 30 mg capsule, -tablet
NEXIUM CAPSULE
SUSTAINED ACTION, -DR 10
MG PACKET, -DR 20 MG
PACKET, -DR 40 MG PACKET
NEXIUM I.V.

omeprazole capsule
sustained action
omeprazole-sodium
bicarbonate
pantoprazole sodium

GASTROINTESTINAL MEDICATIONS

ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
metoclopramide 5 mg/ml
ampul, -5 mg/ml syr

ANTIULCER DRUGS
famotidine 10 mg/ml vial, 200 mg/20 ml vial, -40 mg/4
ml vial, -500 mg/50 ml vial
ranitidine 1,000 mg/40 ml
vial

OTHER ANTIULCER DRUGS
sucralfate oral susp

OTHER GI DRUGS
mesalamine kit
peg 3350-electrolyte
peg-3350 and electrolytes

Page 65 of 139

Drug
peg-3350 with flavor packs
RELISTOR 12 MG/0.6 ML KIT
RELISTOR 8 MG/0.4 ML
SYRINGE, -12 MG/0.6 ML
SYRINGE

Generic

methylnaltrexone bromide
methylnaltrexone bromide

sulfasalazine dr
sulfazine

Tier Requirements/Limits
1
[MO]
4
2
1
1

[MO][MNT]
[MO][MNT]

2

[MO][MNT]

1
3
1
1
2

[MO][MNT]
[MO][MNT][PA]
[MO][MNT]
[MO][MNT]
[MO][MNT][ST]

PROTON PUMP INHIBITORS
NEXIUM DR 2.5 MG PACKET,
-DR 5 MG PACKET

esomeprazole mag trihyd

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
CIALIS

tadalafil

finasteride tablet
tamsulosin hcl
UROXATRAL [G]

alfuzosin hcl

MISCELLANEOUS
bethanechol chloride tablet
ELMIRON

pentosan polysulfate sodium

neomy-polymyxin b 40
mg/ml amp
potassium citrate tablet
sustained action

1
3
1
1

[MO][MNT]

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]
[MO][MNT]
[MO][MNT]

URINARY ANTISPASMODICS
AVODART
DETROL [G]
DETROL LA 2 MG CAPSULE

dutasteride
tolterodine tartrate
tolterodine tartrate

2
2
2

DETROL LA 4 MG CAPSULE
ENABLEX 15 MG TABLET
ENABLEX 7.5 MG TABLET

tolterodine tartrate
darifenacin hydrobromide
darifenacin hydrobromide

2
2
2

oxybutynin

1
2

flavoxate hcl
GELNIQUE PACKET

Page 66 of 139

Drug
oxybutynin chloride er
oxybutynin chloride syrup, tablet
TOVIAZ

Generic

fesoterodine fumarate
solifenacin succinate
solifenacin succinate

2
1
2
2

clindamycin phosphate

2

trospium chloride tablet
VESICARE 10 MG TABLET
VESICARE 5 MG TABLET

Tier Requirements/Limits
1
[MO][MNT]
1
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
30/30]

VAGINAL ANTI-INFECTIVES
CLEOCIN 100 MG VAGINAL
OVULE

clindamycin phosphate
vaginal products
metronidazole vaginal
products
miconazole 3 200 mg vag
supp
terconazole
vandazole
zazole

1
1
1
1
1
1

HEMATOLOGIC

ANTICOAGULANTS
ARIXTRA 2.5 MG SYRINGE
[G]
ARIXTRA 5 MG SYRINGE, 7.5 MG SYRINGE, -10 MG
SYRINGE [G]
COUMADIN TABLET [G]

enoxaparin 30 mg/0.3 ml
syr, -40 mg/0.4 ml syr, -60
mg/0.6 ml syr, -80 mg/0.8
ml syr, -100 mg/ml syr, -120
mg/0.8 ml syr, -150 mg/ml
syr
fondaparinux 2.5 mg/0.5 ml
syr, -5 mg/0.4 ml syr
FONDAPARINUX 7.5 MG/0.6
ML SYR, -10 MG/0.8 ML SYR

fondaparinux sodium

2

[QLL, 30/180]

fondaparinux sodium

4

[QLL, 30/180]

warfarin sodium

2
1

[MO][MNT]
[QLL, 60/180]

1

[MO][QLL, 30/180]

4

[MO][QLL, 30/180]

fondaparinux sodium

Page 67 of 139

Drug
FRAGMIN 2,500 UNITS
SYRINGE, -5,000 UNITS
SYRINGE, -25,000 UNITS/ML
VIAL
FRAGMIN 7,500 UNITS
SYRINGE, -10,000 UNITS
SYRINGE, -12,500 UNITS
SYRINGE, -15,000 UNITS
SYRINGE, -18,000 UNITS
SYRINGE

heparin sod 1,000 unit/ml
vial, -sod 5,000 unit/ml vial,
-sod 10,000 unit/ml vl, -sod
20,000 unit/ml vl
HEPARIN SOD 2,000
UNIT/ML VIAL

heparin-1/2ns 25,000
unit/250
HEPARIN-1/2NS 25,000
UNIT/500

Generic
dalteparin (porcine)

Tier Requirements/Limits
2
[QLL, 30/180]

dalteparin (porcine)

4

[QLL, 30/180]

1

[PAB]

2

[PAB]

1

[PAB]

2

[PAB]

1

[PAB]

1

[PAB]

1
2
1
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

sargramostim
plerixafor
oprelvekin
filgrastim

4
4
3
4

[PA]
[PA]
[PAB]
[PA]

epoetin alfa

2

[MO][MNT][PA][QLL,
12/30]

heparin sodium

heparin sodium(porcine)/nacl

heparin-d5w 20,000 unit/500
ml
heparin-ns 2,000 unit/1,000
ml
jantoven
PRADAXA

dabigatran etexilate mesylate

warfarin sodium tablet
XARELTO 10 MG TABLET
XARELTO 15 MG TABLET, 20 MG TABLET

rivaroxaban
rivaroxaban

[MO][MNT]

HEMATOPOIETIC GROWTH FACTORS
LEUKINE
MOZOBIL
NEUMEGA
NEUPOGEN 300 MCG/0.5 ML
SYR, -480 MCG/1.6 ML VIAL,
-480 MCG/0.8 ML SYR
PROCRIT 2,000 UNITS/ML
VIAL, -3,000 UNITS/ML
VIAL, -4,000 UNITS/ML
VIAL, -10,000 UNITS/ML
VIAL

Page 68 of 139

Drug
PROCRIT 20,000 UNITS/ML
VIAL
PROCRIT 40,000 UNITS/ML
VIAL

epoetin alfa

Generic

epoetin alfa

Tier Requirements/Limits
4
[MO][MNT][PA][QLL,
12/30]
4
[MO][MNT][PA][QLL,
6/30]

MISCELLANEOUS
anagrelide hcl
cilostazol
CINRYZE
CYKLOKAPRON [G]

pentopak
pentoxifylline tablet
sustained action
PROMACTA

c1 esterase inhibitor
tranexamic acid

eltrombopag olamine

tranexamic acid injection

1
1
4
2
1
1

[MO][MNT][PA]
[MO][MNT]
[MO][MNT][PAB]

4
1

[MO][MNT][PA]

2
1
1
1
2
2
2
1

[MO][MNT]
[QLL, 1/30]
[MO][MNT]
[MO][MNT][PA]
[MO][MNT]
[QLL, 1/30]
[MO][MNT]
[MO][MNT]

2

[MO]

[MO][MNT]
[MO][MNT]

PLATELET AGGREGATION INHIBITORS
AGGRENOX

aspirin/dipyridamole

clopidogrel 300 mg tablet
clopidogrel 75 mg tablet
dipyridamole tablet
EFFIENT
PLAVIX 300 MG TABLET [G]
PLAVIX 75 MG TABLET [G]

prasugrel
clopidogrel
clopidogrel

ticlopidine hcl

HORMONAL ANTINEOPLASTIC AGENTS

HORMONAL ANTINEOPLASTIC AGENTS
ELIGARD

leuprolide

IMMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA 200 MG/10 ML
VIAL
ENBREL 25 MG KIT, -25
MG/0.5 ML SYRINGE, -50
MG/ML SYRINGE
HUMIRA

tocilizumab

4

[MO][MNT][PA]

etanercept

4

[MO][MNT]

adalimumab

4

[MO][MNT]
Page 69 of 139

Drug
hydroxychloroquine sulfate
tablet
leflunomide
methotrexate tablet
REMICADE
RHEUMATREX

Generic

Tier Requirements/Limits
1
[MO][MNT]

infliximab
methotrexate

1
1
4
2

[MO][MNT]
[MO][MNT]
[MO][MNT][PA]
[MO][MNT]

immune
immune
immune
immune

2
4
4
4

[PAB]
[PAB]
[PAB]
[MO][PAB]

interferon gamma-1b,recomb.
rilonacept
interferon alfacon-1

4
4
4

[PAN]
[MO][MNT][PA]
[MO][PA]

interferon alfacon-1

4

[PA]

interferon alfa-2b , recomb.

4

[MO][MNT][PAB]

interferon alfa-2b , recomb.

4

[PAB]

peginterferon alfa-2a
peginterferon alfa-2a

4
3

[PA]
[MO][PA]

peginterferon alfa-2b
peginterferon alfa-2b
lenalidomide

4
4
4

[PA]
[PA]
[MNT][PAN]

peginterferon alfa-2b
thalidomide

3
4

[MO][MNT]
[MO][MNT][PAN]

IMMUNOGLOBULINS
GAMASTAN S-D
GAMMAGARD LIQUID
GAMUNEX
GAMUNEX-C 1 GRAM/10 ML
VIAL

globulin - im
globulin - iv
globulin - iv
globulin - iv/sq

IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INFERGEN 15 MCG/0.5 ML
VIAL
INFERGEN 9 MCG/0.3 ML
VIAL
INTRON A 3 MILLION
UNIT/ML PEN, -5 MILLION
UNIT/ML PEN, -10 MILLION
UNIT PEN
INTRON A 6 MILLION
UNIT/ML VL, -10 MILLION
UNITS VIAL
PEGASYS
PEGASYS PROCLICK 135
MCG/0.5
PEGINTRON 50 MCG KIT
PEGINTRON REDIPEN
REVLIMID 5 MG CAPSULE, 10 MG CAPSULE, -15 MG
CAPSULE, -25 MG CAPSULE
[LA]
SYLATRON
THALOMID

Page 70 of 139

Drug

Generic

Tier

Requirements/Limits

2
1
1
3
2

[MO][MNT][PAB]
[PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]

3
2
1
1
1

[MO][MNT][PAB]
[PAB]
[MO][PAB]
[MO][MNT][PAB]

1

[MO][MNT][PAB]

1
1
2
2
4
3
2
2

[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT]

4
2
2
2
1

[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]
[MO][MNT][PAB]

everolimus

4
2

[MO][MNT][PAB]
[MO][MNT][PAB]

everolimus

4

[MO][MNT][PAB]

haemophilus b-tet toxoid
diphther,pertuss,tetanus vac
diphther,pertuss,tetanus vac
human papillomav vacc bival/pf
hepatitis b/haemophilus b vacc

2
2
2
2
2

IMMUNOSUPPRESSANTS
AZASAN

azathioprine

azathioprine sodium
azathioprine tablet
BENLYSTA
CELLCEPT CAPSULE, TABLET [G]
CELLCEPT INJECTION
CELLCEPT ORAL SUSP

belimumab
mycophenolate mofetil
mycophenolate mofetil
mycophenolate mofetil

cyclosporine 50 mg/ml amp
cyclosporine 50 mg/ml vial
cyclosporine capsule, solution
cyclosporine modif 100 mg
cap, -100 mg
gengraf
mycophenolate mofetil
MYFORTIC
NEORAL [G]
NULOJIX
ORENCIA
ORTHOCLONE OKT-3
PROGRAF 0.5 MG CAPSULE,
-1 MG CAPSULE [G]
PROGRAF 5 MG CAPSULE [G]
RAPAMUNE
SANDIMMUNE CAPSULE [G]
SANDIMMUNE SOLUTION

mycophenolate sodium
cyclosporine
belatacept
abatacept/maltose
muronab-cd3
tacrolimus
tacrolimus
sirolimus
cyclosporine
cyclosporine

tacrolimus 0.5 mg capsule, 1 mg capsule
tacrolimus 5 mg capsule
ZORTRESS 0.25 MG TABLET,
-0.5 MG TABLET
ZORTRESS 0.75 MG TABLET

[MO][MNT][PAB]

VACCINES
ACTHIB
ADACEL VIAL
BOOSTRIX
CERVARIX
COMVAX

Page 71 of 139

Drug
DAPTACEL
DIPHTHERIA-TETANUS
TOXOID
ENGERIX-B 10 MCG/0.5 ML
PED VL, -10 MCG/0.5 ML
SYRN, -10 MCG/0.5 ML
SYRN, -20 MCG/ML SYRINGE
GARDASIL VIAL
HAVRIX 720 UNIT/0.5 ML
SYRINGE, -1,440 UNITS/ML
VIAL
IMOVAX RABIES VACCINE
INFANRIX VACCINE VIAL
IPOL VIAL
IXIARO
JE-VAX
MENACTRA 4 MCG/0.5 ML
SYRINGE
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PEDVAXHIB
PROQUAD
RABAVERT
RECOMBIVAX HB 10 MCG/ML
VIAL, -40 MCG/ML VIAL
ROTATEQ
TETANUS DIPHTHERIA
TOXOIDS
TETANUS TOXOID
ADSORBED
TETANUS-DIPHTERIADECAVAC
TRIPEDIA
TWINRIX VACCINE VIAL
TYPHIM VI 25 MCG/0.5 ML
VIAL
VAQTA 25 UNITS/0.5 ML
VIAL
VARIVAX VACCINE
YF-VAX
ZOSTAVAX

Generic
diphther,pertuss,tetanus vac
tetanus,diphtheria toxoid

Tier Requirements/Limits
2
2
[PAB]

hepatitis b virus vaccine

2

human papillomavirus vacc
hepatatis a virus vaccine

2
2

rabies vaccine,human diploid
diphther,pertuss,tetanus vac
poliomyelitis vac,killed
japanese encephalitis vaccine
japanese encephalitis vaccine
meningococcal vac a,c,y,w-135

2
2
2
2
2
2

meningococcal vac a,c,y,w-135
mening vac a,c,y,w-135 dip
measles,mumps&rubella vaccine
haemophilus b vaccine
measles,mumps,rub,varicella
rabies vac,pf chick-emb cell
hepatitis b virus vaccine

2
2
2
2
2
2
2

[PAB]

rotavirus vac, live pentav
tetanus,diphtheria toxoid

2
2

[PAB]

tetanus toxoid,adsorbed

2

[PAB]

tetanus,diphtheria toxoid

2

[PAB]

diphther,pertuss,tetanus vac
hep b vir recomb/hep a vir
typhoid vaccine

2
2
2

hepatatis a virus vaccine

2

varicella virus vaccine live
yellow fever vaccine
varicella vacc/pf

2
2
2

[PAB]

[QLL, 1/999]

Page 72 of 139

Drug

Generic

Tier

Requirements/Limits

diphther,pertuss,tetanus vac
hepatitis b virus vaccine
immune globulin - iv/sq

2
2
4

[PAB]
[MO][PAB]

human papillomavirus vacc
hepatatis a virus vaccine

2
2

diphther,pertuss,tetanus vac

2

poliomyelitis vac,killed
meningococcal vac a,c,y,w-135
hepatitis b virus vaccine

2
2
2

hep b vir recomb/hep a vir
typhoid vaccine

2
2

hepatatis a virus vaccine

2

interferon beta-1a
peginterferon alfa-2a

4
4

[MO][MNT][PAN]
[MO][PA]

peginterferon alfa-2b

4

[MO][PA]

2

[MO][MNT]

IMMUNOLOGICALS AND VACCINES

IMMUNOLOGICALS AND VACCINES
ADACEL SYRINGE
ENGERIX-B 20 MCG/ML VIAL
GAMUNEX-C 10 GRAM/100
ML VIAL, -2.5 GRAM/25 ML
VIAL, -20 GRAM/200 ML
VIAL, -5 GRAM/50 ML VIAL
GARDASIL SYRINGE
HAVRIX 720 UNITS/0.5 ML
VIAL, -1,440 UNITS/ML
SYRINGE
INFANRIX VACCINE
SYRINGE
IPOL SINGLE DOSE SYRINGE
MENACTRA VIAL
RECOMBIVAX HB 10 MCG/ML
SYR
TWINRIX VACCINE SYRINGE
TYPHIM VI 25 MCG/0.5 ML
SYRNG
VAQTA 25 UNITS/0.5 ML
SYRINGE

[PAB]

INTERFERONS
AVONEX PEN
PEGASYS PROCLICK 180
MCG/0.5
PEGINTRON 80 MCG KIT, 120 MCG KIT, -150 MCG KIT

MEDICAL (MISCELLANEOUS) SUPPLIES

DIABETIC SUPPLIES

AIMSCO INS SYR 0.3 ML
29GX1/2, -AIMSCO INS SYR
0.3 ML 30GX5/16, -AIMSCO
SYRING 0.5 ML 31GX5/16, BD INSUL SYR 0.3 ML
31GX15/64, -BD INSUL SYR
0.5 ML 31GX15/64, -BD
INSULIN SYR 0.3 ML

Page 73 of 139

Drug
28GX1/2, -BD INSULIN SYR
0.3 ML 29GX1/2, -BD
INSULIN SYR 0.3 ML
30GX1/2, -BD INSULIN SYR
0.5ML 31GX5/16, -BD
INSULIN SYR 1 ML 25GX1, BD INSULIN SYR 1 ML
25GX5/8, -BD INSULIN SYR
1 ML 26GX1/2, -BD INSULIN
SYR 1 ML 27GX5/8, -BD
INSULIN SYR 1 ML
31GX15/64, -BD INSULIN
SYRINGE 1 ML, -BD INSULIN
U100-3/10 ML SYR, -FIFTY50
INSULIN SYRINGE 0.5 ML, INS SYR 0.3 ML 29GX1/2, INS SYR 0.3 ML 30GX5/16, INS SYR 0.5 ML 28GX1/2, INS SYR 0.5 ML 29GX1/2, INS SYR 0.5 ML 30GX1/2, INS SYR 1 ML 28GX1/2, -INS
SYR 1 ML 30GX5/16, -INS
SYR U100 1 ML 28GX1/2, INS SYRIN 0.3 ML 30GX1/2,
-INS SYRING 0.3 ML
30GX5/16, -INS SYRINGE 1
ML 28GX1/2, -INS SYRINGE
1 ML 30GX1/2, -INS
SYRINGE 1 ML 30GX5/16, INS SYRINGE 3/10 ML, INSUL SYR 0.5 ML 28GX1/2,
-INSUL SYR 0.5 ML
31GX5/16, -0.3 ML SYRINGE,
-0.5 ML SYRINGE, -3/10 ML
SYRINGE, -SAFETY
SYRINGE, -SYR 0.3 ML
29GX1/2, -SYR 0.5 ML
28GX1/2, -SYR 1 ML
30GX5/16, -SYRIN 0.3 ML
29GX1/2, -SYRIN 0.3 ML
30GX1/2, -SYRIN 0.3 ML
30GX5/16, -SYRIN 0.5 ML
31GX5/16, -0.3 ML, -1 MLHARD PK, -INSULN SYR 0.5
ML 30GX5/16, -KINRAY
SYRING 0.5 ML 31GX5/16, -

Generic

Tier

Requirements/Limits

Page 74 of 139

Drug
KMART VALU PLUS SYR 1/2
ML, -KMART VALU PLUS SYR
3/10 ML, -KMART VALU PLUS
SYRINGE 1 ML, -PREFERRED
PLUS 0.3 ML 30GX5/16, PREFERRED PLUS SYRINGE
0.3 ML, -RELI-ON INSULIN
0.3 ML SYR, -RELI-ON
INSULIN 0.5 ML SYR, RELION INS SYR 0.3 ML
29GX1/2, -RELION INS SYR
0.3 ML 30GX5/16, -RELION
INSULIN SYR 0.3 ML, RELION SYRING 0.5 ML
31GX5/16, -SURE-JECT
INSULIN SYR 0.5 ML, -SYR
0.5 ML 30GX5/16, -SYRING
0.5 ML 31GX5/16, -SYRINGE
3/10 ML, -TERUMO INS SYR
0.3 ML 29GX1/2, -U100 0.3
ML 29GX1/2, -U100 0.3 ML
30GX5/16, -U100 0.5 ML
28GX1/2, -U100 0.5 ML
29GX1/2, -U100 0.5 ML
30GX5/16, -U100 1 ML
30GX5/16, -ULTICARE SYR
0.5 ML 31GX5/16, ULTICARE SYRIN 0.3 ML
29GX1/2, -ULTICARE U100
0.3 ML 30GX5/16, -ULTRA
COMFORT 3/10 ML SYR, VALUEPLUS SYR 0.3 ML 29G
1ST TIER UNIFINE PENTP
5MM 31G, -1ST TIER
UNIFINE PNTIP 6MM 31G, 1ST TIER UNIFINE PNTIP
8MM 31G, -1ST TIER
UNIFINE PNTP 12MM 29G, DRUG MART ULTRA
COMFORT SYR, -0.3 ML
29GX1/2, -0.3 ML SYRINGE,
-0.5 ML 28GX1/2, -0.5 ML
29GX1/2, -0.5 ML 30GX5/16,
-0.5 ML 31GX5/16, -0.5 ML
SYR, -0.5 ML SYRINGE, -1
ML 28GX1/2, -1 ML 29GX1/2,

Generic

Tier

Requirements/Limits

2

[MO][MNT]

Page 75 of 139

Drug
-1 ML 30GX5/16, -1 ML
31GX5/16
1ST TIER UNIFINE PNTIP
8MM 31G
AIMSCO MINI ULTRA-THIN
II
AIMSCO ULTRA THIN II
ALCOHOL 70% PREP PADS, 70%, -FIFTY50 ALCOHOL
PREP PADS, -PHARM
CHOICE ALCOHOL PREP
PADS
ALCOHOL PADS
ALCOHOL PREP SWABS
ALCOHOL SWAB
ALCOHOL WIPES
AURORA PEN NEEDLE 6MM
31G, -AURORA PEN
NEEDLES 12MM 29G, AURORA PEN NEEDLES 8MM
31G, -BD PEN NEEDLE
29GX1/2, -BD PEN NEEDLE
29GX3/16, -BD PEN NEEDLE
29GX5/16, -BD PEN NEEDLE
30GX3/16, -BD PEN NEEDLE
MINI 31GX3/16, -BD PEN
NEEDLE NANO 32GX5/32, BD PEN NEEDLE SHORT
31GX5/16, -CLICKFINE PEN
NDL 31GX1/4, -CLICKFINE
PEN NDL 31GX5/16, INSULIN PEN NEEDLE, -LIVE
BETTER PEN NEEDLE 6MM
31G, -LIVE BETTER PEN
NEEDLES 12MM, -LIVE
BETTER PEN NEEDLES 8MM,
-MS PEN NEEDLE 6MM 31G,
-12MM 29G NEEDLES, -8MM
31G NEEDLES, -31G X 3/16,
-31GX3/16, -31GX5/16, 6MM 31G, -S 12MM 29G, -S
29G, -S 31G, -S 31G X 5/16,
-S 5MM 31G, -S 6MM 31G, -S
8MM 31G, -RELION PEN 29G
NEEDLE, -RELION PEN 31G
NEEDLE, -TODAY'S HLT PN

Generic

Tier

Requirements/Limits

2

[MO][MNT]

2

[MO][MNT]

2
2

[MO][MNT]

2
2
2
2
2

[MO][MNT]

Page 76 of 139

Drug
NEEDLE 12MM 29G, TODAY'S HLTH PN NEEDLE
6MM 31G, -TODAY'S HLTH
PN NEEDLE 8MM 31G, UNIFINE PENTIP 12MM 29G,
-UNIFINE PENTIP 6MM 31G,
-UNIFINE PENTIP 8MM 31G
AUTO INJECTOR
AUTOJECT 2
AUTOPEN
BD INTEGRA SYR 1 ML
29GX1/2
BD INTEGRA SYRINGE 1 ML
25GX1
BD SAFTGLD INS 0.3 ML
31GX5/16, -BD SAFTGLD INS
SYR 0.5 ML 30G, -INSULIN
SAFETY SYRINGE
CLICKFINE
CURITY ALCOHOL PREPS
CURITY GAUZE SPONGES
EASY COMFORT INSULIN
SYRINGE
EASY TOUCH ALCOHOL
PREP PADS
EASY TOUCH INSULIN
NEEDLES - DISPOSABLE, INSULIN SYRINGES DISPOSABLE
EASY TOUCH INSULIN
SYRINGE
EASY-TOUCH INSULIN
SYRINGE
EXEL INSULIN SYRINGE
FREESTYLE PRECISION
GLUCOPRO
HEALTHY ACCENTS UNIFINE
PENTIP
HUMAPEN LUXURA HD
HUMAPEN MEMOIR
IN CONTROL PEN NEEDLE
INCONTROL
INJECT-EASE
INSUL PEN NEEDLES 8MM, INSULIN SYR 1/2 ML BULK

Generic

Tier

Requirements/Limits

2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

2

[MO]

2

[MO][MNT]

2
2
2
2

[MO][MNT]

[MO][MNT]

2
2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2
2
2
2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
Page 77 of 139

Drug
PACK, -1 ML SYRN 27X1/2, 1 ML SYRN 28GX1/2, -INSUL
SYR U100, -INSUL SYR U100
0.5 ML, -INSUL SYR U100 1
ML, -INSULIN SYR 0.3 ML, INSULIN SYR 0.5 ML, INSULIN SYR 1 ML, INSULIN SYR U-100, INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE
0.5 ML, -SYRINGE 1 ML
INSULIN SYRINGE 0.3 ML, 0.3 ML, -0.5 ML, -1 ML
INSUMED
INSUPEN

isopropyl alcohol 70% wipe
isopropyl alcohol 70% wipes
LITE TOUCH
LUER-LOK SYRINGE INSULIN
SYRINGES - DISPOSABLE
MAGELLAN INSULIN SAFETY
SYRNG
MAGELLAN INSULIN
SYRINGE
MEDI-JECTOR NEEDLE-FREE
SYR A
MEDI-JECTOR NEEDLE-FREE
SYR B
MEDI-JECTOR NEEDLE-FREE
SYR C
MEDI-JECTOR VISION
MEDI-JECTOR VISION
ADAPTER
MONOJECT 0.5 ML SYRN
28GX1/2
MONOJECT INSULIN SYR U100
NEEDLE FREE SYRINGE KIT
A
NEEDLE FREE SYRINGE KIT
B
NEEDLE FREE SYRINGE KIT
C
NOVOFINE 32
NOVOFINE AUTOCOVER

Generic

Tier

Requirements/Limits

2

[MO][MNT]

2
2
1
2
2
2

[MO][MNT]
[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2
2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2

[MO][MNT]

2
2

[MO][MNT]
[MO][MNT]

[MO][MNT]
[MO][MNT]

Page 78 of 139

Drug
NOVOPEN 3
NOVOPEN JR
NOVOTWIST
ORSINI INSULIN SYRINGE
PRECISION
PRODIGY INSULIN SYRINGE
PRODIGY PEN NEEDLE
SAFESNAP INSULIN
SYRINGE
SAFETYGLIDE SYRINGE
INSULIN SYRINGES DISPOSABLE
SINGLE USE SWAB
SURE COMFORT
SURE COMFORT ALCOHOL
SURE-FINE PEN NEEDLES
SURE-JECT INSULIN
SYRINGE
SURE-PREP ALCOHOL PREP
PADS

terumo ins syringe u100-1 ml

Generic

Tier
2
2
2
2
2
2
2
2

Requirements/Limits
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2

[MO][MNT]

2
2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

2
1
2

[MO][MNT]
[MO][MNT]

2
2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

2

[MO][MNT]

ulticare insulin syringes disposable

1

[MO][MNT]

ULTIGUARD INSULIN
SYRINGES - DISPOSABLE, 30GX0.5 ML SYRINGE, 30GX1 ML SYRINGE
ULTILET ALCOHOL SWAB

2

[MO][MNT]

2
2
2

[MO][MNT]
[MO][MNT]

TERUMO INS SYRINGE
U100-1/2 ML, -INS SYRINGE
U100-1/3 ML
TERUMO SURGUARD

thinpro insulin syringe
TOPCARE CLICKFINE
TOPCARE ULTRA COMFORT
TRUEPLUS INSULIN
SYRINGE
ULTICARE INSULIN
NEEDLES - DISPOSABLE

ultra comfort 1 ml syringe
ULTRACOMFORT INSULIN
NEEDLES - DISPOSABLE, INSULIN SYRINGES DISPOSABLE

Page 79 of 139

Drug
UNIFINE PENTIPS
VANISHPOINT INSULIN
SYRINGES - DISPOSABLE
VGO 20
VGO 30
VGO 40
WEBCOL

Generic

Tier Requirements/Limits
2
[MO][MNT]
2
[MO][MNT]
2
2
2
2

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][PA]
[MO]

1

[MO]

1

[MO]

1

[MO][MNT]

1

[MO]

1
1

[MO]
[MO]

MUSCULOSKELETAL MEDICATIONS

CNS MUSCLE RELAXANTS
carisoprodol 250 mg tablet
orphenadrine 30 mg/ml
ampule

NON-STEROIDAL ANTIINFLAMMATORY AGENTS
ketorolac 15 mg/ml
carpuject, -15 mg/ml
isecure, -30 mg/ml
carpuject, -30 mg/ml
isecure, -300 mg/10 ml vial,
-60 mg/2 ml vial

SALICYLATES AND RELATED DRUGS
salsalate tablet

NUTRITION,BLOOD MODIFIERS,ELECTROLYTES

BLOOD DETOXICANTS
generlac

ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.
dextrose 2.5%-water iv soln,
-25%-water syringe, -30%water iv soln, -40%-water iv
soln, -50%-water abboject, 50%-water iv soln, -50%water syringe, -50%-water
vial, -70%-water iv soln
kcl 40 meq in d5w-lact ringer
magnesium sulfate 50% vial

Page 80 of 139

Drug
nutrilyte
nutrilyte ii
sodium bicarb 4.2% abbjct, bicarb 4.2% syringe, -bicarb
4.2% vial, -bicarb 7.5% vial,
-bicarb 8.4% vial
sodium chloride 0.9% soln, 0.9% soln., -4 meq/ml vl

Generic

Tier Requirements/Limits
1
[MO][PAB]
1
[MO][PAB]
1
[MO]

1

[MO]

1
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

4
1

[MO]
[MO][PAB]

1

[PAB]

1

[MO][PAB]

1
1

[MO]

1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

FLUORIDE PRODUCTS
denta 5000 plus
dentagel
fluoridex daily defense
neutragard advanced
sf
sf 5000 plus
sodium fluoride
dental/mucous membrn
products, -oral drops

INJECTABLE ANTICOAGULANTS
enoxaparin 300 mg/3 ml vial
heparin sod 2,500 unit/ml
vial, -sod 5,000 unit/ml syr, sod 5,000 unit/ 0.5 ml, -sod
5,000 unit/0.5 ml
heparin-d5w 25,000 unit/500
ml, --d5w 25,000 unit/250 ml
heparin-ns 1,000 unit/500 ml

POTASSIUM REMOVING RESINS
kalexate
sps oral susp

POTASSIUM SUPPLEMENTS
epiklor
klor-con 20 meq packet
klor-con m10

Page 81 of 139

Drug
potassium cl 10% (20
meq/15 ml, -cl 10% (40
meq/30 ml, -cl 20% (40
meq/15 ml, -cl er 8 meq
tablet, -unique tablet
formulation
potassium cl 20 meq/100 ml
sol, -cl 2 meq/ml iv sol, -cl
40 meq/100 ml sol

Generic

Tier Requirements/Limits
1
[MO][MNT]

1

[MO]

1
1
1
2
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES
ed k+10
klor-con 10
klor-con 8
KLOR-CON M15

potassium chloride

klor-con m20
magnesium sulf 4% iv soln, sulf 8% iv soln, -50%
syringe
potassium chloride capsule
sustained action, -cl er 10
meq tablet, -cl er 20 meq
tablet
potassium cl 2 meq/ml vial
sodium bicarb 7.5%
abboject, -7.5% syring, bicarb 8.4% abboject, bicarb 8.4% abboject, bicarb 8.4% syringe, -8.4%
syring
sodium cl 2.5 meq/ml vial
tpn electrolytes

1
1

1
1

[PAB]

2

[PAB]

1

[PAB]

IV NUTRITION
AMINOSYN 3.5% IV
SOLUTION, -5% IV
SOLUTION, -7% IV
SOLUTION, -8.5% IV
SOLUTION, -10% IV
SOLUTION

aminosyn 8.5% iv solution

amino acids

Page 82 of 139

Drug
AMINOSYN II 3.5% MDEXTROSE 5%
AMINOSYN II 3.5%DEXTROSE 25%
AMINOSYN II 3.5%DEXTROSE 5%
AMINOSYN II 4.25%DEXTROSE 25%
AMINOSYN II 5% IN 25%
DEXTROSE
AMINOSYN II 7% IV
SOLUTION, -8.5%
ELECTROLYT, -10% IV
SOLUTION, -15% IV
SOLUTION

amino acids

Generic

amino acids

2

[PAB]

amino acids

2

[PAB]

amino acids

2

[PAB]

amino acids

2

[PAB]

amino acids

2

[PAB]

amino acids
amino acids

1
2
2

[PAB]
[PAB]
[PAB]

amino acids
amino acids
amino acids

2
2
1
2
2
2

[PAB]
[PAB]
[PAB]
[PAB]
[PAB]
[PAB]

aa 3%/electrolyte-tpn/glycerin

1
1
2

[PAB]
[PAB]
[PAB]

fat emulsions

1
2
1
2

[PAB]
[PAB]
[PAB]
[PAB]

fat emulsions
fat emulsions

2
2

[PAB]
[PAB]

aminosyn ii 8.5% electrolyt
AMINOSYN II IN DEXTROSE
AMINOSYN II WITH LYTESCA-DW
AMINOSYN M
AMINOSYN-HBC

amino acids
amino acids

aminosyn-hf
AMINOSYN-PF
CLINIMIX
CLINIMIX E 2.75%-10%
SOLUTION, -2.75%-5%
SOLUTION, -4.25%-25%
SOLUTION, -4.25%-5%
SOLUTION, -5%-15%
SOLUTION, -5%-20%
SOLUTION, -5%-25%
SOLUTION

clinisol
freamine iii 8.5% iv soln.
FREAMINE III WITH
ELECTROLYTES

hepatamine

HEPATASOL

amino acids

intralipid 20% iv fat emul
INTRALIPID 30% IV FAT
EMUL [G]
LIPOSYN II
LIPOSYN III 10% IV FAT
EMULSN, -20% IV FAT
EMULSN

Tier Requirements/Limits
2
[PAB]

Page 83 of 139

Drug
liposyn iii 30% iv fat emulsn
NEPHRAMINE
PREMASOL 10% IV
SOLUTION

Generic

amino acids
amino acids

Tier Requirements/Limits
1
[PAB]
2
[PAB]
2
[PAB]

aa 3%/electrolyte-tpn/glycerin
amino acids
amino acids
amino acids

1
2
2
2
2

premasol 6% iv solution
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE

[PAB]
[PAB]
[PAB]
[PAB]
[PAB]

IV REPLACEMENT SOLUTIONS
d5%-1/4ns-kcl 10 meq/l iv
sol, -d5%-1/4ns-kcl 40 meq/l
iv sol, -kcl 10 meq in d5w1/4 ns, -kcl 5 meq in d5w1/4 ns
D5W/KCL 10 MEQ/L IV
SOLUTION

1

potassium chloride/d5w

dextrose 10%-0.2% nacl
dextrose 10%-1/4ns
DEXTROSE 10%-1/4NS-KCL

potassium chloride/d10-0.25ns

dextrose 5%-1/2ns-kcl
dextrose 5%-1/3ns-kcl
DEXTROSE 5%ELECTROLYTE #48

dextrose 5%-water iv soln, 10%-water iv solution
dextrose in lactated ringers
dextrose with sodium
chloride
IONOSOL B WITH
DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE H WITH DEXTROSE

dextrose/electrolytes

1
1
2
1
1
2
1
1
1

electrolyte solutions

2

electrolyte solutions
electrolyte solutions
dextrose/electrolytes
dextrose/electrolytes
electrolyte solutions

2
2
2
1
2
2

dextrose/electrolytes
dextrose/nacl/kcl

2
2

isolyte m with dextrose
ISOLYTE P WITH DEXTROSE
ISOLYTE S IV SOLUTIONEXCEL
ISOLYTE S WITH DEXTROSE
KCL 10 MEQ IN D5W-1/4 NS,
-KCL 20 MEQ IN D5W-1/4 NS

2

Page 84 of 139

Drug
kcl 20 meq in d5w solution, d5w-kcl 30 meq/l iv solution,
-kcl 40 meq in d5w solution
KCL 20 MEQ IN D5W-LACT
RINGER

kcl 20 meq in d5w-ns
kcl 20 meq-ns 1,000 ml iv
soln

KCL 40 MEQ IN D5W-NACL
0.9%
KCL 40 MEQ-NS 1,000 ML IV
SOLN

Generic

potassium chloride/d5w

2

pot chloride/na chlor

2

electrolyte solutions
electrolyte solutions
electrolyte solutions

1
2
1
1
2
2
2

electrolyte solutions
d5w/electrolyte-56 solution

2
2

electrolyte solutions

2
1
2

magnesium sulfate/d5w

plasma-lyte r
POTASSIUM CHLORIDENACL

2

dextrose/nacl/kcl

normosol-m and dextrose
normosol-r and dextrose
NORMOSOL-R PH 7.4
PLASMA-LYTE 148
PLASMA-LYTE 148 IN
DEXTROSE
PLASMA-LYTE 56
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH 7.4

Requirements/Limits

1
1

lactated ringers injection

MAGNESIUM SULFATE-D5W

Tier
1

pot chloride/na chlor

potassium cl 10 meq/100 ml
sol, -cl 30 meq/100 ml sol, cl 10 meq/50 ml sol, -cl 20
meq/50 ml sol
ringers injection
saline 0.45% soln-excel con,
-0.45% soln, -saline 0.9%
soln-excel cont, -0.9%
solution, -3% iv soln, -5% iv
soln
sodium lactate injection

1

1
1

1

VITAMINS
calcitriol capsule, -solution
calcitriol injection
ZEMPLAR CAPSULE

paricalcitol

1
1
2

[MO][MNT][PAB]
[PAB]
[MO][MNT][PAB]
Page 85 of 139

Drug
ZEMPLAR INJECTION

paricalcitol

Generic

Tier Requirements/Limits
2
[PAB]

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS

CONTRACEPTIVES

altavera
alyacen
amethia lo
azurette
camrese
camrese lo
caziant
dasetta
falmina
gildess fe
jolessa
levonest
levonorgestrel
levonorg-eth estrad eth
estrad
loryna
myzilra
necon 1/50-28 tablet
next choice one dose
norethindrone-ethin estradiol
norgestimate-ethinyl
estradiol
norgestrel-ethiny estra
philith
syeda
tilia fe
viorele
wera
zarah
zenchent
zenchent fe

1
1
1
1
1
1
1
1
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO]
[MO][MNT]

1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1
1
1
1
1
1
1
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1
1

[MO][MNT]
[MO][MNT]

[MO][MNT]
[MO][MNT]

ESTROGEN/PROGESTIN COMBINATIONS
estradiol-noreth 0.5-0.1 mg
tb
jevantique
mimvey

Page 86 of 139

Drug

Generic

Tier

Requirements/Limits

1
1

[MO][MNT]
[MO][MNT]

PROGESTIN DRUGS
heather
norethindrone

OPHTHALMIC

ANTIALLERGICS
ALREX

loteprednol etabonate

azelastine hcl ophth drops
cromolyn sodium ophth
drops
epinastine hcl
LASTACAFT

alcaftadine

parcaine
PATADAY
PATANOL

olopatadine hcl
olopatadine hcl

2
1
1
1
2
1
2
2

ANTIGLAUCOMA
acetazolamide sodium
ALPHAGAN P 0.1% DROPS

brimonidine tartrate

apraclonidine hcl
AZOPT

brinzolamide

betaxolol hcl ophth drops
BETIMOL
BETOPTIC S

timolol
betaxolol

brimonidine tartrate
carteolol hcl
COMBIGAN

brimonidine tartrate/timolol

dorzolamide hcl
dorzolamide-timolol
latanoprost
levobunolol hcl
LUMIGAN

bimatoprost

metipranolol
PHOSPHOLINE IODIDE
PILOPINE HS

echothiophate iodide
pilocarpine hcl

timolol maleate ophth drops
TRAVATAN Z

travoprost

1
2
1
2
1
3
2
1
1
2
1
1
1
1
2
1
2
2
1
2

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
2.5/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT][QLL,
2.5/30]
Page 87 of 139

Drug

Generic

Tier

Requirements/Limits

ANTI-INFECTIVE/ANTI-INFLAMMATORY
BLEPHAMIDE S.O.P.

sulfacetamide/prednisolone ac

neomycin-bacitracin-poly-hc
neomycin-polymyxindexameth
neomycin-polymyxin-hc
ophth drops
poly-dex
sulfacetamide-prednisolone
tobramycin-dexamethasone

2
1
1
1
1
1
1

ANTI-INFECTIVES
AZASITE

azithromycin

bacitracin 500 unit/gm
ointmnt
bacitracin-polymyxin eye oint
CILOXAN OINT

ciprofloxacin

ciprofloxacin hcl ophth drops
erythromycin oint
gentak oint
gentamicin sulfate ophth
drops
gentasol
levofloxacin ophth drops
NATACYN

natamycin

neomycin-bacitracinpolymyxin
neomycin-polymyxingramicidin
ofloxacin ophth drops
polymyxin b sul-trimethoprim
romycin
sulfacetamide sodium oint, ophth drops
tobramycin sulfate ophth
drops
tobrasol
TOBREX OINT

1
2
1
1
1
1
1
1
2
1

[QLL, 68/30]

1
1
1
1
1
1

tobramycin

trifluridine ophth drops
tropicamide ophth drops
VIGAMOX

2
1

moxifloxacin

1
2
1
1
2

[MO][MNT]
Page 88 of 139

Drug
ZYMAR
ZYMAXID

gatifloxacin
gatifloxacin

Generic

Tier
2
2

Requirements/Limits

ANTI-INFLAMMATORIES
bromfenac sodium
dexamethasone sodium
phosphate ophth drops
diclofenac sodium ophth
drops
fluorometholone ophth drops
flurbiprofen sodium
FML S.O.P.

ketorolac tromethamine
ophth drops
prednisolone acetate ophth
drops
PREDNISOLONE SODIUM
PHOSPHATE OPHTH DROPS

1
1
1

fluorometholone

1
1
2
1
1

prednisolone sod phosphate

2

MISCELLANEOUS
ak-con
LACRISERT

hydroxypropylmethylcellulose

proparacaine hcl ophth drops
RESTASIS

cyclosporine

1
2
1
2

[MO][MNT]

1

[MO][MNT]

1
1
1
1
1
1
1

[MO]
[MO]
[MO]
[MO]

OPHTHALMIC MEDICATIONS

ANTIGLAUCOMA DRUGS

pilocarpine hcl ophth drops

OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
ak-poly-bac
garamycin ophth drops
gentak ophth drops
gentamicin 3 mg/gm eye oint
neo-polycin
polycin-b
sulfamide

[MO]
[MO]

Page 89 of 139

Drug

OTHER OPHTHALMIC DRUGS

Generic

cyclopentolate hcl ophth
drops
mydral

Tier

Requirements/Limits

1

[MO][MNT]

1

[MO][MNT]

[MO][MNT][QLL, 30
gm/30]
[MO][MNT][QLL,
30/30]
[MO][MNT][PAB][QLL,
540/30]

RESPIRATORY

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT

albuterol sulfate/ipratropium

2

COMBIVENT RESPIMAT

albuterol sulfate/ipratropium

2

ipratropium-albuterol [PartB]

1

ANTICHOLINERGICS
ATROVENT HFA

ipratropium

ipratropium bromide nasal
drops/sprays
ipratropium bromide nebs
[PartB]
SPIRIVA

2
1
1

tiotropium bromide

2

azelastine hcl

2

[MO][MNT][QLL, 26
gm/30]
[MO][MNT]
[MO][MNT][PAB][QLL,
315/30]
[MO][MNT][QLL, 30
capsules/30]

ANTIHISTAMINES
ASTEPRO

azelastine hcl nasal
drops/sprays
carbinoxamine maleate
cetirizine hcl 1 mg/ml syrup
CLARINEX 5 MG TABLET [G]
CLARINEX SYRUP, -2.5 MG
REDITABS, -5 MG REDITABS

clemastine fumarate syrup, fum 2.68 mg tab
cyproheptadine hcl syrup, tablet
desloratadine

1

desloratadine
desloratadine

1
1
3
3

[MO][MNT][QLL, 60
ml/30]
[MO][MNT][QLL, 60
ml/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1
1

[MO][MNT][PA]

1

[MO][MNT]
Page 90 of 139

Drug
dexchlorpheniramine
maleate
diphenhydramine 50 mg
capsule, -elix, -50 mg/ml vial
fexofenadine hcl 60 mg
tablet
hydroxyzine hcl injection
hydroxyzine hcl syrup, tablet
hydroxyzine pamoate
capsule
levocetirizine dihydrochloride
solution, -tablet
palgic

Generic

Tier
1

Requirements/Limits

1
1

[MO][MNT]

1
1

[PA]

1

[PA]

1

[MO][MNT]

1

BETA AGONISTS
albuterol 2.5 mg/0.5 ml sol, 5 mg/ml solution [PartB]
albuterol sul 0.63 mg/3 ml
sol, -sul 1.25 mg/3 ml sol, 0.083% inhal soln [PartB]
albuterol sulfate syrup, tablet, -tablet sustained
action
FORADIL

1
1

formoterol fumarate

1

[MO][MNT]

2

[MO][MNT][QLL,
60/30]
[MO][MNT][PAB][QLL,
90/30]
[MO][MNT]

levalbuterol concentrate

1

metaproterenol sulfate
syrup, -tablet

1

[PartB]

PERFOROMIST [PartB]

formoterol fumarate

3

PROAIR HFA

albuterol

2

PROVENTIL HFA
SEREVENT DISKUS

albuterol
salmeterol

2
2
1
1
2

terbutaline sulfate injection
terbutaline sulfate tablet
VENTOLIN HFA

albuterol

[MO][MNT][PAB][QLL,
60/30]
[MO][MNT][PAB][QLL,
300/30]

[MO][MNT][PAB][QLL,
120/30]
[MO][MNT][QLL, 18
gm/30]
[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium chew
tab, -tablet

1

[MO][MNT]
Page 91 of 139

Drug
SINGULAIR [G]

Generic
montelukast sodium

zafirlukast

Tier Requirements/Limits
2
[MO][MNT]
1
[MO][MNT]

MAST CELL STABILIZERS
cromolyn sodium nebs

1

cromolyn sodium solution

1

[PartB]

[MO][MNT][PAB][QLL,
240/30]

MISCELLANEOUS
acetylcysteine nebs [PartB]
ARALAST NP 500 MG VIAL
CAYSTON
DALIRESP

epinephrine 0.1 mg/ml
syringe
EPIPEN 2-PAK
EPIPEN JR 2-PAK

alpha-1-proteinase inhibitor
aztreonam lysine
roflumilast
epinephrine hcl
epinephrine hcl

promethazine vc
PULMOZYME [PartB]
TOBI [PartB]
XOLAIR

deoxyribonuclease
tobramycin/sodium chloride
omalizumab

1
4
4
2
1
2
2
1
4
4
4

[PAB]
[MO][MNT][PA]
[PA]
[MO][MNT]

[PA]
[MO][MNT][PAB]
[PAB]
[MO][MNT][PA]

NASAL STEROIDS
flunisolide 0.025% spray

1

fluticasone propionate nasal
inhaled steroids

1

NASACORT AQ [G]

triamcinolone acetonide

2

NASONEX

mometasone

2
1

fluticasone furoate

2

mometasone

2

triamcinolone acetonide
nasal inhaled steroids
VERAMYST

[MO][MNT][QLL, 50
ml/30]
[MO][MNT][QLL, 16
gm/30]
[MO][MNT][QLL,
17/30]
[MO][MNT]
[MO][MNT][QLL, 17
gm/30]
[MO][MNT]

STEROID INHALANTS
ASMANEX

budesonide nebs [PartB]
FLOVENT DISKUS

1

fluticasone propionate

2

[MO][MNT][QLL, 2
doses/30]
[MO][MNT][PAB][QLL,
120/30]
[MO][MNT]
Page 92 of 139

Drug
FLOVENT HFA
QVAR

Generic
fluticasone propionate
beclomethasone

Tier Requirements/Limits
2
[MO][MNT]
2
[MO][MNT][QLL,
24/30]

STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
DULERA

salmeterol/fluticasone
salmeterol/fluticasone
mometasone/formoterol

2
2
2

SYMBICORT

budesonide/formoterol fum

2

[MO][MNT]
[MO][MNT]
[MO][MNT][QLL, 13
gm/30]
[MO][MNT][QLL, 11
gm/30]

XANTHINES
aminophylline 250 mg/10 ml
vl
aminophylline tablet
ELIXOPHYLLIN
THEO-24

1

theophylline
theophylline

theochron er 100 mg tablet,
-er 300 mg tablet
theophylline anhydrous
tablet sustained action
theophylline tablet sustained
action

1
2
2
1

[MO][MNT]
[MO][MNT]
[MO][MNT]
[MO][MNT]

1

[MO][MNT]

1

[MO][MNT]

1
1

[MO]
[MO]

1

[MO]

1

[MO][MNT]

RESPIRATORY MEDICATIONS

ANTIHISTAMINES

arbinoxa
diphenhydramine 50 mg/ml
syrng
promethazine 25 mg/ml
ampul, -25 mg/ml vial, -50
mg/ml ampul

BETA-2 ADRENERGIC DRUGS
levalbuterol hcl nebs [PartB]

Page 93 of 139

Drug

LEUKOTRIENE MODIFIERS
montelukast sod 4 mg
granules

Generic

Tier

Requirements/Limits

1

[MO][MNT]

1

[MO]

1
1

[MO][MNT]
[MO][MNT]

METHYL XANTHINE DRUGS
aminophylline 500 mg/20 ml
vl
theochron er 200 mg tablet
theophylline solution

OTHER DRUGS FOR ASTHMA
epinephrine 0.3 mg autoinject
epinephrine 1 mg/ml ampul,
-1 mg/ml vial

1
1

[MO]

TOPICAL

DERMATOLOGY, ACNE
adapalene
amnesteem
avita
claravis
clindamycin phosphate foam
(non-contraceptive), -gel, lotion, -soln, top, -swabs,
applicators
clindamycin-benzoyl perox
gel
ery
erythromycin gel, -soln, top
erythromycin-benzoyl
peroxide
sotret
sulfacetamide sodium lotion
tretinoin 0.025% cream, 0.05% cream, -0.1% cream,
-gel

1
1
1
1
1

1
1
1
1
1
1
1

Page 94 of 139

Drug

DERMATOLOGY, ACTINIC KERATOSIS
CARAC

Generic

fluorouracil

fluorouracil cream, -soln, top
SOLARAZE

diclofenac sodium

Tier

Requirements/Limits

2
1
2

DERMATOLOGY, ANTIBIOTICS
BACTROBAN CREAM

mupirocin calcium

clotrimazole-betamethasone
gentamicin sulfate cream, 0.1% ointment
mupirocin oint
nystatin-triamcinolone
silver sulfadiazine cream
ssd
thermazene

2
1
1
1
1
1
1
1

DERMATOLOGY, ANTIFUNGALS
ciclopirox cream, -gel, lotion, -oil,shampoo,cleanser,
-soln, top
clotrimazole 1% cream, soln, top
econazole nitrate cream
ketoconazole cream, -foam
(non-contraceptive)
ketodan combo packs
nyamyc
nystatin cream, -oint, 100,000 unit/gm powd
nystop
pedi-dri

1
1
1
1
1
1
1
1
1

DERMATOLOGY, ANTIPRURITIC
proctocream-hc [G]
proctosol-hc
proctozone-hc
ZONALON

doxepin

1
1
1
2

Page 95 of 139

Drug

DERMATOLOGY, ANTIPSORIATICS

Generic

calcipotriene
DOVONEX CREAM [G]
OXSORALEN-ULTRA
TAZORAC

calcipotriene
methoxsalen
tazarotene

Tier

Requirements/Limits

1
2
4
3

[PA]
[PA]

DERMATOLOGY, ANTISEBORRHEICS
ketoconazole
oil,shampoo,cleanser
selenium sulfide 2.5% lotion

1
1

DERMATOLOGY, ANTIVIRALS
DENAVIR
ZOVIRAX CREAM, -OINT

penciclovir
acyclovir

2
2

DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate
amcinonide
betamethasone dipropionate
cream, -dp aug 0.05% lot, oint
betamethasone dp 0.05% lot
betamethasone valerate
cream, -lotion, -oint
clobetasol emollient
clobetasol propionate foam
(non-contraceptive), -gel, lotion, -oil,shampoo,cleanser,
-oint, -soln, top
DERMA-SMOOTHE-FS [G]

desonide cream, -lotion, oint
desoximetasone cream, -gel,
-0.25% ointment
diflorasone diacetate
fluocinolone acetonide
cream, -oint, -soln, top
fluocinolone acetonide
oil,shampoo,cleanser

1
1
1
1
1
1

[MO]

1
1

fluocinolone acetonide

2
1
1
1
1
1

[MO]
Page 96 of 139

Drug
fluocinonide emollient
fluocinonide gel, -oint, -soln,
top
fluocinonide-e
fluticasone propionate
cream, -oint
halobetasol propionate
hydrocortisone 1% cream
hydrocortisone 1% cream, 2.5% cream, -2.5% lotion, 1% absorbase, -1%
ointment, -2.5% ointment
hydrocortisone butyrate
hydrocortisone valerate
lokara [G]
mometasone furoate cream,
-lotion, -oint
prednicarbate
procto-pak
triamcinolone acetonide
cream, -lotion, -oint
triderm

Generic

Tier
1
1

Requirements/Limits

1
1

[MO]

1
1
1

1
1
1
1
1
1
1
1

DERMATOLOGY, IMMUNOMODULATORS
ELIDEL
PROTOPIC

pimecrolimus
tacrolimus

2
2

[PA]
[PA]

DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl dental/mucous
membrn products, -gel
lidocaine oint
lidocaine-prilocaine
LIDODERM

1

lidocaine

1
1
2

[PA][QLL, 90/30]

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate cream, lotion
imiquimod cream
laclotion
PANRETIN

podofilox

1

alitretinoin

1
1
4
1
Page 97 of 139

Drug
TARGRETIN GEL
VOLTAREN GEL
ZYCLARA 3.75% CREAM, 3.75% CREAM PUMP

Generic
bexarotene
diclofenac sodium
imiquimod

Tier Requirements/Limits
4
2
[MO][MNT]
2

metronidazole

2
1

doxycycline monohydrate

2

DERMATOLOGY, ROSACEA
METROGEL

metronidazole cream, -gel, lotion
ORACEA

DERMATOLOGY, SCABICIDES AND PEDICULIDES
acticin
malathion
permethrin cream

1
1
1

DERMATOLOGY, WOUND CARE AGENTS
REGRANEX
SANTYL

becaplermin
collagenase

sodium chloride solution

4
2
1

[PA]

MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate
dental/mucous membrn
products
EVOXAC [G]

1

cevimeline

lidocaine hcl viscous
nystatin oral susp
periogard
pilocarpine hcl tablet
triamcinolone acetonide
paste

2
1
1
1
1
1

[MO][MNT]

OTIC
acetasol hc
acetic acid otic drops
cortomycin
DERMOTIC [G]

fluocinolone acetonide

1
1
1
2
Page 98 of 139

Drug
fluocinolone acetonide oil
hydrocortisone-acetic acid
neomycin-polymyxin-hc
suspensions, (not oral)
neomycin-polymyxinhydrocort
ofloxacin otic drops

Generic

Tier Requirements/Limits
1
[MO]
1
1
1
1

UROLOGICAL MEDICATIONS

ANTICHOLINERGIC ANTISPASMODICS
GELNIQUE GEL

oxybutynin

tolterodine tartrate

2
1

[MO][MNT]
[MO][MNT]

1
1

[MO]

OTHER GENITOURINARY PRODUCTS
cytra-k packet
neomy-polymyxin b 40
mg/ml vl

Page 99 of 139

Index:
1ST TIER UNIFINE PENTP 5MM 31G, -1ST
TIER UNIFINE PNTIP 6MM 31G, -1ST TIER
UNIFINE PNTIP 8MM 31G, -1ST TIER
UNIFINE PNTP 12MM 29G, -DRUG MART
ULTRA COMFORT SYR, -0.3 ML 29GX1/2, 0.3 ML SYRINGE, -0.5 ML 28GX1/2, -0.5
ML 29GX1/2, -0.5 ML 30GX5/16, -0.5 ML
31GX5/16, -0.5 ML SYR, -0.5 ML SYRINGE,
-1 ML 28GX1/2, -1 ML 29GX1/2, -1 ML
30GX5/16, -1 ML 31GX5/16, 75
1ST TIER UNIFINE PNTIP 8MM 31G, 75
aa 3%/electrolyte-tpn/glycerin, 83
abacavir, 17
abacavir sulfate, 18
abacavir sulfate/lamivudine, 17
abatacept/maltose, 71
ABILIFY 5 MG TABLET, -10 MG TABLET, -15
MG TABLET, 44
ABILIFY DISCMELT, 44
ABILIFY INJECTION, 44
ABILIFY SOLUTION, -2 MG TABLET, -20 MG
TABLET, -30 MG TABLET, 44
abiraterone acetate, 24
acamprosate calcium, 49
acarbose, 52
ACE INHIBITOR COMBINATIONS, 29
ACE INHIBITORS, 30
acebutolol hcl capsule, 33
acetaminoph-caff-dihydrocodein, 7
acetaminophen-codeine, 6
acetasol hc, 98
acetazolamide capsule sustained action, tablet, 35
acetazolamide sodium, 87
acetic acid otic drops, 98
acetylcysteine nebs, 91
ACTEMRA 200 MG/10 ML VIAL, 69
ACTHIB, 71
acticin, 98
ACTIMMUNE, 70
ACTONEL 30 MG TABLET, 54

ACTONEL 5 MG TABLET, -35 MG TABLET, 150 MG TABLET, 54
ACTOPLUS MET, 52
ACTOPLUS MET XR, 52
ACTOS 15 MG TABLET, 52
ACTOS 30 MG TABLET, 52
ACTOS 45 MG TABLET, 52
acyclovir, 96
acyclovir capsule, -oral susp, -tablet, 19
acyclovir sodium 1 gm vial, 12
acyclovir sodium 500 mg vial, 19
ADACEL SYRINGE, 72
ADACEL VIAL, 71
ADAGEN, 57
adalimumab, 69
adapalene, 94
ADCIRCA, 37
adcirca (tadalafil), 37
adefovir dipivoxil, 19
ADRENOLYTICS, CENTRAL, 30
adriamycin, 21
ADVAIR DISKUS, 92
ADVAIR HFA, 92
afeditab cr, 34
AFINITOR, 23
agalsidase, 57
AGGRENOX, 69
a-hydrocort, 58
AIMSCO INS SYR 0.3 ML 29GX1/2, -AIMSCO
INS SYR 0.3 ML 30GX5/16, -AIMSCO
SYRING 0.5 ML 31GX5/16, -BD INSUL SYR
0.3 ML 31GX15/64, -BD INSUL SYR 0.5 ML
31GX15/64, -BD INSULIN SYR 0.3 ML
28GX1/2, -BD INSULIN SYR 0.3 ML
29GX1/2, -BD INSULIN SYR 0.3 ML
30GX1/2, -BD INSULIN SYR 0.5ML
31GX5/16, -BD INSULIN SYR 1 ML 25GX1,
-BD INSULIN SYR 1 ML 25GX5/8, -BD
INSULIN SYR 1 ML 26GX1/2, -BD INSULIN
SYR 1 ML 27GX5/8, -BD INSULIN SYR 1
ML 31GX15/64, -BD INSULIN SYRINGE 1
ML, -BD INSULIN U100-3/10 ML SYR, Page 100 of 139

FIFTY50 INSULIN SYRINGE 0.5 ML, -INS
SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML
30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS
SYR 0.5 ML 29GX1/2, -INS SYR 0.5 ML
30GX1/2, -INS SYR 1 ML 28GX1/2, -INS
SYR 1 ML 30GX5/16, -INS SYR U100 1 ML
28GX1/2, -INS SYRIN 0.3 ML 30GX1/2, INS SYRING 0.3 ML 30GX5/16, -INS
SYRINGE 1 ML 28GX1/2, -INS SYRINGE 1
ML 30GX1/2, -INS SYRINGE 1 ML
30GX5/16, -INS SYRINGE 3/10 ML, -INSUL
SYR 0.5 ML 28GX1/2, -INSUL SYR 0.5 ML
31GX5/16, -0.3 ML SYRINGE, -0.5 ML
SYRINGE, -3/10 ML SYRINGE, -SAFETY
SYRINGE, -SYR 0.3 ML 29GX1/2, -SYR 0.5
ML 28GX1/2, -SYR 1 ML 30GX5/16, -SYRIN
0.3 ML 29GX1/2, -SYRIN 0.3 ML 30GX1/2,
-SYRIN 0.3 ML 30GX5/16, -SYRIN 0.5 ML
31GX5/16, -0.3 ML, -1 ML-HARD PK, INSULN SYR 0.5 ML 30GX5/16, -KINRAY
SYRING 0.5 ML 31GX5/16, -KMART VALU
PLUS SYR 1/2 ML, -KMART VALU PLUS SYR
3/10 ML, -KMART VALU PLUS SYRINGE 1
ML, -PREFERRED PLUS 0.3 ML 30GX5/16, PREFERRED PLUS SYRINGE 0.3 ML, -RELION INSULIN 0.3 ML SYR, -RELI-ON
INSULIN 0.5 ML SYR, -RELION INS SYR
0.3 ML 29GX1/2, -RELION INS SYR 0.3 ML
30GX5/16, -RELION INSULIN SYR 0.3 ML,
-RELION SYRING 0.5 ML 31GX5/16, SURE-JECT INSULIN SYR 0.5 ML, -SYR 0.5
ML 30GX5/16, -SYRING 0.5 ML 31GX5/16,
-SYRINGE 3/10 ML, -TERUMO INS SYR 0.3
ML 29GX1/2, -U100 0.3 ML 29GX1/2, U100 0.3 ML 30GX5/16, -U100 0.5 ML
28GX1/2, -U100 0.5 ML 29GX1/2, -U100
0.5 ML 30GX5/16, -U100 1 ML 30GX5/16, ULTICARE SYR 0.5 ML 31GX5/16, ULTICARE SYRIN 0.3 ML 29GX1/2, ULTICARE U100 0.3 ML 30GX5/16, -ULTRA
COMFORT 3/10 ML SYR, -VALUEPLUS SYR
0.3 ML 29G, 73
AIMSCO INS SYR 1 ML 29GX1/2, -AIMSCO
SYRING 0.3 ML 31GX5/16, -BD INSULIN
SYR 0.5 ML 30GX1/2, -BD INSULIN SYR 1

ML 31GX5/16, -FIFTY50 INS SYR 1 ML
31GX5/16, -FIFTY50 INSULIN SYRINGE 0.3
ML, -INS SYR 0.5 ML 30GX5/16, -INS SYR
1 ML 29GX1/2, -INS SYR 1 ML 31GX5/16, INS SYRIN 1 ML 29GX1/2, -INSUL SYR 0.3
ML 31GX5/16, -INSUL SYR 0.5 ML
30GX1/2, -1 ML SYRINGE, -SYR 1 ML
29GX1/2, -SYR 1 ML 31GX5/16, -SYRIN 0.3
ML 31GX5/16, -SYRIN 0.5 ML 30GX1/2, SYRIN 0.5 ML 30GX5/16, -SYRIN 1 ML
29GX1/2, -0.5 ML, -1 ML, -1 ML 29GX1/2, 1 ML 31GX5/16, -KINRAY INS SYR 1 ML
31GX5/16, -KINRAY SYRING 0.3 ML
31GX5/16, -PREF PLUS SYRING 1 ML
29GX1/2, -RELI-ON INSULIN 1 ML SYR, RELION INS SYR 1 ML 29GX1/2, -RELION
INS SYR 1 ML 31GX5/16, -RELION SYRING
0.3 ML 31GX5/16, -SURE-JECT INSULIN
SYR 0.3 ML, -SYRING 0.3 ML 31GX5/16, SYRINGE 1/2 ML, -U100 INS SYR 1 ML
29GX1/2, -ULTCARE INS SYR 1 ML
31GX5/16, -ULTICARE INS SYR 1 ML
29GX1/2, -ULTICARE SYR 0.3 ML
31GX5/16, -VH INS SYR 1 ML 29GX1/2, WD MEDIC SYR 1 ML 29GX1/2, 50
AIMSCO MINI ULTRA-THIN II, 75
AIMSCO ULTRA THIN II, 75
ak-con, 89
ak-poly-bac, 89
ala-cort, 96
albendazole, 19
ALBENZA, 19
albuterol, 91
albuterol 2.5 mg/0.5 ml sol, -5 mg/ml
solution, 91
albuterol sul 0.63 mg/3 ml sol, -sul 1.25
mg/3 ml sol, -0.083% inhal soln, 91
albuterol sulfate syrup, -tablet, -tablet
sustained action, 91
albuterol sulfate/ipratropium, 89, 90
alcaftadine, 87
alclometasone dipropionate, 96
ALCOHOL 70% PREP PADS, -70%, -FIFTY50
ALCOHOL PREP PADS, -PHARM CHOICE
ALCOHOL PREP PADS, 76
Page 101 of 139

ALCOHOL PADS, 76
ALCOHOL PREP PADS, 10
ALCOHOL PREP SWABS, 76
ALCOHOL SWAB, 76
ALCOHOL SWABS, 51
ALCOHOL WIPES, 76
aldesleukin, 22
ALDOSTERONE RECEPTOR ANTAGONISTS,
30
ALDURAZYME, 57
alefacept, 25
alemtuzumab, 22
alendronate sodium 35 mg tab, -70 mg tab,
54
alendronate sodium 5 mg tablet, -10 mg tab,
-40 mg tab, 54
alfuzosin hcl, 66
alglucosidase alfa, 57
ALIMTA 500 MG VIAL, 21
ALINIA ORAL SUSP, 19
ALINIA TABLET, 20
aliskiren hemifumarate, 35
aliskiren/amlodipine, 35
aliskiren/amlodipine/hctz, 35
aliskiren/hydrochlorothiazid, 35
aliskiren/valsartan, 35
alitretinoin, 97
ALKYLATING AGENTS, 21
allopurinol sodium, 6
allopurinol tablet, 6
alosetron, 64
ALPHA BLOCKERS, 30
alpha-1-proteinase inhibitor, 92
ALPHAGAN P 0.1% DROPS, 87
ALREX, 86
altavera, 85
altretamine, 21
alyacen, 85
amantadine, 43
ambrisentan, 37
amcinonide, 96
a-methapred 40 mg univial, -125 mg vial, 58
a-methapred 40 mg vial, 58
amethia, 55
amethia lo, 85

amethyst, 55
AMEVIVE, 25
amifostine, 25
amikacin 1,000 mg/4 ml vial, -1,000 mg/4
ml, 10
amikacin sulfate 100 mg/2 ml, -500 mg/2 ml,
-500 mg/2 ml, 14
amiloride hcl tablet, 35
amiloride-hydrochlorothiazide, 35
amino acids, 82, 83
AMINOGLYCOSIDES, 10
aminophylline 250 mg/10 ml vl, 93
aminophylline 500 mg/20 ml vl, 93
aminophylline tablet, 93
aminosalicylic acid, 18
AMINOSYN 3.5% IV SOLUTION, -5% IV
SOLUTION, -7% IV SOLUTION, -8.5% IV
SOLUTION, -10% IV SOLUTION, 82
aminosyn 8.5% iv solution, 82
AMINOSYN II 3.5% M-DEXTROSE 5%, 82
AMINOSYN II 3.5%-DEXTROSE 25%, 82
AMINOSYN II 3.5%-DEXTROSE 5%, 82
AMINOSYN II 4.25%-DEXTROSE 25%, 82
AMINOSYN II 5% IN 25% DEXTROSE, 82
AMINOSYN II 7% IV SOLUTION, -8.5%
ELECTROLYT, -10% IV SOLUTION, -15%
IV SOLUTION, 83
aminosyn ii 8.5% electrolyt, 83
AMINOSYN II IN DEXTROSE, 83
AMINOSYN II WITH LYTES-CA-DW, 83
AMINOSYN M, 83
AMINOSYN-HBC, 83
aminosyn-hf, 83
AMINOSYN-PF, 83
amiodarone, 32
amiodarone 150 mg/3 ml amp, 32
amiodarone 150 mg/3 ml vial, -450 mg/9 ml
vial, -900 mg/18 ml vial, 37
amiodarone hcl tablet, 32
AMIODARONES, 37
AMITIZA, 64
amitriptyline hcl tablet, 41
amlodipine bes/olmesartan med, 31
amlodipine besylate tablet, 34
amlodipine/valsartan, 31
Page 102 of 139

amlodipine/valsartan/hctz, 31
amlodipine-atorvastatin, 38
amlodipine-benazepril 2.5-10, --benazepril 510 mg, 29
amlodipine-benazepril 5-40 mg, --benazepril
10-20 mg, --benazepril 5-20 mg, -benazepril 10-40 mg, 30
ammonium lactate cream, -lotion, 97
amnesteem, 94
amox tr-potassium clavulanate, 14
amoxapine, 41
AMOXAPINE, 41
amoxicillin, 14
amoxicillin-clavulanate er, 14
amphetamine salt combo, 46
amphotericin b injection, 16
ampicillin 125 mg vial, -1 gm vial, -10 gm
vial, 14
ampicillin 250 mg vial, -500 mg vial, -1 gm av vial, -2 gm a-v vial, -2 gm vial, 13
ampicillin trihydrate, 14
ampicillin-sulbactam 1.5 gm vl, -sulb 3 gm
add vial, 13
ampicillin-sulbactam 3 gm vial, -15 gm vl, 14
AMPYRA, 47
AMTURNIDE, 35
amylase/lipase/protease, 64
ANADROL-50, 50
anagrelide hcl, 69
ANALGESICS, 6, 26
anastrozole tablet, 23
ANCOBON, 16
ANDRODERM, 50
ANDROGEL, 50
ANDROGENS, 50
ANDROXY, 50
ANESTHETICS, 10
ANGIOTENSIN II RECEPTOR ANTAGONIST
COMBINATIONS, 31
ANGIOTENSIN II RECEPTOR ANTAGONISTS,
31
ANTABUSE, 48
ANTARA, 33
ANTHRACYCLINES, 21
ANTIACNE DRUGS, 49

ANTIALLERGICS, 86
ANTIANXIETY, 38
ANTIARRHYTHMICS, 32
ANTIBACTERIALS, 10, 14
ANTIBIOTICS, 21
ANTICHOLINERGIC ANTISPASMODICS, 98
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS, 89
ANTICHOLINERGICS, 90
ANTICOAGULANTS, 67
ANTICONVULSANTS, 39
ANTIDEMENTIA, 40
ANTIDEMENTIA DRUGS, 26
ANTIDEPRESSANTS, 41
ANTIDIABETICS, INJECTABLE, 50
ANTIDIABETICS, ORAL, 52
ANTIEMETICS, 62
ANTIFUNGALS, 16
ANTIGLAUCOMA, 87
ANTIGLAUCOMA DRUGS, 89
ANTIHISTAMINES, 90, 93
ANTI-INFECTIVE/ANTI-INFLAMMATORY, 87
ANTIINFECTIVES, 10
ANTI-INFECTIVES, 14
ANTI-INFECTIVES, 88
ANTIINFECTIVES SPECIALIZED
INDICATIONS, 11
ANTI-INFLAMMATORIES, 88
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS, 32
ANTILIPEMICS, MISCELLANEOUS, 33
ANTIMALARIALS, 17
ANTIMETABOLITES, 21
ANTIMITOTIC, TAXOIDS, 22
ANTIMITOTIC, VINCA ALKALOIDS, 22
ANTINEOPLASTIC AGENTS, 21
ANTINEOPLASTIC/IMMUNOSUPPRESSANT
DRUGS, 25
ANTIPARKINSON ANTICHOLINERGIC
DRUGS, 26
ANTIPARKINSONIAN AGENTS, 43
ANTIPSYCHOTIC DRUGS, 26
ANTIPSYCHOTICS, 44
ANTIRETROVIRAL AGENTS, 11, 17
ANTIRETROVIRALS AND PROTEASE INH, 11
Page 103 of 139

ANTISPASMODICS, 63
ANTISPASMODICS/DRUGS AFFECT GI
MOTILITY, 65
ANTITUBERCULAR AGENTS, 18
ANTIULCER DRUGS, 65
ANTIVERTIGO AND ANTIEMETIC DRUGS, 27
ANTIVIRALS, 19
APIDRA, 51
APIDRA SOLOSTAR, 51
APOKYN, 43
apomorphine hcl, 43
apraclonidine hcl, 87
aprepitant, 62
apri, 55
APRISO, 63
APTIVUS, 17
ARALAST NP 500 MG VIAL, 92
aranelle, 55
arbinoxa, 93
ARCALYST, 70
ARICEPT 23 MG TABLET, 40
aripiprazole, 44
ARIXTRA 2.5 MG SYRINGE, 67
ARIXTRA 5 MG SYRINGE, -7.5 MG SYRINGE,
-10 MG SYRINGE, 67
armodafinil, 48
AROMASIN, 23
arsenic trioxide, 24
artemether/lumefantrine, 17
ARTHROTEC 50, 9
ARTHROTEC 75, 9
ASACOL, 63
ASACOL HD, 63
ascomp with codeine, 6
asenapine, 45
ASMANEX, 92
asparaginase, 24
aspirin/dipyridamole, 69
ASTEPRO, 90
ASTRAMORPH-PF 0.5 MG/ML AMP, 27
astramorph-pf 1 mg/ml ampul, 7
astramorph-pf 5 mg/10 ml vial, -10 mg/10 ml
vial, 7
atazanavir sulfate, 18
atenolol tablet, 33

atenolol-chlorthalidone, 33
atomoxetine, 46
atorvastatin calcium, 32
atovaquone, 20
atovaquone/proguanil hcl, 17
atovaquone-proguanil 250-100, 17
atovaquone-proguanil 62.5-25, 13
ATRIPLA, 17
atropine 0.1 mg/ml abboject, -0.1 mg/ml
syringe, -0.05 mg/ml syringe, 32
atropine 0.4 mg/0.5 ml ampul, -0.4 mg/ml
vial, -1 mg/ml ampul, -1 mg/ml vial, 29
atropine 8 mg/20 ml vial, 29
ATROVENT HFA, 90
ATTENTION DEFICIT HYPERACTIVITY
DISORDER, 46
AURORA PEN NEEDLE 6MM 31G, -AURORA
PEN NEEDLES 12MM 29G, -AURORA PEN
NEEDLES 8MM 31G, -BD PEN NEEDLE
29GX1/2, -BD PEN NEEDLE 29GX3/16, -BD
PEN NEEDLE 29GX5/16, -BD PEN NEEDLE
30GX3/16, -BD PEN NEEDLE MINI
31GX3/16, -BD PEN NEEDLE NANO
32GX5/32, -BD PEN NEEDLE SHORT
31GX5/16, -CLICKFINE PEN NDL 31GX1/4,
-CLICKFINE PEN NDL 31GX5/16, -INSULIN
PEN NEEDLE, -LIVE BETTER PEN NEEDLE
6MM 31G, -LIVE BETTER PEN NEEDLES
12MM, -LIVE BETTER PEN NEEDLES 8MM,
-MS PEN NEEDLE 6MM 31G, -12MM 29G
NEEDLES, -8MM 31G NEEDLES, -31G X
3/16, -31GX3/16, -31GX5/16, -6MM 31G, S 12MM 29G, -S 29G, -S 31G, -S 31G X
5/16, -S 5MM 31G, -S 6MM 31G, -S 8MM
31G, -RELION PEN 29G NEEDLE, -RELION
PEN 31G NEEDLE, -TODAY'S HLT PN
NEEDLE 12MM 29G, -TODAY'S HLTH PN
NEEDLE 6MM 31G, -TODAY'S HLTH PN
NEEDLE 8MM 31G, -UNIFINE PENTIP
12MM 29G, -UNIFINE PENTIP 6MM 31G, UNIFINE PENTIP 8MM 31G, 76
AUTO INJECTOR, 77
AUTOJECT 2, 77
AUTONOMIC AND CNS MEDICATIONS, 26
AUTOPEN, 77
Page 104 of 139

AVALIDE 150-12.5 MG TABLET, -300-12.5
MG TABLET, 31
AVALIDE 300-25 MG TABLET, 31
AVAPRO, 31
AVASTIN 100 MG/4 ML VIAL, 22
AVASTIN 400 MG/16 ML VIAL, 25
AVELOX, 14
AVELOX ABC PACK, 14
AVELOX IV, 14
aviane, 55
avita, 94
AVODART, 66
AVONEX, 47
AVONEX ADMINISTRATION PACK, 47
AVONEX PEN, 73
axitinib, 23
azacitidine, 22
AZASAN, 70
AZASITE, 88
azathioprine, 70
azathioprine sodium, 70
azathioprine tablet, 70
azelastine hcl, 90
azelastine hcl nasal drops/sprays, 90
azelastine hcl ophth drops, 87
AZILECT, 43
azithromycin, 88
azithromycin injection, -suspension, -tablet,
14
azithromycin packet, 12
AZOPT, 87
AZOR, 31
aztreonam 1 gm vial, 20
aztreonam 2 gm vial, 12
aztreonam lysine, 92
azurette, 85
baciim, 20
bacitracin 500 unit/gm ointmnt, 88
bacitracin injection, 20
bacitracin-polymyxin eye oint, 88
baclofen tablet, 48
BACTROBAN CREAM, 94
balsalazide disodium, 63
balziva, 55
BANZEL, 39

BARACLUDE SOLUTION, 19
BARACLUDE TABLET, 19
basiliximab, 23
baycadron, 60
BD INTEGRA SYR 1 ML 29GX1/2, 77
BD INTEGRA SYRINGE 1 ML 25GX1, 77
BD SAFTGLD INS 0.3 ML 31GX5/16, -BD
SAFTGLD INS SYR 0.5 ML 30G, -INSULIN
SAFETY SYRINGE, 77
becaplermin, 98
beclomethasone, 92
belatacept, 71
belimumab, 70
benazepril hcl tablet, 30
benazepril-hydrochlorothiazide, 30
bendamustine hcl, 21
BENICAR, 31
BENICAR HCT 20-12.5 MG TABLET, 31
BENICAR HCT 40-25 MG TABLET, -40-12.5
MG TABLET, 31
BENIGN PROSTATIC HYPERPLASIA, 66
BENLYSTA, 70
benztropine 2 mg/2 ml ampule, 26
benztropine 2 mg/2 ml vial, 43
benztropine mesylate tablet, 43
BETA AGONISTS, 91
BETA-2 ADRENERGIC DRUGS, 93
BETA-ADRENERGIC ANTAGONIST DRUGS,
37
BETA-BLOCKER/DIURETIC COMBINATIONS,
33
BETA-BLOCKERS, 33
betaine hcl, 57
betamethasone dipropionate cream, -dp aug
0.05% lot, -oint, 96
betamethasone dipropionate gel, 49
betamethasone dp 0.05% lot, 96
betamethasone valerate cream, -lotion, -oint,
96
betaxolol, 87
betaxolol hcl ophth drops, 87
betaxolol hcl tablet, 33
bethanechol chloride tablet, 66
BETIMOL, 87
BETOPTIC S, 87
Page 105 of 139

bevacizumab, 22, 25
bexarotene, 24, 97
bicalutamide, 23
BICILLIN C-R, 14
BICILLIN L-A, 14
BICNU, 21
BIDIL, 36
bimatoprost, 87
BIOLOGIC RESPONSE MODIFIERS, 22
bisoprolol fumarate, 33
bisoprolol-hydrochlorothiazide, 33
BISPHOSPHONATES, 54
bleomycin sulfate, 21
BLEPHAMIDE S.O.P., 87
BLOOD DETOXICANTS, 80
BOOSTRIX, 71
bortezomib, 22
bosentan, 37
briellyn, 55
brimonidine tartrate, 87
brimonidine tartrate/timolol, 87
brinzolamide, 87
bromfenac sodium, 88
bromocriptine mesylate capsule, -tablet, 43
budeprion sr, 41
budeprion xl, 41
budesonide, 63
budesonide ec, 63
budesonide nebs, 92
budesonide/formoterol fum, 92
bumetanide injection, 35
bumetanide tablet, 35
BUPHENYL TABLET, 57
buprenorphine 0.3 mg/ml syrn, 9
buprenorphine 0.3 mg/ml vial, 26
buprenorphine hcl tab, sl, 48
buprenorphine/naloxone, 49
buproban, 49
bupropion hcl sr, 41
bupropion hcl tablet, 41
bupropion xl, 29
buspirone hcl tablet, 38
busulfan, 21
BUSULFEX, 21
butalb-caff-acetaminoph-codein, 6

butalbital compound-codeine, 28
butorphanol tartrate aerosol, -injection, 6
BYETTA 10 MCG DOSE PEN INJ, 51
BYETTA 5 MCG DOSE PEN INJ, 51
BYSTOLIC, 33
c1 esterase inhibitor, 69
cabergoline, 59
calcipotriene, 95
calcitonin, 55
CALCITONINS, 54
calcitonin-salmon, 54
calcitriol capsule, -solution, 85
calcitriol injection, 85
calcium acetate, 59
calcium acetate capsule, -tablet, 59
CALCIUM ANTAGONISTS, 37
CALCIUM CHANNEL BLOCKERS, 34
CALCIUM RECEPTOR ANTAGONISTS, 55
camila, 55
CAMPATH, 22
CAMPRAL, 49
camrese, 85
camrese lo, 86
CANASA, 63
CANCIDAS, 16
CAPASTAT SULFATE, 18
CAPRELSA, 23
capreomycin, 18
captopril tablet, 30
captopril-hydrochlorothiazide, 30
CARAC, 94
CARAFATE ORAL SUSP, 64
carbamazepine, 39, 40
carbamazepine capsule sustained action, chew tab, -oral susp, -tablet, 39
carbamazepine er, 27
carbamazepine xr, 39
CARBAMAZEPINES, 27
CARBATROL, 39
carbidopa/levodopa/entacap, 43
carbidopa-levodopa, 43
carbidopa-levodopa-entacapone, 29
carbinoxamine maleate, 90
carboplatin, 24
CARDIAC GLYCOSIDES, 38
Page 106 of 139

CARDIOVASCULAR, 29
CARDIOVASCULAR MEDICATIONS, 37
CARDIZEM CD 360 MG CAPSULE, 34
carisoprodol 250 mg tablet, 80
carisoprodol 350 mg tablet, 48
carmustine, 21
carteolol hcl, 87
cartia xt, 34
carvedilol, 33
caspofungin acetate, 16
CAYSTON, 92
caziant, 86
CEENU, 21
cefaclor, 14
CEFACLOR ER, 14
cefadroxil, 14
cefazolin, 11, 14
cefazolin 1 gm add-van vial, 11
CEFAZOLIN 1 GM-D5W BAG, 14
cefazolin 10 gm vial, 14
cefazolin 20 gm bulk vial, -500 mg vial, -1
gm vial, 14
cefdinir, 14
cefepime hcl, 14
cefixime, 16
cefotaxime sodium, 14
cefotetan, 14
cefoxitin, 14
cefoxitin sodium, 14
cefpodoxime proxetil, 14
cefprozil, 14
ceftazidime 1 gm vial, -2 gm vial, -6 gm vial,
14
ceftazidime 500 mg vial, 11
ceftriaxone 1 gm piggyback, -2 gm
piggyback, -2 gm vial, 11
ceftriaxone 1 gm vial, -2 gm add vial, 14
ceftriaxone 250 mg vial, -500 mg vial, -1 gmd5w bag, -2 gm-d5w bag, -10 gm vial, 14
cefuroxime axetil, 15
cefuroxime sod 750 mg vial, -sod 1.5 gm
vial, -sod 7.5 gm vial, 15
cefuroxime tablet, 15
CELEBREX, 9
celecoxib, 9

CELLCEPT CAPSULE, -TABLET, 70
CELLCEPT INJECTION, 71
CELLCEPT ORAL SUSP, 71
CELONTIN, 39
CENTRAL NERVOUS SYSTEM, 38
cephalexin, 15
CEPHALOSPORINS, 11
CEREZYME 200 UNITS VIAL, 57
CEREZYME 400 UNITS VIAL, 61
certolizumab pegol, 25, 63
cerubidine, 21
CERVARIX, 71
cesia, 55
cetirizine hcl 1 mg/ml syrup, 90
cevimeline, 98
CHANTIX, 49
CHELATING AGENTS, 55
chlorambucil, 21
chloramphenicol sod succinate, 15
chlorhexidine gluconate dental/mucous
membrn products, 98
chloroquine phosphate tablet, 17
chlorothiazide, 36
chlorothiazide sodium, 36
chlorpromazine, 44
CHLORPROMAZINE HCL INJECTION, 44
chlorpromazine hcl tablet, 44
chlorthalidone, 36
chlorzoxazone, 48
cholestyramine, 38
cholestyramine light packet, 33
cholestyramine light powder, 38
chorionic gonadotropin injection, 59
CIALIS, 66
ciclodan cream, 12
ciclodan soln, top, 12
ciclopirox cream, -gel, -lotion, oil,shampoo,cleanser, -soln, top, 95
ciclopirox kit, 12
cilostazol, 69
CILOXAN OINT, 88
cimetidine injection, 63
cimetidine solution, -tablet, 63
CIMZIA 200 MG VIAL KIT, -200 MG/ML
SYRINGE KIT, 63
Page 107 of 139

CIMZIA 200 MG/ML STARTER KIT, 25
cinacalcet hcl, 55
CINRYZE, 69
CIPRO SUSPENSION, 15
ciprofloxacin, 15, 88
ciprofloxacin 200 mg/20 ml vl, 13
ciprofloxacin 400 mg/40 ml vl, 15
ciprofloxacin er, 15
ciprofloxacin hcl ophth drops, 88
ciprofloxacin hcl tablet, 15
cisplatin 1 mg/ml vial, 24
cisplatin 100 mg/100 ml vial, 24
citalopram, 29
citalopram hbr 10 mg tablet, -20 mg tablet,
41
citalopram hbr solution, -40 mg tablet, 41
cladribine, 24
claravis, 94
CLARINEX 5 MG TABLET, 90
CLARINEX SYRUP, -2.5 MG REDITABS, -5 MG
REDITABS, 90
clarithromycin er, 15
clarithromycin suspension, -tablet, 15
CLASS II NARCOTICS, 27
CLASS III NARCOTICS, 28
clemastine fumarate syrup, -fum 2.68 mg
tab, 90
CLEOCIN 100 MG VAGINAL OVULE, 67
CLEOCIN HCL 75 MG CAPSULE, 20
CLEOCIN PALMITATE, 20
CLICKFINE, 77
clinda-benzoyl perox 1-5% gel, 49
clindacin p, 49
clindamycin 150 mg/ml addvan, 20
clindamycin hcl, 20
clindamycin hcl 150 mg caps, -300 mg
capsule, 20
clindamycin hcl 75 mg capsule, 11
clindamycin palmitate, 20
clindamycin palmitate hcl, 11
clindamycin ph 300 mg/2 ml vl, -ph 600
mg/4 ml vl, -ph 9 g/60 ml vial, -ph 900
mg/6 ml vl, 11
clindamycin phos-benzoyl perox, 49
clindamycin phosphate, 67

clindamycin phosphate foam (noncontraceptive), -gel, -lotion, -soln, top, swabs, applicators, 94
clindamycin phosphate vaginal products, 67
clindamycin-benzoyl perox gel, 94
CLINDAMYCINS, 11
CLINIMIX, 83
CLINIMIX E 2.75%-10% SOLUTION, -2.75%5% SOLUTION, -4.25%-25% SOLUTION, 4.25%-5% SOLUTION, -5%-15%
SOLUTION, -5%-20% SOLUTION, -5%25% SOLUTION, 83
clinisol, 83
clobetasol emollient, 96
clobetasol propionate cream, 49
clobetasol propionate foam (noncontraceptive), -gel, -lotion, oil,shampoo,cleanser, -oint, -soln, top, 96
clomipramine hcl capsule, 41
clonidine, 30
clonidine hcl tablet, 30
clopidogrel, 69
clopidogrel 300 mg tablet, 69
clopidogrel 75 mg tablet, 69
clotrimazole 1% cream, -soln, top, 95
clotrimazole lozenge, 16
clotrimazole-betamethasone, 94
clozapine, 44
clozapine odt, 26
CNS MUSCLE RELAXANTS, 80
CNS STIMULANT DRUGS, 28
COARTEM, 17
codeine sulfate, 7
co-gesic, 6
colchicine, 6
COLCRYS, 6
colesevelam, 33
colestipol hcl packet, 38
colestipol hcl powder, -tablet, 33
colistimethate 150 mg vial, 20
collagenase, 98
colocort, 63
COMBIGAN, 87
COMBIPATCH, 57
COMBIVENT, 89
Page 108 of 139

COMBIVENT RESPIMAT, 90
COMBIVIR, 17
COMPLERA, 17
compro, 62
COMTAN, 43
COMVAX, 71
constulose, 64
CONTRACEPTIVES, 55, 85
COPAXONE, 47
COREG CR, 33
cormax, 49
cortisone acetate tablet, 58
cortomycin, 98
COSMEGEN, 21
COUMADIN TABLET, 67
CREON, 64
CRESTOR 40 MG TABLET, 32
CRESTOR 5 MG TABLET, -10 MG TABLET, 20 MG TABLET, 32
CRIXIVAN, 17
crizotinib, 24
cromolyn, 64
cromolyn sodium nebs, 91
cromolyn sodium ophth drops, 87
cromolyn sodium solution, 91
cryselle, 55
CUBICIN, 20
CURITY ALCOHOL PREPS, 77
CURITY GAUZE SPONGES, 77
cyclafem, 55
cyclobenzaprine 7.5 mg tablet, 48
cyclobenzaprine hcl capsule sustained action,
-5 mg tablet, -5 mg tablet, -10 mg tablet,
48
cyclopentolate hcl ophth drops, 89
cyclophosphamide tablet, 21
cycloserine, 18
cyclosporine, 71, 89
cyclosporine 50 mg/ml amp, 71
cyclosporine 50 mg/ml vial, 71
cyclosporine capsule, -solution, 71
cyclosporine modif 100 mg cap, -100 mg, 71
cyclosporine modified 25 mg, 25
CYKLOKAPRON, 69

CYMBALTA 20 MG CAPSULE, -30 MG
CAPSULE, 41
CYMBALTA 60 MG CAPSULE, 41
cyproheptadine hcl syrup, -tablet, 90
CYSTADANE, 57
CYSTAGON, 57
cysteamine, 57
cytarabine 20 mg/ml vial, -500 mg vial, 21
cytarabine 500 mg/25 ml vial, -100 mg/ml
vial, -2 g/20 ml vial, 22
cytra-k packet, 99
d5%-1/4ns-kcl 10 meq/l iv sol, -d5%-1/4nskcl 40 meq/l iv sol, -kcl 10 meq in d5w-1/4
ns, -kcl 5 meq in d5w-1/4 ns, 84
d5w/electrolyte-56 solution, 85
D5W/KCL 10 MEQ/L IV SOLUTION, 84
dabigatran etexilate mesylate, 68
dacarbazine, 21
dactinomycin, 21
dalfampridine, 47
DALIRESP, 92
dalteparin (porcine), 67, 68
danazol capsule, 57
dantrolene sodium capsule, 48
dapsone tablet, 20
DAPTACEL, 71
daptomycin, 20
DARAPRIM, 17
darifenacin hydrobromide, 66
darunavir ethanolate, 18
dasatinib, 24
dasetta, 86
daunorubicin hcl, 21
deferasirox, 55
delavirdine mesylate, 18
demeclocycline hcl tablet, 15
DENAVIR, 96
denileukin diftitox, 22
denosumab, 54
denta 5000 plus, 81
dentagel, 81
deoxyribonuclease, 92
depade, 49
DEPO-PROVERA 400 MG/ML VIAL, 23
DERMA-SMOOTHE-FS, 96
Page 109 of 139

DERMATOLOGICAL MEDICATIONS, 49
DERMATOLOGY, ACNE, 94
DERMATOLOGY, ACTINIC KERATOSIS, 94
DERMATOLOGY, ANTIBIOTICS, 94
DERMATOLOGY, ANTIFUNGALS, 95
DERMATOLOGY, ANTIPRURITIC, 95
DERMATOLOGY, ANTIPSORIATICS, 95
DERMATOLOGY, ANTISEBORRHEICS, 95
DERMATOLOGY, ANTIVIRALS, 96
DERMATOLOGY, CORTICOSTEROIDS, 96
DERMATOLOGY, IMMUNOMODULATORS, 97
DERMATOLOGY, LOCAL ANESTHETICS, 97
DERMATOLOGY, MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE, 97
DERMATOLOGY, ROSACEA, 97
DERMATOLOGY, SCABICIDES AND
PEDICULIDES, 98
DERMATOLOGY, WOUND CARE AGENTS, 98
DERMOTIC, 98
desipramine hcl tablet, 41
desloratadine, 90
desmopressin 0.01% solution, -0.01% spray,
-tablet, 60
desmopressin 0.1 mg/ml spray, 61
desmopressin ac 4 mcg/ml amp, 61
desmopressin ac 4 mcg/ml vl, 60
desonide cream, -lotion, -oint, 96
desoximetasone 0.05% ointment, 49
desoximetasone cream, -gel, -0.25%
ointment, 96
desvenlafaxine succinate, 42
DETROL, 66
DETROL LA 2 MG CAPSULE, 66
DETROL LA 4 MG CAPSULE, 66
dexamethasone, 58
dexamethasone 0.5 mg/5 ml elx, -tablet, 58
dexamethasone 0.5 mg/5 ml liq, 60
dexamethasone 10 mg/ml vial, -100 mg/10
ml vl, 61
dexamethasone 120 mg/30 ml vl, -20 mg/5
ml vial, -4 mg/ml vial, 58
DEXAMETHASONE INTENSOL, 58
dexamethasone sodium phosphate ophth
drops, 88
dexchlorpheniramine maleate, 90

DEXILANT, 64
dexlansoprazole, 64
dexmethylphenidate hcl, 46
dexrazoxane, 25
dextroamphetamine sulfate capsule
sustained action, -tablet, 46
dextroamphetamine-amphetamine, 46
dextromethorphan/quinidine, 47
dextrose 10%-0.2% nacl, 84
dextrose 10%-1/4ns, 84
DEXTROSE 10%-1/4NS-KCL, 84
dextrose 2.5%-water iv soln, -25%-water
syringe, -30%-water iv soln, -40%-water iv
soln, -50%-water abboject, -50%-water iv
soln, -50%-water syringe, -50%-water vial,
-70%-water iv soln, 80
dextrose 5%-1/2ns-kcl, 84
dextrose 5%-1/3ns-kcl, 84
DEXTROSE 5%-ELECTROLYTE #48, 84
dextrose 5%-water iv soln, -10%-water iv
solution, 84
dextrose in lactated ringers, 84
dextrose with sodium chloride, 84
dextrose/electrolytes, 84
dextrose/nacl/kcl, 84
DIABETIC SUPPLIES, 73
diazoxide, 59
diclofenac potassium, 9
diclofenac sodium, 94, 97
diclofenac sodium e.c. tab, -tablet sustained
action, 9
diclofenac sodium ophth drops, 88
diclofenac sodium/misoprostol, 9
dicloxacillin sodium, 15
dicyclomine hcl capsule, -syrup, -tablet, 63
dicyclomine hcl injection, 63
didanosine, 17, 18
diflorasone diacetate, 96
diflunisal tablet, 9
DIGITALIS GLYCOSIDES, 35
digoxin, 35
digoxin 0.25 mg/ml ampul, 35
digoxin 0.25 mg/ml syringe, 38
digoxin solution, -tablet, 35
dihydroergotamine 1 mg/ml am, 47
Page 110 of 139

dihydroergotamine 1 mg/ml vl, 47
DILANTIN 100 MG CAPSULE, 39
DILANTIN 30 MG CAPSULE, -CHEW TAB, 39
DILANTIN-125, 39
DILAUDID SOLUTION, 7
dilt xr 120 mg capsule, 37
dilt xr 180 mg capsule, -dilt xr 240 mg
capsule, 34
dilt-cd 120 mg capsule, -er 300 mg capsule,
34
dilt-cd 180 mg capsule, -240 mg capsule, 37
diltiazem, 34
diltiazem 125 mg/25 ml vial, -50 mg/10 ml
vial, 37
diltiazem 24hr cd 120 mg cap, -240 mg cap,
-300 mg cap, 34
diltiazem 24hr cd 180 mg cap, -360 mg cap,
37
diltiazem 24hr er 120 mg cap, -240 mg cap, 300 mg cap, 34
diltiazem 24hr er 180 mg cap, -360 mg cap,
37
diltiazem 25 mg/5 ml vial, -100 mg vial, 34
diltiazem er 120 mg capsule, -240 mg
capsule, -hcl er 240 mg cap, -hcl er 300
mg cap, 37
diltiazem er 60 mg 12-hr cap, -90 mg 12-hr
cap, -120 mg 12-hr cap, -180 mg capsule,
-hcl er 360 mg cap, -hcl er 420 mg cap, 34
diltiazem hcl tablet, 34
diltzac er 120 mg capsule, -180 mg capsule, 240 mg capsule, -300 mg capsule, 34
diltzac er 360 mg capsule, 37
DIOVAN, 31
DIOVAN HCT 160-25 MG TABLET, -320-12.5
MG TAB, -320-25 MG TABLET, 31
DIOVAN HCT 80-12.5 MG TABLET, -160-12.5
MG TAB, 31
diphenhydramine 50 mg capsule, -elix, -50
mg/ml vial, 90
diphenhydramine 50 mg/ml syrng, 93
diphenoxylate-atropine, 64
diphther,pertuss,tetanus vac, 71, 72, 73
DIPHTHERIA-TETANUS TOXOID, 71
dipyridamole tablet, 69

DIRECT RENIN
INHIBITORS/COMBINATIONS, 35
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS), 69
disopyramide, 32
disopyramide phosphate, 32
disulfiram, 48
disulfiram tablet, 49
DIURETICS, 35
divalproex sodium, 39
divalproex sodium er, 39
docetaxel, 22
dofetilide, 32
donepezil, 40
donepezil hcl 10 mg tablet, -odt 10 mg
tablet, 40
donepezil hcl 5 mg tablet, -odt 5 mg tablet,
40
dorzolamide hcl, 87
dorzolamide-timolol, 87
DOVONEX CREAM, 95
doxazosin mesylate, 30
doxepin, 95
doxepin hcl capsule, -solution, 41
DOXIL, 21
doxorubicin 150 mg/75 ml vial, 21
doxorubicin 200 mg/100 ml vial, 21
doxorubicin hcl liposome, 21
doxycycline hyclate capsule, -e.c. cap, -e.c.
tab, -injection, -tablet, 15
doxycycline mono 100 mg tablet, 13
doxycycline mono 50 mg cap, -mono 100 mg
cap, -mono 150 mg cap, 13
doxycycline mono 75 mg capsule, -mono 50
mg tablet, -mono 75 mg tablet, -mono 150
mg tablet, 15
doxycycline monohydrate, 97
dronabinol 10 mg capsule, 62
dronabinol 2.5 mg capsule, -5 mg capsule,
62
dronedarone, 32
DROXIA, 24
DRUGS AFFECTING THE NOSE, 50
DRUGS TO PREVENT AND TREAT
HEADACHES, 28
Page 111 of 139

DUETACT, 52
DULERA, 92
duloxetine, 41
duramorph, 7
dutasteride, 66
e.e.s. 400, 15
EAR-NOSE-THROAT MEDICATIONS, 50
EASY COMFORT INSULIN SYRINGE, 77
EASY TOUCH ALCOHOL PREP PADS, 77
EASY TOUCH INSULIN NEEDLES DISPOSABLE, -INSULIN SYRINGES DISPOSABLE, 77
EASY TOUCH INSULIN SYRINGE, 77
EASY-TOUCH INSULIN SYRINGE, 77
echothiophate iodide, 87
econazole nitrate cream, 95
ed k+10, 82
EDURANT, 17
efavirenz, 18
EFFIENT, 69
ELAPRASE, 57
electrolyte solution/peg's, 64
electrolyte solutions, 84, 85
ELECTROLYTES, 82
ELECTROLYTES, IRRIGATING SOLUTIONS,
ETC., 80
ELIDEL, 97
ELIGARD, 69
eliphos, 57
ELITEK 1.5 MG VIAL, 25
ELIXOPHYLLIN, 93
ELMIRON, 66
ELSPAR, 24
eltrombopag olamine, 69
elvitegr/cobicist/emtric/tenof, 18
EMCYT, 21
EMEND 125 MG CAPSULE, 62
EMEND 40 MG CAPSULE, 62
EMEND TRIFOLD PACK, -80 MG CAPSULE, 62
emoquette, 55
EMSAM, 41
emtricitab/rilpivirine/tenofov, 17
emtricitabine, 17
emtricitabine/tenofovir, 18
emtricitabine/tenofovir/efavir, 17

EMTRIVA, 17
ENABLEX 15 MG TABLET, 66
ENABLEX 7.5 MG TABLET, 66
enalapril maleate tablet, 30
enalapril-hydrochlorothiazide, 30
ENBREL 25 MG KIT, -25 MG/0.5 ML
SYRINGE, -50 MG/ML SYRINGE, 69
ENBREL 50 MG/ML SURECLICK SYR, 25
endocet, 7
ENDOCRINE AND METABOLIC, 50
ENDOCRINE MEDICATIONS, 60
endodan, 7
ENDOMETRIOSIS, 57
enfuvirtide, 11, 17
ENGERIX-B 10 MCG/0.5 ML PED VL, -10
MCG/0.5 ML SYRN, -10 MCG/0.5 ML SYRN,
-20 MCG/ML SYRINGE, 71
ENGERIX-B 20 MCG/ML VIAL, 72
enoxaparin 30 mg/0.3 ml syr, -40 mg/0.4 ml
syr, -60 mg/0.6 ml syr, -80 mg/0.8 ml syr,
-100 mg/ml syr, -120 mg/0.8 ml syr, -150
mg/ml syr, 67
enoxaparin 300 mg/3 ml vial, 81
enpresse, 55
entacapone, 43
entecavir, 19
ENTOCORT EC, 63
enulose, 64
ENZYME REPLACEMENTS, 57
epiklor, 81
epinastine hcl, 87
epinephrine 0.1 mg/ml syringe, 92
epinephrine 0.3 mg auto-inject, 94
epinephrine 1 mg/ml ampul, -1 mg/ml vial,
94
epinephrine hcl, 92
EPIPEN 2-PAK, 92
EPIPEN JR 2-PAK, 92
epirubicin hcl, 21
epitol, 39
EPIVIR HBV, 19
EPIVIR SOLUTION, 17
EPIVIR TABLET, 17
eplerenone, 30
epoetin alfa, 68
Page 112 of 139

eprosartan mesylate, 30
EPZICOM, 17
ergoloid mesylates tablet, 47
ergotamine tartrate/caffeine, 47
ergotamine-caffeine, 47
ERIVEDGE, 24
erlotinib hcl, 24
errin, 55
ertapenem sodium, 12, 20
ery, 94
ERYPED 200, 15
ERYTHROCIN 500 MG ADDVNT VL, 15
ERYTHROCIN 500 MG VIAL, 11
erythrocin stearate, 15
erythromycin e.c. cap, 11
erythromycin ethylsuccinate, 15
erythromycin ethylsuccinate tablet, 15
erythromycin gel, -soln, top, 94
erythromycin lactobionate, 11, 15
erythromycin oint, 88
erythromycin swabs, applicators, 49
erythromycin tablet, 15
erythromycin-benzoyl peroxide, 94
ERYTHROMYCINS, 11
erythromycin-sulfisoxazole, 20
escitalopram oxalate, 42
escitalopram oxalate solution, 41
escitalopram oxalate tablet, 41
esomeprazole mag trihyd, 65, 66
ESTRACE, 57
ESTRADERM, 57
estradiol, 57, 58
estradiol adh. patch, -tablet, 57
estradiol valerate injection, 57
estradiol/noreth ac, 57
estradiol-noreth 0.5-0.1 mg tb, 86
estradiol-noreth 1-0.5 mg tab, 57
estramustine phosphate sodium, 21
estrogen/medroxyprogesterone, 57
ESTROGEN/PROGESTIN COMBINATIONS, 86
ESTROGENS, 57
estrogens,conjugated, 57
estrogens,esterified, 57
estropipate, 57
eszopiclone, 46

etanercept, 25, 69
ethambutol hcl, 18
ethinyl estradiol/norelgest, 56
ethionamide, 18
ethosuximide capsule, -syrup, 39
ethotoin, 40
etidronate disodium, 54
etodolac capsule, -tablet, -tablet sustained
action, 9
etonogestrel/ethin estradiol, 56
etoposide injection, 25
etravirine, 11, 17
everolimus, 23, 71
EVISTA, 60
EVOXAC, 98
EXEL INSULIN SYRINGE, 77
EXELON 13.3 MG/24HR PATCH, 26
EXELON 4.6 MG/24HR PATCH, -9.5 MG/24HR
PATCH, 40
EXELON SOLUTION, 41
exemestane, 23
exenatide, 51
EXFORGE 5-160 MG TABLET, 31
EXFORGE 5-320 MG TABLET, -10-160 MG
TABLET, -10-320 MG TABLET, 31
EXFORGE HCT 5-160-12.5 MG TAB, 31
EXFORGE HCT 5-160-25 MG TAB, -10-16012.5 MG TAB, -10-160-25 MG TAB, -10320-25 MG TAB, 31
EXJADE 125 MG TABLET, 55
EXJADE 250 MG TABLET, -500 MG TABLET,
55
EXTAVIA, 48
ezetimibe, 33
ezetimibe/simvastatin, 33
ezogabine, 40
FABRAZYME 35 MG VIAL, 57
falmina, 86
famciclovir, 19
famotidine 10 mg/ml vial, -200 mg/20 ml
vial, -40 mg/4 ml vial, -500 mg/50 ml vial,
65
famotidine 20 mg/2 ml vial, -20 mg
piggyback, 63

Page 113 of 139

famotidine oral susp, -20 mg tablet, -40 mg
tablet, 63
FANAPT 1 MG TABLET, -2 MG TABLET, -4 MG
TABLET, -6 MG TABLET, -8 MG TABLET, 10 MG TABLET, -12 MG TABLET, 44
FANAPT TITRATION PACK, 44
FARESTON, 23
FASLODEX, 23
fat emulsions, 83
FAZACLO, 44
febuxostat, 6
felbamate, 39
FELBATOL, 39
felodipine er, 34
FEMARA, 23
fenofibrate, 33
fenofibric acid, 33
fenoprofen calcium tablet, 9
fentanyl, 7
fentanyl 0.05 mg/ml ampul, -0.05 mg/ml vial,
-1 mg/20 ml vial, -100 mcg/2 ml vial, -250
mcg/5 ml vial, 27
fentanyl 0.05 mg/ml syringe, 7
fentanyl 2,500 mcg/50 ml vial, 27
fentanyl citrate otfc 200 mcg, 7
fentanyl citrate otfc 400 mcg, -otfc 600 mcg,
-otfc 800 mcg, -cit otfc 1,200 mcg, -cit otfc
1,600 mcg, 7
fesoterodine fumarate, 66
fexofenadine hcl 60 mg tablet, 90
filgrastim, 68
finasteride tablet, 66
fingolimod hydrochloride, 48
flavoxate hcl, 66
flecainide acetate, 32
FLOVENT DISKUS, 92
FLOVENT HFA, 92
fluconazole suspension, -tablet, 16
fluconazole-dext 200 mg/100 ml, 12
fluconazole-dext 400 mg/200 ml, 16
flucytosine, 16
flucytosine capsule, 16
fludarabine phosphate, 24
fludrocortisone acetate tablet, 58
flunisolide 0.025% spray, 92

flunisolide 29 mcg-0.025% spr, 50
fluocinolone acetonide, 96, 98
fluocinolone acetonide cream, -oint, -soln,
top, 96
fluocinolone acetonide oil, 98
fluocinolone acetonide oil,shampoo,cleanser,
96
fluocinonide cream, 49
fluocinonide emollient, 96
fluocinonide gel, -oint, -soln, top, 96
fluocinonide-e, 96
FLUORIDE PRODUCTS, 81
fluoridex daily defense, 81
fluorometholone, 89
fluorometholone ophth drops, 89
fluorouracil, 94
fluorouracil 500 mg/10 ml vial, 22
fluorouracil cream, -soln, top, 94
fluoxetine dr, 41
fluoxetine hcl 10 mg capsule, -20 mg
capsule, 42
fluoxetine hcl 10 mg tablet, 42
fluoxetine hcl 40 mg capsule, -solution, -20
mg tablet, 42
fluoxymesterone, 50
fluphenazine decanoate injection, 44
fluphenazine hcl elix, -tablet, 44
fluphenazine hcl injection, -solution, 44
flurbiprofen sodium, 89
flurbiprofen tablet, 9
flutamide, 23
fluticasone furoate, 92
fluticasone propionate, 92
fluticasone propionate cream, -oint, 96
fluticasone propionate nasal inhaled steroids,
92
fluvastatin sodium, 32
fluvoxamine maleate 100 mg tab, 38
fluvoxamine maleate 25 mg tab, -50 mg tab,
39
FML S.O.P., 89
fomepizole, 59
fondaparinux 2.5 mg/0.5 ml syr, -5 mg/0.4
ml syr, 67

Page 114 of 139

FONDAPARINUX 7.5 MG/0.6 ML SYR, -10
MG/0.8 ML SYR, 67
fondaparinux sodium, 67
FORADIL, 91
formoterol fumarate, 91
FORTEO, 59
fortical, 55
fosamprenavir calcium, 18
foscarnet sodium, 19
fosinopril sodium, 30
fosinopril-hydrochlorothiazide, 30
fosphenytoin 100 mg pe/2 ml vl, 39
fosphenytoin 500 mg pe/10 ml, 39
FOSRENOL, 59
FRAGMIN 2,500 UNITS SYRINGE, -5,000
UNITS SYRINGE, -25,000 UNITS/ML VIAL,
67
FRAGMIN 7,500 UNITS SYRINGE, -10,000
UNITS SYRINGE, -12,500 UNITS SYRINGE,
-15,000 UNITS SYRINGE, -18,000 UNITS
SYRINGE, 68
freamine iii 8.5% iv soln., 83
FREAMINE III WITH ELECTROLYTES, 83
FREESTYLE PRECISION, 77
fulvestrant, 23
furosemide 10 mg/ml syringe, 38
furosemide 10 mg/ml vial, 36
furosemide solution, -tablet, 36
FUZEON 90 MG VIAL, 11
FUZEON CONVENIENCE KIT, 17
gabapentin, 40
gabapentin 100 mg capsule, 39
gabapentin 300 mg capsule, 39
gabapentin 400 mg capsule, 39
gabapentin 600 mg tablet, 39
gabapentin 800 mg tablet, 39
gabapentin solution, 39
GABITRIL 12 MG TABLET, -12 MG TABLET, 16 MG TABLET, -16 MG TABLET, 39
GABITRIL 2 MG TABLET, -2 MG TABLET, -4
MG TABLET, -4 MG TABLET, 39
galantamine er 16 mg capsule, -er 24 mg
capsule, -tablet, 41
galantamine er 8 mg capsule, 41
galantamine hydrobromide, 41

galsulfase, 57
GAMASTAN S-D, 70
GAMMAGARD LIQUID, 70
GAMUNEX, 70
GAMUNEX-C 1 GRAM/10 ML VIAL, 70
GAMUNEX-C 10 GRAM/100 ML VIAL, -2.5
GRAM/25 ML VIAL, -20 GRAM/200 ML
VIAL, -5 GRAM/50 ML VIAL, 72
ganciclovir 250 mg capsule, 19
ganciclovir 500 mg capsule, 19
ganciclovir sodium, 19
garamycin ophth drops, 89
GARDASIL SYRINGE, 73
GARDASIL VIAL, 71
GASTROCROM, 64
GASTROINTESTINAL, 62
GASTROINTESTINAL MEDICATIONS, 65
gatifloxacin, 88
gavilyte-c, 64
gavilyte-g, 64
gavilyte-n, 64
GELNIQUE GEL, 98
GELNIQUE PACKET, 66
gemcitabine, 22
GEMCITABINE HCL, 22
gemfibrozil tablet, 33
GEMZAR, 22
generlac, 80
gengraf, 71
GENITOURINARY, 66
gentak oint, 88
gentak ophth drops, 89
gentamicin 10 mg/ml vial, -40 mg/ml vial, 15
gentamicin 3 mg/gm eye oint, 89
gentamicin 90 mg/ns 100 ml pb, -70 mg/ns
50 ml pb, 10
gentamicin ped 10 mg/ml vial, 10
gentamicin sulfate cream, -0.1% ointment,
94
gentamicin sulfate ophth drops, 88
gentamicin/sodium chloride, 10
gentasol, 88
GEODON 20 MG CAPSULE, 44
GEODON 40 MG CAPSULE, 44

Page 115 of 139

GEODON 60 MG CAPSULE, -80 MG CAPSULE,
44
GEODON INJECTION, 44
gianvi, 55
gildess fe, 86
GILENYA, 48
glatiramer acetate, 47
GLEEVEC, 23
glimepiride 1 mg tablet, 52
glimepiride 2 mg tablet, 53
glimepiride 4 mg tablet, 53
glipizide 10 mg tablet, 53
glipizide 5 mg tablet, 53
glipizide er 10 mg tablet, 53
glipizide er 2.5 mg tablet, 53
glipizide er 5 mg tablet, 53
glipizide xl 10 mg tablet, 53
glipizide xl 2.5 mg tablet, 61
glipizide xl 5 mg tablet, 53
glipizide-metformin, 53
GLUCAGEN 1 MG HYPOKIT, 58
GLUCAGEN 1 MG VIAL, 61
GLUCAGON EMERGENCY KIT, 59
glucagon, human recombinant, 58, 59, 61
GLUCOCORTICOID DRUGS, 60
GLUCOCORTICOIDS, 58
GLUCOPRO, 77
GLUCOSE ELEVATING AGENTS, 58
GLUCOSE ELEVATING DRUGS, 61
glyburide 1.25 mg tablet, 53
glyburide 2.5 mg tablet, 53
glyburide 5 mg tablet, 53
glyburide micro 1.5 mg tab, 53
glyburide micro 3 mg tablet, 53
glyburide micro 6 mg tablet, 53
glyburide-metformin hcl, 53
glycopyrrolate injection, -tablet, 63
glycron 1.5 mg tablet, 53
glycron 3 mg tablet, 53
glycron 4.5 mg tablet, 53
glycron 6 mg tablet, 53
GOUT, 6
granisetron, 62
granisetron hcl 0.1 mg/ml vial, -4 mg/4 ml
vial, -tablet, 62

granisetron hcl 1 mg/ml vial, 62
granisol, 62
griseofulvin oral susp, 17
griseofulvin ultramicrosize, 17
GRIS-PEG, 17
guanabenz acetate tablet, 30
guanfacine hcl, 30
guanidine, 47
GUANIDINE HCL, 47
H2-RECEPTOR ANTAGONISTS, 63
haemophilus b vaccine, 72
haemophilus b-tet toxoid, 71
halobetasol propionate, 96
haloperidol dec 50 mg/ml vial, -dec 100
mg/ml vial, 44
haloperidol decan 50 mg/ml amp, 26
haloperidol decanoate 100, 26
haloperidol injection, 26
haloperidol lactate injection, 44
haloperidol lactate solution, 44
haloperidol tablet, 44
HAVRIX 720 UNIT/0.5 ML SYRINGE, -1,440
UNITS/ML VIAL, 72
HAVRIX 720 UNITS/0.5 ML VIAL, -1,440
UNITS/ML SYRINGE, 73
hctz/valsartan, 31
HEALTHY ACCENTS UNIFINE PENTIP, 77
heather, 86
hecoria, 25
HEMATOLOGIC, 67
HEMATOPOIETIC GROWTH FACTORS, 68
hep b vir recomb/hep a vir, 72, 73
heparin sod 1,000 unit/ml vial, -sod 5,000
unit/ml vial, -sod 10,000 unit/ml vl, -sod
20,000 unit/ml vl, 68
HEPARIN SOD 2,000 UNIT/ML VIAL, 68
heparin sod 2,500 unit/ml vial, -sod 5,000
unit/ml syr, -sod 5,000 unit/ 0.5 ml, -sod
5,000 unit/0.5 ml, 81
heparin sodium, 68
heparin sodium(porcine)/nacl, 68
heparin-1/2ns 25,000 unit/250, 68
HEPARIN-1/2NS 25,000 UNIT/500, 68
heparin-d5w 20,000 unit/500 ml, 68

Page 116 of 139

heparin-d5w 25,000 unit/500 ml, --d5w
25,000 unit/250 ml, 81
heparin-ns 1,000 unit/500 ml, 81
heparin-ns 2,000 unit/1,000 ml, 68
hepatamine, 83
HEPATASOL, 83
hepatatis a virus vaccine, 72, 73
hepatitis b virus vaccine, 71, 72, 73
hepatitis b/haemophilus b vacc, 71
HEPSERA, 19
HERCEPTIN, 22
HEXALEN, 21
HMG-COA REDUCTASE INHIBITORS, 38
HORMONAL ANTINEOPLASTIC AGENTS, 23,
69
HUMALOG 100 UNITS/ML CARTRIDGE, 61
HUMALOG 100 UNITS/ML KWIKPEN, -100
UNITS/ML VIAL, 51
HUMALOG MIX 50-50, 51
HUMALOG MIX 75-25, 51
HUMAN GROWTH HORMONES, 59
human papillomav vacc bival/pf, 71
human papillomavirus vacc, 71, 73
HUMAPEN LUXURA HD, 77
HUMAPEN MEMOIR, 77
HUMIRA, 69
HUMULIN 70-30 PEN, -VIAL, -RELION
HUMULIN 70-30 VIAL, 52
HUMULIN N 100 UNITS/ML PEN, -100
UNITS/ML VIAL, -RELION HUMULIN N 100
UNIT/ML, 52
HUMULIN R 100 UNITS/ML VIAL, -RELION
HUMULIN R 100 UNIT/ML, -500 UNITS/ML
VIAL, 52
HYDANTOINS, 29
hydralazine hcl injection, 36
hydralazine hcl tablet, 36
hydrochlorothiazide capsule, -tablet, 36
hydrocodon-acetaminoph 2.5-325, 28
hydrocodon-acetaminophen 5-300, hydrocodon-acetaminoph 7.5-300, hydrocodon-acetaminophn 10-300, 6
hydrocodone bit-ibuprofen, 6
hydrocodone-acetaminophen elix, -solution, hydrocodon-acetaminoph 2.5-500, -

hydrocodon-acetaminophen 5-325, hydrocodon-acetaminophen 5-500, hydrocodon-acetaminoph 7.5-325, hydrocodon-acetaminoph 7.5-750, hydrocodon-acetaminophn 10-650, hydrocodon-acetaminophn 10-325, hydrocodon-acetaminoph 7.5-500, hydrocodon-acetaminophn 10-500, hydrocodon-acetaminoph 7.5-650, hydrocodon-acetaminophn 10-660, hydrocodon-acetaminophn 10-750, 6
hydrocodone-ibuprofen, 28
hydrocortisone 1% cream, 96
hydrocortisone 1% cream, -2.5% cream, 2.5% lotion, -1% absorbase, -1%
ointment, -2.5% ointment, 96
hydrocortisone butyrate, 96
hydrocortisone rectal, 63
hydrocortisone sod succinate, 58
hydrocortisone tablet, 58
hydrocortisone valerate, 97
hydrocortisone-acetic acid, 98
hydrogesic, 28
hydromorphone, 7
hydromorphone 10 mg/ml vial, -50 mg/5 ml
vial, -500 mg/50 ml via, 7
hydromorphone hcl 1 mg/ml amp, -1 mg/ml
syringe, -2 mg/ml syringe, -2 mg/ml vial, 2 mg/ml amp, -2 mg/ml vl, -4 mg/ml syrin,
-4 mg/ml amp, 27
hydromorphone hcl 10 mg/ml amp, 7
hydromorphone hcl tablet, 7
hydroxychloroquine sulfate tablet, 69
hydroxypropylmethylcellulose, 89
hydroxyurea, 24
hydroxyurea capsule, 24
hydroxyzine hcl injection, 90
hydroxyzine hcl syrup, -tablet, 90
hydroxyzine pamoate capsule, 90
HYPNOTICS, 46
HYPOGLYCEMIC DRUGS, 61
HYPOLIPOPROTEINEMICS, 38
ibandronate sodium, 54
ibuprofen oral susp, -400 mg tablet, -600 mg
tablet, -800 mg tablet, 9
Page 117 of 139

idarubicin hcl, 21
idursulfase, 57
IFEX, 21
ifosfamide, 21
ifosfamide-mesna, 25
iloperidone, 44
imatinib mesylate, 23
imiglucerase, 57, 61
imipenem/cilastatin sodium, 20
imipenem-cilastatin sodium, 20
imipramine hcl tablet, 42
imipramine pamoate, 42
imiquimod, 50, 97
imiquimod cream, 97
immune globulin - im, 70
immune globulin - iv, 70
immune globulin - iv/sq, 70, 72
IMMUNOGLOBULINS, 70
IMMUNOLOGIC AGENTS, 69
IMMUNOLOGICALS AND VACCINES, 72
IMMUNOMODULATORS, 70
IMMUNOSUPPRESSANTS, 70
IMOVAX RABIES VACCINE, 72
IN CONTROL PEN NEEDLE, 77
INCIVEK, 19
INCONTROL, 77
INCRELEX, 59
indapamide, 36
indinavir, 17
INDOCIN ORAL SUSP, 9
indomethacin, 9
indomethacin capsule, -capsule sustained
action, 9
INFANRIX VACCINE SYRINGE, 73
INFANRIX VACCINE VIAL, 72
INFERGEN 15 MCG/0.5 ML VIAL, 70
INFERGEN 9 MCG/0.3 ML VIAL, 70
INFLAMMATORY BOWEL DISEASE, 63
infliximab, 69
INJECTABLE ANTICOAGULANTS, 81
INJECT-EASE, 77
INLYTA, 23
INSUL PEN NEEDLES 8MM, -, 77
INSULIN, 61

INSULIN SYR 1/2 ML BULK PACK, -1 ML
SYRN 27X1/2, -1 ML SYRN 28GX1/2, INSUL SYR U100, -INSUL SYR U100 0.5
ML, -INSUL SYR U100 1 ML, -INSULIN SYR
0.3 ML, -INSULIN SYR 0.5 ML, -INSULIN
SYR 1 ML, -INSULIN SYR U-100, -INSULIN
SYRN 3/10 ML, -SYRINGE 0.3 ML, SYRINGE 0.5 ML, -SYRINGE 1 ML, 77
INSULIN SYRINGE 0.3 ML, -0.3 ML, -0.5 ML,
-1 ML, 78
INSULIN SYRINGE 0.5 ML, -INSULIN
SYRINGE 1 ML, 52
INSUMED, 78
INSUPEN, 78
INTELENCE 100 MG TABLET, 17
INTELENCE 200 MG TABLET, 11
INTELENCE 25 MG TABLET, 11
interferon alfa-2b , recomb., 70
interferon alfacon-1, 70
interferon beta-1a, 47, 73
interferon beta-1a/albumin, 48
interferon beta-1b, 48
interferon gamma-1b,recomb., 70
INTERFERONS, 73
intralipid 20% iv fat emul, 83
INTRALIPID 30% IV FAT EMUL, 83
INTRON A 3 MILLION UNIT/ML PEN, -5
MILLION UNIT/ML PEN, -10 MILLION UNIT
PEN, 70
INTRON A 6 MILLION UNIT/ML VL, -10
MILLION UNITS VIAL, 70
introvale, 55
INVANZ 1 GM ADD-VANTAGE VIAL, 12
INVANZ 1 GM VIAL, 20
INVEGA ER 1.5 MG TABLET, -ER 3 MG
TABLET, 44
INVEGA ER 6 MG TABLET, -ER 9 MG TABLET,
44
INVEGA SUSTENNA 117 MG PREF SY, -156
MG PREF SY, -234 MG PREF SY, 44
INVEGA SUSTENNA 39 MG PREF SYR, -78
MG PREF SYR, 45
INVIRASE, 17
IONOSOL B WITH DEXTROSE 5%, 84
IONOSOL MB-DEXTROSE 5%, 84
Page 118 of 139

IONOSOL T-DEXTROSE 5%, 84
IPOL SINGLE DOSE SYRINGE, 73
IPOL VIAL, 72
ipratropium, 90
ipratropium bromide nasal drops/sprays, 90
ipratropium bromide nebs, 90
ipratropium-albuterol, 90
irbesartan, 31
irbesartan/hctz, 31
irbesartan-hydrochlorothiazide, 31
irinotecan hcl, 24
ISENTRESS CHEW TAB, 11
ISENTRESS TABLET, 18
ISO GENTAMICIN 120 MG/100 ML, 10
isocarboxazid, 42
isochron, 36
isoditrate, 38
ISOLYTE H WITH DEXTROSE, 84
isolyte m with dextrose, 84
ISOLYTE P WITH DEXTROSE, 84
ISOLYTE S IV SOLUTION-EXCEL, 84
ISOLYTE S WITH DEXTROSE, 84
isonarif, 18
isoniazid injection, 18
isoniazid syrup, -tablet, 18
isopropyl alcohol 70% wipe, 78
isopropyl alcohol 70% wipes, 78
ISORDIL, 36
isosorb dinit/hydralazine hcl, 36
isosorbide dinitrate, 36
isosorbide mononitrate, 36
isosorbide mononitrate er, 36
isoton gentamicin 60 mg/100 ml, -80 mg/ns
100 ml pb, -isoton gentamicin 80 mg/100
ml, -100 mg/ns 100 ml, -iso gentamicin
100 mg/100 ml, -60 mg/ns 50 ml pb, isoton gentamicin 60 mg/50 ml, -80 mg/ns
50 ml pb, -isoton gentamicin 80 mg/50 ml,
15
isradipine, 34
ISTODAX, 22
itraconazole capsule, 17
IV NUTRITION, 82
IV REPLACEMENT SOLUTIONS, 84
IXIARO, 72

JAKAFI, 23
jantoven, 68
JANUMET, 53
JANUMET XR, 53
JANUVIA 100 MG TABLET, 53
JANUVIA 25 MG TABLET, -50 MG TABLET, 53
japanese encephalitis vaccine, 72
jevantique, 86
JE-VAX, 72
jinteli, 55
jolessa, 86
jolivette, 55
junel, 55
junel fe, 55
KADIAN ER 10 MG CAPSULE, -ER 200 MG
CAPSULE, 7
KADIAN ER 20 MG CAPSULE, -ER 30 MG
CAPSULE, -ER 50 MG CAPSULE, -ER 60 MG
CAPSULE, -ER 80 MG CAPSULE, -ER 100
MG CAPSULE, 7
KADIAN ER 40 MG CAPSULE, -ER 70 MG
CAPSULE, -ER 130 MG CAPSULE, -ER 150
MG CAPSULE, 27
KALETRA, 18
kalexate, 81
kanamycin sulfate injection, 10
kariva, 55
KCL 10 MEQ IN D5W-1/4 NS, -KCL 20 MEQ
IN D5W-1/4 NS, 84
kcl 20 meq in d5w solution, -d5w-kcl 30
meq/l iv solution, -kcl 40 meq in d5w
solution, 84
KCL 20 MEQ IN D5W-LACT RINGER, 84
kcl 20 meq in d5w-ns, 84
kcl 20 meq-ns 1,000 ml iv soln, 84
kcl 40 meq in d5w-lact ringer, 80
KCL 40 MEQ IN D5W-NACL 0.9%, 84
KCL 40 MEQ-NS 1,000 ML IV SOLN, 85
kelnor 1-35, 55
ketoconazole cream, -foam (noncontraceptive), 95
ketoconazole oil,shampoo,cleanser, 95
ketoconazole tablet, 17
ketodan combo packs, 95
ketodan foam (non-contraceptive), 12
Page 119 of 139

ketoprofen capsule, -capsule sustained
action, 9
ketorolac 15 mg/ml carpuject, -15 mg/ml
isecure, -30 mg/ml carpuject, -30 mg/ml
isecure, -300 mg/10 ml vial, -60 mg/2 ml
vial, 80
ketorolac 15 mg/ml vial, -30 mg/ml vial, -30
mg/ml vial, -tablet, 9
ketorolac tromethamine ophth drops, 89
KINASE INHIBITORS, 23
kionex powder, 55
klor-con 10, 82
klor-con 20 meq packet, 81
klor-con 8, 82
klor-con m10, 81
KLOR-CON M15, 82
klor-con m20, 82
KOMBIGLYZE XR, 54
KUVAN, 57
labetalol hcl 20 mg/4 ml crpj, 37
labetalol hcl 5 mg/ml vial, 34
labetalol hcl tablet, 34
laclotion, 97
lacosamide, 40
LACRISERT, 89
lactated ringers injection, 85
lactulose, 64
lamivudine, 17, 18, 19
lamivudine/zidovudine, 17
lamivudine-zidovudine, 18
lamotrigine, 40
LANOXIN TABLET, 35
lanreotide acetate, 59
lansoprazole dr 15 mg capsule, -dr 15 mg
capsule, -dr 30 mg capsule, -tablet, 65
lansoprazole/amox tr/clarith, 64
lanthanum carbonate, 59
LANTUS, 52
LANTUS SOLOSTAR, 52
lapatinib ditosylate, 24
laronidase, 57
LASTACAFT, 87
latanoprost, 87
LATUDA, 45
LAXATIVES, 64

leena, 55
leflunomide, 69
lenalidomide, 26, 70
lessina, 56
LETAIRIS, 37
letrozole, 23
leucovorin, 25
LEUCOVORIN CALCIUM 10 MG TAB, -15 MG
TAB, 25
leucovorin calcium 100 mg vial, -350 mg vial,
25
leucovorin calcium 5 mg tab, -25 mg tab, 25
leucovorin calcium 50 mg vial, -200 mg vial,
25
leucovorin calcium 500 mg vl, 25
LEUKERAN, 21
LEUKINE, 68
LEUKOTRIENE MODIFIERS, 93
LEUKOTRIENE RECEPTOR ANTAGONISTS, 91
leuprolide, 23, 69
leuprolide acetate injection, 23
levalbuterol concentrate, 91
levalbuterol hcl nebs, 93
LEVEMIR, 52
levetiracetam injection, 40
levetiracetam solution, -tablet, -tablet
sustained action, 40
levobunolol hcl, 87
levocarnitine injection, 57
levocarnitine solution, -tablet, 57
levocetirizine dihydrochloride solution, tablet, 90
levofloxacin injection, -solution, -tablet, 16
levofloxacin ophth drops, 88
levofloxacin-d5w 500 mg/100 ml, 16
levonest, 86
levonorgestrel, 86
levonorg-eth estrad eth estrad, 86
levora-28, 56
levorphanol tartrate tablet, 7
levothroid, 60
levothyroxine, 60
levothyroxine sodium tablet, 60
levoxyl, 60

Page 120 of 139

LEXAPRO 5 MG TABLET, -10 MG TABLET, -10
MG TABLET, 42
LEXAPRO SOLUTION, -20 MG TABLET, -20
MG TABLET, 42
LEXIVA, 18
LIALDA, 63
lidocaine, 97
lidocaine hcl 0.5% vial, -1% vial, 10
lidocaine hcl 1% ampul, -1.5% ampul, -2%
ampul, -4% ampul, -2% vial, 10
lidocaine hcl cream, -lotion, 10
lidocaine hcl dental/mucous membrn
products, -gel, 97
lidocaine hcl viscous, 98
lidocaine oint, 97
lidocaine-prilocaine, 97
LIDODERM, 97
linezolid, 12, 20
liothyronine sodium injection, 60
liothyronine sodium tablet, 60
LIPITOR, 32
LIPOSYN II, 83
LIPOSYN III 10% IV FAT EMULSN, -20% IV
FAT EMULSN, 83
liposyn iii 30% iv fat emulsn, 83
liraglutide, 52, 61
lisinopril tablet, 30
lisinopril-hydrochlorothiazide, 30
LITE TOUCH, 78
LITHIUM, 47
lithium carbonate capsule, -tablet, -tablet
sustained action, 47
lithium citrate, 47
LOCAL ANESTHETICS, 10
lokara, 97
lomustine, 21
LOOP DIURETICS, 38
loperamide 2 mg capsule, 64
loryna, 86
losartan potassium, 31
losartan-hydrochlorothiazide, 31
loteprednol etabonate, 86
LOTRONEX, 64
lovastatin, 32
LOVAZA, 32

low-ogestrel, 56
loxapine, 45
lubiprostone, 64
LUER-LOK SYRINGE INSULIN SYRINGES DISPOSABLE, 78
LUMIGAN, 87
LUNESTA, 46
LUPRON DEPOT 3.75 MG KIT, -11.25 MG
3MO KIT, 23
LUPRON DEPOT 45 MG 6MO KIT, 23
LUPRON DEPOT 7.5 MG KIT, -22.5 MG 3MO
KIT, --4 MONTH KIT, 23
LUPRON DEPOT-PED 11.25 MG KIT, -15 MG
KIT, 23
lurasidone hcl, 45
lutera, 56
LYRICA 25 MG CAPSULE, -50 MG CAPSULE, 75 MG CAPSULE, -100 MG CAPSULE, -150
MG CAPSULE, -200 MG CAPSULE, -225 MG
CAPSULE, 40
LYRICA 300 MG CAPSULE, 40
LYRICA SOLUTION, 29
LYSODREN, 24
MACRODANTIN 25 MG CAPSULE, 20
MAGELLAN INSULIN SAFETY SYRNG, 78
MAGELLAN INSULIN SYRINGE, 78
magnesium sulf 4% iv soln, -sulf 8% iv soln,
-50% syringe, 82
magnesium sulfate 50% vial, 80
magnesium sulfate/d5w, 85
MAGNESIUM SULFATE-D5W, 85
MALARONE 250-100 MG TABLET, 17
MALARONE 62.5-25 MG PED TAB, 17
malathion, 98
maprotiline hcl, 42
maraviroc, 18
margesic h, 7
marlissa, 56
MARPLAN, 42
MAST CELL STABILIZERS, 91
MATULANE, 24
matzim la, 35
MAXALT, 47
MAXALT MLT, 47
measles,mumps&rubella vaccine, 72
Page 121 of 139

measles,mumps,rub,varicella, 72
mebendazole chew tab, 20
mecasermin, 59
mechlorethamine, 21
meclizine hcl tablet, 62
meclofenamate sodium capsule, 9
MEDICAL (MISCELLANEOUS) SUPPLIES, 73
MEDI-JECTOR NEEDLE-FREE SYR A, 78
MEDI-JECTOR NEEDLE-FREE SYR B, 78
MEDI-JECTOR NEEDLE-FREE SYR C, 78
MEDI-JECTOR VISION, 78
MEDI-JECTOR VISION ADAPTER, 78
medroxyprogesterone, 23
medroxyprogesterone acetate injection, 56
medroxyprogesterone acetate tablet, 60
mefenamic acid capsule, 9
mefloquine hcl, 17
MEGACE ES, 23
megestrol, 23
megestrol acetate oral susp, 23
megestrol acetate tablet, 23
meloxicam oral susp, -tablet, 9
melphalan hcl, 21
memantine hcl, 41
MENACTRA 4 MCG/0.5 ML SYRINGE, 72
MENACTRA VIAL, 73
MENEST, 57
mening vac a,c,y,w-135 dip, 72
meningococcal vac a,c,y,w-135, 72, 73
MENOMUNE-A-C-Y-W-135, 72
MENVEO A-C-Y-W-135-DIP, 72
meperidine 10 mg/ml cartrdge, -solution, 27
meperidine 10 mg/ml syringe, -25 mg/ml
vial, -50 mg/ml vial, -100 mg/ml vial, 8
meprobamate, 39
MEPRON, 20
mercaptopurine tablet, 22
meropenem iv 1 gm vial, 12
meropenem iv 500 mg vial, 20
mesalamine, 63
mesalamine kit, 65
mesalamine rectal, 63
mesna, 25
mesna 1 gram/10 ml vial, 25
mesna 100 mg/ml vial, 25

MESNEX TABLET, 25
MESTINON SYRUP, -TABLET SUSTAINED
ACTION, 47
metadate er, 46
metaproterenol sulfate syrup, -tablet, 91
metaxalone, 48
metformin hcl 500 mg tablet, 54
metformin hcl 850 mg tablet, -1,000 mg
tablet, 54
metformin hcl er 1,000 mg tab, 61
metformin hcl er 500 mg tab, 54
metformin hcl er 500 mg tablet, 61
metformin hcl er 750 mg tablet, 54
methadone 40 mg tablet dispr, 27
methadone hcl 5 mg tablet, -10 mg tablet, 8
methadone hcl injection, -solution, 8
methadone intensol, 27
methadose 40 mg tablet dispr, 27
methadose 5 mg tablet, -10 mg tablet, 8
methadose solution, 27
methamphetamine hcl, 46
methazolamide tablet, 36
methenamine hippurate, 20
methimazole tablet, 60
methocarbamol, 48
methocarbamol tablet, 48
methotrexate, 69
methotrexate 1 gm/40 ml vial, -100 mg/4 ml
vial, -200 mg/8 ml vial, -250 mg/10 ml
vial, -50 mg/2 ml vial, 25
methotrexate 100 mg/4 ml vial, 25
methotrexate 25 mg/ml vial, -250 mg/10 ml
vial, -50 mg/2 ml vial, -1 gm vial, 22
methotrexate tablet, 69
methoxsalen, 95
methscopolamine bromide tablet, 63
methsuximide, 39
methyclothiazide, 36
METHYL XANTHINE DRUGS, 93
methyldopa, 36
methyldopa-hydrochlorothiazide, 36
methyldopate hcl, 36
methylergonovine maleate tablet, 59
methylin 5 mg tablet, -10 mg tablet, -20 mg
tablet, 46
Page 122 of 139

methylin er, 46
methylnaltrexone bromide, 64, 65
methylphenidate er 10 mg tab, -20 mg tab, 54 mg tab, 28
methylphenidate er capsule sustained action,
46
methylphenidate hcl solution, 46
methylphenidate hcl tablet, 46
methylphenidate sr, 46
methylprednisolone 40 mg vial, -125 mg vial,
-ss 1 gm vl, 58
methylprednisolone 500 mg vial, 61
methylprednisolone acetate injection, 58
methylprednisolone tab(in convenience
package), -tablet, 58
metipranolol, 87
metoclopramide 5 mg/ml ampul, -5 mg/ml
syr, 65
metoclopramide 5 mg/ml vial, -syrup, -tablet,
62
metolazone, 36
metoprolol 1 mg/ml carpuject, -tart 5 mg/5
ml amp, 37
metoprolol succinate, 34
metoprolol tart 5 mg/5 ml vial, 34
metoprolol tartrate tablet, 34
metoprolol-hydrochlorothiazide, 33
metro iv, 11
METROGEL, 97
metronidazole, 97
metronidazole capsule, -injection, -tablet, 20
metronidazole cream, -gel, -lotion, 97
metronidazole vaginal products, 67
mexiletine hcl capsule, 32
MIACALCIN INJECTION, 55
miconazole 3 200 mg vag supp, 67
microgestin, 56
microgestin fe, 56
midodrine hcl, 36
MIGERGOT, 47
miglustat, 57
MIGRAINE, 47
milnacipran hcl, 42
mimvey, 86

minocycline hcl capsule, -tablet, -tablet
sustained action, 16
minoxidil tablet, 36
mirtazapine 30 mg odt, -30 mg tablet, -45
mg odt, -45 mg tablet, 42
mirtazapine 7.5 mg tablet, -15 mg odt, -15
mg tablet, 42
MISCELLANEOUS, 19, 24, 36, 47, 59, 64, 66,
69, 89, 91
misoprostol, 64
mitomycin injection, 21
mitotane, 24
mitoxantrone 20 mg/10 ml vial, -30 mg/15
ml vial, 26
mitoxantrone 25 mg/12.5 ml vl, 24
M-M-R II VACCINE, 72
modafinil, 48
moexipril hcl, 30
moexipril-hydrochlorothiazide, 30
mometasone, 92
mometasone furoate cream, -lotion, -oint, 97
mometasone/formoterol, 92
MONOJECT 0.5 ML SYRN 28GX1/2, 78
MONOJECT INSULIN SYR U-100, 78
mononessa, 56
montelukast sod 4 mg granules, 93
montelukast sodium, 91
montelukast sodium chew tab, -tablet, 91
morphine, 7, 8, 27
morphine 0.5 mg/ml ampul p-f, -1 mg/ml
ampul p-f, -1 mg/ml syringe, -1 mg/ml
vial, -2 mg/ml syringe, -4 mg/ml syringe, 5 mg/ml vial, -8 mg/ml ampule, -8 mg/ml
syringe, -8 mg/ml vial, -10 mg/ml ampul, 10 mg/ml syringe, -10 mg/ml vial, -15
mg/ml syringe, -15 mg/ml vial, -25 mg/ml
vial, -25 mg/ml vl, -50 mg/ml vial, 27
morphine 0.5 mg/ml vial, -1 mg/ml vial p-f, 8
morphine 4 mg/ml carpuject, -100 mg/10 ml
vial, -300 mg/20 ml vial, 28
MORPHINE SULF 10 MG/5 ML SOLN, -SULF
20 MG/5 ML SOLN, 8
morphine sulf 100 mg/5 ml soln, -tablet, 8

Page 123 of 139

morphine sulf er 15 mg tablet, -sulf er 30 mg
tablet, -sulf er 60 mg tablet, -sulf er 100
mg tab, 8
morphine sulf er 200 mg tab, 8
morphine sulfate er 20 mg cap, -30 mg cap,
-50 mg cap, -80 mg cap, -100 mg cap, 8
morphine sulfate er 60 mg cap, 8
MOUTH/THROAT/DENTAL AGENTS, 98
MOVIPREP, 64
moxifloxacin, 14, 88
MOZOBIL, 68
MULTAQ, 32
MULTIPLE SCLEROSIS AGENTS, 47
mupirocin calcium, 94
mupirocin oint, 94
muronab-cd3, 71
MUSCULOSKELETAL MEDICATIONS, 80
MUSCULOSKELETAL THERAPY AGENTS, 48
MUSTARGEN, 21
MYCOBUTIN, 18
mycophenolate mofetil, 70, 71
mycophenolate sodium, 71
mydral, 89
MYFORTIC, 71
myorisan, 49
MYOZYME, 57
myzilra, 86
nabumetone, 9
nadolol tablet, 34
nadolol-bendroflumethiazide, 33
nafarelin, 57
nafcillin 1 gm add-van vial, -2 gm add-vant
vial, -2 gm vial, 13
nafcillin 1 gm vial, -10 gm bulk vial, -10 gm
vial, 16
nafcillin 1 gm/ 50 ml inj, 16
nafcillin 2 gm/ 100 ml inj, 13
NAGLAZYME, 57
nalbuphine 10 mg/ml ampul, -20 mg/ml
ampul, 26
nalbuphine 100 mg/10 ml vial, -200 mg/10
ml vial, 9
naloxone 0.4 mg/ml ampul, -0.4 mg/ml vial,
29

naloxone 0.4 mg/ml syringe, -1 mg/ml
syringe, -2 mg/2 ml syringe, 49
naltrexone hcl tablet, 49
NAMENDA 5-10 MG TITRATION PK, 41
NAMENDA SOLUTION, -5 MG TABLET, -10
MG TABLET, 41
NAPRELAN, 9
naproxen, 9
naproxen e.c. tab, -oral susp, -tablet, 10
naproxen sodium 275 mg tab, -550 mg tab,
10
naproxen/esomeprazole mag, 10
naratriptan, 28
naratriptan hcl, 47
NARCOLEPSY/CATAPLEXY, 48
NARCOTIC ANALGESICS, 6
NARCOTIC ANALGESICS, CII, 7
NARDIL, 42
NASACORT AQ, 92
NASAL STEROIDS, 92
NASONEX, 92
NATACYN, 88
natamycin, 88
nateglinide, 54
nebivolol hcl, 33
necon 0.5-35-28 tablet, -1/35-28 tablet, -7-77-28 tablet, 56
necon 1/50-28 tablet, 86
NECON 10-11-28 TABLET, 56
NEEDLE FREE SYRINGE KIT A, 78
NEEDLE FREE SYRINGE KIT B, 78
NEEDLE FREE SYRINGE KIT C, 78
nefazodone hcl, 42
nelfinavir mesylate, 18
neomycin sulfate tablet, 16
neomycin-bacitracin-poly-hc, 87
neomycin-bacitracin-polymyxin, 88
neomycin-polymyxin-dexameth, 87
neomycin-polymyxin-gramicidin, 88
neomycin-polymyxin-hc ophth drops, 87
neomycin-polymyxin-hc suspensions, (not
oral), 98
neomycin-polymyxin-hydrocort, 98
neomy-polymyxin b 40 mg/ml amp, 66
neomy-polymyxin b 40 mg/ml vl, 99
Page 124 of 139

neo-polycin, 89
NEORAL, 71
NEPHRAMINE, 83
NEUMEGA, 68
NEUPOGEN 300 MCG/0.5 ML SYR, -480
MCG/1.6 ML VIAL, -480 MCG/0.8 ML SYR,
68
NEURONTIN SOLUTION, 40
neutragard advanced, 81
nevirapine, 18
nevirapine oral susp, 11
nevirapine tablet, 11
NEXAVAR, 23
NEXIUM CAPSULE SUSTAINED ACTION, -DR
10 MG PACKET, -DR 20 MG PACKET, -DR
40 MG PACKET, 65
NEXIUM DR 2.5 MG PACKET, -DR 5 MG
PACKET, 66
NEXIUM I.V., 65
next choice, 56
next choice one dose, 86
niacin, 33
niacin/simvastatin, 33
NIASPAN, 33
nicardipine 25 mg/10 ml ampule, 37
nicardipine 25 mg/10 ml vial, 35
nicardipine hcl capsule, 35
nicotine inhaler, 49
nicotine ns, 49
NICOTROL, 49
NICOTROL NS, 49
nifediac cc, 35
nifedical xl, 35
nifedipine er 30 mg tablet, -60 mg tablet, -90
mg tablet, 35
nifedipine er 90mg tablet, 37
NILANDRON, 23
nilotinib hydrochloride, 24
nilutamide, 23
nimodipine, 35
nisoldipine, 35
nitazoxanide, 19, 20
nitisinone, 57
NITRATES, 36, 38
nitro-bid, 36

NITRO-DUR 0.3 MG/HR PATCH, -0.8 MG/HR
PATCH, 36
nitrofurantoin macrocrystal, 20
nitrofurantoin mcr 100 mg cp, 13
nitrofurantoin mcr 50 mg cap, 20
nitrofurantoin mono-macro, 20
nitrofurantoin oral susp, 20
nitroglycerin, 36, 37
nitroglycerin injection, 36
nitroglycerin patch, 37
NITROLINGUAL, 37
NITROSTAT, 37
nizatidine, 63
NON-NARCOTIC ANALGESICS, 9
NON-STEROIDAL ANTIINFLAMMATORY
AGENTS, 80
nora-be, 56
NORDITROPIN FLEXPRO, 59
NORDITROPIN NORDIFLEX, 59
norethindrone, 86
norethindrone acetate tablet, 60
norethindrone-ethin estradiol, 56, 86
norgestimate-ethinyl estradiol, 56, 86
norgestrel-ethiny estra, 86
normosol-m and dextrose, 85
normosol-r and dextrose, 85
NORMOSOL-R PH 7.4, 85
NORPACE CR 100 MG CAPSULE, 32
nortrel, 56
nortriptyline hcl capsule, -solution, 42
NORVIR, 18
novarel, 59
NOVOFINE 32, 78
NOVOFINE AUTOCOVER, 78
NOVOLIN 70-30 INJECTION, -VIAL, 52
NOVOLIN N, 52
NOVOLIN R INJECTION, 52
NOVOLIN R VIAL, 61
NOVOLOG 100 UNIT/ML CARTRIDGE, 61
NOVOLOG 100 UNIT/ML VIAL, -FLEXPEN
SYRINGE, 52
NOVOLOG MIX 70-30, 52
NOVOPEN 3, 78
NOVOPEN JR, 78
NOVOTWIST, 78
Page 125 of 139

NOXAFIL, 17
NSAIDS, 9
NUCLEOSIDE ANALOGS, 24
NUEDEXTA, 47
NULOJIX, 71
nutrilyte, 80
nutrilyte ii, 80
NUTRITION,BLOOD
MODIFIERS,ELECTROLYTES, 80
NUTRITIONAL/SUPPLEMENTS, 82
NUVARING, 56
NUVIGIL, 48
nyamyc, 95
nystatin 50,000,000 units pwd, -150,000,000
units pwd, -500,000,000 units pwd, 12
nystatin cream, -oint, -100,000 unit/gm
powd, 95
nystatin oral susp, 98
nystatin tablet, 17
nystatin-triamcinolone, 94
nystop, 95
OBSTETRICAL AND GYNECOLOGICAL
MEDICATIONS, 85
ocella, 56
octreotide, 59
octreotide acet 50 mcg/ml amp, -acet 100
mcg/ml amp, -acet 200 mcg/ml vl, 59
octreotide acet 50 mcg/ml syr, -acet 50
mcg/ml vial, -acet 100 mcg/ml syr, -acet
100 mcg/ml vl, -acet 500 mcg/ml syr, -acet
500 mcg/ml vl, 26
octreotide acet 500 mcg/ml amp, -1,000
mcg/ml vial, 59
ofloxacin ophth drops, 88
ofloxacin otic drops, 98
ofloxacin tablet, 16
ogestrel, 56
olanzapine, 45, 46
OLANZAPINE INJECTION, 45
olanzapine odt, 45
olanzapine tablet, 45
olanzapine-fluoxetine hcl, 45
olmesartan med/amlodipine/hct, 31
olmesartan medoxomil, 31
olmesartan medoxomil/hctz, 31

olopatadine hcl, 87
omalizumab, 92
omega-3 acid ethyl esters, 32
omeprazole capsule sustained action, 65
omeprazole-sodium bicarbonate, 65
ondansetron 40 mg/20 ml vial, -4 mg/2 ml
syr, -4 mg/2 ml ampule, 27
ondansetron hcl 4 mg/2 ml vial, -solution, tablet, 62
ondansetron odt, 62
ONGLYZA 2.5 MG TABLET, 54
ONGLYZA 5 MG TABLET, 54
ONTAK, 22
OPHTHALMIC, 86
OPHTHALMIC MEDICATIONS, 89
OPHTHALMIC TOPICAL ANTIBACTERIAL
DRUGS, 89
oprelvekin, 68
ORACEA, 97
ORAL ANTIFUNGAL DRUGS, 12
ORAL DERMATOLOGICAL DRUGS, 49
ORAL HYPOGLYCEMICS AND COMBOS, 61
ORAP, 45
ORENCIA, 71
ORFADIN, 57
orphenadrine 30 mg/ml ampule, 80
orphenadrine 30 mg/ml vial, -60 mg/2 ml
vial, 48
orphenadrine citrate tablet sustained action,
48
orphenadrine compound, 48
orphenadrine compound forte, 48
ORSINI INSULIN SYRINGE, 78
orsythia, 56
ORTHO EVRA, 56
ORTHO TRI-CYCLEN LO, 56
ORTHOCLONE OKT-3, 71
ortho-est, 57
oseltamivir phosphate, 19
OTHER ANTIARRHYTHMICS, 38
OTHER ANTICONVULSANTS, 29
OTHER ANTIDEPRESSANTS, 29
OTHER ANTIHYPERTENSIVES, 38
OTHER ANTIINFECTIVE DRUGS, 12
OTHER ANTIPARKINSON DRUGS, 29
Page 126 of 139

OTHER ANTIULCER DRUGS, 65
OTHER ANTIVIRAL DRUGS, 12
OTHER CNS/AUTONOMIC DRUGS, 29
OTHER DRUGS FOR ASTHMA, 94
OTHER ENDOCRINE DRUGS, 61
OTHER GENITOURINARY PRODUCTS, 99
OTHER GI DRUGS, 65
OTHER MACROLIDES, 12
OTHER OPHTHALMIC DRUGS, 89
OTHER TOPICAL ANTIFUNGALS, 12
OTIC, 98
oxacillin 1 gm add-vantage vl, -2 gm addvantage vl, -2 gm vial, 13
oxacillin 1 gm vial, 16
oxacillin 1 gm/ 50 ml inj, 16
oxacillin 10 gm vial, 16
oxacillin 2 gm/ 50 ml inj, 16
oxaliplatin 100 mg/20 ml vial, 24
oxandrolone 10 mg tablet, 50
oxandrolone 2.5 mg tablet, 50
oxaprozin, 10
oxcarbazepine, 40
OXSORALEN-ULTRA, 95
oxybutynin, 66, 98
oxybutynin chloride er, 66
oxybutynin chloride syrup, -tablet, 66
oxycodone, 8
oxycodone concentrate, 8
oxycodone hcl 10 mg tablet, -20 mg tablet,
28
oxycodone hcl capsule, -5 mg tablet, -15 mg
tablet, -30 mg tablet, 8
oxycodone hcl solution, 28
oxycodone hcl-acetaminophen, 8
oxycodone hcl-aspirin, 8
oxycodone hcl-ibuprofen, 8
oxycodone/acetaminophen, 8
oxycodone-acetaminophen, 8
oxycodone-aspirin, 8
OXYCONTIN, 8
oxymetholone, 50
oxymorphone hcl tablet, 8
oxymorphone hcl tablet sustained action, 8
PACERONE 100 MG TABLET, 32
pacerone 200 mg tablet, -400 mg tablet, 32

paclitaxel 300 mg/50 ml vial, 22
palgic, 91
paliperidone, 44, 45
pamidronate 30 mg/10 ml vial, -60 mg/10 ml
vial, -90 mg/10 ml vial, 54
pamidronate disod 30 mg vial, -disod 90 mg
vial, 61
PANCREATIC ENZYMES, 64
PANCREAZE, 64
PANRETIN, 97
pantoprazole sodium, 65
PARATHYROID HORMONES, 59
parcaine, 87
PARENTERAL ANTIFUNGALS, 12
paricalcitol, 85
paromomycin sulfate capsule, 16
paroxetine cr 12.5 mg tablet, -cr 37.5 mg
tablet, -er 37.5 mg tablet, 42
paroxetine hcl 10 mg tablet, -20 mg tablet,
42
paroxetine hcl oral susp, -30 mg tablet, -40
mg tablet, -cr 25 mg tablet, 42
PASER, 18
PATADAY, 87
PATANOL, 87
pazopanib, 24
pedi-dri, 95
PEDVAXHIB, 72
peg 3350-electrolyte, 65
peg-3350 and electrolytes, 65
peg-3350 with flavor packs, 65
pegademase bovine, 57
PEGANONE, 40
PEGASYS, 70
PEGASYS PROCLICK 135 MCG/0.5, 70
PEGASYS PROCLICK 180 MCG/0.5, 73
peginterferon alfa-2a, 70, 73
peginterferon alfa-2b, 70, 73
PEGINTRON 50 MCG KIT, 70
PEGINTRON 80 MCG KIT, -120 MCG KIT, 150 MCG KIT, 73
PEGINTRON REDIPEN, 70
pegvisomant, 59
pemetrexed disodium, 21
PEN G 1.2 MILLION UNIT/2 ML, 16
Page 127 of 139

pen g procaine/pen g benz, 14
penciclovir, 96
penicillin g 600,000 unit/1 ml, 13
penicillin g benzathine, 14
penicillin g k 5 million unit, 16
penicillin g procaine, 16
penicillin g sodium, 16
penicillin gk 20 million unit, 13
penicillin v potassium, 16
PENICILLINS, 13
PENTASA, 63
pentopak, 69
pentosan polysulfate sodium, 66
pentostatin, 22
pentoxifylline tablet sustained action, 69
PERFOROMIST, 91
perindopril erbumine, 30
periogard, 98
permethrin cream, 98
perphenazine, 45
perphenazine-amitriptyline, 49
phenadoz, 62
phenelzine, 42
phenelzine sulfate tablet, 42
phenytoin, 39
phenytoin 100 mg/2 ml vial, 29
phenytoin 250 mg/5 ml vial, -50 mg/ml
syringe, -50 mg/ml vial, 29
phenytoin 50 mg/ml ampul, 40
phenytoin oral susp, 40
phenytoin sodium, 39
phenytoin sodium extended, 40
philith, 86
PHOSLO, 59
PHOSPHATE BINDER AGENTS, 59
PHOSPHOLINE IODIDE, 87
pilocarpine hcl, 87
pilocarpine hcl ophth drops, 89
pilocarpine hcl tablet, 98
PILOPINE HS, 87
pimecrolimus, 97
pimozide, 45
pindolol, 34
pioglitazone, 61
pioglitazone hcl, 52, 61

pioglitazone hcl/metformin hc, 52
pioglitazone/glimepiride, 52
pioglitazone-metformin, 54
piperacillin, 16
piperacil-tazo 2.25 gm add vl, -piperaciltazobact 2.25 gm vl, -piperacil-tazobact
40.5 gram, 13
piperacil-tazobact 3.375 gm vl, 16
piperacil-tazobact 4.5 gm vial, 16
piroxicam capsule, 10
PLASMA-LYTE 148, 85
PLASMA-LYTE 148 IN DEXTROSE, 85
PLASMA-LYTE 56, 85
PLASMA-LYTE 56 IN DEXTROSE, 85
PLASMA-LYTE A PH 7.4, 85
plasma-lyte r, 85
PLASMODICIDES, 13
PLATELET AGGREGATION INHIBITORS, 69
PLATINUM COORDINATION COMPLEX, 24
PLAVIX 300 MG TABLET, 69
PLAVIX 75 MG TABLET, 69
plerixafor, 68
podofilox, 97
poliomyelitis vac,killed, 72, 73
polycin-b, 89
poly-dex, 87
polyethylene glycol 3350 packet, 64
polymyxin b sulfate injection, 20
polymyxin b sul-trimethoprim, 88
portia, 56
posaconazole, 17
pot chloride/na chlor, 85
potassium chloride, 82
potassium chloride capsule sustained action,
-cl er 10 meq tablet, -cl er 20 meq tablet,
82
potassium chloride/d10-0.25ns, 84
potassium chloride/d5w, 84
POTASSIUM CHLORIDE-NACL, 85
potassium citrate tablet sustained action, 66
potassium cl 10 meq/100 ml sol, -cl 30
meq/100 ml sol, -cl 10 meq/50 ml sol, -cl
20 meq/50 ml sol, 85
potassium cl 10% (20 meq/15 ml, -cl 10%
(40 meq/30 ml, -cl 20% (40 meq/15 ml, -cl
Page 128 of 139

er 8 meq tablet, -unique tablet
formulation, 81
potassium cl 2 meq/ml vial, 82
potassium cl 20 meq/100 ml sol, -cl 2
meq/ml iv sol, -cl 40 meq/100 ml sol, 81
POTASSIUM REMOVING RESINS, 81
POTASSIUM SUPPLEMENTS, 81
POTIGA, 40
PRADAXA, 68
pramipexole dihydrochloride, 43
pramlintide acetate, 52
PRANDIN, 54
prasugrel, 69
pravastatin sodium 10 mg tab, -10 mg tab, 20 mg tab, -20 mg tab, -40 mg tab, -40
mg tab, 32
pravastatin sodium 80 mg tab, 32
prazosin hcl, 30
pre-attached lta kit, 10
PRECISION, 78
prednicarbate, 97
prednisolone 15 mg/5 ml soln, 58
prednisolone 5 mg/5 ml soln, -6.7 mg/5 ml
soln, -15 mg/5 ml soln, 58
prednisolone acetate ophth drops, 89
prednisolone sod phosphate, 89
PREDNISOLONE SODIUM PHOSPHATE
OPHTH DROPS, 89
prednisone, 58
PREDNISONE INTENSOL, 58
prednisone solution, -tab(in convenience
package), -tablet, 58
pregabalin, 29, 40
pregnyl, 59
PREMARIN INJECTION, 57
PREMARIN TABLET, 57
PREMARIN VAGINAL PRODUCTS, 57
PREMASOL 10% IV SOLUTION, 83
premasol 6% iv solution, 83
PREMPRO, 57
prevalite packet, 38
prevalite powder, 33
previfem, 56
PREVPAC, 64

PREZISTA 400 MG TABLET, -600 MG
TABLET, 18
PREZISTA 75 MG TABLET, -150 MG TABLET,
18
PRIFTIN, 18
PRIMAXIN, 20
PRIMAXIN I.M., 20
primidone tablet, 40
PRISTIQ ER 100 MG TABLET, 42
PRISTIQ ER 50 MG TABLET, 42
PROAIR HFA, 91
probenecid, 6
probenecid-colchicine, 6
procainamide hcl injection, 32
PROCALAMINE, 83
procarbazine, 24
prochlorperazine edisylate injection, 62
prochlorperazine maleate rectal, -tablet, 62
PROCRIT 2,000 UNITS/ML VIAL, -3,000
UNITS/ML VIAL, -4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 68
PROCRIT 20,000 UNITS/ML VIAL, 68
PROCRIT 40,000 UNITS/ML VIAL, 68
proctocream-hc, 95
procto-pak, 97
proctosol-hc, 95
proctozone-hc, 95
PRODIGY INSULIN SYRINGE, 78
PRODIGY PEN NEEDLE, 78
progesterone, 60
progesterone capsule, 60
PROGESTIN DRUGS, 86
PROGESTINS, 60
PROGLYCEM, 59
PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE,
71
PROGRAF 5 MG CAPSULE, 71
PROLEUKIN, 22
PROLIA, 54
PROMACTA, 69
promethazine 25 mg/ml ampul, -25 mg/ml
vial, -50 mg/ml ampul, 93
promethazine 25 mg/ml syringe, -50 mg/ml
vial, 62
promethazine hcl rectal, -syrup, -tablet, 62
Page 129 of 139

promethazine vc, 92
promethegan 12.5 mg suppos, 27
promethegan 25 mg supp, -50 mg
suppository, 62
PROMETRIUM, 60
propafenone hcl, 32
proparacaine hcl ophth drops, 89
propranolol hcl capsule sustained action, solution, -tablet, 34
propranolol hcl injection, 34
propranolol-hydrochlorothiazid, 33
propylthiouracil tablet, 60
PROQUAD, 72
PROSOL, 83
PROTECTIVE AGENTS, 25
PROTON PUMP INHIBITOR/ANTI-INFECTIVE
COMBINATIONS, 64
PROTON PUMP INHIBITORS, 64, 66
PROTOPIC, 97
protriptyline hcl, 42
PROVENTIL HFA, 91
PROVIGIL, 48
PSYCHOTHERAPEUTIC-MISCELLANEOUS, 48
PULMONARY ARTERIAL HYPERTENSION, 37
PULMOZYME, 92
pyrazinamide, 18
pyridostigmine, 47
pyridostigmine bromide tablet, 47
pyrimethamine, 17
quasense, 56
quetiapine fumarate, 45
quinapril hcl, 30
quinapril-hydrochlorothiazide, 30
quinidine gluconate injection, 32
quinidine gluconate tablet sustained action,
32
quinidine sulfate tablet, -tablet sustained
action, 32
QUINOLONES, 13
QVAR, 92
RABAVERT, 72
rabies vac,pf chick-emb cell, 72
rabies vaccine,human diploid, 72
raloxifene, 60
raltegravir potassium, 11, 18

ramipril, 30
RANEXA, 36
ranitidine 1,000 mg/40 ml vial, 65
ranitidine hcl 25 mg/ml vial, 63
ranitidine hcl capsule, -syrup, -150 mg tablet,
-300 mg tablet, 63
ranolazine, 36
RAPAMUNE, 71
rapiflux, 42
rasagiline mesylate, 43
rasburicase, 25
RAYOS, 58
REBETOL SOLUTION, 19
REBIF 22 MCG/0.5 ML SYRINGE, -44
MCG/0.5 ML SYRINGE, 48
REBIF TITRATION PACK, 48
RECLAST, 54
reclipsen, 56
RECOMBIVAX HB 10 MCG/ML SYR, 73
RECOMBIVAX HB 10 MCG/ML VIAL, -40
MCG/ML VIAL, 72
REGONOL, 47
REGRANEX, 98
RELENZA, 19
RELISTOR 12 MG/0.6 ML KIT, 65
RELISTOR 12 MG/0.6 ML VIAL, 64
RELISTOR 8 MG/0.4 ML SYRINGE, -12
MG/0.6 ML SYRINGE, 65
REMICADE, 69
REMODULIN, 37
RENAGEL, 59
RENVELA, 59
repaglinide, 54
reprexain, 7
RESCRIPTOR, 18
reserpine tablet, 36
RESPIRATORY, 89
RESPIRATORY MEDICATIONS, 93
RESTASIS, 89
RETROVIR INJECTION, 18
revatio (sildenafil citrate), 37
REVATIO TABLET, 37
REVLIMID 2.5 MG CAPSULE, 26
REVLIMID 5 MG CAPSULE, -10 MG CAPSULE,
-15 MG CAPSULE, -25 MG CAPSULE, 70
Page 130 of 139

REYATAZ, 18
RHEUMATREX, 69
ribapak 200-400 mg dosepack, 12
ribapak 400-400 mg dosepack, -600-600 mg
dosepack, 19
ribapak 600-400 mg dosepack, 19
ribasphere 400 mg tablet, -600 mg tablet, 19
ribasphere capsule, -200 mg tablet, 19
ribavirin, 19
ribavirin capsule, -tablet, 19
rifabutin, 18
rifampin capsule, -injection, 18
rifapentine, 18
rifaximin, 64
rilonacept, 70
rilpivirine hydrochloride, 17
RILUTEK, 47
riluzole, 47
rimantadine hcl, 19
ringers injection, 85
risedronate, 54
RISPERDAL CONSTA 12.5 MG SYR, -25 MG
SYR, 45
RISPERDAL CONSTA 37.5 MG SYR, -50 MG
SYR, 45
risperidone, 45
risperidone 0.25 mg odt, -0.5 mg odt, 45
risperidone 0.25 mg tablet, -0.5 mg tablet,
45
risperidone 1 mg odt, -2 mg odt, -3 mg odt,
45
risperidone 1 mg tablet, -2 mg tablet, -3 mg
tablet, 45
risperidone 4 mg odt, 45
risperidone m-tab 0.5 mg odt, 26
risperidone m-tab 1 mg odt, -2 mg odt, -3
mg odt, 27
risperidone m-tab 4 mg odt, 27
risperidone solution, -4 mg tablet, 45
ritonavir, 18
ritonavir/lopinavir, 18
RITUXAN, 22
rituximab, 22
rivaroxaban, 68
rivastigmine 1.5 mg capsule, 41

rivastigmine 3 mg capsule, 41
rivastigmine 4.5 mg capsule, -6 mg capsule,
41
rivastigmine tartrate, 26, 40, 41
rizatriptan benzoate, 47
ROBAXIN INJECTION, 48
roflumilast, 92
romidepsin, 22
romycin, 88
ropinirole hcl, 43
rosuvastatin calcium, 32
ROTATEQ, 72
rotavirus vac, live pentav, 72
ROXICET SOLUTION, 8
roxicet tablet, 8
rufinamide, 39
ruxolitinib phosphate, 23
SABRIL, 40
SAFESNAP INSULIN SYRINGE, 79
SAFETYGLIDE SYRINGE INSULIN SYRINGES
- DISPOSABLE, 79
SALICYLATES AND RELATED DRUGS, 80
saline 0.45% soln-excel con, -0.45% soln, saline 0.9% soln-excel cont, -0.9%
solution, -3% iv soln, -5% iv soln, 85
salmeterol, 91
salmeterol/fluticasone, 92
salsalate tablet, 80
SANCUSO, 62
SANDIMMUNE CAPSULE, 71
SANDIMMUNE SOLUTION, 71
SANDOSTATIN LAR, 59
SANTYL, 98
SAPHRIS, 45
sapropterin dihydrochloride, 57
saquinavir mesylate, 17
sargramostim, 68
SAVELLA 12.5 MG TABLET, -25 MG TABLET,
-50 MG TABLET, -100 MG TABLET, 42
SAVELLA TITRATION PACK, 42
saxagliptin hcl/metformin hcl, 54
saxagliptin hydrochloride, 54
scopolamine, 62
SELECTIVE ESTROGEN RECEPTOR
MODULATORS, 60
Page 131 of 139

SELECTIVE SEROTONIN REUPTAKE
INHIBITORS, 29
selegiline, 41
selegiline hcl capsule, -tablet, 43
selenium sulfide 2.5% lotion, 95
selfemra, 42
SELZENTRY, 18
SENSIPAR 30 MG TABLET, 55
SENSIPAR 60 MG TABLET, -90 MG TABLET,
55
SEREVENT DISKUS, 91
SEROMYCIN, 18
SEROQUEL 100 MG TABLET, 45
SEROQUEL 200 MG TABLET, 45
SEROQUEL 25 MG TABLET, 45
SEROQUEL 300 MG TABLET, -400 MG
TABLET, 45
SEROQUEL 50 MG TABLET, 45
SEROQUEL XR, 45
sertraline hcl 25 mg tablet, -50 mg tablet, 43
sertraline hcl solution, -100 mg tablet, 43
sevelamer, 59
sevelamer carbonate, 59
sf, 81
sf 5000 plus, 81
silver sulfadiazine cream, 95
SIMCOR, 33
SIMULECT 20 MG VIAL, 23
simvastatin 5 mg tablet, -5 mg tablet, -10
mg tablet, -10 mg tablet, -20 mg tablet, 20 mg tablet, -40 mg tablet, -40 mg tablet,
33
simvastatin 80 mg tablet, -80 mg tablet, 33
SINGLE USE SWAB, 79
SINGULAIR, 91
sirolimus, 71
sitagliptin phos/metformin hcl, 53
sitagliptin phosphate, 53
sodium bicarb 4.2% abbjct, -bicarb 4.2%
syringe, -bicarb 4.2% vial, -bicarb 7.5%
vial, -bicarb 8.4% vial, 80
sodium bicarb 7.5% abboject, -7.5% syring,
-bicarb 8.4% abboject, -bicarb 8.4%
abboject, -bicarb 8.4% syringe, -8.4%
syring, 82

sodium chloride 0.9% soln, -0.9% soln., -4
meq/ml vl, 80
sodium chloride solution, 98
sodium cl 2.5 meq/ml vial, 82
sodium fluoride dental/mucous membrn
products, -oral drops, 81
sodium lactate injection, 85
sodium oxybate, 48
sodium phenylbutyrate, 57
sodium polystyrene sulfonate, 55
SOLARAZE, 94
solia, 56
solifenacin succinate, 66, 67
SOLU-CORTEF 100 MG VIAL, 58
SOLU-CORTEF 250 MG VIAL, 58
somatropin, 59
SOMATULINE DEPOT, 59
SOMAVERT, 59
sorafenib tosylate, 23
sorine, 32
sotalol, 32
sotalol af, 38
sotret, 94
SPIRIVA, 90
spironolactone tablet, 30
spironolactone-hctz, 36
sprintec, 56
SPRYCEL 20 MG TABLET, -50 MG TABLET, 70 MG TABLET, -100 MG TABLET, 24
SPRYCEL 80 MG TABLET, -140 MG TABLET,
24
sps oral susp, 81
sronyx, 56
ssd, 95
stagesic, 7
STALEVO 100, 43
STALEVO 125, 43
STALEVO 150, 43
STALEVO 200, 43
STALEVO 50, 43
STALEVO 75, 43
stavudine, 18
STEROID INHALANTS, 92
STEROID/BETA-AGONIST COMBINATIONS,
92
Page 132 of 139

STRATTERA, 46
streptomycin sulfate injection, 16
STRIBILD, 18
sublimaze, 28
SUBOXONE ORALLY DISSOLVING STRIPS, 49
sucralfate, 64
sucralfate oral susp, 65
sucralfate tablet, 64
sulfacetamide sodium lotion, 94
sulfacetamide sodium oint, -ophth drops, 88
sulfacetamide/prednisolone ac, 87
sulfacetamide-prednisolone, 88
sulfadiazine, 16
SULFADIAZINE TABLET, 16
sulfamethoxazole-trimethoprim, 20
sulfamide, 89
sulfasalazine dr, 65
sulfasalazine tablet, 63
sulfazine, 65
sulfazine ec, 63
sulindac tablet, 10
sumatriptan, 28
sumatriptan 4 mg/0.5 ml cart, -4 mg/0.5 ml
inject, 28
sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml
refill, -6 mg/0.5 ml refill, -6 mg/0.5 ml
syrng, 28
sumatriptan 4 mg/0.5 ml vial, 47
SUMATRIPTAN 5 MG NASAL SPRAY, 28
sumatriptan 6 mg/0.5 ml inject, 47
sumatriptan 6 mg/0.5 ml vial, 47
sumatriptan succinate tablet, 47
sunitinib malate, 24
SUPRAX, 16
SURE COMFORT, 79
SURE COMFORT ALCOHOL, 79
SURE-FINE PEN NEEDLES, 79
SURE-JECT INSULIN SYRINGE, 79
SURE-PREP ALCOHOL PREP PADS, 79
SURMONTIL 100 MG CAPSULE, 43
SUSTIVA, 18
SUTENT, 24
syeda, 86
SYLATRON, 70
SYMBICORT, 92

SYMLIN, 52
SYMLINPEN 120, 52
SYMLINPEN 60, 52
SYNAREL, 57
SYNTHROID, 60
SYPRINE, 55
TABLOID, 22
tacrolimus, 71, 97
tacrolimus 0.5 mg capsule, -1 mg capsule, 71
tacrolimus 5 mg capsule, 71
tadalafil, 66
TAMIFLU 12 MG/ML SUSPENSION, 19
TAMIFLU 30 MG GELCAP, 19
TAMIFLU 45 MG GELCAP, -75 MG GELCAP,
19
TAMIFLU 6 MG/ML SUSPENSION, 19
tamoxifen citrate tablet, 23
tamsulosin hcl, 66
TARCEVA, 24
TARGRETIN CAPSULE, 24
TARGRETIN GEL, 97
TASIGNA, 24
TAXOTERE, 22
tazarotene, 95
TAZORAC, 95
taztia xt, 35
TEGRETOL XR 100 MG TABLET, 40
TEKAMLO, 35
TEKTURNA 150 MG TABLET, 35
TEKTURNA 300 MG TABLET, 35
TEKTURNA HCT, 35
telaprevir, 19
telbivudine, 19
tenofovir disproxil fumarate, 18
terazosin hcl, 31
terbinafine hcl tablet, 17
terbutaline sulfate injection, 91
terbutaline sulfate tablet, 91
terconazole, 67
teriparatide, 59
terumo ins syringe u100-1 ml, 79
TERUMO INS SYRINGE U100-1/2 ML, -INS
SYRINGE U100-1/3 ML, 79
TERUMO SURGUARD, 79
TESTIM, 50
Page 133 of 139

testosterone, 50
testosterone cyp 100 mg/ml, 50
testosterone cyp 200 mg/ml, 50
testosterone enanthate injection, 50
TETANUS DIPHTHERIA TOXOIDS, 72
TETANUS TOXOID ADSORBED, 72
tetanus toxoid,adsorbed, 72
tetanus,diphtheria toxoid, 71, 72
TETANUS-DIPHTERIA-DECAVAC, 72
tetrabenazine, 47
tetracycline hcl capsule, 16
TETRACYCLINES, 13
thalidomide, 70
THALOMID, 70
THEO-24, 93
theochron er 100 mg tablet, -er 300 mg
tablet, 93
theochron er 200 mg tablet, 93
theophylline, 93
theophylline anhydrous tablet sustained
action, 93
theophylline solution, 93
theophylline tablet sustained action, 93
thermazene, 95
thinpro insulin syringe, 79
thioguanine, 22
thioridazine hcl, 45
thiothixene, 45
THYROID AGENTS, 60
THYROID SUPPLEMENTS, 62
tiagabine, 39
ticlopidine hcl, 69
tigecycline, 20
TIKOSYN, 32
tilia fe, 86
timolol, 87
timolol maleate ophth drops, 87
timolol maleate tablet, 34
tinidazole tablet, 20
tiotropium bromide, 90
tipranavir, 17
tizanidine hcl capsule, -tablet, 48
TOBI, 92
tobramycin, 88
tobramycin 10 mg/ml vial, -40 mg/ml vial, 16

tobramycin sulfate in ns, 10
tobramycin sulfate ophth drops, 88
tobramycin/sodium chloride, 92
tobramycin-dexamethasone, 88
tobrasol, 88
TOBREX OINT, 88
tocilizumab, 69
tolazamide, 54
tolbutamide, 54
tolmetin sodium, 10
tolterodine tartrate, 66, 99
TOPCARE CLICKFINE, 79
TOPCARE ULTRA COMFORT, 79
TOPICAL, 94
TOPICAL ANESTHETICS, 10
TOPICAL CORTICOSTEROID DRUGS, 49
TOPICAL DERMATOLOGICAL DRUGS, 50
topiragen, 29
topiramate sprinkle, -tablet, 40
TOPOISOMERASE INHIBITORS, 25
toposar, 25
topotecan hcl, 25
toremifene, 23
torsemide, 36
TORSEMIDE INJECTION, 36
torsemide tablet, 36
TOVIAZ, 66
tpn electrolytes, 82
TRACLEER, 37
tramadol er 100 mg tablet, -er 200 mg
tablet, 26
tramadol hcl er 100 mg tablet, -200 mg
tablet, 9
tramadol hcl er 100 mg tablet, -er 200 mg
tablet, -er 300 mg tablet, 9
tramadol hcl er 300 mg tablet, 26
tramadol hcl tablet, 9
tramadol hcl-acetaminophen, 9
trandolapril, 30
tranexamic acid, 69
tranexamic acid injection, 69
TRANSDERM-SCOP, 62
tranylcypromine sulfate, 43
trastuzumab, 22
TRAVASOL, 83
Page 134 of 139

TRAVATAN Z, 87
travoprost, 87
trazodone hcl tablet, 43
TREANDA, 21
TRECATOR, 18
TRELSTAR 22.5 MG SYRINGE, 26
TRELSTAR 22.5 MG VIAL, 23
TRELSTAR 3.75 MG SYRINGE, -11.25 MG
SYRINGE, 23
TRELSTAR DEPOT, 26
TRELSTAR LA, 26
treprostinil sodium, 37
tretinoin 0.025% cream, -0.05% cream, 0.1% cream, -gel, 94
tretinoin capsule, 24
triamcinolone acetonide, 92
triamcinolone acetonide cream, -lotion, -oint,
97
triamcinolone acetonide nasal inhaled
steroids, 92
triamcinolone acetonide paste, 98
triamterene-hctz, 36
triamterene-hydrochlorothiazid, 36
trianex, 49
TRIBENZOR, 31
TRICOR, 33
triderm, 97
trientine, 55
trifluoperazine hcl, 45
trifluridine ophth drops, 88
trihexyphenidyl hcl, 43
tri-legest fe, 56
TRILIPIX, 33
trilyte with flavor packets, 64
trimethobenzamide hcl capsule, -100 mg/ml,
62
trimethoprim tablet, 20
trimipramine, 43
trimipramine maleate capsule, 43
trinessa, 56
TRIPEDIA, 72
tri-previfem, 56
triptorelin pamoate, 23, 26
TRISENOX, 24
tri-sprintec, 56

trivora-28, 56
TRIZIVIR, 18
TROPHAMINE, 83
tropicamide ophth drops, 88
trospium chloride tablet, 66
TRUEPLUS INSULIN SYRINGE, 79
TRUVADA, 18
TWINRIX VACCINE SYRINGE, 73
TWINRIX VACCINE VIAL, 72
TYGACIL, 20
TYKERB, 24
TYPHIM VI 25 MCG/0.5 ML SYRNG, 73
TYPHIM VI 25 MCG/0.5 ML VIAL, 72
typhoid vaccine, 72, 73
TYZEKA, 19
ULORIC, 6
ULTICARE INSULIN NEEDLES - DISPOSABLE,
79
ulticare insulin syringes - disposable, 79
ULTIGUARD INSULIN SYRINGES DISPOSABLE, -30GX0.5 ML SYRINGE, 30GX1 ML SYRINGE, 79
ULTILET ALCOHOL SWAB, 79
ultra comfort 1 ml syringe, 79
ULTRACOMFORT INSULIN NEEDLES DISPOSABLE, -INSULIN SYRINGES DISPOSABLE, 79
UNIFINE PENTIPS, 79
unithroid 137 mcg tablet, 62
unithroid 25 mcg tablet, -50 mcg tablet, -75
mcg tablet, -88 mcg tablet, -100 mcg
tablet, -112 mcg tablet, -125 mcg tablet, 150 mcg tablet, -175 mcg tablet, -200 mcg
tablet, -300 mcg tablet, 60
urea 40% cream, -45% cream, -40% gel, 40% lotion, 50
URINARY ANTIINFECTIVES, 13
URINARY ANTISPASMODICS, 66
UROLOGICAL MEDICATIONS, 98
UROXATRAL, 66
ursodiol capsule, -tablet, 64
VACCINES, 71
VAGIFEM, 57
VAGINAL ANTI-INFECTIVES, 67
valacyclovir, 19
Page 135 of 139

VALCYTE, 19
valganciclovir, 19
valproate sodium injection, 40
valproic acid capsule, -syrup, 40
valsartan, 31
valsartan-hydrochlorothiazide, 38
VALTURNA 150-160 MG TABLET, 35
VALTURNA 300-320 MG TABLET, 35
VANCOCIN HCL, 20
vancomycin, 20
vancomycin 1 gm vial, -10 gm vial, 20
VANCOMYCIN 500 MG A/V VIAL, -1G/200 ML
BAG, 20
vancomycin 500 mg vial, -750 mg vial, -1 gm
add-van vial, -5 gm vial, 12
VANCOMYCIN HCL CAPSULE, 20
vandazole, 67
vandetanib, 23, 24
VANDETANIB, 24
VANISHPOINT INSULIN SYRINGES DISPOSABLE, 79
VAQTA 25 UNITS/0.5 ML SYRINGE, 73
VAQTA 25 UNITS/0.5 ML VIAL, 72
varenicline tartrate, 49
varicella vacc/pf, 72
varicella virus vaccine live, 72
VARIVAX VACCINE, 72
VASOPRESSINS, 60
velaglucerase alfa, 57
VELCADE, 22
velivet, 56
vemurafenib, 24
venlafaxine hcl, 43
venlafaxine hcl er 150 mg cap, 43
venlafaxine hcl er 225 mg tab, 29
venlafaxine hcl er 37.5 mg cap, -75 mg cap,
43
venlafaxine hcl er 37.5 mg tab, -75 mg tab, 150 mg tab, 43
VENTOLIN HFA, 91
VERAMYST, 92
verapamil 2.5 mg/ml ampul, 35
verapamil 2.5 mg/ml syringe, -2.5 mg/ml
vial, 38
verapamil er, 35

verapamil er pm, 35
verapamil hcl capsule sustained action, 38
verapamil hcl tablet, 35
veripred 20, 58
VESICARE 10 MG TABLET, 66
VESICARE 5 MG TABLET, 67
vestura, 56
VFEND IV, 17
VFEND SUSPENSION, 17
VFEND TABLET, 17
VGO 20, 79
VGO 30, 79
VGO 40, 79
vicodin hp, 7
VICTOZA 2-PAK, 61
VICTOZA 3-PAK, 52
VIDAZA, 22
VIDEX 2 GM PEDIATRIC SOLN, 18
vigabatrin, 40
VIGAMOX, 88
VIIBRYD 10 MG TABLET, -20 MG TABLET, 40 MG TABLET, 43
VIIBRYD TITRATION PACK, 43
vilazodone hydrochloride, 43
VIMOVO, 10
VIMPAT INJECTION, 40
VIMPAT SOLUTION, -TABLET, 40
vinblastine, 22
VINBLASTINE SULFATE, 22
vincristine sulfate, 22
vinorelbine tartrate, 22
viorele, 86
VIRACEPT, 18
VIRAMUNE, 18
VIREAD, 18
vismodegib, 24
VITAMINS, 85
vitazol, 49
VIVELLE-DOT, 58
VOLTAREN GEL, 97
voriconazole, 17
voriconazole injection, 17
voriconazole tablet, 17
vorinostat, 22
VOTRIENT, 24
Page 136 of 139

VPRIV, 57
VYTORIN, 33
warfarin sodium, 67
warfarin sodium tablet, 68
WEBCOL, 79
WELCHOL, 33
wera, 86
XALKORI, 24
XANTHINES, 93
XARELTO 10 MG TABLET, 68
XARELTO 15 MG TABLET, -20 MG TABLET,
68
XENAZINE, 47
XIFAXAN 550 MG TABLET, 64
XOLAIR, 92
XYREM, 48
yellow fever vaccine, 72
YF-VAX, 72
zafirlukast, 91
zaleplon, 46
zamicet, 7
zanamivir, 19
zarah, 86
ZAVESCA, 57
zazole, 67
ZELBORAF, 24
ZEMPLAR CAPSULE, 85
ZEMPLAR INJECTION, 85
zenchent, 86
zenchent fe, 86
ZENPEP, 64
zeosa, 56
ZETIA, 33
ZIAGEN SOLUTION, 18
ZIAGEN TABLET, 18
zidovudine, 18
zidovudine/lamivudine/abacavir, 18
ziprasidone, 44
ziprasidone hcl, 45
zoledronic acid, 54
ZOLINZA, 22
zolpidem tartrate, 46
zolpidem tartrate er, 46
ZOMETA 4 MG/100 ML INJECTION, 54
ZOMETA 4 MG/5 ML VIAL, 54

ZONALON, 95
zonisamide, 40
ZORTRESS 0.25 MG TABLET, -0.5 MG
TABLET, 71
ZORTRESS 0.75 MG TABLET, 71
ZOSTAVAX, 72
zovia 1-35e, 56
zovia 1-50e, 56
ZOVIRAX CREAM, -OINT, 96
ZYCLARA 2.5% CREAM PUMP, 50
ZYCLARA 3.75% CREAM, -3.75% CREAM
PUMP, 97
ZYMAR, 88
ZYMAXID, 88
ZYPREXA 10 MG TABLET, -15 MG TABLET, 20 MG TABLET, 46
ZYPREXA 2.5 MG TABLET, -5 MG TABLET, 7.5 MG TABLET, 46
ZYPREXA INJECTION, 46
ZYPREXA ZYDIS 10 MG TABLET, -15 MG
TABLET, -20 MG TABLET, 46
ZYPREXA ZYDIS 5 MG TABLET, 46
ZYTIGA, 24
ZYVOX 200 MG/100 ML IV SOLN, 12
ZYVOX 600 MG/300 ML IV SOLN, -ORAL
SUSP, -TABLET, 20

Page 137 of 139

Page 138 of 139

Page 139 of 139



---

Source Exif Data:

File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.6
Linearized                      : Yes
Author                          : underhillf
Company                         : 
Created                         : D:20121115
Create Date                     : 2012:11:19 12:12:21-05:00
Last Saved                      : D:20121118
Modify Date                     : 2012:11:19 12:15:46-05:00
Source Modified                 : D:20121119171215
Has XFA                         : No
Language                        : EN-US
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.2-c001 63.139439, 2010/09/27-13:37:26
Metadata Date                   : 2012:11:19 12:15:46-05:00
Creator Tool                    : Acrobat PDFMaker 10.1 for Word
Document ID                     : uuid:f07bdb8d-c392-43c7-8626-9b5bf41f9a4c
Instance ID                     : uuid:0e8a5717-68df-4944-8d71-5ef6b9b60e4f
Subject                         : 2
Format                          : application/pdf
Creator                         : underhillf
Producer                        : Adobe PDF Library 10.0
Page Layout                     : OneColumn
Page Count                      : 139

EXIF Metadata provided by EXIF.tools